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Surgical Management of Secondary Hyperparathyroidism in Chronic Kidney Disease—A Consensus Report of the European Society of Endocrine Surgeons

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Surgical Management of Secondary Hyperparathyroidism in Chronic Kidney Disease—A Consensus Report of the European Society of Endocrine Surgeons Langenbecks Arch Surg (2015) 400:907–927 DOI 10.1007/s00423-015-1344-5 REVIEW ARTICLE Surgical management of secondary hyperparathyroidism in chronic kidney disease—a consensus report of the European Society of Endocrine Surgeons Kerstin Lorenz1 & Detlef K. Bartsch2 & Juan J. Sancho3 & Sebastien Guigard4 & Frederic Triponez5 Received: 12 September 2015 /Accepted: 18 September 2015 /Published online: 2 October 2015 # Springer-Verlag Berlin Heidelberg 2015 Abstract Results Presently, literature reveals scant data, especially, Background Despite advances in the medical management of no prospective randomized studies to provide sufficient secondary hyperparathyroidism due to chronic renal failure levels of evidence to substantiate recommendations for and dialysis (renal hyperparathyroidism), parathyroid surgery surgery in renal hyperparathyroidism. Appropriate surgi- remains an important treatment option in the spectrum of the cal management of renal hyperparathyroidism involves disease. Patients with severe and complicated renal hyperpara- standard bilateral exploration with bilateral cervical thy- thyroidism (HPT), refractory or intolerant to medical therapy mectomy and a spectrum of four standardized types of and patients with specific requirements in prospect of or ex- parathyroid resection that reveal comparable outcome cluded from renal transplantation may require parathyroidec- results with regard to levels of evidence and recommen- tomy for renal hyperparathyroidism. dation. Specific patient requirements may favour one Methods Present standard and actual controversial issues re- over the other procedure according to individualized garding surgical treatment of patients with hyperparathyroid- demands. ism due to chronic renal failure were identified, and pertinent Conclusions Surgery for patients with renal hyperparathy- literature was searched and reviewed. Whenever applicable, roidism in the era of calcimimetics continues to play an im- evaluation of the level of evidence concerning diagnosis and portant role in selected patients and achieves efficient control management of renal hyperparathyroidism according to stan- of hyperparathyroidism. The overall success rate and long- dard criteria and recommendation grading were employed. term control of renal hyperparathyroidism and optimal han- Results were discussed at the 6th Workshop of the European dling of postoperative metabolic effects also depend on the Society of Endocrine Surgeons entitled Hyperparathyroidism timely indication, individually suitable type of parathyroid due to multiple gland disease: An evidence-based perspective. resection and specialized endocrine surgery. * Kerstin Lorenz 2 Department of Visceral, Thoracic and Vascular Surgery, Philipps [email protected] University Marburg, Baldingerstraße 1, Marburg 35043, Germany Detlef K. Bartsch [email protected] 3 Department of General Surgery, Endocrine Surgery Unit, Hospital del Mar, Universitat Autònoma de Barcelona, Passeig Marítim Juan J. Sancho 25-29, Barcelona 08003, Spain [email protected] Sebastien Guigard 4 Department of Thoracic and Endocrine Surgery, University Hospitals [email protected] of Geneva, Switzerland, Rue Gabrielle Perret-Gentil 4, 14, Frederic Triponez Geneva 1211, Switzerland [email protected] 1 Department of General-, Visceral-, and Vascular Surgery, 5 Chirurgie thoracique et endocrinienne, Hôpitaux Universitaires de Martin-Luther University of Halle-Wittenberg, Ernst-Grube-Str. 40, Genève, Rue Gabrielle Perret-Gentil 4, 14, Geneva 1211, Halle (Saale) 06120, Germany Switzerland 908 Langenbecks Arch Surg (2015) 400:907–927 Keywords Renal hyperparathyroidism . Tertiary By contrast, a North American renal data analysis identi- hyperparathyroidism . Parathyroidectomy . Thymectomy . fied 4435 renal HPT patients who underwent PTX in the years Cinacalcet . IOPTH 2007–2009, comparing medical data in the year before and after PTX, and showed that PTX was associated with 2 % postoperative 30-day mortality. Rehospitalization within Introduction 30 days was 29.3 %, and 39 % required intensive care. In the 12 months postoperatively, negative increases compared Considerate synchronous improvement of medical treatment to the year before PTX included higher hospitalization rate by and haemodialysis regimen in patients with chronic kidney 39 %, hospital days in 58 %, and 69 % intensive care admis- disease (CKD) resulted in decreasing severity of renal hyper- sions. Emergency room and observation visits were increased parathyroidism (HPT) requiring parathyroid surgery. Aware- 20-fold. Cause-specific