HYPERPARATHYROIDISM

ADAM STERN PGYII

Hypercalcemia - DDX
Parathyroid related
Malignancy
Primary Hyperpara, Li tx, Familial Hypocalcuric Hypercalcemia Solid tumor, Hematologic Intoxication, Granulomatous Disease Hyperthyroid, Immobilization, Vit A 2ndary Hyperpara, Aluminum, Milk-Alkali

Excessive Vitamin D High bone turnover Renal Failure

Hypercalcemia Workup
Calcium and Phosphorus Serum PTH obtain 1st
if elevated in the setting of hypercalcemia, then hyperparathyroidism is dx If low, check PTHrP, Vitamin A & D, TSH, Cortisol, ACE, 24h urine calcium clearance, review meds.

Ivar Sandstrom
Sweedish Medical Student Discovered Parathyroid gland In 1880 Last major organ Identified in humans

Parathyroid Hormone
Secreted from the chief cells of the parathyroid gland as an 84 amino acid protein.

Calcium Receptor

Calcium Phos PTH Vitamin D Axis

Hyperparathyroid Symptoms
~80% asymptomatic Stones (Kidneys)
Calcium deposition and nephrolithiasis Urinary tract obstruction

Bones
Osteitis Firosa Cystica
Increased osteoclasts Increased bone turnover Reduced cortical bone density

Moans

Fatigue, Depression, Confusion

Hyperparathyroid Symptoms (cont)

Other
N/V, Constipation, Polyuria Short QT

Severe Parathyroid Crisis

Renal Failure from nephrocalcinosis Coma, Cardiac Arrest

Primary Hyperparathyroid
Causes Solitary Adenoma Parathyroid Carcinoma (rare) Multiple endocrine neoplasia (rare)
Hypersecretion of PTH Hypercalcemia, HypOphosphatemia

Primary Hyperparathyroid
Diagnosis
Elevated serum PTH immunoassay (high sens), high calcium, low or normal phos (decr prox tubular reabsorption) Elevated 1,25(OH)2D (low spec) Imaging 99m-technetium sestamibi Ultrasound

Parathyroid Imaging

Primary Hyperparathyroid
Treatment
Surgical Indications Medical
Ca > 11.5, T-score < -2.5, renal stones

Replace volume Facilitate calciuresis (loop diuretics) Bisphosphonates decrease bone reabsorption. Calcitonin Hormonal Therapy Raloxifene, other SERMs Cinacalcet (not FDA approved)

Secondary Hyperparathyroid
1. Vit. D deficiency 2. Primary decreased calcium absorption in elderly 3. Increased phosphate in acute or chronic renal failure
Renal Osteodystrophy
Osteomalacia (low Ca, vit D) Osteitis fibrosa cystica (high PTH)

Adynamic Bone Disease (low PTH)

Secondary Hyperparathyroid
Treatment
Phos Binders Vitamin D analogs
negative feedback on PTH gene transcription Limited use in setting of hypercalcemia

Cinacalcet (Sensipar)

Tertiary Hyperparathyroid
Tertiary Hyperparathyroidism is essentially secondary hyperparathyroidism that is no longer responsive to medications. Also occurs after renal transplant, where hypertrophied glands continue to oversecrete PTH (set point alteration) May require surgery