scholarly journals Normocalcaemic primary hyperparathyroidism: what is the role of parathyroid surgery?

2021 ◽  
Vol 12 ◽  
pp. 204201882199537
Author(s):  
Nivaran Aojula ◽  
Shahab Khan ◽  
Neil Gittoes ◽  
Zaki Hassan-Smith
Keyword(s):  
Primary Hyperparathyroidism ◽  
Serum Calcium ◽  
Fragility Fractures ◽  
Renal Stones ◽  
Careful Consideration ◽  
Normal Serum ◽  
Mineral Density ◽  
Normal Serum Calcium ◽  
To Receive

Primary hyperparathyroidism (PHPT) is classically associated with both an elevated or ‘inappropriately normal’ parathyroid hormone (PTH) level and raised serum calcium. However, in clinical practice, increasing numbers of patients present with raised PTH but normal serum calcium, renal function and vitamin D; this is known as normocalcaemic PHPT (nPHPT). Studies investigating the clinical presentation of this condition have shown that patients may present with hypertension, nephrolithiasis, impaired glucose tolerance, osteoporosis and fragility fractures. The prevalence of such complications in nPHPT is similar to that in classical hypercalcaemic PHPT (hPHPT). Although the National Institute for Health and Care Excellence (NICE) have developed guidelines for the management of PHPT generally, a consensus is yet to be reached on the optimal management of nPHPT specifically. A review of the literature on parathyroidectomy in the treatment of nPHPT revealed that nPHPT patients were more likely to present with multi-glandular disease and significantly less nPHPT patients had an intra-operative PTH fall of >50% compared with those with hPHPT. These findings demonstrate that patients with nPHPT are more likely to receive bilateral neck explorations and require remedial surgery compared with hPHPT patients. Following surgery, improvements in bone mineral density (BMD) and renal stones are generally observed in those with nPHPT. Where surgery is not possible, medical management with alendronate has been shown to be effective in nPHPT patients. Given the higher incidence of multi-gland disease and greater possibility of remedial surgery in nPHPT, careful consideration of risks and benefits should be made on an individualised basis and surgery should be performed by surgeons experienced in four gland exploration.

IDIOPATHIC HYPERCALCEMIA

PEDIATRICS ◽  
1959 ◽  
Vol 24 (2) ◽  
pp. 258-269
Author(s):  
David W. Smith ◽  
Robert M. Blizzard ◽  
Harold E. Harrison
Keyword(s):  
Vitamin D ◽  
Serum Calcium ◽  
Normal Serum ◽  
Early Infancy ◽  
Serum Assay ◽  
Supplemental Vitamin ◽  
Normal Serum Calcium

A case of idiopathic hypercalcemia present from early infancy and diagnosed at 5 years of age is reported in which the serum assay of vitamin D indicated elevated levels. After discontinuation of supplemental vitamin D and a diet low in calcium the concentrations of calcium and vitamin D in the serum gradually returned to normal over a period of 18 months. Roentgenograms of the bones showed evidence of demineralization rather than increased density as reported in other cases of "idiopathic" hypercalcemia. During a subsequent 2-year follow-up the patient has maintained a normal serum calcium. The etiology is discussed with particular reference to the role of vitamin D in this case

scholarly journals Normocalcemic primary hyperparathyroidism: long-term follow-up associated with multiple adenomas

2014 ◽  
Vol 58 (5) ◽  
pp. 583-586 ◽  
Author(s):  
Larissa Pimentel ◽  
Sirley Portela ◽  
Alyne Loureiro ◽  
Francisco Bandeira
Keyword(s):  
Primary Hyperparathyroidism ◽  
Serum Calcium ◽  
Normal Serum ◽  
T Score ◽  
Sestamibi Scan ◽  
Normal Serum Calcium ◽  
Long Term Follow Up ◽  
Serum Pth

