The effects of vitamin D insufficiency in patients with primary hyperparathyroidism

Abstract Vitamin D insufficiency is common in patients with primary hyperparathyroidism (PHPT) and may be associated with more severe and progressive disease. Uncertainty exists, however, as to whether repletion of vitamin D should be undertaken in patients with PHPT. Here we report the effects of vitamin D repletion on biochemical outcomes over 1 yr in a group of 21 patients with mild PHPT [serum calcium <12 mg/dl (3 mmol/liter)] and coexistent vitamin D insufficiency [serum 25 hydroxyvitamin D [25(OH)D] <20 μg/liter (50 nmol/liter)]. In response to vitamin D repletion to a serum 25(OH)D level greater than 20 μg/liter (50 nmol/liter), mean levels of serum calcium and phosphate did not change, and serum calcium did not exceed 12 mg/dl (3 mmol/liter) in any patient. Levels of intact PTH fell by 24% at 6 months (P < 0.01) and 26% at 12 months (P < 0.01). There was an inverse relationship between the change in serum 25(OH)D and that in intact PTH (r = −0.43, P = 0.056). At 12 months, total serum alkaline phosphatase was significantly lower, and urine N-telopeptides tended to be lower than baseline values (P = 0.02 and 0.13, respectively). In two patients, 24-h urinary calcium excretion rose to exceed 400 mg/d, but the group mean 24-h urinary calcium excretion did not change. These preliminary data suggest that vitamin D repletion in patients with PHPT does not exacerbate hypercalcemia and may decrease levels of PTH and bone turnover. Some patients with PHPT may experience an increase in urinary calcium excretion after vitamin D repletion.

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Bone Mineral Density Increases with Vitamin D Repletion in Patients with Coexistent Vitamin D Insufficiency and Primary Hyperparathyroidism

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jc.85.10.3541 ◽

2000 ◽

Vol 85 (10) ◽

pp. 3541-3543 ◽

Cited By ~ 27

Author(s):

V. Kantorovich

Keyword(s):

Bone Mineral Density ◽

Vitamin D ◽

Primary Hyperparathyroidism ◽

Bone Mineral ◽

Vitamin D Insufficiency ◽

Mineral Density

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Appropriate Cutoff for 25OHD Levels in the Diagnosis of Normocalcemic Primary Hyperparathyroidism (NPHPT): A Systematic Review

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.517 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A254-A255

Author(s):

Niharika Yedla ◽

Xiangbing David Wang

Keyword(s):

