The patient underwent parathyroidectomy. The parathyroid adenoma was resected. Histopathological examination revealed well circumscribed lesion, with chief cells arranged within a delicate capillary network.
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
H.When do you suspect primary hyperparathyroidism in a patient with CKD?
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Radwa Ellisy
A. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
parathyroidectomy is indicated in this case as seum calcium is persistently high more than 1 mg more than normal level
B. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
– iPTH is high in all but higher in the tertiary
– calcium is normal or low in secondary, but high in primary and tertiary
– Phosphorus is high in seconary and tertiary, and low in primary
C. When do you suspect primary hyperparathyroidism in a patient with CKD?
If hypophosphatemia, hypercalcemia and presence of nodule
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient. All patients with PHPT are “candidates” for surgery, which offers the only option for cure of the disease. For asymptomatic individuals who meet the Fourth International Workshop on Asymptomatic PHPT guidelines:
1.Serum calcium (>upper limit of normal) :1.0 mg/dL
2.Skeletal:
BMD by DXA: T-score <–2.5 at lumbar spine, total hip, femoral neck, or distal 1/3 radius.
Vertebral fracture by radiograph, CT, MRI, or VFA
3.Renal
Creatinine clearance <60 mL/min
24-hour urine for calcium >400 mg/day and increased stone risk by biochemical stone risk analysis
Presence of nephrolithiasis or nephrocalcinosis by radiograph, ultrasound, or CT
4.Age <50
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
H.When do you suspect primary hyperparathyroidism in a patient with CKD? Hypercalcemia, Hypophosphatemia in the context of parathyroid nodule, keeping with PHPT rather than SHPT
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.Patient is recommended to undergo surgical parathyroidectomy if he has one of the following:
Age < 50
Ca corr level > 1 mg/dl above ULN Ca level
eGFR < 60
Hx of renal stones, or nepphrolithiasis by imaging.
Urine Ca excretion > 400mg/dl
Hx of vertebral or long bone fractures.
T score < -2.5
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
Primary HPT: high PTH, High/normal Ca corr, Low/normal Ph, High/normal Vit D
Secondary high PTH, low Ca corr, high/normal Ph, low Vit, CKD
Tertiary HPT: high PTH, High/normal Ca corr, high/normal Ph, High/normal Vit, ESRD
H.When do you suspect primary hyperparathyroidism in a patient with CKD?
Once the patient is having High PTH, with high Ca corr, low PH and normal vit D, and US parathyroid shows parathyroid adenoma.
Appraise the rationale of medical and surgical parathyroidectomy in this patient.Bone and joint pain
Fractures
Proximal muscle weakness
Extraskeletal calcification such vascular calcifications
Calciphylaxis
Pruritus
Hypercalcemia
Hyperphosphatemia
When do you suspect primary hyperparathyroidism in a patient with CKD?Hypercalcemia, Hypophosphatemia. and solitary adenoma primary hyperparathyroidism should be considered. How to differentiate between primary, secondary, and tertiary hyperparathyroidismprimary hyperparathyroidism is characterized with elevated PTH calcium and low phosphate mild decrease in vitamin D. and 85% of solitary parathyroid adenoma.
in secondary elevated PTH with severe low of vitamin D, low or normal calcium and phosphate level.
tertiary hyperparathyroidism very high PTH with elevated calcium and phosphate and low or normal vit D
Appraise the rationale of medical and surgical parathyroidectomy in this patient. 1. Serum calcium >1 mg/dL (0.25 mmol/L) above upper limit of normal. 2. Skeletal features: a. Fracture by VFA or vertebral X‐ray or b. BMD by T‐score≤−2.5 at any site. 3. Renal features: a. eGFR or CrCl <60 cc/minute or b. Nephrocalcinosis or nephrolithiasis on X‐ray, ultrasound, or other imaging modality c. Urinary calcium excretion >400 mg/day. 4. Age < 50 How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
in primary hyperparathyroidism there is low p and high ca
in secondary hyperparathyroidism high p and low ca
tertiary hyperparathyroidism high PTH without control lead to normal ca.
