What is your PTH threshold for referring an ESKD patient with secondary hyperparathyroidism on maximum medical therapy for parathyroidectomy?

I think PTX should be done pretty much never with PTH <800 and most of the time with values >2000.

Why such a large range? The biggest consideration is symptoms; if present, my threshold approaches 800. However, ascribing symptoms to hPTH is problematic. Hypercalcemia is the most specific finding with bone pain, weakness, pruritus, and hyperphosphatemia trailing behind.

The absence of symptoms pushes my threshold up. How far up depends on my assessment of the patient's comorbidities, age, projected survival, and adherence to diet/ binders. (Do you really want to recommend surgery to patients because they love cheeseburgers?) Transplant status cuts both ways with hPTH often resolving after transplant, but, when PTX is ultimately needed, a th...