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. 2024 Apr-Jun;46(2):e20230024.
doi: 10.1590/2175-8239-JBN-2023-0024en.

Parathyroidectomy: still the best choice for the management of severe secondary hyperparathyroidism

[Article in English, Portuguese]
Luiz Guilherme Fernandes Ramos  1 , Daniela Del Pilar Via Reque Cortes  2 , Luciene Machado Dos Reis  2 , Fabio Luiz de Menezes Montenegro  3 , Sérgio Samir Arap  3 , Marília D'Elboux Guimarães Brescia  3 , Melani Ribeiro Custódio  2 , Vanda Jorgetti  2 , Rosilene Motta Elias  1   2 , Rosa Maria Affonso Moysés  2
Affiliations

Parathyroidectomy: still the best choice for the management of severe secondary hyperparathyroidism

[Article in English, Portuguese]
Luiz Guilherme Fernandes Ramos et al. J Bras Nefrol. 2024 Apr-Jun.

Abstract
in English, Portuguese

Introduction: Management of secondary hyperparathyroidism (SHPT) is a challenging endeavor with several factors contruibuting to treatment failure. Calcimimetic therapy has revolutionized the management of SHPT, leading to changes in indications and appropriate timing of parathyroidectomy (PTX) around the world.

Methods: We compared response rates to clinical vs. surgical approaches to SHPT in patients on maintenance dialysis (CKD 5D) and in kidney transplant patients (Ktx). A retrospective analysis of the one-year follow-up findings was carried out. CKD 5D patients were divided into 3 groups according to treatment strategy: parathyroidectomy, clinical management without cinacalcet (named standard - STD) and with cinacalcet (STD + CIN). Ktx patients were divided into 3 groups: PTX, CIN (cinacalcet use), and observation (OBS).

Results: In CKD 5D we found a significant parathormone (PTH) decrease in all groups. Despite all groups had a higher PTH at baseline, we identified a more pronounced reduction in the PTX group. Regarding severe SHPT, the difference among groups was evidently wider: 31%, 14% and 80% of STD, STD + CIN, and PTX groups reached adequate PTH levels, respectively (p<0.0001). Concerning the Ktx population, although the difference was not so impressive, a higher rate of success in the PTX group was also observed.

Conclusion: PTX still seems to be the best treatment choice for SHPT, especially in patients with prolonged diseases in unresourceful scenarios.

Introdução:: O manejo do hiperparat-ireoidismo secundário (HPTS) é uma tarefa desafiadora com diversos fatores que contribuem para o fracasso do tratamento. A terapia calcimimética revolucionou o manejo do HPTS, levando a alterações nas indicações e no momento apropriado da paratireoidectomia (PTX) em todo o mundo.

Métodos:: Comparamos taxas de resposta às abordagens clínica vs. cirúrgica do HPTS em pacientes em diálise de manutenção (DRC 5D) e pacientes transplantados renais (TxR). Foi realizada uma análise retrospectiva dos achados de um ano de acompanhamento. Pacientes com DRC 5D foram divididos em 3 grupos de acordo com a estratégia de tratamento: paratireoidectomia, manejo clínico sem cinacalcete (denominado padrão - P) e com cinacalcete (P + CIN). Os pacientes com TxR foram divididos em 3 grupos: PTX, CIN (uso de cinacalcete) e observação (OBS).

Resultados:: Na DRC 5D, encontramos uma redução significativa do paratormônio (PTH) em todos os grupos. Apesar de todos os grupos apresentarem um PTH mais elevado no início do estudo, identificamos uma redução mais acentuada no grupo PTX. Com relação ao HPTS grave, a diferença entre os grupos foi evidentemente maior: 31%, 14% e 80% dos grupos P, P + CIN e PTX atingiram níveis adequados de PTH, respectivamente (p< 0,0001). Com relação à população TxR, embora a diferença não tenha sido tão impressionante, também foi observada uma taxa maior de sucesso no grupo PTX.

Conclusão:: A PTX ainda parece ser a melhor escolha de tratamento para o HPTS, especialmente em pacientes com doenças prolongadas em cenários sem recursos.

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Conflict of interest statement

Conflict of Interest Dr. Moysés has received lecture fees from Amgen and Accord laboratories. Drs. Moyses, Jorgetti, and Elias are supported by CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico), though this financial support played no role in the writing of this paper.

Figures

Figure 1.
Figure 1.. Flowchart of patient selection.
Figure 2.
Figure 2.. Parathyroid hormone (PTH) control according to the reference range for each group of patients. 2A. Percentage of patients with PTH ≤ or > 300 pg/mL from the standard (STD), standard plus cinacalcet (STD+CIN), and parathyroidectomy (PTX) groups, respectively represented by white, gray, and black bars. 2B. Percentage of patients with severe hyperparathyroidism with PTH ≤ or > 300 pg/mL from the standard (STD), standard plus cinacalcet (STD+CIN), and parathyroidectomy (PTX) groups, respectively indicated in white, gray, and black bars. 2C. Percentage of kidney transplanted patients with PTH/ionized calcium within the normal range (PTH ≤ 100 pg/mL and ionized calcium ≤ 5.3 mg/dl) and outside the normal range in observational (OBS), cinacalcet (CIN), and parathyroidectomy (PTX) groups, respectively represented by white, gray, and black bars.
See this image and copyright information in PMC

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