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Tertiary hyperparathyroidism — ESENeph MCQ

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HardRenal Bone Disease and Renal AnaemiaTertiary hyperparathyroidismESENeph

A 49-year-old man with CKD G5 not yet on dialysis has persistent hypercalcaemia and bone pain. PTH is 132 pmol/L despite phosphate control, native vitamin D replacement and cinacalcet. Ultrasound shows enlarged parathyroid glands and eGFR is 11 mL/min/1.73 m². What is the most appropriate management?

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Correct answer: D — Refer for parathyroidectomy assessment

Severe refractory hyperparathyroidism with hypercalcaemia and symptoms despite medical therapy should prompt surgical assessment. Increasing phosphate intake would worsen CKD-MBD. Calcium infusions are inappropriate in hypercalcaemia. The pearl is that tertiary hyperparathyroidism reflects autonomous gland hyperplasia and may persist despite medical optimisation.

Reference: KDIGO CKD-MBD Guideline; UK Kidney Association CKD-MBD guidance