Parathyroidectomy Lowers Mortality, Cognitive Impairment, and Sepsis Risk vs. Calcimimetics in Dialysis Patients with SHPT

Patients with end-stage renal disease (ESRD) on dialysis frequently develop secondary hyperparathyroidism (SHPT), a complex condition characterized by excessive parathyroid hormone (PTH) secretion. This imbalance contributes to chronic kidney disease-mineral and bone disorder (CKD-MBD), increasing risks of bone fractures and cardiovascular complications. Current treatments include calcimimetics (CAMs), which suppress PTH secretion, and parathyroidectomy (PTx), a surgical removal of parathyroid glands. While both manage PTH levels, their comparative long-term impact on broader systemic outcomes beyond bone and mineral health, such as mortality, cardiovascular events, and cognitive function, remains largely undefined, presenting a critical gap in treatment guidance.

Researchers conducted a retrospective multicenter cohort study using the TriNetX research network (2010-2024). They included adult dialysis patients with ESRD and severe SHPT, defined by at least one historical intact parathyroid hormone level >600 pg/mL prior to treatment. Patients were divided into two groups: those receiving parathyroidectomy (PTx) and those on calcimimetic (CAM) therapy, with patients receiving both excluded. After 1:1 propensity score matching for demographics, comorbidities, medications, and laboratory variables, 22,580 patients were included (11,290 in each group). Outcomes like all-cause mortality, major adverse cardiovascular events (MACE), fracture, cognitive impairment, and sepsis were compared using Cox proportional hazards models over a follow-up period extending to 7 years.

After rigorous propensity score matching, parathyroidectomy (PTx) was associated with significantly lower risks across several critical outcomes compared to calcimimetic (CAM) therapy. PTx patients experienced a reduced risk of all-cause mortality, with a hazard ratio (HR) of 0.914 (95% confidence interval [CI] 0.860-0.972). Furthermore, PTx conferred a substantial benefit in cognitive health, showing a lower risk of mild cognitive impairment (MCI) with an HR of 0.646 (95% CI 0.436-0.955). The study also highlighted a protective effect against infections, as PTx was linked to a decreased risk of sepsis, reflected by an HR of 0.844 (95% CI 0.765-0.930). No significant differences were observed between the two treatment modalities for MACE, fracture, hungry bone disease, overall cognitive impairment, or malignancy. These findings suggest that the benefits of PTx extend beyond the traditional scope of mineral and bone disorder management.

Parathyroidectomy reduced all-cause mortality by nearly 9% and mild cognitive impairment by over 35% compared to calcimimetic therapy.