Osteoporosis International

, Volume 28, Issue 5, pp 1667–1674 | Cite as

Skeletal effects of vitamin D deficiency among patients with primary hyperparathyroidism

  • J. H. Lee
  • J. H. Kim
  • A. R. Hong
  • S. W. Kim
  • C. S. ShinEmail author
Original Article



Little is known about the association between vitamin D deficiency and the skeletal phenotypes in primary hyperparathyroidism (PHPT) patients. A low 25-hydroxyvitamin D level was associated with a low bone mineral density and deteriorated hip geometry in women with PHPT in an Asian population where vitamin D deficiency is prevalent.


Few studies have examined the effect of vitamin D deficiency on the bone health of primary hyperparathyroidism (PHPT) patients.


We investigated the skeletal effects of vitamin D deficiency in 79 PHPT patients by assessing bone mineral density (BMD), the trabecular bone score (TBS), and hip geometry, which were measured using dual-energy X-ray absorptiometry (27 men with median age 60 years [53;69]; 52 postmenopausal women with median age of 57 years [53;67]). Cross-sectional data were collected from subjects enrolled in an ongoing PHPT cohort study at Seoul National University Hospital from March 2008 to December 2015.


We classified PHPT patients according to 25-hydroxyvitamin D (25(OH)D) levels (<20 vs. ≥20 ng/ml). After adjusting for age and body mass index, women with vitamin D deficiency had lower BMDs at the lumbar spine (LS) and femur neck (FN) than women who had sufficient levels of vitamin D (LS, 0.903 ± 0.138 vs. 0.998 ± 0.184 g/cm2; FN, 0.715 ± 0.084 vs. 0.791 ± 0.113 g/cm2; P < 0.05). However, the total hip BMD and the TBS were not significantly different between the two groups. In the hip geometry analysis, the cross-sectional area, cross-sectional moment of inertia, and section modulus were also significantly lower in women with vitamin D deficiency than in those without. No significant difference was found in the BMD, TBS, or hip geometry according to 25(OH)D levels in men.


Vitamin D deficiency may be associated with a low BMD and deteriorated hip geometry in postmenopausal women with PHPT.


Primary hyperparathyroidism Skeletal effects Vitamin D deficiency 



This work was supported by the Seoul National University Hospital Research Fund (Grant No. 1306-101-499).

Compliance with ethical standards

This study was approved by the Seoul National University Hospital Institutional Review Board (no. 1306-101-499) and informed consent was waived due to the retrospective cohort design.

