October - December 2010, Volume 6, Issue 4

Mircescu G, Stanescu B

Surgical or medical therapy for severe hyperparathyroidism or chronic kidney disease? An appraisal of current practice guidelines

Acta Endo (Buc) 2010, 6 (4): 541-576
doi: 10.4183/aeb.2010.541

Long lasting hypocalcemia, hyperphosphatemia, low calcitriol and high fibroblast growth factor 23 could result in progressive parathyroid gland hyperplasia with high, uncontrolled, parathormone production, e.g. severe secondary hyperparathyroidism (sHPT), in 10% of dialysis patients. Parathyroidectomy (PTX) could be a solution, but has inherent (low) surgical risks and although dramatically decreases parathormone levels, could induce hypoparathyroidism (50-66%) and low turnover bone disease. Moreover, the rate of recurrences is 15-20% at 10 years. Total and subtotal PTX with autografting are equally safe and effective with similar recurrences rates. Calcimimetics are efficient drugs, but with limited effectiveness in sHPT, as only 25% of patients responded to cinacalcet. In the USA, they are more cost-effective than PTX only in patients with >2 years expected dialysis duration. As there are not randomized studies to compare surgical to medical therapy, the strength of evidence allows only for suggestions in guidelines. In countries like Romania, where dialysis vintage is high because of the low transplantation rate and calcimimetics are costly, PTX seems a better solution when parathyroid glands are large (diameter >1cm or\r\ntotal mass >500mg), parathormone levels >800pg/mL, in patients who are not candidates for renal transplantation or are anticipated to stay >2 years on dialysis.

Keywords: parathyroidectomy, severe secondary hyperparathyroidism,\r\ncalcimimetics, cinacalcet, dialysis

Correspondence: Gabriel Mircescu, MD, ?Dr Carol Davila? Teaching Hospital of Nephrology, 4 Calea Grivitei, sector 1, 010731, Bucharest, Romania, Phone: 0040-722-214504; Fax: 0040-21-3189194, E-mail: gmircescu@hotmail.com