What causes hypercalcemia in primary hyperparathyroidism?

Answer

The causes of hypercalcemia that result in a concomitantly elevated parathyroid hormone level are few. These include familial benign (hypocalciuric) hypercalcemia (FHH) (see Related disorders), lithium-induced hypercalcemia, and tertiary hyperparathyroidism. A minority of patients (ie, 10-15%) with hyperparathyroidism have parathyroid hormone levels that are within the reference range but are inappropriately high in the presence of elevated serum calcium concentrations. A subset of patients has normal calcium levels with elevated parathyroid hormone, so-called normocalcemic hyperparathyroidism. However, when considering this diagnosis, all potential causes of secondary hyperparathyroidism (eg, low calcium intake, gastrointestinal disorders, renal insufficiency, vitamin D deficiency, hypercalciuria of renal origin) should be excluded. Patients with normal calcium levels and elevated parathyroid hormone levels in the absence of an identifiable secondary cause should be monitored for progression to hypercalcemia.

Secondary and tertiary hyperparathyroidism are typically diagnosed based on their clinical context. Cancer-induced hypercalcemia is associated with a low parathyroid hormone level but possibly a high parathyroid hormone–related peptide level.

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Yeh MW, Ituarte PH, Zhou HC, et al. Incidence and prevalence of primary hyperparathyroidism in a racially mixed population. J Clin Endocrinol Metab. 2013 Mar. 98 (3):1122-9. [Medline]. [Full Text].
Fraker DL, Harsono H, Lewis R. Minimally invasive parathyroidectomy: benefits and requirements of localization, diagnosis, and intraoperative PTH monitoring. Long-term results. World J Surg. 2009 Sep 10. [Medline].
Agarwal SK, Kester MB, Debelenko LV, et al. Germline mutations of the MEN1 gene in familial multiple endocrine neoplasia type 1 and related states. Hum Mol Genet. 1997 Jul. 6(7):1169-75. [Medline].
Ejlsmark-Svensson H, Sikjaer T, Webb SM, Rejnmark L, Rolighed L. Health related quality of life improves one year after parathyroidectomy in primary hyperparathyroidism: A prospective cohort study. Clin Endocrinol (Oxf). 2018 Sep 29. [Medline].
Bilezikian JP, Silverberg SJ. Clinical practice. Asymptomatic primary hyperparathyroidism. N Engl J Med. 2004 Apr 22. 350(17):1746-51.
Walker MD, Fleischer J, Rundek T, et al. Carotid vascular abnormalities in primary hyperparathyroidism. J Clin Endocrinol Metab. 2009 Sep 15. [Medline]. [Full Text].
Grey A, Lucas J, Horne A, Gamble G, Davidson JS, Reid IR. Vitamin D repletion in patients with primary hyperparathyroidism and coexistent vitamin D insufficiency. J Clin Endocrinol Metab. 2005 Apr. 90 (4):2122-6. [Medline]. [Full Text].
Institute of Medicine, Food and Nutrition Board, Committee to Review Dietary Reference Intakes for Vitamin D and Calcium. Ross AC, Taylor CL, Yaktine AL, Del Valle HB, eds. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academies Press; 2011.
Van Husen R, Kim LT. Accuracy of surgeon-performed ultrasound in parathyroid localization. World J Surg. 2004 Nov. 28(11):1122-6. [Medline].
Solorzano CC, Carneiro-Pla DM, Irvin GL 3rd. Surgeon-performed ultrasonography as the initial and only localizing study in sporadic primary hyperparathyroidism. J Am Coll Surg. 2006 Jan. 202(1):18-24. [Medline].
