Calcitriol loading before total parathyroidectomy (PTx) with autotransplantation in end-stage renal disease patients does not appear to prevent postoperative hypocalcemia, researchers of a small study found.

Of 45 PTx patients who received preoperative high-dose calcitriol (2 μg daily) for 10 days, 13 still developed hungry bone syndrome (HBS; corrected calcium less than 2.1 mmol/L for 4 or more days) after surgery, David Ferreira, MD, of John Hunter Hospital in Australia, and colleagues reported in the Internal Medicine Journal. Calcium levels before surgery were similar between groups.

Patients who developed HBS had significantly higher preoperative levels of parathyroid hormone (PTH; 182.3 vs 130.6 pmol/L) and alkaline phosphatase (341.9 vs 164.6 U/L) than those who did not. For every 10 pmol/L increase in PTH, the risk for HBS increased 8.9%. “Higher PTH and alkaline phosphatase indicate high bone turnover, predisposing for a precipitous fall in calcium after total parathyroidectomy,” Dr Ferreira and his colleagues suggested. High PTH also indicates more severe hyperparathyroidism and a delay in surgery. The HBS group was significantly more likely to achieve PTH normalization after PTx than the no-HBS group (4.49 vs 11.75 pmol/L). In addition, HBS patients had a significantly longer duration of renal replacement therapy (RRT) prior to PTx (6.0 vs 3.7 years). The risk for HBS increased 26% for every additional year on RRT.

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“Earlier surgery at lower PTH levels may decrease the risk of HBS,” Dr Ferreira and his collaborators concluded. “As a large proportion of patients remain hypocalcaemic long after surgery, rigorous monitoring of calcium is warranted to prevent complications.”

Randomized trials investigating the ideal perioperative management strategy are needed, Dr Ferreira’s team stated. They also suggested that preoperative dosing of calcitriol depending on individual HBS risk be further explored.

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Ferreira D, Vilayur E, Gao M, et al. Calcitriol loading before total parathyroidectomy withautotransplant in patients with end-stage kidney disease: Does it prevent postoperative hypocalcaemia? Intern Med J. 2019;49:886-893. doi:10.1111/imj.14209