Case Presentation: Management of Hyperparathyroidism following Surgery
1. MANAGEMENT OF
SECONDARY
HYPERPARATHYROIDISM
Joy A. Awoniyi, PharmD. Candidate 2012
F l o ri d a A g ri c ul t u r a l a n d M e c ha ni ca l Un i v e r si t y
Surgery Elective Rotation
Preceptor: Dr. Lisa Joseph
2. OBJECTIVES
To define hyperparathyroidism
To discuss the pathophysiology of the disease
To distinguish between primary and secondary
hyperparathyroidism
To provide an understanding of the signs and symptoms of
hyperparathyroidism
To reveal the complications of the disease
To discuss the clinical management of
hyperparathyroidism
To review a patient case involving secondary
hyperparathyroidism in end -stage renal disease
3. HYPERPARATHYROIDISM
Hyperparathyroidism the over -
activity of the parathyroid glands
The glands secrete parathyroid
hormone (PTH), which maintains
Calcium, Phosphorus, and Vitamin
D levels
Regulates release of calcium from the
bone
Regulates absorption of calcium in the
intestine
Regulates excretion of calcium in the
urine
In normal functioning
individuals, low calcium stimulates
the release of PTH to restore the
balance
4. HYPERPARATHYROIDISM
Primary Secondary
Hyperparathyroidism Hyperparathyroidism
Enlargement of one or Excessive production
more glands results in of PTH in response to
hyper-secretion of PTH decreased calcium
levels
Most common cause
of hypercalcemia Caused by conditions
that interfere with
Causes: Calcium, Phosphate, o
Hyperplasia r Vitamin D Regulation
A benign tumor (adenoma) Kidney Failure
may form on one of the Malnutrition
glands Vitamin D Deficiency
Parathyroid cancer (rare)
5. CLINICAL PRESENTATION
Symptoms Signs
Phosphorus levels
Bone pain or tenderness Decreased if malabsorption
Increased if kidney failure
Muscle weakness or pain
Decreased calcium levels
Fatigue
Long Bone Fractures Bone tests determine
bone loss or fractures
Bone X-ray
Bone fractures Bone Mineral Density Test
Swollen joints Imaging of the urinary
tract and kidneys to show
Kidney stones deposits
6. COMPLICATIONS
Tertiary hyperthyroidism –
return of calcium to normal
levels without cessation of
PTH secretion
Renal Osteodystrophy –
bone pain and weakness
Increase fracture risk
Pseudogout
Pancreatitis
Urinary Tract Infection
7. TREATMENT
Treatment is aimed at correcting calcium to return PTH
levels back to normal
Medications
Phosphate Binders – Reduce phosphate levels in the body
Sevelamer
Lanthanum Carbonate
Vitamin D – enhances Calcium absorption
Calcitriol
Alfacalcidol
Doxercalciferol
Paricalcitol
Cinacalcet - Increases sensitivity of calcium-sensing receptor
in the Parathyroid gland
8. TREATMENT
Dietary Modifications
CKD patients restrict phosphate intake
Recommended maximum of 900mg/day
Surgery
Kidney Transplant
Parathyroidectomy
9. PATIENT CASE
SECONDARY
HYPERPARATHYROIDISM IN
END-STAGE RENAL DISEASE
10. PATIENT BACKGROUND
EG is a 54 year old Hispanic male who presented to the
Miami Veterans Affairs medical center on 8/12/2011 for
a scheduled right hemithyroidectomy. Following surgery
the patient developed hypocalcaemia.
General Information
Weight – 97.2 kg
Height – 6’3” (75 in)
BMI – 26.84
History of present Illness
Patient was diagnosed with secondary hyperparathyroidism
several years ago. Prior to admission, EG had a right inferior
parathyroidectomy and experienced recurrent symptoms of
hyperparathyroidism.
