ZSFG Morning Report Pearls: Hypercalcemia, PTH, MGUS

Evan discussed a case of a 75M h/o ADPKD s/p CRT, AAA, a/w acute on chronic abd pain, found to have hypercalcemia of 12

What is significant weight loss:

  • >5% unintentional loss in 6-12months in the literature (see below) though no real consensus

Hypercalcemia diagnostic algorithm:

  • Clinical evaluation (Is this an emergency? Is this severe hypercalcemia*? Is the calcium the immediate cause of sx’s**? What are the pertinent demographics for this patient? Family Hx? Have we done a careful med rec?)
  • WHAT is the PTH measurement? Follow algorithm below…
    diagnostic approach to hypercalcemia

 

PTH-related causes of hypercalcemia

  • primary hyperparathyroidism (high PTH)
  • inherited variants of MEN
  • familial hypocalciuric hypercalcemia (mildly elevated PTH)
  • familial isolated hyperparathyroidism
  • hyperparathyroidism-jaw tumor syndrome (obviously)
  • tertiary hyperparathyroidism/renal failure

 

Non-PTH related causes of hypercalcemia

  • malignancy
  • vitamin D/A excess
  • chronic granulomatous disorders
  • medications (i.e. thiazide diuretics, lithium), vitamins, herbals
  • milk alkali (TUMS)
  • adrenal insufficiency
  • acromegaly
  • pheochromocytoma, and the list goes on…

 

*Gradations of Hypercalcemia and treatment:

Mild (<12mg/dL) or asymptomatic:

  • Avoid aggravating factors (i.e. diuretics, lithium use, prolonged bed rest, volume depletion) but don’t need emergent intervention. Adequate hydration=good thing!

Moderate (12-14mg/dL) or mildly symptomatic:

  • May not always require immediate attention but if an acute rise in calcium causes significant sx’s, treat as below

Severe (>14mg/dL) or symptomatic**:

  • Isotonic fluids +/- lasix, calcitonin (from salmon…yum yum)
  • For longer-term control, choose bisphosphonate over denosumab (monoclonal antibody w/ affinity for RANKL)

    treatment of hypercalcemia

 

**Hypercalcemia manifestations:
GI: n/v/constipation/pain
MSK: weakness, bone pain, osteopenia/osteoporosis
Neurologic: decr concentration, confusion, fatigue, stupor, coma
CV: shortening of the QT interval, bradycardia, hypertension
Renal: polyuria, polydipsia, nephrolithiasis, nephrocalcinosis, distal renal tubular acidosis, nephrogenic DI, acute and chronic renal insufficiency

 

 

 

 

Quick and dirty MGUS/Myeloma review courtesy of Rachel Stern:

Monoclonal gammopathy

 

References:
-Wong CJ. Involuntary weight loss. Med Clin North Am. 2014 May;98(3):625-43. doi: 10.1016/j.mcna.2014.01.012. Epub 2014 Mar 21.
One new kid on the block paper and one old timey paper; both good for review of pathophysiology:
*Bilezikian JP. Managmenet of acute hypercalcemia. N Engl J Med. 1992 Apr 30;326(18):1196-203.
*Maier JD et al. Hypercalcemia in the Intensive Care Unit: A review of pathophysiology, diagnosis, and modern therapy. J Intensive Care Med. 2015 Jul;30(5):235-52. doi: 10.1177/0885066613507530. Epub 2013 Oct 15.

Evernote Link:
https://www.evernote.com/shard/s354/sh/803dc6e9-fd2a-403b-9a13-5c59a3eb85fa/62e9ba215bb98132aaa5db4d26f2f8ca

 

 

 

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