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Call
(630) 938-6161
to Schedule a Consultation

25 N Winfield Rd Ste 505
Winfield IL 60190-1295

Kidney Related Hyperparathyroidism

Parathyroidectomy

Prior to Surgery

Decision for surgery should always be made between the patient and their nephrologist prior to seeing a surgeon.

Ultrasound should be obtained to help localize the parathyroid glands and rule out any thyroid nodules that may be cancerous and require thyroid surgery at the same time, or possibly complicate surgery by their presence.

Sestamibi SPECT can be considered to rule out ectopic parathyroid gland (abnormal location), supernumerary glands (rare 5th parathyroid gland), and help with surgical planning in general.

  • 4D CT should be avoided given the large amount iodine contrast given which can compromise kidney function.

Identify and treat any pre-existing Vitamin D deficiency.

Start on prescription Calcitriol at least 2 days prior to surgery.

  • Results in less severe post-operative hypocalcemia (low blood calcium) which is at increased risk due to Hungry Bone Syndrome (bones being starved of calcium for many years).
  • Results in reduced length of stay in the hospital and need for IV calcium replacement following surgery.
Central Neck Dissection

Parathyroidectomy for Kidney Hyperparathyroidism

3 options, each with its own advantages / disadvantages:

3 and ½ parathyroid glands removed, with preservation of original blood supply to the remaining ½ gland.

  • Lowers severity and duration of temporary post-op hypocalcemia (low blood calcium) and lowers risk of permanent hypocalcemia.
    • Shorter hospital stays.
  • All 4 glands identified, gland with the most normal appearance and best-preserved blood supply selected.
    • Half of the selected gland is removed, and a metal clip is placed marking the remnant gland’s location in case of future surgery.
    • The remnant gland is assessed for preserved blood supply.
    • Only after preserved blood supply is ensured, the remaining 3 glands are removed.
  • Small risk that the remnant parathyroid gland can grow and cause recurrent hyperparathyroidism in the future requiring revision surgery.
  • Often performed with cervical thymectomy (removal of thymus tissue through the same incision – see below) to reduce risk for persistent or recurrent hyperparathyroidism.

Typically, the preferred surgery for both secondary and tertiary hyperparathyroidism.

All 4 parathyroid glands are removed without leaving a remnant (½ of a gland with its blood supply intact) or auto-transplantation of parathyroid tissue (see topic listed in the left column).

Eliminates risk for persistent or recurrent hyperparathyroidism.
Considered for patients on permanent dialysis, long-life expectancy, and low likelihood for a kidney transplant.

Should NOT be performed on patients with potential for kidney transplant.

Avoids permanent hypocalcemia by relying on the presence of supernumerary glands (rare occurrence of more than 4 parathyroid glands) and/or parathyroid rests (loose collection of parathyroid cells that retain function, most commonly located in the thymus).

  • Therefore, you DO NOT perform a cervical thymectomy with this surgery.

High risk for temporary and permanent hypocalcemia.

  • Usually longer stays in the hospital because of this.

All 4 parathyroid glands are identified and removed.

The most normal appearing gland is cut into very small pieces.

A pocket is made in a muscle or skin and the tiny pieces of parathyroid tissue are placed into the pocket (referred to as an auto-transplantation).

  • The tiny pieces of parathyroid gland get new blood supply in the pocket and regain function.
    • Location marked with a special metal clip or stitch.
  • Transplant site options:
    • Muscle in the non-dominant forearm.
      • If revision surgery is needed does not require general anesthesia in the operating room, can easily test for recurrence by measuring parathyroid hormone levels in in both arms and comparing values.
      • Requires a second incision site.
    • Sternocleidomastoid muscle in the neck.
      • Uses the same incision as the parathyroidectomy.
      • Would require general anesthesia in the operating for revision surgery, scar tissue from previous surgery.
    • Skin pocket made overlying the chest plate.
      • Requires second incision but within the same surgical field (as opposed to the forearm).
      • Less scar tissue and unlikely need for general anesthesia in the operating room for revision surgery.

Considered in patients with a functioning transplanted kidney, high desire to avoid future surgery, blood supply of all 4 parathyroid glands inadvertently compromised during surgery.

