Surgical treatment of secondary hyperparathyroidism in patients with chronic kidney disease stage 5D: pathomorphological rationale for the extent and technique of operations

Secondary hyperparathyroidism (SHPT) is a severe complication in patients with chronic kidney disease (CKD) stage 5D receiving maintenance hemodialysis. Concomitant thyroid pathology occurs in 83-86% of patients with SHPT, requiring a comprehensive surgical approach. The choice of technique and extent of surgical intervention remains controversial.

Objective. To improve the outcomes of surgical treatment of secondary hyperparathyroidism in patients with CKD stage 5D through pathomorphological justification of the extent and technique of surgical interventions, considering concomitant thyroid diseases.

Material and Methods. Treatment analysis of 130 patients with CKD stage 5D and SHPT (54 men, 76 women; ratio 1:1.41) was conducted. Patients were divided into 2 groups. Group 1 (n=74): parathyroidectomy (PTX) with revision of all possible locations of parathyroid glands (PG) combined with thyroidectomy. Group 2 (n=56): PTX without thyroid intervention, including subgroup 2a (n=47) – PTX with extensive revision, and subgroup 2b (n=9) – selective PTX via minimally invasive approaches. Laboratory tests (Ca, P, iPTH, thyroid hormones), instrumental diagnostics (ultrasound, scintigraphy with ⁹⁹ᵐTc-pertechnetate and ⁹⁹ᵐTc-sestamibi, CT), and pathomorphological examination of removed tissues were performed.

Results. Preoperative iPTH level was 2396.76 (1440.90; 2500.00) pg/ml, 10-20 times higher than target values. Ultrasound revealed thyroid nodules in 83.1% of patients. In Group 1, good results were achieved in 97.3% of patients, recurrence in 2.7% (ectopic PG). In Group 2a, good results were observed in 91.5%, in subgroup 2b – only in 44.4%, recurrences – in 55.6% (p<0.001). Pathomorphologically identified: PG adenomas – 16.5%, diffuse hyperplasia – 29.5%, diffuse-nodular hyperplasia – 51.6%. Diffuse-nodular hyperplasia develops in patients with dialysis duration of 10.44±4.00 years and is refractory to medical therapy. Thyroid pathology included: colloid goiter – 86.5%, toxic diffuse goiter – 2.7%, autoimmune thyroiditis – 15.6%, papillary cancer – 2.7%.

Conclusions. Comprehensive diagnostics using iPTH determination, ultrasound, scintigraphy, and intraoperative revision of all possible PG locations achieves target iPTH levels in 97.3% of patients when combined with thyroidectomy and in 91.5% with isolated PTX with extensive revision. Selective PTX via minimally invasive approaches results in recurrence in 55.6% of cases. Development of diffuse-nodular PG hyperplasia with dialysis duration of 6-14 years indicates the need for early surgical intervention upon appearance of clinical manifestations of SHPT. High frequency of concomitant thyroid pathology (83.1%) requires thorough preoperative diagnostics and readiness to perform thyroidectomy.

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