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Parathyroidectomy in end stage renal disease

Mira Milas, MD, FACS
Section Editor
Sally E Carty, MD, FACS
Deputy Editor
Wenliang Chen, MD, PhD


Parathyroid surgery in patients with end stage renal disease (ESRD) is an effective therapy for normalization or stabilization of calcium and parathyroid hormone (PTH) metabolism, and for improving renal osteodystrophy [1-5].

Although the initial and predominant management of hyperparathyroidism (HPT) in ESRD is with medical therapy, approximately 10 percent of patients ultimately require surgery for ESRD-related HPT (sometimes referred to as renal HPT) [6]. Parathyroid surgery is also an effective therapy for patients with persistent HPT after renal transplantation [7-15].

The surgical techniques of parathyroidectomy in ESRD patients are discussed here. The medical management of HPT in patients with ESRD is discussed elsewhere. (See "Management of secondary hyperparathyroidism and mineral metabolism abnormalities in adult predialysis patients with chronic kidney disease" and "Management of secondary hyperparathyroidism and mineral metabolism abnormalities in dialysis patients" and "Indications for parathyroidectomy in end-stage renal disease" and "Persistent hyperparathyroidism after renal transplantation".)


Although medical therapies, including calcimimetics (eg, cinacalcet), have allowed some patients with end stage renal disease (ESRD) to be treated nonoperatively [7-15], symptomatic patients with markedly elevated parathyroid hormone (PTH) levels should be referred for parathyroid surgery if they become refractory to medical therapy. Preoperative hypocalcemia is a contraindication to surgery. The specific indications for parathyroidectomy in patients with ESRD are reviewed in detail separately. (See "Indications for parathyroidectomy in end-stage renal disease" and "Persistent hyperparathyroidism after renal transplantation".)


Knowledge of both normal and variant patterns of parathyroid anatomy is essential to successful parathyroid surgery. Normal parathyroid anatomy is reviewed elsewhere (see "Surgical anatomy of the parathyroid glands"). Variant patterns of parathyroid anatomy seen in end-stage renal disease (ESRD) patients are briefly discussed below.


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Literature review current through: Sep 2016. | This topic last updated: May 25, 2016.
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  1. Sharma, J, Weber, C. Surgical management of hyperparathyroidism in renal failure. Clin Rev Bone Miner Metab 2007; 5:103.
  2. Rayes N, Seehofer D, Schindler R, et al. Long-term results of subtotal vs total parathyroidectomy without autotransplantation in kidney transplant recipients. Arch Surg 2008; 143:756.
  3. Collaud S, Staub-Zähner T, Trombetti A, et al. Increase in bone mineral density after successful parathyroidectomy for tertiary hyperparathyroidism after renal transplantation. World J Surg 2008; 32:1795.
  4. Mazzaferro S, Pasquali M, Farcomeni A, et al. Parathyroidectomy as a therapeutic tool for targeting the recommended NKF-K/DOQI ranges for serum calcium, phosphate and parathyroid hormone in dialysis patients. Nephrol Dial Transplant 2008; 23:2319.
  5. Milas M, Weber CJ. Near-total parathyroidectomy is beneficial for patients with secondary and tertiary hyperparathyroidism. Surgery 2004; 136:1252.
  6. Foley RN, Li S, Liu J, et al. The fall and rise of parathyroidectomy in U.S. hemodialysis patients, 1992 to 2002. J Am Soc Nephrol 2005; 16:210.
  7. Elder GJ. Parathyroidectomy in the calcimimetic era. Nephrology (Carlton) 2005; 10:511.
  8. Torregrosa JV, Bergua C, Martinez de Osaba MJ, et al. Evolution of secondary hyperparathyroidism after kidney transplantation in patients receiving cinacalcet on dialysis. Transplant Proc 2009; 41:2396.
  9. López V, Toledo R, Sola E, et al. Treatment with cinacalcet in 29 kidney transplant patients with persistent hyperparathyroidism. Transplant Proc 2009; 41:2394.
  10. Tominaga Y, Matsuoka S, Uno N, Sato T. Parathyroidectomy for secondary hyperparathyroidism in the era of calcimimetics. Ther Apher Dial 2008; 12 Suppl 1:S21.
