Primary Hyperparathyroidism Surgery Criteria (2022 Workshop)
Primary Hyperparathyroidism Surgery Criteria (2022 Workshop)
Check whether asymptomatic primary hyperparathyroidism meets the criteria for parathyroidectomy from the Fifth International Workshop (2022): calcium more than 0.25 mmol/L (1 mg/dL) above the upper limit, a T-score of −2.5 or less, a vertebral fracture, eGFR or creatinine clearance below 60, kidney stones or nephrocalcinosis, high 24-hour urine calcium, or age under 50. Any one is enough. The page also shows what changed from the 2014 Fourth Workshop.
Does asymptomatic primary hyperparathyroidism need surgery?
Calcium, bone, kidney, urine calcium, age → criteria metA 57-year-old woman with primary hyperparathyroidism and no symptoms. Adjusted calcium 2.78 mmol/L (upper limit 2.60). Lowest T-score −2.1, no vertebral fracture. eGFR 72. A 6 mm renal stone on ultrasound. 24-hour urine calcium 280 mg.
Fifth International Workshop (2022), recommendation 5.1 — any one is enough
Skeletal: BMD T-score −2.5 or less at any site; or a vertebral fracture on imaging
Renal: eGFR or creatinine clearance below 60 mL/min; nephrolithiasis or nephrocalcinosis on imaging; 24-h urine calcium above 250 mg/day (women) or 300 mg/day (men)
Age below 50 years
- mg to mmol
- calcium 40.078 g/mol: 250 mg = 6.2 mmol, 300 mg = 7.5 mmol, 400 mg = 10 mmol; 0.25 mmol/L = 1 mg/dL
- calcium
- albumin-adjusted total calcium; the margin is measured against your own laboratory’s upper limit
Worked example
A 57-year-old woman with primary hyperparathyroidism and no symptoms. Adjusted calcium 2.78 mmol/L (upper limit 2.60). Lowest T-score −2.1, no vertebral fracture. eGFR 72. A 6 mm renal stone on ultrasound. 24-hour urine calcium 280 mg.
Calcium 2.78 − 2.60 = 0.18 mmol/L, not above 0.25 → not met
T-score −2.1, no fracture, eGFR 72 → not met
Kidney stone on imaging → met
Urine calcium 280 mg a day in a woman is above 250 → met (it would not have counted in 2014)
Age 57 → not met. 2 criteria met → surgery recommended
What changed between the Fourth (2014) and Fifth (2022) Workshops
| Criterion | Fourth Workshop, 2014 | Fifth Workshop, 2022 |
|---|---|---|
| Serum calcium | 1 mg/dL (0.25 mmol/L) above the upper limit | Unchanged |
| Bone density | T-score −2.5 at lumbar spine, total hip, femoral neck or distal 1/3 radius | T-score −2.5 or less at any site |
| Vertebral fracture | By x-ray, CT, MRI or VFA | By imaging |
| Kidney function | Creatinine clearance below 60 mL/min | eGFR or creatinine clearance below 60 mL/min; measured clearance preferred |
| Urine calcium | Above 400 mg (10 mmol) a day AND raised stone risk on biochemical stone-risk analysis | Above 250 mg a day in women, 300 mg a day in men; no stone-risk analysis needed |
| Stones or nephrocalcinosis | By x-ray, ultrasound or CT | On imaging |
| Age | Below 50 | Below 50 — sufficient on its own |
Any one criterion, and FHH excluded first
Most primary hyperparathyroidism is found by chance on a routine calcium, in someone with no symptoms. Surgery is the only cure, and for symptomatic disease — kidney stones, fractures, symptomatic hypercalcaemia — it is recommended outright. For the asymptomatic majority, the International Workshops on primary hyperparathyroidism publish criteria that identify patients likely to benefit from an operation, and the Fifth Workshop in 2022 revised them. Meeting any one is enough, and the workshop is explicit that surgery remains an option for everyone else if patient and physician agree.
The criteria cover four areas. Calcium: more than 0.25 mmol/L (1 mg/dL) above the laboratory’s upper limit. Bone: a T-score of −2.5 or less at any site, or a vertebral fracture on imaging. Kidney: an eGFR or creatinine clearance below 60 mL/min, kidney stones or nephrocalcinosis on imaging, or a 24-hour urine calcium above 250 mg a day in women or 300 mg a day in men. And age below 50, because a younger patient faces decades of exposure.
The main change from the 2014 Fourth Workshop is the urine calcium. In 2014 it had to exceed 400 mg (10 mmol) a day and come with a raised stone risk on a biochemical stone-risk analysis; in 2022 it became 250 mg in women and 300 mg in men, with no stone-risk analysis. A woman passing 280 mg a day now qualifies where she did not before. The kidney function criterion now accepts an eGFR as well as a creatinine clearance, though the workshop notes that a measured clearance is more accurate, and the bone density criterion now reads “any site”.
Two things come before this page. The calcium should be adjusted for albumin (see the corrected calcium calculator), and familial hypocalciuric hypercalcaemia must have been excluded, because it produces the same biochemistry and is not cured by surgery — see the hypercalcaemia cause interpreter. Vitamin D should be replete, since deficiency raises PTH and urine calcium readings are hard to interpret without it. Calculate the eGFR with the CKD-EPI 2021 eGFR calculator. This page supports clinical judgement and does not replace it.
Frequently asked questions
What are the 2022 criteria for parathyroid surgery in asymptomatic primary hyperparathyroidism?
Any one of: calcium more than 1 mg/dL (0.25 mmol/L) above the upper limit; T-score −2.5 or less at any site; vertebral fracture on imaging; eGFR or creatinine clearance below 60 mL/min; kidney stones or nephrocalcinosis on imaging; 24-hour urine calcium above 250 mg/day (women) or 300 mg/day (men); age below 50.
What changed from the 2014 guidelines?
The urine calcium criterion fell from over 400 mg/day with a raised biochemical stone risk to over 250 mg/day in women and 300 mg/day in men. The kidney function criterion now accepts eGFR, and the bone density criterion applies at any site.
Can someone who meets no criteria still have surgery?
Yes. The Fifth Workshop says parathyroidectomy is an option for all patients with primary hyperparathyroidism if patient and physician agree and there is no contraindication.
Why must FHH be excluded first?
Familial hypocalciuric hypercalcaemia gives a high calcium with a normal or raised PTH, like primary hyperparathyroidism, but surgery does not cure it. A calcium:creatinine clearance ratio below 0.01 favours FHH; genetic testing confirms it.
Related calculators
References
- Bilezikian JP, Khan AA, Silverberg SJ, et al. Evaluation and management of primary hyperparathyroidism: summary statement and guidelines from the Fifth International Workshop. J Bone Miner Res. 2022;37(11):2293–2314.
- Bilezikian JP, Brandi ML, Eastell R, et al. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. J Clin Endocrinol Metab. 2014;99(10):3561–3569.
Medical Disclaimer: The tools and content provided here are for educational and reference purposes only. They are not intended to substitute for professional medical advice, diagnosis, or treatment. Clinical decisions should always be based on the comprehensive assessment of a qualified healthcare professional.