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  • • Autonomous, hyperplastic parathyroid glands in a patients with secondary hyperparathyroidism

    • Persistent hypercalcemia following normalization of renal function (usually with renal transplantation)

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Laboratory Findings

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  • • Elevated intact parathyroid hormone levels

    • Elevated serum calcium and phosphate levels

    • Elevated alkaline phosphatase levels

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  • • Consider malignancy in appropriate clinical settings

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  • • Measure serum calcium and intact parathyroid hormone

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Surgery

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  • • Surgical therapy is withheld until all medical approaches have been exhausted

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Indications

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  • • Hyperparathyroidism refractory to all medical therapies

    • Calcium-phosphate product greater than 70

    • Severe bone pain

    • Pruritus

    • Extensive soft-tissue calcification with tumoral calcinosis

    • Calciphylaxis

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Medications

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  • • Phosphate binders

    • Calcium supplementation

    • Vitamin D

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Treatment Monitoring

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  • • Serum calcium level

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Prognosis

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  • • Usually dramatic relief of symptoms once treated (medically or surgically)

    • Few patients continue to have bone pain due to osteomalacia

    • Few patients can have profound hypoparathyroidism because of remineralization of bones ("hungry bones") and because of decreased parathyroid hormone secretion

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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, Zielke A, Rothmund M: Medical and surgical treatment for secondary and tertiary hyperparathyroidism. Scand J Surg 2004;93:288.  [PubMed: 15658670]
Triponez F et al: Less-than-subtotal parathyroidectomy increases the risk of persistent/recurrent hyperparathyroidism after parathyroidectomy in tertiary hyperparathyroidism after renal transplantation. Surgery 2006;140:990.  [PubMed: 17188148]

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