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World Journal of Surgery

, Volume 36, Issue 2, pp 318–326 | Cite as

Initial Parathyroid Surgery in 606 Patients with Renal Hyperparathyroidism

  • Ralph Schneider
  • Emily P. Slater
  • Elias Karakas
  • Detlef K. Bartsch
  • Katja Schlosser
Article

Abstract

Background

The aim of the present study was to evaluate the outcome of different surgical procedures for patients on permanent dialysis who underwent initial parathyroidectomy for renal hyperparathyroidism (rHPT).

Methods

Out of a prospective database of patients who underwent parathyroid surgery for rHPT between 1976 and 2009, patients on permanent dialysis who underwent initial parathyroidectomy were further analyzed regarding perioperative biochemical changes and postoperative outcome.

Results

A total of 606 patients were analyzed. Total parathyroidectomy with autotransplantation (group A) was performed in 504 patients, total parathyroidectomy without autotransplantation in 32 (group B), subtotal parathyroidectomy in 21 (group C), and incomplete parathyroidectomy in 49 (group D).

After surgery, mean calcium levels dropped from 2.76 to 1.91 mmol/l in group A, from 2.67 to 2.11 mmol/l in group B, from 2.70 to 2.09 mmol/l in group C, and from 2.65 to 1.94 mmol/l in group D. The parathyroid hormone level dropped from 1,371.4 pg/ml to 28.8 pg/ml in group A, from 1,078.4 pg/ml to 27.0 pg/ml in group B, from 2,377.9 pg/ml to 61.4 pg/ml in group C, and from 1,010.2 pg/ml to 99.5 pg/ml in group D. Persistent rHPT occurred in 2/504 patients from group A (0.4%), 0/32 patients from group B (0%), 1/21 patients from group C (4.8%), and 2/49 patients from group D (4.1%). After a mean follow-up of 57.6 months, recurrent rHPT occurred in 27/504 patients from group A (5.4%), in 0/32 patients from group B (0%), in 2/21 patients from group C (9.5%), and in 3/49 patients from group D (6.1%).

Conclusions

Total parathyroidectomy with or without autotransplantation is a feasible and safe surgical procedure for patients on permanent dialysis with otherwise uncontrollable rHPT.

