nephrology

1. Post-Parathyroidectomy Hypocalcemia
Dr. Osama El-Shahat
Head of Nephrology Department
New Mansoura General Hospital (international)
Vice president Of Dakahlia Nephrology Group
ISN Educational Ambassador

2.  Introduction
 Operative Strategies
 Total parathyroidcomy with autotransplantion
 Protocol and results
of par thyroidectomy in Mansoura
International Hospital
 Management
 Conclusion
Agenda

3.  Secondary hyperparathyroidism (2HPT) is a common
complication in hemodialysis patients.
 The majority of patients with 2HPT can be managed by
medical treatment with vitamin D sterols and calcimimetics.
 In severe cases of 2HPT, medical therapy alone may be
ineffective.
 Some patients require surgical treatment in the form of
parathyroidectomy (PTX)
Introduction:
Coulston JE, e tal. Br J Surg. 2010 Nov;97(11):1674-9.

4.  Hypocalcemia is a common problem after parathyroidectomy
 The fall in serum calcium is primarily due to functional or
relative hypoparathyroidism, leading to reductions in bone
reabsorption and increases in bone formation, leading to an
increased influx of calcium into bone ,
Introduction:

5.  In some cases, however, the postoperative hypocalcemia is
severe and prolonged, despite normal or even elevated levels
of PTH. This phenomenon, called the hungry
bone syndrome .
 Most often occurs in patients who have developed bone
disease preoperatively due to a chronic increase in bone
resorption induced by high levels of PTH
Introduction:

6.  In addition to reduced serum calcium, reduced serum
phosphate and increased serum potassium levels may be
observed in hungry bone syndrome.
 The decreased serum calcium and phosphate and increased
potassium likely reflect increased bone influx and efflux,
respectively.
Introduction:

7.  The symptoms of hypocalcaemia due to post-operative
hypoparathyroidism usually present in the first 24–72 hours
after surgery
 Features of hypocalcaemia include circumoral or peripheral
paraesthesia, tetany, carpopedal spasm, laryngospasm and
ECG changes progressing from long QT interval to VT arrest
Introduction:

8.  3 glands 3%
 4 glands 84%
 5 or more 13%
Anatomy

9. Subtotal parathyroidcomy (SPTX)
– Resection of 3 ½ parathyroid gland
– The most healthy looking parathyroid gland chosen
– Leaving a portion of viable parathyroid gland and marked
with clip
Total parathyroidcomy with autotransplantion( TPTX+AT)
The most healthy looking parathyroid gland chosen
Implantation of a portion of parathyroid gland
Total parathyroidcomy without autotransplantion( TPTX)
Operative Strategies

10.  The hypocalcemia is generally transient
because normal parathyroid tissue recovers
function quickly (usually within one week),
even after long-term suppression.
Total parathyroidcomy with
autotransplantion

11.  Parathyroid autotransplantation has been
demonstrated to be effective, clinically and
biochemically, with a functional graft survival
rate of 93%
Total parathyroidcomy with
autotransplantion

12. Found only 3 glands
 Total parathyroidectomy
 Thymectomy
 No auto-transplantation
Post-Parathyroidectomy
Hypocalcemia Risk Factors

13.  Reviewed the medical records of 129 secondary
hyperparathyroidism (SHPT) patients on maintenance
hemodialysis (HD) who underwent PTx at China-Japan
Friendship Hospital in 2017.
 Patients at greater risk of experiencing severe hypocalcemia
had higher levels of serum iPTH and lower levels of serum
calcium before surgery, along with mild to no symptoms of
pruritus
 A team led by Xiaoliang Sun, MD, 2017
Post-Parathyroidectomy
Hypocalcemia Risk Factors

14.  Post-operative hypoparathyroidism increases length
of hospitalization, morbidity and cost associated.
 While permanent hypoparathyroidism poses a
significant medical burden with lifetime medication,
Post-Parathyroidectomy
Hypocalcemia

