Vitamin D Deficiency in Primary Hyperparathyroidism

Characteristics of Primary Hyperparathyroidism Complicated by Vitamin D Deficiency

Overall, hypovitaminosis D is associated with a more severe form of PHPT in terms of biochemical and possibly bony features. This observation is not unexpected, because vitamin D deficiency per se is known to stimulate PTH secretion, causing secondary hyperparathyroidism which may be additive to the pre-existing PHPT.^[15] Retrospective studies from the US showed that patients with PHPT having vitamin D deficiency, defined as serum 25-OHD levels <15 ng/mL, <20 ng/mL, or <25 ng/mL had higher circulating levels of PTH, calcium, and alkaline phosphatase, and greater parathyroid adenoma weight compared with their vitamin D-sufficient counterparts.^[9,16–18] Moreover, low serum levels of 25-OHD were shown to be related to persistent elevation of PTH after parathyroidectomy in some, but not all studies.^[17–19]

Data regarding the relationship between serum 25-OHD values and bony manifestations of PHPT were inconsistent. In a series of 243 consecutive patients with PHPT, Moosgard et al^[20] found that low serum levels of 25-OHD were associated with decreased bone mineral density (BMD) in the forearms, femoral neck, and whole body, independently of PTH levels. Conversely, in a smaller cross-sectional study, Carnevale et al^[21] did not find a significant correlation between 25-OHD plasma levels and BMD at the lumbar spine and femoral neck in 62 women with PHPT. While no significant association was found between serum levels of 25-OHD and the prevalence of fractures in the cross-sectional study of Moosgard et al,^[20] one retrospective study from Sweden showed that low serum levels of 25-OHD₃ in the 10-year period preceding parathyroidectomy were an independent risk factor for the occurrence of fractures.^[22] With respect to the possible link between vitamin D deficiency and renal complications of PHPT, available data suggest no significant difference in urinary calcium excretion or in the occurrence of kidney stones between patients with and without vitamin D deficiency.^[5,17]

Table. Overview of studies of vitamin D supplementation in patients with concomitant vitamin D deficiency and primary hyperparathyroidism^a
	Grey et al²⁴	Tucci²⁵	Isidro and Ruano²⁶	Grubbs et al²⁷	Kantorovich et al¹⁵
Design	Prospective audit study	Prospective audit study	Prospective	Retrospective, controlled	Retrospective
Follow-up	12 mo	34 wk	12 mo	6 mo	12 mo
Patient number and gender	n = 25, 23 women	n = 56, 37 women	n = 27, 24 women	n = 112, 87 women	n = 5, gender not reported
Mean age (yr)	68	30	67	58	Not reported
Regimen of vitamin D therapy	Cholecalciferol (vitamin D₃) 50,000 IU/wk for 1 mo, then 50,000 IU/mo for 12 mo	Ergocalciferol (vitamin D₂) 50,000 U/wk for 8 wk, followed by 800 U/day up to 100,000 U/mo to keep serum vitamin D ≥75 mmol/L (30 ng/mL)	Calcifediol (25OH vitamin D) 480–960 IU/d	Ergocalciferol (vitamin D2) 50,000 units two to three times/wk for four to 8 wk to keep serum vitamin D ≥75 mmol/L (30 ng/mL)	Vitamin D2 50,000 U + 1000 mg elemental calcium twice/wk for 5 wk
Mean serum levels of 25-OHD at baseline	11 ng/mL	14 ng/mL	11 ng/mL	18 ng/mL	8 ng/mL
Mean serum levels of 25-OHD after vitamin D therapy	31 ng/mL after one year	37 ng/mL after 34 wk	28 ng/mL after 12 mo	46 ng/mL after four to 8 wk	20 ng/ml after 5 wk
Mean serum levels of calcium at baseline	10.8 mg/dL	11 mg/dL	10.8 mg/dL	10.9 mg/dL	10.1 mg/dL
Mean serum levels of calcium after vitamin D therapy	10.8 mg/dL	10.8 mg/dL	10.9 mg/dL	10.7 mg/dL	10.1 mg/dL
Patients having increase in serum calcium levels	Calcium increased in one patient from 10.5 to 11.3 mg/dL	Calcium increased in two patients from 11.2 to 12.1 mg/dL, and from 11.3 to 12.2 mg/dL at 10 wk	Calcium increased in two patients from 10.8 to 12.4 mg/dL, and from 10.8 to 12 mg/dL. Vitamin D therapy was discontinued in the two patients after 3 mo	Calcium increased in six of 112 patients (5%) to a maximum levels of 11.7 mg/dL	Calcium increased in one patient from 10.5 to 10.9 mg/dL
Baseline mean serum levels of intact PTH	138 pg/mL	144 pg/mL	188 pg/mL	175 pg/mL	107 pg/mL
Serum levels of PTH after vitamin D therapy	102 pg/mL (26% significant reduction, P < 0.004)	133 pg/mL after (7% reduction, not statistically significant)	162 pg/mL (14% reduction, not statistically significant)	164 pg/mL (6% significant reduction, P < 0.01)	104 pg/mL (3% reduction, not Statistically significant)
Change in urine calcium after vitamin D therapy	Two patients had urine calcium >400 mg/24 hr	No significant change	Significant increase in the mean value from 228 to 316 mg/24 hr	Not reported	Significant increase in mean urinary calcium/creatinine ratio from 0.06 to 0.24. Three of the five patients developed hypercalciuria (urinary calcium/creatinine ratio >0.160)

