Life-threatening hypercalcemia in patients with rhabdomyolysis-induced oliguric acute renal failure

In a third of patients presenting with rhabdomyolysis-induced acute renal failure (ARF), a biphasic plasma calcium profile may occur.

We report a case of rhabdomyolysis-induced ARF presenting hypocalcemia during oliguria, followed by a severe hypercalcemia in the polyuric phase. A hypocalcemia-induced acute increase of plasma parathyroid hormone in the early stage of ARF was followed by a down-regulation of parathyroid hormone, 1,25(OH)2 vitamin D and 25(OH) vitamin D during the renal function recovery, associated with an acute hypercalcemia. The plasma calcium increase induced in our patient severe neurological disturbances, life-threatening short QT interval and Brugada-like syndrome at risk of malignant arrhythmias. This complication was treated by hemodialysis and pamidronic acid infusion.

This case confirms that the pathogenesis of the biphasic calcium profile may be related to the massive calcium uptake in the ischemic muscle cells during oliguria, followed by a muscle calcium release later in the polyuric stage of ARF. Therefore, the behavior of calciotropic hormones may be the consequence rather than the cause of plasma calcium changes.

We would like to emphasize the danger of sudden death that may occur in the recovery phase of rhabdomyolysis-induced ARF when the physician might be wrongly convinced that the major risks have disappeared.