Predictive Factors of Secondary Normocalcemic Hyperparathyroidism after Roux-en-Y Gastric Bypass

Objective Aim of this study is to evaluate determinants of secondary normocalcemic hyperparathyroidism (SNHPT) persistence in patients who have undergone Roux-en-Y gastric bypass on vertical-banded gastroplasty. Methods 226 consecutive patients submitted to bariatric surgery were prospectively enrolled and divided in two groups on the basis of preoperative presence of SNHPT. For each patient, we evaluated anthropometric and laboratory parameters. Calcium metabolism (calcemia, PTH, and 25-hydroxy vitamin D serum levels) was studied before surgery and at 6-month intervals (6, 12, and 18 months) as surgical follow-up. Results Based on presurgical SNHPT presence or absence, we defined group 1—201 patients and group 2—25 patients, respectively. Among the group 1, 153 (76%) recovered from this endocrinopathy within 6 months after surgery (group 3), while the remaining 48 patients (24%) had persistent SNHPT (group 4). Comparing the anthropometric and laboratory data of group 3 with group 2, the only statistically significant factor was the elapsed time since a prior effective medically controlled diet that led to a steady and substantial weight loss. We found also a statistically significant difference (p < 0.05) between group 3 and group 4 in term of % of weight loss and PTH levels. Conclusions Patients suitable for bariatric surgery must have history of at least one efficient medically controlled diet, not dating back more than 5 years before surgery. This elapsed time represent the cut-off time within which it is possible to recover from SNHPT in the first semester after Roux-en-Y gastric bypass on vertical-banded gastroplasty. The treatment of vitamin D insufficiency and the evaluation of SNHPT before bariatric surgery should be recommended. The clinical significance of preoperative SNHPT and in particular SNHPT after bariatric surgery remains undefined and further studies are required.

Because almost 70% of gastric bypass patients experience a reversible and transient SNHPT after surgery, some authors consider this condition as a physiological adaptation to surgery-induced weight loss [4,11,18].
The aim of this study is to evaluate the determinants of postbariatric SNHPT persistence in patients who undergo Roux-en-Y gastric bypass on vertical-banded gastroplasty [33].

Methods
Between January 2011 and June 2012, a total of 302 consecutive morbidly obese patients underwent Roux-en-Y gastric bypass on vertical-banded gastroplasty at the Surgical Department Spedali Civili of Brescia, Italy.
A total of 226 (75%) were retrospectively enrolled. Study groups are identified in Figure 1.
The full inclusion and exclusion criteria are listed in Table 1.
We evaluated anthropometric and laboratory parameters such as age, sex, body mass index (BMI), 25-hydroxy vitamin D3 levels, PTH levels, and serum calcium levels. We also determined the elapsed time since a prior medically controlled diet led to a loss of at least 10% of the initial overweight (calculated according to the Lorentz formula, explained in Figure 2), with subsequent weight maintenance for at least 6 months [34].
A Roux-en-Y gastric bypass on vertical-banded gastroplasty [33] was performed in all patients, fashioning a 50 mL capacity gastric pouch and a common limb 150-200 cm long, with the purpose of keeping the biliopancreatic limb-to-common limb ratio at 1 : 2. Consequently, the biliopancreatic limb had a median length of 23% of the total small intestine lenght.
The particular characteristics of this type of functional gastric bypass (widely performed in Italy but not worldwide) are explained in the article by Cariani et al. [33].
Every patient underwent bariatric surgery according to published Italian guidelines for eligibility [35,36].
No patients (0%) received oral calcium or vitamin D supplementation before surgery.
All patients (100%) were discharged with the recommendation for oral multivitamin and trace-element supplementation: 1200-2000 mg/die of calcium citrate and at least 3000 IU/day of vitamin D3.
Only patients who have met the study protocol requirements (e.g., oral supplementation if needed) were included.
Serum calcium levels, PTH levels, and 25-hydroxy vitamin D levels were studied before surgery and at 6-month intervals (6, 12, and 18 months). The normal PTH serum concentration was defined from 11 to 67 pg/mL, normal 25hydroxy vitamin D concentrations from 30 to 60 ng/mL, normal calcium levels from 8.5 to 9.5 mg/dL, and vitamin D  deficiency was defined as a serum concentration lower than 20 ng/mL. Serum calcium levels were assessed by the CA method, in vitro, on the Dimension Vista® System (Siemens). Serum iPTH levels were assessed using the IMMULITE® 2000 System (Siemens). Serum 25-hydroxy vitamin D levels were assessed using the UV/VIS-FAST spectrophotometer (Eureka Lab Division).
Qualitative variables were expressed using the number of patients and percentages; quantitative variables were expressed by using their mean values and standard deviation (SD).
Differences were assessed using analysis of variance (ANOVA) or the Mann-Whitney U test for continuous variables and chi-square (χ 2 ) analysis for categorical variables.
p values less than 0.05 were considered statistically significant.

