Hospital Putrajaya Protocol on

peri-operative management of
parathyroidectomy for renal
hyperparathyroidism

Working Group
Department of Breast & Endocrine Surgery

Endocrinology Unit, Department of Medicine

Nephrology Unit, Department of Medicine

Version 1.0, dated 1st April 2021

Prepared by:

Dr Chiew Ken Seng

Endocrinology Fellow

HPj PTH protocol Version 1.0 dated 1st April 2021 1

Acknowledgements

This guideline was made possible following the collaboration among the various disciplines involved.

Contributors:

Datuk Dr Zanariah Hussein

Senior Consultant Endocrinologist,
Endocrinology Unit, Department of Medicine

Miss Anita Baghawi

Head of Department & Consultant Breast and Endocrine Surgeon,
Department of Breast and Endocrine Surgery

Dr Rafidah Abdullah
Consultant Nephrologist,
Nephrology Unit, Department of Medicine

Dr Azraai Bahari Nasruddin

Consultant Endocrinologist,
Endocrinology Unit, Department of Medicine

Mr Aminnur Hafiz Maliki

Breast and Endocrine Surgery Fellow,
Department of Breast and Endocrine Surgery

Dr Chiew Ken Seng

Endocrinology Fellow,
Endocrinology Unit, Department of Medicine

External reviewer:

Dr Fariz Safhan Mohamad Nor

Consultant Nephrologist and Head,
Department of Nephrology, HTAA Kuantan, Pahang.

HPj PTH protocol Version 1.0 dated 1st April 2021 2

CONTENTS

Acknowledgements ......................................................................................................................... 2
Introduction ..................................................................................................................................... 4
Indications for total parathyroidectomy in ESKD patients ............................................................. 4
Initial management of referral: step-by-step ................................................................................... 4
Upon receiving the referral ......................................................................................................... 5
Pre-operative plans prior to hospital admission .......................................................................... 6
Pre-Operative Management (Inpatient) .......................................................................................... 6
Post-Operative Management ....................................................................................................... 6
Discharge Plan ................................................................................................................................ 8
Audit ............................................................................................................................................... 8
Conclusion ...................................................................................................................................... 8
References ....................................................................................................................................... 9
Appendix A: Form A .................................................................................................................... 10
Appendix B: Form B ..................................................................................................................... 11

HPj PTH protocol Version 1.0 dated 1st April 2021 3

Introduction
Renal hyperparathyroidism will ultimately develop in virtually all patients with end-stage kidney disease
(ESKD).1 Although medical therapy with phosphate binders, active vitamin D analogs and/or calcimimetics
may initially suffice, parathyroidectomy is required in about 15% of patients after 10 years and 38% of
patients after 20 years of ongoing dialysis therapy.2 Parathyroidectomy has been shown to improve quality
of life, increase bone mineral density, reduce fracture risk and increase survival. 3 However, hypocalcemia
can be severe and prolonged following parathyroidectomy. Hungry bone syndrome has been reported to
occur in more than 28% of patients, with some literature reporting a prevalence of up to 95%.3 Our anecdotal
experience has also been consistent with this data and this had resulted in morbidity, prolonged hospital
stay as well as readmissions.

Hence, discussions among all stakeholders (Department of Breast & Endocrine Surgery, Endocrinology
Unit and Nephrology Unit) were held in order to standardize and streamline Hospital Putrajaya’s
perioperative management of parathyroidectomy for renal hyperparathyroidism.

Indications for total parathyroidectomy in ESKD patients

Nephrology services through professional societies (Malaysian Society of Nephrology and Post-Graduate
Renal Society of Malaysia) has published Clinical Practice Guidelines stating the indications of
parathyroidectomy. The indications are as listed below:

1. Failed medical treatment

2. Parathyroid hormone (PTH) level persistently >80pmol/L with hypercalcemia and/or
hyperphosphataemia
3. Pathological fracture related to renal hyperparathyroidism
4. Calciphylaxis after failed medical treatment
5. Radiological changes of renal osteodystrophy
6. Metastatic calcification
7. Intractable pruritus caused by Chronic Kidney Disease-Mineral Bone Disease (CKD-MBD)

Initial management of referral: step-by-step

At current moment, patients walk into general surgical clinic for appointments. These patients generally
were not able to give us adequate work-up information and clinical details. This arrangement will below
will reduce the number of visits necessary for the patients. Patients are referred from other states.

