Secondary hyperparathyroidism: recurrence after total parathyroidectomy with autotransplantation

Abstract

BACKGROUND: Secondary hyperparathyroidism is common in patients with end-stage chronic kidney disease. If drug therapy fails, total parathyroidectomy with autotransplantation of parathyroid tissue into the forearm (PTX-AT) is the most widely used procedure. High recurrence rates of secondary hyperparathyroidism following PTX-AT are reported in the literature. OBJECTIVE: The aim of this study was to evaluate recurrences of secondary hyperparathyroidism following PTX-AT in detail in order to develop strategies to prevent recurrences in the future.METHODS: This retrospective study analysed a singlecentre cohort of 42 patients who underwent PTX-AT for secondary hyperparathyroidism at a tertiary centre in Switzerland. Postoperative PTH levels were evaluated to determine the recurrence and persistence rates and the time to recurrence. Furthermore, the peri-and postoperative outcomes were assessed. Patients on dialysis and patients with a functioning kidney transplant suffering tertiary HPTH were analysed separately. RESULTS: Intraoperative measurements showed that serum PTH decreased to 6.9% (3.3-15.0%) of the preoperative baseline level. After a median follow-up of 89.5 months (IQR 31.9-152.9), persistence of secondary hyperparathyroidism was found in five patients (11.9%) and recurrence in four patients (9.5%), giving a total recurrence rate of 21.4%. CONCLUSION: Recurrence of secondary hyperparathyroidism after PTX remains a problem, occurring in every fifth patient. In our experience, the introduction of intraoperative PTH measurement has helped to lower the rates of persistence and recurrence. Further reductions in the recurrence rate might be achieved with novel, more accurate pre-and intraoperative imaging techniques.

Impact of Dexmedetomidine On Secondary Hyperparathyroidism Recurrence In Uremic Patients Who Received Parathyroidectomy With Auto-Transplantation: A Retrospective Propensity-Matched Study

“…According to the previous study [3] and the historical medical data in our hospital, we hypothesized that uremic patients would have a 10% rate of recurrent SHPT. To detect a 4% (SD = 3%) difference in the incidence of SHPT recurrence between patients received or did not receive DEX with a 0.05 chance of type error and 80% power, 304 patients were required.…”

“…Surgical total parathyroidectomy with auto-transplantation (tPTX-AT) signi cantly improves calcium and phosphorus metabolism, resulting in reduced mortality and morbidity rates. However, due to the pathological changes in the remaining tissue, including in ammation and perioperative stress, the incidence of SHPT recurrence may reach as high as 20% [3,4]. Many cohort studies have demonstrated that perioperative anesthetic and analgesic intervention play a critical role on the long-term prognosis of multiple disease [5,6].…”

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism

“…This is because there may still be a component of kidney dysfunction in patients with tertiary disease, which will affect PTH levels and result in inaccurate diagnosis. As such an elevated serum PTH alone is not sufficient for the diagnosis of persistent or recurrent THPT 298 Clinical Highlight 9-1: Persistent SHPT is the failure of serum PTH level to fall to a certain threshold postoperatively, and recurrent SHPT an initial decrease in serum PTH level followed by an increase at least 6 months postoperatively.…”

“…Consequently, some surgeons perform bilateral transcervical thymectomy as a standard therapy accompanying either subtotal resection or total resection with autotransplantation 270,284,319–321. Other surgeons only perform transcervical thymectomy unilaterally if an ipsilateral gland cannot be located 260,298,322. In general, thymectomy is not performed after total PTX without autotransplant, as patients rely on intrathymic parathyroid tissue for parathyroid function.…”

Persistence of secondary hyperparathyroidism after parathyroidectomy in a patient with chronic kidney disease: a case report

“…При этом субтотальная ПТЭ связана с более высоким риском рецидива [10]. Общая частота персистенции/рецидивов ВГПТ после первичного хирургического лечения составляет от 8 до 38% [11][12][13][14][15][16]. Персистенция после тотальной ПТЭ с АТ наблюдается в 0,4-16% случаев [11][12][13][14], тотальной ПТЭ без АТ -0,5-6,2% [11,14], субтотальной ПТЭ -3,1-22% [11,13,[15][16] и селективной ПТЭ -4,1-25% [11,16].…”