Skip to main navigation menu Skip to main content Skip to site footer

Original article

Vol. 149 No. 4950 (2019)

Secondary hyperparathyroidism: recurrence after total parathyroidectomy with autotransplantation

  • Lukas Steffen
  • Giusi Moffa
  • Philip C. Müller
  • Daniel Oertli
DOI
https://doi.org/10.4414/smw.2019.20160
Cite this as:
Swiss Med Wkly. 2019;149:w20160
Published
04.12.2019

Summary

BACKGROUND

Secondary hyperparathyroidism is common in patients with end-stage chronic kidney disease. If drug therapy fails, total parathyroidectomy with autotransplantation of parathyroid tissue into the forearm (PTX-AT) is the most widely used procedure. High recurrence rates of secondary hyperparathyroidism following PTX-AT are reported in the literature.

OBJECTIVE

The aim of this study was to evaluate recurrences of secondary hyperparathyroidism following PTX-AT in detail in order to develop strategies to prevent recurrences in the future.

METHODS

This retrospective study analysed a single-centre cohort of 42 patients who underwent PTX-AT for secondary hyperparathyroidism at a tertiary centre in Switzerland. Postoperative PTH levels were evaluated to determine the recurrence and persistence rates and the time to recurrence. Furthermore, the peri- and postoperative outcomes were assessed. Patients on dialysis and patients with a functioning kidney transplant suffering tertiary HPTH were analysed separately.

RESULTS

Intraoperative measurements showed that serum PTH decreased to 6.9% (3.3–15.0%) of the preoperative baseline level. After a median follow-up of 89.5 months (IQR 31.9–152.9), persistence of secondary hyperparathyroidism was found in five patients (11.9%) and recurrence in four patients (9.5%), giving a total recurrence rate of 21.4%.

CONCLUSION

Recurrence of secondary hyperparathyroidism after PTX remains a problem, occurring in every fifth patient. In our experience, the introduction of intraoperative PTH measurement has helped to lower the rates of persistence and recurrence. Further reductions in the recurrence rate might be achieved with novel, more accurate pre- and intraoperative imaging techniques.

