PARATHYROIDECTOMY IN DIALYSIS PATIENTS - INDICATIONS, SURGICAL APPROACH, COMPLICATIONS AND CLINICAL MANAGEMENT AFTER SURGERY

Over the last two decades significant advances have been made in the d iagnosis and therapy of renal bone disease. Thus, it has become clear that both secondary hyperparathyroidism (HPTH) and aluminum-induced bo ne disease can co-exist in a large number of dialysis patients (1). Pa tients with overt HPTH are characterized by musculoskeletal symptoms, high PTH levels, X-ray manifestations showing subperiosteal bone erosi ons and bone histology findings of osteitis fibrosa (2). Over the last decades the number of patients developing overt secondary HPTH has st eadily decreased, most likely due to better control of hyperphosphatem ia and, most importantly, the widespread use of vitamin D analogs. On the negative side, the decrease in HPTH may be the result of the conco mitant use of aluminum (Al) containing phosphate binders. Recent data show that in most Western countries Al binders are still commonly used . The direct inhibition of PTH secretion by calcitriol (3) particularl y with the availability of its intravenous form (4, 5), has substantia lly reduced the need for parathyroidectomy (PTX). Nevertheless, in spi te of recent therapeutic advances, some patients with severe overt sec ondary HPTH may receive surgical PTX. Subtotal PTX for renal HPTH was performed 35 years ago in two patients with chronic renal failure (6), Since then, three surgical procedures have been developed for the man agement of overt secondary HPTH with subtotal PTX or total PTX with au totransplantation of parathyroid gland tissue having become the two es tablished surgical approaches. However, recent data from Kaye, d'Amour and Henderson have questioned such procedures and have favored the us e of total PTX (7). This controversial issue will be discussed later. The present review will focus on the indications and surgical approach to PTX, with some anatomical considerations and the clinical course a fter PTX, with special emphasis on the medical management in the post- PTX period.