Utilization of parathyroidectomy for secondary hyperparathyroidism in end-stage renal disease

BACKGROUND The utilization of parathyroidectomy (PTX) to manage secondary hyperparathyroidism (SHPT) refractory to medical management (MTX) in end-stage renal disease (ESRD) in the era of calcimimetics is not well known. METHODS Adult ESRD patients receiving dialysis between August 2007 and December 2011 at our institution with an intact parathyroid hormone (iPTH) level ≥88 pmol/L for 6 months associated with hypercalcemia and/or hyperphosphatemia for at least 50% of that period were included. Baseline characteristics and iPTH, calcium, phosphorus, calcium-phosphorus product and alkaline phosphatase (ALP) at baseline, 6 and 12 months were compared between the two groups (PTX versus MTX) using the χ (2) and paired t-tests. RESULTS Of the total population of 687 patients, 80 (11.6%) satisfied KDOQI criteria for PTX, most of whom did not receive PTX (81.2%). At baseline, PTX patients had been on dialysis longer (P = 0.001), with higher iPTH (P < 0.001), calcium (P = 0.008) and ALP (P = 0.001) and were less likely to be African-American (P = 0.007). Complete follow-up data at 6 months were available on 75 patients (PTX = 15; MTX = 60). PTX had significantly greater reduction in iPTH (93 versus 23%) and ALP (68 versus 0%) compared with MTX. Changes from baseline in calcium, phosphate or calcium-phosphorus product levels and proportion of patients achieving KDOQI target values were not significant for either intervention. Findings were consistent at 12 months. CONCLUSIONS A significant proportion of ESRD patients who met indications for PTX did not receive it. Additional studies are needed to understand the barriers that prevent patients from receiving PTX, thereby resulting in underutilization.