Primary hyperparathyroidism is diagnosed in an asymptomatic 52-year-old woman. Serum calcium is 2.78 mmol/L (ref 2.12–2.62), creatinine clearance is 74 mL/min, and DEXA T-score at the lumbar spine is −1.8. Which of these criteria mandates surgical intervention according to the 2022 international guidelines?
- A Age < 60 years alone
- B Serum calcium > 0.25 mmol/L above upper limit of normal ✓
- C Lumbar spine T-score of −1.8
- D Creatinine clearance 74 mL/min
Explanation
The 2022 Fourth International Workshop criteria for surgery in asymptomatic primary hyperparathyroidism include: serum calcium > 1.0 mg/dL (0.25 mmol/L) above upper limit of normal, creatinine clearance < 60 mL/min, T-score ≤ −2.5 at any site, silent vertebral fractures, 24-hour urinary calcium > 400 mg/day with elevated nephrolithiasis risk, nephrolithiasis or nephrocalcinosis, and age < 50 years. This patient's calcium meets the biochemical threshold. Age < 60 years alone is not a criterion (threshold is < 50 years); T-score of −1.8 does not meet the −2.5 criterion; CrCl of 74 mL/min is above the 60 mL/min threshold.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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