Study Finds Surgery Significantly Underused in Primary Hyperparathyroidism With End-Organ Damage

• Nearly 51% of adults diagnosed with primary hyperparathyroidism present with existing end-organ damage, primarily stage 3 or worse chronic kidney disease.
• Only 19.9% of patients with documented organ damage undergo parathyroidectomy during routine follow-up, highlighting a major gap between clinical guidelines and actual practice.
• Researchers emphasize that while surgery remains underutilized, care pathways must carefully balance patient-level comorbidities and risks rather than prompting a blanket increase in surgical rates.

The study, led by Carolyn D. Seib, MD, MAS, of the Stanford University School of Medicine in California, analyzed administrative and clinical data across a massive national cohort to evaluate real-world management patterns. The findings show that among over 43,000 adults with biochemically diagnosed PHPT, 51.3% exhibited end-organ damage at the time of diagnosis. For these patients, parathyroidectomy occurred in just 19.9% of cases, taking place at a median of 208 days after diagnosis. Among patients initially free of organ damage, 32% developed newly documented evidence of complications during longitudinal follow-up. Of those, exactly 19.9% underwent parathyroidectomy a median of 154 days after the complication was detected.

Guidelines from professional societies explicitly recommend parathyroidectomy for patients showing evidence of end-organ damage because surgery serves as the only definitive treatment for primary hyperparathyroidism. Yet, as Seib and colleagues noted, most patients are managed nonoperatively through observation and selective treatment of complications. This conservative approach often stems from a widespread clinical perception that primary hyperparathyroidism is a low-risk disorder, particularly when disease presentation is mild or asymptomatic. At diagnosis, the most frequent manifestation of organ damage was stage 3 or worse chronic kidney disease at 72.8%, followed by kidney stones at 21.2%, osteoporosis at 21.1%, and atraumatic fractures at 12.4%. During follow-up monitoring, incident complications shifted, with newly developed osteoporosis leading at 18.9%, followed by stage 3 or worse chronic kidney disease at 10.5%, kidney stones at 6.9%, and atraumatic fractures at 5.6%.

In an accompanying commentary published alongside the study, Michael W. Yeh, MD, of the UCLA David Geffen School of Medicine in Los Angeles, pointed out the diagnostic complexities inherent in aging populations. Because kidney function and bone mineral density naturally decline with normal aging, distinguishing whether primary hyperparathyroidism directly drives these changes or merely coexists alongside them presents a substantial clinical hurdle. Yeh referenced an observational study of veterans that found no long-term kidney function benefit from parathyroidectomy, contrasted against a retrospective cohort study tying the surgery to a 24% to 63% reduction in fracture risk over a 10-year period depending on fracture type. Taken together, these data indicate that the skeletal system acts as the principal target organ in primary hyperparathyroidism, where prolonged exposure to elevated parathyroid hormone and hypercalcemia amplifies systemic risk.

To bridge the gap between published guidelines and everyday clinical encounters, healthcare institutions must refine their referral networks.

Ultimately, while parathyroidectomy remains markedly underutilized, the study authors cautioned against a blanket increase in surgical volume. Future clinical efforts must instead prioritize care pathways that improve patient identification, risk stratification, and timely referral while carefully accounting for patient-level heterogeneity in comorbidities and personal preferences. Developing systems of care that emphasize appropriate surgical candidacy remains essential to delivering high-value, patient-centered care.

*Disclaimer: The information provided in this article is for educational and scientific communication purposes only and does not constitute medical advice. Always consult with a qualified healthcare provider regarding any medical condition, diagnosis, or treatment plan.*