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Hypocalcemia After Bariatric Surgery: Prevalence and Associated Risk Factors

Obesity Surgery volume 27, pages 2905–2911 (2017)Cite this article

Abstract

Background

The reported prevalence of hypocalcemia after bariatric surgery ranges from 1% after Roux-en-Y gastric bypass (RYGB) to 25% after bilio-pancreatic diversion-duodenal switch (BPD-DS).

Objective

We aimed to define the prevalence of post-operative hypocalcemia and identify clinical predisposing factors.

Setting

The study was conducted in an Academic Medical Center, USA.

Methods

Retrospective analysis of all patients undergoing bariatric surgery from May 2008 to December 2014 at Mayo Clinic Rochester, Minnesota was performed. Patients with revision surgeries were excluded. Hypocalcemia was defined as the lowest recorded serum calcium occurring at least 2 weeks post-operatively.

Results

Nine hundred ninety-nine patients fulfilled the criteria above. After correction for serum albumin concentration, 36 patients had serum calcium ≤8.9 mg/dl. Mean serum calcium was 8.1 ± 0.6 mg/dl. The prevalence was 1.9% in the RYGB group, 9.3% in the sleeve gastrectomy (SG) group, and 10% in the BPD-DS group.

In all three surgical types, patients with hypocalcemia had significantly lower serum albumin and serum 25 (OH) vitamin D concentrations when compared to their normocalcemic counterparts (P < 0.01). The presence of renal insufficiency and vitamin D deficiency was associated with the highest risk of developing hypocalcemia after surgery [OR 16.8 (6.45–47.7) and 7.1(2.9–17.3), respectively]. Pre-operative renal insufficiency increased the odds of developing hypocalcemia by 20-fold.

Conclusions

In our series, hypocalcemia was identified in 3.6% of patients undergoing all bariatric surgery. Patients who are predisposed to developing post-operative hypocalcemia, such as those with pre-operative renal impairment, or post-operative vitamin D deficiency and renal insufficiency, may benefit from increased surveillance and prevention strategies.

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References

  1. Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. 2009;122(3):248–56. e5

    Article  PubMed  Google Scholar 

  2. Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357(8):741–52.

    Article  PubMed  Google Scholar 

  3. Schauer PR, Bhatt DL, Kashyap SR. Bariatric surgery versus intensive medical therapy for diabetes. N Engl J Med. 2014;371(7):682.

    CAS  PubMed  Google Scholar 

  4. Courcoulas AP, Belle SH, Neiberg RH, et al. Three-year outcomes of bariatric surgery vs lifestyle intervention for type 2 diabetes mellitus treatment: a randomized clinical trial. JAMA Surg. 2015;150(10):931–40.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Peterson LA CL, Furtado M, et al. . Malnutrition in bariatric surgery candidates: multiple micronutrient deficiencies prior to surgery. Obes Surg 2015:1–6.

  6. Bal BS, Finelli FC, Shope TR, et al. Nutritional deficiencies after bariatric surgery. Nat Rev Endocrinol. 2012;8(9):544–56.

    Article  CAS  PubMed  Google Scholar 

  7. Toh SY, Zarshenas N, Jorgensen J. Prevalence of nutrient deficiencies in bariatric patients. Nutrition. 2009;25(11–12):1150–6.

    Article  CAS  PubMed  Google Scholar 

  8. Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring). 2013;21(Suppl 1):S1–27.

    Article  CAS  Google Scholar 

  9. Heber D, Greenway FL, Kaplan LM, et al. Endocrine and nutritional management of the post-bariatric surgery patient: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2010;95(11):4823–43.

    Article  CAS  PubMed  Google Scholar 

  10. Allegretti AS, Nazarian RM, Goverman J, et al. Calciphylaxis: a rare but fatal delayed complication of Roux-en-Y gastric bypass surgery. Am J Kidney Dis. 2014;64(2):274–7.

    Article  PubMed  Google Scholar 

  11. Newbury L, Dolan K, Hatzifotis M, et al. Calcium and vitamin D depletion and elevated parathyroid hormone following biliopancreatic diversion. Obes Surg. 2003;13(6):893–5.

    Article  PubMed  Google Scholar 

  12. Johnson JM, Maher JW, Samuel I, et al. Effects of gastric bypass procedures on bone mineral density, calcium, parathyroid hormone, and vitamin D. J Gastrointest Surg. 2005;9(8):1106–10. discussion 10-1

    Article  PubMed  Google Scholar 

  13. De Prisco C, Levine SN. Metabolic bone disease after gastric bypass surgery for obesity. Am J Med Sci. 2005;329(2):57–61.

    Article  PubMed  Google Scholar 

  14. Scibora LM, Ikramuddin S, Buchwald H, et al. Examining the link between bariatric surgery, bone loss, and osteoporosis: a review of bone density studies. Obes Surg. 2012;22(4):654–67.

    Article  PubMed  Google Scholar 

  15. Chapin BL, LeMar Jr HJ, Knodel DH, et al. Secondary hyperparathyroidism following biliopancreatic diversion. Arch Surg. 1996;131(10):1048–52. discussion 53

    Article  CAS  PubMed  Google Scholar 

  16. Diniz Mde F, Diniz MT, Sanches SR, et al. Elevated serum parathormone after Roux-en-Y gastric bypass. Obes Surg. 2004;14(9):1222–6.

