What Is the Role of Surgery in Secondary and Tertiary Hyperparathyroidism?

Abstract

Secondary hyperparathyroidism (sHPT) contributes significantly to renal osteodystrophy, cardiovascular morbidity, and mortality. Pharmacological management includes phosphate-lowering treatments for persistent overt hyperphosphatemia, calcitriol and vitamin D analogs for hypocalcemia, and less frequent calcimimetics. Refractory sHPT, unresponsive to pharmacological treatments, necessitates an individualized approach to parathyroidectomy (PTx). PTx in refractory sHPT should be considered when parathyroid hormone levels progressively rise or sHPT-related symptoms persist. Subtotal PTx or total PTx with auto-transplantation is preferred for patients eligible for kidney transplantation. For those not considered for kidney transplantation, total PTx is an option. Additional thymectomy, mainly when the lower parathyroid glands cannot be located, may be performed. Tertiary hyperparathyroidism (tHPT) frequently persists at two years of follow-up after kidney transplantation. THPT often involves multiple glands, adversely affecting bone metabolism, cardiovascular risk, and kidney allograft function, thus warranting PTx. Subtotal PTx remains the preferred surgical approach. When glandular autonomy is suspected, the timing of PTx ideally precedes kidney transplantation. If PTx is required post-kidney transplantation, most centers delay surgery until one year after transplantation to improve kidney allograft outcomes. The decision for PTx and its extent and timing must be carefully individualized, balancing the risks and benefits to maximize patient outcomes in both sHPT and tHPT.