Possible prevention of hungry bone syndrome following parathyroidectomy by preoperative use of pamidronate.

A73-year-old female was admitted to our institution after laboratory results during an outpatient follow-up visit for a longstanding hyperparathyroidism revealed a serum calcium concentration of 14.5 mg/dL. She was diagnosed with primary hyperparathyroidism 8 years prior to current presentation. Throughout this time her serum calcium and intact PTH (iPTH) concentrations ranged from 10.2 to 15.0 mg/dL and 56.2 to 2000 pg/mL, respectively. She repeatedly refused parathyroidectomy and was treated with cinacalcet, 30 mg twice a day, for 2 months prior to admission without clear-cut improvement. Her relevant medications also included alendronate during the previous 6 years. Her physical examination was unremarkable. Results of initial laboratory studies revealed calcium 13.9 mg/dL (normal range 8.6-10 mg/dL), phosphorus 4.1 mg/dL (2.6-4.5 mg/dL), albumin 3.5 g/dL (3.9-4.9 g/dL), alkaline phosphatase 158 U/L (30-125 U/L), and vitamin D 25-OH 9 ng/mL (20-100 mg/mL). Treatment with normal saline intravenously was initiated and followed by furosemide diuresis. Cinacalcet was continued at a dose of 30 mg twice a day. Pamidronate, 30 mg, was administered intravenously. Five days later two more doses of pamidronate, 30 mg each, were administered intravenously for a cumulative dose of 90 mg. On day 7 of hospitalization patient was discharged with serum calcium concentration of 11.2 mg/dL. Two weeks later the patient was readmitted with symptoms similar to the first admission. Her serum calcium concentration was 14.6 mg/dL. She received one dose of pamidronate, 90 mg, intravenously. At this point she agreed to undergo parathyroidectomy. Parathyroid scan was consistent with parathyroid adenoma in the posterior left lower pole of the thyroid gland. An adenoma weighing 419 mg was excised from the area of the left inferior thyroid region. Pathologic evaluation confirmed parathyroid adenoma. Intraoperative intact PTH measurements are shown in Table 1. Serial determinations