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The surgical management of renal hyperparathyroidism

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Abstract

Secondary and tertiary hyperparathyroidism (HPT) develop in patients with renal failure due to a variety of mechanisms including increased phosphorus and fibroblast growth factor 23 (FGF23), and decreased calcium and 1,25-dihydroxy vitamin D levels. Patients present with various bone disorders, cardiovascular disease, and typical laboratory abnormalities. Medical treatment consists of controlling hyperphosphatemia, vitamin D/analog and calcium administration, and calcimimetic agents. Improved medical therapies have led to a decrease in the use of parathyroidectomy (PTX). The surgical indications include parathyroid hormone (PTH) levels >800 pg/ml associated with hypercalcemia and/or hyperphosphatemia despite medical therapy. Other indications include calciphylaxis, fractures, bone pain or pruritis. Transplant recipients often show decreased PTH, calcium and phosphorus levels, but some will have persistent HPT. Evidence suggests that PTX may cause deterioration in renal graft function in the short-term calling into the question the indications for PTX in these patients. Pre-operative imaging is only occasionally helpful except in re-operative PTX. Operative approaches include subtotal PTX, total PTX with or without autotransplantation, and possible thymectomy. Each approach has its proponents, advantages and disadvantages which are discussed. Intraoperative PTH monitoring has a high positive predictive value of cure but a poor negative predictive value and therefore is of limited utility. Hypocalcemia is the most common complication requiring aggressive calcium administration. Benefits of surgery may include improved survival, bone mineral density and alleviation of symptoms.

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Authors and Affiliations

  1. Department of Surgery, Division of Metabolic, Endocrine and Minimally Invasive Surgery, Mount Sinai School of Medicine, New York, NY, USA

    Catherine Madorin & Randall P. Owen

  2. Department of Musculoskeletal Biology, University of Liverpool, Liverpool, UK

    William D. Fraser

  3. Department of Otolaryngology-Head and Neck Surgery, Geisinger Medical Center, Danville, PA, USA

    Phillip K. Pellitteri

  4. Division of Nephrology, Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA

    Brian Radbill

  5. ENT Clinic, University of Udine, Piazzale S. Maria della Misericordia, 33100, Udine, Italy

    Alessandra Rinaldo & Alfio Ferlito

  6. Department of Pathology and Laboratory Medicine, University of Pittsburgh, Pittsburgh, PA, USA

    Raja R. Seethala

  7. Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA

    Ashok R. Shaha

  8. Departments of Surgery and Otolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA

    Carl E. Silver

  9. Recanati Miller Transplant Institute, Mount Sinai School of Medicine, New York, NY, USA

    Matthew Y. Suh

  10. Department of Medicine, Division of Endocrinology, Mount Sinai School of Medicine, New York, NY, USA

    Barrie Weinstein

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  1. Catherine Madorin
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  2. Randall P. Owen
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  3. William D. Fraser
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  9. Carl E. Silver
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  11. Barrie Weinstein
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  12. Alfio Ferlito
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Corresponding author

Correspondence to Alfio Ferlito.

Additional information

This paper was written by members and invitees of the International Head and Neck Scientific Group (http://www.IHNSG.com).

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Madorin, C., Owen, R.P., Fraser, W.D. et al. The surgical management of renal hyperparathyroidism. Eur Arch Otorhinolaryngol 269, 1565–1576 (2012). https://doi.org/10.1007/s00405-011-1833-2

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  • DOI: https://doi.org/10.1007/s00405-011-1833-2

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