The Authors Reply

Abstract

The Authors Reply: We thank Elias et al.1.Elias R.M. Goldenstein P.T. Moyses R.M. Parathyroidectomy: better late than never.Kidney Int. 2015; 88Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar for their insightful comments on our recent article on the survival benefit of parathyroidectomy (PTx) for patients with severe secondary hyperparathyroidism (SHPT).2.Komaba H, Taniguchi M, Wada A et al. Parathyroidectomy and survival among Japanese hemodialysis patients with secondary hyperparathyroidism. Kidney Int (in press).Google Scholar We do agree with Elias et al. that their recent study conducted in Brazil3.Goldenstein P.T. Elias R.M. Pires de Freitas do Carmo L. et al.Parathyroidectomy improves survival in patients with severe hyperparathyroidism: a comparative study.PLoS One. 2013; 8: e68870Crossref PubMed Scopus (50) Google Scholar reinforce our findings. In Japan, indication for PTx is considered for patients with intact parathyroid hormone (PTH) levels >500 pg/ml according to the Japanese Society for Dialysis Therapy guideline.4.Fukagawa M. Yokoyama K. Koiwa F. et al.Clinical practice guideline for the management of chronic kidney disease-mineral and bone disorder.Ther Apher Dial. 2013; 17: 247-288Crossref PubMed Scopus (259) Google Scholar In this way, most Japanese patients with severe SHPT undergo PTx before the complications of SHPT (e.g. bone disease and vascular calcification) become life-threatening. Given such background, our results2.Komaba H, Taniguchi M, Wada A et al. Parathyroidectomy and survival among Japanese hemodialysis patients with secondary hyperparathyroidism. Kidney Int (in press).Google Scholar can be interpreted to suggest a survival benefit of PTx for patients with severe, but less serious SHPT. In contrast, Goldenstein et al.3.Goldenstein P.T. Elias R.M. Pires de Freitas do Carmo L. et al.Parathyroidectomy improves survival in patients with severe hyperparathyroidism: a comparative study.PLoS One. 2013; 8: e68870Crossref PubMed Scopus (50) Google Scholar evaluated more seriously ill patients with symptomatic SHPT and highlighted the possible pronounced effect of PTx for more advanced SHPT. Owing to lack of data on preoperative PTH levels, we are unable to directly examine the survival effect of PTx in patients with more severe SHPT. However, as an alternative approach, we selected control patients from those with intact PTH levels >1000 pg/ml and performed a propensity score–matched analysis. As expected, we found a pronounced survival advantage for the PTx group compared with the matched control group (n=773 in each group; hazard ratio, 0.57; 95% confidence interval, 0.39–0.83). Besides indication for PTx, there are several differences among countries in the management of SHPT, including medical treatment before PTx, preferred procedure for PTx, efficacy and adverse effects of PTx, postoperative monitoring and care, and long-term medical management after surgery.5.Ishani A. Liu J. Wetmore J.B. et al.Clinical outcomes after parathyroidectomy in a nationwide cohort of patients on hemodialysis.Clin J Am Soc Nephrol. 2015; 10: 90-97Crossref PubMed Scopus (105) Google Scholar,6.Tentori F. Wang M. Bieber B.A. et al.Recent changes in therapeutic approaches and association with outcomes among patients with secondary hyperparathyroidism on chronic hemodialysis: the DOPPS study.Clin J Am Soc Nephrol. 2015; 10: 98-109Crossref PubMed Scopus (199) Google Scholar In this regard, the study by Goldenstein et al.,3.Goldenstein P.T. Elias R.M. Pires de Freitas do Carmo L. et al.Parathyroidectomy improves survival in patients with severe hyperparathyroidism: a comparative study.PLoS One. 2013; 8: e68870Crossref PubMed Scopus (50) Google Scholar conducted in a different setting and population with different severity of SHPT, is an important addition to the literature. Their similar results likely support the generalizability of our conclusions. We believe that PTx is not necessarily an undesirable outcome, but an effective approach to improve survival of patients with refractory SHPT.