Vol 6 Issue 2 p 12 American Thyroid Association
Patients with symptomatic primary hyperparathyroidism (nephrolithiasis, moderate or severe hypercalcemia, osteoporosis, fragility fractures, or hypercalciuria) are treated surgically with parathyroidectomy unless contraindicated44. Guidelines have been published regarding the management of asymptomatic primary hyperparathyroidism 45. Cinacalcet (a calcimimetic drug that increases the sensitivity of CaSR to extracellular Ca+2) is routinely used in the chronic management of secondary hyperparathyroidism in patients on renal replacement therapy. It can also be used in patients with severe hypercalcemia due to primary hyperparathyroidism 46. A five-year study in patients with mild to moderate primary hyperparathyroidism showed that cinacalcet reduced PTH level and normalized Ca+2 with no change in z-scores of areal bone mineral density (aBMD) 47. A protocol violation in the management of postoperative calcium occurred in three patients as these patients received calcium supplementation although symptoms were absent and the calcium concentration was above 1.85 mmol/L.
Replacement with PTH for Hypoparathyroidism
Acid-base disturbances alter the binding capacity of calcium to albumin and affect the exchange of calcium and hydrogen ions between the intracellular and extracellular space. Acidosis reduces calcium binding to albumin, causing increased ionized calcium levels, while an alkaline environment has the opposite effect. An acidic environment also promotes the exchange of extracellular hydrogen ions for intracellular calcium, increasing ionized calcium levels and vice-versa for alkaline environments. Operating surgeons would routinely provide post-operative plans in the operation notes of each patient including instructions for the timing of blood tests. It was felt that including instructions for the routine prescribing of prophylactic calcium supplementation would improve prescribing rates as these plans were routinely checked by SHOs and added to the patient handover document. This was discussed in a departmental governance meeting and surgeons adopted this practice.
If calcium levels remain below 7 mg/dL despite calcium supplementation, 0.5 μg of calcitriol twice daily can be added. Supplementation can be escalated to include up to 6000 mg calcium per day, 2 μg/day calcitriol, or intravenous magnesium of 1 mg/kg per hour if patients remain symptomatic and hypocalcemic. In severe cases of hypocalcemia, refractory to oral supplementation or with severe symptoms, intravenous calcium should be administered as an initial bolus of 1 to 2 g of calcium in 50 mL of 5% dextrose infused over 20 minutes.
Improving Hypocalcemia and Seeking Medical Help
Specific genetic disorders can affect the body’s ability to maintain calcium balance, leading to Hypocalcemia. Also, as we age, the ability of the skin to produce vitamin D in response to sunlight decreases, and the risk of conditions like kidney disease increases, both contributing to a higher risk of Hypocalcemia in older adults. Due to advancements in anesthesia, operative techniques and antisepsis,better surgical instruments, and understanding of thyroid anatomy and physiology, thyroid surgery is now considered a safe procedure 4,5. These complications include hypocalcemia, recurrent laryngeal nerve injury, hematoma, seroma, stridor, loss of high-pitched voice, thoracic duct injury, wound infection, and tracheal injury 6.
Patient Publications
This time point is useful because some patients who develop hypoparathyroidism after parathyroid surgery will regain parathyroid function within 6 months. A total thyroidectomy is the usual first treatment for papillary cancer, the most common type of thyroid cancer. When papillary cancer spreads outside of the thyroid, it initially spreads into the lymph nodes in the neck around the thyroid. In fact, it is very common to have papillary cancer spread into the lymph nodes in the middle of the neck at the time of surgery.
- Calcium carbonate is the medication of choice, given as 500 to 1000 mg three times a day.
- Without PTH, the kidneys do not conserve filtered calcium and, thus, a relative hypercalciuria ensues.
- A postoperative laryngoscopy had previously shown a good function of both vocal cords.
- Decreased synthesis of vitamin D in the skin is not uncommon and may be due to the lack of sun exposure due to excessive sunscreen usage, skin pigmentation, protective clothing, winter season, increased latitude or aging.
- Intravenous (IV) calcium administration is a treatment procedure where calcium is directly infused into the bloodstream.
Oral doses calcium should be in the amount of 1 to 3 grams of elemental calcium in 3 to 4 divided doses with meals to ensure optimal absorption. Calcium carbonate contains 40% elemental calcium by weight and is relatively inexpensive. Lower amounts of elemental calcium are present in other types of calcium such as calcium lactate (13%), calcium citrate (21%) and calcium gluconate (9%), requiring a larger number of tablets. There are expensive forms of calcium supplements that have relatively few additional advantages. Liquid calcium supplements are available such as calcium glubionate that contains 230 mg of calcium per 10 mL or liquid forms of calcium carbonate. In patients with achlorhydria, a solution of 10% calcium chloride (1- to 30 ml) every 8 hours can also effectively raise calcium levels.
“Hungry Bone Syndrome”
These tests and evaluations allow healthcare providers to identify the underlying cause of the low calcium levels and to determine the most appropriate treatment plan. Pseudohypoparathyroidism, a rare genetic disorder that closely mimics hypoparathyroidism but with a different cause, can lead to hypocalcemia. Despite normal or high levels of PTH, the body fails to respond appropriately, leading to decreased calcium levels.
- Patients who present with hypoparathyroidism and an elevated serum level of PTH should be suspected for possible PHP.
- The normal balance of calcium is often disrupted due to a variety of reasons, leading to Hypocalcemia.
- Understanding this condition, its symptoms, risk factors, and treatment options is the first step towards better health.
It is much more difficult and takes longer to treat hypocalcemia symptoms than to prevent their development. Oral calcium supplementation appears to be the most cost-effective approach. Calcium carbonate is the medication of choice, given as 500 to 1000 mg three times a day. This approach has been demonstrated to reduce postoperative hypocalcemia to approximately 10%. We usually follow synthroid nicotine patients 2 weeks after the surgery with serum calcium and PTH levels. If the levels are within normal ranges, we stop calcium replacement earlier.
- Magnesium and vitamin D levels should be checked with hypocalcemia since these are essential and correctable causes.
- Therefore, in CKD patients, Ca+2 can be low, normal, or high, and in many patients with advanced CKD (stages 4 and 5 and patients on dialysis), serum phosphate is high even in the presence of vitamin D deficiency.
- Regular monitoring of blood calcium levels is crucial for early detection and treatment.
- Brachydactyly is a more specific criterion and can be diagnosed by physical or radiographic examination.
An electrocardiogram (ECG) is a non-invasive test that measures the electrical activity of the heart. It’s used in the diagnosis of hypocalcemia because low levels of calcium can affect heart function, leading to changes in the ECG pattern. The condition is thought to occur due to the saponification process, where released fatty acids bind to calcium, leading to lower available calcium in the bloodstream. Overtreatment with calcium treatmentscan lead to hypercalcemia (high calcium) if you take more calcium or vitamin D than what you need. If the symptoms below occur, go to the nearest hospital emergency center.
Post-Thyroidectomy Hypocalcemia: A Single-Center Experience
Parathyroid preservation surgical techniques are used to decrease the incidence of post-thyroidectomy hypoparathyroidism, which include careful identification of parathyroid glands and meticulous dissection. Parathyroid autotransplantation can also be used to reconstitute parathyroid function after devascularization. Parathyroid autotransplantation involves implanting slices of viable parathyroid tissue into the ipsilateral sternocleidomastoid muscle, or subcutaneously into the muscle in the forearm. Fresh autografts or cryopreserved parathyroid tissue can be used for implantation, with the success rate being approximately 70% for cryopreserved tissue and 90% for fresh, autotransplanted tissue.