In a patient with primary hyperparathyroidism manifested by serum calcium 10.8 mg/dL, intact parathyroid hormone 45 pg/mL, elevated 24‑hour urinary calcium, osteopenia, and a remote history of nephrolithiasis, should definitive treatment be parathyroidectomy?

Parathyroidectomy is Indicated for This Patient with Primary Hyperparathyroidism

This patient meets clear surgical criteria for parathyroidectomy based on the combination of osteopenia and history of nephrolithiasis, even with only mild hypercalcemia (10.8 mg/dL) and a PTH in the normal range (45 pg/mL). The presence of target organ damage—skeletal disease (osteopenia) and renal manifestations (remote kidney stones)—makes surgery the definitive treatment regardless of symptom severity. 1, 2

Why Surgery is Indicated

Target Organ Damage Drives the Decision

• Skeletal involvement (osteopenia) represents bone demineralization from chronic PTH excess, which will progress without definitive treatment and increases fracture risk. 1, 3

• Remote history of nephrolithiasis indicates prior renal damage from hypercalciuria, and elevated 24-hour urinary calcium confirms ongoing pathologic calcium excretion that threatens further stone formation. 1, 4

• Surgery is indicated even in asymptomatic patients given the negative long-term effects of persistent hypercalcemia on bone and kidney, and this patient has already demonstrated both complications. 1, 2

The Biochemical Profile is Consistent with Primary Hyperparathyroidism

• Serum calcium of 10.8 mg/dL with an intact PTH of 45 pg/mL represents "inappropriately normal" PTH—in the setting of hypercalcemia, PTH should be suppressed to near-zero, so a mid-normal PTH confirms autonomous parathyroid function. 1, 5

• Elevated 24-hour urinary calcium excludes familial hypocalciuric hypercalcemia (FHH), which would present with low urinary calcium and would not warrant surgery. 4

• The calcium-to-creatinine clearance ratio calculation is not needed here since elevated 24-hour urinary calcium (>100 mg/day) already rules out FHH. 4

Surgical Approach

Preoperative Localization is Essential

• Obtain sestamibi scan and/or neck ultrasound to localize the adenoma before surgery, as accurate preoperative imaging enables minimally invasive parathyroidectomy (MIP) rather than bilateral neck exploration. 1, 2

• If imaging concordantly identifies a single adenoma, proceed with MIP using intraoperative PTH monitoring to confirm adequate removal of hyperfunctioning tissue. 1, 2

• If imaging is discordant or nonlocalizing, bilateral neck exploration is required, particularly important since PTH ≤50 pg/mL is associated with multigland disease in 58.9% of cases. 2

Common Pitfalls to Avoid

• Do not delay surgery for "observation" in patients with documented target organ damage—osteopenia will worsen and kidney stone risk remains elevated without definitive treatment. 1

• Do not be falsely reassured by "normal" PTH levels—in the context of hypercalcemia, failure to suppress PTH indicates autonomous parathyroid function requiring surgery. 5, 6

• Do not pursue genetic testing for FHH when 24-hour urinary calcium is elevated—this patient's elevated urinary calcium excludes FHH and confirms primary hyperparathyroidism. 4

Postoperative Management

Anticipate Hungry Bone Syndrome

• Monitor ionized calcium every 4-6 hours for the first 48-72 hours postoperatively to detect early hypocalcemia from rapid bone remineralization. 1, 2

• If ionized calcium falls below 0.9 mmol/L (total calcium <7.2 mg/dL), initiate IV calcium gluconate at 1-2 mg elemental calcium/kg/hour, then transition to oral calcium carbonate 1-2 g three times daily plus calcitriol up to 2 μg/day once oral intake resumes. 1, 2