ABSTRACT
Secondary hyperparathyroidism (SHPT) and tertiary hyperparathyroidism (THPT) is common in patients with end-stage renal disease (ESRD) on dialysis and after renal transplantation, respectively. The development of SHPT occurs early in chronic kidney disease (CKD) and progresses as renal function declines. CKD results in hyperphosphatemia, which drives hypocalcemia, high parathyroid hormone (PTH) levels and Vitamin D deficiency. Autonomous function from parathyroid nodule formation after chronic hyperparathyroidism results in THPT despite renal transplantation. Medical therapy with phosphate binders, vitamin D replacement and calcimimetics remain the mainstay of treatment, with surgery indicated for refractory or symptomatic HPT. Parathyroidectomy options include subtotal parathyroidectomy, total parathyroidectomy with or without auto transplantation. Hypocalcemia is the most common complication in up to 30% of patients developing hungry bone syndrome. A titrated calcium protocol is recommended to reduce complications of hypocalcemia. Recurrent SHPT or THPT is commonly attributed to supernumerary or ectopic parathyroid glands, and a fraction of patients may require reoperative surgery. There is a high incidence and prevalence of ESRD from diabetes in Asia, with a corresponding high burden of SHPT. While exact figures are poorly reported, there is limited access to dialysis and kidney transplantation in many of the developing nations. Medical treatment for SHPT is limited to calcium-containing phosphate binders and vitamin D replacements, as calcimimetics are expensive. Surgical treatment with parathyroidectomy is a cost-effective option for many patients, with generally low recurrence and improved survival.
