Hyperparathyroidism Flashcards
primary hyperparathyroidism what is seen on blood investigation ?
High calcium
High PTH levels OR INAPPROPRIATELY NORMAL
Low Phosphate
ALP increased
Renal stones
Urine calcium : creatinine clearance ratio > 0.01
indication for parathyroidectomy in primary hyperparathyroidism ?
nephrolithiasis
serum Calcium > 1mg/dL above normal
Hypercalciuria > 400mg/day
Creatinine clearance < 30% compared with normal
Episode of life threatening hypercalcaemia
Age < 50 years
Neuromuscular symptoms
Reduction in bone mineral density of the femoral neck, lumbar spine, or distal radius of more than 2.5 standard deviations below peak bone mas
Clinical features of Primary hyperparathyroidism
May be asymptomatic if mild
Or
Recurrent abdominal pain (pancreatitis, renal colic)
Changes to emotional or cognitive state
osteitis fibrosa cystica- loss of bone mass
Pseudogout - painful joints
Renal calcium stones
cause of Primary hyperparathyroidism
solitary adenoma (80%), multifocal disease occurs in 10-15% and parathyroid carcinoma in 1% or less
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Treatment of primary hyper parathyroidism
Parathyroidectomy
Ergocalcoferol / cholecalciferol
If osteoporosis - bisphosphonates
Cinacalcet - Cinacalcet has been shown to lower serum calcium and serum intact PTH.
may now be used in selected cases of primary hyperparathyroidism; for example, in those who are symptomatic but not surgical candidates or who decline surgery.
Kidney stones - thiazide diuretics
complication of hyperparathyroidism?
hypercalcemia - nephrogenic DI
cause of Secondary hyperparathyroidism
Parathyroid gland hyperplasia
result of low calcium, and high phosphate - setting of chronic renal failure
clinical features of Secondary hyperparathyroidism
Eventually may develop bone disease, osteitis fibrosa cystica and soft tissue calcifications
Secondary hyperparathyroidism what is seen on blood investigation ?
PTH (Elevated) therefore high ALP
Ca2+ (Low or normal)
Phosphate (Elevated)
Vitamin D levels (Low)
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Indications for surgery in secondary (renal) hyperparathyroidism:
Bone pain
Persistent pruritus
Soft tissue calcifications
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cause for tertiary hyperparathyroidism ?
autonomous secretion of PTH because of long standing secondary hyerparathryosism
= SEEN IN END STAGE RENAL DISEASE
after correction of underlying renal disorder, hyperplasia of all 4 glands is usually the cause
clinical features of tertiary hyperparathyroidism
Metastatic calcification
Bone pain and / or fracture
Nephrolithiasis
Pancreatitis
blood investigation for tertiary hyperparathyroidism ?
Ca2+ (Normal or high) PTH (Elevated) Phosphate levels (Decreased or Normal) Vitamin D (Normal or decreased) Alkaline phosphatase (Elevated)
benign familial hypocalciuric hypercalcaemia distinguished from primary hyperparathyroidism
urine calcium : creatinine clearance ratio <0.01
Diagnosis is usually made by genetic testing and concordant biochemistry (urine calcium : creatinine clearance ratio <0.01-distinguished from primary hyperparathyroidism)
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management of tertiary hyperparathyroidism?
presence of an autonomously functioning parathyroid gland may require surgery. If the culprit gland can be identified then it should be excised. Otherwise total parathyroidectomy and re-implantation of part of the gland may be required.
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in Paget disease there is only what in diagnoses ?
older male with bone pain and an isolated raised ALP
calcium and phosphate are typically normal. Hypercalcaemia may occasionally occur with prolonged immobilisation
other markers of bone turnover include
procollagen type I N-terminal propeptide (PINP)
serum C-telopeptide (CTx)
urinary N-telopeptide (NTx)
urinary hydroxyproline
Mx of paget disease
dications for treatment include:
bone pain
skull or long bone deformity
fracture
periarticular Paget’s
bisphosphonate (either oral risedronate or IV zoledronate)
calcitonin is less commonly used now
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osteomalacia ?
Low serum calcium, low serum phosphate, raised ALP and raised PTH -
