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 Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 16  |  Issue : 1  |  Page : 1-2

The surgical aspect of renal hyperparathyroidism: a summary of the guidelines


Consultant Transplant Surgeon, Sheffield Teaching Hospital, Senior Lecture (Hon) University of Sheffield, Sheffield, United Kingdom

Date of Submission04-Nov-2015
Date of Acceptance04-Dec-2015
Date of Web Publication22-Mar-2016

Correspondence Address:
Ahmed Halawa
MSc, FRCS, MD, MEd, FRCS (Gen), Sheffield Teaching Hospital, University of Sheffield, Sheffield
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-9165.179193

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  Abstract 

Renal hyperparathyroidism is a common disease affecting the vast majority of chronic kidney disease (CKD) patients. With effective medical treatment, only 5-10% of CKD patients require surgical treatment. The medical treatment includes a wide variety of medications to replace the inactive vitamin D, suppress the hyperactive parathyroid glands and also to counteract the hyperphosphatemia. Based on publications from Egypt, the financial difficulties the CKD patients are suffering from does not allow the delivery of successful medical treatment. This is mainly due to the inability to use an effective and more expensive phosphate binder and active vitamin D (1). Also, calcimimetic therapy (e.g cinacalcet) is unaffordable and needs life-long administration. This has led to an increased prevalence of the florid disease compared to developed countries (2). The situation was made worse by the lack of understanding of the principles of diagnosis and surgical treatment of renal hyperparathyroidism among many clinicians. Surgeons rely mainly on imaging in the localization of the hyperplastic glands, which is well known to be not sensitive enough in this multi-gland disease (3). This often led to inadequate surgical management of this disease. Also, the multicentric nature of this condition (multi-gland, rather than a single-gland disease) is often undermined. The published reports from Egypt showed only a few centres dealing with this disease; however the number of patients reported is quite small with variable outcomes (4). The reported outcome demonstrates that more patients require surgery for the poorly controlled hyperparathyroidism that unmasks the lack of appropriate surgical experience in many district areas of Egypt.

Keywords: Chronic kidney disease, hyperparathyroidism, parathryroidectomy, renal


How to cite this article:
Halawa A. The surgical aspect of renal hyperparathyroidism: a summary of the guidelines. J Egypt Soc Nephrol Transplant 2016;16:1-2

How to cite this URL:
Halawa A. The surgical aspect of renal hyperparathyroidism: a summary of the guidelines. J Egypt Soc Nephrol Transplant [serial online] 2016 [cited 2017 Oct 19];16:1-2. Available from: http://www.jesnt.eg.net/text.asp?2016/16/1/1/179193


  Background Top


Renal hyperparathyroidism is a common disease affecting the vast majority of chronic kidney disease (CKD) patients. With effective medical treatment, only 5-10% of CKD patients require surgical treatment. The medical treatment includes a wide variety of medications to replace the inactive vitamin D [1], to suppress the hyperactive parathyroid glands, and also to counteract the hyperphosphataemia. On the basis of publications from Egypt, the financial difficulties the CKD patients are suffering from does not allow the delivery of successful medical treatment. This is mainly due to the inability to use an effective and more expensive phosphate binder and active vitamin D. Moreover, calcimimetic therapy (e.g. cinacalcet) is unaffordable and needs life-long administration. This has led to an increased prevalence of the florid disease compared with that in developed countries [2]. The situation was made worse by the lack of understanding of the principles of diagnosis and surgical treatment of renal hyperparathyroidism among many clinicians. Surgeons rely mainly on imaging in the localization of the hyperplastic glands, which is well known to be not sensitive enough in this multigland disease [3]. This often led to inadequate surgical management of this disease. Moreover, the multicentric nature of this condition (multigland, rather than a single-gland disease) is often undermined.

The published reports from Egypt showed only a few centres dealing with this disease; however, the number of patients reported is quite small with variable outcomes [4]. The reported outcome demonstrates that more patients require surgery for poorly controlled hyperparathyroidism, which unmasks the lack of appropriate surgical experience in many district areas of Egypt.

The following points should be noted:

