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1 • Commonly encountered in Practice • Diagnosis often is made incidentally • The most common causes are primary hyperparathyroidism and malignancy • Diagnostic work-up includes measurement of serum calcium, intact parathyroid hormone (I-PTH), h/o any medications • Hypercalcemic crisis is a life-threatening emergency 2 • Most often asymptomatic – Incidental Dx • Mild Hypercalcemia is asymptomatic • Most important cause is hyper parathyroid • DD is needed to decide the treatment • Optimal step by step evaluation is a must. 3 • 98% of the body calcium is in the skeleton • Only 2% is circulation and only half of this is free calcium (ionized Ca++) • This only is physiologically active • The reminder 1% is bound to proteins • Direct measurement of free Calcium ?? 4 Parathyroid Hormone 1,25 DHC or Vitamin D3 Calcitonin 5 Bone Resorption Intestinal Absorption Renal Excretion 6 (1,000 mg/day) 7 Hormone PTH Effect Bone Increases Indirect Ca Po4 Osteoclasts via Vit. D No direct Vitamin D3 Ca Po4 action Calcitonin Gut Kidney Ca reab Po4 exr. Ca Po4 No direct absorption effect Inhibits No direct Ca Po4 Osteoclasts effect Ca & Po4 excretion 8 Corrected total calcium (mg%) = [(Measured total calcium mg%) + {(4.4 - measured albumin g%) x 0.8}] Example: [12.0 + {(4.4 – 2.4) x 0.8}] = [ 12.0 + (2 x 0.8)] = 12.0 + 1.6 = 13.6 mg% 9 Supplements Vitamin D 2 Calcitriol (Active) 10 Vitamin D is a steroid hormone From dietary sources Action of Sunlight on skin Successive hydroxylations of Cholecalciferol 25 hydroxylation in the Liver 25 hydroxy Cholecalciferol Second hydroxylation in the Kidney at first position 1,25 dihydroxy Cholecalciferol Active Vitamin D (Calcitriol) 11 PTH Calcitriol (D) Calcitonin • 4 PT glands • 84 AA hormone • Low Ca stimulates it • Active bone formation • Main effect is on the Gut • PTH Vit. D • Para follicular C of Thyroid • 34 AA hormone • On Kidney 12 Critical - > 14 mg % Moderate - 12 to 14 mg % Mild – 10.4 to 11.9 mg % Normal – 8.5 to 10.3 mg % 13 PTHrP Calcitriol PTH Ca++ Ca at GIT 14 PTH Vitamin D Genetic Ca++ Endocrine Malignancy Medicines 15 • More than 90 percent of hypercalcemia cases are Primary hyperparathyroidism and malignancy • These conditions must be differentiated early to provide optimal treatment & accurate prognosis • Humoral hypercalcemia of malignancy implies a very limited life expectancy — only a matter of weeks • Primary hyperparathyroidism has a benign course. 16 • Primary hyperparathyroidism • Sporadic, familial, associated with Multiple Endocrine Neoplasia (MEN I or II) • Tertiary hyperparathyroidism • Associated with chronic renal failure • PTH due to Vitamin D deficiency 17 • Vitamin D intoxication • Iatrogenic Vitamin D injections • Usually 25-hydroxyvitamin D2 in over-the-counter supplements • Granulomatous disease – Sarcoidosis, Berylliosis, Tuberculosis • Hodgkin’s lymphoma 18 • Humoral hypercalcemia of malignancy (mediated by PTHrP) – common cause • Solid tumors, especially lung, head and neck squamous cancers • Renal Cell Carcinoma (RCC) • Local osteolysis (mediated by cytokines) • Multiple Myeloma • Breast cancer 19 • Thiazide diuretics (usually mild) - common • Lithium for depressive illnesses • Milk-alkali syndrome (calcium + antacids) • Vitamin A intoxication (including analogs used to treat acne) 20 • Hyperthyroidism • Adrenal insufficiency • Acromegaly • Pheochromocytoma 21 • Familial hypocalciuric hypercalcemia (FHH) mutated calcium-sensing receptor gene • Immobilization, with high bone turnover (e.g., Paget’s disease, bedridden child) • Recovery phase of Rhabdomyolysis 22 • SKELETON • KIDNEY • GIT STONES BONES MOANS GROANS • CNS 23 Renal “stones” • Nephrolithiasis • Nephrogenic Diabetes Insipidus • Dehydration • Nephrocalcinosis 24 Skeleton “bones” • Bone pains • Arthritis • Osteoporosis • Osteitis fibrosa cystica in HPTH 25 Abdominal “Moans” • Nausea, vomiting • Severe anorexia, weight loss • Constipation (not relieved by Rx.) • Abdominal pain (vague and diffuse) • Pancreatitis • Peptic ulcer disease 26 Psychological “Groans” • Impaired concentration • Impaired memory, Depression • Confusion, stupor, coma • Lethargy and severe fatigue • Extreme muscle weakness • Corneal calcification (band keratopathy) 27 Cardiovascular • Hypertension, Increased risk of CHD • ECG changes of shortened QT interval, PR prolonged, QRS widened, ST , Bradycardia • Cardiac arrhythmias; Vascular calcification Others • Itching (Generalized Pruritus) • Keratitis, conjunctivitis 28 Normal calcium ? Suspect Calcium Serum