SURGICAL-TREATMENT OF RENAL HYPERPARATHYROIDISM

Advanced secondary (renal) hyperparathyroidism induced by chronic rena l disturbance is one of the most serious complications for long-term h emodialysis patients. Parathyroidectomy is indicated in patients with severely advanced renal hyperparathyroidism refractory to medical trea tment (including calcitriol pulse therapy) and the clinical effect of parathyroidectomy is striking. However, skeletal deformity, vessel cal cification, and remarkable reduction of bone content is irreversible, and it is important to perform parathyroidectomy at right time. Based on histopathological and pathophysiological investigations, nodular hy perplasia is monoclonal neoplasia with abnormal parathyroid hormone (P TH) response to extracellular calcium and vitamin D. When parathyroid hyperplasia progresses to nodular hyperplasia, parathyroidectomy shoul d be required. Total parathyroidectomy with forearm autograft is the p referable procedure for renal hyperparathyroidism, especially for pati ents who need to continue hemodialysis treatment after parathyroidecto my. Removal of all parathyroid glands, including supernumerary glands, at the initial operation, and proper choice of adequate parathyroid t issue for autograft, are important to prevent persistent and recurrent hyperparathyroidism. Preoperative image diagnosis is useful for local ization, and routine resection of thymic tissue is necessary to remove supernumerary glands. In our series of 548 patients, graft-dependent recurrent hyperparathyroidism was not negligible and the incidence was about 20% at the 5th year postoperatively. Enlarged autografts of par athyroid tissue could be removed from forearm under local anesthesia w ith fewer invasions. The function of autografted parathyroid tissue is nearly satisfactory and no re-transplantation of cryopreserved parath yroid tissue was necessary. To avoid adynamic bone disease, relatively high PTH level is required-over-suppression of PTH by excess of vitam in D and calcium salts should be avoided. In our experience, total par athyroidectomy with forearm autograft is very effective and adequate t reatment for advanced renal hyperparathyroidism, and parathyroid funct ion can be controlled after parathyroidectomy. (C) 1997 Wiley-Liss, In c.