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Hungry bone syndrome after parathyroidectomy in end-stage renal disease patients: review of an alkaline phosphatase-based treatment protocol

  • Nephrology - Original Paper
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Abstract

Aim

Hyperparathyroidism in chronic kidney disease–mineral and bone disorder is associated with significant morbidity and mortality. Parathyroidectomy is widely carried out as treatment despite complications such as hypocalcaemia post-surgery. Our centre has been using an ALP-based protocol to replace calcium postoperatively to prevent hypocalcaemia. We aim to describe and audit our calcium replacement protocol post-parathyroidectomy

Methods

We, retrospectively, analyse 167 end-stage kidney disease patients who had parathyroidectomy with auto-implantation in Singapore General Hospital between January 2008 and December 2013. Their calcium replacement postoperatively was initiated upon patient arrival back in ward on the same day of surgery based on their pre-op ALP prior to occurrence of hypocalcaemia. Patient demographics, surgical and laboratory parameters were reviewed from medical records. Changes in calcium postoperatively were reported to look for incidence of calcium derangement.

Results

Mean calcium levels between pre-operation day and post-operation day 7 ranged from 2.31 to 2.70 mmol/L. Decline in serum calcium was common in all patients prior to starting calcium replacement. Eighteen patients (10.9%) experienced hypocalcaemia immediately post-operation prior to commencement of IV calcium replacement. Patients with immediate post-operation hypocalcaemia had lower pre-operation calcium but higher pre-operation alkaline phosphatase (ALP) and pre-operation intact parathyroid hormone. Hypercalcaemia is common likely from aggressive IV calcium replacement using the protocol. The average length of stay for patients prior to calcium stabilization and discharge was 9 days.

Conclusion

Implementation of an ALP-based prophylactic calcium replacement protocol with daily serum calcium monitoring can ameliorate severe hypocalcaemia post-parathyroidectomy

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References

  1. Tentori F, Blayney MJ, Albert JM et al (2008) Mortality risk for dialysis patients with different levels of serum calcium, phosphorus, and pth: the dialysis outcomes and practice patterns study (DOPPS). Am J Kidney Dis. 52(3):519–530. https://doi.org/10.1053/j.ajkd.2008.03.020

    Article  PubMed  CAS  Google Scholar 

  2. Lee E, Choon J, Choong L, et al. Acknowledgement Singapore Renal Registry Advisory Committee Secretary A/Prof Members Prof A Vathsala A/Prof Terence Kee. 2016:1–84.

  3. Pasch A. Bone mass gain after parathyroidectomy. Kidney Int. 74(6):697–699. https://doi.org/10.1038/ki.2008.321

    Article  Google Scholar 

  4. Li W, Zhang M, Du S et al (2015) Impact of parathyroidectomy on survival among hemodialysis patients: A prospective cohort study. Nephrology. https://doi.org/10.1111/nep.12564

    Article  PubMed  Google Scholar 

  5. Rudser KD, de Boer IH, Dooley A, Young B, Kestenbaum B. Fracture risk after parathyroidectomy among chronic hemodialysis patients. J Am Soc Nephrol. 18(8):2401–2407. https://doi.org/10.1681/ASN.2007010022

    Article  Google Scholar 

  6. See A, Lim AEL, Wong J, et al. The effect of parathyroidectomy on patients’ symptoms in tertiary hyperparathyroidism. Head Neck. April 2019:hed.25750. https://doi.org/10.1002/hed.25750.

