Journal Review in Endocrine Surgery: AAES Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism - Part 1 of 2

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Jul 24, 2023

Guest

Barb Miller

Renowned endocrine surgeons Barb Miller, Sophie Dream, Jessica Liu McMullin, and Herb Chen discuss the guidelines for surgical management of secondary and tertiary renal hyperparathyroidism. They dive into the differences in evaluation and indications for surgery, preoperative planning, perioperative management, the importance of imaging in primary hyperparathyroidism, and distinctions between renal-mediated and primary hyperparathyroidism. A multidisciplinary approach and close monitoring of PTH levels in kidney transplant patients are emphasized.

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INSIGHT

Renal Hyperparathyroidism Is Distinct

Renal-mediated hyperparathyroidism (secondary/tertiary) differs fundamentally from primary hyperparathyroidism in pathophysiology and management.
The AAES guidelines specifically address these renal-based differences to guide surgeons and nephrologists.

INSIGHT

Biochemical Patterns Differ By Type

Primary hyperparathyroidism shows elevated calcium and PTH with normal vitamin D.
Secondary CKD-related hyperparathyroidism often has high PTH with normal/low calcium and low vitamin D, while tertiary becomes autonomous with hypercalcemia.

ADVICE

Check Meds And Ionized Calcium First

Review medications like calcimimetics that lower calcium and can mask hypercalcemia.
Check ionized calcium as serum calcium may be falsely low in CKD patients.

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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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