Onco-Nephrology

Abstract

SummaryHypercalcemia complicates the course of 10%-30% of all patients with malignancies and can be a sign of very poor prognosis and advanced malignancy. Prompt recognition of the nonspecific signs and symptoms of hypercalcemia and institution of therapy can be lifesaving, affording the opportunity to address the underlying etiology. The mechanisms of malignancy-associated hypercalcemia generally fall into three categories: humoral hypercalcemia due to secreted factors (such as parathyroid-related hormone), local osteolysis due to tumor invasion of bone, and absorptive hypercalcemia due to excess vitamin D produced by malignancies. The mainstays of therapy for hypercalcemia are aggressive intravenous volume expansion with saline, bisphosphonate therapy, and perhaps loop diuretics. Adjunctive therapy may include calcitonin and corticosteroids. In refractory cases, gallium nitrate and perhaps denosumab are alternatives. In patients presenting with severe AKI, hemodialysis with a low-calcium bath can be effective. In most cases, therapy normalizes calcium levels and allows for palliation or curative therapy of the malignancy.

A Rare Case of Hypercalcemic Crisis Secondary to a Squamous Cell Carcinoma Arising from a Nonhealing Ulcer

“…Hypercalcemia in the setting of malignancy is associated with poor prognosis and decreased survival (3,20). Severe hypercalcemia (serum calcium >14 mg/dL) can lead to neurologic consequences if the onset of hypercalcemia is rapid.…”

“…Patients with hypercalcemia are usually volume depleted and require aggressive intravenous fluid resuscitation to restore intravascular volume. Volume expansion can be achieved with isotonic saline at 200 to 300 mL/hour, with a goal of urine output of >75 mL/ hour in many patients but may be limited by renal function and cardiac status (3,20). Intravenous bisphosphonates are effective in treating hypercalcemia of malignancy, as they inhibit osteoclastic activity from bone.…”

“…Although bisphosphonates have proven efficacy, they may take as long as 2 to 4 days to show an effect on calcium lowering. Calcitonin is a peptide hormone secreted by the parafollicular cells of the thyroid gland, and its major role is as an adjunctive agent to bisphosphonates (3,20). It can be useful when rapid calcium lowering is desired in the case of hypercalcemic crisis.…”

“…It can be useful when rapid calcium lowering is desired in the case of hypercalcemic crisis. Loop diuretics are usually reserved for individuals who show evidence of volume overload (20). The role of debulking surgery or radiotherapy is not well documented.…”

Malignancy-associated Hypercalcemia: role of Denosumab.

“…Corticosteroids as Hydrocortisone and Prednisone, can prevent the conversion of precursor 25-hydroxyvitamin D into calcitriol and are useful in hypercalcemia mediated by ectopic production of calcitriol. In patients with severe renal failure and oliguria hemodialysis with a low calcium bath may be necessary [18].…”