A 52-year-old male with a past medical history of hypertension and atrial fibrillation, presents with a two-week history of lethargy and polyuria. On examination, Blood pressure was 105/62mm/Hg, heart rate was 110/min. The patient had been maintained on bisoprolol 10 mg, rivaroxaban 2.5 mg BID, Aspirin 75 mg and lisinopril 40 mg. In addition, he reported taking numerous over-the-counter supplements, including 3000 IU vitamin D twice daily, for two years.
Review of his lab tests showed the following:
|
Test |
Value |
|
Random blood sugar |
123 mg/dL |
|
S. Creatinine |
2.7 mg/dL |
|
S.Corrected Calcium |
12.2 mg/dL |
|
S. Phosphorus |
3.1 mg/dL |
|
S. Sodium |
137 mEq/L |
|
S. Potassium |
3.5 mEq/L |
|
iPTH |
18 ng/mL |
|
Alkaline phosphatase |
25 IU/L |
You must be logged in to post a comment.
You cannot copy content of this page
1. Serum 25(OH)D3
2. SPEP/UPEP/ Immunofixation/ Serum FLC
3. CXR/CTchest
4. Serum ACE
5. ESR
6. Full haemogram
7. Liver function tests
8. Any tissue available for biopsy e.g bone marrow,or lungs
The patient presented with acute kidney injury. There is no previous history
of renal impairment and the patient presented clinically with dehydration. So it
is supposed to be a case of AKI until further investigations.
The other lab investigations are normal except serum calcium is elevated.
Hypercalcemia leads to downregulation of aquaporin-2 water channels and
calcium deposition in the medulla with secondary tubulointerstitial injury
and impaired generation of the interstitial osmotic gradient that may lead to
defect in concentrating ability of the renal tubules inducing polyuria and
polydipsia
our index case is hypertensive with AF on oral anticoagulant and antihypertensive drugs. He complains of polyuria for 2 weeks.
other lab investigations:
Interpret the above laboratory investigations.
HyperCa with adequate suppressed PTH
high creatinine presumed AKI vs AKI on CKD in the context of hypercalcemia
rest of the blood tests were normal.
Would you recommend further laboratory investigations for the
Labs showed increased RFT, hypercalcemia, low ALP
In view of OTC intake of vitamin D for a long time, further investigations are required, 25(OH)D, 24hrs urinary profile including U.Ca, serum and urine osmolarity, urine analysis, KUB USG
Ca⬆️and AKI ,
further lab investigation …
125(OH) vit D,
24 hrs urine calcium concentration
tumor markers
1-acute kidney injury, hypercalcemia , hyperphosphatemia with normal pth
2- check vitamin D
24 urine electrolyte including ca , po4 and cr
kub / us
• Interpret the above laboratory investigations.
Patient with renal impairment, AKI rather than CKD, with moderate hypercalcemia in presence of hyperparathyroidism, and low normal Ph. It might be primary hyperparathyroidism causing hypercalcemia leading to nephocalcinosis. As a result patient is having AKI due to obstructive nephropathy.
Would you recommend further laboratory investigations for the patient?
hypercalcaemia /ckd or aki
as pt is on vitamin D and pth not raised therefore check 25oh and 125 OH before other test
The above laboratory investigations. hypercalcemia and AKI , the lab results with in normal levels.
further lab investigation …
125(OH) vit D,
24 hrs urine calcium concentration
tumor markers
A- A case with renal impairment and hypercalcemia with normal other labs
B- 25(OH) vit D assay , pan CT , Abd US to exclude renal stones , urine osmolarity , serum osmolarity , CBC , urine analysis with echocardiogram
Dear doctors, I would like to appreciate your efforts.
you can now read the explanation of this case.
The patient presented with acute kidney injury. The other lab investigations are normal except serum calcium is elevated. Hypercalcemia leads to downregulation of aquaporin-2 water channels and calcium deposition in the medulla with secondary tubulointerstitial injury and impaired generation of the interstitial osmotic gradient that may lead to defect in concentrating ability of the renal tubules inducing polyuria and polydipsia.
