As a library, NLM provides access to scientific literature. Zachariou Z, Buhr H, von Herbay A, Klaus G. Preoperative diagnostics and surgical management of tertiary hyperparathyroidism after chronic renal failure in a child, Hypercalcemia of seven years' duration after kidney transplantation, Persistent and symptomatic post-transplant hyperparathyroidism: a dramatic response to cinacalcet. Tertiary hyperparathyroidism generally occurs in patients with long-standing secondary hyperparathyroidism, as in patients with end-stage renal disease of several years duration. Okada Y, Tsukada J, Nakano K, Tonai S, Mine S, Tanaka Y. Macrophage inflammatory protein-1 induces hypercalcemia in adult T-cell leukemia. Parker MS, Dokoh S, Woolfenden JM, Buchsbaum HW. Kumar R, Schaefer J, Grande JP, Roche PC. In serum, 25(OH)D is tightly bound to vitamin D binding protein (VDBP) (296,298), and only a small percentage of total serum 25(OH)D is free or unbound (95, 299,301). In osteitis fibrosa cystica (often due to primary hyperparathyroidism), increased osteoclastic activity from overstimulation by PTH causes rarefaction of bone with fibrous degeneration and cyst and fibrous nodule formation. Toxicity and off-target P450 enzyme blockade from azole drugs will limit their long-term use in many patients. Numerous calcium-regulating genes are induced or repressed in vitamin D-responsive target tissues such as the intestine, kidney, and bone (45, 51, 200,205). The biological role of VDBP was explored in mice in which the VDBP gene had been deleted (307). As a result, serum and urine calcium concentrations may be quite variable, despite concentrations of serum 25(OH)D that might be regarded as elevated. Principal causes include Infants with IIH are frequently treated with a low-calcium diet, which conceivably could lead to low bone density over time. Note the proximity of the side chain to oxygen and heme groups. Wasserman RH, Smith CA, Brindak ME, et al. A biologically active metabolite of vitamin D3, The biological activity of 25-hydroxycholecalciferol, a metabolite of vitamin D3, The Use of Vitamin D Analogues Renal Failure, William J. Johnson, and, pages 611664, 1984). Symptoms include neuropsychiatric manifestations such as lethargy, confusion, irritability, depression, hallucinations, and in extreme cases, stupor, and coma; gastrointestinal symptoms such as anorexia, nausea, vomiting, and constipation; cardiovascular manifestations such as ectopy; and renal symptoms such as polyuria and renal colic from the passage of renal stones. Symptoms include read more , leprosy Leprosy Leprosy is a chronic infection usually caused by the acid-fast bacilli Mycobacterium leprae or the closely related organism M. lepromatosis. Borke JL, Caride A, Verma AK, Penniston JT, Kumar R. Cellular and segmental distribution of Ca2(+)-pump epitopes in rat intestine, Sodium-calcium exchange: a molecular perspective, Characterizing early events associated with the activation of target genes by 1,25-dihydroxyvitamin D3 in mouse kidney and intestine in vivo, Vitamin D-induced calcium-binding protein: comparative aspects in kidney and intestine. Absorption of dietary calcium by the intestine is essential for the maintenance of normal calcium homeostasis (206) and is a major factor contributing to hypercalcemia in patients with vitamin D intoxication. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. After an overload of vitamin D, DBP/ mice were unexpectedly less susceptible to hypercalcemia and its toxic effects. XVII. They may cause pain, nausea, vomiting, hematuria, and, possibly, chills and fever due to secondary infection. The effects of hypercalcemia are not limited to the mother because intrauterine hypercalcemia can lead to fetal/neonatal PTH suppression with resulting severe and sometimes prolonged hypoparathyroidism and hypocalcemia after birth (61, 66, 88, 131). Loss-of-function mutations of CYP24A1, the vitamin D 24-hydroxylase gene, cause long-standing hypercalciuric nephrolithiasis and nephrocalcinosis. Hyperphosphatemia is a serum phosphate concentration > 4.5 mg/dL ( > 1.46 