Elective total parathyroidectomy without autotransplant in end-stage renal disease

Abstract

Ten patients are reported following parathyroidectomy (PTX). In 9 all identifiable parathyroid tissue in the neck was deliberately removed, and in the tenth (operated 14 years ago) the remnant which had been left probably did not function. Their post-operative course resembled that of patients treated conventionally, and their subsequent course was likewise uneventful with disappearance of all symptoms associated with their osteodystrophy. All patients required oral calcium supplementation but none were given vitamin D compounds after the initial period of repletion following surgery. Mean serum values were (before PTX and current) for calcium 2.63 +/- 0.14 and 2.33 +/- 0.08 mmol/liter, P = NS, for phosphorus 1.96 +/- 0.13 and 1.38 +/- 0.09 mmol/liter, P less than 0.01, and for alkaline phosphatase 713 +/- 191 and 101 +/- 14 IU, P less than 0.05. Evidence for residual parathyroid tissue was present in each case; one patient remained mildly hyperparathyroid and several were mildly hypoparathyroid by the IRMA PTH assay. Bone histomorphometry in five subjects post-PTX showed either normal or low turnover. Radiologically, striking remineralization was seen with disappearance of all erosive changes. We suggest that residual areas of parathyroid tissue are stimulated and continue to secrete hormone even when all the discrete glands have been removed. It is recommended that when indicated, and in the absence of aluminum excess, total PTX without autotransplant should be the preferred form of therapy for long-term dialysis patients.

Long-term Results of Subcutaneous Parathyroid Grafts in Uremic Patients

“…They state that the absence of PTH has no significant clinical consequence on the bones of patients who undergo hemodialysis and who are treated with calcium and cholecalciferol supplements. [6][7][8][9] These conclusions are, however, questioned by other investigators. 10 The ideal blood concentration of intact PTH is not known for uremic subjects.…”

Long-Term Outcome after Total Parathyroidectomy for the Management of Secondary Hyperparathyroidism

“…Although there is some fear of adynamic bone disease in case of hypoparathyroidism and some resistance to constantly supplementing patients with active vitamin D postoperatively, tPTX without autotransplantation has found more followers during the last 5 years [22,23,24]. The procedure had already been suggested in the late 1980s and 1990s [6, 19,25,26,27,28]. In these centers, tPTX without autotransplantation (and mostly also without routine thymectomy) has been proven a useful and in the short and mid-term an easily manageable operative approach for end-stage renal failure patients with severe sHPT.…”

“…There is evidence of continued secretion of iPTH even after tPTX [6,22,23,24,25,26,27, 29], especially in patients remaining on dialysis rather than those being transplanted post-tPTX. Predisposing factors for continuing PTH secretion post-tPTX comprise duration of dialysis post-tPTX (reflecting the overall exposure to PTH stimulation) and no adequate drop of initial calcium levels after tPTX (possibly reflecting the adequacy of operative ablation of parathyroid glands) [29].…”

La calciphylaxie et ses manifestations stomatologiques

“…La parathyroïdectomie subtotale ou l'autotransplantation de tissu parathyroïdien sont très controversés 40,59 . En effet, devant l'urgence, Kang et al 37 estiment qu'il faut intervenir rapidement et de façon agressive si l'on souhaite obtenir une amélioration rapide de l'état général du patient.…”