Parathyroidectomy is indicated when all of the following are present:
(1) high serum levels of parathyroid hormone (intact PTH > 500 pg/mL, with upper range of normal < 60 pg/mL, or serum levels 8.33 times the upper limit of normal)
(2) enlarged parathyroid glands on imaging studies, with the volume of the largest gland > 500 cubic mm
(3) either (a) osteitis fibrosa cystica on radiographs or (b) evidence of high bone turnover using bone metabolic markers
(4) resistance to medical treatment
Resistance to medical treatment is indicated by the presence of one or more of the following:
(1) hypercalcemia
(2) uncontrolled hyperphosphatemia
(3) progressive ectopic calcification
(4) severe symptoms
(5) severe osteitis fibrosa cystica on radiographs
(6) severe skeletal deformities
(7) progressive bone loss
(8) calciphylaxis
(9) anemia resistant to erythropoietin
