The natural history of primary hyperparathyroidism with or without parathyroid surgery after 15 years.
BACKGROUND
Primary hyperparathyroidism (PHPT) often presents without classical symptoms such as overt skeletal disease or nephrolithiasis. We previously reported that calciotropic indices and bone mineral density (BMD) are stable in untreated patients for up to a decade, whereas after parathyroidectomy, normalization of biochemistries and increases in BMD ensue.


OBJECTIVE
The objective of the study was to provide additional insights in patients with and without surgery for up to 15 yr.


METHODS
The study had an observational design.


METHODS
The setting was a referral center.


METHODS
Patients included 116 patients (25 men, 91 women); 99 (85%) were asymptomatic.


METHODS
Fifty-nine patients (51%) underwent parathyroidectomy and 57 patients were followed up without surgery.


METHODS
BMD was measured.


RESULTS
Lumbar spine BMD remained stable for 15 yr. However, BMD started to fall at cortical sites even before 10 yr, ultimately decreasing by 10 +/- 3% (mean +/- sem; P < 0.05) at the femoral neck, and 35 +/- 5%; P < 0.05 at the distal radius, in the few patients observed for 15 yr. Thirty-seven percent of asymptomatic patients showed disease progression (one or more new guidelines for surgery) at any time point over the 15 yr. Meeting surgical criteria at baseline did not predict who would have progressive disease. BMD increases in patients who underwent surgery were sustained for the entire 15 yr.


CONCLUSIONS
Parathyroidectomy led to normalization of biochemical indices and sustained increases in BMD. Without surgery, PHPT progressed in one third of individuals over 15 yr; meeting surgical criteria at the outset did not predict this progression. Cortical bone density decreased in the majority of subjects with additional observation time points and long-term follow-up. These results raise questions regarding how long patients with PHPT should be followed up without intervention.
Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York, New York 10032, USA.
Mishaela R
MR
Rubin
John P
JP
Bilezikian
Donald J
DJ
McMahon
Thomas
T
Jacobs
Elizabeth
E
Shane
Ethel
E
Siris
Julia
J
Udesky
Shonni J
SJ
Silverberg
D000465:Algorithms; D015519:Bone Density; D002118:Calcium / Q000097:blood / Q000652:urine; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D049950:Hyperparathyroidism, Primary / Q000097:blood / Q000150:complications* / Q000601:surgery* / Q000652:urine; D008297:Male; D008875:Middle Aged; D010281:Parathyroid Hormone / Q000097:blood; D016105:Parathyroidectomy; D012189:Retrospective Studies; D013997:Time Factors
D010281:Parathyroid Hormone; D002118:Calcium