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M&M Test 3 > B6-050 CBCL Hyperparathyroidism > Flashcards

B6-050 CBCL Hyperparathyroidism Flashcards

1
Q

parathyroid glands are located

A

on the back of thyroid

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2
Q

cells that produce PTH

A

chief cells

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3
Q

chief cells are stimulated to produce PTH by [3]

A

low calcium
high phosphate
low vitamin D

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4
Q

PTH stimulates osteoblasts to secrete

A

RANKL

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5
Q

RANKL binds to RANK on osteoclasts stimulating them to

A

resorb bone

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6
Q

bone resorption releases [2] ions into blood

A

Ca++
PO43-

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7
Q

decreased calcium levels stimulates PTH to activate […] to increase calcium levels in the blood

A

osteoclasts

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8
Q

PTH stimulates […] in the PCT to activate vitamin D

A

a-1-hydroxylase

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9
Q

PTH stimulates a-1-hydroxylase in the […] to activate vitamin D

A

PCT

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10
Q

once activated in the kidney, […] stimulates GIT to absorb calcium in the gut

A

vitamin D

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11
Q

once activated in the kidney, vitamin D stimulates GI tract to absorb […] in the gut

A

calcium

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12
Q

phosphate is excreted from what part of the kidney?

A

PCT

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13
Q

how does PTH decrease phosphate ions in blood?

A

inhibits transporter for reabsorption of Na+ and phosphate in PCT

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14
Q

decreases the phosphate concentration in blood

A

PTH

**phosphate trashing hormone

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15
Q

calcium is reabsorbed from what part of the kidney?

A

DCT

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16
Q

PTH can directly stimulate the transporter for reabsorption of […] in the DCT

A

Ca++

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17
Q

summarize the effects of PTH on the kidney [4]

A

increase a-1-hydroxylase
increase PO4 excretion in urine
decrease PO4 in serum
increase calcium in serum

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18
Q

overall effects of hypersecretion of PTH [2]

A

hypercalcemia
hypophosphatemia

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19
Q

primary causes of high PTH [3]

A

adenomas
hyperplasia
carcinoma

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20
Q

MEN1 and 2 mutations cause […] hyperparathyroidism

A

primary

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21
Q

most common cause of secondary hyperparathyroidism

A

chronic kidney disease

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22
Q

causes of secondary hyperparathyroidism [3]

A

CKD
vitamin D deficiency
low calcium diet

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23
Q

what stimulates PTH production in CKD? [2]

A

low calcium
high phosphate

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24
Q

hyperparathyroidism due to chronic hypocalcemia

A

secondary

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25
Q

phosphate binds

A

free calcium

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26
Q

how does CKD cause hyperparathyroidism?

A

reduced GFR causes hyperphosphatemia –> hypocalcemia

reduced function of PCT causes hyperphosphatemia and hypocalcemia

reduced function of DCT causes
hyperphosphatemia and hypocalcemia

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27
Q

malabsorptive syndromes like Crohns or celiac can cause

A

decreased absorption of vitamin D –> secondary hyperparathyroidism

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28
Q

How does pancreatic insufficiency cause secondary hyperparathyroidism?

A

pancreatic lipase is important for fat absorption, and vitamin D is absorbed with fat –> decreased absorption of vitamin D

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29
Q

how do gallstones cause secondary hyperparathyroidism?

A

bile is important for fat absorption
vitamin D needs fat to be absorbed

no bile —> decreased absorption of vitamin D

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30
Q

decreased sun exposure can cause

A

secondary hyperparathyroidism

**less formation of active vitamin D

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31
Q

chronic hypocalcemic state that progresses over time, past secondary

A

tertiary hyperparathyroidism

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32
Q

consistent, constant stimulation of the parathyroid leads to

A

hyperplasia

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33
Q

uncontrolled release of PTH independent of any signaling from feedback regulation

A

tertiary hyperparathyroidism

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34
Q

mneumonic for primary hyperparathyroidism

A

bones
stones
groans
thrones
psychiatric overtones

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35
Q

PTH liberates [3] things from bones

A

Ca++
PO43-
hydroxyapatites

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36
Q

excessive PTH causes […] of bone

A

demineralization

**increased risk of fracture

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37
Q

bone density decreases due to constant demineralization

A

osteoporosis

**increased risk of fracture

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38
Q

condition occurring due to increased bone resorption
osteoclasts and connective tissues form cavities that look like cyst

A

osteitis cystica fibrosis

**occurs due to primary hyperparathyroidism –> increased osteoclast activity

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39
Q

nephrocalcinosis

A

calcium and phosphate stones deposit in small parts of kidney tubules or smaller calyxes

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40
Q

nephrolithiasis

A

calcium and phosphate stones form in ureter/renal calyx

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41
Q

[…]calemia decreases smooth muscle activity

A

hypercalcemia

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42
Q

how does hypercalcemia decrease smooth muscle activity

A

increased Ca++ blocks Na+ channels in smooth muscle

**results in reduced GI motility

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43
Q

GI symptoms of primary hyperparathyroidism

A

constipation
abdominal pain
nausea
vomiting

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44
Q

how can primary hyperparathyroidism cause ulcers?

