Presentation of Asymptomatic Primary Hyperparathyroidism: Proceedings of the Third International Workshop

Abstract

1) Data on the extent and nature of cardiovascular involvement in those with mild disease are too limited to provide a complete picture. 2) Patients with mild PHPT have neuropsychological complaints. Although some symptoms may improve with surgery, available data remain inconsistent on their precise nature and reversibility. 3) Surgery leads to long-term gains in spine, hip, and radius bone mineral density (BMD). Because some patients have early disease progression and others lose BMD after 8-10 yr, regular monitoring (serum calcium and three-site BMD) is essential in those followed without surgery. Patients may present with normocalcemic PHPT (normal serum calcium with elevated PTH concentrations; no secondary cause for hyperparathyroidism). Data on the incidence and natural history of this phenotype are limited. 4) In the absence of kidney stones, data do not support the use of marked hypercalciuria (>10 mmol/d or 400 mg/d) as an indication for surgery for patients. 5) Patients with bone density T-score -2.5 or less at the lumbar spine, hip, or distal one third radius should have surgery.

When is surgery indicated for asymptomatic primary hyperparathyroidism?

“…This review will focus on the most recent guidelines, published this year. 1,2,4,5 The past and current guidelines are summarized in Table 1. Surgery is recommended for patients who meet any of these guidelines.…”

“…Age <50 years continues to be a guideline for surgery, as evidence supports greater risk of complications in these patients over time. Silverberg et al 5 have demonstrated in longitudinal cohort studies that asymptomatic PHPT patients will exhibit stable serum calcium and parathyroid hormone levels for up to 12 years, and stable bone density for up to 8 years, after which time significant decrement in bone density begins to occur. Over 15 years, 60% of untreated asymptomatic patients will lose >10% of their bone density.…”

“…Urine calcium (over 24 hours) should still be initially assessed, to rule out familial hypocalciuric hypercalcemia, but it is no longer considered a risk factor for the ultimate development of kidney stones, or an accurate reflection of ''calcium load'' on the kidneys. 5 Renal function remains an important consideration, and has been included in the guidelines since 1990. Rather than adjusting renal function for age and gender, as prior guidelines had, the current guidelines now utilize an absolute threshold, beyond which surgery is supported.…”

“…Although data are not available limited to asymptomatic patients, surgery does decrease the risk of fracture in PHPT patients by 30% over 20 years. 5 There are two areas not currently included in the formal guidelines: neuropsychiatric and cardiovascular disease. There is emerging evidence that many patients with asymptomatic PHPT have some neurocognitive findings that, in some studies, appear to improve modestly after surgery.…”

Hiperparatireoidismo Primário - Diferentes Modalidades De Tratamentos

“…De acordo com os Guidelines para a paratireoidectomia em HPTP, metade dos pacientes apresentará um ou mais critérios para a cirurgia, mesmo que a maioria deles seja assintomática 8 . Os pacientes assintomáticos podem apresentar normocalcemia, porém, a realização precoce da cirurgia nesses casos promove benefícios na DMO 9 . O tratamento clínico é feito com bisfosfonatos, terapia de reposição hormonal (TRH), raloxifeno ou agentes calcimiméticos.…”