Calcitriol loading before total parathyroidectomy with autotransplant in patients with end-stage kidney disease: does it prevent postoperative hypocalcaemia?

BACKGROUND: Hungry bone syndrome (HBS) is one of the most serious complications following parathyroidectomy for severe hyperparathyroidism. There is a lack of literature informing the treatment and risk factors for this condition and the ideal pre-operative strategy for prevention. AIMS: The primary aims were to examine the incidence of HBS with pre-operative calcitriol loading for 10 days and to determine the risk factors for HBS. The secondary aims were to determine the rate of intravenous calcium replacement in those with HBS and to assess whether cinacalcet removal has increased rates of parathyroidectomy in the end-stage kidney disease population. METHODS: We performed a retrospective study from 2011 to 2018 on 45 patients with end-stage kidney disease undergoing total parathyroidectomy with autotransplantation for severe hyperparathyroidism. This was based at the John Hunter and Newcastle Private Hospitals in New South Wales. RESULTS: 28.3% of patients with calcitriol loading undergoing parathyroidectomy fulfilled criteria for HBS. Pre-operative variables that were associated with HBS were elevated parathyroid hormone (P = 0.028) and longer duration of renal replacement therapy (P = 0.033). Rates of total parathyroidectomy were higher after the removal of calcimimetics from the Pharmaceutical Benefits Scheme (P = 0.0024). CONCLUSIONS: HBS remains a common complication of parathyroidectomy, even with prolonged high-dose calcitriol loading. This emphasises the need for further trials investigating other targeted therapies, such as bisphosphonates, to prevent HBS. Those most at risk of HBS are patients with high bone turnover and prolonged renal replacement therapy.

Atrial fibrillation and warfarin use in haemodialysis patients: an individualized holistic approach is important in stroke prevention.

Incidence and prevalence of atrial fibrillation (AF) is higher in haemodialysis (HD) population than general population. AF is associated with higher morbidity and mortality than sinus rhythm in this population. The purpose of this review is to summarize all available evidence regarding use of warfarin in HD patients with AF for stroke prevention. The enormous heterogeneity of available studies does not allow pooling of the data in the form of meta-analysis or systematic review. Current evidence regarding use of warfarin for AF in terms of risk benefit ratio in this population is limited and conflicting. Randomized control trials evaluating the safety and efficacy of anticoagulation in this population by means of risk/benefit assessment tools are urgently needed. However, suitable HD patients with AF should be counselled on their likelihood of reduction of stroke risk and experiencing side-effects before initiating anticoagulant therapy. It is particularly important to incorporate the patient's preferences and willingness to trade off benefit and risk in stroke prevention. An individualized holistic approach optimizing all potential risk factors of bleeding and ischemic stroke in HD patients with AF is recommended.