Peri-parathyroidectomy management in chronic kidney disease or End stage renal disease.

1. Peri-
Parathyroidectomy
Management In
CKD
By:
Hussien Farouk

2. Introduction
 Secondary and Tertiary hyperparathyroidism can
result in Hyporcalcaemia , Hypercalcaemia ,
Hyperphosphataemia , Aneamia , Insomnia , Bone
aches and Fractures.
 TTT is mainly medical by:
1-Active Vit.D3 (One-Alpha).
2-Dietary phosphate restriction + Phosphate binders.
3-Oral calcium.
4-Cinacalcet (If not fit for surgery).
 Surgery is indicated if medical TTT fails, After surgical
and ENT exam. Pre-operatively.

3.  Patients attend 72 hours before operation for administration of:
1-Loading dose of (One-Alpha) 2-3 ug/day to prevent severe hypocalcaemia
during (Bone-Hunger) phase after operation.
2-Oral/I.V Calcium acc. To corrected serum calcium level.
3-Anti-Emetics & Proton-pump inhibitors ,since it is important that patients are
able to take (Oral calcium & Vit.D) on return from theatre.
4-Ensure that patient is at his target weight not overloaded at time of operation.
5-Check Bleeding Profile.
 On Theatre:
1- 450 ml normal saline + 50 ml calcium gluconate 10% (5 Amp) with rate 20
drops/minute (1 cm/ min)
2- Any specimen after surgical excision is put in formalin cup with it’s
anatomical position on it for Histological report.
 Each 10 mL of the injection provides 93 mg calcium equivalent to 1 g
of calcium gluconate.

4. Notes After Operation
1-Corrected serum calcium should be checked on
return from theatre and every 6 hours thereafter until
stable.
Corrected ca = (Albumin-4) x 1.8 + ca
2-Take care that CANNULAS are not outside the vein
to prevent tissue necrosis.
3-Heparin free DIALYSIS if necessary to prevent neck
bleeding.

6. Overview
1-Hypocalcaemia is very common in the early post-operative
period due to (BONE HUNGER SYNDROME) especially in total
parathyroidectomy and auto-transplantation, It takes 5-6 weeks
for the autograft to function.
2-The standard TTT is based on moving calcium into
bloodstream which under normal circumstances made by
normal parathyroid glands (PTH).
3-Both Oral Calcium and Active Vit.D (Calcitriol) can play this
role As Oral Calcium provides a calcium substrate for the
intestinal absorption of calcium & because Calcitriol is vey
deficient in early post-operative period so,

7. Calcitriol increases fractional absorption of this calcium
substrate BUT Calcitriol at higher doses can also mobilize
calcium from bone , which can be beneficial for symptoms even
during (THE BONE HUNGER PHASE).
4- If corrected serum calcium is at low normal value , Oral
therapy should be adequate.
5-If corrected serum calcium is (8 – 8.8 mg/dl) (2 – 2.2 mmol/l)
& patient is SYMPTOMATIC :
Symptoms:
*Parathesia (around mouth , toes & fingers)
*Tetany
*Carpopedal spasm
*Muscle cramps , laryngealspasm or Bronchospasm.

8. laryngealspasm or Bronchospasm.
Give 10 ml calcium gluconate 10% I.V infusion diluted
to 50 ml with normal saline ( rate not exceeding 1.5 –
2.5 mg/dl ca/min ) Over 10 minutes (5-6 cm/min) (100-
120 drops/min) followed by Oral Therapy.
6-If corrected serum calcium is (8 – 8.8 mg/dl) (2 – 2.2 mmol/l)
& patient is ASYMPTOMATIC :
Give oral therapy with Cacium Carbonate (Calcimate)
2.5 g Three times daily + Oral active Vit.D (Calcitriol)
(One-Alpha) 2 ug twice daily.

9. 7-If corrected serum calcium is below (8 mg/dl) (2 mmol/l) &
REGARDLESS THE PRESENCE OR ABSENCE OF
SYMPTOMATS:
Give 40-60 mg/dl calcium gluconate 10% (4-6
Ampoules) I.V infusion diluted in at least 250 ml
normal saline to be given peripherally at rate (2
mg/dl/min) over 6 hours
(0.72 cm/minute) (15 drops/minute)
Then , REPEAT calcium levels 60 minutes after the
infusion has finished , REPEAT the infusion as
necessary until the desired calcium level is reached ,
and then commence oral therapy.

11. N.B: Calcium Chloride has a greater
availability of Calcium in a smaller volume (20
mg/dl in 10 ml compared to 10 mg/dl in 10 ml
for calcium gluconate).
However it is more irritant and needs to be
given slowly to prevent this or any cardiac
problems. So, Calcium gluconate is therefore
the preferred salt.

12. Oral Therapy
1- Ensure that high doses of oral calcium are
given.Oral absorption is inversely propotional to the
dose ,So divided doses are better than larger single
doses.
2-Check Magnesium levels if calcium level is not rising
with TTT as calcium levels cannot be corrected
Magnesium levels are normal.

13. Extravasation Of Calcium
1-Calcium is HYPERTONIC and can cause extensive tissue
damage on extravasation.
2-Central Cannulation is considered for patients requiring I.V
calcium.
3-If Peripheral Cannula is used ensure that the cannula is
patent by flushing with normal saline prior to the calcium
infusion.
4-Explain the potential risks of the infusion to the patient , and
ask the patient to inform you immediately if pain occurs at the
cannula site during infusion.
5-Explain carefully to the nursing staff the need for close
observation of the cannula.

14. 6-Stop the infusion immediately if extravasation is
suspected. Do Not remove the cannula, aspirate to
withdraw as much of the infused fluid as possible.
Instil water for injection in order to reduce local
concentration. Apply heat to disperse the diluted
calcium.
7-Call the plastic surgery on-call team immediately if
extravasation of calcium has occurred as they may be
able to reduce the tissue damage by subcutaneous
lavage.

15. PTH Monitoring And Long-Term
Follow Up
1- PTH is checked on discharge, It is expected to be below the
reference range, but the immediate post-operative care is
entirely based on symptoms and serum calcium.
2-Annual review of PTH is required if the initial results are
satisfactory. We aim at long-term PTH level of 100-150 pg/ml to
reduce the incidence of adynamic bone disease (reduced bone
turn over with subsequent pathological fractures).