is a disease of the parathyroid glands that was caused by some other
disease. The parathyroid glands grew big and went crazy
"secondary" to some other problem.
= caused by something else
= condition of too much parathyroid gland activity
hyper = too much
parathyroid = parathyroid gland
ism = a disease or condition
= SECONDARY HYPERPARATHYROIDISM
"Secondary hyperparathyroidism is the
most incorrectly diagnosed condition in the world. Almost every
doctor makes this mistake, especially kidney doctors"
Secondary Hyperparathyroidism is
Primary Hyperparathyroidism is
hyperparathyroidism is misdiagnosed all the time. Most
endocrinologists diagnose this incorrectly, and nearly all nephrologists
(kidney doctors) diagnose this incorrectly. We have the world's largest
medical practice on parathyroid issues, seeing about 3000 new cases per
year. We see secondary hyperparathyroidism diagnosed incorrectly about 3
times per day in patients that are sent to our clinic. In a 3 month period
from August to December of 2013 we saw 227 patients who were diagnosed
with secondary hyperparathyroidism by their doctors and only 2 actually
had it. If you are reading this because your doctor said you have
secondary hyperparathyroidism, then pay close attention--you almost surely
hyperparathyroidism and need an operation to remove a tumor from your
neck. You should only read this page if your doctor said you have
secondary hyperparathyroidism (so you will lean that you probably do not
IMPORTANT! Almost 100% of hyperparathyroidism is PRIMARY
hyperparathyroidism, which is what 99.9% of this huge website is about.
You should NOT read this page if your doctor did not mention secondary
hyperparathyroidism. You should read this if you have kidney problems, and
you must read this if your doctor said you have high parathyroid hormone
and secondary hyperparathyroidism because you are developing kidney
failure! You will learn that unless you are having kidney dialysis every
other day because you don't have any kidneys, then it is almost guaranteed
you do not have secondary hyperparathyroidism. This is the only page of
this very large website on secondary hyperparathyroidism.
OK, Here we
go: Secondary Hyperparathyroidism:
hyperparathyroidism means the parathyroid glands are overproducing
parathyroid hormone in an attempt to help the body increase
the amount of calcium in the blood. It is the only job of the
parathyroid glands to maintain normal calcium levels and the four
parathyroid glands will increase the production of their hormone
(parathyroid hormone—PTH) if the calcium is too low. When a person has
secondary hyperparathyroidism, then something is causing the parathyroid
glands to become over active, thus we say it is “secondary” (caused
by) something else. Secondary
hyperparathyroidism cannot ever be associated with high blood calcium.
Even a slightly high calcium level excludes the possibility of secondary
hyperparathyroidism. Thus if your calcium level is 10.0 mg/dl or higher
(2.5 mmol/l or higher for our European friends) you cannot have secondary
Secondary hyperparathyroidism only occurs in a few situations where a
patient cannot absorb enough calcium in their diet, or they have kidney
failure requiring dialysis and they lose control of calcium and
phosphorus. Because it is the primary and only job of the parathyroid
glands to help maintain calcium in the normal range, a low calcium level
will cause all four parathyroid glands to produce more parathyroid hormone
(PTH) in an attempt to increase calcium absorption in the intestines, and
to remove calcium out of the bones. The net effect is that the parathyroid
glands will increase the amount of calcium in the blood by taking it out
of the bones—but this can only happen if the blood calcium is low to
start with. Thus the parathyroid glands are overworking “secondary” to
(because of) a low blood calcium level. If you have a high normal, or high
calcium level, you cannot develop secondary hyperparathyroidism.
of Secondary Hyperparathyroidism
are only a few causes of secondary hyperparathyroidism. All of them are
associated with poor absorption of calcium by the intestines, leading to
low normal or low blood calcium. If you don’t have one of these
situations, then you cannot have secondary hyperparathyroidism. Remember,
the parathyroid glands are unhappy and going crazy because the calcium is
low (or phosphorus is high--more about that later).
Causes of Secondary Hyperparathyroidism
failure requiring dialysis (GFR less than 15)
If you are not on dialysis, it is almost impossible
to have secondary hyperparathyroidism
or intestine bypass for obesity surgery
Gastric (stomach) Bypass
Disease (typically severe for many years--extremely
Disease (typically severe for many years--extremely
vitamin D deficiency
Must have low blood calcium levels—cannot
lead to high blood calcium
Diagnosed wrong 95% of the time (patient
actually has primary hyperparathyroidism)
Cannot give parathyroid hormone levels (PTH) more
than 100 pg/ml (8.8 mmol/L)
This is the most common mistake in all of medicine.
