Transcript Tertiary Hyperparathyroidism by Ma. Melmar Anicoche 4-29

MAKATI MEDICAL CENTER
DEPARTMENT OF MEDICINE
MEDICAL GRANDROUNDS
Ma. Melmar S. Anicoche, M.D.
April 29, 2010
Objectives
1.
To discuss the effect of Chronic Kidney Disease
(CKD) on calcium-phosphorus metabolism.
2.
To discuss biochemical complications after
parathyroidectomy.
Patient Profile
L.G. , 61/F, from Binan, Laguna
DOA: February 12, 2010
Chief complaint: Persistently elevated PTH
History of Present Illness
Patient is a diagnosed case of End stage Renal Disease since
2000, on hemodialysis since 2001, three times a week.
 2 years PTA
 Bone pains, weakness,
intermittent abdominal pain
 iPTH: 914.218 (15-65pg/ml)
 Normal calcium, elevated
phosphorus
 Impression: tertiary
hyperparathyroidism
 iPTH: 1,528 pg/ml
 1 year PTA
Admission
 Review of Systems: (-) weight loss, headache, fever,
vomiting, chest pain, bowel movement irregularities
 Past Medical History:
 s/p Bilateral Ureterolithotomy – 1995
 s/p Nephrectomy,left – 1998
 s/p ESWL, right – 2000
 s/p CVA – 2000 & 2007
 Family History:
 (+) Urolithiasis – parents & siblings
 Personal & Social History:
 Nonsmoker
 Nonalcoholic beverage drinker
 BP: 140/70 CR 74 bpm, regular RR 20 cpm T 36.5°C
 Warm moist skin, no active dermatoses
 Pink palpebral conjunctivae, anicteric sclerae
 Supple neck, no palpable lymph nodes, thyroid not enlarged, no masses
 Symmetric chest expansion, no retractions, clear breath sounds
 ,AB at 5th LICS MCL, S1 louder than S2 at the apex, S2 louder than S1 at
the base, no murmurs
 Flabby abdomen (+) 9cm incisional scar on left lower quadrant, (+) 6 cm
incisional scar on right lower quadrant, NABS, soft, nontender, no
organomegaly
 Full and equal pulses, No cyanosis & edema of extremities
 MMT: 5/5 on left lower extremity & both upper & lower extremities,

3/5 left upper extremity; slight limitation of motion on all extremities
Salient Features
61/F
Known case of End Stage Renal Disease
for 10 years, on hemodialysis
Bone pains, weakness and abdominal
pain
Elevated iPTH & phosphorus, normal
calcium
Impression: Tertiary Hyperparathyroidism
Feedback Mechanisms Restoring Calcium Levels to Normal
Reduced GFR
Reduced action of 1,25 (OH) 2D
Vitamin D resistant state
Phosphate retention
Normal or low blood
levels of 1,25 (OH) 2D
Increased need for Vitamin D
Relative or absolute deficiency
of 1,25 (OH) 2D3
Decreased
expression of VDR
in parathyroid
Decreased
intestinal absorption
of Ca
Skeletal
resistance
to PTH
action
Interference with
production of 1,25 (OH) 2D
by kidneys
Decreased
expression of
Ca-sensing
receptor in
parathyroid
Hypocalcemia
Secondary
Hyperparathyroidism
Rickets or
osteomalaci
a
Bone resorption
(Osteitis fibrosa
cystica)
K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease
in Chronic Kidney Disease
Frequency of Measurement of iPTH, Ca & Phos
CKD Stage
GFR Range
iPTH
Ca & Phos
3
30 – 59
Every 12
months
Every 12
months
4
15 – 29
Every 3
months
Every 3
months
5
<15 or
dialysis
Every 3
months
Every month
K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in
Chronic Kidney Disease
Target Range of iPTH, Ca & Phos
CKD Stage
iPTH
(pg/ml)
Ca (mg/dl)
Phos
(mg/dl)
3
35 – 70
8.6 – 10.2
2.7 – 4.6
4
70 – 110
8.6 – 10.2
2.7 – 4.6
5
150 - 300
8.4 – 9.5
3.5 – 5.5
K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in
Chronic Kidney Disease
Outpatient Labs
12
10
8
6
Calcium
Phosphorus
Ja
n
ov
N
Se
pt
Ju
ly
M
ay
M
ar
Ja
n
4
2
0
12
1000
10
800
8
600
6
4
400
2
200
0
1st 2nd 3rd 4th 5th 6th
HD HD HD HD HD HD
Calcium
Phosphorus
PTH
Day of Surgery
12
10
8
Calcium
Potassium
6
4
2
0
0000H
1500H
2300H
Vitamin D
Patients on HD or PD with iPTH
>300pg/ml
Elevated corrected serum calcium and/or
phosphorus levels
Hyperparathyroidism
Characterized by excessive secretion of
PTH
Primary
Secondary
Tertiary
Symptoms are due to the hypercalcemia
itself
Treatment Options
Medical
Surgical
Phosphate Binders
phosphorus or iPTH levels not controlled
despite phosphorus restriction
Calcium-based
Noncalcium, nonaluminum, nonmagnesium
containing
Vitamin D
Patients on HD or PD with iPTH
>300pg/ml
Elevated corrected serum calcium and/or
phosphorus levels
Calcimimetic Drugs
 Activate the calcium-sensing receptor and inhibit
parathyroid cell function
 Results in reduction without normalization of PTH
levels
 Reduction & normalization of calcium
 Cinacalcet
Treatment Options (Surgical)
Subtotal or total parathyroidectomy, with
or without parathyroid tissue
autotransplantation
Ablation of parathyroid tissue by direct
injection of alcohol
Kidney transplantation
Parathyroidectomy in Patients with CKD
 persistent iPTH >800 pg/mL associated with
 hypercalcemia and/or
 hyperphosphatemia that are refractory to medical therapy
 iCa measured every 4 to 6 hours for the first 48 to 72
hours after surgery, and then twice daily until stable.
 Criteria for adequate excision
 50% drop in PTH from the baseline level to the 10-minute
postexcision level or
 50% drop in PTH from the preexcision level at 10 minutes and a
postexcision level below the baseline level.
Surgical Complications after
Parathyroidectomy
Nerve damage
Bleeding
Infection
Biochemical Aberrations in a Dialysis
Patient Following Parathyroidectomy
Severe hypocalcemia
 hypophosphatemia
hyperkalemia.
Cruz, Dinna, et. Al.;American Journal of Kidney Disease, vol 29, No 5
(May) 1997; pp759 - 762
Hungry Bone Syndrome
Severe post-operative hypocalcemia
despite normal or elevated PTH
Occurs in patients who have developed
bone disease preoperatively due to a
chronic increase in bone resorption
induced by high PTH
Diagnosis of Hungry Bone Syndrome
Persistently low serum calcium following
parathyroidectomy
Low or low normal serum phosphate
Rising/raised serum alkaline phosphatase
Low urine calcium
Treatment
Elemental Calcium
Calcium gluconate
Calcium carbonate
Vitamin D
Can Pamidronate Prevent Hungry
Bone Syndrome After
parathyroidectomy?
Bisphosphonates may be beneficial in
preventing hungry bone syndrome by
reducing bone formation
Yuriy Gurevich, DO, and Leonid Poretsky, MD:Can
Pamidronate Prevent Hungry Bone Syndrome after
Parathyroidectomy, a case report
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Calcium
Phosphorus
Current Status of the Patient:
On Dialysis thrice a week
On maintenance medications
Still no match for kidney transplant
Thank You!