Corrected Calcium Levels Research Articles

S1897 A Rare Case of Hypercalcemia in the Setting of Relapsing Multiple Myeloma Presenting as Acute Pancreatitis

Introduction: Hypercalcemia induced pancreatitis has a reported prevalence of 1.5-8%. Most reported cases have been secondary to hyperparathyroidism and few are secondary to malignancies or granulomatous diseases. Despite multiple myeloma (MM) commonly presenting with hypercalcemia, there are very few cases reported in literature of hypercalcemia induced pancreatitis in patients with MM. Case Description/Methods: A 70-year-old male with past medical history significant for MM and chronic kidney disease presented to the hospital with recurrent, constant dull epigastric abdominal pain, non-radiating, 6/10 in intensity, worsened by movement and deep inspiration with no relieving factors. He denied any associated factors. He has undergone a bone marrow transplant in 2017 for his MM but relapsed in 2019. On initial presentation workup was significant for pancytopenia, an elevated lipase level of 1170 and an elevated corrected calcium level of 15. Computed tomography (CT) of the abdomen and pelvis revealed no abnormality of the pancreas. MRCP ruled out choledocholithiasis and gallbladder US was negative for cholelithiasis. He denied alcohol use and triglyceride levels were not significantly elevated. Medication overview did not show any relevant medications that may induce pancreatitis. It was determined that the etiology of his pancreatitis was hypercalcemia in the setting of MM. Discussion: Hypercalcemia is present in 30% of patients with malignancy. MM commonly presents with hypercalcemia (19% of cases) but there are a handful of cases reported of calcium induced pancreatitis MM patients. Extensive workup is required to determine the etiology of acute pancreatitis starting from common to uncommon predisposing factors. In some cases it may remain cryptogenic. Multiple Myeloma patients may present with hypercalcemia in the setting of increased bone resorption caused by osteoclast activation. It is suggested that high serum calcium levels could be responsible for calcium deposit in the pancreatic ducts and activation of pancreatic enzymes, ultimately leading to pancreatitis. It is important as clinicians to keep in mind this rare presentation of hypercalcemia in MM patients in order to treat and manage the disease effectively and in a timely manner, improving patient outcomes. As calcium levels were normalized by hypercalcemia treatment, our patient's presenting symptoms significantly improved and later resolved.

Evaluation of the Increase in Serum Calcium Levels After Unilateral Adrenalectomy.

IntroductionThis study aims to investigate the prevalence and characteristics of patients with elevated serum calcium due to adrenal insufficiency after unilateral adrenalectomy.MethodsThe study included 76 patients who underwent unilateral adrenalectomy from January 2012 to November 2021 and did not have an additional etiologic factor for hypercalcemia, During the postoperative period, the highest calcium value in six months was taken into account as the postoperative value. Calcium values were corrected according to the albumin value.ResultsOf the 76 patients included in the study, serum calcium levels were higher in six patients (7.9%) after adrenalectomy. Unlike the others, a decrease in glomerular filtration rate (GFR) and an increase in serum creatinine values were detected in the postoperative period in this patient group. In this patient group, the corrected calcium level detected an average increase of 1.3 mg/dL.ConclusionAfter unilateral adrenalectomy, hypercalcemia may occur due to adrenal insufficiency. It should also be considered that there may be a decrease in GFR and increased creatinine in these patients.

Higher serum phosphorus and calcium levels provide prognostic value in patients with acute myocardial infarction.

BackgroundAlthough traditional cardiovascular risk factors are closely related to the poor prognosis of acute myocardial infarction (AMI) patients, there are few studies on the relationship of serum phosphorus and calcium with prognosis in AMI patients. The relationship of serum phosphorus and calcium with prognostic biomarkers in AMI remains unclear.Methods and resultsA total of 3,891 AMI patients were enrolled from a prospective cohort study. We investigated the association of serum phosphorus and calcium with prognostic biomarkers. The risk of in-hospital heart failure (HF), post-discharge HF, all-cause mortality and cardiac mortality was estimated across quartiles of serum phosphorus and calcium levels. Serum phosphorus and calcium levels were associated with biomarkers of prognosis. Overall, 969 patients developed in-hospital HF during hospitalization, 549 patients developed post-discharge HF during a median follow-up of 12 months, and 252 patients died, with 170 cardiac deaths since admission. In the fully adjusted model, compared with patients in quartile 2 (Q2), patients with serum phosphorus levels in Q4 were at greater risk of post-discharge HF [sub-distributional hazard ratios (SHR) 1.55; 95% confidence interval (CI), 1.21–1.99], in-hospital HF [odds ratio (OR) 1.84; 95% CI, 1.47–2.31], all-cause mortality (HR 1.59; 95% CI, 1.08–2.32), and cardiac mortality (SHR 1.68; 95% CI, 1.03–2.75). Compared with patients in Q2, patients with corrected calcium levels in Q4 had a higher risk of in-hospital HF (OR 1.62; 95% CI, 1.29–2.04), all-cause mortality (HR 1.99; 95% CI, 1.37–2.88), and cardiac mortality (SHR 1.87; 95% CI, 1.19–2.96; all p-trend < 0.05).ConclusionSerum phosphorus and calcium levels were associated with AMI prognostic biomarkers in AMI. Higher serum phosphorus was independently related to the increased risk of in-hospital HF, postdischarge HF, all-cause mortality and cardiac mortality, and higher serum calcium was independently related to the increased risk of in-hospital HF, all-cause mortality and cardiac mortality after AMI.

