28. 検査値による原因推定 DIFFERENTIAL DIAGNOSIS OF HYPERCALCEMIA
SERUM CALCIUM MG%
Primary hyperparathyoid vs Other r20 :
I
PHPTでは血清Caは≤12.5mg/dLが殆ど. I
b18
I A
>14mg/dLとなることは稀 I
I
0 AX
A
A
I-1 6
8
×; 転移性癌, .X
AA
XAXXX
A A.
XAAXX
B~.K~~-
▲; 悪性腫瘍由来, 液性高Ca血症 x ox
xxxx
X
XXAOA
□; Thyrotoxicosis
AA
OX AX
.
.X
.XXX
XAOXX
110
I
I
16
I
PRIMARY 28 O T H E R
Journal of Bone and Mineral Research 1991;6:S51-9 HYPERPARATHYROlD HYPERCALCEMIAS
29. PHPTでは血清Clは高値である傾向
I
I
r20 : .
.
I
I
I
I
0
..*..
0.
b18 I
...........
0.
I
.............
A
-1 1 0 -
I
...........
0 AX
A A 0
.................... -
I A I A
Discriminant Score I-1 6
......
DIFFERENTIAL DIAGNOSIS OF HYPERCALCEMIA S51 I 0
8
.X
of accuracy for each test are shown in A A
Table 6. In the ab- 105
PHPT vs Otherの鑑別に有用.
A
sence of vomiting and diuretic use, A X X
Xthe Xserum chloride xxxx
D I SC R I MI N A N T S C ORE 00.
00
.. I
xxx
0..
A A.
proved to be the most reliable discriminator, with only 9%
XAAXX 0.. 0 -1 03-
d
A
.
misclassifications. Thus, some have referred to the- serum
B~.K~~ 000.00
x ox
0.22Hct + 0.76Cl
chloride as “the poor man’s PTH assay.” Thyrotoxicosis I
xxxx 0 XAXX
I
I AA
X
and 20% of HHM cases may also showOserum chloride
XXA A 00
. -100- X A.AX
I levels of 103 mEq/liter or higher. Serum calcium levels
-1.5Ca -1.9P-77.4
OX AX 00
1I
AX.
-
X.
.
ex
.X
I above 13.5 mg/dl are unusual in hyperparathyroidism but
.XXX 0 - x
10 are almost the rule in untreated malignancies with hyper-
XAOXX AAXAX
Ca は血清Ca値と,
I
I
calcemia. 0 I X0A.X
I ex
A discriminant function using the serum chloride, cal-
110 -95- AAXAX
4 A
cium, and phosphorus and the hematocrit was derived so
that a positive score indicates primary hyperparathyroid-
正常上限値の差(mg/dL)
ism and a negative score another type of hypercalcemia
I
I X.A.
X
X
I 0
I X.AX
I with an overall accuracy of 95%, and an accuracy of 98% I
I in the absence of vomiting, renal failure, or the use of -90-
-- 0-
1
------
A
X
PHPTではScore>0.
diuretics.
I I
xx
A
ox
I .X
0.22Hct + I
0.76CI - 1.5Ca,,
I
16
1.9P 77.4
0 I XXXA
- -
I X
利尿薬使用により
0 XA.
.
I xxxxx
.XX
0 I X
-5 Calcium excess Caex is the difference between the total
XX. I
serum calcium expressed in milligrams per deciliter in a
I PRIMARY OTHER
I 陰性に傾く.
given patient and the upper limit of normal for a given lab-
oratory. TheA R Y
P R I M hematocrit is expressedO T a percentage, the
as H E R
HYPER- HYPER-
I A h PARATHY ROlD CALCEMIAS
:i
H Y P E R P A R A T H Y R O l D H Y P E R C A phosphorus S
A chloride in millequivalents per liter, and the L C E M I A in ~~ ~
-10 milligrams per deciliter.
0
I The discriminant scores of 100 cases of primary hyper-
I i:
AA FIG. parathyroidism and 64 cases of other hypercakemiasver- FIG. 2. ○; 利尿薬, 嘔吐 in hyperparathyroidism
1. Serum calcium levels in hyperparathyroidism are Serum chloride levels
I sus other hypercalcemicAll 5 patients meanprimary hyperpara- versus other forms of hypercalcemia. The mean of eac
contrasted in Fig. 3. states. The with of each group is
shown by dashes. The bestmisclassified with a is 12.5 mg/dl group is ×; 転移性癌,
X
-15 xx thyroidism who were discriminant level negative score shown by the dashes. The best discriminant lev
I
X
X
(3.12 were taking diuretics. The validitydisease; (A)
mmol/liter). (X) Metastatic bone of this discriminant was 103 mEq/liter (103 mmol/liter): (0)
humoral diuretics or vom
I function using the serum calcium, chloride, and phospho-
▲; 悪性腫瘍由来, (A)humoral hyperca
hypercalcemia of malignancy; (0)thyrotoxicosis. (From iting; (X) metastatic bone disease; 液性高Ca血症
.
