Management of patients with Chronic Kidney Disease (CKD) undergoing parathyroidectomy

Paradigm for Surgery

Decision for surgical parathyroidectomy should be made by the treating renal physician, considering the clinical benefit and risks for an individual patient.

 

  • All advanced CKD patients are considered for subtotal parathyroidectomy and without the need for Central Venous Catheter (CVC) as default; subject to variation with Consultant to Consultant communication for any at risk patients.

 

  • Special considerations should be given for remote and regional patients (same day workup completion), patients on home dialysis (HD and PD), lack of venous access, compliance and others. 

Peri-Operative Preparation

Pre-operative Medication Adjustments (Surgeical Team):

  • Cease: Cinacalcet (Sensipar®) at lease one week prior to surgery

  • Continue: Regular phosphate binders ​

  •  

  • PRELOAD

    • Oral Calcitriol: start or increase dose of Calcitriol to 2.0mcg daily (either as single dose or divided doses) orally for one week prior to surgery unless the adjusted serum calcium is >2.7mmol/L on a recent blood test (preferably within 7-14days). 

 

  • ​​Inform date of surgery to patient and the renal team; and contact CNS of the dialysis unit for preoperative dialysis planning (home or hospital).

Day of Surgery:

  • Check biochemistry on day of surgery for: corrected Calcium (Ca), Phosphate (PO4), intact parathyroid hormone (iPTH), Magnesium, Vitamin D, EUC

  • Intraoperative insertion of Central Venous Catheter (CVC) should be considered in selected patients who are at high risk for postoperative hypocalcaemia, have poor venous access, unplanned surgery without preloading, anticipated significant difficulties for postoperative blood sampling and deemed necessary for urgent intravenous (IV) access. 

  • TARGET

    • Corrected serum calcium within LOW normal range 2.2 – 2.4 mmol/L following parathyroidectomy

Post-operative medications to be charted by Medical Officer:

  • Oral Calcitriol: initiate at 0.5mcg (0.25mcg capsules x 2) TDS then increase, if required, to a maximum of 1.5mcg (0.25mcg x 6) TDS gradually.

  • Oral Calcium: initiate SandoCal/CalSource®(calcium effervescent 1000mg tablet) at least x 1 TDS given away from meals then increase, if required or as tolerated, to a maximum of 3 tablets TDS

  • Continue usual calcium or non-calcium phosphate binders: Prescribed with meals, if serum phosphate (>1.6mmol/L)

  • Oral Magnesium (if hypomagnesemic): Magnesium 500mg (1.64mmol) tablet x 2 BD

Biochemical Monitoring Schedule
Indications for starting IV Calcium
  • Patient is symptomatic with hypocalcaemia

  • Corrected Serum Ca on monitoring is:

    •  <1.8 mmol/L AND/OR

    • 1.8 – 2.1 mmol/L and symptomatic of hypocalcaemia AND/OR

    • >2.1mmol/L and falling rapidly (>20% in 4-6 hours)

  • Calcium gluconate is preferred agent over calcium chloride due to reduced toxic effects on peripheral and central veins. 

Follow up Post Discharge
  • 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.

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