11. PATIENT HISTORY
Past Medical History
Adult dominant polycystic kidney disease (routine hemodialysis)
Uncontrolled Hypertension
Diabetes Mellitus
Coronary artery disease
GERD
Social History
Denies use of tobacco, alcohol, and elicit drugs
Previous smoker, quit 15 years ago
Surgical History
Renal allograft removal (8/2010)
Right inferior parathyroidectomy for parathyroid adenoma (2009)
Bilateral native nephrectomy (2006)
Renal Transplant (2000)
12. MEDICATION PROFILE
Allergies: Shellfish - Pruritis
ADRs: Omeprazole - Thrombocytopenia
Home Medications
1. Metoclopramide 5mg PO Q6hours prn
2. Hydralazine 100mg PO Q8hours
3. Lanthum Carbonate 1000mg PO after meals
4. Lisinopril 40mg PO BID
5. Dialyvite Daily
6. Clonidine 2 patches applied weekly
7. Isosorbide Dinitrate 30mg PO TID
8. Labetalol 600mg PO Q8hours
9. Ranitidine 150mg PO daily
10. Temazepam 30mg PO Qhs
11. Cinacalcet 30mg PO daily
12. Nifedipine PO BID
13. POST-OP INFORMATION
8/12/11
Laboratory Data 3:32 PM
137 99 38* Test Result
107 Calcium 9.9 mg/dL
5.0 27 7.5* EGFR 8mL/min
Vital Signs 9.9
T max –101.7 7.0 107
HR – 48-56 169
BP – 148-169/62-84
RR – 9-14*
Laboratory Data 8:40 PM
Calcium – 8.9mg/dL
14. POST-OP DAY 1
8/13/11
Laboratory Data 5:02AM
Test Result
138 102 49
Calcium 8.2 mg/dL(L)
116
Phosphorus 4.9 mg/dL (H)
5.4* 28 8.6*
EGFR 7mL/min
Vital Signs
T max – 99.2F
HR – 43-58
BP – 112-153/59
RR – 18
Laboratory Data 9:12 PM
Calcium – 8.1mg/dL (L)
15. POST-OP DAY 1
ACTIVE INPATIENT MEDICATIONS
1. Acetaminophen Elixir 650mg/20.3mL PO Q6h PRN
2. Calcium Carbonate 1950mg PO TID
3. Calcium/Vitamin D 1 tablet daily
4. Cinacalcet 150mg PO daily
5. Clonidine Patch 2 topically patches weekly
6. Heparin Injection 5000U/mL SC Q8hours
7. Isosorbide Dinitrate 30mg TID
8. Labetalol 600mg PO Q8H
9. Lanthum Carbonate 1000mg PO before meals
10. Metoclopramide 5mg Q6H PRN
11. Morphine Sulfate 1mg Q6H PRN
12. Multivitamins 1 Tab PO daily
13. Nifedipine SA 60mg PO BID
14. Ranitidine 150mg PO daily
15. Temazepam 30mg PO Qhs
16. Hydralazine 100mg Q8H
16. POST-OP DAY 1
PHYSICAL EXAMINATION
G e n e r al P u l m o n ary
No Acute Distress Lungs clear to auscultation
Well-appearing, well nourished bilaterally
Cooperative
A b d o m e n /GI
Ne u r o Abdomen soft, non-tender
AAO x3 and non-distended
No focal deficits Positive Bowel Sounds
C ar d i ac G e n i t o uri nary
RRR Patient is Anephric, no urine
output
Normal S1 and S2
E x t r e m i tie s
Ne c k
2+ Pedal Pulses
Supple, no JVD
No bleeding from surgical site
17. POST-OP DAY 1
GENERAL SURGERY ASSESSMENT AND PLAN
Cardiac Function
Assessment – Elevated Blood pressure overnight. Returning
to baseline
Plan –Hemodialysis should help control blood pressure.
Advance patient to cardiac diet
Electrolyte Disorder
Assessment – Hypocalcaemia
Plan – recheck calcium every 12 hours and prepare for
discharge if levels return to acceptable range. Heparin lock
IV fluids
Pain Management
Plan – Continue Morphine IV
18. POST-OP DAY 1
NEPHROLOGY ASSESSMENT AND PLAN
Renal Function
Assessment – Patient stable with no signs of volume
overload.
Plan –Hemodialysis today as scheduled
Electrolyte Disorder
Assessment – hyperkalemia, hyperphosphatemia, and
hypocalcaemia are likely an effect of ESRD. Hypocalcaemia
may be be result of parathyroidectomy
Plan – Continue Calcium replacement and monitor every 12
hours. Recommendations to stop Cinacalcet
Mild Anemia
Assessment – Suboptimal status for end stage renal disease
Plan – Follow as an outpatient
19. POST-OP DAY 2
PHYSICAL EXAMINATION
Neuro Pulmonary
AAO x3 Lungs clear to
No focal deficits auscultation bilaterally
Cardiac A bdomen/GI
RRR Abdomen soft, non-
Normal S1 and S2 tender and non-
distended
Neck Positive Bowel Sounds
Incision clean and dry
No sights of Genitourinary
bleeding, hematoma, o
r infection Patient is Anephric, no
urine output
Extremities Hemodialysis removed 3L
yesterday
2+ Pedal Pulses
20. POST-OP DAY 2
8/14/11
Laboratory Data
Calcium – 7.7 mg/dL
(5:49AM)
Vital Signs
T max –97.5F
HR – 42-68 BPM
BP – 139-186/64-81
RR – 11-29
21. POST-OP DAY 2
GENERAL SURGERY ASSESSMENT AND PLAN
Cardiac Function
Assessment – Blood pressure is elevated. Labetalol held due
to bradycardia. Nicardipene drip used for 3 hours and BP
now returning to baseline
Plan – Restart PO blood pressure medications. Reduced
Labetalol dose from 600mg TID to 300mg TID
Electrolyte Disorder
Assessment – Calcium level dropped to 7.7
Plan – Increase supplementation and observe
Pain Management
Plan – Continue Morphine IV
DVT Prophylaxis
Plan – Continue with Heparin and SCDs
22. POST-OP DAY 3
8/15/11
Laboratory Data 5:11AM
Test Result
135 98 53*
Calcium 6.9 mg/dL(L)
137
Phosphorus 4.1 mg/dL
5.6 26 9.1*
EGFR 6 mL/min
Vital Signs
T max – 98.5F
HR – 42-68 BPM
BP – 141-175/74-83
RR – 16-20
No Changes in Physical Examination
23. POST-OP DAY 3
GENERAL SURGERY ASSESSMENT AND PLAN
Cardiac Function
Assessment – Blood pressure was elevated overnight but is
returning to baseline
Plan – Continue PO blood pressure medications.