Conflict of interest



  1. 1.
    Wermers RA, Khosla S, Atkinson EJ, Achenbach SJ, Oberg AL, Grant CS, Melton LJ (2006) Incidence of primary hyperparathyroidism in Rochester, Minnesota, 1993–2001: an update on the changing epidemiology of the disease. J Bone Miner Res 21:171–177CrossRefPubMedGoogle Scholar
  2. 2.
    Christensson T, Hellström K, Wengle B, Alveryd A, Wikland B (1976) Prevalence of hypercalcaemia in a health screening in Stockholm. Acta Med Scand 200:131–137CrossRefPubMedGoogle Scholar
  3. 3.
    Marcocci C, Cetani F (2011) Primary hyperparathyroidism. N Engl J Med 365:2389–2397CrossRefPubMedGoogle Scholar
  4. 4.
    Witteveen J, van Thiel S, Romijn J, Hamdy N (2012) Hungry bone syndrome: still a challenge in the post-operative management of primary hyperparathyroidism. A systemic review of the literature. Eur J Endocrinol 168:R45–R53CrossRefGoogle Scholar
  5. 5.
    Moosgaard B, Vestergaard P, Heickendorff L, Melsen F, Christiansen P, Mosekilde L (2005) Vitamin D status, seasonal variations, parathyroid adenoma weight and bone mineral density in primary hyperparathyroidism. Clin Endocrinol 63:506–513CrossRefGoogle Scholar
  6. 6.
    Silverberg SJ (2007) Vitamin D deficiency and primary hyperparathyroidism. J Bone Miner Res 22(Suppl 2):V100–V104CrossRefPubMedGoogle Scholar
  7. 7.
    Sahota O, Mundey M, San P, Godber I, Lawson N, Hosking D (2004) The relationship between vitamin D and parathyroid hormone: calcium homeostasis, bone turnover, and bone mineral density in postmenopausal women with established osteoporosis. Bone 35:312–319CrossRefPubMedGoogle Scholar
  8. 8.
    Rao DS, Honasoge M, Divine GW, Phillips ER, Lee MW, Ansari MR, Talpos GB, Parfitt AM (2000) Effect of vitamin D nutrition on parathyroid adenoma weight: pathogenetic and clinical implications. J Clin Endocrinol Metab 85:1054–1058PubMedGoogle Scholar
  9. 9.
    Bilezikian JP, Brandi ML, Eastell R, Silverberg SJ, Udelsman R, Marcocci C, Potts JT Jr (2014) Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. J Clin Endocrinol Metab 99:3561–3569CrossRefPubMedGoogle Scholar
  10. 10.
    Woodhouse N, Doyle F, Joplin G (1971) Vitamin-D deficiency and primary hyperparathyroidism. Lancet 298:283–287CrossRefGoogle Scholar
  11. 11.
    Grey A, Lucas J, Horne A, Gamble G, Davidson JS, Reid IR (2005) Vitamin D repletion in patients with primary hyperparathyroidism and coexistent vitamin D insufficiency. J Clin Endocrinol Metab 90:2122–2126CrossRefPubMedGoogle Scholar
  12. 12.
    Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, Murad MH, Weaver CM (2011) Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 96:1911–1930CrossRefPubMedGoogle Scholar
  13. 13.
    Litwic AE, Clynes M, Denison HJ, Jameson KA, Edwards MH, Sayer AA, Taylor P, Cooper C, Dennison EM (2016) Non-invasive assessment of lower limb geometry and strength using hip structural analysis and peripheral quantitative computed tomography: a population-based comparison. Calcif Tissue Int 98:158–164CrossRefPubMedGoogle Scholar
  14. 14.
    Beck T (2003) Measuring the structural strength of bones with dual-energy X-ray absorptiometry: principles, technical limitations, and future possibilities. Osteoporos Int 14(Suppl 5):S81–S88CrossRefPubMedGoogle Scholar
  15. 15.
    International Society for Clinical Densitometry (2015) ISCD official positions: adult. Accessed Nov 25 2016
  16. 16.
    Stein EM, Dempster DW, Udesky J, Zhou H, Bilezikian JP, Shane E, Silverberg SJ (2011) Vitamin D deficiency influences histomorphometric features of bone in primary hyperparathyroidism. Bone 48:557–561CrossRefPubMedGoogle Scholar
  17. 17.
    Walker MD, Cong E, Lee JA, Kepley A, Zhang C, McMahon DJ, Silverberg SJ (2015) Vitamin D in primary hyperparathyroidism: effects on clinical, biochemical, and densitometric presentation. J Clin Endocrinol Metab 100:3443–3451CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Walker MD, Nishiyama KK, Zhou B, Cong E, Wang J, Lee JA, Kepley A, Zhang C, Edward Guo X, Silverberg SJ (2016) Effect of low vitamin D on volumetric bone mineral density bone microarchitecture and stiffness in primary hyperparathyroidism. J Clin Endocrinol Metab 2015:4218Google Scholar
