2006_08_03-Qureshi-Hypercalcemia
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Transcript 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