What are the chances of improvement in quality of life and functional status for a patient with End-Stage Renal Disease (ESRD), calciphylaxis, and fragility fractures undergoing parathyroid surgery for severe primary hyperparathyroidism?

From the Guidelines

Parathyroid surgery can significantly improve quality of life and functional status for patients with End-Stage Renal Disease (ESRD), calciphylaxis, and fragility fractures due to severe primary hyperparathyroidism, with moderate but variable benefits depending on individual factors. The most recent and highest quality study, a systematic review and meta-analysis from 2017 1, suggests that total parathyroidectomy (TPTX) is superior to total parathyroidectomy with autotransplantation (TPTX+AT) in reducing the recurrence of secondary hyperparathyroidism. However, the choice of surgical approach should be individualized, considering the patient's overall health status, age, and rehabilitation potential.

Key benefits of parathyroid surgery include:

• Reduction in calcium levels, potentially alleviating bone pain and improving muscle strength
• Decreased fracture risk, contributing to improved mobility
• Stabilization of calcium-phosphate metabolism, potentially slowing or halting the progression of calciphylaxis
• Improvement in mineral metabolism abnormalities, although dialysis-dependent patients may continue to experience these abnormalities even after surgery

Post-surgical care is crucial for optimal recovery, including:

• Physical therapy (3-5 sessions weekly for 2-3 months)
• Vitamin D supplementation (typically calcitriol 0.25-0.5 mcg daily)
• Calcium supplementation (500-1000 mg daily)
• Possibly cinacalcet (30-90 mg daily) if hypercalcemia persists

Improvement in mobility is likely to be gradual, with maximum benefits seen within 6-12 months post-surgery. The surgery addresses biochemical abnormalities, but functional recovery depends on the extent of pre-existing tissue damage and the patient's overall health status, age, and rehabilitation potential, as noted in the 2018 clinical practice guideline update 1.

From the Research

Improvement in Quality of Life and Functional Status

The chances of improvement in quality of life and functional status for a patient with End-Stage Renal Disease (ESRD), calciphylaxis, and fragility fractures undergoing parathyroid surgery for severe primary hyperparathyroidism can be assessed based on the available evidence.

• Parathyroidectomy has been shown to promote wound healing and prolong survival in patients with calciphylaxis from secondary hyperparathyroidism 2, 3.
• Surgical management of primary hyperparathyroidism has been associated with a reduction in fracture risk 4.
• Parathyroidectomy has been found to have a beneficial effect on bone health, with improved bone mineral density and reduced risk of fractures 5.

Survival and Mortality

The available evidence suggests that parathyroidectomy can improve survival in patients with ESRD and secondary hyperparathyroidism.

• A study found that patients who underwent parathyroidectomy had a significantly longer median survival than those who did not have surgery (36 vs 3 months, P = .021) 2.
• Another study found that patients who underwent parathyroidectomy had a longer median survival compared to those who did not have surgery (39 vs 3 months; P = .017) 3.
• A comparison of parathyroidectomy and cinacalcet for the treatment of secondary hyperparathyroidism in hemodialysis patients found that surgical patients had a better 5-year survival (65.6% vs 57.8%) and were less likely to die within the study period (HR 0.77,95% CI 0.7-0.85, P < 0.0001) 6.

Management of Fragility Fractures

The available evidence suggests that parathyroidectomy can reduce the risk of fragility fractures in patients with primary hyperparathyroidism.

• A study found that parathyroidectomy prevented 1 fracture for every 26 surgeries performed (weighted risk difference, 3.87%, 95% confidence interval, 0.96%-6.62%) and reduced the hazard of fracture by 22% (weighted hazard ratio, 0.78; 95% confidence interval, 0.64-0.95) 4.
• Another study found that parathyroidectomy had a long-term beneficial effect on the skeleton and was probably prudent to refer primary hyperparathyroidism patients for surgery in all cases where increased bone fragility was suspected 5.