Emergency management of hypercalcaemia
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This document discusses the emergency management of hypercalcaemia. It begins by covering calcium distribution and regulation in the body. It then discusses the main causes of hypercalcaemia, which include primary hyperparathyroidism and tumor-related causes. The clinical features and investigations for hypercalcaemia are outlined. Initial management involves fluid resuscitation and diagnosis. Specific treatments discussed include bisphosphonates, calcitonin, cinacalcet, denosumab, steroids, and dialysis. The treatment goal is to tailor the approach to the underlying cause of hypercalcaemia in each case.
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The document discusses the parathyroid glands, which regulate calcium and phosphate levels and produce parathyroid hormone (PTH). It describes hyperparathyroidism and hypoparathyroidism, conditions caused by excessive or deficient PTH respectively, and their symptoms, causes, assessments, and treatment including diet modifications and medications. Surgical removal of the parathyroid glands may be required to treat hyperparathyroidism.
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Approach to a patient with hypercalcaemia
Hypercalcaemia certainly possesses some diagnostic challenges
Cases are too different in ways of presentation and management do need a lot of things to be checked out. This is merely an approach for such patients.
HYPERPARATHYROIDSM.pptx
Hyperparahyroidsm is an endocrinal disorder majorly affecting the parathyroid glands which secrete parathyroid hormone and calcitonin.
A condition characterised by excessive secretion of calcium in blood and Bone resorption and inanbility to metabolise calcium in blood.
Hypercalcemia in children and adolescent
A 20-month-old girl presented with vomiting and dehydration due to hypercalcemia from Williams syndrome. She had experienced 4 episodes of hypercalcemia in the past 2 months. Treatment involved IV hydration, lasix, and steroids to lower her calcium levels. Steroids were able to maintain her calcium below 3 mmol/L. The main treatments for hypercalcemia include IV hydration to increase urinary calcium excretion, loop diuretics like furosemide to further promote calciuresis, and bisphosphonates to inhibit bone resorption for more severe cases. The choice of treatment depends on the severity and underlying cause of the hypercalcemia.
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Testing parathyroid hormone disorders.pptx
The document discusses calcium homeostasis and disorders of calcium and phosphate metabolism. It provides details on:
1. The functions of parathyroid hormone (PTH) and how it regulates calcium levels.
2. Causes of hypocalcemia including hypoparathyroidism and vitamin D deficiency.
3. Causes of hypercalcemia including primary hyperparathyroidism and malignant diseases.
4. How laboratory tests can help diagnose disorders like hypocalcemia and hyperparathyroidism.
Calcium disorders
This document discusses calcium disorders including an overview of calcium, hypercalcemia, hypocalcemia, and inherited calcium disorders. It defines calcium and its roles in the body. Hypercalcemia is defined as a serum calcium level >10.5 mg/dL and can be caused by increased bone resorption, gastrointestinal absorption, or decreased renal excretion. It discusses the etiology, clinical exam, differential diagnosis, investigations, management, and complications of hypercalcemia. Hypocalcemia is defined as a total calcium <8.5 mg/dL and discusses its etiology including hypoparathyroidism, renal insufficiency, hypomagnesemia, vitamin D deficiency, and others. It also discusses the
Parathyroid gland
The document discusses diseases of the parathyroid gland. It describes the structure and regulation of parathyroid hormone (PTH) secretion, including how calcium levels control PTH levels. It also discusses hyperparathyroidism, the most common form being primary hyperparathyroidism caused by a single adenoma or hyperplasia of the parathyroid glands leading to elevated PTH levels and hypercalcemia. Signs and symptoms include fatigue, weakness, kidney stones, and bone disease. The genetics and clinical manifestations of primary hyperparathyroidism are also summarized.
