The rate, cost and outcomes of parathyroidectomy in the united states dialysis population from 2016–2018

Abstract

Background In end-stage kidney disease, patients may undergo parathyroidectomy if secondary hyperparathyroidism cannot be managed medically. This study was designed to estimate the parathyroidectomy rate in the United States (US) and to quantify changes in costs and other outcomes after parathyroidectomy. Methods This was a retrospective observational cohort study using US Renal Data System data for 2015–2018. Parathyroidectomy rates were estimated for adult hemodialysis and peritoneal dialysis patients alive at the beginning of 2016, 2017, and 2018 who were followed for a year or until parathyroidectomy, death, or transplant. Incremental differences in economic and clinical outcomes were compared before and after parathyroidectomy in adult hemodialysis and peritoneal dialysis patients who received a parathyroidectomy in 2016 and 2017. Results The rate of parathyroidectomy per 1,000 person-years decreased from 6.5 (95% CI 6.2-6.8) in 2016 to 5.3 (95% CI 5.0-5.6) in 2018. The incremental increase in 12-month cost after versus before parathyroidectomy was $25,314 (95% CI $23,777-$27,078). By the second month after parathyroidectomy, 58% of patients had a corrected calcium level < 8.5 mg/dL. In the year after parathyroidectomy (versus before), hospitalizations increased by 1.4 per person-year (95% CI 1.3-1.5), hospital days increased by 12.1 per person-year (95% CI 11.2-13.0), dialysis visits decreased by 5.2 per person-year (95% CI 4.4-5.9), and office visits declined by 1.3 per person-year (95% CI 1.0-1.5). The incremental rate per 1,000 person years for hematoma/bleed was 224.4 (95% CI 152.5-303.1), for vocal cord paralysis was 124.6 (95% CI 59.1-232.1), and for seroma was 27.4 (95% CI 0.4-59.0). Conclusions Parathyroidectomy was a relatively uncommon event in the hemodialysis and peritoneal dialysis populations. The incremental cost of parathyroidectomy was mostly attributable to the cost of the parathyroidectomy hospitalization. Hypocalcemia occurred in over half of patients, and calcium and phosphate levels were reduced. Clinicians, payers, and patients should understand the potential clinical and economic outcomes when considering parathyroidectomy.

Hungry bone syndrome after parathyroid surgery

“…Nevertheless, the rate of parathyroidectomy in the United States decreased to ~7 per 1000 dialysis patient‐years between 2002 and 2011, regardless of an increase in mean blood parathyroid hormone concentrations, suggesting the introduction of calcimimetics and uncertainty concerning ideal parathyroid hormone targets 2 . The parathyroidectomy rate decreased further from 6.5 per 1000 person‐years in 2016 to 5.3 per 1000 person‐years in 2018 3 . Moreover, parathyroid surgery should not be too radical, particularly if the patient is a candidate for a future kidney transplantation 4 …”

“…2 The parathyroidectomy rate decreased further from 6.5 per 1000 person-years in 2016 to 5.3 per 1000 personyears in 2018. 3 Moreover, parathyroid surgery should not be too radical, particularly if the patient is a candidate for a future kidney transplantation. 4 One of the complications of parathyroidectomy is hungry bone syndrome due to hyperdynamic calcium reabsorption into bones following parathyroidectomy, with an acute drop in parathyroid hormone concentration.…”

Hypocalcemia Risk of Denosumab Across the Spectrum of Kidney Disease: A Population-Based Cohort Study

“…This risk is similar to those taking cinacalcet (18% incidence of calcium <1.87 mmol/L) or who receive a parathyroidectomy for secondary hyperparathyroidism (31% incidence of calcium <1.87 mmol/L), both of which are strategies used to decrease fracture risk in individuals receiving dialysis. (38)(39)(40)(41) To our knowledge, this is the largest cohort study of new denosumab users focused upon the risk of hypocalcemia after drug administration. Denosumab use has been increasing over the last 10 years, including in populations not studied in the original efficacy trials (ie, those with CKD).…”

“…This risk is similar to those taking cinacalcet (18% incidence of calcium <1.87 mmol/L) or who receive a parathyroidectomy for secondary hyperparathyroidism (31% incidence of calcium <1.87 mmol/L), both of which are strategies used to decrease fracture risk in individuals receiving dialysis. ( 38‐41 )…”

Managing Osteoporosis in Dialysis—A Medical Catch-22

“…3 Indeed, for parathyroidectomy, one study reported that at the end of the first postsurgical year, up to 39% of patients still had hypocalcemia (<8.5 mg/dL) and total mortality was 3.5%. 2 Antifracture strategies in dialysis patients must go beyond a sole focus on parathyroid hormone reduction. Bone strength is dependent on the quality of bone.…”