Indications for parathyroidectomy in end-stage renal disease
- Michael Berkoben, MD
Michael Berkoben, MD
- Associate Professor of Medicine
- Duke University Medical Center
- L Darryl Quarles, MD
L Darryl Quarles, MD
- Section Editor — Renal Osteodystrophy
- Director, Division of Nephrology
- Associate Dean for Research
- The University of Tennessee Health Science Center
Approximately 10 percent of patients with end-stage renal disease (ESRD) undergo parathyroidectomy for secondary hyperparathyroidism . This percentage has remained constant over the past 20 years despite advances in medical therapy .
This topic reviews the pathogenesis of refractory hyperparathyroidism and the indications for parathyroidectomy among patients with ESRD. The medical management of hyperparathyroidism is discussed elsewhere. (See "Management of secondary hyperparathyroidism in adult nondialysis patients with chronic kidney disease" and "Management of secondary hyperparathyroidism in dialysis patients".)
Anatomy of the parathyroid and surgical approaches to parathyroidectomy are discussed elsewhere. (See "Parathyroidectomy in end stage renal disease".)
PATHOGENESIS OF REFRACTORY HYPERPARATHYROIDISM
A subset of patients with ESRD have marked elevations in serum parathyroid hormone (PTH) levels despite medical therapy. (See "Management of secondary hyperparathyroidism in adult nondialysis patients with chronic kidney disease" and "Management of secondary hyperparathyroidism in dialysis patients".)
Several interrelated factors are thought to be involved in the pathogenesis of refractory hyperparathyroidism.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- 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.
- Parfrey PS, Chertow GM, Block GA, et al. The clinical course of treated hyperparathyroidism among patients receiving hemodialysis and the effect of cinacalcet: the EVOLVE trial. J Clin Endocrinol Metab 2013; 98:4834.
- Krause MW, Hedinger CE. Pathologic study of parathyroid glands in tertiary hyperparathyroidism. Hum Pathol 1985; 16:772.
- Gogusev J, Duchambon P, Hory B, et al. Depressed expression of calcium receptor in parathyroid gland tissue of patients with hyperparathyroidism. Kidney Int 1997; 51:328.
- Fukuda N, Tanaka H, Tominaga Y, et al. Decreased 1,25-dihydroxyvitamin D3 receptor density is associated with a more severe form of parathyroid hyperplasia in chronic uremic patients. J Clin Invest 1993; 92:1436.
- Parfitt AM. The hyperparathyroidism of chronic renal failure: a disorder of growth. Kidney Int 1997; 52:3.
- Zhang P, Duchambon P, Gogusev J, et al. Apoptosis in parathyroid hyperplasia of patients with primary or secondary uremic hyperparathyroidism. Kidney Int 2000; 57:437.
- National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003; 42:S1.
- Punch JD, Thompson NW, Merion RM. Subtotal parathyroidectomy in dialysis-dependent and post-renal transplant patients. A 25-year single-center experience. Arch Surg 1995; 130:538.
- 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.
- Sato T, Tominaga Y, Ueki T, et al. Total parathyroidectomy reduces elevated circulating fibroblast growth factor 23 in advanced secondary hyperparathyroidism. Am J Kidney Dis 2004; 44:481.
- Hafner J, Keusch G, Wahl C, et al. Uremic small-artery disease with medial calcification and intimal hyperplasia (so-called calciphylaxis): a complication of chronic renal failure and benefit from parathyroidectomy. J Am Acad Dermatol 1995; 33:954.
- Moorthi RN, Moe SM. CKD-mineral and bone disorder: core curriculum 2011. Am J Kidney Dis 2011; 58:1022.
- http://kdigo.org/home/mineral-bone-disorder/ (Accessed on August 21, 2014).
- Kestenbaum B, Andress DL, Schwartz SM, et al. Survival following parathyroidectomy among United States dialysis patients. Kidney Int 2004; 66:2010.
- Sharma J, Raggi P, Kutner N, et al. Improved long-term survival of dialysis patients after near-total parathyroidectomy. J Am Coll Surg 2012; 214:400.
- Abdelhadi M, Nordenström J. Bone mineral recovery after parathyroidectomy in patients with primary and renal hyperparathyroidism. J Clin Endocrinol Metab 1998; 83:3845.
- Chou FF, Chen JB, Lee CH, et al. Parathyroidectomy can improve bone mineral density in patients with symptomatic secondary hyperparathyroidism. Arch Surg 2001; 136:1064.
- Yano S, Sugimoto T, Tsukamoto T, et al. Effect of parathyroidectomy on bone mineral density in hemodialysis patients with secondary hyperparathyroidism: possible usefulness of preoperative determination of parathyroid hormone level for prediction of bone regain. Horm Metab Res 2003; 35:259.
