Chronic dialysis patient with severe secondary hyperparathyroidism undergoing parathyroidectomy in Indonesia: a case series

Background: Parathyroidectomy is a method of treating secondary hyperparathyroidism associated with Chronic Kidney Disease (CKD), which has been largely abandoned in developed countries due to the existence of calcimimetic drugs which are reported to be effective in treating secondary hyperparathyroidism in this population. However, in developing countries like Indonesia, the availability of Calcimimetic drugs is still rare and expensive, so that parathyroidectomy can be an option. The study aimed to present four case reports of chronic HD patients with SHPT accompanied by clinical symptoms. As far as our knowledge goes, this is the first case series reported from Indonesia. Case Presentation: This research is a multicenter case series study. All patients had undergone dialysis for five years and complained of body aches. All calcium levels were within the normal range, while three patients had hyperphosphatemia and one patient had normal phosphate levels. All patients had iPTH levels >1000 pg/ml in the last six months. Before the surgery, all patients had received long-term phosphate-binding drugs, including calcium-based and non-calcium-based drugs and vitamin D3 agonists. All patients underwent total parathyroidectomy with autotransplantation of parathyroid tissue in the right antebrachial regions, except for the second patient who received the transplant in the left antebrachial region due to an AV fistula in the right arm. Conclusion: In dialysis patients, especially in developing countries, approximately 10.7% of them experience SHPT with PTH levels >1,000 pg/mL, and one study in Indonesia showed that around 35% of patients undergoing chronic hemodialysis had PTH levels >200 pg/ml, making parathyroidectomy a highly possible option considering that medications such as cinacalcet are more expensive and not widely available.