Milk-Alkali Syndrome 101

Below are some key points in diagnosing and managing milk-alkali-syndrome:

Triad of hypercalcemia, metabolic alkalosis, and acute kidney injury associated with the ingestion of large amounts of calcium and absorbable alkali.

  • Excessive amounts of calcium carbonate is considered 4-5 g daily
  • Originally described in association with the use of milk and sodium bicarbonate for the treatment of peptic ulcer disease
  • There may be a resurgence of this disorder due to increased calcium therapy for presenting/treating osteoporosis, more OTC calcium carbonate preparations, and use of calcium carbonate in patients with CKD to minimize secondary hyperparathyroidism
  • Among patients hospitalized with hypercalcemia, milk-alkali syndrome is the 3rd most common cause behind hyperparathyroidism and cancer
  • Pathogenesis remains uncertain as studies have shown that some patients given high amounts of alkali and calcium don’t develop milk-alkali syndrome
  • Although renal impairment is associated, it’s not a prerequisite to develop milk-alkali syndrome
  • Individual variations in the buffering capacity of bone may play role in the susceptibility to development of hypercalcemia
  • Patients at higher risk include
    • Older individuals
    • Those at risk for volume depletion (including patients on thiazide diuretics)
    • Medications that reduce GFR (ie ARB’s, ACE-I, NSAIDS)
  • Diagnosis is based upon the history of ingestion of calcium-rich medications and the exclusion of other causes of hypercalcemia
  • Treatment:
    • Stop offending agent
    • Treat with IV saline and furosemide
    • Hypocalcemia can occur transiently with rapid rise of PTH to supranormal levels which is unique to milk-alaki syndrome

(Medarov. Mayo Clin Proc. 2009 Mar; 84(3): 261–267.)