Atypical cases of secondary hyperparathyroidism in patients with kidney disease and failure: case reports

Authors: Pokorná Anita 1;  Horáček Jiří 2;  Vávrová Jaroslava 3;  Chrobok Viktor 4;  Čelakovský Petr 4;  Šafránek Roman 1,5;  Ryba Miroslav 6;  Řehořková Pavla 7;  Pavlíková Ladislava 3;  Palička Vladimír 3;  Sulková Dusilová Sylvie 1,5
Authors‘ workplace: Hemodialyzační středisko FN Hradec Králové 1;  IV. interní hematologická klinika LF UK a FN Hradec Králové 2;  Osteocentrum, Ústav klinické biochemie a diagnostiky LF UK a FN Hradec Králové 3;  Klinika otorinolaryngologie a chirurgie hlavy a krku LF UK a FN Hradec Králové 4;  Katedra interních oborů LF UK v Hradci Králové 5;  Oddělení nefrologie a dialýzy, Krajská nemocnice Liberec, a. s. 6;  Endokrinologie MUDr. Řehořková s. r. o., Hradecká poliklinika III s. r. o., Hradec Králové 7
Published in: Clinical Osteology 2020; 25(1): 50-57


The text is focused on clinical and laboratory manifestations of secondary hyperparathyroidism, associated with chronic kidney disease and chronic renal failure. Presenting four our case reports, we demonstrate not only the complex and complicated „traditional“ SHPT pathogenesis associated with kidney disease, but also others involving and contributing factors and problems. First, in some patients, it may be difficult to properly recognize between primary and secondary hyperparathyroidism. Additionally, the role of vitamin D deficiency as the crucial factor in parathyroid gland stimulation is demonstrated. Also, the role of dialysis solution composition on parathyroid gland activity is described. All case reports are presented together with commentaries, which contain the pathophysiological explanation as well as the suggested therapeutic approach.


vitamin D – hyperparathyreosis – hyperplasia – parathyroidectomy – parathyroid adenoma – parathyroid gland – secondary kidney disease – kidney failure


Cunningham J, Locatelli F, Rodriguez M. Secondary hyperparathyroidism: pathogenesis, disease progression, and therapeutic options. Clin J Am Soc Nephrol 2011; 6(4): 913–921. Dostupné z DOI: <>.

Moe S, Drüeke T, Cunningham J et al. CKD-MBD: Definition, Evaluation, and Classification of Renal Osteodystrophy: A Position Statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2006; 69(11): 1945–1953. Dostupné z DOI: <>.

KDIGO 2017 Clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease – mineral and bone disorder (CKD-MBD). Kidney Int Suppl (2011); 7(1): 1–59. Dostupné z DOI: <>.

Fraser WD. Hyperparathyroidism. Lancet 2009; 374(9684): 145–168. Dostupné z DOI: <–6736(09)60507–9>.

R Nuti, Merlotti D, Gennari Let al. Vitamin D Deficiency and Primary Hyperparathyroidism. J Endocrinol Invest 2001; 34(7 Suppl): 45–49.

Messa P, Alfiery CM. Secondary and tertiary hyperparathyroidism. Front Horm Res 2019; 51: 91–108. Dostupné z DOI: <>.

Jamal SA, Miller PD. Secondary and tertiary hyperparathyroidism. J Clin Densitom 2013; 16(1): 64–68. Dostupné z DOI: <>.

Duan K, Gomez-Hernandez K, Mete O. Clinicopathological correlates of hyperparathyroidism. J Clin Pathol 2015; 68(10): 771–787. Dostupné z DOI: <–203186>.

Goviale MC, Bellavia M, Damiano G et al. Post-transplantation tertiary hyperparathyroidism. Ann Transplant 2012; 17(3): 111–119.

Phelps KR. Trade-off-the Nephron: A theory to explain the primacy of phosphate in the pathogenesis of secondary hyperparathyroidism. Nutrients 2017: 9(5): 427. Dostupné z DOI: <>.

Lowe H, McMahon DJ, Rubin MR et al. Normocalcemic primary hyperparathyroidism: further characterization of a new clinical phenotype. J Clin Endocrin Metab 2007; 92(8): 3001–3005. Dostupné z DOI: <–2802>.

Centeno PP, Hergerger A, Mun HC et al. Phosphate Acts Directly on the Calcium-Sensing Receptor to Stimulate Parathyroid Hormone Secretion. Nat Commun 2019; 10(1): 4693. Dostupné z DOI: <–019–12399–9>.

Phelps KR. Trade-off-the Nephron: A theory to explain the primacy of phosphate in the pathogenesis of secondary hyperparathyroidism. Nutrients 2017; 9(5): 427. Dostupné z DOI: <>.

Blaine J, Weinman EJ, Cunningham R et al. The Regulation of Renal Phosphate Transport. Adv Chronic Kidney Dis 2011; 18(2): 77–84. Dostupné z DOI: <>.