Calcium Hypocalcemia 8.5 to 10.3 > 10.3 mg % < 8.0 mg % 29 High/Normal Pri PTH Medications Vit D Toxicity > 10.3 mg% I-PTH Suppressed Milk Alkali Cancers/ Lymphoma Suppressed PTHrP 30 Low or Normal PTHrP Low or Normal Endocrine 1, 25 Vit. D If Low Cancer If High Lymphoma Low – FHH High 24 hr. urine calcium N or Sestamibi 31 32 • Increased screening for serum Ca++ and • Wider availability of I-PTH assay • 80% of cases single parathyroid adenoma • Usually benign adenoma or hyperplasia • Rarely parathyroid cancer • High PTH in the setting of hypercalcemia • Slowly progressive – Sestamibi N-scan • 25% require surgery – RLN paralysis 33 64 yrs male - “hyper parathyroid storm” with a serum calcium level of 16.4 mg% 34 • Serum calcium level > 12 mg % at any time • Episodes of hyper parathyroid crisis • Marked hypercalciuria (urinary Ca++ > 400 mg /day) • Nephrolithiasis; Impaired renal function • Osteitis fibrosa cystica – Thinning of cortical bone • Reduced bone density by DEXA scan (Z score < 2) • Classic neuromuscular symptoms, Proximal muscle weakness and atrophy, Hyper reflexia and ataxia • Age younger than 50 years 35 • 25 OH - Vitamin D2 is the supplemental Vit D • Level of 25 OH – Vitamin D3 is to be measured • Macrophages in the granulomas, lymphomas cause extra renal conversion of 25 OH form to the1,25 hydroxy derivative –the active Calcitriol • PTH levels are suppressed; Calcitriol levels • Stop the offending use of Vitamin D • Glucocorticoids – for over one month or more • Manage hypercalcemia vigorously 36 • Most commonly mediated by systemic PTHrP • Humoral Hypercalcemia of malignancy • PTHrP mimics the bone & renal effects of PTH • Normal Calcitriol and suppressed PTH levels • Excessive bone lysis due to primary or bone secondaries can cause hypercalcemia • MM and metastatic Br Ca present in this way. • In Osteolytic hypercalcemia, SAP is markedly • Hodgkin’s lymphoma – production of Calcitriol 37 • Thiazide diuretics increase renal calcium resorption and cause mild hypercalcemia • Resolves after discontinuing the drug • Thiazide unmasks hyperparathyroidism • Milk–alkali syndrome – Ca + Antacids • Lithium – the set point for PTH • Excess Vitamin A - bone resorption and causes hypercalcemia. 38 • FHH – Familial Hypocalciuric Hypercalcemia • AD – 100% penetrance – Ca-R gene mutation • Moderate hypercalcemia with normal/ PTH • 24 hour urinary calcium is very low • No benefit from parathyroidectomy • High bone turnover in Paget’s disease or prolonged immobilization • Recovery phase of Rhabdomyolysis 39 • Ca <12 but > 10.3 mg% – no appreciable clinical benefit – they need evaluation • Any patient with Serum Ca > 12 mg% should be aggressively treated • Ca > 14 mg% is Hypercalcemic crisis • Always correct the Ca value for Sr Albumin 40 I.V. Saline Hydration & Diuresis GlucoCorticoids Bisphosphonates Calcitonin I.M/S.C. 41 • Vigorous I.V. Nacl Diuresis – N Saline • Adequate hydration – urine out put must be maintained 200 ml/hour = 5 L /day • The safest and most effective treatment of Hypercalcemic crisis is saline rehydration • Once the urine out put is maintained – give I.V. Furosemide – a loop diuretic in low doses of 10 to 20 mg • ERT - might be beneficial in PMW – new RCT 42 • In severe hypercalcemia refractory to saline diuresis • Calcitonin (Zycalcit, Miacalcin) 6 -8 U/kg IM/SC (400 i.u) given every six hours. • This treatment has a rapid onset but short duration of effect • Patients develop tolerance to the calciumlowering effect of Calcitonin. 43 • Zoledronic acid (Zometa) - 4 mg IV diluted in 100 ml of N Saline - over at least 15’ once a M • Pamindronate (Pamidria) - 60 mg IV infusion over 4 h initial – repeated after a month • Etidronate (Didronel) - 7.5 mg/kg IV over 4 h daily for 3-7 d; dilute in at least 250 ml of sterile N Saline • They inhibit bone resorption, inhibit the Osteoclastic activity. 44 • Dialysis for refractory Hypercalcemic crisis • Parathyroidectomy for adenomas • Rx. of the underlying cause – Eliminate drugs • Plicamycin (Mithracin) 25 mcg/kg/d IV for 4 d • Gallium nitrate (Ganite) 100 mg/m2/d IV for 5 days in 1 L of NS or 5% Dextrose • Cinacalcet (Sensipar) - 30 mg PO od – (increases sensitivity of calcium sensing receptor) 45 • Hypercalcemia is often asymptomatic • Screen all suspected by doing Sr Calcium • If elevated, do I-PTH and follow algorithm • 90% Hyperparathyroidism and malignancy • Vitamin D toxicity is an important cause • Thiazide diuretics common cause, Vitamin A • Adequate hydration - N Saline + Furosemide • Calcitonin + Zoledronic acid main stay of Rx. 46