MAKATI MEDICAL CENTER DEPARTMENT OF MEDICINE MEDICAL GRANDROUNDS

1. MAKATI MEDICAL CENTERDEPARTMENT OF MEDICINEMEDICAL GRANDROUNDS Ma. Melmar S. Anicoche, M.D. April 29, 2010

2. Objectives • To discuss the effect of Chronic Kidney Disease (CKD) on calcium-phosphorus metabolism. • To discuss biochemical complications after parathyroidectomy.

3. Patient Profile L.G. , 61/F, from Binan, Laguna DOA: February 12, 2010 Chief complaint: Persistently elevated PTH

4. History of Present Illness 2 years PTA 1 year PTA Bone pains, weakness, intermittent abdominal pain iPTH: 914.218 (15-65pg/ml) Normal calcium, elevated phosphorus Impression: tertiary hyperparathyroidism iPTH: 1,528 pg/ml • Patient is a diagnosed case of End stage Renal Disease since 2000, on hemodialysis since 2001, three times a week. Admission

5. Review of Systems: (-) weight loss, headache, fever, vomiting, chest pain, bowel movement irregularities • Past Medical History: • s/p Bilateral Ureterolithotomy – 1995 • s/p Nephrectomy,left – 1998 • s/p ESWL, right – 2000 • s/p CVA – 2000 & 2007 • Family History: • (+) Urolithiasis – parents & siblings • Personal & Social History: • Nonsmoker • Nonalcoholic beverage drinker

6. BP: 140/70 CR 74 bpm, regular RR 20 cpm T 36.5°C Warm moist skin, no active dermatoses Pink palpebral conjunctivae, anicteric sclerae Supple neck, no palpable lymph nodes, thyroid not enlarged, no masses Symmetric chest expansion, no retractions, clear breath sounds ,AB at 5th LICS MCL, S1 louder than S2 at the apex, S2 louder than S1 at the base, no murmurs Flabby abdomen (+) 9cm incisional scar on left lower quadrant, (+) 6 cm incisional scar on right lower quadrant, NABS, soft, nontender, no organomegaly Full and equal pulses, No cyanosis & edema of extremities MMT: 5/5 on left lower extremity & both upper & lower extremities, 3/5 left upper extremity; slight limitation of motion on all extremities

7. Salient Features • 61/F • Known case of End Stage Renal Disease for 10 years, on hemodialysis • Bone pains, weakness and abdominal pain • Elevated iPTH & phosphorus, normal calcium

8. Impression: Tertiary Hyperparathyroidism

9. Feedback Mechanisms Restoring Calcium Levels to Normal

10. K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease

11. Frequency of Measurement of iPTH, Ca & Phos K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease

12. Target Range of iPTH, Ca & Phos K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease

13. Outpatient Labs

15. 1000 800 600 400 200

16. Day of Surgery

17. Vitamin D • Patients on HD or PD with iPTH >300pg/ml • Elevated corrected serum calcium and/or phosphorus levels

18. Hyperparathyroidism • Characterized by excessive secretion of PTH • Primary • Secondary • Tertiary • Symptoms are due to the hypercalcemia itself

19. Treatment Options • Medical • Surgical

20. Phosphate Binders • phosphorus or iPTH levels not controlled despite phosphorus restriction • Calcium-based • Noncalcium, nonaluminum, nonmagnesium containing

21. Vitamin D • Patients on HD or PD with iPTH >300pg/ml • Elevated corrected serum calcium and/or phosphorus levels

22. Calcimimetic Drugs • Activate the calcium-sensing receptor and inhibit parathyroid cell function • Results in reduction without normalization of PTH levels • Reduction & normalization of calcium • Cinacalcet

23. Treatment Options (Surgical) • Subtotal or total parathyroidectomy, with or without parathyroid tissue autotransplantation • Ablation of parathyroid tissue by direct injection of alcohol • Kidney transplantation

24. Parathyroidectomy in Patients with CKD • persistent iPTH >800 pg/mL associated with • hypercalcemia and/or • hyperphosphatemia that are refractory to medical therapy • iCa measured every 4 to 6 hours for the first 48 to 72 hours after surgery, and then twice daily until stable. • Criteria for adequate excision • 50% drop in PTH from the baseline level to the 10-minute postexcision level or • 50% drop in PTH from the preexcision level at 10 minutes and a postexcision level below the baseline level.

25. Surgical Complications after Parathyroidectomy • Nerve damage • Bleeding • Infection

26. Biochemical Aberrations in a Dialysis Patient Following Parathyroidectomy • Severe hypocalcemia • hypophosphatemia • hyperkalemia. Cruz, Dinna, et. Al.;American Journal of Kidney Disease, vol 29, No 5 (May) 1997; pp759 - 762

27. Hungry Bone Syndrome • Severe post-operative hypocalcemia despite normal or elevated PTH • Occurs in patients who have developed bone disease preoperatively due to a chronic increase in bone resorption induced by high PTH

28. Diagnosis of Hungry Bone Syndrome • Persistently low serum calcium following parathyroidectomy • Low or low normal serum phosphate • Rising/raised serum alkaline phosphatase • Low urine calcium

29. Treatment • Elemental Calcium • Calcium gluconate • Calcium carbonate • Vitamin D

30. Can Pamidronate Prevent Hungry Bone Syndrome After parathyroidectomy? • Bisphosphonates may be beneficial in preventing hungry bone syndrome by reducing bone formation Yuriy Gurevich, DO, and Leonid Poretsky, MD:Can Pamidronate Prevent Hungry Bone Syndrome after Parathyroidectomy, a case report

32. Current Status of the Patient: • On Dialysis thrice a week • On maintenance medications • Still no match for kidney transplant

33. Thank You!