References

  1. Silver J, Naveh-Many T. FGF-23 and secondary hyperparathyroidism in chronic kidney disease. Nat Rev Nephrol. 2013;9(11):641–9. doi:.https://doi.org/10.1038/nrneph.2013.147
  2. Vervloet M. Renal and extrarenal effects of fibroblast growth factor 23. Nat Rev Nephrol. 2019;15(2):109–20. doi:.https://doi.org/10.1038/s41581-018-0087-2
  3. Levin A, Bakris GL, Molitch M, Smulders M, Tian J, Williams LA, et al. Prevalence of abnormal serum vitamin D, PTH, calcium, and phosphorus in patients with chronic kidney disease: results of the study to evaluate early kidney disease. Kidney Int. 2007;71(1):31–8. doi:.https://doi.org/10.1038/sj.ki.5002009
  4. Block GA, Klassen PS, Lazarus JM, Ofsthun N, Lowrie EG, Chertow GM. Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. J Am Soc Nephrol. 2004;15(8):2208–18. doi:.https://doi.org/10.1097/01.ASN.0000133041.27682.A2
  5. Lorenz K, Bartsch DK, Sancho JJ, Guigard S, Triponez F. Surgical management of secondary hyperparathyroidism in chronic kidney disease--a consensus report of the European Society of Endocrine Surgeons. Langenbecks Arch Surg. 2015;400(8):907–27. doi:.https://doi.org/10.1007/s00423-015-1344-5
  6. Ganesh SK, Stack AG, Levin NW, Hulbert-Shearon T, Port FK. Association of elevated serum PO(4), Ca x PO(4) product, and parathyroid hormone with cardiac mortality risk in chronic hemodialysis patients. J Am Soc Nephrol. 2001;12(10):2131–8.
  7. Rostand SG, Drüeke TB. Parathyroid hormone, vitamin D, and cardiovascular disease in chronic renal failure. Kidney Int. 1999;56(2):383–92. doi:.https://doi.org/10.1046/j.1523-1755.1999.00575.x
  8. Pitt SC, Sippel RS, Chen H. Secondary and tertiary hyperparathyroidism, state of the art surgical management. Surg Clin North Am. 2009;89(5):1227–39. doi:.https://doi.org/10.1016/j.suc.2009.06.011
  9. 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;(113):S1–130.
  10. Skinner KA, Zuckerbraun L. Recurrent secondary hyperparathyroidism. An argument for total parathyroidectomy. Arch Surg. 1996;131(7):724–7. doi:.https://doi.org/10.1001/archsurg.1996.01430190046012
  11. Triponez F, Clark OH, Vanrenthergem Y, Evenepoel P. Surgical treatment of persistent hyperparathyroidism after renal transplantation. Ann Surg. 2008;248(1):18–30. doi:.https://doi.org/10.1097/SLA.0b013e3181728a2d
  12. Iwamoto N, Sato N, Nishida M, Hashimoto T, Kobayashi H, Yamazaki S, et al. Low parathyroid hormone levels after parathyroidectomy reduce cardiovascular mortality in chronic hemodialysis patients. Clin Exp Nephrol. 2016;20(5):808–14. doi:.https://doi.org/10.1007/s10157-015-1208-x
  13. Rothmund M, Wagner PK, Schark C. Subtotal parathyroidectomy versus total parathyroidectomy and autotransplantation in secondary hyperparathyroidism: a randomized trial. World J Surg. 1991;15(6):745–50. doi:.https://doi.org/10.1007/BF01665309
  14. Casanova D, Sarfati E, De Francisco A, Amado JA, Arias M, Dubost C. Secondary hyperparathyroidism: diagnosis of site of recurrence. World J Surg. 1991;15(4):546–9, discussion 549–50. doi:.https://doi.org/10.1007/BF01675660
  15. Chou F-F, Lee C-H, Chen H-Y, Chen J-B, Hsu K-T, Sheen-Chen S-M. Persistent and recurrent hyperparathyroidism after total parathyroidectomy with autotransplantation. Ann Surg. 2002;235(1):99–104. doi:.https://doi.org/10.1097/00000658-200201000-00013
  16. Tominaga Y, Matsuoka S, Uno N, Tsuzuki T, Hiramitsu T, Goto N, et al. Removal of autografted parathyroid tissue for recurrent renal hyperparathyroidism in hemodialysis patients. World J Surg. 2010;34(6):1312–7. doi:.https://doi.org/10.1007/s00268-010-0412-9
  17. Beck TM, Huber PR, Oertli D. Intraoperative parathormone measurement in patients with primary hyperparathyroidism: a prospective clinical study. Swiss Med Wkly. 2003;133(13-14):206–9.
  18. World Health Organization. WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy. Geneva; 2010.Available from: http://www.ncbi.nlm.nih.gov/books/NBK138650/
  19. R Core Team. A language and environment for statistical computing, R.C. Team, Editor 2015, R Foundation for Statistical Computing, Vienna, Austria.
  20. Agha A, Loss M, Schlitt HJ, Scherer MN. Recurrence of secondary hyperparathyroidism in patients after total parathyroidectomy with autotransplantation: technical and therapeutic aspects. Eur Arch Otorhinolaryngol. 2012;269(5):1519–25. doi:.https://doi.org/10.1007/s00405-011-1776-7
  21. Kievit AJ, Tinnemans JGM, Idu MM, Groothoff JW, Surachno S, Aronson DC. Outcome of total parathyroidectomy and autotransplantation as treatment of secondary and tertiary hyperparathyroidism in children and adults. World J Surg. 2010;34(5):993–1000. doi:.https://doi.org/10.1007/s00268-010-0446-z
  22. Pattou FN, Pellissier LC, Noël C, Wambergue F, Huglo DG, Proye CA. Supernumerary parathyroid glands: frequency and surgical significance in treatment of renal hyperparathyroidism. World J Surg. 2000;24(11):1330–4. doi:.https://doi.org/10.1007/s002680010220
  23. Xu D, Yin Y, Hou L, Dai W. Surgical management of secondary hyperparathyroidism: how to effectively reduce recurrence at the time of primary surgery. J Endocrinol Invest. 2016;39(5):509–14. doi:.https://doi.org/10.1007/s40618-015-0410-8
  24. McWade MA, Paras C, White LM, Phay JE, Mahadevan-Jansen A, Broome JT. A novel optical approach to intraoperative detection of parathyroid glands. Surgery. 2013;154(6):1371–7, discussion 1377. doi:.https://doi.org/10.1016/j.surg.2013.06.046
  25. Wolf HW, Grumbeck B, Runkel N. Intraoperative verification of parathyroid glands in primary and secondary hyperparathyroidism using near-infrared autofluorescence (IOPA). Updates Surg. 2019;71(3):579–85. doi:.https://doi.org/10.1007/s13304-019-00652-1
  26. Ladurner R, Sommerey S, Arabi NA, Hallfeldt KKJ, Stepp H, Gallwas JKS. Intraoperative near-infrared autofluorescence imaging of parathyroid glands. Surg Endosc. 2017;31(8):3140–5. doi:.https://doi.org/10.1007/s00464-016-5338-3
  27. Komaba H, Taniguchi M, Wada A, Iseki K, Tsubakihara Y, Fukagawa M. Parathyroidectomy and survival among Japanese hemodialysis patients with secondary hyperparathyroidism. Kidney Int. 2015;88(2):350–9. doi:.https://doi.org/10.1038/ki.2015.72
  28. Ishani A, Liu J, Wetmore JB, Lowe KA, Do T, Bradbury BD, et al. Clinical outcomes after parathyroidectomy in a nationwide cohort of patients on hemodialysis. Clin J Am Soc Nephrol. 2015;10(1):90–7. doi:.https://doi.org/10.2215/CJN.03520414
  29. Chen H-H, Lin C-J, Wu C-J, Lai C-T, Lin J, Cheng S-P, et al. Chemical ablation of recurrent and persistent secondary hyperparathyroidism after subtotal parathyroidectomy. Ann Surg. 2011;253(4):786–90. doi:.https://doi.org/10.1097/SLA.0b013e318211ccc2
  30. Rajeev P, Lee KY, Tang XJ, Goo TT, Tan WB, Ngiam KY. Outcomes of parathyroidectomy in renal hyperparathyroidism in patients with No access to renal transplantation in Singapore. Int J Surg. 2016;25:64–8. doi:.https://doi.org/10.1016/j.ijsu.2015.11.005

Most read articles by the same author(s)