Milk-alkali syndrome overview

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Overview

Historical Perspective

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Pathophysiology

Causes

Differentiating Milk-alkali syndrome from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

Ecocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

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Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shakiba Hassanzadeh, MD[2]


Overview

Milk-alkali syndrome, also called Burnett's syndrome in honour of the American physician who first described it, is characterized by hypercalcemia caused by repeated ingestion of calcium and absorbable alkali (such as calcium carbonate, or milk and sodium bicarbonate). If untreated, milk-alkali syndrome may lead to metastatic calcification and renal failure.

It was most common in the early 20th century, but there has been a recent increase in the number of cases reported.[1][2]


Overview

Historical Perspective

Pathopysiology

Causes

Differentiating Analgesic nephropathy from other Diseases

Risk Factors

Patients with the following conditions are more susceptible to milk-alkali syndrome: Older age, preexisting chronic renal disease, concurrent vomiting (bulimia nervosa or hyperemesis gravidarum ) and use of certain drugs like thiazide, NSAIDs, and ACE inhibitors.[3][4][5][6][7][8][9]

Screening

There is insufficient evidence to recommend routine screening for milk-alkali syndrome.

Natural History, Complications and Prognosis

Most patients with milk-alkali syndrome are asymptomatic and may be incidentally diagnosed. Prognosis of milk-alkali syndrome is generally good and early diagnosis and treatment, with withdrawal of the offending agent and supportive therapy, usually resolve the symptoms and abnormalities in milk-alkali syndrome (hypercalcemia, alkalosis and renal insufficiency).[10][2][3][11][12][3][2][13][14]

Epidemiology and Demographics

Diagnosis

Diagnostic Study of Choice

Milk-alkali syndrome is diagnosed by history of excessive calcium consumption, hypercalcemia, metabolic alkalosis and variable degrees of renal insufficiency. [3]

History and Symptoms

In patients with milk-alkali syndrome, there is a history of excessive calcium and absorbable alkali consumption.[3] Symptoms of milk-alkali syndrome may inculde: dizziness, vertigo, confusion, apathy, nausea, vomiting, anorexia, distaste for milk, headache, anorexia, pruritus, polydipsia, polyuria, myalgia, tremor, psychosis, and abnormal calcifications (keratopathy, renal calcinosis).[11][12]

Physical Examination

The following should be considered in the physical examination of milk-alkali syndrome: vertigo, confusion, apathy, nausea, vomiting, pruritus, polydipsia, polyuria, myalgia, tremor, psychosis, and abnormal calcifications (keratopathy, renal calcinosis).[11][12][3]

Laboratory Findings

The following laboratory findings are usually seen in milk-alkali syndrome: hypercalcemia, metabolic alkalosis, variable degrees of renal insufficiency, low or normal phosphorus, low Vitamin D, and low PTH.[2][3][15][9]

Electrocardiogram


X-ray

X-ray is not useful in the diagnosis of milk-alkali syndrome. However, X-ray may be useful in excluding other causes of hypercalcemia. Renal calcium deposits are not seen on X-ray in milk-alkali syndrome.[3]

Echocardiography and Ultrasound

Echocardiography is not useful in diagnosis of milk-alkali syndrome. Ultrasound is not useful in the diagnosis of milk-alkali syndrome. However, ultrasound may be helpful in excluding other causes of hypercalcemia.

CT Scan

CT scan is not useful in the diagnosis of milk-alkali syndrome. However, CT scan may be helpful in excluding other causes of hypercalcemia.

MRI

MRI is not useful in the diagnosis of milk-alkali syndrome. However, MRI may be helpful in excluding other causes of hypercalcemia.

Other Imaging Findings

There are no other imaging findings associated with milk-alkali syndrome.

Other Diagnostic studies

There are no other diagnostic studies associated with milk-alkali syndrome.

Treatment

Medical therapy

Treatment of milk-alkali syndrome is mostly supportive and mainly includes withdrawal of the offending agent, hydration and intravenous volume expansion. However, other treatments such as therapy with calcium supplements (in temporary hypocalcemia) and hemodialysis (in acute or chronic irreversible renal insufficiency) may be required.[2][3]

Surgery

Surgical intervention is not recommended for the routine management of milk-alkali syndrome.

Primary Prevention

Effective measures for the primary prevention of milk-alkali syndrome includes public education about the potential adverse effects of calcium supplements. Calcium intake less than 2 g/daily is usually safe, however, 1.2 to 1.5 g/daily of calcium intake should be taken by individuals with risk factors for milk-alkali syndrome.[3][4][5][6][7][8][9]

Secondary Prevention

There are no established measures for the secondary prevention of milk-alkali syndrome.

