Scenario 2 - Part 1:

A 38-year-old male patient with CKD stage III A. The patient’s laboratory investigations through the past six months are shown in table 1

Test

Jan

Feb

March

Apr

May

June

July

S. corrected Calcium 

10.52 mg/dL

9.9 mg/dL

9.8 mg/dL

10.2 mg/dL

10.5 mg/dL

11.5 mg/dL

12.1 mg/dL

S. Phosphorus

3.2 mg/dL

3.1 mg/dL

3.4 mg/dL

3.4 mg/dL

3.2 mg/dL

3.4 mg/dL

3.7 mg/dL

iPTH

367 pg/mL

334 pg/mL

343 pg/mL

 

Neck US revealed a large homogenous hypoechoic lesion on the posterior surface of left thyroid lobe suggesting a parathyroid adenoma.

 

A. Interpret the above laboratory work-up trend.

B. What are the main causes of hypercalcemia?

C. How would you approach this case? 

D. What would you expect from the urinary calcium excretion in this patient? and why?

E. Would 24-hr urine calcium collection help in this patient’s diagnosis?

33 Comments

  • Amna Kununa


    Interpret the above laboratory work-up trend.
    As per KDOQI clinical; practice guidelines on Bone metabolism target levels for CKD III:

    • Pi 2.7-4.6 mg/dl
    • Ca 8.4 – 9.4 mg/dl
    • iPTH 35-70 pg/ml

    interpretation: hypercalcemia, hyperparathyroidism with a normal phosphate level

    B. What are the main causes of hypercalcemia?

    • Serum calcium concentrations are normally maintained within a very narrow range. The minute-to-minute regulation of the ionized calcium concentration is achieved through a tightly regulated calcium-PTH homeostatic system.
    • The increase in PTH release raises the serum calcium concentration via:

    ↑ Bone resorption.
    ↑ intestinal Ca absorption mediated by ↑ production of calcitriol
    ↓ urinary calcium excretion (↑ Ca reabsorption in the distal tubule).

    So hypercalcemia occurs in Primary hyperparathyroidism due to an increase in PTH secretion.

    C. How would you approach this case? 
    Parathyroidectomy 

    D. What would you expect from the urinary calcium excretion in this patient? and why?

    • Around 40% of patients with PHPT are hypercalciuric (high filtered Ca load), and most of the remaining patients have normal values.
    • Lower urinary calcium values may also be seen in patients with PHPT whose calcium intake is extremely low.

    E. Would 24-hr urine calcium collection help in this patient’s diagnosis?
    The 24-hour urinary calcium may also help to distinguish PHPT from FHH

    • An elevated urinary calcium concentration (>200 to 300 mg/day) essentially excludes FHH.
  • Muhammad Soobadar


    A High calcium normal phosphate and high PTH
    B increased bone resorption, decreased GI absorption and decreased excretion
    C NMBI scan and parathyroidectomy
    D urine calcium will be increased as primary hyperparathyroidism can increase calcium excretion exceding reabsorption threshold ( which is higher due to PTH)
    E low urine calcium less than 100- FHH

  • Asma Aljaberi


    A. Interpret the above laboratory work-up trend.
    Patient with CKD 3, and hypercalcemia, normal phosphatemima in presence of constantly high iPTH.

    B. What are the leading causes of hypercalcemia?
    Primary hyperparathyroidism, as CKD3, would not expect to cause secondary hyperparathyroidism at this early stage.

    C. How would you approach this case? 
    Confirm primary hyperparathyroidsm with further biochemical testing and localization study. If confirmed to have primary hyperparathyroidism, send for parathyroidectomy once the adenoma is localized

    D. What would you expect from the urinary calcium excretion in this patient? And why?
    High urinary Ca excretion, as the filtered Ca load in the tubules, is higher than the Ca reabsorption.
    E. Would 24-hr urine calcium collection help in this patient’s diagnosis?
    Yes, primary hyperparathyroidism is usually associated with increase urinary Ca excretion, and that would lead to high urine Ca in 24 hrs collection.

