Massive hypercalcaemia in rhabdomyolysis associated with acute renal failure
Hipercalcemia masiva en la rabdomiólisis asociada a insuficiencia renal aguda
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Dolores" "apellidos" => "Sánchez-de la Nieta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "nombre" => "Francisco" "apellidos" => "Rivera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "nombre" => "Sara" "apellidos" => "Anaya" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 4 => array:3 [ "nombre" => "Minerva" "apellidos" => "Arambarri" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 5 => array:3 [ "nombre" => "Isabel" "apellidos" => "Ferreras" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital General Universitario de Ciudad Real, Ciudad Real, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hipercalcemia masiva en la rabdomiólisis asociada a insuficiencia renal aguda" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11577_16025_35738_en_f111577.jpg" "Alto" => 804 "Ancho" => 1381 "Tamanyo" => 339442 ] ] "descripcion" => array:1 [ "en" => "Evolution of calcium, phosphorous, and creatinine levels during hospitalisation and after discharge" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor:</span></p><p class="elsevierStylePara">Rhabdomyolysis (RD) is the process of cellular necrosis in striated muscle, with the release of intracellular components into the blood stream.<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">Acute renal failure (ARF) appears in 15%-50% of cases of RD, and can be associated with altered calcium metabolism with a biphasic pattern. In the initial oliguric phase, 60% of patients with RD can develop hypocalcaemia.<span class="elsevierStyleSup">2</span> In the recovery phase of ARF, 20%-30% can develop hypercalcaemia.<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">The cases described in the literature of RD with hypercalcaemia equal to or greater than 15mg/dl correspond to patients that initially suffered severe hypocalcaemia.<span class="elsevierStyleSup">3-7</span></p><p class="elsevierStylePara">Here we present the case of RD secondary to intense exercise during grape harvest and associated with ARF, in which, following a mild initial bout of hypocalcaemia, the patient developed severe hypercalcaemia at 15.4mg/dl.</p><p class="elsevierStylePara">Our patient was a 21-year-old male with no relevant medical background. Fifteen days prior to hospitalisation, the patient started to suffer general malaise, muscle pain, vomiting, swelling of the legs, and dark urine followed by oligoanuria, following intense exercise during grape harvest. The patient’s primary physician started treatment with prokinetics, muscle relaxants, and antibiotics (norfloxacin), with no improvement. A physical examination revealed skin and mucosae dehydration and bradypsychia. The patient’s blood pressure was 150/60mm Hg, with a soft abdomen that produced slight pain upon deep palpation. The muscles in the limbs were hardened, and all other results were normal.</p><p class="elsevierStylePara">A laboratory analysis revealed: creatinine: 16.2mg/dl; urea: 411mg/dl; maximum creatinine phosphokinase (CPK): 1000U/l; total protein: 6.3g/dl; albumin: 3.9g/dl; Na: 134mEq/l; K: 4mEq/l; Ca: 7.9mg/dl; P: 9.3mg/dl. A urine analysis revealed red blood cells +++ and urinary sediment: 7-8 red blood cells/field (Figure). Viral serology (for hepatitis B and C and human immunodeficiency virus) was negative. Chest x-ray and abdominal ultrasound results were normal.</p><p class="elsevierStylePara">Given the patient’s severe state of nitrogen retention and symptoms indicative of uremic encephalopathy, we administered two sessions of haemodialysis, intense hydration therapy, and urine alkalinisation. This produced improvements in the clinical symptoms and laboratory results. Despite this improvement, the patient continued to suffer vomiting on the seventh day of treatment; we performed more tests, observing hypercalcaemia at 15.4mg/dl. We administered intense hydration therapy, diuretic treatment, calcitonin, and bisphosphonates. Parathyroid hormone (PTH) levels were 7.97pg/ml, and 25-dihydroxyvitamin D was at 22nmol/l. Upon discharge, the patient’s creatinine level was 1.8mg/dl, CPK was normal, and serum Ca was at 8.5mg/dl. In later follow-up sessions, creatinine was at 0.8mg/dl and Ca and CPK values were with normal ranges (Figure).