Table of Contents
Definition of Hypercalcemia
Hypercalcemia is a condition in which the serum calcium levels are abnormally high. Hypercalcemia can be:
- Mild: 2.6–2.9 mmol/L
- Moderate: 3.0–3.4 mmol/L
- Severe: > 3.4 mmol/L
Normal Calcium Metabolism
There are 4 parathyroid glands situated at the back of the thyroid gland. These parathyroid glands have chief cells which produce the parathyroid hormone. Parathyroid hormone plays a major role in calcium metabolism. The level of serum calcium is regulated by PTH which is made by chief cells in the 4 parathyroid glands.
The role of calcium in the human body includes:
- Formation and maintenance of bone and teeth
- Role in blood clotting
- Hormone release
- Muscle contraction
- Nerve and brain function
- Enzymatic reaction
The normal calcium level in the body is between 2.2–2.6 mmol/L. When the serum calcium levels are low, PTH secretion is increased to raise the calcium levels to the normal range. PTH increases the serum calcium levels by…
- …increasing the osteoclastic resorption of the bone.
- …increasing the intestinal absorption of calcium.
- …increasing the synthesis of calcitriol which in turn increases absorption of dietary calcium.
- …increasing the renal tubular reabsorption of calcium.
- …increasing excretion of phosphate.
Spread of hypercalcemia
Hypercalcemia is a common condition and is often detected incidentally. Mild asymptomatic hypercalcemia occurs in about 1 in 1000 population. The incidence of hypercalcemia is about 25 to 30 per 100,000 populations. Hypercalcemia is more common among the elderly females.
Etiology of Hypercalcemia
Causes of hypercalcemia
Hypercalcemia is a common condition, which is caused by a bunch of very different diseases. Some of these causes include the following.
This is one of the most common causes of hypercalcemia. Primary hyperparathyroidism and malignancies account for more than 90 % of the cases of hypercalcemia. This is a benign condition causing mild or moderate hypercalcemia.
This is the second most common cause of hypercalcemia. It is very important to exclude malignancy from a patient with hypercalcemia. Malignancy usually causes severe hypercalcemia. There are 2 ways that malignancy can cause hypercalcemia, these include:
- Bone metastasis: Metastasis from breast, multiple myeloma, prostate, lymphoma, thyroid and lungs etc. The metastatic disease to the bone activates osteoclast activity releasing calcium to the serum.
- PTH – like peptide: This is commonly secreted from squamous cell carcinoma mainly of the lungs or esophagus. These cancers secrete PTH – like peptide which act similar to parathyroid hormone by activating osteoclast activity to break down bone and release calcium to the blood.
Granulomatous diseases such as sarcoidosis, tuberculosis, etc.
Sarcoidosis is very common and patients with sarcoidosis develop hypercalcemia by activating vitamin D synthesis via macrophages. They develop hypercalcemia usually in the summer months when they are exposed to sunlight because now they absorb more vitamin D and activate more vitamin D through the macrophages. This type of hypercalcemia is unique because it is treated with glucocorticoids just like the normal cases of sarcoidosis.
People who have been bed bound for a couple of years, develop a mild hypercalcemia. This is benign and often does not require any treatment.
Hyperthyroidism also activates osteoclasts which in turn increases the bone resorption and increased serum calcium.
Familial hypocalciuric hypercalcemia
As the name suggests, this disease runs in families. It is an autosomal dominant condition in which the kidney tubules are unable to get rid of the calcium therefore the calcium levels in urine is reduced and the serum calcium levels are raised. Patients with this disease may have a family history of (unnecessary) parathyroidectomy. The majority of the patients are asymptomatic therefore do not require any treatment.
Thiazide diuretics, chronic lithium administration, vitamin D analogues and vitamin A cause hypercalcemia. Other causes of hypercalcemia include adrenal insufficiency, pheochromocytoma, and parenteral nutrition.
Symptoms of Hypercalcemia
Hypercalcemia can be mild or severe. Mild hypercalcemia (calcium < 3mmol/L) is frequently asymptomatic. Severe hypercalcemia produces a number of symptoms. The clinical presentation can be either acute or chronic.
