Introduction: Hypercalcemia is the most common metabolic complication in myeloma. The aim of this study was to evaluate the management strategy of hypercalcemia in myeloma at the nephrology department of Louis Pasteur hospital of Chartres. Patients and Methods: We carried a retrospective study of patients treated for myeloma-related hypercalcemia between January 1, 2019 to December 31, 2021. The clinical, paraclinical, therapeutic and evolutive characteristics were studied. Results: Eight patients were included in this study with a median age of 67 years [41 - 85] and a sex ratio (M/F) of 1. A quarter of patients were known with chronic kidney disease. Four patients (50%) had symptoms of hypercalcemia. Biologically, the mean hemoglobin was 9.8 ± 2.7 g/dl, all patients had an acute kidney injury with a mean creatinine level of 364.1 ± 173.3 mmol/l, a mean serum calcium of 3.42 ± 0.59 mmol/l and three quarter of patients had bone lesions. Five patients (62.5%) were rehydrated with a mean volume of saline of 2700 ± 836.7 ml/24h. Seven patients (87.5%) received biphosphonates and none received diuretics. The mean normalization time of the serum calcium was 5 days. Conclusion: Hypercalcemia is frequent in malignancy and represents a poor prognosis factor of the disease. A well-conducted therapeutic strategy allows rapid normalization.
Calcium is essential for the proper functioning of many tissues and cells in the body. It is the most abundant cation in the body, it plays an essential role in neuronal transmission, enzyme activity, myocardial function, coagulation and other cellular functions. Almost all calcium is intraosseous and only a small percentage is found in cells and extracellular fluids. Serum calcium represents about 1% of the total calcium in the body and is divided into calcemia bound to proteins and ions and ionized calcium which represents the active form [
The aim of this work was to evaluate the therapeutic strategy of hypercalcemia during myeloma.
This was a retrospective, descriptive study carried out over a period of 3 years from January 1, 2019 to December 31, 2021 targeting all patients diagnosed with multiple myeloma during the study period. Were included, all patients with hypercalcemia at diagnosis or during follow-up of myeloma.
The definitions used for the diagnosis of hypercalcemia were [
Mild hypercalcemia: [2.6 à 3 mmol/l[
Moderate hypercalcemia: [3 à 3.5 mmol/l[
Severe hypercalcemia: serum calcium ≥ 3.5 mmol/l
The definition of myeloma was that of the criteria of the International Myeloma Working Group (IMWG) of 2014 [
We studied the evolution of serum calcium on day 1, day 2, day 3 and day 6.
The data was collected using a clinical and paraclinical data collection sheet consisting of a questionnaire filled in from the patient files. Sociodemographic, clinical, biological and therapeutic data were collected retrospectively.
Data were entered with Excel 2019 software and SPSS software version 23.0.0 and analyzed using SPSS software version 23.0.0.
Descriptively, the quantitative data were presented in the form of means and standard deviations or median and extremes depending on the distribution of the variables. Qualitative data was presented as a proportion.
Of the 18 patients diagnosed with myeloma, 8 patients were included (
The median age of the population was 67 years [41 - 85]. Of the 8 patients who presented with hypercalcemia, 4 (50%) were men. Two patients (25%) were carriers of known CKD and only one had heart failure (
Clinically, 4 patients (50%) were dehydrated. At the paraclinic, five patients (62.5%) had anemia with an average hemoglobin level of 9.8 ± 2.7 g/dl. Acute renal failure was present in all patients with a mean serum creatinine of 364.1 ± 173.3 mmol/l. On imaging, 75% of patients had bone lesions. The characteristics of electrophoresis peaks, immunoglobin chains and plasmacytosis are summarized in
Among our patients, 44.44% had hypercalcemia during their follow-up, including 27.78% at the time of myeloma diagnosis. Mean serum calcium was 3.42 ± 0.59 mmol/l at diagnosis. The calcemia of patients during the first week following the diagnosis of hypercalcemia is shown in
Therapeutically, five patients (62.5%) had been rehydrated with an average volume of 0.9% normal saline of 2700 ± 836.7 ml/24h. Seven patients (87.5%) received bisphosphonates (
No patient received diuretics.
