Frontiers | Severe secondary hyperparathyroidism in a chronic kidney disease patient treated with Radiofrequency ablation: One case report (2024)


Front. Med., 22 July 2022

Sec. Nephrology

This article is part of the Research Topic Secondary Hyperparathyroidism: an Ongoing Challenge for the Nephrologist View all 10 articles

Gulimire Muhetaer1Guangyi Liu2Frontiers | Severe secondary hyperparathyroidism in a chronic kidney disease patient treated with Radiofrequency ablation: One case report (3)Ling Zhang3Hong Jiang1*

  • 1Xinjiang Clinical Research Center for Kidney Disease, Division of Nephrology, Department of Internal Medicine, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
  • 2Division of Nephrology, Department of Internal Medicine, Qilu Hospital of Shandong University, Qingdao, China
  • 3Division of Nephrology, Department of Internal Medicine, China-Japan Friendship Hospital, Beijing, China

End-stage renal disease (ESRD) is a global health problem with a high incidence (1) and a steadily increasing prevalence (2). Secondary hyperparathyroidism (SHPT) is a common and serious complication of chronic renal failure (CRF) in dialysis patients (3). It is mainly manifested as parathyroid hyperplasia caused by abnormal calcium and phosphorus metabolism and active vitamin D resistance, resulting in excessive secretion of parathyroid hormone (PTH), which leads to complications such as bone deformity, osteoarthralgia, pruritus, ectopic calcification, and cardiovascular calcification in CKD patients, significantly reducing the quality of life in CKD patients (4, 5). In patients with chronic kidney disease, secondary parathyroid gland hyperplasia needs to be treated as early as possible (6). Currently, there are a variety of treatment options, including vitamin D receptor agonists, xenacax hydrochloride, parathyroidectomy and ablation techniques, etc. (7, 8). Medical treatment is the main choice among these treatments, but it is invalid in patients with severe hyperparathyroidism. So, parathyroidectomy is suggested to do in those patients (9). However, many dialysis patients who have severe cardiopulmonary dysfunction cannot tolerate the trauma caused by surgery as the concept of minimally invasive surgery has been gradually introduced into all fields of surgery and medical treatment. Traditional surgery is no longer the only option. Radiofrequency ablation has been widely applied due to its advantages of less trauma, simple operation, and good repeatability. It has been reported to achieve good effects in treating secondary hyperparathyroidism patients (8). This case reports that one severe secondary hyperparathyroidism patient gets good therapeutic results from parathyroid radiofrequency ablation.

Clinical data

This paper reported a case of secondary hyperparat hyroidism who underwent radiofrequency ablation to eliminate seven parathyroid glands hyperplasia. We report a 28-year-old male ESRD patient caused by primary glomerulonephritis, maintenance hemodialysis for 10 years, 3 times per week, intermittent bone pain for 2 years. Two years ago, he developed severe bone pain accompanied by a left-leaning spine and limited movement when sitting up and could not take care of herself. The blood level of PTH > 2500 pg/mL. Intermittent oral Rocaltrol implosive therapy and intermittent Cinacalcet therapy were used. His height was shortened by 28 cm in the past two years. A tumor appeared in the anterior part of the maxillary hard palate 6 months ago. The serum level of PTH > 2500 pg/ml, alkaline phosphatase 1284.00 U/L, calcium 1.99 mmol/L, inorganic phosphorus 1.54 mmol/L were rechecked. Five parathyroid tissues were detected by parathyroid B-ultrasound (Figure 1). The maximum one was 13 × 7.9 × 8.4 mm. He has a 10-year hypertension history, poor blood pressure control, admission blood pressure of 220/120 mmHg, a history of congenital heart disease, and a patent foramen ovale. The LVEF is 58%. Due to sequelae in 2006, children’s polio history underwent ’ left lower limb correction. CT findings: bilateral lung inflammation, heart shadow, pulmonary artery widening, pericardial effusion, thoracic scoliosis deformity. The pulmonary function examination showed severe restrictive pulmonary ventilation dysfunction. We conducted a multidisciplinary discussion. Refer to the guide, after discussion and communication, we decided to performed ultrasound-guided parathyroid radiofrequency ablation (bilateral) to this patient. In December 11, 2019, bilateral parathyroid radiofrequency ablation was performed. During the operation, local infiltration anesthesia was performed after dilution with 1% lidocaine, and physiological saline was used as isolation belt under the guidance of ultrasound to protect the trachea, skin and surrounding tissues. After that, the mass was isolated from the recurrent laryngeal nerve and bilateral paraproliferative glands were ablated by moving-shot ablation technique under the guidance of ultrasound, In addition to 5 parathyroid glands found by ultrasound, 2 parathyroid glands were detected buring surgery and total 7 parathyroid glands were eliminated (Figure 2), compression hemostasis was performed in the operation area. The patients without hoarseness, numbness of hands and feet, drinking cough and other discomfort complaints after operation. And the serum level of PTH reduced to 309 pg/mL. The paraproliferative gland was completely ablated reexamined by ultrasonography. After 3 days of symptomatic treatment such as calcium supplementation, the PTH level reduced to 96. 9 pg/mL, and discharged. During the follow-up, intermittent calcitriol, Caltrate and other medicines have been discontinued. On November 15,2021, the serum PTH level was 146.8 pg/ml, and the ALP level was 80 U/L. Bone pain disappeared. And the patients can basically stand on their own. The patient was followed up continuously.


