TOPLINE

In a large national cohort, researchers found that end-organ damage from primary hyperparathyroidism was more common than previously reported, affecting 51% of patients at diagnosis and a further 32% of those without baseline damage during follow-up; however, parathyroidectomy remained uncommon despite most patients meeting guideline criteria for surgery.

METHODOLOGY

• Primary hyperparathyroidism — a common endocrine disorder associated with osteoporosis, kidney stones, and chronic kidney disease (CKD) — is best treated with parathyroidectomy, but most patients are managed with observation alone.
• Researchers conducted a cohort study using national electronic health record and claims data from the US (2010-2023), identifying adults with a new biochemical diagnosis of primary hyperparathyroidism defined as a parathyroid hormone level > 65 pg/mL within 1 month after a second elevated calcium level (a serum calcium level > 10.2 mg/dL or an ionized calcium level > 1.3 mmol/L or > 5.3 mg/dL).
• A total of 43,399 patients with primary hyperparathyroidism (mean age, 67.9 years; 78% women) were included after excluding those with an estimated glomerular filtration rate < 30 mL/min/1.73 m² in the year before diagnosis, prior CKD stages 4 and 5, end-stage kidney disease, kidney transplant, or dialysis.
• The primary outcome was end-organ damage associated with primary hyperparathyroidism — including osteoporosis, atraumatic fracture, kidney stones, or incident CKD stage 3 or worse — at or after diagnosis. Secondary outcomes included parathyroidectomy after diagnosis and the proportion of patients meeting guideline criteria for surgery.
• Patients were followed until their last follow-up date or until parathyroidectomy; among the subset of patients who did not develop evidence of end-organ damage during the study, the median follow-up duration was 1269 days.

TAKEAWAY

• At diagnosis of primary hyperparathyroidism, 51.3% of patients had end-organ damage; 19.9% of these patients underwent parathyroidectomy during follow-up.
• Among 21,120 patients without end-organ damage at the diagnosis of primary hyperparathyroidism, 32.0% developed new end-organ damage during follow-up after a median of 516 days; just under 20% of these patients underwent parathyroidectomy.
• A total of 22,977 (52.9%) patients met the criteria for surgery at the diagnosis of primary hyperparathyroidism, and an additional 8608 (19.8%) developed at least one criterion after diagnosis, representing 31,585 patients (72.8% of the cohort); of those who met the criteria for surgery, 6999 (22.2%) underwent parathyroidectomy during follow-up, a median of 244 days after diagnosis.
• Among patients without baseline end-organ damage, the estimated 5-year cumulative incidence was 43.5% for any end-organ damage; severe hypercalcemia (> 11.2 mg/dL) was associated with a 45% higher hazard of end-organ damage than mild hypercalcemia (10.3-11.2 mg/dL; hazard ratio, 1.45; 95% CI, 1.32-1.60); however, this association attenuated over time.

IN PRACTICE

“The high prevalence of [primary hyperparathyroidism]-associated morbidity found in this national population calls for increased attention to the evaluation and management of these patients. Despite 67% of patients having [primary hyperparathyroidism]-associated morbidity and 72% meeting multidisciplinary guidelines for surgical management, fewer than 25% of patients underwent parathyroidectomy,” the authors wrote.

SOURCE

The study was led by Lia D. Delaney, MD, MS, Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine in Palo Alto, California. It was published online in JAMA Surgery.

LIMITATIONS

This was an observational study, so the researchers could not prove that primary hyperparathyroidism directly caused end-organ damage. The timing of end-organ damage depended on when clinicians detected it. Finally, although the study used a large linked electronic health record and claims database, some care may have occurred outside the contributing health systems, and some patients may have changed insurance during follow-up.

DISCLOSURES

This research was supported by the National Institutes of Health, National Institute on Aging. One author disclosed receiving grants from the National Institute on Aging during the conduct of the study.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.