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1. HypoCalemia
Practical Approach
Mohammed Abdel Gawad
Nephrology Consultant - Alexandria - Egypt
MD Nephrology - Mansoura University - Egypt
European Specialty Examination in Nephrology (ESENeph)
NephroTube Founder/Admin
Member of ISN education SoMe team
Co-chair of AFRAN Web & Media Committee
drgawad@gmail.com
@Gawad_Nephro
NephroTube, 11-August-2021

2. To download the lecture contact me
drgawad@gmail.com
For more Nephrology lectures visit
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4. Calcium Homeostasis

5. • Although over 99% of the total body calcium is
located in bone, calcium is a critical cation in
both the extracellular and intracellular spaces.
Plasma (mmol/L) Interstitial fluid
(mmol/L)
Intracellular fluid
(mmol/L)
Na+ 142 144 10
K+ 4 4 160
Ca2+ 2.5 2.5 1.5
Mg2+ 1.0 0.5 13
Cl- 102 114 2
HCO3
- 26 30 8
PO4
2- 1.0 1.0 57
SO4
2- 0.5 0.5 10

6. ECF Calcium
• Extracellular fluid (ECF) calcium is moderately
bound to plasma proteins (46%), primarily
albumin.
• Unbound or ionized calcium is the
physiologically active form and is the fraction
that is homeostatically regulated.
Ca

7. ECF Calcium
• total serum calcium level = includes both
bound + unbound calcium.
• The normal total calcium serum concentration
range is 8.5 to 10.5 mg/dL.
Ca

8. ECF Calcium
Corrected Ca for Hypoalbuminemia

9. Increase
serum Ca
Increase
serum Pi
Increase Ca
reabsorption
PTH
Increase Pi
excretion
Decrease
serum Pi
M.Gawad. www.nephrotube.blogspot.com
So low serum Ca & high
serum Pi will stimulate
PTH release & vise verca
PTH Action:
increase serum Ca and
decrease serum Pi

10. Increase
serum Ca
Increase
serum Pi
Increase Ca
reabsorption
PTH
Increase Pi
excretion
Vit D
Calcidiol
25-OH-D
Calcitriol
1,25-(OH)2-D
α1 hydroxylase
Increase Ca
& Pi
reabsorption
Decrease
serum Pi
Active vit D
Action:
increase serum Ca & Pi
M.Gawad. www.nephrotube.blogspot.com

11. Calcium
Flux between body compartments

12. Kidney International Reports (2021) 6, 2049–2058

13. Calcitonin Hormone

14. Talk Outline
• Clinical presentation
• Diagnostic approach
• Treatment Stepwise approach

15. Talk Outline
• Clinical presentation
• Diagnostic approach
• Treatment Stepwise approach

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19. Talk Outline
• Clinical presentation
• Diagnostic approach
• Treatment Stepwise approach

20. Talk Outline
• Clinical presentation
• Diagnostic approach
• Treatment Stepwise approach

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22. Endocrine (2020) 69:485–495

24. Talk Outline
• Clinical presentation
• Diagnostic approach
• Treatment Stepwise approach

25. Talk Outline
• Clinical presentation
• Diagnostic approach
• Treatment Stepwise approach

26. © 2021 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

27. © 2021 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
• Initially, IV calcium: 1 or 2 g of calcium gluconate in 50 mL of D5W or NS can be infused over 10 to 20
minutes. May repeat after 10 to 60 minutes if needed to resolve symptoms.
• This should be followed by a slow infusion of calcium in patients with persistent hypocalcemia (eg,
hypoparathyroidism, pancreatitis):
 Preparation: An IV solution containing 1 mg/mL of elemental calcium is prepared by adding 11 g of
calcium gluconate (equivalent to 1000 mg elemental calcium) to normal saline or 5% dextrose water
to provide a final volume of 1000 mL.
 Infusion rate: This solution is administered at an initial infusion rate of 50 mL/hour (equivalent to 50
mg elemental/hour).

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• Ionized calcium remains the gold standard for assessing calcium status
• If the total calcium is measured, it should be corrected for any abnormalities
in serum albumin.

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• Initially, 1.5 to 2 g of elemental calcium daily, in
divided doses.
• In addition to calcium, patients with vitamin D
deficiency or hypoparathyroidism require vitamin D
supplementation.

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