Second Chances or Setbacks: The Impact of Parathyroidectomy on Graft Failure Post-Kidney Transplantation

Background: Tertiary hyperparathyroidism (tHPT) is a common complication in kidney transplant (KT) recipients, often persisting despite successful graft function. However, the optimal treatment for improving long-term graft survival remains unclear. Parathyroidectomy (PTX) offers a definitive approach to restoring calcium homeostasis. This study aims to assess the effect of parathyroidectomy on graft failure, the need for dialysis, and renal osteodystrophy in the two groups. Study Design: A retrospective analysis of electronic medical records from a multi-institutional database (TriNetX) was completed. Patients diagnosed with tHPT after KT were divided into two groups based on the type of intervention: cinacalcet or PTX. Patients were followed for up to 5 years, starting from the day after initiating cinacalcet or PTX. Propensity score matching (PSM) was used to balance demographics, comorbidities, creatinine levels before intervention, and vitamin D deficiency. Cox regression analysis was performed to determine measures of association. Results: 811 patients were included in each treatment group after PSM. During the study period, 42.8% (n=347/811) of patients receiving Cinacalcet became dialysis-dependent, compared to 30.9% (n=251/811) of those who underwent surgery (p<0.01). Regarding renal osteodystrophy, 10.8% (n=74/684) of patients on cinacalcet developed the condition, while only 5.1% (n=32/628) in the PTX group experienced it (p<0.01). Additionally, 17.2% of those on cinacalcet experienced graft failure, compared to 12.6% in the PTX group (p<0.04). Conclusions: Patients who underwent parathyroidectomy experienced lower rates of kidney transplant failure and dialysis, outperforming Cinacalcet, a finding that should be cautiously interpreted regarding its clinical relevance. Improved electrolyte balance and PTH levels may be associated with a lower rate of renal osteodystrophy.