Total parathyroidectomy with autotransplantation in haemodialysed patients with secondary hyperparathyroidism--should it be abandoned?

The development of secondary hyperparathyroidism is almost universal in patients with end-stage renal disease. Medical management frequently fails and in such circumstances parathyroidectomy becomes a necessity. Total parathyroidectomy with autotransplantation of parathyroid tissue into the patient's forearm has been advocated as the surgical procedure of choice. In a previous publication we reported our experience with this technique in six haemodialysed patients. We now extend our follow-up to 19 patients over an observation period ranging from 6 to 66 months. Five of these patients required graft removal because of recurrent secondary hyperparathyroidism. Despite total graft removal, two patients had clinical and laboratory evidence of persistent hyperparathyroidism. Histology of the removed graft tissue demonstrated severe hyperplasia as well as invasion of adjacent muscle, adipose tissue, and vascular channels by parathyroid cells. This raises the possibility of local and distant metastatic spread of parathyroid tissue resulting in hyperparathyroidism. We suggest that parathyroid autotransplantation is potentially hazardous and should in fact be abandoned.