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Hungry Bone Syndrome (HBS)

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Parathyroid Gland Disorders

Abstract

Hungry bone syndrome (HBS) refers to the rapid, profound, and prolonged hypocalcemia associated with hypophosphatemia and hypomagnesemia, and is exacerbated by suppressed parathyroid hormone (PTH) levels, which follows parathyroidectomy in patients with severe primary hyperparathyroidism (PHPT) and pre-operative high bone turnover. It is a relatively uncommon, but a serious adverse effect of parathyroidectomy. The hallmark of HBS is profound and persistent hypocalcemia that persists beyond 4 days post-operatively. Symptomatic patients or those with profound hypocalcemia less than 7.6 mg/dL will need emergent intravenous calcium treatment. There are no clear guidelines for the management of the HBS, but treatment is aimed at replenishing the severe calcium deficit and at restoring normal bone turnover with the use of high doses of calcium and active metabolites or analogues of vitamin D. Adequate correction of magnesium deficiency and normalization of bone turnover are required for resolution of the hypocalcemia, which may last for several months after successful surgery. Adequate pre-operative treatment with bisphosphonates may reduce the severity and duration of post-operative hypocalcemia. However, data are lacking to elucidate the long-term effects on bone mineral density if utilized in this patient population. In patients with PHPT and vitamin D deficiency, vitamin D supplementation merits consideration. Thus far, it appears that vitamin D supplementation will help to improve bone mineral density, bone resorption markers, and reduce PTH levels before parathyroidectomy without causing adverse effects.

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References

  1. Witteveen JE, van Thiel S, Romijn JA, Hamdy NA. Hungry bone syndrome: still a challenge in the post-operative management of primary hyperparathyroidism: a systematic review of the literature. Eur J Endocrinol. 2013;168(3):R45–53.

    Article  CAS  PubMed  Google Scholar 

  2. Jain N, Reilly RF. Hungry bone syndrome. Curr Opin Nephrol Hypertens. 2017;26(4):250–5.

    Article  PubMed  Google Scholar 

  3. Brasier AR, Nussbaum SR. Hungry bone syndrome: clinical and biochemical predictors of its occurrence after parathyroid surgery. Am J Med. 1988;84(4):654–60.

    Article  CAS  PubMed  Google Scholar 

  4. Karunakaran P, Maharajan C, Ramalingam S, Rachmadugu SV. Is hungry bone syndrome a cause of postoperative hypocalcemia after total thyroidectomy in thyrotoxicosis? A prospective study with bone mineral density correlation. Surgery. 2018;163(2):367–72.

    Article  PubMed  Google Scholar 

  5. Kim KM, Park JB, Bae KS, Kang SJ. Hungry bone syndrome after parathyroidectomy of a minimally invasive parathyroid carcinoma. J Korean Surg Soc. 2011;81:344–9.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Pfleiderer AG, Ahmad N, Draper MR, Vrotsou K, Smith WK. The timing of calcium measurements in helping to predict temporary and permanent hypocalcaemia in patients having completion and total thyroidectomies. Ann R Coll Surg Engl. 2009;91:140–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Sousa A, Salles JM, Soares JM, de Moraes GM, Carvalho JR, Rocha PR. Course of ionized calcium after thyroidectomy. World J Surg. 2010;34(5):987–92.

    Article  Google Scholar 

  8. Kaplan EL, Bartlett S, Sugimoto J, Fredland A. Relation of postoperative hypocalcemia to operative techniques: deleterious effect of excessive use of parathyroid biopsy. Surgery. 1982;92:827–34.

    CAS  PubMed  Google Scholar 

  9. Zamboni WA, Folse R. Adenoma weight: a predictor of transient hypocalcemia after parathyroidectomy. Am J Surg. 1986;152:611–5.

