1. Tertiary hyperparathyroidism & postoperative hypocalcemia Brock Lanier, M.D. MCV/VCU Department of Surgery M&M 12 April 2012 1

2. 2 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 presentation Pre-hospital evaluation.

3. Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Post DDRTx serum Cr (mg/dL) 3

4. 4 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. Post transplant course significant for persistent hyperCa 2+. Serum PTH values markedly elevated (see next slides). Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Case presentation Pre-hospital evaluation.

5. Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Post DDRTx serum Ca 2+ (mg/dL) 5

6. Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Post DDRTx serum PTH (pg/mL) 6

7. 7 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. Post transplant course significant for persistent hyperCa 2+. 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). Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Case presentation Pre-hospital evaluation.

8. 8 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 Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Case presentation Pre-hospital evaluation.

9. 9 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. Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Case presentation Pre-hospital evaluation.

10. 10 3/23/2012 OR: neck exploration, parathyroidectomy x4, LUQ abdominal wall SQ autograft implant. -Path: hyperplasia x 4 glands. -Standard postop Ca 2+ repletion protocol initiated. o CaCl 2 gm IV q4 h started and then titrated down and PO supplementation stated as serum Ca 2+ 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). Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Case presentation Hospital course.

11. Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia POD #0-8 serum Ca 2+ (mg/dL) trend 11

12. 12 3/23/2012 OR: neck exploration, parathyroidectomy x4, LUQ abdominal wall SQ autograft implant. -Path: hyperplasia x 4 glands. -Standard postop Ca 2+ repletion protocol initiated. o CaCl 2 gm IV q4 h started and then titrated down and PO supplementation stated as serum Ca 2+ 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. Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Case presentation Hospital course.

13. 13 4/5/2012 (POD #13): Re-admit for symptomatic hypocalcemia (numbness and tingling in B fingers, next slide). Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Case presentation Hospital re-admission.

14. Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Postoperative serum Ca 2+ (mg/dL) trend 14

15. 15 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 Ca 2+ (next slide). : Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Case presentation Hospital re-admission.

16. Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Re-admission serum Ca 2+ (mg/dL) trend 16

17. 17 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 Ca 2+. 4/9/2012 (POD #17): d/c home, eucalcemic on stable PO regimen (PO only x ~ 72 hr). Alternative plans for outpatient surveillance implemented. Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Case presentation Hospital re-admission.

18. 18 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 & postoperative symptomatic hypocalcemia Tertiary hyperparathyroidism (HPT) Refractory disease after RTx, surgically treated.

19. 19 Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Tertiary hyperparathyroidism (HPT) S. C. Pitt, R. S. Sippel, and H. Chen, Surg Clin 2009, PMID 19836494.

20. Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Post DDRTx serum Ca 2+ (mg/dL) 20

21. 21 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. Tertiary hyperparathyroidism & postoperative symptomatic hypocalcemia Tertiary hyperparathyroidism (HPT) Refractory disease after RTx, surgically treated.

22. 22 For this reason patients are placed on an aggressive Ca 2+ 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 symptomatic hypocalcemia Tertiary hyperparathyroidism (HPT) Refractory disease after RTx, surgically treated.

23. Tertiary hyperparathyroidism & postoperative hypocalcemia Brock Lanier, M.D. MCV/VCU Department of Surgery M&M 12 April 2012 23