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Below is a step-by-step approach upon receiving a referral letter. Referring doctors are encouraged to send
a letter via email (hpjparathyroid@gmail.com), to reduce inconvenience to the patients. However, it is
expected the referrals can be received via a physical letter and phone call.

Upon receiving the referral

1. The referral is received via physical letter, telephone or via e-mail.
2. A standardized request form (Form A) would then be provided to the referring team via a printed
copy or e-mail.
• If a physical letter is received - counter or medical officers will need to return the letter to
the patient and provide Form A (Appendix A) together.
• If a phone call referral is received, letter can be email-ed to hpjparathyroid@gmail.com.

The standardized form would include:

List of medications, including details of:

• Vitamin D
• Calcium supplements
• Cinacalcet
• Phosphate binders (Eg. Sevelamer)
Blood investigations
• iPTH
• Calcium/Magnesium/Phosphate/Albumin
• Serum ALP
Parathyroid localization studies
• Ultrasound, CT, Sestamibi etc.
Radiological evidence of hyperparathyroidism-related bone disease (If
applicable)
• Any fractures?
• X-rays, bone scintigraphy etc.
Cardiac assessment (Compulsory)
• ECG
• Echocardiogram
Doctor/Nurse in-charge
• Name, phone number and e-mail

3. The referring team would then complete the form (Form A) and e-mail it to
hpjparathyroid@gmail.com (password: 4parathyroidectomy@gmail.com)
4. Assigned surgical MO would review the e-mails every Friday
5. Nephrologist would review the e-mails every Monday.
6. If the referral is incomplete, further communication via e-mail will be made.

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 7. Once the referral has been completed and accepted, the patient’s appointment date will be
informed to the referring doctor via e-mail
8. The appointment will be scheduled to be on combined surgical-endocrine clinic every Tuesday
9. It is the responsibility of the referring doctor to inform the patient of the assigned appointment
date.

Pre-operative plans prior to hospital admission

Patients may or may not be required to have additional medications and plans on the days leading up to
surgery.

10. Calcium and Vitamin D supplementation may be required in selected patients

11. If required, a memo containing instructions for pre-operative preparation would be addressed to
the referring doctor

Pre-Operative Management (Inpatient)

Patients are only admitted a day prior to surgery. The patients' respective Haemodialysis centres must
ensure all routine dialysis is performed prior to surgery. Patients will only be dialysed in hospital post-
operatively.

• The patient is usually admitted a day prior to the surgery

• Upon admission, pre-operative blood investigations should include serum calcium, phosphate,
magnesium, albumin, alkaline phosphatase and intact parathyroid hormone (iPTH)
• Inform Nephrology and Endocrine teams
• Cinacalcet and phosphate binders should be ceased the day prior to surgery
• Ensure patient is fasted 6 hours prior to surgery

Post-Operative Management
• Central venous line is inserted in the operation theatre
• Start the infusion at 5% calcium gluconate based on the serum alkaline phosphatase level
o Dilute 30ml of calcium gluconate 10% (3 ampoules) into 60ml with Dextrose 5% or
Normal Saline
Alkaline Phosphatase (ALP) Infusion rate
> 700 IU/L 40 ml/hour
500 – 700 IU/L 20 ml/hour
< 500 IU/L 10 ml/hour

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 • Once the patient returns from the operation theatre, immediately measure serum calcium,
phosphate, magnesium and albumin
• Titrate the 5% calcium gluconate infusion based on the table below:

Corrected Calcium Infusion rate

< 1.8 mmol/L Increase by 4 ml/hour
1.8 – 2.0 mmol/L Increase by 2 ml/hour
2.0 – 2.4 mmol/L Maintain
2.4 – 2.8 mmol/L Reduce by 4 ml/hour
Above 2.8 mmol/L Stop infusion

