LONG-TERM FOLLOW-UP AFTER TOTAL PARATHYROIDECTOMY WITHOUT PARATHYROIDREIMPLANTATION IN CHRONIC-RENAL-FAILURE

Forty-three patients with secondary or autonomous hyperparathyroidism complicating chronic renal failure (CRF) underwent total parathyroidec tomy (PTX) (follow-up 2-18 years, mean 8.7 years). Five were on conser vative treatment for CRF, 35 on regular dialysis, and only three had a functioning allograft. At PTX, the most frequent findings were uncont rollable hypercalcaemia, musculo-skeletal pain, radiographic changes i n the phalanges, and raised plasma parathyroid hormone (PTH) concentra tion. Pre-operatively, all patients were loaded with dihydrotachystero l or 1-alpha-OH cholecalciferol. Postoperatively, they were maintained on tapering doses of the same drugs and, briefly, oral calcium supple ments. Five glands were identified and removed in two patients, four i n 35 patients, three in three patients and only two in one patient. Al l had changes of hyperplasia and adenoma formation, except for one wit h a parathyroid carcinoma. Prompt symptomatic and radiographic improve ment occurred, with normalization of plasma calcium and alkaline phosp hatase. Postoperative PTH levels were available in 33 patients (23 by intact PTH assay): they were persistently high in 10/33 (2/23 intact); normal in seven (6 intact); low in 11 (3 intact), and undetectable in four (3 intact), Thus, PTX was incomplete in the majority of patients . Following transplantation, 3/20 (3/18 intact) patients still had det ectable PTH. Only one patient developed symptomatic recurrent parathyr oid disease requiring re-operation, and complications were few. Small dosages of vitamin D continue to be required, but not calcium suppleme ntation, and no clinical effects of possible adynamic bone have been n oted. At later renal transplantation in 27 patients, an easily treatab le, uncomplicated hypocalcaemia was noted in 33%. Up to 18 years after operation (median 9 years) almost all patients are well, without clin ical or radiographic bone disease. 'Total' PTX seems preferable to alt ernative surgical approaches, including reimplantation of parathyroid tissue, because residual tissue is usually left behind.