Endocrine Abstracts

Tertiary hyperparathyroidism reflects parathyroid hyperplasia, with autonomous secretion of parathyroid hormone (PTH), in spite of high plasma calcium concentration. Parathyroidectomy is an efficient therapy for stabilization of calcium and PTH metabolism in patients with end-stage kidney disease.

We report a case of a 68-year old man with end-stage kidney disease under hemodialysis for nine years, due to long-standing uncontrolled hypertension. He presented with high total plasma calcium levels (11.0 mg/dl) and high serum PTH (2638 pg/ml), regardless of therapy with cinacalcet. Parathyroid scintigraphy revealed a hyperfunctioning lower right parathyroid. Cervical CT-scan was consistent with enlargement of both right and left inferior parathyroid glands. Patient underwent successful subtotal parathyroidectomy, with reduction in intra-operative PTH from 2996 pg/ml to 364 pg/ml. After surgery plasma calcium levels fell to 7.1 mg/dl, but remained stable afterwards under supplementation with calcium carbonate and calcitriol.

Refractory hyperparathyroidism in patients with end-stage kidney disease is associated with bone and joint pain and/or fractures, muscle weakness, extraskeletal calcification and calciphylaxis. Parathyroidectomy ameliorates symptoms and stabilizes calcium and phosphorus levels, as seen in this case.