  • Mohamed Abdulahi Hassan


     Interpret the above laboratory work-up trend.high PTH with hypercalcemia
    with normal phosphate
    What are the main causes of hypercalcemia?any conditions that increase intestinal calcium absorption like hypervitaminosis of VITAMN D, lower renal excretion and reabsorption.
    it could be either hyperparathyroidism, malignancy
    . How would you approach this case? parathyroid adenoma plus high pth parathyroidectomy would ultimate treatment.
    What would you expect from the urinary calcium excretion in this patient? and why?
    hypercalciuria due to filtering of calcium load
    24-hour urine collection helps to differentiate between the causes hypercalcemia. urinary calcium excretion which exceeds 200 mg/24hour nearly suggestive of primary hyperparathyroidism. urinary calcium below 100 mg/24 hour is consistent with familial hypocalciuric hypercalcemia

  • Asmaa Salih KHUDHUR


    A. Interpret the above laboratory work-up trend.
    hypercalcemia
    high PTH
    normal p

    What are the main causes of hypercalcemia?
    primary hyperparathyroidism
    granuluomatus disease
    hypervitaminosis D
    milk alkali syndrome
    drugs like thiazid
    C. How would you approach this case? Surgical parathyroidectomy
    What would you expect from the urinary calcium excretion in this patient? and why?Hypercalciuria
    Would 24-hr urine calcium collection help in this patient’s diagnosis?
    yes it’s high

  • Khaldon Rashed Ahmed Moqbil


    A-Hypercalcemia normal phosphate and primary hyperparathyroidism
    b-Primary hyperparathyroidism or tertiary in CKD, Malignancy, Granulomatous disease e.g., TB, sarcoidosis, Drugs, Immobilization, Thyrotoxicosis, Milk-alkali syndrome , Familial hypocalciuric hypercalcemia
    c- surgery
    d hypercalcuria
    e high

  • Rania Mahmoud


    A. Interpret the above laboratory work-up trend.Hypercalcemia, normal phosphate level and hyperparathyroidism

    B. What are the main causes of hypercalcemia?Primary hyperparathyroidism,some medications , iatrogenic, malignancy, sarcoidosis, familial hypocaciuric hypercalcimia , hypervitaminosis D

    C. How would you approach this case? hyperparathyroidism with parathyroid adenoma is due to primary hyperparathyroidism. So, a parathyroidectomy is recommended to control his condition. 
    D. What would you expect from the urinary calcium excretion in this patient? and why?

    • Hypercalciuric,due to increased filtered load of calcium

    E. Would 24-hr urine calcium collection help in this patient’s diagnosis?24 hour calcium is expected to be high in hyperparathyroidim

  • Alaa Abdel Nasser


    A- hypercalcemia, normal phosphate level and hyperparathyroidism
    B- Mostly a case of primary hyperparathyroidism
    C- Exclude other causes like drugs, malignancy, familial hypocalcuric hypercalcemia,
    treatment is surgical excision of the adenoma
    d-24-hour urinary calcium — Measurement of 24-hour urinary calcium excretion is not always required for the diagnosis of PHPT, but it is routinely measured in patients with asymptomatic PHPT in order to assess the risk of renal complications (when urine calcium is high) and thus determine subsequent management.
    E-For patients with hypercalcemia and PTH that is only minimally elevated or inappropriately normal given the patient’s hypercalcemia, the 24-hour urinary calcium may also help to distinguish PHPT from FHH
    Approximately 40 percent of patients with PHPT are hypercalciuric, and most of the remaining patients have normal values . An elevated urinary calcium concentration (>200 to 300 mg/day) essentially excludes FHH.
    If calcium excretion is <200 mg/day (5.0 mmol/day), FHH or PHPT with concomitant vitamin D deficiency are possibilities. Lower urinary calcium values may also be seen in patients with PHPT whose calcium intake is extremely low
    Approximately 75 percent of affected persons with FHH excrete less than 100 mg of calcium in urine daily

  • Mahmud ISLAM


    Hypercalcemia is associated with hyperparathyroidism, presented here as a nodule. Phosphorus is normal. In CKD patients, it could be low, but this patient has CKD. Probably not on P lowering medication.
    surgical intervention is needed
    24 hour calcium is expected to be high in hyperparathyroidim

  • Rabab Elrefaey


    Thank you everyone for your valuable answers.
    Now The explanation of this part is discussed below.

