Therapy of hypercalcemia of malignancy

An appreciation of the pathogenesis of the hypercalcemia of malignancy is essential to its management. At the outset, since most patients with symptomatic hypercalcemia of malignancy are dehydrated, infusion of 2 to 3 liters of saline per day will at least partially reduce serum calcium levels. Induction of calciuresis by infusing larger volumes of saline simultaneously with parenteral administration of furosemide may reduce the serum calcium concentration to normal in the short term. Of major importance in long-term therapy, however, are drugs that inhibit bone resorption, a major cause of hypercalcemia. These include calcitonin, plicamycin, glucocorticoids, prostaglandin synthetase inhibitors, and the diphosphonates. These agents may provide long-term control of hypercalcemia in many patients. Reduction of intestinal calcium absorption by dietary means or by glucocorticoid therapy is often effective in the rare subset of patients with increased serum levels of 1,25-dihydroxyvitamin D. Oral and intravenous phosphorus therapy may be effective via unknown mechanisms in some patients. The diphosphonates, in particular, should greatly facilitate management of both acute and chronic hypercalcemia of malignancy. Daily intravenous infusion of etidronate disodium (etidronate) with saline over a period of three to six days, for example, appears to be a safe and effective means of restoring serum calcium concentrations to the normal range. Study results have shown that more than 90 percent of patients have a response to etidronate. Oral administration of the drug has been demonstrated to maintain normal serum calcium concentrations.

Hypophosphatemic rickets/osteomalacia in linear sebaceous nevus syndrome: a variant of tumor-induced osteomalacia

A severe form of vitamin D-resistant rickets is associated with the linear sebaceous nevus syndrome. We investigated the pathophysiology underlying defective bone mineralization in two individuals and examined the effects of 1,25-dihydroxyvitamin D (1,25(OH)2D, calcitriol) therapy on the clinical and biochemical abnormalities. Both patients had fasting hypophosphatemia, markedly diminished TmP/GFR, and elevated alkaline phosphase activity in the presence of normocalcemia. Before treatment with calcitriol, serum 1,25(OH)2D concentrations were reduced but serum 25-hydroxyvitamin D (25(OH)D) concentrations were normal. Administration of calcitriol increased serum 1,25(OH)2D concentrations and led to an increase in TmP/GFR and serum phosphorus levels and to a decrease in alkaline phosphatase activity. However, the renal tubular maximum for reabsorption of inorganic phosphate, normalized according to glomerular filtration rate, and serum phosphorus levels remained abnormally low even in the patient who also received phosphate supplementation. Bone histomorphologic studies in the adult patient showed extreme osteomalacia, which partially improved with calcitriol. These data demonstrate that the putative skin lesion-derived factor results in both a renal tubular defect in phosphate reabsorption and in 1,25-(OH)2 D deficiency. The vitamin D-resistant rickets of linear sebaceous nevus syndrome is a variant of tumor-induced osteomalacia.

Kidney function in rats with corticomedullary nephrocalcinosis: effects of alterations in dietary calcium and magnesium

Single-nephron and whole-kidney function were studied in female rats with corticomedullary nephrocalcinosis, and in animals where the lesion had been prevented either by a dietary magnesium supplement or by using a diet with a calcium:phosphorus ratio in excess of 1. At the single-nephron level, rats with nephrocalcinosis had prolonged tubular fluid transit times. Proximal transit time was 19.42 +/- 1.98 (mean +/- S.E. of mean) vs. 11.58 +/- 0.19 s for controls; distal transit time was 62.64 +/- 9.16 vs. 31.50 +/- 1.03 s for controls. Although single-nephron function is altered in nephrocalcinosis, data obtained from rats in metabolism cages indicate that whole-kidney function is largely unaffected by the lesion.

A single case of hypophosphatemic rickets with hypercalciuria

A single case of hypophosphatemic rickets with hypercalciuria and an elevated level of serum 1,25 dihydroxyvitamin D is reported. The characteristic features (genu valgum, rickets, short stature, increased renal phosphate excretion, decreased serum phosphorus level, elevated serum alkaline phosphatase level, and normal serum calcium level) were comparable to those in hypophosphatemic vitamin D resistant rickets. Massive doses of 1 alpha-hydroxyvitamin D were not effective for the rickets and the biochemical defect in this patient. Long-term phosphate supplementation on its own resulted in the reversal of all clinical and biochemical abnormalities except for the decreased ratio between the maximum tubular reabsorption rate for phosphorus and the glomerular filtration rate. In this patient, the concentration of serum 1,25 dihydroxyvitamin D seemed to be controlled by the concentration of serum phosphorus rather than by the serum parathyroid hormone level. It is noted that this is the first case of a single hypophosphatemic rickets with hypercalciuria.