Normocalcemic primary hyperparathyroidism (NPHPT) is a condition characterized by elevation of the parathyroid hormone (PTH) in the presence of normal serum calcium and the absence of secondary causes. The case described illustrates the long-term follow-up of a postmenopausal woman with NPHPT patient who progressed with multiple adenomas. This case reports a 77-year-old female who has chronic generalized pain and osteoporosis. Her initial serum PTH was 105 pg/mL, with total serum calcium of 9.6 mg/dL, albumin 4.79 g/dL, phosphorus 2.8 mg/dL, and 25OHD after supplementation was 34.6 ng/mL. The bone densitometry (BMD) results were as follows: lumbar spine: T-score -3.0, femoral neck: T-score -2.6 and distal radius: -4.2. Other causes of secondary hyperparathyroidism were ruled out and cervical ultrasound and Tc-99-Sestamibi scan were negative. She used oral alendronate and three infusions of zoledronic acid for treatment of osteoporosis. In the 10th year of follow-up, after successive negative cervical imaging, ultrasound showed a nodule suggestive of an enlarged right inferior parathyroid gland. PTH levels in fluid which was obtained during fine-needle aspiration (FNA) were over 5,000 pg/mL and a Sestamibi scan was negative. The patient underwent parathyroidectomy, and a histological examination confirmed parathyroid adenoma. Post-operatively serum PTH remained elevated in the presence of normal serum calcium levels. A follow-up cervical ultrasound showed a new solid nodule suggestive of an enlarged right superior parathyroid gland. PTH levels in the aspiration fluid were remarkably high. A second parathyroidectomy was performed, with the excision of a histologically confirmed parathyroid adenoma. In conclusion, this is an unusual presentation of NPHPT and highlights the long-term complications.

scholarly journals Presentation of Asymptomatic Primary Hyperparathyroidism: Proceedings of the Third International Workshop

2009 ◽  
Vol 94 (2) ◽  
pp. 351-365 ◽  
Author(s):  
Shonni J. Silverberg ◽  
E. Michael Lewiecki ◽  
Leif Mosekilde ◽  
Munro Peacock ◽  
Mishaela R. Rubin
Keyword(s):  
Natural History ◽  
Primary Hyperparathyroidism ◽  
Serum Calcium ◽  
Task Force ◽  
International Workshop ◽  
Normal Serum ◽  
Mineral Density ◽  
The Third ◽  
History Of ◽  
Asymptomatic Primary Hyperparathyroidism

Abstract Background: At the Third International Workshop on Asymptomatic Primary Hyperparathyroidism (PHPT) in May 2008, recent data on the disease were reviewed. We present the results of a literature review on issues arising from the clinical presentation and natural history of PHPT. Methods: Questions were developed by the International Task Force on PHPT. A comprehensive literature search for relevant studies was reviewed, and the questions of the International Task Force were addressed by the Consensus Panel. Conclusions: 1) Data on the extent and nature of cardiovascular involvement in those with mild disease are too limited to provide a complete picture. 2) Patients with mild PHPT have neuropsychological complaints. Although some symptoms may improve with surgery, available data remain inconsistent on their precise nature and reversibility. 3) Surgery leads to long-term gains in spine, hip, and radius bone mineral density (BMD). Because some patients have early disease progression and others lose BMD after 8–10 yr, regular monitoring (serum calcium and three-site BMD) is essential in those followed without surgery. Patients may present with normocalcemic PHPT (normal serum calcium with elevated PTH concentrations; no secondary cause for hyperparathyroidism). Data on the incidence and natural history of this phenotype are limited. 4) In the absence of kidney stones, data do not support the use of marked hypercalciuria (>10 mmol/d or 400 mg/d) as an indication for surgery for patients. 5) Patients with bone density T-score −2.5 or less at the lumbar spine, hip, or distal one third radius should have surgery.

