hungry bone syndrome2

7/22/2019 Hungry Bone Syndrome2

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Drug History: Penicillin 1,200,000 monthly (10 year)

Post surgery Caco3 tab III TDS

Calcitriol tab I TDS

Calcitonin amp II qd


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Test Result

WBC 4200

Hb 9.8

MCV 84

Plt 119000

BS 94

Cr 0.6

Na 141

K 4.2

Ca 5.2P 3

Mg 1.7

AST 40.2

ALT 41.1

ALP 3378


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Check Ca- P QID

Mg dailyECG Daily


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Primary HyperpathyroidismSingle adenomas account for up to 89 percent of

cases of primary hyperparathyroidismPatients are usually asymptomatic and have mild

hypercalcemia, occasionally, patients are

normocalcemic, and elevated parathyroidhormone levels are detected


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Symptoms and signs of excess parathyroid hormone

secretion Symptoms and signs of hypercalcemia

Bone disease

Nephrolithiasis

Hypophosphatemia

Increased production of calcitriol

Proximal renal tubular acidosis

Hypomagnesemia

Hyperuricemia and gout

Anemia


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Clinical manifestations of hypercalcemia

Renal

Polyuria

Polydipsia

Nephrolithiasis

Nephrocalcinosis

Distal renal tubular acidosis Nephrogenic diabetes insipidus

Acute and chronic renalinsufficiency

Gastrointestinal

Anorexia, nausea, vomiting

Bowel hypomotility andconstipation

Pancreatitis

Peptic ulcer disease

Musculoskeletal

Muscle weakness

Bone pain

Osteopenia/osteoporosis

Neurologic Decreased concentration

Confusion

Fatigue

Stupor, coma

Cardiovascular Shortening of the QT interval

Bradycardia

Hypertension


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Bones

Stones

Abdominal moans

Psychic groans


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Management of primary hyperparathyroidism

Patients with symptomatic primary hyperparathyroidism

should have parathyroid surgery

Cost of follow-up visits and tests may ultimately exceed the

costs of surgery


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Comparison of new and old guidelines for parathyroid surgery in asymptomatic PHPT

Measurement 1990 2002 2008

Serum calcium (>upper limit of

normal)

1-1.6 mg/dl (0.25-0.4

mmol/liter)1.0 mg/dl (0.25 mmol/liter)

1.0 mg/dl (0.25

mmol/liter)

24-h urine for calcium >400 mg/d (>10 mmol/d) >400 mg/d (>10 mmol/d) Not indicated

Creatinine clearance (calculated) Reduced by 30 percent Reduced by 30 percent Reduced to


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Hungry bone syndrome following parathyroidectomy

Hypocalcemia is a common problem after parathyroidectomydue to functional or relative hypoparathyroidism

Severe and prolonged postoperative hypocalcemia despitenormal or even elevated levels of parathyroid hormone (PTH).called the hungry bone syndrome

Hypocalcemia

Hypophosphatemia Hypomagnesemia

Hyperkalemia


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Criteria for the diagnosis of the hungry bone syndrome

On the third postoperative day (13%)

Calcium concentration below 8.5 mg/dL

phosphate concentration below 3.0 mg/dL

Hungry bone syndrome following parathyroidectomy inpatients with secondary hyperparathyroidism due to end-

stage renal disease (20%)


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Risk factors Volume of the resected adenoma

Preoperative blood urea nitrogen concentration

Preoperative alkaline phosphatase concentration

Older age


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Hypocalcemia after parathyroidectomy


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PREVENTION Oral calcium 2 to 3 grams per day two days prior to

surgery

Intravenous calcitriol (2 mcg at the end of each

hemodialysis treatment) begun three to five days prior to

surgery and continued postoperatively

Preoperative administration of bisphosphonates


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TREATMENT Oral calcium supplementation 2 to 4 g of elemental

calcium

Intravenous calcium - frank tetany, latent tetany

(Chvostek's or Trousseau's sign), or a plasma calciumconcentration below 7.5mg/dL

Intravenous calcium (90 to 180 mg of calcium gluconatein 50 mL of 5 percent dextrose) infused over 10 to 20

minutes.Then solution containing 1 mg/mL of elemental calcium

gluconate infused by rate of 50 mL/h (typical requirement0.5 to 1.5 mg/kg/hour)


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The calcium should be diluted in dextrose and water or

saline, because concentrated calcium solutions are

irritating to veins.

The intravenous solution should not contain bicarbonate

or phosphate, which can form insoluble calcium salts. If

these anions are needed, another intravenous line (in

another limb) should be used.


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Calcitriol in doses up to 4 mcg/day Thiazide diuretic 25 to 100 mg daily

Hypomagnesemia

Hypocalcemic-hypomagnesemic patient with tetany should

receive 50 meq of intravenous magnesium given slowly

over 8 to 24 hours, in normomagnesemic patient with

hypocalcemia, it has been suggested to repeat this dose

daily for three to five days

Hypophosphatemia

Hyperkalemia


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Recommendations Caco3 tab III TDS I TDS or QID

Calcitriol tab I TDS Increase doses Calcitonin amp II qd DC

Mgso4 50 meq /24hr


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9/25Test 1 2 3 4

Ca 5.2 6.8 6.8 7.4

P 3.8 3.7 3.7 3.5

Mg 1.17

Caco3 tab I TDS

Calcitriol tab I TDS I QID

Ca Gluconate 10 vial in 1 liter D/W over 24 hr

Oxazepam tab I Hs


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9/27Test 1 2 3 4

Ca 7.4 7 6.5 7

P 3.5 4.7 3.5 4

Mg 1.4

Caco3 tab I TDS

Calcitriol tab I QID II QID


Oxazepam tab I Hs

Hydrochlorthiazide tab I TDS


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9/29Test 1 2 3 4

Ca 6.8 7.1 6.5 6.4

P 3.9 3.5 4 3.5

Caco3 tab I TDS

Calcitriol tab II QID III QID


Oxazepam tab I Hs

Hydrochlorthiazide tab TDS


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10/1Test 1 2 3 4

Ca 7.5 6.2 7.5 7.8

P 4.2 3.9 3.7 4.3

Caco3 tab I TDS

Calcitriol tab III QID IV QID


Oxazepam tab I Hs

Hydrochlorthiazide tab TDS


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10/210/7Test 10/2 10/3 10/4 10/5 10/6 10/7

Ca 7.5 7.5 8 8.1 8.3 8.3

P 4.2 3.9 4.3 4 4.1 4.3

Caco3 tab I TDS II TDS

Calcitriol tab IV QID V QID


Oxazepam tab I Hs

Hydrochlorthiazide tab I TDS TDS

hungry bone syndrome2

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