Surgical management of secondary hyperparathyroidism in chronic kidney disease—a consensus report of the European Society of Endocrine Surgeons

Abstract

Background Despite advances in the medical management of secondary hyperparathyroidism due to chronic renal failure and dialysis (renal hyperparathyroidism), parathyroid surgery remains an important treatment option in the spectrum of the disease. Patients with severe and complicated renal hyperparathyroidism (HPT), refractory or intolerant to medical therapy and patients with specific requirements in prospect of or excluded from renal transplantation may require parathyroidectomy for renal hyperparathyroidism. Methods Present standard and actual controversial issues regarding surgical treatment of patients with hyperparathyroidism due to chronic renal failure were identified, and pertinent literature was searched and reviewed. Whenever applicable, evaluation of the level of evidence concerning diagnosis and management of renal hyperparathyroidism according to standard criteria and recommendation grading were employed. Results were discussed at the 6th Workshop of the European Society of Endocrine Surgeons entitled Hyperparathyroidism due to multiple gland disease: An evidence-based perspective.Results Presently, literature reveals scant data, especially, no prospective randomized studies to provide sufficient levels of evidence to substantiate recommendations for surgery in renal hyperparathyroidism. Appropriate surgical management of renal hyperparathyroidism involves standard bilateral exploration with bilateral cervical thymectomy and a spectrum of four standardized types of parathyroid resection that reveal comparable outcome results with regard to levels of evidence and recommendation. Specific patient requirements may favour one over the other procedure according to individualized demands. Conclusions Surgery for patients with renal hyperparathyroidism in the era of calcimimetics continues to play an important role in selected patients and achieves efficient control of hyperparathyroidism. The overall success rate and longterm control of renal hyperparathyroidism and optimal handling of postoperative metabolic effects also depend on the timely indication, individually suitable type of parathyroid resection and specialized endocrine surgery.

Long–term mortality after parathyroidectomy among chronic kidney disease patients with secondary hyperparathyroidism: a systematic review and meta-analysis

“…In the era of calcimimetics, surgery continues to play an important role in efficient control of renal HPT. 15,16 However, most of the existing studies involve small sample sizes and only evaluate intermediate outcomes such as serum Ca and P levels, iPTH, vascular compliance and vascular calcification. These studies, individually or jointly, are not powerful enough for evaluation of mortality or cardiovascular events.…”

Multigland primary hyperparathyroidism—frequently considered, seldom encountered

“…Progress in the medical treatment and hemodialysis protocols, adequate vitamin D replacement, the use of calcimimetics (cinacalcet), 'conservative' guidelines issued by nephrologists and increasing access to renal transplantation have all contributed to a decrease in the number of patients with severe SHPT deemed to benefit from parathyroidectomy. The paper by Lorenz et al [3] reviews the selection criteria for parathyroidectomy suggested by the international practice guidelines (Kidney Disease Improving Global Outcome, KDIGO) and emphasizes that currently, surgery is restricted to those who fail medical treatment and its main indications are the correction of metabolic abnormalities rather than improving severity of symptoms or bone disease [3]. In parallel with an erosion of the role of surgeons in selecting the patients for surgery, there has been a strong influence of the medical community on the type of operation to be offered to individual patients.…”

“…This is the topic covered by the third paper in this series of publications [3]. Progress in the medical treatment and hemodialysis protocols, adequate vitamin D replacement, the use of calcimimetics (cinacalcet), 'conservative' guidelines issued by nephrologists and increasing access to renal transplantation have all contributed to a decrease in the number of patients with severe SHPT deemed to benefit from parathyroidectomy.…”

“…The general agreement is that for patients expecting a renal transplant, the operation should be subtotal parathyroidectomy or total parathyroidectomy and autotransplant. Bilateral cervical thymectomy has been shown to reduce persistence and recurrence rate hence it is recommended [3].…”

“…Three separate manuscripts published in this issue of LAS review the recent literature published on multigland disease in the context of hereditary and sporadic forms of PHPT [1,2] and the secondary hyperparathyroidism in chronic renal failure [3].…”