Haematological emergencies managing hypercalcaemia in adults and children with haematological disorders

Abstract

SummaryHypercalcaemia is a common metabolic complication of malignant disease often requiring emergency intervention. Although it is more frequently associated with solid tumours, malignancy-associated hypercalcaemia (MAH) is seen in a significant number of patients with blood diseases. Its association with myeloma and adult T-cell leukaemia/lymphoma is well recognized but the incidence of hypercalcaemia in other haematological neoplasms, affecting adults and children, is less clearly defined. Haematologists need to be familiar with the clinical manifestations of, the differential diagnosis to be considered and the most effective management strategies that are currently available for MAH. The key components of management of MAH include aggressive rehydration, specific therapy to inhibit bone resorption and, crucially, treatment of the underlying malignancy. Bisphosphonates have revolutionized the management of MAH over the last 20 years, however the elucidation of molecular pathways implicated in MAH is facilitating the development of more targeted approaches to treatment.

Limiting early mortality: Do's and don'ts in the management of patients with newly diagnosed multiple myeloma

“…In cases of mild hypercalcemia where the serum calcium is less than 12 mg/dL, aggressive rehydration with isotonic fluids (i.e., Normal Saline) to restore intravascular volume and induce calcium diuresis along with the use of corticosteroids such as dexamethasone or prednisone should suffice in temporizing the serum calcium level [33]. However, any form of hydration undertaken should be monitored carefully so as to avoid congestive heart failure exacerbations especially in elderly patients.…”

“…In patients with moderate to severe hypercalcemia where the serum calcium is more than 12 mg/dL, an ECG should be done to ensure no rhythm changes predisposing to arrhythmias are present. In addition to the aforementioned measures of hydration and corticosteroids, antibone resorption therapy with bisphosphonates like zoledronic acid (4 mg IV infused over 15-30 min) or pamidronate (60-90 mg IV infused over 2 hr) must be instituted [33]. These should be administered early after the presentation, as they tend to have a slow onset of action in between 2 and 3 days.…”

“…Patients with MM may experience osteolysis leading to hypercalcemia as a result of an increased activation of osteoclasts [33]. Several factors such as RANKL, IL-6 and MIP-1a associated with the malignant bone marrow plasma cells support this osteoclastic activity [34].…”

“…The incidence of hypercalcemia (defined as a serum calcium level greater than or equal to 11 mg/dL with values corrected for serum albumin) in newly diagnosed MM patients is around 15-20% [35]. Patients may be asymptomatic or present with a varied combination of symptoms such as anorexia, nausea, vomiting, polyuria, polydipsia, constipation, weakness, or confusion [33]. Hypercalcemia may lead to acute renal insufficiency as a result of direct renal vasoconstriction and natriuresis-induced volume contraction [36,37].…”

Caso clínico: hipercalcemia refractaria asociada a linfoma b, una emergencia oncológica

“…En casos como el descrito, los niveles de fósforo pueden encontrarse falsamente normales o elevados secundariamente a la insuficiencia renal aguda, además de la posible existencia de factores concomitantes, como la inmovilización o la presencia de metástasis óseas. 7 El manejo terapéutico va encaminado a f a v o r e c e r l a c a l c i u r e s i s m e d i a n t e l a hiperhidratación y deberá valorarse el empleo de furosemida. 3,7 En los casos graves, en los que exista insuficiencia renal, debe considerarse el empleo de una técnica de depuración extrarrenal.…”