Advertisement

CEN Case Reports

, Volume 7, Issue 2, pp 229–233 | Cite as

Extreme hypercalcemia in a kidney transplant recipient

  • Erol Demir
  • Cagla Karaoglan
  • Gulcin Yegen
  • Betul Sair
  • Halil Yazici
  • Aydin Turkmen
  • Mehmet Sukru Sever
Case Report
  • 69 Downloads

Abstract

Post-transplant hypercalcemia is a major problem in renal transplant recipients, which may negatively affect both graft and patient survival. In this paper, we present a 66-year-old male kidney transplant recipient, who was admitted to our clinic with symptoms of fever, nausea, vomiting and lethargy. Laboratory data showed good renal function; however, a serum calcium level of 22.1 mg/dL. The patient was treated by isotonic saline together with furosemide and methylprednisolone. Because of treatment resistance, subcutaneous calcitonin and ibandronate were added to the treatment protocol as well. Since all these medications were not effective, hemodialysis with low-calcium (1.25 mmol/L) dialysate was applied for three consecutive days, which resulted in normalization of serum calcium. Several investigations were carried out for diagnosing the underlying etiology. Positron-emission tomography (PET)/CT revealed a strong diffuse uptake of FDG in the bones and spleen. A bone marrow biopsy showed diffuse interstitial infiltration of CD20 + neoplastic B cells and, thus, post transplant lymphoproliferative disease (PTLD) was diagnosed. Tacrolimus was switched to everolimus, mycophenolate mofetil was stopped, while treatment with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) was initiated. Despite all therapeutic interventions, the patient died of septic shock in the intensive care unit on the 10th day of emergency service admission. Importance of hemodialysis as an emergent treatment modality in extreme hypercalcemia, and unfavorable course of PTLD were underlined.

Keywords

Hypercalcemia Kidney transplantation Hemodialysis Lymphoproliferative disorders 

Notes

Author contributions

ED, CK and HY performed the collection and interpretation of the data. CK prepared the manuscript. ED, HY, SM, BS and MSS critically revised the paper. All authors read and approved the final version.

Compliance with ethical standards

Conflict of interest

The authors have declared that no conflict of interest exists.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Written informed consent was obtained from the patient’s parents for publication of this case report and accompanying images. A copy of the written consent may be requested for review from the corresponding author.

References

  1. 1.
    Julian BA, Quarles LD, Niemann KM. Musculoskeletal complications after renal transplantation: pathogenesis and treatment. Am J Kidney Dis. 1992;19:99.CrossRefGoogle Scholar
  2. 2.
    Pihlstrøm H, Dahle DO, Mjøen G, et al. Increased risk of all-cause mortality and renal graft loss in stable renal transplant recipients with hyperparathyroidism. Transplantation. 2015;99:351.CrossRefGoogle Scholar
  3. 3.
    Mesa P, Cafforio C, Alfieri C. Clinical impact of hypercalcemia after kidney transplant. G Ital Nefrol: Organo Ufficiale Della Societa Italiana di Nefrologia. 2009;27:47–55.Google Scholar
  4. 4.
    Reinhardt W, Bartelworth H, Jockenhovel F, et al. Sequential changes of biochemical bone parameters after kidney transplantation. Nephrol Dial Transpl. 1998;13:436–42.CrossRefGoogle Scholar
  5. 5.
    Douthat WG, Chiurchiu CR, Massari PU. New options for the management of hyperparathyroidism after renal transplantation. World J Transpl. 2012;2:41–5.CrossRefGoogle Scholar
  6. 6.
    Leca N, Laftavi M, Gundroo A, et al. Early and severe hyperparathyroidism associated with hypercalcemia after renal transplant treated with cinacalcet. Am J Transpl. 2006;6:2391–5.CrossRefGoogle Scholar
  7. 7.
    Garvin PJ, Castaneda M, Linderer R, et al. Management of hypercalcemic hyperparathyroidism after renal transplantation. Arch Surg. 1985;120:578.CrossRefGoogle Scholar
  8. 8.
    Evenepoel P, Van Den Bergh B, Naesens M, et al. Calcium metabolism in the early posttransplantation period. J Am Soc Nephrol. 2009;4:665–72.CrossRefGoogle Scholar
  9. 9.
    Evenepoel P, Bammens B, Claes K, et al. Measuring total blood calcium displays a low sensitivity for the diagnosis of hypercalcemia in incident renal transplant recipients. J Am Soc Nephrol. 2010;5:2085–92.CrossRefGoogle Scholar
  10. 10.
    Ziegler R. Hypercalcemic crisis. J Am Soc Nephrol. 2001;12:3–9.Google Scholar
  11. 11.
    Mitchell HR, Dalkin AC. Onco-nephrology: the pathophysiology and treatment of malignancy-associated hypercalcemia. Clin J Am Soc Nephrol. 2012;7:1722–9.CrossRefGoogle Scholar
  12. 12.
    Keeling CA, Abrahamson MJ, Harloe DG. Fatal hyperparathyroid crisis. Postgrad Med J. 1987;63:111–2.CrossRefGoogle Scholar
  13. 13.
    Haller C, Breslau C. Immobilization-induced hypercalcemia in a renal transplant recipient with persistent hyperparathyroidism. Am J Med Sci. 1992;92:223–5.Google Scholar
  14. 14.
    Allen UD, Preiksaitis JK. Epstein-Barr virus and posttransplant lymphoproliferative disorder in solid organ transplantation. Am J Transpl. 2013;13:107–20.CrossRefGoogle Scholar
  15. 15.
    David DS, Sakai S, Brennan BL, et al. Hypercalcemia after renal transplantation. Long-term follow-up data. N Engl J Med. 1973;289:398–401.CrossRefGoogle Scholar
  16. 16.
    Arber DA, George TI. Bone marrow biopsy involvement by non-Hodgkin’s lymphoma: frequency of lymphoma types, patterns, blood involvement, and discordance with other sites in 450 specimens. Am J Surg Pathol. 2005;29:1549–57.CrossRefGoogle Scholar
  17. 17.
    Daroszewska A, Bucknall RC, Chu P, et al. Severe hypercalcemia in B-cell lymphoma: combined effects of PTH-rP, IL-6 and TNF. Postgrad Med J, 1999:75;672–674.Google Scholar

Copyright information

© Japanese Society of Nephrology 2018

Authors and Affiliations

  1. 1.Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
  2. 2.Department of Pathology, Istanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey

Personalised recommendations