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Importance of Ca in body:
Bone mineralization. Blood coagulation. Neuromuscular transmission. Neurotransmitter release. Contraction of all muscle types. Cell membrane permeability and excitability. Secretion of glands.
Control Of Ca Homeostasis
1- PTH:
raises plasma Ca level if it is lowered by: -Vit. D activation Ca absorption. - Ca reabsorption in DCT. - PO4 reabsorption in PCT. - Ca mobilization from bone.
2- CALCITONIN:
lowers plasma Ca level if it is raised by: - Ca absorption. - PO4 reabsorption in PCT. - Ca mobilization from bone. 3- VITAMIN D: - Ca absorption. - Ca bone uptake and deposition.
Definition
Hyperparathyroidism is an endocrine disorder caused by excessive secretion of parathyroid hormone (PTH) from the parathyroid glands.
Statistics
Incidence
28 per 100,000 Americans can be expected to develop
Prevalence
Primary hyperparathyroidism in adults: 1/500-1000
population. Its true prevalence in children is unknown, but it is considered rare Prevalence of secondary and tertiary hyperparathyroidism depends on prevalence of the underlying disease Postmenopausal women have the highest incidence of primary hyperparathyroidism and fractures Prevalence increases with age, but hyperparathyroidism can affect people of all ages, including children
Statistics
Gender Primary hyperparathyroidism
to unity in people younger than 40 years to 5:1 in those older than 75 years
Primary
Common disease that occurs when one or more of the parathyroid glands becomes overactive. Patients with primary disease are almost always hypercalcemic In 85% of patients with primary hyperparathyroidism, hypercalcemia is due to a parathyroid adenoma. Loss of sensitivity of these proliferating chief cells to normal extracellular calcium concentrations occurs Hypercalcemia is usually discovered during a routine serum chemistry profile
Secondary
Occurs in patients with kidney failure or severe vitamin D deficiency. The vast majority of cases demonstrate only chief cell hyperplasia Patients are almost always normocalcemic Approximately 20% of patients with hyperparathyroidism have renal calculi
Etiology
Common causes
Primary hyperparathyroidism: most cases (85%) - single parathyroid gland malfunctioning and developing into an adenoma. 15% of cases, multiple adenomas or hyperplasia Ectopic parathyroid glands Secondary hyperparathyroidism: vitamin D deficiency chronic kidney disease
Etiology
Secondary hyperparathyroidism
Pseudohypoparathyroidism due to parathyroid
hormonereceptor G protein mutation Less common conditions associated with vitamin D deficiency or resistance include
malabsorption cholestatic liver or biliary disease drugs (eg, anticonvulsants, rifampin, ketoconazole, 5-
FU/leucovorin)
Etiology
Secondary hyperparathyroidism:
Chronic kidney disease or end-stage renal disease
(ESRD) Vitamin D deficiency Metastatic prostate cancer Iatrogenic causes such as lithium administration: may decrease the ability of circulating levels of calcium that are within the reference range to suppress PTH secretion (mechanism unclear)
Symptoms
Disease of bones, stones, abdominal groans and psychic moans" Skeletal manifestations
Bone and joint pain esp. in hand and feet (pseudogout).
Renal
manifestations
Gastrointestinal
peptic symptoms.
manifestations
Symptoms
Neuromusculopsychologic
manifestations
proximal muscle weakness, easy fatigability, depression,
inability to concentrate, and memory problems that are often poorly characterized and may not be noted by the patient.
Cardiovascular
manifestations
Signs
Primary hyperparathyroidism: Signs of dehydration due to hypercalcemia Bradycardia, with or without irregular heartbeat Decreased muscle tone and somnolence Gastric and/or duodenal ulcer Secondary hyperparathyroidism: Skeletal deformity Decreased muscle tone Bone pain on palpation Short stature
Symptoms
Primary hyperparathyroidism: Symptoms of early disease, when present, are specific to hypercalcemia Muscle weakness Psychiatric symptoms, including depression, dementia, confusion, and stupor Increased sleepiness Nausea, vomiting Acute abdominal pain (which might be the result of pancreatitis), constipation Polyuria, polydipsia Frequent and occasionally painful urination and dysuria Back pain (from kidney stones) Heartburn or associated pain from acid reflux
Diagnosis
Serum calcium Intact PTH Serum phosphorus Urine calcium 25-hydroxyvitamin D Bone densitometry Radiography Technetium-99m-sestamibi scanning
Treatment
Calcitriol
(secondary hyperparathyroidism due to CKD)
Ergocalciferol
(secondary hyperparathyroidism due to CKD)
Paricalcitol
(secondary hyperparathyroidism due to CKD)
Lifestyle adjustments