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Xia J, Tan AJ, Biglione B, Cucka B, Ko L, Nguyen ED, Khoury CC, Robinson MK, Nigwekar SU, Kroshinsky D. Nephrogenic Calciphylaxis Arising after Bariatric Surgery: A Case Series. Am J Nephrol 2023; 55:196-201. [PMID: 37487472 DOI: 10.1159/000531784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/22/2023] [Indexed: 07/26/2023]
Abstract
Nephrogenic calciphylaxis is associated with multiple risk factors including long-term dialysis dependence, hyperphosphatemia, hypercalcemia, parathyroid hormone derangements, vitamin K deficiency, obesity, diabetes mellitus, warfarin use, and female sex. Bariatric surgery is known to cause altered absorption, leading to mineral and hormonal abnormalities in addition to nutritional deficiency. Prior case reports on calciphylaxis development following bariatric surgery have been published, though are limited in number. We report a case series of five bariatric patients from a single institution who developed nephrogenic calciphylaxis between 2012 and 2018. These patients had a history of bariatric surgery, and at the time of calciphylaxis diagnosis, demonstrated laboratory abnormalities associated with surgery including hypercalcemia (n = 3), hyperparathyroidism (n = 2), hypoalbuminemia (n = 5), and vitamin D deficiency (n = 5), in addition to other medication exposures such as vitamin D supplementation (n = 2), calcium supplementation (n = 4), warfarin (n = 2), and intravenous iron (n = 1). Despite the multifactorial etiology of calciphylaxis and the many risk factors present in the subjects of this case series, we submit that bariatric surgery represents an additional potential risk factor for calciphylaxis directly stemming from the adverse impact of malabsorption and overuse of therapeutic supplementation. We draw attention to this phenomenon to encourage early consideration of calciphylaxis in the differential for painful skin lesions arising after bariatric surgery as swift intervention is essential for these high-risk patients.
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Affiliation(s)
- Joyce Xia
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA,
| | - Alice J Tan
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bianca Biglione
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bethany Cucka
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lauren Ko
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emily D Nguyen
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Dermatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Charbel C Khoury
- Department of Nephrology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Malcolm K Robinson
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Metabolic and Bariatric Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sagar U Nigwekar
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Lorenz FJ, Goldenberg D. Hypocalcemia after parathyroidectomy in patients with a history of bariatric surgery. Endocrine 2023; 79:571-576. [PMID: 36305997 DOI: 10.1007/s12020-022-03234-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/13/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE A growing body of literature has suggested that a history of bariatric surgery increases the risk of hypocalcemia after subsequent thyroidectomy, however little is known about the risk after parathyroidectomy. The purpose of this study was to determine the incidence of hypocalcemia after parathyroidectomy in patients with prior bariatric surgery. METHODS The TriNetX Research Network was queried using diagnosis and procedure codes to identify patients with a history of bariatric surgery who were subsequently diagnosed with primary hyperparathyroidism (PHP) and underwent parathyroidectomy between 2012 and 2022. The rate of hypocalcemia after parathyroidectomy was compared between those with a history of bariatric surgery and controls who underwent parathyroidectomy alone, matched for demographics, body mass index (BMI) ≥ 30 kg/m2, and history of calcium or vitamin D supplementation. RESULTS There were 34,483 included patients diagnosed with PHP who underwent parathyroidectomy. Of this cohort, 1.4% (n = 472) had prior bariatric surgery. There were 90% females and 10% males in this subset of patients, and the average age was 58 years. Compared to matched controls who underwent parathyroidectomy alone, these patients had a significantly increased risk of hypocalcemia within 0-1 month (RR, 95% CI, P) (17.2% vs. 9.3%; 1.8, 1.3-2.6, P < 0.001), 1-6 months (8.5% vs. 2.5%; 3.3, 1.8-6.3, P < 0.001) and 6-12 months (6.8% vs. 2.3%; 2.9, 1.5-5.7, P < 0.001) following surgery. CONCLUSION The current study is the first to indicate that patients with a history of bariatric surgery are at increased risk for short-term and permanent hypocalcemia after parathyroidectomy. Further research is required to determine optimal prevention and treatment strategies to decrease associated morbidity in this subset of patients.
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Affiliation(s)
- F Jeffrey Lorenz
- College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - David Goldenberg
- Department of Otolaryngology-Head and Neck Surgery, Penn State College of Medicine, Hershey, PA, USA.
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Protracted Hypocalcemia following 3.5 Parathyroidectomy in a Kidney Pancreas Recipient with a History of Robotic-Assisted Roux-en-Y Gastric Bypass. Case Rep Transplant 2018; 2018:2182083. [PMID: 30140481 PMCID: PMC6081600 DOI: 10.1155/2018/2182083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 06/12/2018] [Indexed: 01/01/2023] Open
Abstract
Background 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. Case Report 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. Discussion 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.