Results
There were 156 female (69%) and 70 (31%) male patients. Anthropometric and laboratory variables of all patients are listed in Table 2.
Each patient had a history of at least 1 medically controlled diet which failed to result in a steady and substantial weight loss and BMI normalization.
Before surgery, 25 patients (11%) had normal serum PTH levels, 9 patients (4%) had insufficient 25-hydroxy vitamin D levels (20-30 ng/mL), 84 (37%) had vitamin D deficiency (<20 ng/mL), and 133 (59%) had normal vitamin D levels (30-60 ng/mL). All the enrolled patients were normocalcemic. We used this pre-surgical data, to identify 2 subgroups of patients: those with presurgical SNHPT (group 1-201 patients) and patients without it (group 2-25 patients). (Table 3 and Figure 1). Table 3 shows that group 1 and group 2 were statistically different just because of the level of PTH and the elapsed time since a prior medically controlled diet had led to a loss of at least 10% of the initial overweight, with a weight maintenance for at least 6 months afterward.
Six months after surgery, all group 2 patients (11%) had maintained calcium-metabolism homeostasis, the oral calcium and vitamin D supplements were suspended. This group of patients never developed SNHPT throughout the duration of study follow-up.
Among the group 1, 153 (76%) recovered from this endocrinopathy within 6 months after surgery (group 3), while the remaining 48 patients (24%) had persistent SNHPT (Group 4), as listed in Table 4.   Comparing the anthropometric and laboratory data of group 3 with group 2, the only statistically significant factor was the elapsed time since a prior effective medically controlled diet that led to a steady and substantial weight loss (Table 4).
Patients who failed to follow an effective medically controlled diet within 5 years before surgery (group 4) were found to have higher PTH serum levels than those who followed an effective diet; the SNHPT also lingered for at least 6 months after surgery. By 18 months after surgery, all patients (100%) were able to achieve homeostasis of calcium-metabolism.
Oral supplementation of calcium and vitamin D was suspended 12 months after surgery for the patients who had recovered from SNHPT within the first semester of followup (group 3). Group 4, however, required an increase in oral supplementation at the 12-month follow-up visit, to 6000 IU/ day of cholecalciferol and at least 1800 mg/day of calcium citrate. This supplementation was suspended at the 18-month follow-up visit after confirmation due to laboratory resolution of SNHPT (Table 4).
Premenopausal women (aged > 45 years) have a relative risk of 1.8 compared with younger women of developing SNHPT [11,12]. The lower postsurgical intake of calcium rich nourishment, due to increase of lactose intolerance and changing in food preferences, contributes to the decreasing serum 25-hydroxy vitamin D levels [8,13]. Surgically induced lipid and liposoluble vitamin malabsoption, along with gastric restriction [16], reduces their exposure to bile, boosting nutritional deficiency [24]. Magnesium deficiency, typical in bariatric patients, might reduce calcium absorption, which could then lead to SNHPT [15,16]. Protein, microelements (chromium, copper, selenium, and zinc), essential minerals (iodine and iron), and soluble vitamins (thiamine, cobalamin, riboflavin, and vitamin C) malabsorption may contribute to SNHPT, as may adiponectin, adipokines, and estradiol [16].
Because almost 70% of gastric bypass patients show a reversible and transient SNHPT, during postsurgical follow-up [4,22,31,32], some authors consider this condition to be a physiological adaptation to surgery-induced weight loss [4,11,18]. Other authors suggest that bariatric surgery is not the main cause of SNHPT, but rather that this particular form of hyperparathyroidism is indeed a consequence of pathological obesity itself [1,2,4,5,21,38].
Laboratory analyses are fundamental to reaching an accurate diagnosis, since this clinical condition is mainly nonspecific and symptomatically silent [30].
There is no agreement onto the efficacy of postsurgical calcium citrate supplementation to reduce the incidence of metabolic disorders [10,11,[38][39][40][41]. Moreover, because SNHPT is most often present prior to bariatric surgery, current guidelines suggest stabilizing this dysmetabolism before surgey [41]. The American Association of Clinical Endocrinologists, the Obesity Society, and the American Society of Metabolic and Bariatric Surgery (AACE/TOS/ASMBS) guidelines suggest oral administration 1500-2000 mg per day of calcium citrate and at least 3000 IU (75 μg) per day of vitamin D2 or D3 after surgery, with the chance to boost the latter administration until reaching serum 25-hydroxy vitamin D levels of >30 ng/mL (75 mmol/L). In cases of severe vitamin D malabsorption, oral doses of vitamin D2 or D3 may need to be as high as 50,000 units 1 to 3 times weekly to daily, and more recalcitrant cases may require concurrent oral calcitriol.
In our study, we established the importance of the presurgical diet in the resolution of SNHPT, especially when a medically controlled diet, dating back no more than 5 years before surgery, led to a loss of at least 10% of the initial overweight with weight maintenance for at least 6 months afterward.
Forty-eight (24%) patients with presurgical SNHPT recovered from this condition within 18 months after surgery. These patients had no effective medically controlled diet in the 5 years before surgery (  long-standing morbid obesity. These patients' BMI values had borderline statistically significant elevation compared with patients not affected by SNHPT. After surgery, the patients with presurgical SNHPT had a statistically significant (p < 0 05) greater weight loss either than patients who never had SNHPT or patients who recovered within the first semester after bariatric surgery; this difference persisted throughout study follow-up ( Figure 3). Even though the group of patients with presurgical SNHPT recovered from this disorder within 18 months after surgery, their serum PTH levels were statistically significantly (p < 0 05) higher than those of other patients throughout the duration of study follow-up. (Figure 4).
Patients with obesity suitable for bariatric surgery must have history of at least 1 medically controlled diet, not dating back more than 5 years before surgery, that led to a loss of at least 10% of the initial overweight, with a subsequent weight maintenance for at least 6 months. Patients who had an effective diet within this timeframe may reasonably anticipate a recovery from SNHPT in the first semester after Roux-en-Y gastric bypass on vertical-banded gastroplasty [33].
Patients without this history need a presurgical medically controlled diet and assessment of calcium metabolism. The aim of this diet is not recovery from obesity but the advancement of better postsurgical clinical outcomes and SNHPT resolution. Furthermore, patients must be taught to follow a healthy and balanced lifestyle in order to avoid sudden weight loss that might lead to endocrine disorders. Just as their obesity took time to develop, so should it take time to be healed.

