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Refractory hyperparathyroidism and indications for parathyroidectomy in adult patients on dialysis

Refractory hyperparathyroidism and indications for parathyroidectomy in adult patients on dialysis
Literature review current through: Jan 2024.
This topic last updated: Nov 29, 2023.

INTRODUCTION — This topic reviews refractory hyperparathyroidism and the indications for parathyroidectomy among patients on chronic dialysis. The medical management of hyperparathyroidism is discussed elsewhere. (See "Management of secondary hyperparathyroidism in adult nondialysis patients with chronic kidney disease" and "Management of secondary hyperparathyroidism in adult patients on dialysis".)

Surgical approaches to parathyroidectomy are discussed elsewhere. (See "Parathyroidectomy in end-stage kidney disease".)

DEFINITIONS AND PATHOGENESIS — We define refractory hyperparathyroidism as severe, persistent, and progressive elevation of serum parathyroid hormone (PTH) that cannot be treated adequately by medical therapy (including both vitamin D analogs and calcimimetics) without causing significant hyperphosphatemia or hypercalcemia.

There is no consensus on a PTH level that defines refractory hyperparathyroidism. Some clinicians define refractory hyperparathyroidism as a PTH level persistently >800 pg/mL, which is the level at which parathyroidectomy is often considered in symptomatic patients. Other clinicians use the Kidney Disease: Improving Global Outcomes (KDIGO) PTH target threshold for treatment, which is nine times above the upper limit of normal for the PTH assay (ie, 585 pg/mL if upper range of normal is 65 pg/mL). However, a parathyroidectomy is generally not performed at this level of PTH. (See "Management of secondary hyperparathyroidism in adult patients on dialysis".)

Severe hyperparathyroidism that is refractory to medical therapy suggests tertiary hyperparathyroidism, in which there is autonomous secretion of PTH that is not responsive to the plasma calcium concentration [1]. Tertiary hyperparathyroidism is often associated with hypercalcemia (in the absence of medications such as calcitriol, vitamin D, or calcium-containing phosphate binders) and symptoms and signs of high bone turnover. (See 'Signs and symptoms' below.)

Tertiary hyperparathyroidism develops after prolonged parathyroid stimulation from hypocalcemia, calcitriol deficiency, and hyperphosphatemia. These stimuli increase PTH synthesis and parathyroid cell proliferation [2-5]. Somatic mutations in the proliferating parathyroid cells lead to monoclonal expansion or adenomatous transformation of the tissue that can manifest as nodular hyperplasia and enlargement of the parathyroid glands [6]. Such transformed parathyroid cells do not respond to the normal PTH-suppressive stimuli, such as normalization of the serum calcium concentration or treatment with calcitriol. This lack of response to PTH-suppressive stimuli may be caused by reduced expression of the extracellular calcium-sensing receptor [2], lower-density of the vitamin D receptor [3], and decreased expression of klotho and fibroblast growth factor receptor 1 [7].

EPIDEMIOLOGY — The prevalence of refractory hyperparathyroidism is difficult to estimate because of variability in the definition and evolution in the medical therapies used to treat hyperparathyroidism. Because it is a definitive treatment for refractory hyperparathyroidism, the rate of parathyroidectomy is used to provide an estimate of prevalence.

Among patients on dialysis, the rate of parathyroidectomy for refractory hyperparathyroidism is approximately 7 to 10 per 1000 patient-years [8,9]. This rate has remained largely constant over the past several years despite advances in medical therapy, including the development of calcimimetic agents, such as cinacalcet, which decrease the risk for hypercalcemia [10].

Cinacalcet reduces the risk of parathyroidectomy [11,12]. This was demonstrated in the Evaluation of Cinacalcet Hydrochloride Therapy to Lower Cardiovascular Events (EVOLVE) randomized trial, in which patients were assigned to receive cinacalcet or placebo in addition to conventional therapy including phosphate binders and/or active vitamin D or synthetic analogs [11]. The rate of parathyroidectomy was lower in cinacalcet-treated patients compared with placebo (relative hazard ratio [HR] 0.44, 95% CI 0.36-0.54) [10,11].

