The Question
A 63-year-old woman with stage 3 chronic kidney disease and long-standing hypertension is evaluated for fatigue and diffuse bone pain. She takes lisinopril and hydrochlorothiazide. Examination shows no focal neurologic deficits or volume depletion. Laboratory studies show calcium 11.6 mg/dL, phosphorus 2.1 mg/dL, creatinine 1.5 mg/dL, intact parathyroid hormone 142 pg/mL, and 25-hydroxyvitamin D 31 ng/mL. Bone density testing shows low bone mass at the distal radius. She has no history of malignancy. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
Post-Call Recovery Reads
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C
Explanation
Clinical Pearl:
Primary hyperparathyroidism is treated definitively with parathyroidectomy in symptomatic patients and in those with guideline-based operative indications such as hypercalcemia, reduced kidney function, osteoporosis, or nephrolithiasis.
Explanation:
This patient has primary hyperparathyroidism, suggested by elevated calcium with an inappropriately elevated parathyroid hormone level and low phosphorus. She has operative indications because she is symptomatic with bone pain, has chronic kidney disease with reduced renal function, and has skeletal involvement on bone density testing, so surgery is the standard next step. Bisphosphonates can improve bone density in selected nonsurgical patients but do not address the source of excess parathyroid hormone and are not the best next step here. Calcitriol would be used for hypocalcemia or certain cases of secondary hyperparathyroidism, not for hypercalcemia from primary hyperparathyroidism. Sestamibi scanning is for preoperative localization after the decision for surgery has already been made, not for establishing whether surgery is indicated. Observation is inappropriate because she meets clear treatment criteria under current endocrine guidance.
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