A

Ca++ activates gastrin and stimulates parietal cells to increase HCl in stomach

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45
Q

how can primary hyperparathyroidism cause pancreatitis?

A

Ca++ activates pancreatic enzymes in pancreatic ducts –> autodigestion causing significant abdominal pain

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46
Q

how does primary hyperparathyroidism causes nephrogenic diabetes insipidus?

A

Ca++ inhibits ADH –> less water is reabsorbed

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47
Q

symptoms of nephrogenic DI caused by primary hyperparathyroidism

A

polyuria: increased urine output
polydipsia: to compensate for water lost in bloodstream there is excessive thirst

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48
Q

how does primary hyperparathyroidism cause decreased mental function?

A

Ca++ can bind to Na+ channels in brain and block electrical activity

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49
Q

neurological manifestations of primary hyperparathyroidism

A

lethargy
depression
AMS: can progress to coma due to severe hypercalcemia
reduction of deep tendon reflexes

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50
Q

Ca++ in the channel will hinder […] from entering cells of smooth muscles or neurons

A

Na+

**causes slow activity and neurological symptoms

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51
Q

Ca++ in the channel will hinder Na+ from entering cells of […] and […]

A

smooth muscle
neurons

**causes slow activity and neurological symptoms

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52
Q

how does secondary hyperparathyroidism caused by CKD effect the kidneys?

A

kidney is damaged and unable to resorb calcium

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53
Q

how does secondary hyperparathyroidism caused by CKD effect the GI tract?

A

kidney damage prevents activation of vitamin D
without activated vitamin D, GI tract cannot absorb calcium

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54
Q

how does secondary hyperparathyroidism caused by CKD effect the bones?

A

increase bone demineralization due to hypocalcemia

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55
Q

group of conditions caused by CKD leading to secondary hyperparathyroidism that damages bone

A

renal osteodystrophy

since PTH cannot get Ca++ from kidneys or GI, it causes massive demineralization of bone

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56
Q

demineralization causing cystic cavities in bone

A

osteitis cystica fibrosa

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57
Q

[…]calcemia shortens the QT interval

A

hypercalcemia

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58
Q

seen in secondary and tertiary hyperparathyroidism when there is too much Ca++ and it deposits around the vessels

A

calciphylaxis

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59
Q

Ca++ deposition around vessels causing ischemia/necrosis of skin lesions

A

calciphylaxis

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60
Q

calcium in the serum may appear low if […] is also low

A

albumin

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61
Q

equation for correction of calcium

A

serum Ca + 0.8 x (4-albumin)

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62
Q

medications that can cause hypercalcemia

A

thiazides
lithium
calcium supplements
vitamin D supplements

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63
Q

typically, if calcium is elevated, PTH is

A

decreased

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64
Q

elevated calcium with normal/high PTH

A

PTH mediated hypercalcemia

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65
Q

first step in diagnosing hypercalcemia

A

recheck serum calcium
check PTH levels

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66
Q

85% of primary hyperparathyroidism occurs due to

A

solitary parathyroid adenoma

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67
Q

expected labs for primary hyperparathyroidism

A

elevated PTH
elevated serum calcium
elevated urine calcium
low phosphate

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68
Q

should you biopsy parathyroid carcinoma?

