OR21-5 Hypocalciuria is Common and Associated with Delayed Parathyroidectomy in Patients with Primary Hyperparathyroidism

Abstract

Background A 24-hour urine collection is routinely obtained in the workup of primary hyperparathyroidism (PHPT) to measure calcium and creatinine excretion, rule out familial hypocalciuric hypercalcemia, and guide diagnosis and management. Although hypercalciuria is expected and frequently observed in PHPT, hypocalciuria and/or a low urine calcium (uCa) to creatinine clearance ratio (UCCCR) may occur. Variables including race, age, renal function, and 25-OH vitamin D levels can affect urinary calcium excretion. Given the utility of obtaining urine calcium excretion in patients with PHPT, we performed a retrospective analysis on patients with PHPT to evaluate the effect of clinical variables on urinary calcium excretion, and to test the hypothesis that hypocalciuria may delay parathyroidectomy in PHPT. Methods We retrospectively reviewed charts of patients with PHPT with available 24-hour uCa who underwent successful parathyroidectomy at our institution between 2009 and 2021. We extracted available demographic, clinical, and laboratory data including first available uCa and creatinine excretion prior to parathyroidectomy, age, gender, ethnicity, BMI, eGFR, serum calcium, phosphorus, PTH, 25-hydroxyvitamin D, and 24-hour sodium excretion. The association between these parameters and uCa and UCCR was assessed in univariate and multivariate models. We compared characteristics of PHPT patients with vs. without hypocalciuria, and duration between uCa measurement and parathyroidectomy. Results 643 PHPT patients were included in this analysis. 8.4% of patients had a 24-hr uCa excretion rate below 100mg/day, and 18.7% had a UCCR<1%.Compared to PHPT patients with UCCCR≥1%, those with UCCCR<1% had a significantly higher proportion of African Americans (22.2% vs 9.1%; p=0.0029), a lower mean serum calcium (p=0.0027), and 25-hydroxyvitamin D (p=0.035). In multivariate analysis, gender, race, serum calcium, serum 25-OH-vitamin D, and 24-hour urine sodium were all significant predictors of UCCCR. The UCCCR<1% group had a significantly longer median time from uCa measurement to parathyroidectomy [8.4 (Interquartile range IQR: 3.3-29.4) vs. 4.2 (IQR: 2.4-8.7) months, p<0.001).Compared to PHPT patients with 24-hr uCa≥100 mg/day, those with 24-hr uCa<100 mg/day had significantly lower mean serum calcium (p=0.002), eGFR (p<0.0001), urine sodium excretion (p=0.036), and significantly greater serum phosphorus (p=0.0085) and PTH (0.0078). In multivariate analysis, race, BMI, serum calcium, eGFR and urine sodium were all significant predictors of 24-hr uCa. The uCa<100 mg/day group had a significantly longer median time from uCa measurement to parathyroidectomy [9.7 (IQR: 3.3-32.2) vs. 4.2 (IQR: 2.4-8.8) months, p<0.001). Conclusions Although elevated uCa is used as a diagnostic marker and indication for parathyroidectomy in PHPT, hypocalciuria and UCCCR<1% are relatively common in PHPT patients, and associated with a significant delay in parathyroidectomy. Intrinsic (race, gender) and extrinsic (vitamin D status, renal function, sodium intake/excretion) factors are all determinants of calcium excretion in PHPT. Presentation: Monday, June 13, 2022 12:00 p.m. - 12:15 p.m.