Over 2.5 million individuals globally are receiving renal replacement therapy due to end-stage renal disease (ESRD) (1). Secondary hyperparathyroidism, a prevalent complication impacting nearly all patients with ESRD, is a maladaptive response to disturbed calcium balance, causing detrimental effects on multiple organ systems, including the cardiovascular system and skeletal structure (2, 3). To mitigate these risks, the National Kidney Foundation established the Kidney Disease: Improving Global Outcomes (KDIGO) 2017 organization suggests maintaining parathyroid hormone (PTH) below 600 pg/mL in patients with ESRD (4).

The ideal treatment strategy for secondary hyperparathyroidism, whether it be medical managements or parathyroidectomy, remains a subject of ongoing debate. Parathyroidectomy is typically reserved for patients whose lab values or symptoms do not respond to medical treatment (5, 6). While the use of cinacalcet has increased as part of medical management strategies, alongside standard treatments such as vitamin D analogs and phosphate binders (7), this increase has not led to a decline in surgical interventions. In fact, the frequency of parathyroidectomy procedures has escalated by 3.5 times from 2006 to 2016 (8). Despite these advancements, the proportion of patients on dialysis with PTH levels exceeding 600 pg/mL has increased from 11.1% in 2010 to 24.1% in 2021, indicating a growing population with inadequately controlled PTH (9). Therefore, it is imperative to compare the therapeutic effects between parathyroidectomy and medical treatments because preferential nonoperative management of secondary hyperparathyroidism may lead to persistently elevated PTH levels and the subsequent risk of end-organ damage that could be prevented with parathyroidectomy.

Guidelines for recommending parathyroidectomy differ across organizations. The KDIGO 2017 guidelines advise parathyroidectomy for patients with chronic kidney disease stages 3a to 5 with severe hyperparathyroidism unresponsive to medical therapy (4), whereas the Association of American Endocrine Surgeons' recent guidelines highlight the potential of parathyroidectomy to reduce cardiovascular and all-cause mortality in patients with secondary hyperparathyroidism (6). Considering the growing body of research comparing medical and surgical treatments, our meta-analysis aimed to assess the clinical advantages of parathyroidectomy compared to medical management in reducing mortality and managing secondary hyperparathyroidism among patients undergoing dialysis.