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A New Perspective on Hypercalcemia
Taipei Veterans General Hospital, Hsin-Chu branch
Director of Nephrologist
Steve Chen
Ca
HypercalcemiaHypercalcemia
Mild: S-Ca >10.5 mg/dlModerate: S-Ca >12 mg/dl Severe: S-Ca >14 mg/dl 1 mmol/L = 4mg/dlpH ↓0.1 = free Ca↑0.05mmol/L 1g/dl albumin binds about 0.8mg/dl Ca
Etiology of Etiology of HypercalcemiaHypercalcemia
– MMalignancyalignancy– EEndocrinopathiesndocrinopathies
HyperparathyroidismHyperparathyroidism HyperthyroidismHyperthyroidism Adrenal insufficiencyAdrenal insufficiency
– DrugsDrugs Hypervitaminosis D/AHypervitaminosis D/A Thiazides, LithiumThiazides, Lithium
– ImmobilizationImmobilization
(90%)
Symptoms & signs of Symptoms & signs of HypercalcemiaHypercalcemia
Clinical Features(1)Clinical Features(1)– GeneralGeneral
Malaise, weakness, dehydration, polydipsiaMalaise, weakness, dehydration, polydipsia
– NeurologicNeurologic Confusion, apathy, decreased memory, irritabilityConfusion, apathy, decreased memory, irritability HallucinationsHallucinations, headache, ataxia, headache, ataxia Hyporeflexia, hypotoniaHyporeflexia, hypotonia
– CardiovascularCardiovascular HTN, dysrhythmiasHTN, dysrhythmias EKG abnormalitiesEKG abnormalities
– Short QT & ST, Wide T-waveShort QT & ST, Wide T-wave
Symptoms & signs of Symptoms & signs of HypercalcemiaHypercalcemia
Clinical Features (2)Clinical Features (2)– GastrointestinalGastrointestinal
N/V, anorexia, weight lossN/V, anorexia, weight loss Constipation, abdominal painConstipation, abdominal pain PUD, PancreatitisPUD, Pancreatitis
– SkeletalSkeletal Fractures, bone pain, deformitiesFractures, bone pain, deformities
– UrologicUrologic PolyuriaPolyuria Renal insufficiencyRenal insufficiency NephrolithiasisNephrolithiasis
Renal failure in Renal failure in hypercalcemiahypercalcemia
ECV↓: Bartter-like effect Arterial vasoconstrictionKUf↓GFR↓ATNNephrocalcinosisTubulointerstitial fibrosis
ELECTROLYTE DISORDERSELECTROLYTE DISORDERS
Memory AidMemory Aid– StonesStones ---- ---- Renal CalculiRenal Calculi– BonesBones ---- ---- OsteolysisOsteolysis– MoansMoans ---- ---- Psychiatric disordersPsychiatric disorders– Groans ----Groans ---- Abdominal (PUD, Abdominal (PUD,
Pancreatitis)Pancreatitis)
Hypercalcemia
Hypercalcemic crisis: >15mg/dlHypercalcemic crisis: >15mg/dl
De-compensated hypercalcemia: Fatal! myocardial calcinosis: cardiac arrest hypercalcemic renal failure CNS (coma) gradual or sudden onset mostly from pHPT
Compensated hypercalcemia: 70%: malignancy 20%: primary hyperparathyroidism (pHPT) 10%: others
iPTH↑ in hypercalcemiaiPTH↑ in hypercalcemia
pHPTTertiary HPT: CRF history Ectopic HPT: rareFamilial Hypocalciuria Hypercalcemia(FHH)
UCa/Cr < 0.01 Lithium-induced, long-term
Principles of treatmentPrinciples of treatment
IV N/S until ECF volume restored Loop diuretics: Lasix 40-100 mg IV q2-4HrsHemodialysisUrine output > 3 L/dayMonitor for ↓K+ and ↓Mg+Decrease bone resorption in severe cases
bisphosphonates: pamindronate 60- 80 mg iv over 4 Hrs
calcitonin: 2- 8 U SC Hydrocortisone
Measures Dosage Side effects
IV saline 4~ 6 L/D K ↓ Mg ↓
Furosemide 40~ 500 mg/D K ↓ Mg ↓
Clodronate 300mg IV,
6 ~ 8Hr,
for 2 ~ 6D
Renal insufficiency
Calcitonin 200~ 500IU/D Escape
Prednisone 40~ 100/D Cushing
HD Ca-free Dialysis-related
Surgery for Surgery for asymptomaticasymptomatic primary primary hyperparathyroidismhyperparathyroidism
