A case of sarcoidosis followed by hypercalcemia in a hemodialysis patient

Hypercalcemia is frequently observed in maintenance hemodialysis (HD) patients. Mineral and bone disorder and severe vascular calcifications can occur, leading to cardiovascular events. Therefore, the prevention of hypercalcemia would be a pivotal strategy in sustaining maintenance HD. In many cases, hypercalcemia in HD patients is caused by severe secondary hyperparathyroidism, and/or excess of subsequent treatment, such as vitamin D analogue and calcium reagents. We report a case of sarcoidosis-related hypercalcemia in a HD patient. A 65-year-old male had been undergoing maintenance HD due to chronic renal failure caused by polycystic kidney disease since April 2004. Secondary hyperparathyroidism had been well controlled by administration of precipitated calcium carbonate, sevelamer and alfacalcidol. However, the concentration of serum Ca became elevated and then intact PTH gradually decreased. Since serum Ca continued to elevate despite discontinuation of alfacalcidol, we were forced to discontinue precipitated calcium carbonate, conduct low calcium-HD, and administer elcatonin as a series of treatments to counteract hypercalcemia until August 2007. Chest X-rays showed bilateral hilar lymphadenopathy. Tuberculin reaction test was negative. Moreover, gallium scintigram showed abnormal accumulation of gallium in the hilar lymph nodes, and bronchoalveolar lavage showed an increase in the number of total cells, lymphocyte ratio, and CD4/CD8 ratio. The patient was diagnosed with sarcoidosis. The hypercalcemia improved with corticosteroid therapy within 2 weeks. We should consider the possibility of sarcoidosis in HD patients with intractable hypercalcemia.