📢 Tweetorial alert🔥 #Medtweetorial
⚡⚡Hypercalcemia: how would u approach and treat❓
Hope, u enjoyed our latest post renalfellow.org/2020/06/17/ske… by Dominique Tomacruz
and VA by Denise Arellano @TheSkeletonKG
💥Let’s discuss hypercalcemia ... more🔏💡
⚡⚡Hypercalcemia: how would u approach and treat❓
Hope, u enjoyed our latest post renalfellow.org/2020/06/17/ske… by Dominique Tomacruz
and VA by Denise Arellano @TheSkeletonKG
💥Let’s discuss hypercalcemia ... more🔏💡
Let’s start with a que
How do you define Hypercalcemia❓
How do you define Hypercalcemia❓
Yup ❗❗U guessed it right ☑️
💥Hypercalcemia is total serum Ca+ > 10.5mg/dl and is classified as
🔆Mild: 10.5 to 11.9 mg/dL
🔆Moderate: 12.0 to 13.9 mg/dL
🔆Hypercalcemic crisis: > 14.0
aafp.org/afp/2003/0501/…
💥Hypercalcemia is total serum Ca+ > 10.5mg/dl and is classified as
🔆Mild: 10.5 to 11.9 mg/dL
🔆Moderate: 12.0 to 13.9 mg/dL
🔆Hypercalcemic crisis: > 14.0
aafp.org/afp/2003/0501/…
♨️Wait a minute
✳️Did u adjust the serum Ca levels (before correction) for serum albumin levels❓
💥Each 1 g/dL ⬇️serum albumin levels ↓⬇️ total Ca by approx 0.8 mg/dL
✳️Did u adjust the serum Ca levels (before correction) for serum albumin levels❓
💥Each 1 g/dL ⬇️serum albumin levels ↓⬇️ total Ca by approx 0.8 mg/dL
📣 Quiz time 🧐!!!!
🔥What is the most common cause of hypercalcemia❓
🔥What is the most common cause of hypercalcemia❓
Your impression is probably correct ☑️
💥Approx 90% of all cases of ↑ Ca are caused by malignancy or HPTH
💥30% of cancer pt have ↑ Ca during the course
💥other causes r hypervitaminosis D, thiazides, renal failure, and rarely familial disorders.
pubmed.ncbi.nlm.nih.gov/1763670/
💥Approx 90% of all cases of ↑ Ca are caused by malignancy or HPTH
💥30% of cancer pt have ↑ Ca during the course
💥other causes r hypervitaminosis D, thiazides, renal failure, and rarely familial disorders.
pubmed.ncbi.nlm.nih.gov/1763670/
💢 Clinical history can help you determine the etiology
In PHPT: ⏫ Ca is generally longstanding, mild and asymptomatic
❇️Malignancy related: assoc. with advanced stages; severe ⏫ Ca
❇️Review all medications (Especially Ca, vit D,thiazides)
❇️Look for prior Ca values
In PHPT: ⏫ Ca is generally longstanding, mild and asymptomatic
❇️Malignancy related: assoc. with advanced stages; severe ⏫ Ca
❇️Review all medications (Especially Ca, vit D,thiazides)
❇️Look for prior Ca values
💥But here is an easy algorithm to assist with further workup 😎
Remember the Foremost step is obtaining the iPTH level
academic.oup.com/ndt/article/33…
Remember the Foremost step is obtaining the iPTH level
academic.oup.com/ndt/article/33…
what symptoms would u expect in pt of hypercalcemia❓
💦 Patients with mild hypercalcemia may be asymptomatic
💢Symptoms may vary from nonspecific N/V ⏭️ neurological such as confusion and even coma🧠 (when ⏫ Ca levels > 14 mg/dl).
💢Symptoms may vary from nonspecific N/V ⏭️ neurological such as confusion and even coma🧠 (when ⏫ Ca levels > 14 mg/dl).
💢 O/E may reveal
🌠CNS: confusion, paresis, hypotonia, Hyporeflexia
🌠GI: Fecal impaction (from constipation), Pancreatitis
🌠CVS: Arrhythmias
🌠Eyes👁️: Band keratopathy
🌠Signs of dehydration, kidney failure, malignancy
🌠CNS: confusion, paresis, hypotonia, Hyporeflexia
🌠GI: Fecal impaction (from constipation), Pancreatitis
🌠CVS: Arrhythmias
🌠Eyes👁️: Band keratopathy
🌠Signs of dehydration, kidney failure, malignancy
what is the mechanism of AKI in hypercalcemia❓
💥 AKI in ⏫ Ca can be due to
🌟Prerenal azotemia
🌟Direct vasoconstrictive effect on arteriolar smooth m/s
🌟⏬ glomerular ultrafiltration coefficient (Kf)
🌟Nephrocalcinosis/Nephrolithiasis
tandfonline.com/doi/full/10.10…
🌟Prerenal azotemia
🌟Direct vasoconstrictive effect on arteriolar smooth m/s
🌟⏬ glomerular ultrafiltration coefficient (Kf)
🌟Nephrocalcinosis/Nephrolithiasis
tandfonline.com/doi/full/10.10…
How do u decide the urgency of Rx in ↑ Ca ❓
🔥Pts with mild ⬆️ Ca (10.5-12 mg/dL) → usually asymptomatic →don’t require acute Rx
✳️Treat the cause
✳️Avoid dehydration/Advise pt to drink fluids approx 3 l /d (maintain U.O of 2 to 2.5l.
