Hypercalcaemia and Hypercalciuria

Jamie
 Calcium Metabolism

Kidney excretes 250 mmol Total Body Calcium

calcium per day and store circa 1kg
resorbes 245 mmol
giving a net loss
of 5 mmol / day Mainly found
in bone
Is Patient truly
hypercalcaemic
Diagnostic Pathway
Measure calcium
Adj Ca < 2.8
and albumin

Adj Ca > 2.8 Adj Ca > 3.5 Life threatening……Bleep Med Reg..

Measure PTH
PTH PTH detectable
undetectable or high…

Why is ca high enough Why is PTH present

Familial
to suppress PTH? Inappropriately?
Hypocalcuric
Hypercalcaemia
Chimpanzees Primary
Hyperparathyroidism
 CHIMPANZEES
CHIMPANZEES
C = Calcium supplementation
H = Hyperparathyroidism
I = Iatrogentic (Drugs such as Thiazides, or Immobility
after surgery)
M = Milk Alkali syndrome
P = Paget disease of the bone
A = Acromegaly and Addison's Disease
N = Neoplasia (common cause)
Z = Zolinger-Ellison Syndrome (MEN Type I)
E = Excessive Vitamin D
E = Excessive Vitamin A
S = Sarcoidosis …well all granulomatous diseases really
 Hypercalcaemia: Clinical Features
Clinical features
• Neurological and Psychological
– Lethergy, confusion, irritability, depression.
• Gastrointestinal
– Anorexia, abdopain, nausea, constipation.
• Renal Features
– Polydipsia, polyuria, urolethiasis
• Cardiac Arrhythmias
 Hypercalciuria
200 mg calcium excreted in urine per 24 hours

Hypercalciuria

Absorptive
Resorptive
Hypercalciuria Renal Leak Hypercalciuria
hypercalciuria
(Type I and II)

Decreased dietary
calcium leads to decreased Obligatory renal Loss Almost always
Urinary calcium hyperparathyroidism

In clinical practice types 1 and 2 often overlap and distinguishing between them
seems like intellectual masturbation as it does not affect therapy as far as I can see
but am prepared to be shot down…
 Treatment Options: Diet
• Limit calcium to 600 – 800 mg daily
• Reduce dietary oxalate levels
• Avoid excessive animal protein (<1.7 g /kg/day)
• Reduce sodium intake
• Increase dietary fiber (12 – 24 g/ day)
• Limit ETOH and Caffine
• Increase fluid intake to manage 2 l urine / day
Treatment Options: Pharmacology
• Absorptive (Type 1)
– Thiazides:
– Orthophosphates (reduce Vit D)
– Calcium Binding Agents (Sodium Cellulose
Phosphate)
• If using SCP then restrict dietary oxalate (as free
intestinal calcium is the natural intra intestinal binding
agent so … SCP can lead to hyperoxaluria.
Hypercalciuria and stone formation