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Emergency management of hypercalcaemia
- 1. Update on the emergency management of hypercalcaemia Asif Ali, PhD FRCP Consultant Physician (Diabetes and Endocrinology) Milton Keynes University Hospital NHS Foundation Trust
- 2. Calcium distribution and functions in health Bone • Approximately 1.1 kg in the body, nearly 99% in bone • Contributes to structural strength • Acts as a reservoir Non bone • Diffusible vs. non diffusible (albumin bound) • Nerve conduction, coagulation cascade, muscle contraction, second messenger pathways
- 3. Calcium balance in health
- 4. Regulation of PTH secretion
- 7. Hypocalcaemia Hypercalcaemia CommonUncommon Spectrum of calcium disorders Normocalcaemia
- 8. Hypercalcaemia-causes PTH dependent • Primary hyperparathyroidism Parathyroid adenoma(s), hyperplasia, carcinoma • Secondary and tertiary hyperparathyroidism • Familial hypocalciuric hypercalcaemia PTH independent • PTHrP related or due to cytokines • Mainly squamous cell cancers, haematological malignancies • Granulomatous disorders
- 9. Important causes of hypercalcaemia Primary hyperparathyroidism • Common • Female preponderance • Less common in people <50 • Easy to cure, but not all need treatment • May be associated with monogenic disorders Tumour related hypercalcaemia • May be common depending on the clinical setting • People with cancers may have hyperparathyroidism • Treatment similar but not identical
- 10. Clinical features Kidney • Diabetes insipidus • Acute kidney injury • Calculi/calcification CNS • Depressant effect • Drowsiness • Confusion Gut • Constipation • Reduced GI motility CVS • Hypertension • Hypotension (due to dehydration) • Bradyarrhythmias • Shortened QTc
- 11. Investigations • U&Es • LFTs • Calcium and phosphate • FBC • PTH • Vitamin D • Thyroid • Cortisol if clinically relevant
- 12. Let the PTH guide investigations Hypercalcaemia PTH elevated or ‘normal’ PTH suppressed • Hyperparathyroidism • FHH • Lithium • CT • Myeloma screen • Nuclear imaging
- 13. Initial management • Fluid resuscitation • Establish diagnosis • Treat specific cause
- 14. Hypercalcaemia is serious when… • Rapidly rising calcium • >3.5 mmol/l • Associated with serious CNS features • Cancer related (suppressed PTH) • Associated with kidney injury
- 15. Specific treatment of hypercalcaemia Osteoclast inhibition • Bisphosphonates • Calcitonin • Denosumab Calcium removal • Furosemide • Dialysis PTH suppression • Cinacalcet Treating granulomatous disorders • Steroids
- 16. Bisphosphonates • Work by inhibiting osteoclasts • Useful in all nearly all forms of hypercalcaemia • Consider timing of parathyroidectomy • Caution with renal failure • Peak effects may take 2-5 days • Zoledronate more efficacious and longer lasting than Pamidronate
- 17. Calcitonin • Fairly rapid acting • Rarely effective when bisphosphonates have failed • May develop tachyphylaxis-may be used with steroids • 100 units 6, hourly
- 18. Cinacalcet • Useful in hyperparathyroidism (1°,2°,3°) • Allosteric activator of the calcium sensing receptor (calcimimetic) • Treatment of choice in parathyroid cancer (esp metastatic) • Increasing doses
- 19. Denosumab • Monoclonal antibody to RANKL • Inhibits osteoclasts • May cause long lasting hypocalcaemia • May be a useful tool in certain circumstances- bisphosphonate resistance, renal failure • Prolia® 60 mg sc • Xgeva® 120 mg sc
- 20. Denosumab mode of action
- 21. Steroids • In granulomatous disorders such as TB, Sarcoidosis • In conjunction with calcitonin if tachyphylaxis develops
- 22. The right tool for the job “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail” Abraham Maslow, 1962
- 23. Summary • Hypercalcaemia is common • Sometimes it is an emergency • Primary hyperparathyroidism and cancer are common causes of hypercalcaemia • Always check PTH • Treatment tailored to the context
- 24. Thank you!