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Hypercalcemia
1. Hypercalcemia
Dr Vilas Naik,Dr Vilas Naik, DM (Nephrology)DM (Nephrology)
Fellowship in Nephrology and KidneyFellowship in Nephrology and Kidney
transplant, Toronto, Canadatransplant, Toronto, Canada
3. Case
• 65/ male, Mr SH.
• PMHx
– CAD- anterior wall thrombolysed- aug 10, s/p CABG
October 2010
– Burning feet- 3 yrs, multivitamins and sym meds
• HOPI:
– very low appetite and weight loss, nausea & vomiting-
1m.
– Admitted for evaluation of the same: 3rd
may 2011
4. Case: 4th
May 11
• Investigations:
– Hb- 9.8 gms, TLC- 4200, plat- 1.13
– Creatinine- 3.1 mg%
(eGFR= 20.16 ml/min)
– Electrolytes:134/5.3/97
– LFT- normal
– Total Prot/ Sr Albu- 6.9 / 3.4
5. Case
• UGI scopy:- grade 2 GERD
• Sr Vitamin and folate- N
• NCS- demyelinating polyneuropathy
• Progressive confusion- CT brain- WNL,
– MRI brain- N,
– CSF- WNL.
• Chest X-Ray: WNL
• USG:
– RK- 9.6 x 4.8
– LK – 9.8 x 4.2
6. Case- 11th
may 2011
• Progressive worsening of LOC, stuporous
• Creatinin 2.1 3.1 5.1 7 mg%
• Urine output- 1.5 to 2 L
• Referred to nephrology for potential
dialysis
8. Interpretation of results
• Hypercalcemia: almost always ⇑ in physiologically
important ionized (or free) Ca
• 40 to 45 % bound to protein, principally albumin
• Increased protein binding - elevation in the serum
tCa without rise in the iCa----
– Hyperalbuminemia: severe dehydration & rare patients
with multiple myeloma who have a calcium-binding
paraprotein.
– pseudohypercalcemia (or factitious hypercalcemia), as
iCa normal.
9. Case- 12th
may
• Clinically:
– BP- 130/80, no edema, volume depleted
– Chest clear- SpO2- 98 % on room air
– No lymphadynopathy
– CNS- stuporous, no focal neurodeficit.
10. Treatment
Aim:
• lowering the serum calcium concentration
– inhibiting bone resorption,
– increasing urinary calcium excretion,
– or decreasing intestinal calcium absorption
• if possible, treating the underlying disease
Start treatment urgently
Start evaluating for the cause
11. Treatment
• Normal saline
• Furosemide: bolus f/b drip to match UO
Both increase urinary Ca excretion
• Steroids- decrease 1-25 (OH)2 D3, intestinal absorption
inhibited.
• Calcitonin - Inhibits bone reabsorption
• Biphosphonates- inhibits bone reabsorption
13. In our patient…..
• NS bolus 2 L, then 250 ml/hr
• Lasix- bolus, drip to match urine output
• Hydrocort 100mg 6 hrly
• Biphosphonate:
– 4 mg in 100 ml NS over 30 min
14. Case
• Creat 7.1 6.1 4.8 3 1.8 mg%
• Parallel decrease in Sr Ca
• Clinical and biochemical improvement
• CBC- still pancytopenia
17. Our patient….
• Sr electrophoresis- no M band
• Skeletal survey- no lytic lesions
• Sr immunofixation- negative
• Sr 25 hydroxy and 1-25 dihydroxy vit D3
levels- normal
• Sr iPTH (appropriately collected and sent)
22. Causes
• Primary hyperparathyroidism & malignancy: -90%
• Malignancy often evident clinically by the time it
causes hypercalcemia
• hypercalcemia of malignancy-higher calciums &
more symptomatic from than primary hyper PTH.
23. Approach
Hypercalcemia affecting the kidney
Mechanisms
– Nephrogenic DI:
• downregulation of aquaporin-2 water channels
• calcium deposition in the medulla with secondary
tubulointerstitial injury
• Decreased medullary osmolality and hence
decreased concentrating ability
24. Hypercalcemia affecting the kidney
• Nephrolithiasis
• Renal tubular acidosis type 1
• Renal insufficiency
– Severe vasoconstriction
– CSR stimulation (loop on Henley)- volume depletion
– calcification, degeneration, and necrosis of the tubular
cells
– Tubular atrophy
27. Follow of the patient
• Creatinine- 1.2 mg%
• Pancytopenia persistent
• Otherwise healthy
• Decided to go to Mumbai for hematology
evaluation
28. Follow up of the patient
• Complete hematology work up was
negative
• Follow up till 2014 november – mild
thrombocytopenia, otherwise healthy
Editor's Notes
Even though he was malnourished, his Sr Albu was significantly preserved- at this point he was significantly volume depleted.
But ATN can be a process in almost any disease, glomerulonephritis can also have a component of ATN, ischemic and toxic ATN. He had a foleys in place since- 7 days, so had PCs in urine.