Q. Can you explain why patients with renal failure have hyperparathyroidism?

A. Yes but first, a quick note about the parathyroid. Unlike other endocrine organs, the
parathyroid gland is not controlled by the pituitary. It secretes parathyroid hormone in response
to serum calcium levels. Thats it. No pituitary/hypothalamic input. The function of parathyroid
hormone is to raise serum calcium; so when the calcium level drops below normal, thats the
signal for the parathyroid to start secreting parathyroid hormone.
Hyperparathyroidism can be caused by a number of different things. Primary
hyperparathyroidism occurs when the parathyroids are over-functioning because of some
intrinsic parathyroid gland problem (for example, a parathyroid adenoma thats busy secreting
parathyroid hormone). Secondary hyperparathyroidism occurs when the parathyroids are
overfunctioning because something is causing chronic hypocalcemia (the something is usually
chronic renal failure). Tertiary hyperparathyroidism occurs when the parathyroids are
autonomously over-functioning (this happens in a few patients with secondary
hyperparathyroidism). Theres also something called pseudohyperparathyroidism, which occurs
when a carcinoma (usually squamous cell lung carcinoma) secretes a protein that acts so much
like parathyroid hormone that it actually raises serum calcium. This type of situation is called a
paraneoplastic syndrome, and it occurs with other malignancies and hormones too (for
example, small cell lung carcinoma can secrete proteins that acts like ADH or ACTH).
Getting back to the kidney: in chronic renal failure, phosphate is not excreted well, and vitamin
D is not converted to its active form very readily. Calcium phosphate forms in the circulation,
leading to a decrease in free serum calcium. The hypocalcemia then stimulates the parathyroids
to grow and secrete parathyroid hormone, and voila, you have hyperparathyroidism.
The signs and symptoms of primary hyperparathyroidism have been referred to as stone, bone,
moan and groan:
Stone: kidney stones, nephrocalcinosis (calcification of renal interstitium and tubules),
calciphylaxis (calcification of vessels leading to ischemia in skin, other organs).
Bone: bone pain. Stimulated osteoclasts erode bone (leading to thin, delicate, fragile
trabeculae). If hyperparathyroidism goes on long enough, patients can get osteitis fibrosa
cystica (thinned cortex and fibrotic marrow with hemorrhage and cysts) and brown tumors
(big masses of osteoclasts and hemorrhagic (brown) debris that can be mistaken for
neoplasms check out the radiograph, above).
Moan: mental changes (depression, lethargy, seizures).
Groan: gastrointestinal problems (ulcers, constipation, nausea, pancreatitis, gallstones).