Risk of acute coronary syndrome after parathyroidectomy in patients with end‐stage renal disease: A population‐based cohort study in Taiwan

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Cardiovascular (CV) disease is the most critical cause of mortality and morbidity in patients undergoing dialysis. The United States Renal Data System (USRDS) indicated that acute myocardial infarction (AMI) and congestive heart failure (CHF) have been recognized as the leading causes of death in elderly patients undergoing dialysis since 1999.1 In Taiwan, AMI has been the leading cause of hospitalization in patients with end‐stage renal disease (ESRD) since 2001.2 The incidence of acute coronary syndrome (ACS) in patients undergoing dialysis has been reported to be 1.78 per 100 person‐years in Taiwan and 10.2% within a 2.2‐year follow‐up in the United States, respectively.3 Compared to the general population, the survivals of the patients with advanced chronic kidney disease after AMI were much shorter, with a mean survival period of only 22 months.5 The risk factors for AMI and ACS in ESRD include the male sex, old age, smoking, physical inactivity, hypertension (HTN), diabetes mellitus (DM), hyperlipidaemia (HL), and anaemia.3 The mechanisms underlying incident ACS episodes included accelerated coronary calcification,6 platelet‐activation factors and thrombosis,7 and autonomic dysfunction.8
Secondary hyperparathyroidism (SHPT) is prevalent in patients undergoing dialysis. Several studies have reported a close relationship between SHPT and the increased risk of CV events, including AMI, stroke, and CV death.9 Only 22% of patients with severe SHPT who received medical therapy may achieve the ideal serum parathyroid hormone (PTH) level.11 In a multi‐centre randomized controlled trial, the investigators concluded, in dialysis patients with moderate to severe SHPT, treatment with calcimimetic failed to reduce the risk of CV events or death.12 Parathyroidectomy (PTX) is the main treatment for severe SHPT refractory to medical treatment. Conzo et al. reported that PTX may effectively reduce the PTH level and maintain appropriate levels up to 5 years.13 Previous studies have reported a reduced risk of major CV events, including stroke, AMI, peripheral arterial disease and mortality in patients with SHPT who underwent PTX.14
In spite of the aforementioned sporadic clinical observations favouring PTX in dialysis patients, large scaled studies investigating the changes in the risk of ACS in dialysis patients who underwent PTX are scant. The objective of the present study was to investigate the risk of incident ACS in these patients in a nationally representative cohort. We hypothesized that dialysis‐dependent ESRD patients with severe SHPT who have undergone PTX have a reduced risk of ACS.

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