    A. Interpret the above laboratory work-up trend.

    High PTH level together with hypercalcemia is not common in this early stage of CKD. Secondary hyperparathyroidism is usually associated with hyperplastic symmetrical glandular enlargement without an adenoma. The patient has neck ultrasound suggesting parathyroid adenoma which is the cause of both hyperparathyroidism and hypercalcemia.
    
    B. What are the main causes of hypercalcemia?

    Hypercalcemia is a relatively common clinical problem. It results when the entry of calcium into the circulation exceeds the excretion of calcium into the urine or deposition in bone. This occurs when there is accelerated bone resorption, excessive gastrointestinal absorption, or decreased renal excretion of calcium. In some disorders, however, more than one mechanism may be involved. As examples, hypervitaminosis D increases both intestinal calcium absorption and bone resorption, and primary hyperparathyroidism increases bone resorption, tubular calcium reabsorption, renal synthesis of calcitriol (1,25-dihydroxyvitamin D, the most active metabolite of vitamin D), and intestinal calcium absorption.

    C. How would you approach this case? 
    High PTH level together with parathyroid adenoma is mostly secondary to primary hyperparathyroidism. So, a parathyroidectomy is recommended to control his condition. 
    .
    D. What would you expect from the urinary calcium excretion in this patient? and why?
    Most patients with primary hyperparathyroidism are hypercalciuric, despite that PTH increases calcium reabsorption in the renal tubules. This happens because of the higher filtered calcium load (significant increase in calcium going to the renal tubules). The higher filtered calcium load usually exceeds the higher rate of urinary calcium absorption.

    E. Would 24-hr urine calcium collection help in this patient’s diagnosis?
    24-hour urine collection helps to differentiate between the causes of PTH mediated- hypercalcemia. High urinary calcium excretion >200 mg/24hour is highly suggestive of primary hyperparathyroidism. Low urinary calcium <100 mg/24 hour is consistent with familial hypocalciuric hypercalcemia (FHH) that does not require parathyroidectomy.

  • Asmaa Salih KHUDHUR


    A. Interpret the above laboratory work-up trend.
    There’s hypercalcimia, hypophosphatemia and elevated iPTH with us finding of parathyroid adenoma suggestive the diagnosis of primary hyperparathyroidism.

    B. What are the main causes of hypercalcemia?
    Primary hyperparathyroidism 
    Malignancies 
    Granulomatous disease like sarcoidosis or TB
    Familial hypocalciuric hypercalcemia
    Milk alkali syndrome
    Hypervitaminosis D
    Drugs like thiazide 

    C. How would you approach this case?
    detailed history of renal stones , osteoporosis or fracture, symptoms of hypercalcimia like nausea and vomiting , any psychiatric symptoms, abdominal US ,DEXA scan , endocrinologist consultation.

    D.What would you expect from the urinary calcium excretion in this patient? and why?
    The urinary calcium is high .

    E. Would 24-hr urine calcium collection help in this patient’s diagnosis?
    Yes, it help to differentiate primary hyperparathyroidism from familial hypocalciuric hypercalcimia.

