Comparative effectiveness of parathyroidectomy versus cinacalcet in severe secondary hyperparathyroidism among hemodialysis patients in Sudan: a retrospective cohort study

BACKGROUND: Severe secondary hyperparathyroidism (SHPT) is a frequent consequence of long-term hemodialysis and remains a major management challenge in resource-limited settings. The comparative benefit of surgical parathyroidectomy (PTx) and medical therapy with the calcimimetic cinacalcet is still debated, particularly where access and adherence barriers exist. METHODS: A retrospective cohort analysis was conducted at Baraha Medical City, Sudan, including adults on maintenance hemodialysis with severe SHPT (intact parathyroid hormone (iPTH) ≥ 800 pg/mL) treated between 2018 and 2022. Participants received either PTx (n = 41) or cinacalcet (n = 68). The principal endpoint was biochemical improvement within 3–6 months, defined as iPTH < 600 pg/mL or ≥ 30% reduction from baseline. Secondary outcomes included symptomatic relief, correction of serum calcium and phosphate, treatment adherence, complications, and one-year mortality. RESULTS: A biochemical response was achieved in over 90% of surgical patients compared with 47.1% of those treated with cinacalcet (p < 0.001). At 3–6 months, symptom improvement was noted in 75% of the PTx group versus 54% of the cinacalcet group (p = 0.04). Surgery also resulted in higher normalization rates for calcium and phosphate. At one-year, sustained symptom control persisted in 90.2% of surgical patients versus 29.4% with cinacalcet (p < 0.001). Hospitalizations and mortality were numerically lower after PTx, though not statistically significant. High adherence to cinacalcet was observed in only 27.9%, with discontinuation mainly due to financial or supply limitations. CONCLUSIONS: PTx produced superior biochemical and clinical outcomes compared with cinacalcet, although the impact of calcimimetic therapy was hindered by restricted availability and suboptimal adherence. Extended follow-up is needed to evaluate long-term skeletal and cardiovascular effects and explore delivery models that improve treatment continuity. CLINICAL TRIAL REGISTRATION: This was a retrospective observational cohort study and not a prospective interventional clinical trial; therefore, trial registration was not applicable.