Siperstein A, Berber E, Barbosa GF, Tsinberg M, Greene AB, Mitchell J, et al. Predicting the success of limited exploration for primary hyperparathyroidism using ultrasound, sestamibi, and intraoperative parathyroid hormone: analysis of 1158 cases. Ann Surg. 2008 Sep. 248(3):420-8. [Medline].
Soon PS, Delbridge LW, Sywak MS, Barraclough BM, Edhouse P, Sidhu SB. Surgeon performed ultrasound facilitates minimally invasive parathyroidectomy by the focused lateral mini-incision approach. World J Surg. 2008 May. 32(5):766-71. [Medline].
Hoang JK, Williams K, Gaillard F, Dixon A, Sosa JA. Parathyroid 4D-CT: Multi-institutional International Survey of Use and Trends. Otolaryngol Head Neck Surg. 2016 Dec. 155 (6):956-60. [Medline].
Rodgers SE, Hunter GJ, Hamberg LM, Schellingerhout D, Doherty DB, Ayers GD, et al. Improved preoperative planning for directed parathyroidectomy with 4-dimensional computed tomography. Surgery. 2006 Dec. 140(6):932-40; discussion 940-1. [Medline].
Eichhorn-Wharry LI, Carlin AM, Talpos GB. Mild hypercalcemia: an indication to select 4-dimensional computed tomography scan for preoperative localization of parathyroid adenomas. Am J Surg. 2011 Mar. 201(3):334-8; discussion 338. [Medline].
Yeh R, Tay YD, Tabacco G, et al. Diagnostic Performance of 4D CT and Sestamibi SPECT/CT in Localizing Parathyroid Adenomas in Primary Hyperparathyroidism. Radiology. 2019 May. 291 (2):469-76. [Medline]. [Full Text].
Chazen JL, Gupta A, Dunning A, Phillips CD. Diagnostic accuracy of 4D-CT for parathyroid adenomas and hyperplasia. AJNR Am J Neuroradiol. 2012 Mar. 33 (3):429-33. [Medline]. [Full Text].
Tian Y, Tanny ST, Einsiedel P, et al. Four-Dimensional Computed Tomography: Clinical Impact for Patients with Primary Hyperparathyroidism. Ann Surg Oncol. 2018 Jan. 25 (1):117-21. [Medline].
Suh YJ, Choi JY, Kim SJ, et al. Comparison of 4D CT, ultrasonography, and 99mTc sestamibi SPECT/CT in localizing single-gland primary hyperparathyroidism. Otolaryngol Head Neck Surg. 2015 Mar. 152 (3):438-43. [Medline].
Bahl M, Sepahdari AR, Sosa JA, Hoang JK. Parathyroid Adenomas and Hyperplasia on Four-dimensional CT Scans: Three Patterns of Enhancement Relative to the Thyroid Gland Justify a Three-Phase Protocol. Radiology. 2015 Nov. 277 (2):454-62. [Medline]. [Full Text].
Ramirez AG, Shada AL, Martin AN, et al. Clinical efficacy of 2-phase versus 4-phase computed tomography for localization in primary hyperparathyroidism. Surgery. 2016 Jun 11. [Medline].
Griffith B, Chaudhary H, Mahmood G, et al. Accuracy of 2-Phase Parathyroid CT for the Preoperative Localization of Parathyroid Adenomas in Primary Hyperparathyroidism. AJNR Am J Neuroradiol. 2015 Dec. 36 (12):2373-9. [Medline]. [Full Text].
Memeh KO, Palacios JE, Khan R, Guerrero MA. PRE-OPERATIVE LOCALIZATION OF PARATHYROID ADENOMA: PERFORMANCE OF 4D MRI PARATHYROID PROTOCOL. Endocr Pract. 2019 Apr. 25 (4):361-5. [Medline].
Ozturk M, Polat AV, Celenk C, Elmali M, Kir S, Polat C. The diagnostic value of 4D MRI at 3T for the localization of parathyroid adenomas. Eur J Radiol. 2019 Mar. 112:207-13. [Medline].
Nael K, Hur J, Bauer A, et al. Dynamic 4D MRI for Characterization of Parathyroid Adenomas: Multiparametric Analysis. AJNR Am J Neuroradiol. 2015 Nov. 36 (11):2147-52. [Medline]. [Full Text].
