Indications for parathyroidectomy in tertiary hyperparathyroidism include:
Bisphosphonates are generally not recommended in end-stage renal disease as they reduce bone turnover, leading to osteomalacia, mixed uremic osteodystrophy, and adynamic bone disease. They can also cause a worsening of hyperparathyroidism.
The evaluation of hypercalcemia depends on parathyroid hormone (PTH) levels. Hypercalcemia with an elevated or inappropriately normal PTH (PTH-dependent) is caused by very few disorders, mainly primary hyperparathyroidism (PHPT). Parathyroid adenoma causes nearly 90% of PHPT. Other etiologies include parathyroid hyperplasia and carcinoma. Parathyroidectomy is indicated for patients with PHPT who have:
Less common causes of PTH-dependent hypercalcemia include familial hypocalciuric hypercalcemia (FHH), lithium-induced hypercalcemia, tertiary hyperparathyroidism (in renal failure patients), and ectopic PTH production by malignant tumors (rare). FHH is a rare autosomal dominant disorder caused by an abnormal calcium-sensing receptor on the parathyroid cells. FHH can be differentiated from PHPT by measuring urinary calcium excretion, which is markedly low in FHH but normal to high in PHPT.