Control of severe hyperparathyroidism in dialysis patients with nodular hyperplasia

Secondary hyperparathyroidism is one of the most important abnormalities in chronic kidney disease-mineral and bone disorder (CKD-MBD). Despite the recent development of therapeutic modalities including new phosphate binders, new vitamin D analogues and cinacalcet, many patients with very severe hyperparathyroidism still remain uncontrollable. Several studies have demonstrated that such refractory patients have markedly enlarged parathyroid glands with nodular hyperplasia composed of cells with decreased numbers of vitamin D and calcium-sensing receptors [1]. Percutaneous ethanol injection therapy (PEIT) of parathyroid glands was originally developed as an alternative to conventional surgical parathyroidectomy in Europe during the 1980s. Together with the advances in imaging techniques allowing identification of the glands to be destroyed, this therapy became a more sophisticated and practical therapeutic modality to control severe hyperparathyroidism during the early 1990s in Japan [2]. In this ‘selective PEIT’, glands with nodular hyperplasia are destroyed by ethanol injection, and remaining glands with diffuse hyperplasia are controlled by subsequent medical therapy. Analysis of the prognosis of parathyroid function following these procedures clearly suggests that patients with one nodular gland were best suited to selective PEIT [3]. The Japanese Society for Parathyroid Intervention, originally named as the Japanese Society for PEIT of Parathyroid, was established in 1996. The initial purpose of this society was to standardize the indication and protocol of PEIT. As a result, we published clinical guidelines for