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  • • Induced abnormality of endogenous mechanisms that ensure calcium homeostasis

    • Increased parathyroid hormone (PTH) secretion in response to low plasma concentration of ionized calcium

    • Can see a hyperplasia of parathyroid chief cells

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Epidemiology

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  • • Secondary hyperparathyroidism develops in 1-28% of patients who undergo dialysis

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Symptoms and Signs

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  • • Similar symptoms to primary hyperparathyroidism

    • Complaints of significant bone pain

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Laboratory Findings

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  • • Elevated intact PTH level

    • Low or normal serum calcium level

    • Elevated serum phosphorous level (when results from renal disease)

    • Normal or low serum phosphorous level (when results from malabsorption or rickets)

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Imaging Findings

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  • • Similar (or more severe) skeletal changes as seen with primary hyperparathyroidism

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  • • In patients with secondary hyperparathyroidism, a higher serum calcium concentration is needed to suppress PTH secretion

    • Associated with renal disease as well as malabsorption syndromes

    • Almost universal complication of hemodialysis and peritoneal dialysis

    • When associated with renal disease, often due to phosphate retention, failure of kidneys to generate 1,25 dihydroxyvitamin D, resistance of bones to PTH action, and decreased serum calcium concentration

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  • • Measure serum intact PTH level

    • Measure serum calcium and phosphorous level

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  • • Goal is to decrease stimulation of the parathyroid gland by limiting serum hyperphosphatemia and supplementing both calcium and vitamin D

    • Will often resolve after correction of renal function (ie, with renal transplantation)

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Surgery

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  • • Subtotal parathyroidectomy or total parathyroidectomy with parathyroid autograft

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Indications

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  • • Hypercalcemia

    • Normocalcemia with severe renal osteodystrophy, bone pain, elevated alkaline phosphatase, bone fracture, torn tendon, pruritus, soft-tissue calcification, calciphylaxis, enlarged parathyroid gland

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Medications

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  • • PO or IV calcitriol

    • Adjusting calcium and phosphorous concentration in dialysate solutions

    • Limiting phosphorous intake

    • Phosphate binders

    • Nonhypercalcemic vitamin D derivative and calcimimetics are being developed

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Treatment Monitoring

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  • • Serum calcium and intact PTH levels

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Complications

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  • • Profound hypocalcemia following subtotal parathyroidectomy for renal osteodystrophy, both because of "hungry bones" and because of decreased PTH secretion

    • Mortality is < 1% for parathyroidectomy in patients with secondary hyperparathyroidism despite significant comorbidities

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Prognosis

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  • • 1-10% of patients who undergo successful kidney grafting have persistent secondary hyperparathyroidism and hypercalcemia

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Prevention

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  • • Should start early in the course of chronic renal failure when intact PTH is normal or only slightly elevated

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References

Pasieka JL, Parsons LL: A prospective surgical outcome study assessing the impact of parathyroidectomy on symptoms in patients with secondary and tertiary hyperparathyroidism. Surgery 2000;128:531.  [PubMed: 11015085]
Savio RM et al: Parathyroidectomy for tertiary hyperparathyroidism associated with X-linked dominant hypophosphatemic rickets. Arch Surg 2004;139:218.  [PubMed: 14769584]
Schlosser K, ...

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