Familial Hypocalciuric Hypercalcemia Types 1 and 3 and Primary Hyperparathyroidism: Similarities and Differences

J Clin Endocrinol Metab. 2016 May;101(5):2185-95. doi: 10.1210/jc.2015-3442. Epub 2016 Mar 10.


Context: Familial hypocalciuric hypercalcemia (FHH) is a genetically heterogeneous condition resembling primary hyperparathyroidism (PHPT) but not curable by surgery; FHH types 1, 2, and 3 are due to loss-of-function mutations of the CASR, GNA11, or AP2S1 genes, respectively.

Objective: This study aimed to compare the phenotypes of patients with genetically proven FHH types 1 or 3 or PHPT.

Design, setting, and patients: This was a mutation analysis in a large cohort, a cross-sectional comparison of 52 patients with FHH type 1, 22 patients with FHH type 3, 60 with PHPT, and 24 normal adults.

Intervention: There were no interventions.

Main outcome measures: Abnormalities of the CASR, GNA11, and AP2S1 genes, blood calcium, phosphate, and PTH concentrations, urinary calcium excretion were measured.

Results: In 133 families, we detected 101 mutations in the CASR gene, 68 of which were previously unknown, and in 19 families, the three recurrent AP2S1 mutations. No mutation was detected in the GNA11 gene. Patients with FHH type 3 had higher plasma calcium concentrations than patients with FHH type 1, despite having similar PTH concentrations and urinary calcium excretion. Renal tubular calcium reabsorption levels were higher in patients with FHH type 3 than in those with FHH type 1. Plasma calcium concentration was higher whereas PTH concentration and urinary calcium excretion were lower in FHH patients than in PHPT patients. In patients with FHH or PHPT, all data groups partially overlapped.

Conclusion: In our population, AP2S1 mutations affect calcium homeostasis more severely than CASR mutations. Due to overlap, the risk of confusion between FHH and PHPT is high.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adaptor Protein Complex 2 / genetics*
  • Adaptor Protein Complex sigma Subunits / genetics*
  • Adult
  • Calcium / blood
  • Cross-Sectional Studies
  • DNA Mutational Analysis
  • Female
  • GTP-Binding Protein alpha Subunits / genetics*
  • Genotype
  • Humans
  • Hypercalcemia / blood
  • Hypercalcemia / congenital*
  • Hypercalcemia / genetics
  • Hyperparathyroidism, Primary / blood
  • Hyperparathyroidism, Primary / genetics*
  • Male
  • Middle Aged
  • Mutation
  • Parathyroid Hormone / blood
  • Phenotype
  • Receptors, Calcium-Sensing / genetics*


  • AP2S1 protein, human
  • Adaptor Protein Complex 2
  • Adaptor Protein Complex sigma Subunits
  • GNA11 protein, human
  • GTP-Binding Protein alpha Subunits
  • Parathyroid Hormone
  • Receptors, Calcium-Sensing
  • Calcium

Supplementary concepts

  • Hypocalciuric hypercalcemia, familial, type 1