Nephrolithiasis Associated with Normocalcemic or Hypercalcemic Primary Hyperparathyroidism: An Update on Medical Management

Primary hyperparathyroidism (PHPT) is a disease involving a broad range of alterations of calcium homeostasis, sustained by parathyroid hormone (PTH) levels that are clearly abnormal. The anomalies directly associated with hyperparathyroidism are nephrolithiasis and fibrocystic bone disease. Since PHPT resolves when abnormal parathyroid tissue is removed, surgery is clearly the only definitive approach to this type of hyperparathyroidism. However there are large subgroups of patients for whom medical therapy should be considered instead of surgery. Pharmacological therapy consists largely of biphosphonates, or calciomimetics such as cinacalcet. Recent preliminary data suggests however that cinacalcet could also be effective in the specific group of patients with primary hyperparathyroidism associated with nephrolithiasis. Finally, since cinacalcet reduces calcemia in most PHPT patients without improving bone mass, whereas biphosphonates and especially alendronate improve bone mass, it could make sense to combine the two drugs in PHPT patients with concomitant bone loss and possibly nephrolithiasis who cannot or do not wish to undergo surgery.