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Parathyroidectomy in Chronic Kidney Disease;

Peri-Operative Management

By

Ahmed Halawa

Consultant Transplant Surgeon

Sheffield Teaching Hospitals

United Kingdom

and

Osama El Shahat

Consultant Nephrologist

Mansoura International Hospital

Egypt

Parathyroidectomy.course@yahoo.com

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INTRODUCTION

Secondary (renal) and tertiary hyperparathyroidism can result in hypercalcaemia,

hyperphosphataemia, anaemia, insomnia, muscle and joint aches and pains, brown

tumours and fractures.

The treatment is mainly medical. It consists of the following elements:

1. Vitamin D3 replacement in its active form (One alpha, Calcitriol)

2. Dietary phosphate restriction coupled with phosphate binders (Not aluminium

hydroxide).

3. Oral Ca

4. Ca-a- ketoglutarate

5. Cinacalcet (if the patient is not fit for surgery or refused surgery)

Surgery is indicated if medical treatment fails. Only 5-10% of patients will come to

surgery.

Four glands exploration without radiological localization is the treatment of choice

except in recurrent hyperparathyroidism, where imaging is required (ultrasound

scan and parathyroid isotope scan).

All patients are assessed by the surgeon who organises an ENT vocal cord

examination pre-operatively.

Ensure this information is in the notes

The patients attend a pre-assessment clinic during the week prior to admission. In the

72 hours prior to theatre, the patients require a loading dose of Calcitriol or One-

alpha Calcidol (2 to 3 µg daily) to prevent severe hypocalcaemia during the ‘hungry

bone’ phase. Methylene blue, if available, (5 mg/kg dissolved in 500 ml Normal

Saline) is infused over 1 hour prior to theatre. Ensure that the patient is at his target

weight prior to infusion. Methylene blue is essential for redo parathyroidectomy.

Ensure that anti-emetic medications are prescribed on the medication chart at the

clerking to ensure that nausea can be treated promptly during the post-operative

period, since it is important that patients are able to take oral calcium and vitamin D

supplements on return from theatre.

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Serum calcium should be checked on return from theatre and every 6 hours thereafter

until stable, if necessary calcium should be infused intravenously.

Care must be taken to ensure that cannulas are not tissued (outside the vein) or

considerable tissue necrosis will result. Ward staff must be instructed to observe

cannulas for any sign of pain or inflammation.

Heparin-free dialysis or the use of minimal heparin is recommended prior to surgery.

Check clotting screen on the morning of surgery

Post-surgical patients who require dialysis should be on minimal heparin or heparin-

free if possible. A potentially serious complication of parathyroidectomy is bleeding

into the neck which may obstruct the airway necessitating immediate surgical

decompression. A plan should be made to ensure the calcium level is followed up in

the weeks following discharge of the patient.

MANAGEMENT OF POST-PARATHYROIDECTOMY HYPOCALCAEMIA

Overview

Hypocalcaemia is very common in the early post-operative period due to “hungry

bone syndrome” especially in total parathyroidectomy and auto-transplantation (the

operation of choice). It takes 5-6 weeks for the autograft to function.

The standard treatment strategy is based on moving calcium into the bloodstream.

Under normal circumstances, this is most effective by normal parathyroid glands or

by parathormone hormone (PTH) itself. Both oral calcium and active vitamin D

(Calcitriol) can play this role. Oral calcium provides a calcium substrate for the

intestinal absorption of calcium. Calcitriol increases fractional absorption of this

substrate because serum Calcitriol is otherwise very deficient (the result of PTH

deficiency during the early post-operative period). In effect, Calcitriol or oral calcium

accomplishes the same goal, and either can be adjusted with similar effect. At higher

doses Calcitriol can also mobilize calcium from bone, which can be beneficial for

symptoms even during the “hungry bones” phase.

Always check calcium level in the corrected value

Oral therapy should be adequate if the value is low but within the normal range 8.8 –

10.4 mg/dl (2.2 - 2.6 mmol/l).

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Calcium 8 – 8.8 mg/dl (2 - 2.2 mmol/l)

If the patient is symptomatic

Symptoms present as “neuromuscular irritability” state:

Paraesthesia (usually fingers, toes and around mouth).

Tetany.

Carpopedal spasm (wrist flexion and fingers drawn together).

Muscle cramps, also could present as laryngeal or bronchospasm (difficulty in

breathing).

Give 10 ml calcium gluconate 10% as an intravenous infusion diluted to 50 ml with

Normal Saline over 10 minutes (rate not exceeding 1.5 – 2.5mg/dl Ca/min) followed

by oral therapy.

If the patient is asymptomatic

Give oral therapy with Calcium Carbonate (e.g. Calcichew 2.5 g three times daily) in

addition to oral active vitamin D (e.g. Calcitriol 2 µg twice daily).

Calcium < 8 mg/dl (< 2 mmol/l)

Treat as follows regardless to the presence or absence of symptoms:

Give 40-60 mg/dl calcium gluconate 10% as an intravenous infusion diluted in at least

250 ml Normal Saline to be given peripherally.

Infusion is given over 6 hours (rate of 2 mg/dl/min)

Be aware of fluid overload

Repeat calcium levels 60 minutes after the infusion has finished.

Repeat the infusion as necessary until the desired calcium level is reached, and then

commence oral therapy.

NB. Calcium Chloride has a greater availability of calcium in a smaller volume (20

mg/dl in 10 ml compared to 10 mg/dl in 10 ml for calcium gluconate). However, it is

more irritant and needs to be given slowly to prevent this or any cardiac problems.

Calcium gluconate is therefore the preferred salt.

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Oral therapy

Ensure that high doses of oral calcium are given. Oral absorption is inversely

proportional to the dose, so divided doses are better than larger single doses.

Preparations available

Calcichew, Calcium 500 = 500 mg Ca (12.6 mmol Ca).

Sandocal 400 = 400 mg Ca (10 mmol Ca). This is a dispersible preparation.

Remember: Check magnesium levels if calcium level is not rising with treatment as

calcium levels cannot be corrected until magnesium levels are normal.

Extravasation of calcium

Calcium is hypertonic and can cause extensive tissue damage on extravasation. It is

sensible to consider central cannulation for patients requiring intravenous calcium. If

a peripheral cannula is used ensure that the cannula is patent by flushing with normal

saline prior to the calcium infusion. Explain the potential risks of the infusion to the

patient, and ask the patient to inform you immediately if pain occurs at the cannula

site during infusion. Explain carefully to the nursing staff the need for close

observation of the cannula.

Stop the infusion immediately if extravasation is suspected. Do not remove the

cannula, aspirate to withdraw as much of the infused fluid as possible. Instil water for

injection in order to reduce the local concentration. Apply heat to disperse the diluted

calcium.

If extravasation of calcium has occurred contact the plastic surgery on-call team

immediately as they may be able to reduce the tissue damage by subcutaneous

lavage.

PTH monitoring and long-term follow up

PTH (the intact hormone) is checked on discharge, it is expected to be below the

reference range, but the immediate post-operative care is entirely based on symptoms

and serum calcium.

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Annual review of PTH is required if the initial results are satisfactory. We aim at

long-term PTH level of 100 - 150 pg/ml to reduce the incidence of adynamic bone

disease (reduced bone turn over with subsequent pathological fractures).

REFERENCES

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4. KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease in

Chronic Kidney Disease. Accessed from:

https://www.kidney.org/professionals/kdoqi/guidelines_bone/guide13c.htm

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patients undergoing thyroidectomy. Curr Opin Oncol. 2011 Nov 9.