Table 2

Indications for surgery in asymptomatic PHPT (2013)47

Indications for surgery in asymptomatic PHPT
Serum calcium	>0.25 mmol/L above the upper limit of normal
Bone	BMD by DXA: T-score (or Z-score if age<50 years)<−2.5 at lumbar spine, total hip, femoral neck or distal 1/3 radius Vertebral fracture by x-ray, CT, MRI or VFA*
Renal	Creatinine clearance <60 mL/min† 24 hours urine for calcium>400 mg/day and increased stone risk by biochemical analysis† Presence of nephrolithiasis or nephrocalcinosis by x-ray, ultrasound or CT
Age	<50 years

Patients need to meet only one criterion for consideration of surgery.
*A history of fragility fracture at any site would define symptomatic PHPT and the patient would be automatically considered a surgical candidate.
†Chronic kidney disease and hypercalciuria are not relevant as these patients strictly speaking do not have NPHPT. BMD, bone mineral density; DXA, dual-energy x-ray absorptiometry; NPHPT, normocalcaemic primary hyperparathyroidism; VFA, vertebral fracture assessment.