Immobilization Related Hypercalcemia in ESRD: Is Denosumab a Viable Treatment Option?

Author Type(s)

Faculty, Resident/Fellow

Document Type

Abstract

Publication Date

2022

Journal Title

Journal of the American Society of Nephrology

Department

Medicine

Abstract

Introduction: The most common abnormality of mineral bone disease seen in ESRD is renal osteodystrophy. However, persistent parathyroid hormone (PTH) independent hypercalcemia raises the possibility of immobilization or malignancy. Denosumab is a potential treatment option but its efficacy and safety in ESRD remains poorly studied. We describe 2 ESRD patients with immobilization related hypercalcemia that was successfully treated with denosumab. Case Description: Case 1: 54 year old man with well controlled diabetes and Chronic Kidney Disease (CKD), started on hemodialysis (HD) after cardiac arrest with poor neurological recovery. Case 2: 57 year old man with laparoscopic gastric sleeve complicated by hemorrhagic shock and Acute Kidney Injury (AKI) needing HD. Course of hypercalcemia described in table. Neither patients experienced hypocalcemia as a side effect. Discussion: Immobilization related hypercalcemia occurs when osteoclastic bone resorption exceeds osteoblastic bone formation causing an imbalance in the bone remodeling process. Denosumab is a monoclonal antibody that binds and inhibits RANKL reducing osteoclast maturation and bone resorption. Both our patients were not on any drugs that could cause hypercalcemia and had no evidence of underlying granulomatous disease. Although PTHrP was mildly elevated in both patients, it was attributed to ESRD itself and we hypothesize that hypercalcemia was due to prolonged immobilization. Intravenous hydration is an unsafe option in ESRD. HD using low Ca dialysate is an option, but both patients were resistant to this. Both patients had improvement in Ca levels with denosumab and neither experienced hypocalcemia as a side effect probably due to ongoing hemodialysis. Case reports describe patients with ESRD and hypercalcemia who were successfully treated with denosumab. It offers advantages compared to bisphosphonates with its rapid onset, longer action and no dose adjustment for kidney function. Learning objectives: Denosumab is a potential treatment option for immobilization or malignancy related hypercalcemia in ESRD. Hypocalcemia which is a common side effect of denosumab could be averted in ESRD patients due to ongoing HD. (Table Presented).

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