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Approach to a Patient of Hypercalcemia

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Dr P Velayutham, Coimbatore    20 November 2018

  1. Hypercalcemia is defined as serum calcium levels more than 2 SD above mean. Serum calcium in normal adults is between 8.6 and 10.4 mg/dL. Severe hypercalcemia refers to serum calcium >14 mg/dL. Hypercalcemic crisis refers to serum calcium >14 mg/dL with neuro, cardiac, renal symptoms.
  2. For every 1 g/dL drop in serum albumin below 4 g/dL, measured serum calcium decreases by 0.8 mg/dL.
  3. Corrected calcium = Measured Ca + (0.8 × [4 - albumin]).
  4. Ambient pH influences protein-binding to calcium. Metabolic acidosis –Decreased protein binding -------- increased ionized calcium; metabolic alkalosis – increased protein binding -------------- decreased ionized calcium.
  5. Fall in pH by 0.1 increases serum calcium by 0.4 mg/dL.
  6. Clinical symptoms of hypercalcemia (acute) – General: Fatigue, weight loss; CVS: Short QT, arrhythmia, syncope; GI: Anorexia, nausea and vomiting, constipation, pancreatitis; Renal: Polyuria, dehydration, AKI, renal stones; Others: Bone pain, irritability, psychosis.
  7. Lab pitfalls in primary hyperparathyroidism (PHPT) – Low Ca and high phosphorus diet can obscure hypercalcemia; Very low vitamin D status can obscure hypercalcemia; Low vitamin D can be a manifestation of PHPT; Hypercalcemia can be masked if presentation is with acute pancreatitis; Intact PTH can be high normal in 10-15% of the people with PHPT; High Ca and high iPTH can be seen in 20% familial hypocalciuric hypercalcemia (FHH).
  8. Correct calcium levels for prevailing serum albumin. PHPT and malignancy account for most of the cases with hypercalcemia. Use of multiple variables helps in arriving at diagnosis easily.
  9. Hypercalcemic crisis requires urgent medical intervention.

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