Answer to: “Asterixis as an atypical expression of hypercalcemia”

Ameneiros-Lago, Eugenia; Carballada-Rico, Carmen; Fernández-Fernández, Francisco-José

doi:10.1016/j.medcle.2019.03.045

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In the first place, it is rare that a mild hypercalcaemia like that of this patient (corrected plasma calcium of 10.54mg/dl at the time of admission) produced symptoms. As the authors correctly state, the symptoms of hypercalcaemia depend on its severity and the speed of its onset. In this case, as the patient has CRF, it is probable that there was previous hypocalcaemia, and the sudden variation in calcium levels would explain the symptoms, despite having a corrected calcium level close to normal. A review of the previous calcium figures could confirm this aspect. Secondly, the patient presents hypercalcaemia of neoplastic origin with slightly elevated levels of intact parathormone (iPTH), when the typical development in tumour hypercalcaemia is for the parathormone to be suppressed. The authors explained that the hypercalcaemia was probably due to PTHlike production, and that this hypercalcaemia did not reach the level of suppressing the elevated parathormone due to hyperthyroidism secondary to the patient's CRF. Therefore, high iPTH levels in the presence of CRF do not rule out a neoplastic origin and this possibility should be maintained in the differential diagnosis.Additionally, we consider it relevant to make some comments regarding the treatment of hypercalcaemia in CRF patients. In general, as the authors note, the use of loop diuretics in conjunction with fluid therapy is not recommended to increase urinary calcium excretion, as they can cause volume depletion. However, in patients with kidney failure or heart failure, its use may be indicated to prevent fluid overload. Regarding bisphosphonate treatment, there are limitations for its use in patients with kidney failure.<a class="elsevierStyleCrossRef" href="#bib0030">2</a> Zoledronic acid and pamidronate are the bisphosphonates of choice for the treatment of malignancy-associated hypercalcaemia. Bisphosphonates are eliminated through the kidney by glomerular filtration and proximal tubular secretion, and they can cause kidney damage by direct nephrotoxicity. Focal glomerulosclerosis and nephrotic proteinuria associated with treatment with pomidronate at high doses and with a rapid infusion rate of zoledronic acid have also been described. In the summary of product characteristics of both drugs, their use in patients with severe kidney failure, defined as creatinine clearance below 30ml/min, is not recommended, although in situations in which malignancy-associated hypercalcaemia constitutes a vital threat, then they could be considered. There are some published cases of pamidronate treatment in patients with malignancy-associated hypercalcaemia and severe CRF on dialysis, without relevant adverse effects, although there are many doubts about the appropriate dose or the interval between doses.<a class="elsevierStyleCrossRef" href="#bib0035">3</a> Denosumab, a monoclonal antibody that works by inhibiting osteoclast-mediated bone resorption, is not eliminated by the kidney and is an alternative to bisphosphonates in patients with malignancy-associated hypercalcaemia and severe chronic kidney failure.<a class="elsevierStyleCrossRef" href="#bib0040">4</a> As a last resort, in patients with severe hypercalcaemia and kidney failure, who do not respond to previous measures, hemodialysis with a low calcium dialysate could be evaluated.In conclusion, we could say that the presence of CRF can introduce some peculiarities in the diagnostic evaluation and treatment of a patient with hypercalcaemia. There could be severe clinical manifestations with slightly elevated calcium levels, and there could be elevated levels of iPTH that do not rule out malignant hypercalcaemia. Furthermore, the presence of severe CRF can make it difficult to manage hypercalcaemia." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Ameneiros-Lago E, Carballada-Rico C, Fernández-Fernández F-J. Respuesta a: «Asterixis como forma de presentación atípica de hipercalcemia». Med Clin (Barc). 2020;154:374–375." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Asterixis como forma de presentación atípica de hipercalcemia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "I. Grafia" 1 => "J. Marco-Hernández" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin" "fecha" => "2019" "volumen" => "152" "paginaInicial" => "121" "paginaFinal" => "124" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0030" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bisphosphonate therapy in metastatic carcinoma patients with chronic renal failure: are bisphosphonates an enemy or crony?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F.D. Koseoglu" 1 => "C. Arslan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00520-015-2672-2" "Revista" => array:6 [ "tituloSerie" => "Support Care Cancer" "fecha" => "2015" "volumen" => "23" "paginaInicial" => "1489" "paginaFinal" => "1491" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25763753" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0035" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of pamidronate to treat hypercalcemia in an oncology dialysis patient: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S. Mahmoud" 1 => "H. Mitwally" 2 => "H. Soliman" 3 => "I. El Madhoun" 4 => "M. Khatib" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Case Rep" "fecha" => "2018" "volumen" => "19" "paginaInicial" => "1087" "paginaFinal" => "1089" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0040" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Denosumab for tumor-induced hypercalcemia complicated by renal failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Bech" 1 => "H. de Boer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.7326/0003-4819-156-12-201206190-00026" "Revista" => array:6 [ "tituloSerie" => "Ann Intern Med" "fecha" => "2012" "volumen" => "156" "paginaInicial" => "906" "paginaFinal" => "907" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22711097" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015400000009/v2_202005120646/S2387020620301236/v2_202005120646/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015400000009/v2_202005120646/S2387020620301236/v2_202005120646/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620301236?idApp=UINPBA00004N"]

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Vol. 154. Issue 9.

Pages 374-375 (May 2020)

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