Would you recommend further laboratory investigations for the patient?
Hypercalcemia may be due to other causes: VitD intoxication or Multiple myeloma.
Other recommended investigation: Serum 25(OH)D3. TSH. HBA1C. Total protein. Serum protein electrophoresis. US abdomen. Chest x-ray.
Dehydrated
AKI
hypercalcimia
low K and P serum level
low PTH
Low ALP
i will ask for
vit D25 (OH) level
LFT
MM screen
TB screen
CXR
Lab interpretation hypercalcimia renal imperment G4 normal pth normal alkaline phosphatase
Further investigation
Vit d level,chest x-ray to exclude sarcoidosis ppE for exclusion of mm
Lab Results Interpretation:
Work-Up:
his patient is dehydrated because of the polyuria caused by the hypercalcemia (because of vitamin D intake), this has resulted in AKI.
PTH is adequately suppressed by the high Ca.
These findings would essentially allow us to exclude other potential causes of hypercalcemia.
US KUB, CXR/CT chest
Serum 25(OH)D2, SPEP .
THIS PATIENT HAS AKI ( ? AKI ONTOP OF CKD NO BASELINE KFT ) MOSTLIKLY PRERENAL AS A RESILT OF DEHYDRATION CAUSED BY POLYURUA HYPERCALCEMIA INDUCED MOSTLY DUE TO VIT D INTAKE , WHICH ALSO THE CAUSE OF PTH SUPRESSION . NEEDS FOR FURTHER INESTIGATION ULTRASOUND , VIT D LEVEL , URINE CALCIUM , THYROIED FUNCTION . DETAILED HISTORY IS VERY IMPORTANT
A. CKD 4, hypercalcimia, suppressed PTH, low Alkaline phosphotase
B. 25 OH vitamin D level, ECG, ultrasound of kidneys
Thankyou dr Israa. But why you consider this as a case of CKD?.
From the clinical presentation, What about prerenal AKI?
searching for the cause of hypercalcemia is essential as well.
-The patient has high calcium level and this high calcium level seems to suppress the iPTH . she have a CKD stage 4 (eGFR 23,3)
-further laboratory investigation are 24 h Urin for Calcium (To exclude familial hypocalciuric hypercalcemia) and 25 OH Vitamin D level will be initialy needed to further assesst this situation.
Furthermore can LDH level (may be high in lymphoproliferative diseases ) , serum electrophoresis (To exclude myeloma) and Magnesium level (OTC supplement), Chest X ray (Sarcoidosis?),
TSH , liver and Ultrasound of abdomen (Lymphnode, metastasis )
Thanks dr Nour.
Is this AKI or CKD?
There is no previous history of renal impairment and the patient presented clinically with dehydration. So it is supposed to be a case of AKI until further investigations.
the patient has high calcium level and this high calcium level seems to suppress the iPTH . she have a CKD stage 4 (eGFR 23,3)
Thanks dr Nour.
There is no previous history of renal impairment and the patient presented clinically with dehydration. So it is supposed to be a case of AKI until further investigations.
The patient has high calcium and low phosphorus with suppressed PTH, which rules out hyperparathrosms. we need to check for 25 (OH) vitamin D to check for toxicity (defined as more than 150 ng/ml). Still can explain the hypercalcemia here. Normal ALP rules out bone resorption problems.
Thank you dr Mahmud.
There is no previous history of renal impairment and the patient presented clinically with dehydration. So it is supposed to be a case of AKI until further investigations.
The above results show advanced CKD with hypercalcemia
With advanced CKD expected serum calcium to be low
so hypercalcemia may be due to other causes
Other recommended investigation
Thanks dr kamal.
There is no previous history of renal impairment and the patient presented clinically with dehydration. So it is supposed to be a case of AKI until further investigations.