A

no, risk for seeding

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69
Q

hypercalcemia caused by a parathyroid carcinoma can be treated with

A

cinacalcet

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70
Q

primary treatment of parathyroid carcinoma

A

surgical resection

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71
Q

excessive PTH secretion as a secondary response to hypocalcemia

A

secondary hyperparathyroidism

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72
Q

chronic hypocalcemia causes parathyroid […]

A

hyperplasia

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73
Q

results from progression of secondary hyperparathyroidism

A

tertiary hyperparathyroidism

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74
Q

prolonged hypocalcemia causes development of autonomous parathyroid function and hypercalcemia

A

tertiary hyperparathyroidism

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75
Q

in tertiary hyperparathyroidism, […] remains despite discontinuation of vitamin D and calcium supplements

A

hypercalcemia

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76
Q

most commonly occurs in CKD or post kidney transplant

A

tertiary hyperparathyroidism

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77
Q

in tertiary hyperparathyroidism, […] remains high despite vitamin D therapy and correction of hyperphosphatemia

A

PTH

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78
Q

inheritance pattern of FHH

A

autosomal dominant

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79
Q

parathyroid glands and kidney detect serum calcium concentrations via

A

calcium sensing receptor

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80
Q

FHH is an [….] mutation of CaSR

A

inactivating

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81
Q

parathyroid gland perceives serum calcium is low due to decreased sensitivity, leading to increased PTH secretion and serum calcium

A

FHH

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82
Q

paradoxical hypocalciuria in the setting of hypercalcemia

A

FHH

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83
Q

does FHH resolve with surgery?

A

no

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84
Q

mild hypercalcemia since childhood

85
Q

Ca/Cr clearance ratio <0.01

86
Q

malignancy is the most common cause of

A

non-PTH mediated hypercalcemia

87
Q

elevated PTHrP

A

non-PTH mediated hypercalcemia

88
Q

metastasis to bone of breast cancer or multiple myeloma causes efflux of calcium from the bone

A

local osteolytic hypercalcemia

**type of non-PTH mediated hypercalcemia

89
Q

what kind of study is required prior to performing parathyroidectomy?

A

localization:
sestimibi scan
thyroid US
neck CT

90
Q

[…] allows determination of the biochemical cure while the patient is undergoing parathyroidectomy

A

intra operative PTH monitoring

91
Q

binds to extracellular CaSR on parathyroid cells and decreases their response to low serum calcium

A

cinacalcet

92
Q

medication that reduces PTH and calcium but does not affect bone mass

A

cinacalcet

93
Q

bisphosphonates [4]

A

alendronate
risidronate
ibandronate
zolendronic acid

94
Q

medication that inhibits osteoclast mediated bone resorption

A

bisphosphonates

95
Q

medication that does not affect PTH but lowers calcium and improves bone mass

A

bisphosphonates

96
Q

primary treatment of malignancy related hypercalcemia

A

bisphosphonates

97
Q

vertebral fracture due to low bone density is indication for

A

parathyroidectomy

98
Q

serum calcium […] above the upper limit of normal is indication for parathyroidectomy

A

greater than 1.0 mg/dl

99
Q

nephrolithiasis or nephrocalcinosis seen on imaging is indication for

A

parathyroidectomy

100
Q

age less than […] is indication for parathyroidectomy

101
Q

sites of hydroxylation of Vitamin D and where they occur

A

25- liver
1 and 24- kidney

102
Q

[…]calcemia causes inhibition of PTH

A

hypercalcemia

103
Q

[…]calcemia results in the secretion of PTH

A

hypocalcemia

104
Q

hypercalcemia stimulates osteoblasts to

A

build more bone

lowering serum calcium and phosphate

105
Q

hypercalcemia will cause the kidneys to increase excretion of

106
Q

hypocalcemia will stimulate osteoclasts to

A

resorb bone

increases serum calcium and phosphate

107
Q

hypocalcemia will cause the kidneys to excrete […] and retain […]

A

excrete phosphorus
retain calcium

108
Q

PTH is synthesized and excreted due to

A

decreased calcium levels

109
Q

PTH will cause the bone to release [2]

A

calcium and phosphorus

110
Q

PTH will cause the kidneys to

A

resorb calcium
excrete phosphate

111
Q

PTH will cause the GI tract to

A

increase calcium and phosphate absorption indirectly via vitamin D

112
Q

is PTH under hypothalamic control?

A

no responds directly to calcium

113
Q

rate limiting enzyme in vitamin D activation

A

1-a-hydroxylase

114
Q

inactivates vitamin D during excess calcium and phosphate

A

24-hydroxylase

115
Q

PTH acts on osteoblasts to secrete more

116
Q

RANKL binds to RANK on […] to activate them

A

osteoclasts

117
Q

RANKL-RANK bind stimulates

A

osteoclasts differentiation and activation

118
Q

osteoblasts secrete […] which binds to RANKL to prevent it from binding RANK

119
Q

what organs hydroxylate vitamin D to its active form?

