Abstract: FR-PO641
A Case of Delayed Onset Hungry Bone Syndrome After Subtotal Parathyroidectomy in ESRD Patient with Secondary Hyperparathyroidism
Session Information
- Trainee Case Reports - IV
October 26, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 402 Bone and Mineral Metabolism: Clinical
Authors
- Kareem, Samer, Westchester Medical center, Valhalla, New York, United States
- Kapoor, Aromma, Westchester Medical center, Valhalla, New York, United States
- Klein, Michael D., Westchester Medical center, Valhalla, New York, United States
Introduction
Hungry bone syndrome (HBS) is an important postoperative complication of parathyroidectomy done for severe hyperparathyroidism of renal origin; occuring in 27.8 to 72% of cases. It is marked by hypocalcemia (most severe in the first 24-48 hrs) associated with hypophosphatemia, hypomagnesemia and elevated Alkaline phosphatase. We are reporting a case where hungry bone syndrome is seen to develop more than one week post-op ,and did not respond to standard management despite normal magnesium and Phosphorus levels.
Case Description
52 yr old male with ESRD on HD underwent subtotal parathyroidectomy for management of severe secondary hyperparathyroidism (PTH 2024 pg/ml) in spite of high dose of cinacalcet and calcitriol. Post -op PTH dropped to 63.5 pg/ml. The lowest reading of Ca was 8.2mg/dl in the immediate post-op period and was treated with Ca and vitamin D analogs as per standard guidelines.Two weeks later patient reported symptoms of tetany on dialysis and serum Ca was 6.8 mg/dl. Serum Phos remained 3.3 -4.5mg/dl range and ALP 282 u/l with a normal Magnesium. Calcium was persistently low despite treatment with IV calcium ; requiring a prolonged hospital stay.
Discussion
HBS is characterised by prolonged and severe postoperative hypocalcemia and hypophosphatemia as a result of extensive and accelerated remineralisation of bone following sudden decrease of parathyroid hormone. This syndrome should be anticipated when there is evidence of severe parathyroid bone disease with marked elevation of serum ALP and PTH levels. Other factors that predict the development of HBS include old age, high BMI, and high pre-op BUN. HBS is seen within 24 hrs of a total parathyroidectomy in patients with SHPT. The post operative fall in serum calcium has been strongly correlated with the severity of bone disease which can be diagnosed only with pre-operative bone biopsy not by serum chemistries. This case shows that patients might develop severe hypocalcemia in the later time despite a normal serum calcium postoperatively. We recommend , patients undergoing total parathyroidectomy should have their serum calcium and phosphate levels closely monitored in the following 2 weeks to safeguard against the development of severe and symptomatic hypocalcemia and to provide guidance on the intensity of calcium supplementation.