Background: There are over 650 liver transplants performed in the UK each year and about 5000 throughout Europe. After transplantation patients suffer from bone loss due to multiple factors. We present a unique case of severe Vitamin D deficiency resulting in life threatening hypocalcaemia following liver transplantation.
Case: A 65-year-old Indian lady underwent an uncomplicated liver transplant, for hepatocellular carcinoma related to Hepatitis C. Pre and immediately post operatively, her calcium measurements were normal. By day 13 her corrected calcium had dropped to 1.38 mmol/l. She was suffering from jaw spasm and her ECG showed a dangerously prolonged QT interval of 618 ms. Subsequent investigations revealed a magnesium of 0.83 mmol/l, creatinine of 139 umol/l, PTH of 527 ng/l, 25-OH Vitamin D of <14 nmol/l (<5.6 ng/ml) and the transplanted liver appeared to be functioning with no signs of rejection. She was initially treated with 20 ml of 10% Calcium Gluconate and 5 mcg of 1-alfacacidiol. However, her Corrected Calcium remained low at 1.43 mmol/l. She was then given a further 100 ml of 10% Calcium Gluconate infusion over 10 h, resulting in a corrected calcium to 1.98 mmol/l. She was commenced on regular Adcal D3 two tablets three times a day and Calcitriol 1mcg once a day. She also received a once off dose of Ergocalciferol 300000 IU intramuscularly. Over the following 6 weeks we were able to successfully titrate down her dose of calcitriol and Adcal D3.
Conclusion: This unusual case highlights the importance of monitoring for hypocalcaemia and its prompt management in order to prevent arrhythmias and significant bone loss in the postoperative care of transplant patients.