Acute renal failure and unknown cause hypercalcemia (case report)

Transcription

1 Acute renal failure and unknown cause hypercalcemia (case report) Clinic for hemodialysis CCU Sarajevo

2 ... What is hypercalcemia???

3 ... What is hypercalcemia??? The definition of hypercalcemia is having an abnormally high concentration of calcium in blood Calcium helps your body to maintain your bones. It also plays an important role in contracting muscles, releasing hormones and ensuring that your nerves and brain function properly. Hypercalcemia is defined as total serum calcium > 10.2mg/dl (>2.5 mmol/l) or ionized serum calcium > 5.6 mg/dl (>1.4 mmol/l) Severe hypercalcemia is definied as total serum calcium > 14mg/dl (>3.5 mmol/l) Hypercalcemic crises is present when severe neurological symptoms or cardiac arrhythmias are present in a patient with a serum calcium>14 mg/dl (>3.5 mmol/l)

4 ... What is hypercalcemia???

5 What are the symptoms???

6 Causes Complications

7 The path to the diagnosis

8

9 ... What is the differential diagnosis of hypercalcemia???... PTH-mediated (high, normal PTH) Primary hyperparathyreoidism (sporadic) Familaial MEN-I and Iia FHH Tretiary hyperparathyreodism PTH-independent (low PTH) Hypercalcemia of malignancy Vitamin D intoxication Chronic granulomatous disorders Medications (Thiazide diuretics, Lithium, Teriparatide, excessive Vitamin A, Theopylline toxcity)

10 When hypercalcemia is combined with an acute kidney injury, it significantly narrows the differential diagnosis. We present a case of hypercalcemia and acute renal failure in a patient with multiple unusual laboratory findings, attention to which was critical in establishing a correct diagnosis.

11 Hypercalcemia can result from excessive bone resorption, renal calcium retention, excessive intestinal calcium absorption, or a combination of these conditions. Hypercalcemia may also provoke acute renal failure (ARF) or hypertension, or aggravate the tubular necrosis that is frequently found in cases of ARF. Moysés-Neto M, Guimarães FM, Ayoub FH, Vieira-Neto OM, Costa JA, Dantas M. In an orginal aritcle Acute renal failure and hypercalcemia showed that ARF associated with hypercalcemia was related with comorbidity in all cases (cancer, multiple myeloma, hyperparathyroidism, sarcoidosis, vitamin D intoxication, and leprosy). Different kinds of treatment induced a rapid fall in serum calcium concentration. All patients were treated with hydration and diuretics, and three patients also received calcitonin. Serum creatinine concentration always fell simultaneously with the decrease in serum calcium in all cases. All patients progressed with non-oliguric renal failure.

12 In acute renal failure(arf), patients are frequently hypocalcemic. But... There is no rule without any exeption!!! Usually, the presence of hypercalcemia associated with ARF is indicative of the presence of comorbidity * *Moysés-Neto M, Guimarães FM, Ayoub FH, Vieira-Neto OM, Costa JA, Dantas M. Acute renal failure and hypercalcemia

13 CASE REPORT

14 ... CASE REPORT... A 70-year-old man presented to the our department of Clinic for hemodialysis with complaint of substernal chest pain for week ago. Chest pain was described as being sharp, 7/10 in intensity, being non-radiating, and being with no aggravating or alleviating factors. Chest pain was associated with dyspnea and that was a reason for hospitalization on Clinic for pulmonary deaseas. After diagnostic procedure we found the pulmonary embolism (CT verificated). Also we found elevated calcium levels, anemia, and acute kidney injury. The hypercalcemia persisted despite therapy with fluids and bisphosphonates 5 years ago. He was found to have nonparathyroid hormone (PTH) mediated hypercalcemia years ago.

15 On review of systems, patient denied any fever, chills, cough, abdominal pain, myalgia, arthralgia, rash, or weight loss. His medical comorbidities included hypertension, dislipidaemia and diabetes mellitus. He was an ex-smoker and did not use any recreational drugs or alcohol.

16 ... CASE REPORT... His physical examination at the time of admission revealed a disoriented and confused elderly man. He was oriented to only his name. Initial vital signs showed temperature 36.7 degrees C, pulse 90 beats per minute, respiratory rate 16 breaths per minute, and blood pressure 150/80 mm of hg, with an oxygen saturation of 100% on room air. He had dry oral mucous membranes and a poor skin turgor. Pupils were equally round and reactive to light and accommodation. There was no jugular venous distention. Chest exam showed atonic bilateral air entry with rare expiratory whistles. Cardiovascular exam showed normal heart sounds without murmurs, gallops, or rubs. Abdomen was soft, with no visceromegaly and with normal bowel sounds. Extremities were warm and well perfused without edema, cyanosis, or clubbing.