When do you suspect primary hyperparathyroidism in a patient with CKD?low p
high ca
A-surgery to be recommended if one of the following is present: 1. Serum calcium >1 mg/dL (0.25 mmol/L) above upper limit of normal. 2. Skeletal features: a. Fracture by VFA or vertebral X‐ray or b. BMD by T‐score≤−2.5 at any site. 3. Renal features: a. eGFR or CrCl <60 cc/minute or b. Nephrocalcinosis or nephrolithiasis on X‐ray, ultrasound, or other imaging modality c. Urinary calcium excretion >400 mg/day. 4. Age < 50 b- hper ca with low phos and with noduler
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.Surgery to be recommended if one of the following is present:
Age younger than 50 years, serum calcium level >1 mg/dL above the normal limit
Urinary calcium excretion > 400 mg per 24 hours (10 mmol per day)
Creatinine clearance was reduced by more than 30 percent compared with age-matched persons
Bone density (lumbar spine, hip, or forearm) that is > 2.5 standard deviations below peak bone mass (T score -2.5)
Nephrocalcinosis or nephrolithiasis on X‐ray, ultrasound, or other imaging modality
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?Primary :high PTH, high calcium and low phosphorous Secondary : high PTH, low calcium, high phosphorous Tertiary : high PTH, high calcium, high phosphorous
H.When do you suspect primary hyperparathyroidism in a patient with CKD? Hypercalcemia, hypophosphatemia and in presence of a single solitary parathyroid nodule, primary hyperparathyroidism is to be considered.
Indications of Parathyroidectomy in Asymptomatic Hyperparathyroidism
Age younger than 50 years, serum calcium level >1 mg/dL above the normal limit
Urinary calcium excretion > 400 mg per 24 hours (10 mmol per day)
Creatinine clearance was reduced by more than 30 percent compared with age-matched persons
Bone density (lumbar spine, hip, or forearm) that is > 2.5 standard deviations below peak bone mass (T score -2.5)
Medical surveillance is not desirable or possible
Surgery requested by the patient
How to differentiate between primary, secondary, and tertiary hyperparathyroidismprimary ca increases, phosphorus decreases , pth increases
secondary ca normal or low , phosphorus high , pth increases
Tertiary ca increases, phosphorus increases , pth increases
When do you suspect primary hyperparathyroidism in a patient with CKD?in case of hypercalcemia , hypophosphatemia with high pth level and radiological evidence of parathyroid adenoma
Adenoma should be removed because it will lead to uncontrolled hypercalcemia with later bad consequences. In primary hyperparathyroidism, we expect hypercalcemia with hypophosphatemia, while in secondary hyper PTH, high P and low Ca is the reason. In tertiary Hyperparathyroidism, there is uncontrol of the PTH secretion, which will normalize the calcium
Rational of medical and surgical treatment of hyperparathyroidism
Medical treatment; will mostly be failed;
a) Patient non-compliance. b) parathyroid adenoma resists response to medical treatment because the adenoma will become hyporesponsive as there is a deficient CaSR.
Surgical treatment
a) A definitive treatment of tertiary and primary hyperparathyroidism. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
Primary hyperparathyroidism.
High PTH.
Hypercalcemia.
Hypophosphatemia.
Nirmal or reduce vitD level.
85% due to solitary parathyroid adenoma, with a great differential, is FHH.
2. Secondary hyperparathyroidism.
High PTH.
Normal or hypocalcemia.
Sever vitD deficiency.
Most common causes ;( CKD, and VitD deficiency).
3. Tertiary hyperparathyroidism
Sever high level of PTH.
Hypercalcemia.
Hyperphosphatemia.
Normal o reduce vitD.
Most common cause; (chronic untreated secondary hyperparathyroidism, ESKD).
When do you suspect primary hyperparathyroidism in a patient with CKD?
F. Appraise the rationale of surgical parathyroidectomy in this patient. Surgery to be recommended if one of the following is present: 1. Serum calcium >1 mg/dL (0.25 mmol/L) above upper limit of normal. 2. Skeletal features: a. Fracture by VFA or vertebral X‐ray or b. BMD by T‐score≤−2.5 at any site. 3. Renal features: a. eGFR or CrCl <60 cc/minute or b. Nephrocalcinosis or nephrolithiasis on X‐ray, ultrasound, or other imaging modality c. Urinary calcium excretion >400 mg/day. 4. Age < 50
H. When do you suspect primary hyperparathyroidism in a patient with CKD?
In cases of hypercalcemia, hypophosphatemia and in presence of a single solitary parathyroid nodule, primary hyperparathyroidism is to be considered.
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
PRIMARY HYPERPARA IS TREATED SURGICALY DD PRIMARY .. HIGH PTH , HIGH CALCIUM AND LOW PHOSPHOROU Secondary : HIGH PTH,LOW CALCIUM , HIGH PHOSPHOROUS TERTIARY : HIGH PTH HIGH CALCIUM AND ,HIGH PHOSPHOROUS
H.When do you suspect primary hyperparathyroidism in a patient with CKD? WHEN THERE IS HIGH PTH WITH HYPERCALCEMIA WITH NO CACLIUM SUPPLEMENTAION AND LOW OR NORMAL PHOSPHOROUS
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
Surgical parathyroidectomy is the treatment for primary hyperparathyroidism as there will be no response to medical treatment.