Keywords

Parathyroid Gland Hypoparathyroidism Parathyroid Tissue Recurrent Laryngeal Nerve Palsy Adynamic Bone Disease 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Slatopolsky E (1998) The role of calcium, phosphorus and vitamin D metabolism in the development of secondary hyperparathyroidism. Nephrol Dial Transplant 13(Suppl 3):3–8PubMedCrossRefGoogle Scholar
  2. 2.
    Llach F (1995) Secondary hyperparathyroidism in renal failure: the trade-off hypothesis revisited. Am J Kidney Dis 25:663–679PubMedCrossRefGoogle Scholar
  3. 3.
    Triponez F, Clark OH, Vanrenthergem Y et al (2008) Surgical treatment of persistent hyperparathyroidism after renal transplantation. Ann Surg 248:18–30PubMedCrossRefGoogle Scholar
  4. 4.
    Fukagawa M, Kazama JJ, Shigematsu T (2002) Management of patients with advanced secondary hyperparathyroidism: the Japanese approach. Nephrol Dial Transplant 17:1553–1557PubMedCrossRefGoogle Scholar
  5. 5.
    Arnold A, Brown MF, Urena P et al (1995) Monoclonality of parathyroid tumors in chronic renal failure and in primary parathyroid hyperplasia. J Clin Invest 95:2047–2053PubMedCrossRefGoogle Scholar
  6. 6.
    Felsenfeld AJ (1997) Considerations for the treatment of secondary hyperparathyroidism in renal failure. J Am Soc Nephrol 8:993–1004PubMedGoogle Scholar
  7. 7.
    Tominaga Y, Matsuoka S, Uno N et al (2008) Parathyroidectomy for secondary hyperparathyroidism in the era of calcimimetics. Ther Apher Dial 12(Suppl 1):S21–S26PubMedCrossRefGoogle Scholar
  8. 8.
    Tominaga Y, Tanaka Y, Sato K et al (1997) Histopathology, pathophysiology, and indications for surgical treatment of renal hyperparathyroidism. Semin Surg Oncol 13:78–86PubMedCrossRefGoogle Scholar
  9. 9.
    Shih ML, Duh QY, Hsieh CB et al (2009) Total parathyroidectomy without autotransplantation for secondary hyperparathyroidism. World J Surg 33:248–254. doi: 10.1007/s00268-008-9765-8 PubMedCrossRefGoogle Scholar
  10. 10.
    Fassbinder W, Brunner FP, Brynger H et al (1991) Combined report on regular dialysis and transplantation in Europe, XX, 1989. Nephrol Dial Transplant 6(Suppl 1):5–35Google Scholar
  11. 11.
    Stanbury SW, Lumb GA, Nicholson WF (1960) Elective subtotal parathyroidectomy for renal hyperparathyroidism. Lancet 1(7128):793–799PubMedCrossRefGoogle Scholar
  12. 12.
    Rothmund M, Wagner PK, Schark C (1991) Subtotal parathyroidectomy versus total parathyroidectomy and autotransplantation in secondary hyperparathyroidism: a randomized trial. World J Surg 15:745–750. doi: 10.1007/BF01665309 PubMedCrossRefGoogle Scholar
  13. 13.
    Neonakis E, Wheeler MH, Krishnan H et al (1995) Results of surgical treatment of renal hyperparathyroidism. Arch Surg 130:643–648PubMedCrossRefGoogle Scholar
  14. 14.
    Henry JF, Denizot A, Audiffret J et al (1990) Results of reoperations for persistent or recurrent secondary hyperparathyroidism in hemodialysis patients. World J Surg 14:303–306. doi: 10.1007/BF01658510 PubMedCrossRefGoogle Scholar
  15. 15.
    Ogg CS (1967) Total parathyroidectomy in treatment of secondary (renal) hyperparathyroidism. Br Med J 4:331–334PubMedCrossRefGoogle Scholar
  16. 16.
    Gasparri G, Camandona M, Abbona GC et al (2001) Secondary and tertiary hyperparathyroidism: causes of recurrent disease after 446 parathyroidectomies. Ann Surg 233:65–69PubMedCrossRefGoogle Scholar
  17. 17.
    Kaye M, D’Amour P, Henderson J (1989) Elective total parathyroidectomy without autotransplant in end-stage renal disease. Kidney Int 35:1390–1399PubMedCrossRefGoogle Scholar
  18. 18.
    Kaye M, Rosenthall L, Hill RO et al (1993) Long-term outcome following total parathyroidectomy in patients with end-stage renal disease. Clin Nephrol 39:192–197PubMedGoogle Scholar
  19. 19.
    Stracke S, Jehle PM, Sturm D et al (1999) Clinical course after total parathyroidectomy without autotransplantation in patients with end-stage renal failure. Am J Kidney Dis 33:304–311PubMedCrossRefGoogle Scholar
