Is hungry bone syndrome a cause of postoperative hypocalcemia after total thyroidectomy in thyrotoxicosis? A prospective study with bone mineral density correlation

Karunakaran, Poongkodi; Maharajan, Chandrasekaran; Ramalingam, Srinivasan; Rachmadugu, Suresh Venkatesh

doi:10.1016/j.surg.2017.09.008

Cited by 29 publications

(18 citation statements)

References 30 publications

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“…According to a prospective study with 40 thyrotoxic subjects and 40 euthyroid controls undergoing total thyroidectomy, thyrotoxic osteodystrophy was an important predisposing factor for postoperative hungry bone syndrome and baseline BMD reflects the severity of hypocalcaemia 7. This study also described elevated serum ALP correlated strongly with postoperative hypocalcaemia, which reflects the increased activity of the osteoblast 4.…”

Section: Discussionmentioning

confidence: 73%

Hungry bone syndrome after thyroidectomy for thyroid storm

Kusuki

Mizuno

2019

BMJ Case Rep

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A 39-year-old man was admitted to our hospital with the diagnosis of thyroid storm due to Graves’ disease. Near-total thyroidectomy was performed after 1 month’s pharmacological treatment, and he presented with tetany next morning. Serum corrected calcium value was 5.7 mg/dL. Procollagen type 1 N-terminal propeptide increased considerably, while tartrate-resistant acid phosphatase 5b decreased. These changes indicated that bone formation exceeded bone resorption in reverse after thyroidectomy. Calcium gluconate was administered intravenously for 14 days, before the patient was discharged. Oral administration of calcium and active forms of vitamin D was continued for 4 months. Rapid skeletal uptake of calcium from blood caused severe and persistent hypocalcaemia, which is called hungry bone syndrome. When patients with Graves’ disease have severe thyrotoxicosis, high serum alkaline phosphatase levels and low bone mineral densities, they are at high risk for hungry bone syndrome after thyroidectomy, and should be educated for the symptoms of hypocalcaemia.

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Section: Discussionmentioning

confidence: 73%

Hungry bone syndrome after thyroidectomy for thyroid storm

Kusuki

Mizuno

2019

BMJ Case Rep

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“…11,12 The phenomenon of hungry bone resulting from remineralization of bone loss associated with thyrotoxicosis induced osteoporosis is implicated as an important cause of post-thyroidectomy hypocalcemia. [13][14][15][16][17] Hence, Vitamin D, which is an independent predictor of bone health and a potentially correctable factor was extensively studied for its role in the development of PH in thyrotoxic subjects. However, the results are variable owing to; geographic variation in vitamin D deficiency prevalence; the lack of uniformity in the utilization of 25OHD vs. 1, 25dihydroxycholecalciferol for assessment of vitamin D status; differences in the assay method and cut-off values for defining the reference range.…”

Section: Discussionmentioning

confidence: 99%

“…In a previous report, we have shown that HBS occurred exclusively in thyrotoxic subjects undergoing TT and correlated with the severity of bone demineralization. 13,17 Furthermore, the author has shown in the previously published reports that the radical technique of TT was associated with higher rates of PH in thyrotoxic subjects and facilitates rapid recovery of bone mineral density. 33,34 Moreover, 25OHD levels were not different in subjects exhibiting and not exhibiting PH among thyrotoxic subjects.…”

Section: Discussionmentioning

confidence: 99%

The utility of serum 25-hydroxyvitamin D in predicting post-thyroidectomy hypocalcemia in thyrotoxic subjects: a single-center cohort study

