Hyperparathyrodism

Hypoparathyrodism
Dr. A. WAHYUDI PABABBARI, SpPD,FINASIM
 Calcium Regulation

• 99% of body calcium in skeleton

• Miscible Pool: 40% bound to protein,
13% complexed w/ anions, 47% free
ionized
• PTH: Increased Ca, Decreased PO4,
Increased Vitamin D
• Vitamin D: Increased Ca, Increased
PO4, Decreased PTH (slow)
• Kidney, Bones, GI Tract
Calcium Regulation
Localization
• 4 glands in 87 % of
patients ; range 2 - 6
glands
• Internal carotid artery
to AP window
• Superior parathyroid
glands within 1 cm of
RLN piercing
cricothyroid membrane
 Biologic Effects of PTH

• To regulate ionized [Ca2+] levels by concerted

effects on three principal target organs: bone,
intestinal mucosa, and kidney

• Other hormones related to Calcium : Vitamin D,

Calcitonin

• Inhibits the reabsorption of phosphate in the

renal proximal tubule
 Hyperparathyrodism

• Usually asymptomatic
• Fatigue and weakness
• Bone and joint pain (fracture of long bone),
stones and hematuria(reflect decreased bone
density & nephrolithiasis)
• Osteitis fibrosa cystica (Brown tumor) and
nephrocalcinosis rare
 Etiology of hyperparathyrodism
Primary hyperPTH (most common)
Parathyroid adenoma (85%), Frank
Parathyroid hyperplasia (15%) hypercalcemia
Parathyroid carcinoma (< 1%)

Secondary HyperPTH
Usually renal failure

Tertiary HyperPTH
Chronic Renal Failure; low or normal Ca
 HYPERCALCEMIA

Hypercalcemia

 total serum calcium >

10.5 mg/dl ( >2.5 m mol/L))
or ionized serum calcium
> 5.6 mg/dl ( >1.4 m
mol/L )

Normal serum calcium levels are 8 to

10 mg/dl
 GRADING OF
HYPERCALCEMIA
 Clinical manifestation of
hypercalcemia
• Hyperpolarization of cell membranes

• Ca 10.5 – 11.9 mg /dl can be asymptomatic

• Ca > 12 mg/dl  multisystem manifestations :

Renal : polyuria , nephrolithiasis
GI : anorexia , nausea , vomiting , constipation , pancreatitis
Neuro - psychiatric : weakness , fatigue , confussion, psychosis,
stupor , coma
Cardiovascular : Shortened QT interval on ECG, bradyarrhythmias
and heart block and cardiac arrest
• Cornea : band keratopathy
PATHOPHYSIOLOGY
 Diagnosis of Hyper-PTH
• Elevated serum Ca 3 X
• Elevated PTH
• Other :
– Albumin
– Alkaline Phosphatase
– Phosphorous
– BUN/Cr
– 24-hour urine Ca
– Bone Mineral Density
 Medical Management
Severe Hypercalcemia
– Saline-furosemide  diuresis
– Bisphosphonates (onset of action 24-
48h)
– Calcitonin (immediate onset)
– Hemodialysis
 Surgical Management
NIH Guidelines (2002)
• Serum calcium is greater than 1 mg/dL above the upper
limits of normal
• Previous episode of life-threatening hypercalcemia
• Creatinine clearance is reduced below 70% of normal;
• Kidney stone is present
• Urinary calcium is markedly elevated (> 400 mg/24 h);
• BMD at the lumbar spine, hip, or distal radius is
substantially reduced (> 2.5 SD below peak bone mass;
T score < –2.5)
• < 50 years of age
• Long-term medical surveillance is not desired or
possible
 Surgical Management
• Adenoma
• Unilateral vs. Bilateral Exploration
• rPTH vs. Frozen Section
• Hyperplasia/Multiple adenomata
• Subtotal – less hypocalcemia
• Subtotal w/ autotransplantation – MEN,
Renal Failure
• Total w/ Cryopreservation – up to 1 year
HYPOPARATHYRODISM
 Hypoparathyrodism
Etiology Neonatal
Iatrogenic • 2º to maternal
hyperparathyroidism
• Neck irradiation
• Surgically induced Autoimmune Genetic or
Infiltrative Diseases developmental disorders
• Hemachromatosis • DiGeorge Syndrome
• Sarcoidosis • Calcium sensor mutation
• Thalassemia
• Wilson's disease
• Amyloidosis
• Metastatic carcinoma
 Sign and Symptoms of
Hypocalcemia
• Neuro : Paresthesias, fasciculations, muscle
spasm, tetany, irritability, movement
disorder, seizzure, psychosis
• Visual : cataracts, optic neuritis,
papilledema
• Pulmonary : bronchospasm
• CV : prolonged QT, CHF, Hypotension
• GI : dysphagia, abdominal pain, biliary colic
 Signs of hypocalcaemia
Chvostek’s sign:
Tap facial nerve  twitching of
facial muscles

