Despite an evolution in medical treatments for secondary hyperparathyroidism (SHPT), including the introduction of the first oral calcimimetic in 2004, parathyroidectomy (PTx) use has been steadily increasing among the dialysis population with Medicare coverage, a new study finds.
Of 379,835 patients with SHPT in the 2006-2016 US Renal Data System, 1.1% were treated with PTx, 10.5% cinacalcet, 64.1% phosphate binders, 4.6% vitamin D analogs, and 22.9% no treatment.
From 2006 to 2016, calcimimetic use significantly increased 3.5-fold, PTx use 3.4-fold, and phosphate binder use 1.7-fold, Aarti Mathur, MD, PhD, of Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues reported in Surgery. There was no clear trend for vitamin D prescription, perhaps because it is included in the dialysis bundled payment.
Compared with 2006-2009, PTx treatment significantly increased 52% during 2010-2013 and 106% during 2014-2016. Approximately 20% of patients were prescribed a combination of all medical therapies for SHPT before undergoing PTx. The PTx rate was 0.1% at 1 year, 1.9% at 5 years, and 6.5% at 10 years after dialysis initiation.
“The combination of differences in [parathyroid hormone] targets, lack of consensus in treatment strategies among guidelines, and practice variation all likely contribute to the variation and overlap of treatments and the rise in parathyroidectomy rates that surgeons performing these procedures should be aware of,” Dr Mathur’s team wrote.
PTx use increased the most among patients who were aged 18-64 years, Black, female, Southern, poor, and waitlisted for kidney transplantation. The investigators noted that KDIGO guidelines recommend delaying kidney transplantations in patients with severe SHPT until their disease is adequately managed, which has likely led to the increased rate of PTx in this group.
Mathur A, Ahn JB, Sutton W, Zeiger MA, Segev DL, McAdams-DeMarco M. Increasing rates of parathyroidectomy to treat secondary hyperparathyroidism in dialysis patients with Medicare coverage. Surgery. Published online March 18, 2022. doi:10.1016/j.surg.2022.02.005