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Bone Disease: Preparing for Your Parathyroidectomy
PATIENT EDUCATION Feature Editor: Catherine M. Goeddeke-Merickel, MS, RD, LD
Bone Disease: Preparing for Your Parathyroidectomy Elaine McCall, MS, RD,* and Melody Keinholz, BS†
Introduction
What Is a Parathyroidectomy?
ATIENTS WITH ESRD typically present with some form of bone mineral disease (BMD) due to secondary hyperparathyroidism. Secondary hyperparathyroidism develops in patients with ESRD because of various mechanisms that include increased phosphorus and decreased calcium and 1,25-dihydroxy vitamin D levels.1 Individualized medical therapy usually consists of controlling hyperphosphatemia with a prescribed nutrition plan, phosphate binders, and administering vitamin D/analog and calcimimetic agents to lower parathyroid hormone (PTH). However, some patients, despite medical therapy interventions, have persistently elevated phosphorous (.5.5 mg/dL) and PTH levels greater than 800 pg/mL, which may result in cardiovascular disease (vascular calcification) and reduced bone mass.1,2 Calciphylaxis, the calcification of small arterial vessels, may even occur, which can result in skin necrosis due to this change in BMD. For those individuals with persistently elevated PTH, calcium, or phosphorus and for those who are symptomatic (fractures, bone pain, pruritus), there is the surgical option to have a parathyroidectomy. Research suggests that a parathyroidectomy improves bone mineral density (decreases risk of fractures) and blood pressure through calcium stabilization and relieves some uremic pruritus.2,3 Although a parathyroidectomy can serve to improve a patient’s quality of life, the surgery may appear intimidating and the etiology of BMD very complicated. One of the many roles of a renal registered dietitian is to bridge this knowledge gap. There are currently not many tools to help inform, educate, and comfort patients as they consider and agree to this surgery. This education tool will aid registered dietitians and other allied clinical professionals in helping patients better understand BMD disease and what to expect with parathyroidectomy.
A parathyroidectomy is a surgery to remove the parathyroid glands. The parathyroid glands are found in the neck. Healthy parathyroid glands are approximately the size of a pea and help control the level of calcium in the blood.
P
Why Do I Need a Parathyroidectomy? When your phosphorus, calcium, and PTH remain very high despite taking your phosphate binders and other medications, it may be time to consider a parathyroidectomy. All of the bones in your body are constantly ’’turning over’’ (just like your skin) and making new bone. Excessively high phosphorus, PTH, and calcium levels are an indication that your bones are turning over too quickly. This can put you at high risk for fractures, osteoporosis, heart disease, and something very painful called ‘‘calciphylaxis.’’ Calciphylaxis is a serious disease in which calcium builds up in the small blood vessels, which causes them to harden and eventually die. Calciphylaxis can cause painful skin ulcers and may even lead to death.
After Your Parathyroidectomy *Univeristy of Virginia Lynchburg Dialysis, Lynchburg, VA †Virginia Tech Dietetic Internship, Blacksburg, VA Financial Disclosure: The authors declare that they have no relevant financial interests. Address correspondence to Elaine McCall, MS, RD, Univeristy of Virginia Lynchburg Dialysis, 103 Clifton St, Lynchburg, VA 24501. E-mail:
[email protected] Ó 2013 by the National Kidney Foundation, Inc. All rights reserved. 1051-2276/$36.00 http://dx.doi.org/10.1053/j.jrn.2013.06.001
Journal of Renal Nutrition, Vol 23, No 5 (September), 2013: pp e101-e102
Most people are in the hospital 2 to 4 days after parathyroid surgery. After surgery, your bones are ‘‘hungry’’ and will need a lot of extra calcium. Your calcium levels will be checked every few hours. While in the hospital, you may be given calcium through your veins (intravenously) because it can be absorbed by your body faster. You will also be prescribed oral (taken by mouth) medications to maintain your calcium: e101
e102
MCCALL AND KEINHOLZ
Table 1. Parathyroid Glands4 Signs and Symptoms of Hypocalcemia Muscle cramps Cardiac dysrhythmias Twitching Low blood pressure Seizures Irritability Tingling and burning (pins and needles)
1. Calcitriol (Calcijex or Rocaltrol) is a form of vitamin D that increases the absorption of calcium. 2. Calcium supplements that are prescribed by your doctor and recommended by your dietitian. The long-term goal is for your bones to rebuild properly and decrease the risk of bone disease. It is important that you take your calcitriol and calcium supplement as prescribed. This will avoid low calcium (hypocalcemia), which can have serious side effects. If your phosphorus levels are high, you may need to also keep taking your phosphate binders. After several months, blood calcium levels usually stabilize to normal. Do not forget to bring a list of your medications after being discharged from the hospital to the dialysis center. This is really important.