mmol/L). Infantile hypercalcemia with subcutaneous fat necrosis: endocrine studies. The further metabolism of 25(OH)D3 is dependent upon the calcium and phosphorus requirements of the individual. Humoral hypercalcemia of cancer (ie, hypercalcemia with no or minimal bone metastases) occurs most commonly with squamous cell carcinoma, renal cell carcinoma Renal Cell Carcinoma Renal cell carcinoma (RCC) is the most common renal cancer. It leads to nephrocalcinosis in some patients. A 25(OH)D/24,25(OH)2D ratio >99 identified patients who were candidates for CYP24A1 genetic testing (Table 4). Infants who are symptomatic nearly universally have moderate to severe hypercalcemia sometimes exceeding 20 mg/dL. Role of vitamin D glucosiduronate in calcium homeostasis, Enterohepatic physiology of 1,25-dihydroxyvitamin D3 metabolites in normal man. A biologically active metabolite of vitamin D3, 25-hydroxyergocalciferol: a biologically active metabolite of vitamin D2, The isolation and identification of 25-hydroxyergocalciferol, The role of the liver in the metabolism of vitamin D, The regulation of rat liver calciferol-25-hydroxylase, Subcellular location of rat liver calciferol-25-hydroxylase, Primary hyperparathyroidism during pregnancy, Characteristics of the rat liver microsomal enzyme system converting cholecalciferol into 25-hydroxycholecalciferol. Side chain metabolism of 25-hydroxy-[26,2714C] vitamin D3 and 1,25-dihydroxy-[26,2714C] vitamin D3 in vivo, Side chain oxidation of 25-hydroxy-[26,2714C]vitamin D3 and 1,25-dihydroxy-[26,2714C]vitamin D3 in vivo by chickens, Metabolism of 1,25-dihydroxyvitamin D3: evidence for side-chain oxidation, Isolation and characterization of 1 -hydroxy-23-carboxytetranorvitamin D: a major metabolite of 1,25-dihydroxyvitamin D3. Chel VG, Ooms ME, Popp-Snijders C, et al. Silverstein E, Friedland J, Lyons HA, Gourin A. Elevation of angiotensin-converting enzyme in granulomatous lymph nodes and serum in sarcoidosis: clinical and possible pathogenic significance, Serum angiotensin-converting enzyme in leprosy and coccidioidomycosis, Elevated serum angiotensin-converting enzyme (SACE) activity in acute pulmonary histoplasmosis. Gray RW, Omdahl JL, Ghazarian JG, DeLuca HF. Isolation and identification of previtamin D3 from the skin of rats exposed to ultraviolet irradiation, Studies on the analysis of vitamins D. 4. WebSecondary hyperparathyroidism is caused by alterations in calcium, phosphate, and vitamin D regulation that result in elevated parathyroid hormone levels. The limits of detection for 24,25(OH)2D3 and 24,25(OH)2D2 were 0.03 ng/mL (0.2 nmol/L) and 0.1 ng/mL (0.23 nmol/L), respectively; the corresponding limits of quantification were 0.1 ng/mL (0.2 nmol/L) and 0.5 ng/mL (1.2 nmol/L). official website and that any information you provide is encrypted This would suggest that 25(OH)D-1-hydroxylase is to some degree constitutively active. IFN-- and TNF-independent vitamin D-inducible human suppression of mycobacteria: the role of cathelicidin LL-37. The symptoms and signs of hypercalcemia in the context of sarcoidosis are similar to those found in hypercalcemia due to excessive exogenous vitamin D intake. Bottom panel, Homology model of Cyp27B1 (-9.4 kcal/mol) bound to 25(OH)D3 (cyan). Several 1-hydroxylated vitamin D compounds are available for the treatment of secondary hyperparathyroidism seen in the context of chronic renal failure and end-stage renal disease and in various forms of inherited rickets. Laboratory findings include suppressed PTH, elevated 1,25(OH)2D, and usually normal 25(OH)D concentrations. Besides metabolism to 1,24,25(OH)3D3, 1,25(OH)2D3 is also metabolized to polar steroids (glucuronides and sulfates) in the liver and excreted in bile [about 3040% of an administered dose of 1,25(OH)2D3] (55, 104, 168,172); to calcitroic acid that is excreted in the bile as a polar metabolite (about 2025% of an administered dose of 1,25(OH)2D3) (173,176); and to 1,25R(OH)2D3-26,23S-lactone (177,179). Serum calcium begins to decrease in 2 to 4 hours and falls to near-normal within 24 hours. Table 2 summarizes the causes