  • Abdulrahman Almutawakel


    HYPERCALCEMIA WITH NORMAL PHOSPHOROUS AND HIGH PTH BUT NOT TO THAT VERY HIGH LEVEL , SO WITH HYPERCALCEMIA NEEDS TO MAKE DD LIST AND NEEDS FOR ISOTOP SCAN FOR PARATHYROIED , NEEDS FOR PARATHYROIEDECTOMY WITH CLOSED OBSERVATION POST SURGERY FOR CALCIUM , PHOSPHOROUS , iPTH ,IN THSI CASE 24 HRs URURINARY CALCIUM EXPECTED TO BE HIGH BECOUSE OF HYPERCALCEMIA NAD HYPERPARA ,IT WILL BE OF HELP TO DEFERNTIATE FROM FAMILIAL HPOCALCIURIC HYPERCALCEMIA

  • Israa Hammoodi


    A. Interpret the above laboratory work-up trend.

    Hypercalcimia and hyperparathyroidism, normal s. Phosphorous
    B. What are the main causes of hypercalcemia?

    Primary hyperparathyroidism, iatrogenic, malignancy, sarcoidosis, familial hypocaciuric hypercalcimia
    C. How would you approach this case?

    Parathyroidectomy

    D. What would you expect from the urinary calcium excretion in this patient? and why?

    Would be high due to hypercalcimia

    E. Would 24-hr urine calcium collection help in this patient’s diagnosis?

    Yes useful to differentiate primary hyperparathyroidism in which urine calcium would be high from familial hypocalciuric hypercalcimia in which urine calcium would be low

  • KAMAL ELGORASHI


    Interpret the above laboratory work-up trend. hyperparathyroidism with hypercalcemia
    What are the main causes of hypercalcemia?

    • Primary hyperparathyroidism.
    • Familial hypocalciuric hypercalcemia.
    • Malignancy

    How would you approach this case? Surgical removal of parathyroid adenoma.
    Monitor post-surgery PTH, Ca, Pi, and vitD levels.
    What would you expect from the urinary calcium excretion in this patient? and why?24 urinary calcium level is high in pHPT
    Would 24-hr urine calcium collection help in this patient’s diagnosis?Yes to differentiate it from familial hypocalciuric hypercalcemia

  • Nour Al Natout


    A. Hypercalcemia, primary hyperparathyroidism.
    B. Primary hyperparathyroidism from adenoma, hyperplasia, cancer like myeloma.
    MEN1(pancreas, parathyreoind, pituitary) and MEN2a(pheochromocytoma).
    Drugs: thiazide, exogenous.
    C. Details about history , family history, symptoms (bones, stone, abdominal groans, psychatric overtone, Thrones).
    Ultrasound of abdomen. Surgery is the definitive treatment.observe if asymptomatic . 24 hour urin collection.
    DHigh urinary calcium above 300 due to exceeded resorption capacity in PCT.
    E. yes , it will support the hypothesis that it is a primary hyperparathyroidism.
    In secondary hyperparathyroidism, the resorption of calcium from kidney is high . Urinary calcium will be normal.
    In Familial Hypocalciuric hypercalcemia , urinary calcium creatinin ratio is under 0.01.

  • Mahmoud Elsheikh


    interpret the above laboratory work-up trend.

    • Normal phosphorus level 
    • raised serum calcium
    • High PTH

    B. What are the main causes of hypercalcemia?

    • Primary hyperparathyroidism or tertiary in CKD, Malignancy, Granulomatous disease e.g., TB, sarcoidosis, Drugs, Immobilization, Thyrotoxicosis, Milk-alkali syndrome , Familial hypocalciuric hypercalcemia

    C. How would you approach this case?

    • Ask for history of renal stone, osteoporosis or fracture, nausea, vomiting, fatigue , weakness, and constipation, family history of parathyroid disease
    • Admission to HDU; ECG, IV fluids resuscitation, Urea & electrolytes, Organise U/S kidney, ureter, and bladder, DEXA scan for osteoporosis
    • Consult with endocrinologist, surgeon

    D.What would you expect from the urinary calcium excretion in this patient? and why?

    • to be high 
    • due to increased filtered load of calcium.

