Hazards of delay: Impact of parathyroidectomy timing on outcomes in secondary hyperparathyroidism of renal origin.

Abstract

Background: Surgical management is recommended in patients with secondary hyperparathyroidism when parathyroid hormone levels exceed 9 times the normal, and medical management has failed to control parathyroid hormone levels or associated complications. We aimed to examine the impact of the timing of parathyroidectomy on clinical outcomes in patients with secondary hyperparathyroidism and parathyroid hormone exceeding 9 times the normal.

Methods: In this retrospective cohort study using the TriNetX database, we included adults with a parathyroid hormone level of ≥600 pg/mL with concurrent stage 5 chronic kidney disease or an estimated glomerular filtration rate of ≤15 mL/min/1.73 m² who underwent parathyroidectomy. Patients with prior kidney transplants were excluded. Parathyroidectomy timing was classified as early (≤2 years) or delayed (>2 years) from the index parathyroid hormone elevation. Cohorts were propensity score matched based on demographics, Charlson comorbidities, body mass index, laboratory values, dialysis dependence, and medication use. A secondary matched analysis compared outcomes in kidney transplant recipients undergoing parathyroidectomy before versus after transplantation. Outcomes measured were fatigue, hypercalcemia, osteoporosis, and cardiovascular complications after the index event.

Results: A total of 1,413 patients underwent parathyroidectomy without prior kidney transplant. Of these, 916 (64.8%) underwent early and 497 (35.2%) underwent delayed parathyroidectomy. Kidney transplant occurred in 15.8% of early and 35.8% of delayed patients at median intervals of 1.8 and 3.9 years. After matching at the index parathyroid hormone elevation (n = 730), the mean age was 44 years, with 50% female and 43% Black. Delayed parathyroidectomy was associated with a higher risk of malaise and fatigue (hazard ratio = 1.5; P = .02), osteoporosis (hazard ratio = 1.63; P = .04), and hypercalcemia (hazard ratio = 1.42; P = .01). Cardiovascular complications were significantly more frequent in the delayed group. In a secondary analysis of kidney transplant recipients (n = 1,054), parathyroidectomy performed after transplantation was associated with a 2.6-fold increased hazard of graft failure.

Conclusions: In patients with secondary hyperparathyroidism undergoing parathyroidectomy, early surgery performed at a parathyroid hormone level of 9 times the normal may mitigate the risk of complications.