Parathyroidectomy in chronic renal failure

Abstract

1. 1. The primary predisposing factors to secondary hyperparathyroidism are the duration of renal disease and, secondarily, the duration of dialysis. 2. 2. Subjective symptoms alone are poor indicators of parathyroid disease and their resolution is not guaranteed by parathyroidectomy. 3. 3. Radiologic changes are clinically important and the most consistent finding in hyperparathyroidism. Such changes are most likely to improve if they are minimal at the time of surgery. 4. 4. The serum calcium level alone is of no value in evaluating calcium metabolism or bony changes. An elevated parathormone level together with a normal or elevated serum calcium level indicates hyperparathyroidism. More importantly, an elevated serum alkaline phosphatase level correlates well with the presence and extent of bone disease. 5. 5. There is no significant difference between total parathyroidectomy with autotransplantation and subtotal parathyroidectomy in terms of success or recurrence. Subtotal parathyroidectomy is less likely to result in symptomatic hypocalcemia. However, total parathyroidectomy and autotransplantation offer the surgeon easy access in the event of recurrent disease. 6. 6. Postoperative hypocalcemia is not necessary to insure the success of parathyroidectomy. 7. 7. Resolution of pruritis and bone pain may be expected after parathyroidectomy. Improvement in radiologic changes can be expected in about 60 per cent of cases, with improvement more likely in those with minimal bone changes. Vascular calcifications are unlikely to be corrected and the response of soft tissue metastatic calcification is variable. Parathyroidectomy is a therapeutic measure that should be considered early in the management of hyperparathyroidism in patients with chronic renal failure. By the time bony changes appear, conservative therapy will fail to halt further progression. The bone disease reflected by radiologic changes and serum alkaline phosphatase values is most likely to be improved if parathyroidectomy is performed when the bone changes first become apparent. Surgery should be performed early to preclude those vascular and metastatic calcifications that cannot be corrected once established. A reasonable overall success rate (78 per cent in our study) can be expected. The operation should have no mortality and, with care in operative technique, only minimal morbidity.