A

liver and kidney

120
Q

in the liver, […] will hydroxylate the 25 position of vitamin D

A

25 hydroxylase

121
Q

in the kidney […] will hydroxylate the 1 position of vitamin D

A

1-a-hydroxylase

122
Q

Vitamin D functions in the gut to

A

promote calcium uptake and transport into the blood stream

123
Q

increases the rate of calcium transport

A

vitamin D (calcitriol)

124
Q

vitamin D stimulates calcium […] in bones

A

resorption

125
Q

vitamin D acts on the kidneys to

A

decrease excretion of calcium and phosphate

126
Q

vitamin D acts on the GI tract to

A

increase absorption of calcium and phosphate

127
Q

how many parathyroid glands are typically present?

128
Q

superior parathyroid glands derive from

A

4th pharygeal pouch

129
Q

inferior parathyroid glands derive from

A

3rd pharyngeal pouch

130
Q

calcium homeostasis is controlled by [3]

A

PTH
vitamin D
calcitonin

131
Q

increase calcium levels in times of hypocalcemia [2]

A

PTH and vitamin D

132
Q

decreases calcium levels in in times of hypercalcemia

A

calcitonin

133
Q

PTH […] and vitamin D […] renal phosphate reabsorption

A

PTH decreases and vitamin D increases renal phosphate reabsorption

134
Q

a mutation in CaSR will stimulate the release of

A

PTH

increasing serum calcium

135
Q

binds to CaSR and alters its sensitivity resulting in decreased parathyroid responsiveness

A

cinacalcet

136
Q

inhibit osteoclast mediated bone resorption resulting in decreased calcium

A

bisphosphonates

137
Q

most common cause of primary hyperparathyroidism

A

parathyroid adenoma

138
Q

autosomal dominant mutation in CaSR gene

139
Q

renal failure and vitamin D cause […] hyperparathyroidism

140
Q

expected labs for primary parathyroidism

A

hypercalcemia
hypophosphatemia

141
Q

expected labs for secondary parathyroidism

A

hypocalcemia
hyperphosphatemia

142
Q

refractory hyperparathyroidism resulting from chronic kidney disease

143
Q

expected PTH and Ca+ values in tertiary hyperparathyroidism

A

elevated PTH
elevated Ca+

144
Q

hyperparathyroidism caused by chronically low calcium and/or elevated phosphate

145
Q

expected PTH, calcium, phosphate, ALP labs for secondary hyperparathyroidism

A

elevated PTH
low calcium
elevated phosphate (in CKD, may be normal in vitamin deficiency)
elevated ALP

146
Q

MEN1 syndrome involves tumors in [3]

A

pituitary
pancreas
parathyroid

147
Q

primary role of PTH

A

regulation of calcium and phosphate

148
Q

How does PTH affect calcium and phosphate metabolism in the kidney?

A

increases reabsorption of Calcium
inhibits reabsorption of phosphate

149
Q

PTH stimulates the hydroxylation of

A

25-hydroxy vitamin D

150
Q

does PTH affect bicarb?

A

yes, stimulates secretion of bicarb in the kidney

151
Q

what is the active form of vitamin D?

A

1,25-OH vitamin D

152
Q

PTH stimulates […] to produce 1,25-OH

A

1a-hydroxylase

153
Q

1a-hydroxylase in the kidney is stimulated by [3]

A

PTH
low serum calcium
low serum phosphate

154
Q

PTH increases calcium reabsorption in the kidney via a basolateral receptor coupled to […]

A

adenylate cyclase

155
Q

25 hydroxylation of vitamin D occurs in the

156
Q

activation of vitamin D requires [3]

A

UV light exposure
hepatic function
kidney function

157
Q

cacitonin is induced by […]calcemia

A

hypercalcemia

158
Q

the liver produces what form of vitamin D?

A

25-hydroxy D3

159
Q

in CKD, decreased GFR causes the reduced excretion of

160
Q

what medication can have the side effect of elevated serum calcium?

161
Q

how do thiazides lead to elevated serum calcium levels?

A

block the NaCl channels in the DCT
causes hyper polarization of apical membrane, resulting in increased reabsorption of calcium by voltage gated calcium channels

162
Q

PTH functions at the level of the kidney to [3]

A

increase calcium reabsorption
inhibit phosphate reabsorption
induce 1-alpha-OH activity

163
Q

hypertension
fatigue
memory issues

are symptoms of

A

hypercalciemia

164
Q

expected serum PTH, calcium, phosphate, and vitamin D levels in primary hyperparathyroidism

A

elevated PTH
elevated calcium
low/normal phosphate
normal vitamin D

165
Q

PTH functions at the level of bone to induce osteoblasts to

A

secrete RANKL

166
Q

what does RANKL do?

