Hyperparathyroidism

Question 1

What is Hyperparathyroidism?

Answer 1

Increased secretaries of parathyroid hormone (PTH)

• ⬆️ PTH = ⬆️ Ca+

Question 2

What does PTH regulate?

Answer 2

1. Calcium
2. Phosphorus
   How?
   -stimulates bone reabsorption of calcium
   -Stimulates renal tubular reabsorption of calcium
   -Activation of Vitamin D

Question 3

Primary Hyperparathyroidism

Answer 3

Due to ⬆️ PTH which leads to disorders of Ca+, Phosp, and bone metabolism.

Most common cause: Benign Tumor or hyperplasia of parathyroid gland
Adenoma - TUMOR

Question 4

Secondary Hyperparathyroidism

Answer 4

MOST COMMON
Compensation for conditions that cause/induce hypocalcemia 
- Vitamin D deficiency 
- Malabsorption 
- CKD
- Hyperphosphatemia

Question 5

Tertiary Hyperparathyroidism

Answer 5

• Occurs when hyperplasia of the parathyroid gland
• There is a loss of negative feedback from circulating Ca+ levels
• Autonomous secretion of PTH EVEN if Ca+ levels are normal

Example: patients who’ve have a kidney transplant after long TX of dialysis due to CKD

Question 6

Clinical manifestations I

Answer 6

• Decreased bone density: PTH takes Ca+ from bone
• Cyst Formation: Ca+ depletion from bone leads to cyst in bones
• General weakness: ⬆️Ca+ = electrical conduction & muscle contractions. Muscle will not be able to perform.
• Hypercalciuria: ⬆️ Ca+ in urine

Question 7

Clinical Manifestations II

Answer 7

• Calculi Formation (Nephrolithiasis) : High risk for Renal Stones
• Osteoporosis: 2/2 decreased bone density
• Fractures: Long bone, rib, and vertebral fractures

Question 8

Cardiovascular Manifestations

Answer 8

• Dysrhythmia: increased calcium, heart goes into dysthymia
• Shortened QT intervals: ⬆️Ca+= faster contractions. This leads to shortened QT intervals
• Hypertension: 2/2 Shortened QT intervals which are 2/2 ⬆️ contractions due to ⬆️Ca+

Question 9

Neurological Manifestations

Answer 9

• Shortened attention span
• emotional irritability
• hyperactive deep tendon reflexes
• HA
• parathesia
• confusion, depression, delirium, psychosis, coma

Question 10

Musculoskeletal Manifestations

Answer 10

Decalcification of Bones leads to:

• backache - weakness
• fatigue - pain on weight bearing
• osteoporosis - pathological fractures of long bones
• decreased muscle tone
• muscle atrophy: ⬆️ ca+= ⬆️ muscle contraction. Too much that muscle stop responding = ⬇️ muscle tone = muscle atrophy

Question 11

Gastrointestinal Manifestations

Answer 11

• Anorexia
• vague abdominal pain
• N/V -weight loss
• constipation - pancreatitis
• Peptic Ulcer disease (PUD)
• Cholelothiasis: Stone formation

Question 12

Renal manifestations

Answer 12

• Hypercalciuria
• Renal stones
• UTI
• Polyuria: A lot of solutes in your urine. Body wants to dilute. Starts to pull water into bladder & kidneys = polyuria

Question 13

Integumentary Manifestations

Answer 13

• REMEMBER THAT* (Lecture)
• Moist Skin

-Skin necrosis

Question 14

Diagnostic for Hyperparathyroidism

Answer 14

• ⬆️PTH
• ⬆️ Serum Ca+ > 10 mg/dL Normal (8.5-10.3)
• ⬆️ urine Ca+
• ⬇️ Phosphate < 3mg/dL Normal ( 2.5-4.5)
• Electrolytes (Na+, Cl, Cr, amylase)
• Bone-density: detects bone loss
• X-rays, UTZ, MRI, Thiallium Scan: looking for depletion in the bone , used to R/O cancer of the bone

Question 15

Surgical treatment for Hyperparathyroidism

Answer 15

Parathyroidectomy (partial/ complete)
- parathyroidectomy leads to rapid reduction of ⬆️ Ca+ lvls
Auto-transplantation
- normal parathyroid tissue it implanted in forearm or by sternocleidomastoid muscle
- this allows PTH to continue to normalize Ca+ lvls

Question 16

Criteria for Parathyroidectomy

Answer 16

1. ⬆️ Ca+ levels > 12 mg/dL Normal (8.5-10.3)
2. ⬆️ urine Ca+ > 400 mg/dL
3. Decreased bone mineral density
4. Renal calculi

Question 17

Non surgical treatment for Hyperparathyroidism

Answer 17

• Diet: ⬇️Ca+ ⬆️ Phosphorus ⬆️ Fluid
• Monitor : PTH, Ca+, phosphorus, renal function (BUN, Cr)
• Monitor Urine: Urinary calcium
• Ambulation: less stress= less calcium
  Fat= less likely for osteomyelitis
  Bedrest = ⬆️ calcium excretion & ⬆️ risk for calculi formation

Question 18

Pharmacological management Hyperparathyroidism I

Answer 18

Phosphorus Supplement: Bisphosphonates
- ⬇️ Ca+ levels. Inhibits osteoclasts bone reabsorption & rapidly normalizes serious Ca+ lvls.
Estrogen/ Progestin
- ⬇️ serum & urine Ca+ levels. Delays demineralization of skeleton
Oral Phosphate
- Inhibit calcium- absorbing effects of Vitamin D in GI

Question 19

Pharmacological management of Hyperparathyroidism II

Answer 19

Diuretics 
-  ⬆️urinary excretion of Ca+
Calcimimetic Agent: Sensipar
- ⬆️ sensitivity of Ca+ receptors in parathyroid gland = ⬇️ PTH release
- ⬇️ PTH release = ⬇️ Ca+ lvls
- Spares Ca+ storage in bones

Question 20

Complication fo Hyperparathyroidism

Answer 20

• Tetany: Unpleasant thing,ing of hands & mouth. Removal of parathyroid = rapid ⬇️Ca+ = Tetany & Hemorrhage
• Hemorrhage: Ca+ essential for clotting
• Laryngospasms
• (+) Chvostek sign: abnormal hyper excited FACIAL NERVE
• (+) Trousseau sign: BP cuff inflates= Carpopedal spasm (HAND)

Question 21

Hypercalcemic Crisis

Answer 21

• ⬆️Serum Ca+ >15 mg/dL Normal (8.5-10.3)

- results in Neurological, Cardiovascular, and Renal symptoms

Question 22

Pharmacological management of Hypercalcemic Crisis

Answer 22

-Rehydration: Large Vol BOLUS (3) - 1000 cc NaCl or D5W.
Trying to ⬇️ Ca+ or patient becomes asymptotic
- Diuretic: promotes Renal excretion of Ca+
- Phosphate Therapy
- Cytotoxic agents: Mithramycin- ⬇️ serum Ca+
- Dialysis: VERY symptomatic
- Calcitonin* google* opposes action of PTH

Question 23

Interactions for Hyperparathyroidism & Hypercalcemic Crisis

Answer 23

• I&O
• IV Calcium Gluconate
• Monitor electrolytes
• Frequently monitor s/s (+) Chvostek & Trousseau sign
• Mobility to promote Bone calcification