Parathyroid interventions for secondary hyperparathyroidism in hemodialyzed patients.

Although parathyroidectomy (PTX) is the ultimate treatment for secondary hyperparathyroidism (SHPT) that is resistant to medical treatment, recent advances in ultrasonographic techniques have increased the treatment options in Japan. Percutaneous ethanol injection therapy (PEIT) of the parathyroid was approved under the national health insurance system in 2004, and there have been trials of direct injection of vitamin D (VD) preparations. We followed 30 patients for at least 1 year who had undergone PEIT at the same institution. The overall mean concentration of intact parathyroid hormone (PTH) fell from 865.3 +/- 388.4 pg/mL to 291.9 +/- 277.8 pg/ mL, or 34% of the pretreatment value. The effect was even more pronounced for one or two glands, with 68.4% reaching the target of intact PTH <= 300 pg/mL recommended in the K/DOQI guidelines, in comparison with 36.4% of cases of hypertrophy of three or four glands. The average time taken to achieve the target PTH concentration was 4 months. No correlation was found between the response to PEIT and the total parathyroid volume, or the volume of glands with suspected nodular hyperplasia. Cases in which PTH does not fall sufficiently after five or more injections should be considered refractory to PEIT and evaluated for PTX. Following PEIT, PTH falls relatively slowly, whereas after total PTX with forearm autograft the PTH concentration falls immediately and may still be less than 60 pg/mL 4 or 5 years later. Bone biopsies performed 1 year after total PTX with autograft showed a change from an osteitis fibrosa pattern to an adynamic bone disease pattern. In some cases of hypertrophy of three to four glands, markers of bone metabolism kept decreasing more than did PTH, corresponding to marked improvement in the patients' quality of life. Important considerations for treatment selection include: (i) ultrasonography of the cervical region as screening; (ii) earlier recognition of the limits of medical therapy; and (iii) the number of affected glands, the age of the patient, and the likely course postintervention.