How Do I Feel If My Calcium Is Too Low? Hypocalcemia is low calcium in your blood and can result in seizures and even death. Table 1 for a listing of the signs and symptoms of hypocalcemia.
What Should I Do If I Experience Symptoms of Hypocalcemia? Contact your physician and dietitian immediately and do not skip dialysis treatments. Also, if you have been prescribed cinacalcet/Sensipar in the past, please
MY PRESCRIPTION Calcium supplement: _______STRENGTH:_______ Take_____pills______times/day__________meals. (before, between, after) Calcitriol:________________________STRENGTH:_________ Take______pills_____times/day__________meals Phosphate binders:_____________________STRENGTH:_________ Take_____pills______times/day________meals DATE:______ Calcium level:_______ Phosphorus level:_______iPTH level:______ DATE:______ Calcium level:_______ Phosphorus level:_______iPTH level:______ DATE:______ Calcium level:_______ Phosphorus level:_______iPTH level:______ My dietitian is______________Phone number:____________________ Doctor name: _____________ Phone number: :____________________ iPTH, intact parathyroid hormone.
be aware that your physician should have stopped this prescription.
References 1. Madorin C, Owen RP, Fraser WD, et al. The surgical management of renal hyperparathyroidism. Eur Arch Otorhinolaryngol. 2012;269:1565-1576. 2. Yano S, Sugimoto T, Tsukamoto T, et al. Effect of parathyroidectomy on bone mineral density in hemodialysis patients with secondary hyperparathyroidism: possible usefulness of preoperative determination of parathyroid hormone level for prediction of bone regain. Horm Metab Res. 2003;35:259-264. 3. Puccini M, Carpi A, Cupisti A, et al. Total parathyroidectomy without autotransplantation for the treatment of secondary hyperparathyroidism associated with chronic kidney disease: clinical and laboratory long-term followup. Biomed Pharmacother. 2010;64:359-362. 4. Society for Endocrinology. Secondary hyperparathyroidism. http:// www.yourhormones.info/endocrine_conditions/secondary_hyperparathyroi dism.aspx. Accessed May 8, 2013.
Bone Disease: Preparing for Your Parathyroidectomy Elaine McCall, MS, RD,* and Melody Keinholz, BS†
Introduction
What Is a Parathyroidectomy?
ATIENTS WITH ESRD typically present with some form of bone mineral disease (BMD) due to secondary hyperparathyroidism. Secondary hyperparathyroidism develops in patients with ESRD because of various mechanisms that include increased phosphorus and decreased calcium and 1,25-dihydroxy vitamin D levels.1 Individualized medical therapy usually consists of controlling hyperphosphatemia with a prescribed nutrition plan, phosphate binders, and administering vitamin D/analog and calcimimetic agents to lower parathyroid hormone (PTH). However, some patients, despite medical therapy interventions, have persistently elevated phosphorous (.5.5 mg/dL) and PTH levels greater than 800 pg/mL, which may result in cardiovascular disease (vascular calcification) and reduced bone mass.1,2 Calciphylaxis, the calcification of small arterial vessels, may even occur, which can result in skin necrosis due to this change in BMD. For those individuals with persistently elevated PTH, calcium, or phosphorus and for those who are symptomatic (fractures, bone pain, pruritus), there is the surgical option to have a parathyroidectomy. Research suggests that a parathyroidectomy improves bone mineral density (decreases risk of fractures) and blood pressure through calcium stabilization and relieves some uremic pruritus.2,3 Although a parathyroidectomy can serve to improve a patient’s quality of life, the surgery may appear intimidating and the etiology of BMD very complicated. One of the many roles of a renal registered dietitian is to bridge this knowledge gap. There are currently not many tools to help inform, educate, and comfort patients as they consider and agree to this surgery. This education tool will aid registered dietitians and other allied clinical professionals in helping patients better understand BMD disease and what to expect with parathyroidectomy.
A parathyroidectomy is a surgery to remove the parathyroid glands. The parathyroid glands are found in the neck. Healthy parathyroid glands are approximately the size of a pea and help control the level of calcium in the blood.