217 Calciphylaxis arising following bariatric surgery

Calciphylaxis is a rare, highly morbid disease leading to vascular calcification and cutaneous necrosis, typically associated with end-stage renal disease (ESRD). While the pathogenesis and risk factors of calciphylaxis are poorly understood, some cases of calciphylaxis in patients who had previously undergone gastric bypass have been reported. The objective of this study is to report cases and describe an association between nutritional deficiencies in the context of bariatric surgery and calciphylaxis. Retrospective study in one large academic hospital that serves as a referral center for calciphylaxis in Boston, Massachusetts between 2012-2018 involving 11 patients who had bariatric surgery prior to calciphylaxis. Median time between bariatric surgery and calciphylaxis diagnosis was 2 years and 2 months, (range 7 months – 30 years). Parathyroid hormone levels were significantly higher in patients with ESRD compared to those with non-uremic calciphylaxis (p=0.036). Corrected calcium levels were significantly higher in patients who had malabsorptive compared to restrictive procedures (p=0.01). Limitations include retrospective nature, sample size, and missing weight loss data from remote bariatric surgical cases. Recognition of risk factors for calciphylaxis and careful evaluation of therapies for other comorbidities in patients who have undergone bariatric procedures is essential to improve outcomes for this rare but problematic disease.

Vitamin D and calcium, together and separately, play roles in female reproductive performance

Vitamin D (VD) deficiency reduces the chances of successful fertilization; however, it remains to be validated whether this effect is dependent or not on calcium. To address this question, we generated several situation using a mouse model in which VD content was either increased or decreased in a normo or hypocalcemia context. After the measurement of serum 25-hydroxyvitamin D2, calcium and phosphorus levels, an analysis was carried out in terms of oocytes maturation as well as reproductive performance. VD overdose, despite the fact that it resulted in an increased number of mature oocytes, reduced developmental competence and offspring survival. VD deficiency (VDD), on the contrary, reduced the number and percentage of mature oocytes, blastocyst rate, as well as fertility rate and offspring survival. Hypo-calcemia when VD levels were normal, had a similar effect than VDD. The effects of VDD were reversed by a diet that corrected calcium level. Therefore, both VD overdose (in a context of normal calcium level) VD deficiency as well as hypo-calcemia have an effect on female reproductive function. In conclusion, although closely related, VD and calcium act in part independently of each other in defining the “optimum” for female reproductive performance.

The rate, cost and outcomes of parathyroidectomy in the united states dialysis population from 2016–2018

BackgroundIn end-stage kidney disease, patients may undergo parathyroidectomy if secondary hyperparathyroidism cannot be managed medically. This study was designed to estimate the parathyroidectomy rate in the United States (US) and to quantify changes in costs and other outcomes after parathyroidectomy.MethodsThis was a retrospective observational cohort study using US Renal Data System data for 2015–2018. Parathyroidectomy rates were estimated for adult hemodialysis and peritoneal dialysis patients alive at the beginning of 2016, 2017, and 2018 who were followed for a year or until parathyroidectomy, death, or transplant. Incremental differences in economic and clinical outcomes were compared before and after parathyroidectomy in adult hemodialysis and peritoneal dialysis patients who received a parathyroidectomy in 2016 and 2017.ResultsThe rate of parathyroidectomy per 1,000person-years decreased from 6.5 (95% CI 6.2-6.8) in 2016 to 5.3 (95% CI5.0-5.6) in 2018. The incrementalincrease in 12-month cost after versus before parathyroidectomy was $25,314(95% CI $23,777-$27,078). By the secondmonth after parathyroidectomy, 58% of patients had a corrected calcium level< 8.5 mg/dL. In the year afterparathyroidectomy (versus before), hospitalizations increased by 1.4 perperson-year (95% CI 1.3-1.5), hospital days increased by 12.1 per person-year(95% CI 11.2-13.0), dialysis visits decreased by 5.2 per person-year (95% CI4.4-5.9), and office visits declined by 1.3 per person-year (95% CI1.0-1.5). The incremental rate per 1,000person years for hematoma/bleed was 224.4 (95% CI 152.5-303.1), for vocal cordparalysis was 124.6 (95% CI 59.1-232.1), and for seroma was 27.4 (95% CI0.4-59.0).ConclusionsParathyroidectomy was a relatively uncommon event in the hemodialysis and peritoneal dialysis populations. The incremental cost of parathyroidectomy was mostly attributable to the cost of the parathyroidectomy hospitalization. Hypocalcemia occurred in over half of patients, and calcium and phosphate levels were reduced. Clinicians, payers, and patients should understand the potential clinical and economic outcomes when considering parathyroidectomy.

