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Calcium and Vitamin D Supplements in the Management of Postsurgical Hypoparathyroidism

THIS PATIENT CONTACTED ME WITH QUESTIONS ABOUT THE MANAGEMENT OF HER POSTSURGICAL HYPOPARATHYROIDISM (WHICH CAUSES LOW SERUM CALCIUM LEVELS—SHE WORRIED ABOUT THE FACT THAT HER URINE CALCIUM WAS HIGH ON HER NEEDED CALCIUM AND VITAMIN D SUPPLEMENTATION:

My usual tx for hypoparaT is around 2000 mg calcium (Ca++) per day in 2 or 3 divided doses with meals (Ca++ carbonate or Ca++ citrate are fine). That should be enough Ca++ for most people. Any further adjusting of the Ca++ level is done with calcitriol, which is an activated form of vitamin D. We have to use that instead of Vitamin D2 or D3 (the typical Vit D supplement products) because parathyroid hormone (PTH) is needed for the activation step in the body. If you’re hypoparathyroid, we have to give a form of Vit D that skips that step.

I'll just go through your email and address your questions as they come:

--in hypoparaT Ca++ blood levels should be low normal or even a bit low, as long as symptoms are controlled (little or no tingling or cramping or spasms)--this helps avoid exposing the kidneys to too much Ca++, which can cause kidney failure over years.

--you mention albumin in the urine--that's likely unrelated to the Ca++ issues but if present above certain levels indicates kidney disease, such as the type caused by diabetes. The only way the Ca++ issue would relate to albumin in the urine would be that if you had low renal function due to some other problem, or likely future deterioration in function due to some other problem, you'd want to be as careful as you can that the Ca++ doesn't add to the kidney trouble.

--That said, it is critically important to keep adequate Ca++ levels in the blood, and it sounds like you're where you need to be, so I wouldn't worry about the urine Ca++ level. This is never going to be an ideal situation--hypoparaT puts the patient between a rock and a hard place--renal damage from the Ca++ tx is a real risk if things aren't done very carefully. It's not an easy disease for the doctor to manage.

--I especially wouldn't worry about the urine Ca++ if you don't have recurring kidneys stones or known renal insufficiency

--you are correct--active Vit D mainly helps gut absorption of dietary Ca++ and Ca++ tablets. It also tells the kidneys to reabsorb Ca++ into the blood and reduce loses via the urine. PTH does the same thing to Ca++ in the kidney but if you're missing that then the Vit D is more important. Eventually though, once the blood levels of Ca++ get high enough the Vit D effect is overwhelmed and Ca++ "spills" in the urine--and you want that--if it didn't happen you could get a dangerous high Ca++ in the blood. That's why I say, for the most part, let the kidneys do their thing and ignore the urine Ca++. The kidneys, if they're working right, are smarter than we are--we shouldn't be trying to outguess them.

--I think I've answered your question about Ca++ intake already--whatever combination of around 1800-2000mg Ca++/day plus calcitriol that results in the goal Ca++ level (right around the low end of normal) and good symptom control. If those criteria are met then I wouldn't adjust anything to "fix" the urine Ca++. If there are stones or other significant renal disease going on besides the hypoparaT then that is a complicated situation your doctor (preferably an endocrinologist or nephrologist in that case) has to figure out.

--I don't have a clue what good potassium bicarbonate would do--manipulating urine pH is something nephrologists do and if you need that you should be seeing one--I doubt you need it though, and my knee-jerk answer is don't take it, especially on your own, without the advise of the doctor managing this problem.

--You said "Vit K2"--Vitamin K affects blood clotting and has nothing to do with this--I assume you mean Vit D2, and I've already addressed that--D2 and D3 build up the storage form of Vit D but they can't be converted to the active form in HypoparaT (or for that matter, if there is significant kidney damage from any cause, because the activation step is done by the kidney). So, no, Vit D2 or D3--the stuff you can get over the counter--would be of no use in the situation as you described it to me. Calcitriol is your only Vit D (there are other similar prescription products but I just use calcitriol).

jkr
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