hospitalizations for acute myocardial ness of the metabolic problems increased, and earlier medical infarction (HR 1.4; 95 % CI 1.60–2.46) and dysrhythmia (HR treatment may obviate parathyroid surgery in some patients 1.3; 95 % CI 1.16–1.78) were increased, while fracture risk developing renal HPT. Nevertheless, medical treatment does remained unaffected (HR 0.82; 95 % CI 0.6–1.1) [2]. The not achieve satisfactory adjustment of renal HPT and correlat- overall 2 % postoperative mortality rate after PTX was divided ed complications in all renal HPT patients. For these, parathy- into 0.9 % in-hospital, and 1.1 % within 30 days. Mortality in roid surgery represents a valuable option for an efficient de- the year following PTX was 9.8 %. Cause-specific analysis of finitive treatment or may bridge the time from overt renal HPT increased hospitalization after PTX identified cerebrovascular until renal transplantation may be performed. events (relative risk (RR) 1.83; 95 % CI 1.38–2.34), acute While parathyroidectomy (PTX) is a long-established and myocardial infarction (RR 1.98; 95 % CI 1.60–2.46), and accepted concept in the treatment for renal HPT, timing, extent dysrhythmia (RR 1.44; 95% CI 0.80–1.02). Cause-specific and the best type of surgery remain a constant matter of de- morbidity after PTX identified observation/emergency room bate. This debate is refreshed with the advent of innovative visits (RR 20.4; 95 % CI 16.8–24.9) and ambulatory treatment medical treatment utilizing calcium receptor antagonists, for hypocalcaemia treatment (RR 17.9; 95 % CI 11.8–24.5) calcimimetics (further referred to as cinacalcet). Very recent [2]. This alarmingly negative result of post-PTX course spe- nephrologists’ published data represent markedly the central cifically regarding mortality and hypocalcaemia raises several issues of debate and contradictory perspectives regarding op- questions and concerns. The main challenging questions are timal management of renal HPT and the potential benefit from whether patients in this data system were operated too late parathyroid surgery. In a longitudinal international cohort ob- and/or by surgeons and/or in institutions with insufficient ex- servation study of therapeutic approach and outcome among perience, respectively. Moreover, postsurgical follow-up renal HPT patients on haemodialysis, data were split into four proved to be insufficient and post-PTX metabolic adjustment phases from 1996 to 2011, and samples were analysed for was poorly managed. specific questions. Median parathyroid hormone (PTH) levels Both studies represent conflicting appraisal of the role PTX increased significantly from the start in 1996 to the actual should take in the management of renal HPT. Noteworthy, phase 5, from 153 pg/ml in Europe, Australia and New both publications do not include any cooperating surgeon in Zealand to 252 pg/ml (p trend <0.001), and likewise in North their data analyses and interpretation. Moreover, both studies America from 160 to 318 pg/ml (p trend<0.001) [1]. With the were supported by a pharmaceutical company manufacturing increasing use of intravenous vitamin D analogues and the most frequently administered drug cinacalcet, an allosteric cinacalcet in the treatment of renal HPT starting 2005, the rate calcium receptor modulator. of PTX declined significantly (p<0.001). Greater elevation of Against this background it appears appropriate to address PTH at 300–450 pg/ml was associated with increased all- the current issues of debate regarding management and treat- cause mortality (hazard ratio (HR)=1.09; 95 % CI 1.01– ment of renal HPT according to evidence from published data 1.18). PTH>600 pg/ml (HR 1.23; 95 % CI 1.12–1.34) and and recommendations from the endocrine surgeon perspective was also associated with increased cardiovascular and all- in a consensus conference approach. cause mortality and cardiovascular hospitalization. In a no- treatment study subgroup, very low PTH levels of <50 pg/ ml were associated with increased mortality (HR 1.25; 95 % Methods CI 1.04–1.51) [1]. While the association of significantly in- creased mortality and hospitalization support surgery as valu- A literature review was performed including publications in able treatment option to acquire immediate and durable ad- English language from recent years concerning medical and justment of PTH level when medication is unsuccessful, the surgical treatment of renal HPT identified by Pubmed search. similar association of morbidity with very low PTH levels Whenever applicable, effort was made to state the level of raises concerns regarding patients in the post-PTX follow-up. evidence in order to arrive at substantiated account of current Langenbecks Arch Surg (2015) 400:907–927 909 knowledge and open clinical questions. The grading level of Prevalent basic PTX rates and PTX incidence at follow-up/ incidence was adapted from the criteria according
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