Effectiveness of a Nutritional Mobile Application for Management of Hyperphosphatemia in Patients on Hemodialysis: A Multicenter Open-Label Randomized Clinical Trial.

This study aims to determine the effectiveness of a phosphate mobile app (PMA), MyKidneyDiet-Phosphate Tracker ©2019, on hemodialysis (HD) patients with hyperphosphatemia. A multicenter, open-label, randomized controlled trial design allowed randomization of patients with hyperphosphatemia to either the usual care group (UG; receiving a single dietitian-led session with an education booklet) or the PMA group (PG). Thirty-three patients in each intervention group completed the 12-week study. Post-intervention, serum phosphorus levels were reduced in both groups (PG: −0.25 ± 0.42 mmol/L, p = 0.001; UG: −0.23 ± 0.33 mmol/L, p < 0.001) without any treatment difference (p > 0.05). Patients in both groups increased their phosphate knowledge (PG: 2.18 ± 3.40, p = 0.001; UG: 2.50 ± 4.50, p = 0.003), without any treatment difference (p > 0.05). Dietary phosphorus intake of both groups was reduced (PG: −188.1 ± 161.3 mg/d, p < 0.001; UG: −266.0 ± 193.3 mg/d, p < 0.001), without any treatment difference (p > 0.05). The serum calcium levels of patients in the UG group increased significantly (0.09 ± 0.20 mmol/L, p = 0.013) but not for the PG group (−0.03 ± 0.13 mmol/L, p = 0.386), and the treatment difference was significant (p = 0.007). As per phosphate binder adherence, both groups reported a significant increase in Morisky Medication Adherence Scale scores (PG: 1.1 ± 1.2, p < 0.001; UGa: 0.8 ± 1.5, p = 0.007), without any treatment difference (p > 0.05). HD patients with hyperphosphatemia using the PMA achieved reductions in serum phosphorus levels and dietary phosphorus intakes along with improved phosphate knowledge and phosphate binder adherence that were not significantly different from a one-off dietitian intervention. However, binder dose adjustment with meal phosphate content facilitated by the PMA allowed stability of corrected calcium levels, which was not attained by UC patients whose binder dose was fixed.

Association of Albumin-Corrected Serum Calcium Levels with Colorectal Cancer Survival Outcomes.

In epidemiological studies, higher calcium intake has been associated with decreased colorectal cancer (CRC) incidence. However, whether circulating calcium concentrations are associated with CRC prognosis is largely unknown. In this retrospective cohort analysis, we identified 498 patients diagnosed with stage I–IV CRC between the years of 2000 and 2018 in whom calcium and albumin level measurements within 3 months of diagnosis had been taken. We used the Kaplan–Meier method for survival analysis. We used multivariate Cox proportional hazards regression to identify associations between corrected calcium levels and CRC survival outcomes. Corrected calcium levels in the highest tertile were associated with significantly lower progression-free survival rates (hazard ratio (HR) 1.85; 95% confidence interval (CI) 1.28–2.69; p = 0.001) and overall survival (HR 1.86; 95% CI 1.26–2.74, p = 0.002) in patients with stage IV or recurrent CRC, and significantly lower disease-free survival rates (HR 1.44; 95% confidence interval (CI) 1.02–2.03; p = 0.040) and overall survival rates (HR 1.72; 95% CI 1.18–2.50; p = 0.004) in patients with stage I–III disease. In conclusion, higher corrected calcium levels after the diagnosis of CRC were significantly associated with decreased survival rates. Prospective trials are necessary to confirm this association.

FREQUENCY OF HYPOCALCAEMIA IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Background: Chronic kidney disease is a major public health problem worldwide. Kidney failure is becoming increasingly common and is associated with poor health outcomes and high medical expenditures. Objective: To determine the frequency of hypocalcemia among patients with chronic kidney disease. Setting: Department of General Medicine, Hayatabad Medical Complex, Peshawar. Duration of study: Six months 6/5/2019 to 6/11/2019. Study design: Cross sectional study. Materials and Methods: Total 194 patients were included in the study. Detail history, clinical examination and laboratory investigation was preformed for the confirmation of CKD. From all the patients at admission, 3cc of blood was obtained under strict aseptic technique and was immediately sent to hospital laboratory to detect hypocalcaemia and hypocalcaemia was considered positive if the serum corrected calcium level &lt;8.5mg/dL. Results: Stages of CKD was analyzed as 17(9%) patients had CKD stage 1, 29(15%) patients had stage 2, 54(28%) had stage 3, 51(26%) had stage 4, 43(22%) had stage 5 respectively. More over 50(26%) patients had hypocalcemia while 144(74%) patients didnt. Seventy four 74(38%) patients had duration of CKD ≤ 6 months while 120(62%) patients had duration of CKD &gt;6 month. Mean duration of CKD was 7 months with standard deviation ± 3.78. One hundred and forty 140 (72%) patients had weight ≤80 Kgs while 54(28%) patients weight &gt;80 Kgs. Mean weight was 76 Kgs with standard deviation ± 15.29. Conclusion: Frequency of hypocalcemia was found about 26% in patients with chronic kidney disease.

