Abstract:
Background and Aims: Parathyroidectomy (PTX) is an important treatment method for the refractory renal secondary hyperparathyroidism (SHPT) not controlled by drugs. However, permanent hypoparathyroidism, adynamic bone disease or refractory osteomalacia may probably occur after PTX, and the studies regarding its long-term efficacy are still limited in our country. Therefore, this study was designated to further evaluate the safety as well as the short- and long-term therapeutic effect of PTX on refractory renal SHPT.
Methods: One-hundred and thirty-nine patients with refractory renal SHPT depend on long-term dialysis who received PTX in the Second Affiliated Hospital of Anhui Medical University from January 2011 to December 2014 were recruited. The clinical data and blood parameters that included intact parathyroid hormone (iPTH), calcium, phosphorus, hemoglobin (Hb) and hematocrit (Hct) were collected before operation and 3 d, 6 months, 1 year, 2 years and 3 years after operation. Meanwhile, the degree of symptom relief, postoperative complications and follow-up conditions were observed and recorded.
Results: The success rate of PTX in 139 patients was 95.7% (133/139). The total number of parathyroid glands removed during operation was 537, and the average number of the parathyroid glands removed per case was 3.86. Transient recurrent laryngeal nerve injury occurred in 12 patients (8.6%) after operation, including hoarseness in 9 cases (6.5%) and choking cough when drinking water in 3 cases (2.2%), which were all recovered spontaneously without treatment within 3 months. Postoperative hypocalcemia or vitamin D deficiency occurred in 120 patients (86.3%), which were effectively controlled after treatment with cinacalcet, calcium supplementation, and active vitamin D supplementation. No surgical complications such as wound infection, bleeding, asphyxia, and hypothyroidism occurred in the whole group of patients. The anemia parameters in all patients were improved by different degrees, and the values of Hb and Hct were increased significantly at 6 months after surgery and remained stable during the follow-up period; postoperative iPTH level was significantly reduced, and the blood levels of calcium, phosphorus and calcium-phosphorus product reached the lowest at 3 d after operation, which were still lower than those before operation during the follow-up for 3 years. and all the changes were statistically different from preoperative conditions (all P<0.05). No death occurred during the follow-up. The preoperative symptoms of the patients such as bone pain, intractable skin itching, insomnia, ectopic calcification, muscle weakness with atrophy were significantly relieved within 1 day after surgery; there were no progressive exacerbation in patients with height shrinkage or skeletal deformities during follow-up; the anorexia, and general nutritional status and self-care ability were improved to varying degrees within 3 months after surgery. Eleven patients (7.9%) showed sustained SHPT, of whom 4 cases (2.9%) had incomplete removal of the parathyroid glands during operation, and 1 case (0.7%) had a parathyroid small gland that failed to remove during operation and 6 cases (4.3%) had mediastinal ectopic parathyroid glands which were identified by postoperative examination. During the follow-up period, the iPTH levels in 5 patients (3.5%) with unremoved glands all were higher than 800 pg/mL, with obvious symptoms of muscle weakness and intractable skin itching, and PTX was performed again; 6 patients (4.3%) had ectopic parathyroid glands were given medical treatment, because they refused to be re-operated for the greater risk of surgery; recurrence occurred in 8 patients (5.8%) after operation, of whom 6 cases (4.3%) were caused by the recurrence of the forearm grafts, which were all resected under local anesthesia, and 2 cases (1.4%) were caused by the excessive hyperplasia of the residual glands in the neck, which were treated by second operation, and then the symptoms were improved. All patients undergoing second surgery had no obvious clinical symptoms or recurrence at the end of follow-up.
Conclusion: PXT can improve the clinical symptoms, and the anemia parameters as well as the calcium and phosphorus metabolism in patients with refractory renal SHPT, with favorable short-term efficacy and long-term efficacy. So, it is a safe and effective method for the treatment of refractory renal SHPT.