Acute presentation of hypercalcemia
- GI symptoms: Anorexia, nausea, vomiting, constipation, abdominal pain
- CNS symptoms: Confusion, weakness, lethargy, hyporeflexia, altered mental status, coma
- CVS symptoms: Hypertension, occasional bradycardia, and 1st degree heart block; ECG changes such as shortened QT interval, J waves & widening T waves
- Renal symptoms: Polyuria or nocturia, polydipsia (develop nephrogenic diabetes insipidus; these patients may develop severe dehydration), renal colic (nephrolithiasis)
Chronic presentation of hypercalcemia
- Osteoporosis with bone pain
- Nephrocalcinosis (deposition of calcium in renal parenchyma)
- Band keratopathy (corneal degeneration characterized by calcium deposition)
Investigations of Hypercalcemia
Several serum calcium and phosphate levels should be performed to get a diagnosis of hypercalcemia. To find the cause of hypercalcemia several other tests are done. The serum PTH is:
The most likely cause in this setting is hyperparathyroidism.
Normal or slightly increased
Check the urinary calcium levels. If 24-hour urinary calcium levels are less than 100mcg/d or single urinary calcium creatinine ratio is less than 0.01, suspect familial hypocalciuric hypercalcemia. Otherwise, primary hyperparathyroidism is the most likely cause.
Low or undetectable
This suggests that the parathyroid function is appropriate for the calcium levels. Therefore further testing will be needed to determine the cause of hypercalcemia. These include:
- Protein electrophoresis or immunofixation to exclude myeloma
- Serum TSH to exclude hyperthyroidism
- 09:00 hours cortisol and and/or ACTH test to exclude Addison’s disease
- Raised calcitriol (1, 25 (OH) 2D) in granulomatous diseases
- Serum Angiotensin Converting Enzyme: Raised levels in sarcoidosis
- Evaluate for bone metastasis
- Consider immobilization
- Hydrocortison suppression test: Give the patient 40 mg of hydrocortisone 3 times daily for 10 days leads to suppression of plasma calcium levels in sarcoidosis, Vitamin D mediated hypercalcemia and some malignancies
Differential Diagnosis of Hypercalcemia
- Primary hyperparathyroidism
- Lithium therapy
- Tertiary hyperparathyroidism
- Ectopic PTH secretion (very rare)
Hypercalcemia of malignancy
- Multiple myeloma
- Metastasis to bone
- Breast cancer
High vitamin D levels
- Vitamin D intoxication – Iatrogenic or self-administered
- Granulomatous diseases such as sarcoidosis or TB
- Addison’s disease
- Thiazide diuretics
- Vitamin A
- Vitamin D analogues
- Lithium therapy
- Sever secondary hyperparathyroidism
- Aluminium intoxication
- Milk-alkali syndrome
Management of Hypercalcemia
Treatment of acute severe hypercalcemia
Patients with acute severe hypercalcemia present with dehydration, nausea, vomiting, nocturia and polyuria. Immediate treatment is compulsory if the patient is seriously ill or the serum calcium levels are more than 3.5 mmol/L.
1. IV fluids
This is the most important part of the treatment. Many patients with hypercalcemia are dehydrated due to vomiting and nephrogenic diabetes insipidus. These patients require at least 4–6L of fluid a day to keep them rehydrated. However, there is a risk of fluid overload. So, if the patient develops crackles in the lungs or edema of the legs, give them a shot of Furosemide to reduce the fluid in the body.
2. IV bisphosphonates
Bisphosphonates is an anti resorptive agent which suppresses bone resorption and pushes the serum calcium back into the bone thus reducing the serum calcium levels.
This is the treatment of choice for hypercalcemia of malignancy or an undiagnosed cause. Pamidronate is preferred as it is long acting and the effect lasts at least for 2 weeks. The only problem with this drug is that it takes about 24 to 48 hours for the drug to start working. Zoledronate is an alternative.
Calcitonin can be given together with Pamidronate. Calcitonin inhibits resorption of the bone and increases the renal excretion of calcium. The effect of calcitonin begins within a couple of hours and wears off after about 2 days. Therefore when Calcitonin and Pamidronate are given together, calcitonin begins to act within a couple of hours and after 2 days as its effect wears off, the bisphosphonate begins to act.
Glucocorticoids are effective in vitamin D mediated hypercalcemia such as granulomatous diseases and vitamin D intoxication. Glucocorticoids act by inhibiting the production of calcitriol (1, 25 (OH) 2D).
4. Mobilize the patient