In Reply We thank Bertocchio and Gaschen et al for their interest in our study,1 their insightful comments, and the opportunity to provide clarifications. First, parathyroid hormone (PTH) can, indeed, be elevated in vitamin D insufficiency, a common cause of secondary hyperparathyroidism (sHPT). Elevated PTH is usually associated with normocalcemia in sHPT, in contrast to primary hyperparathyroidism (pHPT), where elevated PTH is typically associated with hypercalcemia. Therefore, vitamin D insufficiency is unlikely to have misclassified any of the patients in the pHPT cohort based on our inclusion criteria. Indisputably, 25-hydroxy vitamin D level should be part of the clinical evaluation of all patients with suspected pHPT. This is most important in the diagnostic setting of normocalcemic pHPT or in hypercalcemia with normal (but inadequately suppressed) PTH, both of which scenarios were excluded from our cohort.1,2 It should be noted that low 25-hydroxy vitamin D in pHPT is frequently the result of high PTH levels (PTH-mediated conversion of 25-hydroxy vitamin D into 1,25-dihydroxyvitamin D) rather than the cause.
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Alore EA, Ramsey DJ, Makris KI. Diagnosis and Management of Hyperparathyroidism—Reply. JAMA Intern Med. 2019;179(12):1733–1734. doi:10.1001/jamainternmed.2019.5087
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