✳️Avoid immobilization
✳️Treat the cause
✳️Avoid dehydration/Advise pt to drink fluids approx 3 l /d (maintain U.O of 2 to 2.5l.
✳️Avoid immobilization
🔥First step🔥
💦Restore ECV with IV fluids.
💦 Give 0.9% NS, 200-250 mL/h
💦Target adequate U.O. (>100 ml per hour)
✳️It induces calciuresis , ⬇️ Ca by 1 to 3 mg/dL
Don’t forget to monitor pt’s volume status
💦Restore ECV with IV fluids.
💦 Give 0.9% NS, 200-250 mL/h
💦Target adequate U.O. (>100 ml per hour)
✳️It induces calciuresis , ⬇️ Ca by 1 to 3 mg/dL
Don’t forget to monitor pt’s volume status
♨️Why so much fluids?
Because Pts with ⬆️Ca r usually profoundly volume depleted,
Wondering why❓
⬆️Ca -induce
❇️Nausea and vomiting
❇️Nephrogenic DI
❇️Activation of CaSR in TALH → natriuresis &↑ vol. depletion
karger.com/Article/PDF/16…
Because Pts with ⬆️Ca r usually profoundly volume depleted,
Wondering why❓
⬆️Ca -induce
❇️Nausea and vomiting
❇️Nephrogenic DI
❇️Activation of CaSR in TALH → natriuresis &↑ vol. depletion
karger.com/Article/PDF/16…
🌟 U can consider loop diuretics (Forced saline diuresis)
⏭️ Inhibit NKCC2 in TALH ⏭️ ⬆️ urinary Ca excretion
🔥Important facts
🌠Reserved for volume overloaded pts
🌠High doses r required
🌠Monitor electrolyte / U.O
pubmed.ncbi.nlm.nih.gov/18711156
⏭️ Inhibit NKCC2 in TALH ⏭️ ⬆️ urinary Ca excretion
🔥Important facts
🌠Reserved for volume overloaded pts
🌠High doses r required
🌠Monitor electrolyte / U.O
pubmed.ncbi.nlm.nih.gov/18711156
☀️Other adjunctive agent is
Calcitonin💉
💫Dose - 4–8 U/kg im/s.c
💫Rapidly ⬇️Ca within 6hr
💫osteoclast bone resorption
💫Effect is limited due to tachyphylaxis ( within 48 hours)
Calcitonin💉
💫Dose - 4–8 U/kg im/s.c
💫Rapidly ⬇️Ca within 6hr
💫osteoclast bone resorption
💫Effect is limited due to tachyphylaxis ( within 48 hours)
💢Bisphosphonates
☀️Highly effective in malignancy-associated ⬆️ Ca
☀️⬇️ osteoclast activity and ⬇️bone resorption
☀️Look for S/E like ⏬ Mg and ↓⏬PO4
🔥Dose adjustment as per KFT
Here is dosing for i.v bisphosphonates used in Rx 👇👇
cjasn.asnjournals.org/content/7/10/1…
☀️Highly effective in malignancy-associated ⬆️ Ca
☀️⬇️ osteoclast activity and ⬇️bone resorption
☀️Look for S/E like ⏬ Mg and ↓⏬PO4
🔥Dose adjustment as per KFT
Here is dosing for i.v bisphosphonates used in Rx 👇👇
cjasn.asnjournals.org/content/7/10/1…
When do u use HD in management of hypercalcemia❓
Volume overload
Oliguria
All of the above
Volume overload
Oliguria
All of the above
💥HD with ⏬Ca dialysate (≤1 mmol/L) is an effective measure in pts with acute ⬆️Ca, refractory to other therapies, and associated with significant AKI with oliguria and volume overload
💢 Now, let’s discuss role of steroids 🤔
✳️Useful in case of hematological malignancy and granulomatous disorders,
✳️MOA: Inhibit 1 a-hydroxylase, ↓ Ca absorption
✳️Useful in case of hematological malignancy and granulomatous disorders,
✳️MOA: Inhibit 1 a-hydroxylase, ↓ Ca absorption
Other rarely used agents :
💦Denosumab (Mab against RANKL)
❇️Useful in refractory and malignancy a/s ↑ Ca
No dose adjustment in Kidney failure, but monitor for low Ca
💦 Gallium nitrate ( in hypercalcemia of malignancy)
🔥 Can be nephrotoxic
ajkd.org/article/S0272-…
💦Denosumab (Mab against RANKL)
❇️Useful in refractory and malignancy a/s ↑ Ca
No dose adjustment in Kidney failure, but monitor for low Ca
💦 Gallium nitrate ( in hypercalcemia of malignancy)
🔥 Can be nephrotoxic
ajkd.org/article/S0272-…
🔥My favorite part 🙂
Let us summarize all agents 👇👇
Let us summarize all agents 👇👇
"🔥Stones, bones, groans🔥". Give a read to an interesting case oF hypercalcaemia on @RenalFellowNtwk by @TheSkeletonKG @DTomacruzMD
renalfellow.org/2020/07/20/ske…
renalfellow.org/2020/07/20/ske…
• • •
Missing some Tweet in this thread? You can try to
force a refresh