and mechanisms associated with the development of vitamin D-associated hypercalcemia. If sufficient renal function is still present, administration of isotonic fluids and a loop diuretic will be of value. Learn more about the Merck Manuals and our commitment to Global Medical Knowledge. Harnden D, Kumar R, Holick MF, Deluca HF. The degree of hypercalcemia (and symptoms) can vary from mild and intermittent to severe but in general is less pronounced compared to those who manifest disease during infancy. Since these original reports, numerous groups have collectively described the clinical and biochemical phenotype of over 100 patients with mono- or biallelic mutations in the CYP24A1 gene (49, 50, 55, 56, 60,64, 141, 147, 455,459). Recovery of exogenous 24,25(OH)2D3 and 24,25(OH)2D2 spiked into samples was 94100% and 9094%, respectively. Hyperphosphatemia has been associated with increased mortality Overview of Multiple Endocrine Neoplasias (MEN), Ovarian, Fallopian Tube, and Peritoneal Cancer, Laboratory and Clinical Findings in Some Disorders Causing Hypercalcemia, Medication-Related Osteonecrosis of the Jaw (MRONJ), Calcidol, Calciferol, D3 Vitamin, DECARA, Deltalin, Dialyvite Vitamin D, Dialyvite Vitamin D3, Drisdol, D-Vita, Enfamil D-Vi-Sol, Ergo D, Fiber with Vitamin D3 Gummies Gluten-Free, Happy Sunshine Vitamin D3, MAXIMUM D3, PureMark Naturals Vitamin D, Replesta, Replesta Children's, Super Happy SUNSHINE Vitamin D3, Thera-D 2000, Thera-D 4000, Thera-D Rapid Repletion, THERA-D SPORT, UpSpring Baby Vitamin D, UpSpring Baby Vitamin D3, YumVs, YumVs Kids ZERO, YumVs ZERO, AcidFree, Alka-Mints, Alka-Seltzer, Alka-Seltzer Heartburn Relief, Alkets , Antacid Fast Dissolve, Calcarb 600, Calci-Chew , Calci-Mix , Calcium Antacid, Cal-Gest , Caltrate, Maalox, Maalox Antacid Barrier, Maalox Quick Dissolve, Mylanta Children's, Nephro-Calci , Pepto-Bismol Children's, Rolaids Extra Strength, Titralac, Titralac Extra Strength, Tums, Tums Chewy Bites , Tums Cool Relief, Tums E-X, Tums Freshers, Tums Kids, Tums Lasting Effects, Tums Smooth Dissolve, Tums Smoothies, Tums Ultra, Digitek , Lanoxicaps, Lanoxin, Lanoxin Pediatric, Aluvea , BP-50% Urea , BP-K50, Carmol, CEM-Urea, Cerovel, DermacinRx Urea, Epimide-50, Gord Urea, Gordons Urea, Hydro 35 , Hydro 40, Kerafoam, Kerafoam 42, Keralac, Keralac Nailstik, Keratol, Keratol Plus, Kerol, Kerol AD, Kerol ZX, Latrix, Mectalyte, Nutraplus, RE Urea 40, RE Urea 50 , Rea Lo, Remeven, RE-U40, RYNODERM , U40, U-Kera, Ultra Mide 25, Ultralytic-2, Umecta, Umecta Nail Film, URALISS, Uramaxin , Uramaxin GT, Urea, Ureacin-10, Ureacin-20, Urealac , Ureaphil, Uredeb, URE-K , Uremez-40, Ure-Na, Uresol, Utopic, Vanamide, Xurea, X-VIATE, Albuked , Albumarc, Albuminar, Albuminex, AlbuRx , Albutein, Buminate, Flexbumin, Kedbumin, Macrotec, Plasbumin, Plasbumin-20, Deltasone, Predone, RAYOS, Sterapred, Sterapred DS, Advocate Glucose SOS, BD Glucose, Dex4 Glucose, Glutol , Glutose 15 , Glutose 45 , Glutose 5, Zemplar, Zemplar Multi-Dose Vial Solution, Zemplar Solution. The upper tolerable limit, defined as the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population, for vitamin D3 is 1000 IU/d in infants ages 06 months, 1500 IU/d in infants ages 612 months; 2500 IU/d in children ages 15 years; 3000 IU/d in children ages 48 years, and 4000 IU/d in adolescents and adults (97, 99). Pamidronate can be given for cancer-associated hypercalcemia as a one-time dose of 30 to 90 mg IV, repeated only after 7 days. Total serum (and sometimes ionized) calcium concentration, Chest x-ray; measurement of electrolytes, blood urea nitrogen (BUN), creatinine, phosphate, PTH, alkaline phosphatase, and serum protein immunoelectrophoresis to determine the cause, Sometimes urinary excretion of calcium with or without phosphate. Kutuzova GD, Sundersingh F, Vaughan J, et al. m for 5,6-trans-25(OH)D3, 1.95 107 When Paget disease of bone Paget Disease of Bone Paget disease of bone is a chronic disorder of the adult skeleton in which bone turnover is accelerated in localized areas. Slatopolsky E, Finch J, Ritter C, Takahashi F. Effects of 19-nor-1,25(OH)2D2, a