  20. 20.
    Ockert S, Willeke F, Richter A et al (2002) Total parathyroidectomy without autotransplantation as a standard procedure in the treatment of secondary hyperparathyroidism. Langenbecks Arch Surg 387:204–209PubMedCrossRefGoogle Scholar
  21. 21.
    Lorenz K, Ukkat J, Sekulla C et al (2006) Total parathyroidectomy without autotransplantation for renal hyperparathyroidism: experience with a qPTH-controlled protocol. World J Surg 30:743–751. doi: 10.1007/s00268-005-0379-0 PubMedCrossRefGoogle Scholar
  22. 22.
    Saunders RN, Karoo R, Metcalfe MS et al (2005) Four gland parathyroidectomy without reimplantation in patients with chronic renal failure. Postgrad Med J 81:255–258PubMedCrossRefGoogle Scholar
  23. 23.
    Richards ML, Wormuth J, Bingener J et al (2006) Parathyroidectomy in secondary hyperparathyroidism: Is there an optimal operative management? Surgery 139:174–180PubMedCrossRefGoogle Scholar
  24. 24.
    Nicholson ML, Veitch PS, Feehally J (1996) Parathyroidectomy in chronic renal failure: comparison of three operative strategies. J R Coll Surg Edinb 41:382–387PubMedGoogle Scholar
  25. 25.
    Schlosser K, Zielke A, Rothmund M (2004) Medical and surgical treatment for secondary and tertiary hyperparathyroidism. Scand J Surg 93:288–297PubMedGoogle Scholar
  26. 26.
    Schlosser K, Veit JA, Witte S et al (2007) Comparison of total parathyroidectomy without autotransplantation and without thymectomy versus total parathyroidectomy with autotransplantation and with thymectomy for secondary hyperparathyroidism: TOPAR PILOT-trial. Trials 8:22PubMedCrossRefGoogle Scholar
  27. 27.
    Tominaga Y, Matsuoka S, Uno N (2009) Surgical and medical treatment of secondary hyperparathyroidism in patients on continuous dialysis. World J Surg 33:2335–2342. doi: 10.1007/s00268-009-9943-3 PubMedCrossRefGoogle Scholar
  28. 28.
    Tominaga Y, Matsuoka S, Sato T (2005) Surgical indications and procedures of parathyroidectomy in patients with chronic kidney disease. Ther Apher Dial 9:44–47PubMedCrossRefGoogle Scholar
  29. 29.
    Dotzenrath C, Cupisti K, Goretzki E et al (2003) Operative treatment of renal autonomous hyperparathyroidism: cause of persistent or recurrent disease in 304 patients. Langenbecks Arch Surg 387:348–354PubMedGoogle Scholar
  30. 30.
    Bro S, Olgaard K (1997) Effects of excess PTH on nonclassical target organs. Am J Kidney Dis 30:606–620PubMedCrossRefGoogle Scholar
  31. 31.
    Ogata H, Koiwa F, Ito H et al (2006) Therapeutic strategies for secondary hyperparathyroidism in dialysis patients. Ther Apher Dial 10:355–363PubMedCrossRefGoogle Scholar
  32. 32.
    Blacher J, Guerin AP, Pannier B et al (1999) Impact of aortic stiffness on survival in end-stage renal disease. Circulation 99:2434–2439PubMedGoogle Scholar
  33. 33.
    Davies MR, Hruska KA (2001) Pathophysiological mechanisms of vascular calcification in end-stage renal disease. Kidney Int 60:472–479PubMedCrossRefGoogle Scholar
  34. 34.
    Block GA, Hulbert-Shearon TE, Levin NW et al (1998) Association of serum phosphorus and calcium × phosphate product with mortality risk in chronic hemodialysis patients: a national study. Am J Kidney Dis 31:607–617PubMedCrossRefGoogle Scholar
  35. 35.
    Rostand SG, Drueke TB (1999) Parathyroid hormone, vitamin D, and cardiovascular disease in chronic renal failure. Kidney Int 56:383–392PubMedCrossRefGoogle Scholar
  36. 36.
    Block GA, Port FK (2000) Re-evaluation of risks associated with hyperphosphatemia and hyperparathyroidism in dialysis patients: recommendations for a change in management. Am J Kidney Dis 35:1226–1237PubMedCrossRefGoogle Scholar
  37. 37.
    Ganesh SK, Stack AG, Levin NW et al (2001) Association of elevated serum PO(4), Ca × PO(4) product, and parathyroid hormone with cardiac mortality risk in chronic hemodialysis patients. J Am Soc Nephrol 12:2131–2138PubMedGoogle Scholar
  38. 38.
    Foley RN, Parfrey PS (1998) Cardiovascular disease and mortality in ESRD. J Nephrol 11:239–245PubMedGoogle Scholar
