Ann Surg Treat Res.  2022 Nov;103(5):264-270. 10.4174/astr.2022.103.5.264.

Impact of enhanced recovery after surgery program for hungry bone syndrome in patients on maintenance hemodialysis undergoing parathyroidectomy for secondary hyperparathyroidism

• Wang L
• Zhang X
• Hu F
• Yuan H
• Gao Z
• He L
• Zou S

• KMID: 2534847
• DOI: http://doi.org/10.4174/astr.2022.103.5.264

Abstract

Purpose
Hungry bone syndrome after parathyroidectomy is an important clinical problem in patients on maintenance hemodialysis. We examined the effect of an enhanced recovery after surgery (ERAS) program on the incidence of hungry bone syndrome after parathyroidectomy in this population.
Methods
This single-institution, retrospective study analyzed 108 patients on hemodialysis who underwent parathyroidectomy for secondary hyperparathyroidism. Patients were classified into the pre-ERAS (n = 52) and post-ERAS (n = 56) groups. The ERAS program identified high-risk patients and enforced aggressive measures to normalize calcium levels following parathyroidectomy.
Results
There was no significant difference in age, sex, body weight, presenting symptoms, preoperative calcium and alkaline phosphatase levels, postoperative intact parathyroid levels, postoperative calcium levels at 1 and 24 hours after parathyroidectomy, and 30-day readmission rates between the groups. The post-ERAS group had significantly higher levels of postoperative calcium at 48 and 72 hours after parathyroidectomy, but a lower incidence of hungry bone syndrome and shorter postoperative length of stay. Patients with hungry bone syndrome had higher preoperative levels of alkaline phosphatase and intact parathyroid, longer postoperative length of stay, and were less likely to have been part of the ERAS program. High preoperative alkaline phosphatase levels and absence of the ERAS program were independent risk factors for hungry bone syndrome after parathyroidectomy.
Conclusion
The ERAS program reduced the incidence of hungry bone syndrome and shortened the postoperative length of stay in patients on maintenance hemodialysis who underwent parathyroidectomy for secondary hyperparathyroidism.

Keyword

Enhanced recovery after surgery; Hemodialysis; Hungry bone syndrome; Parathyroidectomy; Secondary hyperparathyroidism

Reference

1. Lau WL, Obi Y, Kalantar-Zadeh K. Parathyroidectomy in the management of secondary hyperparathyroidism. Clin J Am Soc Nephrol. 2018; 13:952–961. PMID: 29523679.

2. Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group. KDIGO 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD). Kidney Int Suppl (2011). 2017; 7:1–59. PMID: 30675420.

3. Kim SM, Long J, Montez-Rath ME, Leonard MB, Norton JA, Chertow GM. Rates and outcomes of parathyroidectomy for secondary hyperparathyroidism in the United States. Clin J Am Soc Nephrol. 2016; 11:1260–1267. PMID: 27269300.

4. Steinl GK, Kuo JH. Surgical management of secondary hyperparathyroidism. Kidney Int Rep. 2020; 6:254–264. PMID: 33615051.

5. Ferrandino R, Roof S, Ma Y, Chan L, Poojary P, Saha A, et al. Unplanned 30-day readmissions after parathyroidectomy in patients with chronic kidney disease: a nationwide analysis. Otolaryngol Head Neck Surg. 2017; 157:955–965. PMID: 28949797.

6. Tan PG, Ab Hadi IS, Zahari Z, Yahya MM, Wan Zain WZ, Wong MP, et al. Predictors of early postoperative hypocalcemia after total parathyroidectomy in renal hyperparathyroidism. Ann Surg Treat Res. 2020; 98:1–6. PMID: 31909044.

7. Jain N, Reilly RF. Hungry bone syndrome. Curr Opin Nephrol Hypertens. 2017; 26:250–255. PMID: 28375869.

8. Kritmetapak K, Kongpetch S, Chotmongkol W, Raruenrom Y, Sangkhamanon S, Pongchaiyakul C. Incidence of and risk factors for post-parathyroidectomy hungry bone syndrome in patients with secondary hyperparathyroidism. Ren Fail. 2020; 42:1118–1126. PMID: 33143476.

