Patients with severe secondary hyperparathyroidism (SHPT) who are on hemodialysis or have received a kidney transplant have better survival when treated with parathyroidectomy rather than the calcimimetic cinacalcet, according to new study findings.
In a propensity-score matched cohort study of 2023 patients treated with surgery and 2023 treated with cinacalcet from the US Renal Data System, the 5-year survival rate was significantly higher with surgery: 65.7% vs 57.9%, a team led by Eyas Alkhalili, MBBS, of Texas Tech Health Sciences Center in El Paso, Texas, reported in the World Journal of Surgery. The parathyroidectomy group also had a significant 23% lower risk of death within the study period compared with the cinacalcet group, according to a Cox regression analysis. Among kidney transplant recipients, those treated with parathyroidectomy vs cinacalcet had a significant 53% lower risk of death.
“Our study shows that the survival advantage of surgery over medical therapy persists more than a decade later and surpasses that of cinacalcet,” Dr Alkhalili’s team wrote. “Parathyroidectomy in ESRD patients, however, is associated with significant perioperative risks including a two percent 30-day postoperative mortality [rate] reported in the literature and 3.7% mortality risk in our study. Due to these risks, clinicians [need to] follow the KDIGO guidelines and only refer patients with severe refractory disease for surgery.”
Mean parathyroid hormone (PTH) levels were significantly higher in the surgery than cinacalcet group prior to therapy (2067 vs 1425 pg/dL, respectively) but dropped significantly lower after surgery (68 vs 516 pg/dL, respectively). Of the patients who underwent surgery, 17% subsequently received cinacalcet.
The parathyroidectomy group had significantly higher rates of calcific uremic arteriolopathy (calciphylaxis): 2.3% vs 1.1%) and pathologic fractures (27.8% vs 24.9%), the investigators reported. Rates of new-onset coronary artery disease and cerebrovascular disease were comparable.
Alvarado L, Sharma N, Lerma R, et al. Parathyroidectomy versus cinacalcet for the treatment of secondary hyperparathyroidism in hemodialysis patients. World J Surg. Published online January 12, 2022. doi:10.1007/s00268-022-06439-7