    Article  PubMed  Google Scholar 

  17. Jesudason DR, Clifton P. Interpreting different measures of glomerular filtration rate in obesity and weight loss: pitfalls for the clinician. Int J Obes. 2012;36(11):1421–7.

    Article  CAS  Google Scholar 

  18. Slater GH, Ren CJ, Siegel N, et al. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg. 2004;8(1):48–55. discussion 4-5

    Article  PubMed  Google Scholar 

  19. Hamoui N, Kim K, Anthone G, et al. The significance of elevated levels of parathyroid hormone in patients with morbid obesity before and after bariatric surgery. Arch Surg. 2003;138(8):891–7.

    Article  CAS  PubMed  Google Scholar 

  20. Ernst B, Thurnheer M, Schmid SM, et al. Evidence for the necessity to systematically assess micronutrient status prior to bariatric surgery. Obes Surg. 2009;19(1):66–73.

    Article  PubMed  Google Scholar 

  21. Wang C, Guan B, Yang W, Yang J, Cao G, Lee S. Prevalence of electrolyte and nutritional deficiencies in Chinese bariatric surgery candidates. Surg Obes Relat Dis. 2015.

  22. Institute of Medicine: Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D, and fluoride. National Academy of Sciences. Washington, DC1997.

  23. Seres DS. Surrogate nutrition markers, malnutrition, and adequacy of nutrition support. Nutr Clin Pract. 2005;20(3):308–13.

    Article  PubMed  Google Scholar 

  24. McMahon MM, Sarr MG, Clark MM, et al. Clinical management after bariatric surgery: value of a multidisciplinary approach. Mayo Clin Proc. 2006;81(10):S34–45.

    Article  CAS  PubMed  Google Scholar 

  25. Schafer AL, Weaver CM, Black DM, et al. Intestinal calcium absorption decreases dramatically after gastric bypass surgery despite optimization of vitamin D status. J Bone Miner Res. 2015;30(8):1377–85.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Barger-Lux MJ, Heaney RP, Recker RR. Time course of calcium absorption in humans: evidence for a colonic component. Calcif Tissue Int. 1989;44(5):308–11.

    Article  CAS  PubMed  Google Scholar 

  27. Moize V, Geliebter A, Gluck ME, et al. Obese patients have inadequate protein intake related to protein intolerance up to 1 year following Roux-en-Y gastric bypass. Obes Surg. 2003;13(1):23–8.

    Article  PubMed  Google Scholar 

  28. Tondapu P, Provost D, Adams-Huet B, et al. Comparison of the absorption of calcium carbonate and calcium citrate after Roux-en-Y gastric bypass. Obes Surg. 2009;19(9):1256–61.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Hewitt S, Sovik TT, Aasheim ET, et al. Secondary hyperparathyroidism, vitamin D sufficiency, and serum calcium 5 years after gastric bypass and duodenal switch. Obes Surg. 2013;23(3):384–90.

    Article  PubMed  Google Scholar 

  30. Goode LR, Brolin RE, Chowdhury HA, et al. Bone and gastric bypass surgery: effects of dietary calcium and vitamin D. Obes Res. 2004;12(1):40–7.

    Article  CAS  PubMed  Google Scholar 

  31. Lu CW, Chang YK, Chang HH, et al. Fracture risk after bariatric surgery: a 12-year nationwide cohort study. Medicine (Baltimore). 2015;94(48):e2087.

    Article  Google Scholar 

  32. Nakamura KM, Haglind EG, Clowes JA, et al. Fracture risk following bariatric surgery: a population-based study. Osteoporos Int. 2014;25(1):151–8.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Endocrinology, Metabolism and Nutrition, Mayo Clinic, 200 1st Street SW Rochester, Rochester, MN, 55905, USA

    Meera Shah, Anu Sharma, Robert A. Wermers, Kurt A. Kennel & Manpreet S. Mundi

  2. Division of Breast, Metabolic and Gastrointestinal Surgery, Mayo Clinic, 200 1st Street SW Rochester, Rochester, MN, 55905, USA

    Todd A. Kellogg

Authors
  1. Meera Shah
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  2. Anu Sharma
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Correspondence to Meera Shah.

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Disclosure Statement

M.S. and M.S.M had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. A.S. participated in data analysis and manuscript preparation. A.S., K.A.K, R.A.W, and T.A.K participated in critical review of the manuscript. The authors report no conflicts of interest.

This article does not contain any studies with human participants or animals performed by any of the authors. For this type of study formal consent is not required.

This project was supported by Grant Number UL1TR000135 from the National Center for Advancing Translational Science (NCATS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

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Shah, M., Sharma, A., Wermers, R.A. et al. Hypocalcemia After Bariatric Surgery: Prevalence and Associated Risk Factors. OBES SURG 27, 2905–2911 (2017). https://doi.org/10.1007/s11695-017-2705-7

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  • DOI: https://doi.org/10.1007/s11695-017-2705-7

Keywords

  • Hypocalcemia
  • Roux-en-Y gastric bypass
  • Sleeve gastrectomy
  • Bilio-pancreatic diversion
  • Duodenal switch
  • Renal impairment
  • Vitamin D deficiency