Hyperparathyroidism, Tertiary

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

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

Laboratory Findings

• • Elevated intact parathyroid hormone levels

  • Elevated serum calcium and phosphate levels

  • Elevated alkaline phosphatase levels

• • Consider malignancy in appropriate clinical settings

• • Measure serum calcium and intact parathyroid hormone

Surgery

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

Indications

• • Hyperparathyroidism refractory to all medical therapies

  • Calcium-phosphate product greater than 70

  • Severe bone pain

  • Pruritus

  • Extensive soft-tissue calcification with tumoral calcinosis

  • Calciphylaxis

Medications

• • Phosphate binders

  • Calcium supplementation

  • Vitamin D

Treatment Monitoring

• • Serum calcium level

Prognosis

• • 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

References