Hyperparathyroidism (Smarty PANCE)

What percentage of adenomas are not single but found in more than one gland?

5% of adenomas are found in more than one gland

Diagnosis of hyperparathyroidis?

Diagnosis of hyperparathyroidism is based on blood tests to confirm high levels of parathyroid hormone and then testing for blood levels of calcium, phosphate, and vitamin D to confirm the type of hyperparathyroidism

What is the "33 to 1" rule?

Most patients with primary hyperparathyroidism have a ratio of serum (Cl-) to phosphate > 33

What lab finding is elevated in all three types of hyperparathyroidism?

PTH (parathyroid hormone) is always elevated

What is the most likely diagnosis if a patient has a PALPABLE neck mass, hypercalcemia, and elevated PTH?

Parathyroid carcinoma (vast majority of other causes of primary HPTH have nonpalpable parathyroids)

Where is parathyroid hormone produced?

Parathyroid hormone comes from the parathyroid glands which are buried within the thyroid gland

How does parathyroid hormone function in the body?

Parathyroid hormone gets the bones to release calcium, it gets the kidneys to reabsorb more calcium so it's not lost in the urine, and it synthesizes calcitriol, which is also known as 1,25-dihydroxycholecalciferol, or active vitamin D. Active vitamin D then goes on to cause the gastrointestinal tract to increase calcium absorption. Altogether, these effects help to keep the extracellular levels of calcium within a narrow range that's between 8.5 to 10 mg/dl.

How does parathyroid hormone affect calcium and phosphate levels in the blood?

Parathyroid hormone increases blood calcium and decreases phosphate level.

What does "Thrones" refer to in hypercalcemia?

Polyuria (frequent urination) caused by impaired sodium and water reabsorption

One more time - what are the labs in primary hyperparathyroidis?

Primary hyperparathyroidism will have high calcium and low phosphate.

Lab findings of primary hyperparathyroidism

Primary hyperparathyroidism will have ↑ PTH, ↑ calcium and ↓ phosphate

Although most recommend surgery for asymptomatic primary hyperparathyroidism when is it considered mandatory?

R - Renal insufficiency (CR ↓ by 30%) O - Osteoporosis (T score < -2.5) A - Age < 50 C - Calcium 1 mg/dl above upper limit of normal H - Hypercalciuria (400 mg/day Ca 2 excretion)

One more time - what are the labs in secondary hyperparathyroidism in chronic renal disease?

Secondary hyperparathyroidism in chronic renal disease will have low calcium, elevated phosphate, and low vitamin D

Causes of secondary HPTH?

Secondary hyperparathyroidism is caused by chronic hypocalcemia which cause the parathyroid gland to makes excess parathyroid hormone. Causes include calcium wasting caused by renal failure or decreased GI calcium absorption, rickets or osteomalacia; calcium levels are usually low. Chronic kidney disease is the most common cause of secondary hyperparathyroidism.

Lab findings of secondary hyperparathyroidism

Secondary hyperparathyroidism will have ↓ calcium, ↑ phosphate, and ↓ vitamin D

Treatment of secondary hyperparathyroidism?

Sometimes with secondary hyperparathyroidism, surgery is used, but normally treatment is aimed at managing the hyperphosphatemia with phosphate binders and to increase the levels of vitamin D, using supplements and calcitriol analogs.

What plain x-ray findings are classic for HPTH?

Subperiosteal bone resorption (usually in hand digits) are said to be "pathognomonic" for HPTH!

What is the definitive treatment of primary and tertiary hyperparathyroidism?

Surgery! Treatment of primary and tertiary hyperparathyroidism is done by removing the abnormal parathyroid glands with surgery. Calcimimetics, drugs that imitate the action of calcium by attaching to the calcium-sensing receptors on parathyroid cells, are used if surgery is not possible

What do "Psychiatric overtones" refer to in hypercalcemia?

Symptoms like depressed mood and confusion

How can you remember the symptoms of tertiary hyperparathyroidis?

Tertiary hyperparathyroidism causes all of the same symptoms, but can also have elevated phosphate levels and as a result deposits of calcium-phosphate can settle in blood vessels and soft tissues

Define tertiary HPTH

Tertiary hyperparathyroidism is a situation where individuals who have had secondary hyperparathyroidism for many years develop primary hyperparathyroidism. In tertiary hyperparathyroidism parts of the parathyroid gland start making parathyroid hormone independently of blood calcium levels - resulting in hypercalcemia.

