1. Speaker: Dr. Dibbendhu Khanra
Chairperson: Dr. A.K. Banerjee

2. Calcium
an unparallel hero
 most abundant mineral of body
 maintenance of strong bones
 neuro-mascular action
 blood clotting, blood pressure
 hormone regulation
-most over-the-counter sold drug
- 43% Indian women on supplement
- prescribed by doctors commonly

3. Calciuma sinister in disguise
HypercalcaemiaToday’s concern!
..Some cases..
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4. Mr. K is a 41 year old patient
– Mild depression
– Behavioral abnormality
– Headache
– Fatigue
– Difficulty concentrating
– TSH - 2.06 (0.5 – 4.00)
– calcium 12.4 mg/dl
(8.4 – 10.4 mg/dl)

5. 
Mrs. C is a 57 year old patient, well

t-score – 1.3 (spine), 2. 8 (femur)

Calcium – 12. 5 (8.4 – 10.4 mg/dl)

weight loss and generalised weakness

Cough and hemoptysis

6. •
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A 58-year-woman presented to ER
progressive Multiple sclerosis
Osteoporosis
calcium, 600 mg, 3 times daily
5000-IU cholecalciferol supplement OD
tremors
Altered sensorium
serum calcium 15.2 mg/dL

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30-year-old female
Fever, cough
Polyuria, polydypsia, GI upset
constipation, confusion, headache
CECT chest – hilar lympahedenopathy
serum calcium, 13.8 mg/d

8. •
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50-year-old male
Diabetic for 10 years
Poorly controlled with OHA
HTN, anasarca, anaemia
serum calcium 14.8 mg/d

9. 


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

Calcium metabolism
Defining hypercalcaemia
Causes of hypercalcaemia
Cl/f of hypercalceimia
Diagnosis to hypercalcaemia
Management

10. 10

11. 11

13. 13

14. Causes
PTH
Genetic
 Ca++
Vitamin
D
Endocrine
Malignancy
Medicines

15. Renal
‘stone’
Abdominal
‘moan’
Skeletal
‘bone’
Psychis
‘groan’
Also…
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16. Digitalis toxicity

17. A = high calcium levels means
primary hyperparathyroidism
unless the PTH is near zero
B = normocalcemic" hyperparathyroidism.
this is the only group that we believe should
have a urinary calcium level performed

18. It is IMPOSSIBLE to tell the difference between
FHH and primary hyperparathyroidism
based upon the results of a 24-hour urine test
1. Urinary calcium can be
anything (very low to very high)
in Pr HyperPTHism.
2. The arbitrary cut off of urinary
ca excretion/ 24 hr 100 lacks any
rationality.
3. Nor elevated serum ca neither
elevated urinary ca has any
association with renal stones.
4. Low urinary ca does not always
mean FHH.
FHH is so rare, that few doctors will ever see it.
FHH is diagnosed incorrectly about 95-99% of the time

19. Corrected serum calcium=
Ionized calcium + 0.8(4-serum albumin)
calcium is high and PTH
is high, d/g is primary
hyperparathyroidism.
IF calcium Familial
is mildly
Hypocalciuric
raised in background of
Hypercalcemia
Sestamibi
highly
elevated
N-scan
PTH, then urinary ca can
be ordered to rule out
FHH
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20. Neuropsychiatric complaints
Calcium 12.4 mg/dl
iPTH – 509 (12-72 pg/ml)
Thallium subtraction study:
Left lower lobe parathyroid adenoma

21. Weight loss and generalised weakness
Calcium – 12. 5 (8.4 – 10.4 mg/dl)
iPTH 21 (10 – 65.0 pg/ml)
PTHrp - elevated
Lung biopsy with IHC:
Well differentiated, low grade squamous cell lung carcinoma

22. •
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calcium, cholecalciferol supplement
serum calcium14.6 mg/dL (15.2 mg/dL)
iPTH - 4 pg/mL (N12-65 pg/mL
25-OH D level 103 ng/mL (N>30 ng/ml)
Vit D overdose
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23. •
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CECT chest – hilar lympahedenopathy
serum calcium, 13.8 mg/d
iPTH - 4 pg/mL (N12-65 pg/mL
1, 25-OH D level elevated
Serum ACEase – highly raised
Hilar LN Bx – non caseating granulomas
Sarcoidosis
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24. •
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T2DM
CKD
serum calcium 14.8 mg/d
iPTH – 209 (12-72 pg/ml)
Hypercalcemia Associated with Renal Failure

25. Hypercalcemia Associated with Renal Failure
Secondary Hyperparathyroidism
Hypocalcaemia is the common denominator
Reversible (adaptive) growth of parathyroid gland
• Resistance to the normal level of PTH
• Increased level of FGF23
• Reduction in 1,25(OH)2 vitamin D
Tertiary Hyperparathyroidism
• Long-standing, inadequately treated chronic renal failure
• True clonal outgrowth (irreversible)
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26. Observation
Pharmacological
Non
Pharmacological
Surgery
Dialysis

