[Primary hyperparathyroidism: new concepts, new recommendations]

Today, primary hyperparathyroidism (PHPT) is frequently diagnosed at an asymptomatic stage. New international guidelines presented at the Endocrine Society congress update the management of this disease. Normocalcemic PHPT is part of the diagnostic spectrum of PHPT, its natural history is poorly known, and monitoring is proposed once secondary HPT has been eliminated. Bone involvement, classically predominant in cortical bone, also affects trabecular bone. Osteodensitometry is poorly effective at the vertebral level and new methods (trabecular bone score [TBS], vertebral fracture assessment [VFA]) should improve the assessment of the risk of fracture. The kidney is the most frequently symptomatic organ, and an imaging workup as well as urinary tests are recommended in all patients when searching for causes of lithiasis or nephrocalcinosis. More than 10% of PHPT cases are related to a germinal mutation: these patients should be identified to optimize their management and that of their relatives. Medical treatment is reserved for patients for whom surgery is not indicated or possible: cinacalcet is effective for calcemia, the bisphosphonates are effective for bone involvement. Vitamin D deficiency can be corrected as long as calcemia and creatinuria are monitored. Surgical treatment is recommended in case of pronounced hypercalcemia, bone or renal involvement, and age less than 50 years and in patients in whom monitoring is refused or impossible. Studies have shown that asymptomatic PHPT evolves little in monitored patients.