  39. 39.
    Coen G, Pierantozzi A, Spizzichino D et al (2010) Risk factors of one year increment of coronary calcifications and survival in hemodialysis patients. BMC Nephrol 11:10PubMedCrossRefGoogle Scholar
  40. 40.
    Naves-Diaz M, Passlick-Deetjen J, Guinsburg A et al (2010) Calcium, phosphorus, PTH and death rates in a large sample of dialysis patients from Latin America. The CORES Study. Nephrol Dial Transplant 26:1938–1947PubMedCrossRefGoogle Scholar
  41. 41.
    Pilz S, Tomaschitz A, Drechsler C et al (2010) Parathyroid hormone level is associated with mortality and cardiovascular events in patients undergoing coronary angiography. Eur Heart J 31:1591–1598PubMedCrossRefGoogle Scholar
  42. 42.
    Pontoriero G, Cozzolino M, Locatelli F et al (2010) CKD patients: the dilemma of serum PTH levels. Nephron Clin Pract 116:c263–c268PubMedCrossRefGoogle Scholar
  43. 43.
    Wada M, Nagano N, Nemeth EF (1999) The calcium receptor and calcimimetics. Curr Opin Nephrol Hypertens 8:429–433PubMedCrossRefGoogle Scholar
  44. 44.
    Block GA, Martin KJ, de Francisco AL et al (2004) Cinacalcet for secondary hyperparathyroidism in patients receiving hemodialysis. N Engl J Med 350:1516–1525PubMedCrossRefGoogle Scholar
  45. 45.
    Slatopolsky EA, Burke SK, Dillon MA, The RenaGel Study Group (1999) RenaGel, a nonabsorbed calcium- and aluminum-free phosphate binder, lowers serum phosphorus and parathyroid hormone. Kidney Int 55:299–307PubMedCrossRefGoogle Scholar
  46. 46.
    Slatopolsky E, Dusso A, Brown A (1999) New analogs of vitamin D3. Kidney Int (Suppl) 73:S46–S51CrossRefGoogle Scholar
  47. 47.
    Martin KJ, Gonzalez EA, Gellens ME et al (1998) Therapy of secondary hyperparathyroidism with 19-nor-1alpha, 25-dihydroxyvitamin D2. Am J Kidney Dis 32(2 Suppl 2):S61–S66PubMedCrossRefGoogle Scholar
  48. 48.
    Martin KJ, Gonzalez EA, Gellens M et al (1998) 19-Nor-1-alpha-25-dihydroxyvitamin D2 (paricalcitol) safely and effectively reduces the levels of intact parathyroid hormone in patients on hemodialysis. J Am Soc Nephrol 9:1427–1432PubMedGoogle Scholar
  49. 49.
    Hirata M, Katsumata K, Masaki T et al (1999) 22-Oxacalcitriol ameliorates high-turnover bone and marked osteitis fibrosa in rats with slowly progressive nephritis. Kidney Int 56:2040–2047PubMedCrossRefGoogle Scholar
  50. 50.
    Wilson RE, Hampers CL, Bernstein DS et al (1971) Subtotal parathyroidectomy in chronic renal failure: a seven-year experience in a dialysis and transplant program. Ann Surg 174:640–654PubMedCrossRefGoogle Scholar
  51. 51.
    Drueke TB, Zingraff J (1994) The dilemma of parathyroidectomy in chronic renal failure. Curr Opin Nephrol Hypertens 3:386–395PubMedCrossRefGoogle Scholar
  52. 52.
    Kinnaert P, Salmon I, Decoster-Gervy C et al (2000) Long-term results of subcutaneous parathyroid grafts in uremic patients. Arch Surg 135:186–190PubMedCrossRefGoogle Scholar
  53. 53.
    Patow CA, Norton JA, Brennan MF (1986) Vocal cord paralysis and reoperative parathyroidectomy. A prospective study. Ann Surg 203:282–285PubMedCrossRefGoogle Scholar
  54. 54.
    Billings PJ, Milroy EJ (1983) Reoperative parathyroid surgery. Br J Surg 70:542–546PubMedCrossRefGoogle Scholar
  55. 55.
    Hampl H, Steinmuller T, Frohling P et al (1999) Long-term results of total parathyroidectomy without autotransplantation in patients with and without renal failure. Miner Electrolyte Metab 25:161–170PubMedCrossRefGoogle Scholar
  56. 56.
    Takagi H, Tominaga Y, Uchida K et al (1984) Subtotal versus total parathyroidectomy with forearm autograft for secondary hyperparathyroidism in chronic renal failure. Ann Surg 200:18–23PubMedCrossRefGoogle Scholar
  57. 57.
    Tominaga Y, Uchida K, Haba T et al (2001) More than 1,000 cases of total parathyroidectomy with forearm autograft for renal hyperparathyroidism. Am J Kidney Dis 38(4 Suppl 1):S168–S171PubMedCrossRefGoogle Scholar
  58. 58.
