A patient is admitted to ICU because of severe symptomatic hypercalcaemia. List the manifestations and common causes. It is found to be due to metastatic carcinoma of the breast. How should the hypercalcaemia be treated?
(see J Am Soc Nephrol 2001; 12: S3-9) (a) Manifestations include
-kidney: polyuria, polydipsia, muscle weakness, oliguria, renal failure
-GIT : anorexia, nausea, vomiting, constipation
-CNS : weakness, lethargy and depression
-CVS : hypertension, shortened QT
-Musculoskeletal: bone pain
-hyperparathyroidism (primary, secondary, tertiary)
-Vit D intoxication
-recovery stage of pancreatitis or rhabdomyolysis.
(b) Treatment, if due to metastatic carcinoma of breast:
- rehydration with saline
- frusemide if fluid overloaded
- aggressive diuresis has a limited potential to remove calcium and may lead to renal dysfunction if inappropriate negative fluid balances ensues.
- Bisphosphonates are first line therapy in malignancy. They prevent osteolysis
- Calcitonin may be adjuvant
- Haemodialysis may be necessary if acute oliguric renal failure occurs.
This question closely resembles Question 8 from the second paper of 2000 (How would you determine the aetiology of severe hypercalcaemia? List the treatments appropriate for each aetiology) and Question 9 from the second paper of 2013 (List the clinical features of severe symptomatic hypercalcaemia and outline the treatment of this condition).
Question 18.1 from the the first paper of 2011 also deals with hypercalcaemia of malignancy, but in the context of a clinical scenario.
Causes and consequences of hypercalcemia are treated in slightly greater detail elsewhere.
Primary endocrine causes
Random miscellaneous causes
Early manifestations (levels < 3.5mmol/L)
Late manifestations (levels over 3.5mmol/L)
- Dilute serum calcium
- Rehydration with IV fluids
- Decrease calcium resportion from bone
- Gallium nitrate
- Decrease calcium resportion from renal tubule
- Loop diuretics (this has fallen out of favour)
- Decrease calcium absorption from the gut
- Corticosteroids (also they decrease the 1,25-dihydroxyvitamin D production by monocytes within granulomae)
- Forcibly remove excess calcium from the circulation
- EDTA administration (as chelating agent)
Laupacis, Andreas, and Dean Fergusson. "Drugs to minimize perioperative blood loss in cardiac surgery: meta-analyses using perioperative blood transfusion as the outcome." Anesthesia & Analgesia 85.6 (1997): 1258-1267.
Levi, Marcel, et al. "Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints." The Lancet 354.9194 (1999): 1940-1947.