Beyond the Gland: How Parathyroidectomy Enhances Cardiovascular Health in Dialysis-Independent End-Stage Renal Disease Patients

BACKGROUND: The comparative effect of parathyroidectomy vs cinacalcet on long-term cardiovascular outcomes in dialysis-independent tertiary hyperparathyroidism remains unclear. STUDY DESIGN: A retrospective cohort study was performed using the TriNetX global research network. Adults with tertiary hyperparathyroidism and dialysis-independent end-stage renal disease were identified and stratified by treatment (parathyroidectomy vs cinacalcet). Propensity score matching (1:1) balanced demographics, comorbidities, cardiovascular history, and medication use. Time-to-event analyses were conducted using Cox proportional hazards regression for up to 5 years of follow-up. RESULTS: After matching, 880 patients were included in each cohort (mean age 53 ± 14 years; female patients 49.0% vs 51.3%). Parathyroidectomy was associated with a lower risk of major adverse cardiovascular events compared with cinacalcet (hazard ratio [HR] 0.64, 95% CI 0.52 to 0.78; p < 0.001). MI (12.5% vs 15.4%; HR 0.64, 95% CI 0.52 to 0.78) and heart failure hospitalization (20.0% vs 26.3%; HR 0.62, 95% CI 0.55 to 0.71) were reduced after parathyroidectomy. Coronary revascularization was less frequent (coronary artery bypass graft 0% vs 2.2%, p = 0.001; percutaneous coronary intervention 1.8% vs 2.8%, HR 0.79, 95% CI 0.72 to 0.90). Secondary outcomes demonstrated lower hazards of atrial fibrillation (HR 0.33, 95% CI 0.21 to 0.55), ventricular arrhythmia (HR 0.73, 95% CI 0.70 to 0.85), hypertensive heart disease (HR 0.49, 95% CI 0.41 to 0.59), heart failure (HR 0.64, 95% CI 0.59 to 0.76), and peripheral vascular disease (HR 0.73, 95% CI 0.67 to 0.92). Findings were consistent in sensitivity and competing-risk analyses. CONCLUSIONS: Parathyroidectomy was associated with a durable reduction in cardiovascular events compared with cinacalcet in dialysis-independent tertiary hyperparathyroidism. These findings support consideration of surgical management to mitigate long-term cardiovascular risk.