This article has no abstract; the first 100 words appear below.
Foreword
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors' clinical recommendations.
Stage
A 62-year-old woman is found on routine laboratory testing to have a serum calcium level of 10.8 mg per deciliter (2.7 mmol per liter) (normal range, 8.4 to 10.4 [2.1 to 2.7]). The serum intact parathyroid hormone (PTH) concentration is 70 pg per milliliter (normal range, 15 to 75). Her history is notable only for hypertension that is well controlled with an angiotensin-receptor blocker; there is no history of kidney stones or fractures. Her family history is negative for hypercalcemia or endocrine tumors. Her 24-hour urinary calcium and creatinine levels are 280 mg and 1050 mg, respectively, and the ratio . . .
Dr. Marcocci reports receiving consulting fees, board membership fees, and speaker's fees from Amgen. No other potential conflict of interest relevant to this article was reported.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
An version of this article is available at NEJM.org.
We thank Dr. John P. Bilezikian for helpful discussions during the preparation of an earlier version of the manuscript.
Source Information
From the Department of Endocrinology and Metabolism, Section of Endocrinology and Bone Metabolism, University of Pisa, Pisa, Italy.
Address reprint requests to Dr. Marcocci at Via Paradisa 2, 56124 Pisa, Italy, or at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
Key Clinical Points
EVALUATION AND TREATMENT OF PRIMARY HYPERPARATHYROIDISM
• Primary hyperparathyroidism is the most common cause of hypercalcemia, affecting at least 1 in 1000 persons (more with increased age).
• Most patients with primary hyperparathyroidism are asymptomatic at diagnosis.
• An elevated or unexpectedly “normal” parathyroid hormone level simultaneous with an elevated albumin-adjusted calcium level generally is diagnostic of primary hyperparathyroidism.
• Neck imaging is not indicated for diagnosis, but it is useful for localization before planned parathyroidectomy.
• Parathyroidectomy should be recommended for patients with symptomatic primary hyperparathyroidism and for patients with asymptomatic primary hyperparathyroidism who meet criteria established by international guidelines, as well as those for whom surveillance is not feasible.
• Surveillance (including measurement of calcium levels and bone mineral density) is an option for patients with asymptomatic primary hyperparathyroidism, but monitoring is needed because disease progression may occur.
HEPATITIS-B-VACCINES
CKD-Micro1
CKD Algorithm