A)hypercalcemia with renal impairment
B)urine ca
V.D
U/s kidney
myeloma screen
Interpret the above laboratory investigations:
Would you recommend further laboratory investigations for the patient?
Hypercalcemia with low iPTH could be due to the following:
1. High vitamin D
In the index case, he is on 3000 IU of vitamin D twice daily for two years.
The Institute of Medicine has defined the “tolerable upper intake level” for vitamin D as 100 mcg (4000 iu) daily for healthy adults.
And for patients with malabsorption, high doses of vitamin D of 10,000 to 50,000 units daily may be necessary to replete vitamin D in some patients. Careful monitoring is required to avoid toxicity.
2. Granulomatous diseases (1.25 vitD).
3. Normal vitD – MM, vit A excess, milk-alkali, thyrotoxicosis
4. malignancy (high PTHrP).
Work up:
Excellent dr Amna.
The most notable and eye-catching results are considerable hypercalcemia and an increased Cr level, both of which are consistent with AKI or AKI on CKD owing to dehydration.
iPTH and ALP levels are on the low end, which may be an impact of vitamin D intoxication
Other investigations include:
These findings would essentially allow us to exclude other potential causes of hypercalcemia.
US KUB, CXR/CTchest
Serum 25(OH)D2, SPEP/UPEP, Serum FLC, ESR,
Serum ACE, QUNTIFERON test
This patient has hypercalcemia with secondary hypoparathyroidism and low ALP .
He Has AKi with high screat .
he is having low reads of BP and tachycardia despite being on bisoprolol 10mg ,
This patient need cardiac evaluation as he may have some sort of amyloidosis with hypercalcemia and cardiac infiltration
will need full cardiology assessment + echo
need to send LFT and M.M Work up which include Serum and urine protein Electrophoresis. This patient may have RTA and because of that his K is low so will need to check his ABG as well .
Interpret the above laboratory investigations.
Other investigations:
These would basically to rule out other causes of hypercalcemia
1-
RENAL impairment ?AKI
hypercalcemia with normal PTH and normal blood sugars
2- ask for
25(OH )D3 ,1,25 (OH )2D3
UPCR ,UACR ,urine analysis
myeloma screen (renal impairment –hypercalcemia )
Interpret the above laboratory investigations.
-Would you recommend further laboratory investigations for the patient?
-Interpret the above laboratory investigations.
A 52-year-old male with a past medical history of HTN & AF, presents with a two-week history of lethargy and polyuria.Stable vital signs with over dose of vit D.
He taking numerous over-the-counter supplements, including 3000 IU vitamin D twice daily, for two years.
Patient has hypercalcemia , Low level of of ALP & PTH
S.cr 2.7 mg/dl >> for further investigation ( aki or ckd )
Bood sugar normal
Normal level of S. phosp levels , K and Na
-Would you recommend further laboratory investigations for the patient?
Check 25-hydroxy Vit.D
Urine analysis
RFT
Uric Acid
FBC
Iron study
Renal ultrasound to exclude any stone
Chest Xray
ECG
bone X-rays to determine if there’s significant bone loss
Interpret the above laboratory investigations.
AKI- Hpercalcemia- Low levels of ALP
Would you recommend further laboratory investigations for the patient?
Vitamin D level
Urinalysis
FBC
Iron study
Renal ultrasound
Chest Xray
52y/o/m known as HTN , AF , c/o lethargy and polyurea since 2 w
stable vital signs
under treatment vit d 3000IU /twice /d/2y
the investigation revealed
blood sugar normal
normal pi and K and Na
s.cr 2.7 mg/dl >> for further investigation ( aki or ckd )
corrected ca 12.2mg/dl >>>hypercalcemia
low PTH and alkaline phosphatase due to suppression of parathyroid gland by over dose vit D
RECOMMENDED INVESTIGATION
complete renal function – urine analysis
renal sonar
vit. D level
Interpret the above laboratory investigations.
Would you recommend further laboratory investigations for the patient?