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Parathyroidectomy for Secondary HPT — RACP Adult Medicine MCQ

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HardNephrologyParathyroidectomy for Secondary HPTRACP Adult Medicine

A 55-year-old man with chronic kidney disease stage 4 and secondary hyperparathyroidism has been on cinacalcet, phosphate binders, and vitamin D analogues for 2 years. His PTH remains >10× ULN (1,500 pg/mL) and he has progressive bone disease and ectopic calcification. What surgical intervention should be considered?

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Correct answer: B — Subtotal parathyroidectomy

Refractory secondary hyperparathyroidism (PTH persistently >800–1000 pg/mL despite maximal medical therapy, with symptomatic bone disease, progressive vascular/ectopic calcification, or calciphylaxis) is an indication for parathyroidectomy. Total parathyroidectomy with forearm autotransplantation (of a small portion of parathyroid tissue) is the preferred surgical approach, allowing future adjustment of parathyroid tissue if needed. Subtotal parathyroidectomy (leaving half a gland in situ) is an alternative. Post-operative hypocalcaemia ('hungry bone syndrome') requires careful management with IV calcium and calcitriol.

Reference: KHA-CARI – 2013 – CKD-MBD; KDIGO – 2017 – CKD-MBD Update