Antecedent | Effectif n = 8 | |
---|---|---|
Yes | No | |
Chronic kidney disease | 2 | 6 |
Neoplasia (prostate) | 1 | 7 |
Granulomatosis | 0 | 8 |
Parathyroid pathology | 0 | 8 |
Heart failure | 1 | 7 |
Patient | monoclonal peak | Heavy chain | Light chain k (g/l) | Light chain l (g/l) | Plasmacytosis (%) | |
---|---|---|---|---|---|---|
pic | Concentration (g/l) | |||||
n˚1 | a | 10.3 | 12126.0 | 9.6 | 5 | |
n˚2 | g | 45.3 | IgA | 240.0 | 15.6 | |
n˚3 | 35.0 | 5942.7 | 80 | |||
n˚4 | 10356.0 | 35.0 | 45 | |||
n˚5 | b | 41.4 | IgA | 3707.0 | 16.9 | 78 |
n˚6 | g | 49.3 | IgG | 651.0 | 11.6 | 30 |
n˚7 | b | 20.9 | IgG | 259.0 | 11.6 | 10 |
n˚8 | g | 26.4 | IgA | 2259.0 | 0.9 | 21 |
Hypercalcemia is frequently observed in myeloma. A study of a large cohort of 2129 patients with newly diagnosed symptomatic myeloma reported a prevalence of 19.5% [
Intravenous rehydration with isotonic saline is administered to restore the patient’s volume, maintain adequate urine output. In our patients, the decision to hydrate was taken based on the volume of each patient and the volume of the infusion determined taking into account the underlying cardiovascular and renal status. The average rehydration was 2700 ± 836.7 ml/24h the first three days following the diagnosis of hypercalcemia. The use of diuretics in case of hypercalcemia is subject to discussion. A critical review of nine case series concluded that the routine use of loop diuretics in the treatment of cancer-associated hypercalcemia provided no additional benefit [
The use of bone resorption inhibitors is essential. Pamidronate and zoledronate are the main osteoclastic function blockers used in this indication. Two double-blind randomized trials comparing a single dose of zoledronate with a single dose of pamidronate showed superiority of zoledronate for the treatment of hypercalcemia. In our series, half of the patients were put on pamidronate. This is because all our patients had impaired renal function with the majority of them having a GFR < 30 ml/min contraindicating the use of zoledronate. In our study, all the patients normalized their calcemia on the 8th day with an average of 5.25 days. The literature reports a normalization rate of 88.4% and 69.7% respectively under zoledronate and pamidronate on the 10th day [
Denosumab was not used in our patients. Normalization of serum calcium was obtained with rehydration alone or combined with bisphosphonates. This practice is consistent with the recommendations which reserve the use of these antibodies for severe hypercalcemia not responding to the use of bisphosphonates or in the event of contraindications to the latter [
Limitations of the study
The limited number of cases of hypercalcemia during myeloma and more generally the number myeloma diagnosed in our service during the study period limited the possibility of carrying out an analytical study to try to highlight the effectiveness of each of the treatment components but also to be able to study the factors associated with the occurrence of hypercalcemia during myeloma pathology.
Hypercalcemia is the most common metabolic complication of multiple myeloma. It is associated with worse prognosis of the myeloma. The treatment tripod is based on the restoration of the patient’s blood volume, the inhibition of bone resorption and the specific treatment of myeloma. The therapeutic practices in our center are in line with the various therapeutic recommendations.
All authors declare no conflicts of interest.
Informed consent from each patient was obtained.
Ndongo, M., Ndiaye, B., Nankeu, N., Sy, A., Attia, H., Lahouel, F., Berroudja, D.Z., Bensalem, T., Benyaghla, S.A.T., Albert, C., Seck, S.M. and Ka, E.H.F. (2022) Evaluation of the Therapeutic Management of Hypercalcemia in Myeloma at the Nephrology Department of Louis Pasteur Hospital of Chartres: About 8 Cases. Open Journal of Nephrology, 12, 403-409. https://doi.org/10.4236/ojneph.2022.124041