Download 2006_08_03-Qureshi-Hypercalcemia

Case 1

53F presents to ED with dysuria

PMHx: HTN, Hyperlipidemia,

UTI is diagnosed and oral Abx script given

Getting ready for discharge, but on routine labs you
notice Ca2+= 3.3 mmol/L

On further history the patient states she has no
symptoms and has been otherwise well.

Management? Disposition?
Case 2

70M with known Lung CA, presents with
acute psychosis and Ca= 3.4 mmol/L

Management?
Hypercalcemia
Lab Rounds
Sultana Qureshi, PGY-2
August 3, 2006
Calcium Metabolism
Effect on
bones
Effect on gut Effect on kidneys
Parathyroid hormone
Ca++, PO4 levels in blood
Supports
osteoclast
resorption
Increases
Supports Ca++ resorption and
absorption via Vit PO4 excretion, activates 1D
hydroxylation
Vit D
Ca++, PO4 levels in blood
-
Ca++ and PO4
absorption
-
Calcitonin
Ca++, PO4 levels in blood
when hypercalcemia is
present
Inhibits
osteoclast
resorption
-
Promotes Ca++ and PO4 excretion
Hormone
Definition

Total Corrected Serum Ca2+ >2.62 mmol/L
OR

Ionized Ca2+ > 1.35 mmol/L

Corrected = measured Ca2+ + 0.02 (40-albumin)

Or for every ↓5 of albumin, add 0.1 to serum Ca
Symptoms
“Bones, Stones, Groans, Moans”

General



Bone pain
Fractures/Deformities







Constipation
Abdo pain
Anorexia & W.L.,
NV
PUD, pancreatitis




Dysrhythmias
ECG changes
HTN, vascular calcification
Renal (Stones)

GI (Groans)

Cardiovascular

Weakness, malaise,
dehydration
Skeletal (Bones)



Nephrolithiasis
Polyuria, polydipsia, nocturia
Nephrogenic DI
Renal failure
Neurologic




Hypotonia, Hyporefelxia, ataxia
Myopathy
Paresis
Altered LOC/Coma
Symptoms (cont’d)
“Bones, Stones, Groans, Moans”

Psychiatric (Moans)
>
3mmol/L
Increased alertness
 Anxiety/Depression
 Cognitive Dysfunction
 Organic Brain Syndromes

>
4mmol/L

Psychosis
ECG
Changes:
-shortening of QT
-prolongation of PR
-ST depressions
U- waves
Severe:
-bradyarrythmias
-BBB and high AV block
-potentiates Digoxin effects
-Cardiac Arrest
Causes

90% of cases due to
 Primary Hyperparathyroidism
 25-75/100 000 (US)
 mcc Parathyroid adenoma
 Usually mild hyperCa
 High PTH
(30-50%)
 Malignancy (40%)
 20-30% of Cancer patients
 Poor prognosis – 1 yr survival = 10-30%
 Lung/Breast/Kidney/Myeloma/Leukemia
 More likely to be encountered in ED
 Low PTH
 2 mechanisms: PTHrP or osteolytic
Other common causes

Iatrogenic/Drugs
 Thiazides
 Lithium
 Hypervitaminosis A &

D
Granulomatous Disease
 Sarcoidosis
 Tuberculosis
Other less common causes:
Parathyroid hormone-related
Sporadic, familial, associated with multiple
endocrine neoplasia I or II
Tertiary hyperparathyroidism
Associated with chronic renal failure or vitamin D
deficiency
Vitamin D-related
Vitamin D intoxication
Usually 25-hydroxyvitamin D2 in over-the-counter
supplements
Hodgkin's lymphoma
Genetic disorders
Familial hypocalciuric hypercalcemia: mutated
calcium-sensing receptor
Medications
Milk-alkali syndrome (from calcium antacids)
Other endocrine disorders
Hyperthyroidism
Adrenal insufficiency
Acromegaly
Pheochromocytoma
Other
Immobilization, with high bone turnover (e.g., Paget's
disease, bedridden child)
Recovery phase of rhabdomyolysis

Who needs immediate ED treatment?
 Ca
> 3.5 mmol/L
 Ca
> 3 mmol/L with symptoms
Management

Four Goals
1) Correct Hypovolemia
2) Increase renal calcium excretion
3) Reduce osteoclastic activity
4) Treat primary disorder
Management

1) Correct Hypovolemia
 Decreases
Ca by 0.4 - 0.6
 Increases GFR & Na load to kidneys, thus Ca excretion
 Various recommendations



NS IV @ 200-300cc/hr.
Usually require 2-4L per day X 1-3 days.
Aim for U/O of 200 cc/hr
 Caution
with elderly, poor LV function
 Also, correct co-existing electrolyte abnormalities
Management

2) Increase renal calcium excretion
 Correcting
Hypovolemia
 Lasix 10-40 mg IV q6-8h
 Dialysis in patients with renal failure
Management

3) Reduce osteoclastic activity

Bisphosphonates




Calcitonin



In severe cases, 4 un/kg SQ q6h
Starts working with a few hours
Glucocorticoids



Pamidronate 60-90 mg IV over 4 hours
Max effect in 72 hours
More effective in hyperCa of malignancy
In Vit D mediated hyperCa (Vit D intoxication, hematologic
malignancies, Granulomatous disease)
Hydrocortisone 200-300mg IV qd X 3 days
Mythramycin, Gallium Nitrate, IV phosphate – no longer used
Case 1

53F presents to ED with dysuria

PMHx: HTN, Hyperlipidemia,

UTI is diagnosed and oral Abx script given

Getting ready for discharge, but on routine labs you
notice Ca2+= 3.3 mmol/L

On further history the patient states she has no
symptoms and has been otherwise well.

Management?
Case 2

70M with known Lung CA, presents with
acute psychosis and Ca= 3.4 mmol/L
The End