Fibroblast Growth Factor-23 in Pre-Dialysis Chronic Kidney Disease Patients and its Correlation with Carotid Artery Calcification.

Fibroblast growth factor 23 (FGF-23) is a phosphate metabolism regulator in patients with chronic kidney disease (CKD). The present study is aimed to examine the FGF-23 level in pre-dialysis patients with CKD and its correlation with carotid artery calcification (CAAC). This cross-sectional study included patients with CKD and controls. The patients were compared with controls having similar distribution of age and sex to determine serum FGF-23 level in Indian healthy adult population. Detailed medical history, physical examination, and investigations were done for each patient. Atherosclerotic risk factors, cardiovascular comorbidities, and drug history were recorded. Carotid calcification was observed using carotid ultrasound. In total, 62 patients with a mean age of 50.0 years were enrolled. Majority of the patients had hypertension (66.1%), followed by diabetes (27.4%) and dyslipidemia (3.2%). Mean serum corrected calcium levels were significantly higher in patients with CAAC compared to the patients without CAAC (9.21 ± 1.34 vs. 8.53 ± 0.93 mg/dL; P = 0.014). The FGF-23 levels were significantly higher in patients with CAAC compared to those without CAAC (396.0 vs. 254.0 pg/mL; P = 0.008). CAAC was found to be present in both early and late stages of CKD. Multivariate analysis showed that log FGF-23 and serum corrected calcium remained as independent determinants of CAAC. The prevalence of CAAC increased with the ascending quartiles of FGF23. In conclusion, FGF-23 was found to be independently associated with CAAC in CKD.

Vitamin D repletion in primary hyperparathyroid patients undergoing parathyroidectomy leads to reduced symptomatic hypocalcaemia and reduced length of stay: a retrospective cohort study.

Vitamin D deficiency co-exists with and can confuse the diagnosis of primary hyperparathyroidism (PHPT). Vitamin D replete (VDR) status may prevent significant postparathyroidectomy hypocalcaemia; however, reports from previous studies are conflicting. This study aimed to assess differences in early and/or late postoperative hypocalcaemia and length of stay (LOS) postparathyroidectomy between VDR and vitamin D non-replete (VDNR) PHPT patients. This was a retrospective cohort study of a prospectively maintained single surgeon operative database. All records of patients who underwent parathyroidectomy over a four-year period (July 2014 to December 2018) were extracted. Data were collected on vitamin D and corrected calcium levels pre- and postoperatively as well as postoperative complications and LOS. On presentation, there were 91 (47.9%) VDR and 99 (52.1%) VDNR patients. Following vitamin D therapy there were 148 (77.9%) VDR and 42 (22.1%) VDNR. The multivariate analysis showed that vitamin D status was the only significant factor impacting on the hypocalcaemia symptoms (OR 4.9, 95% CI 1.8-13.7, p = 0.002) and the most significant factor for the calcium supplementation (OR 6.5, 95% CI 2.1-19.4, p = 0.001). Bilateral neck exploration was associated with increased likelihood of transient hypocalcaemia (p = 0.007) but no other post-op complication. Median LOS was significantly shorter for VDR (1 day) versus VDNR (1.5 days) patients (p = 0.001). There is a statistically significant increased likelihood of postoperative hypocalcaemia symptoms, requirement for calcium supplements and increased LOS in VDNR patients. This study suggests optimising preoperative vitamin D status improves patient experience and could reduce healthcare costs.

Low serum calcium is associated with perioperative blood loss and transfusion rate in elderly patients with hip fracture: a retrospective study

