DOI: http://dx.doi.org/10.18203/2349-2902.isj20205359

The utility of serum 25-hydroxyvitamin D in predicting post-thyroidectomy hypocalcemia in thyrotoxic subjects: a single-center cohort study

Poongkodi Karunakaran, Deepak Thomas Abraham

Abstract


Background: The role of preoperative vitamin D deficiency as a predictor of post-thyroidectomy hypocalcemia in thyrotoxic subjects is controversially reported. This prospective cohort study determined the utility of serum 25-hydroxyvitamin D (25OHD) levels in predicting transient hypocalcemia in thyrotoxic and euthyroid patients undergoing total thyroidectomy (TT).

Methods: Subjects with new-onset hyperthyroidism (n=97; age=median (Inter-Quartile Range); 38 (18) years; M:F=25:72) and age; sex-matched euthyroid cohorts (n=231; age=37 (18) years; M:F=40:191) undergoing TT were evaluated for serum corrected-calcium, intact parathormone and 25OHD levels at baseline, 48-hour and 6-months post-TT, p value <0.05 was considered significant.

Results: The incidence of transient hypocalcemia in thyrotoxic subjects was 58.8% (57/97) versus 22.5% (52/179) in euthyroid cohorts. In receiver operating characteristic analysis predicting transient hypocalcemia for the test-variable preoperative 25OHD, the area under curve (AUC) among euthyroid subjects was 0.725 (95% CI: 0.641-0.809; p<0.001) with a threshold of 17.6 ng/mL with sensitivity and specificity of 65.4% and 64.2% respectively. In thyrotoxic subjects, the AUC was 0.573 (95% CI; 0.452-0.694; p=0.222) with poorer predictability and was less than that of euthyroid subjects.

Conclusions: Preoperative 25OHD below 17.6 ng/ml was reliable in predicting transient postoperative hypocalcemia in euthyroid subjects though with a limited sensitivity and specificity but unreliable in thyrotoxic subjects undergoing TT.


Keywords


Euthyroid, Hyperthyroidism, Postoperative hypocalcemia, Thyroidectomy, Thyrotoxicosis, 25-hydroxycholecalciferol, Vitamin D deficiency

Full Text:

PDF

References


Liu ZW, Masterson L, Fish B. Thyroid surgery for Graves’ disease and Graves’ ophthalmopathy. Cochrane Database Systematic Rev. 2015:CD010576.

Thomusch O, Machens A, Sekulla C. The impact of surgical technique on postoperative hypoparathyroidism in bilateral thyroid surgery: a multivariate analysis of 5846 consecutive patients. Surg. 2003;133:180-5.

Thomusch O, Machens A, Sekulla C. Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany. World J Surg. 2000;24:1335-41.

Bott KJ, Markogiannakis H, Skandarajah A. Preoperative vitamin D deficiency predicts postoperative hypocalcemia after total thyroidectomy. World J Surg. 2011;35:10-2.

Unsal IO, Calapkulu M, Sencar ME. Preoperative vitamin D levels as a predictor of transient hypocalcemia and hypoparathyroidism after parathyroidectomy. Scientific Reports. 2020;10:95-8.

Kim WW, Chung SH, Ban EJ. Is preoperative vitamin D deficiency a risk factor for postoperative symptomatic hypocalcemia in thyroid cancer patients undergoing total thyroidectomy plus central compartment neck dissection? Thyroid. 2015;25:911-8.

Wang X, Zhu J, Liu F. Preoperative vitamin D deficiency and postoperative hypocalcemia in thyroid cancer patients undergoing total thyroidectomy plus central compartment neck dissection. Oncotarget. 2017;8:78113-9.

Manzini G, Malhofer F, Weber T. Can preoperative vitamin D deficiency predict postoperative hypoparathyroidism following thyroid surgery? Langenbeck’s Arch Surg. 2019;404:55-61.

Lee GH, Ku YH, Kim H. Vitamin D level is not a predictor of hypocalcemia after total thyroidectomy. Langenbeck’s Arch Surg. 2015;10:1007-11.

Holick MF. The vitamin D deficiency pandemic: Approaches for diagnosis, treatment and prevention. Rev Endocrine Metab Dis. 2017;18:24-31.