Final Comments
We evaluated the alterations in the parathyroid axis through its effect on calcium absorption following Roux-en-Y gastric bypass on vertical-banded gastroplasty (RYGBP-on-VBG). Up to date, our findings have not been reported in literature yet. Previous studies investigated the prevalence of SNHPT in obese patients after several bariatric operations but not after RYGBP-on-VBG. Different types of bariatric surgery have different effects on body weight loss and different incidence of SNHPT. How bariatric operations induce SNHPT remains unknown, probably determined by nonsurgical and surgical factors: (iv) Limited intake of daily products due to intolerance after surgery In our study we recorded greater postoperative weight loss in patients with preoperative SNHPT.
This finding could be accidental and erroneous, maybe due to the limitations of the study: (i) Retrospective study with a relative small sample size (ii) Lack of food intake analysis among two groups of patients (with presurgical SNHPT and without presurgical SNHPT, group 1 and group 2, resp.) (iii) Poorness of variable analysis (e.g., the lack of correction for confounding factors due to the unavailability of data as seasonality, physical activity, sun exposure, sunscreen, and phototype) Other limitations of our study: (i) Adherence to vitamin or mineral supplements was indirectly estimated based on patients information (ii) Unavailability of data such as albumin levels (to define ionized calcium level) and magnesium levels due to retrospective analysis Therefore, as also highlighted in our paper, the treatment of vitamin D insufficiency and the evaluation of SNHPT before bariatric surgery should be recommended.
The clinical significance of preoperative SNHPT and in particular SNHPT after bariatric surgery remains undefined and further studies are required.

Additional Points
Answer the Study Importance Questions. It is well known that patients could develop nutritional deficiencies after bariatric surgery. Secondary normocalcemic hyperparathyroidism is a clinical condition related to morbid obesity and needs to be stabilized prior to surgery. We analyzed predictive factors of secondary normocalcemic hyperparathyroidism in a large cohort of patients submitted to bariatric surgery. We established the importance of the presurgical diet in the resolution of SNHPT.

Conflicts of Interest
The authors declared no conflict of interest.