A

induces osteoclasts to promote bone reabsorption and increase serum levels of calcium and phosphate

167
Q

how does PTH stimulate bone reabsorption?

A
  1. induces osteoblasts to secrete RANKL
  2. RANKL stimulates osteoclasts to resorb bone
168
Q

monoclonal antibody used to block the function of RANKL

169
Q

[hyper or hypocalcemia]
muscle spasms

A

hypocalcemia

170
Q

[hyper or hypocalcemia]
tetany

A

hypocalcemia

171
Q

[hyper or hypocalcemia]
hypotension

A

hypocalcemia

172
Q

[hyper or hypocalcemia]
trousseau sign

A

hypocalcemia

**carpal spasm when bp cuff is inflated for 2-3min

173
Q

[hyper or hypocalcemia]
chvostek sign

A

hypocalcemia

**twitching of facial muscle when facial nerve is entrapped

174
Q

[hyper or hypocalcemia]
coma

A

hypercalcemia

175
Q

[hyper or hypocalcemia]
constipation

A

hypercalcemia

176
Q

[hyper or hypocalcemia]
esophagitis

A

hypercalcemia

177
Q

[hyper or hypocalcemia]
nephrolithiasis

A

hypercalcemia

178
Q

asymptomatic hypercalcemia is associated with

179
Q

a calcium to creatinine clearance greater than 0.01 is associated with

A

hyperparathyroidism

180
Q

a calcium to creatinine clearance ratio less than 0.01 is associated with

A

FHH

**due to reduced excretion of calcium

181
Q

formula to calculate fractional excretion of calcium

A

(Ca urine x Cr plasma) / (Ca plasma x Cr urine)

182
Q

FHH is due to a mutation in

A

CaSR

**reduces its affinity for calcium

183
Q

both calcium and PTH mildly elevated
patient asymptomatic

184
Q

patients diagnosed with FHH will have a family history of

A

asymptomatic elevated serum calcium and PTH

185
Q

parathyroid adenoma is the most common cause of

A

primary hyperthyroidism

186
Q

causes of secondary hyperparathyroidism [3]

A

CKD
vitamin D deficiency
dietary calcium malabsorption

187
Q

non-PTH mediated hypercalcemia is usually caused by

A

malignancy

188
Q

medications that can cause hypercalcemia [2]

A

thiazides
lithium

189
Q

medications that can be used to treat hypercalcemia if surgery is not an option

A

cinacalcet
alendronate

190
Q

best option to cure parathyroid adenoma

A

surgical resection

191
Q

a patient with primary hyperparathyroidism will have increased […] in urine [2]

A

calcium
phosphate

192
Q

describe the expected lab results for primary hyperparathyroidism

A

elevated Ca
low/normal phosphate
elevated PTH

**30% of patients will have hypercalciuria

193
Q

the superior and middle thyroid veins drain into the

A

internal jugular vein

194
Q

the inferior thyroid vein drains into the

A

left brachiocephalic

195
Q

the facial vein drains into the

A

retromandibular vein –> internal jugular

196
Q

the external jugular vein is located anterior to the

197
Q

nerves located posterior-lateral to the trachea and thyroid glands

A

recurrent laryngeal nerves

198
Q

damage to the sympathetic chain during parathyroidectomy results in

A

Horner’s syndrome

199
Q

damage to the recurrent laryngeal nerves during parathyroidectomy results in

A

hoarse voice

200
Q

describe the expected labs in secondary hyperparathyroidism

A

elevated PTH
decreased Ca
increased serum phosphate (in CKD)
decreased calcitriol

201
Q

osteoporosis with a bone density score of less than […] is indication for parathyroidectomy

202
Q

patient age […] is indication for parathyroidectomy

A

less than 50

203
Q

calcium level […] is indication for parathyroidectomy

A

greater than 1.0 mg/dl above normal

204
Q

undetectable PTH indicates

A

non-PTH mediated hypercalcemia

**often caused by malignancy

205
Q

[….] fracture is indication for parathyroidectomy

206
Q

creatinine clearance [….] is indication for parathyroidectomy

A

less than 60 mL/min

207
Q

24 urine calcium [….] is indication for parathyroidectomy

A

greater than 400 mg/day

208
Q

[…] or […] seen on kidney imaging is indication for parathyroidectomy

A

nephrolithiasis
nephrocalcinosis

M&M Test 3 (16 decks)

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