</p><p class="elsevierStylePara">Reviewing the medical literature, we can observe more than 60 cases published since 1970 of hypercalcaemia associated with RD.<span class="elsevierStyleSup">3-9</span> We can also note that the majority of cases described of hypercalcaemia >15mg/dl, such as in our case, initially present severe hypocalcaemia.<span class="elsevierStyleSup">3-7</span> Our patient had mild hypocalcaemia at 7.9mg/dl during the oligoanuric phase, and later developed hypercalcaemia at 15.4mg/dl. In a similar manner, Grobety et al. described two cases of patients with mild hypocalcaemia during initial phases of RD, at 7.4mg/dl and 7.6mg/dl, who later developed severe hypercalcaemia at 15.6mg/dl and 15mg/dl, respectively.<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">Hypocalcaemia in RD tends to appear in the oliguric phase of ARF, is normally temporary, and can occasionally be severe and symptomatic. Treatment with calcium salts and/or vitamin D derivatives should be avoided, since this could aggravate the state of hypercalcaemia produced in the recovery phase of RD.<span class="elsevierStyleSup">9</span> Our patient did not require treatment, since the hypocalcaemia was mild and asymptomatic.</p><p class="elsevierStylePara">Hypercalcaemia in RD tends to occur in the phase of recovery of diuresis in the associated ARF; this is primarily due to the release of calcium deposited in the muscles into the bloodstream, along with mild hyperparathyroidism caused by renal failure.<span class="elsevierStyleSup">4,9</span> The majority of cases of hypercalcaemia are self-limiting, and may only need observation and adequate hydration.<span class="elsevierStyleSup">2</span> However, certain patients require treatment with bisphosphonates, calcitonin, and loop diuretics,<span class="elsevierStyleSup">2 </span>as in our case.</p><p class="elsevierStylePara">Our patient did not require sequential PTH measurements during hospitalisation, but during the phase of recovery from diuresis, he did develop severe hypercalcaemia with suppressed PTH, as in the majority of described cases. However, calcitriol levels were normal, in contrast with the low levels described by other authors.<span class="elsevierStyleSup">3,4</span></p><p class="elsevierStylePara">To conclude, the majority of cases of ARF associated with RD and severe hypercalcaemia initially present the form of severe hypocalcaemia, and occasionally mild hypocalcaemia. We described a case of severe hypercalcaemia in a patient with an initial mild decrease in calcium levels. This suggests that severe hypercalcaemia following mild hypocalcaemia might be the result of approaching the case of RD when it was already substantially progressed, or due to outside factors. Our case may have been one of late RD, although we cannot confirm this, since we do not have laboratory analyses from before the patient was hospitalised. However, when presented with a patient with ARF and RD, we must monitor calcium kinetics alterations, even when serum calcium levels in the initial phase are normal or only slightly low.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors have no conflicts of interest to declare.</p><p class="elsevierStylePara"><a href="grande/11577_16025_35738_en_f111577.jpg" class="elsevierStyleCrossRefs"><img src="11577_16025_35738_en_f111577.jpg" alt="Evolution of calcium, phosphorous, and creatinine levels during hospitalisation and after discharge"></img></a></p><p class="elsevierStylePara">Figure 1. Evolution of calcium, phosphorous, and creatinine levels during hospitalisation and after discharge</p>" "pdfFichero" => "P1-E543-S3700-A11577-EN.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11577_16025_35738_en_f111577.jpg" "Alto" => 804 "Ancho" => 1381 "Tamanyo" => 339442 ] ] "descripcion" => array:1 [ "en" => "Evolution of calcium, phosphorous, and creatinine levels during hospitalisation and after discharge" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. 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Schweiz Med Wochenschr 1992;122(29):1087-90. <a href="http://www.ncbi.nlm.nih.gov/pubmed/1641614" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003200000005/v0_201502091606/X2013251412001759/v0_201502091607/en/main.assets" "Apartado" => array:4 [ "identificador" => "35437" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor - Brief Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003200000005/v0_201502091606/X2013251412001759/v0_201502091607/en/P1-E543-S3700-A11577-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251412001759?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 20 | 5 | 25 |
