Endocrine Abstracts

Introduction: Hyperparathyroidism is common in patients with end-stage renal failure (ESRF): up to 20% require treatment for hyperparathyroidism within 10 years of commencing haemodialysis. Despite the significant cost of long-term medical treatment with calcimimetics and poor patient compliance, only a minority of patients are referred for surgery, usually due to their significant co-morbidity.

Methods: Outcome data of patients with secondary or tertiary hyperparathyroidism undergoing subtotal parathyroidectomy in our department from 2012 to 2014 were reviewed. All patients underwent bilateral neck exploration with nerve monitoring. Serum parathyroid hormone (PTH) and calcium levels were measured postoperatively.

Results: 25 patients (median age 52 years) underwent subtotal parathyroidectomy. 18/25 patients (72%) had ESRF and secondary hyperparathyroidism whilst 7/25 patients (28%) had post-transplant tertiary hyperparathyroidism. The majority of patients had evidence of osteopaenia or osteoporosis on bone densitometry and 17/25 patients (68%) had some degree of hypercalcaemia at referral. At least four parathyroid glands were identified intra-operatively in 19/25 patients (76%) and a subtotal procedure was performed, leaving ~50 mg of parathyroid tissue in-situ. In 6/25 patients, three or fewer parathyroid glands were identified, and in these patients all the identified glands were excised. 24/25 patients (96%) had serum PTH levels <14 pmol/l at most recent follow up (range 3–24 months). Normocalcaemia was achieved in 16/17 (94%) of the patients who were hypercalcaemic pre-operatively. Post-operative complications included severe transient hypocalcaemia requiring i.v. calcium infusion in two patients, and one patient required emergency reoperation for bleeding. One patient experienced temporary unilateral recurrent laryngeal nerve palsy which recovered fully within 3 months post-surgery.

Conclusion: Subtotal parathyroidectomy can deliver biochemical success in >90% of patients with renal hyperparathyroidism. It offers a safe and cost-effective alternative to medical treatment, particularly in patients with poor compliance, and without the risk of future adynamic bone disease associated with total parathyroidectomy.