From the Guidelines
Parathyroidectomy is recommended for patients with primary hyperparathyroidism who meet specific criteria, including symptomatic patients, those with serum calcium levels greater than 1 mg/dL above the upper limit of normal, osteoporosis, estimated glomerular filtration rate less than 60 mL/min, or presence of kidney stones. The decision to perform parathyroidectomy is based on the presence of specific clinical criteria, rather than the level of parathyroid hormone (PTH) concentration 1.
Indications for Parathyroidectomy
The following are indications for parathyroidectomy:
- Symptomatic patients
- Patients with serum calcium levels greater than 1 mg/dL above the upper limit of normal
- Patients with osteoporosis (T-score less than -2.5 at any site)
- Estimated glomerular filtration rate less than 60 mL/min
- Presence of kidney stones on imaging or history of kidney stones
- Patients with significant hypercalciuria (>400 mg/day) or those who cannot participate in appropriate follow-up
Preoperative Evaluation
Before surgery, localization studies like sestamibi scanning or ultrasound are typically performed to identify the abnormal gland(s) 1.
Surgical Approach
There are two accepted curative operative strategies for primary hyperparathyroidism: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP) 1. The choice of procedure depends on the specific clinical circumstances and the expertise of the surgeon.
Postoperative Care
After parathyroidectomy, patients should be monitored for potential complications, including recurrent laryngeal nerve injury, hypoparathyroidism, and bleeding 1.
Monitoring and Follow-up
Asymptomatic patients who do not meet the criteria for parathyroidectomy may be monitored with annual serum calcium measurements and bone density testing every 1-2 years 1.
From the Research
Criteria for Parathyroidectomy
The decision to perform a parathyroidectomy is based on several factors, including the presence of symptoms, the level of hypercalcemia, and the presence of end-organ damage.
- Patients with primary hyperparathyroidism (PHPT) who have symptoms such as osteoporosis, hypercalciuria, vertebral fractures, and nephrolithiasis are considered candidates for parathyroidectomy 2.
- Asymptomatic patients with PHPT who are at risk of progression or have subclinical evidence of end-organ sequelae are also considered candidates for parathyroidectomy 2.
- The criteria for evaluating the outcome of parathyroidectomy include the level of serum calcium and parathyroid hormone (PTH) 3.
- Patients with a serum calcium level > 10.6 mg/dL and elevated intact PTH (iPTH) levels are considered to have recurrent hyperparathyroidism 3.
- Factors that are positively associated with parathyroidectomy include nephrolithiasis and non-Hispanic white race/ethnicity, while age, Elixhauser Comorbidity Index score, decreased estimated glomerular filtration rate, and diagnosis of osteoporosis are inversely related to surgery 4.
Medical Treatment
Medical treatment options are available for patients with primary, secondary, and tertiary hyperparathyroidism.
- Cinacalcet, a calcium sensing receptor agonist, can be used to decrease PTH and calcium levels in patients with primary hyperparathyroidism, secondary hyperparathyroidism caused by uremia, and tertiary hyperparathyroidism 5.
- Newer analogues of vitamin D, such as paricalcitol, have also been introduced and may have an advantage over traditional compounds such as alphacalcidol and calcitriol 5.
- Vitamin D receptor activators (VDRAs) are widely used for the treatment of secondary hyperparathyroidism, but have calcemic and phosphatemic effects that limit their use to a subset of patients 6.