Hyperparathyroidism in Emergency Medicine Follow-up

Updated: Oct 18, 2016
  • Author: Philip N Salen, MD; Chief Editor: Erik D Schraga, MD  more...
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Follow-up

Further Outpatient Care

Calcium levels must be periodically monitored for several months postparathyroidectomy.

If calcium levels begin to rise postoperatively, the patient needs to be evaluated for possible accessory parathyroid glands.

Monitor asymptomatic patients for worsening hypercalcemia, deteriorating bone density or renal function, and other complications of hyperparathyroidism.

If the serum calcium concentration falls below 8 mg/dL postparathyroidectomy with a concomitant rise in serum phosphate level, consider the possibility of postsurgical hypoparathyroidism.

Untreated mild hyperparathyroidism is not associated with rapid bone loss at any of the commonly measured skeletal sites: femur, forearm, and lumbar spine. Therefore, while periodic monitoring of bone mineral density in patients with primary hyperparathyroidism is recommended, doing so every 1–2 years is unnecessary since several years of follow-up are required for the decline in the average patient’s bone mineral density to surpass the smallest detectable change. [27]

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Further Inpatient Care

Admit patients with significant symptoms due to hyperparathyroid-induced hypercalcemia and substantial elevations of calcium levels.

Patients who are markedly symptomatic or those with significant electrolyte disturbances should be evaluated by endocrinologists and surgeons experienced in parathyroid removal.

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Deterrence/Prevention

Although patients should refrain from the ingestion of more calcium than is recommended for adults (1200-1500 mg/d), the calcium intake should not be excessively restricted (to < 750 mg/d) because calcium-poor diets may promote processes associated with excessive secretion of parathyroid hormone (PTH).

Because many patients with asymptomatic primary hyperparathyroidism have levels of 25-hydroxyvitamin D that are at the lower end of the reference range or frankly low, the addition of a low level of supplementation achievable with a multivitamin (400 IU of vitamin D daily) is advisable.

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Complications

Maternal hyperparathyroidism can lead to profound hypocalcemia and tetany, coma, and death in newborns in a syndrome known as neonatal severe hyperparathyroidism.

Nocturia and polyuria may result from the effects of elevated calcium levels on the renal tubule.

Approximately 20% of patients with hyperparathyroidism have nephrolithiasis.

CNS disturbances, coma, and death may result from markedly elevated serum calcium levels when left untreated.

Skeletal sequelae, osteoporosis or pathologic fractures, may occur.

Cardiovascular complications, such as heart failure, valvular or vascular calcifications, may occur.

Surgical complications include the following:

  • Hypoparathyroidism
  • Recurrent laryngeal nerve damage
  • Hemorrhage
  • Infection
  • Unsuccessful surgery
    • Persistent or recurrent disease occurs in a low percentage of individuals who undergo surgery for primary hyperparathyroidism. [26]
    • Persistent primary hyperparathyroidism is defined as the presence of elevated serum calcium levels and PTH levels documented within 6 months of the initial operation. The most common cause of persistent primary hyperparathyroidism is the presence of a missed parathyroid adenoma, which is usually in an ectopic location in this setting. Less commonly, persistent disease may be secondary to inadequate resection of unappreciated multigland disease. [26]
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Prognosis

The prognosis is excellent for patients after successful parathyroidectomy.

  • Asymptomatic patients who do not have indications for surgery have an excellent prognosis. Significant bone loss and other symptoms may be absent for years in subsequent follow-up visits.
  • The skeletal status of individuals with primary hyperparathyroidism plays an important role in management decisions. Surgical intervention is often recommended for patients with primary hyperparathyroidism and low bone mineral density, based on data from observational studies that demonstrate increases in bone mineral density after surgical treatment. [27]
  • The prognosis of secondary hyperparathyroidism is related to the underlying advanced chronic renal failure and resultant chronic hypocalcemia.
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Patient Education

Educate patients about prescribed medications. Educate patients regarding the importance of periodic laboratory and radiologic testing.

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