Preoperative Vitamin D Supplementation in Patients With Vitamin D Deficiency Undergoing Total Thyroidectomy

Preoperative Vitamin D Supplementation to Reduce Hypocalcemia Following Total Thyroidectomy: Systematic Review and Meta-Analysis of Randomized Clinical Trials

OBJECTIVE

This study aims to determine whether preoperative supplementation of vitamin D reduces the incidence of hypocalcemia following total thyroidectomy.

METHODS

Conducted in conformity with the PRISMA statement, a systematic review and meta-analysis of randomized clinical trials (RCT) was performed assessing postoperative hypocalcemia and postoperative symptomatic hypocalcemia.

RESULTS

The search strategy yielded 3808 potentially relevant publications, with eight RCTs ultimately included. These eight trials included a total of 902 patients (22.73% male, n = 205/902), with a median age of 48.9 years (95% CI, 43.5-53.5). Four trials administered only vitamin D in the interventional arm, three trials administered both calcium and vitamin D in the interventional arm, and one trial administered vitamin D in the interventional arm and calcium in both arms. Pooled results from the eight included trials showed a reduced risk of postoperative hypocalcemia in the intervention arm (RR, 0.77; 95% CI, 0.62-0.96; p = 0.02). When excluding the studies that administered calcium supplements in addition to vitamin D, the pooled results showed a similar reduced risk of postoperative hypocalcemia (RR, 0.74; 95% CI, 0.57-0.96; p = 0.03). Analysis of six trials reporting the incidence of postoperative symptomatic hypocalcemia (n = 564) showed a reduced risk in the vitamin D arm, with or without calcium, compared to the control arm (RR, 0.56; 95% CI, 0.34-0.93; p = 0.023).

CONCLUSIONS

Our findings suggest that preoperative vitamin D administration, with or without calcium carbonate, significantly reduces the risk of postoperative hypocalcemia and symptomatic hypocalcemia in patients undergoing total thyroidectomy.

LEVEL OF EVIDENCE: 1

Preoperative Calcium or Vitamin D Supplement in Thyroidectomy: A Systematic Review and Meta-Analysis

OBJECTIVES

The objective of this systematic review and meta-analysis was to assess the role of preoperative calcium and vitamin D supplementation in patients who underwent total thyroidectomy.

DATA SOURCES

The search for randomized controlled trials was performed in the OVID Medline and Embase databases.

REVIEW METHODS

The last search was made on September 16, 2024. Three independent reviewers evaluated full-text articles from relevant reports based on eligibility criteria. The quality of the included studies was assessed by two reviewers according to the ROB 2 tool.

RESULTS

This systematic review and meta-analysis considered 13 studies with 1504 participants. There were positive results in treatment outcomes including the mean postoperative calcium level (MD, 0.30 mg/dL: 95% CI, 0.15 to 0.44); the 48 h of postoperative hypocalcemia (OR, 0.41; 95% CI, 0.27 to 0.62); the postoperative symptomatic hypocalcemia (OR, 0.38; 95% CI, 0.24 to 0.62); the IV calcium supplementation (OR, 0.32; 95% CI, 0.18 to 0.58); and length of hospital stays (MD, -0.29; 95% CI, -0.51 to -0.07) as compared to the control group. Readmission rates showed no significant differences between the groups (OR, 0.15; 95% CI, 0.01 to 3.08).

CONCLUSIONS

Preoperative calcium and vitamin D supplementation in patients who underwent total thyroidectomy results in reduction of postoperative symptomatic hypocalcemia. The finding is critical because it offers a feasible and effective solution that could improve patient care while potentially reducing the burden of numerous blood tests during the postoperative period.

REGISTRATION

This systematic review protocol was registered with PROSPERO (registration number CRD42021278859).

LEVEL OF EVIDENCE

1 Laryngoscope, 135:1267-1277, 2025.

Gastrointestinal surgery, malabsorptive conditions, and postoperative hypocalcemia after neck surgery

BACKGROUND

Postoperative hypocalcemia is a common complication of thyroid and parathyroid surgery. Patients with prior gastric bypass face increased risk of postoperative hypocalcemia, but the impact of other malabsorptive conditions is not well understood. In this study, we evaluated the relationship between multiple medical and surgical malabsorptive states and hypocalcemia after thyroid and parathyroid surgery.