Low vitamin D does NOT cause high blood calcium. If your doctor
said you have secondary hyperparathyroidism because your vitamin D
is low, then almost 100% he/she is wrong and you have primary
of Primary vs. Secondary Hyperparathyroidism
biggest mistake made by all types of doctors, including nephrologists and
endocrinologists is to confuse primary hyperparathyroidism with secondary
hyperparathyroidism. This is VERY important since primary
hyperparathyroidism must be cured with surgery while secondary
hyperparathyroidism is treated with vitamin D (and calcium). Think of
these two as opposites! If you simply remember that secondary
hyperparathyroidism cannot ever be associated with high blood calcium,
then you will get this correct almost all the time. If it is so simple,
then why do doctors get this wrong all the time? We wish we could tell you
that answer, but this mistake is the reason we made the Vitamin-D-Pro
app—so people could tell primary hyperparathyroidism from secondary
hyperparathyroidism. This is why the app asks questions about stomach
surgery, kidney stones and dialysis on the front page. Vitamin D can have
great benefits for many people, but must be avoided in people with high
blood calcium (primary
hyperparathyroidism is caused by a tumor of a parathyroid gland. This
leads to high blood calcium in almost all cases. Primary
hyperparathyroidism is treated with surgery to remove the parathyroid
tumor from the neck. Primary hyperparathyroidism CANNOT be treated with
vitamin D. In fact, giving vitamin D to a patient with high blood calcium
can be dangerous and can cause the blood calcium to rise to very high
levels and even cause heart attacks and stroke. Primary
hyperparathyroidism is discussed in detail in other articles, but you can
remember the difference because primary hyperparathyroidism is
“primarily a parathyroid problem”. There is nothing else that caused
the parathyroid glands to become active. The person developed a tumor on a
parathyroid gland (in their neck).
hyperparathyroidism is NOT caused by a parathyroid tumor. Secondary
hyperparathyroidism is treated with high doses of vitamin D, often
including high doses of calcium (depending on the situation).
Why do Doctors Confuse Primary
Hyperparathyroidism as Secondary?
here folks... we are about to confuse you. Primary
hyperparathyroidism is almost always associated with low vitamin D.
About 92% of our last 23,000 patients being operated on for primary
hyperparathyroidism (and having a parathyroid tumor removed from their
neck) had low vitamin D (less than 30 ng/ml in the U.S. and less than 80
nmol/L in most other countries) (different units of measure).
is the low vitamin D that confuses doctors. They all make the
assumption that the low vitamin D is the problem, and therefore jump
immediately to the conclusion that the patient has secondary
hyperparathyroidism. Since low
vitamin D is common, and giving vitamin D is a good thing, they just
assume the patient has low vitamin D and this has somehow caused a problem
with the parathyroid glands that has lead to high blood calcium.
This cannot happen. There is no mechanism by which a low vitamin D
level can lead to high blood calcium. Vitamin D is required for calcium
absorption in the intestines, and therefore, you cannot, under any
circumstance have high blood calcium because of the low vitamin D. If
your calcium is high (even slightly high) and your vitamin D is low, then
the excess calcium in the blood must have come from somewhere other than
the intestines and your diet. The only other source of calcium is your
bones—and that is the primary action of parathyroid hormone.
if the calcium is high and the vitamin D is low, the patient is almost
guaranteed to have primary hyperparathyroidism and a parathyroid tumor in
their neck. The body has turned off vitamin D production because the
body doesn’t want more calcium. There is too much calcium in the blood
already and thus the body does not want to absorb any more calcium from
the intestines—so it turns off the vitamin D, and vitamin D levels fall.
Almost all patients with a parathyroid tumor have low vitamin D.
It is inappropriate to give vitamin D to a patient with high blood
calcium. If the user of this app has calcium levels above 10.1 mg/dl (2.6
mmol/L) then it will not make recommendations for them in the vitamin
store, and will tell them that taking vitamin D can be dangerous.
you cannot have secondary hyperparathyroidism and have high blood calcium.
Secondary hyperparathyroidism can ONLY be seen with calcium levels that
are mid-normal, low normal, or low.
Disease and Increasing Parathyroid Hormone Levels
hyperparathyroidism occurs in all (yes, all) patients who have kidney
failure, HOWEVER, they must have such severe kidney failure that they
are on dialysis. This is another amazingly common mistake made by almost
all nephrologists. Yes, it is true, at least 90% of kidney doctors can't
tell the difference between primary and secondary hyperparathyroidism.