  11. Yokoyama K. Clinical issues regarding cinacalcet hydrochloride in Japan. Ther Apher Dial 2009; 13 Suppl 1:S12.
  12. Bergua C, Torregrosa JV, Cofán F, Oppenheimer F. Cinacalcet for the treatment of hypercalcemia in renal transplanted patients with secondary hyperparathyroidism. Transplant Proc 2007; 39:2254.
  13. Narayan R, Perkins RM, Berbano EP, et al. Parathyroidectomy versus cinacalcet hydrochloride-based medical therapy in the management of hyperparathyroidism in ESRD: a cost utility analysis. Am J Kidney Dis 2007; 49:801.
  14. El-Amm JM, Doshi MD, Singh A, et al. Preliminary experience with cinacalcet use in persistent secondary hyperparathyroidism after kidney transplantation. Transplantation 2007; 83:546.
  15. Wüthrich RP, Martin D, Bilezikian JP. The role of calcimimetics in the treatment of hyperparathyroidism. Eur J Clin Invest 2007; 37:915.
  16. Ritter, H, Milas, M. Parathyroidectomy: Bilateral Neck Exploration. In: Operative techniques in Otolaryngology, Terris, D (Eds), Elsevier, St. Louis 2009. p.44.
  17. Pattou FN, Pellissier LC, Noël C, et al. Supernumerary parathyroid glands: frequency and surgical significance in treatment of renal hyperparathyroidism. World J Surg 2000; 24:1330.
  18. Tominaga Y, Tanaka Y, Sato K, et al. Histopathology, pathophysiology, and indications for surgical treatment of renal hyperparathyroidism. Semin Surg Oncol 1997; 13:78.
  19. Matsuoka S, Tominaga Y, Sato T, et al. Relationship between the dimension of parathyroid glands estimated by ultrasonography and the hyperplastic pattern in patients with renal hyperparathyroidism. Ther Apher Dial 2008; 12:391.
  20. Kebebew E, Duh QY, Clark OH. Tertiary hyperparathyroidism: histologic patterns of disease and results of parathyroidectomy. Arch Surg 2004; 139:974.
  21. Nichol PF, Starling JR, Mack E, et al. Long-term follow-up of patients with tertiary hyperparathyroidism treated by resection of a single or double adenoma. Ann Surg 2002; 235:673.
  22. Triponez F, Kebebew E, Dosseh D, et al. Less-than-subtotal parathyroidectomy increases the risk of persistent/recurrent hyperparathyroidism after parathyroidectomy in tertiary hyperparathyroidism after renal transplantation. Surgery 2006; 140:990.
  23. Pitt SC, Sippel RS, Chen H. Secondary and tertiary hyperparathyroidism, state of the art surgical management. Surg Clin North Am 2009; 89:1227.
  24. Sosa, JA, Udelsman, R. The parathyroid glands: Secondary hyperparathyroidism in renal failure. In: Sabiston Textbook of Surgery, 18th edition, Townsend (Ed), Saunders, 2007.
  25. Tominaga Y, Matsuoka S, Uno N, et al. Removal of autografted parathyroid tissue for recurrent renal hyperparathyroidism in hemodialysis patients. World J Surg 2010; 34:1312.
  26. Echenique-Elizondo M, Amondarain JA, Vidaur F, et al. Parathyroid subcutaneous pre-sternal transplantation after parathyroidectomy for renal hyperparathyroidism. Long-term graft function. World J Surg 2007; 31:1403.
  27. Tominaga Y, Matsuoka S, Sato T. Surgical indications and procedures of parathyroidectomy in patients with chronic kidney disease. Ther Apher Dial 2005; 9:44.
  28. Lorenz K, Ukkat J, Sekulla C, et al. Total parathyroidectomy without autotransplantation for renal hyperparathyroidism: experience with a qPTH-controlled protocol. World J Surg 2006; 30:743.
  29. Shen WT, Kebebew E, Suh I, et al. Two hundred and two consecutive operations for secondary hyperparathyroidism: has medical management changed the profiles of patients requiring parathyroidectomy? Surgery 2009; 146:296.
  30. Schlosser K, Endres N, Celik I, et al. Surgical treatment of tertiary hyperparathyroidism: the choice of procedure matters! World J Surg 2007; 31:1947.
  31. Tominaga Y, Uchida K, Haba T, et al. More than 1,000 cases of total parathyroidectomy with forearm autograft for renal hyperparathyroidism. Am J Kidney Dis 2001; 38:S168.