- Rudser KD, de Boer IH, Dooley A, et al. Fracture risk after parathyroidectomy among chronic hemodialysis patients. J Am Soc Nephrol 2007; 18:2401.
- Rault R, Magnone M. The effect of parathyroidectomy on hematocrit and erythropoietin dose in patients on hemodialysis. ASAIO J 1996; 42:M901.
- Jemcov TK, Petakov M, Bogdanovic A, et al. Parathyroidectomy and improving anemia. Arch Surg 2008; 143:97.
- Chow TL, Chan TT, Ho YW, Lam SH. Improvement of anemia after parathyroidectomy in Chinese patients with renal failure undergoing long-term dialysis. Arch Surg 2007; 142:644.
- Yasunaga C, Nakamoto M, Matsuo K, et al. Effects of a parathyroidectomy on the immune system and nutritional condition in chronic dialysis patients with secondary hyperparathyroidism. Am J Surg 1999; 178:332.
- Tzanno-Martins C, Futata E, Jorgetti V, Duarte AJ. Restoration of impaired T-cell proliferation after parathyroidectomy in hemodialysis patients. Nephron 2000; 84:224.
- Pizzarelli F, Fabrizi F, Postorino M, et al. Parathyroidectomy and blood pressure in hemodialysis patients. Nephron 1993; 63:384.
- Ifudu O, Matthew JJ, Macey LJ, et al. Parathyroidectomy does not correct hypertension in patients on maintenance hemodialysis. Am J Nephrol 1998; 18:28.
- Schmid T, Müller P, Spelsberg F. Parathyroidectomy after renal transplantation: a retrospective analysis of long-term outcome. Nephrol Dial Transplant 1997; 12:2393.
- Ferreira GF, Montenegro FL, Machado DJ, et al. Parathyroidectomy after kidney transplantation: short-and long-term impact on renal function. Clinics (Sao Paulo) 2011; 66:431.
- Evenepoel P, Claes K, Kuypers D, et al. Natural history of parathyroid function and calcium metabolism after kidney transplantation: a single-centre study. Nephrol Dial Transplant 2004; 19:1281.
- Evenepoel P, Sprangers B, Lerut E, et al. Mineral metabolism in renal transplant recipients discontinuing cinacalcet at the time of transplantation: a prospective observational study. Clin Transplant 2012; 26:393.
- Messa P, Cafforio C, Alfieri C. Clinical impact of hypercalcemia in kidney transplant. Int J Nephrol 2011; 2011:906832.
- Gwinner W, Suppa S, Mengel M, et al. Early calcification of renal allografts detected by protocol biopsies: causes and clinical implications. Am J Transplant 2005; 5:1934.
- Egbuna OI, Taylor JG, Bushinsky DA, Zand MS. Elevated calcium phosphate product after renal transplantation is a risk factor for graft failure. Clin Transplant 2007; 21:558.
- Rostaing L, Moreau-Gaudry X, Baron E, et al. Changes in blood pressure and renal function following subtotal parathyroidectomy in renal transplant patients presenting with persistent hypercalcemic hyperparathyroidism. Clin Nephrol 1997; 47:248.
- Chan YL, Posen S, Savdie E, et al. Total parathyroidectomy and renal function in patients with chronic renal failure. Miner Electrolyte Metab 1983; 9:57.
- Tzanakis I, Alifieris E, Kagia S, et al. Does parathyroidectomy affect residual diuresis in hemodialysis patients? Nephron 2000; 86:402.
- Hercz G, Pei Y, Greenwood C, et al. Aplastic osteodystrophy without aluminum: the role of "suppressed" parathyroid function. Kidney Int 1993; 44:860.
- Slatopolsky E. The interaction of parathyroid hormone and aluminum in renal osteodystrophy. Kidney Int 1987; 31:842.
- Andress DL, Ott SM, Maloney NA, Sherrard DJ. Effect of parathyroidectomy on bone aluminum accumulation in chronic renal failure. N Engl J Med 1985; 312:468.
- Ishani A, Liu J, Wetmore JB, et al. Clinical outcomes after parathyroidectomy in a nationwide cohort of patients on hemodialysis. Clin J Am Soc Nephrol 2015; 10:90.
- PATHOGENESIS OF REFRACTORY HYPERPARATHYROIDISM
- POTENTIAL INDICATIONS FOR PARATHYROIDECTOMY
- Symptomatic patients
- Asymptomatic patients
- Patients awaiting transplantation
- Renal transplant recipients
- PRESURGICAL EVALUATION AND TREATMENT
- Aluminum exposure
- Nonaluminum-related bone diseases
- RISKS AND OUTCOMES OF PARATHYROIDECTOMY
- SUMMARY AND RECOMMENDATIONS