    Article  CAS  PubMed  Google Scholar 

  10. Heath DA, Van’t Hoff W, Barnes AD, Gray JG. Value of 1-α-hydroxy vitamin D3 in treatment of primary hyperparathyroidism before parathyroidectomy. BMJ. 1979;1:450–2.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Chia SH, Weisman RA, Tieu D, Kelly C, Dillmann WH, Orloff LA. Prospective study of perioperative factors predicting hypocalcemia after thyroid and parathyroid surgery. Arch Otolaryngol Head Neck Surg. 2006;132:41–5.

    Article  PubMed  Google Scholar 

  12. Westerdahl J, Lindblom P, Valdemarsson S, Tibblin S, Bergenfelz A. Risk factors for postoperative hypocalcemia after surgery for primary hyperparathyroidism. Arch Surg. 2000;135:142–7.

    Article  CAS  PubMed  Google Scholar 

  13. Brossard JH, Garon J, Lepage R, Gascon-Barre M, D’Amour P. Inhibition of 1,25(OH)2D production by hypercalcemia in osteitis fibrosa cystica: influence on parathyroid hormone secretion and hungry bone disease. Bone Miner. 1993;23:15–26.

    Article  CAS  PubMed  Google Scholar 

  14. Norman JG, Politz DE. Safety of immediate discharge after parathyroidectomy: a prospective study of 3,000 consecutive patients. Endocr Pract. 2007;13:105–13.

    Article  PubMed  Google Scholar 

  15. Wong WK, Wong NA, Farndon JR. Early postoperative plasma calcium concentration as a predictor of the need for calcium supplement after parathyroidectomy. Br J Surg. 1996;83:532–4.

    Article  CAS  PubMed  Google Scholar 

  16. Silva BC, Bilezikian JP. Parathyroid hormone: anabolic and catabolic actions on the skeleton. Curr Opin Pharmacol. 2015;22:41–50.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Ma YL, Cain RL, Halladay DL, Yang X, Zeng Q, Miles RR, Chandrasekhar S, Martin TJ, Onyia JE. Catabolic effects of continuous human PTH (1–38) in vivo is associated with sustained stimulation of RANKL and inhibition of osteoprotegerin and gene-associated bone formation. Endocrinology. 2001;142(9):4047–54.

    Article  CAS  PubMed  Google Scholar 

  18. Parfitt AM. The actions of parathyroid hormone on bone: relation to bone remodeling and turnover, calcium homeostasis, and metabolic bone disease. Part III of IV parts; PTH and osteoblasts, the relationship between bone turnover and bone loss, and the state of the bones in primary hyperparathyroidism. Metabolism. 1976;25:1033–69.

    Article  CAS  PubMed  Google Scholar 

  19. Eriksen EF, Mosekilde L, Melsen F. Trabecular bone remodeling and balance in primary hyperparathyroidism. Bone. 1986;7:213–21.

    Article  CAS  PubMed  Google Scholar 

  20. Charles P, Mosekilde L, Jensen FT. Primary hyperparathyroidism: evaluated by 47calcium kinetics, calcium balance and serum bone-Gla-protein. Eur J Clin Investig. 1986;16:277–83.

    Article  CAS  Google Scholar 

  21. Mosekilde L. Primary hyperparathyroidism and the skeleton. Clin Endocrinol. 2008;69:1–19.

    Article  CAS  Google Scholar 

  22. Ge Y, Yang G, Wang N, Zha X, Yu X, Mao H, Sun B, Zeng M, Zhang B, Xing C. Bone metabolism markers and hungry bone syndrome after parathyroidectomy in dialysis patients with secondary hyperparathyroidism. Int Urol Nephrol. 2019;51(8):1443–9.

    Article  CAS  PubMed  Google Scholar 

  23. Falko JM, Bush CA, Tzagournis M, Thomas FB. Case report. Congestive heart failure complicating the hungry bone syndrome. Am J Med Sci. 1976;271:85–9.

