SAT-513 Cut To The Bone: Hypocalcemia From Hungry Bone Syndrome In A Dialysis Patient

Background: Hungry bone syndrome is a life-threatening complication focused on prevention following parathyroidectomy in ESRD patients, requiring pre-operative optimization of serum calcium levels Case: A 35-year-old male with a past medical history of HTN, polycystic kidney disease and ESRD on peritoneal dialysis presented with numbness around the mouth and fingers, diffuse body aches and generalized weakness. He underwent total parathyroidectomy for tertiary hyperparathyroidism three days prior to presentation at another medical facility. Physical exam was unremarkable. Labs were significant for profound hypocalcemia of 5.8mg/dl [8.6-10.3mg/dl] and ionized calcium of 0.59mmol/L [1.12-1.32mmol/L]. The diagnosis of hungry bone syndrome was made based on the clinical setting. He received massive doses of IV and oral calcium along with IV calcitriol. Calcium was also added to each bag of peritoneal dialysate. Serum calcium levels remained low for three days despite optimal therapy with improvement after day four of admission. On the day of discharge, the serum calcium level was 7.8mg/dl [8.6-10.3mg/dl] with complete resolution of symptoms. He was discharged on calcitriol and calcium carbonate. Discussion: Hungry bone syndrome is a life-threating complication of parathyroidectomy. It is characterized by a severe drop in serum total calcium concentration and prolonged hypocalcemia for more than four days post parathyroidectomy. Hypocalcemia is generally transient because the degree of bone disease is typically mild but in some cases, the postoperative hypocalcemia is severe and prolonged. This most often occurs in patients who have developed bone disease preoperatively due to a chronic increase in bone resorption induced by high levels of PTH. The focus of hungry bone syndrome should be on prevention with pre-operative management of serum calcium and vitamin D levels. IV Calcitriol 2mcg is administered at the end of dialysis beginning three to five days prior to surgery, continued post-operatively as well. 2-3g of oral calcium is started two days prior to surgery. Once the serum calcium levels are within the reference range, IV calcitriol can be switched to an oral formulation. Despite adequate pre-op management, the risk of developing hungry bone syndrome in ESRD patients is high, requiring aggressive calcium supplementation Conclusion: Correction of serum calcium levels within the reference range prior to parathyroidectomy in ESRD patient is imperative to reduce the incidence of hungry bone syndrome.