Variables 1990 Guidelines 2002 Guidelines
S-Ca
24-Hr U-Ca
↓ in C-Cr
BMD
Age
1~1.6 mg/dl +UNL
> 400mg
30%
Z score < -2.0, forearm
<50 Y/O
1.0mg/dl + UNL
> 400mg
30%
Z score < -2.5 at any site
< 50 Y/O
Monitoring for asymptomatic primary Monitoring for asymptomatic primary hyperparathyroidism hyperparathyroidism
Bilezikian et al, J Bone Miner Res 17, 2002Bilezikian et al, J Bone Miner Res 17, 2002 Variables 1990 Guidelines 2002 Guidelines
S-Ca
24 Hr U-Ca
S-Cr
C-Cr
BMD
Abdominal sono
Every 6M
Annual
Annual
Annual
Annual
Annual
Every 6M
--
Annual
--
Annual at 3 sites
--
Things to rememberThings to remember
– Treat the patient, not the lab valueTreat the patient, not the lab value– Rate of correction should mirror rate of Rate of correction should mirror rate of
changechange– Correct in orderly fashionCorrect in orderly fashion
1. Volume1. Volume 2. pH2. pH 3. Potassium, Calcium, Magnesium3. Potassium, Calcium, Magnesium 4. Sodium and Chloride4. Sodium and Chloride
– Consider impact of interventions overallConsider impact of interventions overall
U(electrolyte)/UcrU(electrolyte)/Ucr
Uca/Ucr(UCACR) > 0.2 mg/mg Hypercalciuria
Urine Albumin-Creatinine Ratio(UACR) > 30 mg/G Albuminuria
Urine Protein-Creatinine Ratio(UPCR) > 20 mg/G Proteinuria
Hypercalciuric stone disease: XLHypercalciuric stone disease: XLO Devuyst and Y Prison: KI 2008(Belgium)O Devuyst and Y Prison: KI 2008(Belgium)
Dent’s disease: CLCN5/CLC-5/ Cl/H exchanger
PT/TAL/IC α
Renal:
Trafficking defect: endocytosis
PT dysfunction: Fanconi syndrome
Nephrocalcinosis, stones
Impaired urine acidification
Renal failure
Extra-renal:
Rickets
Lowe’s diseaseOCRL/OCRL1/ Phosphatidylinositol 4,5-biphosphate 5-phosphatase
PT
Renal:
PT dysfunction: Fanconi syndrome
Proximal RTA
Nephrocalcinosis, stones
Extra-renal:
Mental retardation, growth delay
Cataract, rickets, cryptorchidism Neuromuscular/behavior abnormality
Hypercalciuric stone disease: ADHypercalciuric stone disease: ADO Devuyst and Y Prison: KI 2008(Belgium)O Devuyst and Y Prison: KI 2008(Belgium)
AD Hypocalcemia ( Bartter syndrome V)CASR/CaSR/ calcium sensing receptor
PT/TAL/DCT/CD
Renal: gain-of-function
Low serum PTH
Hypocalcemia, Hypercalciuria
Nephrocalcinosis, stones
Salt-losing nephropathy; Hypokalemia (CaSR→ ROMK↓)
Extra-renal: basal ganglia calcifications, seizures
Distal RTA (RTA I)SLC4A1/ AE1/ Cl/HCO3 exchanger
ICα
Renal:
Impaired anion exchange in IC α
Metabolic acidosis
Hypercalciuria
Nephrocalcinosis, stones
Extra-renal:
Osteomalacia, rickets
Growth retardation
Hypercalciuric stone disease; ARHypercalciuric stone disease; ARO Devuyst and Y Prison: KI 2008(Belgium)O Devuyst and Y Prison: KI 2008(Belgium)
Ante-natal Bartter’s syndrome I: NKCC2/ Na-K-2Cl cotransporter 2 Hyperprostaglandin E syndrome
Ante-nasal Bartter’s syndrome II: ROML/ K channel Hyperpostagladin E syndrome 2
Bartter’s syndrome III: CLC-Kb/ Cl channel Familial hypomagnesemia with hypercalciuria and
nephrocalcinosis: FHHNC Distal RTA with progressive nerve deafness: ATP6V1B1/
B1 subunits of proton pump Distal RTA with preserved hearing/late onset hearing loss:
ATP6V0A4 / A4 subunits of proton pump
FHHNCFHHNC CLND 16/ Claudin-16/ paracellin-1 tight junction
protein TAL, DCT Renal:
Impaired para-cellular transport of Ca/Mg: calcium and magnesium wasting Nephrocalcinosis, stones Renal failure
