Tertiary Hyperparathyroidism

Background

• Tertiary hyperparathyroidism occurs following treatment of chronic secondary hyperparathyroidism (hypersecretion of parathyroid hormone to maintain normal calcium), most commonly after renal transplantation for chronic kidney disease, but can develop after other rare causes of secondary hyperparathyroidism including rickets and oncogenic osteomalacia. The enlarged parathyroid continues to secrete excessive parathyroid hormone, elevating serum calcium levels.

Evaluation

• Patients may be asymptomatic with only biochemical or radiographic abnormalities. The combination of elevated parathyroid hormone and elevated serum calcium is the hallmark of the disease.
• Patients may also present with complications of tertiary hyperparathyroidism including nephrolithiasis, pancreatitis, soft tissue vascular calcification, and peptic ulcer disease.
• Measure parathyroid hormone, serum calcium, creatinine, albumin, phosphate, alkaline phosphatase, and vitamin D levels.
• Consider parathyroid imaging only if needed to guide reoperation planning required.

Management

• For patients with tertiary hyperparathyroidism after renal transplantation, consider waiting at least 1 year after transplantation to allow for metabolic imbalances to normalize before deciding to perform surgery (Weak recommendation).
• Perform bilateral neck exploration in all patients. Consider subtotal or total parathyroidectomy (with or without autotransplantation).
• Monitor for postoperative hypocalcemia and consider oral calcium carbonate (2-3 g) with or without calcitriol immediately following parathyroidectomy to prevent postoperative hypocalcemia.