Parathyroidectomy shows no effect on kidney function in older adults with hyperparathyroidism

1. Parathyroidectomy shows no effect on kidney function in older adults with hyperparathyroidism
Subanalysis suggests the procedure may preserve kidney function in younger patients if done early
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2222
URL goes live when the embargo lifts
An emulated randomized trial performed using observational data from more than 43,000 adults with primary hyperparathyroidism found that parathyroidectomy had no estimated effect on long-term kidney function in older adults when compared to observation. However, early parathyroidectomy may preserve kidney function in patients younger than 60 years of age with primary hyperparathyroidism. The study is published in Annals of Internal Medicine.

Primary hyperparathyroidism is a common endocrine disorder associated with an increased risk for chronic kidney disease (CKD). The only treatment is surgical removal of one or more abnormal parathyroid glands (parathyroidectomy). Current guidelines recommend parathyroidectomy in patients with primary hyperparathyroidism and CKD, in part to mitigate the risk for and effects of CKD progression. However, there are limited data documenting the association of parathyroidectomy with long-term kidney function to support this recommendation.

Researchers from the Stanford University School of Medicine studied 43,697 adults diagnosed with primary hyperthyroidism to compare the incidence of a sustained decline in estimated glomerular filtration rate (eGFR) of at least 50 percent for those treated with parathyroidectomy versus nonoperative management. The researchers found that the weighted cumulative incidence of a sustained eGFR decline of at least 50 percent was 5.1 percent at 5 years, regardless of how primary hyperparathyroidism was managed. In the overall cohort, there was no difference in the adjusted rate of a sustained decline in eGFR among patients treated with parathyroidectomy versus nonoperative management. However, subgroup analyses indicated that patients younger than 60 years treated with early parathyroidectomy were more likely to preserve long-term kidney function.

According to the authors, these findings suggest that preservation of kidney function should not be a primary consideration when making treatment decisions about parathyroidectomy in older adults with primary hyperparathyroidism and that focus on fracture risk and quality of life is more important in this group. However, clinicians should discuss the potential benefit of early parathyroidectomy to reduce the risk for CKD and associated complications in patients younger than 60 years who are diagnosed with primary hyperparathyroidism.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Carolyn D. Seib, MD, MAS, please email Rachel Baker at rebaker@stanford.edu.
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2. Physicians debate best management strategy for patient with benign prostatic hyperplasia
‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center
Abstract: https://www.acpjournals.org/doi/10.7326/M23-0113
URL goes live when the embargo lifts
In a new Annals ‘Beyond the Guidelines’ feature, a general internal medicine physician and a urologist discuss treatment options for benign prostatic hyperplasia (BPH) and how they would apply their recommendations to a patient who wishes to learn more about his options. All ‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine.

Lower urinary tract symptoms due to BPH are common among older patients assigned male sex at birth, regardless of gender identity. As many as 80% of patients 70 years of age and older are symptomatic. In 2021, the American Urological Association (AUA) published guidelines on the initial evaluation and medical management of lower urinary tract symptoms attributed to BPH and a separate guideline on surgical management. The AUA recommends pharmacologic interventions as a first-line treatment, and recommends surgery for patients who develop chronic kidney disease, refractory urinary retention, or recurrent urinary tract infections, and in those who do not respond to medical therapy.

BIDMC Grand Grounds discussants, C. Christopher Smith, MD, an internal medicine physician, an Associate Professor of Medicine at Harvard Medical School, and a member of the Division of General Medicine at BIDMC, and Ajay Singla, MD, a urologist, lecturer on surgery at Harvard Medical School and Director of the Center for Pelvic Floor Disorder, Neuro-Urology & Urodynamics in the Division of Urology at BIDMC recently debated the case of a 64-year-old man with 1 decade of lower urinary tract symptoms (LUTS) and a diagnosis for BPH. The patient has had no diagnostic testing to date and wishes to explore other treatment options.

In their assessment, both Drs. Smith and Singla agree with the AUA that for most patients, alpha-blockers should be the medications of first choice. Dr. Smith recommends the use of a validated symptom scoring index, such as the IPSS, but does not feel the score is necessary in order to establish a diagnosis of BPH. However, Dr. Singla advises deriving the IPSS for all patients with LUTS. Dr. Smith prefers to refer patients to urology for whom medical therapy has been ineffective and agrees with the other indications for referral as recommended by the AUA. Dr. Singla considers a transurethral resection of prostate (TURP) to be the gold standard procedure for patients who meet Dr. Smith’s criteria for a urology referral.

A complete list of ‘Beyond the Guidelines’ topics is available at www.annals.org/grandrounds.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. For an interview with the discussants, please contact Kendra McKinnon at Kmckinn1@bidmc.harvard.edu.
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