Parathyroid Surgery in the Treatment of Pediatric Chronic Kidney Disease-Mineral and Bone Disorder: Regional Experience and Review

Background: Childhood-onset chronic renal failure is an important disease entity within Australasia and the associated mineral and bone disorder causes faltering mobility and growth, and significant cardiovascular morbidity in early adulthood. A poorly described group of children will require parathyroid surgery because of refractory disease. Aim: To review paediatric cases requiring parathyroid surgery in the treatment of Chronic Kidney Disease-Mineral and Bone Disorder at Starship Hospital between 1996-2010. A secondary objective was to estimate the percentage of children requiring parathyroid surgery amongst those children at risk i.e. those on renal replacement therapy. Methods: The departmental renal database was searched and eleven cases were found from a total of 310 children-years treated with renal replacement during the study period. Retrospective medical record review was performed including operative indications, renal replacement modalities, growth parameters, operative technique, biochemical assays, follow-up and recurrence. Results: Indications for surgery were biochemical as well as clinical: bone pain, pathological fractures, faltering mobility and growth retardation. The type of surgery varied, but the majority involved subtotal parathyroid excision. All parathyroid tissue excised was hypertrophic. Surgery provided relief of symptoms within months and parathyroid hormone levels reduced on average from 100.7 pmol/L to 3.1 pmol/L two months following the operation. After a median follow-up of 9 years there has been one case of recurrence of hyperparathyroidism. Conclusions: Subtotal parathyroid excision is safe and effective in treating refractory Chronic Kidney Disease-Bone and Mineral Disorder in children. The risk of requiring parathyroid surgery while on renal replacement therapy is estimated as 3.5% per children-year treated.