I A Lafferty and the hematocrit wasof calcium metabolismKeller cemia of malignancy; (0)thyrotoxicosis. (From Laffert
rus FW 1988 Disorders tested prospectively by and
and Keller”’) among 37 patients with G (ed.) Diagnosis
parathyroid function. In: Mendelsohn verified primary hy- FW 1981 Primary hyperparathyroidism. Arch Intern Me
-20
perparathyroidism and found to be correct in 35 for 95% □; Thyrotoxicosis
and Pathology of Endocrine Diseases. Copyright a1988, 141:1761. Copyright 1981, American Medical Associa
I X
J.B. Lippincott Co.) This formula is not applicable to sepa- tion.)
overall accuracy.
1
rating primary hyperparathyroidism from either normal
subjects or patients with secondaryJournal of Bone and Mineral Research 1991;6:S51-9
PRIMARY OTHER
HYPERPARATHY ROIDS HYPERCACCEMIAS hyperparathyroidism.
37. 高Ca血症; 治療
From the ICU book
NEJM 2005;352:373-9
症候性 or Ca >14(Ion Ca >3.5mmol/L)で開始
補液 ＆ 利尿, リン補正
大量補液; 急性期では200-500ml/hrで開始. 脱水, 心機能に応じて調節
フロセミド; 20-40mg IV, 脱水症改善されればすぐに導入.
尿細管でのCa再吸収阻害. 排尿によるWash out
リンの補充; 低P(≤3.0mg/dL)あれば補正. >3.0mg/dLを維持する
38. 高Ca血症; 治療
From the ICU book
NEJM 2005;352:373-9
1st line medication
Bisphosphonate IV
･ Zoledronate(ゾメタ® 4mg)
4mgをNS, 5%TZ 50mlに溶解して, ≥15minかけてDIV
･ Pamidronate(アレディア® 15, 30mg)
60-90mgをNS, 5%TZ50-200mlに溶解して≥2hrかけてDIV
効果は2-4日で出現, 4-7日で60-90%が正常化
効果発現が遅いため, 高Caと診断されればすぐに投与！
4-10日目で再投与しても良い
腎不全患者では透析の適応.
40. Bisphosphonateは腎障害(+)患者には注意
動物実験上で, Azotemiaとの関連が示唆されている.
American Society of Clinical Oncologyでは,
Cre≤3.0mg/dLならば特にDose調節する必要は無いとしている.
実際, Bisphosphonateが腎障害増悪に直接関与したとの
人間を対象としたEvidenceはまだ無し.
前述のRCTではCre>4.5mg/dLは母集団より除外されている.
→ 逆に言えば, Cre<4.5mg/dLならばOK？
NEJM 2005;352:373-9
40
41. 高Ca血症; 治療
From the ICU book
NEJM 2005;352:373-9
2nd line medications
Glucocorticoids; PSL 60mg po 10日間
Hydrocortisone(ソル･コーテフ等) 200mg/day IV, 3日間継続
リンパ性腫瘍の増殖抑制, Vit Dの作用の抑制
Mitharamycin, Picamycin(Mithracin®) 未承認
Calcitonin(エルシトニン® 10U) SQ, IM 4-8U/kg 12hr
上記ならば50kgの患者で200-400U.
国内の保険適用量は40U IM or 2-3hrでDIV, q12hr.
圧倒的に量が少ない！ >> 効かない, 効果が短いといった印象.
高Ca血症の原因への対応(骨再吸収の抑制)
42. Primary Hyperparathyroidism
外科治療Criteria
血中Ca濃度 >=12mg/dL @ Any time
Hyperparathyroid crisis(致死的な高Caの既往)
著明な高Ca尿症(>400mg/d)
腎石症
腎障害
嚢胞性線維性骨炎
骨皮質密度の低下
骨量の低下(年齢調節-2SD未満, Z score <2)
神経筋症状(近位筋委縮, 筋力低下, 反射亢進, 歩行障害)
年齢 <50yr
(Ann Intern Med 1991;114:593-7)