Figure 1. B-ultrasound image before parathyroid radiofrequency ablation.



SHPT is mainly characterized by calcium and phosphorus metabolism disorder, increased serum PTH secretion, and hyperparathyroidism. It is crucial to control the calcium, phosphorus, and PTH of patients with SHPT. The KDIGO guidelines suggest that PTH should be maintained at 2 ∼ 9 times the standard upper limit (9). It is recommended that patients with stage 5 CKD should use calcium analogs, calcitriol or vitamin D analogs, or combination treatment. This patient received intermittent administration of calcitriol and Sinakase oral. But the PTH level continued to rise. And multiple parathyroid glands were detected; the long diameter was more than 1cm of the largest one. Above mentioned reasons, combined with KDIGO’s recommendation, parathyroidectomy is recommended for CKD G3a ∼ G5D patients with severe hyperparathyroidism if medical treatment fails. However, many dialysis patients with cardiopulmonary dysfunction increase the risk of anesthesia complications and can’t stand the trauma caused by surgery. The clinical manifestations of this patient were bone pain, maxillary hard palate mass, shortening of height, and Poor cardiopulmonary function with malnutrition. Parathyroidectomy cannot be tolerated after evaluation, but traditional surgery is no longer the only option. Radiofrequency ablation has been widely used due to its advantages of less trauma, simple operation, and good repeatability. Radiofrequency ablation, laser ablation, and microwave ablation have been reported to have achieved good results in the treatment of secondary patients (8) and become an effective treatment method. Xu et al.’s study showed the iPTH and calcium levels controlled in 2 patients with SHPT by radiofrequency ablation (10). Although there are still controversies over surgical methods, efficacy, and safety, it is pointed out that there are still controversies over surgical techniques, effectiveness, and safety. However, radiofrequency ablation can also be regarded as an alternative therapy for patients with severe heart and lung function complications that increase general anesthesia risk and have achieved good efficacy (11). Therefore, we performed radiofrequency ablation for this patient. Seven parathyroid glands were eliminated during the operation. The PTH was also well reduced after the procedure. In SHPT patients, more glands may be affected, and the degree and number of glandular hyperplasia can seriously affect the prognosis of patients. The ectopic glands may exist in different locations, for example, the thyroid, cervical sheath, thymus, and upper mediastinum. Those glands cannot be approached by radiofrequency ablation adjacent to critical anatomical structures such as blood vessels or the esophagus. It will result in the failure of radiofrequency ablation and persistent SHPT after ablation. Studies have shown that the frequency of ectopic parathyroidosis in SHPT patients is about 15% (12). The proportion of patients with more than 4 glands is 2.5–30% (13). In this case, 5 parathyroids were detected by ultrasound. However, 7 parathyroids were seen in radiofrequency ablation operations. After another exploration, the ablated parathyroids were completely ablated. This shown that the positioning of instruments and doctors is particularly important, and experienced doctors can obtain better results through their own experience and repeated exploration to help find excess ectopic parathyroids. Alkaline phosphatase (ALP) is an indicator of osteogenesis, which reflects the high transport state of bone metabolism. Therefore, the higher level of ALP and the higher metabolic status of bone indicated the higher incidence of low level of serum calcium. Some studies have also pointed out that low calcium level after radiofrequency ablation is closely correlated with preoperative ALP (14). Higher ALP level before ablation will lead to more obvious postoperative hypocalcemia. In this patient, the level of ALP was very high before operation, and serum calcium decreased to 1.47 mmol/L after operation. Therefore, we actively supplement calcium and recheck PTH which also decreased compared with the first day after operation.

