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Family Medicine  (Expert Forum)
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Hyperparathyroidism (?), lab concerns, trying to decide about surgery
Answered by
Kevin Pho, MD - Internal Medicine
Kevin Pho, MD Boston - MA
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MedHelp Member's Question

Hyperparathyroidism (?), lab concerns, trying to decide about surgery

by Mike-87, Feb 10, 2006 12:00AM
I have been diagnosed with primary hyperparathyroidism based on lab work-ups from last year and have been monitoring my condition.  Here is a summary of my labs.  Concerns with a couple questions follow.



8/01 Ca=10.0 mg/dL

1/05 Ca=11.1

6/05 Ca=11.2

8/05 Ca=10.7, PTH=94 pg/mL

10/05 Ca=10.4, PTH=58, 24-Hr Urine Ca=598.0 mg/24-Hr

11/05 Ca=10.8

12/05 Ca=10.3 & another at 10.4

1/06 Ca=10.8, PTH=48, 24-Hr Urine Ca=675.7, 24-Hr Urine Creatinine=2.1 g/24-Hr



Concerns/Questions:

1 – I am trying to make a decision with regards to having a parathyroidectomy but have concerns since my PTH was normal again this week.  Could there have been lab error?

2 – I am concerned about the amount of calcium washing through my kidneys.  This seems to be increasig.  How long do I have before I have kidney problems?

3 – Recommendations?  I see my Endo again next Monday.



Thanks!

Doctor's Answer

by Kevin Pho, MD, Feb 11, 2006 12:00AM
To answer your questions:

1) About 80 percent of those with hyperparathyroidism have a high PTH.  The other 20 percent have PTH's in the normal range that are "inappropriately" high.  Thus, a normal PTH level does not rule out hyperparathyroidism.



2) A serum creatinine can be obtained, and a GFR (glomerular filtration rate) calculated.  These values can evaluate the kidney function.



3) The diagnosis of hyperparathyroidism is made via biochemical testing.  You can obtaing vitamin D metabolites to further confirm the diagnosis.  



There are some surgeons that attempt imaging studies prior to surgery.  However, this is not very reliable - with only 40 to 80 percent obtaining positive results.  MRI, ultrasound or a nuclear scan can all be considered.



These options can be discussed with your personal physician.



Followup with your personal physician is essential.



This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.



Kevin, M.D.

kevinmd_b
Member Comments (2)

by Mike-87, Feb 11, 2006 12:00AM
Dr. Kevin,



Thank you for your response and clarification with regards to a PTH level that is in the normal range but “inappropriately” high.  I have familiarized myself with the following criteria regarding parathyroid surgery.



- Serum Ca 1.0 mg/dL > upper limit (mine 10.8)

- 24-Hr urine Ca > 400mg (mine 675.7) !!!

- 30% reduction in creatinine clearance (please help w/this per below) ???

- Bone mineral density T-score < -2.5 at any site (my DXA scan is normal)

- Age < 50 years (I’m 41)



My GFR:

- This has me very confused, please help!

- Mine seems a bit high but stable, agree?

- Should I be concerned?



Weight 188 lbs, Age 41, Height 5’8”, white male



Serum Creatinine’s (fasting):

8/01 – 1.2 mg/dL

1/05 – 1.2

6/05 – 1.2

11/05 – 1.3

12/05 – 1.4 & 1.2



From DaVita (http://www.davita.com/gfr_calculator/)

- No weight input ???

- 71 mL/min > Stage 2 ???



From Cockcroft-Gault Calc (http://www.nephron.com/cgi-bin/CGSI.cgi)

- With age & weight input

- 96.9 mL/min > reduced or no ???



Finally, given the above condition of my kidneys, to what degree should I be concerned about my 24-Hr urinary calcium being so high?



Thanks again,

Mike



PS - I am new to medhelp.org.  Should I be paying again for these add on questions?

by Cherri JS, Aug 09, 2007 04:53PM
Hello,

Since I am new to the forum I may be posting in the wrong place.  : )

In 2002 I was diagnosed with pituitary Cushing's and subsequent surgery showed indeed I had an ACTH producing pituitary tumor.  I have been told I no longer have Cushing's.  

For 7 months post op I felt great.  Then I began having trouble with fatigue, increased blood pressure (140/100), tachycardia, low grade fevers, aches and pains, extreme foot pain, restless legs, headaches, nausea, constant throat clearing, a feeling of fullness in my neck, trouble swallowing, choke easily, itchy skin, dry brittle nails, metallic taste in mouth, severe heartburn, frequent large ovarian cysts, abdominal pain, and the 40 pounds I lost post op all came back and then I lost 17 pounds in a month, and I had a couple of ulcers.  

About 6 months ago I was hospitalized with extreme flank pain and it was discovered that I had a huge kidney stone.  I had lithotripsy surgery the next morning and it took over a week to pass all the stone fragments.  The pathology showed that the stone was 100% uric acid.  Urine tests showed elevated uric acid and calcium and the urologist told me I could easily get either uric acid or calcium stones with those levels.  I was put on potassium citrate to help keep me from producing uric acid stones.  However, three months later I was found to have several small stones and calcification in the left kidney.  I was then sent to an endocrinologist.  

My endocrinologist told me he suspected adrenal insufficiency, hyperparathyroidism and M.E.N. based on my family history.  He ran a PTH test, vitamin D, urine calcium, phosphorous, magnesium, c-reactive protein, DHEAs, aldosterone, c-peptide, blood calcium, chloride, estradiol, and creatinine blood.  The results:

PTH:  61 (normal range 12 - 65)
Vitamin D:  14.9 (normal 32 - 100)
urine calcium: 280.3 (normal 8.5 - 277)
phosphorous: 3.8 (normal 2.5 - 5.5)
magnesium blood: 1.8 (normal 1.8 - 2.4)
c-reactive protein: 5.9 (normal 0 - 4.9)
DHEAs: 43 (normal 45 - 270)
aldosterone: 5.4 (normal 7 - 30)
c-peptide: 12.0 (normal 0.4 - 2.1)
calcium blood:  5.4 (normal 4.5 - 5.6)
chloride: 108 (normal 95 - 105)
estradiol: 6.5 (normal 7 - 30)
creatinine blood:  0.6 (normal 0.7 - 1.5)

From the results I was told I was adrenal insufficient and that I needed vitamin D supplementation.  I was put on 1,000 IUs of Vitamin D3.  Several months later I was re-tested and my blood calcium level had dropped to the low end of the normal range.  I was then put on calcium supplementation and my vitamin D was retested.  My vitamin