Parathyroidectomy Associates with Reduced Mortality in Taiwanese Dialysis Patients with Hyperparathyroidism: Evidence for the Controversy of Current Guidelines

Abstract

Parathyroidectomy is recommended by the clinical guidelines for dialysis patients with unremitting secondary hyperparathyroidism (SHPT). However, the survival advantage of parathyroidectomy is debated because of the selection bias in previous studies. To minimize potential bias in the present nationwide cohort study, we enrolled only dialysis patients who had undergone radionuclide parathyroid scanning to ensure all patients had severe SHPT. The parathyroidectomized patients were matched with the controls based on propensity score for parathyroidectomy. Mortality hazard was estimated using multivariate Cox proportional hazard models adjusting for comorbidities before scanning (model 1) or over the whole study period (model 2). Our results showed that among the 2786 enrolled patients, 1707 underwent parathyroidectomy, and the other 1079 were controls. The crude mortality rates were lower in the parathyroidectomized patients than in the controls. In adjusted analyses for the population matched on propensity score, parathyroidectomy was associated with a significant 20% to 25% lower risk for all-cause mortality (model 1: hazard ratio 0.76, 95% confidence interval 0.61 to 0.94; model 2: hazard ratio 0.80, 95% confidence internal 0.64 to 0.98). We concluded that parathyroidectomy was associated with a reduced long-term mortality risk in dialysis patients with severe SHPT.

Total parathyroidectomy with forearm auto-transplantation improves the quality of life and reduces the recurrence of secondary hyperparathyroidism in chronic kidney disease patients

“…Diagnosis criteria were as below: Nuclide scanning showed 1 or more hot nodules with highly concentrated 131I, and low iodine intake capability in thyroid tissue other than nodules was evaluated; size of the hot nodules was inspected by ultrasonography or computerized tomography scan to confirm the nodular goiter; clinical manifestations presented decreased arrhythmia, limb numbness, and limb proximal muscle strength; serum 25-hydroxyvitamin D (25OHD) < 30 ng/mL or estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m 2 . [ 16 , 17 ] The patients were included into this study following the criteria: patients were with good adherence for systematic treatment and observations; and patients were diagnosed with SHPT by preoperative clinical symptom, signs, and biochemical and X ray manifestations (patients were included into SHPT patients group when [ 1 ] patients having intact PTH (iPTH) levels of >600 pg/mL accompanied with obvious calcium and phosphorus metabolic disorders [ 2 ] ; patients unresponsive to available medical therapy [ 3 ] ; patients suffering from severe osteoporosis and skeletal deformity observed by radiological examination [ 4 ] ; patients showing severe clinical symptoms, such as bone pain, cutaneous pruritus, and coronary artery calcification (CAC). Patients with the following symptoms were excluded from the study: patients suffering from congenital, genetic, autoimmune, or cardiovascular diseases; patients with a history of heavy smoking, alcohol abuse, drug abuse, psychiatric problems, and patients in pregnant or suckling period; patients suffering from severe anemia, bleeding, coagulation dysfunction, and patients unsuitable for general anesthesia; patients having deformities in neck bone or soft tissues and patients suffering from morbid obesity; patients underwent neck operation, radiological treatment, and with hypertrophic scar; patients who had large thyroid nodules, thyroiditis, substernal ectopic parathyroid, and parathyroid carcinoma patients; patients who had a high PTH >35 pmoL/L and serum calcium >2.60 mmoL/L [ 18 ] ; and patients who had bone hunger syndrome.…”

“…[ 3 ] SHPT in patients can lead to high-turnover bone disease, interstitial and vascular calcifications, and as well as cardiovascular mortality and morbidity. [ 4 – 7 ] The diagnosis of SHPT in patients mainly relies on high-resolution ultrasonography with color Doppler imaging (US/CD) and 99 mTc-methoxyisobutylisonitrile (MIBI) scintigraphy. [ 8 ] Owing to the high occurrence and recurrence of SHPT, the patients’ quality of life is seriously affected.…”

Parathyroidectomy in dialysis patients: Indications, methods, and consequences

“…Hence, the impact of PTX on survival has been extensively examined. Several studies support the beneficial effect of PTX on all‐cause and cardiovascular mortality . This beneficial effect was confirmed in a systematic review and meta‐analysis performed by Chen and collaborators; PTX was associated with a reduction in both all‐cause and cardiovascular mortality (28% and 37%, respectively) compared with medical treatment .…”

Risk of acute coronary syndrome after parathyroidectomy in patients with end‐stage renal disease: A population‐based cohort study in Taiwan

“…Patients with ESRD without SHPT might also be included in the non‐PTX group. A recent study by Ho et at . included radionuclide parathyroid scanning as the enrolling criteria for patients with SHPT and reported reduced mortality in ESRD patients who received PTX, which increased the specificity of the enrolees; however, the exclusion percentage seemed high.…”