TERITARY HYPERPARATHYROIDISM IN STAGE III CHRONIC KIDNEY DISEASE: THE NEED FOR PARATHYROIDECTOMY
LAUREN HEATH1, AUDREY BROOME1, JACINTA WONG1, AKSHAY ATHAVALE1,2,3
1Department of Renal Medicine, Gosford Hospital, 2Faculty of Medicine, Health and Human Sciences, Macquarie University, 3School of Medicine and Public Health, University of Newcastle
Background: Chronic kidney disease (CKD) related hyperparathyroidism is seen in patients with progressive CKD. Over-secretion of parathyroid hormone (PTH) may be triggered by hyperphophataemia, reduced calcitriol and hypocalcaemia. Prolonged hyperparathyroidism causes nodular hyperplasia of the parathyroid glands and autonomous PTH secretion, termed tertiary hyperparathyroidism.
Case Report: An 86-year-old female with a history of hyperparathyroidism was referred for management of stage III CKD.
Investigations demonstrated serum creatinine (sCr) 110 umol/L, estimated glomerular filtration rate (eGFR) 40mL/min, corrected calcium 2.67 mmol/L, phosphate 1.19 mmol/L, PTH 33.7 pmol/L and 25-hydroxy-vitamin-D 100 nmol/L. Parathyroid four-dimensional computed tomography demonstrated enlargement of the right inferior gland.
After three months, the patient presented with widespread rash related to hyperparathyroidism. Investigations demonstrated creatinine 90 umol/L, eGFR 50 mL/min, corrected calcium 2.49 mmol/L and PTH 61.2 pmol/L. Corrected calcium peaked at 2.95 mmol/L with PTH 21.3 pmol/L and treatment with denosumab was implemented.
Three gland surgical parathyroidectomy demonstrated enlargement of the right upper, lower, and left lower glands. The remaining gland was normal and not resected. Histopathology demonstrated nodular hyperplasia with asymmetric enlargement. The right inferior gland measured 27x24x8 mm and weighed 2.018 g. Following surgery, PTH reduced to 15.2 pmol/L with corrected calcium 2.28 mmol/L.
Conclusion: We present an unusual case of tertiary hyperparathyroidism in a patient with stage III chronic kidney disease. Clinicians should be aware of severe parathyroid dysfunction with mild-moderate chronic kidney disease.
Biography:
Dr Lauren Heath is a third year nephrology advanced trainee based in Sydney. She is interested in chronic kidney disease, renal physiology and decision-making in end stage kidney disease.