Diet calcium carbonate, phosphorus and acidifying and alkalizing salts as factors influencing silica urolithiasis in rats fed tetraethylorthosilicate

Three experiments were conducted to determine the effects of excess dietary calcium carbonate, phosphorus and urine acidifying and alkalizing salts on silica urolith formation in a model using rats fed dextrose-based diets containing 2% tetraethylorthosilicate (TES). Diets containing 2% TES lowered weight gains to 91-95% of gains made by rats fed non-TES diets. Urine silica concentrations of rats fed TES were generally in the range of 50-60 mg/dl. In experiment 1, rats fed TES with no additional dietary calcium carbonate had a silica urolith incidence of 35%. With additions of 1 and 2% calcium carbonate to the basal-TES diet, respective urolith incidences were 45 and 60% (r = 0.99, P less than 0.02). In experiment 2, monobasic sodium phosphate (MP) providing 0.2% additional phosphorus resulted in a mean urine pH of 6.42 and no uroliths. Dibasic sodium phosphate (DP) without and with 0.5% sodium bicarbonate (SB) resulted in respective urine pH values of 6.78 and 7.14 and urolith incidences of 15 and 20% (MP less than DP and DP + SB, P less than 0.05). However, the uroliths were small averaging less than 1 mg. In experiment 3, substitution of autoclaved egg albumin for casein, the protein source in experiments 1 and 2, resulted in urine pH of 7.45 and a silica urolith incidence of 46%. An equal-molar mixture of MP and DP providing an added 0.2% phosphorus resulted in a urine pH of 7.07 and reduced the urolith incidence to 4%, and 0.75% of dietary ammonium chloride either with or without the added 0.2% phosphorus gave urine acidification and complete protection from uroliths.(ABSTRACT TRUNCATED AT 250 WORDS)

Controversies in neonatal nutrition

The assessment of growth parameters remains one of the most practical and valuable tools to estimate nutritional status in neonates. Growth assessment in full-term infants is performed by using charts developed by the National Center for Health and Statistics. The assessment of post-natal growth in premature infants is controversial and can be performed by using either intrauterine or extrauterine standards. The selection of appropriate growth charts should be based on clinical, demographic, ethnic, and socioeconomic similarities of the population used for reference. Daily energy intakes ranging from 100 to 120 kcal/kg/day have been recommended for full-term infants, while higher intakes ranging from 114 to 181 kcal/kg/day have been recommended for premature neonates. Full-term infants should be nursed or nipple fed on demand; however, premature infants should ideally be tube fed by intermittent gastric feeding (gavage). Continuous gastric and transpyloric feedings are indicated in selected infants. Human milk is a preferred food for full-term infants during the first six months of life; however, this precept does not suggest that all infants who are exclusively breast-fed will grow adequately. Preterm human milk is also a preferred food for the low birthweight infant, provided nutritional supplements are used. It is unclear whether the supplementation of vitamin D, iron, and fluoride in full-term breast-fed infants should be started at birth, at the time of initiation of solid foods, or at the age of six months. The routine supplementation of multivitamins, folic acid, and vitamin E to all low birthweight infants is controversial. Most investigators suggest vitamin supplementation be given until the intake of formula or breast milk is sufficient to meet daily requirements. Vitamin E appears to exert a protective effect in premature infants against the development of severe retinopathy. The supplementation of vitamin E should be dependent upon the serum vitamin E concentration. It is controversial whether iron supplementation for premature infants should be initiated soon after birth or at two months of age, or whether higher doses of iron should be given to very low birthweight infants. If iron supplementation is started at birth, vitamin E status should be closely monitored. Although the optimal intakes of calcium and phosphorus in infant feedings have not been firmly established, the levels of calcium and phosphorus in human milk appear to be inadequate for the growing low birthweight infant.(ABSTRACT TRUNCATED AT 400 WORDS)

[Biological and bone histomorphometric studies in hypophosphatemic vitamin-resistant rickets treated with 1,25-(OH)2D and phosphorus]