Thimmappa V, Smith A, Wood J, Shires CB, Langsdon S, Sebelik M. Management protocol for primary hyperparathyroidism in a single institution: utility of surgeon performed ultrasound. Gland Surg. 2018 Aug. 7 (Suppl 1):S53-8. [Medline]. [Full Text].
[Guideline] Bilezikian JP, Brandi ML, Eastell R, et al. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. J Clin Endocrinol Metab. 2014 Oct. 99 (10):3561-9. [Medline]. [Full Text].
[Guideline] The American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons position statement on the diagnosis and management of primary hyperparathyroidism. Endocr Pract. 2005 Jan-Feb. 11(1):49-54. [Medline].
Sharata A, Kelly TL, Rozenfeld Y, et al. Management of Primary Hyperparathyroidism: Can We Do Better?. Am Surg. 2017 Jan 1. 83 (1):64-70. [Medline].
Chow CC, Chan WB, Li JK, et al. Oral alendronate increases bone mineral density in postmenopausal women with primary hyperparathyroidism. J Clin Endocrinol Metab. 2003 Feb. 88(2):581-7. [Medline].
Parker CR, Blackwell PJ, Fairbairn KJ, Hosking DJ. Alendronate in the treatment of primary hyperparathyroid-related osteoporosis: a 2-year study. J Clin Endocrinol Metab. 2002 Oct. 87(10):4482-9. [Medline].
De Luca F, Baron J. Molecular biology and clinical importance of the Ca(2+)-sensing receptor. Curr Opin Pediatr. 1998 Aug. 10(4):435-40. [Medline].
Strippoli GF, Tong A, Palmer SC, Elder G, Craig JC. Calcimimetics for secondary hyperparathyroidism in chronic kidney disease patients. Cochrane Database Syst Rev. 2006. (4):CD006254. [Medline].
Boggs JE, Irvin GL, Molinari AS, Deriso GT. Intraoperative parathyroid hormone monitoring as an adjunct to parathyroidectomy. Surgery. 1996 Dec. 120(6):954-8. [Medline].
Gordon LL, Snyder WH, Wians F, et al. The validity of quick intraoperative parathyroid hormone assay: an evaluation in seventy-two patients based on gross morphologic criteria. Surgery. 1999 Dec. 126(6):1030-5. [Medline].
Greene AB, Butler RS, McIntyre S, et al. National trends in parathyroid surgery from 1998 to 2008: a decade of change. J Am Coll Surg. 2009 Sep. 209(3):332-43. [Medline].
Baumann DS, Wells SA Jr. Parathyroid autotransplantation. Surgery. 1993 Feb. 113(2):130-3. [Medline].
Lew JI, Irvin GL 3rd. Focused parathyroidectomy guided by intra-operative parathormone monitoring does not miss multiglandular disease in patients with sporadic primary hyperparathyroidism: a 10-year outcome. Surgery. 2009 Dec. 146(6):1021-7. [Medline].
Singh Ospina NM, Rodriguez-Gutierrez R, Maraka S, et al. Outcomes of Parathyroidectomy in Patients with Primary Hyperparathyroidism: A Systematic Review and Meta-analysis. World J Surg. 2016 Oct. 40 (10):2359-77. [Medline].
Caldwell M, Laux J, Clark M, Kim L, Rubin J. Persistently Elevated PTH After Parathyroidectomy at One Year: Experience in a Tertiary Referral Center. J Clin Endocrinol Metab. 2019 Oct 1. 104 (10):4473-80. [Medline]. [Full Text].
Lang BH, Wong IY, Wong KP, Lo CY. Eucalcemic parathyroid hormone elevation after parathyroidectomy for primary sporadic hyperparathyroidism: risk factors, trend, and outcome. Ann Surg Oncol. 2012 Feb. 19 (2):584-90. [Medline]. [Full Text].
Ning L, Sippel R, Schaefer S, Chen H. What is the clinical significance of an elevated parathyroid hormone level after curative surgery for primary hyperparathyroidism?. Ann Surg. 2009 Mar. 249 (3):469-72. [Medline].
