HYPOCALCEMIA

Cholatip Pongskul
28 Feb 2015

Free (ionized)
40%

Bound to anion

Total calcium
8.5 10.5 mg/dl

Bound to
albumin
45%

Total Ca decrease 0.8 mg/dL for every 1 g/dL reduction in SAlb

1,000 mg

500 mg

ECF
1000 mg
9,800 mg

10,000 mg

800,000 mg
(99%)

800 mg

200 mg

The regulation of calcium and phosphate homeostasis

by PTH, vitamin D and FGF23

DEFINITION
Normal Serum calcium: 8.5
mg/dl 10.5 mg/dl
A decrease in the calcium
levels below 8.5mg/dl is
termed hypocalcemia

Etiologies of hypocalcemia
Decreased PTH action or effect
Defect in vitamin D metabolism
Shift of calcium out of ECF

Decreased PTH action of effect

1.Parathyroid agenesis
a)Isolated
b)DiGeorge Syndrome
2.Parathyroid destruction
a)Surgical
b)Radiation
c)Infiltration by metastases or systemic
diseases
d)Autoimmune
3.Reduced Parathyroid function
a)Hypomagnesemia
b)Activating CaSR mutations
4.PTH resistance - Pseudohypoparathyroidism

Chronic hypomagnesaemia

Intracellular magnesium deficiency

Interferes with secretion and peripheral response

Mechanism: Effects on adenylate cyclase p

Defects in vitamin D metabolism

1.Nutritional
2.Malabsorption
3.Drugs
a)Inhibitors of bone resorption
(bisphosphonate, calcitonin)
b)Cinacalcet
c)Calcium chelators (EDTA, citrate)
d)Foscarnrt (due to intravascular complexing
with calcium)
e)Phenytoin (due to conversion of Vit D to
inactive metabolites)

Shift of calcium of out ECF

1.Hyperphosphatemia
2.Tumor lysis
3.Acute pancreatitis
4.Osteoblastic metastasis
5.Acute respiratory alkalosis
6.Sepsis or severe illness

PATHOPHYSIOLOGY
Decrease in extracellular Ca2*+

The membrane potential on the outside becomes less

Less amount of depolarisation is required to initiate actio

Increased excitability of muscle and nerve tissue

Clinical evaluation
Family history of hypocalcemia:
genetic
Chronic hypocalcemia: mutation of
CsR, pseudohypoparathyroidism
Post ablative
Autoimmune
Other clinical features

Clinical features
Onset
1.Acute hypocalcemia
i. Critically ill patients
ii. Drugs: Citrates, ACEIs

2.Transient hypocalcemia
Sepsis, Burns, Acute renal failure,
transfusions
ii. Drugs: Protamine, Heparin, Glucagon
i.

3.Chronic hypocalcemia

True
hypocalcemia
Serum
magnesium
Normal

Low
Determine cause
Replace Mg

Serum
phosphorus
High

Low

PTH

Calcidiol,
calcitriol

High
Tumor lysis
Pseudohypoparathyroidism
Renal failure

Low-nutritional
Low
Malabsorption
drugs
Hypoparathyroidism

High-type II vit D
dependent ricket

Treatment approach
Severity
Symptoms (paresthesia, carpopedal
spasm, tetany, seizure)
Sighs (Chovsteks, bradycardia, impaired
cardiac contractility, prolong QT)

Absolute level of calcium

Rate of decrease

IV calcium
Acutely symptomatic
Asymptomatic with acute decrease <
7.5 mg/dl
May develop serious complication if
untreated
Not as initial for asymptomatic renal
failure with hypophosphatemia

10% calcium gluconate

90 mg of elemental calcium per 10 ml.
Dilute with NSS or DW
10-20 ml. in 50 ml 5DW over 10 20
min., more rapidly cause cardiac arrest
Infusion 0.5-1.5 mg/kg/hr.
Avoid bicarbonate, phosphate solution
Maintain calcium at low normal

Oral calcium
Mild degree of acute hypocalcemia
(7.5-8 mg/dl)
Chronic hypocalcemia
1500-2000 mg of elemental calcium
Vit D supplement for vit D deficiency
or hypoparathyroidism

Concurrent
hypomagnesemia
Treatment if Mg < 1 mg/dl
10% MgSO4 iv 10-20 min.
Oral Mg 300-400 mg/day in
concurrent loss

Hypoparathyroidism
Treatment goal: relieve symptoms and
maintain Ca in low normal (8-8.5 mg/dl)
High Ca level
Hypercalciuria
Renal stone

Urinary Ca should be < 300 mg/d

Thiazide can reduce hypecalciuria
Calcitriol should be given

TREATMENT (ACQUIRED
AND HEREDITARY
HYPOPARATHYROIDISM)

1. Vitamin D [40,000-120,000 U/d]

or 1,25(OH)2*D3*(calcitriol) [0.51microgm/day] ?
2. High oral calcium intake.
3. Thiazide diuretics?
(Hydrochlorothizide 12.5-50mg)

VITAMIN D DEFICIENCY
Inadequate diet and/or exposure to
sunlight
Investigations may show: vitamin D
metabolites, calcium, PTH,
phosphate
Hypocalcaemia itself causes steatorrhoea
Treatment: Various metabolites can be
given depending on the disorder

Key points
Management of hypocalcemia
depends on severity and cause
IV calcium in acute symptomatic
Calcitriol is most potent vit D
Calcium level should maintain at
lower limit in hypoparathyroidism