title: Persisting Hypocalcemia After Surgical Parathyroidectomy: The Differential Effectiveness of Calcium Citrate Versus Calcium Carbonate With Acid Suppression.
abstract: The effectiveness of oral calcium (Ca) may be contingent on a patient׳s factors beyond compliance, such as proton-pump inhibitor use and the choice of calcium supplements. A 32-year-old Hispanic male with end-stage renal disease on peritoneal dialysis underwent successful surgical parathyroidectomy (intact parathyroid hormone level: 2,328pg/mL; postsurgical: 287-69pg/mL [normal: 8.5-72.5]). His postoperative course was complicated by severe and recurrent hypocalcemia as outpatient and he needed repeated admissions for intravenous Ca gluconate. Initially, severe hypocalcemia (corrected Ca: 4.8-5.6mg/dL; nadir ionized Ca: 0.57-0.69mmol/L) was attributed solely to medical noncompliance with oral Ca carbonate (3750mg, 3×/day between meals) and calcitriol (2-4mcg/day). Recognizing coexisting treatment with proton-pump inhibitor, oral Ca supplement was changed to calcium citrate (2,850mg, 3×/day) with prompt resolution of hypocalcemia (corrected Ca: 8.1-8.3mg/dL). This current case and the included literature review emphasize the disproportionate effectiveness of Ca citrate in subjects with achlorhydria.
authors.affiliation: Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi.
authors.forename: Sabahat
authors.initials: S
authors.lastname: Afshan
authors.affiliation: Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi.
authors.forename: Abdeen R
authors.initials: AR
authors.lastname: Farah Musa
authors.affiliation: Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi.
authors.forename: Vonda
authors.initials: V
authors.lastname: Echols
authors.affiliation: Department of Anesthesiology, Simulation and Interprofessional Education Center, University of Mississippi Medical Center, Jackson, Mississippi.
authors.forename: Anna A
authors.initials: AA
authors.lastname: Lerant
authors.affiliation: Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi; FMC Extracorporeal Life Support Center, Fresenius Medical Care of Hungary, University of Debrecen Medical and Health Sciences Center, Debrecen, Hungary. Electronic address: tiborfulop.nephro@gmail.com.
authors.forename: Tibor
authors.initials: T
authors.lastname: Fülöp
mesh_terms: D000328:Adult; D002119:Calcium Carbonate / Q000627:therapeutic use*; D019355:Calcium Citrate / Q000627:therapeutic use*; D004347:Drug Interactions; D006801:Humans; D006996:Hypocalcemia / Q000188:drug therapy*; D007676:Kidney Failure, Chronic / Q000601:surgery / Q000628:therapy; D008297:Male; D016105:Parathyroidectomy / Q000009:adverse effects; D054328:Proton Pump Inhibitors / Q000627:therapeutic use; D006435:Renal Dialysis
chemical_list: D054328:Proton Pump Inhibitors; D002119:Calcium Carbonate; D019355:Calcium Citrate
keywords: Calcium citrate; End-stage renal disease; Hungry bone syndrome; Parathyroidectomy; Proton-pump inhibitor