Calcitriol loading before total parathyroidectomy with autotransplant in patients with end‐stage kidney disease: does it prevent postoperative hypocalcaemia?

Abstract

Background Hungry bone syndrome (HBS) is one of the most serious complications following parathyroidectomy for severe hyperparathyroidism. There is a lack of literature informing the treatment and risk factors for this condition and the ideal pre‐operative strategy for prevention. Aims The primary aims were to examine the incidence of HBS with pre‐operative calcitriol loading for 10 days and to determine the risk factors for HBS. The secondary aims were to determine the rate of intravenous calcium replacement in those with HBS and to assess whether cinacalcet removal has increased rates of parathyroidectomy in the end‐stage kidney disease population. Methods We performed a retrospective study from 2011 to 2018 on 45 patients with end‐stage kidney disease undergoing total parathyroidectomy with autotransplantation for severe hyperparathyroidism. This was based at the John Hunter and Newcastle Private Hospitals in New South Wales. Results 28.3% of patients with calcitriol loading undergoing parathyroidectomy fulfilled criteria for HBS. Pre‐operative variables that were associated with HBS were elevated parathyroid hormone (P = 0.028) and longer duration of renal replacement therapy (P = 0.033). Rates of total parathyroidectomy were higher after the removal of calcimimetics from the Pharmaceutical Benefits Scheme (P = 0.0024). Conclusions HBS remains a common complication of parathyroidectomy, even with prolonged high‐dose calcitriol loading. This emphasises the need for further trials investigating other targeted therapies, such as bisphosphonates, to prevent HBS. Those most at risk of HBS are patients with high bone turnover and prolonged renal replacement therapy.

Forestalling Hungry Bone Syndrome after Parathyroidectomy in Patients with Primary and Renal Hyperparathyroidism

“…Alternatively, an approach based on a 10-day calcitriol loading protocol before PTx in individuals with RHPT might decrease the rate of HBS, yet, it is not unanimously agreed upon. One study on 45 participants who received this mentioned type of intervention developed HBS (28.3% of them) following total PTx with auto-transplantation; HBS positively correlated with pre-operatory PTH levels, and with duration of dialysis before surgery [127]. In addition to calcium and calcitriol supplementation, the use of dialysis represents another key factor to the outcome of HBS in patients with chronic kidney disease, as similarly seen in influencing other endocrine complications of the renal condition [133][134][135].…”

“…An amount of 23 studies were retrospective and 4 were of prospective, prospective-retrospective type, respectively, longitudinal and a national database cohort. Considering the number of enrolled participants per study, 12 studies included less than 100 participants per study, as follows: 19 (n = 2), 35, 37 (n = 2), 41, 45, 53, 62, 77, 79, 84; 9 studies enrolled between 100 and 200 individuals per study (of 108, 115, 120, 130, 131, 141, 148, 167, and 196), 3 studies had between 200 and 300 patients per study (specifically, 252, 260, and 297) while 3 larger studies had more than 700 patients per study (N = 796, 1846, and 7171), regardless the study design, a total of 12,468 patients with RHPT [1,4,17,30,40,84,85,[104][105][106][107][108][109][110]112,116,117,[123][124][125][126][127][128][129][130][131][132] (Table 5).…”

“…Especially in individuals with chronic renal failure who are expected to display HBS with a much higher prevalence than patients with PHPT, active implementation of intra-and post-operatory protocols contribute to a better outcome. A few studies followed the results of using such protocols [123][124][125]127]. For example, one single-center study highlighted some aspects related to standard ERAS (enhanced recovery after surgery) program in patients with RHPT who were referred for total PTx without self-transplantation in order to avoid HBS.…”

“…Table 5. Original studies in patients confirmed with RHPT who developed HBS following PTx; the display starts with the most recent publication [1,4,17,30,40,84,85,[104][105][106][107][108][109][110]112,116,117,[123][124][125][126][127][128][129][130][131][132].…”

Pre‐operative Cinacalcet Administration Reduces Immediate Post‐operative Hypocalcemia Following Total Parathyroidectomy in Severe Renal Hyperparathyroidism

“…Yet, there is little knowledge on how we can effectively reduce or prevent this complication. The use of pre-operative loading calcium and/or calcitriol supplement has controversial results [11][12][13][14][15]. On the other hand, studies have shown that poorly controlled severe RHPT (manifested as high pre-operative PTH levels) led to more severe and more frequent hypocalcemia [16][17][18][19].…”