15.  In addition to patient morbidity and mortality, post-
parathyroidectomy hypocalcaemia leads to greater
healthcare costs due to the need for extra biochemical
testing, electrolyte supplementation and increased
length of hospital stays
Post-Parathyroidectomy
Hypocalcemia

16. Protocol
of parathyroidectomy
for patients with ESRD

18.  The patients attend a pre-assessment clinic during
the week prior to admission.
 In the72 hours prior to theatre, the patients require a
loading dose of Calcitriol or alpha Calcidol (2 to 3
μg daily) to prevent severe hypocalcaemia during
the ‘hungry bone’ phase.
Preoperative:

19.  Insertion of CVP .
 2 amp. Of ca gluconate diluted in 50cc 0.9% Nacl
over 1 hour during the surgery .
Intraoperative

20.  Check S.ca & phosphorus on return from theatre then
every 6 h. till for 2 days then every 12 h. for 3 days then
daily .
 IV Ca infusion which , changing the dose according to
S.Ca level .
 Send the removed glands for histopathological
examination.
 Check PTH 1 week after the operation .
Postoperative

21. Remember:
◦ Check magnesium levels if calcium level is not
rising with treatment as calcium levels cannot be
corrected until magnesium levels are normal.
Postoperative

22.  To present our experience in total
parathyroidectomy with auto-transplantation
of parathyroid gland and thymectomy.
Mansoura International Hospital
experience

23.  Retrospective review of 128 cases underwent total
parathyroidectomy, thymectomy and auto-transplantation performed
over five years period. Patients were selected based on symptoms of
CKD-MBD with intact PTH level of 1200 pg/ml and above. No
preoperative imaging was required due to lack of acceptable
sensitivity in multi-gland disease. 4 glands excision was performed.
A part of a relatively healthy gland (equivalent to size of normal
gland) were auto-transplanted into sternomastoid muscle pouches.
Patients & methods:

24. Clinical data
Male Femal Total
Count 76 52 128
Age (yr.) 42.71 42.51 42.63
Duration of HD(yr.) 7.48 6.88 7.26
59%
41%
Male

25. S. PTH

26. S. Ca

27. S. Po4
Pre-op Post-op
0
1
2
3
4
5
6
5.9
3.4

28. Post operative S. Ca

29.  128 patients had curative surgery with the mean postoperative
PTH 108.27pg/ml. Six patients had persistent
hyperparathyroidism where one or 2 glands were not found in
the neck and one patient had recurrence .
 8 patients developed symptomatic hypocacemia, 4 of them
required hospitalization>
 One case developed vocal cord fixation.
 Hemothorax related to central venous line one case.
 Thrombophlebitis related to Ca infusion 5 cases.
Results

33.  In 2015, The FDA approved, in rhPTH (1-84), named
Natpara®, a bioenginerred rhPTH, for the management
of chronic hypoparathyroidism not well controlled with
conventional therapy.
Management

34.  replacement treatment with rhPTH is an attractive
option for subjects with hypoparathyroidism who are
unable to maintain stable and safe serum and urinary
calcium levels.
 Since therapy with rhPTH is a long-term management
option in hypoparathyroidism, more long-term safety
data are needed.
Management

35.  Cryopreservation is another method to avoid permanent
hypoparathyroidism following parathyroidectomy
 Cryopreservation involves the freezing and storage of
parathyroid tissue in case permanent
hypoparathyroidism occurs
Management

36.  allotransplantation has had variable results usually due
to rejection by alloimmunization or inflammatory
responses causing fibrosis compromising graft survival
Management

37.  New stem cell research has yielded promising results
regarding the generation of parathyroid-like cells.
 Ignotski et al. and Bingham et al. have demonstrated a
method of generating cells producing parathyroid
hormone RNA and parathyroid hormone from two
different human embryonic stem cell lines
Management

38. Evaluation and management for postoperative
hypoparathyroidism may present challenges.
The degree of symptomatology, ranging from no
manifestations to tetany, seizures, cardiac dysrhythmias,
Increased recognition of this issue and implementation of
the best medical and surgical strategies can prevent bad
clinical outcomes and a diminished quality of life.
Conclusion

42. Thank YOU