  7. Jain N, Reilly RF (2017) Hungry bone syndrome. Curr Opin Nephrol Hypertens. 26(4):250–255. https://doi.org/10.1097/MNH.0000000000000327

    Article  PubMed  Google Scholar 

  8. Rajeev P, Lee KY, Tang XJ, Goo TT, Tan WB, Ngiam KY (2016) Outcomes of parathyroidectomy in renal hyperparathyroidism in patients with No access to renal transplantation in Singapore. Int J Surg. 2016(25):64–68. https://doi.org/10.1016/j.ijsu.2015.11.005

    Article  Google Scholar 

  9. Jia X, Wang R, Zhang C, Cui M, Xu D. Long-Term Outcomes of Total Parathyroidectomy With or Without Autoimplantation for Hyperparathyroidism in Chronic Kidney Disease: a meta-analysis. Ther Apher Dial. 19(5):477–485. https://doi.org/10.1111/tap.2015.19.issue-5

  10. Disease CK., Features M, Metabolism M, Failure, K., Affecting, F., Phosphorus, S., Guidelines, B. D. (2003). K/DOQI clinical practice guidelines for bon. Am J Kidney Dis. 2003;42(4 Suppl 3):S1–201. https://www.ncbi.nlm.nih.gov/pubmed/14520607.

  11. Goh BL, Yudisthra MG, Hisham AN. Alkaline phosphatase predicts calcium requirements after total parathyroidectomy in patients receiving dialysis. Br J Surg. 97(2):185–188. https://doi.org/10.1002/bjs.6818

    Article  CAS  Google Scholar 

  12. Cozzolino M, Gallieni M, Corsi C, Bastagli A, Brancaccio D. Management of calcium refilling post-parathyroidectomy in end-stage renal disease. J Nephrol. 17(1):3–8. https://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&DbFrom=pubmed&Cmd=Link&LinkName=pubmed_pubmed&LinkReadableName=RelatedArticles&IdsFromResult=15151253&ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

  13. Loke SC, Kanesvaran R, Yahya R, Fisal L, Wong TW, Loong YY. Efficacy of an intravenous calcium gluconate infusion in controlling serum calcium after parathyroidectomy for secondary hyperparathyroidism. Ann Acad Med Singapore. 38(12):1074–1080. https://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&DbFrom=pubmed&Cmd=Link&LinkName=pubmed_pubmed&LinkReadableName=RelatedArticles&IdsFromResult=20052443&ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

  14. Tan JH, Tan HCL, Loke SC, Arulanantham SAP (2017) Novel calcium infusion regimen after parathyroidectomy for renal hyperparathyroidism. Nephrology. 22(4):308–315. https://doi.org/10.1111/nep.2017.22.issue-4

    Article  PubMed  CAS  Google Scholar 

  15. Ge P, Liu S, Sheng X, et al. Serum parathyroid hormone and alkaline phosphatase as predictors of calcium requirements after total parathyroidectomy for hypocalcemia in secondary hyperparathyroidism. Head Neck. https://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&DbFrom=pubmed&Cmd=Link&LinkName=pubmed_pubmed&LinkReadableName=RelatedArticles&IdsFromResult=28963816&ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

  16. Florescu M, Plumb T, Smith-Shull S, Nieman J, Mandalapu P, Islam KM (2014) Calcium supplementation after parathyroidectomy in dialysis and renal transplant patients. Int J Nephrol Renovasc Dis 7:183–190. https://www.dovepress.com/international-journal-of-nephrology-and-renovascular-disease-journal.

  17. Nakagawa M, Emoto A, Nasu N, Hirata Y (2000) Calcium supplement necessary to correct hypocalcemia after total parathyroidectomy for renal osteodystrophy. 35–40.

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Renal Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore

    Jiunn Wong & Hui Lin Choong

  2. Department of Pharmacy, Sengkang General Hospital, Singapore, Singapore

    Wing Hang Fu

  3. Department of Surgery, Singapore General Hospital, Singapore, Singapore

    Ee Lim Amy Lim & Chung Fai Jeremy Ng

Authors
  1. Jiunn Wong
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  2. Wing Hang Fu
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  3. Ee Lim Amy Lim
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  4. Chung Fai Jeremy Ng
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  5. Hui Lin Choong
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Correspondence to Jiunn Wong.

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Wong, J., Fu, W.H., Lim, E.L.A. et al. Hungry bone syndrome after parathyroidectomy in end-stage renal disease patients: review of an alkaline phosphatase-based treatment protocol. Int Urol Nephrol 52, 557–564 (2020). https://doi.org/10.1007/s11255-020-02387-0

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