Hypercalcemia (CMPP)

Parathyroid Causes of Hypercalcemia

Primary Hyperparathyroidism

Familial Hypocalciuric Hypercalcemia (FHH)

Non-Parathyroid Causes of Hypercalcemia

Malignancy

Elevated Vitamin D

Granulomatous Disease

Medication

Milk-Alkali Syndrome

Immobilization

Parenteral Nutrition

Hyperthyroidism

Presentation of Hypercalcemia

Kidney Stones

Bone Pain (Increased osteoclast, osteoporosis, osteomalacia, fracture, arthritis)

Abdominal Groans (Anorexia, Nausea, Constipation, Pancreatitis, PUD, Polyuria, Polydipsia)

Neuropsychiatric if Ca >14 (Anxiety, Depression, Lethargy, Coma)

When does hypercalcemia present

Ca > 12

What tests should be ordered for initial hypercalcemia work-up

PTH

Ionized Ca

Phos

Renal Functions

Vitamin D

What are some f/u testing for hypercalcemia

24 hour urine

DEXA Scan

Primary Hyperparathyroidism

Excessive PTH production and release

Cause of Primary Hyperparathyroidism

(#1) Adenoma of Parathyroid

Hyperplasia of Parathyroid

Parathyroid Carcinoma

Presentation of Primary Hyperparathyroidism

Most are asymptomatic

Usually found as incidental serum Ca elevation

How will labs appear for Primary Hyperparathyroidism

Total Ca = Elevated

Ionized Ca = Elevated

PTH = Elevated or Upper Normal

Phos = Low or Low Normal

Urine Excretion of Ca = Elevated

What imaging can be done for hypercalcemia

Sestamibi Scan / SPECT

Dual Isotope Scintigraphy

Neck U.S

Sestamibi Scan

A radiotracer imaging study that loss for hyperfunctioning parathyroid tissue

What is a barrier to Sestamibi Scans

Coexisitng thyroid disease will muddy result

Dual Isotope Scintigraphy

A radioactive imaging where isotopes specfiic for the thyroid and parathyroid are used

What is the limitations of neck u/s for hyperparathyroidism

Operator dependent

Difficult with thyroid disease

Osteitis Fibrosa Cystica

A rare condition due to chronic PTH changing the bone

Presentation of Osteitis Fibrosa Cystica

Bone Pain

Fractures

Swelling

Deformity

Imaging Findings of Osteitis Fibrosa Cystica

Brown Tumors

Subperiosteal Reabsorption

Salt and Pepper Skull

Loss of lamina dura of the teeth

Brown Tumors

Areas of demineralization forming bone cysts

Sign of Osteitis Fibrosa Cystica

Where is Subperiosteal Reabsorption for Osteitis Fibrosa Cystica most common

Distal Phalanges

Clavicles

Indication for Conservative Tx of Primary Hyperparathyroidism

Patient > 50

Ca < 12

What is the conservative management of primary hyperparathyroidism?

Limit dietary Ca to 800-1000 mg daily

Physical activity for bone stimulation

Increase fluid

Maintain vitamin D 25-OH

Avoid Ca increasing medications

Follow ionized Ca, PTH, and Cr

Bone Density Scan every 1-2 years

Indications for Primary Hyperparathyroidism surgery tx

Symptomatic

Age < 50

Serum Ca > 12 + 24 hour urine Ca > 400

GFR < 60

Bone Density (DEXA) is at least -2.5 (Osteoporosis)

Pancreatitis

PUD

GERD

Tx of Primary Hyperparathyroidism

Bisphosphonates

Parathyroidectomy

Cinacalcet (If surgery is not option)

Bisphosphonates

A medication that inhibits bone resportion

Cincalcet (Sensipar)

A medication that stimulates CaSR in the parathyroid to inhibit PTH

What should be montiored for Cinacalcet

Serum Ca

Serum PTH

Familial Hypocalciuric Hypercalcemia (FHH)

a autosomal dominant mutation of the CaSR on chromosome 2

Presentation of FHH

Variable

Can be asymptomatic

Can be lifethreat

How will labs reflect FHH

Elevated Ca

Elevated Mg

Normal / Mild Elevated PTH

Hypocalciuria

FeCa < 1%

What cancers often cause hypercalcemia

Prostate

Thyroid

Breast

Lung

Kidney

MM

How does cancer cause hypercalcemia

Metastatic lesion to bone cause release of skeletal Ca

Some lesions also secrete PTHrP

How will labs reflect cancer induced hypercalcemia

Ca > 13

Normal PTH

Cause of Vitamin D Toxicity

Intake of >40,000 U

Granulomatous Disease

Presentation of Vitamin D Toxicity

Hypercalcemia

Kidney Stones

Weakness

Headache

Polyuria

Metallic Taste

Tx for Vitamin D Toxicity

Stop Supplement

Severe Cases = Give glucocortiocoids

What medications cause hypercalcemia

Thiazide Diuretics

Lithium

How does thiazide diuretics cause hypercalcemia

retention of Ca leading to mild hypercalcemia

How does lithium cause hypercalcemia

decreases parathyroid sensivity to Ca

reduces renal excretion of Ca

How do granulomas cause hypercalcemia

They can produce Vitamin D1,25 OH

What granulomatous disease canuse hypercalcemia

Sarcoidosis

TB

How will labs reflect granulomas induced hypercalcemia

High Ca

High Vitamin D 1,25 OH

Low PTH

How does thyrotoxicosis cause hypercalcemia

thyroid hormone having some direct osteoclastic like activity

How will labs reflect hypercalcemia secondary to thyrotoxciossi

High Ca

Low PTH

High Phos

Tx for Thyrotoxicosis Hypercalcemia

Treat the thyroid

What conditions cause hypercalcemia via immoblization

Teens

Paget’s of Bone

Thyrotoxiocosis

How will labs reflect hypercalcemia due to immobilization

High Serum Ca

High Urine Ca

Elevated Alk Phos

Milk-Alkali Syndrome

a triad syndrome

• Hypercalcemia

• Metabolic Alkalosis

• Renal Insufficency

Cause of Milk-Alkali Syndrome

ingesting > 2g of Ca daily with alkali

how will labs reflect milk-alkali syndrome

Elevated Ca

Decreased PTH

Decreased Phos

Increased bicarb

Alkalosis

Who is Milk-Alkali Syndrome commonly seen in

Elderly

Underlying renal disease

Tx for AMS Secondary to Hypercalcemia

Saline Diuresis

Loop Diuretics

Bisphosphonates

Goals for Tx AMS Secondary to Hypercalcemia

Restore Renal Perfusion

Increase Ca Excretion

Decrease Skeletal Resorption