Table. Overview of studies of vitamin D supplementation in patients with concomitant vitamin D deficiency and primary hyperparathyroidism^a

Grey et al²⁴

Tucci²⁵

Isidro and Ruano²⁶

Grubbs et al²⁷

Kantorovich et al¹⁵

Design

Prospective audit study

Prospective

Retrospective, controlled

Retrospective

Follow-up

12 mo

34 wk

12 mo

6 mo

12 mo

Patient number and gender

n = 25, 23 women

n = 56, 37 women

n = 27, 24 women

n = 112, 87 women

n = 5, gender not reported

Mean age (yr)

Not reported

Regimen of vitamin D therapy

Cholecalciferol (vitamin D₃) 50,000 IU/wk for 1 mo, then 50,000 IU/mo for 12 mo

Ergocalciferol (vitamin D₂) 50,000 U/wk for 8 wk, followed by 800 U/day up to 100,000 U/mo to keep serum vitamin D ≥75 mmol/L (30 ng/mL)

Calcifediol (25OH vitamin D) 480–960 IU/d

Ergocalciferol (vitamin D2) 50,000 units two to three times/wk for four to 8 wk to keep serum vitamin D ≥75 mmol/L (30 ng/mL)

Vitamin D2 50,000 U + 1000 mg elemental calcium twice/wk for 5 wk

Mean serum levels of 25-OHD at baseline

11 ng/mL

14 ng/mL

11 ng/mL

18 ng/mL

8 ng/mL

Mean serum levels of 25-OHD after vitamin D therapy

31 ng/mL after one year

37 ng/mL after 34 wk

28 ng/mL after 12 mo

46 ng/mL after four to 8 wk

20 ng/ml after 5 wk

Mean serum levels of calcium at baseline

10.8 mg/dL

11 mg/dL

10.8 mg/dL

10.9 mg/dL

10.1 mg/dL

Mean serum levels of calcium after vitamin D therapy

10.8 mg/dL

10.9 mg/dL

10.7 mg/dL

10.1 mg/dL

Patients having increase in serum calcium levels

Calcium increased in one patient from 10.5 to 11.3 mg/dL

Calcium increased in two patients from 11.2 to 12.1 mg/dL, and from 11.3 to 12.2 mg/dL at 10 wk

Calcium increased in two patients from 10.8 to 12.4 mg/dL, and from 10.8 to 12 mg/dL. Vitamin D therapy was discontinued in the two patients after 3 mo

Calcium increased in six of 112 patients (5%) to a maximum levels of 11.7 mg/dL

Calcium increased in one patient from 10.5 to 10.9 mg/dL

Baseline mean serum levels of intact PTH

138 pg/mL

144 pg/mL

188 pg/mL

175 pg/mL

107 pg/mL

Serum levels of PTH after vitamin D therapy

102 pg/mL (26% significant reduction, P < 0.004)

133 pg/mL after (7% reduction, not statistically significant)

162 pg/mL (14% reduction, not statistically significant)

164 pg/mL (6% significant reduction, P < 0.01)

104 pg/mL (3% reduction, not Statistically significant)

Change in urine calcium after vitamin D therapy

Two patients had urine calcium >400 mg/24 hr

No significant change

Significant increase in the mean value from 228 to 316 mg/24 hr

Not reported

Significant increase in mean urinary calcium/creatinine ratio from 0.06 to 0.24. Three of the five patients developed hypercalciuria (urinary calcium/creatinine ratio >0.160)

Clinical Significance of Vitamin D Deficiency in Primary Hyperparathyroidism, and Safety of Vitamin D Therapy

Characteristics of Primary Hyperparathyroidism Complicated by Vitamin D Deficiency

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Clinical Significance of Vitamin D Deficiency in Primary Hyperparathyroidism, and Safety of Vitamin D Therapy

Characteristics of Primary Hyperparathyroidism Complicated by Vitamin D Deficiency

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