Five children aged 6 to 15 years were studied. They presented all the biological signs of hypophosphatemic vitamin resistant rickets: normal calcemia, hypophosphatemia, decrease in phosphorus Tm and normal PTH plasma level. Two children had never been given vitamin D treatment previously. The 1.25 (OH)2D has been given in 4 doses a day, to a total of 1 microgram/day, for one year. Phosphate was administered for the same time, doses varying from 40 to 150 mg/kg/day. Bone biopsies were performed at the onset and the end of treatment. Normal growth concerning bone age was observed in 3 cases. In the two others, growth remained disturbed. Radiological recovery was observed in all cases. Treatment induced and increase in serum phosphate. Tm PO4/FG remained lower than normal and even decreased during treatment. After one year of treatment, the osteoid volumes and surfaces decreased in all cases but did not always return to normal. The thickness index of osteoid and the speed of calcification were improved in 4 cases and worsened in the 5th. In two previously untreated patients an increase in plasma PTH and in the osteoclastic surface of resorption were observed on the bone biopsy during treatment.

Healing of bone disease in X-linked hypophosphatemic rickets/osteomalacia. Induction and maintenance with phosphorus and calcitriol

Although conventional therapy (pharmacologic doses of vitamin D and phosphorus supplementation) is usually successful in healing the rachitic bone lesion in patients with X-linked hypophosphatemic rickets, it does not heal the coexistent osteomalacia. Because serum 1,25-dihydroxyvitamin D levels are inappropriately low in these patients and high calcitriol concentrations may be required to heal the osteomalacia, we chose to treat five affected subjects with high doses of calcitriol (68.2 +/- 10.0 ng/kg total body weight/d) and supplemental phosphorus (1-2 g/d) performing metabolic studies and bone biopsies before and after 5-8 mo of this therapy in each individual. Of these five patients, three (aged 13, 13, and 19 yr) were receiving conventional treatment at the inception of the study and therefore showed base-line serum phosphorus concentrations within the normal range. The remaining two untreated patients (aged 2 and 37 yr) displayed characteristic hypophosphatemia before calcitriol therapy. All five patients demonstrated serum calcitriol levels in the low normal range (22.5 +/- 3.2 pg/ml), impaired renal phosphorus conservation (tubular maximum for the reabsorption of phosphate per deciliter of glomerular filtrate, 2.13 +/- 0.20 mg/dl), and osteomalacia on bone biopsy (relative osteoid volume, 14.4 +/- 1.7%; mean osteoid seam width, 27.7 +/- 3.7 micron; mineral apposition rate, 0.46 +/- 0.12 micron/d). On high doses of calcitriol, serum 1,25-dihydroxyvitamin D levels rose into the supraphysiologic range (74.1 +/- 3.8 pg/ml) with an associated increment in the serum phosphorus concentration (2.82 +/- 0.19 to 3.78 +/- 0.32 mg/dl) and improvement of the renal tubular maximum for phosphate reabsorption (3.17 +/- 0.22 mg/dl). The serum calcium rose in each patient while the immunoactive parathyroid hormone concentration measured by three different assays remained within the normal range. Most importantly, repeat bone biopsies showed that high doses of calcitriol and phosphorus supplements had reversed the mineralization defect in all patients (mineral apposition rate, 0.88 +/- 0.04 micron/d) and consequently reduced parameters of bone osteoid content to normal (relative osteoid volume, 4.1 +/- 0.7%; mean osteoid seam width, 11.0 +/- 1.0 micron). Complications (hypercalcemia and hypercalciuria) ensued in four of these five patients within 1-17 mo of documented bone healing, necessitating reduction of calcitriol doses to a mean of 1.6 +/- 0.2 micrograms/d (28 +/- 4 ng/kg ideal body weight per day). At follow-up bone biopsy, these four subjects continued to manifest normal bone mineralization dynamics (mineral apposition rate, 0.88 +/-0.10 micrometer/d) on reduced doses of 1.25-dihydroxyvitamin D with phosphorus supplements (2 g/d) for a mean of 21.3 +/- 1.3 mo after bone healing was first documented. Static histomorphometric parameters also remained normal (relative osteoid volume, 1.5 +/- 0.4%; mean osteoid seam width, 13.5 +/- 0.8 micrometer). These data indicate that administration of supraphysiologic amounts of calcitriol, in conjunction with oral phosphorus, results in complete healing of vitamin D resistant osteomalacia in patients with X-linked hypophosphatemic rickets. Although complications predictably require calcitriol dose reductions once healing is achieved, continued bone healing can be maintained for up to 1 yr with lower doses of 1,25-dihydroxyvitamin D and continued phosphorus supplementation.