  1. Surgery is indicated when medical treatment fails to control the disease in a well-dialyzed patient [5].
  2. The diagnosis of renal hyperparathyroidism is purely clinical and biochemical, not radiological.
  3. Indirect laryngoscopy is required preoperatively, and the results should be documented in the patient's notes.
  4. No radiological investigations are required (for the first-time operation) because of the multifocal nature of the disease; radiological investigations are not sensitive and even misleading. If the patient is referred with any imaging demonstrating activity in less than four glands, the clinician should appreciate the multifocal nature of the disease (four glands or more are involved in the disease process) [6],[7].
  5. For recurrent hyperparathyroidism, Sestamibi scan (parathyroid isotope scan) and CT/MRI of the neck are compulsory. Frozen section facility is highly recommended when dealing with the recurrent/persistent disease [5].
  6. Loading dose of active vitamin D is commenced 2 days (alfacalcidol 3-6 μg/day in three divided doses) for normocalcemic patients before the operation and continued during the postoperative period to reduce the incidence of 'Hungary Bone Syndrome'.
  7. The standard approach is four-gland exploration aiming at either subtotal (removing 3½ glands), total parathyroidectomy without autotransplantation, or total parathyroidectomy with autotransplantation (into three to four sternomastoid pouches marked by PROLENE stitches). Bilateral thymectomy is an integral step of the operation [5].
  8. Autopsy and surgical studies demonstrated that intrathymic parathyroid glands occur in up to 40%. There is an increased incidence of clinically significant supernumerary glands especially in the thymus in 15% of cases. This highlights the importance of thymectomy as an essential part of the operation [8].
  9. It is recommended to keep postoperative parathyroid hormone (PTH) between 150 and 300 pg/ml to reduce the incidence of adynamic bone disease [9].
  10. Many surgeons reported 90-95% initial success rate. However, recurrence of hyperparathyroidism reaches up to 30% even in the expert hand. Hypoparathyroidism is quite common. It may complicate up to 30% of cases [8].
  11. There are no adequately powered prospective randomized controlled trails comparing the three operations, but total parathyroidectomy is associated with less recurrence rate with higher incidence of adynamic bone disease. Total parathyroidectomy and autotransplantation have the theoretical advantage of removing the implanted parathyroid tissues in case of recurrence of the disease [5].
  12. The details of the operation should include the number of glands removed and the location of each of these glands. This should be documented clearly in both the patient's notes and the histology report of the specimen for future references.
  13. Intravenous calcium infusion is commenced immediately in the postoperative period guided by regular serum calcium measurement [10]. Be aware of calcium extravasation, as it is hypertonic and can cause tissue necrosis. Stop the infusion immediately if extravasation is suspected. Do not remove the cannula; aspirate to withdraw as much of the infused fluid as possible. Instil water for injection to reduce the local concentration. Apply heat to disperse the diluted calcium. Consider central line if appropriate for calcium infusion [11],[12].
  14. Magnesium should be checked postoperatively once as hypocalcaemia will not be corrected in the presence of hypomagnesaemia [10].
  15. PTH is checked on discharge and regularly monitored during the follow-up.
  16. Cinacalcet is not recommended as a routine treatment of secondary hyperparathyroidism in patients with end-stage renal disease. It is indicated if the patient is medically or surgically unfit or refused surgery [13].


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Afifi A. Renal Osteodystrophy in Developing Countries. Artificial Organs 2002; 26 : 767-769. doi: 10.1046/j.1525-1594.2002.07068.x.  Back to cited text no. 1
    
2.
Barsoum RS. Burden of chronic kidney disease: North Africa. Kidney International Supplements 2013; 3 :164-166.  Back to cited text no. 2
    
3.
Lai EC, Ching AS, Leong HT. Secondary and tertiary hyperparathyroidism; role of preoperative localization. ANZ J Surg. ANZ J Surg 2007; 10 :880-882.   Back to cited text no. 3
    
4.
Saafan HA, Salam MA, Elshafey IA, Kader AH, Hamza AH. Tertiary Hyperparathyroidism in Children on Chronic Dialysis: Role of Surgery. Annals of Pediatric Surgery 2007; 3 :69-74.  Back to cited text no. 4
    
5.
Guidelines for the surgical management of endocrine disease andtraining requirements for endocrine surgery, 2003. British Association of Endocrine and Thyroid Surgeons (BAETS). Accessed from: http://www.baets.org.uk/wp-content/uploads/2013/02/BAETS-Guidelines-2003.pdf  Back to cited text no. 5
    
6.
Fuster D, Terrogosa JV, Setoain X, Domenesh B, Campistol JM, Rubello D, Pons F. Localising imaging in secondary hyperparathyroidism. Minerva Endocrinol 2008; 33 :203-212.  Back to cited text no. 6
    
7.
Harris L, Yoo J, Driedger A, Fung K, Franklin J, Gary D, Holiday R. Accuracy of technetium-99m SPECT-CT hybrid images in predicting the precise intraoperative anatomical location of parathyroid adenomas. Head and Neck 2008; 30 :509-517.  Back to cited text no. 7
    
8.
Schlosser K, Schmitt CP, Bartholomaeus JE, et al. Parathyroidectomy for renal hyperparathyroidism in children and adolescents. World J Surg 2008; 32 :801-806.  Back to cited text no. 8
    
9.
KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease. Available at: http://www2.kidney.org/professionals/KDOQI/guidelines_bone/ [Last accessed on 2016 Feb].  Back to cited text no. 9
    
10.
Wang TS, Roman SA, Sosa JA. Postoperative calcium supplementation in patients undergoing thyroidectomy. Curr Opin Oncol 2012; 24 :22-28.   Back to cited text no. 10
    
11.
Al-Benna S, O′Boyle C, Holley J. Extravasation injuries in adults. ISRN Dermatol 2013; 2013 :856541. doi: 10.1155/2013/856541.  Back to cited text no. 11
    
12.
Drug Side Effect. Available at: http://www.drugs.com/sfx/cal-g-side-effects.html (Last accessed on 2016 Feb].  Back to cited text no. 12
    
13.
NICE guidelines, 2007. Available at: https://www.nice.org.uk/guidance/ta117/chapter/1-guidance [Last accessed on 2016 Feb].  Back to cited text no. 13
    




 

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