3.17.08 hyperparathyroidism stern

8/13/2019 3.17.08 Hyperparathyroidism Stern

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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

3.17.08 hyperparathyroidism stern

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