  32. Rothmund M, Wagner PK, Schark C. Subtotal parathyroidectomy versus total parathyroidectomy and autotransplantation in secondary hyperparathyroidism: a randomized trial. World J Surg 1991; 15:745.
  33. Ockert S, Willeke F, Richter A, et al. Total parathyroidectomy without autotransplantation as a standard procedure in the treatment of secondary hyperparathyroidism. Langenbecks Arch Surg 2002; 387:204.
  34. Nakamura M, Fuchinoue S, Teraoka S. Clinical experience with percutaneous ethanol injection therapy in hemodialysis patients with renal hyperparathyroidism. Am J Kidney Dis 2003; 42:739.
  35. Kerby JD, Rue LW, Blair H, et al. Operative treatment of tertiary hyperparathyroidism: a single-center experience. Ann Surg 1998; 227:878.
  36. Saunders RN, Karoo R, Metcalfe MS, Nicholson ML. Four gland parathyroidectomy without reimplantation in patients with chronic renal failure. Postgrad Med J 2005; 81:255.
  37. de Francisco AL, Fresnedo GF, Rodrigo E, et al. Parathyroidectomy in dialysis patients. Kidney Int Suppl 2002; :161.
  38. Echenique-Elizondo M, Díaz-Aguirregoitia FJ, Amondarain JA, Vidaur F. Parathyroid graft function after presternal subcutaneous autotransplantation for renal hyperparathyroidism. Arch Surg 2006; 141:33.
  39. Lumachi F, Basso SM. Pathophysiology and treatment of nonfamilial hyperparathyroidism. Recent Pat CNS Drug Discov 2014; 9:164.
  40. Hsu YC, Hung CJ. Intramuscular and subcutaneous forearm parathyroid autograft hyperplasia in renal dialysis patients: A retrospective cohort study. Surgery 2015; 158:1331.
  41. Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group. KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney Int Suppl 2009; :S1.
  42. Steddon S, Sharples E. Clinical Practice Guideline CKD- Mineral and Bone Disorders (CKD-MBD). http://www.renal.org/guidelines/modules/ckd-mineral-and-bone-disorders-(ckd-mbd)#sthash.gAf5swRM.dpbs.
  43. Chou FF, Chan HM, Huang TJ, et al. Autotransplantation of parathyroid glands into subcutaneous forearm tissue for renal hyperparathyroidism. Surgery 1998; 124:1.
  44. Monchik JM, Bendinelli C, Passero MA Jr, Roggin KK. Subcutaneous forearm transplantation of autologous parathyroid tissue in patients with renal hyperparathyroidism. Surgery 1999; 126:1152.
  45. Nicholson ML, Veitch PS, Feehally J. Parathyroidectomy in chronic renal failure: comparison of three operative strategies. J R Coll Surg Edinb 1996; 41:382.
  46. Lal G, Nowell AG, Liao J, et al. Determinants of survival in patients with calciphylaxis: a multivariate analysis. Surgery 2009; 146:1028.
  47. Milas M, Bush RL, Lin P, et al. Calciphylaxis and nonhealing wounds: the role of the vascular surgeon in a multidisciplinary treatment. J Vasc Surg 2003; 37:501.
  48. Stephen AE, Milas M, Garner CN, et al. Use of surgeon-performed office ultrasound and parathyroid fine needle aspiration for complex parathyroid localization. Surgery 2005; 138:1143.
  49. Boltz MM, Zhang N, Zhao C, et al. Value of Prophylactic Cervical Thymectomy in Parathyroid Hyperplasia. Ann Surg Oncol 2015; 22 Suppl 3:S662.
  50. Ikeda Y, Kurihara H, Morita N, et al. The role of quick bio-intact PTH(1-84) assay during parathyroidectomy for secondary hyperparathyroidism. J Surg Res 2007; 141:306.
  51. Triponez F, Dosseh D, Hazzan M, et al. Accuracy of intra-operative PTH measurement during subtotal parathyroidectomy for tertiary hyperparathyroidism after renal transplantation. Langenbecks Arch Surg 2006; 391:561.
  52. Seehofer D, Rayes N, Klupp J, et al. Predictive value of intact parathyroid hormone measurement during surgery for renal hyperparathyroidism. Langenbecks Arch Surg 2005; 390:222.
