Intervention for recurrent secondary hyperparathyroidism from a residual parathyroid gland

Abstract

There is a significant recurrence rate of secondary (renal) hyperparathyroidism after total parathyroidectomy (PTx) with forearm autograft. The lesions responsible for recurrent hyperparathyroidism are mainly the parathyroid autografts, but in some cases there are previously undetected residual or ectopic parathyroid glands. In Kojinkai hospitals, 155 haemodialysis outpatients had total PTx and forearm autograft for severe renal hyperparathyroidism and, during the past 18 years, 40 of them developed recurrent or persistent renal hyperparathyroidism. Five patients were treated by percutaneous ethanol injection therapy (PEIT): four patients had residual parathyroid glands and one patient had an ectopic parathyroid gland. The results of PEIT depended on the functioning of the parathyroid autografts. In two patients with non-functioning autografts, the effect of PEIT was remarkable; both showed 'hungry bone' syndrome and became hypoparathyroid. In the three patients with functioning autografts, the clinical course after PEIT was mild, but resection of the autograft was required in one patient. When an echo-guided approach is possible, PEIT for residual parathyroid glands is an effective intervention for the management of recurrent renal hyperparathyroidism; however, there is a risk of hypoparathyroidism in patients with non-functioning parathyroid autografts. As parathyroid autografts consist of multiple nodules, echo-guided injection of ethanol or calcitriol to each nodule is almost impossible and therefore resection of the autograft is indicated for autograft-dependent recurrent renal hyperparathyroidism.