However, an analysis of data from a national database spanning 2002 to 2011 showed that, although the rate of parathyroidectomies decreased between 2004 and 2005 (coinciding with availability of cinacalcet in the United States), the rate rose again in 2006 and remained stable thereafter, despite more widespread cinacalcet use [10]. A suggested reason for the discrepancy is that doses used in EVOLVE were higher than those used in clinical practice [10].

It is unclear whether the introduction of newer calcimimetic agents may reduce rates of parathyroidectomy among patients on dialysis. In patients on dialysis, the intravenous calcimimetic etelcalcetide lowers PTH levels more than cinacalcet [13,14] and is effective in many cases of severe hyperparathyroidism [15].

Refractory hyperparathyroidism requiring parathyroidectomy is far less common among chronic kidney disease (CKD) patients who are not on dialysis. In an analysis of 32,971 admissions for parathyroidectomy for secondary hyperparathyroidism performed in the United States between 2002 and 2011, 76 percent were performed in patient who had diagnostic or procedure codes specific for dialysis, whereas the remainder had other codes for kidney failure or transplantation [10].

SIGNS AND SYMPTOMS — The most common signs and symptoms of refractory hyperparathyroidism include [16,17]:

Bone and joint pain

Fractures

Proximal muscle weakness

Extraskeletal calcification (eg, in the vasculature)

Calciphylaxis

Pruritus

Hypercalcemia

Hyperphosphatemia

Bone and joint pain can be from osteitis fibrosa cystica, which is a high-turnover form of renal osteodystrophy resulting from unremitting hyperparathyroidism [17]. Pain is primarily present in weight-bearing joints, such as hips, knees, ankles, and lower back, and is generally relieved by rest [16]. Periarticular calcium deposits may cause acute joint inflammation and manifest with pain and stiffness [17]. Some patients present with nontraumatic or nonhealing fractures [16]. Spontaneous tendon ruptures, primarily involving the quadriceps, Achilles, and patellar tendons can occur, although these are uncommon [18-21].

Extraskeletal calcification may occur in vasculature and may be visible on imaging or present as calciphylaxis. (See "Calciphylaxis (calcific uremic arteriolopathy)" and "Vascular calcification in chronic kidney disease".)

Brown tumors, which are fibrotic, cystic, lytic bone lesions, can also occur in severe refractory hyperparathyroidism. A rare disfiguring manifestation of severe hyperparathyroidism is Leontiasis ossea or lion face syndrome [22].

Most clinical manifestations of hyperparathyroidism generally occur at a parathyroid hormone (PTH) level of over 1000 pg/mL. In the studies reporting on tendon rupture, patients had PTH levels of 1400 to 2000 pg/mL [20,21]. However, certain manifestations are often difficult to ascribe solely to hyperparathyroidism due to their nonspecific nature and overlap with other symptoms common among patients on dialysis. As examples: hyperphosphatemia is ubiquitous and difficult to control among patients on dialysis regardless of refractory hyperparathyroidism; hypercalcemia may occur from use of vitamin D analogs or calcium-containing phosphate binders; and bone pain is common with other types of renal osteodystrophy, including those not associated with hyperparathyroidism.

POTENTIAL INDICATIONS FOR PARATHYROIDECTOMY — Most experts agree that patients who have refractory hyperparathyroidism and significant associated signs and symptoms should be referred for parathyroidectomy. A much more controversial issue is whether patients with refractory hyperparathyroidism, but limited or no associated signs or symptoms, should also undergo parathyroidectomy. Among such patients, there is no consensus regarding indications for parathyroidectomy.

Symptomatic patients — We generally refer for a parathyroidectomy patients who have severe hyperparathyroidism despite optimal medical management that is accompanied by hyperparathyroid-related signs and symptoms. Parathyroidectomy is effective in treating the signs and symptoms of severe hyperparathyroidism [23-27].

Optimal medical management is defined as treatment with phosphate binders, active vitamin D analogs, and calcimimetics. (See "Management of secondary hyperparathyroidism in adult patients on dialysis" and "Management of secondary hyperparathyroidism in adult patients on dialysis", section on 'Treatment approach'.)

