Department of Endocrine Surgery, Endocrine Surgery Unit, University of Sydney, Australia; Department of Surgery, University of Groningen, University Medical Centre Groningen, The Netherlands.
Department of Surgery, University of Groningen, University Medical Centre Groningen, The Netherlands.
Surgery. 2021 Feb;169(2):275-281. doi: 10.1016/j.surg.2020.08.014. Epub 2020 Oct 12.
The landscape of patients with end-stage renal disease is changing with the increasing availability of kidney transplantation. In the near future, a less aggressive approach to treat secondary hyperparathyroidism might be beneficial. We report outcomes of parathyroidectomy for end-stage renal disease-related hyperparathyroidism comparing the outcomes of limited, subtotal, and total parathyroidectomy.
We performed a retrospective analysis of prospectively collected data. Patients were divided into 3 parathyroidectomy subgroups: limited (<3 glands removed), subtotal (3-3.5 glands), and total (4 glands) parathyroidectomy. Primary outcome was serum levels of parathyroid hormone. Secondary endpoints were serum levels of calcium, phosphate, and alkaline phosphatase, postoperative complications, and persistent or recurrent disease rates.
In total, 195 patients were included for analysis of whom 13.8% underwent limited parathyroidectomy, 46.7% subtotal parathyroidectomy, and 39.5% total parathyroidectomy. Preoperative parathyroid hormone levels (pg/mL) were 471 (210-868), 1,087 (627-1,795), and 1,070 (475-1,632) for the limited, subtotal, and total parathyroidectomy groups, respectively (P < .001). A decrease in serum parathyroid hormone was seen in all groups; however, postoperative levels remained greater in the limited parathyroidectomy group compared to the subtotal and total parathyroidectomy groups (P < .001). Serum calcium, phosphate, and alkaline phosphatase levels decreased in all groups to within the reference range. In the limited parathyroidectomy group, persistent disease and recurrence occurred more frequently (P = .02 and P = .07, respectively).
Subtotal parathyroidectomy is the optimal strategy in an era with an increasing availability of kidney transplantation and improved regimens of dialysis. In this changing practice, the approach to parathyroid surgery, however, might shift to a less aggressive and patient-tailored approach.
随着肾移植的可用性不断增加，终末期肾病患者的情况正在发生变化。在不久的将来，采用不那么激进的方法来治疗继发性甲状旁腺功能亢进可能会有益。我们报告了比较局限性、次全性和全甲状旁腺切除术治疗终末期肾病相关甲状旁腺功能亢进的结果。
我们对前瞻性收集的数据进行了回顾性分析。患者被分为 3 个甲状旁腺切除术亚组：局限性（<3 个腺体切除）、次全性（3-3.5 个腺体）和全甲状旁腺切除术（4 个腺体）。主要结局是甲状旁腺激素的血清水平。次要终点是血清钙、磷和碱性磷酸酶水平、术后并发症和持续性或复发性疾病的发生率。
共纳入 195 例患者进行分析，其中 13.8%接受局限性甲状旁腺切除术，46.7%接受次全性甲状旁腺切除术，39.5%接受全甲状旁腺切除术。局限性、次全性和全甲状旁腺切除术组的术前甲状旁腺激素水平（pg/mL）分别为 471（210-868）、1087（627-1795）和 1070（475-1632）（P<0.001）。所有组的血清甲状旁腺激素均下降；然而，局限性甲状旁腺切除术组术后水平仍高于次全性和全甲状旁腺切除术组（P<0.001）。所有组的血清钙、磷和碱性磷酸酶水平均降至参考范围内。在局限性甲状旁腺切除术组中，持续性疾病和复发更为常见（P=0.02 和 P=0.07）。
在肾移植可用性不断增加和透析方案不断改进的时代，次全甲状旁腺切除术是最佳策略。在这种不断变化的实践中，甲状旁腺手术的方法可能会转向不那么激进和个体化的方法。
