tailieunhanh - Access: Acid-Base, Fluids, and Electrolytes - part 8

Một số bệnh nhân có thể có tăng nhẹ Ca2 + với một nồng độ PTH trong phạm vi trên của bình thường (không thích hợp cao), những người khác có thể có một huyết thanh Ca2 + tập trung ở tứ phân vị trên phạm vi bình thường và một hơi cao tập trung PTH, cả hai của các phân nhóm bệnh nhân | DISORDERS OF SERUM CALCIUM 335 TABLE 9-18 Continued Some patients may have mildly elevated Ca2 with a PTH concentration that is in the upper range of normal inappropriately elevated others may have a serum Ca2 concentration in the upper quartile of the normal range and a slightly elevated PTH concentration both of these subgroups of patients were demonstrated to have parathyroid adenomas An elevated PTH concentration may be seen rarely with lithium and FHH if the patient is on lithium and it can be safely discontinued PTH concentration should be remeasured in 1-3 months in all other etiologies PTH is suppressed PTHrP is immunologically distinct from PTH and specific assays are commercially available C-terminal fragment PTHrP assays may be increased in pregnancy and in patients with chronic kidney disease Evaluation of serum calcidiol and calcitriol concentrations If malignancy is not obvious and PTH concentration is suppressed one needs to rule out vitamin D intoxication or granulomatous diseases by measuring calcidiol and calcitriol concentrations Vitamin D or calcidiol ingestion will result in an increased calcidiol concentration and often mild to moderately elevated calcitriol concentration Elevated calcitriol concentration is observed with calcitriol ingestion and in those diseases where stimulation of 1-a-hydroxylase occurs including granulomatous diseases lymphoma and primary hyperparathyroidism Abbreviations BUN blood urea nitrogen IFE immunofixation electrophoresis FHH familial hypocalciuric hypercalcemia PTH parathyroid hormone PTHrP parathyroid hormone-related protein 336 DISORDERS OF SERUM CALCIUM TABLE 9-19 Treatment Medical General Principles Treatment of hypercalcemia will depend on the degree of serum Ca2 concentration elevation and is directed at increasing renal excretion blocking bone resorption and reducing intestinal absorption Volume expansion and loop diuretics alone may be sufficient in the patient with mild-to-moderate hypercalcemia mg