Tertiary hyperparathyroidism after renal transplantation: surgical strategy

An analysis of our experience with tertiary hyperparathyroidism (III HPT) in renal transplantations between 1981 and 1996 was reviewed to examine a variety of laboratory and clinical variables in this population.

A total of 3233 kidney transplantations were performed; 48 patients underwent parathyroidectomy for III HPT. Five patients were excluded from analysis due to the development of renal dysfunction. The index 43 patients were divided into two groups. Group I consisted of 31 patients (72%) with either enlargement of all parathyroid glands (n = 26) or 3/4 gland enlargement (n = 5). These patients were assumed to have hyperplasia and underwent subtotal parathyroidectomy or total parathyroidectomy. Group II consisted of 12 patients (28%) with single (7/12; 58%) or two-gland enlargement (5/12; 42%). Group II patients underwent resection of only the enlarged glands.

Laboratory and clinical parameters showed no difference between the groups during long-term follow-up. Most patients in groups I and II were eucalcemic after parathyroidectomy. However, postoperative hypercalcemia and hypocalcemia did occur in group I (mean postoperative calcium: group I = 9.29 +/- 0.63 mg/dL; group II = 9.42 +/- 0.58 mg/dL).

Four gland parathyroid enlargement is a frequent finding in III HPT, although asymmetric enlargement can occur. Histologically, this represents sporadic adenomas and asymmetric hyperplasia. Intraoperative findings should dictate surgical strategy; with asymmetric enlargement only the enlarged parathyroid glands should be resected.