Indications for Treatment of Primary Hyperparathyroidism

The clinical presentation of primary hyperparathyroidism has changed from patients with symptomatic disease to those with only biochemical evidence of disease incidentally found on routine laboratory examination. Asymptomatic PHT has spurred investigation into the natural history of this disease and indications for treatment. It is accepted that surgery is indicated in patients who present with symptomatic PHPT such as kidney stones, nephrocalcinosis, renal dysfunction, osteopenia with fractures, osteitis fibrosa cystica, and altered neurologic function, delirium, or coma (stones, bones, moans, psychiatric overtones).


Surgical indications in patients with primary hyperparathyroidism. (Adopted from the 2002 National Institutes of Health Workshop)

1. Significant bone, renal, gastrointestinal, or neuromuscular symptoms typical of primary hyperparathyroidism

In asymptomatic patients

 2. Serum calcium     Elevation by 1 mg/dl or more above the normal range (i.e., ≥11.5 mg/dl in most laboratories)
 3. 24-hour urine calcium excretion  Marked elevation (e.g., >400 mg)
 4. Creatinine clearance  Decreased levels (e.g., reduced by ≥30% compared with age-matched normal persons)
 5. Bone density  Reduction in bone density of more than 2.5 standard deviations below peak bone mass at any measured site (hip, lumbar spine, wrist)
 6. Age  Younger than 50 years


Patients with asymptomatic PHPT who do not undergo surgery should be followed closely by measuring serum calcium level every 6 months, annual measurement of serum creatinine concentration and annual bone density measurement.


Treatment of Secondary Hyperparathyroidism

Secondary hyperparathyroidism in patients with chronic kidney disease can lead to significant bone and cardiovascular disease and impare quality of life.  The medical management of seconday hyperparathyroidism include dietary control, vitamin D metabolites, and calcimimetics (medications that mimic the action of calcium).  These may decrease the need for parathyroid surgery before kidney transplantation.  Parathyroid surgery is indicated when aggressive medical mangement fails to control severe hyperparathyroidism.  Surgical management of secondary hyperparathyroidism include subtotal parathyroidectomy or total parathyroidectomy and autotranplantaion. 


Treatment of Tertiary Hyperparathyroidism

Successful kidney transplantation corrects the physiologic and metabolic abnormalitis seen in secondary hyperparathyroidism, and parathyroid hormone levels drop significanly in the first few months after the transplantation.  Medical management with calcimimetics may be effective in the setting of recurrent or persistent disease.  Failure of medical management, significant hypercalcemia or bone loss are some of the indications for surgery in persistent or recurrent hyperparathyroidism after kidney transplant.   Localiztion studies should be considered in these patients; however, they may not be as sensitive as in the setting of primary hyperparathyroidism.  Surgical managemnt is similar to secondary hyperparathyroidism and include subtotal parathyroidectomy or total parathyroidectomy and autotransplantation.