Variable practice patterns in the surgical management of renal hyperparathyroidism.

Background: Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The American Association for Endocrine Surgery published clinical practice guidelines that address the surgical treatment of secondary and tertiary hyperparathyroidism. The purpose of this study is to determine practice patterns for the surgical management of secondary and tertiary hyperparathyroidism prior to guideline publication.

Methods: With the approval of the American Association for Endocrine Surgery, a Qualtrics email survey was sent to the Association's membership in 2022 about current clinical decision making for surgical treatment of secondary and tertiary hyperparathyroidism. Respondents were divided into groups based on surgical subspecialty (endocrine surgery versus non-endocrine surgery), yearly parathyroidectomy volume, and yearly parathyroidectomy volume for surgical treatment of secondary and tertiary hyperparathyroidism. Descriptive statistics were performed; the role of volume was evaluated.

Results: There were 142 responses from 795 solicited email addresses (18% response rate); 114 (84%) identified as endocrine surgeons. The majority (62%) perform >50 parathyroidectomies yearly, but most perform <10 parathyroidectomies for surgical treatment of secondary and tertiary hyperparathyroidism per year (<10/y, 53.7%; 10-30/y, 41.9%; >30/y, 4.4%). Subtotal parathyroidectomy is most commonly performed for surgical treatment of secondary (83%) and tertiary (52%) hyperparathyroidism, but transcervical thymectomy variably performed for both. There was no consensus regarding starting calcitriol preoperatively (always 43%, never 25%, depends on vitamin D levels 24%) or stopping cinacalcet (2 weeks prior 28%, day of surgery 29%, postoperatively 20%). Surgeons who perform >10 parathyroidectomies per year for surgical treatment of secondary and tertiary hyperparathyroidism were less likely to consider the patient's preoperative vitamin D levels to inform their decision to start calcitriol before surgery (<10 cases/year, 34%; ≥10 cases/year 15%; P = .023), were more likely to have a postoperative hypocalcemia protocol managed by the surgical team (<10 cases/year, 49%; ≥10 cases/year, 58%; P = .029), and were more likely to use intraoperative parathyroid hormone monitoring for tertiary hyperparathyroidism (<10 cases/year, 70%; ≥10 cases/year, 87%; P = .046).

Conclusion: The majority of respondents perform <10 parathyroidectomies yearly for surgical treatment of secondary and tertiary hyperparathyroidism. Subtotal parathyroidectomy was most commonly performed, but there was little other consensus regarding preoperative management, intraoperative decision-making, and postoperative care. Opportunity exists through guideline dissemination to improve heterogeneity of care provided to surgical treatment of secondary and tertiary hyperparathyroidism patients.