Hyperparathyroidism with hypercalcaemia in chronic kidney disease: primary or tertiary?

Area of Science:

• Nephrology
• Endocrinology
• Surgical Pathology

Background:

• Advanced chronic kidney disease (CKD) complicates the diagnosis of hyperparathyroidism (HPT).
• Secondary and tertiary HPT are common in CKD, but primary HPT can also occur.
• Severe hypercalcemia and markedly elevated parathyroid hormone (PTH) levels pose diagnostic challenges.

Purpose of the Study:

• To highlight diagnostic challenges of hyperparathyroidism (HPT) in patients with advanced chronic kidney disease (CKD).
• To discuss the pathophysiology, etiologies, and literature relevant to HPT in CKD.
• To propose an appropriate diagnostic approach for CKD patients with HPT and hypercalcemia.

Main Methods:

• Case report of a middle-aged Filipino male with CKD.
• Presentation included intractable nausea, vomiting, severe refractory hypercalcemia, and PTH > 2400 pg/mL.
• Literature review on HPT in CKD and diagnostic strategies.

Main Results:

• Confirmed diagnosis of a large parathyroid adenoma.
• Successful resolution of HPT and hypercalcemia following surgical resection.
• Patient experienced acute-on-chronic kidney injury and severe hypercalcemia requiring hemodialysis.

Conclusions:

• Primary HPT can present with extreme severity in CKD patients.
• Prompt diagnosis and surgical intervention are crucial for managing severe hypercalcemia and HPT in CKD.
• This case underscores the importance of considering primary HPT in CKD patients with markedly elevated PTH and hypercalcemia.