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In the surgical treatment of secondary hyperparathyroidism (2HPT) of chronic kidney disease (CKD), a parathyroidectomy (PTx) of 4 glands can only be presumed as 'total', and indications for autoimplantation are complex. Intraoperative rapid parathyroid hormone assay could be useful to predict a radical resection. We evaluated iPTH levels 20 min and 24 h after a 4-gland PTx in 35 patients to determine the predictive value of intraoperative iPTH assay. We analysed retrospectively 35 patients affected by 2HPT of CKD, 13 undergoing total parathyroidectomy (TP) and 22 TP + autoimplantation (TPai), after removing 4 glands in 33 cases and 5 glands in 2. Intact PTH assays were acquired after 40 min before induction of anaesthesia, after removing both ipselateral glands, at 20 min after surgery and on postoperative day 1. 20 min after 4-gland PTx, a decrease of iPTH levels >80 % of the preoperative value was observed in 27 of 35 cases (77.1 %) and <80 % in 8 of 35 cases (22.8 %). In 6 of these 8 patients, iPTH levels were within the normal range 24 h after surgery. Although the intraoperative iPTH assays are of interest in the treatment of 2HPT, the predictive value of this method is not entirely satisfactory. In fact, a 4-gland PTx ensures euparathyroidism in most cases, even when intraoperative iPTH assays are not trustworthy; however, intraoperative iPTH assay, although not a perfect 'tool', is a proved aid for the surgeon in making his decision.

Background: Subtotal parathyroidectomy (SP) and total parathyroidectomy (TP) with autotransplantation (TPai) are the most commonly adopted operations for the treatment of secondary hyperparathyroidism (2HPT). TP without autotransplantation had previously been confined to patients with advanced dialytic vintage, not eligible for kidney transplantation. Over the years, the procedure has gained more widespread use, but there is no precise knowledge on the immediate and long-term effects., Methods: The authors analyzed the immediate and long-term results of TP without autotransplantation, that is after the systematic removal of at least four glands in 20 patients operated for 2HPT, which were compared with results from TPai in an equal number of cases., Results: An improvement of the typical clinical symptoms was found in every patient undergoing surgery, and a significant reduction in intact PTH (iPTH) serum levels was achieved. Immediate normalization of iPTH level was observed in 11/20 TP cases, hypoparathyroidism in 4/20 and persistent HPT in 5/20 cases. One year of follow-up showed a slight increase in hypoparathyroidism, with 1/20 (5%) recurrence of the disease. One-year TPai results showed a similar percentage of euparathyroidism, as well as a higher longterm recurrence rate (4/20, 20%), although values do not reach statistical significance., Conclusions: TP may still be considered the operation of choice in patients with aggressive forms of 2HPT or of advanced dialytic vintage, with no access to renal transplantation, because of its low recurrence rate (5%). Post-operative aparathyroidism is rare, while hypoparathyroidism and hypocalcemia can be well controled by medical treatment.

Aim: The authors analyze the short and long-term results of surgical treatment in 70 consecutive patients operated on from for secondary Hyperparathyroidism (2HPT) of chronic kidney disease (CKD)., Material of Study: Seventy patients affected by 2HPT of CKD, in hemodialytic treatment, were observed from January 1999 to January 2009. Twenty-seven patients were submitted to total parathyroidectomy (TP), 36 pts were submitted to total parathyroidectomy plus subcutaneous autoimplantation (TP ai), 7 pts were submitted to subtotal parathyroidectomy (SP)., Results: An improvement of the typical clinical symptoms was found in every patient undergoing surgery, and a significant reduction in intact parathyroid hormone (iPTH) serum levels was achieved TP determined a lower incidence of one year relapse. After TPai 9/36 pts successfully underwent renal transplantation., Discussion: To date surgical treatment of 2HPT is still controversial. SP and TPai are the most commonly adopted surgical interventions while TP had been previously been confined to patients with advanced dialytic vintage or for the treatment of recurrence, for the risks arising from aparathyroidism. TP allows a lower long-term relapse incidence and managing the resulting hypoparathyroidism appears straightforward with medical treatment., Conclusions: The Authors are in favour of early surgical intervention to prevent cardiovascular complications. TPai may be the operation of choice in patients eligible for kidney transplantation while TP carachterized by a lower incidence of long term relapse, is reserved to patients not eligible for transplantation and affected by a more "aggressive" forms of 2HPT.

To date surgical treatment of secondary hyperparathyroidism (HPTs) is still controversial. Subtotal parathyroidectomy with sparing of a part of not-nodular gland and total parathyroidectomy with autotransplantation (subcutaneous or muscular) represent the most common procedures with the aim to warrant a condition of euparathyroidism. Total parathyroidectomy (or so presumed) represent an unusual therapeutic option as the risks arising from aparathyroidism and from the need of a substitutive therapy are largely known. The authors evaluate the surgical results collected from 47 consecutive patients affected by HPTs and Chronic Renal Failure (CRF) and operated on between January 1999 and January 2006. Probably, a proper indication to the type of surgical procedure could be based on the severity of the disease, on the age of the patient and on the expectation of transplant. The significant incidence of recurrence and persistent disease is due to autoimplantation or residual gland hypertrophy after subtotal parathyroidectomy, to the presence of supernumerary or ectopic glands, to cervico-mediastinic hypertrophy of cellular foci. The identification and removal of supernumerary glands, which may cause persisting hyperparathyroidism, is mandatory.