Early parathyroidectomy within 1 year of diagnosis of primary hyperparathyroidism (PHPT) is measured by a reduction in estimated glomerular filtration rate (eGFR) of at least 50% compared to observation (no surgery) did not reduce the risk of sustained decline in renal function, ) Adults over the age of 60.
However, early parathyroidectomy was associated with a reduced adjusted risk of renal decline in newly diagnosed PHPT patients younger than 60 years.
The findings, based on data from nearly 43,000 veterans, publish online April 11th Annals of internal medicine.
“An important takeaway from our study is that older people [age 60 or older] In patients with primary hyperparathyroidism, preserving renal function should not be the primary consideration in deciding whether to undergo parathyroidectomy,” said lead author Carolyn D. Seib, MD. rice field. Medscape Medical News on mail.
“It is also important that physicians discuss with their patients the potential long-term benefits of parathyroidectomy related to reduced risk of fractures, kidney stones, cardiovascular disease, and improved quality of life. These are weighed against the risks of surgery for the patient,” said Seib, a surgeon at Palo Alto VA Medical Center in California.
“However, in patients younger than 60 years, early parathyroidectomy may prevent progression to chronic kidney disease (CKD) and warrants stronger consideration.
A parathyroidectomy is a low-risk outpatient procedure for most adults, she said.
“Potential complications of surgery include temporary or permanent hoarseness, hypoparathyroidism (postoperative hypoparathyroidism), bleeding requiring return to the operating room, and general anesthesia-related All of these are rare.
“Patients should seek out an experienced parathyroid surgeon because mass-surgeon surgery is associated with a lower risk of complications,” she emphasized.
Furthermore, parathyroidectomy is the only treatment for primary hyperparathyroidism.
Does Parathyroidectomy Delay Loss of Renal Function?
Multidisciplinary guidelines recommend parathyroidectomy to at least partially reduce the risk of CKD progression and associated effects in patients with PHPT and eGFR <60 mL/min/1.73 m.2the researchers write.
However, it is not clear whether parathyroidectomy delays loss of renal function in adults with PHPT.
The guidelines state that “If the patient has no obvious end-organ damage (i.e., eGFR > 60 mL/min/1.73 m2normal bone density, and no history of kidney stones or fractures,” Seib said.
To address the evidence gap, researchers used observational data to emulate a randomized, targeted trial.
In this type of study, “patients are not randomly assigned to treatment, but complex statistical techniques are used to adjust for baseline confounders, emulate random treatment assignment, and We describe biases that may affect the timing of patients receiving treatment.”
Using data from the National Veterans Health Administration, the researchers found that elevated serum calcium levels (>32.55 mmol/L or >10.2 mg) followed by elevated parathyroid hormone (>65 ng/mL) within 6 months. We identified 43,697 veterans with a new biochemical diagnosis of PHPT, defined as . /dL), from 2000 to 2019.
Of these patients, 3804 underwent parathyroidectomy within 1 year of diagnosis of PHPT, 39,893 did not, and a watchful waiting approach was adopted instead.
Patients with an eGFR greater than 30 mL/min/1.73 m were required for inclusion in the analysis.2 12 months prior to PHPT diagnosis to rule out secondary or tertiary hyperparathyroidism.
The primary outcome was a sustained reduction in eGFR of at least 50% from baseline.
Across the cohort, patients had a mean pretreatment eGFR of 71.8 mL/min/1.73 m.2Their average age was 67, 88% were male and 68% were white.
After a median follow-up of 4.9 years, 6.7% of patients had at least a 50% reduction in eGFR.
The cumulative incidence of this eGFR decline was 5.1% and 12.0%, respectively, in patients who did not undergo surgery, compared with 5.1% at 5 years and 10.8% at 10 years in patients who underwent early parathyroidectomy. was.
In the overall population, the risk of at least a 50% reduction in eGFR was similar in the early parathyroidectomy and observation groups (adjusted hazard ratio [HR]0.98; 95% CI, 0.82–1.16).
However, digging deeper, parathyroidectomy was associated with reduced risk of primary outcomes in patients younger than 60 years (adjusted HR, 0.75; 95% CI, 0.59–0.93), but not in patients older than 60 years. This was shown not to be the case in the patient (adjusted HR, 1.08). 95% CI, 0.87–1.34).
“When participating in shared decision-making for older adults [age 60 and older] When using PHPT, clinicians should not consider parathyroidectomy for the potential benefit of preserving renal function,” the researchers reiterated.
“For younger patients, clinicians should discuss the potential benefits of parathyroidectomy to reduce the risk of CKD and related complications in adults with PHPT,” they conclude.
This study was funded by the National Institute on Aging.writers No related financial relationships have been reported.
Anne of internal medicine. Published online on April 10, 2023. overview
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