A 58-year-old woman with end-stage renal disease on hemodialysis for 12 years presents with persistent hypercalcemia (serum calcium 11.2 mg/dL), markedly elevated PTH at 1280 pg/mL, and severe bone pain. Imaging shows all four parathyroid glands enlarged. Medical management with cinacalcet and phosphate binders has failed. What is the most appropriate surgical management?
- A Subtotal parathyroidectomy (3.5 gland removal)
- B Total parathyroidectomy with forearm autotransplantation ✓
- C Total parathyroidectomy without autotransplantation
- D Focused parathyroidectomy of the largest gland only
Explanation
This patient has tertiary hyperparathyroidism due to refractory secondary hyperparathyroidism in chronic kidney disease. When medical therapy fails, surgery is indicated. Total parathyroidectomy with forearm autotransplantation is the preferred procedure in this setting because it removes all hyperplastic tissue while leaving a small autograft in the forearm that can be easily accessed under local anesthesia if hyperplasia recurs. Subtotal parathyroidectomy carries a higher recurrence risk in dialysis patients. Total parathyroidectomy alone risks adynamic bone disease and persistent hypocalcemia. Focused surgery is inappropriate when all four glands are enlarged.
Reference: Schwartz's Principles of Surgery, 11th ed.
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Written and medically reviewed by the StethoPrep medical team.