Raised PTH with normal calcium (secondary or normocalcaemic primary hyperparathyroidism)
BioMG follows French guidelines. Adapt it to the guidelines and the tests available where you practise.
First-line tests
Fasting laboratory tests in the morning
- Serum calcium
- Serum albumin
- PTH (on the same sample as the serum calcium)
- Serum phosphate
- Serum magnesium
- Serum creatinine with eGFR
- 25-hydroxyvitamin D
- Ionised calcium (high-normal total calcium or albumin < 35 g/L)if neededDoubtful situation: total calcium in the upper range of normal, or hypoalbuminaemia < 35 g/L; demanding sampling, not reimbursed in community practice in France [1].
- IgA anti-tissue transglutaminase antibodies (if chronic diarrhoea, weight loss or deficiency suggesting malabsorption)if needednon-French guidelineThe 2022 European consensus proposes this test, with faecal calprotectin, to look for coeliac disease or IBD among the causes of secondary hyperparathyroidism [2]. The French consensus cites these causes without specifying the test [1,3].
24-hour urine collection
- Urinary calcium
- 24-hour urinary creatinine (to calculate FeCa)
Also consider
- High serum calcium? If serum calcium is high, see the page "Hypercalcaemia".
- Low calcium? If serum calcium is low, see the page "Hypocalcaemia".
Do not order
- Albumin-"corrected" calcium: it adds nothing and misclassifies more often than total calcium; in hypoalbuminaemia, measure ionised calcium [1].
- Bone turnover markers as a routine: not recommended in primary hyperparathyroidism [1].
- Dynamic tests (calcium load, cinacalcet, thiazide) in routine practice: none is robust; they are for a trained team [1,3].
Recheck after correction
After at least 6 months of normal vitamin D status and correction of causes (in the morning, fasting)
- Serum calcium
- Serum albumin
- PTH (on the same sample as the serum calcium)
- Serum creatinine with eGFR
- 25-hydroxyvitamin D (check correction)
Sources (8)
- Bouillet B, Bertocchio JP, Nominé-Criqui C, Kerlan V. Chapter 2: Primary hyperparathyroidism: diagnosis. Consensus SFE-AFCE-SFMN 2024 sur l'hyperparathyroïdie primaire. Ann Endocrinol (Paris). 2025;86(1):101691.
- Bollerslev J, Rejnmark L, Zahn A, Heck A, Appelman-Dijkstra NM, et al. European expert consensus on practical management of specific aspects of parathyroid disorders in adults and in pregnancy: recommendations of the ESE Educational Program of Parathyroid Disorders. Eur J Endocrinol. 2022;186(2):R33-R63.
- Kamenický P, Houillier P, Vantyghem MC. Chapter 4: Differential diagnosis of primary hyperparathyroidism. Consensus SFE-AFCE-SFMN 2024 sur l'hyperparathyroïdie primaire. Ann Endocrinol (Paris). 2025;86(1):101693.
- Assurance maladie. Nomenclature des actes de biologie médicale (NABM), version 105 : actes 0983 (parathormone) et 1139 (25-OH-vitamine D).
- National Institute for Health and Care Excellence (NICE, Royaume-Uni). Hyperparathyroidism (primary): diagnosis, assessment and initial management. NICE guideline NG132, 23 mai 2019.
- Bilezikian JP, Khan AA, Silverberg SJ, Fuleihan GE, Marcocci C, Minisola S, et al. Evaluation and management of primary hyperparathyroidism: summary statement and guidelines from the Fifth International Workshop. J Bone Miner Res. 2022;37(11):2293-2314.
- Wilhelm SM, Wang TS, Ruan DT, Lee JA, Asa SL, Duh QY, et al. The American Association of Endocrine Surgeons guidelines for definitive management of primary hyperparathyroidism. JAMA Surg. 2016;151(10):959-968.
- Frey S, Mosbah H, Donatini G, Brunaud L, Chabre O, Vezzosi D. Chapter 9: Indications for the treatment of primary hyperparathyroidism. Consensus SFE-AFCE-SFMN 2024 sur l'hyperparathyroïdie primaire. Ann Endocrinol (Paris). 2025;86(1):101698.