Normocalcemic primary hyperparathyroidism — «new era» in diagnosis of an old disease

2017 ◽  
Vol 63 (4) ◽  
pp. 236-244
Author(s):  
Irina A. Baranova ◽  
Tatyana A. Zykova
Keyword(s):  
Primary Hyperparathyroidism ◽  
Early Stage ◽  
International Workshop ◽  
Normal Serum ◽  
Mineral Density ◽  
New Era ◽  
Increased Risk ◽  
Normal Serum Calcium ◽  
History Of ◽  
Symptomatic Form

During the last century, primary hyperparathyroidism (PHPT) passed from the category of rare severe diseases to a common endocrine disorder with a prevalence of mild forms. Over the last 10—20 years, widespread screening for osteoporosis has led to the «new era» in diagnosis of PHPT when patients are diagnosed at the stage of an isolated elevated parathyroid hormone with stable normal serum calcium levels and the absence of secondary causes of hyperparathyroidism. This phenomenon was called normocalcemic primary hyperparathyroidism (nPHPT); according to the literature data, its prevalence varies from 0.4 to 16.7% due to the lack of unified diagnostic criteria. The clinical picture and natural history of the disease are poorly explored, and it is still unclear if nPHPT is a separate disease entity or if it is an early stage of hypercalcemic PHPT. A number of studies have shown that complications of nPHPT (osteoporosis and urolithiasis) are similar to those of the symptomatic form of PHPT despite stable normocalcemia. However, these patients were often referred to specialized metabolic centers due to a decrease in the bone mass or nephrolithiasis, therefore the rate of complications in them may be overestimated. There are also controversial data on an increased risk of cardiovascular diseases due to metabolic disorders in this pathology. As a new clinical nosology, normocalcemic PHPT was first officially recognized at the Third International Workshop on Management of Asymptomatic PHPT in 2008, but there have been yet no common recommendations for its treatment. Some studies have shown a response to medical therapy and improved indicators of bone mineral density after parathyroidectomy in these patients. According to the experts of the Fourth International Workshop in 2014, nPHPT remains one of the key topics for further research.

scholarly journals A quick intraoperative parathyroid hormone assay in the surgical management of patients with primary hyperparathyroidism: a study of 206 consecutive cases

2002 ◽  
pp. 783-788 ◽  
Author(s):  
E Vignali ◽  
A Picone ◽  
G Materazzi ◽  
S Steffe ◽  
P Berti ◽  
...  
Keyword(s):  
Parathyroid Hormone ◽  
Primary Hyperparathyroidism ◽  
Serum Calcium ◽  
False Negative ◽  
Parathyroid Tissue ◽  
Normal Serum ◽  
Neck Exploration ◽  
True Negative ◽  
Normal Serum Calcium ◽  
Intraoperative Parathyroid Hormone

OBJECTIVE: The traditional surgical approach for patients with primary hyperparathyroidism (PHPT) consists of the identification of at least four glands and in the removal of all hyperfunctioning parathyroid tissue. DESIGN: To evaluate whether intraoperative parathyroid hormone (PTH) monitoring will allow a more limited surgical procedure by confirming complete removal of all hyperfunctioning tissue. METHODS: Plasma samples were obtained from 206 consecutive patients with sporadic PHPT before skin incision, during manipulation of a suspected adenoma, and 5 min (T-5) and 10 min after removal of abnormal parathyroid tissue. PTH was measured by a quick immunochemiluminescent assay (QPTH). The operative success was defined by a decrease of PTH greater than 50% of the highest pre-excision value. RESULTS: A >50% decrease of PTH occurred in 203 patients and was evident at T-5 in the majority of cases. All but three had normal serum calcium the day after surgery and afterwards. PTH concentration did not show a >50% decrease in the remaining three cases after completion of surgery. One patients had negative neck exploration and remained hypercalcemic; the other two had normal serum calcium at follow-up. Thus, the intraoperative QPTH correctly predicted the outcome of surgery in 201 patients (97.5%) (200 true positive and 1 true negative), and provided three false positive and two false negative results. CONCLUSIONS: The intraoperative QPTH measurement represents a useful tool to assist the surgeon during parathyroidectomy. It indicates whether all hyperfunctioning parathyroid tissue has been removed, limiting the procedure to a unilateral neck exploration in most cases.