METHODS

We performed a retrospective cohort study of patients who underwent total thyroidectomy and/or parathyroidectomy in Optum's deidentified Clinformatics Data Mart Database (2004-2022). Patients were categorized as having surgical (foregut/midgut: gastrectomy, intestinal bypass, enterectomy, enterostomy, pancreatectomy, or hindgut: colectomy/colostomy) or medical (Crohn or Celiac disease) malabsorptive conditions. The primary outcomes were early (<7 days) and late (7-365 days) postoperative hypocalcemia. Logistic regression was performed to determine the associations between malabsorptive conditions and outcomes.

RESULTS

Of 25,400 patients (56.9% total thyroidectomy, 40.8% parathyroidectomy, and 2.4% both procedures), 4.0% had a pre-existing malabsorptive condition. Early postoperative hypocalcemia occurred in 8.8% of patients, and late hypocalcemia in 18.3%. Thyroidectomy was associated with a greater likelihood of hypocalcemia than parathyroidectomy (odds ratio: 1.22; P < .001). Pancreatectomy was associated with twice the adjusted odds of postoperative hypocalcemia (odds ratio: 2.27; P = .031) across both procedures. Patients with prior foregut/midgut surgery were at higher risk after total thyroidectomy (odds ratio: 1.65, P = .002). This association was significant in late (odds ratio: 1.82, P < .001) rather than early hypocalcemia (odds ratio: 1.33, P = .175). Hindgut surgery and medical malabsorption did not demonstrate such associations.

CONCLUSION

Prior foregut and midgut resections may predispose patients to postoperative hypocalcemia, particularly in patients undergoing total thyroidectomy.

Preoperative Vitamin D and Calcium Administration in Patients Undergoing Thyroidectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Objective

This systematic review and meta-analysis aimed to assess whether preoperative administration of calcium and vitamin D prevents postoperative hypocalcemia.

Data Sources

A computerized search in Medline, Embase, and CENTRAL databases was performed.

Review Methods

Trials comparing preoperative calcium and vitamin D administration with either placebo or nothing were eligible for inclusion. The primary outcomes were the occurrence of laboratory hypocalcemia, mean postoperative calcium level, and symptomatic hypocalcemia. The secondary outcomes were the development of permanent hypoparathyroidism and length of hospitalization. Continuous outcomes were represented as standardized mean difference (SMD), and dichotomous outcomes were represented as risk ratio (RR).

Results

Nine trials that enrolled 1079 patients were found eligible. Postoperative laboratory hypocalcemia occurred less in patients who received preoperative calcium and vitamin D, but it was not statistically significant (RR = 0.77, 95% CI: 0.60-1.00; P = .05). Mean postoperative calcium level was significantly higher in the intervention group (SMD = 0.10, 95% CI: 0.07-0.12; P < .00001). The number of patients with symptomatic hypocalcemia was significantly lower in the intervention group (RR = 0.54, 95% CI: 0.38-0.76; P = .0005). There was no significant difference between the 2 groups in cases of permanent hypoparathyroidism and length of hospitalization.

Conclusion

Administration of calcium and vitamin D preoperatively achieves lower rates of postthyroidectomy symptomatic hypocalcemia in comparison with no intervention.

A meta-analysis of randomized controlled trials of tonifying kidney and strengthen bone therapy on nondialysis patients with chronic kidney disease-mineral and bone disorder

BACKGROUND

Correction of calcium, phosphorus, and parathyroid hormone disorders is the standard of treatment in nondialysis patients with chronic kidney disease-mineral and bone disorder (CKD-MBD). However, the side effects and adverse reactions are still the main problems. Moreover, the lack of protection of kidney function in the treatment dramatically affects patients' health. Although Traditional Chinese Medicine, specifically tonifying kidney and strengthen bone (TKSB) therapy, is wildly applied to patients with CKD-MBD in China, the evidence of TKSB therapy in the treatment of CKD-MBD is limited. Thus, we conducted this meta-analysis to evaluate the efficacy and safety of TKSB therapy combined with Western medicine (WM) for nondialysis patients with CKD-MBD.

