More than 1,000 cases of total parathyroidectomy with forearm autograft for renal hyperparathyroidism

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Abstract

Between March 1981 and December 2000, we performed 1,053 total parathyroidectomies with forearm autograft for advanced renal hyperparathyroidism (HPT). Based on histopathologic and pathophysiologic investigations, surgical treatment should be considered when parathyroid glands show nodular hyperplasia. Measuring parathyroid volume by ultrasonography was useful to detect nodular glands and to determine surgical indications. The clinical effect of parathyroidectomy on the symptoms and biochemical variables was striking. Skeletal deformity, progressive bone loss, and vessel calcification leading to high mortality risk could not be alleviated by even successful surgery, however. To prevent cardiovascular complications, parathyroidectomy should be performed in the relatively early stage of renal HPT. Total parathyroidectomy with forearm autograft is a suitable procedure for renal HPT, especially in patients who require long-term hemodialysis. For surgeons, it is important to remove all parathyroid glands, including supernumerary glands, at the initial operation and to choose adequate parathyroid tissue for the autograft to prevent persistent and recurrent HPT. Although the risk of graft-dependent recurrent HPT is not negligible, enlarged transplanted parathyroid tissue can be removed easily and noninvasively from the forearm under local anesthesia. There is no risk of hypofunction of the autograft. © 2001 by the National Kidney Foundation, Inc.

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Patients

Between March 1981 and December 2000, 1,053 patients underwent initial total parathyroidectomy with forearm autograft for advanced renal HPT in our institutions. In 9 patients, parathyroidectomy was performed after successful renal transplantation, whereas all other patients were treated by hemodialysis or peritoneal dialysis. There were 467 women and 586 men. Mean ± SD age at parathyroidectomy was 50.4 ± 29.8 years (range, 19 to 87 years). Mean ± SD duration of hemodialysis before

Number of removed glands and weight

At the initial operation, more than four glands could be identified in 97.5% of all explorations. In 12.2% of patients, supernumerary glands were resected at the initial parathyroidectomy. Supernumerary glands were located most commonly in the thymic tongue (46.2%), and 66.7% of them were recognized microscopically by histopathologic examination.3 The mean ± SD of total glandular weight was 3,486.7 ± 2,267.3 mg, and glands weighing 200 to 500 mg were most common.

Clinical effect

Parathyroid surgery usually had

Discussion

Several issues were crucial in our decision regarding surgical indications for renal HPT. The first was the size of the parathyroid glands. Parathyroid hyperplasia induced by uremia may be divided into diffuse and nodular hyperplasia. The latter exhibits at least one well-circumscribed, encapsulated nodule, and each nodule usually consists of a single cell type with fat-free accumulation.7 It was confirmed that nodular hyperplastic parathyroid tissue had a higher growth potential than diffuse

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Copyright © 2001 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.