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 |
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Interpret the above laboratory work-up trend.
As per KDOQI clinical; practice guidelines on Bone metabolism target levels for CKD III:
interpretation: hypercalcemia, hyperparathyroidism with a normal phosphate level
B. What are the main causes of hypercalcemia?
↑ 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?
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
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
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.
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
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
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
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?
E. Would 24-hr urine calcium collection help in this patient’s diagnosis?24 hour calcium is expected to be high in hyperparathyroidim
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
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
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.
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.
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
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
Interpret the above laboratory work-up trend. hyperparathyroidism with hypercalcemia
What are the main causes of hypercalcemia?
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
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.
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?
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
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?
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
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.
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
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.
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
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
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?
Excellent dr Ben. Thankyou
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.
Great dr Weam
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
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.
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?
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?
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