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endo.hyperparathyroidism.v1

Hyperparathyroidism (primary, secondary, tertiary)

endocrinologychronicsubacuteacuteadultoutpatientacuteinpatienttransition
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Hyperparathyroidism dossier — primary (SBM/AAES surgical criteria), secondary (KDIGO CKD-MBD), tertiary (post-transplant). FHH (urine Ca:Cr <0.01) MUST be excluded before parathyroidectomy. Cinacalcet for non-surgical or carcinoma; bisphosphonate / denosumab for bone protection. Hypercalcemic crisis (>14) requires aggressive IV NS + calcitonin + bisphosphonate ± HD. Open: manifest, problem-package, RxCUI verification, SBM-criteria + KDIGO calculators absent, tests.

Entry points (5)

  • lab_abnormality
    Incidental hypercalcemia on routine labs (4th International Workshop Bilezikian JCEM 2014)
    incidental_hypercalcemia
  • symptom
    Recurrent calcium-containing kidney stones (4th International Workshop 2014 surgical criterion)
    kidney_stones
  • symptom
    Fragility fracture or osteoporosis (4th International Workshop 2014 T-score criterion)
    fragility_fracture
  • lab_abnormality
    Elevated PTH in CKD — secondary HPT (KDIGO 2017 CKD-MBD)
    high_pth_in_ckd
  • symptom
    Bones, stones, groans, psychiatric overtones — symptomatic pHPT (AACE/ACE 2022 PHPT)
    bones_stones_groans_moans

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Age <50 favours surgery (4th International Workshop Bilezikian JCEM 2014 PMID 25162666; AACE/ACE 2022)
  • serum_calcium_ionized_or_totalrequired
    lab • used at INITIAL_WORKUP
    Confirm hypercalcemia; ionized preferred in critical illness (AACE/ACE 2022 PHPT; 4th International Workshop 2014)
  • pth_intactrequired
    lab • used at INITIAL_WORKUP
    Inappropriate or high PTH with hypercalcemia diagnostic (AACE/ACE 2022 PHPT diagnostic criteria)
  • phosphaterequired
    lab • used at INITIAL_WORKUP
    Low phos in primary; high in secondary CKD (KDIGO 2017 CKD-MBD; AACE/ACE 2022)
  • alkaline_phosphataserequired
    lab • used at INITIAL_WORKUP
    Bone turnover marker (4th International Workshop 2014; NICE 2019)
  • vit_d_25_OHrequired
    lab • used at INITIAL_WORKUP
    Repletion required before surgery; deficiency raises PTH (AACE/ACE 2022; Bilezikian JCEM 2014)
  • magnesiumrequired
    lab • used at INITIAL_WORKUP
    Hypomag mimics hypoparathyroidism (AACE/ACE 2022 PHPT workup)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    CKD impacts surgical criteria (eGFR <60 = criterion per 4th International Workshop 2014) + secondary HPT (KDIGO 2017)
  • 24h_urine_ca_creatininerequired
    lab • used at INITIAL_WORKUP
    Differentiate FHH — urine Ca:Cr <0.01 (4th International Workshop Bilezikian 2014; AACE/ACE 2022)
  • tsh
    lab • used at INITIAL_WORKUP
    Hyperthyroid mimicker (AACE/ACE 2022 differential)
  • dexa_t_scorerequired
    imaging • used at INITIAL_WORKUP
    T-score ≤-2.5 = surgical criterion (4th International Workshop 2014; AACE/ACE 2022)
  • renal_ultrasound
    imaging • used at INITIAL_WORKUP
    Nephrolithiasis = surgical indication (4th International Workshop 2014; NICE 2019)
  • sestamibi_or_neck_us
    imaging • used at BRANCHING_WORKUP
    Adenoma localisation pre-op (AAES 2016 PMID 27532368; AACE/ACE 2022)
  • 4d_ct_neck
    imaging • used at BRANCHING_WORKUP
    Reoperative or non-localising sestamibi (AAES 2016; AACE/ACE 2022)
  • lithium_or_thiaziderequired
    history • used at CONTEXT
    Drug-induced PTH elevation (AACE/ACE 2022; 4th International Workshop 2014 exclusion)
  • current_medsrequired
    medication • used at CONTEXT
    Reconciliation (AACE/ACE 2022)

