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Die symptomatische Hypokalzämie nach Thyreoidektomie

Prävention durch eine Kombination von Prophylaxe und risikoadaptierter Substitution

Symptomatic hypocalcemia after thyroidectomy

Prevention by a combination of prophylaxis and risk-adapted substitution

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A Kommentar to this article was published on 30 October 2018

A Kommentar to this article was published on 19 October 2018

Zusammenfassung

Hintergrund

Behandlungsschemata zur Hypokalzämie nach Thyreoidektomie bestehen entweder aus einer Prophylaxe oder einer täglichen Substitution von Kalzium/Vitamin D3.

Fragestellung

Kann durch eine Kombination einer einmaligen Prophylaxe mit einer risikoadaptierten Substitution die Symptomatik vermindert werden?

Material und Methoden

Nach Einführung eines neuen Algorithmus wurden die Verläufe prospektiv dokumentiert und mit einem historischen Kollektiv verglichen. Der Algorithmus bestand aus einer einmaligen postoperativen Prophylaxe (1 g Kalziumglukonat 10 % in 250 ml, i. v.) und einer risikoadaptierten Substitution: Patienten ohne Risiko (PTH [Parathormon] > 15 pg/ml) erhielten keine Therapie. Patienten mit leichtem Risiko (PTH ≥ 6 ≤ 15 pg/ml sowie Ca ≥ 2,0 mmol/l) 3 g Kalzium, Patienten mit hohem Risiko (PTH ≥ 6 ≤ 15 pg/ml sowie Ca < 2,0 mmol/l) 3 g Kalzium und 2 × 0,5 µg/Tag Kalzitriol und Patienten mit sehr hohem Risiko (PTH < 6 pg/ml) 4 g Kalzium und 2 × 0,5 µg/Tag Kalzitriol.

Ergebnisse

Die Studie umfasst 415 Patienten (230 prospektiv, 185 retrospektiv). Die Kalziumwerte der Patienten mit Substitutionsschema stiegen am 1. postoperativen Tag signifikant an (0,0001), die Zahl der Patienten mit laborchemisch kritischer Hypokalzämie (Ca < 2,0 mmol/l) fiel um die Hälfte ab (27 % vs. 12,2 %; p = 0,0001). Es fand sich eine signifikant geringere Rate an symptomatischen Patienten (24,9 % vs. 13,0 %; p = 0,002) und eine deutliche Reduktion der Patienten mit verlängerter stationärer Verweildauer (10,8 % vs. 6,5 %; p = 0,08). Die Rate der permanenten Hypokalzämie war vergleichbar (2,2 % vs. 2,1 %; p = 0,9). In den Risikogruppen fand sich eine signifikant unterschiedliche symptomatische Hypokalzämierate: Bei Patienten mit keinem Risiko (n = 170) in 2,2 %, mit geringem Risiko (n = 36) in 25 %, mit hohem Risiko (n = 13) in 69,2 % bei sehr hohem Risiko (n = 11) in 72 %.

Schlussfolgerung

Das Behandlungsschema ist praktikabel, verringert signifikant die Symptomatik, auch im Vergleich zur Literatur und diskriminiert eindeutig die unterschiedlichen Risikogruppen.

Abstract

Background

Treatment of hypocalcemia after thyroidectomy consists of an individual substitution, prophylaxis or a daily administration of calcium/vitamin D3.

Objective

Does prophylactic therapy combined with a risk-adapted substitution of calcium and vitamin D3 reduce symptomatic hypocalcemia compared to individual substitution?

Material and methods

After implementation of a new algorithm, patient data were prospectively documented and analyzed compared to a historical patient population. The algorithm consisted of a single prophylactic i. v. administration of calcium (1 g calcium gluconate 10% in 250 ml saline) and a risk-adapted oral administration of calcium and vitamin D3 after surgery. Patients without risk (parathyroid hormone, PTH > 15 pg/ml) were not treated. Patients with a low risk (PTH ≥ 6 ≤ 15 pg/ml and Ca > 2.0 mmol/l) received 3 g calcium, patients with a high risk (PTH ≥ 6 ≤ 15 pg/ml and Ca < 2.0 mmol/l) received 3 g calcium and 2 × 0.5 µg vitamin D3 and patients with a very high risk (PTH < 6 pg/ml) got 4 g calcium and 2 × 0.5 µg vitamin D3.

Results

In this study 415 patients were included (230 prospectively and 185 retrospectively). Serum calcium of patients with individual substitution increased significantly at day 1 (p = 0.0001) and the number of patients with critical hypocalcemia (Ca < 2.0 mmol/l) decreased by half (27% vs. 12.2%; p = 0.0001). There was a significantly lower rate of symptomatic patients (24.9% vs 13.0%; p = 0.002) and a clear reduction of patients with a prolonged hospitalization (10.8% vs. 6.5%; p = 0.08). The rate of permanent hypocalcemia was comparable (2.2% vs. 2.1%). In the risk groups there was a significantly different rate of hypocalcemia: patients without risk (n = 170) in 2.2%, patients with low risk (n = 36) in 25%, patients with high risk (n = 13) in 69.2% and patients with very high risk (n = 11) in 71%.

Conclusion

This new treatment regimen is practicable, significantly lowers the symptoms, also in comparison to the literature and shows a clear differentiation between the risk groups.

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Authors and Affiliations

  1. Klinik für Allgemein- und Visceralchirurgie, Referenzzentrum für Schilddrüsen- und Nebenschilddrüsenchirurgie, Krankenhaus Martha-Maria, Stadenstraße 58, 90491, Nürnberg, Deutschland

    S. Coerper, J. Dehnel & W. Stengl

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Correspondence to S. Coerper.

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Interessenkonflikt

S. Coerper, J. Dehnel und W. Stengl geben an, dass kein Interessenkonflikt besteht.

Alle beschriebenen Untersuchungen am Menschen wurden mit Zustimmung der zuständigen Ethik-Kommission, im Einklang mit nationalem Recht sowie gemäß der Deklaration von Helsinki von 1975 (in der aktuellen, überarbeiteten Fassung) durchgeführt. Von allen beteiligten Patienten liegt eine Einverständniserklärung vor.

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Coerper, S., Dehnel, J. & Stengl, W. Die symptomatische Hypokalzämie nach Thyreoidektomie. Chirurg 89, 909–916 (2018). https://doi.org/10.1007/s00104-018-0631-4

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