Bonatti Hugo, Iqbal Naureen, Kling Catherine, Melvin Willie, Broome James
Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
Meritus Surgical Specialists, Hagerstown, MD, USA.
Case Rep Transplant. 2018 Jul 24;2018:2182083. doi: 10.1155/2018/2182083. eCollection 2018.
Hypocalcemia is a frequent complication of parathyroidectomy for secondary/tertiary hyperparathyroidism. In patients with a history of prior Roux-en-Y gastric bypass (RYGBP), changes in nutritional absorption make management of hypocalcemia after parathyroidectomy difficult.
A 41-old-year morbidly obese female with c-peptide negative diabetes mellitus and renal failure had RYGBP. Following significant weight loss she underwent simultaneous pancreas-kidney transplantation. She had excellent transplant graft function but developed tertiary hyperparathyroidism with calciphylaxis. She underwent resection of 3.5 glands leaving a small, physiologic remnant remaining in situ at the left inferior position. She was discharged on postoperative day one in good condition, asymptomatic with serum calcium of 7.6 mg/dL and intact PTH of 12 pg/mL. The patient had to be readmitted on postoperative day #14 for severe hypocalcemia of 5.0 mg/dl and ionized calcium 2.4 mg/dl. She required intravenous calcium infusion to achieve calcium levels of >6.5 mg/dl. Long-term treatment includes 5 g of elemental oral calcium TID, vitamin D, and hydrochlorothiazide. She remains in the long term on high-dose medical therapy with normal serum calcium levels and PTH levels around 100 pg/mL.
Our patient's protracted hypocalcemia originates from a combination of 3.5 gland parathyroidectomy, altered intestinal anatomy post-RYGBP, and potentially her pancreas transplant causing additional metabolic derangement. Alternative bariatric procedures such as sleeve gastrectomy may be more suitable for patients with renal failure or organ transplants in whom adequate absorption of vitamins, minerals, and drugs such as immunosuppressants is essential.
低钙血症是继发性/三发性甲状旁腺功能亢进症甲状旁腺切除术后常见的并发症。对于有Roux-en-Y胃旁路术（RYGBP）病史的患者，营养吸收的改变使得甲状旁腺切除术后低钙血症的管理变得困难。
一名41岁的病态肥胖女性，患有C肽阴性糖尿病和肾衰竭，接受了RYGBP手术。体重显著减轻后，她接受了胰肾联合移植。她的移植肾功能良好，但出现了三发性甲状旁腺功能亢进并伴有钙化防御。她接受了3.5个甲状旁腺的切除，在左下方位置保留了一个小的生理性残余甲状旁腺。术后第一天她情况良好出院，无症状，血清钙为7.6mg/dL，完整甲状旁腺激素为12pg/mL。患者在术后第14天因严重低钙血症再次入院，血钙水平为5.0mg/dl，离子钙为2.4mg/dl。她需要静脉输注钙剂以使血钙水平>6.5mg/dl。长期治疗包括每日三次口服5g元素钙、维生素D和氢氯噻嗪。她长期接受高剂量药物治疗，血清钙水平正常，甲状旁腺激素水平约为100pg/mL。
我们患者的持续性低钙血症源于3.5个甲状旁腺切除、RYGBP术后肠道解剖结构改变以及可能的胰腺移植导致的额外代谢紊乱。替代的减肥手术，如袖状胃切除术，可能更适合肾衰竭或器官移植患者，对于这些患者，维生素、矿物质和免疫抑制剂等药物的充分吸收至关重要。
