Kidney Week

Abstract: PUB095

An Unusual Case of Rapid Development of Tertiary Hyperparathyroidism in a Patient on Dialysis After Subtotal Parathyroidectomy

Session Information

• Publication Only

Category: Fluid, Electrolytes, and Acid-Base Disorders

• 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

• Le, Cindy, University of Massachusetts Chan Medical School, Worcester, Massachusetts, United States

Cindy Le, MD

• Chughtai, Ahmad, University of Massachusetts Chan Medical School, Worcester, Massachusetts, United States

Ahmad Chughtai, MD

• Apple, Benjamin J., University of Massachusetts Chan Medical School, Worcester, Massachusetts, United States

Benjamin J. Apple, MD

• Abramov, Konstantin, University of Massachusetts Chan Medical School, Worcester, Massachusetts, United States

Konstantin Abramov, MD

Introduction

It is known that CKD and ESRD can be complicated with secondary hyperparathyroidism (SHPT) that may be refractory to treatment warranting surgical intervention in order to prevent long term side effects of hyperparathyroidism. There have been rare instances where, despite parathyroidectomy, patients may continue to have recurrent SHPT which would warrant further work up. Here, we describe the case of a dialysis patient who previously had a subtotal parathyroidectomy for secondary hyperparathyroidism and subsequently rapidly developed tertiary hyperparathyroidism.

Case Description

The patient is a 60 year old male with past medical history of ESRD secondary to focal segmental glomerulosclerosis on HD, SPHT s/p subtotal parathyroidectomy (2021) complicated by hungry bone syndrome, pulmonary hypertension, malignant teratoma of his diaphragm s/p resection and cisplatin therapy, and gastric sleeve surgery (2015) with recurrent rapidly progressive SHPT after partial parathyroidectomy. There was an increase in PTH from 53 to 2500s in 8 months which then continued to uptrend.

Discussion

It is well understood that ESRD patients develop disturbances in the metabolism of calcium and phosphate, leading to secondary hyperparathyroidism and parathyroid gland hyperplasia. These metabolic disturbances impact multiple organs, including bone, skin, vasculature, brain, and blood. Patients with SHPT who undergo parathyroidectomy have improved quality of life compared to medical management, including higher physical function, decreased symptoms,and improved overall mental health. Although parathyroidectomy often improves the metabolic disturbances and associated quality of life of those with ESRD-related SHPT, there is a rare chance of recurrent secondary hyperparathyroidism. Known risk factors include initiation of HD three years prior to parathyroidectomy, elevated PTH levels over 106.5 pg/mL, and post-operative phosphorous levels over 5.9 mg/d. Recurrent SHPT can occur for various reasons including parathyromatosis, supernumerary parathyroid, or hyperplasia of remnant tissue. This case provides a rare instance of rapid development of hyperparathyroidism in the setting of subpartial thyroidectomy. This case highlights the role of work up with various imaging studies for recurrent SHPT and the role of repeat surgical intervention with rapid progression in elevated PTH levels.