Parathyroidectomy Associated With Morbidity, Mortality
Single-center study reveals a hospitalization rate of 14% following total parathyroidectomy without autotransplantation.
Studies have shown that parathyroidectomy reduces serum intact parathyroid hormone levels (iPTH) in patients with secondary hyperparathyroidism, but the clinical impact of the surgery has been less clear.
A new study found that a small proportion of patients undergoing the procedure experience morbidity and mortality.
Christopher Thiam Seong Lim, MD, and colleagues at Serdang Hospital in Malaysia, examined clinical outcomes for 90 patients (mean age 48 years) who underwent total parathyroidectomy without autotransplantation (TPTx) at their institution from 2010 to 2014. More than half of the patients (54.4%) were male, 90% were receiving maintenance hemodialysis, and 10% were on peritoneal dialysis (mean dialysis duration 8 years). Symptomatic bone pain was the reason for surgery in 95.6% of cases. Fractures and calciphylaxis were the surgical indications in 3.3% and 1.1% of cases.
According to results published online ahead of print in the Clinical Kidney Journal, most patients had 4 glands removed, but in 17% of cases not all glands could be located. Almost all excised glands showed hyperplasia of some degree. By 1 year, serum iPTH had fallen below 8 pmol/L in all patients, and 31% had undetectable levels. Just 1 patient had a relapse.
Despite biochemical improvement, 25 hospitalizations among 14 patients (15.6%) occurred in the first year post-TPTx. Five hospitalizations were due to hypocalcemia, 4 to hypercalcemia, 4 to fluid overload, 4 to vascular access sepsis, 2 to other sepsis, and 3 to other vascular access. One hospitalization each was due to stroke, fracture, and acute coronary syndrome. The mean hospital stay was 14.4 days.
The mortality rate was 1.1% during the first 30 days and 4.4% at one year. This rate is lower than that documented in some previous studies possibly due to the small sample size or better care. Sepsis was the cause of death in 75% of cases and acute coronary syndrome in 25%.
“Our study has demonstrated that the procedure of PTX does come with small but significant risks of mortality and morbidity,” stated Dr Lim and colleagues. “Although PTX is still the treatment of choice in cases of severe SHPT, there may be an increased role for calcimimetics to be considered as nonoperative treatment for SHPT in high cardiac risk patients.”
The authors acknowledged a number of study limitations, including a relatively small sample size and the inclusion of patients from a single center. The study included only patients on maintenance dialysis, so the applicability of their results to other dialysis populations is unknown. In addition, the researchers noted that they were unable to determine whether the adverse outcomes were due to the surgery or the increased morbidity that patients with end-stage renal disease experience when undergoing elective general surgery procedures.
Thiam Seong Lim C, Kalaiselvam T, Kitan N, and Leong Goh B. Clinical course after parathyroidectomy in adults with end-stage renal disease on maintenance dialysis. Clin Kid J, 2017;1–5. doi: 10.1093/ckj/sfx086