Parathyroid hormone (PTH) is formed in the parathyroid glands and secreted into the blood stream. Intact PTH consists of a single polypeptide chain containing 84 amino acids and has a molecular weight of approximately 9500 daltons.
The biologically active N‑terminal fragment has a half‑life of only a few minutes. Selective measurement of the (mainly) intact parathyroid hormone permits direct ascertainment of the secretory activity of the parathyroid glands.
PTH, together with vitamin D and calcitonin, brings about mobilization of calcium and phosphate from the skeletal system and increases the uptake of calcium in the intestine and the excretion of phosphate via the kidneys. The constancy of the blood calcium level is ensured by the interaction of PTH and calcitonin. The secretion of PTH is inhibited by high calcium concentrations and promoted by low calcium concentrations. Parathyroid gland disorders lead to elevated or depressed blood calcium levels (hypercalcemia or hypocalcemia) brought about by a change in the secretion of PTH. Detection of subfunctioning parathyroid glands (hypoparathyroidism) requires the use of a highly sensitive test in order to be able to measure PTH levels well below normal.
Hyperfunctioning of the parathyroid glands results in an increased secretion of PTH (hyperparathyroidism). Primary causes are adenomas of the parathyroid glands. In secondary hyperparathyroidism the blood calcium level is low as a result of other pathological states (e.g. vitamin D deficiency).
Today, great significance is attached to the determination of the PTH and calcium concentrations when assessing hyperparathyroidism. The determination of PTH intraoperatively during adenoma resection in the parathyroid glands has also been reported for primary hyperparathyroidism, secondary hyperparathyroidism relating to renal failure, and tertiary hyperparathyroidism post renal transplant surgery. Because PTH has a reported half life of 3‑5 minutes, a significant drop in PTH levels after resection of the abnormal gland or glands enables the surgeon to assess the completeness of resection and whether all hyperfunctioning parathyroid tissue has been removed from the patient.
The NACB guidelines recommend that baseline samples be obtained preoperation and pre‑excision of the suspected hyperfunctioning gland. Specimens for PTH testing should be drawn at 5 and 10 minutes post resection and that a > 50 % reduction in PTH levels from the highest baseline be used as criteria for surgical success. Additional samples may be necessary as it has been shown that sensitivity can increase with time. Failure of PTH to drop below recommended levels indicates that either 1) residual hyperfunctioning tissue is still present and further exploration may be necessary, as was in the case of two patients, both with a fifth ectopic parathyroid gland requiring further surgery, 7 or 2) a spike in PTH levels during adenoma mobilization occurred. Intraoperative PTH measurements offer fast, reliable assessment when all hyperfunctioning parathyroid tissue has been removed during the surgical process.