  • Without auto-transplantation the risk for permanent hypocalcemia would be very high.

Temporary hypocalcemia expected until transplanted parathyroid tissue recruits blood supply and recovers function.

  • Longer hospital stays likely.

Risk of auto-transplanted parathyroid tissue developing recurrent hyperparathyroidism requiring revision surgery in the future.

  • Requires wide removal of surrounding tissue which may cause some muscle morbidity, difficult to identify the auto-transplanted parathyroid tissue sometimes requiring multiple surgeries to fully remove.

Often performed with cervical thymectomy (removal of thymus tissue through the same incision – see below) to reduce risk for persistent or recurrent hyperparathyroidism.

Central Neck Dissection

Role for Cervical Thymectomy (removal of thymus tissue through the same incision)

Thymus gland is located high in the chest (mediastinum).

During embryology (development of a fetus), the thymus gland forms in the same location as the parathyroid glands high in the neck, and travel along the same path to their locations lower in the neck / mediastinum.

  • As a result, sometimes entire parathyroid glands (referred to as ectopic glands – in an unexpected location), or loose clusters (‘rests’) of functioning parathyroid cells can travel into the mediastinum with the thymus.
  • These ectopic parathyroid glands and rests of parathyroid cells will dysfunction in the same way as other parathyroid glands effected by kidney related hyperparathyroidism.
    • Up to 37% of patients have parathyroid cell rests in the thymus.
    • 5-30% of kidney related hyperparathyroidism patients have supernumerary (> 4) parathyroid glands and 12 – 40% of patients have ectopic glands.
      • Both are most commonly located in the thymus.
  • Therefore, there is high risk for persistent or recurrent hyperparathyroidism if the thymus is not also resected.

Should be performed during subtotal parathyroidectomy or total parathyroidectomy with auto-transplantation to reduce likelihood of persistent or recurrent hyperparathyroidism.

  • Slightly higher risk for temporary hypocalcemia.

Should NOT be performed in total parathyroidectomy without auto-transplantation.

  • Relies on ectopic parathyroid gland and functioning rests of parathyroid cells to prevent permanent hypocalcemia.

Choice of operation should be made after careful discussion between patient and surgeon, considering each individual patient’s circumstances and intra operative findings.

Surgical outcomes / cure rates are the highest and complication rates are the lowest when surgery is performed by a high-volume surgeon (> 50 parathyroidectomy surgeries per year).

To read more about the Parathyroidectomy surgery including what to expect, as well as details regarding recovery and risks see Parathyroidectomy.

Central Neck Dissection

Role of Intraoperative PTH Monitoring

Role in kidney related hyperparathyroidism is less clear compared to Primary Hyperparathyroidism (pHPT) (see Parathyroidectomy for pHPT).

Impaired clearance of PTH in the blood for patients with kidney failure effects the half-life of the hormone and therefore compromises the ability to apply traditional criteria to determine cure (drop of PTH levels > 50% of baseline, into the normal range, with a pattern of decline within 10-15 minutes of parathyroid removal).

  • Chronic or progressive kidney disease causing sHPT.
    • Variety of surgical approaches and varying definitions of cure lead to difficulty identifying consensus criteria / protocol.
    • Rates of recurrent and persistent disease were lower when intraoperative PTH monitoring is used to guide further exploration.
    • Suggested criteria include 60-80% decrease from baseline at 10–20 minutes following removal of the last the last parathyroid gland predicts post operative cure.
  • tHPT.
    • Patients who have undergone kidney transplant have improved kidney function and therefore theoretically more normal clearance of PTH.
    • There is more literature addressing this but still no definitive criteria / protocol.
    • Failure of post excision PTH levels to decline may indicate the presence of ectopic or supernumerary glands, or functional rests of parathyroid cells in the thymus.
    • Similarly, rates of recurrent and persistent hyperparathyroidism were lower when intraoperative PTH monitoring is used to guide further exploration.
    • Suggested criteria include > 50-80% decrease by 15–20 min following removal of the last parathyroid gland predicts post operative cure.
Central Neck Dissection

Postoperative Hypocalcemia

Extremely common and highly expected following parathyroidectomy for Kidney Related Hyperparathyroidism.