• If the 5% calcium gluconate infusion requires adjustment in infusion rate, measure serum calcium
and albumin 6 hourly
• However, if the 5% calcium gluconate infusion does not require any rate adjustment, the serum
calcium and albumin may be measured the next morning
• Upon each review, assess for clinical features of hypocalcemia:
o Paraesthesias of lips and toes
o Muscle spasm and tetany
o Larynospasm
o Confusion
o Seizures
o Chovstek sign: Facial muscle spasm with tapping of the facial nerve
o Hyperactive deep tendon reflexes
o Prolonged QTc on ECG (perform daily ECG or PRN basis)
• Start oral calcium and vitamin D supplements once patient is able to tolerate orally
o Tab Alfacalcidol 6mcg TDS
o Tab Calcium Carbonate 3g TDS (taken at least 30 minutes before meal to minimize its
phosphate binding effect and subsequently, it’s bioavailability)
• Measure serum phosphate daily
o Correct severe hypophosphatemia (<0.6mmol/L) if present
o 10mmol KH2PO4 (1 ampoule) in 100cc normal saline over 4 hours
• Measure serum magnesium at least once every 3 days
• Correct hypomagnesaemia if present
o 10mmol MgSO4 (1 ampoule) in 100cc normal saline over 2 hours
• If hypocalcemic and on dialysis infusion, dialysis after surgery is performed using 1.75mmol/L
calcium dialysate (high calcium dialysate). The first 2 dialysis session post-operative is

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 performed heparin-free. Subsequent dialysis sessions are performed with tight heparin. This may
change in accordance to Nephrology review; if necessary.

Discharge Plan
All patients will be given Form B; with all the dates of blood investigation dates given clearly in the referral
letter. The patients' haemodialysis centre staffs are responsible to follow through all the plans.

• Discharge is planned by the endocrine team when the patient has a stable calcium level and not
requiring intravenous calcium
• Follow up instructions to be provided to the patient’s dialysis center upon discharge
o Choice of calcium bath dialysate (1.25 / 1.5 / 1.75 mmol/L)
o Serial measurements of serum calcium/phosphate/albumin levels
With each dialysis session for one week
Then weekly for one month
Then fortnightly for one month
• At each measurement, the dialysis staff in-charge is required to update the nephrology medical
officer via whatsapp at 017-672202046
o The nephrology medical officer would then discuss with the Endocrine Fellow in-charge
of the case to adjust the dose of alfacalcidol, oral calcium supplements and calcium
dialysate
• Surgical clinic appointment is in 6 weeks upon discharge

Audit
Audit will be performed at least yearly to improve the protocol and guidelines. The management team will
arrange regular multidisciplinary meetings to address any issues immediately if necessary.

Conclusion
This standard operating procedure standardized the peri-operative management of renal hyperparathyroid
ESKD patients. This will ensure patients are delivered the best of care in accordance to current clinical
evidence and best available guidelines.

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References
1. Torer N, Torun D, Torer N, Micozkadioglu H, Noyan T, Ozdemir FN, Haberal M. Predictors of
early postoperative hypocalcemia in hemodialysis patients with secondary hyperparathyroidism.
Transplant Proc. 2009 Nov;41(9):3642-6. doi: 10.1016/j.transproceed.2009.06.207.
2. Schneider R, Slater EP, Karakas E, Bartsch DK, Schlosser K. Initial parathyroid surgery in 606
patients with renal hyperparathyroidism. World J Surg. 2012 Feb;36(2):318-26. doi:
10.1007/s00268-011-1392-0.
3. Milas, M. (2020). Parathyroidectomy in end-stage kidney disease. In J. A. Medlin (ed.),
UpToDate. Retrieved March 24, 2020, from
https://www.uptodate.com/contents/parathyroidectomy-in-end-stage-kidney-disease
4. Parathyroid Protocol, Department of Surgery, Hospital Putrajaya (2013)
5. Parathyroidectomy: Post Operative Care Protocol, Department of Nephrology, Hospital Selayang
6. Protocol for Parathyroidectomy, Department of Nephrology, Hospital Kuala Lumpur
7. 1st Malaysian CKD MBD and Parathyroidectomy guidelines & SOP

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Appendix A: Form A

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Appendix B: Form B

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