Normocalcaemic primary hyperparathyroidism: what is the role of parathyroid surgery?

Abstract

Primary hyperparathyroidism (PHPT) is classically associated with both an elevated or ‘inappropriately normal’ parathyroid hormone (PTH) level and raised serum calcium. However, in clinical practice, increasing numbers of patients present with raised PTH but normal serum calcium, renal function and vitamin D; this is known as normocalcaemic PHPT (nPHPT). Studies investigating the clinical presentation of this condition have shown that patients may present with hypertension, nephrolithiasis, impaired glucose tolerance, osteoporosis and fragility fractures. The prevalence of such complications in nPHPT is similar to that in classical hypercalcaemic PHPT (hPHPT). Although the National Institute for Health and Care Excellence (NICE) have developed guidelines for the management of PHPT generally, a consensus is yet to be reached on the optimal management of nPHPT specifically. A review of the literature on parathyroidectomy in the treatment of nPHPT revealed that nPHPT patients were more likely to present with multi-glandular disease and significantly less nPHPT patients had an intra-operative PTH fall of >50% compared with those with hPHPT. These findings demonstrate that patients with nPHPT are more likely to receive bilateral neck explorations and require remedial surgery compared with hPHPT patients. Following surgery, improvements in bone mineral density (BMD) and renal stones are generally observed in those with nPHPT. Where surgery is not possible, medical management with alendronate has been shown to be effective in nPHPT patients. Given the higher incidence of multi-gland disease and greater possibility of remedial surgery in nPHPT, careful consideration of risks and benefits should be made on an individualised basis and surgery should be performed by surgeons experienced in four gland exploration.

Perioperative changes of FGF23 in patients undergoing surgery for primary hyperparathyroidism

“…We could not determine the postoperative correlation between PTH and FGF23 because postoperative plasma PTH values were not measured. Current review showed that measuring of postoperative plasma PTH values could be supplied by the continuously monitored albumin-adjusted serum calcium followed with clinical investigations including symptoms of hypercalcemia and presence of end organ diseases (renal stones, fragility fractures and osteoporosis) ( 25 ). We could not evaluate the continuously monitored calcium/albumin levels due to the fact that we assayed plasma samples and postoperative serum calcium levels were retrieved from medical notes.…”

A Genetic Polymorphism in the WDR72 Gene is Associated With Calcium Nephrolithiasis in the Chinese Han Population

“…Presumably, reduction in serum PTH levels associated with rs12654812 may result from a decrease in serum phosphate levels caused by diminished renal reabsorption. Since patients with hyperparathyroidism are usually associated with impair glucose tolerance ( Aojula et al, 2021 ), that kidney stone variance may negatively correlated with serum glucose level through decreased serum PTH.…”

Primary hyperparathyroidism: Disease of diverse genetic, symptomatic, and biochemical phenotypes

“…Of note, neither the guidelines of the Fourth International Workshop 80 or the American Society of Endocrine Surgeons 5 mention that parathyroidectomy in patients with NCHPT improves BMD, cardiovascular risk factors, and quality of life, which has been shown by several recent studies. 57,[101][102][103][104] Parathyroid imaging studies are appropriate once it has been established that a patient has NcPHPT and surgery is considered. Unfortunately, there is limited data on the utility of imaging in patients with NcPHPT and the data available are conflicting.…”