Liver granulomatosis is not an exceptional cause of hypercalcemia with hypoparathyroidism in dialysis patients

In 4 of our patients on chronic dialysis, we were intrigued by the associat ion of hypercalcemia + hyperphosphatemia and normal intact PTH, with anicte ric cholestasis without cytolysis. This picture occured in 2 patients after they resumed dialysis because of a transplant rejection and in a third one after discontinuation of corticosteroids, prescribed for an idiopathic thr ombocytopenia. No patient was under calcitriol, CaCO3 therapy, and their hy percalcemia persisted on a low calcium dialyzate (1.25 mmol/l). Obvious eti ologies of hypercalcemia were not found : vitamin D or A intoxication, hype rparathyroidism, aluminum intoxication, hemopathy, HIV infection. The hypot hesis of a granulomatous disease was made and a liver biopsy was performed showing granulomas with giant epitheloid cells. In one case foreign materia l (silicon ?) was present in the macrophages. Extensive investigations for sarcoidosis, tuberculosis and mycosis were negative. In 2 cases the so-call ed "dialysis" granulomatosis actually occured in transplanted patients, sug gesting the role of a transplantation related factor (toxic or virus). In t he last case HCV seroconversion was present. In the 4 cases, corticotherapy led to the disappearance of hypercalcemia and to an increase of PTH. Our patients had the biological pattern of low bone turnover disease (hyper calcemia and normal intact PTH) and bone biopsy performed in 2 showed osteo malacia or ABD without aluminum. The association of this pattern with chole stasis should evoke liver granulomatosis, which should be confirmed by a li ver biopsy and lead to a treatment by corticosteroids. The masking effect o f previous corticoid therapy for transplantation should be pointed out. In 2 cases serial monitoring of plasma calcitriol showed a relation between de creasing high normal calcitriol with prednisone and normalization of calcem ia, suggesting the role of inappropriate synthesis of calcitriol by the gra nuloma. In conclusion, liver granulomatosis should be looked for in dialysi s patients on the association of unexplained hypercalcemia and normal PTH w ith anicteric cholestasis, and confirmed by a liver biopsy. Although still of unknown etiology, its evolution is favourable under corticotherapy.