Hemodialysis is considered the renal replacement technique of choice to control life-threatening
hypercalcemia. In this case series, the experience with
continuous venovenous hemodiafiltration (
CVVHDF) with regional
citrate anticoagulation to control five hypercalcemic crises in four patients is summarized. Overall maximum ionized and total
calcium levels ranged from 1.72 to 2.01 mmol/L and 3.1 to 4.2 mmol/L, respectively. All patients presented with impaired consciousness,
cardiac arrhythmias, or acute
oliguria, despite
therapy.
Trisodium citrate was administered at 3 mmol/h (hourly
calcium replacement 1.15-2.75 mmol). This allowed a controlled decrease in ionized
calcium levels below 1.4 mmol/L within 4 hours (interquartile range [IQR], 2.5-10) and resolution of neurological symptoms within 15.5 hours (IQR, 12-22.8). The duration of
CVVHDF was 1 day in those patients in whom
hypercalcemia was the reason for admission. Four asymptomatic episodes of mild
hypocalcemia occurred in two patients. No patient developed relevant abnormalities of serum
sodium levels or pH, experienced
cardiac arrhythmia, or required transfusion of blood products during
CVVHDF. One patient with metastatic
bronchial carcinoma experienced rebound hypercalcemic crisis 13 days after a 1 day session of
CVVHDF with regional
citrate anticoagulation. In conclusion,
CVVHDF with regional
citrate anticoagulation appears to be effective and potentially safe to rapidly normalize
calcium levels in hypercalcemic crisis.