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
Primary :high PTH, high calcium and low phosphorous
Secondary : high PTH, low calcium, high phosphorous
Tertiary : high PTH, high calcium, high phosphorous
H. When do you suspect primary hyperparathyroidism in a patient with CKD?
When high PTH,high calcium with no calcium supplements and low or normal phosphorous
Ultrasound examination of the neck on the gland
F. Ptx is the definitive treatment in primary Hyperparathyroidism.
G.primary : high PTH, leading to high calcium and low phosphate.
Secondary: low calcium leading to high PTH , high phosphate
Tretiary: high pth irresponsive to treatment, with high /normal calcium and high phosphate in patient with CKD.
H. High PTH, high calcium without obvious exogenous intake of supplement , low phosphate and ultrasound examination suspicious for adenoma.
Urinary calcium above 300 mg/24h
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
According to this patient clinical status surgery is indicated, surgery will improve his symptoms as well as bone disorders
Calcimimetic therapy may provoke to have a role in reducing the need for surgery and may be an alternative in those whom surgery has contraindications.
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
Primary Hyperparathyroidism- High calcium-High PTH- High ALP-Low Phosphate
Secondary Hyperparathyroidism- Low calcium-High PTH-Low phosphate and Low VD with CKD
Tertiary Hyperparathyroidism- Normal/High calcium- High PTH and usually resistance to Cinacalcet therapy.
H.When do you suspect primary hyperparathyroidism in a patient with CKD?
Hypercalcemia, Hypophosphatemia and high urinary free calcium, US shown single solitary parathyroid nodule are suspected with Primary Hyperparathyroidism.
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
This is a young patient and a parathyroidectomy is indicated in order to maintain good bone health
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
Primary: caused by adenoma of one or more parathyroid glands or hyperplasia of all four glands
Reduced PO4
Elevated PTH
Elevated 1,25(OH)2D
Elevated U-Ca
Secondary: may be caused by deficiency in vitamin D or uremia
Increased PO4 and renal impairment
Elevated PTH
Reduced 1,25(OH)2D
Tertiary: most often is the result of a long-standing, severe secondary hyperparathyroidism, which has turned autonomous once the cause of the secondary hyperparathyroidism has been removed
Increased PO4
Increased PTH
H.When do you suspect primary hyperparathyroidism in a patient with CKD?
History of Nephrolithiasis
Hypercalcemia associated with a normal or low phosphate level
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
The patient is young age and parathyroid adenoma which is an indicatiion for parathyroidectomy
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
History from patient then laboratory check for serum level of ca po4 pth if
High Ca, High or normal iPTH, Low PO4, and adenoma by US scan is a primary hyperparathyroidism
If: Low Ca, High PTH, High PO4 usually in the setting of CKDis a secondary hyperparathyroidism
If: High Ca, High PTH, High PO4, after prolonged SHPT, adenoma by US scan teriarry hyperparathyroidism
H. When do you suspect primary hyperparathyroidism in a patient with CKD?
High level of PTH out of proporion to stage of CKD , persistence of hypercalcemia in ckd ,unexpainedrecurant kidney stones,24 hr urine is high in ckd patient.
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
This patient needed the parathyroidectomy as he has progressive rise in his serum Ca, and this approach is more definitive.Medical therapy with Cinacalcet may decrease Ca and PTH but not bone resorption (in some studies).Not sure if Cinacalcet is labelled for PHPTEtelcalcetide decreases the PTH-calcium setpoint without changing maximum and minimum PTH secretion in mice with primary hyperparathyroidism, not sure about trials in human subjects
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism? Primary: High Ca, High or normal iPTH, Low PO4, adenoma by US scan Secondary: Low Ca, High PTH, High PO4 usually in the setting of CKD Tertiary: High Ca, High PTH, High PO4, after prolonged SHPT, adenoma by US scan
H. When do you suspect primary hyperparathyroidism in a patient with CKD? if high PTH levels is found but with normal or high calcium and low PO4 NOT the usual high PO4 in CKD
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.this patient indicated for surgical PTX as he has adenoma and hypercalcemia
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?primary HPT —–high calcium ,high PTH ,low po4
secondary HPT >>low calcium ,high PTH ,high po4 (in ckd )
tertiary >>high calcium ,high PTH ,high po4
Appraise the rationale of medical and surgical parathyroidectomy in this patient.This patient is young with an age of less than 50, so better to go for surgical resection.
How to differentiate between primary, secondary, and tertiary hyperparathyroidism? 1ry: high PTH, hypophosphatemia, hypercalcemia, and increased 24 hr urine calcium 2ry: high PTH, Hyperphosphatemia, hypocalcemia, plus the advanced stage of CKD 3ry: high PTH, Hyperphosphatemia, hypercalcemia, plus history of longstanding secondary hyperparathyroidism
When do you suspect primary hyperparathyroidism in a patient with CKD? In the absence of a clear cause, hypercalcemia should raise the suspicion of either Primary or tertiary PTH.