BackgroundTo investigate whether hypocalcemia influenced total blood loss and transfusion rate in elderly patients with hip fracture.MethodsFrom our hip fracture database, patients were consecutively included between January 2014 and December 2020. Serum calcium level was corrected for albumin concentration, and hypocalcaemia was defined as corrected calcium < 2.11 mmol/L. Hemoglobin and hematocrit were obtained on admission day and postoperative day, and blood transfusions were collected. According to the combination formulas of Nadler and Gross, the total blood loss of each patient was calculated. Risk factors were further analyzed by multivariate linear regression.ResultsA total of 583 consecutive elderly hip fracture patients were finally included (mean age 79.32 ± 8.18 years, 68.61% female). On admission, the mean serum corrected calcium level was 2.17 ± 0.14 mmol/L, and the prevalence of hypocalcemia was 33.11% (95% CI: 29.42–37.02). When comparing patients with normal calcium, hypocalcemia patients exhibited a higher blood transfusion rate (7.69% vs 16.06%, P < 0.05), and significantly larger total blood loss (607.86 ± 497.07 ml vs 719.18 ± 569.98 ml, P < 0.05). Multivariate linear regression analysis showed that male, anemia on admission, time from injury to hospital, intertrochanteric fracture, blood transfusion and hypocalcemia were independently associated with increased total blood loss (P < 0.05).ConclusionHypocalcemia is common in elderly patients with hip fracture, and significantly associated with more total blood loss and blood transfusion. The other risk factors for increased total blood loss are male, anemia on admission, time from injury to hospital, intertrochanteric fracture, and blood transfusion.Level of evidenceLevel III, retrospective study.

Predictors of Central Nervous System (CNS) Involvement in North American Adult T-Cell Leukemia Lymphoma (ATLL) and Their Survival Pattern

▪Introduction:North American-ATLL (NA-ATLL) is a distinct genomic and clinical entity when compared with Japanese ATLL. Despite the frequent CNS involvement by this entity there are no prognostication tools to identify variables associated with higher risk. We studied one of the largest NA-ATLL cohorts in the United States at a minority rich ethnically diverse New York City based tertiary care center to identify discrete variables that may be associated with CNS involvement. Additionally, we examined the predictive power of the previously validated International Prognostic Index (IPI) developed for Diffuse Large B-cell Lymphoma (DLBCL) in terms of CNS involvement as well as overall survival in our cohort.In our previous work, we assigned CNS involvement of ATLL if: 1) cerebrospinal fluid (CSF) cytology or flow cytometry was positive; 2) CNS imaging was positive for disease involvement or 3) physical exam was compatible with neurologic involvement.Methods and results:Of 65 NA-ATLL patients (pts), 20 (30.77%) had CNS involvement by ATLL meeting above mentioned criteria. The median age of all pts in our dataset was 59 years. Pts were divided into non- CNS involved NA-ATLL (non-CNS NA-ATLL) and CNS involved NA-ATLL (CNS NA-ATLL) groups. Parameters to predict CNS involvement were outlined as leukocytosis (>11000 per microliter [μL]), elevated acute lymphocytic count (>4000/ μL), elevated lactate dehydrogenase (LDH) (>190 units/liter [u/l]), generalized lymphadenopathy (LAD) defined as involvement of 2 or more non-contiguous nodal sites, elevated corrected serum calcium levels (>10.5 mg/deciliter), bone marrow (bm) involvement and serosal involvement defined as pleural or peritoneal involvement. These variables were chosen given our prior work identifying them as critical to predict OS in our general NA-ATLL population.We then performed the Fisher test of proportions to determine if the variables above mentioned were different between the CNS NA-ATLL and the non-CNS NA-ATLL. We did not find significant associations when analyzing gender (p=0.0535), leukocytosis (p= 0.4001), lymphocytosis (p =0.57), hypercalcemia (p= 0.7661), elevated LDH (p= 0.4898), generalized LAD (p=0.271), serosal involvement (p= 0.05088) or bone marrow involvement (p=1). We only found a strong association when examining ATLL subtypes, being the acute/lymphomatous variant strongly associated with CNS involvement (p=2.226e10 -5).To identify variables that can have an impact in OS in CNS NA-ATLL vs non-CNS NA-ATLL we calculated Kaplan Meier survival curves. We did not find any difference based on age (p=0.23), gender (p=0.95), leukocytosis (p= 0.074), lymphocytosis (p =0.21), hypercalcemia (p= 0.094), elevated LDH (p= 0.37), generalized LAD (p=0.28), and serosal involvement (p= 0.1) in the overall survival. The only significant association we found was bone marrow involvement in predicting poor OS in CNS NA-ATLL group (p= 0.038).Next, we determined IPI scores (age>60, ECOG performance status>2, Ann Arbor stage III/IV, serum LDH score >190 u/L and more than 1 extra-nodal site) in our CNS NA ATLL and non-CNS NA ATLL cohorts. We sought to determine if: 1) this prognostication tool is predictive in NA-ATLL and 2) if these variables can be used to identify CNS involvement in our cohort.CNS pts with a higher IPI score (>3) showed tendency towards a lower survival rate (p=0.089) than non-CNS pts (p=0.3). IPI score of 3 or more was not predictive of CNS involvement in our sample (p=1).Conclusions:NA-ATLL is a rare and protean disease with poor prognosis and CNS involvement is prevalent. With the variables used we did not find clear predictors of CNS associated disease other than patients presented with the lymphomatous and acute subtypes. We also observed than bone marrow involvement portends a dismal prognosis for individuals with CNS involvement. Future studies with a larger cohort could provider further insight on discovering predictors for CNS involvement in NA ATLL. [Display omitted] DisclosuresShah: Celgene/BMS: Research Funding; Janssen: Research Funding. Gritsman: iOnctura: Research Funding. Shastri: GLC: Consultancy; Kymera Therapeutics: Research Funding; Guidepoint: Consultancy; Onclive: Honoraria. Verma: BMS: Research Funding; GSK: Research Funding; Incyte: Research Funding; Medpacto: Research Funding; Curis: Research Funding; Eli Lilly: Research Funding; Stelexis: Consultancy, Current equity holder in publicly-traded company; Novartis: Consultancy; Acceleron: Consultancy; Celgene: Consultancy; Stelexis: Current equity holder in publicly-traded company; Throws Exception: Current equity holder in publicly-traded company. Janakiram: Amgen: Honoraria.

