Outcome of parathyroidectomy for patients with renal disease and hyperparathyroidism: predictors for recurrent hyperparathyroidism

Background: A small group of patients with renal disease-related secondary or tertiary hyperparathyroidism require surgical parathyroidectomy. Among them, 5-20% require further re-exploration and excision of parathyroid tissue because of recurrent disease. The aims of the present study were to review the characteristics and outcomes of patients undergoing parathyroidectomy for renal disease related hyperparathyroidism and to identify the risk factors for recurrent hyperparathyroidism. Methods: Review of data from a dedicated head and neck database at Royal Prince Alfred Hospital between 1988 and 2004. Results: There were 115 patients of whom 68 (59%) patients were treated with subtotal parathyroidectomy (STP), 43 (37%) were treated with total parathyroidectomy (TP) and 4 (3%) were treated with TP with autotransplant. Of those, 11 (9.6%) patients developed recurrent hyperparathyroidism (9 had STP, 1 had TP and 1 had TP with autotransplant). On re-exploration, persistent hyperplastic parathyroid tissue was located at the site of partially excised parathyroid gland (64%), autotransplanted parathyroid tissue (9%), anterior mediastinum (18%) and intrathyroidal parathyroid (9%). Predictors for recurrent hyperparathyroidism are STP (P = 0.049), preoperative symptom of calciphylaxis or calcinosis (P = 0.024), elevated preoperative calcium level (P = 0.007) and elevated post-operative PTH levels (P = 0.014). Post-operative PTH levels less than 10 pmol/L has a positive predictive value of 97.5% for cure (P = 0.02). Conclusion: More aggressive surgical approach could be indicated in patients with preoperative hypercalcaemia and calcinosis/calciphylaxis. Post-operative PTH can be utilized as a marker for cure after parathyroidectomy in hyperparathyroidism of renal disease.