Lab findings of tertiary hyperparathyroidism

Tertiary hyperparathyroidism will have ↑ calcium (just like primary hyperparathyroidism), but it's distinguished from primary hyperthyroidism if the person has—or used to have—chronic kidney disease. Phosphate levels will depend on whether the person has had a kidney transplant.

What is the incidence of primary HPTH in the United States?

The incidence of primary HPTH in the United States is 1/1,000-1/4,000

What is the initial medical treatment of hypercalcemia in primary HPTH?

The initial medical treatment of hypercalcemia in primary HPTH includes IV fluids and furosemide—NOT thiazide diuretics

What are the etiologies of primary HPTH and percentages?

The most most common cause of primary hyperparathyroidism is parathyroid adenoma which is a benign tumor ( 85%), Hyperplasia (10%), Carcinoma ( 1%)

What are the risk factors for primary HPTH?

The risk factors for primary HPTH include family history, MEN-I and MEN-IIa, irradiation

What does "Bones" refer to in hypercalcemia?

Bone pain from hormone-driven demineralization releasing calcium

What carcinomas are commonly associated with hypercalcemia?

Breast cancer metastases, prostate cancer, kidney cancer, lung cancer, pancreatic cancer, multiple myeloma

What does "Stones" refer to in hypercalcemia?

Calcium-based kidney stones or gallstones due to hypercalciuria

How are changes in the body's levels of extracellular calcium detected?

Changes in the body's levels of extracellular calcium are detected by a surface receptor in parathyroid cells that's called the calcium-sensing receptor. These changes affect the amount of parathyroid hormone that's released by the parathyroid gland.

What does "Groans" refer to in hypercalcemia?

Constipation and muscle weakness due to decreased muscle contractions

Define primary HPTH

In primary hyperparathyroidism, the parathyroid gland is responsible for the problem, because it makes parathyroid hormone independently of the calcium level. Excess parathyroid hormone stimulates osteoclasts to break down bone and makes the kidneys hold on to calcium and get rid of phosphate - resulting in hypercalcemia and hypophosphatemia. It's marked by elevated calcium and low phosphorus. Usually caused by a PTH secreting parathyroid ADENOMA

Define secondary HPTH

In secondary hyperparathyroidism, the parathyroid gland is normal but ↑ PTH by a physiologic response to hypocalcemia or vitamin D deficiency

How can you remember the symptoms of primary hyperparathyroidis?

The symptoms of primary hyperparathyroidism can be remembered as stones, thrones, bones, groans, and psychiatric overtones - Stones is for calcium-based kidney stones or gallstones that can form - Thrones refers to the toilet to remind you of the polyuria or frequent urination that results from impaired sodium and water reabsorption. - Bones is for bone pain that results after chronic hormone-driven demineralization in order to release calcium. - Groans is for constipation and muscle weakness, both of which are partly due to decreased muscle contractions. - Psychiatric overtones refers to symptoms like a depressed mood and confusion.

How can you remember the symptoms of secondary hyperparathyroidis?

The symptoms of secondary hyperparathyroidism are the same four stones, thrones, bones, groans, and psychiatric overtones + bone resorption (osteodystrophy) + calcification in blood vessels and soft tissues, because the high levels of phosphate cause it to find and stick to any available calcium, which forms bone-like crystals in places that they shouldn't be

What is the main job of the parathyroid glands?

Their main job is to keep blood calcium levels stable

Why place 30 to 40 mg of sliced parathyroid gland in the forearm after surgery?

To retain parathyroid function; if HPTH recurs, remove some of the parathyroid gland from the easily accessible forearm

What are the methods of imaging the parathyroids?

Ultrasound, Sestamibi scan, CT, MRI, and PET scans. These help localize parathyroid adenomas or hyperplasia in conditions like primary hyperparathyroidism.

What is the differential diagnosis of hypercalcemia, remembered by "CHIMPANZEES"

What is the differential diagnosis of hypercalcemia can be remembered by "CHIMPANZEES": - C: Calcium overdose - H: Hyperparathyroidism (1°, 2°, 3°), Hyperthyroidism, Hypocalciuric Hypercalcemia (familial) - I: Immobility/Iatrogenic (thiazide diuretics) - M: Metastasis/Milk alkali syndrome (rare) - P: Paget's disease (bone) - A: Addison's disease/Acromegaly - N: Neoplasm (colon, lung, breast, prostate, multiple myeloma) - Z: Zollinger-Ellison syndrome - E: Excessive vitamin D - E: Excessive vitamin A - S: Sarcoid