Sometimes Less Is More:  Comment on “Effect of Incomplete Parathyroidectomy Preserving Entire Parathyroid Glands on Renal Graft Function”

The most effective therapy for tertiary hyperparathyroidism (tHPT) after renal transplantation is parathyroidectomy (PT).¹ Most patients present with 4-gland hyperplasia, which is successfully treated with subtotal (3.5-gland) PT. However, a subset of patients with tHPT will have only 1 or 2 enlarged glands at the time of the operation, and the surgical management of these patients has been a topic of considerable debate. Some experienced groups advocate subtotal or total PT for all patients with tHPT; at the University of Wisconsin, we have strongly supported a practice of “limited” PT or resection of only the 1 or 2 enlarged glands in this subset of patients. Our operative strategy is based on the fact the patients who have a limited PT have an equivalent cure rate but a lower incidence of temporary and permanent hypocalcemia compared with those who undergo a more aggressive resection.^2- 3 In this article, Jäger and colleagues⁴ examined the incidence of postoperative PT renal graft deterioration in patients with tHPT. They justly emphasize that “the most important goal in treatment is preservation of renal graft function” and found that renal graft deterioration occurred with the more aggressive surgical resection of PGs. Conversely, limited or “incomplete” PT did not negatively affect renal graft function. Importantly, the cure rates following limited or aggressive resection were identical. Thus, Jäger et al provide data to support the practice of limited PT in select patients with tHPT and stress the importance of surgical experience and judgment. Sometimes, less surgical intervention leads to more benefit for the patient.