Hyperkalemia Following Parathyroidectomy in Patients with Renal Hyperparathyroidism—New Thresholds for Urgent Perioperative Dialysis

Abstract

Parathyroidectomy (PTX) is a mainstay of treating secondary hyperparathyroidism (SHPT) in patients with kidney failure in order to reduce the incidence of cardiovascular events (CVE), increase overall survival and improve quality of life. Perioperative hyperkalemia may lead to devastating cardiac complications. Distinct preoperative thresholds for serum potassium levels (SPL) were defined, but neither their usefulness nor consecutive risks are understood. This study compared the results and efficacy of different clinical procedures in preventing or treating perioperative hyperkalemia, including postoperative urgent hemodialysis (UHD). Methods: Patients from Charité-Universitätsmedizin Berlin and Rheinland Klinikum Lukaskrankenhaus, Neuss, undergoing PTX due to SHPT between 2008 and 2018 were analyzed retrospectively with regard to demographic parameters, surgery specific conditions and perioperative laboratory results. Comparisons of patient values from both centers with focus on perioperative hyperkalemia and the need for UHD were performed. Results: A total of 251 patients undergoing PTX for SHPT were included (Neuss: n = 121 (48%); Berlin: n = 130 (52%)). Perioperative hyperkalemia (SPL ≥ 5.5 mmol/L) was noted in 134 patients (53%). UHD on the day of surgery was performed especially in patients with intraoperative hyperkalemia, in females (n = 40 (16%) vs. n = 27 (11%); p = 0.023), in obese patients (n = 27 (40%) vs. n = 50 (28%), p = 0.040) and more often in patients treated in Neuss (n = 42 (35%) vs. 25 (19%); p = 0.006). For patients treated in Neuss, the intraoperative hyperkalemia cut-off level above 5.75 mmol/L was the most predictive factor for UHD (n = 30 (71%) vs. n = 8 (10%); p < 0.001). Concerning secondary effects of hyperkalemia or UHD, no patient died within the postoperative period, and only three patients suffered from acute CVE, with SPL > 5.5 mmol/L measured in only one patient. Conclusion: Perioperative values could not predict postoperative hyperkalemia with the need for UHD. Previously defined cut-off levels for SPL should be reconsidered, especially for patients undergoing PTX. Early postoperative dialysis in patients with postoperative hyperkalemia can be performed with a low risk for complications and may be indicated for all patients with increased perioperative SPL.

Predictors of hyperkalemia after total parathyroidectomy in patients with drug-refractory secondary hyperparathyroidism

“…Even with the best of our preoperative preparations, we can see that postoperative hyperkalemia can still occur after PTX + AT, and the prevention of postoperative hyperkalemia places a higher demand on our patient management. Bures et al (19) suggested that early postoperative dialysis treatment with assessment of low risk of postoperative complications may be useful in reducing the incidence of postoperative hyperkalemia.…”

Treatment for secondary hyperparathyroidism focusing on parathyroidectomy

“…In the case of postoperative severe hyperkalemia, urgent dialysis is required to prevent cardiovascular events. The risk factors of hyperkalemia after PTx for SHPT are not well demonstrated, although the relationships of hyperkalemia with gender, age, obesity, and preoperative serum potassium levels are mentioned in small-sized studies ( 107 – 109 ).…”

Optimal Timing of Hemodialysis Before Surgery

“…Hyperkalemia, an important risk factor for cardiac death in patients treated with hemodialysis, occurs more commonly with a longer hemodialysis-free interval and is exacerbated by fasting prior to surgery . In a study of elective parathyroidectomy in 251 patients treated with hemodialysis, perioperative hyperkalemia (serum potassium level >5.5 mEq/L) occurred in 53% of patients . The stress of surgery combined with the increased hemodialysis-free interval may increase surgical mortality.…”