F)surgical is the best option in this case
G)1ry : high ca ,high pth normal po4
2ry low ca ,high or normal po4 and high pth in CKD patient
3ry :high pth ,high ca ,high po4 or normal in ESRD
H)high ca in ckd patient with high 24 h urine ca excretion .
high pth not responding to medication
Appraise the rationale of medical and surgical parathyroidectomy in this patient this patient is below 50yrs old which is an indicatiion for parathyroidectomy in 1ry hyperparathyroidism, the patient has adenoma which will not respond to medical treatment.How to differentiate between primary, secondary, and tertiary hyperparathyroidism? 1ry: high PTH, hypophosphatemia, hypercalcemia, and increased 24 hr urine calcium
2ry: high PTH, Hyperphosphatemia, hypocalcemia, plus advanced stage of CKD
3ry: high PTH, Hyperphosphatemia, hypercalcemia, plus history of longstanding secondary hyperparathyroidism
When do you suspect primary hyperparathyroidism in a patient with CKD1- level of PTH out of proporion to stage of CKD
2- hypercalcemia in ckd
3- unexpained kidney stones
4- 24 hr urine is high in ckd patient
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
Although parathyroidectomy improves bone density and may have modest effects on some quality-of-life symptoms, long-term, observational data, and short-term, randomized trial data show that a large subgroup of patients with asymptomatic PHPT can be safely followed without surgery because they do not have disease progression, as evidenced by stable biochemical abnormalities and bone mineral density (BMD) for up to a decade. Throughout the first year of monitoring, one-third of patients may develop illness (worsening hypercalcemia, hypercalciuria, nephrolithiasis) and benefit from surgery. Most patients with BMD over 8–10 years also lose it. This modest set of observational data implies that long-term (>8–10 years) surveillance in asymptomatic individuals is not ideal for skeletal results.
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?1ry: high PTH, high Ca, low PO4
2ndry: high PTH, low Ca, high PO4
Tertiary: high PTH, high Ca, high PO4
H.When do you suspect primary hyperparathyroidism in a patient with CKD?
Hypercalcaemia in the absence of culprit drugs and/or PTH suppression should lead doctors to “non-secondary” HPT—either tertiary or primary, as in this instance. The latter may coexist with secondary HPT and be harder to detect.
PHPT: high Ca and low PO4, contrary to CKD: ionized calcium is typically maintained in the normal range unless CKD is quite advanced (GFR well below 30 mL/min/1.73 m2 ).
Secondary HPT should be entertained. While most patients with moderate to advanced CKD and evidence of elevated PTH have normal or low serum calcium concentrations, a fraction with low bone turnover may have mild hypercalcemia
Thanks dr Weam. In cases of hypercalcemia, hypophosphatemia and in presence of a single solitary parathyroid nodule, primary hyperparathyroidism is to be considered.
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
Surgical parathyroidectomy in this patient may be the best option because he already had end-organ damage in the form of CKD. Other indication for surgery is uncontrolled hypercalcemia.
Medical treatment i.e., cinacalcet may be considered in absent of end-organ damage and hypercalcemia which is amenable to medical therapy, or unfit patient for surgery.
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?Hyperparathyroidism (HPT) is characterized by abnormally high parathyroid hormone (PTH) levels in the blood due to parathyroid gland overactivity. HPT is further classified based on the underlying cause: primary HPT (pHPT), secondary HPT (sHPT), or tertiary HPT (tHPT). pHPT is characterized by elevated PTH and calcium levels and is usually caused by parathyroid adenomas or hyperplasia, or, in rare cases, parathyroid carcinomas. Although pHPT is often asymptomatic, symptoms such as bone pain, gastric ulcers, and kidney stones may be present in severe or untreated cases. sHPT is characterized by high PTH and low calcium levels and may be caused by chronic kidney disease (CKD), vitamin D deficiency, insufficient calcium intake, or malabsorption. sHPT is also called reactive HPT, as the increase in PTH production is a physiological response to hypocalcemiarather than an abnormality of the parathyroid glands. If sHPT and elevated serum PTH levels persist, tHPT may develop, resulting in a shift from low to high serum calcium levels. Diagnostics and classification involve evaluating calcium, PTH, and phosphate levels, and, in the case of sHPT, identifying the underlying cause (e.g., CKD). Surgery is the primary treatment option for most patients with pHPT or tHPT. Patients who do not undergo surgery can be managed with either calcimimetics or if osteoporosis is present, bisphosphonates. In sHPT, management focuses on treating the underlying cause H.When do you suspect primary hyperparathyroidism in a patient with CKD?
