Hypercalcemia final
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Transcript of Hypercalcemia final
HYPERCALCEMIAThe Nuts and Bolts
DEFINITION• Total S. Ca >10.3 mg/dl + Normal S. Albumin
• Ionized S. Ca > 5.2 mg/dl
CAUSES
1. Related to PTH2. Malignancy3. Vitamin D-related4. Medications5. Other endocrine6. Genetic7. Other
PTH Related• Primary hyperparathyroidism
• Adenoma(s) • MEN I or II• Carcinoma
• Familial hypocalciuric hypercalcemia
• Tertiary hyperparathyroidism• CRF• Vitamin D deficiency
Malignancy related• Humoral hypercalcemia (mediated by PTHrP)
• Solid tumors• Lung• Head and neck squamous cancers• Renal cell tumors
• Local osteolysis (mediated by cytokines) • Multiple myeloma
• Ectopic Vit D3 secretion• Hodgkin’s lymphoma
Vitamin D related• Vitamin D intoxication
• Granulomatous disease• Sarcoidosis• Berylliosis• Tuberculosis
• Hodgkin’s lymphoma
Medications• Thiazide diuretics (usually mild)
• Lithium
• Milk-alkali syndrome (from calcium antacids)
• Vitamin A intoxication (including analogs used to treat acne)
Endocrine disorders• Hyperthyroidism
• Adrenal insufficiency
• Acromegaly
• Pheochromocytoma
Genetic disorders• Familial hypocalciuric hypercalcemia
• Mutated calcium-sensing receptor
• Normal PTH in 80-85% of patients
• Benign inherited condition
Others• Immobilization
• High bone turnover• Paget’s disease, bedridden child
• Recovery phase of rhabdomyolysis
MOST COMMON• Primary hyperparathyroidism
• Malignancy• Multiple myeloma• Breast carcinoma
• Account for 90% cases
SYMPTOMS• Renal
• Musculoskeletal
• Gastrointestinal
• Neurological
• Cardiac
• Others
Renal• Nephrolithiasis
• Nephrocalcinosis
• Polyuria
• Polydipsia
Musculoskeletal• Bone pain
• Osteopenia
• Fractures
• Muscular weakness, especially proximal myopathy
Gastrointestinal• Nausea
• Vomiting
• Lack of appetite
• Constipation
• Peptic ulcers
• Pancreatitis
Neurological• Tiredness
• Lethargy
• Inability to concentrate
• Increased sleepiness
• Depression
• Confusion
• Coma
Cardiac• Bradycardia
• First-degree AV block
• Arrhythmias
• Shortened QT interval
Others• Itching
• Keratitis
• Conjunctivitis
• Corneal calcification, band keratopathy
• Carpal tunnel syndrome• Occasionally with hyperparathyroidism
DIAGNOSIS
TREATMENT EMERGENCY• Rehydrate:-
• 4–6 L of 0.9% saline on day 1• 3–4 L for several days thereafter
• Intravenous bisphosphonates:-• Hypercalcaemia of malignancy• Undiagnosed cause• Pamidronate, Zoledronate
• Prednisolone:- • Myeloma, Sarcoidosis, Vitamin D excess (ineffective usually)
• Calcitonin:-• Short-lived action
• Oral phosphate
TREATMENT MEDICAL• High fluid intake
• Avoid high calcium intake
• Avoid high vitamin D intake
• Exercise
TREATMENT SPECIFIC• Primary hyperparathyroidism – Sx
• Malignancy – Rx for malignancy
• Vit D excess – ↓ Vit D intake
• Avoid ppting drugs
• Treat endocrine disorders
• Treat CRF