Challenges in Parathyroidectomy in End-Stage Kidney Disease: Preoperative Preparation, Localisation, and Surgery. A Case Series and Evidence-Based Approach

Renal hyperparathyroidism is a frequent and serious complication of end-stage kidney disease (ESKD), contributing to vascular calcifications, bone pain, and cardiovascular morbidity. For patient’s refractory to medical therapy, parathyroidectomy (PTX) offers definitive treatment, alleviating symptoms, improving quality of life, and potentially enhancing survival. However, PTX in ESKD presents distinct intra-operative and post-operative challenges. This study evaluated the peri-operative and clinical considerations of PTX in ESKD, with emphasis on operative planning, gland localisation, post-operative hypocalcaemia, and recurrence risk. A literature review and retrospective analysis were conducted on eight dialysis-dependent patients with renal hyperparathyroidism unresponsive to medical treatment, all assessed by a multidisciplinary team prior to surgery. Three patients developed complications due to persistently elevated parathyroid hormone (PTH) levels, while the remainder were discharged in stable condition. These findings underscore the need for meticulous patient selection, comprehensive pre-operative counselling, and multidisciplinary decision-making. Surgical indications should be guided by symptom burden, biochemical derangements, and persistently elevated PTH. Although comparative evidence between surgical and medical approaches remains limited, PTX is associated with survival benefits and cost-effectiveness. Persistent post-operative PTH elevation may be linked to increased mortality, highlighting the importance of long-term follow-up and structured post-operative management