Management of patients with Chronic Kidney Disease (CKD) undergoing parathyroidectomy
Paradigm for Surgery
Failure to control the secondary hyperparathyroidism in Chronic Kidney Disease (CKD) patients by Medical management are candidates for subtotal parathyroidectomy. Post-operative hypocalcaemia is the most common complication following parathyroidectomy in dialysis patients with a reported incidence of up to 95%. Calcium replacement is required to prevent symptomatic hypocalcaemia.
This guideline gives brief recommendations on calcium replacement and monitoring of dialysis patients and CKD patients undergoing parathyroidectomy. Any deviation from the guideline will require Consultant Renal Physician to Consultant Surgeon discussion.
Clinical manifestations of Hypocalcaemia
Mild Hypocalcaemia
This is often asymptomatic. Early features include peri-oral and peripheral paresthesia.
Moderate Hypocalcaemia
Neuromuscular irritability including muscle twitching leading to carpo-pedal spasm.
Severe Hypocalcaemia
Cardiovascular instability leading to hypotension, cardiac arrhythmia or heart failure. Severe neuromuscular irritability can cause tetany, laryngospasm or seizures. This is a life-threatening emergency.
Aims of this Protocol
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To standardise the management of patients with CKD undergoing Parathyroidectomy across metropolitan Perth.
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To medically prepare patients in a away to minimise the severity of hypocalcaemia.
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To stop the reliance on peripheral IV Calcium Gluconate infusion. Close monitoring and oral Caltrate and Calcitriol replacement is effective in the majority of these patients.
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Peripheral IV Calcium Gluconate infusion should only be used in consultation with the Consultant Surgeon or the Consultant Renal Physician.
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Early recognition of patient who are at risk of severe hypocalcaemia and to anticipate those who need Surgical insertion of Central Venous Catheter (CVC). This will be done at request of the Consultant Renal Physician to the Surgical team.
Medical Management
Pre-operative medication adjustments
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Cease cinacalcet (if applicable) 10 to 14 days prior to surgery.
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Continue regular dose of phosphate binders (i.e. calcium carbonate, magnesium, sevelamer, lanthanum, and/or sucrofericoxyhydroxide)
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Start or increase dose of Calcitriol to 1.5 microg (2x 0.25microg) tds for at 7 days prior to surgery unless the adjusted serum calcium is >2.7mmol/L on a recent blood test (must be done within 7 days).
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Refer to the FSFHG “Guideline for Pre-operative and Pre-Intervention Management of Medications” document with regard to anticoagulation/ antiplatelet medication.
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Once a surgical date is set, surgical booking team will inform the patient, renal team, and dialysis CNS to arrange for preoperative dialysis planning (home or hospital).
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Day of Surgery
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Ensure patient has been dialysed on the day prior to surgery.
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Check biochemistry: corrected Calcium (Ca), Phosphate (PO4), Parathyroid Hormone (PTH), Magnesium (Mg), Vitamin D, EUC.
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Renal transplant recipients should receive their usual immunosuppressant medications.
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Assess need for type of surgery including risks of hypocalcemia and need for CVC insertion (ONLY considered after direct request to Surgical team from Renal Physician).
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High risk of Hungry Bone Syndrome
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Poor venous access
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Anticipated need for frequent blood sampling.
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Urgent intravenous (IV) medication administration access.
Post-operative calcium replacement
Oral replacement
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Prescribe Caltrate (calcium carbonate) 600 mg tablets. Suggested starting dose is 2 tablets three times daily (2tds) of calcium 3600 mg. Increase, if required, to 3 tablets three times daily (2 tds) of calcium 5400 mg.
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Continue Calcitriol 1.5 microg daily (2tds). Increase, if required, to 3 tds of Calcitriol 2.25 microg.
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Doses to be titrated according to corrected serum calcium, phosphate, bicarbonate and/or clinical need as per medical officer.
Biochemical Monitoring Schedule
Indications for starting IV Calcium
Patient is symptomatic with hypocalcaemia with Corrected Serum Ca (adjusted) on monitoring is:
<1.8mmol/L AND/OR
1.8 – 2.1mmol/L and symptomatic of hypocalcaemia AND/OR
>2.1mmol/L but falling rapidly (>10% in 4 - 6 hours) – on 2 consecutive blood levels not maintained by oral replacement
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Calcium gluconate is the preferred agent over calcium chloride due to reduced toxic effects on peripheral veins.
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This must be administered using an infusion pump via a CVC only unless otherwise discussed with the patient’s usual nephrologist.
Post operative Management
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It may be necessary to commence a calcium infusion postoperatively in recovery. Refer to section 3.2 (Post-operative calcium replacement).
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Important: Calcium gluconate is highly thrombophlebitic and can cause extensive subcutaneous necrosis if extravasated. CVC line is required for IV calcium infusion (as per section 3.2)
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Nurse patient with a head elevation of >30° for 24 hrs postoperation.
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Administer all routine postoperative care such as oxygen therapy, observations, drain care and acute pain management as per site policies and protocol, and document in the patient’s digital medical record (DMR)
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Observe for any signs and symptoms associated with airway obstruction including but not limited to, changes to voice, breathing rate/effort, confusion or stridor.
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Inform the Medical Officer (MO) of any concerns regarding the amount of swelling or drainage, or if frank drainage is noted in the drain or from the surgical site.
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Initiate a MET call for any threats to the patient’s airway. Consultant Surgeon must be contacted directly and immediately.
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Ensure a stitch cutter is available at the patient’s bedside for emergency airway management.
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Surgical drain should only be removed after surgical review (usually after 24hours).
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The patient may have a renal diet and fluids when tolerated as ordered by the MO.
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Do not withhold oral calcium supplements.
Patient education
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Instruct the patients to notify the Nurse immediately if they experience any difficulty breathing, as this maybe an early sign of complications such as airway obstruction(stridor).
Discharge management
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Ensure patient education is provided to the patient and follow up appointments are booked.
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Calcium level may rise rapidly 3-5 weeks after Parathyroidectomy. Discuss with Renal Physician for advice andmanagement.
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Haemodialysis patients: Serum calcium should be checked three times per week until stable.
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Checking is generally performed at the commencement of the normal haemodialysis session.
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Peritoneal dialysis patients: Serum calcium should be checked three times per week until stable. This will be booked through Home Dialysis Therapies or Renal Clinics. Requirements for calcium supplements and calcitriol upon discharge are likely to vary considerably between individualpatients.Medication adjustment isto be supervised by Renal Physician or Senior Renal Registrar with responsibility for the relevant clinicalarea.
Follow up Post Discharge
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Requirements for calcium supplements and calcitriol upon discharge are likely to vary considerably between individual patients and must be closely monitored.
POST DISCHARGE BIOCHEMICAL MONITORING SCHEDULE:
For Home Haemodialysis patients: The first HD session post discharge must be preferably organised within the incentre unit with formal review of patient, results and discharge regimen prior to discharge.
Peritoneal dialysis and renal transplant patients: Arrange biochemical monitoring with Home Therapies, Senior Renal Registrar or usual Renal Physician.