title: The surgical management of renal hyperparathyroidism.
abstract: Secondary and tertiary hyperparathyroidism (HPT) develop in patients with renal failure due to a variety of mechanisms including increased phosphorus and fibroblast growth factor 23 (FGF23), and decreased calcium and 1,25-dihydroxy vitamin D levels. Patients present with various bone disorders, cardiovascular disease, and typical laboratory abnormalities. Medical treatment consists of controlling hyperphosphatemia, vitamin D/analog and calcium administration, and calcimimetic agents. Improved medical therapies have led to a decrease in the use of parathyroidectomy (PTX). The surgical indications include parathyroid hormone (PTH) levels >800 pg/ml associated with hypercalcemia and/or hyperphosphatemia despite medical therapy. Other indications include calciphylaxis, fractures, bone pain or pruritis. Transplant recipients often show decreased PTH, calcium and phosphorus levels, but some will have persistent HPT. Evidence suggests that PTX may cause deterioration in renal graft function in the short-term calling into the question the indications for PTX in these patients. Pre-operative imaging is only occasionally helpful except in re-operative PTX. Operative approaches include subtotal PTX, total PTX with or without autotransplantation, and possible thymectomy. Each approach has its proponents, advantages and disadvantages which are discussed. Intraoperative PTH monitoring has a high positive predictive value of cure but a poor negative predictive value and therefore is of limited utility. Hypocalcemia is the most common complication requiring aggressive calcium administration. Benefits of surgery may include improved survival, bone mineral density and alleviation of symptoms.
authors.affiliation: Department of Surgery, Division of Metabolic, Endocrine and Minimally Invasive Surgery, Mount Sinai School of Medicine, New York, NY, USA.
authors.forename: Catherine
authors.initials: C
authors.lastname: Madorin
authors.forename: Randall P
authors.initials: RP
authors.lastname: Owen
authors.forename: William D
authors.initials: WD
authors.lastname: Fraser
authors.forename: Phillip K
authors.initials: PK
authors.lastname: Pellitteri
authors.forename: Brian
authors.initials: B
authors.lastname: Radbill
authors.forename: Alessandra
authors.initials: A
authors.lastname: Rinaldo
authors.forename: Raja R
authors.initials: RR
authors.lastname: Seethala
authors.forename: Ashok R
authors.initials: AR
authors.lastname: Shaha
authors.forename: Carl E
authors.initials: CE
authors.lastname: Silver
authors.forename: Matthew Y
authors.initials: MY
authors.lastname: Suh
authors.forename: Barrie
authors.initials: B
authors.lastname: Weinstein
authors.forename: Alfio
authors.initials: A
authors.lastname: Ferlito
mesh_terms: D002118:Calcium / Q000378:metabolism; D000089703:Fibroblast Growth Factor-23; D006801:Humans; D006962:Hyperparathyroidism, Secondary / Q000209:etiology / Q000378:metabolism / Q000601:surgery*; D016030:Kidney Transplantation; D010281:Parathyroid Hormone / Q000097:blood; D016105:Parathyroidectomy; D010758:Phosphorus / Q000378:metabolism; D051437:Renal Insufficiency / Q000150:complications* / Q000378:metabolism / Q000628:therapy; D016896:Treatment Outcome
chemical_list: C000717427:FGF23 protein, human; D010281:Parathyroid Hormone; D010758:Phosphorus; D000089703:Fibroblast Growth Factor-23; D002118:Calcium
references.citation: Nephrol Dial Transplant. 2007 Oct;22(10):2909-16