Levi M, Gratton E, Forster IC et al. Mechanisms of Phosphate Transport. Nat Rev Nephrol 2019; 15(8): 482–500. Dostupné z DOI: <–019–0159-y>.

Rodriguez M, Lorenzo V. Parathyroid Hormone, a Uremic Toxin. Semin Dial 2009; 22(4): 363–368. Dostupné z DOI: <–139X.2009.00581.x>.

Lau WL, Obi Y, Kalantar-Zadeh. Parathyroidectomy in the Management of Secondary Hyperparathyroidism. Clin J Am Soc Nephrol 2018; 13(6): 952–961. Dostupné z DOI: <>.

Li C, Liang LV, Wang H et al. Total parathyroidectomy versus total parathyroidectomy with autotransplantation for secondary hyperparathyroidism: systematic review and meta-analysis. Ren Fail 2017; 39(1): 678–687. Dostupné z DOI: <>.

Wetmore JB. Parathyroidectomy: complex decisions about a complex procedure. Clin J Am Soc Nephrol 2016; 11(7): 1133–1135. Dostupné z DOI: <>.

Holick M. Vitamin D deficiency. N Engl J Med 2007; 357(3): 266–281. Dostupné z DOI: <>.

Rodriguez M. The calcium-sensing receptor: a key factor in the pathogenesis of secondary hyperparathyroidism. Am J Physiol Renal Physiol 2005; 288(2): F253-F264. Dostupné z DOI: <>.

Martinez Cordellat I. Hyperparathyroidism: Primary or Secondary Disease? Rheumatol Clin 2012; 8(5): 287–291. Dostupné z DOI: <>.

van der Sande FM, Ter Meulen JAK, Kotanko P et al. Dialysate Calcium Levels: Do They Matter? Hemodialysis Int 2019, 47(1–3):230–235. Dostupné z DOI: <>.

Kuragano T, Furuta M, Yahiro M et al. Acetate free citrate-containing dialysate increase intact-PTH and BAP levels in the patients with low intact-PTH. BMC Nephrology 2013; 14:18. Dostupné z DOI: <–2369–14–18>.

Šafránek R, Moučka P, Vávrová J et al. Changes of Serum Calcium, Magnesium and Parathyroid Hormone Induced by Hemodialysis With Citrate-Enriched Dialysis Solution. Kidney Blood Press Res 2015; 40(1): 13–21. Dostupné z DOI: <>.

Carsote M, Paduraru DN, Nica AE et al. Parathyroidectomy: is vitamin D a player for a good outcome? J Med Life 2016; 9(4): 348–352.

Redman C, Bodenner D, Brendan N et al. Role of Vitamin D Deficiency in Continued Hyperparathyroidism Following Parathyroidectomy. Head Neck 2009; 31(9): 1164–1167. Dostupné z DOI: <>.

Russo D, Tripepi R, Fabio Malberti F et al. Etelcalcetide in Patients on Hemodialysis with Severe Secondary Hyperparathyroidism. Multicenter Study in “Real Life”. J Clin Med 2019; 8(7): 1066. Dostupné z DOI: <>.

Dusilova Sulkova S, Horacek J, Zivny P et al. Primary hyperparathyroidism associated with hypocalcemia in a patient presenting with kidney disease. Int Nephrol Urol 2010; 42(3): 835–839. Dostupné z DOI: <–010–9743–6>.

Jain N, Reilly RF. Hungry Bone Syndrome. Curr Opin Nephrol Hypertens 2017; 26(4): 250–255. Dostupné z DOI: <>.

Dusilová Sulková S, Šafránek R, Vávrová J et al. Low-dose Cholecalciferol Supplementation and Dual Vitamin D Therapy in Haemodialysis Patients. Int Urol Nephrol 2015; 47(1): 169–176. Dostupné z DOI: <–014–0842–7>.

Khan A, Bilezikian J. Primary Hyperparathyroidism: Pathophysiology and Impact on Bone. CMAJ 2000; 163(2): 184–187.

Treiber G, Marchal F, Nobecourt E. After Parathyroidectomy: Difficult Short-Term Medical Management in Patients With End-Stage Renal Disease? Hemodial Int 2018; 22(3): 419–420. Dostupné z DOI: <>.

Yalla N, Bobba G, Guo G et al. Parathyroid hormone reference ranges in healthy individuals classified by vitamin D status. J Endocrinol Invest 2019; 42(11): 1353–1360. Dostupné z DOI: <–019–01075-w>.

Bellorin-Font E, Vasquez-Rios G, Martin KJ. Controversies in the Management of Secondary Hyperparathyroidism in Chronic Kidney Disease. Curr Osteoporosis Int 2019; 17(5): 333–342. Dostupné z DOI: < 10.1007/s11914–019–00533-x.>.

Clinical biochemistry Paediatric gynaecology Paediatric radiology Paediatric rheumatology Endocrinology Gynaecology and obstetrics Internal medicine Orthopaedics General practitioner for adults Radiodiagnostics Rehabilitation Rheumatology Traumatology
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