Goldfarb M, Gondek S, Irvin GL 3rd, Lew JI. Normocalcemic parathormone elevation after successful parathyroidectomy: long-term analysis of parathormone variations over 10 years. Surgery. 2011 Dec. 150 (6):1076-84. [Medline].
Mittendorf EA, McHenry CR. Persistent parathyroid hormone elevation following curative parathyroidectomy for primary hyperparathyroidism. Arch Otolaryngol Head Neck Surg. 2002 Mar. 128 (3):275-9. [Medline]. [Full Text].
Solorzano CC, Mendez W, Lew JI, et al. Long-term outcome of patients with elevated parathyroid hormone levels after successful parathyroidectomy for sporadic primary hyperparathyroidism. Arch Surg. 2008 Jul. 143 (7):659-63; discussion 663. [Medline]. [Full Text].
Carty SE, Roberts MM, Virji MA, Haywood L, Yim JH. Elevated serum parathormone level after "concise parathyroidectomy" for primary sporadic hyperparathyroidism. Surgery. 2002 Dec. 132 (6):1086-92; discussion 1092-3. [Medline].
Ryder CY, Jarocki A, McNeely MM, et al. Early biochemical response to parathyroidectomy for primary hyperparathyroidism and its predictive value for recurrent hypercalcemia and recurrent primary hyperparathyroidism. Surgery. 2020 Aug 4. [Medline].
Biskobing DM. Significance of elevated parathyroid hormone after parathyroidectomy. Endocr Pract. 2010 Jan-Feb. 16(1):112-7. [Medline].
Brito K, Edirimanne S, Eslick GD. The extent of improvement of health-related quality of life as assessed by the SF36 and Paseika scales after parathyroidectomy in patients with primary hyperparathyroidism--a systematic review and meta-analysis. Int J Surg. 2015 Jan. 13:245-9. [Medline]. [Full Text].
Sheldon DG, Lee FT, Neil NJ, Ryan JA Jr. Surgical treatment of hyperparathyroidism improves health-related quality of life. Arch Surg. 2002 Sep. 137 (9):1022-6; discussion 1026-8. [Medline]. [Full Text].
Mallick R, Nicholson KJ, Yip L, Carty SE, McCoy KL. Factors associated with late recurrence after parathyroidectomy for primary hyperparathyroidism. Surgery. 2020 Jan. 167 (1):160-5. [Medline].
Lou I, Balentine C, Clarkson S, Schneider DF, Sippel RS, Chen H. How long should we follow patients after apparently curative parathyroidectomy?. Surgery. 2017 Jan. 161 (1):54-61. [Medline]. [Full Text].
Block GA, Bushinsky DA, Cunningham J, Drueke TB, Ketteler M, Kewalramani R, et al. Effect of Etelcalcetide vs Placebo on Serum Parathyroid Hormone in Patients Receiving Hemodialysis With Secondary Hyperparathyroidism: Two Randomized Clinical Trials. JAMA. 2017 Jan 10. 317 (2):146-55. [Medline]. [Full Text].
Forrest KY, Stuhldreher WL. Prevalence and correlates of vitamin D deficiency in US adults. Nutr Res. 2011 Jan. 31 (1):48-54. [Medline].
Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group. KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney Int Suppl. 2009 Aug. S1-130. [Medline].
Giustina A, Adler RA, Binkley N, et al. Controversies in Vitamin D: Summary Statement From an International Conference. J Clin Endocrinol Metab. 2019 Feb 1. 104 (2):234-40. [Medline]. [Full Text].
Di Iorio B, Bellasi A, Russo D, INDEPENDENT Study Investigators. Mortality in kidney disease patients treated with phosphate binders: a randomized study. Clin J Am Soc Nephrol. 2012 Mar. 7 (3):487-93. [Medline]. [Full Text].
Lung BE, Komatsu DEE. Calcitriol. 2018 Jan. [Medline]. [Full Text].