references.pmid: 17517792
references.citation: Surgery. 2004 Dec;136(6):1252-60
references.pmid: 15657584
references.citation: Kidney Int. 2010 Nov;78(10):975-80
references.pmid: 20844473
references.citation: Am J Clin Pathol. 2002 Dec;118(6):895-902
references.pmid: 12472283
references.citation: Nephron. 1982;30(2):143-8
references.pmid: 7048113
references.citation: Semin Surg Oncol. 1997 Mar-Apr;13(2):87-96
references.pmid: 9088064
references.citation: Kidney Int. 2008 Jun;73(11):1296-302
references.pmid: 18337714
references.citation: Surgery. 1998 Oct;124(4):677-83; discussion 683-4
references.pmid: 9780988
references.citation: J Nephrol. 2010 Nov-Dec;23(6):619-25
references.pmid: 20658451
references.citation: J Am Soc Nephrol. 2004 Aug;15(8):2208-18
references.pmid: 15284307
references.citation: Arch Intern Med. 1969 Oct;124(4):397-407
references.pmid: 5823010
references.citation: Surgery. 2010 Oct;148(4):867-73; discussion 873-5
references.pmid: 20800255
references.citation: Nephrol Dial Transplant. 1999 Oct;14(10):2398-406
references.pmid: 10528664
references.citation: Kidney Int. 1997 Jan;51(1):328-36
references.pmid: 8995751
references.citation: Transplant Proc. 2005 Apr;37(3):1459-61
references.pmid: 15866638
references.citation: Arch Surg. 2006 Feb;141(2):129-34; discussion 134
references.pmid: 16490888
references.citation: World J Surg. 2008 Aug;32(8):1795-801
references.pmid: 18311499
references.citation: Arch Pathol Lab Med. 1981 Aug;105(8):421-7
references.pmid: 6894851
references.citation: J Am Coll Surg. 2003 Nov;197(5):739-46
references.pmid: 14585407
references.citation: Clin Chem. 2006 Jun;52(6):1112-9
references.pmid: 16614003
references.citation: Cancer. 1973 Mar;31(3):600-5
references.pmid: 4693587
references.citation: Surgery. 2003 Oct;134(4):713-7; discussion 717-9
references.pmid: 14605634
references.citation: Horm Metab Res. 2003 Apr;35(4):259-64
references.pmid: 12778370
references.citation: Langenbecks Arch Surg. 2010 Jan;395(1):73-80
references.pmid: 19705144
references.citation: Asian J Surg. 2005 Apr;28(2):82-5
references.pmid: 15851358
references.citation: Surgery. 1998 Jul;124(1):1-5
references.pmid: 9663244
references.citation: World J Surg. 2008 May;32(5):815-21
references.pmid: 18338208
references.citation: Endocrinology. 2011 Jan;152(1):4-10
references.pmid: 21084445
references.citation: Am J Kidney Dis. 2003 Oct;42(4 Suppl 3):S1-201
references.pmid: 14520607
references.citation: Arch Pathol Lab Med. 2003 Jan;127(1):64-7
references.pmid: 12521369
references.citation: Am J Kidney Dis. 2001 Nov;38(5 Suppl 5):S20-33
references.pmid: 11689384
references.citation: Am J Med Sci. 2010 May;339(5):420-4
references.pmid: 20234299
references.citation: World J Surg. 1998 Oct;22(10):1098-102; discussion 1103
references.pmid: 9747174
references.citation: Lancet. 2009 Jul 11;374(9684):145-58
references.pmid: 19595349
references.citation: Surgery. 2001 Oct;130(4):645-50; discussion 650-1
references.pmid: 11602895
references.citation: ANZ J Surg. 2003 May;73(5):284-8
references.pmid: 12752283
references.citation: J Clin Endocrinol Metab. 1998 Nov;83(11):3845-51
references.pmid: 9814456
references.citation: Br J Surg. 2005 Oct;92(10):1282-7
references.pmid: 15988794
references.citation: Kidney Blood Press Res. 2004;27(3):191-6
references.pmid: 15256817
references.citation: Ann Surg Oncol. 2006 Jan;13(1):96-102
references.pmid: 16378160
references.citation: Clin Transplant. 2000 Oct;14(5):457-63
references.pmid: 11048990