METHODS

Two investigators conducted systematic research of randomized controlled trials of TKSB therapy for CKD-MBD from 7 electronic databases. Methodological quality evaluations were performed using the Cochrane collaboration tool, and data analysis was conducted by RevMan v5.3 software and STATA v15.0.

RESULTS

In total, 8 randomized controlled trials involving 310 patients met the criteria of meta-analysis. The complete results showed that compared with WM alone, TKSB treatment could improve the clinical efficacy rate (risk ratio = 4.49, 95% confidence interval [CI]: [2.64, 7.61], P  .00001), calcium (weighted mean difference [WMD] = 0.11, 95% CI: [0.08, 0.14], P < .00001), serum creatinine (WMD = 45.58, 95% CI: [32.35, 58.8], P < .00001) phosphorus (WMD = 0.11, 95% CI: [0.08, 0.13], P < .00001), parathyroid hormone (WMD = 16.72, 95% CI: [12.89, 20.55], P < .00001), blood urea nitrogen levels (WMD = 0.95, 95% CI: [0.26, 1.64], P = .007) on nondialysis patients with CKD-MBD, which was beneficial to improve the patients' bone metabolic state and renal function. In addition, evidence shows that, compared with WM alone, TKSB treatment is safe and does not increase side effects.

CONCLUSION

The systematic review found that TKSB therapy combined with WM has a positive effect on improving renal function and correcting bone metabolism disorder in nondialysis patients with CKD-MBD, which shows that Traditional Chinese Medicine is effective and safe in treating CKD-MBD. However, more high-quality, large-sample, multicenter clinical trials should be conducted to assess the safety and efficacy of TKSB therapy in treating nondialysis patients with CKD-MBD.Systematic review registration: INPLASY2020120086.

Prevention of hypocalcemia and hypoparathyroidism after total thyroidectomy. Recommendations of the Francophone Association of Endocrine Surgery (AFCE) with the French Society of Endocrinology (SFE) and the French Society of Nuclear Medicine (SFMN)

Postoperative hypoparathyroidism, resulting from removal and/or devascularization of one or more parathyroid glands, is a feared complication of total thyroidectomy. Two forms, which are distinguished by their frequency, their time to onset and their duration as well as by their presentation, must be individualized: early postoperative hypocalcemia, often secondary to early hypoparathyroidism is a frequent and often transient situation occurring within the first days after surgery; permanent hypoparathyroidism, which is rarer, manifests when parathyroid function remains impaired for more than six months after surgery. Because of their severity, these conditions must be known and ideally prevented during total thyroidectomy. The objective of this article is to provide surgeons with practical recommendations for the prevention, diagnosis, and treatment of hypoparathyroidism after total thyroidectomy. These recommendations, which are the fruit of a medico-surgical consensus, were developed by the Francophone Association of Endocrine Surgery (AFCE), the French Society of Endocrinology (SFE) and the French Society of Nuclear Medicine and Molecular Imaging. (SFMN). The content, grade and level of evidence for each recommendation was decided after consultation within a panel of experts, based on an analysis of recent literature.

The role of preoperative vitamin D and calcium in preventing post-thyroidectomy hypocalcaemia: a systematic review

BACKGROUND

The thyroid gland plays an important endocrine function regulating metabolism, growth and development. A variety of benign and malignant conditions necessitate surgical removal of the thyroid gland, either in its entirety, or partially. Thyroidectomy is the most commonly undertaken endocrine surgery. Hypocalcaemia, occurring at a rate of approximately 25%, is the most common complication following total thyroidectomy. Hypocalcaemia can increase healthcare costs requiring further investigations, treatment and delaying discharge. Severe hypocalcaemia can be potentially life threatening. It has been demonstrated that routine post-operative supplementation with Vitamin D and calcium, can reduce post-operative hypocalcaemia, at present it is unclear whether preoperative supplementation has a similar effect.

