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Refractory Hyperparathyroidism — RACP Adult Medicine MCQ

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HardNephrologyRefractory HyperparathyroidismRACP Adult Medicine

A 65-year-old man with CKD stage G5 (eGFR 10) on haemodialysis has refractory secondary hyperparathyroidism (PTH 120 pmol/L, target 2-9× ULN) despite phosphate binders, calcitriol, and cinacalcet at maximum dose. He has osteitis fibrosa cystica on X-ray and hypercalcaemia (calcium 2.85 mmol/L). What is the most appropriate next step?

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Correct answer: E — Parathyroidectomy

Refractory secondary (now tertiary) hyperparathyroidism with very elevated PTH despite maximum medical therapy, hypercalcaemia, and skeletal complications (osteitis fibrosa cystica) is an indication for parathyroidectomy. Subtotal parathyroidectomy or total parathyroidectomy with autotransplantation is performed. Post-operative hungry bone syndrome (hypocalcaemia from rapid bone uptake of calcium) must be anticipated.

Reference: KDIGO – 2024 – CKD-MBD; ANZET 2024