PubMed · 2683115
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M Sundaram. 1989. Renal osteodystrophy.. https://doi.org/10.1007/bf00368608
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Parathyroid excess may happen as a result of autonomous overactivity of the parathyroid glands (primary hyperparathyroidism). Secondary hyperparathyroidism is the consequence of chronic hypocalcemia, leading to parathyroid hyperplasia. Long-lasting secondary hyperparathyroidism may turn to autonomy in the sense of tertiary hyperparathyroidism. In primary hyperparathyroidism indications for surgical intervention are renal, intestinal or osseous organ manifestations, as well as relevant clinical symptoms of the so-called hypercalcemic syndrome. In truly asymptomatic primary hyperparathyroidism, observation is justified. However, the patients need regular supervision. If there is progression indicating health risk, the strategy must switch from observation to operation. Secondary hyperparathyroidism has must be treated by surgery if renal osteodystrophy progresses or tertiary hyperparathyroidism develops.
Nearly all patients with chronic renal failure exhibit some degree of secondary hyperparathyroidism (sHPT), defined as parathyroid hyperplasia and elevated serum parathyroid hormone (PTH) levels. Despite improvements in the medical management of patients with sHPT continue to develop progressive bone disease manifested by osteitis fibrosa cystica, soft tissue calcification and myopathy, pruritus, bone and joint pain and calciphylaxis may accompany the bone disorder. When medical therapy fails, parathyroidectomy becomes necessary. This is not sufficiently explained by the failure to administer calcitriol to control serum phosphate and calcium concentration or to deliver sufficient dialysis. The continuous increase of the proportion of patients exhibiting severe uncontrolled HPT with increasing time of dialysis points to a more basic underlying biological problem; an even higher proportion of patients shows also nodular, rather than diffuse hyperplasia. It was commonly believed that after restoration of normal renal function with successful transplantation, the hyperplastic parathyroid glands would involute and return to normal function state. After renal transplantation some patients continue to have a HPT. This disease entity is recognized and termed as tertiary Hyperparathyroidism (tHPT). After establishing a diagnosis of hyperparathyroid bone disease, in patients with sHPT and tHPT a parathyroidectomy (PTX) frequently becomes necessary to decrease the mass of the hyperplastic parathyroid tissue. The surgical procedure remains controversial. Some surgeons prefer subtotal PTX, others prefer total PTX with autotransplantation of a small amount of tissue to the arm, because the transplanted tissue can be removed in the event of a recurrent HPT. Successful surgical intervention for sHPT and tHPT significantly reduces preoperative symptoms and leeds to restoration of bone disease and therefore supports PTX for patients with s and tHPT. In our experience total PTX with autograft has proven to be a satisfactory procedure. Subtotal PTX is also an effective procedure and the choice of operative technique should be left to the surgeon.
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