Parathyroidectomy (PTx) might cut the risk of early death in chronic kidney disease patients on dialysis who have secondary hyperparathyroidism (SHPT).
PTx was associated with a 28% reduction in death from any cause and a 37% reduction in cardiovascular mortality compared with medical therapy over a year or more of follow up, according to results of a meta-analysis published in Renal Failure.
The meta-analysis, by Lin Chen, of Shandong University of Traditional Chinese Medicine in China, and colleagues, included 13 cohort studies involving 22 053 patients. The investigators focused on studies that compared any type of PTx (i.e., total PTx with or without autotransplantation and subtotal PTx) with any SHPT drug treatment. Twelve of the studies reported all-cause mortality and 6 reported cardiovascular mortality. The investigators deemed the studies to be of high quality.
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Cinacalcet was introduced in 2004, but the investigators found its timing had no influence on results. In addition, most of the studies adjusted for confounders such as age, sex, body mass index (BMI), diabetes, duration of dialysis, and dialysis modality.
“The post-PTx survival improvement is most likely attributed to multifactorial causes,” according to Chen and colleagues. High levels of intact parathyroid hormone might spur atherosclerosis, calcification, and myocardial injuries, whereas PTx controls serum minerals contributing to these processes. Other possibilities include improvement in left ventricular function, fracture risk, anemia, hypertension, cardiac autonomic nervous system, calciphylaxis, immune system function, muscle strength, and/or fibroblast growth factor 23.
A notable limitation of the review is the possibility of confounding by indication. Patients unable to undergo PTx due to severe SHPT or comorbidities were perhaps more likely to join the comparator group. Future reviews of large clinical trials are needed to determine the exact effects of PTx and whether mortality rates differ by type of procedure.
PTx is not without risks. The investigators noted that it is associated with short-term mortality and hospitalization. Surgical complications also are possible, including bilateral palsy of recurrent laryngeal nerves. In addition “cinacalcet may be the first choice for patients in whom sHPT is hardly manageable by PTx,” Chen’s team stated.
