Abstract: SA-PO259
Severe Hypercalcemia Mitigated by Etelcalcetide in Continuous Renal Replacement Therapy
Session Information
- Bone and Mineral Metabolism: Calcium, Magnesium, Kidney Stones
November 09, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Bone and Mineral Metabolism
- 402 Bone and Mineral Metabolism: Clinical
Authors
- Tolwani, Ashita J., University of Alabama at Birmingham, Birmingham, Alabama, United States
- Rajasekaran, Arun, University of Alabama at Birmingham, Birmingham, Alabama, United States
Introduction
Secondary hyperparathyroidism (SHPT) is associated with increased bone turnover, risk of fractures, vascular calcifications, and cardiovascular and all-cause mortality. We describe a critically ill ESRD patient with SHPT who developed hypercalcemia with prolonged immobilization managed with continuous renal replacement therapy (CRRT) using regional citrate anticoagulation (RCA) without calcium supplementation and treatment with intravenous etelcalcetide.
Case Description
A 51 year old lady with ESRD on hemodialysis (HD) underwent aortic and mitral valve replacement. She received maintenance HD for 10 days after cardiac surgery. Post-surgical course was complicated by hypoxic respiratory failure, mesenteric ischemia, and septic shock warranting mechanical ventilation, colectomy and vasopressor use. In the setting of SHPT with high turnover bone disease and prolonged immobilization, she developed pathological bilateral subcapital femoral neck fractures with diffuse osteopenia 2 months after admission. She had elevated systemic ionized calcium (1.6 mmol/L), phosphorus (6.7 mg/dl), ALP (426 U/L), bone-specific ALP (90 mcg/L), and PTH (780 pg/ml) levels. The patient was started on citrate based CRRT without the use of a calcium infusion 10 days after cardiac surgery; and was treated with intravenous etelcalcetide 5 mg thrice weekly to mitigate severe hypercalcemia. After 3 weeks, she had a reduction in systemic ionized calcium (1.1 mmol/L), phosphorus (3.5 mg/dl), ALP (316 U/L), and PTH (310 pg/ml) levels. She eventually died from worsening septic shock.
Discussion
Etelcalcetide, a novel second-generation calcimimetic, has made significant advances in managing SHPT via improved control of PTH and FGF-23 levels. It can be used in critically ill patients with severe hypercalcemia and SPHT on CRRT as no renal dosing is required. RCA provides anticoagulation for CRRT by chelating calcium in the circuit and requires a systemic calcium infusion to replace calcium. Patients with severe hypercalcemia can be managed effectively with citrate-based CRRT without the need for systemic calcium replacement as long as systemic ionized calcium levels are monitored frequently.