The surgical management of renal hyperparathyroidism

Catherine Madorin, Randall P. Owen, William D. Fraser, Phillip K. Pellitteri, Brian Radbill, Alessandra Rinaldo, Raja R. Seethala, Ashok R. Shaha, Carl E. Silver, Matthew Y. Suh, Barrie Weinstein, Alfio Ferlito

Research output: Contribution to journalArticlepeer-review

64 Scopus citations

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.

Original languageEnglish
Pages (from-to)1565-1576
Number of pages12
JournalEuropean Archives of Oto-Rhino-Laryngology
Volume269
Issue number6
DOIs
StatePublished - Jun 2012

Keywords

  • Hyperparathyroidism
  • Parathyroidectomy
  • Renal hyperparathyroidism
  • Secondary hyperparathyroidism
  • Tertiary hyperparathyroidism

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