As noted above, the threshold parathyroid hormone (PTH) value that provides an indication for parathyroidectomy among patients with signs or symptoms is not known. We believe that, for most patients, parathyroidectomy should not be performed unless PTH levels are consistently >800 pg/mL [28]. This is because many of the symptoms that may be attributed to hyperparathyroidism (such as pain, weakness, and pruritus) are nonspecific and are present in patients on dialysis who do not have significant hyperparathyroidism. PTH levels lower than 800 pg/mL are less likely to be the cause of such symptoms.

Symptoms should be critically evaluated to make sure that other obvious causes are not present. The medical management should be reviewed to make sure treatment is optimized. (See "Management of secondary hyperparathyroidism in adult patients on dialysis", section on 'Treat high parathyroid hormone'.)

The following signs and symptoms potentially warrant parathyroidectomy in the setting of elevated PTH values. Data supporting parathyroidectomy are provided.

Hypercalcemia and refractory hyperphosphatemia – Hypercalcemia and refractory hyperphosphatemia are the most common reasons for parathyroidectomy to treat refractory hyperparathyroidism [23]. Other causes of hypercalcemia should be excluded, and the treatment of hyperphosphatemia should be reviewed before the parathyroidectomy to be certain that medical options have been tried. (See "Diagnostic approach to hypercalcemia" and "Management of hyperphosphatemia in adults with chronic kidney disease", section on 'Patients on dialysis'.)

Parathyroidectomy effectively treats hyperparathyroidism-related hypercalcemia and hyperphosphatemia [24-26]. In a study of 1402 patients, the median calcium concentration fell from 9.6 to 7.9 mg/dL, and the serum phosphorus fell from 6.8 to 3.8 mg/dL following parathyroidectomy [29].

Bone pain, pruritus, and myopathy – Bone pain and/or fractures; severe, unexplained muscle weakness; or pruritus are potential indications for parathyroidectomy. These symptoms are nonspecific, however, and, as noted above, commonly observed in patients on dialysis who do not have refractory hyperparathyroidism. Symptoms should not be attributed to hyperparathyroidism (particularly if the PTH is <800 pg/mL) unless other causes have been excluded. (See "Chronic kidney disease-associated pruritus", section on 'Diagnosis' and "Myopathies of systemic disease".)

Bone pain, in particular, may be due to other forms of renal osteodystrophy, such as adynamic bone disease, which may be worsened by parathyroidectomy. While adynamic bone disease is virtually excluded by PTH >800 pg/mL, lower PTH values (particularly closer to 450 pg/mL) do not conclusively exclude this form of bone disease [27]. Thus, if parathyroidectomy is considered in a patient who has bone pain and PTH <800 pg/mL, a bone biopsy should be performed first. (See "Evaluation of renal osteodystrophy".)

Parathyroidectomy effectively treats hyperparathyroidism-related bone pain, pruritus, and myopathy [24-26]. In one study that included 91 end-stage kidney disease (ESKD) patients (80 on dialysis and 11 transplant patients), symptoms of bone pain and weakness were alleviated in 95 percent [24].

Calciphylaxis – Calciphylaxis (calcific uremic arteriolopathy) is associated with severe hyperparathyroidism and is a potential indication for parathyroidectomy. However, parathyroidectomy has not been conclusively shown to provide a beneficial effect. (See "Calciphylaxis (calcific uremic arteriolopathy)", section on 'Summary and recommendations'.)

There have been no systematic or prospective evaluations of the effectiveness of parathyroidectomy due to the sporadic nature of calciphylaxis. Observational reports have suggested improved survival among patients with calciphylaxis who underwent parathyroidectomy. As an example, in a retrospective review of the literature, 38 of 58 patients (66 percent) who underwent parathyroidectomy survived compared with 13 of 37 patients (35 percent) who did not undergo parathyroidectomy [30].

In addition to alleviating the signs and symptoms of hyperparathyroidism, parathyroidectomy may also improve survival and other outcomes, although only observational studies are available. (See 'Asymptomatic patients' below.)

