Research Article| Volume 165, ISSUE 1, P142-150, January 2019

Total versus subtotal parathyroidectomy for secondary hyperparathyroidism

Published:November 06, 2018DOI:


      It remains unclear whether total or subtotal parathyroidectomy for secondary hyperparathyroidism yields the best outcomes. We investigated mortality, cardiovascular events, hip fracture, and recurrent parathyroidectomy after total versus subtotal parathyroidectomy in patients on renal replacement therapy.


      Using the Swedish Renal Registry, the surgical registry for thyroid and parathyroid surgery, and the National Inpatient Registry, we identified patients who underwent parathyroidectomy between 1991 and 2013. We calculated the risk of outcome after total versus subtotal parathyroidectomy using COX's regression, adjusting for age, sex, cause of renal disease, time with a functioning graft before and after parathyroidectomy, Charlson comorbidity index, year of surgery, prevalent cardiovascular disease, time on dialysis, renal transplantation at parathyroidectomy, and treatment with calcimimetics before parathyroidectomy.


      There were 824 patients who underwent parathyroidectomy, 388 total and 436 subtotal. There was no difference in mortality or risk of incident hip fracture between groups. Comparing the subtotal with the total parathyroidectomy, the adjusted hazard ratio (95% confidence interval) for cardiovascular events was 0.43 (0.25–0.72) and for recurrent parathyroidectomy 3.33 (1.33–8.32).


      There was a higher risk of cardiovascular events in patients after total parathyroidectomy compared with subtotal parathyroidectomy, but a lower risk of recurrent parathyroidectomy.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Goldsmith D
        • Kothawala P
        • Chalian A
        • Bernal M
        • Robbins S
        • Covic A
        Systematic review of the evidence underlying the association between mineral metabolism disturbances and risk of fracture and need for parathyroidectomy in CKD.
        Am J Kidney Dis. 2009; 53: 1002-1013
        • Block GA
        • Klassen PS
        • Lazarus JM
        • Ofsthun N
        • Lowrie EG
        • Chertow GM
        Mineral metabolism, mortality, and morbidity in maintenance hemodialysis.
        J Am Soc Nephrol. 2004; 15: 2208-2218
        • Kim SM
        • Long J
        • Montez-Rath ME
        • Leonard MB
        • Norton JA
        • Chertow GM
        Rates and outcomes of parathyroidectomy for secondary hyperparathyroidism in the United States.
        Clin J Am Soc Nephrol. 2016; 11: 1260-1267
        • Akaberi S
        • Clyne N
        • Sterner G
        • Rippe B
        • Reihner E
        • Wagner P
        • et al.
        Temporal trends and risk factors for parathyroidectomy in the Swedish dialysis and transplant population—A nationwide, population-based study 1991–2009.
        BMC Nephrol. 2014; 15: 75
        • Ivarsson KM
        • Akaberi S
        • Isaksson E
        • Reihner E
        • Rylance R
        • Prutz KG
        • et al.
        The effect of parathyroidectomy on patient survival in secondary hyperparathyroidism.
        Nephrol Dial Transplant. 2015; 30: 2027-2033
        • Sharma J
        • Raggi P
        • Kutner N
        • Bailey J
        • Zhang R
        • Huang Y
        • et al.
        Improved long-term survival of dialysis patients after near-total parathyroidectomy.
        J Am Coll Surg. 2012; 214 (discussion 407–8): 400-407
        • Isaksson E
        • Ivarsson K
        • Akaberi S
        • Muth A
        • Sterner G
        • Karl-Goran P
        • et al.
        The effect of parathyroidectomy on risk of hip fracture in secondary hyperparathyroidism.
        World J Surg. 2017; 41: 2304-2311
        • Ishani A
        • Liu J
        • Wetmore JB
        • Lowe KA
        • Do T
        • Bradbury BD
        • et al.
        Clinical outcomes after parathyroidectomy in a nationwide cohort of patients on hemodialysis.
        Clin J Am Soc Nephrol. 2015; 10: 90-97
        • Tang JA
        • Salapatas AM
        • Bonzelaar LB
        • Friedman M
        Parathyroidectomy for the treatment of hyperparathyroidism: Thirty-day morbidity and mortality.
        Laryngoscope. 2018; 128: 528-533
        • Chen J
        • Jia X
        • Kong X
        • Wang Z
        • Cui M
        • Xu D
        Total parathyroidectomy with autotransplantation versus subtotal parathyroidectomy for renal hyperparathyroidism: A systematic review and meta-analysis.
        Nephrology (Carlton). 2017; 22: 388-396
        • Schon S
        • Ekberg H
        • Wikstrom B
        • Oden A
        • Ahlmen J
        Renal replacement therapy in Sweden.
        Scand J Urol Nephrol. 2004; 38: 332-339
        • Ludvigsson JF
        • Andersson E
        • Ekbom A
        • Feychting M
        • Kim JL
        • Reuterwall C
        • et al.
        External review and validation of the Swedish national inpatient register.
        BMC Public Health. 2011; 11: 450
      1. Scandinavian quality register for thyroid parathyroid and adrenal surgery Web site. Available from: Accessed 26 March 2018.

      2. Swedish National Board of Health and WelfareWeb site. Available from: http://www.socialstyrelsense/klassificeringochkoder/diagnoskodericd-10/konverteringstabeller/ Accessed 26 March 2018.

        • Charlson ME
        • Pompei P
        • Ales KL
        • MacKenzie CR
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Quan H
        • Sundararajan V
        • Halfon P
        • Fong A
        • Burnand B
        • Luthi JC
        • et al.
        Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.
        Med Care. 2005; 43: 1130-1139
        • Kidney Disease: Improving Global Outcomes CKDMBDWG
        KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD).
        Kidney Int Suppl. 2009; : S1-130
        • London GM
        • Marty C
        • Marchais SJ
        • Guerin AP
        • Metivier F
        • de Vernejoul MC
        Arterial calcifications and bone histomorphometry in end-stage renal disease.
        J Am Soc Nephrol. 2004; 15: 1943-1951
        • Fotheringham J
        • Balasubramanian SP
        • Harrison B
        • Wilkie M
        Post-parathyroidectomy parathyroid hormone levels: The impact on patient survival—A single-centre study in a stage 5 chronic kidney disease population.
        Nephron Clinical Practice. 2011; 119: c113-c120
        • Lee SA
        • Lee MJ
        • Ryu GW
        • Jhee JH
        • Kim HW
        • Park S
        • et al.
        Low serum intact parathyroid hormone level is an independent risk factor for overall mortality and major adverse cardiac and cerebrovascular events in incident dialysis patients.
        Osteoporos Int. 2016; 27: 2717-2726
        • Hernandes FR
        • Canziani ME
        • Barreto FC
        • Santos RO
        • Moreira VM
        • Rochitte CE
        • et al.
        The shift from high to low turnover bone disease after parathyroidectomy is associated with the progression of vascular calcification in hemodialysis patients: A 12-month follow-up study.
        PLoS One. 2017; 12e0174811
        • Barreto DV
        • Barreto Fde C
        • Carvalho AB
        • Cuppari L
        • Draibe SA
        • Dalboni MA
        • et al.
        Association of changes in bone remodeling and coronary calcification in hemodialysis patients: A prospective study.
        Am J Kidney Dis. 2008; 52: 1139-1150
        • Kestenbaum B
        • Andress DL
        • Schwartz SM
        • Gillen DL
        • Seliger SL
        • Jadav PR
        • et al.
        Survival following parathyroidectomy among United States dialysis patients.
        Kidney Int. 2004; 66: 2010-2016