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.