Hyperparathyroidism in Kidney Disease

Abstract

Extensive investigations of the parathyroid glands were instigated by the cure of generalized osteitis fibrosa cystica by surgical removal of a parathyroid adenoma by Mandl (1) in 1925. It was early noted that renal calculi were often found in cases of parathyroid tumor (2). Later work showed that these stones consisted chiefly of calcium phosphate and that the tendency to their formation was definitely decreased when the urine was made more acid (3). Removal of the parathyroid tumor. resulted in the disappearance of this tendency to calculus formation and of the alkalinity of the urine.Albright, Baird, Cope, and Bloomberg (4), in their discussion of 83 cases of parathyroid tumor with hyperparathyroidism, brought out the fact that 43 of these showed clinical evidence of renal damage. These kidney lesions were attributed to damage resulting from the deposition of calcium in the renal parenchyma or to the formation of calculi in the pelves, such calcium depositions being manifestations of primary hyperparathyroidism. However, these authors suggested the possibility that parathyroid enlargement may be secondary to renal impairment: " It seems conceivable therefore that a chronic renal insufficiency with phosphate retention and a high inorganic phosphorus level might likewise cause hyperplasia of all parathyroid tissue which might go on to multiple tumor formation" and later, "In these cases the kidney damage may be the cause and not the result of the parathyroid tumors."p Bergstrand (5) studied the parathyroid glands in an extensive series of autopsies, and in most of the cases where he found them enlarged, there was also some damage to the kidneys. Pappenheimer and Wilens (6) carefully weighed the parathyroid glands from a large series of necropsies. They found the parathyroids taken from unselected nephritics to average more than 50 per cent greater in weight than those taken from non-nephritic controls. Seven severe nephritics showed an increase of 109 per cent over the same control series. The enlargement was diffusely hyperplastic in character, resembling the enlargement which has been reported in rickets (7,8), and which may exist in pregnancy (9, 10). Adenomata were found in only three of 56 nephritics and in two of 74 controls. Jarrett, Peters, and Pappenheimer (11) report that they have induced a similar enlargement of the parathyroids by producing chronic renal insufficiency in rats.In previous reports from this laboratory evidence of functional hyperactivity of the parathyroid glands in rickets (12) and in pregnancy (13) has been presented. We have used the same approach in our investigation of parathyroid activity in the present series of nephritic patients,' to determine whether the hyperplasia noted by Pappenheimer and Wilens (6) is accompanied by a hyperfunction. The patients were selected on the basis of elevation of the blood urea nitrogen, most of them having chronic rather than acute renal insufficiency. The controls were thirtyeight normal persons-thirty women and eight men. Determinations of ca...

Experience With the Hamilton and Highman Test for Parathyroid Hyperfunction in Chronic Nephritis, Toxic Goiter, and Paget's Disease of Bone

“…Our series of nephritic cases accords with that of Highman and Hamilton (12) in that the patients had chronic nephritis and elevatidn of blood urea nitrogen. Most of our cases showed phosphorus retention and somewhat lowered plasma protein concentration; this is likewise true of Highman's series.…”

“…Highman and Hamilton found abnormally great amounts of parathyroid hormone in the blood of 20 of 23 patients with chronic nephritis and elevated blood urea nitrogen (12). Shelling and Remsen (13) reported a case of renal rickets with elevated concentrations of nitrogen and inorganic phosphorus in the blood, which case showed increased parathyroid hormone in the blood according to the Hamilton and Schwartz test, and at postmortem examination showed four markedly enlarged parathyroid glandules.…”

“…It was thought that the meaning of the test would be clarified through such studies. These thoughts were formulated and some of our results obtained before publication of Highman and Hamilton's communication concerning the parathyroid function test in nephritis (12).…”

The Calcium Content of the Kidney as Related to Parathyroid Function

“…Enlargement of the parathyroid glands is of regular occurrence in human cases of chronic renal disease (1-3), and may be experimentally induced in rats by reduction of functional kidney tissue (4,5). This enlargement is attended by an increase in circulating parathormone (6). Injection of parathormone increases the calcium content of the renal tissue (7)(8)(9), and its continued administration in large doses brings about severe histological damage (10).…”