Subtotal parathyroidectomy in dialysis-dependent and post-renal transplant patients. A 25-year single-center experience
J. D. Punch, N. W. Thompson and R. M. Merion
Department of Surgery, University of Michigan Medical School, Ann Arbor, USA.
OBJECTIVE: To determine long-term results and durability of
parathyroidectomy in patients with chronic renal failure and renal
transplant recipients. DESIGN: Retrospective chart review and structured
telephone interviews. SETTING: Tertiary-care academic medical center.
PATIENTS: Ninety-one consecutive patients (80 undergoing long-term
dialysis, 11 with posttransplant hyperparathyroidism). Mean follow-up was 8
years (minimum follow-up, 2 years; longest follow-up, 25 years). The most
common indications for operation were bone pain (70% [56/80]) and weakness
(46% [37/80]) in patients with renal failure and hypercalcemia (91%
[10/11]) in renal transplant recipients. INTERVENTION: Subtotal
parathyroidectomy without remnant gland implantation. MAIN OUTCOME
MEASURES: Postoperative morbidity and mortality, relief and recurrence of
symptoms. RESULTS: Symptoms were successfully ameliorated in 95% (86/91) of
patients. Clinically significant complications occurred in 5% (5/91) of
patients (one patient each with wound hematoma, wound infection, and
permanent recurrent laryngeal nerve paralysis and two patients with
permanent hypoparathyroidism). Recurrence occurred in five (5%) of 91
patients. Two of these patients required four operations each to eradicate
all hyperfunctioning accessory glands. The other three recurrences were
caused by hyperplasia of the remnant gland left in the neck. These were
easily treated by simple excision, with no morbidity. The actuarial rate of
recurrent hyperparathyroidism was 4.1% at 1 year and 11.7% at 20 years.
Overall hospital mortality was 3% (3/91). None of the deaths was directly
attributable to parathyroidectomy. CONCLUSIONS: We recommend subtotal
parathyroidectomy without remnant implantation as a safe and durable
intervention for hyperparathyroidism associated with renal failure and
following renal transplantation. This intervention is associated with an
acceptably low recurrence rate over extremely long periods of follow-up.
