This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student rotated under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

60 year old, lady, presented to the ER complaining of *Back Pain. *Abdominal Pain. * Vomiting. * Decreased Appitite. For the last week. PMH: Diverticulitis

She was sitting on the bed in pain, not in distress. She was not cyanosed or jaundiced. She was alert but slightly confused. And she's over weight. -Vital Signs BP 140/95 Pulse 90 beats/min RR 14 breath/min Temp 38.1

She showed limited movement in the Lumbar spine. With no focal neurological changes. Other systems were clear.

What’s Your Impression ?

CBC : HgH 7.8 (L). WBC 3 x 10^9/L (L). MCV 87 FL (N). PLT106 x10^9/L (L). MCH 34 g/dl (N). ESR: 80 mm per hour

U & E: Na 140 mmol/L (N). K 4 mmol/L (N). Creatinine 200 mmol/L (H). Urea 9 mmol/L (H). Corrected Ca 3.6 mmol/L (H). Albumin 40 g/L

LFTs: Bilirubin 5 mimol/L (N). ALT 40 iu/L (N). AST 30 iu/L (N). Alkaline Phosphatase 60 iu/L (N). PTH 40 pg/ml (N).

X Ray of the chest, spine and Skull

* Multiple Myloma. * Bone Metastasis. * Primary Hyper Parathyroidism.

*Electrophoresis of Serum & urine. * Bone Marrow aspiration.

Hypercalcaemia : Rehadrate with IV saline, IV bisphosphonate. Supportive measurs: -Pain control by analgesia ( avoid NSAIDs) -Correct the Anemia by transfusions or Erythropoietin. - Treat Infections, broad spectrum antibiotics. Chemotherapy : Cyclophosphamide and prednisolon.

 Hyperparathyroidism (primary or tertiary).  Malignant diseases (multiple myeloma, breast cancer, bronchus, thyroid, prostate, renal cell and lymphoma).  excess action of vitamin D ( self administration or sarcoidosis ).  Endocrine diseases ( thyrotoxicosis, addison’s disease, MEN)  Drugs (thiazides, lithium, vitamin A and retinoic acid)  Excess calcium intake.  Familial hypocalciuric hypercalcaemia (rare).

They are classically summarized by the mnemonic "stones, bones, abdominal groans and psychic moans”  " Stones " refers to kidney stones, nephrocalcinosis, and diabetes insipidus (polyuria and polydipsia).kidney stones, nephrocalcinosis, and  " Bones " refers to bone-related complications, osteitis fibrosa cystica, which results in pain and sometimes pathological fractures, osteoporosis, osteomalacia, and arthritis.osteoporosis, osteomalacia, and arthritis.  “Abdominal Groans” refers to gastric related symptoms such as Abdominal pain, vomiting, constipation and anorexia.  " Psychic moans” which includes depression, memory loss, psychosis, ataxia, delirium, and coma.depression, memory loss, psychosis, ataxia, delirium, and coma.

 HTN.  Dehydration.  Hyperthermia.

 Serum calcium and phosphate : phosphate is low in primary hyperparathyroidism and some cases of malignancy, normal or inappropriately high in other causes of hypercalceamia.  PTH level : high in hyperparathyroidism.  Radiology (lytic lesions, subperiosteal erosions in the phalanges).

If PTH is undetectable the following tests should be done:  - protein electrophoresis for myeloma.  -TSH to exclude hyperthyroidism.  - synacthen test to exclude Addison’s disease.  - hydrocortisone suppression test, +ve in sarcoidosis, vitamin D-mediated hypercalceamia and some malignancies.

Correct the underlying cause, if Ca> 3.5 mmol/L. Aim to reduce Ca: - Fluids: Rehydration IV saline. - Diuretics: Fursomaid IV. Avoid Thiazids - Bisphosphonates