Last reviewed: 28 Jun 2021
Last updated: 24 May 2018



History and exam

Key diagnostic factors

  • presence of risk factors
  • features of chronic renal failure
  • features of underlying malabsorption syndrome

Other diagnostic factors

  • muscle cramps and bone pain
  • perioral tingling or paresthaesia in fingers or toes
  • Chvostek's sign
  • Trousseau's sign
  • bowed legs or knock knees
  • fractures

Risk factors

  • ageing
  • chronic renal failure
  • vitamin D deficiency: inadequate sunlight exposure
  • nutritional deficiency (especially absence of dairy products and fish)
  • vitamin D deficiency: malabsorption
  • vitamin D deficiency: hepatic dysfunction
  • vitamin D deficiency: genetic disorder
  • vitamin D deficiency: obesity
  • medication use

Diagnostic investigations

1st investigations to order

  • serum calcium
  • serum intact parathyroid hormone (iPTH)
  • serum creatinine
  • serum urea nitrogen

Investigations to consider

  • serum phosphorus
  • serum 25-hydroxyvitamin D
  • serum magnesium
  • ultrasound neck
  • sestamibi scan
  • high-resolution contrast CT scan neck and upper chest
  • MRI neck and upper chest

Treatment algorithm



Hugh Gallagher, PhD, FRCP

Consultant Nephrologist

Honorary Senior Lecturer

Renal Medicine

Epsom & St Helier University Hospitals NHS Trust



HG declares that he has no competing interests.

Louise Ross, MBBS

Clinical Research Fellow & Specialist Renal Registrar

Renal Medicine

Epsom & St Helier University Hospitals NHS Trust



LR declares that she has no competing interests.


Dr Hugh Gallagher and Dr Louise Ross would like to gratefully acknowledge Dr Brendan C. Stack Jr, Dr David J.A. Goldsmith, and Dr Kiran Haresh Kumar Patel, previous contributors to this monograph. BCS, DJAG, and KHKP declare that they have no competing interests.

Peer reviewers

Fong-Fu Chou, MD

Department of Surgery

Chang Gung Memorial Hospital-Kaohsiung Medical Center

Chang Gung University College of Medicine

Kaohsiung Hsien



Not disclosed.

Victor Schneider, MD

Clinical Associate Professor of Medicine

Uniformed Health Services University of the Health Sciences




VS declares that he has no competing interests.

Use of this content is subject to our disclaimer