Long-term Outcomes Of Different Operative Strategies For Hyperparathyroidism In Chronic Kidney Disease-system Review And Meta Analysis

Chronic kidney disease is a worldwide public health problem. It is reported that the incidence of chronic kidney disease is as high as 200-400 cases per million per year. Renal hyperparathyroidism is a prevalent complication of chronic kidney disease. Conventional therapy interventions include modulation of calcium and phosphorous balance by dietary intake and dialysis, administration of active vitamin D compounds. Despite the initiation of new therapeutic agents and intensified dialysis, there are still patients develop severe hyperparathyroidism require parathyroidectomy. Before the calcimimetics era, parathyroidectomy was required in 2.5% of dialysis patients for year. About 15% of patients after 10 years and 38% of patients after 20 years of dialysis need parathyroidectomy. There are three different surgical procedures for choice:subtotal parathyroidectomy, total parathyroidectomy with autotransplantation, total parathyroidectomy without autotransplantation.Compared with subtotal parathyroidectomy, total parathyroidectomy with autotransplantation can reduce the difficulty of re-operation, but there are no substantial differences in the high recurrence rates(range 5-80%) of either procedure. Total parathyroidectomy without autotransplantation can reduce the recurrence rate, but it was considered to be associated with dreaded complications, such as adynamic bone disease or severe ongoing hypocalcemia. At present, which is the better surgical procedure is still controversial.To compare the different operative strategies for hyperparathyroidism in chronic kidney disease, two system reviews and meta analysis were conducted- total parathyroidectomy with autotransplantation versus subtotal parathyroidectomy, total parathyroidectomy versus total parathyroidectomy with autotransplantation.Part I Total parathyroidectomy with autoransplantation versus subtotal parathyroidectomyPurposeTo compare total parathyroidectomy with autotransplantation versus subtotal parathyroidectomy for hyperparathyroidism in chronic kidney disease with respect to long-term outcomes.MethodsA literature search was undertaken using Medline, EMBASE and CBM from inception to December 2013. Study quality was assessed using the Newcastle-Ottawa Scale. Data were analyzed using Review Manager version 5.1.0.ResultsA total of 13 studies comprising 1589 patients were identified. Compared with^ subtotal parathyroidectomy, patients in total parathyroidectomy with autotransplantation group had higher "requiring reoperation because of recurrence or persistence" (OR:2.68,95% CI 1.50-4.81, p-0.0009). There were no differnce in clinical success, radiological success, recurrence, recurrence or persistence, long-term Hypocalcemia.ConclusionsCompared with subtotal parathyroidectomy, total parathyroidectomy with autotransplantation is associated with higher "requiring reoperation because of recurrence or persistence". However, total parathyroidectomy with autotransplantation may reduce the difficulty of re-operation, and the absence of detail on the incidence of cardiovascular events or the mortality rate is disappointing, it is hard to say which operative strategy is better for hyperparathyroidism in chronic kidney disease.Part II Total parathyroidectomy versus total parathyroidectomy with autotransplantationPurposeTo compare total parathyroidectomy versus total parathyroidectomy with autotransplantation for hyperparathyroidism in chronic kidney disease with respect to long-term outcomes.MethodsA literature search was undertaken using Medline, EMBASE and CBM from inception to December 2013. Study quality was assessed using the Newcastle-Ottawa Scale. Data were analyzed using Review Manager version 5.1.0.ResultsA total of 7 cohort study studies comprising 771 patients were identified. Compared with total parathyroidectomy with autotransplantation, patients in total parathyroidectomy group had lower "recurrence" (OR:0.08,95%CI 0.03-0.21; P<0.00001), lower "recurrence or persistence" (OR:0.11,95%CI 0.05-0.25; P<0.00001), lower "requiring reoperation because of recurrence or persistence" (OR: 0.17,95%CI 0.06-0.54; P=0.002), higher "hypoparathyroidism" (OR:2.97,95%CI 1.09-8.08; P=0.03). None of the patients in these 7 studies were recorded severe hypocalcemia or adynamic bone disease.ConclusionsCompared with total parathyroidectomy with autotransplantation, total parathyroidectomy is associated with lower "requiring reoperation because of recurrence or persistence" and without severe hypocalcemia or adynamic bone disease. However, the absence of detail on the incidence of cardiovascular events or the mortality rate is disappointing.