A 42-year-old man on haemodialysis for 12 years has tertiary hyperparathyroidism with PTH 1400 pg/mL, hypercalcaemia persisting despite cinacalcet and adjusted vitamin D analogues, intractable pruritus, and skin necrosis of the thighs consistent with calciphylaxis. What is the most appropriate surgical management?
- A Subtotal parathyroidectomy leaving 40 mg of tissue
- B Total parathyroidectomy with immediate autotransplantation of parathyroid tissue into the forearm ✓
- C Focused excision guided solely by sestamibi imaging
- D Total thyroidectomy with parathyroid preservation
Explanation
Refractory secondary or tertiary hyperparathyroidism in chronic kidney disease, with hypercalcaemia despite medical therapy, PTH persistently above roughly 800 pg/mL, intractable pruritus or calciphylaxis, warrants four-gland exploration. Total parathyroidectomy with autotransplantation of minced parathyroid tissue into forearm muscle is preferred because it allows easy access for resection if graft-dependent hyperparathyroidism recurs, while avoiding permanent hypoparathyroidism. Focused excision fails because all four glands are hyperplastic, and subtotal reoperation in the neck is hazardous.
Reference: Williams Textbook of Endocrinology, 14th ed.
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Written and medically reviewed by the StethoPrep medical team.