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Parathyroidectomy Refractory sHPTH — ESENeph MCQ

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ModerateHaemodialysisParathyroidectomy Refractory sHPTHESENeph

A 65-year-old man with CKD G5D on haemodialysis develops severe secondary hyperparathyroidism (PTH 250 pmol/L) refractory to maximum Cinacalcet and active vitamin D. His calcium is 2.8 mmol/L and phosphate 2.5 mmol/L despite maximal binder therapy. He has brown tumours on X-ray. What is the definitive surgical option?

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Correct answer: D — Subtotal parathyroidectomy or total parathyroidectomy with forearm autotransplantation

Refractory secondary hyperparathyroidism that fails medical management (calcimimetics, active vitamin D, phosphate control) requires parathyroidectomy. Options are subtotal parathyroidectomy (removing 3.5 of 4 glands, leaving a remnant) or total parathyroidectomy with autotransplantation of a small fragment into the forearm (allowing future monitoring and removal if recurrence occurs). Brown tumours (osteoclastomas from excessive PTH) typically regress after successful parathyroidectomy. Post-operative hungry bone syndrome requires intensive calcium and vitamin D replacement.

Reference: KDIGO 2017 – CKD-MBD; NICE – Hyperparathyroidism Pathway