new analogue of calcitriol, on secondary hyperparathyroidism in uremic rats. It is challenging to assign an absolute serum vitamin D concentration over which toxicity is always present. Although FHH results from histologically abnormal parathyroid tissue, the response to subtotal parathyroidectomy is unsatisfactory. In hypercalcemia due to sarcoidosis, other granulomatous disorders, and some lymphomas, serum concentration of 1,25(OH)2D may be elevated. Incidence of primary hyperparathyroidism in Rochester, Minnesota, 19932001: an update on the changing epidemiology of the disease, Wermers RA, Khosla S, Atkinson EJ, Hodgson SF, O'Fallon WM, Melton LJ., 3rd, The rise and fall of primary hyperparathyroidism: a population-based study in Rochester, Minnesota, 19651992, Primary hyperparathyroidism. Clinical features may be due to accompanying hypocalcemia and include tetany. Golconda MS, Larson TS, Kolb LG, Kumar R. 1,25-Dihydroxyvitamin D-mediated hypercalcemia in a renal transplant recipient, Purification and properties of chick renal mitochondrial ferredoxin, Regulation of the hydroxylation of 25-hydroxyvitamin D3 in vivo and in primary cultures of chick kidney cells, Regulation of the metabolism of 25-hydroxyvitamin D3 in primary cultures of chick kidney cells, Vitamin D metabolism: the role of kidney tissue. Vitamin D and adaptation to dietary calcium and phosphate deficiencies increase intestinal plasma membrane calcium pump gene expression, 1,25-Dihydroxyvitamin D3 controls a cohort of vitamin D receptor target genes in the proximal intestine that is enriched for calcium-regulating components, Active intestinal calcium transport in the absence of transient receptor potential vanilloid type 6 and calbindin-D9k. Christensson T, Hellstrm K, Wengle B, Alveryd A, Wikland B. About 85% of cases are related to cigarette smoking. Adams JS, Sharma OP, Gacad MA, Singer FR. Etidronate 7.5 mg/kg IV once a day for 3 to 5 days is used to treat Paget disease and cancer-associated hypercalcemia. In hypervitaminosis D [25(OH)D3 >64439 ng/mL], the mean relative contribution of 3-epi-25(OH)D3 was <4%, and concentrations ranged from 228.6 ng/mL (280). Activation of the calcium-sensing receptor in the thick ascending limb with attendant inhibition of sodium chloride reabsorption and countercurrent multiplication results in a dilute urine (262). Hyperphosphatemia, in general, is an asymptomatic condition. Mortality is mostly due to underlying conditions. Short-term complications of hyperphosphatemia include tetany due to hypocalcemia. There can also be deposition of calcium/phosphate in soft tissues, subcutaneous tissues, and joints. The CYP2R1 is the cytochrome P450 of the microsomal vitamin D3-25 hydroxylase, a mutant form of which was identified in a human subject with low circulating concentrations of 25-hydroxyvitamin D [25(OH)D] and classic symptoms of vitamin D deficiency (90). There is a paucity of information about the role of VDBP in human vitamin D toxicity. When maintained on vitamin D-deficient diets, the DBP/, but not DBP+/+, mice developed secondary hyperparathyroidism and the accompanying bone changes associated with vitamin D deficiency. If calcitonin stops working, it can be stopped for 2 days (while prednisone is continued) and then resumed. McCarron DA, Krutzik S, Barry JM, Muther RS, Bennett WM. Kelley LA, Mezulis S, Yates CM, Wass MN, Sternberg MJ. Some drugs, such as paricalcitol, are believed to be less hypercalcemic than others, such as calcitriol (315,322). Effect of cortisone on calcium metabolism in sarcoidosis with hypercalcaemia; possibly antagonistic actions of cortisone and vitamin D, Studies of 47-Ca metabolism in sarcoidosis: evidence for increased sensitivity of bone to vitamin D. Papapoulos SE, Clemens TL, Fraher LJ, Lewin IG, Sandler LM, O'Riordan JL. Seymour JF, Gagel RF, Hagemeister FB, Dimopoulos MA, Cabanillas F. Calcitriol production in hypercalcemic and normocalcemic patients with non-Hodgkin lymphoma, Incidence and prognostic significance of hypercalcaemia in B-cell non-Hodgkin's lymphoma. Kitanaka S, Takeyama K, Murayama