While secondary HPT is the dominant disorder of parathyroid structure and function in patients with CKD, hypercalcaemia in the absence of culprit medications and/or non-suppression of PTH should direct clinicians toward ‘non-secondary’ HPT—either tertiary or, as in this case, primary
THE best management of parathyroid adenoma surgical interference parathyroidectomy
1ryhyperparathyroidism >>>> hypercalcemia ,,normal phosphate , . mild high PTH and urinary calcium high apparent cause as adenoma
2ryhyperparathyroidism as in early stag CKD Hpocalemia , hyperphosphatemia . ALP normal or high and hyperplasia parathyroid gland 3ryhyperparathyroidism :- hypercalcemia , hyperphosphatemia , high ALP
Thank you. Surgery to be recommended if one of the following is present: 1. Serum calcium >1 mg/dL (0.25 mmol/L) above upper limit of normal. 2. Skeletal features: a. Fracture by VFA or vertebral X‐ray or b. BMD by T‐score≤−2.5 at any site. 3. Renal features: a. eGFR or CrCl <60 cc/minute or b. Nephrocalcinosis or nephrolithiasis on X‐ray, ultrasound, or other imaging modality c. Urinary calcium excretion >400 mg/day. 4. Age < 50
G – primary HPT…..high PTH , high calcium and low po4
secondary HPT…high PTH , low calcium with high po4
tertiary HPT….very high PTH , normal or high calcium and high po4
H – if high PTH levels with normal or high calcium and low po4 instead of calssic high po4 in these patients
A. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
parathyroidectomy is indicated in this case as seum calcium is persistently high more than 1 mg more than normal level
B. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
– iPTH is high in all but higher in the tertiary
– calcium is normal or low in secondary, but high in primary and tertiary
– Phosphorus is high in seconary and tertiary, and low in primary
C. When do you suspect primary hyperparathyroidism in a patient with CKD?
If hypophosphatemia, hypercalcemia and presence of nodule
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
All patients with PHPT are “candidates” for surgery, which offers the only option for cure of the disease. For asymptomatic individuals who meet the Fourth International Workshop on Asymptomatic PHPT guidelines:
1.Serum calcium (>upper limit of normal) :1.0 mg/dL
2.Skeletal:
3.Renal
4.Age <50
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
H. When do you suspect primary hyperparathyroidism in a patient with CKD?
Hypercalcemia, Hypophosphatemia in the context of parathyroid nodule, keeping with PHPT rather than SHPT
F- surgical parathyroidectomy
renal cause- urine calcium >400 , renal stone, egfr <60
bone- fractures , osteoporosis
biochemical ca more than 0.25 mmol/l
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.Patient is recommended to undergo surgical parathyroidectomy if he has one of the following:
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
Primary HPT: high PTH, High/normal Ca corr, Low/normal Ph, High/normal Vit D
Secondary high PTH, low Ca corr, high/normal Ph, low Vit, CKD
Tertiary HPT: high PTH, High/normal Ca corr, high/normal Ph, High/normal Vit, ESRD
H. When do you suspect primary hyperparathyroidism in a patient with CKD?
Once the patient is having High PTH, with high Ca corr, low PH and normal vit D, and US parathyroid shows parathyroid adenoma.
Appraise the rationale of medical and surgical parathyroidectomy in this patient.Bone and joint pain
Fractures
Proximal muscle weakness
Extraskeletal calcification such vascular calcifications
Calciphylaxis
Pruritus
Hypercalcemia
Hyperphosphatemia
When do you suspect primary hyperparathyroidism in a patient with CKD?Hypercalcemia, Hypophosphatemia. and solitary adenoma primary hyperparathyroidism should be considered.
How to differentiate between primary, secondary, and tertiary hyperparathyroidismprimary hyperparathyroidism is characterized with elevated PTH calcium and low phosphate mild decrease in vitamin D. and 85% of solitary parathyroid adenoma.
in secondary elevated PTH with severe low of vitamin D, low or normal calcium and phosphate level.
tertiary hyperparathyroidism very high PTH with elevated calcium and phosphate and low or normal vit D
Appraise the rationale of medical and surgical parathyroidectomy in this patient.
1. Serum calcium >1 mg/dL (0.25 mmol/L) above upper limit of normal.
2. Skeletal features:
a. Fracture by VFA or vertebral X‐ray or
b. BMD by T‐score≤−2.5 at any site.
3. Renal features:
a. eGFR or CrCl <60 cc/minute or
b. Nephrocalcinosis or nephrolithiasis on X‐ray, ultrasound, or other imaging modality
c. Urinary calcium excretion >400 mg/day.
4. Age < 50
How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
in primary hyperparathyroidism there is low p and high ca
in secondary hyperparathyroidism high p and low ca
tertiary hyperparathyroidism high PTH without control lead to normal ca.
