Life-threatening tertiary hyperparathyroidism in the critically ill

Background Tertiary hyperparathyroidism typically occurs in patients who have recovered from renal failure after renal transplantation. This report describes a syndrome of tertiary hyperparathyroidism after recovery from multiple organ failure (MOF) with acute oliguric renal failure (AORF). Methods Six patients with MOF including AORF are presented. Increased parathyroid hormone (PTH) levels were documented as early as 3 weeks after injury or septic insult and remained increased in some patients for several weeks. Results The resultant increase in calcium levels led to recurrent bouts of bradycardia, often leading to asystole requiring cardiopulmonary resuscitation. Hypercalcemic-induced bradycardia was refractory to hydration, loop diuresis, atropine, and external pacing. Definitive treatment requires bisphosphonate therapy, which must be repeated until organ function has returned to normal. Conclusions A new syndrome of life-threatening tertiary hyperparathyroidism is described in patients with critical illness. This syndrome probably is being overlooked frequently in critical care units. Early diagnosis and prophylactic treatment with bisphosphonate may preclude the life-threatening cardiac arrhythmias.