Rickets of prematurity: calcium and phosphorus supplementation

Seventy-four infants weighing less than 1500 gm at birth were fed enterally from birth until day 47. Group A (18 infants) were given SMA Gold Cap: group B (18 infants), supplementary calcium to 21 mmol/L (84 mg/dl); group C (16 infants), further calcium supplementation to 31.2 mmol/L (125 mg/dl); and group D (22 infants), milk with calcium content 31.2 mmol/L (125 mg/dl) and phosphorus supplementation to 15.7 mmol/L (49 mg/dl). The addition of calcium reduced the radiologic evidence of rickets, and combined calcium and phosphorus supplementation maintained plasma alkaline phosphatase activity within the normal range for 6 weeks.

Renal magnesium and phosphate wastage in a patient with hypercalciuria and nephrocalcinosis: effect of oral phosphorus and magnesium supplements

We report a 29-year-old man with a mild decrease in glomerular filtration, nephrocalcinosis, hypercalciuria and a renal magnesium leak. He had other features of 'congenital magnesium-losing kidney', such as arthritis and hyperuricemia, short stature and recurrent urinary tract infections, but had no radiological chondrocalcinosis. In addition, pallidal calcification was found. The patient also had a renal phosphate leak. Phosphorus supplements resulted in a decrease in urinary calcium excretion, indicating that hypercalciuria was at least partially a consequence of phosphorus depletion. Plasma and urine magnesium were not affected by phosphorus supplements. Addition of magnesium supplements resulted in a transient and modest decrease in urinary calcium excretion, with no modification in plasma magnesium.

Hypercalciuric rickets: metabolic studies and pathophysiological considerations

Extensive metabolic studies were performed in a 14-year-old boy suffering from the rare clinical entity known as childhood idiopathic hypercalciuria associated with dwarfism, renal tubular abnormalities and bone lesions. The salient features were: hyperphosphaturia with hypophosphatemia, hypercalciuria with normocalcemia, elevated serum 1,25-dihydroxycholecalciferol[1,25(OH)2D3] levels, marked intestinal hyperabsorption of calcium and phosphorus, with low serum parathyroid hormone (PTH) and urinary adenosine 3':5'-cyclic monophosphate (c-AMP). Bone biopsy confirmed the clinical and radiological diagnosis of rickets. It appears that the following pathophysiological sequence is operating: primary renal phosphate leak with hypophosphatemia, increased 1,25(OH)2D3 synthesis, enhanced intestinal calcium absorption which in turn inhibits release of PTH and c-AMP. Hypercalciuria is seen to be secondary to both avid intestinal calcium absorption and depressed PTH activity, and rickets the result of phosphate depletion. Treatment with oral phosphorus only resulted in an acceleration of growth rate, cure of rickets, and return of urinary calcium excretion to normal values.

Hypercalcaemia in extremely low birthweight infants

We report 10 cases of hypercalcaemia associated with hypophosphataemia in the first two weeks of life in extremely low birthweight infants (birthweight less than 1000 g). At the time of diagnosis, the infants were fed mainly with expressed breast milk but they had also received intravenous nutrition. After treatment with additional phosphate plasma calcium concentrations returned to normal. There was a high incidence of rickets of prematurity in these infants.

Bone histomorphometry in vitamin D-deficient rats infused with calcium and phosphorus

Defective mineralization of bone and cartilage is the classical histological finding in vitamin D deficiency. Whether this represents a direct effect on mineral deposition or is a consequence of the decreased calcium and phosphorus levels that result from impaired intestinal absorption is not clear. A method has been developed in which vitamin D-deficient rats have plasma calcium and phosphorus levels maintained in the normal range by continuous infusion. Histomorphometric analysis of undecalcified tibiae from these animals was compared with that of rats given vitamin D. Epiphyseal growth plate thickness, trabecular osteoid volume, and mean osteoid seam width were not increased. Moreover, the administration of two time-spaced courses of tetracycline revealed that the mineralization rate and the time interval between apposition and subsequent mineralization of osteoid (mineralization lag time) were identical to those in rats treated with vitamin D. Trabecular bone volume was increased (osteosclerosis) in the vitamin D-deficient rats. In vitamin D-deficient controls without infusions, the osteosclerosis was mostly osteoid, whereas the excess bone was well mineralized in the vitamin D-deficient rats infused with calcium and phosphorus. Osteosclerosis in vitamin D-deficient animals may result from both decreased bone resorption and increased osteoid apposition. This study provides firm evidence that vitamin D is not essential for mineralization in young growing rats. Decreased availability of calcium and phosphorus thus may be the sole basis of the mineralization defect seen in vitamin D deficiency.

