Primärer Hyperparathyreoidismus – Diagnostik und Therapie

Der primäre Hyperparathyreoidismus ist eine häufige Ursache der Hyperkalzämie. Oft bleibt das Krankheitsbild über Jahre unerkannt. Während es milde Verläufe gibt, treten doch häufig erhebliche Organschäden auf, und es kann sogar zu lebensbedrohlichen Zuständen kommen. Dieser Artikel gibt einen Überblick über die notwendige Diagnostik bei primärem Hyperparathyreoidismus, über wichtige Differenzialdiagnosen und über die verschiedenen Therapieoptionen.

Abstract

Hypercalcemia as a laboratory result is often diagnosed during evaluation for osteoporosis. Any form of hypercalcemia should be evaluated further. Owing to fluctuating calcium levels, the measurement should be repeated and corrected for elevated albumin levels by calculation or by measuring ionized calcium. In the diagnosis of primary hyperparathyroidism, measurement of parathyroid hormone, creatinine/glomerular filtration rate, phosphate, 25-OH vitamin D3 and 24-hour urine values are essential for differential diagnosis. Kidney ultrasound is used to detect nephrocalcinosis or kidney stones, and dual-energy X-ray absorptiometry (DXA) to determine bone mineral density (BMD) at the lumbar spine, femoral neck, total femur, and distal forearm. Complete cure is only possible through surgical resection of the adenoma(s). The indication for surgery is dependent on the age of the patient, existing complications, and the patient’s preference. Diagnostic imaging should only be performed if surgery is planned. Typically, neck ultrasound and 99mTc MIBI scintigraphy are sufficient to localize the parathyroid adenoma. Presurgical diagnostic evaluation of the thyroid is reasonable for surgical planning. Vitamin-D deficiency should be normalized before surgery. Postsurgical calcium and vitamin-D administration will prevent postsurgical hypocalcemia and hungry-bone disease, and may optimize the outcome of BMD. Treatment of osteoporosis without fractures might not be necessary, owing to normalization of BMD several years after parathyroid surgery. The continuation of specific anti-osteoporotic treatment with bisphosphonates post-surgery did not have any advantage and hence cannot be recommended.

Schlüsselwörter

Hyperkalzämie - Hyperparathyreoidismus - konservatives Vorgehen - Operationsindikation - Osteoporose

Key words

hypercalcemia - hyperparathyroidism - medical treatment - indication to surgery - osteoporosis

• Literatur

• 1 Bilezikian JP, Brandi ML, Rubin M. et al. Primary hyperparathyroidism: new concepts in clinical, densitometric and biochemical features. J Intern Med 2005; 257: 6-17
• 2 Yanevskaya LG, Karonova T, Sleptsov IV. et al. Clinical phenotypes of primary hyperparathyroidism in hospitalized patients who underwent parathyroidectomy. Endocr Connect 2021; 10: 248-255
• 3 Andersson P, Rydberg E, Willenheimer R. Primary hyperparathyroidism and heart disease? a review. Eur Heart J 2004; 25: 1776-1787
• 4 Zheng MH, Li FXZ, Xu F. et al. The Interplay Between the Renin-Angiotensin-Aldosterone System and Parathyroid Hormone. Front Endocrinol 2020; 11: 539
• 5 Pepe J, Cipriani C, Sonato C. et al. Cardiovascular manifestations of primary hyperparathyroidism: a narrative review. Eur J Endocrinol 2017; 177: R297-R308
• 6 Bilezikian JP, Cusano NE, Khan AA. et al. Primary hyperparathyroidism. Nat Rev Dis Primer 2016; 2: 16033
• 7 Sharretts JM, Simonds WF. Clinical and Molecular Genetics of Parathyroid Neoplasms. Best Pract Res Clin Endocrinol Metab 2010; 24: 491-502
• 8 Bilezikian JP, Brandi ML, Eastell R. et al. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. J Clin Endocrinol Metab 2014; 99: 3561-3569
• 9 Gollisch K, Siggelkow H. [Asymptomatic primary hyperparathyroidism: Operation or observation?]. Internist 2021; 62: 496-504
• 10 Eastell R, Brandi ML, Costa AG. et al. Diagnosis of asymptomatic primary hyperparathyroidism: proceedings of the Fourth International Workshop. J Clin Endocrinol Metab 2014; 99: 3570-3579
• 11 Cipriani C, Biamonte F, Costa AG. et al. Prevalence of Kidney Stones and Vertebral Fractures in Primary Hyperparathyroidism Using Imaging Technology. J Clin Endocrinol Metab 2015; 100: 1309-1315
• 12 Ejlsmark-Svensson H, Rolighed L, Harsløf T. et al. Risk of fractures in primary hyperparathyroidism: a systematic review and meta-analysis. Osteoporos Int 2021; 32: 1053-1060
• 13 Fisher SB, Perrier ND. Primary hyperparathyroidism and hypertension. Gland Surg 2020; 9: 142-149
• 14 Orr LE, Zhou H, Zhu CY. et al. Skeletal effects of combined medical and surgical management of primary hyperparathyroidism. Surgery 2020; 167: 144-148
• 15 Miyaoka D, Imanishi Y, Kato E. et al. Effects of denosumab as compared with parathyroidectomy regarding calcium, renal, and bone involvement in osteoporotic patients with primary hyperparathyroidism. Endocrine 2020; 69: 1-8
• 16 Nasiri S, Soroush A, Hashemi AP. et al. Parathyroid adenoma Localization. Med J Islam Repub Iran 2012; 26: 103-109
• 17 Kluijfhout WP, Pasternak JD, Drake FT. et al. Use of PET tracers for parathyroid localization: a systematic review and meta-analysis. Langenbecks Arch Surg 2016; 401: 925-935
• 18 Walker MD, Silverberg SJ. Primary hyperparathyroidism. Nat Rev Endocrinol 2018; 14: 115-125
• 19 Abdulla AG, Ituarte PHG, Harari A. et al. Trends in the frequency and quality of parathyroid surgery: analysis of 17,082 cases over 10 years. Ann Surg 2015; 261: 746-750
• 20 Cesareo R, Di Stasio E, Vescini F. et al. Effects of alendronate and vitamin D in patients with normocalcemic primary hyperparathyroidism. Osteoporos Int 2015; 26: 1295-1302