Control of severe hyperparathyroidism in dialysis patients with nodular hyperplasia

Secondary hyperparathyroidism is one of the most im- portant abnormalities in chronic kidney disease-mineral and bone disorder (CKD-MBD). Despite the recent de- velopment of therapeutic modalities including new phos- phate binders, new vitamin D analogues and cinacalcet, manypatientswithveryseverehyperparathyroidismstillre- mainuncontrollable.Severalstudieshavedemonstratedthat such refractory patients have markedly enlarged parathy- roid 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 alterna- tive to conventional surgical parathyroidectomy in Europe during the 1980s. Together with the advances in imaging techniques allowing identification of the glands to be de- stroyed, this therapy became a more sophisticated and prac- tical therapeutic modality to control severe hyperparathy- roidism during the early 1990s in Japan (2). In this 'selec- tive 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 follow- ing these procedures clearly suggests that patients with one nodular gland were best suited to selective PEIT (3). The Japanese Society for Parathyroid Intervention, orig- inally named as the Japanese Society for PEIT of Parathy- roid, 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