Today, I review, link to, and excerpt from The Curbsiders‘ #281 Hypercalcemia: Calci-fun! with Dr. Carl Pallais. June 28, 2021 | By Nora Taranto.*
*Credits
- Producer, Writer, Infographic, Cover Art: Nora Taranto MD
- Hosts: Matthew Watto MD, FACP; Nora Taranto MD
- Reviewer: Yan Emily Yuan MD, MSc
- Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com
- Guest: Carl Pallais MD, MPH
All that follows is from the above resource.
Absorb all (but not too much) of the Calcium for your brain hole as Dr. Carl Pallais (Brigham and Women’s Hospital) walks us through his approach to Hypercalcemia. We learn about how tightly our body regulates calcium and what to do when that regulation goes awry. Not to mention that PTH is the name to remember (and phosphorus, if you need a quick stand-in while that PTH is pending).
Show Segments
- Intro, disclaimer, guest bio
- Dr. Pallais One-Liner
- Case from Kashlak
- Definitions: What’s a Normal Calcium Level, and how to adjust for Albumin
- Causes of hypercalcemia
- How Lithium works!
- Testing for Hypercalcemia: Get that PTH, and that phos
- Symptoms of Hypercalcemia, and Questions on History
- Indications for Surgery for Parathyroidectomy
- Management of Hypercalcemia and Hypercalcemic Emergency
- Outro
Hypercalcemia Pearls
- In interpreting serum calcium, always correct for Albumin. Add 0.8 g/dL to the Calcium level for every point drop in Albumin.
- Only order ionized calcium levels in the inpatient setting (In ambulatory labs, samples may sit out for some time, which can artificially change the result).
- Ask your hypercalcemic patients about Calcium/Vitamin D supplementation, calcitriol, Thiazides, and Lithium. Remember the stones (kidney), bones (fractures), groans (GI), and psychiatric overtones (depression, fatigue, coma) of hypercalcemia!
- When you see elevated calcium, check basic metabolic panel, phosphorus, albumin, PTH, and 25-OH Vitamin D to start.
- The first goal in working up hypercalcemia is to determine if it is PTH-mediated. A phosphorus level is a quick marker of whether PTH is turned on or off. (Phosphorus Low = PTH receptors may be activated, either by PTH or PTHrP; calcium supplements can also lower phosphorus levels).
- Check kidney function when you see hypercalcemia because kidney injury can prevent calcium excretion and make fluid resuscitation difficult.
- The mainstay of treatment for Hypercalcemia is Fluids. Use furosemide if needed to keep patients from becoming volume overloaded as you give fluids.
- Many medications will “unmask” primary hyperparathyroidism, which was brewing in the background before. A true increase in Calcium on a Thiazide or Lithium with a normal to elevated PTH may represent hyperparathyroidism. Thus, monitoring and surgical intervention may be warranted.
- To Risk Stratify Asymptomatic Primary Hyperparathyroidism: Do a 24-hour urine collection (to measure urine calcium along with creatinine), renal imaging (to assess for stones), a bone density (include wrist/spine), and spine imaging (to assess for asymptomatic vertebral fractures).
Hypercalcemia Show Notes
Start Here.
