Parathyroidectomy in Chronic Renal Failure Linda J. Cordell, MD, Salt Lake City, Utah J. Gary Maxwell, MD, Salt Lake City, Utah Glenn D. Warden, MD, Salt Lake City, Utah

of calcium metabolism is inevitable in chronic renal failure. Early recognition and management of the problem by the administration of vitamin D, calcium supplements, and phosphate binders are important. However, as patients are maintained on dialysis for longer periods, the number in whom medical therapy fails increases. The remaining options are renal transplantation, parathyroidectomy, or both. Renal transplantation is effective in treating hyperparathyroidism in 80 to 99 per cent of cases [l-3]. In noncandidates for transplantation, parathyroidectomy is a safe and reasonable alternative treatment of hyperparathyroidism. Disturbance

Material and Methods Over the 6 year period from January 1973 through December 1978,44 patients at the University of Utah Medical Center underwent parathyroidectomy for hyperparathyroidism secondary to chronic renal failure. Medical management had been unsuccessful in preventing the progression of the disease. There were 29 female and 15 male patients. Their mean age was 38.3 years with a range of 15 to 66 years. The origin of the renal disease in these patients was variable, ranging from chronic glomerulonephritis in 25 patients to drug-induced and polycystic kidney disease. Two patients had renal disease secondary to diabetes mellitus. In all patients, renal failure had been diagnosed more than 3 years earlier. All patients had been receiving chronic dialysis, one peritoneal dialysis and the remainder hemodialysis. Although 3 patients who required parathyroidectomy had been undergoing dialysis for less than 6 months, 29 patients had been treated longer than 2 years. One patient had had successful renal transplantation 3.5 years before parathyroidectomy. All patients receiving dialysis were dialyzed the day before surgery and the second day after surgery. Para-

From the Department of Surgery, University of Utah College of Medicine, Salt Lake City, Utah. Reprint requests should be addressed to Linda J. Cordell. MD, Department of Surgery, University of Utah College of Medicine, 50 N. Medical Drive, Salt Lake City, Utah 84132. Presented at the 31st Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 23-26, 1979.

Volume 136, December 1979

thyroidectomy was performed through a collar incision in the standard manner of exploration with the patient under general anesthesia. An attempt was made to identify and to verify by frozen section all parathyroid glands before excision. Eight patients had all glands removed with transplantation of a portion of one gland to either a forearm muscle or the sternocleidomastoid muscle. The remaining patients had approximately 30 mg of a viable gland left in place and identified by a clip, silk suture, or both. The specific variables evaluated retrospectively in this study were subjective symptoms, serum calcium, parathormone, and alkaline phosphatase levels, and radiologic findings. Results

Secondary hyperparathyroidism manifests itself in clinical, radiologic, and metabolic abnormalities (Table I). Presenting symptoms in all 44 patients were related primarily to musculoskeletal pain and weakness as well as to intractable itching. In addition, direct clinical manifestations of hypercalcemia such as pathologic fractures and metastatic calcifications presented problems. One patient had previously had renal stones, whereas another had documented peptic ulcer disease. The remaining complaints, although often present in chronically uremic patients, were related to altered calcium metabolism primarily because of the direct relation between the severity of the problems and the length and severity of the hyperparathyroidism. The radiologic changes seen in renal osteodystrophy range from diffuse demineralization and subperiosteal resorption of bone to osteomalacia, bone cysts, and pathologic fractures. Five patients had no bony changes. Twenty-three patients had the severe changes of diffuse demineralization, erosion, pathologic fractures, or all three. Eleven had minimal bone changes as manifested by subperiosteal resorption in the extremities. Twelve patients had soft tissue calcifications, and 4 had evidence of vascular calcification inappropriate for their age. Metabolic variables studied included serum calcium, alkaline phosphatase, and parathyroid hor-



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Clinical Manifestations of Hyperparathyroidism In Chronic Renal Failure Preoperative Clinical Manifestations

Clinical Bone pain Muscle pain and weakness Itching Pathologic fractures Soft tissue calcifications Gastrointestinal problems: ulcer disease, constipation, nausea, vomiting Mental changes Radiologic Severe Resorption, demineralization Soft tissue calcification Vascular calcification No chanaes Not indi&ed Metabolic Calcium >ll.O

Parathyroidectomy in chronic renal failure.

Parathyroidectomy in Chronic Renal Failure Linda J. Cordell, MD, Salt Lake City, Utah J. Gary Maxwell, MD, Salt Lake City, Utah Glenn D. Warden, MD, S...
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