What are the indications for surgery for tertiary hyperparathyroidism?
- Although all patients with dialysis-dependent renal failure develop secondary hyperparathyroidism, only a minority of patients develop tertiary hyperparathyroidism, which develops when somatic mutations occur within one or more of the hyperplastic parathyroids resulting in adenomatous transformation.
- Medical management with phosphate binders, active vitamin D analogues (calcitriol), and calcimimetics (Cinacalcet) will keep the PTH, calcium, and phosphate levels under control in most patients.
- Most experts agree that parathyroidectomy is indicated in patients who, despite optimal medical management, have refractory hyperparathyroidism (PTH > 800 pg/mL) and significant associated signs and symptoms.
- The most common signs and symptoms include hypercalcemia with hyperphosphatemia (calcium × phosphate product = > 50), bone and joint pain and/or fractures, proximal muscle weakness, extraskeletal calcification and/or calciphylaxis, and pruritus.
- Indications for parathyroidectomy in asymptomatic patients with refractory hyperparathyroidism is more controversial, but some recommend it for patients who have PTH > 1000 pg/mL, who are younger (i.e., age < 65 years), and who do not have other significant comorbidities.
