A retrospective analysis of the management of renal hyperparathyroidism; evaluating changes in practice and outcome in an era of calcimimetics

Purpose: Hyperparathyroidism (HPT) is a common and significant complication of chronic kidney disease (CKD). Both parathyroidectomy and cinacalcet, are used routinely in an effort to manage this cohort. Unfortunately, there remains no guideline consensus on how best to combine these treatments into an effective strategy. We look to assess the efficacy of these interventions and identify factors predicting recurrence and the development of post-operative complications. We also examine changes in our practice nationally following the arrival of cinacalcet as an alternative or an abridge to definitive surgical management. Methods: This was a nationwide study. We conducted a retrospective analysis of a prospectively maintained database. All patients who underwent a parathyroidectomy as management of secondary or tertiary HPT between 1999 and 2023 were included. A control group of patients managed with cinacalcet were also included. Results: Our cohort included 155 patients managed with parathyroidectomy and 203 patients treated with cinacalcet. Pre-operative Alkaline phosphatase > 200 IU/L was predictive of hungry bone syndrome (HBS) on univariate (P = 0.003) and multivariate (P = 0.002) analysis, whilst a PTH > 1000 pg/ml (P = 0.012) was also predictive of HBS on univariate analysis. In an attempt to identify an optimal PTH cut off to trigger surgical referral we found mean serum PTH levels were significantly higher at 5 years in the cohort of patients who had a PTH > 1000 pg/ml prior to surgical intervention (39 ± 32 Vs 374 ± 544, P = 0.045). Conclusions: Our findings re-emphasise the efficacy and safety of parathyroid surgery in the management of renal HPT and suggest earlier surgical referral may improve the incidence of post-operative HBS and recurrent HPT.