Secondary Hyperparathyroidism

  • The pathophysiology of secondary hyperparathyroidism:
    • Is multifactorial and can result from:
      • Phosphorous retention
      • Altered vitamin D metabolism and resistance
      • Altered metabolism of PTH
      • Impaired calcemic response to PTH
      • Possible genetic mutations
  • The condition most commonly occurs in patients:
    • With a history of chronic renal failure
  • Gastric bypass:
    • Has also been an increasingly recognized cause of altered vitamin D metabolism
  • Patients will commonly have:
    • An elevated PTH level and normal serum calcium:
      • In such a setting, vitamin D levels should be measured:
        • If low, treated for a minimum of 6 weeks with supplemental vitamin D
  • Secondary hyperparathyroidism:
    • Is most commonly managed medically with the use of:
      • Calcimimetic agents:
        • For example cinacalcet
      • Phosphate binders
      • Adequate calcium intake
      • Vitamin D replacement
  • Cinacalcet:
    • Works by binding the calcium-sensing receptors on the chief cells of the parathyroid gland:
      • Increasing its sensitivity to extracellular calcium
  • Surgical treatment is indicated in patients with:
    • Renal osteodystrophy
    • Calciphylaxis
    • Calcium phosphate product of ≥ 70
    • Soft tissue calcium deposition and tumoral calcinosis
    • Calcium level greater than 11 mg/dL with an inappropriately high level of PTH
  • Renal osteodystrophy:
    • Is a major issue in hemodialysis patients:
      • The aluminum present in the dialysate bath:
        • Accumulates in the bone:
          • Contributes to the development of osteomalacia
  • Osteitis fibrosa cystica:
    • A type of renal osteodystrophy:
      • Is characterized by marrow fibrosis and increased bone turnover
    • Bone cysts, osteopenia, and decreased bone strength develop
    • To halt the progression of this disease process:
      • These patients with secondary hyperparathyroidism are treated surgically
  • Calciphylaxis:
    • Is a rare vascular disorder:
      • In which calcium is deposited in the media of small- to medium-sized arteries
        • As a result, ischemic damage:
          • To the dermal and epidermal structures develops
    • The ulcerated lesions:
      • Are extremely painful and can become infected with subsequent sepsis, and eventually death
    • Patients with early signs of calciphylaxis:
      • Should undergo an urgent parathyroidectomy:
        • Although there is some evidence that aggressive management of serum calcium and parathyroid levels:
          • With cinacalcet may be beneficial
    • Care should be taken in wound care management:
      • Because aggressive debridement can lead to chronic nonhealing wounds:
        • Since wound healing is very poor in these patients
  • Uremic pruritus:
    • Is characterized by severe itching:
      • That is thought to result from increased deposition of calcium salt in the dermis:
        • Without the visible lesions of calciphylaxis
    • Parathyroidectomy:
      • Seems to alleviate these symptoms and halts progression to the more serious skin and vascular complications seen with calciphylaxis

#Arrangoiz #ParathyroidSurgeon #ParathyroidExpert #EndocrineSurgery #HeadandNeckSurgeon #MSMC #Miami #MountSinaiMedicalCenter #Mexico #Teacher #Surgeon

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