Parathyroidectomy is associated with lower mortality and fewer cardiac complications in patients with secondary hyperparathyroidism.

Abstract

Secondary hyperparathyroidism can be treated with calcimimetics such as cinacalcet or surgically with parathyroidectomy. The adoption of cinacalcet has reduced the frequency of surgical management. This study evaluates the long-term outcomes of parathyroidectomy versus cinacalcet in patients with renal-origin secondary hyperparathyroidism who previously received conventional therapy. We conducted a retrospective analysis using electronic health records (2004-2025) from the TriNetX platform. Patients with renal-origin secondary hyperparathyroidism and a medication history of vitamin D or phosphate binders were included. Those treated with cinacalcet for ≥6 months were compared to those who underwent parathyroidectomy without cinacalcet use or kidney transplantation. Propensity score matching (1:1) controlled for demographics, comorbidities, and cardiovascular therapies. Cox proportional hazards models estimated hazard ratios and 95% confidence intervals for mortality and cardiac outcomes. Among 11,581 patients, 1,478 (12.8%) underwent parathyroidectomy and 10,103 (87.2%) received cinacalcet. After matching, 1,227 patients were included in each group. Over a median follow-up of 4 years, parathyroidectomy was associated with lower risks of mortality (hazard ratio 0.68, 95% confidence interval 0.58-0.80) and composite cardiac events (0.75, 0.64-0.87). It was also associated with lower risks of ischemic heart disease, heart failure, and arrhythmias. Among patients with parathyroid hormone ≤585 pg/mL, parathyroidectomy remained associated with lower mortality (hazard ratio 0.73, 95% confidence interval 0.59-0.90) and cardiac risk (0.62, 0.50-0.77). Parathyroidectomy may provide superior long-term survival and cardiovascular outcomes compared to cinacalcet, even in patients with moderately elevated parathyroid hormone.