  53. Komaba H, Goto S, Fukagawa M. Critical issues of PTH assays in CKD. Bone 2009; 44:666.
  54. Ohe MN, Santos RO, Kunii IS, et al. Intraoperative PTH cutoff definition to predict successful parathyroidectomy in secondary and tertiary hyperparathyroidism. Braz J Otorhinolaryngol 2013; 79:494.
  55. Ito F, Sippel R, Lederman J, Chen H. The utility of intraoperative bilateral internal jugular venous sampling with rapid parathyroid hormone testing. Ann Surg 2007; 245:959.
  56. Barczynski M, Konturek A, Hubalewska-Dydejczyk A, et al. Utility of intraoperative bilateral internal jugular venous sampling with rapid parathyroid hormone testing in guiding patients with a negative sestamibi scan for minimally invasive parathyroidectomy--a randomized controlled trial. Langenbecks Arch Surg 2009; 394:827.
  57. Bergenfelz A, Algotsson L, Roth B, et al. Side localization of parathyroid adenomas by simplified intraoperative venous sampling for parathyroid hormone. World J Surg 1996; 20:358.
  58. Alvarado R, Meyer-Rochow G, Sywak M, et al. Bilateral internal jugular venous sampling for parathyroid hormone determination in patients with nonlocalizing primary hyperparathyroidism. World J Surg 2010; 34:1299.
  59. Agarwal A, Waghray A, Gupta S, et al. Cryopreservation of parathyroid tissue: an illustrated technique using the cleveland clinic protocol. J Am Coll Surg 2013; 216:e1.
  60. Greene AB, Butler RS, McIntyre S, et al. National trends in parathyroid surgery from 1998 to 2008: a decade of change. J Am Coll Surg 2009; 209:332.
  61. de Menezes Montenegro FL, Custódio MR, Arap SS, et al. Successful implant of long-term cryopreserved parathyroid glands after total parathyroidectomy. Head Neck 2007; 29:296.
  62. Guerrero MA, Evans DB, Lee JE, et al. Viability of cryopreserved parathyroid tissue: when is continued storage versus disposal indicated? World J Surg 2008; 32:836.
  63. Melck AL, Carty SE, Seethala RR, et al. Recurrent hyperparathyroidism and forearm parathyromatosis after total parathyroidectomy. Surgery 2010; 148:867.
  64. Caccitolo JA, Farley DR, van Heerden JA, et al. The current role of parathyroid cryopreservation and autotransplantation in parathyroid surgery: an institutional experience. Surgery 1997; 122:1062.
  65. Obrador GT, Pereira BJ, Kausz AT. Chronic kidney disease in the United States: an underrecognized problem. Semin Nephrol 2002; 22:441.
  66. Centers for Disease Control and Prevention (CDC). Prevalence of chronic kidney disease and associated risk factors--United States, 1999-2004. MMWR Morb Mortal Wkly Rep 2007; 56:161.
  67. Clark LE, Khan I. Outcomes in CKD: what we know and what we need to know. Nephron Clin Pract 2010; 114:c95.
  68. Yeh SM, Hwang SJ, Chen HC. Treatment of severe metastatic calcification in hemodialysis patients. Hemodial Int 2009; 13:163.
  69. Mittendorf EA, Merlino JI, McHenry CR. Post-parathyroidectomy hypocalcemia: incidence, risk factors, and management. Am Surg 2004; 70:114.
  70. Stracke S, Keller F, Steinbach G, et al. Long-term outcome after total parathyroidectomy for the management of secondary hyperparathyroidism. Nephron Clin Pract 2009; 111:c102.
  71. Low TH, Clark J, Gao K, et al. Outcome of parathyroidectomy for patients with renal disease and hyperparathyroidism: predictors for recurrent hyperparathyroidism. ANZ J Surg 2009; 79:378.
  72. Wilhelm SM, Lee JA, Ruan DE, et al. The American Association of Endocrine Surgeons (AAES) guidelines for definitive management of primary hyperparathyroidism. JAMA Surg 2016.
  73. Udelsman R, Åkerström G, Biagini C, et al. The surgical management of asymptomatic primary hyperparathyroidism: proceedings of the Fourth International Workshop. J Clin Endocrinol Metab 2014; 99:3595.