Cost-Effectiveness of Therapy

There is insufficient evidence about the cost-effectiveness of therapy in milk-alkali syndrome.

Future or Investigational Therapies

No further or investigational therapies have been suggested in milk-alkali syndrome.

References

  1. Caruso JB, Patel RM, Julka K, Parish DC (2007). "Health-behavior induced disease: return of the milk-alkali syndrome". J Gen Intern Med. 22 (7): 1053–5. doi:10.1007/s11606-007-0226-0. PMID 17483976. Unknown parameter |month= ignored (help)
  2. 2.0 2.1 2.2 2.3 2.4 Beall DP, Henslee HB, Webb HR, Scofield RH (2006). "Milk-alkali syndrome: a historical review and description of the modern version of the syndrome". Am. J. Med. Sci. 331 (5): 233–42. PMID 16702792. Unknown parameter |month= ignored (help)
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 Medarov BI (2009). "Milk-alkali syndrome". Mayo Clin Proc. 84 (3): 261–7. doi:10.1016/S0025-6196(11)61144-0. PMC 2664604. PMID 19252114.
  4. 4.0 4.1 Beall DP, Scofield RH (1995). "Milk-alkali syndrome associated with calcium carbonate consumption. Report of 7 patients with parathyroid hormone levels and an estimate of prevalence among patients hospitalized with hypercalcemia". Medicine (Baltimore). 74 (2): 89–96. doi:10.1097/00005792-199503000-00004. PMID 7891547.
  5. 5.0 5.1 Whiting SJ, Wood R, Kim K (1997). "Calcium supplementation". J Am Acad Nurse Pract. 9 (4): 187–92. PMID 9274239.
  6. 6.0 6.1 Patel AM, Goldfarb S (2010). "Got calcium? Welcome to the calcium-alkali syndrome". J Am Soc Nephrol. 21 (9): 1440–3. doi:10.1681/ASN.2010030255. PMID 20413609.
  7. 7.0 7.1 Felsenfeld AJ, Levine BS (2006). "Milk alkali syndrome and the dynamics of calcium homeostasis". Clin J Am Soc Nephrol. 1 (4): 641–54. doi:10.2215/CJN.01451005. PMID 17699269.
  8. 8.0 8.1 Picolos MK, Lavis VR, Orlander PR (2005). "Milk-alkali syndrome is a major cause of hypercalcaemia among non-end-stage renal disease (non-ESRD) inpatients". Clin Endocrinol (Oxf). 63 (5): 566–76. doi:10.1111/j.1365-2265.2005.02383.x. PMID 16268810.
  9. 9.0 9.1 9.2 Arroyo M, Fenves AZ, Emmett M (2013). "The calcium-alkali syndrome". Proc (Bayl Univ Med Cent). 26 (2): 179–81. doi:10.1080/08998280.2013.11928954. PMC 3603742. PMID 23543983.
  10. Ali, Rimsha; Patel, Chinmay (2020-05-30). "Milk-Alkali Syndrome". NCBI Bookshelf. PMID 32491432 Check |pmid= value (help). Retrieved 2020-07-14.
  11. 11.0 11.1 11.2 Orwoll ES (1982). "The milk-alkali syndrome: current concepts". Ann Intern Med. 97 (2): 242–8. doi:10.7326/0003-4819-97-2-242. PMID 7049033.
  12. 12.0 12.1 12.2 Texter EC, Laureta HC (1966). "The milk-alkali syndrome". Am J Dig Dis. 11 (5): 413–8. doi:10.1007/BF02233637. PMID 5327389.
  13. George S, Clark JD (2000). "Milk alkali syndrome-an unusual syndrome causing an unusual complication". Postgrad Med J. 76 (897): 422–3. doi:10.1136/pmj.76.897.422. PMC 1741646. PMID 10878206.
  14. Jenkins JK, Best TR, Nicks SA, Murphy FY, Bussell KL, Vesely DL (1987). "Milk-alkali syndrome with a serum calcium level of 22 mg/dl and J waves on the ECG". South Med J. 80 (11): 1444–9. doi:10.1097/00007611-198711000-00028. PMID 3686151.
  15. Kapsner P, Langsdorf L, Marcus R, Kraemer FB, Hoffman AR (1986). "Milk-alkali syndrome in patients treated with calcium carbonate after cardiac transplantation". Arch Intern Med. 146 (10): 1965–8. PMID 3532984.

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