Milk Alkali Syndrome- Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

Milk-alkali syndrome is a condition resulting from ingestion of excessive amounts of calcium and absorbable alkali (e.g., sodium bicarbonate and calcium carbonate):

  • Usually occurs during self-treatment for indigestion, peptic ulcer, or gastroesophageal reflux disease, or as part of osteoporosis prevention
  • Characterized by hypercalcemia, metabolic alkalosis, and renal insufficiency
  • System(s) affected: Endocrine/Metabolic; GI; Renal/Urologic
  • Synonym(s): Burnett syndrome; Milk poisoning; Milk drinker syndrome

Epidemiology

Incidence

  • 3rd most common cause of hypercalcemia, with a prevalence of 9–12% among hospitalized patients with hypercalcemia
  • Recent increase associated with osteoporosis prevention

Prevalence

Infrequent

Risk Factors

  • Chronic use of calcium-containing antacids or supplements
  • Chronic kidney disease
  • Vitamin D supplementation
  • Thiazide diuretic therapy

General Prevention

Avoid excess milk and/or absorbable antacids.

Pathophysiology

Exact mechanism unclear:

  • Increased calcium absorption may lead to suppression of parathyroid hormone, which leads to the kidneys retaining increased bicarbonate. This eventually leads to alkalosis, which also causes increased calcium resorption in the kidneys.

Etiology

Excess intake of milk and alkali as therapy for gastrointestinal problems accompanied with gastric hyperacidity (e.g., peptic ulcer, esophageal reflux) or for prevention of osteoporosis

Commonly Associated Conditions

  • Peptic ulcer disease
  • Hiatal hernia
  • Gastroesophageal reflux
  • Osteoporosis
  • Hypertension
  • Hyperparathyroidism
  • Hypercalcemia of malignancy

Hypercalcaemia, Renal failure, metabolic alkalosis, sodium bicarbonate, calcium absorption, osteoporosis prevention, metabolic acidosis,

Diagnosis

History of excessive calcium and absorbable alkali intake resulting in hypercalcemia, metabolic acidosis, and renal impairment

History

  • Calcium-containing supplement use
  • Food distaste, anorexia
  • Constipation
  • Dizziness, weakness
  • Headache
  • Mental status changes, irritability, depression
  • Myalgias
  • Nausea, vomiting
  • Polydipsia
  • Polyuria

Physical Exam

  • Band keratopathy
  • Dehydration
  • Periarticular calcinosis

Diagnostic Tests & Interpretation

Lab

Check calcium, renal function, lytes, BUN, creatinine, alkaline phosphatase, and PTH.

Initial lab tests

  • Mild alkalosis
  • Hypercalcemia
  • Normocalciuria
  • Decreased urine phosphate
  • Increased BUN and serum creatinine levels
  • Normal alkaline phosphatase level

Pathological Findings

  • Nephrocalcinosis
  • Ectopic calcification

Differential Diagnosis

Other causes of hypercalcemia:

  • Excessive osteolysis with malignant disease
  • Vitamin intoxication
  • Thyroid disease
  • Sarcoidosis
  • Thiazide diuretic treatment
  • Hyperparathyroidism

Treatment

Medication

First Line

  • To treat hypercalcemia:
    • Isotonic sodium chloride: 0.9% IV when serum calcium exceeds 15 mg/dL (3.75 mmol/L; see Hypercalcemia) plus
    • Furosemide: 80–100 mg IV q2h for 24 hours after volume depletion has been corrected
  • Precautions: Replace sodium and potassium losses associated with furosemide use.

Second Line

  • Bisphosphonates inhibit bone resorption.
  • Dialysis is occasionally indicated.

Additional Treatment

General Measures

  • Withdraw milk and alkali (1)[B].
  • Hydration (1)[B]
  • Treat hypercalcemia.
  • Goal is to maintain urine volume of 3 L/d

Issues for Referral

Renal insufficiency

In-Patient Considerations

Initial Stabilization

Withdraw milk and alkali.

Admission Criteria

  • IV treatment to avoid calcinosis (usually with sodium chloride solution)
  • Renal dialysis for significant renal insufficiency

Ongoing Care

Follow-Up Recommendations

Avoid excess alkali.

Patient Monitoring

  • Kidney function
  • Fluid intake and output
  • Urine electrolytes

Diet

  • Increased fluid intake
  • Avoid excess milk and alkali.

Patient Education

Appropriate diet

Prognosis

Favorable with appropriate therapy

Complications

  • Psychosis
  • Stupor
  • Coma
  • Renal failure

References

1. Medarov BI et al. Milk-alkali syndrome. Mayo Clin Proc. 2009;84:261–7.

Additional Reading

Ulett K, Wells B, Centor R et al. Hypercalcemia and acute renal failure in milk-alkali syndrome: a case report. J Hosp Med. 2010;5:E18–20.

Codes

ICD9

275.42 Hypercalcemia

Snomed

43258006 milk alkali syndrome (disorder)

Clinical Pearls

  • Inquire if patient uses over-the-counter antacids or calcium supplements.
  • Daily calcium supplementation should not exceed 2 g.
  • Hydration and withdrawal of calcium sources are the mainstays of treatment.

About the author

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