Abstract
Since Slatopolsky reported that the intermittent high doses of calcitriol could suppress PTH secretion effectively in secondary hyperparathyroidism due to chronic renal failure, intravenous and oral calcitriol pulse therapy have enjoyed widespread acceptance. However, patients with far-advanced renal hyperparathyroidism are refractory to calcitriol pulse therapy and parathyroidectomy is required. Out of 157 cases who underwent parathyroidectomy for renal hyperparathyroidism between January 1991 and April 1994 at our department, 37 cases (23.6%) required parathyroidectomy because they were refractory to calcitriol pulse therapy. From evaluation of the preoperative and histopathological findings, we assessed the limitations of calcitriol pulse therapy. Our criteria as indications for parathyroidectomy in renal hyperparathyroidism include high PTH (C-PTH ≧20 ng/ml or M-PTH ≧50 ng/ml), the detection of swollen parathyroid glands by image diagnosis, high turnover bone or osteitis fibrosa findings on X-ray film and being refractory to medical treatment. In all but one case, the PTH level exceeded our citeria. In 4 cases, ectopic calcification, especially vascular calcification advanced and patients complained of ischemic symptoms. We emphasize that parathyroidectomy should be performed in patients with our criteria, before progression of vascular calcification and skeletal deformity. Some, 95% of these cases had more than one nodular hyperplastic glands. We estimated by previous pathophysiological examination that nodular hyperplasia was aggressively hyperplastic, with a high growth potential, abnormal PTH secretion and a diminished number of vitamin D receptors.
These clinical and pathophysiological results imply that when renal hyperparathyroidism is advanced, our criteria for parathyroidectomy indication are met, or when the parathyroid glands develop nodular hyperplasia, even calcitriol pulse therapy is not effective for hyperparathyroidism and so parathyroidectomy is required.
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Tominaga, Y., Numano, M., Uchida, K. et al. Parathyroidectomy for patients with renal hyperparathyroidism refractory to calcitriol pulse therapy. J Bone Miner Metab 12 (Suppl 1), S99–S104 (1994). https://doi.org/10.1007/BF02375684
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DOI: https://doi.org/10.1007/BF02375684