Long-term results of total parathyroidectomy without autotransplantation in patients with and without renal failure -: An argument for total parathyroidectomy alone

The optimal surgical procedure for severe renal secondary hyperparathyroidism (sHPT) is still a point of controversy. Total parathyroidectomy (PTX) without autotransplantation was abandoned for fear of an adynamic bone condition; however, in the case of autotransplantation recurrent sHPT is frequent and promotes atherosclerosis. We studied 11 hemodialysis patients (age 59 +/- 12 years) on dialysis for 18 (12-30) years in whom total PTX was performed due to severe sHPT (group I; intact PTH: 1,240 +/- 230 pg/ml), and 5 patients (age 55 +/- 10 years) without renal insufficiency who inadvertently received total PTX during thyroid surgery (group II). After total PTX (group 1, 26 +/- 18 [9-59] months; group II, 252 +/- 188 [22-480] months) both groups showed no measurable intact PTH levels. Calcium homeostasis was maintained by oral substitution with calcium (group I, calcium dialysate of 2.0 mmol/l), vitamin D and calcitriol (serum parameters in groups I and II: calcium 2.4 and 2.2 mmol/l; phosphate 1.8 and 1.1 mmol/l; 25(OH)-vitamin D-3 21 and 34 ng/ml; 1,25(OH)(2)-vitamin D-3 32 and 41 pg/ml, respectively). In group I, after total PTX there was a rapid and sustained improvement in bone pain with markedly enhanced physical activity and endurance. High turnover osteopathy markedly improved as indicated by declining levels of native osteocalcin (90 +/- 17 vs. 26 +/- 18 ng/ml), bone alkaline phosphatase (74 +/- 12 vs. 12 +/- 6 ng/ml), and carboxyterminal crosslinked telopeptide of type-I collagen (65 +/- 16 vs. 40 +/- 21 ng/ml) but increasing levels of carboxyterminal propeptide of type-I procollagen (120 +/- 36 vs. 148 +/- 41 ng/ml). Recalcification of bone was excellent as demonstrated by X-ray and confirmed by bone histology. Itching extravascular calcific deposits and calcifications of blood vessel and cardiac valves immediately stopped after total PTX. Moreover, 6 sHPT patients suffered from severe atherosclerotic lesions such as thoracic aortic aneurysm (n=3) or abdominal aortic aneurysm (n=3) which showed size progression before but not after total PTX when annually controlled by ultrasonography. In group II, even long after total PTX, there was no clinical, radiological, histological or biochemical evidence for low turnover osteopathy. In conclusion, our data indicate that substitution with vitamin D-3 metabolites and calcium can prevent deleterious bone effects of hypoparathyroidism in hemodialysis patients and in patients with normal kidney function and may compensate for the missing PTH action. Over this, a better survival rate is expected as a consequence of the beneficial effect of total PTX on the progression of atherosclerotic lesions. We suggest reconsideration of total PTX without autotransplantation in dialysis patients with severe sHPT who are not eligible for renal transplantation.