Karunakaran

Abraham

2020

Int Surg J

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Background: The role of preoperative vitamin D deficiency as a predictor of post-thyroidectomy hypocalcemia in thyrotoxic subjects is controversially reported. This prospective cohort study determined the utility of serum 25-hydroxyvitamin D (25OHD) levels in predicting transient hypocalcemia in thyrotoxic and euthyroid patients undergoing total thyroidectomy (TT).Methods: Subjects with new-onset hyperthyroidism (n=97; age=median (Inter-Quartile Range); 38 (18) years; M:F=25:72) and age; sex-matched euthyroid cohorts (n=231; age=37 (18) years; M:F=40:191) undergoing TT were evaluated for serum corrected-calcium, intact parathormone and 25OHD levels at baseline, 48-hour and 6-months post-TT, p value <0.05 was considered significant.Results: The incidence of transient hypocalcemia in thyrotoxic subjects was 58.8% (57/97) versus 22.5% (52/179) in euthyroid cohorts. In receiver operating characteristic analysis predicting transient hypocalcemia for the test-variable preoperative 25OHD, the area under curve (AUC) among euthyroid subjects was 0.725 (95% CI: 0.641-0.809; p<0.001) with a threshold of 17.6 ng/mL with sensitivity and specificity of 65.4% and 64.2% respectively. In thyrotoxic subjects, the AUC was 0.573 (95% CI; 0.452-0.694; p=0.222) with poorer predictability and was less than that of euthyroid subjects.Conclusions: Preoperative 25OHD below 17.6 ng/ml was reliable in predicting transient postoperative hypocalcemia in euthyroid subjects though with a limited sensitivity and specificity but unreliable in thyrotoxic subjects undergoing TT.

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“…Hyperthyroidism increases bone turnover which over time can lead to thyrotoxic osteodystrophy. After total thyroidectomy for hyperthyroidism, hypocalcemia can result from rapid recalcification of bones after loss of thyroid hormone stimulation [16].…”

Section: Discussionmentioning

confidence: 99%

Thyroid Storm with Multiorgan Failure Treated with Plasmapheresis

Miller

Silver

2019

Case Reports in Endocrinology

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Background Thyroid storm is a severe manifestation of thyrotoxicosis and can present with multiorgan failure. First line treatment of thyroid storm is directed towards decreasing thyroid hormone production and peripheral conversion of T4 to T3, and treating adrenergic symptoms. When medical therapy fails, plasmapheresis is an alternative treatment option. Here we present a patient with thyroid storm and multiorgan failure who was treated with plasmapheresis. CaseA 50-year-old male with a history of hyperthyroidism, hypertension, and congestive heart failure presented to another hospital with fever and altered mentation. He was found to have pneumonia on imaging and was started on antibiotics. He developed shock complicated by atrial fibrillation with rapid ventricular rate which was treated with amiodarone. He was transferred to our hospital for further management. On arrival, TSH was <0.01 mIU/L, free T4 was >7 ng/dL and total T3 was 358 ng/dL. The endocrinology team determined he was in thyroid storm. His medical treatment of thyroid storm was aggressively titrated to maximal therapy. His hospital course was complicated by transaminitis, respiratory failure requiring intubation, shock requiring vasopressor support, kidney failure requiring continuous renal replacement therapy, and heart failure. Despite maximal anti-thyroid therapy, he had not improved clinically and T4 and T3 remained markedly elevated. A 4-day course of plasmapheresis was initiated resulting in marked lowering of T4 and T3 and clinical stability. ConclusionWhile current guidelines for plasmapheresis for thyroid storm recommend individualized decision making, no further clarification is provided on who would be a good candidate for the procedure. We present a patient with thyroid storm and multiorgan failure who was treated with plasmapheresis after failing maximal medical therapy. Given the significant improvement seen with plasmapheresis, endocrinologists should consider this mode of treatment earlier in the course of thyroid storm when patients are not improving with medical therapy alone.

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Is hungry bone syndrome a cause of postoperative hypocalcemia after total thyroidectomy in thyrotoxicosis? A prospective study with bone mineral density correlation

Cited by 29 publications

References 30 publications

Hungry bone syndrome after thyroidectomy for thyroid storm

Hungry bone syndrome after thyroidectomy for thyroid storm

The utility of serum 25-hydroxyvitamin D in predicting post-thyroidectomy hypocalcemia in thyrotoxic subjects: a single-center cohort study

Thyroid Storm with Multiorgan Failure Treated with Plasmapheresis

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