HYPOCALCEMIA

HYPOCALCEMIHYPOCALCEMIAA

Jeffri Indra Setiawan, MDJeffri Indra Setiawan, MD

NILAI NORMAL NILAI NORMAL CALCIUMCALCIUM

Calcium, plasma: 4.5 - 5.5 meq/L ; Calcium, plasma: 4.5 - 5.5 meq/L ;

9 - 10.5 mg/dL (2.2 - 2.6 mmol/L 9 - 10.5 mg/dL (2.2 - 2.6 mmol/L ))

REGULATION OF THE SERUM REGULATION OF THE SERUM CALCIUMCALCIUM (Figure 5.1)(Figure 5.1)

Vitamin D Liver 25 OHD Kidney 1,25 diOHD

PTH

Serum calcium Bone resorption

Renal tubular Calcium reabsorption

Gut Calcium reabsorption

CAUSES OF CAUSES OF HYPOCALCEMIAHYPOCALCEMIA

HypoalbuminemiaHypoalbuminemiaDisturbance in parathroid systemDisturbance in parathroid system

HypoparathyroidismHypoparathyroidismSurgicalSurgicalInfiltrativeInfiltrativeIdiopathicIdiopathic

PseudohypoparathyroidismPseudohypoparathyroidismHypomagnesiaHypomagnesiaDisturbances in vitamin D systemDisturbances in vitamin D system

Lanjutan …Lanjutan …

Decreased intake-nutritionalDecreased intake-nutritionalDecreased absorption-malabsorptionDecreased absorption-malabsorptionDecreased production of 25(OH)D-Decreased production of 25(OH)D-liver deseaseliver deseaseIncreased metabolism of 25(OH)DIncreased metabolism of 25(OH)D

PhenobarbitalPhenobarbitalPhenytoinPhenytoinAlcoholAlcoholGlutethimideGlutethimide

Lanjutan …Lanjutan …Accelerated loss of 25(OH)DAccelerated loss of 25(OH)D

Nephrotic syndromeNephrotic syndrome

Disturbances of enterohepatic Disturbances of enterohepatic circulationcirculation

Decreased production of 1,25(OH)2DDecreased production of 1,25(OH)2D

HereditaryHereditary

Renal deseaseRenal desease


Removal of calcium from serumRemoval of calcium from serumHyperphosphatemiaHyperphosphatemia

LaxativesLaxativesPhosphate enemasPhosphate enemasCytotoxic treatment of leukimias Cytotoxic treatment of leukimias

and lymphomasand lymphomasRhabdomyolysis Rhabdomyolysis

Osteoblastic metastases Osteoblastic metastases Acute pancreatitisAcute pancreatitis

Sign & symtompsSign & symtomps1.Psychiatric1.Psychiatric2.Neuromuscular2.Neuromuscular

a. Tetanya. Tetanyb. seizuresb. seizuresc. Intellectual impairmentc. Intellectual impairmentd. Extrapyramidal disordersd. Extrapyramidal disorderse. Myopathye. Myopathy

3.Ectodermal3.Ectodermal4.Ocular cataracts4.Ocular cataracts5.Dental5.Dental6.Cardiovascular6.Cardiovascular

Diagnostic evaluation of the Diagnostic evaluation of the patient with hypocalcemiapatient with hypocalcemia

Fig.5.3Fig.5.3 Measure serum albumin levelMeasure serum albumin level

Hypoalbuminemia Hypoalbuminemia HypoalbuminemiaHypoalbuminemiaaccounts for hypocalcemia accounts for hypocalcemia for hypocalcemiafor hypocalcemia

Measure magnesium levelMeasure magnesium level

HypomagnesemiaHypomagnesemia Magnesium level normalMagnesium level normal<0,8 mEq/L<0,8 mEq/L

Evaluate serum phosphate and Evaluate serum phosphate and draw PTH leveldraw PTH level

Elevated PTH Elevated PTH Low PTH and high PO4 Low PTH and high PO4

Low serum PO4 Low serum PO4 Normal or high PO4 Normal or high PO4 Hypoparathyroid Hypoparathyroid

Vitamin D deficiency Vitamin D deficiency Pseudohypoparathyroidism Pseudohypoparathyroidism

Confirm with clinical picture,Confirm with clinical picture, measurement of vitamin D metabolites,measurement of vitamin D metabolites, and/or response to PTH infusionand/or response to PTH infusion

Diagnostic evaluation of the Diagnostic evaluation of the patient with hypocalcemiapatient with hypocalcemia

Fig.5.3Fig.5.3

Measure serum albumin levelMeasure serum albumin level

Hypoalbuminemia Hypoalbuminemia HypoalbuminemiaHypoalbuminemiaaccounts for hypocalcemia accounts for hypocalcemia for hypocalcemiafor hypocalcemia

Measure magnesium Measure magnesium levellevel

HypomagnesemiaHypomagnesemia Magnesium level Magnesium level normalnormal

<0,8 mEq/L<0,8 mEq/LEvaluate serum phosphate Evaluate serum phosphate

andanddraw PTH leveldraw PTH level

Lanjutan …Lanjutan …Evaluate serum phosphate and Evaluate serum phosphate and draw PTH leveldraw PTH level

