Total parathyroidectomy in patients with chronic kidney disease: Avoiding repeat surgery

Renal hyperparathyroidism (RHPT) is a common complication of renal failure and it is associated with significant morbidity and mortality. The aim of this study was to determine the patient characteristics which might predict persistent or recurrent hyperparathyroidism after surgery and to assess the long-term effect of unsuccessful surgery. This is a retrospective study of all chronic kidney disease patients who required a total parathyroidectomy (TP) because of failed medical management from January 1999 to December 2014. Patient characteristics, preoperative imaging, operative findings, and patient outcome were all studied. Differences between groups (dialysis-dependent and nondialysis-dependent; preoperative imaging and no imaging) were tested by the Chi-square statistic test and P <0.05 was regarded statistically significant. Eighty-eight patients underwent TP during this period and were followed up for a median of 35.5 months (range 1-119 months). Seventy (80%) had removal of all parathyroid glands with associated fall in parathyroid hormone level. There were no statistically significant differences in surgical success rates in neither the dialysis-dependent versus nondialysis-dependent groups nor the preoperative imaging versus no imaging groups. Two patients underwent repeat parathyroid surgery for persistent hyperparathyroidism and 16 were followed up without surgery. Preoperative imaging did not direct surgical management nor reduce surgical failure rate in this series. The long-term effects of pharmaceutical developments in this area are unknown but are likely to change indications for initial parathyroidectomy and reoperation. An agreed protocol is essential for the management of patients with RHPT.