Hyperparathyroidsim Flashcards
Bloods in hyperparathyrodism
Hyponatremia
High corrected calcium
Low phosphate
PTH ABNORMALLY normal - should be low
normal vit D
What is primary hyperparathyroidism normally caused by
primary adenoma of the parathyroid gland.
Bloods in secondary hyperparathyroidsim
LOW calcium
HIGH PTH
Vit D low
High phosphate
Abnormal electrolytes
Why does CKD cause 2ndry hyperparathyroidsims
Nephron fails -> phosphate build up - osteocytes work to release FGF23 excrete more phosphate BUT also reduces calcium absorption in gut and reduces calcium release from bones -> LOW
More PTH produced by body
Bloods in tertiary hyperparathyroidism
High calcium
Abnoomally high phospate (poor excretion renal failure)
Low vit D
Abnormal renal function
What causes tertiary hyperparathyroidism
Consistent raised PTH from 2ndry, parathyroid gland hypertrohies - ignores negative feedback from calcium lvels
What is hypercalcemia defined as
Serum calcium level >2.6 mmol/L
High calcium symptoms
Nomrally asymptomatic
May be unusually thirsty
urinate frequently
Become constipated
indications for measuring serum calcium
Symptoms of hypercalcemia
Osteoporosis or previous fragility fracture
Renal stone
Incidental finding of >2.6 calcium
Chronic non differentiated symptoms
Indications fro measuring PTH level
Calcium is >2.6 on at least 2 separate occasions OR
>2,.5 mmol/L on 2 separate occasions and primary hyperPTHism suspected
When refer for primary hyperparathyroidism
above the midpoint of the reference range and primary hyperparathyroidism is suspected or
below the midpoint of the reference range with a concurrent albumin-adjusted serum calcium level of 2.6 mmol/litre or above.
How to differentiate hyperparathyroidism primary vs familial hypocaliuric hypercalcemia
Urine calcium excretion with:
24-hour urinary calcium excretion
random renal calcium:creatinine excretion ratio
random calcium:creatinine clearance ratio.
What assess in people with confirmed primaray hyperPTHism
Symptoms and comorbidities
Measure eGFR or creatinein
DEXA of lumbar spine and hip
US of renal tract
Measure vit D
How is referred for parathyroid surgery with primary hyperparathyrodisim?
Sympotms of hypercalcemia
End organ disease
Calcium >2.85
Surgeries for hyperparathyrodisim
4 gland exploration
Focused parathyrodiectomy
Post surgery management of primary hyperparathyrodisim
Measure calcium 3-6 months after to confirm sucess
Monitor once a year if successul
Non surgical managemnet of orimary hyperparathyroidism
Cincacalcet - calcimimetic
Nisphophonates
What calcium levels can offer cinacalcet
> 2.85 w symptoms
3.0 with or without symptoms
Who consider bisphosphonates in
Reduce fracture risk if increased risk
DONT offer if chronic ypercalcemia from primary hyperparathyrodisim
What risk need to assess with hyperPTH ism
Cardiovascular
Osteoporosis - fracture risk
Hyperparathyroidism in pregnancy what stop, what increased risk of
Cinacalcet, bisphosphonates
More risk of hypertensive disease
Cuases of primary hyperparathyrodisim
85%: solitary adenoma
10%: hyperplasia
4%: multiple adenoma
1%: carcinoma
How to remember hyperPTH symptoms
Bones, stones, abdo graons, pscyhic mones
Possible presentations with hyperparathyroidism
Polydipsia, polyuria
Depression
Anorexia, nausea, constipation
Peptic ulcers
Pancreatitis
Bone pain/fracture
Renal stones
HPTN
What can be ass with hyperPTHism
HPTN
Multiple endocrine neoplasia - MEN I + II
X ray findings in hyperPTHism
Pepperpot skull
Osteitis fibrosa cystica
Definitive management of hyperPTH ism
total parathyroidectomy
When can conservative management be offered
Ca less than 0.25 above upper limit of normal AND
>50 years and no evidence end organ damage
What is parathyroid hormone produced in response to
LOW calcium and HIGH phosphate in blood
Role of PTH
stimulates osteocasts to increase Ca release
Acitvates vit D in kidneys -> increase absorption of Ca and phosphate
What inhibits PTH release
High calcium
Activated vit D
Bloods in hyperPTH
High calcium
High PTH
Hypoposphatemia (lost in urine)
Treating secondary hyperPTHism
Low phosphate diet
Ergocalciferol - low Vit D
Phosphate binders eg senglomer
Treat CKD
Bloods in secondary hyperPTHism
HIGH PTH
normal/low calcium
HIGH phosphate
When does 2ndry -> tertiary hyperparathyroidims and mangaenet
When calcium goes high and PTH is extremely high
Treat the same as primary hyperPTHism
INherited causes of hyperparathyroidsim
MEN
Jaw tumour syndromme
Familial isolated rimary hyperPTH
Risk for primary hyperPTH
Women
Older
FH - multi-gland, MEN
Primary hyperparathyroidism comlications
Osteoporosis and fragility fractures
Kidney stones and kidney injury
Hypertension and heart disease
Numerous gastrointestinal disorders including peptic ulcer disease, pancreatitis and gall stones
Parathyroidectomy comlpications
General for surgery
Recurrent or superior laryngeal nerve damage
Post op hypocalacemia if remove too mich
Failure to identify adenoma or disease peristency post surgery
When is surgery indicated primary hyperarathyroidism
Symptomatic disease - hypercalcemia, osteoporosis+/- fragility fractues
Renal stone or nephrocaclinosis
Age <50
Serum calcium >2.85
eGFR <60
Medical treatment of hypeparathyroidism
Calcitonin - reduces serum calciu
Cinacalcet - calcium muimetic
Desonumab - impairs resorbtion
Bisphosphonates
What is PTH level if hypercalcemia of malignancy
Low
Biochemistry primary vs seoncdary vs tertiary hyperparathyroidism
Primary - both PTH and Ca elevated
Secondary - PTH elecated calcium low or normal, vit D low
Tertiary - Calcium high or noraml, elevated PTH, elevated ALP, normal or decreased phosphate and calcium
What causes secnodary hyperaparthyroidsim
Chronic renal disease due to low calcium -< hyperplasia PTH gland
Surgery indications secondary yyperaparathyroidsim
Medication unless:
Bone pain
Persistent pruritis
Soft issue calcifications
Management of tertiary hyperparathyroidism
Allow 12 months post transplant - may resolve
Total parathyroidectomy and reimplantation of part of gland
Unless gland causing identified then remove that
Secondary hyperparathyorisim symptoms
-> bone disease, osteitis fibrosa cystica and soft tissue calcifications
