Background: Secondary hyperparathyroidism (SHPT) is severe complication of chronic kidney disease, characterized by high serum parathyroid hormone (PTH), parathyroid gland hyperplasia, and disturbances in mineral metabolism. Effective management of SHPT includes measures to prevent hyperphosphataemia and excess PTH, to maintain serum calcium within the normal range. In dialysis patients with severe SHPT, medical treatment may fail and parathyroidectomy (PTX) is indicated for definitive treatment. However, PTX does not always lead to disease compensation. In this case only a combined surgical and medical approach could help to control SHPT.
Case presentation: We presented the clinical case of patient with an 8-year history of renal insufficiency secondary to chronic glomerulonephritis. Long-term disease decompensation (PTH level of 2500 pg/ml, severe hypercalcemia 2.8 mmol/l and hyperphosphatemia 2.03 mmol/l) led to multiple fractures in the spine, ribs and sternum handle, extraskeletal calcification. The ultrasound and SPECT/CT with MIBI revealed hyperplasia of four parathyroid glands in a typical place and the fifth parathyroid gland, ectopied in the mediastinum. Despite the surgical removal of four parathyroid glands, PTH and calcium levels remained high. The surgical resection of ectopic parathyroid tissue is not feasible due to anatomical difficulties. In the postoperative period, we prescribed combination therapy with Paricalcitol, calcium supplements and Denosumab with positive effect - the compensation of phosphorus-calcium metabolism parameters, bone pain reduction, an increase in motor activity and overall well-being.
Conclusions: Dialysis patients with severe SHPT need the timely initiated treatment, to control the disease and its complications and improve the quality of life.