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Secondary hyperparathyroidism is a major metabolic complication in patients under chronic hemodialysis (CHD) treatment. Parathyroidectomy (PTx) remains a valid treatment option, especially when PTH-lowering therapies fail to respond to medical or pharmacological therapy, as advocated in the 2017 CKD-MBD Guideline update in patients with CKD G3a–G5D (2B, moderate level of evidence). The objective is to describe the results and complications of 61 PTx performed in 52/519 patients (under CHD through years 1996-2022.
In this retrospective observational study, PTx criteria were: high level of PTH, alkaline phosphatase (ALP), Ca, and, or P unresponsive to available treatments and clinical manifestations of hyperparathyroidism. In all patients, an ultrasonography was performed to establish glands size. When necessary, a Tc-99m-sestamibi scan was done. A 18F-coline PET/CT was carried out in one case to confirm the suspicion of ectopic para-aortic glands.
Fifty-two patients (25 F, 27 M) underwent a first subtotal PTx (49 conventional and 3 laparoscopic surgeries) at a mean age of 47,2+15 years old, time under hemodialysis 5,46+3 years. Nine patients required a second PTx due to recurrence or ectopic gland.
The mean pre-first surgery laboratory values of ALP and PTH were 1181+730 IU/L and 1772+706 pg/mil, respectively. At surgery, three incident papillary thyroid carcinomas were found and excised.
In the short-term, the complications observed were: 1 persistent symptomatic hypocalcemia responsive to oral Ca, which subsided in 6 months, 1 tetany crisis, 1 persistent hyperphosphatemia and 1 right vocal cord paralysis. In the long term, recurrence developed in 3 patients, persistence of hyperparathyroidism due to insufficient resection was diagnosed in another 3, and supernumerary or ectopic glands not previously detected were identified in 3. A patient remains with hypoparathyroidism, managed with oral Ca, at more than 15 years post PTx.
At long-term follow-up: 25 patients died under HD treatment, 5 were lost to follow-up, 18 received a functional kidney graft, and 4 are still on HD.
Dividing the PTx population before or after year 2012 (when calcimimetics became available), no significant changes appeared in the number of PTx/year (1.4 and 1.75 pre and post-the-year 2012, respectively).
The difficulties identified to manage hyperthyroidism were: non-continuous supply or direct non-supply of calcimimetics, new phosphate binders or vitamin D analogs due to insufficient or lack of coverage, non-concentration of surgeons in the same institution where the dialysis service locates, inexperience of surgeons in subtotal PTx.
PTx is still an alternative of treatment for secondary hyperparathyroidism, with a low incidence of complications and good long-term evolution. Recurrence is relatively common but usually responds to a second surgery.