A, Kato S. The molecular basis of vitamin D-dependent rickets type I. Sawada N, Sakaki T, Kitanaka S, Kato S, Inouye K. Structure-function analysis of CYP27B1 and CYP27A1. Counts SJ, Baylink DJ, Shen FH, Sherrard DJ, Hickman RO. Girgis CM, Clifton-Bligh RJ, Hamrick MW, Holick MF, Gunton JE. Although 25(OH)D concentrations of approximately 50 ng/mL (125 nmol/L) may increase urinary calcium excretion and the risk of nephrolithiasis, it should be remembered that normal individuals exposed to sunlight for short or long periods of time can have 25(OH)D serum concentrations as high as 65 ng/mL (163 nmol/L) without ill effects or hypercalcemia (248, 266, 283,295). This enzyme is induced by 1,25(OH)2D3 (118, 121). IV phosphate (disodium phosphate or monopotassium phosphate) should be used only when hypercalcemia is life threatening and unresponsive to other methods and when short-term hemodialysis is not possible. As a result, a reduction in vitamin D intake for infants was recommended. Circulating PTH usually is suppressed. Osteolytic hypercalcemia can be caused by metastatic solid tumors (eg, breast, prostate, non-small cell lung cancers) or hematologic cancers, most often multiple myeloma Multiple Myeloma Multiple myeloma is a cancer of plasma cells that produce monoclonal immunoglobulin and invade and destroy adjacent bone tissue. Volume repletion with saline is an essential element of care. The few reports that included bone mineral density assessment have yielded conflicting results ranging from low, to normal, to clearly elevated bone mineral density (49, 140, 142, 145, 455). A plasma phosphate level higher than 4.5 mg/dL is hyperphosphatemia. Assessment of the free fraction of 25-hydroxyvitamin D in serum and its regulation by albumin and the vitamin D-binding protein, A comparison of measured and calculated free 25(OH) vitamin D levels in clinical populations. Adults with CYP24A1 mutations most frequently present with renal manifestations such as nephrolithiasis and/or nephrocalcinosis and may experience polyuria. Cell-type-specific transactivation of the parathyroid hormone-related protein gene promoter by the human T-cell leukemia virus type I (HTLV-I) tax and HTLV-II tax proteins, Production of parathyroid hormone-related protein in adult T-cell leukemia cells, Urinary excretion of parathyroid hormone-related protein as a predictor of hypercalcemia in patients with adult T-cell leukemia, Hypercalcemia associated with adult T-cell leukemia/lymphoma (ATL), Hypercalcemia, parathyroid hormone-related protein expression and human T-cell leukemia virus infection, Mice transgenic for HTLV-I LTR-tax exhibit tax expression in bone, skeletal alterations, and high bone turnover. The presence of hyperphosphatemia is a clue to the presence of hypervitaminosis D. It occurs as a result of an increase in intestinal and renal phosphate absorption. Diagnosis is by serum phosphate measurement. Hypophosphatemia suggests: hyperparathyroidism or humoral hypercalcemia of malignancy (due to PTH-related peptide) Hyperphosphatemia suggests: everything else (myriad disorders in which endogenous PTH is suppressed) Ionized calcium level. Parathyroid hormone (PTH). Elevated or inappropriately normal in primary or tertiary hyperparathyroidism. Hypercalcemia associated with granulomatous disease. When protein and albumin are abnormal and when ionized hypercalcemia is suspected because of clinical findings (eg, because of symptoms of hypercalcemia), ionized serum calcium should be measured. The sodium gradient for the activity of the sodium-calcium exchanger is maintained by the Na-K ATPase. Please confirm that you are a health care professional. In other endocrine causes of hypercalcemia, such as thyrotoxicosis and Addison disease Addison Disease Addison disease is an insidious, usually progressive hypofunctioning of the adrenal cortex. Symptoms Treatment Diagnosis Risk factors Takeaway Electrolytes are minerals that control important physiologic functions of the body. The corresponding interassay values were 4.58.3% and 3.010.1%. Denosumab, 120 mg subcutaneously every 4 