[Incidence of lithiasic recurrence after a diuretic therapy, alone or combined with treatment by a thiazide diuretic or phosphorus]

The preventive affects on recurrent renal calcium stones of water diuresis alone or combined with drugs aimed at lowering urinary calcium were evaluated prospectively in 51 patients with calcium nephrolithiasis. Following clinical and metabolic examination, the patients were allocated at random to 3 treatment groups: water diuresis alone (group I, n = 19) or associated with hydrochlorothiazide 50 mg/day (group II, n = 19) or with a neutral phosphate preparation 1500 mg/day (group III, n = 13). Results were assessed on the number of recurrences; 24-h urinary calcium was measured at regular intervals. The mean follow-up (2 years; range 1-4 years) was the same in all 3 groups. A significant fall in recurrence rate as compared with pre-treatment values was observed in groups I and II. The recurrence rate was the same in both groups during treatment. However, less patients had recurrences in group I (1/19) than in group II (5/19). No significant fall in recurrence rate was observed in group III, owing to some patients in this group having frequent recurrences. The recurrence rate was unrelated to clinical findings and biochemical values ( oxaluria , calciuria) measured before treatment and to the urinary Ca/Cr ratio calculated during treatment. This study confirms that water diuresis is effective in preventing recurrent renal calcium stones and that diuretics of the thiazide group reduce the number of patients with recurrences.

Skeletal calcium homeostasis and countermeasures to prevent disuse osteoporosis

Maintenance of a skeleton capable of resisting the stresses of everyday life is dependent on the mechanical forces applied to the skeleton during normal activity in a 1-G environment. When the effects of 1-G on the longitudinal skeleton are removed, as with space travel or inactivity, bone and bone mineral are lost because bone resorption is greater than bone formation. Ninety healthy young men were studied during 5-36 weeks of continuous bed rest. During inactivity, urinary calcium increases rapidly and by the sixth week of bed rest, output has risen by 100 mg/day, plateaus for several weeks, and then decreases but remains above ambulatory baseline thereafter. This occurred even though they received vitamin D supplements throughout the study. Calcium balance becomes negative after 2 weeks and by the end of the first month, 200 mg/day is lost. The loss continues at this rate for at least 36 weeks. Calcaneal mineral loses 5% of its mass each month. Attempts to prevent disuse osteoporosis with both mechanical and biochemical means, including exercise, skeletal compression, increased hydrostatic pressure to the lower body, supplemental calcium and/or phosphorus, calcitonin, or etidronate were not successful.

Premature cranial synostosis in X-linked hypophosphatemic rickets: possible precipitation by 1-alpha-OH-cholecalciferol intoxication

A child suffering from X-linked hypophosphatemic rickets developed vitamin D intoxication under treatment with 1-alpha-OH-cholecalciferol (1(OH)D3) and phosphorus. Beside the usual findings in this condition he showed precocious synostosis of the skull with signs of raised intracranial pressure. In view of earlier reports of coincidence of craniostenosis and X-linked hypophosphatemic rickets, we conclude that the possibility exists that intoxication with 1(OH)D3 has been the precipitating factor. In addition we found hypersensitivity to 1(OH)D3 2 months after cessation of treatment, and normal levels of calcitriol (1,25(OH)2D3) at the same time.

Rickets in a preterm infant during intravenous alimentation

A preterm baby given intravenous feeding developed severe rickets. Laboratory investigation revealed hypophosphatemia as the main cause of this picture. Recovery was achieved by giving extra phosphorus supplementation. This case demonstrates that conventional infusates do not meet the phosphorus requirement of rapidly growing infants.

[Diet and chronic renal failure]

In the last 10 years the diet severely restricted in proteins advocated by GIORDANO and GIOVANNETTI in the treatment of chronic renal failure has fallen out of use because in the long term it induced cachectic states in most patients. In recent months, however, experimental studies have pointed to the negative effect protein intake may have on renal function. Glomerular hyperfiltration induced by protein intake may lead to proteinuria and glomerulosclerosis, which in turn aggravates impaired renal function and glomerular hyperfiltration. Some clinical studies appear to confirm the beneficial effect on the progression of renal failure when diets containing 15-30 g protein per day are instituted. This new approach may be of considerable practical importance but at present most of these studies need confirmation and generalized uncontrolled administration of diets severely restricted in proteins is not yet justified.