End-Stage Renal Disease Related Hyperparathyroidism:Towards a Patient-Tailored Journey

Hyperparathyroidism is a common consequence of end-stage renal disease (ESRD). Patients with hyperparathyroidism related to ESRD may experience symptoms such as pruritus, muscle weakness, concentration difficulties, and feeling depressed. Moreover, these patients have an increased risk of mortality and cardiovascular events. The treatment algorithm consists of vitamin D repletion, phosphate binders, calcimimetics, and parathyroidectomy. Over time, the patient with chronic kidney disease moves through advancing stages of kidney disease, towards dialysis treatment or kidney transplantation with, in parallel, different stages of hyperparathyroidism. Which treatment is most optimal in each stage of the disease for the individual patient, is a matter of debate. This thesis focusses on providing evidence-based recommendations for the treatment of patients with hyperparathyroidism related to ESRD. In the first chapters of this thesis, the pathophysiology and outcomes of hyperparathyroidism in dialysis patients and kidney transplant recipients are evaluated. Next, chapter 4 to 7 describe the outcomes of parathyroidectomy in terms of success rates, impact on kidney function and quality of life. The final chapters (8 to 12) evaluate the role of parathyroidectomy and cinacalcet in the treatment algorithm of ESRD-related hyperparathyroidism. Based on the results of this thesis, Van der Plas created a treatment algorithm for patients with ESRD-related hyperparathyroidism. Dialysis patients who are expected to receive a kidney transplant in the near future, are recommended to await the transplant for spontaneous resolution of hyperparathyroidism, bridging with calcimimetics. Patients who received a kidney transplant with persistent hyperparathyroidism are advised to undergo parathyroidectomy