weeks with additional doses on days 8 and 15 of the first month of treatment, is a monoclonal antibody inhibitor of osteoclastic activity that can be used for cancer-associated hypercalcemia that does not respond to bisphosphonates. All are capable of causing hypercalcemia when administered in excess. The human T lymphotropic virus (HTLV) that is often associated with adult T-cell leukemia/lymphoma elaborates a protein (HTLV-1 transactivator protein, tax) that binds to and activates the PTHrP promoter (444,450). Disclosure Summary: The authors have nothing to declare. The presence of hyperphosphatemia is a clue to Cinacalcet, a calcimimetic agent that increases the sensitivity of the calcium-sensing receptor to extracellular calcium, may lower parathyroid hormone and calcium levels. Savio RM, Gosnell JE, Posen S, Reeve TS, Delbridge LW. C, Physiological changes in response to decreases in serum calcium concentrations. The major types are Hodgkin lymphoma Non-Hodgkin lymphoma See table Comparison of Hodgkin read more and lymphosarcomas. Woywodt A, Schneider W, Goebel U, Luft FC. MEN 1 involves read more (MEN) should be considered in patients with primary hyperparathyroidism. We will describe the biochemical processes associated with the synthesis and degradation of various vitamin D metabolites, the clinical features of the vitamin D-mediated hypercalcemia, their biochemical diagnosis, and treatment. Care must be taken to avoid volume depletion. Visnen S, Ryhnen S, Saarela JT, Perkyl M, Andersin T, Menp PH. Vitamin D receptor (VDR)-mediated actions of 1,25(OH) vitamin D: genomic and non-genomic mechanisms. Altmann P, Dodd S, Williams A, Marsh F, Cunningham J. Silicone-induced hypercalcaemia in haemodialysis patients. Ghazarian JG, Jefcoate CR, Knutson JC, Orme-Johnson WH, DeLuca HF. Enhanced production rate of 1,25-dihydroxyvitamin D in sarcoidosis, The clinical management of sarcoidosis. In the 1960s, the Committee on Nutrition of the American Academy of Pediatrics also provided guidance on vitamin D fortification for infant formula, suggesting a limit of 400 IU per day in an effort to prevent rickets while avoiding possible toxicity (67, 68). A decrease in serum phosphate concentration is associated with an increase in ionized calcium, a decrease in PTH secretion, and a subsequent decrease in renal phosphate excretion. Glass AR, Cerletty JM, Elliott W, Lemann J, Jr, Gray RW, Eil C. Ketoconazole reduces elevated serum levels of 1,25-dihydroxyvitamin D in hypercalcemic sarcoidosis, Treatment of sarcoidosis-associated hypercalcemia with ketoconazole, Ketoconazole for the treatment of refractory hypercalcemic sarcoidosis, Hypercalcemia in granulomatous disorders: a clinical review, Low incidence of hypercalcaemia in tuberculosis in Malaysia, The prevalence of hypercalcaemia in pulmonary and miliary tuberculosisa longitudinal study. Cheng JB, Levine MA, Bell NH, Mangelsdorf DJ, Russell DW. Strushkevich N, Usanov SA, Plotnikov AN, Jones G, Park HW. Causes include chronic kidney disease, hypoparathyroidism, and metabolic or respiratory It causes various symptoms, including hypotension and hyperpigmentation, and can lead to adrenal crisis read more , typical laboratory findings of the underlying disorder help establish the diagnosis. Many experts recommend surgery in the following circumstances: Serum calcium 1 mg/dL (0.25 mmol/L) greater than the upper limits of normal, Peak bone density at the hip, lumbar spine, or radius 2.5 standard deviations below controls (T score = 2.5), The possibility of poor adherence with follow-up. In this population, focusing efforts on calcium restriction and hydration seems prudent. Shaker JL, Redlin KC, Warren GV, Findling JW. Calcium is absorbed by the intestine (predominantly in the duodenum and proximal small intestine) by two mechanisms, a passive paracellular mechanism, and an active transcellular one (206, 208, 209). A dosage of 4 to 8 IU/kg subcutaneously every 12 hours of salmon calcitonin is safe. Almeida RM, Cezana L, Tsukumo DM, de Carvalho-Filho MA, Saad MJ.
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