Trousseau’s sign:
Inflate arm cuff > diastolic BP 3
minutes
carpopedal spasm
• Flexion at Wrist
• Flexion at MCP joints
• Flexion of thumb against palm
• Extension of PIP joints and DIP
joints
• Adduction of fingers (forms a
cone)
 Treatment of hypocalcemia
due to HypoPTH

Calcium gluconate in saline

Vitamin D
Calcium
Calcitriol
Thiazide
 Osteoporosis
Osteoporosis is a disease characterized by low bone
mass and microarchitectural deterioration of bone tissue,
leading to
Enhanced bone fragility
Increase in fracture risk

1 in 2 white and Asian postmenopausal ♀ and at least 1 in 8

older ♂ and ♀ of other racial are likely to have an
osteoporotic fracture at some time during their lifetime.

World Health Organization issued diagnostic criteria for

postmenopausal women based on measurements of bone
mineral density (BMD) or bone mineral content.
Osteoporosis

• Clinical manifestations are vertebral and

hip fractures, although fractures can
occur at any skeletal site  no pain

• Osteoporosis is defined as a BMD T

score of –2.5 standard deviations below
the young adult mean value
 Epidemiology
Osteoporosis  health problem especially
postmenopausal women
Osteoporosis affects >10 million
individuals in the US, but only a small
proportion are diagnosed and treated

Increased hip fractur in Asia  global

issue  health care, social and economic
problems.
Claus Christiansen, Am J Med 1993 dan WHO 1998
 Osteoporosis
• Primary Osteoporosis
• Osteoporosis tipe 1  ♀
• Osteoporosis tipe 2  ♂
• Osteoporosis Juvenile
• Osteoporosis Adulthood
• Secondary Osteoporosis
 Fracture of Osteoprosis

Vertebrae
Distal Radius
Collum femoris
 Risk Factor
Non-Modifiable : Modifiable :
History OP in 1st degree Smoking
relative Low Body Weight
History of fracture in adult Early menopause
Sex Alcoholism
Advanced age Low Ca intake
Race Inadequate physical
activity
Disease n drugs
 PATHOGENESIS OF OSTEOPOROSIS FRACTURES

Heredity
Aging
Inadequate
Peak bone
mass Low bone
density
Menopause
Fractures
Increased
Local Bone loss
Factors
Trauma

Sporadic
factors
 Diagnostic

• X-ray exam  > 40% bone loss

• Bone mineral density  DEXA - Dual
Energy X-ray Absorptiometry (gold stardard)
• Biochemical exam.
blood : calsium, PTH, osteocalcin
urine : urine calcium, NTx (N-telopeptide)
Bone loss typically seen in X ray exam if bone density less then
40% or more
USG as diagnostic tool for OP
 Dual Energy X-ray Absorptiometry (DEXA)
10
 CLASSIFICATION OF
BONE MINERAL DENSITY LEVELS

DESCRIPTIONS MEANING
Normal BMD BMD above – 1 SD from the
young normal mean

Low BMD or osteopenia BMD between - 1 SD and –

2.5 SD

Osteoporosis BMD is reduced < – 2.5 SD

Severe or established BMD is reduced < – 2.5 SD

osteoporosis in the presence of fractures
WHO Technical Report Series. Geneva: WHO, 1994
 WHO SHOULD HAVE BMD MEASSURE?

The National Osteoporosis Foundation recommend BMD

measurements:
for postmenopausal women > 65 yrs,
those < 65 yrs should have one or more risk factors
of osteoporosis besides menopause

The International Society for Clinical Densitometry (ISCD)

recommed BMD measurement:
for postmenopausal women > 65 yrs, and men > 70 yr
those younger than postmenopausal women and men
< 50 y.o. with one or more risk factors
 Osteoporosis therapy

• Increase bone density

Sodium fluorida
Paratiroid hormone
Steroid anabolic
Calcium

• Inhibit bone resorption

Estrogen ( Primarin, Livial)
Calcitonin ( Miacalcic)
Bisphosphonate ( Risendronate, alendronate)
SERMs –Selective Estrogen Receptor Modulators (Raloxifen)
 Calcium
A G E (year) CALCIUM (mg)
< 0.5 400
0.5 – 1 600
1 – 10 800
11 – 24 1200 – 1500
25 – 49 1000
Menopause (with estrogen R/) < 65 1000
Menopause (without estrogen R/) < 65 1500
Pregnant or breast feeding 1200 – 1500
Women > 65 1500
How to prevent Osteoporosis
• Calcium supplement
• Stop smoking
• Stop alcohol
• Exercise ( osteoporosis
exercise)