Extra-renal: Convulsions, tetany, chondrocalcinosis, neuro-muscluar manifestations
TRP V 5 knockout mice modelTRP V 5 knockout mice model
Transient receptor potential channels (TRP): Gate-keeper proteins
TRP V5 in kidney: ECaC 1 TRP V6 Hypercalciuria Diuresis: CaSR, apical in principal cells + Ca in lumen ﹡
→AQP2 Acid urine: CaSR, apical in intercalated cells + Ca in
lumen → H+APTase Hyperphosphaturia
Rene Bindels: Radboud University Nijmegen Medical Center, Netherlands
Nonparathyroidal hypercalcemiaNonparathyroidal hypercalcemia
Malignancy: 50% PTHrP↑ Calcitriol IL-1, IL-6, IL-11, TGF-β, INF, GM-CSF, PGs
Mechanical(immobilization): fracture, AIP Hyperthyroidism Adrenal insufficiency Granulomatous(Infectious): TB, Histoplasmosis,
Sarcoidosis, AIDS
PTH-related peptide: pathologicalPTH-related peptide: pathologicalGR Mundy et al: JASN 2008(Vanderbilt University, Tennessee)GR Mundy et al: JASN 2008(Vanderbilt University, Tennessee)
Tumor cellsPTHrP
Kidney
Osteoclast
Bone
Ca↑ TGF β
Ca re-absorption ↑
PTHrP related tumor syndromes PTHrP related tumor syndromes GR Mundy et al: JASN 2008(Vanderbilt University, Tennessee)GR Mundy et al: JASN 2008(Vanderbilt University, Tennessee)
Humoral hypercalcemia of malignancy Hypercalcemia Plasma PTHrP ↑ Nephrogenous cAMP↑ Metabolic alkalosis ; 1,25(OH)2 VD↓ (Hyperchloremic acidosis ; VD ↑in primary hyperparathyroidism)
Localized osteolysis ±Hypercalcemia No increase in PTHrP and cAMP
Hypercalcemia: Hypercalcemia: nonparathyroidal and nonmalignantnonparathyroidal and nonmalignant
Iatrogenic hypercalcemia Munchausen syndrome( Vitamin D user) Vitamin A intoxification Thiazides Tamoxifen Theophylline Salicylic acid intoxification
Milk alkali syndrome from Sippy dietMilk alkali syndrome from Sippy dietLin et al, NDT 17: 708-14, 2002Lin et al, NDT 17: 708-14, 2002
Absorption of free Ca in upper intestinal tract: CaCO3+H (gastric secretion)→free Ca via trans-cellular pathway→CaCO3 by NaHCO3 in duodenum
Absorption of free Ca in downstream intestinal tract: CaCO3+H →free Ca via para-cellular pathway only if HPO4 deficiency→ Ca(PO4)2
Potential HCO3 load: CHO→H (bacterial fermentation)+ OA( non oxalate)
Triads: Hypercalcemia + Metabolic alkalosis + CKD; 1,25(OH)2VD low or low normal
Calcium(>4G/D) Alkali syndrome Calcium(>4G/D) Alkali syndrome Post-menopausal women: CaCO3(+VD3) Pregnant women: hyperemesis→ ECV→
Calcium via gut Transplant recipients/HD patients: CaCO3Patients with bulimia(anorexia nervosa):
food fetishes in Calcium Betel nuts chewers: a lime paste from
ground oyster: CaO + Ca(OH)2Thiazide users
Calcium Alkali syndrome Calcium Alkali syndrome
THAL
NKCC
ROMK
Na K ATP ase
Ca, Mg pH
Na/K
K
2Cl
CaSRNegative
Positive
Calcium Alkali syndrome Calcium Alkali syndrome
DCT
NCC
TRPV5
Na K ATP ase
pH pH
Na
Ca
Calcium flow
2Cl
CaSRPositive
PositiveCaSR
CaATPase
NCX
Betel nut chewing Betel nut chewing
pH= 7.47; HCO3 36meq/L; pCO2 50mmHg Na 137meq/L; K 3.2meq/L; Cl 91meq/L BUN/Cr 47/9.7 mg/dl Ca/Pi 12.8/5.7 mg/dl; Salb 3.9g/dl
FEk= 6.5% ; TTKG 7.0 Ca/Cr=0.64 (mmol/mmol) Calcium load=1.4mmol/sample x 40=52mmol/D
saliva Ca= 12mmol/L x (0,5ml/min x 12hr)=4 ~5mmol/D typical diet Ca=20mmol/D
Primary HPT plus Primary HPT plus
SarcoidosisThyrotoxicosisPaget’s disease
Schmaldienst et al, NDT 16: 2423-25, 2001
Primary HPT: novel patternPrimary HPT: novel pattern
Hypercalcemia with low-normal i-PTH in serum Hollenberg et al, AJM 91: 547-548, 1991