    E. Would 24-hr urine calcium collection help in this patient’s diagnosis?

    • 24-h urine calcium/creatinine ratio > 0.02 favor the diagnosis of PHPT
    • Ratio < 0.01 generally suggest the diagnosis of familial hypercalciuric hypercalcemia
  • MOHAMMED HAJI HASSAN


    A. Interpret the above laboratory work-up trend.
    Hypercalcemia-Normal level of phosphate- High PTH level

    B. What are the main causes of hypercalcemia?
    Solid tumors such as Primary and tertiary Hyperparathyroidism
    Granulomatous disease(TB-Sarcoidosis)
    Drugs(thiazide diuretics, lithum etc)
    familial hyporcalciuric hypercalcemia

    C. How would you approach this case? 
    do detailed family history and physical examinations, check signs of hypercalcemia
    do detailed laboratory and radiological investigations

    D. What would you expect from the urinary calcium excretion in this patient? and why?
    Urinary calcium excretion is expected to be High since the calcium level exceeds the capacity of the kidney to reabsorb the calcium.
    E. Would 24-hr urine calcium collection help in this patient’s diagnosis?
    yes its useful especially to differentiate between FHH and PHPT
    if is high it shows PHPT, if is low it indicates FHH

  • Riaan Flooks


    A. Interpret the above laboratory work-up trend.

    • Persistent and Worsening Hypercalcemia
    • Elevated PTH with radiological features of an adenoma
    • Normal Phosphate

    B. What are the main causes of hypercalcemia?

    • Hypercalcemia secondary to Increased Calcium Mobilization:
    • Primary Hyperparathyroidism
    • MEN 1 and 2A
    • Psueodhyperparathyroidism
    • Renal Failure
    • Malignancies
    • Hyperthyroidism
    • Immobilzation
    • Addison’s Disease
    • Hypercalcemia due to Increased Absorption of Calcium from GIT:
    • Granulomatous Disease
    • Sarcoidosis
    • Tuberculosis
    • Histoplasmosis
    • Hypercalcemia due to Decreased urinary excretion of Calcium:
    • Thiazide diuretics
    • Familial Hypercalcemic Hypocalciuria
    • Drugs:
    • Lithium
    • Vitamin D
    • Vitamin A
    • Growth Hormone
    • Estrogen/antiestrogens
    • Theophylline
    • Other causes:
    • AKI
    • Serum protein disorders
    • ICU Hypercalcemia
    • Idiopathic hypercalcemia of infancy

    C. How would you approach this case? 

    1. Enquire about Medication use, symptoms and evaluate for possible signs (BP, P, Volume status, neurological examination and eye examination)
    2. Confirm a True Hypercalcemia
    3. Measure Intact PTH
    4. Determine the urinary Ca excretion
    5. Measure 25(OH)D and 1,25(OH)2 D

    D. What would you expect from the urinary calcium excretion in this patient? and why?

    • Elevated Calcium Excretion in the urine

    E. Would 24-hr urine calcium collection help in this patient’s diagnosis?

    • Yes
    • Large amounts of hypercalciuria is an indication for parathyroidectomy
    • It will also differentiate between PHPT and Familial Hypercalcemia Hypocalciuria
  • Rabab ALaa Eldin keshk Rabab


    A. Interpret the above laboratory work-up trend.
    Persistence hypercalcimia with normal level of po4 and elevated pth with parathyroid adenoma
    B. What are the main causes of hypercalcemia?
    Primary or tertiary hyperparathyroidism
    Malignancy ,Granulomatous disease e.g., TB, sarcoidosis,Drugs e.g., vitamin D, A, lithium, thiazide diuretics ,Immobilization
    Thyrotoxicosis,Milk-alkali syndrome (anti-acids, calcium carbonate therapy)
    Familial hypocalciuric hypercalcemia
    C. How would you approach this case?
    ask about symptoms of hypercalcemia polyuria ,polydipsia ,stone ,constipation ,abdominal pain
    ask about family hx of similar condition and gland problem to exclude familial hypercalcimia hypocalciuric,and MEN
    Ask for urinary calcium sestamibi scan
    dexa scan
    D. What would you expect from the urinary calcium excretion in this patient? and why?
    Mostly high urinary calcium excretion because this patient has primary hyperparathyroidism and elevated ca exceed absorptive capacity of kidney
    E. Would 24-hr urine calcium collection help in this patient’s diagnosis?
    Yes, this is essential and help in the diagnosis of PHPT.
    24-h urinary calcium > 400 is considered indication for surgery
    Importantly 24-h urine calcium/creatinine ratio > 0.02 favor the diagnosis of PHPT but ratio < 0.01 generally suggest the diagnosis of familial hypercalciuric hypercalcemia