Asymptomatic patients — We refer for parathyroidectomy select patients on dialysis who have PTH levels persistently >1000 pg/mL despite optimal medical management, even in the absence of associated clinical symptoms [31]. Among such patients, parathyroidectomy may reduce mortality, cardiovascular risk, and the risk of fracture, although benefits have only been shown in observational studies.

Optimal medical management is defined as treatment with phosphate binders, active vitamin D analogs, and calcimimetics. (See "Management of secondary hyperparathyroidism in adult patients on dialysis" and "Management of secondary hyperparathyroidism in adult patients on dialysis", section on 'Treatment approach'.)

However, this is a controversial issue, and there is little consensus among experts regarding the indication for parathyroidectomy [32].

In particular, there is concern that increased PTH alone is insufficient evidence of high-turnover bone disease. However, in our experience, very high PTH concentrations (such as that which provides indication for parathyroidectomy) correlate better with bone turnover than do those in target range of two to nine times the upper limit of normal.

Some clinicians use bone-specific alkaline phosphatase in addition to PTH as an indication for parathyroidectomy; concordantly, elevated levels of PTH and alkaline phosphatase have been proposed as a useful indicator of severity. However, in a large bone biopsy study, both PTH and bone-specific alkaline phosphatase were able to predict high-turnover bone disease, and the combination of the two tests added minimal additional predictive value [33].

The selection of patients for parathyroidectomy must be individualized, depending on age and comorbidities. We generally reserve parathyroidectomy for younger patients (ie, <65 years) who have few comorbidities. Such patients are most likely to tolerate surgery and reap the potential long-term benefits of parathyroidectomy.

The absence of clinical symptoms may warrant a closer examination for underlying bone disease since symptoms are often subtle and many patients who actually do have bone disease may not describe pain. However, even in patients who do have subtle symptoms that may be attributed to hyperparathyroidism, these symptoms would not provide an indication for parathyroidectomy with PTH <1000 pg/mL.

Possible benefits of parathyroidectomy include decreased mortality, increased bone density and reduced fracture risk, decreased resistance to erythropoietin, and improved nutrition [34-46]. These are discussed below.

Survival – Outcomes data following parathyroidectomy are entirely from observational studies. A number of studies have suggested that parathyroidectomy is associated with increased survival [34,35,47]. In one study, 150 patients on dialysis who underwent parathyroidectomy at one institution were compared with 1044 matched control patients who did not undergo parathyroidectomy, identified from the United States Renal Data System (USRDS) registry [35]. The mean PTH value among the parathyroidectomy cohort was 1776 pg/mL. At a mean follow-up of 3.6 years, compared with controls, parathyroidectomy was associated with decreased mortality (hazard ratio [HR] 0.68, 95% CI 0.52-0.89).

Improved survival may be related to decreased cardiovascular mortality. In a study of 4428 patients who underwent parathyroidectomy and were compared with matched controls who did not undergo parathyroidectomy despite severe hyperparathyroidism, parathyroidectomy was associated with 34 and 41 percent lower risks for all-cause and cardiovascular mortality at one year [47]. This survival benefit was not evident in patients who had persistent secondary hyperparathyroidism postoperatively. In fact, the hazard ratio for mortality was lowest in those with the lowest postoperative PTH levels.

However, there is a relatively high mortality immediately following the procedure, and morbidity increases during the first year following parathyroidectomy. Using data obtained from the medical evidence report (which provides diagnostic information on all new ESKD patients in the United States), the United Network for Organ Sharing (UNOS) database, and Medicare claims, one analysis compared adverse events that occurred before and after parathyroidectomy in 4435 selected ESKD patients [48].

Mortality was 2 percent during the immediate hospitalization and in the 30 days following discharge. Twenty-five percent of patients required an intensive care unit (ICU) admission during the immediate hospitalization.

Twenty-four percent of patients were rehospitalized in the 30 days following discharge, and 29 percent of these required an ICU admission. One-year morbidity and mortality rates have been reported from analyses of data from the USRDS [34,48].

It is not clear whether these results may be generalized to a broader ESKD population, since all included patients were Medicare participants who were undergoing in-center hemodialysis.

