66 y/o F ESRD who p/w hypercalcemia and renal mass but found to have milk-alkali syndrome
Dr. Thomas Jacobs | Morning Report | 03/28/2017 | video
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Workup of Hypercalcemia
- High PTH
- Primary hyperparathyroidism and FHH (Familial Hypocalciuric Hypercalcemia)
- Can be elevated in 2nd Hyperparathyroidism due to ESRD because of lack of 1,25-OH Vitamin D and hypocalcemia triggering increased PTH. Over time, this can lead to Parathyroid hyperplasia and even an autonomous nodule (Tertiary Hyperparathyroidism), which is when you would then see hypercalcemia
- Low PTH
- Malignancy (Can be from metastasis to bone, MM or PTHrP)
- Vitamin D Excess
- Increased bone turnover (Thyrotoxicosis, Immoblization, Paget's, Hypervitaminosis A)
- Adrenal Insufficiency
- Milk-Alkali Syndrome
- Medications (Thiazides)
Posted 03/29/17 10:03:10 PM by Ying Liu
- High PTH
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Bisphosphonates and Renal Disease
- Zolendronate and Pamidronate are the two main IV bisphosphonates approved in the U.S.
- Bisphosphonates are cleared renally and associated with nephrotoxity from ATN and collapsing FSGS. There is limited data in ESRD
- Could use denosumab (RANKL inhibitor) in patients with CKD
Posted 03/29/17 10:04:15 PM by Ying Liu
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Hypercalcemia and Renal Cell Carcinoma (RCC)
- Seen in as many as 20% of patients; most common paraneoplastic syndrome
- 75% of the cases have high-stage lesions but presence of hypercalcemia is not significantly correlated with tumor grade or survival
- Some cases mediated by metastasis to bones but others are mediated by PTHrP as RCC cells can produce both PTH and PTHrP
- PTHrP binds to PTH receptors in both bone and renal tissue leading to increased bone resorption and decreased renal clearance of calcium
Posted 03/29/17 10:04:51 PM by Ying Liu
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Milk-Alkali Syndrome
- Triad of Hypercalcemia, metabolic alkalosis and acute kidney injury associated with ingestion of large amounts of calcium and absorbable alkali
- Traditionally caused by calcium carbonate but can also be seen with calcium acetate
- Can be exacerbated by reduced GFR and thiazide diuretics
- Withdrawing the Ca source is the treatment of choice
Posted 03/29/17 10:05:28 PM by Ying Liu
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For further reading...
Posted 03/29/17 10:11:41 PM by Ying Liu
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