When do you suspect primary hyperparathyroidism in a patient with CKD?low p
high ca
A-surgery to be recommended if one of the following is present:
1. Serum calcium >1 mg/dL (0.25 mmol/L) above upper limit of normal.
2. Skeletal features:
a. Fracture by VFA or vertebral X‐ray or
b. BMD by T‐score≤−2.5 at any site.
3. Renal features:
a. eGFR or CrCl <60 cc/minute or
b. Nephrocalcinosis or nephrolithiasis on X‐ray, ultrasound, or other imaging modality
c. Urinary calcium excretion >400 mg/day.
4. Age < 50
b- hper ca with low phos and with noduler
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.Surgery to be recommended if one of the following is present:
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?Primary :high PTH, high calcium and low phosphorous
Secondary : high PTH, low calcium, high phosphorous
Tertiary : high PTH, high calcium, high phosphorous
H. When do you suspect primary hyperparathyroidism in a patient with CKD? Hypercalcemia, hypophosphatemia and in presence of a single solitary parathyroid nodule, primary hyperparathyroidism is to be considered.
Indications of Parathyroidectomy in Asymptomatic Hyperparathyroidism
How to differentiate between primary, secondary, and tertiary hyperparathyroidismprimary ca increases, phosphorus decreases , pth increases
secondary ca normal or low , phosphorus high , pth increases
Tertiary ca increases, phosphorus increases , pth increases
When do you suspect primary hyperparathyroidism in a patient with CKD?in case of hypercalcemia , hypophosphatemia with high pth level and radiological evidence of parathyroid adenoma
Adenoma should be removed because it will lead to uncontrolled hypercalcemia with later bad consequences. In primary hyperparathyroidism, we expect hypercalcemia with hypophosphatemia, while in secondary hyper PTH, high P and low Ca is the reason. In tertiary Hyperparathyroidism, there is uncontrol of the PTH secretion, which will normalize the calcium
Rational of medical and surgical treatment of hyperparathyroidism
a) Patient non-compliance.
b) parathyroid adenoma resists response to medical treatment because the adenoma will become hyporesponsive as there is a deficient CaSR.
a) A definitive treatment of tertiary and primary hyperparathyroidism.
How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
2. Secondary hyperparathyroidism.
3. Tertiary hyperparathyroidism
When do you suspect primary hyperparathyroidism in a patient with CKD?
Thank you again for your great efforts.
F. Appraise the rationale of surgical parathyroidectomy in this patient.
Surgery to be recommended if one of the following is present:
1. Serum calcium >1 mg/dL (0.25 mmol/L) above upper limit of normal.
2. Skeletal features:
a. Fracture by VFA or vertebral X‐ray or
b. BMD by T‐score≤−2.5 at any site.
3. Renal features:
a. eGFR or CrCl <60 cc/minute or
b. Nephrocalcinosis or nephrolithiasis on X‐ray, ultrasound, or other imaging modality
c. Urinary calcium excretion >400 mg/day.
4. Age < 50
H. When do you suspect primary hyperparathyroidism in a patient with CKD?
In cases of hypercalcemia, hypophosphatemia and in presence of a single solitary parathyroid nodule, primary hyperparathyroidism is to be considered.
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
PRIMARY HYPERPARA IS TREATED SURGICALY
DD
PRIMARY .. HIGH PTH , HIGH CALCIUM AND LOW PHOSPHOROU
Secondary : HIGH PTH,LOW CALCIUM , HIGH PHOSPHOROUS
TERTIARY : HIGH PTH HIGH CALCIUM AND ,HIGH PHOSPHOROUS
H. When do you suspect primary hyperparathyroidism in a patient with CKD? WHEN THERE IS HIGH PTH WITH HYPERCALCEMIA WITH NO CACLIUM SUPPLEMENTAION AND LOW OR NORMAL PHOSPHOROUS
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
Surgical parathyroidectomy is the treatment for primary hyperparathyroidism as there will be no response to medical treatment.
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
Primary :high PTH, high calcium and low phosphorous
Secondary : high PTH, low calcium, high phosphorous
Tertiary : high PTH, high calcium, high phosphorous
H. When do you suspect primary hyperparathyroidism in a patient with CKD?
When high PTH,high calcium with no calcium supplements and low or normal phosphorous
Ultrasound examination of the neck on the gland
F. Ptx is the definitive treatment in primary Hyperparathyroidism.
G.primary : high PTH, leading to high calcium and low phosphate.
Secondary: low calcium leading to high PTH , high phosphate
Tretiary: high pth irresponsive to treatment, with high /normal calcium and high phosphate in patient with CKD.
H. High PTH, high calcium without obvious exogenous intake of supplement , low phosphate and ultrasound examination suspicious for adenoma.