27. Critical - > 14 mg %
1
Moderate - 12 to 14 mg %
2
Mild – 10.4 to 11.9 mg %
3
• Aggressive therapy
• Start therapy
• When symptomatic
• When PrHyperPTHism
• No therapy
• Except PrHyperPTHism
Normal – 8.5 to 10.3 mg %
Hypercalcaemia should always be treated
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28. - thiazide and lithium
- volume depletion
- prolonged bed rest or inactivity
- high calcium diet (>1000 mg/day)
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29. A
B
I.V. Saline
Hydration
Bisphosphonates
Dexa
methasone
Calcitonin
D
C
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30. Dr. Harold Copp isolated
calcitonin from salmon sperm

31. Bisphos
phonate:
MOA
Osteonecrosis
of Jaw (ONJ)
mandible > maxilla
Matrix metalloproteinase 2

32. Treating hypercalcaemia is multidrug approach
In HF, CKD; lowers ca by 1-3 mg/dl
Routine use not recommended
Do not give bisphosphonates until patient is fully rehydrated
contraindicated in patients with cr cl <10 mL/min
Caution with NSAIDS, ACE inhibitors, aminoglycosides
Calcitonin and hydration provide a rapid
reduction, while a bisphosphonate provides a sustained
effect

33. Monitoring
Surgery
• Serum calcium level
 Mildly elevated calcium
> 1 mg % above normal
 No previous episodes of
• Creatinine clearance
life threatening
hypercalcemia
< 60 ml/minute
 Normal renal function
• Bone density: T score <–2.5
 Normal bone status
at Any of 3 sites
• Age younger than 50 years
Serum ca
serum creatinine
Bone density
Significant symptoms
– Rx surgery
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34. Minimally Invasive Parathyroidectomy (MIP)
 an outpatient procedure
 Pre-op localization with Sestamibi Tc scan
 cervical block anesthesia
 minimal surgical incision
 Intra-op PTH level obtained before and 5 mins after removal
 If PTH levels fall by greater than 50% operation terminated
 IF PTH Levels fall by less than 50%, full neck exploration
 clear-cut cost benefit
 Accepted in asymptomatic patients
 not proper for multiple tumour or large tumours

35. • If an enlarged gland is found, a
• all four glands be
normal gland should be sought.
sought
• if an intra-operative frozen
section biopsy of a normal-sized • most of the total
parathyroid
tissue
second
gland
confirms
its
mass be removed.
histologic normality, no further
exploration, biopsy, or excision is • unnecessary surgery
& un-acceptable rate
needed.
of hypoparathyroidism
• recurrence
rate
of
hyperand hypocalcamia.
parathyroidism may be high if a
second abnormal gland is
missed.
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36. • totally remove three
glands with partial
excision of the fourth
gland
• care is taken to leave
a good blood supply
for the remaining
gland
• total parathyroidectomy with
immediate transplantation of
a portion of a removed,
minced parathyroid gland
into the muscles of the
forearm
• surgical excision is easier
from the ectopic site in the
arm if there is recurrent
hyperfunction
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37.  calcium 12.4 mg/dl
(8.4 – 10.4 mg/dl)
 parathyroid adenoma
 M/N= Surgery (MIP)

38.  Malignancy related
hypercalcaemia
(Breast, Lung, Lymphoma,
Thyroid, Kidney, Prostate,
Multiple Myeloma)
 N Saline
 calcitonin
 Zoledronic acid

39. • Vit D overdose
• Half life of Vit D is very short
no further treatment required
• Withhold Vit D
• Steroid can be used
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40. •
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Acute symptomatic hypercalcaemia
Sarcoidosis (granulomatous disease; DHCC related)
NS
Steroid
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41. • Hypercalcemia Associated with Renal Failure
• Secondary hyperparathyroidism
• calcitriol

42. • Dialysis if life threatening
Secondary hyperparatyroidism
• restriction of dietary phosphate,
• the use of non-absorbable antacids
• careful, selective addition of calcitriol
Tertiary Hyperparatyroidism
• Partial removal of parathyroid gland
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43. S
U
M
M
A
R
Y
Dialysis
Controversial
Malignancy or Vit D
associated cases
Avoid factors
that can
aggravate
hypercalcemia
In CKD
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44. • Most common cause of hypercalcaemia is primary
hyperparathyroidism
• Any hypercalcaemia should be worked up and treated.
• First investigation to seek for is an intact PTH
• Surgery is often provided to apparently aysmptomtic
patients of primary hyperparathyroidism
• FHH, practically does NOT occur
• Hydration is the mainstay of therapy
• Managing hypercalcaemia is a multidrug approach
• Calcitriol can be given in CKD associated hypercalaemia

45. THANK YOU
ddk3987@gmail.com
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