Journal Review in Endocrine Surgery: AAES Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism - Part 2 of 2

Jul 27, 2023

Controversies and complexities of evaluating and managing patients with secondary and tertiary hyperparathyroidism. Surgical options, preserving blood supply, monitoring PTH levels, recurrence risks, auto transplantation, postoperative care, and management of calcium levels discussed.

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ADVICE

Plan Four-Gland Exploration And Remnant Size

Do perform a four-gland exploration for secondary hyperparathyroidism and choose subtotal versus total with autotransplant based on gland morphology and patient factors.
Leave a larger remnant (around 15–16 mg) in dialysis patients to target PTH ~200–300 pg/mL rather than a 'normal' gland size.

INSIGHT

No One-Size Operation Wins Universally

Trials show no clear superiority of subtotal versus total with autotransplant for recurrence, but totals can increase immediate morbidity like longer OR time and hungry bone symptoms.
Let surgeon judgment and patient context guide the choice rather than a one-size-fits-all rule.

ADVICE

Use Selective Thymectomy

Consider routine thymectomy to reduce recurrence from ectopic thymic glands, but tailor it if remnant blood supply or pre-op imaging argues against it.
Avoid routine thymectomy when doing total parathyroidectomy without autotransplant to reduce permanent hypoparathyroidism risk.

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In this two-part series, we come to you LIVE! from the 2023 Annual meeting of the American Association of Endocrine Surgeons in Birmingham, Alabama. If you think evaluating and managing patients with primary hyperparathyroidism is difficult, patients with secondary and tertiary hyperparathyroidism can be even more difficult to evaluate and manage. Join Drs. Barb Miller, Sophie Dream, Jessica Liu McMullin, and Herb Chen as they break down the controversies and complexities associated with evaluation and management of these patients and discuss the recently published AAES guidelines on the definitive surgical management of patients with secondary and tertiary renal hyperparathyroidism. Part 1 focuses on the impetus for creation of these guidelines, the differences in evaluation and indication for surgery when seeing patients with renally mediated hyperparathyroidism, and preoperative planning. Part 2 focuses on intraoperative and postoperative management, parathyroid autotransplantation, and renal transplant recipients.

Hosts:
- Barbra S. Miller, MD (Moderator), Clinical Professor of Surgery, The Ohio State University, @OSUEndosurgBSM
- Sophie Dream, MD, Assistant Professor of Surgery, Medical College of Wisconsin, @SDreamMD,
- Jessica Liu McMullin, MD, Endocrine Surgery Fellow, University of Alabama – Birmingham, @jess_mcmullin
- Herbert Chen, MD, Professor and Chair of Surgery, University of Alabama – Birmingham, @herbchen

Learning objectives:
- Understand the epidemiology and pathogenesis of kidney-related parathyroid disease and how these entities differ from primary hyperparathyroidism
- Describe the diagnosis of kidney-related hyperparathyroidism and its different presentations
- Define the indications for surgical intervention
- Recognize the different approaches and extents of surgery for treating the different types of renally mediated hyperparathyroidism including thymectomy and parathyroid autotransplantation
- Detail methods for safe and effective perioperative management

References:
- Dream S, Kuo LE, Kuo JH, Sprague SM, Nwariaku FE, Wolf M, Olson JA Jr, Moe SM, Lindeman B, Chen H. The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism. Ann Surg. 2022 Sep 1;276(3):e141-e176. doi: 10.1097/SLA.0000000000005522. Epub 2022 Jul 18. PMID: 35848728.
- Wilhelm SM, Wang TS, Ruan DT, et al. The American Association of Endocrine Surgeons Guidelines for definitive management of primary hyperparathyroidism. JAMA Surg. 2016;151:959–968.
- Ketteler M, Block GA, Evenepoel P, et al. Executive summary of the 2017 KDIGO Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) Guideline Update: what’s changed and why it matters. Kidney Int. 2017;92:26–36.
- Andress DL, Coyne DW, Kalantar-Zadeh K, et al. Management of secondary hyperparathyroidism in stages 3 and 4 chronic kidney disease. Endocr Pract. 2008;14:18–27.
- Cozzolino M, Brancaccio D, Gallieni M, et al. Pathogenesis of parathyroid hyperplasia in renal failure. J Nephrol. 2005;18:5–8.
- Lau WL, Cobi Y, Kalantar-Zadeh K. Parathyroidectomy in the management of secondary hyperparathyroidism. Clin J Am Soc Nephrol. 2018;13:952–961.
- Parfrey PS, Chertow GM, Block GA, et al. The clinical course of treated hyperparathyroidism among patients receiving hemodialysis and the effect of cinacalcet: the EVOLVE trial. J Clin Endocrinol Metab. 2013;98:4834–4844.
- Costa-Hong V, Jorgetti V, Gowdak LH, et al. Parathyroidectomy reduces cardiovascular events and mortality in renal hyperparathyroidism. Surgery. 2007;142:699–703.
- McManus C, Oh A, Lee JA, et al. Timing of parathyroidectomy for tertiary hyperparathyroidism with end-stage renal disease: a cost-effectiveness analysis. Surgery. 2021;169:94–101.
- Finnerty BM, Chan TW, Jones G, et al. Parathyroidectomy versus cinacalcet in the management of tertiary hyperparathyroidism: surgery improves renal transplant allograft survival. Surgery. 2019;165:129–134.

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