Article Text

  1. A. Sequeira,
  2. P. Patel,
  3. J. Laborde,
  4. B. Leblanc,
  5. M. Carter,
  6. N. Alexander,
  7. J. Blondin
  1. Louisiana State University and Health Sciences Center, Shreveport, LA


Introduction End-stage renal disease (ESRD) patients have hyperplastic hyperparathyroid glands. We present a case where administration of calcimimetics unmasked underlying autonomous parathyroids.

Case A 43 yo male with ESRD on hemodialysis for 15 years, s/p transplant, was admitted for evaluation of symptomatic hypercalcemia. Over the last 10 months, his biointact parathyroid hormone levels (biPTH) ranged between 500 and 600 (80-160 pg/mL). Five months prior to admission, he had been started on cinacalcet and paricalcitol. Since then, his calcium and phosphorus ranged between 9.9 and 11.9 and 5.3 and 7.7 mg/dL, respectively, with elevated biPTH. Labs on admission (post hemodialysis) were Ca 14.8 mg/dL, phos 5.8 mg/dL, alk phos 96 U/L, and albumin 3.1 mg/dL. With a possibility of drug-induced hypercalcemia the above-mentioned medications and calcium acetate were stopped. Other data obtained were intact PTH 451 (iPTH 8-74 pg/mL), PTHrP < 2.5 (< 1.4 pmol/L), 1, 25 vit D 84.6 (15.9-55.6 pg/mL), 25 vit D 7 (8.9-4.7 ng/mL), a normal serum immunoelectrophoresis, and a negative PPD. A chest CT and abdominal ultrasound were unremarkable. A bone scan revealed increased uptake in the skull. He was started on parenteral calcitonin and dialyzed regularly over the next several days. However, his calcium remained between 14 and16 mg/dL. His 1, 25 vit D level dropped to < 5. At parathyroidectomy, a 600 mg right lower lobe adenoma was removed. The remaining parathyroid glands appeared normal. The iPTH failed to normalize. A sestamibi scan revealed the presence of an accessory gland along the left sternocleidomastoid. A 1.58 g adenoma was resected from within the muscle. His iPTH immediately decreased to 29 pg/mL.

Discussion Vitamin D analogues and cinacalcet have been approved for the management of hyperparathyroidism in ESRD. The persistence of an elevated PTH, in spite of calcimimetics, should raise suspicion of an autonomous change. A fifth parathyroid gland is present in 3-5% of the population. This should always be suspected when PTH fails to fall in spite of removal of an adenoma or in the presence of normal-sized glands.

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