Urinary calcium above 300 mg/24h
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
H. When do you suspect primary hyperparathyroidism in a patient with CKD?
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
According to this patient clinical status surgery is indicated, surgery will improve his symptoms as well as bone disorders
Calcimimetic therapy may provoke to have a role in reducing the need for surgery and may be an alternative in those whom surgery has contraindications.
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
Primary Hyperparathyroidism- High calcium-High PTH- High ALP-Low Phosphate
Secondary Hyperparathyroidism- Low calcium-High PTH-Low phosphate and Low VD with CKD
Tertiary Hyperparathyroidism- Normal/High calcium- High PTH and usually resistance to Cinacalcet therapy.
H. When do you suspect primary hyperparathyroidism in a patient with CKD?
Hypercalcemia, Hypophosphatemia and high urinary free calcium, US shown single solitary parathyroid nodule are suspected with Primary Hyperparathyroidism.
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
H. When do you suspect primary hyperparathyroidism in a patient with CKD?
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
The patient is young age and parathyroid adenoma which is an indicatiion for parathyroidectomy
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
History from patient then laboratory check for serum level of ca po4 pth if
High Ca, High or normal iPTH, Low PO4, and adenoma by US scan is a primary hyperparathyroidism
If: Low Ca, High PTH, High PO4 usually in the setting of CKDis a secondary hyperparathyroidism
If: High Ca, High PTH, High PO4, after prolonged SHPT, adenoma by US scan teriarry hyperparathyroidism
H. When do you suspect primary hyperparathyroidism in a patient with CKD?
High level of PTH out of proporion to stage of CKD , persistence of hypercalcemia in ckd ,unexpainedrecurant kidney stones,24 hr urine is high in ckd patient.
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
This patient needed the parathyroidectomy as he has progressive rise in his serum Ca, and this approach is more definitive.Medical therapy with Cinacalcet may decrease Ca and PTH but not bone resorption (in some studies).Not sure if Cinacalcet is labelled for PHPTEtelcalcetide decreases the PTH-calcium setpoint without changing maximum and minimum PTH secretion in mice with primary hyperparathyroidism, not sure about trials in human subjects
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
Primary: High Ca, High or normal iPTH, Low PO4, adenoma by US scan
Secondary: Low Ca, High PTH, High PO4 usually in the setting of CKD
Tertiary: High Ca, High PTH, High PO4, after prolonged SHPT, adenoma by US scan
H. When do you suspect primary hyperparathyroidism in a patient with CKD?
if high PTH levels is found but with normal or high calcium and low PO4 NOT the usual high PO4 in CKD
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.this patient indicated for surgical PTX as he has adenoma and hypercalcemia
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?primary HPT —–high calcium ,high PTH ,low po4
secondary HPT >>low calcium ,high PTH ,high po4 (in ckd )
tertiary >>high calcium ,high PTH ,high po4
Appraise the rationale of medical and surgical parathyroidectomy in this patient.This patient is young with an age of less than 50, so better to go for surgical resection.
How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
1ry: high PTH, hypophosphatemia, hypercalcemia, and increased 24 hr urine calcium
2ry: high PTH, Hyperphosphatemia, hypocalcemia, plus the advanced stage of CKD
3ry: high PTH, Hyperphosphatemia, hypercalcemia, plus history of longstanding secondary hyperparathyroidism
When do you suspect primary hyperparathyroidism in a patient with CKD? In the absence of a clear cause, hypercalcemia should raise the suspicion of either Primary or tertiary PTH.
usually, hypercalcemia is associated with PHPTH
F)surgical is the best option in this case
G)1ry : high ca ,high pth normal po4
2ry low ca ,high or normal po4 and high pth in CKD patient
3ry :high pth ,high ca ,high po4 or normal in ESRD
H)high ca in ckd patient with high 24 h urine ca excretion .
high pth not responding to medication
Appraise the rationale of medical and surgical parathyroidectomy in this patient this patient is below 50yrs old which is an indicatiion for parathyroidectomy in 1ry hyperparathyroidism, the patient has adenoma which will not respond to medical treatment.How to differentiate between primary, secondary, and tertiary hyperparathyroidism? 1ry: high PTH, hypophosphatemia, hypercalcemia, and increased 24 hr urine calcium
2ry: high PTH, Hyperphosphatemia, hypocalcemia, plus advanced stage of CKD
3ry: high PTH, Hyperphosphatemia, hypercalcemia, plus history of longstanding secondary hyperparathyroidism
When do you suspect primary hyperparathyroidism in a patient with CKD1- level of PTH out of proporion to stage of CKD
2- hypercalcemia in ckd
3- unexpained kidney stones
4- 24 hr urine is high in ckd patient
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
Although parathyroidectomy improves bone density and may have modest effects on some quality-of-life symptoms, long-term, observational data, and short-term, randomized trial data show that a large subgroup of patients with asymptomatic PHPT can be safely followed without surgery because they do not have disease progression, as evidenced by stable biochemical abnormalities and bone mineral density (BMD) for up to a decade. Throughout the first year of monitoring, one-third of patients may develop illness (worsening hypercalcemia, hypercalciuria, nephrolithiasis) and benefit from surgery. Most patients with BMD over 8–10 years also lose it. This modest set of observational data implies that long-term (>8–10 years) surveillance in asymptomatic individuals is not ideal for skeletal results.
