Clinical Aspects of Hypercalcaemia Flashcards
What are the different levels of acute hypercalcaemia?
- < 3mmole/L - asymptomatic
- 3-3.5mmole/L - well tolerated if risen slowly, but may be symptomatic requiring prompt treatment
- > 3.5mmole/L - urgent correction and risk of dysrhythmia and coma
What are the four categories of causes of hypercalcaemia?
- Parathyroid mediated
- Non-parathyroid mediated
- Medication
- Miscellaneous
What are the parathyroid causes of hypercalcaemia?
- Primary hyperparathyroidism (sporadic)
- Familial hypocalciuric hypercalcaemia
- Tertiary hyperparathyroidism (renal failure)
What are the non-parathyroid causes of hypercalcaemia?
- Hypercalcaemia of malignancy
- Vit D intoxication
- Chronic granulomatous disorders
- Chronic granulomatous disorders (sarcoid, TB)
What are the medications that can cause hypercalcaemia?
- Thiazide diuretics
- Lithium
- Teriparatide
- Excess Vit A
What are the miscellaneous causes of hypercalcaemia?
- Hyperthyroidism
- Acromegaly
- Pheochromocytoma
- Adrenal insufficiency
What are the clinical features of hypecalcaemia?
Renal:
• Polyuria (urine ++)
• Polydipsia (thirst ++)
• Nephrolithiasis (kidney stones)
GI:
• Anorexia
• Nausea + vomiting
• Constipation
MSK:
• Muscle weakness
• Osteopenia/osteoporosis
- Decreased concentration
- Shortened QT interval
What is the saying to remember clinical features of hypercalcaemia?
Bone, stones, groans and psychic moans
- Nausea, vomiting (groans)
- Personalty changes
What are the two main causes of hypercalcaemia?
Primary hyperparathyroidism (sporadic) or Hypercalcaemia of malignancy
What do you need to look for in the history and examination of hypercalcaemia?
History: • Symptoms of hypercalcaemia • Systemic enquiry • Medications • FH
Examination:
• Lymph nodes
• Concerns about malignancy (breast, lung etc.)
What investigations are used for hypercalcaemia?
- U+Es
- Ca
- PO4
- Alk phos
- Myeloma screen
- Serum ACE (screen for sarcoidosis)
- PTH!!
- Consider ECG
After confirming hypercalcaemia, what is the first investigation?
- Recheck Ca and albumin, ensure corrected calcium calculated
- Check PTH
If PTH is normal or high, what are possible causes?
Primary hyperparathyroidism or Familial hypocalciuric hypercalcaemia (rare) or tertiary hyperparathyroidism (renal failure)
If PTH is low, what are possible causes?
Malignancy or drug causes
What are the features of primary hyperparathyroidism ?
- Most are asymptomatic
- Most are sporadic but linked to neck irradiation or prolonged lithium use
Causes: • Parathyroid adenoma • Four gland hyperplasia (• MEN type 1 or 2A) (• Parathyroid carcinoma)
What are the investigation of primary hyperparathyroidism?
- Ca, PTH
- U+Es (renal function)
- Abdominal imagining (renal calculi)
- DEXA: osteoporosis
- 24hr urine collection for Ca (exclude FHH)
- Vit D
What abdominal imaging is used for primary hyperparathyroidism?
- (Para)thyroid ultrasound
- Nuclear medicine scan - give tracer and abnormal gland will take it up
- 4D-CT
When is surgery indicated in primary hyperparathyroidism?
- Symptoms due to hypercalcaemia
- Serum Ca
- Osteoporosis
- Kidney stones
- < 50yrs
What is the treatment for primary hyperparathyroidism?
- Generous fluid intake (for polyuria)
- Cinacalet (mimics effect of Ca on chief cells to decrease release of PTH)
- Surgery
What is Familial Hypocalciuric Hypercalcaemia?
Autosomal dominant disorder of the calcium sensing receptor
PTH may be normal or slightly elevated, and high Ca as not excreted via kidneys
What is the investigation and treatment of FHH?
Positive family history, screen young family members for diagnosis.
Benign, no therapy indicated.
What must be excluded before surgery for hyperparathyroidism?
Familial hypercalciuric hypercalcaemia
What are the two types of multiple endocrine neoplasia?
MEN type 1 and type 2A
What can multiple endocrine neoplasia cause?
Primary hyperparathyroidism
