From the Guidelines
Vitamin D is indicated in hungry bone syndrome, specifically in the form of active vitamin D derivatives, to reduce the incidence of severe hypocalcemia. According to a recent study published in Kidney International in 2025 1, preoperative and postoperative use of active vitamin D derivatives may reduce the incidence of severe hypocalcemia in patients undergoing parathyroidectomy.
Key Points to Consider
- Hungry bone syndrome occurs after parathyroidectomy in patients with severe hyperparathyroidism, leading to profound hypocalcemia, hypophosphatemia, and hypomagnesemia.
- Vitamin D supplementation, typically in the form of calcitriol, enhances intestinal calcium absorption, promotes bone mineralization, and helps correct the severe calcium imbalance.
- Treatment should begin immediately after the diagnosis of hungry bone syndrome and continue until hypocalcemia resolves and bone remineralization is complete.
- Regular monitoring of serum calcium, phosphate, and magnesium levels is necessary to adjust dosing appropriately during treatment.
Treatment Recommendations
- Vitamin D supplementation: 0.5-2 mcg daily of calcitriol.
- Calcium supplementation: 1-3 g of elemental calcium daily.
- Monitoring: regular checks of serum calcium, phosphate, and magnesium levels to adjust dosing as needed. As noted in the study 1, several recent reports highlight the risks of iatrogenic hypocalcemia in situations of rapid bone (re)-mineralization after correction of hyperparathyroid bone disease, making vitamin D supplementation a crucial component of treatment.
From the Research
Vitamin D in Hungry Bone Syndrome
- Vitamin D is indicated in the treatment and prevention of hungry bone syndrome, as it helps to replenish the calcium deficit and normalize bone turnover 2, 3, 4, 5.
- Preoperative treatment with vitamin D can help to prevent hungry bone syndrome by improving bone turnover and reducing the risk of hypocalcemia 2, 3.
- Postoperative treatment with active metabolites of vitamin D, such as alfacalcidol and calcitriol, can help to prevent or minimize the development of hungry bone syndrome 2, 3, 4.
- The use of vitamin D supplements in the prevention of hungry bone syndrome has been studied, but the results are inconclusive, with one study finding no significant difference in the incidence of hungry bone syndrome between patients who received preoperative vitamin D supplementation and those who did not 6.
Risk Factors for Hungry Bone Syndrome
- Risk factors for the development of hungry bone syndrome include large parathyroid adenomas, age > 60 years, high preoperative levels of serum PTH, calcium and alkaline phosphatase, and vitamin D deficiency 3, 5.
- Patients with radiological evidence of bone disease are at higher risk of developing hungry bone syndrome than those without skeletal involvement 5.
Treatment of Hungry Bone Syndrome
- Treatment of hungry bone syndrome is aimed at replenishing the severe calcium deficit using high doses of calcium supplemented by high doses of active metabolites of vitamin D 4, 5.
- Adequate correction of magnesium deficiency and normalization of bone turnover are required for resolution of the hypocalcemia, which may last for a number of months after successful surgery 5.