Surgical treatment of the parathyroid gland in patients with end-stage renal disease.

During the period from December 1984 to December 1986, ten patients with end-stage renal disease were evaluated with hyperparathyroidism refractory to medical management. Symptoms were bone pain in eight patients and pruritus and constipation in two. Two patients with bone pain also had impaired mentation. Biochemical preoperative assessment revealed calcium levels between 8.7 and 11.2 milligrams per deciliter, with a median of 10.5 milligrams per deciliter. Phosphate levels were normal in all but three patients, and the phosphate-calcium product was greater than 80 in two. Parathyroid hormone levels assessed with the radioimmunoassay method were elevated in all patients, and results of ultrasound of the neck, done in seven patients, revealed hyperplastic glands in six patients and normal glands in one patient. All patients underwent surgical exploration of the neck with removal of four parathyroid glands and immediate autotransplantation. No complications related to the operative procedure occurred. Postoperative calcium levels ranged between 6.5 and 9.5 milligrams per deciliter on the first postoperative day and normalized by the sixth day. Four patients experienced symptomatic hypocalcemia requiring intravenous calcium supplementation for one to six days postoperatively. The mean hospital stay was four days (three to seven days). All patients had histologically confirmed four gland parathyroid hyperplasia. Marked improvement of symptoms was accomplished in all patients after a period of three to 30 days. One patient required revision of the forearm parathyroid transplant after four months. One patient required calcium supplementation taken orally, two patients required 1,25-Dihydroxyvitamin D3 and five required treatment with both. Two patients did not require any further medical treatment, and no patient had recurrent symptoms after a mean follow-up period of eight months. We recommend total parathyroidectomy with autotransplantation in patients with end-stage renal disease as a safe and effective procedure for symptomatic refractory hyperparathyroidism. Symptom relief can be accomplished in the vast majority of patients.