Hypercalcemia

Original Editors - Whitney Browning & Natalie Elliott from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Whitney Browning, Natalie Elliott, Elaine Lonnemann, Admin, Lucinda hampton, 127.0.0.1, WikiSysop and Kim Jackson  

Introduction

Hypercalcemia is a condition in which the calcium level in the blood is above normal. Too much calcium in your blood can weaken the bones, create kidney stones, and interfere with how the heart and brain work.

Hypercalcemia is usually a result of overactive parathyroid glands. Other causes of hypercalcemia include cancer, certain other medical disorders, some medications, and taking too much of calcium and vitamin D supplements.

• Signs and symptoms of hypercalcemia range from nonexistent to severe. Treatment depends on the cause.
• Normal calcium levels range from 8.2-10.2 mg/dL. Mild hypercalcemia occurs when this level raises to 12mg/dL and severe hypercalcemia is classified as serum calcium at 14mg/dL.

Epidemiolgy

The prevalence of hypercalcemia in the general population is approximately 1% to 2%. Most of the cases (90%) of hypercalcemia are due to primary hyperparathyroidism and malignancy-associated hypercalcemia.

Etiology

Common causes of hypercalcemia include: 

• Overactivity of parathyroid glands
• Cancer-specifically lung and breast cancer as well as multiple myeloma can increase the risk of hypercalcemia. This is considered to be due to the fact that some malignant tumors can produce a protein that acts similar to the parathyroid hormone which stimulates the release of calcium from the bones into the bloodstream. 
• Other disease effects-some people with cancer that causes them to spend increased time lying down or in bed may cause bones to release calcium into the blood due to the lack of weight-bearing.
• Medications-Lithium, a drug used to treat bipolar disorder, may increase the release of parathyroid hormone and cause hypercalcemia. Also, Thiazie diuretics can cause elevated calcium levels by decreasing the amount of calcium excreted in the urine. 
• Supplements-eating or drinking too much calcium or Vitamin D
• Dehydration-less fluid in your blood causes the calcium levels to increase

Characteristics/Clinical Presentation

Many of the symptoms of hypercalcemia are ones that are characteristic of other conditions. More-severe cases produce signs and symptoms related to the parts of the body affected by the high calcium levels in the blood. Examples include:

• Gastrointestinal symptoms like pain, nausea, and vomiting. Hypercalcemia can lead to peptic ulcer disease and pancreatitis.
• Bone related complications like bone pain. Hypercalcemia can lead to osteoporosis, osteomalacia, arthritis and pathological fractures.
• Renal stones causing pain.
• Fatigue and malaise.
• Polyuria, polydipsia, and constipation.
• Lethargy, confusion, depression and memory loss.

Severe hypercalcemia inhibits neuromuscular and myocardial depolarization leading to muscle weakness and arrhythmias.

Diagnosis

Hypercalcemia is diagnosed by blood tests revealing increased serum calcium levels. However, other tests may need to be done in order to determine the underlying cause of hypercalcemia. These may include: Chest X-Ray; CT Scan; MRI; Mammogram

These tests may help determine whether client has lung cancer, breast cancer, other malignancies, or sarcoidosis (a granulomatous disease of the lungs). 

Treatment

The treatment of hypercalcemia varies depending upon how elevated the calcium is, as well as the cause. Medical approaches used to decrease blood calcium level include medications and interventions.

All clinicians and nurses should educate the patients on maintaining hydration, changes in diet and limiting calcium intake. The patient and family should be told about the symptoms of hypercalcemia and when to seek assistance. Physical therapy should be involved to ensure that the patient remains mobile and active (see below). If the patient has a metastatic disease associated with hypercalcemia, the hospice, palliative care, and pain teams should be involved to ensure that the quality of life is not compromised.

A dietitian should be consulted to educate the patient on what type of foods to avoid. With such a team approach, it is hoped that the patient outcomes will improve.

Medications used to treat hypercalcemia include:

• Bisphosphonates, which decrease bone breakdown
• Calcitonin, a medication that can lower elevated calcium levels
• Gallium nitrate, used to treat cancer-related hypercalcemia
• Sensipar (cinacalcet), which lowers calcium in the blood
• Steroids: These drugs may be used in some situations, although steroids can also lower calcium in some instances. The cause of the hypercalcemia will dictate whether steroids are advised or not.

If hypercalcemia is very severe, dialysis may be needed.

Physical Therapy Management

• Weightbearing exercises to prevent osteoporosis and immobility
• Prevention of fractures 
• Ensure adequate hydration
• Quality of life measures
• Strength/ROM
• Patient and Family Education

Prognosis

The prognosis of patients with hypercalcemia depends upon the etiology of the elevation:

• Prognosis is very poor with malignancy that has progressed into development of hypercalcemia.
• Prognosis is excellent when the underlying cause is treatable and treatment is initiated promptly.