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Abstract: SA-PO504

Post-Operative Severe Hypercalcemia: A Tale of Two Patients

Session Information

Category: Fluid‚ Electrolyte‚ and Acid-Base Disorders

  • 1002 Fluid‚ Electrolyte‚ and Acid-Base Disorders: Clinical

Authors

  • Belal, Amer Ashaab, University of Florida College of Medicine, Gainesville, Florida, United States
  • Badour, Sanaa, University of Florida College of Medicine, Gainesville, Florida, United States
  • Adewuyi, Joel O., University of Florida College of Medicine, Gainesville, Florida, United States
  • Kazory, Amir, University of Florida College of Medicine, Gainesville, Florida, United States
Introduction

Calcium sulfate beads are increasingly used as a means for delivery of local antibiotics in periprosthetic joint infections. Hypercalcemia is an emerging complication after placement of the beads that is poorly characterized. Certain subset of patients (e.g. those with chronic kidney disease [CKD]) seem to be particularly susceptible and need to be risk stratified prior to surgery.

Case Description

A 72-year-old woman with a medical history significant for CKD and metastatic papillary thyroid cancer to the right femur was admitted for second revision of right total hip arthroplasty. Her serum calcium (Ca) was noted to rise rapidly from 9.1 mg/dL preoperatively to 11.1 mg/dL on postoperative day (POD) 3. She underwent workup for causes of hypercalcemia with PTH that was appropriately suppressed at 4 pg/m, ionized Ca elevated at 2.0 mmml/L, VitD(25)OH within normal range at 30.65 ng/mL as was VitD(1,25)OH at 25.3 pg/mL. PTHrP was unremarkable at 4 pmol/L, as was Angiotensin Converting Enzyme at 80 U/L. Labs were inconsistent with multiple myeloma. Her serum creatinine (Cr) remained relatively stable at 4 mg/dL during this time. Further investigation revealed that she had insertion of calcium sulfate beads during surgery. Her Ca continued to rise and peaked on POD 7 at 15.8 mg/dL despite medical management including aggressive hydration with 150-200 cc/hour of normal saline, 8 doses of calcitonin, as well as pamidronate on POD 5. Only after 23 days, did her Ca return to a normal level below 10 mg/dL.
Contrast this with the case of a 77-year-old woman with normal renal function (Cr 0.7 mg/dL) that was admitted due to prosthetic joint infection of the knee, also with intraoperative placement of calcium sulfate antibiotic eluting beads. Her serum Ca preoperatively was 8.3 mg/dL and rose to 14.1 mg/dL on POD 2, but responded to conventional medical therapy with steady decline and return to normal range of less than 10 mg/dL within 7 days.

Discussion

These two cases serve to raise awareness regarding post-operative hypercalcemia that can result from calcium sulfate beads used for local antibiotic therapy. Of note, in patients with advanced CKD, hypercalcemia can be prolonged despite appropriate medical therapy leading to increased morbidity. With increasing use of calcium-eluting beads, we propose that this point needs to be included in pre-operative risk stratification