Serum calcium levels in newly detected essential hypertensive patients

Background: Systemic hypertension is global disease responsible for significant mortality and morbidity. Essential or primary hypertension accounts for the majority of people with hypertension. Although our understanding of the pathophysiology of essential hypertension has grown a lot, its aetiology still remains hypothetical. Few studies in literature have found some correlation with serum calcium levels and blood pressure of the individuals.Methods: A total 200 patients, 100 newly diagnosed essential hypertensive and 100 normotensive patients were included in the study. A detailed history and clinical profile was taken. Blood sample was collected and serum calcium, serum albumin were determined and corrected calcium was calculated and the results were tabulated and appropriate statistical analysis was done.Results: The mean total serum calcium and corrected calcium levels were significantly lowered in essential hypertensive compared to the normotensive individuals. There was no correlation between total serum and corrected calcium levels against systolic and diastolic blood pressure. There was also no difference in serum total and corrected calcium levels among different subsets in essential hypertensive group.Conclusion: Essential hypertension still remains the most common form of hypertension present worldwide causing significant mortality and morbidity. Despite increased advances in medicine and large number of studies done in context with the cause of essential hypertension, its aetiology still remains hypothetical. Even though studies have shown some correlation of calcium fractions with hypertension, the aetiology is still unclear.

The relationship between disease prognosis and serum calcium and corrected calcium levels in COVID-19 patients

Objectives: The present study aimed to evaluate whether low serum calcium (Ca) and corrected calcium (cCa) levels could predict disease prognosis and mortality in patients with COVID-19. Methods: In this study, we retrospectively enrolled 206 eligible patients with COVID-19, diagnosed at Turkey Kanuni Sultan Süleyman Training and Research Hospital between March 12, 2020 and June 15, 2020. Results: Serum Ca level was 8.8 ± 0.57 mg/dL and the serum cCa level was 8.99 ± 0.53 in all patients. The patients were divided into two groups, such as hypocalcemic and non-hypocalcemic patients. We observed that serum Ca levels of patients who died were significantly lower than that of surviving patients. A significant negative correlation was found between serum cCa level and albumin level. A significant positive correlation was found between serum cCa level and C-reactive protein, lactate dehydrogenase, ferritin, procalcitonin, troponin, CURB-65 score, and quick Sepsis-related Organ Failure Assessment (q-SOFA) score. Univariate logistic regression analysis revealed that age, respiratory rate, saturation, heart rate, lymphocyte, serum calcium, D-dimer, CURB-65 score, and q-SOFA score were independent predictors of high-risk group of mortality. Conclusions: This study confirms that the severity of COVID-19 is associated with lower concentrations of serum Ca. The cCa levels were associated with certain prognostic factors. Serum Ca and cCa levels could be an early and helpful marker to improve management of patients with COVID-19. We recommend evaluation of calcium in patients on initial presentation and serial monitoring during hospitalization in order to perform timely and appropriate corrective actions.

Assessing the impact of clinical pharmacy services on the healthcare outcomes of patients attending an outpatient haemodialysis unit in a rural hospital in Egypt: a quasi-experimental study

Abstract Objectives This study aimed to investigate the impact of newly introduced clinical pharmacy services on the health care of chronic haemodialysis patients attending an outpatient haemodialysis unit in a rural hospital with limited resources in Alexandria, Egypt. Methods A quasi-experimental pre-/post-test study was conducted from November 2016 till June 2018. Clinical pharmacists collected relevant information using a pre-specified form. Patients’ data were reviewed for drug-related problems (DRPs), which were documented using the Pharmaceutical Care Network Europe (PCNE) classification system, version 8.02 and resolved by the clinical pharmacists. Measured values of calcium, phosphorus and haemoglobin were compared with target levels set by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Proportions of patients achieving therapeutic values of each parameter were compared before and after implementing the program using the McNemar test. We also reported the analysis of DRPs identified and addressed by the clinical pharmacy team. Key findings A total of 685 DRPs were identified during the follow-up period. Improper dose and inappropriate drug selection were the most common DRPs (45.8% and 18.9%, respectively). There was a statistically significant increase in the proportion of patients achieving target corrected calcium levels (30% pre-intervention versus 69.6% post-intervention, P = 0.001) and haemoglobin levels (9.1% pre-intervention versus 31.9% post-intervention, P = 0.003), but not in phosphorus levels (18.6% pre-intervention versus 22% post-intervention, P = 0.7). Conclusions Clinical pharmacists were able to resolve frequent DRPs and improve some markers of health care in haemodialysis patients.