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?1ry: high PTH, high Ca, low PO4
2ndry: high PTH, low Ca, high PO4
Tertiary: high PTH, high Ca, high PO4
H. When do you suspect primary hyperparathyroidism in a patient with CKD?
Hypercalcaemia in the absence of culprit drugs and/or PTH suppression should lead doctors to “non-secondary” HPT—either tertiary or primary, as in this instance. The latter may coexist with secondary HPT and be harder to detect.
PHPT: high Ca and low PO4, contrary to CKD: ionized calcium is typically maintained in the normal range unless CKD is quite advanced (GFR well below 30 mL/min/1.73 m2 ).
Secondary HPT should be entertained. While most patients with moderate to advanced CKD and evidence of elevated PTH have normal or low serum calcium concentrations, a fraction with low bone turnover may have mild hypercalcemia
Thanks dr Weam.
In cases of hypercalcemia, hypophosphatemia and in presence of a single solitary parathyroid nodule, primary hyperparathyroidism is to be considered.
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?Hyperparathyroidism (HPT) is characterized by abnormally high parathyroid hormone
(PTH) levels in the blood due to parathyroid gland overactivity. HPT is further classified based on the underlying cause: primary HPT (pHPT), secondary HPT (sHPT), or tertiary HPT (tHPT). pHPT is characterized by elevated PTH and calcium levels and is usually caused by parathyroid adenomas or hyperplasia, or, in rare cases, parathyroid carcinomas. Although pHPT is often asymptomatic, symptoms such as bone pain, gastric ulcers, and kidney stones may be present in severe or untreated cases. sHPT is characterized by high PTH and low calcium levels and may be caused by chronic kidney disease (CKD), vitamin D deficiency, insufficient calcium intake, or malabsorption. sHPT is also called reactive HPT, as the increase in PTH production is a physiological response to hypocalcemia rather than an abnormality of the parathyroid glands. If sHPT and elevated serum PTH levels persist, tHPT may develop, resulting in a shift from low to high serum calcium levels. Diagnostics and classification involve evaluating calcium, PTH, and phosphate levels, and, in the case of sHPT, identifying the underlying cause (e.g., CKD). Surgery is the primary treatment option for most patients with pHPT or tHPT. Patients who do not undergo surgery can be managed with either calcimimetics or if osteoporosis is present, bisphosphonates. In sHPT, management focuses on treating the underlying cause
H. When do you suspect primary hyperparathyroidism in a patient with CKD?
THE best management of parathyroid adenoma
surgical interference parathyroidectomy
1ryhyperparathyroidism >>>> hypercalcemia ,,normal phosphate , . mild high PTH and urinary calcium high
apparent cause as adenoma
2ryhyperparathyroidism as in early stag CKD Hpocalemia , hyperphosphatemia . ALP normal or high and hyperplasia parathyroid gland
3ryhyperparathyroidism :-
hypercalcemia , hyperphosphatemia , high ALP
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
1ry HPT
SHPT .
3ry HPT
H. When do you suspect primary hyperparathyroidism in a patient with CKD?
Thank you.
Surgery to be recommended if one of the following is present:
1. Serum calcium >1 mg/dL (0.25 mmol/L) above upper limit of normal.
2. Skeletal features:
a. Fracture by VFA or vertebral X‐ray or
b. BMD by T‐score≤−2.5 at any site.
3. Renal features:
a. eGFR or CrCl <60 cc/minute or
b. Nephrocalcinosis or nephrolithiasis on X‐ray, ultrasound, or other imaging modality
c. Urinary calcium excretion >400 mg/day.
4. Age < 50
F. Appraise the rationale of medical and surgical parathyroidectomy in this patient.
G. How to differentiate between primary, secondary, and tertiary hyperparathyroidism?
H. When do you suspect primary hyperparathyroidism in a patient with CKD?
G – primary HPT…..high PTH , high calcium and low po4
secondary HPT…high PTH , low calcium with high po4
tertiary HPT….very high PTH , normal or high calcium and high po4
H – if high PTH levels with normal or high calcium and low po4 instead of calssic high po4 in these patients
Thanks dr Mark.
could you please answer the remaining question. (Appraise the rationale of medical and surgical parathyroidectomy in this patient.)