Our Summary

This paper looks at a condition called renal hyperparathyroidism, which can happen when kidney disease gets very bad. This condition can cause a lot of health problems, and if it doesn’t get better with normal treatment, doctors might have to perform a surgery called a parathyroidectomy. One of the big problems with this surgery is that the condition can come back. This study wanted to know if the size of the remaining parathyroid after surgery and the success of the surgery, including how often the condition comes back, are related.

The researchers looked at data from patients who had this surgery at their hospital between 1990 and 2022. They defined the surgery as removing 3 parathyroid glands and part of the fourth, leaving about 75-100 mg. After the surgery, they aimed for a certain hormone level.

They found data for 204 patients who fit their criteria, and 139 of them had data for follow-up. Of these, 58% were women and the average age was 45 years. There were a few complications, including 2 blood clots and 1 nerve injury, but no one had to be readmitted for treatment with calcium.

Using their defined size for the remaining parathyroid, the condition came back in only 10% of patients, usually after about 5 years. In cases where the condition returned, the hormone level after surgery was less likely to drop below their target, but this wasn’t statistically significant. The condition did not return in any of the 19 patients who later received a kidney transplant.

In conclusion, using a target remaining size of 75-100 mg in this surgery for renal hyperparathyroidism results in low complication rates. A kidney transplant seems to increase the chances of a lasting cure.

FAQs

  1. What is the likelihood of recurrent renal hyperparathyroidism after a subtotal parathyroidectomy?
  2. What is the target remnant size aimed for during a subtotal parathyroidectomy for renal hyperparathyroidism?
  3. Does renal transplantation have any impact on the recurrence of renal hyperparathyroidism after subtotal parathyroidectomy?

Doctor’s Tip

A helpful tip a doctor might tell a patient about parathyroidectomy is to follow up regularly with your healthcare provider to monitor your parathyroid hormone levels and ensure that any potential recurrence of renal hyperparathyroidism is caught early. Additionally, patients who later receive a kidney transplant may have a lower risk of recurrence, so discussing this option with your healthcare provider may be beneficial.

Suitable For

Patients who are typically recommended for parathyroidectomy are those with renal hyperparathyroidism due to end-stage kidney disease who are on dialysis and have not responded to other treatments. These patients may have high levels of parathyroid hormone and calcium in their blood, leading to symptoms such as bone pain, fractures, and kidney stones. Parathyroidectomy is considered when medical management fails to control these symptoms and complications.

In this study, patients who underwent initial subtotal parathyroidectomy for renal hyperparathyroidism on dialysis were included. The surgery involved resection of 3 parathyroid glands ± partial resection of the fourth gland, leaving a remnant of approximately 75-100 mg. The goal of the surgery was to achieve a postresection intraoperative parathyroid hormone level of 150-250 pg/mL.

The study found that using a target remnant size of 75-100 mg resulted in low complication rates, with only a small percentage of patients experiencing recurrent renal hyperparathyroidism. Recurrence occurred at a median interval of 58.6 months and was more likely to occur in patients who did not undergo kidney transplantation. Patients who later received kidney transplantation did not experience recurrence of renal hyperparathyroidism.

Overall, patients with renal hyperparathyroidism on dialysis who have failed medical management may be recommended for parathyroidectomy, particularly if they have not undergone kidney transplantation. The surgery can help control symptoms and complications associated with high parathyroid hormone levels and improve outcomes for these patients.

Timeline

Before parathyroidectomy:

  1. Patient is diagnosed with renal hyperparathyroidism due to end-stage kidney disease.
  2. Patient undergoes dialysis to manage their condition.
  3. Surgical intervention is recommended when the condition becomes refractory.
  4. Patient undergoes initial subtotal parathyroidectomy, with resection of 3 parathyroid glands ± partial resection of the fourth gland leaving a remnant of ∼75-100 mg.
  5. Postresection intraoperative parathyroid hormone goal is 150-250 pg/mL.

After parathyroidectomy:

  1. Patient experiences surgical complications such as hematomas and recurrent laryngeal nerve injury, although these are rare.
  2. Recurrent renal hyperparathyroidism is uncommon, occurring in 10% of cases at a median interval of 58.6 months.
  3. In cases of recurrence, the postresection intraoperative parathyroid hormone level may not drop below 250 pg/mL, but this is not statistically significant.
  4. Recurrence did not occur in patients who later received kidney transplantation.
  5. Overall, subtotal parathyroidectomy with a target remnant size of 75-100 mg results in low complication rates and durable cure is more likely with renal transplantation.

What to Ask Your Doctor

  1. What is the purpose of a parathyroidectomy for renal hyperparathyroidism?
  2. What is the success rate of a subtotal parathyroidectomy for renal hyperparathyroidism?
  3. What are the potential complications of a parathyroidectomy?
  4. How is the size of the parathyroid remnant determined during the surgery?
  5. What is the target postresection intraoperative parathyroid hormone level?
  6. How often do patients experience recurrent renal hyperparathyroidism after a parathyroidectomy?
  7. How long is the recovery period after a parathyroidectomy?
  8. Will I need to take any medication or make any lifestyle changes after the surgery?
  9. How will a parathyroidectomy impact my overall kidney health and function?
  10. What follow-up care is necessary after a parathyroidectomy for renal hyperparathyroidism?

Reference

Authors: Baugh KA, Yip L, Ramonell KM, Carty SE, McCoy KL. Journal: Surgery. 2024 Mar;175(3):788-793. doi: 10.1016/j.surg.2023.09.016. Epub 2023 Nov 8. PMID: 37945480