Although there are still some differences in surgical methods, efficacy, and safety in the clinical guidelines and related studies, radiofrequency ablation is an effective treatment for patients with severe hyperthyroidism who cannot tolerate surgery. In this case, the patient’s bone pain disappeared after radiofrequency ablation. At present, the level of PTH is maintained between 136–242 pg/ml (Figure 3). The patient can stand on their own, and the quality of his life has been improved significantly, also very satisfied with this treatment. Based on this patient’s experience, we consider that when patients suffer from cardiopulmonary dysfunction due to basic diseases, and can’t perform or endure the trauma caused by surgery, radiofrequency ablation can be widely used because of its advantages of small trauma, simple operation and repeatability, the levels of serum iPTH, calcium and phosphorus can also be effectively reduced after surgery, so as to achieve the effect similar to surgical resection. Of course, it also requires longer follow-up and clinical indicators to comprehensively determine the clinical efficacy. Therefore, it is very important to choose the most suitable treatment according to the individual differences of patients when choosing treatment plans.


Figure 3. Relevant clinical test values before and after parathyroid radiofrequency ablation Reference values: Ca (2.11–2.52 mmol/L); P (0.85–1.51 mmol/L); parathyroid hormone (PTH) (12–65 pg/ml); alkaline phosphatase (ALP) (45–125 U/L).

Data availability statement

The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Ethics statement

Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.


This work was supported by the Xinjiang Uygur Autonomous Region Project Application of bone disease information processing system in end-stage kidney disease (2020E02118) to HJ.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


We would like to thank the patients and their family for their participation in this study.


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Keywords: hyperplastic parathyroid gland, radiofrequency ablation, secondary hyperparathyroidism, chronic kidney disease, parathyroid hormone

Citation: Muhetaer G, Liu G, Zhang L and Jiang H (2022) Severe secondary hyperparathyroidism in a chronic kidney disease patient treated with Radiofrequency ablation: One case report. Front. Med. 9:876692. doi: 10.3389/fmed.2022.876692

Received: 15 February 2022; Accepted: 15 June 2022;
Published: 22 July 2022.

Edited by:

Claudia Torino, Italian National Research Council, Italy

Reviewed by:

Goce Spasovski, Saints Cyril and Methodius University of Skopje, North Macedonia
Mojtaba Akbari, Saints Cyril and Methodius University of Skopje, North Macedonia
Anna Eremkina, Endocrinology Research Center, Russia

Copyright © 2022 Muhetaer, Liu, Zhang and Jiang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Hong Jiang,

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Frontiers | Severe secondary hyperparathyroidism in a chronic kidney disease patient treated with Radiofrequency ablation: One case report (2024)


How is secondary hyperparathyroidism treated in chronic kidney disease? ›

Secondary hyperparathyroidism treatment

Surgery to remove the parathyroid glands, either completely or leaving a small amount of gland in place. A newer class of drugs called calcimimetics (cinacalcet, etelcalcitide) that mimic the action of calcium on tissues and suppress the production of PTH.

What foods should you avoid if you have hyperparathyroidism? ›

Avoid refined foods, such as white breads, pastas, and sugar. Use healthy cooking oils, such as olive oil or coconut oil. Reduce or eliminate trans-fatty acids, found in commercially-baked goods, such as cookies, crackers, cakes, and donuts, French fries, onion rings, processed foods, and margarine.

Should you take vitamin D if you have hyperparathyroidism? ›

Vitamin D replacement in the setting of PHPT has been shown to have positive impact when monitored by your physician. Some patients can increase their vitamin D levels by taking supplements either by using daily or weekly doses.

What are the long term effects of secondary hyperparathyroidism? ›

Complications of hyperparathyroidism are mainly related to the long-term effect of too little calcium in your bones and too much calcium in your bloodstream. Common complications include: Osteoporosis. The loss of calcium from bones often results in weak, brittle bones that break easily (osteoporosis).