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Panazzolo DG, Braga TG, Bergamim A, Pires B, Almeida H, Kraemer-Aguiar LG. Hypoparathyroidism after Roux-en-Y gastric bypass--a challenge for clinical management: a case report. J Med Case Rep 2014; 8:357. [PMID: 25348653 PMCID: PMC4232227 DOI: 10.1186/1752-1947-8-357] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 09/01/2014] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION In this report, we describe challenges we encountered in the clinical management of a patient with hypoparathyroidism who had previously undergone a bariatric procedure. CASE PRESENTATION We report the case of a 38-year-old Caucasian woman who had undergone a Roux-en-Y gastric bypass procedure for treatment of obesity. She also had a past history of right lobectomy to treat a benign thyroid nodule. Another thyroid nodule was diagnosed after her bariatric surgery, so a new thyroid surgery was performed. Permanent hypoparathyroidism occurred after the second thyroid surgery. A Roux-en-Y gastric bypass resulted in important weight loss, but the preferential site of calcium absorption was bypassed. The lack of endogenous parathyroid hormone secretion due to post-surgical hypoparathyroidism abolished the physiological mechanism that compensates the reduced calcium absorption, which was a challenge for us to overcome. In this report, we describe our clinical therapeutic choices to maintain normocalcemia and normophosphatemia in this patient. Higher doses of exogenous calcium citrate, calcitriol and cholecalciferol were used, but hypocalcemia was still present. To improve vitamin D absorption with resultant improvement of calcium homeostasis, we speculated that adding pancrelipase to meals would increase lipid absorption and possibly fat-soluble vitamins, including vitamin D. Only after the addition of pancrelipase did the patient improve without weight regain according to clinical and laboratory assessments. CONCLUSION The use of exogenous pancreatic enzymes improved calcium homeostasis in this bariatric patient. The role of these enzymes on vitamin D absorption and subsequent rise in calcium levels in hypoparathyroid patients who undergo bariatric procedures need further investigation.
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Affiliation(s)
| | | | | | | | | | - Luiz Guilherme Kraemer-Aguiar
- Obesity Unit, Polyclinic Piquet Carneiro; Endocrinology, Department of Internal Medicine, Medical Sciences Faculty, State University of Rio de Janeiro, Av, Marechal Rondon, 381, Rio de Janeiro 20950-003, Brazil.
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Chen Y, Lubitz CC, Shikora SA, Hodin RA, Gaz RD, Moore FD, McKenzie TJ. Primary Hyperparathyroidism After Roux-en-Y Gastric Bypass. Obes Surg 2014; 25:700-4. [DOI: 10.1007/s11695-014-1444-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Campos GM, Ziemelis M, Paparodis R, Ahmed M, Davis DB. Laparoscopic reversal of Roux-en-Y gastric bypass: technique and utility for treatment of endocrine complications. Surg Obes Relat Dis 2013; 10:36-43. [PMID: 24120983 DOI: 10.1016/j.soard.2013.05.012] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 04/24/2013] [Accepted: 05/25/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND The anatomic and physiologic changes with Roux-en-Y gastric bypass (RYGB) may lead to uncommon but occasionally difficult to treat complications such as hyperinsulinemic hypoglycemia with neuroglycopenia and recalcitrant hypocalcemia associated to hypoparathyroidism. Medical management of these complications is challenging. Laparoscopic reversal of RYGB anatomy with restoration of pyloric function and duodenal continuity is a potential treatment. The objective of this study was to present the indications, surgical technique, and clinical outcomes of laparoscopic reversal of RYGB. METHODS Prospective study of consecutive patients offered laparoscopic reversal of RYGB. RESULTS Five patients with remote laparoscopic RYGB underwent laparoscopic reversal of RYGB to normal anatomy (n = 2) or modified sleeve gastrectomy (n = 3). Indications were medically refractory hyperinsulinemic hypoglycemia with neuroglycopenia (n = 3), recalcitrant hypocalcemia with hypoparathyroidism (n = 1), and both conditions simultaneously (n = 1). Before reversal, all patients had a gastrostomy tube placed in the excluded stomach to document improvement of symptoms. Laparoscopic reversal was accomplished successfully in all patients. Three postoperative complications occurred: bleeding that required transfusion, gallstone pancreatitis, and a superficial trocar site infection. Average length of stay was 3 days. At a mean follow-up of 12 months (range 3 to 22), no additional episodes of neuroglycopenia occurred, average number of hypoglycemic episodes per week decreased from 18.5 ± 12.4 to 1.5 ± 1.9 (P = .05), and hypocalcemia became responsive to oral replacement therapy in both patients. CONCLUSIONS Laparoscopic reversal of RYGB to normal anatomy or modified sleeve gastrectomy is feasible and may be a therapeutic option for selected patients with medically refractory hyperinsulinemic hypoglycemia and/or recalcitrant hypocalcemia associated with hypoparathyroidism.
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Affiliation(s)
- Guilherme M Campos
- Department of Surgery, Division of General Surgery, Section of Foregut and Bariatric Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
| | - Martynas Ziemelis
- Department of Surgery, Division of General Surgery, Section of Foregut and Bariatric Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Rodis Paparodis
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Muhammed Ahmed
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Dawn Belt Davis
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
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Abstract
Calciphylaxis is a devastating disorder with a mortality rate of 80% due to sepsis and organ failure. Hallmarks of this rare disease are arteriolar media calcification, thrombotic cutaneous ischemia, and necrotic ulcerations. Different mechanisms of vascular calcification can lead to calciphylaxis. Early diagnosis by deep cutaneous ulcer biopsy is most important for prognosis. Here, dermatologists play a significant role although treatment usually needs an interdisciplinary approach. Surgical procedures had been the cornerstone of treatment in the past including parathyroidectomy, but recently new medical treatments emerged aiming to normalize disturbances of minerals to reduce the serum concentration of sodium phosphate and to prevent precipitation and calcification. Multimodal therapy is warranted but only aggressive surgical debridement of cutaneous ulcers has shown significant outcome improvement.
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology and Allergology, Academic Teaching Hospital Dresden-Friedrichstadt, 01067 Dresden, Germany
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