Incidence of and risk factors for hungry bone syndrome in 84 patients with secondary hyperparathyroidism

Abstract

IntroductionSecondary hyperparathyroidism develops in nearly all patients with end-stage renal disease. Parathyroidectomy is often performed when medical therapy fails. The most common postoperative complication, hungry bone syndrome (HBS), requires early recognition and treatment.Materials and methodsA total of 84 patients who underwent parathyroidectomy because of secondary hyperparathyroidism were investigated. Detailed analysis of laboratory parameters (calcium, phosphate, parathyroid hormone, hemoglobin, and urea levels) and baseline characteristics (age at time of surgery, duration of renal replacement therapy, and medication) was performed to detect preoperative predictors for the development of HBS.ResultsAverage overall follow-up of the cohort was 4.7 years. Within this time frame, 13 of 84 patients had to undergo a second surgery because of recurrent disease, and HBS occurred in 51.2%. Only decreased preoperative calcium levels and younger age at time of surgery were significant predictors of HBS. Minimal levels of calcium were detected 3 weeks after surgery. Preoperative vitamin D therapy could not prevent HBS and could not shorten the duration of intravenous calcium supplementation.ConclusionHBS is a very common complication after parathyroidectomy. Younger patients and patients with low preoperative calcium levels were at higher risk for the development of HBS. Remarkably, preoperative vitamin D therapy could not prevent HBS and had no impact on the length of intravenous calcium supplementation. Intensive monitoring of calcium levels must be performed for at least 3 weeks after surgery.

Surgical management of secondary hyperparathyroidism in chronic kidney disease—a consensus report of the European Society of Endocrine Surgeons

“…Moreover, assessed parathyroid mass may be used to predict response to medical treatment [13]. 99 Tc sestamibiscintigraphy with/without single-photon emission computed tomography (SPECT) is appreciated by some surgeons to exclude ectopic parathyroid localization despite convincing evidence in defined multiglandular disease. Therefore, enhanced localization measures including 99 Tc sestamibi-scintigraphy with/without SPECT and CT, MRI, (11) C-methionine PET-CT or 18 F-FDG-PET-CT as well as selective venous catheterization with PTH assessment presently appear to be reserved for special indications and possibly rare reoperative situations, since standard conventional bilateral exploration in renal HPT does not rely on preoperative localization [14][15][16].…”

“…Young age (<36 years), low preoperative calcium levels (<10 md/dl), elevated alkaline phosphatase (>1.92 mmol/l) and elevated presurgery PTH (>150 pmol/l), and subperiosteal bone resorption were recognized as preoperative risk factors [95,99,100] (EL 3-4).…”

Leczenie ciężkiej, zagrażającej życiu hipokalcemii ludzkim rekombinowanym teryparatydem pacjentów z pooperacyjną niedoczynnością przytarczyc — seria przypadków

“…Based on endoscopy with the sampling of duodenal specimens and the determination of anti-transglutaminase antibodies, malabsorption syndrome was ruled out as a potential cause of impaired calcium absorption in the digestive tract. A frequent complication following surgical treatment of primary hyperparathyroidism is hungry bone syndrome (HBS), especially in patients with advanced bone changes associated with this disease [31]. Our patient suffered from generalised bone pain, low mineral density of lumbar spine (BMD L1-L4 T-score -3.4), and elevated serum levels of alkaline phosphatase (ALP), which could indicate enhanced bone remodelling with intensive re-calcification of bone tissue.…”

“…Most HBS definitions include the presence of hypocalcaemia in a patient subjected to surgery for hyperparathyroidism, as well as hypophosphatemia and hypomagnesaemia as an effect of bone remineralisation [28,33]. Some authors define HBS-related hypocalcaemia as the values < 8.5 mg/dL and hypophosphatemia as the values < 3.0 mg/dL [27] with hypocalcaemia persisting for over four days despite calcium ion supplementation, with normal vitamin D levels in serum [31]. Parathormone serum levels are normal or elevated [27,28,34].…”

“…It is commonly believed that the factors predisposing for HBS include old age, the size of removed parathyroid glands, high preoperative calcium, ALP and PTH levels, changes in bone system (bone cysts, brown tumours, subperiosteal bone resorption, osteopaenia, osteoporosis), vitamin D deficiency [27,28,35], or parathyroid cancer [36]. On the other hand, Latus et al [31], having analysed 84 patients after surgery for secondary hyperparathyroidism, found that the risk of HBS is higher in younger patients and in patients with low preoperative calcium levels. These authors also observed that preoperative vitamin D therapy did not prevent HBS and had no impact on the duration of postoperative intravenous calcium supplementation [31].…”