The changing profile of hypercalcemia in a tertiary care setting in North India: an 18-month retrospective study

Clinical, Biochemical, and Histological Manifestations and Long-Term Outcomes of Renal Sarcoidosis - A Single Center Study

Background

Renal involvement in sarcoidosis is rare. We evaluated the pattern of renal involvement in sarcoidosis, its clinical course, renal histology, and response to treatment.

Materials and Methods

We retrospectively analyzed the data of all cases with sarcoidosis exhibiting renal involvement referred to our department between January 2010 and December 2021.

Results

A total of 33 patients (age: 50.6 ± 12.6 years, males: 57.6%) were analyzed. Common presenting symptoms were weight loss (81.8%; n = 27), fever (75.8%; n = 25), and vomiting (63.6%; n = 21). A total of 14 (42.4%) patients had granulomatous interstitial nephritis (GIN), 13 (39.4%) had isolated hypercalcemia, and six (18.2%) had GIN along with hypercalcemia. Renal biopsy was performed in 20 (60.6%) patients, and all showed GIN, with concomitant glomerular disease in four (12.1%) patients. Mean serum creatinine and 24-h urine protein at presentation were 4.3 ± 2.1 mg/dL and 2.5 ± 0.9 g/day, respectively. All patients received oral prednisolone 1 mg/kg/day with subsequent tapering, concomitantly with azathioprine. Mycophenolate mofetil was used in three (9.1%) patients who developed azathioprine-induced hepatoxicity. After a median follow-up of 24 months (8-120 months), mean serum creatinine and 24-h urine protein improved to 1.9 ± 1.5 mg/dL and 1.1 ± 0.6 g/day, respectively, (P = 0.005). On follow-up, two patients (6.1%) became dialysis-dependent, and three (9.1%) succumbed: one due to a cardiovascular event and two to sepsis and septic shock.

Conclusion

Granulomatous interstitial nephritis was the most common diagnosis in sarcoidosis patients with kidney failure. Early steroid treatment improves kidney function.

Clinical and Biochemical Profiles of Hospitalized Patients with Hypercalcaemia from a Tertiary Care Centre in North India

Background and aims: The profile of hypercalcaemia in hospitalized patients in India seems to be changing. However, studies evaluating the profile of hypercalcaemia in hospitalized settings in India are extremely limited. This prospective study aims to evaluate the clinical and biochemical profile of hospitalized patients with hypercalcaemia from a tertiary care centre in north India. Materials and methods: Clinical and biochemical profiles of subjects with hypercalcaemia detected during hospitalization/hospitalized with hypercalcaemia were assessed. A total of 91 subjects with sustained hypercalcaemia, who were eligible, underwent further investigation as per the institutional protocol and the data collected were analyzed. Results: The mean age of participants was 57.88 ± 14.23 years, with 62.64% of participants being females. The most common symptoms were nausea and anorexia, which were observed in all patients. The most common clinical sign was dehydration, which was observed in 32.97% of subjects. Primary hyperparathyroidism was the most common cause (41.76%), followed by suspected or confirmed malignancy/solid tumours in 15.38% of subjects. Other causes were advanced chronic liver disease (10.99%), multiple myeloma (9.89%), vitamin D toxicity (8.79%), granulomatous disorders (2.20%) and drug-i nduced disorders (1.10%). Forty-one subjects (45.05%) developed acute kidney injury and 14 subjects (15.38%) developed acute pancreatitis as a complication. Six subjects (6.59%) died during the course of hospitalization because of either primary disease or other secondary complications. Conclusions: Clinicians should be aware of changing patterns of hypercalcaemia in a hospital setting. Hypercalcaemia in hospitalized patients is associated with significant complications and mortality. Further large-scale prospective studies are needed to understand the changing pattern of hypercalcaemia in hospitalized patients from India.