Comparison of serum corrected and ionized calcium levels in patients with acute kidney injury

Introduction: Acute kidney injury (AKI) is common in hospitalized patients (1.92%). The effect of serum corrected and ionized calcium levels in predicting emergency hemodialysis in patients with AKI is unknown. In this study, we aimed to compare serum corrected and ionized calcium levels in patients who were diagnosed with AKI in the emergency service.Methods: Our study was planned retrospectively. Group 1: Patients with AKI who underwent at least one session of emergency hemodialysis. Group 2: The patients with AKIN stage 1-3 who did not undergo hemodialysis. Serum corrected and ionized calcium, creatinine and albumin values of the patients at the time of admission were analyzed. All data of the study were recorded by SPSS 19.0. For statistical significance, p &amp;lt;0.050 was accepted.Results: The mean serum corrected calcium levels were lower in group 1 than in group 2, and the difference was statistically significant (p &amp;lt;0.001). The mean ionized calcium levels in blood gas were lower in group 1 than in group 2, and the difference was statistically significant (p = 0.002).Conclusions: Serum corrected, and ionized calcium levels can be useful in predicting emergency hemodialysis in patients with AKI.

An Interesting Case of Isolated Bone Marrow Sarcoidosis

Introduction: About 30% cases of sarcoidosis have extrapulmonary manifestations but only 7% of patients present without any lung involvement. Among those 7%, most of the patients have manifestations on the skin but isolated bone marrow sarcoidosis has not been commonly reported. This case represents an unusual manifestation of isolated bone marrow sarcoidosis presenting with very high calcium levels. Case Presentation: A 58-year-old female presented to us with fatigue, poor appetite, and nausea. She did not report any weight changes. Her cancer screening was up to date. On examination, she appeared dehydrated. No neck swelling was appreciated. Cardiac, respiratory, abdominal, and neurological examinations were normal. Complete blood count showed hemoglobin of 10.6 mg/dL, white blood cell count of 3.8 k/dL, and platelet count of 87 x109/L. Metabolic panel revealed hypercalcemia with corrected calcium levels as high as 12.6 mg/dL. Ionized calcium was 8.1 mg/dL (normal 4.8 - 5.6). Her parathyroid hormone (PTH) level was elevated up to 64.6 mg/dL and then further increased to 134.3 mg/dL. A 24-hour urinary calcium level was normal. 1, 25-dihydroxy (1,25-OH) and 25-OH vitamin D levels were 97 mg/dL (normal 18–72) and 31.2 mg/dL, respectively. Serum protein electrophoresis and light chain analysis were normal. Hyperparathyroidism was suggested as a cause of hypercalcemia. Ultrasound of the neck and sestamibi scan showed a right lower pole parathyroid adenoma. Paraneoplastic hypercalcemia was also one of the differentials. Parathyroid hormone related peptide (PTHrP) was 9 pg/mL (normal 14 - 27). Colonoscopy was normal. Computerized tomography showed normal lungs, liver and spleen. No masses and lymphadenopathy was seen. A bone marrow biopsy was done for pancytopenia. Patient underwent parathyroid adenoma removal followed by a drop in serum calcium level (8.2 mg/dL). Patient was discharged on calcium carbonate and vitamin D tablets. Upon outpatient follow-up, calcium level started to rise again up to 9.8 mg/dL. Despite discontinuation of supplemental calcium and vitamin D, calcium continued to uptrend (11.5 mg/dL 4 weeks later). Angiotensin converting enzyme (ACE) level came back as high as 129 (normal level < 40 mcg/L). Meanwhile, the bone marrow biopsy results showed that 40% of bone marrow was occupied by non-caseating granulomas suggesting sarcoidosis. Patient was started on steroids for isolated bone marrow sarcoidosis, and eventually her serum calcium level normalized. Conclusion: An isolated bone marrow sarcoidosis is an extremely rare manifestation of extrapulmonary sarcoidosis. It can present with pancytopenia and should be sought in patients with persistent hypercalcemia. In addition, our case was challenging due to the presence of a concurrent hyperparathyroidism which was initially thought to be the only explanation of our patient’s hypercalcemia.

