Treatment of secondary and tertiary hyperparathyroidism - surgical viewpoints

Nearly all patients with chronic renal failure exhibit some degree of secon dary hyperparathyroidsm (sHPT), defined as parathyroid hyperplasia and elev ated serum parathyroid hormone (PTH) levels. Despite improvements in the medical management of patients with sHPT contin ue to develop progressive bone disease manifested by osteitis fibrosa cysti ca, soft tissue calcification and myopathy, pruritus, bone and joint pain a nd calciphylaxis may accompany the bone disorder. When medical therapy fail s, parathyroidectomy becomes necessary. This is not sufficiently explained by the failure to administer calcitriol to control serum-phosphat and calci um concentration or to deliver sufficient dialysis. The continuos increase of the proportion of patients exhibiting severe uncontrolled HPT with incre asing time of dialysis points to a more basic underlying biological problem ; an even higher proportion of patients shows also nodular, rather than dif fuse hyperplasia. It was commonly believed that after restoration of normal renal function wi th successfull transplantation, the hyperplastic parathyroid glands would i nvolute and return to normal function state. After renal transplantation some patients continue to have a HPT. This dise ase entity is recognized and termed as tertiary Hyperparathyroidism (tHPT). After establishing a diagnosis of hyperparathyroid bone disease, in patien ts with sHPT and tHPT a parathyroidectomy (PTX) frequently becomes necessar y to decrease the mass of the hyperplastic parathyroid tissue. The surgical procedure remains controversial. Some surgeons prefere subtotal PTX, other s prefere total PTX with autotransplantation of a small amount of tissue to the arm, because the transplantated tissue can be removed in the event of a recurrent HPT. Successfull surgical intervention for sHPT and tHPT significantly reduces p reoperative symptoms and leeds to restoration of bone desease and therefor supports PTX for patients with s and tHPT. In our experience total PTX with autograft has proven to be a satisfactory procedure. Subtotal PTX is also an effective procedure and the choice of op erative technique should be left to the surgeon.