Post on 04-Jun-2018
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HYPERPARATHYROIDISM
ADAM STERN
PGYII
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Hypercalcemia - DDX
Parathyroid related Primary Hyperpara, Li tx, Familial Hypocalcuric
Hypercalcemia
Malignancy Solid tumor, Hematologic
Excessive Vitamin D Intoxication, Granulomatous Disease
High bone turnover Hyperthyroid, Immobilization, Vit A
Renal Failure 2ndary Hyperpara, Aluminum, Milk-Alkali
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Hypercalcemia
Workup Calcium and Phosphorus
Serum PTHobtain 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.
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Ivar Sandstrom
Sweedish Medical
Student
DiscoveredParathyroid gland
In 1880
Last major organ
Identified in humans
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Parathyroid Hormone
Secreted from the chief cells of
the parathyroid gland as an 84
amino acid protein.
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Calcium Receptor
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Calcium Phos PTH
Vitamin D Axis
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Hyperparathyroid -
Symptoms ~80% asymptomatic
Stones (Kidneys)
Calcium deposition and nephrolithiasisUrinary tract obstruction
BonesOsteitis Firosa Cystica
Increased osteoclasts Increased bone turnover
Reduced cortical bone density
MoansFatigue, Depression, Confusion
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Hyperparathyroid
Symptoms (cont) Other
N/V, Constipation, Polyuria
Short QT
SevereParathyroid Crisis
Renal Failure from
nephrocalcinosisComa, Cardiac Arrest
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Primary
Hyperparathyroid Causes
Solitary Adenoma
Parathyroid Carcinoma (rare)Multiple endocrine neoplasia (rare)
Hypersecretion of PTH
Hypercalcemia,HypOphosphatemia
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Primary
Hyperparathyroid Diagnosis
Elevated serum PTH immunoassay
(high sens), high calcium, low ornormal phos (decr prox tubularreabsorption)
Elevated 1,25(OH)2D (low spec)
Imaging99m technetium sestamibiUltrasound
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Parathyroid Imaging
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Primary
Hyperparathyroid Treatment
Surgical Indications Ca > 11.5, T-score < -2.5, renal stones
Medical Replace volume
Facilitate calciuresis (loop diuretics)
Bisphosphonatesdecrease bonereabsorption.
Calcitonin
Hormonal TherapyRaloxifene, other SERMs
Cinacalcet (not FDA approved)
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Secondary
Hyperparathyroid1. Vit. D deficiency
2. Primary decreased calcium
absorption in elderly3. Increased phosphate in acute orchronic renal failure
Renal Osteodystrophy Osteomalacia (low Ca, vit D)
Osteitis fibrosa cystica (high PTH)
Adynamic Bone Disease (low PTH)
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Secondary
Hyperparathyroid Treatment
Phos Binders
Vitamin D analogs negative feedback on PTH gene
transcription
Limited use in setting of
hypercalcemia
Cinacalcet (Sensipar)
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Tertiary
Hyperparathyroid Tertiary Hyperparathyroidism is
essentially secondary
hyperparathyroidism that is nolonger responsive to medications.
Also occurs after renal transplant,
where hypertrophied glands continue
to oversecrete PTH (set pointalteration)
May require surgery