Block GA, Bushinsky DA, Cheng S, et al. Effect of Etelcalcetide vs Cinacalcet on Serum Parathyroid Hormone in Patients Receiving Hemodialysis With Secondary Hyperparathyroidism: A Randomized Clinical Trial. JAMA. 2017 Jan 10. 317 (2):156-64. [Medline]. [Full Text].
Effect of Cinacalcet on Cardiovascular Disease in Patients Undergoing Dialysis. N Engl J Med. 2012 Nov 3. [Medline].
Hsu YH, Yu HY, Chen HJ, Li TC, Hsu CC, Kao CH. The Risk of Peripheral Arterial Disease after Parathyroidectomy in Patients with End-Stage Renal Disease. PLoS One. 2016. 11 (6):e0156863. [Medline]. [Full Text].
van der Plas WY, Dulfer RR, Engelsman AF, et al. Effect of parathyroidectomy and cinacalcet on quality of life in patients with end-stage renal disease-related hyperparathyroidism: a systematic review. Nephrol Dial Transplant. 2017 Nov 1. 32 (11):1902-8. [Medline].
Rothmund M, Wagner PK, Schark C. Subtotal parathyroidectomy versus total parathyroidectomy and autotransplantation in secondary hyperparathyroidism: a randomized trial. World J Surg. 1991 Nov-Dec. 15(6):745-50. [Medline].
Rayes N, Seehofer D, Schindler R, et al. Long-term results of subtotal vs total parathyroidectomy without autotransplantation in kidney transplant recipients. Arch Surg. 2008 Aug. 143 (8):756-61; discussion 761. [Medline]. [Full Text].
Conzo G, Perna A, Candela G, et al. Long-term outcomes following "presumed" total parathyroidectomy for secondary hyperparathyroidism of chronic kidney disease. G Chir. 2012 Nov-Dec. 33 (11-12):379-82. [Medline].
Schlosser K, Bartsch DK, Diener MK, et al. Total Parathyroidectomy With Routine Thymectomy and Autotransplantation Versus Total Parathyroidectomy Alone for Secondary Hyperparathyroidism: Results of a Nonconfirmatory Multicenter Prospective Randomized Controlled Pilot Trial. Ann Surg. 2016 Nov. 264 (5):745-53. [Medline].
Hirai T, Nakashima A, Takasugi N, Yorioka N. Association of nodular hyperplasia with resistance to cinacalcet therapy for secondary hyperparathyroidism in hemodialysis patients. Ther Apher Dial. 2010 Dec. 14(6):577-82. [Medline].
Okada M, Tominaga Y, Izumi K, Nobata H, Yamamoto T, Hiramitsu T, et al. Tertiary hyperparathyroidism resistant to cinacalcet treatment. Ther Apher Dial. 2011 Jun. 15 Suppl 1:33-7. [Medline].
Yu Z, Gu L, Pang H, Fang Y, Yan H, Fang W. Sodium thiosulfate: an emerging treatment for calciphylaxis in dialysis patients. Case Rep Nephrol Dial. 2015 Jan-Apr. 5 (1):77-82. [Medline]. [Full Text].
Wermers RA, Khosla S, Atkinson EJ, Achenbach SJ, Oberg AL, Grant CS. Incidence of primary hyperparathyroidism in Rochester, Minnesota, 1993-2001: an update on the changing epidemiology of the disease. J Bone Miner Res. 2006 Jan. 21(1):171-7. [Medline].
Coston SD, Pelton JJ. Success of cervical exploration for patients with asymptomatic primary hyperparathyroidism. Am J Surg. 1999 Jan. 177(1):69-74. [Medline].
Felsenfeld AJ. Considerations for the treatment of secondary hyperparathyroidism in renal failure. J Am Soc Nephrol. 1997 Jun. 8 (6):993-1004. [Medline]. [Full Text].
Switzer NJ, Marcil G, Prasad S, et al. Long-term hypovitaminosis D and secondary hyperparathyroidism outcomes of the Roux-en-Y gastric bypass: a systematic review. Obes Rev. 2017 May. 18 (5):560-6. [Medline].
Goldenstein PT, Elias RM, Pires de Freitas do Carmo L, et al. Parathyroidectomy improves survival in patients with severe hyperparathyroidism: a comparative study. PLoS One. 2013. 8 (8):e68870. [Medline]. [Full Text].