    Article  CAS  PubMed  Google Scholar 

  24. Ajmi S, Sfar R, Trimeche S, Ben AK, Nouira M. Scintigraphic findings in hungry bone syndrome following parathyroidectomy. Rev Esp Med Nucl. 2010;29:81–3.

    Article  CAS  PubMed  Google Scholar 

  25. Rathi MS, Ajjan R, Orme SM. A case of parathyroid carcinoma with severe hungry bone syndrome and review of literature. Exp Clin Endocrinol Diabetes. 2008;116:487–90.

    Article  CAS  PubMed  Google Scholar 

  26. Kuzucu A, Soysal O, Savli H. Giant mediastinal parathyroid adenoma presenting with a hyperparathyroid crisis and leading to postoperative hungry bone syndrome. Eur J Surg. 2002;168:747–9.

    Article  CAS  PubMed  Google Scholar 

  27. Chen CH, Wang PW, Liu RT, Tung SC, Jean WY, Lu YC, Kao CL, Chen L. Ectopic parathyroid adenoma with severe hungry bone syndrome: a case report. Changgeng Yi Xue Za Zhi. 1996;19:196–202.

    CAS  PubMed  Google Scholar 

  28. Shoback D. Hypoparathyroidism. N Engl J Med. 2008;359:391–403.

    Article  CAS  PubMed  Google Scholar 

  29. Hussain A, Mahmood H, Geddoa E, Hamish M, Reda AH. Parathyroid adenoma and hypercalcemia in a patient presenting with multiple pathological fractures of the long bones. Int J Surg. 2008;6:465–8.

    Article  CAS  PubMed  Google Scholar 

  30. Scott RD, Falconer CW, Fitzpatrick K, Proter GM. Magnesium depletion and hypocalcaemia after removal of parathyroid carcinoma. Scot Med J. 1976;21:37–42.

    Article  CAS  PubMed  Google Scholar 

  31. Demirci H, Suyani E, Karakoc A, Toruner FB, Yetkin I, Ayvaz G, Taneri F, Cakir N, Arslan M. A longstanding hungry bone syndrome. Endocrinologist. 2007;17:10–2.

    Article  Google Scholar 

  32. Silaghi H, Valea A, Ghervan C, Silaghi AC. Ectopic intrathyroid parathyroid adenoma: diagnostic and therapeutic challenges due to multiple osteolytic lesions. Case report. Med Ultrason. 2011;13:241–4.

    PubMed  Google Scholar 

  33. Jones CT, Sellwood RA, Evanson JM. Symptomatic hypomagnesaemia after parathyroidectomy. BMJ. 1973:3391–2.

    Google Scholar 

  34. Ahuja MM, Chopra IJ. Coexistent hyperthyroidism and hyperparathyroidism. Metabolism. 1968;17:854–66.

    Article  CAS  PubMed  Google Scholar 

  35. Davies DR, Friedman M. Complications after parathyroidectomy. Fractures from low calcium and magnesium convulsions. J Bone Joint Surg. 1966;48:117–26.

    Article  CAS  Google Scholar 

  36. Varthakavi P, Thayil G, Amin S, Mehtalia SD, Soneji SL, Joshi VR. Hypocalcaemic congestive heart failure—a post-parathyroidectomy complication. Indian Heart J. 1985;37:311–4.

    CAS  PubMed  Google Scholar 

  37. Anderberg B, Gillquist J, Larsson L, Lundstrom B. Complications to subtotal parathyroidectomy. Acta Chir Scand. 1981;147:109–13.

    CAS  PubMed  Google Scholar 

  38. Graal MB, Wolffenbuttel BH. Consequences of long-term hyperparathyroidism. Neth J Med. 1998;53:37–42.

    Article  CAS  PubMed  Google Scholar 

  39. Natsui K, Tanaka K, Suda M, Yasoda A, Shigeno C, Konishi J, Nakao K. Oxyphil parathyroid adenoma associated with primary hyperparathyroidism and marked post-operative hungry bone syndrome. Intern Med. 1996;35:545–9.

