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

Tertiary hyperparathyroidism & postoperative hypocalcemia

Brock Lanier, M.D.

MCV/VCU Department of Surgery M&M

12 April 2012

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• 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).

Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia

Case presentationPre-hospital evaluation.


Post DDRTx serum Cr (mg/dL)

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• 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).




Post DDRTx serum Ca2+ (mg/dL)

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Post DDRTx serum PTH (pg/mL)

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• 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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• 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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• 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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• 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).


Case presentationHospital course.


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

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• 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.- 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.


Case presentationHospital course.

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


Case presentationHospital re-admission.


Postoperative serum Ca2+ (mg/dL) trend

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• 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).

: Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia



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

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• 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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• 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.


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

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


Post DDRTx serum Ca2+ (mg/dL)

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• 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 re-mineralization) and delayed autograft recovery/function both increase the risk for transient hypocalcemia.



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• 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 re-excision for persistent HPT.



Tertiary hyperparathyroidism & postoperative hypocalcemia

Brock Lanier, M.D.

MCV/VCU Department of Surgery M&M

12 April 2012

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