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  • Title: Secondary hyperparathyroidism in chronic renal failure.
    Author: Malmaeus J.
    Journal: Scand J Urol Nephrol Suppl; 1983; 70():1-63. PubMed ID: 6351238.
    Abstract:
    The overall aim of this investigation was to study the function, anatomy and histopathology of the parathyroid glands, and different clinical aspects of parathyroid surgery, in relation to renal disease. The investigation was divided into six parts: The indications for parathyroidectomy and the clinical outcome after surgery in patients with secondary hyperparathyroidism (HPT) were analysed and a comparison was made regarding these aspects between subtotal parathyroidectomy (PTXsubtot) and total parathyroidectomy with autotransplantation to the forearm (PTXtrpl). The long-term function of autotransplanted parathyroid tissue was also assessed. The anatomy of the parathyroid glands and its implications for the strategy in parathyroid surgery were evaluated. A study was also made of the pathology of the parathyroids in patients with different stages of renal impairment. Furthermore, baseline biochemical and radiological data pertinent to the diagnosis of progressive secondary HPT and renal bone disease were obtained from a random sample of a population of uraemic patients and patients with kidney transplants, and analysed. It was found that both PTXsubtot and PTXtrpl are effective in reverting clinical symptoms and biochemical changes in secondary HPT. A recurrence is more easily managed, however, after PTXtrpl. It was also demonstrated that PTXtrpl constitutes a valuable method for restoring parathyroid function to normal as a long-term measure in patients with uraemia and secondary HPT. The anatomical study disclosed a high incidence of supernumerary glands. These glands were either located in the upper thymic horn or in the thyreo-thymic ligament or as rudimentary glands in the fat tissue surrounding the parathyroids. It is concluded that parathyroid surgery in patients with HPT secondary to uraemia should include a thymic resection and excision of fat tissue surrounding the parathyroids in order to avoid persistent or recurrent HPT. Histopathological signs of stimulation of the parathyroids were present even at subclinical levels of renal impairment, and increased in parallel with advancing renal disease. In patients with end-stage chronic renal disease all parathyroid glands were affected. Therefore, a radical operation, i.e. PTXsubtot or PTXtrpl should always be performed when uraemic patients with parathyroid disease are subjected to parathyroid surgery. Hypercalcaemia was the main indication for parathyroid surgery among our patients despite a low incidence of symptomatic renal bone disease. Since hypercalcaemia renders attempts at parathyroid suppression by pharmacological means impossible, and since the clinical outcome after parathyroid surgery was favourable in our series, early surgical intervention is recommended when secondary HPT cannot be controlled by conventional medical procedures.
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