12-phase flow (12)

  1. 1FRAME
    Confirm pHPT — hypercalcemia + non-suppressed PTH; rule out FHH via urine Ca:Cr ratio (AACE/ACE 2022; 4th International Workshop Bilezikian 2014)
    inputs: serum_calcium_ionized_or_total, pth_intact, 24h_urine_ca_creatinine
    advance: Diagnosis confirmed and FHH excluded
  2. 2ENTRY
    Incidental hypercalcemia / stones / fractures / osteoporosis / CKD high PTH (AACE/ACE 2022; KDIGO 2017)
    inputs: age
    advance: Engine entered
  3. 3CONTEXT
    Vit D, drugs — lithium / thiazide; CKD; family history MEN1/2 / FHH (AACE/ACE 2022; 4th International Workshop 2014)
    inputs: lithium_or_thiazide, current_meds
    advance: Context complete
  4. 4RED_FLAGS
    Hypercalcemic crisis — Ca >14, AKI, AMS (AACE/ACE 2022 emergency management; NICE 2019)
    inputs: serum_calcium_ionized_or_total
    actions: hypercalcemia
    advance: Stabilised
  5. 5INITIAL_WORKUP
    Ca, PTH, phos, ALP, 25-OH vit D, Mg, BMP, 24-h urine Ca:Cr, TSH; DEXA; renal US (AACE/ACE 2022; 4th International Workshop 2014 workup)
    inputs: serum_calcium_ionized_or_total, pth_intact, phosphate, alkaline_phosphatase, vit_d_25_OH, magnesium, creatinine_egfr, 24h_urine_ca_creatinine, dexa_t_score
    actions: panel.hormone, panel.renal
    advance: Stage-1 returned
  6. 6BRANCHING_WORKUP
    Sestamibi + US for adenoma; 4D-CT if reoperative; SPECT-CT; genetic if MEN1/2 / familial (AAES 2016 PMID 27532368; AACE/ACE 2022)
    inputs: sestamibi_or_neck_us, 4d_ct_neck
    advance: Localisation if surgical
  7. 7DIFFERENTIAL
    Primary HPT vs FHH vs malignancy (PTHrP / lytic) vs granulomatous vs vit D tox vs lithium (AACE/ACE 2022 differential; 4th International Workshop 2014)
    advance: Diagnosis confirmed
  8. 8RISK_STRATIFICATION
    SBM 2014 / AAES 2016 surgical criteria — age <50, Ca >1 above normal, eGFR <60, urine Ca >400, stones, T-score ≤-2.5 (4th International Workshop Bilezikian JCEM 2014 PMID 25162666; AAES 2016)
    inputs: age, serum_calcium_ionized_or_total, creatinine_egfr, dexa_t_score
    advance: Surgical decision made
  9. 9TREATMENT
    Surgical: focused parathyroidectomy with intraop PTH, cure 95-98% (AAES 2016; AACE/ACE 2022); medical: cinacalcet, bisphosphonate / denosumab, vit D repletion, hydration (4th International Workshop 2014); CKD secondary — phosphate binders + active vit D + cinacalcet / etelcalcetide (KDIGO 2017 PMID 28838766)
    inputs: serum_calcium_ionized_or_total, creatinine_egfr, vit_d_25_OH
    advance: Plan documented
  10. 10DISPOSITION
    Outpatient unless hypercalcemic crisis or postoperative (AACE/ACE 2022; NICE 2019)
    advance: Disposition documented
  11. 11MONITORING
    Calcium, PTH, eGFR, DEXA q1-2 yr, urine Ca q1 yr; postop hungry bone monitoring (4th International Workshop 2014 surveillance; AACE/ACE 2022)
    inputs: serum_calcium_ionized_or_total
    advance: Schedule documented
  12. 12FOLLOWUP
    Endo / surgery follow-up; family screen if MEN; bone health long-term (AACE/ACE 2022; 4th International Workshop 2014)
    advance: Follow-up booked