METHODS

This systematic review includes randomised controlled trials on human adult subjects, who received preoperative Vitamin D and/or calcium, and which studied the effect on post-operative hypocalcaemia following total or near total thyroidectomy. There were no restrictions in respect of post-operative supplementation regimen. Studies were limited to those published in English.

RESULT

Seven of the eleven trials demonstrated a reduction in either laboratory or clinical hypocalcaemia with preoperative supplementation. This benefit was most likely to be seen when postoperative supplementation was performed on an as needed basis. IV calcium was required to treat resistant or severe hypocalcaemia, in five of the eleven trials, in each of these five trials, rates of IV replacement were lower in the preoperative supplementation group.

CONCLUSION

The use of preoperative Vitamin D, with or without calcium, may provide a modest reduction in the incidence of laboratory and clinic hypocalcaemia following total or near total thyroidectomy. There is a trend toward a reduced requirement for IV calcium with preoperative supplementation. Larger robust randomised trials are needed to provide a definitive answer. Preoperative supplementation can be considered in patients undergoing total or near total thyroidectomy.

Management of Graves' hyperthyroidism: present and future

INTRODUCTION

Graves' disease (GD) is an autoimmune disorder due to loss of tolerance to the thyrotropin receptor (TSHR) and ultimately caused by stimulatory TSHR antibodies (TSHR-Ab). GD may be associated with extrathyroidal manifestations, mainly Graves' orbitopathy. Treatment of GD relies on antithyroid drugs (ATDs), radioactive iodine (RAI), thyroidectomy. The major ATD limitation is the high recurrence rate after treatment. The major drawback of RAI and thyroidectomy is the inevitable development of permanent hypothyroidism.

AREAS COVERED

Original articles, clinical trials, systematic reviews, meta-analyses from 1980 to 2021 were searched using the following terms: Graves' disease, management of Graves' disease, antithyroid drugs, radioactive iodine, thyroidectomy, Graves' orbitopathy, thyroid-eye disease.

EXPERT OPINION

ATDs are the first-line treatment worldwide, are overall safe and usually given for 18-24 months, long-term treatment may decrease relapses. RAI is safe, although associated with a low risk of GO progression, particularly in smokers. Thyroidectomy requires skilled and high-volume surgeons. Patients play a central role in the choice of treatment within a shared decision-making process. Results from targeted therapies acting on different steps of the autoimmune process, including iscalimab, ATX-GD-59, rituximab, blocking TSHR-Ab, small molecules acting as antagonists of the TSHR, are preliminary or preclinical, but promising in medium-to-long perspective.

Effects of tonifying kidney and strengthen bone therapy on non-dialysis patients with chronic kidney disease-mineral and bone disorder: A protocol for the systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Correction of calcium (Ca), phosphorus (P), and parathyroid hormone (PTH) disorders is the standard of treatment in non-dialysis patients with chronic kidney disease-mineral and bone disorder (CKD-MBD), but the side effects and adverse reactions brought by western medicine (WM) are still the main problems. More importantly, the lack of protection of kidney function in the treatment greatly affects the health of patients. Although traditional Chinese medicine (TCM), specifically tonifying kidney and strengthen bone (TKSB) therapy is wildly applied for patients with CKD-MBD in China, the evidence of TKSB therapy in the treatment of CKD-MBD is limited. Thus, we pretent to conduct this protocol to evaluate the efficacy and safety of TKSB therapy combined with WM for non-dialysis patients with CKD-MBD.

METHODS

A system research of randomized controlled trials (RCTs) of TKSB therapy for CKD-MBD will be conducted by 2 investigators from 7 electronic databases. Methodological quality evaluations will be performed by using the Cochrane collaboration tool and data analysis will be conducted by RevMan V5.3 software and STATA v15.0.

RESULTS

The results of this paper will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This research will determine the safety and efficacy of TKSB therapy in treating non-dialysis patients with CKD-MBD.

INPLASY REGISTRATION NUMBER

INPLASY2020120086.