Surgical management of presternal recurrence in hyperparathyroidism related to chronic kidney disease

Objective To evaluate the surgical management and outcomes of recurrence localized in presternal autografts after total parathyroidectomy with autograft for hyperparathyroidism related to chronic kidney disease. Methods A retrospective cohort study was conducted including patients submitted to total parathyroidectomy with presternal autograft between 2000 and 2024 who developed biochemical recurrence according to Brazilian Society of Nephrology criteria and required reoperation. Only cases occurring more than six months after an initially effective surgery were included. The primary outcome was sustained biochemical resolution. Results Twenty-four patients required reoperation due to recurrence in the presternal autograft. All were on hemodialysis at initial surgery. Mean CKD duration was 96-months and mean preoperative PTH level was 1445.4 pg/mL. Thirty-one reoperations were performed; most patients (87.5%) required only one procedure. The mean interval between initial surgery and first graft reoperation was 62.6-months. No invasive growth beyond anatomical limits was observed. Mean intraoperative PTH reduction was 80.8%. Considerable variability was observed between intraoperative PTH reduction and subsequent clinical outcomes. Total graft removal was feasible when indicated. Conclusion Reoperation for recurrence in presternal autografts was feasible in this series and was associated with satisfactory biochemical control, even in patients requiring multiple procedures. The anatomical characteristics of the presternal region allowed controlled resections without evidence of invasive growth beyond the graft bed. Level of Evidence 3.