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PRACTICE: Michail Kaklamanos and Petros Perros Milk alkali syndrome without the milk BMJ 2007; 335: 397-398 [Full text]

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Innappropriately normal PTH in hypercalcaemia

Olly G Donnelly   (27 August 2007)

Evaluation of Milk Alkali Syndrome

Shirwan A. Mirza, MD, FACP, FACE   (27 August 2007)

Milk alkali syndrome ... without the milk

NAZAR R DESSOUKI   (28 August 2007)

Vitamins and Minerals

Hugh Mann   (28 August 2007)

Is it indeed Milk Alkali Syndrome?

Gabor Cserep   (29 August 2007)

Innappropriately normal PTH in hypercalcaemia 27 August 2007
Olly G Donnelly, SpR Clinical Oncology Cookridge Hospital, Leeds, LS16 6QB Send response to journal: Re: Innappropriately normal PTH in hypercalcaemia	Dear editor, Kaklamanos and Peros have neglected an important point in their discussion of an interesting case. Parathyroid hormone (PTH) release is commonly suppressed by other causes of hypercalcaemia so the finding of a normal or 'high-normal' PTH level should always prompt consideration of primary hyperparathyroidism. Mishcis-Troussard et al. found that 20 out of 271 (7%) patients undergoing surgery for primary hyperparathyroidism had PTH values in the normal range. As a lesson of the week I think it should be highlighted that normal PTH values do not exclude hyperparathyroidism. {Q J Med 2000; 93: 365-367.C. MISCHIS-TROUSSARD, P. GOUDET, B. VERGES, P. COUGARD1, C. TAVERNIER and J.-F. MAILLEFERT; Primary hyperparathyroidism with normal serum intact parathyroid hormone levels } Competing interests: None declared
Evaluation of Milk Alkali Syndrome 27 August 2007
Shirwan A. Mirza, MD, FACP, FACE, Chairman: Department of Medicine, Consultant Endocrinologist Auburn, New York, 13021 Send response to journal: Re: Evaluation of Milk Alkali Syndrome	I have seen a dozen cases of milk alkali syndrome over the course of a few years. Whenever I write my diagnosis as milk alkali syndrome, I get some raised eyebrows, as the primary care physicians and nurses know that the patient is not a milk drinker. I admit that, for this reason, I do like the term “calcium alkali syndrome" suggested by the authors. There are a few diagnostic pearls that the authors failed to mention: 1. You have to pull out history of calcium intake “like a tooth” from hospitalized patients who are frequently obtunded by hypercalcemia. Asking about calcium is not enough. Most calcium supplements might not have the word “calcium” in the name; such as Tums, Rolaids, and Oyster shells to name a few in the United States. It is probably wise to ask what supplements and herbs, or vitamins do they take. Whether, they take any medications over the counter for heartburn since most patients take calcium carbonate for this purpose. 2. The calcium supplement need not be calcium carbonate to cause milk alkali syndrome. 3. Any calcium supplement overdose even citrate could cause milk alkali syndrome provided that there is alkalosis. For example any calcium supplement would cause milk alkali syndrome in conjunction with diuretic use or history of vomiting. 4. Chloride is of high diagnostic yield. The authors failed to mention serum chloride level in the case presentation. In primary hyperparathyroidism serum chloride level is usually high, or high normal (=> 106 mmol/L_. In milk alkali syndrome or malignancy-induced hypercalcemia, serum chloride level is typically < 100 mmol/L. In this setting, patients who look healthy most likely have milk alkali syndrome, and the sick ones (with weight loss, anemia, renal dysfunction, and constitutional symptoms) need to be evaluated for malignancy. 5. The authors should have not specified the type of IV fluids. The preferred IV fluid is an adequate volume of 0.9% saline (barring cardiac decompensation). In the renal tubules, calcium follows sodium in excretion into the urine. 6. Using IV pamidronate was a rush to judgment in this case and was unnecessary in this patient or in any milk alkali syndrome case. Milk alkali syndrome is not caused by bone resorption, so you do not need IV pamidronate to prevent bone resorption. Discontinuation of calcium supplements, correction of alkalosis and copious IV hydration are the only measures that are needed in “calcium alkali syndrome”. Competing interests: None declared
Milk alkali syndrome ... without the milk 28 August 2007
NAZAR R DESSOUKI, CONSULTANT SURGEON ST BERNARDS HOSPITAL GIBRALTAR Send response to journal: Re: Milk alkali syndrome ... without the milk	Calcium-alkali syndrome is caused by the ingestion of large amounts of calcium and absorbable alkali with resulting hypercalcemia. If unrecognized and untreated, milk-alkali syndrome can lead to metastatic calcification and renal failure. This syndrome was originally recognized in the 1920s during administration of the Sippy regimen, consisting of milk and bicarbonate, for treatment of peptic ulcer disease. With the development of nonabsorbable alkali and histamine-2 blockers for treatment of peptic ulcer disease, milk-alkali syndrome became a rare cause of hypercalcemia; however, with increased use and promotion of calcium carbonate for dyspepsia and as calcium supplementation, a resurgence of calicum-alkali syndrome has occurred in the last few years. Competing interests: None declared
Vitamins and Minerals 28 August 2007
Hugh Mann, Physician Eagle Rock, MO 65641 USA Send response to journal: Re: Vitamins and Minerals	Life and health are a symphony of chemicals, which must be present in the right proportions. Too much is just as bad as too little. Today, everyone is worried about getting enough calcium, as if it's impossible to get enough. This is false and dangerous reasoning. Too much calcium can cause constipation, irritability, insomnia, headaches, kidney stones, peptic ulcer, and psychosis. Why don't the experts who recommend supplements warn people about the dangers of excess chemicals? Perhaps it's because many of these experts also sell supplements. A healthy diet is like a good recipe: you need the right ingredients in the right proportions. Too much of one ingredient can ruin your dish, your diet, and your health. Competing interests: None declared
Is it indeed Milk Alkali Syndrome? 29 August 2007
Gabor Cserep, Consultant in Nephrology Renal Unit, PCC Building, Colchester General Hospital, Turner Road, Colchester CO4 5JR Send response to journal: Re: Is it indeed Milk Alkali Syndrome?	This case highlights an interesting problem which is emerging more and more frequently in our health conscious society. The importance of calcium supplementation for health reasons appears in the press on a regular basis. People do not know about the side effects of taking too much calcium frequently with additional vitamin D. The other frequent situation is the one in the article that dyspepsia is remedied with calcium based antacids. However, I missed two important data from the article. Alkalosis was assumed but never tested neither by an ABG nor by serum bicarbonate and chloride levels. I also missed the exact content of the indigestion tablet, which is quite important as multiple different products exist on the market. I think because of the two missing pieces of information we cannot label the patient as having Milk Alkali Syndrome but we have to be satisfied with the diagnosis of hypercalcaemia caused by oral calcium overdose. Hypercalcaemia on its own can cause alkalosis and renal insufficiency via different pathologic mechanisms. Hypercalcaemia with hypercalciuria can inhibit the ROM-K channel causing reduced reabsorption of sodium, potassium, chloride and calcium in the loop of Henle. The resulting volume contraction, the hypokalaemia and increased distal tubular sodium delivery can increase proximal tubule bicarbonate reabsorption, collecting tubule bicarbonate generation and cause elevated creatinine value. Competing interests: None declared