Effectiveness of surgical treatment of primary hyperparathyroidism with urolithiasis: correction of symptoms, laboratory parameters and stone-forming risk

Background. Parathyroidectomy is the only effective method to improve the clinical and laboratory manifestations of the primary hyperparathyroidism (PHPT) and reduce the risk of urinary calculi formation. However, there are controversies about the existence of renal form of PHPT and about the effectiveness of surgery with regard to the risk of stone formation.

Aims. To evaluate the effectiveness of PHPT surgical treatment in relation to clinical, laboratory parameters, as well as the risk of stone formation.

Materials and methods. In a prospective single-arm observation one-center nonrandomized study we included patients with PHPT in whom parathyroidectomy was performed in 2012–2015. We analyzed clinical and laboratory parameters before and after surgery in a period from 1 to 3 years.

Results. The study included 105 patients, of whom 35 (33.3%) had urolithiasis. Blood calcium after the surgery decreased from 2.72 mmol/l [2,56; 2,97] to 2,3 mmol/l [2,2; 2,35], p < 0.001. Blood calcium concentration decreased to normal values in all patients. Parathyroid hormone level decreased from 206 pg/ml [123; 347] to 72,8 pg/ml [30; 113], p < 0.001. Clinical symptoms questionnaire estmation decreased from 4 points [3; 6] to 2 points [1; 4], p < 0.001. In patients with urolithiasis clinical symptoms before treatment were more pronounced – 5 points [3; 7] vs. 4 points [3; 5] (p = 0.015) and decreased more significantly – by 3 points [2; 4] vs 2 points [1; 3]. The daily calcium urine excretion decreased from 11.4 mmol/day [8.9; 13.9] to 5.4 mmol/day [4.1; 6.8], p < 0.001. In 2 cases (5.7%; CI, 0.7–19.2%) we observed the progression of urolithiasis after surgery. The age of patients correlated with daily calcium urine excretion after surgery (r = 0.69; p = 0.028).

Conclusions. Parathyroidectomy normalizes blood calcium and parathyroid hormone, improves clinical symptoms and reduces the risk of stone formation.

hypercalciuria, parathyroidectomy, primary hyperparathyroidism, urolithiasis

1. Мокрышева Н.Г. Первичный гиперпаратиреоз. Эпидемиология, клиника, современные принципы диагностики и лечения: Дис. … д-ра мед. наук. – М.; 2011. [Mokrysheva NG. Pervichniy giperparatireoz. Epidemiologiya, klinika, sovremennye principy diagnostiki i lecheniya[dissertation]. Moscow; 2011. (In Russ.)]

2. Kuo LE, Wachtel H, Fraker D, Kelz R. Reoperative parathyroidectomy: who is at risk and what is the risk? J Surg Res. 2014;191(2):256-261. doi: 10.1016/j.jss.2014.05.073.

3. Cheng SP, Lee JJ, Liu TP, et al. Quality of life after surgery or surveillance for asymptomatic primary hyperparathyroidism: a meta-analysis of randomized controlled trials. Medicine (Baltimore). 2015;94(23):e931. doi: 10.1097/MD.0000000000000931.

4. Mollerup CL. Risk of renal stone events in primary hyperparathyroidism before and after parathyroid surgery: controlled retrospective follow up study. BMJ. 2002;325(7368): 807-807. doi: 10.1136/bmj.325.7368.807.

5. Rodman JS, Mahler RJ. Kidney stones as a manifestation of hypercalcemic disorders. Urol Clin North Am. 2000;27(2): 275-285. doi: 10.1016/s0094-0143(05)70257-3.

6. Berger AD, Wu W, Eisner BH, et al. Patients with primary hyperparathyroidism – why do some form stones? J Urol. 2009;181(5):2141-2145. doi: 10.1016/j.juro.2009.01.028.

7. Palmieri S, Eller-Vainicher C, Cairoli E, et al. Hypercalciuria may persist after successful parathyroid surgery and it is associated with parathyroid hyperplasia. J Clin Endocrinol Metab. 2015;100(7):2734-2742. doi: 10.1210/jc.2014-4548.

8. Webb SM, Puig-Domingo M, Villabona C, et al. Development of a new tool for assessing health-related quality of life in patients with primary hyperparathyroidism. Health Qual Life Outcomes. 2013;11:97. doi: 10.1186/1477-7525-11-97.

9. Usta A, Alhan E, Cinel A, et al. A 20-year study on 190 patients with primary hyperparathyroidism in a developing country: Turkey experience. Int Surg. 2015;100(4):648-655. doi: 10.9738/INTSURG-D-14-00094.1.

10. Рожинская Л.Я. Современные представления об этиологии, клинической картине, диагностике и лечении первичного гиперпаратиреоза. // Лечащий врач. – 2009. – №3. – С. 22–27. [Rozhinskaya LY. Sovremennye predstavleniya ob etiologii, klinicheskoy kartine, diagnostike ilechenii pervichnogo giperparatireoza. Lechaschiy vrach. 2009;(3): 22-27. (In Russ.)]

11. Gopal RA, Acharya SV, Bandgar T, et al. Clinical profile of primary hyperparathyroidism from western India: a single center experience. J Postgrad Med. 2010;56(2):79-84. doi: 10.4103/0022-3859.65279.

12. Starup-Linde J, Waldhauer E, Rolighed L, et al. Renal stones and calcifications in patients with primary hyperparathyroidism: associations with biochemical variables. Eur J Endocrinol. 2012;166(6):1093-1100. doi: 10.1530/EJE-12-0032.

13. Алаев Д.С., Котова И.В. Нефролитиаз при первичном гиперпаратиреозе. // Альманах клинической медицины. – 2013. – №28. – С. 58–60. [Alaev DS, Kotova IV. Nephrolithiasis in primary hyperparathyroidism. Almanac of clinical medicine. 2013;(28):58-60. (In Russ.)]

14. Norman J, Goodman A, Politz D. Calcium, parathyroid hormone, and vitamin D in patients with primary hyperparathyroidism: normograms developed from 10,000 cases. Endocr Pract. 2011;17(3):384-394. doi: 10.4158/EP09346.OR.

15. Black CE, Berg RL, Urquhart AC. 24-hour urinary calcium in primary hyperparathyroidism. Clin Med Res. 2013;11(4): 219-225. doi: 10.3121/cmr.2013.1164.

16. Sorensen MD, Duh QY, Grogan RH, et al. Differences in metabolic urinary abnormalities in stone forming and nonstone forming patients with primary hyperparathyroidism. Surgery. 2012;151(3):477-483. doi: 10.1016/j.surg.2011.07.039.