    Yu I, DeVita MV, Komisar A (1998) Long-term follow-up after subtotal parathyroidectomy in patients with renal failure. Laryngoscope 108:1824–1828PubMedCrossRefGoogle Scholar
  59. 59.
    Hargrove GM, Pasieka JL, Hanley DA et al (1999) Short- and long-term outcome of total parathyroidectomy with immediate autografting versus subtotal parathyroidectomy in patients with end-stage renal disease. Am J Nephrol 19:559–564PubMedCrossRefGoogle Scholar
  60. 60.
    Zaraca F, Mazzaferro S, Catarci M et al (1999) Prospective evaluation of total parathyroidectomy and autotransplantation for the treatment of secondary hyperparathyroidism. Arch Surg 134:68–72PubMedCrossRefGoogle Scholar
  61. 61.
    Saliba W, El-Haddad B (2009) Secondary hyperparathyroidism: pathophysiology and treatment. J Am Board Fam Med 22:574–581PubMedCrossRefGoogle Scholar
  62. 62.
    Wagner PK, Seesko HG, Rothmund M (1991) Replantation of cryopreserved human parathyroid tissue. World J Surg 15:751–755. doi: 10.1007/BF01665310 PubMedCrossRefGoogle Scholar
  63. 63.
    Shoback D (2008) Clinical practice. Hypoparathyroidism. N Engl J Med 359:391–403PubMedCrossRefGoogle Scholar
  64. 64.
    Borot S, Lapierre V, Carnaille B et al (2010) Results of cryopreserved parathyroid autografts: a retrospective multicenter study. Surgery 147:529–535PubMedCrossRefGoogle Scholar
  65. 65.
    Caccitolo JA, Farley DR, van Heerden JA et al (1997) The current role of parathyroid cryopreservation and autotransplantation in parathyroid surgery: an institutional experience. Surgery 122:1062–1067PubMedCrossRefGoogle Scholar
  66. 66.
    Eknoyan G, Levin NW (2003) K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 42(4 Suppl 3):S1–S201CrossRefGoogle Scholar
  67. 67.
    Society of Nephrology (2009) KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD). Kidney Int 76(Suppl 113):S1–S130Google Scholar
  68. 68.
    Hampl H, Steinmuller T, Stabell U et al (1991) Recurrent hyperparathyroidism after total parathyroidectomy and autotransplantation in patients with long-term hemodialysis. Miner Electrolyte Metab 17:256–260PubMedGoogle Scholar
  69. 69.
    Skinner KA, Zuckerbraun L (1996) Recurrent secondary hyperparathyroidism. An argument for total parathyroidectomy. Arch Surg 131:724–727PubMedCrossRefGoogle Scholar
  70. 70.
    Tominaga Y, Numano M, Tanaka Y et al (1997) Surgical treatment of renal hyperparathyroidism. Semin Surg Oncol 13:87–96PubMedCrossRefGoogle Scholar
  71. 71.
    Kinnaert P, Nagy N, Decoster-Gervy C et al (2000) Persistent hyperparathyroidism requiring surgical treatment after kidney transplantation. World J Surg 24:1391–1395. doi: 10.1007/s002680010230 PubMedCrossRefGoogle Scholar
  72. 72.
    Neyer U, Hoerandner H, Haid A et al (2002) Total parathyroidectomy with autotransplantation in renal hyperparathyroidism: low recurrence after intra-operative tissue selection. Nephrol Dial Transplant 17:625–629PubMedCrossRefGoogle Scholar
  73. 73.
    Akerstrom G, Malmaeus J, Bergstrom R (1984) Surgical anatomy of human parathyroid glands. Surgery 95:14–21PubMedGoogle Scholar
  74. 74.
    Wang C (1976) The anatomic basis of parathyroid surgery. Ann Surg 183:271–275PubMedCrossRefGoogle Scholar
  75. 75.
    Nanka O, Sedy J, Vitkova I et al (2006) Surgical anatomy of parathyroid glands with emphasis on parathyroidectomy. Prague Med Rep 107:261–272PubMedGoogle Scholar
  76. 76.
    Schlosser K, Endres N, Celik I et al (2007) Surgical treatment of tertiary hyperparathyroidism: the choice of procedure matters! World J Surg 31:1947–1953. doi: 10.1007/s00268-007-9187-z PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2011

Authors and Affiliations

  • Ralph Schneider
    • 1
  • Emily P. Slater
    • 1
  • Elias Karakas
    • 1
  • Detlef K. Bartsch
    • 1
  • Katja Schlosser
    • 1
  1. 1.Department of Visceral, Thoracic and Vascular SurgeryPhilipps UniversityMarburgGermany

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