  • Hungry bone syndrome – following a period of prolonged elevated PTH levels and high activity of osteoclasts (causing breakdown of bone and release of calcium into the blood), with a sudden drop of PTH into more normal ranges there is unopposed osteoblast activity (building new bone and absorbing calcium from the blood stream).
    • The bones have essentially been starved of calcium for a long period but can now aggressively absorb calcium from the blood stream.
      • Risk for severe and prolonged hypocalcemia following surgery.
    • Signs of hypocalcemia include numbness and tingling in the lips and fingertips, as well as cramping in the hands and feet.
      • When severe, hypocalcemia can be life threatening causing heart arrythmias and seizures.
    • Calcium levels typically reach their lowest values 48 – 72 hours following surgery.
    • More common in patients with sHPT than tHPT.
  • Aggressively treat by starting calcitriol 2 days before surgery, immediately starting oral calcium following surgery, adding IV calcium as needed (occasionally requiring continuous infusion via a central line – large IV), continuing calcitriol following surgery, stopping calcimimetics (sensipar, cinacalet) immediately following surgery.
    • For patients on dialysis, high calcium bath can be used.
Thyroid Anatomy

Stay in the Hospital following Surgery

As opposed to parathyroidectomy for pHPT, all parathyroidectomy patients for Kidney Related Hyperparathyroidism are admitted afterwards.

4 – 10 days for sHPT and 2 – 3 days for tHPT.

  • May require admission to the ICU for continuous IV infusion and close monitoring of calcium levels.

Readmission rate to the hospital for hypocalcemia ranges from 4-17%.

Risks

The result of no residual functioning parathyroid tissue causing permanent hypocalcemia (low blood calcium).

  • Requiring daily oral calcium and calcitriol supplementation, sometimes up to 2-3 times per day.

Risk is as high as ~9%.

  • Limited data suggests this is lowest with subtotal parathyroidectomy.

Risk of recurrent laryngeal nerve injury (nerve controlling the movement of the vocal cord, helping to produce voice and assist in swallowing).

  • Similar to surgery for pHPT
    • 5-15% for temporary weak and hoarse voice.
    • 1-2% for permanently weak and hoarse voice.

1-2% risk for bleeding requiring surgery to control it.

  • Similar to surgery for pHPT.
  • Uncontrolled bleeding can cause life threatening difficulty breathing.

Postoperative surgical site infections are very low, ~ 1%.

  • For both the neck incision and if a separate incision is made for a distant auto-transplantation (e.g., in the forearm).
  • Similar to surgery for pHPT.

Persistent disease

  • Due to insufficient resection of parathyroid tissue (too large of remnant left during subtotal resection or missed supernumerary or ectopic gland)

Recurrent disease

  • Ongoing chronic kidney disease can cause further hyperplasia of the remnant parathyroid gland, auto transplanted parathyroid tissue, or rests of parathyroid cells in the thymus.

sHPT

  • Persistent – PTH levels never drop completely (< 200-300, no set definition) following surgery.
  • Recurrent – PTH levels initially drop adequately, but then start to rise again 6 months following surgery (> 200 -300, no set definition).

tHPT

  • Persistent – Elevated calcium levels with elevated or high normal PTH levels following surgery.
  • Recurrent – Calcium levels initially drop to normal, but then start to rise again 6 months following surgery.

Should be considered for persistent or recurrent HPT that cannot be controlled medically.

  • Pre-operative imaging important to rule out ectopic location.
    • If not performed previously, bilateral cervical thymectomies should be performed.
  • In cases of auto-transplantation, the autograft is the most common site of recurrence.
    • If in the forearm, blood draws in both arms can be used to confirm this.
    • Removal of the autograft (graftectomy) can be challenging due to growth into the surrounding tissues requiring aggressive resection of surrounding muscle and other soft tissues.
      • Can sometimes result in morbidity of the muscle, therefore when choosing a forearm auto-transplant site, opt for non-dominant arm.

To learn more about Parathyroid:

 

Return to the Parathyroid main page here.

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