OPERATIVE TREATMENT OF TERTIARY HYPERPARATHYROIDISM - A SINGLE-CENTEREXPERIENCE

Objective To review the experience with the operative treatment of ter tiary hypeuparathyroidism (TH) from a single renal transplant center. Summary Background Data Most patients with chronic renal failure shaw evidence of secondary hyperparathyroidism by the time maintenance hemo dialysis begins. Persistent secondary hyperparathyroidism (i.e.,TH) re quiring surgical intervention is uncommon in the authors' experience. Methods Charts of patients who underwent parathyroidectomy for TH were reviewed retrospectively. information obtained included demographics, laboratory data, symptoms, operative procedure (including morbidity a nd mortality rates], and pathology. Comparisons of demographic data an d allograft survival were made between the transplant population as a whole and a matched cohort group of patients. Results Thirty-eight pat ients from 4344 renal transplant procedures during a 29-year period re quired parathyroidectomy for TH. A[I patients had hypercalcemia; 20 we re asymptomatic and 18 had varying symptoms. Mean lime from renal tran splantation to parathyroidectomy was 997 +/- 184 days, with a mean pre operative calcium level of 12.2 +/- 0.14 mg/dl. Total parathyroidectom y with parathyroid autograft was performed in 26 of 34 primary procedu res. There were no deaths. The operative morbidity rate was 6% (wound separation and vocal cord hemiparesis, one each), Pathology was report ed in all patients and recently reviewed in 28 patients. Twenty-lour h ad diffuse hyperplasia and nine had nodular hyperplasia; one had an ad enoma. Parathyroid glands diagnosed as nodular hyperplasia were signif icantly larger by total mass than those with diffuse hyperplasia. Comp arison of allograft survival between the study group and a matched coh ort group of patients revealed no difference in long-term graft surviv al. Conclusions Operative intervention is recommended in patients with an asymptomatic increase in serum calcium to > 12.0 mg/dl persisting for >1 year after the transplant, acute hypercalcemia (calcium >12.5 m g/dl) in the immediate posttransplant period, and symptomatic hypercal cemia.