Hypercalcaemia
Kaveesha Rajapaksa
F2
Case
91 year old gentleman
B/g Mild myelodysplastic syndrome, CKD, Hypertension
Admitted 22/9 feeling unwell, AKI on CKD (EGFR 28), left hip pain and constipation.
Calcium noted to be 3.1
Elevated calcium since at least the start of August (prior calcium was in 2013)
Hypercalcaemia
Defined as corrected calcium levels greater than 2.65 on 2 occasions
Presentation –Polyuria and polydipsia. Abdominal pain, bone pain, kidney stones,
constipation, depression, agitation, gastric ulcers (calcium increases gastrin release)
Causes – 90% of hypercalcaemia is caused by primary hyperparathyroidism + malignancy
(includes lung cancer, myeloma etc.)
Malignancy is the commonest cause when it is not pth related – related to PTHrP or bone
metastases. It is also the commonest cause in hospitalised patients
Other causes include sarcoidosis, vitamin D toxicity, thyrotoxicosis, adrenal insufficiency,
familial hypocalciuric hypercalcaemia
Investigations
ECG – QT interval
Bloods – PTH, vitamin d, alkaline phosphatase, phosphate, TSH, cortisol
Urine calcium and phosphate
review drug card – thiazides, lithium, vitamin d/calcium supplements
Secondary – CXR, CTCAP, USS neck, Urinary bence-jones proteins, serum electrophoresis
(+/- bone marrow aspirate)
Referral to endocrine specialists
Condition PTH Serum Serum Alkaline Urine Calcium Urine Phosphate
Phosphate Phosphatase
Hyperparathyroidism High Low Normal-high High (in 67% of High
patients)
Malignancy Variable Often low High (except in Variable High
haematological
malignancy, when
normal)
Vitamin D excess Low Normal-high Low High High
Granulomatous disease Low Normal-high Normal-high High Normal
Familial hypocalciuric Normal-high Normal or Normal Low (<200 mg/day) Normal
hypercalcemia low
Calcium alkali syndrome Low Normal-high Normal Normal Normal
Management
IV/PO fluids. 3-4 litres a day. Increase circulating volume and remove calcium via the
kidneys
Treat the cause. If primary hyperparathyroidism, surgery may be indicated. If malignancy
confirmed, referral and treatment.
If malignancy is not treated, calcium will rise again rapidly (2-4 weeks).
IV bisphosphonates – not suitable if poor renal function (EGFR <30). Acceptable in
hypercalcaemia of malignancy (if EGFR>10).
Other treatment options – prednisolone (useful in myeloma, sarcoidosis, vitamin d
toxicity), denosumab, cinacalcet
Back to the case
Parathyroid <2.5, phosphate was initially high (could be red herring due to CKD), urinary
calcium >4, ALP normal, vitamin D normal
Normal TSH, Normal 9am cortisol
No adverse drugs on the drug card
2 biggest differentials at this point – malignancy or granulomatous disease
CTAP – no tumours or lymphadenopathy. CT skeletal survery nil. Myeloma screen
negative (including bone marrow aspirate)
Back to the case
Initially reduced with IVI to 2.71. However the level climbed back 3.1 despite continual
IVI within a few days. Pain and constipation managed with analgesics and laxatives
Due to his renal function there was some debate about giving bisphosphonates. After
discussion with renal, settled on pamidronate
Sent for PTH-rP
Level normalised within 5 days as expected
Unfortunately patient self-discharged on 7/10 so cause and results of PTH-rP remains
unknown
Questions?
References
https://patient.info/doctor/hypercalcaemia (Accessed 10/10/17)
https://cks.nice.org.uk/hypercalcaemia (Accessed 10/10/17)
