2. TOPICS TO BE
COVERED
1. ROLE OF CALCIUM
2.HOMEOSTASIS OF
CALCIUM
3.HYPERCALCE
MIA a)CAUSES
b)CLINICAL
FEATURES
C)MANAGEMENT
4.HYPOCALCE
MIA a)CAUSES
b)CLINICAL FEATURES
3. Introduction
Calcium is one of the most abundant mineral in
the human body and it has many important
biological Functions
1-2kgs of Calcium is present normally in
human body out of which 99% is in the
skeleton
Remaining amount -distributed in the
ECF(0.25%) and other soft tissues(0.75%)
Concentration in ECF-1.1-1.3mmol/L
Concentration in ICF- 100nmol/L
4. Distribution of calcium outside skeletal
system
In Blood , total Ca concentration is normally 8.5-10.5
mg/dl, of which approx 50% is ionized(normal value-
4.8 mg/dl)
Remainder is bound ionically to negatively
charged proteins- Predominantly albumin and
immunoglobulins or lossely complexed with
PO4 , citrate ,SO4 and other anions.
Influenced by pH.
Metabolic acidosis decrease protein binding
increase ionized calcium.
Metabolic alkalosis increase protein
5.
6.
7.
8. As ionized form is the active form of
calcium, serum calcium levels should be
adjusted for abnormal serum albumin
levels
Corrected calcium
For every 1-g/dL drop in serum albumin
below 4 g/dL, measured serum calcium
decreases by 0.8 mg/dL.
Corrected calcium =
Measured Ca + [0.8 x (4 - measured
albumin)]
9. FUNCTIONS of Calcium
1. Muscle contraction
2. Neuromuscular / nerve
conduction
3. Intracellular signalling
4. Bone formation
5. Coagulation
6. Enzyme regulation
7. Maintainance of plasma
membrane stability
12. Hypercalcemia is defined as total serum
calcium
> 10.2 mg/dl or ionized serum calcium > 5.6
mg/dl
Severe hypercalemia is defined as total
serum
calcium > 14 mg/dl
Hypercalcemic crisis is present when
severe neurological symptoms or cardiac
arrhythmias are present in a patient with a
serum calcium > 14 mg/dl
13.
14. CAUSES FOR HYPERCALCEMIA
I.Parathyroid-related
-Primary hyperparathyroidism
-Lithium therapy
II.Malignancy-related
-Solid tumor with metastases (breast)
-Solid tumor with humoral mediation of hypercalcemia (lung, kidney)
Squamous cell Carcinoma Lung and Renal Cracinoma
-Hematologic malignancies (multiple myeloma, lymphoma, leukemia)
III.Vitamin D-related
-Vitamin D intoxication
- 1,25(OH)2D; sarcoidosis and other granulomatous diseases
IV.Associated with high bone turnover
-Hyperthyroidism
-Immobilization
-Thiazides
V.Associated with renal failure
-Severe secondary hyperparathyroidism
-Aluminum intoxication
15. MECHANISM OF
HYPERCALCEMIA IN
LUNG CANCERS
PRODUCTION OF HUMORAL FACTORS BY PRIMARY
TUMOR,COLLECTIVELY KNOWN AS HUMORAL
HYPERCALCEMIA OF MALIGNANCY(HHM) IN ALMOST 80 %
OF CASES
1)TUMOR PRODUCED PARATHYROID HORMONE RELATED
PROTEIN(PTHrp)
2)PRODUCTION OF 1,25 DIHYDROXYCALCITRIOL
THE REST 20% ARE DUE TO METASTASIS TO THE BONE
LEADING TO OSTEOLYSIS
19. DIAGNOSTIC
APPROACH
HISTORY AND PHYSICAL EXAMINATION
• NOTE:PATIENT WITH PRIMARY
HYPERTHYROIDISM ARE USUALLY
ASSYMTOMMATIC .
• IF HYPERCALCEMIA IS PRESENT FOR
MORE THAN 6 MONTHS PRIMARY
HYPERTHYROIDISM IS MOST CERTAIN.
