番茄社区

Most older adults with primary hyperparathyroidism (PHPT) did not receive definitive parathyroidectomy, researchers reported.

In a retrospective analysis of over 210,000 Medicare beneficiaries, only 30% underwent this operation within a year of their initial diagnosis, reported Carolyn Dacey Seib, MD, of Stanford University School of Medicine in California, and colleagues.

Out of the 131,723 of these patients with PHPT who met consensus guidelines criteria for undergoing this operative management -- defined as diagnosis of osteoporosis, nephrolithiasis, or stage 3 chronic kidney disease (CKD) -- only 29.6% underwent a parathyroidectomy, they stated in .

"Parathyroidectomy is the only definitive treatment for PHPT," Seib's group wrote, adding that "Evidence based criteria for the operative management of PHPT have expanded significantly since the were published in 1991."

"However, despite more and evidence that operative cure results in benefits across multiple dimensions, including a reduced risk of fractures and symptomatic nephrolithiasis and improved quality of life, rates of parathyroidectomy for the management of PHPT are low and have been declining over time," they stated.

In terms of meeting consensus guideline criteria, having a history of nephrolithiasis was the one factor that was tied to the highest chance of undergoing a parathyroidectomy within a year of PHPT diagnosis (odds ratio 1.43, 95% CI 1.39-1.47). On the other hand, stage 3 CKD was associated with a far lower chance of surgical treatment (OR 0.71, 95% CI 0.68-0.74), while a diagnosis of osteoporosis neither increased nor decreased the chances of a parathyroidectomy (OR 1.01, 95% CI 0.99-1.03).

Other clinical factors were also predictive of a patient not receiving surgical treatment, and instead receiving nonoperative management of PHPT, such as older age. Compared with patients ages 66-75, those who ages 76-85 were 32% (OR 0.68, 95% CI 0.67-0.70) less likely to undergo surgery while those older than age 85 were 73% (OR 0.27. 95% CI 0.26-0.29) less likely to undergo surgery.

People who were moderately to severely frail were also significantly less likely to undergo parathyroidectomy than robust patients (OR 0.60, 95% CI 0.56-0.64). Additionally, those with comorbidities -- defined as a score of 2 or higher on the Carlson Comorbidity Index -- were also significantly less likely to undergo a parathyroidectomy (OR 0.77, 95% CI 0.75-0.79).

The population-based study consisted only of Medicare claims from beneficiaries with an initial diagnosis of PHPT between 2006 and 2016 based on ICD-9 and ICD-10 codes. Patients were excluded if they had stage 4 or 5 CKD, were on dialysis, had a history of kidney transplant, or with possible secondary or tertiary hyperparathyroidism. Nearly 80% of the cohort was female, and more than half were between ages 66-75. Also, nearly 90% of the group was white.

In an , Martin Almquist, MD, PhD, and Martin Nilsson, MD, both of Lund University in Sweden, pointed out that the inclusion of additional patient information, such as serum and urinary calcium levels, as well as levels of 25-hydroxy vitamin D, would've been beneficial. Other study limitations included a lack of data on preoperative localization studies, they noted.

Nonetheless, Almquist and Nilsson praised the authors for pinpointing an area "an area where the medical community can improve" and that more patients with PHPT should be appropriately treated according to guidelines.

Comment