Outcomes of parathyroidectomy with autotransplantation in nephrogenic secondary hyperparathyroidism
Alina Georgescu1, Bogdan Stanescu1,3, Adrian Zugravu1,2, Gabriel Mircescu2,3 & Corin Badiu1,3
Background: One of the major complications developed by patients with end stage renal disease (ESRD) is secondary hyperparathyroidism (SHPT), due to hypocalcaemia, hyperphosphatemia and 1,25(OH)2D deficiency with parathyroid hyperplasia and high PTH levels as earliest changes, which may require parathyroidectomy (PTX).
Study design and objectives: This study aimed to evaluate the indications, the particularities and outcomes post-PTX of patients suffering from secondary hyperparathyroidism due to chronic kidney disease (CKD).
Patients and methods: A total of 196 patients, 112 F (57.14%), aged 51.66±11.27 (ranged 2181 years) with hyperparathyroidism and ESRD underwent PTX with (194 patients) or without (2 patients) autotransplantation from 1999 to 2009.
Results: Duration of the ESRD was 8.76±5.06 years. The ESRD was treated by hemodialysis in 65.82% cases. A total of 16 cases were submitted to kidney transplantation with a rejection in 10 cases. At the time of the PTX, 6 patients were with kidney transplantation. The medical therapy of SHPT was vitamin D and phosphate binders, calcimimetics were not used in this group. The increased parathyroid volume was evaluated by ultrasonography (sensitivity 92.45% versus pathology), in 159 patients. Tertiary HPT was diagnosed in 53 (27.04%) patients despite medical treatment. The evaluation was performed 24 h before and after surgery. Preoperative values were for PTH=1721.84±839.84 pg/ml, Ca=9.94±1.28 mg/dl and P=6.38±1.90 mg/dl; Ca x Ph product above 75 mg2/dl2 was found in 23.97% (n=47) cases. Surgery was performed by removing all parathyroid glands but one which was dissected to a equivalent volume of a normal parathyroid. Autotransplantation consisted in placement of this remnant parathyroid in the jugular notch area, by keeping the vascular supply from the cervical vessels. PTX effect was the decrease of PTH values to 48.13±58.18 pg/ml, calcium to 6.93±1.29 mg/dl and phosphate to 4.90±1.90 mg/dl, while the product Ca x Ph decreased in 195 cases under 75 mg2/dl2. Postoperative evolution was uneventful in all cases, but the global prognosis is decided by the kidney disease.
Conclusion: Parathyroidectomy in ESRD is an important part of management in secondary or tertiary HPT, cervical autotransplantation being an useful surgical alternative.