Bone density and fracture risk – Parathyroidectomy may increase bone density and reduce the risk of fracture. Multiple single-center case series have reported increased bone mineral density after parathyroidectomy [36-38]. One retrospective, case-control study found that parathyroidectomy was associated with reduced risk for hip fracture (0.68, 95% CI 0.54-0.86) and all fractures (0.69, 95% CI 0.57-0.83) [39].

Other – Some studies have suggested improvements in erythropoietin-resistant anemia [40-42], nutritional status, and humoral and cellular immunity [43,44].

PATIENTS AWAITING TRANSPLANTATION — For patients who are actively awaiting transplantation and have refractory hyperparathyroidism, we consult with the transplant center regarding the timing of parathyroidectomy. There is variability among transplant centers in the recommended approach for potential transplant recipients who have refractory hyperparathyroidism.

Most transplant experts suggest parathyroidectomy for patients with severe refractory hyperparathyroidism and moderate to severe symptoms, particularly if transplantation is not imminent. For patients with refractory hyperparathyroidism who have mild or no symptoms, transplant nephrologists have differing recommendations, although the threshold PTH for parathyroidectomy is typically lower compared with patients who are not awaiting transplantation. (See "Kidney transplantation in adults: Persistent hyperparathyroidism after kidney transplantation", section on 'Prevention'.)

A rationale for performing parathyroidectomy prior to transplant is that refractory hyperparathyroidism fails to resolve in many patients after transplantation (see "Kidney transplantation in adults: Persistent hyperparathyroidism after kidney transplantation", section on 'Pathophysiology') [49-51]. Persistent hyperparathyroidism following transplantation may lead to hypercalcemia, hypophosphatemia, and decreased graft function [52-54]. In addition, parathyroidectomy may be safer if performed prior to transplantation. Parathyroidectomy performed after transplantation has been associated with abrupt deterioration of kidney allograft function [55].

For potential recipients of deceased-donor kidneys, but not living-donor kidneys, the decision regarding parathyroidectomy may also depend on the anticipated time on the waiting list, which will vary based upon the geographic region. The indications for parathyroidectomy for patients who are expected to have a prolonged wait on the deceased-donor waiting list are likely the same as for patients who are not awaiting transplantation. (See 'Symptomatic patients' above and 'Asymptomatic patients' above.)

KIDNEY TRANSPLANT RECIPIENTS — The indications for parathyroidectomy in transplant recipients are discussed separately. (See "Kidney transplantation in adults: Persistent hyperparathyroidism after kidney transplantation".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic kidney disease-mineral and bone disorder".)

SUMMARY AND RECOMMENDATIONS

Definition of refractory hyperparathyroidism – We define refractory hyperparathyroidism as persistent and progressive elevations of serum parathyroid hormone (PTH) that cannot be lowered to acceptable levels by medical therapy (including both vitamin D analogs and calcimimetics) without causing significant hyperphosphatemia or hypercalcemia. (See 'Definitions and pathogenesis' above.)

Symptomatic patients – We refer for parathyroidectomy most patients on dialysis who have persistent hyperparathyroidism (PTH levels >800 pg/mL), which is refractory to medical therapies and is accompanied by clearly related signs and symptoms. Parathyroidectomy is effective in mitigating most hyperparathyroidism-associated signs and symptoms. It is important to exclude other potential causes of the signs and symptoms prior to parathyroidectomy. (See 'Symptomatic patients' above.)

Asymptomatic patients – We perform parathyroidectomy for selected patients on dialysis who have very severe, sustained hyperparathyroidism (PTH levels >1000 pg/mL) that is refractory to medical therapies, even if not accompanied by associated signs and symptoms. The selection of patients must be individualized, depending on age and comorbidities. We generally reserve parathyroidectomy for younger patients (ie, <65 years) and with few comorbidities. Potential but unproven benefits may include improved survival, fracture risk, nutrition, and anemia. (See 'Asymptomatic patients' above.)

Patients awaiting transplantation – For patients with refractory hyperparathyroidism who are actively awaiting transplantation, decisions regarding parathyroidectomy should be jointly made with the transplant center. (See 'Patients awaiting transplantation' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Robert E Cronin, MD, and Michael Berkoben, MD, who contributed to earlier versions of this topic review.

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