9. Stefanova D, Ullmann TM, Limberg J, Moore M, Beninato T, Zarnegar R, et al. Risk factors for prolonged length of stay and readmission after parathyroidectomy for renal secondary hyperparathyroidism. World J Surg. 2020; 44:3751–3760. PMID: 32737558.

10. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017; 152:292–298. PMID: 28097305.

11. Wang C, Lai Y, Li P, Su J, Che G. Influence of enhanced recovery after surgery (ERAS) on patients receiving lung resection: a retrospective study of 1749 cases. BMC Surg. 2021; 21:115. PMID: 33676488.

12. Yip L, Carty SE, Holder-Murray JM, Recker A, Nicholson KJ, Boisen ML, et al. A specific enhanced recovery protocol decreases opioid use after thyroid and parathyroid surgery. Surgery. 2021; 169:197–201. PMID: 32690334.

13. Lide RC, Creighton EW, Yeh J, Troughton M, Hollowoa B, Merrill T, et al. Opioid reduction in ambulatory thyroid and parathyroid surgery after implementing enhanced recovery after surgery protocol. Head Neck. 2021; 43:1545–1552. PMID: 33502069.

14. Ho LY, Wong PN, Sin HK, Wong YY, Lo KC, Chan SF, et al. Risk factors and clinical course of hungry bone syndrome after total parathyroidectomy in dialysis patients with secondary hyperparathyroidism. BMC Nephrol. 2017; 18:12. PMID: 28073343.

15. Sun X, Zhang X, Lu Y, Zhang L, Yang M. Risk factors for severe hypocalcemia after parathyroidectomy in dialysis patients with secondary hyperparathyroidism. Sci Rep. 2018; 8:7743. PMID: 29773914.

16. Cantor TL. Lack of evidence for administering vitamin D analogs to kidney failure patients to improve survivability. Clin Nephrol. 2009; 72:97–104. PMID: 19640366.

17. EVOLVE Trial Investigators. Chertow GM, Block GA, Correa-Rotter R, Drüeke TB, Floege J, et al. Effect of cinacalcet on cardiovascular disease in patients undergoing dialysis. N Engl J Med. 2012; 367:2482–2494. PMID: 23121374.

18. Zhang Y, Lu Y, Feng S, Zhan Z, Shen H. Evaluation of laboratory parameters and symptoms after parathyroidectomy in dialysis patients with secondary hyperparathyroidism. Ren Fail. 2019; 41:921–929. PMID: 31573378.

19. Cheng SP, Lee JJ, Liu TP, Yang TL, Chen HH, Wu CJ, et al. Parathyroidectomy improves symptomatology and quality of life in patients with secondary hyperparathyroidism. Surgery. 2014; 155:320–328. PMID: 24035616.

20. Goldfarb M, Gondek SS, Lim SM, Farra JC, Nose V, Lew JI. Postoperative hungry bone syndrome in patients with secondary hyperparathyroidism of renal origin. World J Surg. 2012; 36:1314–1319. PMID: 22399154.

21. Mullen MG, LaPar DJ, Daniel SK, Turrentine FE, Hanks JB, Smith PW. Risk factors for 30-day hospital readmission after thyroidectomy and parathyroidectomy in the United States: an analysis of National Surgical Quality Improvement Program outcomes. Surgery. 2014; 156:1423–1431. PMID: 25456925.

22. Iannuzzi JC, Fleming FJ, Kelly KN, Ruan DT, Monson JR, Moalem J. Risk scoring can predict readmission after endocrine surgery. Surgery. 2014; 156:1432–1440. PMID: 25456927.

23. van der Plas W, Kruijff S, Sidhu SB, Delbridge LW, Sywak MS, Engelsman AF. Parathyroidectomy for patients with secondary hyperparathyroidism in a changing landscape for the management of end-stage renal disease. Surgery. 2021; 169:275–281. PMID: 33059930.

24. Jimeno-Fraile J, Cao H, Sancho-Insenser J, Lorente-Poch L, Sitges-Serra A. Muscle strength, physical performance, and metabolic changes after subtotal parathyroidectomy for secondary hyperparathyroidism. Surgery. 2021; 169:846–851. PMID: 33218703.