• HYPERCALCEMIA WITH RENAL STONES
FAVOURS LONG DURATION AND IS UNLIKELY
DUE TO MALIGNANCY
• USE OF VITAMIN D ,CALCIUM
SUPPLEMENTATIONS AND LITHUIM SHOULD
21. NOTE
• As a general rule, primary
hyperparathyroidism is the etiology in
OPD patients who are assymptommatic
with Sr Ca Concentrations of <11.0
mg/dl
• On the other hand malignancy is often the
cause in symptommatic patients with
abrupt onset and serum calcium levels
higher than 14 mg/dl and survival is <6
months after detection of hypercalcemia.
22.
23.
24. TREATME
NT
• MEASURES TO INCREASE URINARY
EXCRETION
• MEASURE TO INHIBIT BONE
RESORPTION
• MEASURE TO DECREASE
INTESTINAL ABSORPTION
• SPECIFIC TREATMENT
25.
26. MEASURES TO INCREASE
URINARY
EXCRETION
1) Volume Restoration expansion and saline diuresis are most
useful and effective measures to correct hypercalcemia
0.9 % NaCl is infused to correct dehydration for volume
expansion and diuresis.(almost 4-6 litres is required to cause
flushing of calcium)hence always use cautiously in HEART
FAILURE AND ELDERLY patients to avoid pulmonary oedema
2)FURUSEMIDE – Additive effect with 0.9 NS as it leads to forced
Diuresis.
3)HAEMODIALYSIS- Reserved for treatment of patients with
severe hypercalcemia and in CRF
27. MEASURE TO INHIBIT
BONE
RESORPTION
1)BISPHOSPHONATES- PAMIDRONATE is the most
potent and most widely used bisphosphonate
DOSAGE-60-90 mg IV over 4 hours
2)PLICAMYCIN-Rarely used owing to high toxicity
3)CALCITONIN
MOA-Inhibits bone resorption and increases urinary
excretion useful in acute crisis
DOSAGE-4IU/KG s.c 12hourly
35. TYPES OF HYPOCALCEMIA
1. CHRONIC HYPOCALCEMKIA-
CKD,VIT D DEFICIENCY
2. ACUTE HYPERCALCEMIA- SEEN
IN SEPSIS BURNS, ICU SETTINGS
WHERE CITRATED BLOOD HAS
BEEN GIVEN FREQUENTLY
3.TRANSIENT HYPOCALCEMIA-
AFTER PARATHYROID SURGERY
43. ACUTE
MANAGEME
NT
• Goals of Therapy
• Total Serum Ca 8.6-10.2 mg/dl (2.15-
2.55 mmol/L) or
• Ionized serum Ca > 4.5 mg/dl or >
1.12 mmol/L
• Manage underlying illness
44. Management
Mild to moderate : Oral
supplementation
IV Calcium
Intermittent iv boluses for severe symptomatic (total
serum ca < 7.5 mg/dl or ionzied Ca < 4 mg/dl
Symptomatic hypocalcemia is an emergency
Administer 1 g Calcium chloride or Ca
Gluconate(1000 mg of elemental
calcium/10ml) iv over 10 minutes
Refractory hypocalcemia: Continuous infusion of
elemental calcium
45. NOTE : AVOID RINGER LACTATE WHEN INFUSING CALCIUM
PREPARATIONS
50. TAKE HOME MESSAGE
1)Metabolic acidosis decrease protein binding
increase ionized calcium.
Metabolic alkalosis increase protein binding,decrease ionized
calcium.
2)Corrected calcium
For every 1-g/dL drop in serum albumin below 4
g/d L, measured serum calcium decreases by 0.8mg/dL.
3) ALWAYS RULE OUT MALIGNANCY WHEN PATIENT
PRESENTS WITH ACUTE HYPERCALCEMIA
4)GLUCOCORTICOIDS ARE USEFUL IN Mx OF
HYPERCALCEMIA
51. TAKE HOME MESSAGE
5) In Hypoalbuminemia the Total
calcium levels are reduced but
ionized calcium is normal
6)CHVOSTEK’S SIGN &TROSSEAU’S SIGN are
specific physical
signs of hypocalcemia
7) AVOID RINGER LACTATE WHEN INFUSING
CALCIUM PREPARATIONS