Total parathyroidectomy with autotransplantation vs. subtotal parathyroidectomy for secondary hyperparathyroidism: lower recurrence rates but comparable cardiovascular outcomes.

OBJECTIVE

This study aimed to compare the long-term efficacy and cardiovascular outcomes of total parathyroidectomy with autotransplantation (TPTX+AT) versus subtotal parathyroidectomy (SPTX) in maintenance hemodialysis (MHD) patients with refractory secondary hyperparathyroidism (SHPT).

METHODS

This retrospective cohort study enrolled MHD patients with SHPT who underwent parathyroidectomy between January 2020 and December 2022, with follow-up through December 2025. Patients were divided into TPTX+AT and SPTX groups. Serum intact parathyroid hormone (iPTH), corrected calcium, phosphorus, alkaline phosphatase, and 25-hydroxyvitamin D were measured preoperatively, on postoperative day 1, and at 3, 6, 12, and 36 months. Operative time, hospital stay, early complications, and long-term outcomes including SHPT recurrence, mortality, cardiovascular events, and permanent hypoparathyroidism were recorded.

RESULTS

Of 217 patients, 113 underwent TPTX+AT and 104 underwent SPTX. Operative time was longer with TPTX+AT (129.42 ± 34.74 min vs. 114.49 ± 29.71 min, P < 0.001). At 36 months, iPTH levels were significantly lower in the TPTX+AT group (209.74 ± 103.51 pg/mL vs. 464.53 ± 184.60 pg/mL, P < 0.001). SHPT recurrence was lower with TPTX+AT (14.16% vs. 36.54%, P < 0.001), while permanent hypoparathyroidism occurred only in the TPTX+AT group (5.31% vs. 0%, P = 0.049). All-cause mortality (13.27% vs. 13.46%), cardiovascular mortality (7.08% vs. 6.73%), and cardiovascular events (19.47% vs. 16.35%) were similar between groups (all P > 0.05).

CONCLUSION

TPTX+AT achieves more durable biochemical control and lower SHPT recurrence but carries a definite risk of permanent hypoparathyroidism, with equivalent survival and cardiovascular outcomes, underscoring the need for individualized surgical selection.