references.citation: Am J Kidney Dis. 1998 Sep;32(3):384-91
references.pmid: 9740153
references.citation: Nephrol Dial Transplant. 2007 Feb;22(2):584-91
references.pmid: 17035377
references.citation: Surgery. 2000 Dec;128(6):1029-34
references.pmid: 11114639
references.citation: Laryngoscope. 2003 Nov;113(11):1857-69
references.pmid: 14603039
references.citation: Kidney Int. 2005 Feb;67(2):760-71
references.pmid: 15673327
references.citation: Plast Reconstr Surg. 1996 Sep;98(4):671-8
references.pmid: 8773689
references.citation: Am J Kidney Dis. 2000 Mar;35(3):465-8
references.pmid: 10692272
references.citation: Surgery. 1999 Dec;126(6):1152-8; discussion 1158-9
references.pmid: 10598201
references.citation: Surg Clin North Am. 2009 Oct;89(5):1227-39
references.pmid: 19836494
references.citation: Langenbecks Arch Surg. 2006 Nov;391(6):561-5
references.pmid: 16909294
references.citation: Kidney Int. 2005 Oct;68(4):1793-800
references.pmid: 16164656
references.citation: Arch Surg. 1995 May;130(5):538-42; discussion 542-3
references.pmid: 7748094
references.citation: World J Surg. 2000 Nov;24(11):1391-5
references.pmid: 11038212
references.citation: Chin Med J (Engl). 2007 Oct 20;120(20):1777-82
references.pmid: 18028770
references.citation: Surgery. 2006 Feb;139(2):174-80
references.pmid: 16455325
references.citation: Vasa. 1998 Aug;27(3):137-43
references.pmid: 9747147
references.citation: Kidney Int. 2004 Nov;66(5):2010-6
references.pmid: 15496173
references.citation: J Am Soc Nephrol. 2001 Oct;12(10):2131-2138
references.pmid: 11562412
references.citation: Surgery. 2006 Dec;140(6):990-7; discussion 997-9
references.pmid: 17188148
references.citation: Arch Surg. 1996 Jul;131(7):724-7
references.pmid: 8678771
references.citation: Nephrol Dial Transplant. 2007 Jun;22(6):1730-7
references.pmid: 17371780
references.citation: J Am Soc Nephrol. 2002 Nov;13(11):2762-9
references.pmid: 12397047
references.citation: Arch Surg. 2002 Mar;137(3):341-4
references.pmid: 11888464
references.citation: Kidney Int. 1998 Jul;54(1):210-5
references.pmid: 9648081
references.citation: Miner Electrolyte Metab. 1983 Mar-Apr;9(2):57-61
references.pmid: 6687751
references.citation: Nephrol Dial Transplant. 1998 Jun;13(6):1384-7
references.pmid: 9641165
references.citation: World J Surg. 2000 Nov;24(11):1330-4
references.pmid: 11038202
references.citation: Ann Surg. 2002 Jan;235(1):99-104
references.pmid: 11753048
references.citation: J Clin Endocrinol Metab. 1948 Aug;8(8):637-57
references.pmid: 18877062
references.citation: Am J Nephrol. 2007;27(1):36-43
references.pmid: 17215573
references.citation: Arch Surg. 2001 Sep;136(9):1064-8
references.pmid: 11529832
references.citation: J Am Soc Nephrol. 2007 Aug;18(8):2401-7
references.pmid: 17634437
references.citation: Am J Surg. 1999 Oct;178(4):332-6
references.pmid: 10587194
references.citation: Ann Surg. 2001 Jan;233(1):65-9
references.pmid: 11141227
references.citation: Nephrol Dial Transplant. 1999;14 Suppl 1:63-5
references.pmid: 10048455
references.citation: Kidney Int. 2006 Aug;70(4):771-80
references.pmid: 16820797
references.citation: Arch Surg. 2004 Sep;139(9):974-7
references.pmid: 15381615
references.citation: Am J Clin Pathol. 1981 Mar;75(3):345-7
references.pmid: 7211756
references.citation: Am J Kidney Dis. 2001 Oct;38(4 Suppl 1):S168-71
references.pmid: 11576947
references.citation: Ann Surg. 1998 Jun;227(6):878-86
references.pmid: 9637551
references.citation: Kidney Int. 2004 Jan;65(1):282-8