Electrolyte Disorder
Assessment – Calcium level decreased. Patient received only
one dose per records
Plan – Increase supplementation and observe. Nephrology
suggests IV calcium replacement
Pain Management
Plan – Pain controlled with Vicodin
DVT Prophylaxis
Plan – Continue with Heparin and bilateral SCDs. Patient needs
to ambulate
24. POST-OP DAY 4
8/15/11
Laboratory Data 6:00AM
135 91 65* Test Result
184 Calcium 8.4 mg/dL
5.0 26 11.2* EGFR 5 mL/min
Vital Signs
T max – 98.1F
HR – 52-68 BPM
BP – 151-194/80-94
RR – 20
Patient discharged following dialysis as Calcium levels
returned to normal with instructed to follow up with the
surgical outpatient clinic in one week
25. DISCHARGE MEDICATION LIST
1. Calcium Carbonate 1950mg PO TID
2. Cinacalcet 150mg PO daily
3. Clonidine TTS-3 Patch 2 topically patches weekly
4. Dialyvite 1 tab daily
5. Isosorbide Dinitrate 30mg TID
6. Labetalol 600mg PO Q8H
7. Lanthum Carbonate 1000mg PO before meals
8. Metoclopramide 5mg Q6H PRN
9. Nifedipine SA 60mg PO BID
10. Ranitidine 150mg PO daily
11. Temazepam 30mg PO Qhs
12. Hydralazine 100mg Q8H
26. PATIENT-SPECIFIC
RECOMMENDATIONS
The National Kidney foundation published guidelines
with recommendations for Calcium and phosphate
control in patients with CKD
For Stage V CKD (CrCl <15mL/min) the guidelines
recommend the following
Monitoring
Calcium and Phosphorus every 1-3 months
PTH and alkaline phosphatase ever 3 -6 months
Therapeutic Targets
PTH – 150-300 pg/mL EG’s most recent level was 303.9pg/mL
Phosphate – 3.5 – 5.5 mg/dL
Calcium – 8.4 – 9.5 mg/dL
27. CASE SUMMARY
EG underwent a procedure to remove his parathyroid
gland. After surgery, the patient’s intact PTH level is still
elevated, but trending toward the recommended level
Serum Intact PTH
1200
1101
1000
800 752.3
600
173.4
400
200
0 303.9
Serum Intact PTH
28. CASE SUMMARY
In patients who undergo dialysis, hypo - and hypercalcaemia
are reported to be associated with increased mortality
This makes EG’s calcium level a very important monitoring
parameter
Calcium and Phosphorus Levels
12
10
8
Value (mg/dL)
6
Calcium
4
Phosphorus
2
0
29. REFERENCES
KDIGO cl inical practice guidelines for the
diagnosis, ev aluation, prevention and treatment of chronic
kidney disease-mineral and bone disorder (CKD -M BD). Ki dney Int
2009; 76(113):S1.
Quarles LD, Cronin RE. M anagement of Secondary
hyperparathyroidism and mineral metabolism abnormalities in
adult predialysis patients with chronic kidney disease. UpToDate
Website. Last Updated 2/17/2011.
“Hyperparathyroidism”. M edlinePlus by the National I nstitutes of
Health. A vailable at: www.nlm.nih.gov/medlineplus/ency/article
/001215.htm. A ccessed on 8/16/2011.
Utiger RD. Editorial: Treatment of Primary Hyperparathyroidism. N
Eng J Med. 1999;341(7): 1301 -1302.