  • HASSAN ALYAMMAHI


    A. Interpret the above laboratory work-up trend.
    This patient has rising Ca levels NOT supressing parathyroid glands (Hyperparathyroidism), his PO4 is normal as his kidney in stage 3A can still exert the phosphaturic effect of PTH.

    B. What are the main causes of hypercalcemia?
    Primary or Tertiary hyperparathyroidism
    Granulomatous disease
    Malignancies
    Hypervitaminosis D
    Drugs eg Thiazide
    Thyrotoxicosis
    Milk-Alkali syndrome

    C. How would you approach this case?
     Ask about symptoms of hypercalcemia (bones, stones, moans, and psychiatric manifestation), Ask about family history looking for MEN-1 and MEN-2Check Rx history.Ask for vit D levelsCa:Creatinine ratio in urine

    D. What would you expect from the urinary calcium excretion in this patient? and why?
    Urinary Ca excretion is expected to be high, since the absorptive capacity for Ca in proximal tubules is exceeded by the Ca load coming from bone resorption.

    E.  Would 24-hr urine calcium collection help in this patient’s diagnosis?
    Even though 24-hour calcium excretion is often measured in PHPT patients with no symptoms to see if they are at risk for kidney problems, it is not usually needed to diagnose PHPT (when urine calcium is high). In people with hypercalcemia and PTH that is either slightly increased or normal, 24-hour urine calcium may help distinguish PHPT from FHH.

  • Emad mohamed mokbel Salem


    A. Interpret the above laboratory work-up trend.CKD 3A WITH increasing HYPERCALCEMIA AND ELEVATED PTH (primary HPTH )
    po4 within normal limit
    parathyroid adenoma
    ============
    B. What are the main causes of hypercalcemia?1-parathyroidism related (primary or tertiary ,FHH,lithium )
    2-malignancy (HHM ,LOH )
    3-drugs
    4-granulomatous disorders
    ============================
    C. How would you approach this case? this patient has hypercalcemia with high PTH
    ask about symptoms of hypercalcemia (polyuria ,polydipsia ,stone ,constipation ,abdominal pain )
    2-ask about family hx of similar condition and gland problem (to r/o FHH,AND MEN )
    3-ASK ABOUT THE COMPONENT OF MEN (1 AND 2A)
    =====================
    ix ask for urinary calcium
    sestamibi scan
    dexa scan
    ==================
    D. What would you expect from the urinary calcium excretion in this patient? and why?high urinary calcium excretion bec this patient has primary HPT

    . Would 24-hr urine calcium collection help in this patient’s diagnosis?yes to differentiate between hyperparathroidism and FHH

  • Rihab Elidrisi


    Interpret the above laboratory work-up trend.HyperPTH and hypercalcemia, This patient has CKD as well with a PTH level of 300 +, which can be in CKD patients, but the NEck US showed the adenoma, which is in favour of primary hyper PTH.

    What are the main causes of hypercalcemia?Primary hyper PTH
    immobilization
    malignancy
    granulomatous disease

     How would you approach this case? This patient will need a full clinical assessment, including history taking and examination

    What would you expect from the urinary calcium excretion in this patient? And why?The urinary Ca excretion in this patient will be high as it exceeds the capacity of the kidney to reabsorb the ca in PCT . For that this patient will have renal stone

    Would 24-hr urine calcium collection help in this patient’s diagnosis?Yes it is will confirme the PHPTH .
     24-h urine calcium/creatinine ratio > 0.02 favor the diagnosis of PHPT with sensitivity and specificity of 85% and 88% respectively.