Clinical Profile and Outcomes of Patients With Hypercalcemia in an Indian Tertiary Care Center

Hypercalcemia is a complex medical condition characterized by elevated levels of serum calcium (>10.5 mg/dL) in the bloodstream, often arising from various underlying etiologies. This condition presents a significant clinical challenge due to its diverse clinical manifestations and potential for serious complications. Profiling and understanding hypercalcemia is essential for accurate diagnosis, appropriate management, and improved patient outcomes. In this study, we delve into the comprehensive profiling of hypercalcemia, encompassing its epidemiology, pathophysiology, clinical presentation, and diagnostic approaches. We explore the multifaceted etiological factors contributing to hypercalcemia, including primary hyperparathyroidism, malignancies, granulomatous disorders, medications, and more. We highlight the intricate interplay between parathyroid hormone, vitamin D, and other regulatory mechanisms that influence calcium homeostasis, shedding light on the underlying molecular pathways. Furthermore, we discuss the diverse clinical manifestations of hypercalcemia, ranging from asymptomatic cases to severe, life-threatening complications involving the renal, gastrointestinal, cardiovascular, and neuromuscular systems. Accurate diagnosis is pivotal, and we evaluate the array of laboratory tests, imaging modalities, and specialized assays that aid in identifying the root cause of hypercalcemia. We emphasize the importance of a systematic approach to differential diagnosis and the significance of risk stratification to guide clinical decision-making. The evolving landscape of treatment options for hypercalcemia is also explored, encompassing both acute management and long-term strategies tailored to the underlying etiology. We assess the role of hydration, pharmacological agents, and surgical interventions, underscoring the need for individualized therapeutic plans based on the severity and underlying cause of hypercalcemia. In conclusion, the profiling of hypercalcemia is a multidimensional endeavor that necessitates a comprehensive understanding of its underlying mechanisms, diverse clinical presentations, and diagnostic intricacies. This study intends to serve as a valuable resource for healthcare professionals, offering insights into the complex terrain of hypercalcemia.

Prevalence and Etiological Profile of Hypercalcemia in Hospitalized Adult Patients and Association with Mortality

Background

The etiology of hypercalcemia varies according to the clinical setting. Hitherto, data on the prevalence and profile of hypercalcemia in hospitalized Asian-Indian patients are limited. Hence, we conducted a prospective observational study to determine the prevalence and etiological profile of hypercalcemia in hospitalized Asian-Indian patients and its association with 6-month mortality.

Materials and Methods

We conducted a prospective observational study wherein all the patients (aged >12 years) admitted to the general medicine wards of a tertiary care hospital in North India between January 1, 2016, and June 30, 2017, were screened. Finally, patients with sustained hypercalcemia (defined as corrected serum total calcium ≥10.4 mg/dl documented twice at least 24 h apart) were included in this study. These patients were followed up throughout the hospital course and thereafter till 6 months from the date of discharge.

Results

Out of 9902 patients, 150 patients had sustained hypercalcemia (prevalence 1.5%). The most common cause of hypercalcemia was malignancy (41.3%), followed by primary hyperparathyroidism (PHPT, 32.7%). Vitamin D intoxication was responsible for hypercalcemia in 8.7% of patients; 2.7% of patients had hypercalcemia of advanced chronic liver disease. Nevertheless, a definite etiology could not be identified in 7.3% of the patients with hypercalcemia. At the end of 6 months of follow-up, the cumulative mortality rate was 28%. Underlying malignancy and higher calcium levels were the significant determinants of mortality.

Conclusions

The prevalence of hypercalcemia in Asian-Indian patients admitted to a tertiary care hospital was 1.5%. The most common etiology was malignancy, followed by PHPT.

Hypercalcaemic encephalopathy as a presenting manifestation of sarcoidosis

A 66-year-old woman presented to us with features of encephalopathy with asterixis, preceded by unsteadiness of gait and behavioural abnormalities. On subsequent investigations, hypercalcaemic crisis and compromised renal function were noted. Stepwise approach to determine the cause behind hypercalcaemia with compromised renal function revealed underlying granulomatous disease (sarcoidosis). Later, development of maculopapular rash and subsequent biopsy from the lesion confirmed the diagnosis of sarcoidosis. Her clinical and biochemical parameters improved considerably on initiation of conservative pharmacological therapy.

