Hypercalcemia

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Hypercalcemia

• Gen. Med 3 !!!

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Hypercalcemia

• DDx
• Diagnostic approach
• Clinical manifestations
• Treatment

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Chronic renal failurePseudohypoparathyroidismVit
amin D deficiencyAcute loss of Ca

Differential Diagnosis
1 Hyperparathyroidism 3 Hyperparathyroidism
FHH (PTH can be normal)
normal
PTH
Malignancy Vitamin D excess ? Bone
turnover Thiazides, Milk-alkali

• Hypoparathyroidism

Calcium
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Diagnostic Approach

• Calcium level should be repeated to confirm
  diagnosis
• Ca, albumin, ionized Ca
• Hyperparathyroidism
• iPTH levels
• Malignancy
• PTHrP (squamous cell lung cancer, renal, breast,
  bladder)
• Osteolysis
• Vitamin D excess
• 25 (OH) Vit. D
• Granulomas (sarcoid, TB, histo)
• Vitamin D intoxication
• Increased bone turnover
• Hyperthyroidism, Pagets disease
• Others
• thiazides, milk-alkali syndrome, adrenal
  insufficiency

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Lytic vs. Blastic Bone Mets

• Lytic bone metastasis
• Breast
• Lung
• Thyroid
• Kidney
• Multiple Myeloma
• Diagnostic study?
• Bone Survey

• Blastic bone metastasis
• Prostate
• Infamous lymphoma
• Transitional cell ca
• Treated breast
• APUDoma (carcinoid)
• Diagnostic study?
• Bone Scan

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Vitamin D Excess

• Vit. D to 25-OH Vit. D (calcidiol) to
  1,25-(OH)2 Vit. D (calcitriol)
• SLiK Vit. D
• Calcitriol as treatment for hypoparathyroidism or
  for hypocalcemia and hyperparathyroidism of renal
  failure.
• Tx Stopping calcitriol, increasing salt and
  fluid intake, or hydration with IV NS may be
  enough.
• Treatment of calcidiol may need to be more
  aggressive.

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Signs and Symptoms

• Bones, stones, abdominal groans, and psychic
  moans.
• Malaise, fatigue, headaches, diffuse aches and
  pains, constipation.
• Patients are often dehydrated
• Lethargy and psychosis when hypercalcemia is
  severe.
• Calcifications in skin, cornea, conjunctiva, and
  kidneys.

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Treatment

• Aimed at lowering serum calcium concentration
  and, if possible, correcting or decreasing the
  underlying disease.
• Increase urinary calcium excretion
• Volume expansion with IV fluids
• Lasix (once fluid repletion has been achieved)
• Inhibit bone resorption
• Calcitonin
• Bisphosphonates
• Pamidronate, ibandronate, etidronate
• More potent than calcitonin and saline, preferred
  agents for malignancy-related hypercalcemia.

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The End

• Questions?