Which patients with primary hyperparathyroidism should undergo parathyroidectomy?
All patients with primary hyperparathyroidism and “classic” symptoms attributable to the disease (e.g., kidney stones, severe bone disease/fragility fractures, overt neuromuscular syndrome) should undergo surgical intervention; however, most patients do not have these classic symptoms. The National Institutes of Health (NIH) established criteria to assist clinicians in determining which patients with “asymptomatic” HPT should undergo surgery. If the patient meets any one of the criteria then surgery is recommended:
• Age < 50 years
• Serum calcium level > 1 mg/dL above normal
• Bone mineral density reduced > 2.5 standard deviations below mean peak adult value (T score)
• Impaired renal function (glomerular filtration rate < 60 mL/minute)
• Severe hypercalciuria (24-hour calcium > 400 mg/24 hr)
• Silent nephrolithiasis on radiography, ultrasonography, or computed tomography (CT)
• Silent vertebral fractures on spine radiography, CT, or magnetic resonance imaging (MRI)
• Patients unwilling or unable to undergo surveillance
If the patient does not meet any of the criteria, then either surgery or continued surveillance are reasonable and safe options.