Synopsis
Distinguish autonomous and compensatory PTH excess using calcium-phosphate-renal physiology, then choose surgery, renal management or surveillance appropriately.
- Primary hyperparathyroidism is autonomous PTH secretion, usually with hypercalcaemia and low or low-normal phosphate, from a single adenoma more often than multi-gland disease.
- Secondary hyperparathyroidism is an appropriate compensatory response to hypocalcaemic stimuli such as CKD, vitamin D deficiency, malabsorption or low calcium intake.
- Tertiary hyperparathyroidism is autonomous secretion after prolonged secondary stimulation, classically in advanced CKD or after transplantation, and usually produces hypercalcaemia.
- PTH is interpreted against simultaneous calcium, phosphate, eGFR, vitamin D and the longitudinal trend; an isolated concentration cannot name the subtype.
- Exclude familial hypocalciuric hypercalcaemia before primary parathyroid surgery when the phenotype or urinary calcium suggests it, because surgery does not correct FHH.
- NICE recommends surgical referral for primary disease with hypercalcaemic symptoms, renal or skeletal end-organ disease, or adjusted calcium at least 2.85 mmol/L, while individual factors still matter.
- Neck ultrasound and sestamibi imaging localise abnormal glands after a surgical decision; negative imaging does not disprove biochemical primary disease.
- CKD-mineral bone disorder is managed from serial phosphate, calcium and PTH patterns with renal specialists; indiscriminate PTH normalisation can cause adynamic bone disease.
Investigation priorities
Establish whether PTH response is appropriate at the time of confirmed calcium disturbance.
Management branches
Repeated hypercalcaemia has a non-suppressed PTH without advanced CKD.
- Review medicines and family history, correct relevant vitamin D deficiency carefully, and assess urinary calcium before labelling sporadic primary disease.
- Measure renal function, renal stone burden and DXA including the forearm, documenting symptoms and pregnancy or hereditary considerations.
- Refer for parathyroid surgery using NICE indications and patient preference; use localisation imaging only after surgery is being pursued.
Key medicines
CinacalcetInitiate and titrate through the relevant endocrine or renal specialist protocol according to the licensed indication, calcium, PTH response and tolerability; NICE commissioning criteria apply in refractory dialysis-associated secondary disease.Hypocalcaemia, nausea and vomiting are common concerns. Check calcium soon after initiation or dose changes, review interactions, and do not allow biochemical improvement to replace surgery when a curative operation is appropriate.
Activated vitamin D analogueUse alfacalcidol or calcitriol only within the renal or hypoparathyroid protocol, titrating small regimen changes against calcium, phosphate and PTH after native vitamin D deficiency has been addressed where appropriate.Hypercalcaemia and hyperphosphataemia promote vascular and soft-tissue calcification. Do not prescribe as interchangeable with nutritional colecalciferol, and monitor frequently during titration.