[Medical-surgical integrated approach in the treatment of non-paraneoplasic hyperparathyroidism: our experience].

OBJECTIVE: Hyperparathyroidism is a generalized alteration of calcium, phosphorus and bone metabolism due to an increased secretion of parathyroid hormone (PTH). In addition to the paraneoplastic ectopic type, we can distinguish three eutopic types of hyperparathyroidism, i.e., the primary form, mostly due to a benign or malignant tumor of parathyroid gland, the secondary form, typical of kidney disease and tertiary form, due to the progression of secondary forms. There is not agreement, in medical literature, on the treatment of these patients. To establish the correct therapeutic approach in patients with hyperparathyroidism, we have followed a group of symptomatic subjects suffering from primary, secondary and tertiary hyperparathyroidism, taking into account the therapeutic needs. MATERIALS AND METHODS: We followed for 12 months 155 patients suffering from primary, secondary and tertiary hyperparathyroidism; 82 were in end stage kidney disease, 93 were hypertensive. Subjects with primary forms has been treated, before parathyroidectomy, with idration (physiological solution of NaCl), bisphosphonates i.v. (pamidronate 60-90 mg in 4-6h) and, if serum calcium was higher than 12 mg/dl, loop diuretics (furosemide 40 mg/day). Subjects with secondary forms has been treated with hypophosphoric diet, phosphate bindings (calcium carbonate 1 g/day) and oral calcitriol (1 microg/d) before subtotal parathyroidectomy. After surgery it was administered support therapy with calcium gluconate (40 ml/day) and vitamin D (2.5mg/d) until serum calcium normalization. RESULTS: There were 55 cases of post surgery hypertensive attack treated with clonidine (300 microg/d); 8 months later there was not relapses but in all patients there was reduction of serum calcium concentration that required a substitutive treatment (calcium 1 g/day and calcitriol 1 microg/day). There was 1 case of heavy hypocalcemic state treated with calcium gluconate i.v. (40 ml/day). CONCLUSIONS: A correct approach to a non-paraneoplastic hyper-parathyroid patient need of an integration of both current medical and surgical options. In primary forms the first option is the surgical approach supported by medical treatment. In secondary forms medical approach is preferable to control renal and vascular complications, while surgical therapy is to prefer in non-responders to medical therapy forms.