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.