P
Why Do I Need a Parathyroidectomy? When your phosphorus, calcium, and PTH remain very high despite taking your phosphate binders and other medications, it may be time to consider a parathyroidectomy. All of the bones in your body are constantly ’’turning over’’ (just like your skin) and making new bone. Excessively high phosphorus, PTH, and calcium levels are an indication that your bones are turning over too quickly. This can put you at high risk for fractures, osteoporosis, heart disease, and something very painful called ‘‘calciphylaxis.’’ Calciphylaxis is a serious disease in which calcium builds up in the small blood vessels, which causes them to harden and eventually die. Calciphylaxis can cause painful skin ulcers and may even lead to death.
After Your Parathyroidectomy *Univeristy of Virginia Lynchburg Dialysis, Lynchburg, VA †Virginia Tech Dietetic Internship, Blacksburg, VA Financial Disclosure: The authors declare that they have no relevant financial interests. Address correspondence to Elaine McCall, MS, RD, Univeristy of Virginia Lynchburg Dialysis, 103 Clifton St, Lynchburg, VA 24501. E-mail:
[email protected] Ó 2013 by the National Kidney Foundation, Inc. All rights reserved. 1051-2276/$36.00 http://dx.doi.org/10.1053/j.jrn.2013.06.001
Journal of Renal Nutrition, Vol 23, No 5 (September), 2013: pp e101-e102
Most people are in the hospital 2 to 4 days after parathyroid surgery. After surgery, your bones are ‘‘hungry’’ and will need a lot of extra calcium. Your calcium levels will be checked every few hours. While in the hospital, you may be given calcium through your veins (intravenously) because it can be absorbed by your body faster. You will also be prescribed oral (taken by mouth) medications to maintain your calcium: e101
e102
MCCALL AND KEINHOLZ
Table 1. Parathyroid Glands4 Signs and Symptoms of Hypocalcemia Muscle cramps Cardiac dysrhythmias Twitching Low blood pressure Seizures Irritability Tingling and burning (pins and needles)
1. Calcitriol (Calcijex or Rocaltrol) is a form of vitamin D that increases the absorption of calcium. 2. Calcium supplements that are prescribed by your doctor and recommended by your dietitian. The long-term goal is for your bones to rebuild properly and decrease the risk of bone disease. It is important that you take your calcitriol and calcium supplement as prescribed. This will avoid low calcium (hypocalcemia), which can have serious side effects. If your phosphorus levels are high, you may need to also keep taking your phosphate binders. After several months, blood calcium levels usually stabilize to normal. Do not forget to bring a list of your medications after being discharged from the hospital to the dialysis center. This is really important.
How Do I Feel If My Calcium Is Too Low? Hypocalcemia is low calcium in your blood and can result in seizures and even death. Table 1 for a listing of the signs and symptoms of hypocalcemia.
What Should I Do If I Experience Symptoms of Hypocalcemia? Contact your physician and dietitian immediately and do not skip dialysis treatments. Also, if you have been prescribed cinacalcet/Sensipar in the past, please
MY PRESCRIPTION Calcium supplement: _______STRENGTH:_______ Take_____pills______times/day__________meals. (before, between, after) Calcitriol:________________________STRENGTH:_________ Take______pills_____times/day__________meals Phosphate binders:_____________________STRENGTH:_________ Take_____pills______times/day________meals DATE:______ Calcium level:_______ Phosphorus level:_______iPTH level:______ DATE:______ Calcium level:_______ Phosphorus level:_______iPTH level:______ DATE:______ Calcium level:_______ Phosphorus level:_______iPTH level:______ My dietitian is______________Phone number:____________________ Doctor name: _____________ Phone number: :____________________ iPTH, intact parathyroid hormone.
be aware that your physician should have stopped this prescription.
References 1. Madorin C, Owen RP, Fraser WD, et al. The surgical management of renal hyperparathyroidism. Eur Arch Otorhinolaryngol. 2012;269:1565-1576. 2. Yano S, Sugimoto T, Tsukamoto T, et al. Effect of parathyroidectomy on bone mineral density in hemodialysis patients with secondary hyperparathyroidism: possible usefulness of preoperative determination of parathyroid hormone level for prediction of bone regain. Horm Metab Res. 2003;35:259-264. 3. Puccini M, Carpi A, Cupisti A, et al. Total parathyroidectomy without autotransplantation for the treatment of secondary hyperparathyroidism associated with chronic kidney disease: clinical and laboratory long-term followup. Biomed Pharmacother. 2010;64:359-362. 4. Society for Endocrinology. Secondary hyperparathyroidism. http:// www.yourhormones.info/endocrine_conditions/secondary_hyperparathyroi dism.aspx. Accessed May 8, 2013.