SUN-LB085 Complicated Hungry Bone Syndrome Due to Tertiary Hyperparathyroidism in a Patient with Kidney Transplant: A Case to Remember

Abstract

Introduction: Hyperparathyroidism with parathyroid hyperplasia can result from prolonged stimulation of parathyroid glands in chronic kidney disease which may persist after kidney transplant. Timing of parathyroidectomy is still matter of study. Here we present a case of hungry bone syndrome in a patient with tertiary hyperparathyroidism due to ESRD after subtotal parathyroidectomy 13 years after kidney transplant. Case presentation: A 54-year-old female, with past medical history of type 1 diabetes mellitus, celiac disease and tertiary hyperparathyroidism (status post living donor right kidney transplantation in 13 years ago) was admitted to the hospital for elective subtotal parathyroidectomy. The patient was previously being managed with vitamin D analogs, however, due to progression of her osteoporosis and systemic symptoms despite normal renal function after the transplant, decision was made to proceed for surgical intervention. The patient underwent subtotal parathyroidectomy (3 gland removal) and her postoperative period was complicated by the development of hungry bone syndrome. She developed persistent severe hypocalcemia with ionized calcium of 3.7mg/dl (normal range 4.5-5mg/dl) and total serum calcium of 6.1mg/dl (normal range 8.4-10mg/dl) associated with generalized weakness and perioral numbness and tingling which was treated with high doses of calcitriol and intravenous calcium gluconate. Frequent electrolyte and EKG monitoring with appropriate supplementation was provided to maintain electrolyte balance and prevent cardiac arrhythmias. The patient was treated successfully and was discharged to home on oral medication after total 15 days of hospitalization once appropriate and steady calcium levels were reached. Discussion: Transient hypocalcemia is common after parathyroidectomy; however, hunger bone syndrome is a life-threatening complication after total or subtotal parathyroidectomy for the long-term tertiary hyperparathyroidism. Close postoperative monitoring and prompt treatment are necessary to treat the severe electrolytes deficiency, especially refractory hypocalcaemia. There are no clear recommendations about whether parathyroidectomy for tertiary hyperparathyroidism due to ESRD after kidney transplant is superior to that before kidney transplant in terms of decreasing the risk of development of Hunger Bone syndrome.