Parathyroid

Disorders
 Diagnostic Approach to
Hyperparathyroidism

↑Calcium Obtain ↓Calcium

↓Phosphorus Calcium and Phosphate ↑Phosphorus

Possible Primary or Tertiary Hyperparathyroidism Possible Secondary Hyperparathyroidism

Obtain Obtain
PTH, Vitamin D and BMP PTH, Vitamin D and BMP
↑↑PTH ↑PTH
↓↓GFR Normal GFR ↑PTH

Tertiary Hyperparathyroidism Primary vs FHH Secondary Hyperparthyroidism

Obtain ↓↓GFR ↓↓Vitamin D

Urine Calcium
CKD Vitamin D deficiency
↑Urine calcium ↓Urine calcium

Obtain
DEXA scan and Renal U/S Primary FHH

Obtain
Thyroid U/S or Sestamibi Scan or CT scan
 Treatment of
Hypoparathyroidism

Type Purpose of Treatment Treatment

Replete Calcium - Calcium and Vit D

Hypo-
Replete Magnesium - Magnesium
parathyroidism
Increase PTH - Recombinant PTH

Hypoparathyroidism

Calcium <7.5 or symptoms Calcium >7.5

IV Calcium Oral Calcium and Vitamin D

Monitor for calcium stones

Refractory

Recombinant PTH
 Treatment of
Hyperparathyroidism

Type/
Purpose of Treatment Treatment
Complication
1° or 3° Hyperparathyroidism Remove parathyroid - Parathyroidectomy 2° Hyperparathyroidism
1° or 3° Hyper-
Suppress PTH - Cinacalcet
parathyroidism

Calcium > 11.5? Suppress bone injury - Bisphosphonates Hyperphosphatemia?

- Sevelamer
PLUS Treat CKD
2° Hyper- - Calcium and Vit D
Add Sevelamer
parathyroidism
Renal Involvement
Treat Vit D deficiency - Vit D
-CKD 3 or worse?
-Hypercalciuria?
Severe - IV normal saline PLUS
-Nephrolithiasis?
Hypercalcemia Lower serum calcium - Bisphosphonates PLUS
( > 14) - Calcitonin Hypocalcemia?
PLUS

Skeletal Involvement
Slow Progression Bisphosphonates Add Calcium
- BMD < -2.5 or Fractures?
and Vitamin D
Calcimimetics: Cinacalcet

Cinacalcet

Surgical candidate Not a surgical candidate

PTH synthesis &
secretion
CaR
Perform
Cinacalcet
Parathyroidectomy Ca

Parathyroid Cell