This graph shows kidney function on the bottom "X" axis with the
green areas being great kidney function where the kidney can filter over
90 ml of blood every minute (called GFR, meaning glomerular filtration
rate). As the kidneys fail, they filter (clean) less of the blood, so that
a kidney that can only filter between 30 and 60 ml per minute (about a
coffee cup full) are said to have Stage III kidney failure. The vertical
"Y" axis shows parathyroid hormone levels. This graph shows that
parathyroid hormone (PTH) levels (a measure of the activity of the
parathyroid glands) remains normal (between 15 and 65 pg/ml) until
patients have a GFR less than 15. The blue dots are PTH levels in 300
patients with worsening kidney failure showing that the PTH does not rise
until the GFR is less than 20, or really, less than 15. And, it needs to
be less than 15 for about 6-12 months before the PTH levels start to rise.
You cannot have Stage II, or Stage III kidney failure and have secondary
hyperparathyroidism. This does not happen. In fact, it is very rare to
have Stage IV kidney failure and have secondary hyperparathyroidism. It is
almost 100% true that you cannot have secondary hyperparathyroidism unless
you have Stage V (5) kidney failure and are on dialysis. If you are not on
dialysis, then you almost surely do not have secondary
hyperparathyroidism. This mistake is made very commonly. Also remember,
you cannot have secondary hyperparathyroidism if your calcium is not low
normal or low.
if you have 1) kidney failure of some form, 2) your parathyroid hormone
(PTH) is high, 3) your calcium is 10.0 mg/dl or higher, and 4) you have
not been on dialysis for 1 year or more, then you have PRIMARY
hyperparathyroidism and you do not have secondary hyperparathyroidism. Why
is this important? Because it is very likely that the parathyroid tumor is
what is killing your kidney! Are you listening? We see this mistake
made every single day. If your PTH is high and your doctors say you have
secondary hyperparathyroidism and you are not on dialysis, then you almost
for sure have PRIMARY hyperparathyroidism and you need to get your
parathyroid TUMOR out of your neck because it is killing your
kidneys. PLEASE read this again. This page will save at least
100 patient's lives every day. Parathyroid tumors kill kidneys (over a
number of years), and if you
have high PTH levels and you are not on dialysis, then it is very likely
the parathyroid tumor is either directly responsible for the kidney
failure, or it is making it much worse. You cannot have secondary
hyperparathyroidism unless your calcium is very low, and you cannot have
secondary hyperparathyroidism if your GFR is over 25.
Vitamin-D-Pro app was designed
exactly for this purpose. It will absolutely tell you if you have
secondary hyperparathyroidism or primary hyperparathyroidism. Get it
in the Apple
store, or get it in the Google Play
store. You need to have
your blood test results--just plug them into the app and the computer will
tell you primary vs. secondary hyperparathyroidism and tell you if you
need to take vitamin D or if you need to have an operation to remove the
tumor from your neck. We made this app because MOST doctors can't
get this right! It costs $1.99
Why did the
secondary hyperparathyroidism occur?
common thread for all of these conditions is that the intestines do not
absorb enough calcium because there is either 1) a problem with the
intestine wall so that the calcium cannot get from inside the intestines
through the intestine wall and into the blood, or 2) not enough
vitamin D to help transport the calcium through the intestine wall.
Remember, the only thing vitamin D does in the human body (with a few
exceptions) is to transport calcium from our food into our blood through
the intestine wall. Vitamin D is a
transport molecule for calcium. Thus if a person has a very low
vitamin D level, they will have problems absorbing calcium that they eat
into their blood. This is why most milk has vitamin D added to it, and why
almost all calcium pills you can buy have vitamin D in them. To understand
why kidney failure causes secondary hyperparathyroidism you have to
remember that the active form of vitamin D is produced by the kidney! Thus
if the kidneys have failed, the patient cannot activate the vitamin D and
therefore they cannot absorb calcium in their diet.
to have secondary hyperparathyroidism, you MUST have a low blood
calcium--which is what caused the parathyroid glands to go crazy.
If your doctor says that you have high blood calcium because you have a
low vitamin D level, he/she is wrong. It is impossible for low vitamin D
to cause a high blood calcium. Vitamin D is required to absorb calcium
from our diets through our intestine wall, and if the vitamin D is low
then you can't absorb enough calcium and your blood calcium goes LOW.
HOWEVER, this is RARE, and can ONLY occur in the diseases above. And, you
are VERY SICK from these other diseases, so it isn't a surprise.
Hyperparathyroidism: How Many Parathyroid
Glands are Bad?
Patients with primary hyperparathyroidism have the disease because they
grew a tumor on one (or two) of their parathyroid glands. Patients with
primary hyperparathyroidism almost never have 4 bad glands (see photos
of parathyroid tumors we took out of people--it isn't gross!).