scholarly journals P114 Effect of vitamin D on parathyroid hormone, serum calcium and bone mineral density in patients with primary hyperparathyroidism being managed conservatively

Rheumatology ◽  
2021 ◽  
Vol 60 (Supplement_1) ◽  
Author(s):  
Mahrukh Khalid ◽  
Vismay Deshani ◽  
Khalid Jadoon
Keyword(s):  
Bone Mineral Density ◽  
Vitamin D ◽  
Parathyroid Hormone ◽  
Primary Hyperparathyroidism ◽  
Bone Mineral ◽  
Serum Calcium ◽  
Mineral Density ◽  
Neck Of Femur ◽  
Vitamin D Levels ◽  
Significant Difference

Abstract Background/Aims  Vitamin D deficiency is associated with more severe presentation of primary hyperparathyroidism (PTHP) with high parathyroid hormone (PTH) levels and reduced bone mineral density (BMD). We analyzed data to determine if vitamin D levels had any impact on PTH, serum calcium and BMD at diagnosis and 3 years, in patients being managed conservatively. Methods  Retrospective analysis of patients presenting with PHPT. Based on vitamin D level at diagnosis, patients were divided into two groups; vitamin D sufficient (≥ 50 nmol/L) and vitamin D insufficient (≤ 50 nmol/L). The two groups were compared for age, serum calcium and PTH levels at diagnosis and after mean follow up of 3 years. BMD at forearm and neck of femur (NOF) was only analyzed in the two groups at diagnosis, due to lack of 3 year’s data. Results  There were a total of 93 patients, 17 males, mean age 70; range 38-90. Mean vitamin D level was 73.39 nmol/L in sufficient group (n = 42) and 34.48 nmol/L in insufficient group (n = 40), (difference between means -38.91, 95% confidence interval -45.49 to -32.33, p < 0.0001). There was no significant difference in age, serum calcium and PTH at the time of diagnosis. After three years, there was no significant difference in vitamin D levels between the two groups (mean vitamin D 72.17 nmol/L in sufficient group and 61.48 nmol/L in insufficient group). Despite rise in vitamin D level in insufficient group, no significant change was observed in this group in PTH and serum calcium levels. BMD was lower at both sites in vitamin D sufficient group and difference was statistically significant at NOF. Data were analyzed using unpaired t test and presented as mean ± SEM. Conclusion  50% of patients presenting with PHPT were vitamin D insufficient at diagnosis. Vitamin D was adequately replaced so that at 3 years there was no significant difference in vitamin D status in the two groups. Serum calcium and PTH were no different in the two groups at diagnosis and at three years, despite rise in vitamin D levels in the insufficient group. Interestingly, BMD was lower at forearm and neck of femur in those with sufficient vitamin D levels and the difference was statistically significant at neck of femur. Our data show that vitamin D insufficiency does not have any significant impact on PTH and calcium levels and that vitamin D replacement is safe in PHPT and does not impact serum calcium and PTH levels in the short term. Lower BMD in those with adequate vitamin D levels is difficult to explain and needs further research. Disclosure  M. Khalid: None. V. Deshani: None. K. Jadoon: None.

scholarly journals Primary Hyperparathyroidism

2018 ◽  
Vol 103 (11) ◽  
pp. 3993-4004 ◽  
Author(s):  
John P Bilezikian
Keyword(s):  
Primary Hyperparathyroidism ◽  
Serum Calcium ◽  
Target Organ ◽  
Organ Involvement ◽  
Mineral Density ◽  
Clinical Phenotypes ◽  
New Concepts ◽  
Clinical Presentations ◽  
Surgical Guidelines ◽  
Normal Albumin