Systematic Review ◽

Vitamin D ◽

Primary Hyperparathyroidism ◽

International Workshop ◽

Normal Subjects ◽

Vitamin D Insufficiency ◽

Hydroxyvitamin D ◽

Pubmed Search ◽

The Difference ◽

A Prospective Study

Abstract Introduction: The Fourth International Workshop in 2014 delineated guidelines for the diagnosis of NPHPT which include ruling out secondary causes of hyperparathyroidism, and recommended cutoffs for 25 vitamin D (25OHD) to be ≥20ng/mL. Keeping in mind that the exact levels to optimize 25OHD in hyperparathyroid states are unknown, we aim to review possible variation in the prevalence of NPHPT if 25OHD cutoffs were to be raised to rule out vitamin D deficiency with more specificity. Methods: A PubMed search was conducted with key words “normocalcemic primary hyperparathyroidism” to review studies about NPHPT and 25OHD status. 533 articles were found, and 127 articles were identified by title/abstract screening with year of publication between 2014 to 2020. Ten studies were identified for the systematic review based on full text review for relevance. Results: Studies have been conducted in various countries across all continents to characterize NPHPT further. 5/10 studies used 25OHD cutoff of ≥20ng/mL and 4 studies had a cutoff of ≥30ng/mL and 1 study looked into the difference in prevalence with both cutoffs. All 3 studies from Italy used the higher cutoff. Rosario et al from Brazil reported a decrease in prevalence of NPHPT from 6.8% (25OHD≥20ng/mL) to 0.74% by supplementing those subjects to 25OHD ≥30ng/mL without any increase in serum calcium or parathyroid hormone (PTH) levels.1 Wang et al found that when total 25OHD levels were kept between 30–40 ng/mL, free 25OHD levels were actually lower compared to normal subjects.2 Conclusion: The levels of 25OHD that would define deficiency in NPHPT remain undetermined and both >20 ng/mL and >30ng/mL have been studied as cutoffs. It is well known that vitamin D insufficiency (25D 20-30ng/mL) drives up PTH and supplementation to 30-40ng/mL is required to reduce such effects. Wang et al suggest that free 25OHD levels correlate better with PTH as compared to total 25OHD and maybe a more reliable marker of 25OHD status. We suggest that a diagnostic criterion of ≥30ng/mL would be more appropriate in ruling out 25OHD deficiency in this special population. The role of free 25OHD levels in PHPT needs further evaluation. References: 1. Rosário PW, Calsolari MR. Normocalcemic Primary Hyperparathyroidism in Adults Without a History of Nephrolithiasis or Fractures: A Prospective Study. Horm Metab Res. 2019 Apr;51(4):243–247. doi: 10.1055/a-0859-1020. Epub 2019 Mar 6. PMID: 30840998. 2. Wang X, Meng L, Su C, Shapses SA. LOW FREE (BUT NOT TOTAL) 25-HYDROXYVITAMIN D LEVELS IN SUBJECTS WITH NORMOCALCEMIC HYPERPARATHYROIDISM. Endocr Pract. 2020 Feb;26(2):174–178. doi: 10.4158/EP-2019-0325. Epub 2019 Sep 26. PMID: 31557077

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Primary Hyperparathyroidism with Multiple Fractures and Brown Tumors in a 14-year-old Girl: Case Report & Review of Literature

Bangladesh Journal of Nuclear Medicine ◽

10.3329/bjnm.v22i2.51765 ◽

2021 ◽

Vol 22 (2) ◽

pp. 130-136

Author(s):

Nasim Khan ◽

Nazmun Nahar ◽

Rawshan Ara ◽

Fahima Akter Dowel ◽

Shakila Zaman Rima ◽

...

Keyword(s):

Vitamin D ◽

Primary Hyperparathyroidism ◽

Parathyroid Adenoma ◽

Tumor Resection ◽

Good Health ◽

Vitamin D Insufficiency ◽

Multiple Fractures ◽

Brown Tumors ◽

Variable Presentation

Primary hyperparathyroidism (PHPT) presenting as pathological fractures with brown tumors is very rare in children. The rarity and variable presentation of PHPT can make its diagnosis a challenge – especially in the developing countries where malnutrition may mask hypercalcemia. We report a case of a 14–year-old girl who presented with muscle pain, multiple fractures and bone pain. Laboratory tests revealed normocalcemia with vitamin D insufficiency. Subsequent biochemical, radiographic and scintigraphic findings were consistent with primary hyperparathyroidism due to a parathyroid adenoma. Tumor resection was done in a local hospital and histopathology confirmed parathyroid adenoma. Following parathyroidectomy, fractures were treated conservatively with supplementation of calcium and vitamin D. We found her quite capable of self-care and walking in good health at 1 year follow up. Though rare, PHPT-causing brown tumors related skeletal fractures is an important differential diagnosis in the evaluation of patients presenting with multiple foci of radiotracer uptake in bone scintigraphy. Bangladesh J. Nuclear Med. 22(2): 130-136, Jul 2019

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AB0641 EFFECT OF AGE ON PARATHYROID HORMONE RESPONSE TO VITAMIN D INSUFFICIENCY IN PRIMARY HYPERPARATHYROIDISM

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2021-eular.3288 ◽

2021 ◽

Vol 80 (Suppl 1) ◽

pp. 1354.1-1354

Author(s):

V. Deshani ◽

M. Khalid ◽

K. Jadoon

Keyword(s):