    Article  CAS  PubMed  Google Scholar 

  40. Agarwal G, Mishra SK, Kar DK, Singh AK, Arya V, Gupta SK, Mithal A. Recovery pattern of patients with osteitis fibrosa cystica in primary hyperparathyroidism after successful parathyroidectomy. Surgery. 2002;132:1075–83.

    Article  PubMed  Google Scholar 

  41. Gopal RA, Acharya SV, Bandgar T, Menon PS, Dalvi AN, Shah NS. Clinical profile of primary hyperparathyroidism from western India: a single center experience. J Postgrad Med. 2010;56:79–84.

    Article  CAS  PubMed  Google Scholar 

  42. Bhansali A, Masoodi SR, Reddy KS, Behera A, das Radotra B, Mittal BR, Katariya RN, Dash RJ. Primary hyperparathyroidism in North India: a description of 52 cases. Ann Saudi Med. 2005;25:29–35.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Pradeep PV, Jayashree B, Mishra A, Mishra SK. Systematic review of primary hyperparathyroidism in India: the past, present, and the future trends. Int J Endocrinol. 2011;74:2–44.

    Google Scholar 

  44. Malabu UH, Founda MA. Primary hyperparathyroidism in Saudi Arabia: a review of 46 cases. Med J Malaysia. 2007;62:394–7.

    CAS  PubMed  Google Scholar 

  45. See AC, Soo KC. Hypocalcaemia following thyroidectomy for thyrotoxicosis. Br J Surg. 1997;84(1):95–7.

    CAS  PubMed  Google Scholar 

  46. Garla VV, Salim S, Kovvuru KR, Subauste A. Hungry bone syndrome secondary to prostate cancer successfully treated with radium therapy. BMJ Case Rep. 2018;2018

    Google Scholar 

  47. Jakubauskas M, Beiša V, Strupas K. Risk factors of developing the hungry bone syndrome after parathyroidectomy for primary hyperparathyroidism. Acta Med Litu. 2018;25(1):45–51.

    PubMed  PubMed Central  Google Scholar 

  48. Ho LY, Wong PN, Sin HK, Wong YY, Lo KC, Chan SF, Lo MW, Lo KY, Mak SK, Wong AK. Risk factors and clinical course of hungry bone syndrome after total parathyroidectomy in dialysis patients with secondary hyperparathyroidism. BMC Nephrol. 2017;18(1):12.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  49. Yang G, Zha X, Mao H, Yu X, Wang N, Xing C. Hypocalcemia-based prediction of hungry bone syndrome after parathyroidectomy in hemodialysis patients with refractory secondary hyperparathyroidism. J Int Med Res. 2018;46(12):4985–94.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Spiegel AM, Marx SJ, Brennan MF, Brown EM, Downs RW Jr, Gardner DG, Attie MF, Aurbach GD. Parathyroid function after parathyroidectomy: evaluation by measurement of urinary cAMP. Clin Endocrinol. 1981;15:65–73.

    Article  CAS  Google Scholar 

  51. Lee IT, Sheu WH, Tu ST, Kuo SW, Pei D. Bisphosphonate pretreatment attenuates hungry bone syndrome postoperatively in subjects with primary hyperparathyroidism. J Bone Miner Metab. 2006;24:255–8.

    Article  CAS  PubMed  Google Scholar 

  52. Vercauteren M, Boeckx E, Adriaensen H. Parathyroidectomy and postoperative hypocalcemia: a retrospective study. Acta Anaesthesiol Belg. 1988;39:59–63.

    CAS  PubMed  Google Scholar 

  53. Raef H, Ingemansson S, Sobhi S, Sultan A, Ahmed M, Chaudhry M. The effect of vitamin D status on the severity of bone disease and on the other features of primary hyperparathyroidism (pHPT) in a vitamin D deficient region. J Endocrinol Invest. 2004;27:807–12.

