Renal Sarcoidosis with Hypercalcemia: What to Do When Prednisone Has Not Normalised Calcium

Clinical scenario

This protocol applies to patients with renal sarcoidosis presenting with hypercalciuria or mild hypercalcemia (serum calcium 11 mg/dl or less), without nephrolithiasis.

Previous line — target not reached

Initial corticosteroid therapy with Prednisone was the standard first approach for this degree of calcium elevation. When that treatment does not achieve normalisation of serum and urine calcium levels, a further step is warranted — and that is what this protocol addresses.

Next-line approach (partial)

After corticosteroid failure, the protocol moves to a cytotoxic agent. More than one option exists within this class — the specific agent, how it is selected, and all associated guidance remain in the full structured regimen.

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References

In isolated hypercalciuria, treatment may begin with a reduction in calcium intake, increased fluids and avoidance of sun.
Mild hypercalcemia may also be treated with a reduction in dietary calcium and increased fluid intake.
For more significant hypercalcemia (e.g. Ca >11 mg/dl) or nephrolithiasis, corticosteroid therapy is usually implemented at 20-40 mg daily.
Cytotoxic drugs include: methotrexate, azathioprine, mycophenolate and leflunomide.

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