Outcomes Of The Treatment Of Secondary Hyperparathyroidism

b. Surgical treatment outcome

The most reliable surgical treatment for SHPT is PTx, which is ultimately required if medical treatment is unsuccessful. After PTx, PTH improves dramatically. Postoperatively, as the hungry bone syndrome improves, hypocalcemia develops, and calcium preparations and vitamin D preparations are often required. After PTx, bone density improves as bone metabolism improves,

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Reports from the United States Renal Database System (USRDS) have shown that it reduces the risk of fractures [23, 24].

A report from Japan also found that when comparing the PTx group and non-PTx group in patients with advanced SHPT using propensity score match, the overall mortality rate and cardiovascular mortality rate were significantly lower in the PTx group. It has been shown that the risk of mortality due to cardiovascular events is reduced by 34% and 41%, respectively, compared to the non-PTx group [25]. Similarly, from USRDS data, the PTx group, non-PTx group

A group matching report also showed that PTx improved overall mortality [26]. In addition, it has been reported that PTx improves LVH, improves anemia, improves insomnia, improves cognitive function, reduces peripheral artery disease (PAD), and lowers blood pressure [27-31]. Furthermore, PTx is a treatment with good cost-effectiveness. Regarding the safety of PTx, the mortality rate within 30 days after PTx was reported to be 2.0-3.1% [26, 32].

c. Medical treatment vs. surgical treatment

In addition to conventional medical treatments, the emergence of calcimimetics such as cinacalcet, followed by evocalcet, and etelcalcetide has made it necessary to reposition PTx, which had been the mainstream treatment up until then. Although no literature directly compares the effectiveness of calcimimetics and PTx on overall mortality, there is a meta-analysis comparing medical treatment including calcimimetics and PTx. It has been shown that overall mortality rate and cardiovascular mortality rate are improved in the group receiving PTx compared to medical treatment [33, 34]. Furthermore, according to a systematic review that examined the improvement of QOL with cinacalcet and PTx in patients with SHPT, the 36-item Medical Outcomes Study Short-Form Health Survey (SF-36), PTx was found to be effective in improving physical component score and mental component score. On the other hand, cinacalcet showed no improvement in physical component score or mental component score, indicating that PTx was more effective in improving QOL [35]. Regarding cost-effectiveness, PTx is said to be superior to cinacalcet [36, 37].

Conclusion

Advances in medical treatment, including calcimimetics, have led to a change in the treatment of SHPT from surgical to medical treatment. The effectiveness of medical treatment has also been proven, and it is considered the first choice for treating SHPT. However, if medical treatment is ineffective or impossible, surgical treatment is recommended promptly. For future endocrine surgeons, PTx for SHPT has become a surgery that is rarely experienced. However, on the other hand, although the number of cases requiring PTx is small, it is thought that there will always be cases in the future, and therefore PTx is considered to be one of the surgical techniques essential to endocrine surgeons. I have been fortunate enough to have a lot of experience with PTx for SHPT.

Endocrine surgeons must establish surgical techniques, preoperative diagnosis, intraoperative diagnosis, follow-up, etc. for reliable PTx, and pass them on to the next generation.

Reference:

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PTx Study Group (PSSJ) Working Group

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