  74. Morita SY, Somervell H, Umbricht CB, et al. Evaluation for concomitant thyroid nodules and primary hyperparathyroidism in patients undergoing parathyroidectomy or thyroidectomy. Surgery 2008; 144:862.
  75. Adler JT, Chen H, Schaefer S, Sippel RS. Does routine use of ultrasound result in additional thyroid procedures in patients with primary hyperparathyroidism? J Am Coll Surg 2010; 211:536.
  76. Bentrem DJ, Angelos P, Talamonti MS, Nayar R. Is preoperative investigation of the thyroid justified in patients undergoing parathyroidectomy for hyperparathyroidism? Thyroid 2002; 12:1109.
  77. Beus KS, Stack BC Jr. Synchronous thyroid pathology in patients presenting with primary hyperparathyroidism. Am J Otolaryngol 2004; 25:308.
  78. Erbil Y, Salmaslioğlu A, Kabul E, et al. Use of preoperative parathyroid fine-needle aspiration and parathormone assay in the primary hyperparathyroidism with concomitant thyroid nodules. Am J Surg 2007; 193:665.
  79. Krause UC, Friedrich JH, Olbricht T, Metz K. Association of primary hyperparathyroidism and non-medullary thyroid cancer. Eur J Surg 1996; 162:685.
  80. Masatsugu T, Yamashita H, Noguchi S, et al. Thyroid evaluation in patients with primary hyperparathyroidism. Endocr J 2005; 52:177.
  81. Milas M, Mensah A, Alghoul M, et al. The impact of office neck ultrasonography on reducing unnecessary thyroid surgery in patients undergoing parathyroidectomy. Thyroid 2005; 15:1055.
  82. Ogawa T, Kammori M, Tsuji E, et al. Preoperative evaluation of thyroid pathology in patients with primary hyperparathyroidism. Thyroid 2007; 17:59.
  83. Ryan S, Courtney D, Timon C. Co-existent thyroid disease in patients treated for primary hyperparathyroidism: implications for clinical management. Eur Arch Otorhinolaryngol 2015; 272:419.
  84. Sidhu S, Campbell P. Thyroid pathology associated with primary hyperparathyroidism. Aust N Z J Surg 2000; 70:285.
  85. Wagner B, Begic-Karup S, Raber W, et al. Prevalence of primary hyperparathyroidism in 13387 patients with thyroid diseases, newly diagnosed by screening of serum calcium. Exp Clin Endocrinol Diabetes 1999; 107:457.
  86. Gasparri G, Camandona M, Bertoldo U, et al. The usefulness of preoperative dual-phase 99mTc MIBI-scintigraphy and IO-PTH assay in the treatment of secondary and tertiary hyperparathyroidism. Ann Surg 2009; 250:868.
  87. de la Rosa A, Jimeno J, Membrilla E, et al. Usefulness of preoperative Tc-mibi parathyroid scintigraphy in secondary hyperparathyroidism. Langenbecks Arch Surg 2008; 393:21.
  88. Pham TH, Sterioff S, Mullan BP, et al. Sensitivity and utility of parathyroid scintigraphy in patients with primary versus secondary and tertiary hyperparathyroidism. World J Surg 2006; 30:327.
  89. Cheng SP, Liu CL, Chen HH, et al. Prolonged hospital stay after parathyroidectomy for secondary hyperparathyroidism. World J Surg 2009; 33:72.
  90. Cheong YT, Taib NA, Normayah K, Hisham AN. Total parathyroidectomy under local anaesthesia for renal hyperparathyroidism. Asian J Surg 2009; 32:51.
  91. Sun Y, Cai H, Bai J, et al. Endoscopic total parathyroidectomy and partial parathyroid tissue autotransplantation for patients with secondary hyperparathyroidism: a new surgical approach. World J Surg 2009; 33:1674.
  92. Barbaros U, Erbil Y, Yildirim A, et al. Minimally invasive video-assisted subtotal parathyroidectomy with thymectomy for secondary hyperparathyroidism. Langenbecks Arch Surg 2009; 394:451.
  93. Ismail M, Maza S, Swierzy M, et al. Resection of ectopic mediastinal parathyroid glands with the da Vinci robotic system. Br J Surg 2010; 97:337.
  94. Veroux M, Giuffrida G, Gagliano M, et al. Evaluation of thyroid disease in kidney transplantation candidates: management and follow-up. Transplant Proc 2009; 41:1142.