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Refractory Tertiary HPT Total Parathyroidectomy — ESENeph MCQ

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HardHaemodialysisRefractory Tertiary HPT Total ParathyroidectomyESENeph

A 55-year-old man with ESKD on haemodialysis develops a serum calcium of 3.2 mmol/L, phosphate 0.6 mmol/L, and PTH 185 pmol/L (>15x upper limit). He has a palpable left thyroid/parathyroid mass. ALP is 650 U/L. X-rays show severe subperiosteal resorption and a brown tumour of the mandible. Despite maximum cinacalcet (90 mg BD), calcium and PTH remain elevated. What is the definitive management?

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Correct answer: D — Total parathyroidectomy with autotransplantation

This patient has severe tertiary hyperparathyroidism (autonomous parathyroid function with hypercalcaemia) refractory to maximal medical therapy. The palpable mass, brown tumour, and extreme PTH elevation suggest a very large, potentially adenomatous parathyroid gland. Total parathyroidectomy with autotransplantation of a small fragment into the forearm muscle is the definitive treatment. Subtotal parathyroidectomy is an alternative. Autotransplantation allows some residual PTH production to prevent permanent hypoparathyroidism while enabling easy surgical access if hyperparathyroidism recurs. Post-operatively, severe hungry bone syndrome is expected (precipitous calcium drop), requiring intensive calcium and calcitriol supplementation.

Reference: https://guidelines.ukkidney.org