Prevalence, causes and associated mortality of hypercalcaemia in modern hospital care

BACKGROUND

Studies examining hypercalcaemia in inpatients were largely published over 20 years ago, and it is likely the epidemiology of hypercalcaemia has changed related to increased lifespan and changes in prevalence of the underlying causes such as malignancy.

AIM

To explore the epidemiology of hypercalcaemia in a modern tertiary hospital setting in Australia, and evaluate the risk of mortality associated with hypercalcaemia.

METHOD

A retrospective study was performed in all inpatients with elevated blood calcium levels admitted from July 2013 to June 2018. ICD coding data identified primary diagnoses and mortality. Electronic medical records were reviewed in n=292 patients admitted across 12 months from January to December 2017, to determine the causes of hypercalcaemia.

RESULTS

Hypercalcaemia occurred in 1819 admissions (0.93% of all hospital admissions), during the 5 year period. The admission primary diagnoses were: malignancy (20% of cases), cardiovascular disease (17%), and gastrointestinal disease (11%). The top causes of hypercalcaemia among the 292 cases where electronic records were reviewed were malignancy (26%), primary hyperparathyroidism (25%) and hyperparathyroidism in the setting of chronic kidney disease (12%). Mortality occurred in 17% of these admissions. Non-survivors had significantly higher calcium levels, phosphate and white cell count, and had lower haemoglobin and albumin levels.

CONCLUSION

Hypercalcaemia occurred in ~1% of admissions with main causes being malignancy and primary hyperparathyroidism, similar to historical studies. Hypercalcaemia in hospitalised patients is associated with high mortality and higher levels may be a marker for more severe underlying disease. This article is protected by copyright. All rights reserved.

Does Baseline PTH Influence Recovery of Bone Mineral Density, Trabecular Bone Score and Bone Turnover Markers? A Prospective Study Following Curative PArathyroidectomy in Primary Hyperparathyroidism

OBJECTIVE

This prospective study was carried out to assess trabecular bone score, bone mineral density (BMD), and bone biochemistry in Indian subjects with symptomatic primary hyperparathyroidism (PHPT), and to study the influence of baseline parathyroid hormone (PTH) on recovery of these parameters following curative surgery.

METHODS

This was a 2-year prospective study conducted at a tertiary care centre in southern India. Baseline assessment included demographic details, mode of presentation, bone mineral biochemistry, BMD, trabecular bone score (TBS), and bone turnover markers (BTMs). These parameters were reassessed at the end of the first and second years following curative parathyroid surgery.

RESULTS

Fifty-one subjects (32 men and 19 women) with PHPT who had undergone curative parathyroidectomy were included in this study. The mean (SD) age was 44.6 (13.7) years. The TBS, BTMs, and BMD at lumbar spine and forearm were significantly worse at baseline in subjects with higher baseline PTH (≥250 pg/mL) when compared to the group with lower baseline PTH (<250 pg/mL). At the end of 2 years, the difference between high versus low PTH groups (mean ± SD) persisted only for forearm BMD (0.638±0.093 versus 0.698±0.041 g/cm2; P =.01). However, on follow-up visits in the first and second year after curative parathyroidectomy, there was no significant difference in BTMs, BMD at the femoral neck, lumbar spine, and TBS between the 2 groups stratified by baseline PTH.

CONCLUSION

The BMD at the forearm remained significantly worse in individuals with high baseline PTH even at 2 years after surgery, while other parameters including TBS improved significantly from baseline.

ABBREVIATIONS

25(OH)D = 25-hydroxyvitamin D; BMD = bone mineral density; BMI = body mass index; BTMs = Bone turnover markers; CTX = C-terminal telopeptide of type 1 collagen; DXA = dual energy X-ray absorptiometry; P1NP = N-terminal propeptide of type 1 procollagen; PHPT = primary hyperparathyroidism; PTH = parathyroid hormone; TBS = trabecular bone score.