| 2024 October | 166 | 40 | 206 |
| 2024 September | 139 | 58 | 197 |
| 2024 August | 157 | 60 | 217 |
| 2024 July | 190 | 62 | 252 |
| 2024 June | 146 | 49 | 195 |
| 2024 May | 168 | 46 | 214 |
| 2024 April | 141 | 51 | 192 |
| 2024 March | 133 | 25 | 158 |
| 2024 February | 121 | 41 | 162 |
| 2024 January | 143 | 34 | 177 |
| 2023 December | 94 | 32 | 126 |
| 2023 November | 125 | 57 | 182 |
| 2023 October | 124 | 85 | 209 |
| 2023 September | 116 | 40 | 156 |
| 2023 August | 108 | 23 | 131 |
| 2023 July | 105 | 35 | 140 |
| 2023 June | 126 | 29 | 155 |
| 2023 May | 129 | 34 | 163 |
| 2023 April | 100 | 23 | 123 |
| 2023 March | 108 | 45 | 153 |
| 2023 February | 76 | 53 | 129 |
| 2023 January | 87 | 35 | 122 |
| 2022 December | 117 | 40 | 157 |
| 2022 November | 91 | 48 | 139 |
| 2022 October | 103 | 74 | 177 |
| 2022 September | 121 | 34 | 155 |
| 2022 August | 104 | 46 | 150 |
| 2022 July | 92 | 63 | 155 |
| 2022 June | 77 | 48 | 125 |
| 2022 May | 127 | 48 | 175 |
| 2022 April | 145 | 67 | 212 |
| 2022 March | 127 | 53 | 180 |
| 2022 February | 123 | 46 | 169 |
| 2022 January | 198 | 58 | 256 |
| 2021 December | 135 | 59 | 194 |
| 2021 November | 125 | 58 | 183 |
| 2021 October | 121 | 42 | 163 |
| 2021 September | 100 | 50 | 150 |
| 2021 August | 108 | 53 | 161 |
| 2021 July | 113 | 33 | 146 |
| 2021 June | 68 | 22 | 90 |
| 2021 May | 111 | 38 | 149 |
| 2021 April | 200 | 92 | 292 |
| 2021 March | 133 | 36 | 169 |
| 2021 February | 118 | 22 | 140 |
| 2021 January | 79 | 30 | 109 |
| 2020 December | 75 | 35 | 110 |
| 2020 November | 98 | 13 | 111 |
| 2020 October | 66 | 17 | 83 |
| 2020 September | 61 | 12 | 73 |
| 2020 August | 65 | 20 | 85 |
| 2020 July | 61 | 20 | 81 |
| 2020 June | 93 | 14 | 107 |
| 2020 May | 88 | 17 | 105 |
| 2020 April | 69 | 26 | 95 |
| 2020 March | 55 | 9 | 64 |
| 2020 February | 58 | 26 | 84 |
| 2020 January | 91 | 28 | 119 |
| 2019 December | 90 | 19 | 109 |
| 2019 November | 73 | 24 | 97 |
| 2019 October | 59 | 21 | 80 |
| 2019 September | 55 | 22 | 77 |
| 2019 August | 68 | 14 | 82 |
| 2019 July | 57 | 21 | 78 |
| 2019 June | 65 | 16 | 81 |
| 2019 May | 49 | 16 | 65 |
| 2019 April | 112 | 25 | 137 |
| 2019 March | 69 | 27 | 96 |
| 2019 February | 41 | 20 | 61 |
| 2019 January | 64 | 21 | 85 |
| 2018 December | 113 | 34 | 147 |
| 2018 November | 101 | 11 | 112 |
| 2018 October | 91 | 12 | 103 |
| 2018 September | 120 | 17 | 137 |
| 2018 August | 87 | 13 | 100 |
| 2018 July | 72 | 9 | 81 |
| 2018 June | 54 | 11 | 65 |
| 2018 May | 89 | 10 | 99 |
| 2018 April | 81 | 11 | 92 |
| 2018 March | 59 | 10 | 69 |
| 2018 February | 87 | 10 | 97 |
| 2018 January | 74 | 8 | 82 |
| 2017 December | 79 | 9 | 88 |
| 2017 November | 65 | 9 | 74 |
| 2017 October | 65 | 9 | 74 |
| 2017 September | 61 | 11 | 72 |
| 2017 August | 44 | 14 | 58 |
| 2017 July | 51 | 12 | 63 |
| 2017 June | 58 | 6 | 64 |
| 2017 May | 64 | 10 | 74 |
| 2017 April | 61 | 12 | 73 |
| 2017 March | 37 | 12 | 49 |
| 2017 February | 47 | 14 | 61 |
| 2017 January | 46 | 13 | 59 |
| 2016 December | 70 | 6 | 76 |
| 2016 November | 108 | 11 | 119 |
| 2016 October | 155 | 8 | 163 |
| 2016 September | 219 | 5 | 224 |
| 2016 August | 249 | 7 | 256 |
| 2016 July | 227 | 12 | 239 |
| 2016 June | 143 | 0 | 143 |
| 2016 May | 160 | 0 | 160 |
| 2016 April | 150 | 0 | 150 |
| 2016 March | 125 | 0 | 125 |
| 2016 February | 130 | 0 | 130 |
| 2016 January | 144 | 0 | 144 |
| 2015 December | 145 | 0 | 145 |
| 2015 November | 145 | 0 | 145 |
| 2015 October | 113 | 0 | 113 |
| 2015 September | 90 | 0 | 90 |
| 2015 August | 87 | 0 | 87 |
| 2015 July | 109 | 0 | 109 |
| 2015 June | 51 | 0 | 51 |
| 2015 May | 46 | 0 | 46 |
| 2015 April | 8 | 0 | 8 |
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