A Rare Presentation of Multiple Endocrine Neoplasia Type 1

Background: Multiple endocrine neoplasia type 1 (MEN1) is a rare, autosomal dominant inherited syndrome caused by mutations in the MEN1 tumor suppressor gene with a reported incidence of 2 in 100,000.Clinical Case: A 26-year-old Caucasian female was seen for surveillance screening given positive familial mutation in the MEN1 gene. She had a significant family history of pathogenic MEN1 in her son, brother, father and paternal aunt. On presentation, she denied any history of headache, nipple discharge, kidney stones, fractures, heart burn, abdominal pain, diarrhea, hypoglycemia, flushing, lightheadedness. She was on hormonal IUD for contraception and had not had menstrual cycles for the last 6 months. Vital signs and physical examination were unremarkable. Her initial evaluation included a normal calcium of 9.8mg/dL (RR:8.6-10.6mg/dL), PTH of 70pg/ml (RR:12-88pg/ml), 25OH-vitamin-D of 11ng/ml (RR:20-80ng/ml). She had normal gastrin, chromogranin A, glucagon, and vasoactive intestinal peptide levels. Prolactin was 17.6ng/ml (RR:3.3-26.7 ng/ml). MRI pituitary showed a 6mm lesion representing a Rathke’s cleft cyst, not compressing surrounding structures.Two months following the initial encounter, she presented with abdominal pain, nausea, vomiting. She was found to have an obstructing renal stone requiring stent placement. Calcium was 10.1mg/dl. She was also noted to have an incidental pancreatic tail mass of 4.2cm on CT abdomen. She underwent laparoscopic robotic distal spleno-pancreatectomy. Surgical pathology showed a well differentiated 3.5cm neuroendocrine tumor with negative margins, which stained positively for insulin. She had not reported symptoms of weight gain or any episodes suspicious for sympathoadrenal activation or neuroglycopenia, and was again confirmed after surgery.Patient was re-admitted to the hospital for right-sided flank pain and was found to have a new 6mm obstructing calculus with moderate hydronephrosis of the right kidney. Corrected calcium level was found to be mildly elevated at 11.1mg/dL. Repeat PTH was stable at 81pg/ml, and urinary calcium was elevated at 447.3mg/24h (RR:50-250mg/24h). Subsequently, she underwent 3.5 gland parathyroidectomy and thymectomy. On POD20, PTH was 29pg/ml and calcium was 8.6mg/dl.Conclusion: This case highlights a rare presentation of MEN1 with an asymptomatic insulinoma and nephrolithiasis, despite having normal calcium and PTH levels initially. Primary hyperparathyroidism is the most common presentation of MEN1, seen in up to 90% of patients. The second most common finding in MEN1 patients, reported in 70% of the cases, are entero-pancreatic tumors, the most common being gastrinoma. Insulinoma, which is less common and is seen in only 10-30% patients, needs documentation of Whipple’s triad. Interestingly, our patient never had any history of hypoglycemia.

Calcitriol-Mediated Hypercalcemia from Hepatic Granulomatosis Following Percutaneous Cholecystostomy Tube

Granulomatous conditions can present with calcitriol-mediated hypercalcemia via increased 1-hydroxylase activity—activity that is not inhibited by calcium or calcitriol—indicating a lack of feedback inhibition. Differential diagnosis of granulomatosis is quite broad and can require extensive workup as highlighted by this case. Our patient is a 69-year-old white female admitted to the hospital with altered mental status and hypotension. Initial evaluation was concerning for infection, due to leukopenia and thrombocytopenia. CT abdomen revealed cholecystitis, percutaneous cholecystostomy tube was placed, and the patient’s mental status improved. One month after discharge, the patient presented to the hospital with a corrected calcium of 15.2 mg/dl. PTH was 22 pg/mL with normal renal function and phosphorus. The patient was treated with intravenous fluids, calcitonin, and zoledronic acid. Calcitriol was 69 pg/ml (18–75 pg/ml) and corrected calcium responded by time of discharge. During outpatient follow up, she was found to have corrected calcium 11.2 mg/dl and calcitriol 166 pg/ml with appropriately low PTH. Additional workup of apparent calcitriol-mediated hypercalcemia with whole-body CT imaging, tuberculosis screening, and flow cytometry only notable for possible right cervical lymphadenopathy on CT. Subsequent lymph node biopsy was benign. The patient completed a 30-day course of prednisone 20 mg daily followed by prednisone taper and her corrected calcium and calcitriol levels normalized. However, after discontinuation of prednisone, lab work demonstrated increase in calcium and liver enzymes. Repeat CT scan showed multiple hypoechoic areas with subsequent biopsy consistent with necrotizing hepatic granulomatosis. PAS-A, Fite, and AFB stains were negative for fungi and mycobacteria. Removal of cholecystostomy tube resulted in complete resolution of hypercalcemia and elevated calcitriol levels. Foreign body-induced granulomatosis is associated with PTH-independent hypercalcemia. Silicone has been implicated in foreign body granuloma. Hepatic granulomatosis is associated with percutaneous tube, especially with prolonged placement (approximately 11 months in this case). Removal of the foreign body is associated with improvement in hypercalcemia. Follow-up liver ultrasound demonstrated complete resolution of hepatic granulomas at three months following removal of the cholecystostomy tube.