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Asymmetric Parathyroid CKD Tertiary Transition — ESENeph MCQ

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HardHaemodialysisAsymmetric Parathyroid CKD Tertiary TransitionESENeph

A 60-year-old man with CKD G5D develops severe secondary hyperparathyroidism. His parathyroid imaging shows a single dominant gland measuring 2.5 cm with the other three glands appearing normal. What does a single enlarged gland suggest?

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Correct answer: B — A dominant (asymmetric) gland may represent monoclonal/adenomatous transformation (tertiary hyperparathyroidism developing within secondary disease) – focused parathyroidectomy of the dominant gland may be more appropriate than subtotal parathyroidectomy

While secondary hyperparathyroidism in CKD typically causes diffuse four-gland hyperplasia, some patients develop asymmetric/nodular transformation – one or more glands undergo monoclonal expansion (nodular hyperplasia) resembling an adenoma. This represents transition toward tertiary hyperparathyroidism. A single dominant gland with normal remaining glands on sestamibi/ultrasound may be amenable to focused (minimally invasive) parathyroidectomy rather than subtotal parathyroidectomy. Intraoperative PTH monitoring (>50% decline from baseline confirms adequate resection) guides the extent of surgery.

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