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Abstract: PO0364

Unexplained Persistent Hypercalcemia After Liver Transplantation

Session Information

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.
PatientAge / GenderMedical HistoryCause of liver failureAssociated AKIImmunosuppressionCalcium levels (mg/dL)Treatment of hypercalcemiaHypercalcemia work upOther Complications
A54 F-HTN
-DM
-CVA
-Vitamin D deficiency
(no supplementation)
NASH CirrhosisHepatorenal

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
B27 M-Alcohol abuse
-Alpha 1 antitrypsin deficiency
-Vitamin d deficiency (50,000 units weekly)
Alcoholic hepatitisATN + Bile cast nephropathy

Dialysis dependent prior to transplant
TacrolimusPreop = 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
C36 M-Alcohol abuse
-Vitamin D deficiency
(50,000 units weekly)
Alcoholic hepatitisATN

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.