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hypercalcaemia

hypercalcaemia

see also calcium

Aetiology:

  • primary hyperparathyroidism
  • hypercalcaemia of malignancy - bone metastases / SCC lung / Ca kidney / multiple myeloma / lymphoma
  • sarcoidosis/vitamin D intoxication/milk-alkali synd./immobilisation
  • thyrotoxicosis/thiazides/familial hypocalciuric hypercalcaemia

Clinical effects:

  • “bones, stones, groans & psychic moans”
  • abdominal pain, nausea, vomiting, constipation, anorexia, 
  • polyuria, polydipsia, hypotension, weakness, clouding of consciousness
  • depression, weight loss, tiredness, pyrexia, renal calculi, renal failure, corneal calcification
  • shortened QTc, sudden cardiac arrest

Investigation:

  • hyperparathyroidism supported by:
    • low plasma phosphate/raised plasma chloride/low-normal plasma bicarb.
    • raised PTH if renal function normal
    • raised urinary c-AMP if renal function normal (but also in malingant cause)
    • XR hands - subperiosteal erosions; bone cysts elsewhere;
  • malignancy supported by:
    • low plasma albumin, lowish chloride, hypokalaemia, alkalosis, raised phosphate, raised alk. phosphatase
  • if albumin raised:
    • consider dehydration (raised urea) or cuffed specimen
  • if albumin normal or low:
    • if phosphate low or normal & urea normal
      • ⇒ primary or tertiary hyperparathyroidism likely
    • if phosphate high or normal:
      • if raised alkaline phosphatase:
        • bone metastases (most common primary: breast, kidney, lung, thyroid, prostate, ovary, colon)
        • sarcoidosis (serum ACE raised in hypercalcaemia due to sarcoidosis)
        • thyrotoxicosis
      • if normal alkaline phosphatase:
        • myeloma (plasma protein raised)
        • vit D excess (serum 25-OH vitD raised in Vit.D intoxication)
        • milk-alkali syndrome
        • (sarcoidosis, thyrotoxicosis, raised bicarb)
  • CXR, bone scan for metastases
  • AXR - renal/ureteric calculi or nephrocalcinosis - hyperPTH/sarcoidosis
  • CT abdo to excl. renal carcinoma if microhaematuria present

Management:

  • Rx underlying cause
  • if Ca > 3.5mM or hypotensive, severe abdominal pain, vomiting, pyrexia, clouding of consciousness:
    • rehydrate with IV NSaline eg. 4-6L over 24h as needed
    • monitor Na, K, Mg & urea
    • frusemide / furosemide / Lasix 125mg slow IV (< 4mg/min) up to every 3h, monitoring CVP, U&E
    • salmon calcitonin 8U/kg 8h IM to inhibit osteoclasts
    • plicamycin 
    • if hypercalcaemia of malignancy:
    • if multiple myeloma, sarcoid, vit D overdose:
      • hydrocortisone 250mg/24h IVI may be effective
    • cinacalcet:
      • increases the sensitivity of a sensor that responds to serum calcium concentration & then secretes parathyroid hormone, thus it reduces parathyroid hormone secretion which in turn reduces serum calcium levels.
      • introduced in Australia in 2005 as oral tablets taken once daily for secondary hyperparathyroidism, but may need bd dosing for primary hyperparathyroidism or parathyroid carcinoma.
  • if primary hyperparathyroidism ⇒ neck exploration by experienced neck surgeon, etc;
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hypercalcemia
hypercalcaemia.txt · Last modified: 2018/05/22 11:15 (external edit)