Media Gallery

Normal parathyroid glands as seen during a thyroidectomy. The large arrow points to the superior parathyroid. The thinner arrow points to the inferior parathyroid. The forceps points toward the recurrent laryngeal nerve. The patient's head is toward the top right.
Hyperparathyroidism. Technetium-99m (99mTc) sestamibi radionuclide scan. The early image (top left) shows uptake in the salivary glands and thyroid. The later images (right and bottom) show washout from the thyroid but persistence in the region of the right inferior thyroid lobe (arrows). This proved to be a right parathyroid adenoma.
Sestamibi parathyroid scan with SPECT scan. The orange indicates radionuclide accumulation. The findings indicate the presence of a right-sided parathyroid adenoma just behind the thyroid lobe. At exploration, this patient was found to have adjacent double adenomas on the right.
Sestamibi parathyroid scan with SPECT scan showing an ectopic mediastinal parathyroid adenoma adjacent to the aortic arch. This patient had undergone a failed neck exploration. A transthoracic, robotic excision was curative.
A small, left inferior parathyroid adenoma as demonstrated on a 4D-CT scan. The left panel is a single image from the early contrast phase showing intense enhancement. The right panel shows rapid washout of contrast. The white arrows point to the adenoma.
The panels show a transverse and longitudinal (sagittal) view of a left superior parathyroid adenoma on ultrasonography. The caliper marks designate the adenoma. Adenomas are typically homogeneous and hypoechoic.

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Author

Lawrence Kim, MD, FACS, FACE Professor, Department of Surgery, Division of Surgical Oncology and Endocrine Surgery, University of North Carolina at Chapel Hill School of Medicine

Lawrence Kim, MD, FACS, FACE is a member of the following medical societies: American Association of Clinical Endocrinologists, American Association of Endocrine Surgeons, American College of Surgeons, American Thyroid Association, Association for Academic Surgery, Association of VA Surgeons, International Association of Endocrine Surgeons, Society of Surgical Oncology, Society of University Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Michelle Whittier Krause, MD, MPH Associate Professor of Medicine, Division of Nephrology, University of Arkansas for Medical Sciences

Michelle Whittier Krause, MD, MPH is a member of the following medical societies: American Society of Nephrology, International Society of Nephrology, National Kidney Foundation

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Don S Schalch, MD Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics

Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

Chief Editor

Romesh Khardori, MD, PhD, FACP Professor of Endocrinology, Director of Training Program, Division of Endocrinology, Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Additional Contributors

Daniel Einhorn, MD, FACP, FACE Medical Director, Scripps/Whittier Diabetes Institute; Associate Clinical Professor of Medicine, University of California, San Diego, School of Medicine

Daniel Einhorn, MD, FACP, FACE is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, Phi Beta Kappa, Society of Nuclear Medicine and Molecular Imaging

Disclosure: Nothing to disclose.

Elizabeth H Harris, MD, FACE Clinical Assistant Professor, Division of Endocrinology, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine

Elizabeth H Harris, MD, FACE is a member of the following medical societies: American Association of Clinical Endocrinologists, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Acknowledgements

Vitaly Kantorovich, MD Assistant Professor and Director of the UAMS Weight Control Program, Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences and Staff Physician, Central Arkansas Veterans Healthcare System

Vitaly Kantorovich, MD is a member of the following medical societies: The Endocrine Society

Disclosure: Nothing to disclose.

Antoine Makdissi, MD Assistant Professor of Medicine, University of Arkansas for Medical Sciences College of Medicine

Disclosure: Nothing to disclose.

What causes hypercalcemia in primary hyperparathyroidism?

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