Abstract: PO0364
Unexplained Persistent Hypercalcemia After Liver Transplantation
Session Information
- Biochemical Aspects of Mineral and Bone Disease
October 22, 2020 | Location: On-Demand
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Report
- 402 Bone and Mineral Metabolism: Clinical
Authors
- Muaddi, Luba, Allegheny General Hospital - Western Pennsylvania Hospital Medical Education Consortium, Pittsburgh, Pennsylvania, United States
- Sureshkumar, Kalathil K., Allegheny General Hospital - Western Pennsylvania Hospital Medical Education Consortium, Pittsburgh, Pennsylvania, United States
- Chopra, Bhavna, Allegheny General Hospital - Western Pennsylvania Hospital Medical Education Consortium, Pittsburgh, Pennsylvania, United States
Introduction
Hypercalcemia has been reported as a sequela of chronic liver disease in association with hyperbilirubinemia. Previous reports of hypercalcemia post liver transplant were thought to be potential rare complication of altered bone metabolism under intense immunosuppression and from prolonged immobilization. However the pathogenesis of this rare phenomenon has not been clarified to this date. We present cases of unexplained severe persistent hypercalcemia in three liver transplant recipients.
Case Description
Hypercalcemia post liver transplant in 3 recipients described in Table 1 and calcium trends shown in Figure 1.
Discussion
Extensive work up for hypercalcemia was negative in our patients. Although immobilization could be contributory, other unrecognized possibilities are plausible. Immunosuppression with steroids and other agents, especially cyclosporine, has been hypothesized to cause calcium imbalance by inhibiting T cell activation and transcription of interleukin-2 which are involved in bone turnover. Depletion of T cells upregulates osteoclastogenesis through prostaglandin production; by interfering with receptor activator of nuclear factor kappa ligand (RANK-L) and osteoprotegerin on osteoblasts. However, only one patient was on cyclosporine. Other, yet unidentified, factors modifying calcium metabolism could be involved. We would like to draw attention to this fascinating phenomenon in order to gain more insight.
Low dialysate calcium, pharmacotherapy (Calcitonin, Pamidronate and Denusomab) along with improved mobility had successfully lowered serum calcium in these patients. One patient had hypocalcemia after Denusomab administration, hence needed careful monitoring.
Descriptions of hypercalcemia cases post liver transplant.
| Patient | Age / Gender | Medical History | Cause of liver failure | Associated AKI | Immunosuppression | Calcium levels (mg/dL) | Treatment of hypercalcemia | Hypercalcemia work up | Other Complications |
| A | 54 F | -HTN -DM -CVA -Vitamin D deficiency (no supplementation) | NASH Cirrhosis | Hepatorenal Dialysis dependent prior to transplant | Cellcept Cyclosporin | Preop = 9.2 Peak =20.2 on week 8 post transplant Last follow up= 12.9 | Calcitonin Pamidronate Denosumab Frequent HD low calcium bath | -SPEP neg -PTH = 8 -PTHrP <2 -25 hydroxy-D = 38 -1,25 hydroxy-D = 9 -Phos wnl -Malignancy screening neg -T bili wnl - TSH wnl | -Neutropenia -Failure to thrive - Prolonged Immobilization |
| B | 27 M | -Alcohol abuse -Alpha 1 antitrypsin deficiency -Vitamin d deficiency (50,000 units weekly) | Alcoholic hepatitis | ATN + Bile cast nephropathy Dialysis dependent prior to transplant | Tacrolimus | Preop = 8.7 Peak = 14 on week 10 post transplant Last follow up= 9.9 | Discontinued Vitamin D supplementation Calcitonin Frequent HD low calcium bath | -SPEP neg -PTH = 7 -PTHrP <2 -25 hydroxy-D <5 -1,25 hydroxy-D < 5 -Phos wnl - T bili wnl - TSH wnl | -Pericardial effusion with tamponade -Shock -Critical care myopathy -Muscle spasms -Dermal fungal infection |
| C | 36 M | -Alcohol abuse -Vitamin D deficiency (50,000 units weekly) | Alcoholic hepatitis | ATN Dialysis dependent prior to transplant | Prograf Cellcept Prednisone | Preop = 8.3 Peak = 14.5 on week 18 post transplant Last follow up= 9.4 | Discontinued Vitamin D supplementation Calcitonin Denosumab Frequent HD low calcium bath | -SPEP neg -PTH = 18 -PTHrP <2 -25 hydroxy-D =7 -1,25 hydroxy-D =12 -Phos wnl -T bili wnl - TSH wnl | -T-cell mediated rejection -CMV viremia -Pericardial effusion -Critical care myopathy |
Figure 1: Calcium trends and treatments.