title: Kidney Disease Improving Global Outcomes guidelines and parathyroidectomy for renal hyperparathyroidism.
abstract: BACKGROUND
  Patients with end-stage renal disease develop hypocalcemia, resulting in secondary hyperparathyroidism (SHPT). No clear criterions exist to aid in surgical decision making for SHPT. The 2009 Kidney Disease Improving Global Outcomes (KDIGO) guidelines provide target ranges for serum calcium, phosphate, and parathyroid hormone (PTH) levels in patients with end-stage renal disease. Parathyroidectomy can help achieve these targets. The study purpose was to examine how parathyroidectomy for SHPT impacts KDIGO targets during immediate and long-term follow-up and to evaluate KDIGO categorization with receipt of additional surgical intervention.
  
  
  METHODS
  A retrospective review of a prospective parathyroidectomy database was performed. Included patients had SHPT, were on dialysis, and underwent parathyroidectomy. Calcium, phosphate, and PTH values were classified as below, within, or above KDIGO targets.
  
  
  RESULTS
  Between 2000 and 2013, 36 patients with SHPT met criteria. Subtotal parathyroidectomy was performed in 89%, total parathyroidectomy in 11%. Follow-up time was 54 ± 7 mo. Eight patients (22%) required additional surgery. Twenty-eight patients (76%) were alive at the last follow-up. At the last-follow up, patients had phosphate (46%), and PTH (17%) above KDIGO ranges. Factors associated with reoperation were assessed. Patient PTH within or above target immediately postoperative had a higher rate of reoperation (P < 0.01). At the last follow-up, higher phosphate (P = 0.054) and PTH (P < 0.001) were associated with higher reoperation rates, but calcium (P = 0.33) was not.
  
  
  CONCLUSIONS
  PTH and phosphate levels above KDIGO indices were associated with additional surgical intervention. Many patients had laboratory indices above range at the last follow up, suggesting more patients had persistent or recurrent disease than those who underwent reoperation. Patients may benefit from more aggressive medical and/or surgical management.
authors.affiliation: Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas. Electronic address: Sarah.Oltmann@utsouthwestern.edu.
authors.forename: Sarah C
authors.initials: SC
authors.lastname: Oltmann
authors.affiliation: Department of Surgery, University of Wisconsin, Madison, Wisconsin.
authors.forename: Tariq M
authors.initials: TM
authors.lastname: Madkhali
authors.affiliation: Department of Surgery, University of Wisconsin, Madison, Wisconsin.
authors.forename: Rebecca S
authors.initials: RS
authors.lastname: Sippel
authors.affiliation: Department of Surgery, University of Wisconsin, Madison, Wisconsin.
authors.forename: Herbert
authors.initials: H
authors.lastname: Chen
authors.affiliation: Department of Surgery, University of Wisconsin, Madison, Wisconsin.
authors.forename: David F
authors.initials: DF
authors.lastname: Schneider
mesh_terms: D000328:Adult; D000368:Aged; D015415:Biomarkers / Q000097:blood; D002118:Calcium / Q000097:blood; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006962:Hyperparathyroidism, Secondary / Q000097:blood / Q000209:etiology / Q000601:surgery*; D007676:Kidney Failure, Chronic / Q000097:blood / Q000150:complications*; D008297:Male; D008875:Middle Aged; D010281:Parathyroid Hormone / Q000097:blood; D016105:Parathyroidectomy; D010710:Phosphates / Q000097:blood; D017410:Practice Guidelines as Topic; D012008:Recurrence; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D010281:Parathyroid Hormone; D010710:Phosphates; D002118:Calcium
keywords: KDIGO; Mineral and bone disorder; Parathyroidectomy; Renal hyperparathyroidism; Secondary hyperparathyroidism