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Handbook of Parathyroid Diseases pp 215–227Cite as

Bone Density and Fracture Risk in Primary Hyperparathyroidism

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Abstract

Since the advent of autoanalyzers for biochemical screening in the 1970s, osteitis fibrosa cystica has become a rare finding, with about 80% of PHPT in Western countries now being identified through routine laboratory testing in patients without well-defined skeletal symptoms [1]. These patients most often have mild or sometimes intermittent hypercalcemia. It is important to distinguish between PHPT and familial hypocalciuric hypercalcemia (FHH). Patients with FHH typically have inappropriately normal PTH levels, although 10–20% have been reported to have absolute elevation of serum PTH [2]. FHH is associated with normal parathyroid glands, and does not require surgery or medical treatment. It is differentiated from PHPT by performing a 24-h measurement of urine calcium and creatinine and determining the ratio of the clearance of calcium to the clearance of creatinine. Data compiled from five studies showed that a ratio of less than 0.01 had a sensitivity of 85%, a specificity of 88%, and a positive predictive value of 85% to detect FHH; a ratio of greater than 0.02 essentially ruled out the possibility of FHH [3]. In the same review, about 12% of patients with PHPT had a ratio below 0.01 and 49% had a ratio above 0.02, with the remainder between the two values. The clinical utility of urinary calcium/creatinine clearance ratios is described in more detail in the chapter on diagnosis. This is an important differential diagnosis in order to avoid an unnecessary neck exploration. Some patients with normal serum calcium and inappropriately high PTH levels are being detected in the evaluation for factors contributing to osteoporosis. These patients have been classified as having “normocalcemic primary hyperparathyroidism,” a disorder associated with substantial skeletal involvement that may represent the earliest form of primary hyperthyroidism. In a longitudinal cohort study of 37 such patients (age 32–78, median 58 years; 95% female) followed for 1–8 years (median 3 years), 7 (19%) became hypercalcemic, all within the first 3 years of observation [4]. Three of the hypercalcemic patients had parathyroid surgery, with excision of a single parathyroid adenoma in two and excision of two hyperplastic glands in the third. Four normocalcemic patients also had surgery, with a single adenoma excised in one patient, a single hyperplastic gland excised in two others, and two hyperplastic glands removed from the fourth.

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Authors and Affiliations

  1. New Mexico Clinical Research & Osteoporosis Center, 300 Oak Street NE, Albuquerque, NM, 87106, USA

    E. Michael Lewiecki MD, FACP, FACE

  2. Colorado Center for Bone Research, Lakewood, CO, USA

    Paul D. Miller MD

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  1. E. Michael Lewiecki MD, FACP, FACE
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Correspondence to E. Michael Lewiecki MD, FACP, FACE .

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Editors and Affiliations

  1. , Dept of Endocrinology and Metabolism, McMaster University, [not given], Hamilton, L8S4L8, Ontario, Canada

    Aliya A. Khan, MD

  2. Mt. Zion Medical Center, Dept. Surgery, University of California, San Francisco, Divisadero St. 1600, San Francisco, 94115, California, USA

    Orlo H. Clark

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Lewiecki, E.M., Miller, P.D. (2012). Bone Density and Fracture Risk in Primary Hyperparathyroidism. In: Khan, MD, A., Clark, O. (eds) Handbook of Parathyroid Diseases. Springer, Boston, MA. https://doi.org/10.1007/978-1-4614-2164-1_13

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