HYPERPARATHYROIDISM – Etiology, Risk Factors, Signs and Symptoms, Complications and Management
Hyperparathyroidism is an excess of parathyroid hormone in the bloodstream due to over activity of parathyroid glands. These oval, grain-of-rice-sized glands are located in your neck. The parathyroid glands produce parathyroid hormone, which helps maintain an appropriate balance of calcium in the bloodstream and in tissues that depend on calcium for proper functioning.
ETIOLOGY
- Primary hyperparathyroidism: it occurs because of some problem with one or more of the four parathyroid glands: a noncancerous growth (adenoma) on a gland is the most common cause, enlargement (hyperplasia) of two or more parathyroid glands accounts for most other cases. A cancerous (malignant) tumor is a rare cause of primary hyperparathyroidism
- Secondary hyperparathyroidism: it is the result of another condition that lowers calcium levels
- Severe calcium deficiency
- Severe vitamin D deficiency
- Chronic kidney failure: kidneys convert vitamin D into a form that body can use. If kidneys function poorly, useable vitamin D may decline and calcium levels drop. Chronic kidney failure is the most common cause of secondary hyperparathyroidism
RISK FACTORS
- Woman who has gone through menopause
- Severe calcium or vitamin D deficiency
- Inherited disorder, such as multiple endocrine neoplasia, type I, which usually affects multiple glands
- Radiation treatment for cancer that has exposed neck to radiation a drug most often used to treat bipolar disorder
SIGNS AND SYMPTOMS
- Fragile bones that easily fracture (osteoporosis)
- Kidney stones
- Excessive urination
- Abdominal pain
- Tiring easily or weakness
- Depression or forgetfulness
- Bone and joint pain
- Frequent complaints of illness with no apparent cause
- Nausea, vomiting or loss of appetite
DIAGNOSTIC EVALUATION
- Blood tests: if the result of a blood test indicates elevated calcium in your blood
- Bone mineral density test (bone densitometry): the most common test to measure bone mineral density is dual energy X-ray absorptiometry, or a DXA scan. This test uses special X-ray devices to measure how many grams of calcium and other bone minerals are packed into a segment of bone
- Urine tests: a 24-hour collection of urine can provide information on how well kidneys function and how much calcium is excreted in urine. This test may help in judging the severity of hyperparathyroidism or diagnosing a kidney disorder causing hyperparathyroidism.
- Ultrasound: ultrasound uses sound waves to create images of your parathyroid glands and surrounding tissue. A small device held against your skin (transducer) emits high-pitched sound waves and records the sound wave echoes as they reflect off internal structures. A computer converts the echoes into images on a monitor.
- Sestamibi scan: sestamibi is a specifically designed radioactive compound that is absorbed by overactive parathyroid glands and can be detected on computerized tomography (CT) scans. A small dose of the compound is injected into your bloodstream before the imaging test is done
COMPLICATIONS
- Osteoporosis: the loss of calcium often results in osteoporosis, or weak, brittle bones that fracture easily.
- Kidney stones: the excess of calcium in blood may cause small, hard deposits of calcium and other substances to form in kidneys. A kidney stone usually causes significant pain as it passes through the urinary tract
- Cardiovascular disease: although the exact cause-and-effect link is unclear, high calcium levels are associated with cardiovascular conditions, such as high blood pressure (hypertension) and certain types of heart disease
- Neonatal hyperparathyroidism: severe, untreated hyperparathyroidism in pregnant women may cause dangerously low levels of calcium in newborns
MANAGEMENT
Your doctor may recommend no treatment and regular monitoring if:
- Your calcium levels are only slightly elevated
- Your kidneys are functioning normally
- Your bone density is normal or only slightly below normal
- You have no other symptoms that may improve with treatment
- If you choose this watch-and-wait approach, you will likely need a test to check your blood-calcium levels at least twice a year and have other monitoring tests done at least once a year
Surgical Management
Surgery is the most common treatment for primary hyperparathyroidism and provides a cure in at least 90 percent of all cases. A surgeon will remove only those glands that are enlarged or have a tumor (adenoma). If all four glands are affected, a surgeon will likely remove only three glands and perhaps a portion of the fourth – leaving some functioning parathyroid tissue
Complications from surgery are not common. Risks include:
- Damage to nerves controlling the vocal cords
- Long-term low calcium levels requiring the use of calcium and vitamin D supplements
Drugs
- Calcimimetics: a calcimimetic is a drug that mimics calcium circulating in the blood. Therefore, the drug may trick the parathyroid glands into releasing less parathyroid hormone. This drug is solid as cinacalcet (sensipar). The Food and Drug Administration approved cinacalcet to treat hyperparathyroidism caused by chronic kidney disease or parathyroid cancer
- Hormone replacement therapy: for women who have gone through menopause and have signs of osteoporosis, hormone replacement therapy may help bones retain calcium. This treatment, usually a combination estrogen and progestin, does not address the underlying problems with the parathyroid glands. Prolonged use of hormone replacement therapy can increase the risk of cardiovascular disease and some cancers. Work with your doctor to evaluate the risks and benefits to help you decide what is best for you.
- Bisphosphonates: bisphosphonates also prevent the loss of calcium from bones and may lessen osteoporosis caused by hyperparathyroidism
LIFESTYLE AND HOME REMEDIES
- Monitor how much calcium and vitamin D you get in your diet. The Institute of Medicine recommends 1,000 milligrams (mg) of calcium a day for adult’s ages 19 to 50 and men ages 51-70. That calcium recommendation increases to 1,200 mg a day if you are a woman age 51 or older or a man age 71 or older. The Institute of Medicine also recommends 600 international units (IUs) of vitamin D a day for adults ages 19 to 70 and 800 IUs a day for adults age 71 and older.
- Drink plenty of water. Drink six to eight glasses of water daily to lessen the risk of kidney stones
- Exercise regularly. Regular exercise, including strength training, helps maintain strong bones.
- Do not smoke. Smoking may increase bone loss as well as increase your risk of a number of serious health problems
- Avoid calcium-raising drugs. Certain medications, including some diuretics and lithium, can raise calcium levels
NURSING MANAGEMENT
- Protect the patient from injury
- Monitor for possible complications
- Provide patient education independent
- Adjust activities and reduce intensity
- Provide positive atmosphere, while acknowledging the difficulty of situation for the client
- Assist patients with activities/monitor clients use of assistive device such as walker
- Helps minimize frustration, rechanneling of energy
- To protect client from injury
- To remove cause of hypersecretion of parathormones
- Loop diuretic used with normal saline to cause diuresis and to reduce calcium levels
- Obtain baseline serum potassium, calcium, phosphate, and magnesium levels before treatment
- Provide at least 3 liters of fluid per day, including cranberry or prune juice, to increase urine acidity and help prevent calculus formation
- Take safety precaution to minimize the risk for injury from fall
- Schedule care to allow the patient with muscle weakness as much rest as possible
- Provide comfort measures to alleviate bone pain
- Administer antacids, as appropriate to prevent pelvic ulcers
- Auscultate the lungs regularly. Check for signs of pulmonary edema in the patient receiving large amounts of normal saline solution, especially if he has pulmonary or cardiac disease
- Check for elevated serum calcium levels if the patient is receiving cardiac glycosides
- Assess the patient for parathyroid poisoning, musculoskeletal changes, and renal impairment
- Observe the patient for signs of pain and monitor him for effectiveness of analgesics and comfort measures
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