Total parathyroidectomy with autotransplantation versus subtotal parathyroidectomy for renal hyperparathyroidism: A systematic review and meta‐analysis

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Secondary hyperparathyroidism (SHPT), a prevalent disorder associated with chronic kidney disease (CKD), contributes to an increased morbidity and mortality in haemodialysis patients.1 There are several options of treatments depending on the CKD stage and type of biochemical abnormalities. Conventional therapy interventions involve dietary phosphate restriction and phosphate binders, administration of active D compounds and calcimimetics.2 Most patients with mild‐to‐moderate SHPT can be managed by those medical modalities. However, when severe SHPT was present, only 22% of patients were reported to achieve levels of PTH < 31.8pmol/L (300 pg/mL), the upper limit of the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) target range for PTH, with medical therapy .3 Some patients cannot use these drugs for the high cost or drug‐related nausea and vomiting.4 Some drugs are even not readily available in some countries or regions. In such cases, parathyroidectomy (PTX), which can drastically improve biochemical parameters and reduce the risk for all‐cause and cardiovascular mortality in CKD patient with SHPT, should be considered.5
Most of the practical guidelines recommended PTX to patients with end‐stage renal disease and severe SHPT who failed to respond to pharmacological therapy.6 However, there has been an ongoing discussion on the optimal surgical procedures: SPTX, TPTX or TPTX + AT.8 TPTX removes all identifiable parathyroid tissue, which was considered to be associated with dreaded complications, such as severe hypocalcaemia or adynamic bone disease. SPTX and TPTX + AT leaves enough residual parathyroid tissue to support mineral homeostasis. Compared with SPTX, TPTX + AT, not requiring general anaesthesia and cervical re‐exploration, was reported with relative ease and safety. However, no substantial difference has been reported in the recurrence rates (range 5–80%) between the two procedures. While some authors are convinced that TPTX + AT is the superior form of treatment, others still insist on SPTX.11Heretofore, some epidemiological prospective studies with small sample size have been performed to compare the efficacy between the two different surgical procedures. This meta‐analysis was thus conducted based on the published literatures to evaluate and compare the two surgeries (TPTX + AT vs SPTX) on long‐term outcomes.

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