What is the new treatment for secondary hyperparathyroidism? ›

Parsabiv is a novel calcimimetic agent indicated for the treatment of secondary hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on hemodialysis.

How do you fix secondary hyperparathyroidism? ›

Medical treatments include vitamin D analogs, calcimimetics, and phosphate binders to restore calcium, phosphorus, and the PTH levels within normal range. Early consultation with nephrologists is important to manage the outcomes. Surgery is the last option if patients do not respond to appropriate medical treatments.

Can you eat eggs with hyperparathyroidism? ›

The underlying condition that is causing secondary hyperparathyroidism needs to be treated; for example, treating vitamin D deficiency with vitamin D supplements. You can reduce your intake of phosphate by restricting the amount of milk, cheese, eggs and dairy products that you eat.

What is the most common cause of secondary hyperparathyroidism? ›

The most common causes of secondary hyperparathyroidism are kidney failure and vitamin D deficiency. In kidney failure, the kidney is no longer able to make enough vitamin D or remove all of the phosphorus that is made by the body, which leads to low calcium levels.

What foods flush calcium levels? ›

Salty foods can decrease the amount of calcium your body can absorb. When you consume a lot of salt, more blood calcium is flushed out of your body through your pee.

What personality changes occur with hyperparathyroidism? ›

Primary Hyperparathyroidism and Psychopathology
Degree of HypercalcemiaSerum Calcium Level (mg/dL)Symptoms
Mild to moderate10–14Depression, apathy, irritability, lack of initiative, or lack of spontaneity
Severe>14Delirium with psychosis, catatonia, or lethargy; may progress to coma
Jul 1, 2017

Does parathyroid affect weight? ›

Hyperparathyroidism patients sometimes experience chronic fatigue, which makes them less active and more prone to weight gain. Conversely, if a parathyroid tumor is removed, the body is better equipped than ever before to maintain consistent calcium levels.

How does hyperparathyroidism affect the brain? ›

A lot of patients who have hyperparathyroidism will complain of things like overwhelming fatigue. They get what they call brain fog, where their short-term memory is affected. And some people have difficulty with simple calculations. Basically, they just feel like their brain isn't functioning well.

What is the difference between hyperparathyroidism and secondary hyperparathyroidism? ›

Primary hyperparathyroidism causes high levels of calcium in your blood and pee, and low levels of phosphate in your blood. Secondary hyperparathyroidism causes low levels of vitamin D, normal or low levels of calcium and high levels of phosphate in your blood.

Can chronic kidney disease causes secondary hyperparathyroidism? ›

Defect in the activation of vitamin D in the kidneys due to chronic kidney disease (CKD) leads to hypocalcemia and hyperphosphatemia, resulting in a compensatory increase in parathyroid gland cellularity and parathyroid hormone production and causing secondary hyperparathyroidism (SHP).

How do you treat hyperparathyroidism in the kidneys? ›

Treatment consists of supplying vitamin D and reducing phosphate intake. In later stages calcimimetics might be added. RHPT refractory to medical treatment can be managed surgically with parathyroidectomy. Risks of surgery are small but not negligible.

What two medications are given for the prevention and treatment of secondary hyperparathyroidism associated with renal failure? ›

There are three (3) types of drugs for secondary hyperparathyroidism—vitamin D supplements, active vitamin D (or vitamin D analogs) and cinacalcet.

What is the surgery for secondary hyperparathyroidism? ›

The three main types of surgery for secondary hyperparathyroidism are subtotal parathyroidectomy (i.e. removal of 3 and ½ of the parathyroids), 4 gland excision and autotransplantation (i.e. removing all 4 parathyroid glands and placing a piece of a parathyroid in the forearm), and PTH-guided parathyroidectomy (i.e. ...

How is hypoparathyroidism treated in CKD patients? ›

Conventional treatment in patients with chronic hypoparathyroidism is oral calcium and active vitamin D (eg, calcitriol), as well as parenteral forms of vitamin D and thiazide diuretics as needed [1, 4, 5].

How to treat hypercalcemia in Ckd? ›

What's the treatment for hypercalcemia and renal failure?
  1. saline infusion to increase urination and flush out excess calcium.
  2. calcitonin, a medication that reduces blood calcium levels.
  3. removal of the parathyroid gland in people with hyperparathyroidism.
  4. bisphosphonates for hypercalcemia caused by cancer.
Nov 17, 2023


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