    Article  CAS  PubMed  Google Scholar 

  54. Laitinen O. Bone, calcium, and hydroxyproline metabolism in hyperparathyroidism and after removal of parathyroid adenoma. Acta Med Scand. 1977;202:39–42.

    Article  CAS  PubMed  Google Scholar 

  55. Meydan N, Barutca S, Guney E, Boylu S, Savk O, Culhaci N, Ayhan M. Brown tumors mimicking bone metastases. J Natl Med Assoc. 2006;98:950–3.

    PubMed  PubMed Central  Google Scholar 

  56. Hisham AN, Aina EN, Zanariah H. Recognition and management of hungry bone syndrome—a case report. Med J Malaysia. 2000;55:132–4.

    CAS  PubMed  Google Scholar 

  57. Yong TY, Li JY. Mediastinal parathyroid carcinoma presenting with severe skeletal manifestations. J Bone Miner Metab. 2010;28:591–4.

    Article  PubMed  Google Scholar 

  58. Corsello SM, Paragliola RM, Locantore P, Ingraudo F, Ricciato MP, Rota CA, Senes P, Pontecorvi A. Post-surgery severe hypocalcemia in primary hyperparathyroidism preoperatively treated with zoledronic acid. Hormones. 2010;9:338–42.

    Article  PubMed  Google Scholar 

  59. França TC, Griz L, Pinho J, Diniz ET, Andrade LD, Lucena CS, Beserra SR, Asano NM, Duarte AP, Bandeira F. Bisphosphonates can reduce bone hunger after parathyroidectomy in patients with primary hyperparathyroidism and osteitis fibrosa cystica. Rev Bras Reumatol. 2011;51:131–7.

    Article  PubMed  Google Scholar 

  60. Turner J, Gittoes N, Selby P, Society for Endocrinology Clinical Committee. Society for Endocrinology endocrine emergency guidance: emergency management of acute hypocalcaemia in adult patients. Endocr Connect. 2016;5(5):G7–8.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Kelly A, Levine MA. Hypocalcemia in the critically ill patient. J Intensive Care Med. 2013;28(3):166–77.

    Article  PubMed  Google Scholar 

  62. Cooper MS, Gittoes NJ. Diagnosis and management of hypocalcaemia. BMJ. 2008;336:1298–302.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Anwar F, Abraham J, Nakshabandi A, Lee E. Treatment of hypocalcemia in hungry bone syndrome: a case report. Int J Surg Case Rep. 2018;51:335–9.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Florakis D, Karakozis S, Tseleni-Balafouta S, Makras P. Lessons learned from the management of hungry bone syndrome following the removal of an atypical parathyroid adenoma. J Musculoskelet Neuronal Interact. 2019;19(3):379–84.

    CAS  PubMed  PubMed Central  Google Scholar 

  65. Adamson BB, Gallacher SJ, Byars J, Ralston SH, Boyle IT, Boyce BF. Mineralisation defects with pamidronate therapy for Paget’s disease. Lancet. 1993;342:1459–60.

    Article  CAS  PubMed  Google Scholar 

  66. Shane E, Jacobs TP, Siris ES, Steinberg SF, Stoddart K, Canfield RE, Bilezikian JP. Therapy of hypercalcemia due to parathyroid carcinoma with intravenous dichloromethylene diphosphonate. Am J Med. 1982;72:939–44.

    Article  CAS  PubMed  Google Scholar 

  67. Gurevich Y, Poretsky L. Possible prevention of hungry bone syndrome following parathyroidectomy by preoperative use of pamidronate. Otolaryngol Head Neck Surg. 2008;138:403–4.

    Article  PubMed  Google Scholar 

  68. Kumar A, Ralston SH. Bisphosphonates prevent the hungry bone syndrome. Nephron. 1996;74:729.

    Article  CAS  PubMed  Google Scholar 

  69. Boyle IT, Fogelman I, Boyce B, Thomson JE, Beastall GH, McIntosh WB, McLennan I. 1-α-Hydroxyvitamin D3 in primary hyperparathyroidism. Clin Endocrinol. 1977;7(Suppl):215s–22s.

