Clinical Manifestations of Pseudo-clubbing and Management in the Setting of Severe Secondary/Tertiary Hyperparathyroidism with ESKD

Introduction: Secondary hyperparathyroidism frequently complicates chronic kidney disease (CKD) and can evolve into tertiary hyperparathyroidism due to prolonged parathyroid gland stimulation. This progression significantly impacts bone metabolism and overall health. We report a case of a 27-year-old male patient with severe long-standing secondary/tertiary hyperparathyroidism and end-stage renal disease (ESRD), presenting with pseudoclubbing of the fingers and thumbs. Case Description: Patient is a 27 year old man with a history of bilateral congenital renal hypoplasia on peritoneal dialysis at six months of age, cadaveric kidney transplant recipient at 6 years old, which failed in October 2020, leading to a transition to hemodialysis. Currently, he undergoes hemodialysis four times per week, for 18 to 20 hours weekly, with excellent clearance. Recent lab findings have been significant for elevated blood urea nitrogen, creatinine, Phosphorous, PTH (1409-1846 pg/mL), and a normal calcium consistent with severe tertiary hyperparathyroidism. Patient noted to have pseudoclubbing on physical exam, which is indicative of significant systemic effects. The patient's current hemodialysis regimen has led to excellent clearance, although severe hyperparathyroidism and pseudo clubbing persist, necessitating ongoing comprehensive management. The patient is on calcimimetics and active vitamin D analogs to suppress PTH secretion and manage mineral metabolism. Given the severity of hyperparathyroidism and presence of pseudoclubbing, surgical intervention (parathyroidectomy) is currently being considered. Discussion: This case underscores the complexity of managing severe secondary/tertiary hyperparathyroidism in ESRD patients. Pseudoclubbing, although rare, requires meticulous clinical attention and intervention. A multidisciplinary approach involving nephrologists, endocrinologists, and surgeons is crucial for optimizing outcomes. Continuous monitoring of labs, individualized treatment plans, and proactive management of complications are vital for improving quality of life and prognosis in patients with advanced renal disease and associated endocrine disorders. Further research is needed to explore optimal management practices for patients with similar presentations, including rare manifestations like pseudoclubbing.