references.pmid: 14675061
references.citation: Ann Surg. 2008 Jul;248(1):18-30
references.pmid: 18580203
references.citation: J Nephrol. 2005 May-Jun;18(3):221-8
references.pmid: 16013007
references.citation: World J Surg. 2007 Oct;31(10):1947-53
references.pmid: 17665243
references.citation: Br J Pharmacol. 1996 Aug;118(8):1995-2000
references.pmid: 8864534
references.citation: Kidney Int. 1999 Aug;56(2):642-9
references.pmid: 10432404
references.citation: J Cardiovasc Pharmacol. 1994;23 Suppl 2:S23-6
references.pmid: 7518541
references.citation: Kidney Int Suppl. 2009 Aug;(113):S1-130
references.pmid: 19644521
references.citation: Nephron. 2000 Nov;86(3):402-3
references.pmid: 11096325
references.citation: Otolaryngol Clin North Am. 2010 Apr;43(2):433-40, x-xi
references.pmid: 20510725
references.citation: Nephrol Dial Transplant. 2004 May;19(5):1281-7
references.pmid: 14993493
references.citation: Kidney Int. 2011 Jun;79(12):1370-8
references.pmid: 21389978
references.citation: Kidney Int Suppl. 2002 May;(80):161-6
references.pmid: 11982831
references.citation: Nephron. 2000 Mar;84(3):224-7
references.pmid: 10720892
references.citation: Am Surg. 2007 Mar;73(3):281-3
references.pmid: 17375788
references.citation: Surgery. 2003 Dec;134(6):1038-41; discussion 1041-2
references.pmid: 14668738
references.citation: Surgery. 2000 Dec;128(6):967-71;discussion 971-2
references.pmid: 11114631
references.citation: Kidney Int. 2003 Apr;63(4):1483-90
references.pmid: 12631365
references.citation: Surgery. 2008 Dec;144(6):949-55; discussion 954-5
references.pmid: 19041002
references.citation: World J Surg. 1991 Nov-Dec;15(6):745-50
references.pmid: 1767541
references.citation: Hum Pathol. 1985 Aug;16(8):772-84
references.pmid: 4018775
references.citation: Ann Surg. 2002 May;235(5):673-8; discussion 678-80
references.pmid: 11981213
references.citation: Am J Surg Pathol. 1998 May;22(5):538-44
references.pmid: 9591722
references.citation: Surgery. 2005 Dec;138(6):1066-71; discussion 1071
references.pmid: 16360392
references.citation: J Am Soc Nephrol. 2005 Feb;16(2):520-8
references.pmid: 15615819
references.citation: Kidney Int. 1998 Nov;54(5):1704-13
references.pmid: 9844148
references.citation: Br J Surg. 2010 Nov;97(11):1674-9
references.pmid: 20641052
references.citation: Arch Pathol Lab Med. 2009 Jun;133(6):950-9
references.pmid: 19492889
references.citation: Kidney Int. 2006 Jun;69(11):1945-53
references.pmid: 16641930
references.citation: Nephrol Dial Transplant. 2011 Aug;26(8):2691-5
references.pmid: 21303965
references.citation: Surgery. 2005 Apr;137(4):431-5
references.pmid: 15800491
references.citation: Surgery. 2009 Dec;146(6):1130-7
references.pmid: 19958940
references.citation: Arch Surg. 1991 Oct;126(10):1213-8; discussion 1218-9
references.pmid: 1929821
references.citation: Trials. 2007 Sep 18;8:22
references.pmid: 17877805
references.citation: Surgery. 1984 Jan;95(1):14-21
references.pmid: 6691181
references.citation: Hum Pathol. 2003 Jan;34(1):54-64
references.pmid: 12605367
references.citation: Clin J Am Soc Nephrol. 2006 Jul;1(4):825-31
references.pmid: 17699293
references.citation: J Otolaryngol. 2001 Oct;30(5):266-70
references.pmid: 11771018
references.citation: Am J Kidney Dis. 1991 Sep;18(3):320-5
references.pmid: 1882823
references.citation: Nephrol Dial Transplant. 2005 Aug;20(8):1714-20
references.pmid: 15919696
references.citation: Langenbecks Arch Surg. 2002 Oct;387(5-6):204-9
references.pmid: 12410355