For a 71‑year‑old patient with primary hyperparathyroidism (serum calcium 10.8 mg/dL, intact PTH 45 pg/mL, elevated 24‑hour urinary calcium, osteopenia, and prior nephrolithiasis), do you still recommend parathyroidectomy?

Surgical Approach for 71-Year-Old with Primary Hyperparathyroidism

Yes, parathyroidectomy remains strongly indicated for this 71-year-old patient with primary hyperparathyroidism who meets multiple surgical criteria including prior nephrolithiasis, osteopenia, elevated urinary calcium, and documented hypercalcemia. 1

Why Surgery Is Indicated Despite Age

Age alone is not a contraindication to parathyroidectomy. The patient meets clear surgical indications established by the Endocrine Society: history of nephrolithiasis, osteopenia (bone disease), elevated 24-hour urinary calcium (hypercalciuria >300 mg/24hr), and corrected calcium 10.8 mg/dL (0.5 mg/dL above the upper limit of normal 10.3 mg/dL). 1

Specific Surgical Criteria Met:

• Prior nephrolithiasis – This alone is an absolute indication for surgery regardless of calcium level 1
• Osteopenia – Bone disease (T-score approaching -2.5) warrants surgical intervention 1, 2
• Elevated 24-hour urinary calcium – Hypercalciuria increases stone recurrence risk 1
• Symptomatic disease – The patient likely has symptoms that may be attributed to aging but are actually from hyperparathyroidism 3

Safety in Elderly Patients

Parathyroidectomy in octogenarians and nonagenarians is safe with minimal morbidity. A study of 54 consecutive patients aged 80+ years (mean 83.6 years) showed 0% perioperative mortality, only 9% complication rate (urinary tract infection, bladder perforation, transient hypocalcemia), and average hospitalization of 1.9 days. 3 At age 71, this patient is considerably younger than this cohort.

All patients in the elderly cohort were symptomatic (none had truly asymptomatic disease), and parathyroidectomy resulted in significant improvement in fatigue, weight loss, nocturia, bone pain, constipation, and major depression. 3 Many symptoms attributed to "normal aging" are actually reversible manifestations of hyperparathyroidism. 3, 4

Why Medical Management Is Inadequate

Medical therapy cannot address the underlying disease and does not prevent complications. 5

• Cinacalcet lowers serum calcium but does not improve bone mineral density and has only modest effects on PTH 6
• Bisphosphonates (alendronate) improve BMD at the lumbar spine but do not lower calcium 6
• Combination therapy lacks strong evidence for efficacy 6
• None of these agents prevent kidney stones, which is a critical concern given this patient's prior nephrolithiasis 7

The PTH level of 45 pg/mL is inappropriately normal in the setting of hypercalcemia (10.8 mg/dL), confirming autonomous parathyroid hormone secretion characteristic of primary hyperparathyroidism. 1 In a normal individual, PTH should be suppressed (below 20 pg/mL) when calcium is elevated. 1

Stone Risk Considerations

This patient has already formed stones and remains at high risk for recurrence. After successful parathyroidectomy, urinary calcium decreases significantly (from 319 to 156 mg/day), calcium oxalate supersaturation drops (8.6 to 5.7), and calcium phosphate supersaturation falls (1.6 to 0.9). 7 Medical management cannot achieve these reductions.

Elevated 24-hour urinary calcium is a specific surgical indication because it predicts ongoing stone formation. 1 The patient's prior nephrolithiasis combined with persistent hypercalciuria creates a compelling case for definitive surgical cure.

Referral Pathway

Refer immediately to both endocrinology and an experienced high-volume parathyroid surgeon. 1

• Endocrinology will confirm the diagnosis, exclude secondary causes (vitamin D deficiency has been ruled out if 25-OH vitamin D >20 ng/mL), and coordinate perioperative management 1
• High-volume parathyroid surgeon ensures optimal outcomes, as surgical expertise significantly impacts success rates and complication rates 1, 3

Preoperative localization imaging (ultrasound and/or 99mTc-sestamibi SPECT/CT) should be obtained only after biochemical diagnosis is confirmed and surgery is planned. 1 Imaging is for surgical planning, not diagnosis. 1

Common Pitfalls to Avoid

• Do not delay surgery based on age alone – 22% of elderly patients in one series had a mean 5-year delay before surgical referral, during which symptoms persisted unnecessarily 3
• Do not attribute symptoms to "normal aging" – fatigue, cognitive changes, bone pain, and depression may all be reversible with parathyroidectomy 3, 4
• Do not restrict dietary calcium – maintain normal calcium intake (1000-1200 mg/day) as restriction can worsen negative calcium balance and bone loss 1, 6
• Do not supplement with high-dose vitamin D until after surgery, as this can worsen hypercalcemia 1

Postoperative Monitoring

Anticipate "hungry bone syndrome" after removal of hyperfunctioning parathyroid tissue, especially given the osteopenia. 1 Measure ionized calcium every 4-6 hours for the first 48-72 hours postoperatively. 1 If ionized calcium drops below 0.9 mmol/L (≈3.6 mg/dL), initiate IV calcium gluconate infusion at 1-2 mg elemental calcium/kg/hour. 1 Transition to oral calcium carbonate 1-2 g three times daily plus calcitriol up to 2 µg/day once oral intake is feasible. 1