From July 2013 to December 2018, 201 patients with SHPT and ESRD were prospectively enrolled in the study. All patients were enrolled in a dialysis protocol at admission.
Patient history and demographic data are listed in Table 1. The male/female ratio was almost 2:1. The median patient age at dialysis was 78 months. Except for ESRD, which was significant, the most common causes of SHPT were hypertension, coronary heart disease, anemia, diabetes and chronic viral hepatitis. Three patients received a kidney transplant, but all were placed back on dialysis years later.
Table 1
Preoperative patient characteristics
Variables
|
No. of pts.
|
Percentage %
|
Mean ± SD
|
Sex (male/female)
|
134/67
|
|
|
Age (years)
|
|
|
46 ± 12
|
Duration of dialysis (months)
|
|
|
78 ± 34
|
Diabetes
|
13
|
6.5
|
|
Hypertension
|
178
|
88.8
|
|
Stroke history
|
50
|
25.2
|
|
Drinking history
|
48
|
24.3
|
|
Renal transplant history
|
4
|
2.0
|
|
The most common indication for PTX was failure to control PTH levels; 197 patients (98.0%) had a preoperative PTH level > 800 pg/ml. The median preoperative value of PTH was 2033 pg/ml. The preoperative blood calcium level was 3.62 mmol/L (Table 2). All patients underwent total PTX with autotransplantation.
Table 2
Laboratory data before and after surgery
Variables
|
Preoperative
|
Postoperative
|
6 months
|
Calcium (mg/dl)
|
3.62
|
1.84
|
1.99
|
Phosphorus (mg/dl)
|
2.30
|
1.60
|
1.43
|
PTH (pg/ml) (months)
|
2033.6
|
62.5
|
149.68
|
However, in only 186 (92.5%) patients, the PTH levels decreased to normal 7 days postoperatively. Thirteen patients still had PTH levels > 200 pg/ml. Five patients underwent reoperation months later, and PTH levels finally decreased to normal. The rest of the patients are currently under observation.
In 162 (80.60%) patients, 4 glands were found, and 3 glands were found in 21 (10.45%) patients. Four of the patients underwent reoperation, and the left gland was found. In 11 (5.47%) patients, 5 glands were found. There was only 1 patient who had 6 glands. However, 2 glands were found in 2 (0.9%) patients, and 1 gland was found in 5 (2.49%) patients, whose PTH levels decreased to normal after the operation (Fig. 1).
The anatomic locations of the parathyroid glands also varied. Glands were found in the thoracic cavity in 4 (2.3%) patients, the thyroid gland in 4 (2.3%) patients, the posterior esophagus in 3 (1.72%) patients and the carotid sheath in 1 (0.57%) patient (Fig. 2).
As expected, the PTH levels decreased significantly after surgery to a median of 62.5 pg/ml, with 186 patients having PTH levels within normal limits 7 days postoperatively and 191 patients 6 months postoperatively (Table 2). All patients required calcium supplementation after surgery, and normalization occurred in 2 to 7 days. Three patients received emergency dialysis because of hyperkalemia. There were no other postoperative complications reported, such as bleeding or recurrent laryngeal nerve injury.
The responses to the SF-36 health survey are shown in Table 3. The surveys completed prior to surgery showed that SHPT patients had lower scores than the general population in all 8 individual and 2 component summary scales, with a more significant decrease in the physical health scales. Six months after surgery, patients improved significantly on 8 scales: PF, RP, BP, GH, VT, PCS, MH, MCS (p < 0.001), and SF (p = 0.002). RE was also improved, but not significant (p = 0.087).
Table 3
SF-36 health survey results
SF-36 scale
|
Preoperative
|
Postoperative 6 months
|
p
|
Physical functioning (PF)
|
48.57 ± 15.06
|
76.55 ± 17.43
|
< 0.001
|
Role physical (RP)
|
53.24 ± 30.44
|
84.74 ± 18.20
|
< 0.001
|
Pain (BP)
|
41.31 ± 20.21
|
74.50 ± 17.95
|
< 0.001
|
General health (GH)
|
11.10 ± 5.70
|
17.46 ± 6.42
|
< 0.001
|
Role emotional (RE)
|
51.23 ± 4.80
|
52.40 ± 3.49
|
.087
|
Social functioning (SF)
|
48.86 ± 7.36
|
54.38 ± 13.71
|
.002
|
Vitality (VT)
|
29.43 ± 24.76
|
84.84 ± 18.37
|
< 0.001
|
Emotional well-being (MH)
|
49.71 ± 4.17
|
64.00 ± 10.84
|
< 0.001
|
Physical component
summary (PCS)
|
38.56 ± 25.80
|
63.32 ± 31.06
|
< 0.001
|
Mental component
summary (MCS)
|
46.19 ± 17.47
|
62.53 ± 17.26
|
< 0.001
|
Significant progress at the 6-month follow-up was obtained on the following SF-36 scales: pain, role-physical, and physical functioning. The most commonly reported symptoms preoperatively were joint pain, bone pain, pruritus, weakness, and difficulty standing, which were all significantly decreased 7 days postoperatively, and the decrease continued 6 months postoperatively.