Secondary/Tertiary Hyperparathyroidism

In patients with secondary/tertiary hyperparathyroidism, all parathyroid glands become enlarged and make too much parathyroid hormone. This causes several blood salt imbalances. The cause of this particular type of hyperparathyroidism is due to a disease process outside the parathyroid glands, but which influences the glands significantly. In secondary hyperparathyroidism (SHPT), the parathyroid secrets extra PTH in response to hypocalcemia (low calcium blood levels), vitamin D deficiency, and/or hyperphosphatemia (high blood phosphorus), often due to renal failure or dialysis. High PTH levels can lead to serious health conditions, such as:
  • Weakening of the bones 
  • Calciphylaxis (when calcium forms clumps in the skin and leads to ulcers and potentially death of surrounding tissue) 
  • Cardiovascular issues 
  • Abnormal fat and sugar metabolism 
  • Itching 
  • Anemia 
Tertiary hyperparathyroidism (THPT) develops when independent hypersecretion of PTH continues despite correcting the primary cause of secondary hyperparathyroidism.

Risk Factors

A risk factor is anything that increases a person's chance of getting a disease. Different diseases have different risk factors. Some risk factors can be controlled with lifestyle changes. Other risk factors cannot be changed.

Risk factors that contribute to secondary and tertiary hyperparathyroidism include medical or dietary conditions that cause low blood calcium levels, low vitamin D levels, or low phosphorous levels. These include: 
  • Kidney failure and kidney disease 
  • Not enough calcium in the diet 
  • Excess calcium loss in the urine 
  • Aluminum poisoning 
  • Certain types of cancer 
  • Malnutrition 
  • Malabsorption 
  • Vitamin D disorders
Having one or more of the above risk factors does not mean that you will develop hyperparathyroidism. Understanding your risk factors will help you determine, what, if any, precautions and special screening you should consider.

Symptoms

If you have secondary or tertiary hyperparathyroidism, you may experience a range of symptoms from mild to non-specific, or you may experience severe symptoms. 

Some of the signs of hyperparathyroidism include: 
  • Kidney stones 
  • Fragile bones that easily fracture (osteoporosis) 
  • Excessive urination 
  • Abdominal pain 
  • Tiring easily or weakness 
  • Depression or forgetfulness 
  • Bone and joint pain 
  • Frequent complaints of illness with no apparent cause 
  • Nausea, vomiting, or loss of appetite
Having one or more of the above symptoms does not mean that you have a form of hyperparathyroidism. If you think you have this condition, please call your doctor.

Secondary Hyperparathyroidism: When the parathyroid has to work to secrete more PTH in response to lower calcium levels, low vitamin D levels, and/or low phosphorous levels, the condition is known as secondary hyperparathyroidism. The most common cause of this form of hyperparathyroidism is kidney failure. The kidneys convert vitamin D into a form that the body can use. If the kidneys are not functioning properly, they cannot process vitamin D correctly, nor can they properly clear phosphorous levels from the blood, leading to lower calcium levels. Eventually, as the disease progresses, some of the treatments for kidney failure may lead to abnormally high levels of calcium in the blood.

Conditions that may lead to secondary hyperparathyroidism include:
  • Severe calcium deficiency caused by any number of factors, such as the digestive system not absorbing enough calcium. 
  • Severe vitamin D deficiency because vitamin D helps the body absorb calcium from food. When there is insufficient vitamin D, calcium levels drop and the parathyroid will respond by producing more PTH.
  • Long-term lithium therapy
  • Abnormally high blood magnesium levels
Tertiary Hyperparathyroidism: The most common cause of tertiary hyperparathyroidism is persistent low calcium levels after a kidney transplant. 

When the kidneys are in chronic failure, the body cannot eliminate toxins, which can lead to low vitamin D levels, low calcium levels, and low phosphorous levels. These lower levels stimulate the parathyroid glands to enlarge. In a small percentage of cases, the condition of hypersecretion of PTH continues after a kidney transplant. 

Treatment

Treatment for secondary and tertiary hyperparathyroidism may include monitoring, medical therapy, and surgery to remove affected parathyroid glands. This surgery is referred to as a parathyroidectomy. Most patients with secondary/tertiary hyperparathyroidism are not candidates for minimally invasive parathyroidectomy but require a standard parathyroidectomy. 

Minimally Invasive Parathyroidectomy (MIP) 
This surgery is performed as a treatment for primary hyperparathyroidism under local analgesia with sedation, with a small incision to remove the enlarged parathyroid gland(s). While removing the gland(s), the surgeon talks with the patient to ensure that the recurrent laryngeal nerve is not affected by the surgery. After removal of the affected gland(s), and while the patient is still under sedation, the surgeon performs a blood test to check the patient's parathyroid hormone level in the operating room. This blood test will allow the surgeon to confirm that all enlarged parathyroid glands have been removed before the patient leaves the operating room. Patients will recover in the hospital for 24 to 72 hours so that blood calcium levels can continue to be monitored. 

At Yale Endocrine Surgery, our multidisciplinary team is highly experienced in treating secondary and tertiary hyperparathyroidism. Before any procedure, our surgeons will answer all your questions and address all your concerns so that you feel comfortable with what to expect before, during, and after your surgery. 

Monitoring 
Initially, the course of action may be for your endocrinologist to watch your condition if: 
  • Your kidneys are functioning normally 
  • Your calcium levels are only slightly elevated 
  • Your bone density is normal or only slightly below normal 
  • You have no other symptoms that may improve with treatment
When monitoring hyperparathyroidism, blood levels are generally checked twice a year for calcium while other levels can be checked once a year. Medical Therapy Medical therapy may be helpful in some cases. Different medications are used to treat hyperparathyroidism depending on the symptoms of the condition and the possible causes. In these cases, the patient should work with their endocrinologist to determine the best course of treatment.

Medical Therapy
Medical therapy may be helpful in some cases. Different medications are used to treat hyperparathyroidism depending on the symptoms of the condition and the possible causes. In these cases, the patient should work with their endocrinologist to determine the best course of treatment.