Long-term results of total parathyroidectomy without autotransplantation in patients with and without renal failure - An argument for total parathyroidectomy alone

The optimal surgical procedure for severe renal secondary hyperparathyroidi sm (sHPT) is still a point of controversy. Total parathyroidectomy (PTX) wi thout autotransplantation was abandoned for fear of an adynamic bone condit ion; however, in the case of autotransplantation recurrent sHPT is frequent and promotes atherosclerosis. We studied 11 hemodialysis patients (age 59 +/- 12 years) on dialysis for 18 (12-30) years in whom total PTX was perfor med due to severe sHPT (group I; intact PTH: 1,240 +/- 230 pg/ml), and 5 pa tients (age 55 +/- 10 years) without renal insufficiency who inadvertently received total PTX during thyroid surgery (group II). After total PTX (grou p 1, 26 +/- 18 [9-59] months; group II, 252 +/- 188 [22-480] months) both g roups showed no measurable intact PTH levels. Calcium homeostasis was maint ained by oral substitution with calcium (group I, calcium dialysate of 2.0 mmol/l), vitamin D and calcitriol (serum parameters in groups I and II: cal cium 2.4 and 2.2 mmol/l; phosphate 1.8 and 1.1 mmol/l; 25(OH)-vitamin D-3 2 1 and 34 ng/ml; 1,25(OH)(2)-vitamin D-3 32 and 41 pg/ml, respectively). In group I, after total PTX there was a rapid and sustained improvement in bon e pain with markedly enhanced physical activity and endurance. High turnove r osteopathy markedly improved as indicated by declining levels of native o steocalcin (90 +/- 17 vs. 26 +/- 18 ng/ml), bone alkaline phosphatase (74 /- 12 vs. 12 +/- 6 ng/ml), and carboxyterminal crosslinked telopeptide of t ype-I collagen (65 +/- 16 vs. 40 +/- 21 ng/ml) but increasing levels of car boxyterminal propeptide of type-I procollagen (120 +/- 36 vs. 148 +/- 41 ng /ml). Recalcification of bone was excellent as demonstrated by X-ray and co nfirmed by bone histology. Itching extravascular calcific deposits and calc ifications of blood vessel and cardiac valves immediately stopped after tot al PTX. Moreover, 6 sHPT patients suffered from severe atherosclerotic lesi ons such as thoracic aortic aneurysm (n=3) or abdominal aortic aneurysm (n= 3) which showed size progression before but not after total PTX when annual ly controlled by ultrasonography. In group II, even long after total PTX, t here was no clinical, radiological, histological or biochemical evidence fo r low turnover osteopathy. In conclusion, our data indicate that substituti on with vitamin D-3 metabolites and calcium can prevent deleterious bone ef fects of hypoparathyroidism in hemodialysis patients and in patients with n ormal kidney function and may compensate for the missing PTH action. Over t his, a better survival rate is expected as a consequence of the beneficial effect of total PTX on the progression of atherosclerotic lesions. We sugge st reconsideration of total PTX without autotransplantation in dialysis pat ients with severe sHPT who are not eligible for renal transplantation.