Doctor and older woman_0514 Viewpoint
The patient complained about fatigue, persistent pruritis, and non-specific myalgias.
A 60-year-old woman with a history of type 2 diabetes mellitus, hypertension, and ESRD on thrice-weekly hemodialysis for the past 2 years, via left upper extremity arteriovenous fistula, has complained about fatigue, persistent pruritis, and non-specific myalgias over the past few months. The patient has been compliant with her dialysis treatments.
Medications include atenolol, insulin, epogen, sevelamer carbonate 2 pills per meal, calcitriol 0.5 mcg orally 3 times per week, and cinacalcet 90 mg twice daily. Laboratory work-up is significant for kt/v 1.4, phosphorus 7.2 mg/dL, corrected calcium of 9.9 mg/dL, and parathyroid hormone (PTH) level of 1100 pg/mL. Recent radiographs performed to investigate lower extremity pain show progressive arterial calcification.
Submit your diagnosis to see full explanation.
This case was prepared by Kevin T. Harley, MD, Assistant Clinical Professor of Medicine, Division of Nephrology & Hypertension, University of California, Irvine.
- Sharma J, Raggi P, Kutner N, et al. Improved long-term survival of dialysis patients after near-total parathyroidectomy. J Am Coll Surg 2012;214:400-407.
- Kestenbaum B, Andress DL, Schwartz SM, et al. Survival following parathyroidectomy among United States dialysis patients. Kidney Int 2004;66:2010-2016.
- Palmer SC, Nistor I, Craig JC, et al. Cinacalcet in patients with chronic kidney disease: a cumulative meta-analysis of randomized controlled trials. PLoS Med 2013;10:e1001436.
Patients with uncontrolled hyperparathyroidism can experience worsened fatigue and pruritis, as well as muscular and bone pain. To date no randomized controlled trials have successfully investigated continued vitamin D plus calcimimetic therapy versus near-total parathyroidectomy in ESRD patients with uncontrolled hyperparathyroidism. One observational, matched-cohort study used data from the US Renal Data System to study the effects of parathyroidectomy in ESRD patients. Surgically treated patients had a 1-month mortality rate of about 3%, which was higher than that of the non-surgically treated patients. But longer term mortality rates in surgically treated patients were improved. It should be noted this study occurred prior to the introduction and regular use of calcimimetics. A meta-analysis of 5 trials published in 2013 showed that calcimimetic use did lower the rate of surgical parathyroidectomy, but other important patient outcomes were not significantly improved. There is no set PTH level at which surgical treatment for tertiary/uncontrolled hyperparathyroidism in ESRD patients is strongly recommended.
Most specialists would recommend consideration of surgical intervention in patients with active symptoms related to the uncontrolled parathyroid disease, who have uncontrolled hypercalcemia or hyperphosphatemia, and/or PTH levels not at goal levels despite active vitamin D and calcimimetic use. Patients who undergo near-total parathyroidectomy require very close monitoring of serum calcium levels and other manifestations of the hungry bone syndrome post-operatively.