Slide 1

Tertiary hyperparathyroidism &
postoperative hypocalcemia
Brock Lanier, M.D.
MCV/VCU Department of Surgery M&M
12 April 2012

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Slide 2

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Case presentation
Pre-hospital evaluation.

• HPI: 68 y/o woman referred for surgical evaluation
and management of tertiary hyperparathyroidism.
• ERSD (HTN) and s/p DDRTx (1/3/2011). Renal
allograft function has been excellent (see next slide).

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Slide 3

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Post DDRTx serum Cr (mg/dL)

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Slide 4

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Case presentation
Pre-hospital evaluation.

• HPI: 68 y/o woman referred for surgical evaluation
and management of tertiary hyperparathyroidism.
• ERSD (HTN) and s/p DDRTx (1/3/2011). Renal
allograft function has been excellent.
• Post transplant course significant for persistent
hyperCa2+. Serum PTH values markedly elevated
(see next slides).

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Slide 5

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Post DDRTx serum Ca2+ (mg/dL)

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Slide 6

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Post DDRTx serum PTH (pg/mL)

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Slide 7

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Case presentation
Pre-hospital evaluation.

• HPI: 68 y/o woman referred for surgical evaluation
and management of tertiary hyperparathyroidism.
• ERSD (HTN) and s/p DDRTx (1/3/2011). Renal
allograft function has been excellent.
• Post transplant course significant for persistent
hyperCa2+. Serum PTH values markedly elevated.
• Pt referred to surgical oncology clinic for evaluation
and mgmt thereof.
• Surgical intervention recommended but deferred by
patient x several months (Aug 2011 until Feb 2012).

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Slide 8

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Case presentation
Pre-hospital evaluation.

• PMHx: HTN, ESRD (previous PD, now functional
allograft), post-txp DM, tertiary hyperparathyroidism.
• PSHx: DDRTx (1/2011), Tenkoff catheter insertion
and removal, C-section x2.
• Meds: Prednisone 10 mg qd, FK 3 mg bid, MMF 750
mg bid, Sensipar 60 mg bid, ASA, lisinopril, Norvasc,
Glipizide, famotidine, KCl.
• NKDA

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Slide 9

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Case presentation
Pre-hospital evaluation.

• FamHx: HTN, DM, CVA in several family members, no
h/o malignancy or endocrine dysfxn.
• Social hx: Married w/ adult children. Retired
elementary school teacher for special needs
children. Denies tobacco, EtOH, and illicit drug use.

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Slide 10

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Case presentation
Hospital course.

• 3/23/2012 OR: neck exploration, parathyroidectomy
x4, LUQ abdominal wall SQ autograft implant.
-

Path: hyperplasia x 4 glands.
Standard postop Ca2+ repletion protocol initiated.
o CaCl 2 gm IV q4 h started and then titrated down and PO
supplementation stated as serum Ca2+ levels allow.
o Often 5-7 days required before eucalcemia is achieved.

• POD #5: Febrile, UTI treated and resolved with ABX.
• POD #8: D/c home.
-

Calcium trended down postoperative (see next slide).

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Slide 11

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

POD #0-8 serum Ca2+ (mg/dL) trend

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Slide 12

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Case presentation
Hospital course.

• 3/23/2012 OR: neck exploration, parathyroidectomy
x4, LUQ abdominal wall SQ autograft implant.
-

Path: hyperplasia x 4 glands.
Standard postop Ca2+ repletion protocol initiated.
o CaCl 2 gm IV q4 h started and then titrated down and PO
supplementation stated as serum Ca2+ levels allow.
o Often 5-7 days required before eucalcemia is achieved.

• POD #5: Febrile, UTI treated and resolved with ABX.
• POD #8: D/c home.
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Calcium trended down postoperative.
At time of d/c, prn repletion requirements were minimal
(single Ca gluc 2 gm x1/d); PO repletion was stable (2400
mg PO qid); and calcitriol was increased (1 ug PO bid).
D/c plans included close f/u lab values as outpatient.

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Slide 13

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Case presentation
Hospital re-admission.

• 4/5/2012 (POD #13): Re-admit for symptomatic
hypocalcemia (numbness and tingling in B fingers,
next slide).

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Slide 14

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Postoperative serum Ca2+ (mg/dL) trend

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Slide 15

: Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Case presentation
Hospital re-admission.

• 4/5/2012 (POD #13): Re-admit for symptomatic
hypocalcemia (numbness and tingling in B fingers).
- IV repletions initiated with symptom resolution.
- PO repletions increased (calcitriol to 1.5 ug PO bid).

• 4/6/2012 (POD #14): last IV dose required.
• 4/7 – 4/9/2012: stable, then increasing serum Ca2+
(next slide).

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Slide 16

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Re-admission serum Ca2+ (mg/dL) trend

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Slide 17

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Case presentation
Hospital re-admission.

• 4/5/2012 (POD #13): Re-admit for symptomatic
hypocalcemia (numbness and tingling in B fingers).
- IV repletions initiated with symptom resolution.
- PO repletions increased (calcitriol to 1.5 ug PO bid).

• 4/6/2012 (POD #14): last required IV dose.
• 4/7 – 4/9/2012: stable then increasing serum Ca2+.
• 4/9/2012 (POD #17): d/c home, eucalcemic on stable
PO regimen (PO only x ~ 72 hr). Alternative plans for
outpatient surveillance implemented.

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Slide 18

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Tertiary hyperparathyroidism (HPT)
Refractory disease after RTx, surgically treated.

• Tertiary (HPT) most often occurs in the setting after
renal txp.
• It is (almost always) caused by hyperplasia of the
(four) parathyroid glands. Indications for operation,
next slide.

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Slide 19

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Tertiary hyperparathyroidism (HPT)
S. C. Pitt, R. S. Sippel, and H. Chen, Surg Clin 2009, PMID 19836494.

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Slide 20

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Post DDRTx serum Ca2+ (mg/dL)

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Slide 21

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Tertiary hyperparathyroidism (HPT)
Refractory disease after RTx, surgically treated.

• Tertiary (HPT) most often occurs in the setting after
renal txp.
• It is (almost always) caused by hyperplasia of the
(four) parathyroid glands. Indications for operation,
next slide.
• Reports indicate about 1-5% of RTx patients require
surgical management.
• “Hungry bone syndrome” (accelerated bone remineralization) and delayed autograft
recovery/function both increase the risk for transient
hypocalcemia.
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Slide 22

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Tertiary hyperparathyroidism (HPT)
Refractory disease after RTx, surgically treated.

• For this reason patients are placed on an aggressive
Ca2+ supplementation schedule postoperatively,
initially IV then transitioned to PO.
• Only a small fraction of patients (<5%) require
subsequent surgical intervention, i.e. autograft reexcision for persistent HPT.

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Slide 23

Tertiary hyperparathyroidism &
postoperative hypocalcemia
Brock Lanier, M.D.
MCV/VCU Department of Surgery M&M
12 April 2012

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