  • Hagar Ali


    A)hypercalcemia ,normal phosphorus with hyper parathyroid level ,us revealed parathyroid gland adenoma
    B)in this case PHP
    C)history of kidney stone ,mood changes dehydration (hypercalcemia symptoms ),drug history
    lab: VD
    24 h urine ca
    D)I expect it to be high due to increase filtered load of ca
    F)to differentiate between PHP and FHH

  • Ahmed Wagih


    the patient has hypercalcemia, hypophosphatemia, elevated PTH, and us finding of parathyroid adenoma, so this patient has primary hyperparathyroisism.
    What are the main causes of hypercalcemiacauses of hypercalcemia can be classsified according to PTH level
    1- with high PTH: primary hyperparathyroidism
    2- upper normal or mildly elevated; familial hypocalciuric hypercalcemia
    3- suppressed PTH: which is the normal response to hypercalcemia, means the problem outside the parathyroid gland like vit d disorders or parathyroid hormone related peptides

    How would you approach this case 1-history: include renal stone, fragility fractures. GIT symptoms 2ry to hypercalcemia, psychiatric symptoms
    2- abdomenal imaging to detect kidney stones
    3- DXA scan
    4- genetic test; to rule out MEN syndromes
    What would you expect from the urinary calcium excretion in this patient? and why?24 hr urine calcium excretion is usually between 100-300 mg/day, hypercalciuria is present when 24 hr urine calcium exceeds 400mg/day, in this patient 24 hr urine will not straight forward as he ckd which will decrease calcium excretion

    Would 24-hr urine calcium collection help in this patient’s diagnosis? the patient has fullblown picture of 1ry hyperparathyroidism markedly elevated PTH, us finding, AND hypercalcemia . SO FHH is not a possibility

  • Ben Lomatayo


    A. Interpret the above laboratory work-up trend.

    • Normal and stable phosphorus level or over time
    • Progressive raise in serum calcium during the follow up
    • High PTH, not suppressed by progressively raised calcium

    B. What are the main causes of hypercalcemia?

    • Primary hyperparathyroidism or tertiary in CKD
    • Malignancy
    • Granulomatous disease e.g., TB, sarcoidosis
    • Drugs e.g., vitamin D, A, lithium, thiazide diuretics
    • Immobilization
    • Thyrotoxicosis
    • Milk-alkali syndrome (anti-acids, calcium carbonate therapy)
    • Familial hypocalciuric hypercalcemia

    C. How would you approach this case?

    • Ask for history of renal stone disease
    • Ask for history of osteoporosis or fracture
    • Ask for symptoms of hypercalcemia e.g., nausea, vomiting, fatigue , weakness, and constipation
    • Ask for family history of parathyroid disease
    • Examine for any palpable neck mass
    • Admission to HDU
    • ECG
    • IV fluids resuscitation
    • Urea & electrolytes
    • Rule out vitamin D deficiency
    • Organise U/S kidney, ureter, and bladder
    • Organize DEXA scan for osteoporosis
    • Consult with endocrinologist
    • Consults with endocrine surgeon

    D.What would you expect from the urinary calcium excretion in this patient? and why?

    • This is expected to be high due to increased filtered load of calcium. After reabsorption in the PCT, the excess calcium will be excreted into the urine leading to hypercalciuria (The re-absorptive PCT capacity is exceeded). This is the reason for developing stone disease in PHPT

    E. Would 24-hr urine calcium collection help in this patient’s diagnosis?

    • Yes, this is sensitive and may be an adjunct to the diagnosis of PHPT
    • 24-h urinary calcium > 400 is considered indication for surgery
    • Importantly 24-h urine calcium/creatinine ratio > 0.02 favor the diagnosis of PHPT with sensitivity and specificity of 85% and 88% respectively.
    • Ratio < 0.01 generally suggest the diagnosis of familial hypercalciuric hypercalcemia
  • Weam El Nazer


    A. Interpret the above laboratory work-up trend.Persistent hypercalcemia with low normal phosphorus and high PTH is most likely primary hyperparathyroidism.