  19. 19.
    Rolighed L, Rejnmark L, Sikjaer T, Heickendorff L, Vestergaard P, Mosekilde L, Christiansen P (2014) Vitamin D treatment in primary hyperparathyroidism: a randomized placebo controlled trial. J Clin Endocrinol Metab 99:1072–1080Google Scholar
  20. 20.
    Kim H, Lee SH, Kim J, Lim KH, Ahn SH, Kim BJ, Koh JM (2015) The association of vitamin D with femoral neck strength: an additional evidence of vitamin D on bone health. J Clin Endocrinol Metab 100:3118–3125Google Scholar
  21. 21.
    Hwang S, Choi HS, Kim KM, Rhee Y, Lim SK (2015) Associations between serum 25-hydroxyvitamin D and bone mineral density and proximal femur geometry in Koreans: the Korean National Health and Nutrition Examination Survey (KNHANES) 2008–2009. Osteoporos Int 26:163–171Google Scholar
  22. 22.
    Martin EN, Haney EM, Shannon J, Cauley JA, Ensrud KE, Keaveny TM, Zmuda JM, Orwoll ES, Harrison SL, Marshall LM (2015) Femoral volumetric bone density, geometry, and strength in relation to 25-hydroxy vitamin D in older men. J Bone Miner Res 30:562–569CrossRefPubMedGoogle Scholar
  23. 23.
    Silva BC, Leslie WD, Resch H, Lamy O, Lesnyak O, Binkley N, McCloskey EV, Kanis JA, Bilezikian JP (2014) Trabecular bone score: a noninvasive analytical method based upon the DXA image. J Bone Miner Res 29:518–530CrossRefPubMedGoogle Scholar
  24. 24.
    Choi HS, Oh HJ, Choi H, Choi WH, Kim JG, Kim KM, Kim KJ, Rhee Y, Lim S-K (2010) Vitamin D insufficiency in Korea—a greater threat to younger generation: the Korea National Health and Nutrition Examination Survey (KNHANES) 2008. J Clin Endocrinol Metab 96:643–651CrossRefPubMedGoogle Scholar
  25. 25.
    Clements M, Davies M, Fraser D, Lumb G, Mawer EB, Adams P (1987) Metabolic inactivation of vitamin D is enhanced in primary hyperparathyroidism. Clin Sci (Lond) 73:659–664CrossRefGoogle Scholar
  26. 26.
    Bolland MJ, Grey AB, Gamble GD, Reid IR (2005) Association between primary hyperparathyroidism and increased body weight: a meta-analysis. J Clin Endocrinol Metab 90:1525–1530CrossRefPubMedGoogle Scholar
  27. 27.
    Bringhurst FR, Demay MB, Kronenberg HM (2015) Hormones and disorders of mineral metabolism. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM (eds) Williams textbook of endocrinology, 13th edn. Elsevier, Philadelphia, pp 1271–1272Google Scholar
  28. 28.
    Powe CE, Evans MK, Wenger J et al (2013) Vitamin D-binding protein and vitamin D status of black Americans and white Americans. N Engl J Med 369:1991–2000CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Gough IR, Balderson GA, Lloyd HM, Galligan J, Willgoss D, Fryar BG (1988) The effect of intravenous magnesium sulphate on parathyroid function in primary hyperparathyroidism. World J Surg 12:463–468CrossRefPubMedGoogle Scholar
  30. 30.
    Khosla S, Melton LJ 3rd, Riggs BL (2011) The unitary model for estrogen deficiency and the pathogenesis of osteoporosis: is a revision needed? J Bone Miner Res 26:441–451CrossRefPubMedGoogle Scholar
  31. 31.
    Gennari C, Agnusdei D, Nardi P, Civitelli R (1990) Estrogen preserves a normal intestinal responsiveness to 1, 25-dihydroxyvitamin D3 in oophorectomized women. J Clin Endocrinol Metab 71:1288–1293CrossRefPubMedGoogle Scholar
  32. 32.
    Ooms MELP, Roos JC, van der Vijgh WJ, Popp-Snijders C, Bezemer PD, Bouter LM (1995) Vitamin D status and sex hormone binding globulin: determinants of bone turnover and bone mineral density in elderly women. J Bone Miner Res 10:1177–1184CrossRefPubMedGoogle Scholar
  33. 33.
    Ross AC, Manson JE, Abrams SA et al (2011) The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J Clin Endocrinol Metab 96:53–58CrossRefPubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2017

Authors and Affiliations

  • J. H. Lee
    • 1
  • J. H. Kim
    • 1
  • A. R. Hong
    • 1
  • S. W. Kim
    • 1
  • C. S. Shin
    • 1
    Email author
  1. 1.Department of Internal MedicineSeoul National University College of MedicineSeoulSouth Korea

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