Parathyroidectomy in ESRD: The Challenge of Determining the Right Patient

Introduction: Bone mineral disorders in patients with chronic kidney disease continue to be an enigma. The decision of when to refer patients for parathyroidectomy continues to be complex and multiple providers presented with same case may elect variable choices. Case Description: Our patient is middle aged female with end stage renal disease on hemodialysis in center twice weekly. Given the circumstances of her sudden renal failure and discussions of her goals of care and quality of life she elected twice weekly treatments. During her years of dialysis, she developed significant hyperparathyroidism. On cinacalcet and oral calcitriol she struggled with nausea and vomiting that exacerbated her baseline gastroparesis. When her parathyroid hormone levels reached 1,999 pg/mL we referred her to a surgeon for possible parathyroidectomy. We discussed the risks and benefits of the procedure including hungry bone syndrome and a prolonged postoperative hospitalization due to the need for intravenous (IV) calcium replacement. The patient elected to pursue parathyroidectomy. She was discharged from the hospital after four days. Post hospitalization, she was continued on IV vitamin D and liquid calcium supplementation. She developed hypocalcemia to 6.1 mg/dl and went to an emergency room for an infusion. Another episode she had severe hypophosphatemia at 0.6 mg/dL and required emergency room visit for phosphorus supplementation. The hypophosphatemia was thought due to poor oral intake but also due to the binding effect of the calcium supplementation in a patient with gastroparesis. Another unique factor is ensuring the IV vitamin D at dialysis is continued despite low parathyroid hormone levels. Discussion: This case presentation begs the question of parathyroidectomy or not; the challenges it exposes are the need for supplementation for hypocalcemia. One can argue that we traded the cinacalcet for the dependence on liquid calcium supplementation. One could also consider whether she would have tolerated etelcalcetide but the medication is also associated with gastrointestinal side effects. After her parathyroidectomy, the parathyroid hormone level is lower, but the patient continues to suffer from chronic gastroparesis and now chronic hypocalcemia and hypoparathyroidism. It could be helpful to have a specialist in bone health and ESRD, which may not be available in every facility, in guiding treatment plans.