Stones left unturned: Missed opportunities to diagnose primary hyperparathyroidism in patients with nephrolithiasis

A thorough evaluation for primary hyperparathyroidism: More than a stone's throw away

BACKGROUND

Primary hyperparathyroidism (PHPT) is a treatable cause of nephrolithiasis. However, PHPT is not consistently evaluated in nephrolithiasis patients. Symptoms of parathyroid disease were explored in relation to evaluation of PHPT in nephrolithiasis patients.

METHODS

Patients with nephrolithiasis on imaging between 2017 and 2021 were identified. Measurement of serum calcium levels after nephrolithiasis diagnosis was determined. Patients with hypercalcemia (≥ 10.2 ​mg/dL) were identified. Characteristics associated with parathyroid hormone (PTH) evaluation and specialist referral were assessed.

RESULTS

Of 2264 nephrolithiasis patients with calcium levels measured, 383 (17.1 ​%) had hypercalcemia. Of those, 107 (27.9 ​%) had PTH levels drawn. PTH was more often assessed in patients with higher median calcium levels, recurrent nephrolithiasis, depression, and osteopenia/osteoporosis. PTH was elevated (>64 ​pg/mL) or non-suppressed (40-64 ​pg/mL) in 68 (63.6 ​%) patients. Of those, 31 (45.6 ​%) were referred to a parathyroid specialist. Referred patients had higher PTH and calcium levels than those without referral, and higher rates of osteopenia/osteoporosis.

CONCLUSIONS

PTH evaluation in hypercalcemic nephrolithiasis patients was low. The majority of patients evaluated had elevated or non-suppressed PTH levels, but only a fraction were referred to a specialist.

Systematic review of the risk of urolithiasis following parathyroidectomy in patients with primary hyperparathyroidism

OBJECTIVE

Parathyroidectomy (PTX) is the conclusive therapy for primary hyperparathyroidism (PHPT), but its effect on the risk of urolithiasis is inconclusive. We comprehensively reviewed the currently available research to investigate the impact of PTX on the likelihood of urolithiasis among individuals suffering PHPT.

METHODS

Internet-based articles in English language released on Cochrane, PubMed, Scopus, Web of knowledge, and Embase up to September, 2023 were comprehensively reviewed. Each publication in contrast to the incidence, occurrence, or recurrence of urolithiasis after PTX versus medical treatment in PHPT patients was included. The outcome with pooled relative risks (RRs) and corresponding 95% confidence intervals (CIs) was examined employing DerSimonian and Laird's model of random effects. To determine the range of the real effect size of a future study in 95% of all populations, a prediction interval (PI) was also established.

RESULTS

Finally, ten studies involving 74,190 patients were included. Results from randomized-controlled trials (RCTs) and observational studies (OSs) both revealed that PTX did not substantially lessen the vulnerability of urolithiasis among individuals with PHPT (RCTs: pooled relative risk [RR] 0.42, 95%CI 0.13-1.41, p = 0.163; OSs: pooled RR 1.37, 95%CI 0.96 to 1.97, p = 0.084). The PI (RCT: 0.03 to 5.96; OSs: 0.44-4.20) containing 1.0 suggested the possibility of consistent results in future studies. Subgroup and sensitivity analyses supported the above findings, and no evidence showed publication bias.

CONCLUSION

Our analysis from the available RCTs or OSs did not give adequate or exact proof that the average effect of PTX lowers the incidence of urolithiasis among PHPT persons based on the random-effects model. Future research shall take into account the common effect of PTX as well as the prerequisites of preventive stone procedures, which will further help us assess the effectiveness of PTX in reducing kidney calculus comorbidity and develop techniques to avoid stone sequelae in these individuals.

Residual risks of comorbidities after parathyroidectomy in a nationwide cohort of patients with primary hyperparathyroidism

PURPOSE

Primary hyperparathyroidism (PHPT) is a common endocrine disorder with increasing incidence, while epidemiologic data in Asian population has been lacking. Therefore, we aimed to identify the incidence, prognosis, and prognostic factors of PHPT patients who underwent parathyroidectomy in Korea.

METHODS

In this retrospective nationwide cohort, patients with PHPT were defined as those with diagnostic codes of PHPT and procedural codes for parathyroidectomy, excluding chronic renal failure or secondary hyperparathyroidism based on National Health Insurance Services database in Korea in 2002-2018. Main primary outcomes were all-cause mortality, cardiovascular, and cerebrovascular events.

RESULTS

A total of 5561 patients were diagnosed with PHPT and had parathyroidectomy. The mean age was 54.5 years, and 71.8% were women. The age-standardized incidence was 10.1/100,000 person-year in 2018, rising from 1.7/100,000 person-year in 2002. During a mean of 5.9 years, history of cardiovascular disease, mood disorder, and genitourinary stone had increased risks of mortality with hazard ratios (HRs) of 1.59 (95% confidence interval [CI] 1.10-2.29), 1.43 (CI 1.14-1.80), and 1.40 (CI 1.09-1.80), respectively. History of hypertension, cerebrovascular disease, diabetes mellitus, and mood disorder were risk factors for cardiovascular events with HRs of 1.42 (CI 1.22-1.66), 1.29 (CI 1.05-1.58), 1.22 (CI 1.07-1.40), and 1.14 (CI 1.00-1.29), respectively. Mood disorder was a significant risk factor for cerebrovascular events (HR 1.30, CI 1.11-1.52).

CONCLUSION

The incidence of PHPT patients who underwent parathyroidectomy has been rising in Korea as reported in other countries. Patients with complications, especially mood disorder, had increased cardiovascular and cerebrovascular events and mortality risks.