Practical use of parenteral calcimimetics for severe secondary hyperparathyroidism. A case report

Secondary hyperparathyroidism (SHPT) leads to bone disorders and cardiovascular complications in long-term dialysis patients. SHPT is caused by hyperphosphatemia. Abnormalities of calcium-sensing receptor (CaSR) are associated with the pathogenesis of SHPT. Clinical trials have shown that calcimimetics significantly reduce the risks of parathyroidectomy, bone fracture and cardiovascular hospitalization among long-term dialysis patients with SHPT. Etelcalcetide, a novel calcimimetic compound, acts as a direct CaSR agonist, restores the sensitivity of the CaSR in parathyroid cells, and decreases serum parathyroid hormone without inducing hypercalcemia or hyperphosphatemia. Etelcalcetide's properties allow it to be administered intravenously thrice weekly at the end of a hemodialysis treatment session improving medication adherence.

Parathyroid hormone in Sri Lankan pregnant women: Vitamin D and other determinants

Introduction Determinants of parathyroid hormone level during pregnancy have been less frequently studied. We aimed to describe the serum parathyroid hormone (PTH) and its determinants in Sri Lankan pregnant women in a community setting. Materials and methods In this cross-sectional analysis, 390 pregnant mothers in their third trimester were enrolled from primary care centers of 15 health divisions in the Colombo District in Sri Lanka. Venous blood was analyzed for a total 25-hydroxyvitamin-D [25(OH)D], serum parathyroid hormone (PTH), serum calcium, and alkaline phosphatase. The bone quality was assessed in terms of speed of sound (SOS) using the quantitative ultrasound scan (QUS). Univariate and multivariate regression analysis was used to examine the determinants of PTH concentration in blood. Results Median serum 25(OH)D was 17.5ng/mL. Most (61.6%) were vitamin D deficient (<20ng/mL). Median PTH was 23.7pg/mL. Only 0.8% had hyperparathyroidism (PTH >65pg/mL). The correlation between 25(OH)D and PTH was weak but significant (r = -0.197; p<0.001). SOS Z-score was below the cut-off (≤−2) in fifty-six women (14.7%), and SOS did not relate significantly to PTH. In regression analysis, serum 25(OH)D, serum calcium, body mass index, educational level, and weeks of pregnancy were significant independent variables when adjusted. The model explained 16% of the variation in the PTH level. Conclusions A high prevalence of vitamin D deficiency was observed among Sri Lankan pregnant women in the present study. Serum 25(OH)D, calcium, weeks of pregnancy, and educational level were determinants of serum PTH.

PTH after Thyroidectomy as a Predictor of Post-Operative Hypocalcemia

Post-thyroidectomy hypocalcemia is a frequent complication with significant morbidity, and has been shown to increase hospital stay and readmission rates. The evaluation of serum parathyroid hormone (PTH) levels after thyroidectomy represents a reliable method to predict post-thyroidectomy hypocalcemia, but it remains infrequently used. This retrospective study investigates serum PTH values 3 h after thyroidectomy as a predictor of hypocalcemia. In this study, we enrolled 141 patients aged between 27 and 71 years eligible for total thyroidectomy who presented with multinodular goiter, suspicious nodule on cytological examination, Graves’ disease, or toxic multinodular goiter. Three hours after total thyroidectomy, 53 patients (37.6%) showed a reduction in serum PTH. Of these patients 75.5% developed hypocalcemia by 24 h after surgery and 100% were hypocalcemic after 48 h (p < 0.001). There was no significant difference attributable to the different thyroid diseases, nor to the age of the patients. PTH at 3 h after total thyroidectomy accurately predicts post-operative hypocalcemia. The early detection of patients at risk of developing post-operative hypocalcemia allows for prompt supplementation of calcium and Vitamin D in order to prevent symptoms and allows for a safe and timely discharge.

Systems-Level Opportunities in the Management of Primary Hyperparathyroidism: An Informatics-Based Assessment

Context Primary hyperparathyroidism (PHPT), a leading cause of hypercalcemia and secondary osteoporosis, is underdiagnosed. Objective To establish a foundation for an electronic medical record-based intervention that would prompt serum parathyroid hormone (PTH) assessment in patients with persistent hypercalcemia and identify care gaps in their management. Design Retrospective cohort study. Setting Tertiary academic health system. Patients Outpatients with persistent hypercalcemia, who were then categorized as having classic or normohormonal PHPT. Main Outcome Measures The frequencies of serum parathyroid hormone (PTH) measurement in patients with persistent hypercalcemia, and their subsequent workup with bone mineral density (BMD) assessment, and ultimately, medical therapy or parathyroidectomy. Results Among 3151 patients with persistent hypercalcemia, 1526 (48%) had PTH measured, from whom 1377 (90%) were confirmed to have classic (49%) or normohormonal (41%) primary hyperparathyroidism (PHPT). PTH was measured in 65% of hypercalcemic patients with osteopenia or osteoporosis (p&lt;0.001). Upon median two year follow-up, bone density was assessed in 275 (20%) patients with either variant of PHPT (p=0.003). Of women ≥ 50 years of age with classic PHPT, 95 (19%) underwent BMD assessment. Of patients with classic or normohormonal PHPT, 919 patients (67%) met consensus criteria for surgical intervention, though only 143 (15%) underwent parathyroidectomy. Conclusions Within a large academic health system, over half of patients with confirmed hypercalcemia were not assessed for PHPT, including many patients with preexisting bone disease. Care gaps in BMD assessment and medical or surgical therapy represent opportunities to avoid skeletal and other complications of PHPT.