Edafe O, Antakia R, Laskar N. Systematic review and meta-analysis of predictors of post-thyroidectomy hypocalcaemia. British J Surg. 2014;101:307-20.

Edafe O, Balasubramanian SP. Incidence, prevalence and risk factors for post-surgical hypocalcaemia and hypoparathyroidism. Gland Surg. 2017;8:09-13.

Michie W, Duncan T, Hodges DW. Mechanism of hypocalcaemia after thyroidectomy for thyrotoxicosis. Lancet. 1971;297:508-14.

Dembinski TC, Yatscoff RW, Blandford DE. Thyrotoxicosis and hungry bone syndrome-a cause of posttreatment hypocalcemia. Clinical Biochem. 1994;27:69-74.

See ACH, Soo KC. Hypocalcaemia following thyroidectomy for thyrotoxicosis. British J Surg. 1997;84:95-7.

Nicholls JJ, Brassill MJ, Williams GR. The skeletal consequences of thyrotoxicosis. J Endocrinol. 2012;213:209-21.

Karunakaran P, Maharajan C, Ramalingam S. Is hungry bone syndrome a cause of postoperative hypocalcemia after total thyroidectomy in thyrotoxicosis? a prospective study with bone mineral density correlation. Surg. 2018;163:367-72.

Holick MF, Binkley NC, Ferrari HA. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011;96:1911-30.

Sousa AA, Salles JMP, Soares JMA. Predictors factors for post-thyroidectomy hypocalcaemia. Revista Colegio Brasileiro Cirurgioes. 2012;39:10-2.

Eismontas V, Slepavicius A, Janusonis V. Predictors of postoperative hypocalcemia occurring after a total thyroidectomy: results of prospective multicenter study. BMC Surg. 2018;18:87-9.

D’Orazi V, Sacconi A, Trombetta S. May predictors of difficulty in thyroid surgery increase the incidence of complications? Prospective study with the proposal of a preoperative score. BMC Surg. 2019;18:447-52.

Cho JN, Park WS, Min SY. Predictors and risk factors of hypoparathyroidism after total thyroidectomy. Int J Surg. 2016;34:47-52.

Yamashita H, Murakami T, Noguchi S. Postoperative tetany in Graves disease: important role of vitamin D metabolites. Annals Surg. 1999;229:237-45.

Qubaisi M, Haigh PI. Hypocalcemia after total thyroidectomy in graves disease. The Permanente Journal. 2019;10:812-8.

Nelson KL, Hinson AM, Lawson BR. Postoperative calcium management in same-day discharge thyroid and parathyroid surgery. Otolaryngol Head Neck Surg. 2016;154:854-60.

Mazeh H, Khan Q, Schneider DF. Same-day thyroidectomy program: eligibility and safety evaluation. Surg. 2012;152:1133-41.

Reinhart HA, Snyder SK, Stafford SV. Same day discharge after thyroidectomy is safe and effective. Surg. 2018;10:101-6.

Arer IM, Kus M, Akkapulu N. Prophylactic oral calcium supplementation therapy to prevent early post thyroidectomy hypocalcemia and evaluation of postoperative parathyroid hormone levels to detect hypocalcemia: a prospective randomized study. Int J Surg. 2017;38:9-14.

Langner E, Tincani AJ, Negro A. Use of prophylactic oral calcium after total thyroidectomy: a prospective study. Arch Endocrinol Metabol. 2017;61:447-54.

Rodríguez MD, Ramírez LM, Gallardo LG. Hungry bone syndrome related to hyperythyroidism. Anales Med Interna. 2006;23:326-8.

Loredana D, Pasquale GG. Hungry bone syndrome after parathyroidectomy for primary hyperthyroidism. Surg. 2014;10:417-22.

Ronde W, Have SMTH, Daele PLA. Hungry bone syndrome, characterized by prolonged symptomatic hypocalcaemia, as a complication of the treatment of hyperthyroidism. Nederlands Tijdschrift. 2004;148:231-4.

Karunakaran P, Maharajan C, Mohamed KN. Rapid restoration of bone mass after surgical management of hyperthyroidism: a prospective case control study in Southern India. Surg. 2016;159:771-6.

Karunakaran P, Maharajan C, Chockalingam R. The effect of total thyroidectomy on the recovery of bone mineral density in subjects with hyperthyroidism. Surg. 2019;165:80-4.