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Post-liver Transplantation Hypercalcemia approach

Post-liver Transplantation Hypercalcemia approach

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Post-liver Transplantation Hypercalcemia approach

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  1. Post-liver Transplantation Hypercalcemia approach Presentation: Intern 蘇柏先

  2. Case • 42y/o, man, chronic hepatitis B, liver cirrhosis (Child B) • 2006/5  living related liver transplantation • Perioperative accident:Massive blood loss s/p transfusion(about 16400ml) • Immunosuppressant drugs: Prograf (FK506) Blood level:22.8(6/7)26.2(6/8)21.5(6/9) (Normal range:4~20ng/mL) • Ionized Calcium:1.35 mmol/L (Normal range:1.09~1.30mmol/L)

  3. Calcium Metabolism

  4. Actions of the Hormones Involved in Calcium Homeostasis • Carroll MF, Schade DS: A practical approach to hypercalcemia. • Am Fam Physician 2003 May 1; 67(9): 1959-66

  5. Spectrum of Hypercalcemia • Carroll MF, Schade DS: A practical approach to hypercalcemia. • Am Fam Physician 2003 May 1; 67(9): 1959-66

  6. Clinical Manifestations of Hypercalcemia • Carroll MF, Schade DS: A practical approach to hypercalcemia. • Am Fam Physician 2003 May 1; 67(9): 1959-66

  7. Causes of Hypercalcemia • Carroll MF, Schade DS: A practical approach to hypercalcemia. • Am Fam Physician 2003 May 1; 67(9): 1959-66

  8. Representative Normogram for Interpreting Serum Intact PTH Levels • Carroll MF, Schade DS: A practical approach to hypercalcemia. • Am Fam Physician 2003 May 1; 67(9): 1959-66

  9. Carroll MF, Schade DS: A practical approach to hypercalcemia. • Am Fam Physician 2003 May 1; 67(9): 1959-66

  10. Discussion (I) • Hyperparathyroidism ? Check PTH level, 24hr urinary Ca++ level • Malignancy ? Check PTHrP, Alkaline phosphatase, Calcitriol

  11. Discussion (II) • Patient immobilization ? 1. Immobilization following SCI triggers an increase in osteoclastic bone resorption. 2. The cascade of events that links the lack of mechanical forces on bone with enhanced resorption may involve altered piezoelectric effects in bone. 3. Muscle activity transmits a bone formation signal through the osteocyte. Ref: http://www.emedicine.com/pmr/topic54.htm

  12. Discussion (III) • Numerous calcium perfusions to prevent transfusion-induced hypocalcemia ? 1. Blood is treated with citrate to bind ionized calcium (Ca2+) and prevent its action as a cofactor in the coagulation cascade. 2. During OLT, patients are at increased risk of citrate toxicity and subsequent hypocalcemia because aconitase, a citrate-metabolizing enzyme, is not produced. 3. Hypocalcemia is treated with intraoperative calcium as needed to prevent ventricular hypocontractility and decrease peripheral vascular resistance. Ref: Bartosh SM, Sprague SM, Nakagawa Y, et al: Severe hypercalcemia following neonatal liver transplantation. Miner Electrolyte Metab 1995; 21(6): 428-30

  13. Discussion (IV) • Tacrolimus (FK506) side effect ? Blood level: 22.8 (6/7)  26.2 (6/8)  21.5 (6/9)

  14. Conclusion • Hyperparathyroidism • Malignancy Special conditions in this patient: • Patient immobilization • Numerous calcium perfusions to prevent transfusion-induced hypocalcemia • Tacrolimus (FK506) side effect

  15. Thanks for Your attention !!