Surgical Management of Renal

HyperparathyroidismMY Chan

Queen Mary Hospital

BackgroundRenal hyperparathyroidism (Renal HPT)

Secondary: overproduction of parathyroid hormone (PTH) in response to hypocalcaemia

Tertiary: excessive secretion of PTH after longstanding secondary hyperparathyroidism

Epidemiology11-15 per 1000 patient-years1

1–2% of patients with secondary HPT require parathyroidectomy each year2

1. Slinin Y, Foley RN, Collins AJ. Clinical epidemiology of parathyroidectomy in hemodialysis patients: the USRDS waves 1, 3, and 4 study. Hemodialysis international. International Symposium on Home Hemodialysis [Internet]. 2007 Jan;11(1):62–71.

2. Triponez F, Clark O, Vanrenthergem Y, et al. Surgical treatment of persistent hyperparathyroidism after renal transplantation. Ann Surg 2008;248:18.

Indications Not well established No studies to define biochemical criteria K/DOQI Clinical Practice Guidelines for Bone

Metabolism and Disease in Chronic Kidney Disease1

Severe hyperparathyroidism (>88 pmol/L) with hypercalcaemia and/or hyperphosphataemia resistant to medical therapy

Calciphylaxis with documented elevated PTH

1. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease.Am J Kidney Dis 42:S1-S202; 2003 (suppl 3)

Pre-operative ImagingTo locate any ectopic or supernumerary gland(s)Technetium Tc-99m sestamibi (MIBI) scintigraphy

Sensitivity of 44-82% in published works1

Ultrasound scanSensitivity of 24-54% in published studies1

Limited reports on CT and MRINot a must before operation

Limited value because of the poor results in identifying all the glands in multi-gland disease

1. Lai ECH, Ching ASC, Leong HT. Secondary and tertiary hyperparathyroidism: role of preoperative localization. ANZ journal of surgery [Internet]. 2007 Oct [cited 2013 Jan 27];77(10):880–2.

Operative StrategiesSubtotal parathyroidectomy (SPTX)

Resection of 3 ½ parathyroid gland The most healthy looking parathyroid gland chosenLeaving a portion of viable parathyroid gland and

marked with clip

Total parathyroidectomy with autotransplantation (TPTX+AT)The most healthy looking parathyroid gland chosen Implantation of a portion of parathyroid gland

Total parathyroidectomy without autotransplantation (TPTX)

Operative StrategiesTakagi et al (1984)1

20 of 43 patients underwent SPTX23 underwent TPTX+AT

40% in SPTX group required IV calcium supplement 91% in TPTX+AT group

Mean duration of administration15.6 days in SPTX group59.5 days in TPTX+AT group

1. Takagi H, Tominaga Y, Uchida K, Yamada N, Kawai M, Kano T, et al. Subtotal versus total parathyroidectomy with forearm autograft for secondary hyperparathyroidism in chronic renal failure. Annals of surgery [Internet]. 1984 Jul;200(1):18–23.

Operative StrategiesRetrospective study by Lorenz et al. (2006)1

23 patients underwent TPTX64 patients underwent SPTXNormalization of PTH

74% in TPTX group63% in SPTX group

Symptomatic hypocalcaemia requiring intravenous supplement

2 patients (8.7%) in TPTX group0 patients in SPTX group

No comparison of long-term results between 2 groups

1. Lorenz K, Ukkat J, Sekulla C, Gimm O, Brauckhoff M, Dralle H. Total parathyroidectomy without autotransplantation for renal hyperparathyroidism: experience with a qPTH-controlled protocol. World journal of surgery [Internet]. 2006 May [cited 2013 Jan 15];30(5):743–51.

Operative StrategiesRetrospective study by Schneider et al (2012)1

606 patients with mean follow-up of 57.6 monthsNo significant difference in terms of perioperative drop in calcium / PTH and rate of nerve palsyPersistent disease requiring reoperation

4.8% in SPTX group 0.4% in TPTX+AT group 0% in TPTX group

Recurrent disease requiring reoperation 9.5% in SPTX group 5.4% in TPTX+AT group 0% in TPTX group

1. Schneider R, Slater EP, Karakas E, Bartsch DK, Schlosser K. Initial parathyroid surgery in 606 patients with renal hyperparathyroidism. World journal of surgery [Internet]. 2012 Feb [cited 2013 Jan 19];36(2):318–26.

Operative StrategiesPros Cons

SPTX Lesser requirement of post-operative calcium supplement

✗ Higher rate of persistent / recurrent disease

✗ Difficulty in reoperation

TPTX+AT Allow easy access / differentiation in recurrence

Decreased rate of recurrence

✗ Larger requirement of calcium supplements than SPTX immediately post-op

TPTX Low rate of recurrence

✗ Possibly higher chance of adynamic bone disease

✗ Cryopreservation required

Operative StrategiesCervical thymectomy

Retrospective study by Schneider et al. (2011) 461 patients underwent parathyroidectomy with

routine bilateral cervical thymectomy 44.5% of patients had intrathymic parathyroid

glandEctopic gland in 38%Supernumerary gland in 5.2%

Should be carried out if not all 4 glands found

1. Madorin C, Owen RP, Fraser WD, Pellitteri PK, Radbill B, Rinaldo A, et al. The surgical management of renal hyperparathyroidism. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery [Internet]. 2012 Jun [cited 2013 Jan 19];269(6):1565–76.

OutcomesComplications

Hypocalcaemia1 (“Hungry bone syndrome”)High risk group: long-standing HPT, increased ALP,

extensive bone resorption on X-ray Recurrent laryngeal nerve palsy (<1% with permanent

injury) Bleeding and haematoma, wound infection

Increased short-term mortality (3.1 vs. 1.2% 30-day mortality)2

Decreased long-term mortality (median survival 53 vs. 47 months)2

Other benefits: improved bone density, pruritis and calciphylaxis

1. Schlosser K, Zielke a, Rothmund M. Medical and surgical treatment for secondary and tertiary hyperparathyroidism. Scandinavian journal of surgery : SJS : official organ for the Finnish Surgical Society and the Scandinavian Surgical Society [Internet]. 2004 Jan;93(4):288–97

2. Madorin C, Owen RP, Fraser WD, Pellitteri PK, Radbill B, Rinaldo A, et al. The surgical management of renal hyperparathyroidism. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery [Internet]. 2012 Jun [cited 2013 Jan 19];269(6):1565–76..

ConclusionsParathyroidectomy is an effective treatment of

renal hyperparathyroidism

Pre-operative imaging may help but is not necessary

Thorough exploration aiming to identify all 4 glands is essential no matter which type of operation is chosen

No evidence to show any type of operation is superior than the others

Thank You