    B. What are the main causes of hypercalcemia?parathyroid adenoma, one of the causes of primary hyperparathyroidism.

    C. How would you approach this case? 
    Check the medication, ask about the family history of hypercalcemia, and send for 25 vitamin D and 24-hour urinary calcium excretion, or the ca/cr ratio.

    D. What would you expect from the urinary calcium excretion in this patient? and why?the expected urinary calcium is high> 200-300mg per day

    E. Would 24-hr urine calcium collection help in this patient’s diagnosis?
    The diagnosis of PHPT does not usually require 24-hour urinary calcium excretion, although it is frequently assessed in asymptomatic PHPT patients to assess the risk of renal problems (when urine calcium is high) and establish care. 24-hour urine calcium may assist in identifying PHPT from FHH in individuals with hypercalcemia and PTH that is either mildly increased or abnormally normal considering their hypercalcemia.

  • Elsayed Ghorab


    THE above lab revealed
    hypercalcemia
    normal phosphate level
    hyper parathyrodism
    neck US revealed parathyroid adenoma
    the most probably cause of hypercalcemia
    the 1ry HPT from adenoma

    expected from the urinary calcium excretion in this patient? and why?increased urinary ca / creatinine ratio
    and confirm the cause of hypercalcemia is 1ry hyperparathyrodism
    by  24-hr urine calcium collection

    • Rabab Elrefaey


      Thank you dr Elsayed. Also 24-hour urine collection helps to differentiate between the causes of PTH mediated- hypercalcemia. High urinary calcium excretion >200 mg/24hour is highly suggestive of primary hyperparathyroidism. Low urinary calcium <100 mg/24 hour is consistent with familial hypocalciuric hypercalcemia (FHH) that does not require parathyroidectomy.

  • Ashraf Ahmed Mahmoud


    A. Interpret the above laboratory work-up trend ?

    • gradual increase s.Ca in last 4 months and lastly hypercalcemia.
    • normal serum phosphate.
    • primary hyperparathyroidism.

    B. What are the main causes of hypercalcemia?

    • Parathyroid adenoma suggesting primary hyperparathyroidism

    C. How would you approach this case? 

    • do 24 hour urinary ca and urinary calcium/creatinine ratio

    D. What would you expect from the urinary calcium excretion in this patient? and why?

    • increased urinary calcium.
    • due to adenoma causing primary hyperparathyroidism.

    E. Would 24-hr urine calcium collection help in this patient’s diagnosis?

    • yes to differentiate it from familial hypocalciuric hypercalcemia
  • Ibrahim Omar


    A. Interpret the above laboratory work-up trend.

    • persistent and worsening hypercalcemia.
    • persistent hyperparathyroidism.
    • maintained normal serum phosphate.
    • Parathyroid adenoma suggesting primary hyperparathyroidism.

    B. What are the main causes of hypercalcemia?

    • 1ry hyperparathyroidism.

    C. How would you approach this case? 

    • checking urinary calcium/creatinine ratio

    D. What would you expect from the urinary calcium excretion in this patient? and why?

    • increased urinary calcium/creatinine ratio > 0.2

    E. Would 24-hr urine calcium collection help in this patient’s diagnosis?

    • yes to differentiate it from familial hypocalciuric hypercalcemia
  • Mark Nagy Zaki Amin Mark


    A- increasing calcium levels more in the last 4 months with normal po4 and increased PTH values
    B – most common two causes are hyperparathyroidism and malignancy
    C – this is a case of hypercalcemia with high PTH level so malignancy and other causes of vit D excess are excluded
    then we perform 24 h urinary calcium excretion to differ between primary hyperparathyroidism and familial hypocalciuric hypercalcemia in which this test would be less than normal in contrast to hyperparathyroidism cases
    D – it would be high or normal as it is mostly a case of primary hyperparathyroidism due to parathyroid adenoma as evidenced in neck US results.
    E – yes it would be helpful as mentioned before

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