Impact of parathyroidectomy on cardiovascular outcomes and survival in chronic hemodialysis patients with secondary hyperparathyroidism. A retrospective study of 50 cases prior to the calcimimetics era.

Giovanni Conzo,Luigi Santini,Cristina Pietra,Alessandra F Perna,Diego Ingrosso,Antonietta Palazzo,Giovambattista Capasso,Ersilia Satta,Giovanni Docimo,Vincenzo Savica

doi:10.1186/1471-2482-13-s2-s4

Abstract

BackgroundIn chronic hemodialysis patients with secondary hyperparathyroidism, pathological modifications of bone and mineral metabolism increase the risk of cardiovascular morbidity and mortality. Parathyroidectomy, reducing the incidence of cardiovascular events, may improve outcomes; however, its effects on long-term survival are still subject of active research.We compared, in hemodialysis patients, the results of parathyroidectomy, in terms of cardiovascular outcomes and mortality, with those present in patients following medical treatment only, prior to the diffusion of calcimimetics.MethodsFrom January 2004 to December 2006, 30 hemodialysis patients, affected by severe and unresponsive secondary hyperparathyroidism, underwent parathyroidectomy - 15 total parathyroidectomy and 15 total parathyroidectomy + subcutaneous autoimplantation. During a 5-year follow-up, patients did not receive a renal transplantation and were evaluated for biochemical modifications and major cardiovascular events - death, cardiovascular accidents, myocardial infarction and peripheral vascular disease. Results were compared with those obtained in a control group of 20 hemodialysis patients, affected by secondary hyperparathyroidism, and refusing surgical treatment, and following medical treatment only.ResultsThe groups were comparable in terms of age, gender, dialysis vintage, and comorbidities. Postoperative cardiovascular events were observed in 18/30 - 54% - surgical patients and in 4/20 - 20%- medical patients, with a mortality rate respectively of 23.3% in the surgical group vs. 15% in the control group. Parathyroidectomy was not associated with a reduced risk of cardiovascular morbidity and survival rate was unaffected by surgical treatment.ConclusionsIn secondary hyperparathyroidism hemodialysis patients affected by severe cardiovascular disease, surgery did not modify cardiovascular morbidity and mortality rates. Therefore, in secondary hyperparathyroidism hemodialysis patients, resistant to medical treatment, only an early indication to calcimimetics, or surgery, in the initial stage of chronic kidney disease - mineral bone disorders, may offer a higher long-term survival. Further studies will be useful to clarify the role of secondary hyperparathyroidism in determining unfavorable cardiovascular outcomes and mortality in hemodialysis population.

Highlights

Further studies will be useful to clarify the role of secondary hyperparathyroidism in determining unfavorable cardiovascular outcomes and mortality in hemodialysis population
Incidence of secondary hyperparathyroidism (2HPT) in the setting of chronic kidney disease-mineral bone disorder (CKD-MBD), increases with dialysis vintage, and, prior to the calcimimetic era, parathyroidectomy (PTx) became necessary in 15% of cases after 10 years, which rose to 38% after 20 years [1]
In the present series, PTx did not demonstrate a protective effect against major cardiovascular events, with respect to the incidence observed in the medical control group and the mortality rate, in patients affected by severe preoperative cardiovascular diseases, was unaffected by surgery (Figure 2), probably because surgery was indicated in 2HPT advanced stages

Summary

Introduction

Incidence of secondary hyperparathyroidism (2HPT) in the setting of chronic kidney disease-mineral bone disorder (CKD-MBD), increases with dialysis vintage, and, prior to the calcimimetic era, parathyroidectomy (PTx) became necessary in 15% of cases after 10 years, which rose to 38% after 20 years [1]. Calcimimetics, well tolerated allosteric modulators of the calcium-sensing receptor, inhibiting glandular hyperplasia and significantly reducing circulating iPTH levels without exacerbating hyperphosphatemia or hypercalcemia, have been shown to exert a major beneficial impact on 2HTP management. They determine a reduction of fractures, hospitalizations and of PTxs in CKDMBD population [4,5]. In hemodialysis patients, the results of parathyroidectomy, in terms of cardiovascular outcomes and mortality, with those present in patients following medical treatment only, prior to the diffusion of calcimimetics

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Discussion

Conclusion