Parathyroidectomy for renal hyperparathyroidism in children and adolescents

Renal hyperparathyroidism (rHPT) almost inevitably develops in pediatric patients with end-stage chronic kidney disease (CKD) and may require parathyroidectomy (PTX) despite intensified conservative therapy. Long-term duration of uncontrolled rHPT may result in disabling osteodystrophy and vascular calcifications. Only a few reports on children undergoing PTX for rHPT are available and mainly consist of case reports with short follow-up periods. To study this entity, we analyzed the course of 23 pediatic patients who underwent PTX for rHPT.

Twenty-three patients with a mean age of 15 years and who underwent PTX for rHPT between 1986 and 2006 were evaluated. Surgical indications and techniques, specific postoperative management, and follow-up courses are described.

Preoperative mean serum (s-) calcium was 2.7+/-0.05 mmol/L (normal range=2.2-2.7 mmol/L); s-phosphate was 1.8+/-0.1 mmol/L (normal range=0.8-1.6 mmol/L), and mean intact parathyroid hormone (PTH) level was 1240.1+/-160.1 pg/ml (normal range=11-65 pg/ml). Twenty-one patients underwent initial PTX and two patients underwent reoperative PTX. Total PTX with parathyroid autotransplantation (AT) was performed in 18 patients. In three patients less than four parathyroid glands were identified and no AT was performed consecutively. Postoperatively, no complications with respect to bleeding or vocal cord damage were recorded. The postoperative values of s-calcium, s-phosphate, and PTH decreased to or below normal range (s-calcium=2.0+/-0.1 mmol/L, s-phosphate=1.2+/-0.1 mmol/L, PTH=50.1+/-11.2 pg/ml). All 15 children below the age of 15 years required calcium intravenously. Follow-up was obtained in all patients 69.6+/-11.4 months after PTX. Bone pain resolved in all previously symptomatic patients. S-calcium was 2.2+/-0.2 mmol/L, s-phosphate was 1.4 +/- 0.3 mmol/L, and PTH was 90.2+/-21.5 pg/ml. No patient required repeated parathyroid autografting, and only one underwent an explantation of his AT six years after initial PTX.

Total PTX with AT in pediatric patients with rHPT is a safe and effective procedure. It should be considered if rHPT is refractory to conservative treatment, in view of the risk of potentially lethal vascular calcifications developing in the majority of adults with childhood onset of CKD.