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

Abstract

Objective: To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism. Background: Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT. Methods: Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content. Results: These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation. Conclusions: Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.

Resolution of Secondary Hyperparathyroidism after Kidney Transplantation and the Effect on Graft Survival

“…Of these 73 patients, 69 were in the hypercalcemic HPT group, and 4 were in the normocalcemic HPT group. The median (IQR) length from KT to PTx was 12 (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24) months. The mean ( ± SD) length of follow-up after PTx was 39.4 ± 19.0 months.…”

“…32 The American Association of Endocrine Surgeons (AAES) guidelines recommend PTx as the treatment of choice for patients with hypercalcemic HPT, and referral for PTx should be placed within 12 months post-KT. 16 However, the reported rate of PTx in KT recipients with HPT was low, ranging from 6.6% to 28.2%. 6,11,33 The PTx rate in our cohorts was 19.3% in the persistent HPT with hypercalcemia group and 0.5% in the normocalcemic HPT group, which further demonstrates that PTx is underused for HPT among KT recipients.…”

“…The cost-effectiveness of PTx and cinacalcet pre-KT or post-KT has been simulated, and PTx pre-KT may be the most cost-effective option 32 . The American Association of Endocrine Surgeons (AAES) guidelines recommend PTx as the treatment of choice for patients with hypercalcemic HPT, and referral for PTx should be placed within 12 months post-KT 16 . However, the reported rate of PTx in KT recipients with HPT was low, ranging from 6.6% to 28.2% 6,11,33 .…”

“…Kidney Disease: Improving Global Outcomes guidelines provide limited guidance on the management of HPT and bone disease post-KT 15 Parathyroidectomy (PTx) is believed to be the treatment of choice for KT recipients with HPT. [16][17][18][19] Due to a lack of consensus and lack of patient enthusiasm for additional surgery, referral for parathyroidectomy is often delayed, in many cases up to a year after KT. 20 In our study, we sought to study the prevalence and risk factors for persistent HPT post-KT at our high-volume institution and its effect on long-term graft survival.…”

Pre‐operative Cinacalcet Administration Reduces Immediate Post‐operative Hypocalcemia Following Total Parathyroidectomy in Severe Renal Hyperparathyroidism

“…It has been used to control mild RHPT [1][2][3][5][6][7][8]. Parathyroidectomy, on the other hand, is reserved for severe RHPT not responsive to medical treatment [9] and/or when PTH levels are persistently high ([ 800 pg/mL [88.0 pmol/L]) [10].…”