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18 Table No 2 curve of calcium level in serum 5 4,5 4,6 4 3,97 3,5 3,49 3,33 Ca 3 2,99 2,

19 The patient presented with classical symptoms of a hypercalcemic syndrome and acute renal failure, serum calcium and parathyroid hormone levels were 3.97 mmol L(-1) and 1261 pg/m L(-1), and urea was 43,7 mmol/l, creatinine was 651 mmol/l respectively. In addition to the basic labs, the X ray hands and chest organs, Neck US and MRI were performed, as well as endocrinologists consultation. Ultrasound showed hypo echoic oval to round area of diameter up to 5.2x5.3 mm in the upper and dorsal right half of the right which most likely corresponds to the increased parathyroid gland not recorded by the MRI. Bone digestion markers were: P1-NP 183 ng / ml, beta cross plasma 1.40 ng / ml and osteocalcin 114ng/ml. Parathyroid area scintigraphy indicated an enlarged right upper parathyroid gland

20 ... How we treated the patient... He was treated with massive intravenous normal saline hydration of 200 ml per hour and furosemide. He had an adequate urine output (4.0 cc/kg/hr). After 12 hours of treatment, serum ionized Ca level was still elevated (3.49/3.33 mmol/l). Hemodialysis was performed using a low-ca dialysate to relieve hypercalcemia. After stabilizing the patient and reducing the calcium levels ( Ca 2.99 mmol/l), patient had 4 hemodialysis and parathyroidectomy afterwards.

21 ... DISSCUSION...

22 ... Disscusion... In acute renal failure(arf), patients are frequently hypo-calcemic. But... There is no rule without exception!!! Usually, the presence of hypercalcemia associated with ARF is indicative of the presence of comorbidity * Moysés-Neto M, Guimarães FM, Ayoub FH, Vieira-Neto OM, Costa JA, Dantas M. Acute renal failure and hypercalcemia

23 ... Disscusion... In this report, we described a case of a 70 yeras old man with severe hypercalcemia refractory to volume expansion, loop diuretics, bisphosphonates and hemodialysis with PTH concentrations in excess of 1261 pg/ml. Diagnostic evaluation confirmed the presence of a hypo echoic oval to round area of diameter up to 5.2x5.3 mm in the upper and dorsal right half of the right which most likely corresponds to the increased parathyroid gland not recorded by the MRI. HPT and hypercalcemia resolved rapidly following adenoma resection.

24 We believe that our patient's findings reflect the most severe clinical manifestations of primary (in contrast to tertiary) HPT ever described in a patient with ARF While HPT caused by parathyroid adenoma is common, this case is novel for several reasons. First, severe hypercalcemia is rare in primary HPT. This degree of hypercalcemia results only when primary HPT is exceptionally severe (this case) or when tertiary HPT (autonomous PTH hypersecretion after long-standing renal insufficiency) develops. Vasoconstriction induced by severe hypercalcemia is an important contributing cause of the acute renal failure observed in this patient. The resultant decline in glomerular filtration rate (GFR) most likely accounted for his normal to slightly elevated serum phosphorus concentrations, which are typically low normal in primary HPT.

25 Disease Sarcoidosis Multiple myeloma In the setting of hypercalcemia where primary or tertiary HPT Lymphoma is suspected, physicians should investigate other etiologies Other (e.g. malignancy, thiazide or lithium use, milk alkali syndrome, malignancy hyper-vitaminosis D and granulomatous disease) in addition to Drugs (e.g. HPT. Iatrogenic hypercalcemia can also result from use of thiazides, high-dose oral calcium and activated vitamin D derivatives, lithium) which are commonly given to patients with end-stage renal Hypervitaminosis D disease but are rarely used in patients with lesser degrees Thyrotoxicosis of impaired kidney function. Primary HPT PTH concentration Low Low Low Low Low Low Low High Table 3 PTH concentrations in various etiologies of hypercalcemia

26 ... Disccusion... Second, the markedly elevated PTH concentration (>1200 pg/ml) observed in this case is more typical of secondary (or tertiary) HPT If HPT is confirmed, secondary HPT should be entertained like in our case. Subtotal parathyroidectomy should be considered in patients with signs or symptoms referable to HPT, including calcific uremic arteriolopathy (calciphylaxis), fracture, bone pain, myopathy, neuropathy, recalcitrant pruritus or refractory hypertension.

27 ... Take a home message... All physicians encountering patients with HPT must be familiar with the multiple etiologies of hypercalcemia and understand that ionized calcium is typically maintained in the normal range unless CKD is quite advanced (GFR well below 30 ml/min/1.73 m2). While uncommon, hypercalcemia and HPT may exist concurrently from unrelated etiologies. Malignancies, including multiple myeloma, non-hodgkin's lymphoma and tumors metastatic to bone can lead to frank or relative hypercalcemia. However, elevated PTH concentrations typically only occur with concomitant primary HPT (adenoma, carcinoma), and current assays are able to distinguish PTH from rare PTH-related peptide-secreting neoplasms. Thiazide diuretics, oral calcium supplementation (including milk alkali syndrome) and hyper-vitaminosis D can also result in iatrogenic, PTH-independent hypercalcemia.

28 ... Take a home message... Rapid diagnosis and rapid treatment start of hypercalcemia has vital importance. Hypercalcemia and acute renal failure requires intensive hydration, daily hemodialysis and preservation of diuresis, as well as diagnosing the causes of hypercalcemia.

29 ... Thank you for your attention!!!...