Vitamin D ◽

Parathyroid Hormone ◽

Primary Hyperparathyroidism ◽

Vitamin D Deficiency ◽

Age Groups ◽

Vitamin D Insufficiency ◽

Hormone Response ◽

Vitamin D Levels ◽

Significant Difference ◽

The Impact

Background:Primary hyperparathyroidism (PHPT) is a common endocrine condition, commonly seen with increasing age. In vast majority, it is diagnosed incidentally and causes no particular symptoms. Symptoms are usually related to acute hypercalcaemia or the complications of chronically elevated serum calcium level. Vitamin D deficiency is common among general population and in patients with PHPT. Studies in secondary hyperparathyroidism (SHPT) have shown that parathyroid hormone (PTH) response is affected by age, with those over 80 showing greater rise in PTH levels. We wanted to see if age has a similar impact on PTH response to vitamin D in those with PHPT.Objectives:To evaluate the impact of age on PTH response to vitamin D insufficiency in those with PHPT.Methods:Patients with primary hyperparathyroidism (PHPT), attending general endocrine clinic of a district general hospital, were divided into two groups based on age; less than 70 (n=73) and 70 and above (n=61).Each group was subdivided into vitamin D insufficient (VDI) and vitamin D sufficient (VDS) subgroups. We compared calcium and parathyroid hormone levels and forearm BMD (presented as T score) in VDI and VDS subgroups in the two age groups, at the time of diagnosis. Data were analyzed using unpaired t-test and presented as mean ± SEM, using Graphpad Prism 9.0.1.Results:There was significant difference in Vitamin D levels in VDI and VDS subgroups, in both age groups (<70; mean vitamin D 27.98 vs. 68.44, p<0.0001; ≥70; mean vitamin D 34.44 vs. 75.74, p<0.0001). The two groups were significantly different in terms of age (mean age 58 vs. 76, p<0.0001). Although there was no difference in calcium and forearm BMD in VDI and VDS, in both age groups, those under 70 showed a greater PTH response to vitamin D insufficiency (mean PTH 19.29 vs. 12.91 respectively, p<0.001).Conclusion:While in SHPT, those with increasing age show greater rise in PTH levels, our data show that in PHPT, younger patients show a greater PTH rise in response to vitamin D insufficiency. Further work is needed to elucidate the underlying mechanisms.References:[1]Wyskida et al., Parathyroid hormone response to different vitamin D levels in population-based old and very-old Polish cohorts, Experimental Gerontology, Volume 127, 2019, 110735, ISSN 0531-5565, https://doi.org/10.1016/j.exger.2019.110735.[2]Malik M Z, Latiwesh O B, Nouh F, et al. (August 15, 2020) Response of Parathyroid Hormone to Vitamin D Deficiency in Otherwise Healthy Individuals. Cureus 12(8): e9764. doi:10.7759/cureus.9764Disclosure of Interests:None declared.

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Primary hyperparathyroidism and vitamin D deficiency

Terapevticheskii arkhiv ◽

10.26442/00403660.2021.10.201081 ◽

2021 ◽

Vol 93 (10) ◽

pp. 1221-1226

Author(s):

Gyuzel E. Runova ◽

Olga O. Golounina ◽

Irina V. Glinkina ◽

Valentin V. Fadeev

Keyword(s):

Vitamin D ◽

Primary Hyperparathyroidism ◽

Vitamin D Deficiency ◽

Severe Disease ◽

Preoperative Assessment ◽

Vitamin D Insufficiency ◽

Parathyroid Glands ◽

Cellular Mechanisms ◽

Vitamin D Levels

Primary hyperparathyroidism (PHPT) is the third most common endocrine disease after diabetes mellitus and thyroid pathology. Recent epidemiological and experimental data have shown that long-term maintenance of low vitamin D levels in the blood can lead to the development of hyperplastic processes in the cells of the parathyroid glands, followed by autonomous production of parathyroid hormone. In PHPT vitamin D insufficiency or deficiency according to various sources occurs with a frequency of 5377% of cases. The literature review indicates more severe disease in patients with concomitant vitamin D deficiency. The expediency of preoperative assessment of vitamin D levels in all patients with PHPT in order to minimize the risk of hypocalcemia after parathyroidectomy is discussed. This article presents the relationship between vitamin D deficiency and PHPT, as well as possible methods for correcting vitamin D deficiency in PHPT. Molecular and cellular mechanisms of the occurrence of pathological processes in the parathyroid glands under conditions of low vitamin D levels are presented.

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