    Article  Google Scholar 

  70. Hallgrimsson P, Nordenstrom E, Bergenfelz A, Almquist M. Hypocalcaemia after total thyroidectomy for Graves’ disease and for benign atoxic multinodular goitre. Langenbecks Arch Surg. 2012;397(7):1133–7.

    Article  PubMed  Google Scholar 

  71. Sywak MS, Palazzo FF, Yeh M, Wilkinson M, Snook K, Sidhu SB, et al. Parathyroid hormone assay predicts hypocalcaemia after total thyroidectomy. ANZ J Surg. 2007;77(8):667–70.

    Article  PubMed  Google Scholar 

  72. Bahn Chair RS, Burch HB, Cooper DS, Garber JR, Greenlee MC, Klein I, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011;21(6):593–646.

    Article  PubMed  CAS  Google Scholar 

  73. Yamashita H, Noguchi S, Murakami T, Uchino S, Watanabe S, Ohshima A, et al. Predictive risk factors for postoperative tetany in female patients with Graves’ disease. J Am Coll Surg. 2001;192(4):465–8.

    Article  CAS  PubMed  Google Scholar 

  74. Pesce CE, Shiue Z, Tsai HL, Umbricht CB, Tufano RP, Dackiw AP, et al. Postoperative hypocalcemia after thyroidectomy for Graves’ disease. Thyroid. 2010;20(11):1279–83.

    Article  CAS  PubMed  Google Scholar 

  75. Welch KC, McHenry CR. Total thyroidectomy: is morbidity higher for Graves’ disease than nontoxic goiter? J Surg Res. 2011;170(1):96–9.

    Article  PubMed  Google Scholar 

  76. Snyder S, Govednik C, Lairmore T, Jiang DS, Song J. Total thyroidectomy as primary definitive treatment for Graves’ hyperthyroidism. Am Surg. 2013;79(12):1283–8.

    Article  PubMed  Google Scholar 

  77. Kisakol G, Kaya A, Gonen S, Tunc R. Bone and calcium metabolism in subclinical autoimmune hyperthyroidism and hypothyroidism. Endocr J. 2003;50(6):657–61.

    Article  CAS  PubMed  Google Scholar 

  78. Lal G, Ituarte P, Kebebew E, Siperstein A, Duh QY, Clark OH. Should total thyroidectomy become the preferred procedure for surgical management of Graves’ disease? Thyroid. 2005;15(6):569–74.

    Article  PubMed  Google Scholar 

  79. Wilhelm SM, McHenry CR. Total thyroidectomy is superior to subtotal thyroidectomy for management of Graves’ disease in the United States. World J Surg. 2010;34(6):1261–4.

    Article  PubMed  Google Scholar 

  80. Yamashita H, Noguchi S, Murakami T, Uchino S, Watanabe S, Ohshima A, et al. Calcium and its regulating hormones in patients with Graves’ disease: sex differences and relation to postoperative tetany. Eur J Surg. 2000;166(12):924–8.

    Article  CAS  PubMed  Google Scholar 

  81. Jafari M, Pattou F, Soudan B, Devos M, Truant S, Mohiedine T, et al. Prospective study of early predictive factors of permanent hypocalcemia after bilateral thyroidectomy. Ann Chir. 2002;127(8):612–8.

    Article  CAS  PubMed  Google Scholar 

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  1. Faculty of Medicine, University of Alexandria, Alexandria, Egypt

    Mahmoud F. Sakr

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Sakr, M.F. (2022). Hungry Bone Syndrome (HBS). In: Parathyroid Gland Disorders. Springer, Cham. https://doi.org/10.1007/978-3-031-07418-9_11

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