Abstract Background Primary hyperparathyroidism (PHPT), the most common cause of hypercalcemia, is most often identified in postmenopausal women. The clinical presentation of PHPT has evolved over the past 40 years to include three distinct clinical phenotypes, each of which has been studied in detail and has led to evolving concepts about target organ involvement, natural history, and management. Methods In the present review, I provide an evidence-based summary of this disorder as it has been studied worldwide, citing key concepts and data that have helped to shape our concepts about this disease. Results PHPT is now recognized to include three clinical phenotypes: overt target organ involvement, mild asymptomatic hypercalcemia, and high PTH levels with persistently normal albumin-corrected and ionized serum calcium values. The factors that determine which of these clinical presentations is more likely to predominate in a given country include the extent to which biochemical screening is used, vitamin D deficiency is present, and whether parathyroid hormone levels are routinely measured in the evaluation of low bone density or frank osteoporosis. Guidelines for parathyroidectomy apply to all three clinical forms of the disease. If surgical guidelines are not met, parathyroidectomy can also be an appropriate option if no medical contraindications are present. If either the serum calcium or bone mineral density is of concern and surgery is not an option, pharmacological approaches are available and effective. Conclusions Advances in our knowledge of PHPT have guided new concepts in diagnosis and management.

Normal serum calcium levels in albino mice

1967 ◽  
Vol 22 (1) ◽  
pp. 325-326 ◽  
Author(s):  
Reed M. Stringham ◽  
Carlos A. Bonilla ◽  
Ivan M. Lytle
Keyword(s):  
Serum Calcium ◽  
Normal Serum ◽  
Normal Serum Calcium ◽  
Albino Mice

CTRP3 is Significantly Decreased in Patients with Primary Hyperparathyroidism and Closely Related with Osteoporosis

2019 ◽  
Vol 128 (03) ◽  
pp. 152-157
Author(s):  
Derya Demirtas ◽  
Fettah Acıbucu ◽  
Filiz Alkan Baylan ◽  
Erdinc Gulumsek ◽  
Tayyibe Saler
Keyword(s):  
Primary Hyperparathyroidism ◽  
Serum Levels ◽  
Dual Energy ◽  
Control Group ◽  
Mineral Density ◽  
Urine Calcium ◽  
X Ray ◽  
Complement C1q ◽  
Necrosis Factor

Abstract Background Adipokines derived from adipocytes are one of the important factors that act as circulating regulators of bone metabolism. Complement C1q/tumor necrosis factor-related protein-3 (CTRP3), a paralog of adiponectin, is are member of the CTRP superfamily. The aim of this study was to investigate the role of serum CTRP3 in the development of osteoporosis in patients with primary hyperparathyroidism. Methods This study included 53 patients with diagnosed primary hyperparathyroidism and 30 healthy controls. Laboratory tests for the diagnosis of primary hyperparathyroidism and serum levels of CTRP3 measured for all patients. Bone mineral density was obtained on lumbar spine 1 and 4 by dual energy X-ray absorptiometry. Results Serum CTRP3 levels were lower in patients with primary hyperparathyroidism than in the control group (p<0.001). In addition, primary hyperparathyroidism patients are were divided into two groups as, with and without osteoporosis; the levels of CTRP3 were lower in patients with osteoporosis than in patients without osteoporosis (p=0.004). In logistic regression analysis, only CTRP3 levels independently determined the patients to be osteoporosis (p<0.05). According to this analysis, decreased CTRP3 (per 1 ng/mL) levels were found to increase the risk of patients for osteoporosis by 6.9%. When the CTRP3 cut-off values were taken as 30 ng/mL, it determined osteoporosis with 76.4% sensitivity and 73.2% specificity. CTRP3 and urine calcium levels were independently associated with T score in dual energy X-ray absorptiometry. Conclusions CTRP3 levels were significantly decreased in patients with primary hyperparathyroidism, and it is also related to osteoporosis.

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