Preoperative parathyroid imaging in CKD-related secondary hyperparathyroidism: a systematic review and diagnostic...

In secondary hyperparathyroidism (SHPT), imaging must characterize multifocal disease and identify ectopic or supernumerary tissue before surgery, but the comparative accuracy and optimal hierarchy of available modalities remain uncertain. We compared the main preoperative imaging techniques used for parathyroid localization in patients with chronic kidney disease (CKD).

MEDLINE, Embase, and Web of Science were searched from inception through 31 May 2026 for gland-, lesion-, or site-level diagnostic accuracy studies in adults with CKD, kidney failure, or kidney transplantation, using surgical and/or histopathological confirmation. An arm-based Bayesian bivariate network meta-analysis jointly estimated sensitivity and specificity for ultrasonography (US), non-subtraction technetium-99m methoxyisobutylisonitrile (⁹⁹ᵐTc-MIBI) planar scintigraphy, ⁹⁹ᵐTc-MIBI single-photon emission computed tomography/computed tomography (SPECT/CT), and ¹⁸F-fluorocholine (¹⁸F-FCH) positron emission tomography/computed tomography (PET/CT). Balanced accuracy and comparative effects versus US were also estimated. Risk of bias was assessed using QUADAS-3.

Ten studies including 479 participants contributed 24 test arms. Estimated sensitivity was 89.6% [95% credible interval (CrI) 81.9-94.5] for ¹⁸F-FCH PET/CT, 68.8% (56.0-79.2) for MIBI SPECT/CT, 64.2% (51.0-75.6) for US, and 45.9% (32.8-59.4) for planar MIBI. Specificity estimates ranged from 76.4% to 83.8% and were imprecise. Compared with US, ¹⁸F-FCH PET/CT showed higher sensitivity (odds ratio 4.83, 95% CrI 3.20-7.48) and balanced accuracy (+11.9 percentage points, 95% CrI 0.1-20.6), with no clear specificity difference. Findings were directionally consistent in sensitivity analyses.

¹⁸F-FCH PET/CT had the highest estimated sensitivity and balanced accuracy, although evidence was limited and specificity remained uncertain. A clinically guided hierarchy beginning with US and progressing to ¹⁸F-FCH PET/CT may improve comprehensive glandular mapping and support multidisciplinary operative planning in SHPT. 4D-CT and dual-isotope scintigraphic techniques also appear promising as alternative or complementary strategies, although SHPT-specific evidence remains limited and requires further dedicated comparative studies.