Elevated PTHElevated PTH Low PTH and high PO4 Low PTH and high PO4

Low serum POLow serum PO44 Normal or high PO Normal or high PO44 Hypoparathyroid Hypoparathyroid

Vitamin D deficiency Vitamin D deficiency Pseudohypoparathyroidism Pseudohypoparathyroidism

Confirm with clinical picture,Confirm with clinical picture, measurement of vitamin D metabolites,measurement of vitamin D metabolites, and/or response to PTH infusionand/or response to PTH infusion

Therapeutic Approach Therapeutic Approach 1.Acute hypocalcemia1.Acute hypocalcemia

Calcium Gluconate 10gr 20-30 ml 1xCalcium Gluconate 10gr 20-30 ml 1x(Per 10 ml(Per 10 ml90 mg kalsium)90 mg kalsium)

2.Chronic hypocalcemia 2.Chronic hypocalcemia Increasing Intestinal Absorption of Increasing Intestinal Absorption of CalciumCalcium- Vitamin D Therapy- Vitamin D Therapy- Increasing Calcium Intake- Increasing Calcium Intake

(calcium Lactate tablet)(calcium Lactate tablet)3. Tx underlying Desase3. Tx underlying Desase

HYPERCALCEMIAHYPERCALCEMIA

Causes of Hypercalcemia Causes of Hypercalcemia HyperparathyroidismHyperparathyroidism

AdenomaAdenoma

HyperplasiaHyperplasia

Multiple endocrine neoplasia Multiple endocrine neoplasia syndromesyndrome

FamilialFamilial


Malignancy asociatedMalignancy asociated

Metastatic resorption of boneMetastatic resorption of bone

Secretion of PTH-like substanceSecretion of PTH-like substance

Osteoclast activation factorOsteoclast activation factor

ProstaglandinsProstaglandins

Hormonal therapy of breast cancerHormonal therapy of breast cancer

Lanjutan …Lanjutan …Granulomatosus disordersGranulomatosus disorders

SarcoidosisSarcoidosis

BeryliosisBeryliosis

TuberculosisTuberculosis

HistoplasmosisHistoplasmosis

CoccidioidomycosisCoccidioidomycosis

Paget’s diseasePaget’s disease

Addison’s diseaseAddison’s disease

ThyrotoxicosisThyrotoxicosis


Vitamin D intoxicationVitamin D intoxicationMilk-alkali syndromeMilk-alkali syndromeImmobilization Immobilization ThiazidesThiazidesRecovery from acute renal failureRecovery from acute renal failurePostrenal transplantPostrenal transplant

Sign & SymtompsSign & Symtomps1.Sign & symtomps associated 1.Sign & symtomps associated

with hypercalcemia include ;with hypercalcemia include ; AnorexiaAnorexia Nausea & VomitingNausea & Vomiting ConstipationConstipation Polyuria, nocturia, and Polyuria, nocturia, and

polydipsiapolydipsia HypertensionHypertension


Confusion, stupor, and comaConfusion, stupor, and coma Acute and chronic renal Acute and chronic renal

insufficiencyinsufficiency NephrolithiasisNephrolithiasis Metastatic calcificationMetastatic calcification Peptic ulcer disease, pancreatitisPeptic ulcer disease, pancreatitis Electrocsrdiogrsphic changesElectrocsrdiogrsphic changes

2. 2. Signs & symptoms associated with Signs & symptoms associated with underlying disease processes underlying disease processes includeinclude

a.Hyperparathyroidism; anemia, a.Hyperparathyroidism; anemia, myopathy, hyperchloremic acidosis, myopathy, hyperchloremic acidosis, hypophosphatemia, bone disease, hypophosphatemia, bone disease, pseudogoutpseudogout

b.Sarcoides; disturbances on chest x-b.Sarcoides; disturbances on chest x-rays, lymphadenopathyrays, lymphadenopathy

c.Systemic manifestation of c.Systemic manifestation of malignancy malignancy

d.Thyrotoxicosis d.Thyrotoxicosis

Diagnostic evaluation of the Diagnostic evaluation of the

patient with hypercalcemiapatient with hypercalcemia Fig.5.2Fig.5.2

Hypercalcemia Hypercalcemia

Do : PTH level

Low or undetectable PTH Elevated PTHDo : History : Vitamin D intoxication Do : Chest x-ray Milk-alkali syndrome IVP

Urinalysis Abdominal flat plateChest x-ray :

Sarcoidosis,

malignancy

IVP : Malignancy

T3/T4 : Thyrotoxicosis

Bone surveyAnd Metastatic malignancyalkaline Paget’s diseasephosphatase

Negative Positive for malignancy

in presense of GI symptoms Do: Upper GI/Lower GI

Negative Positive for malignancy

Surgery for

hyperparathyroidism

Negative

Venous localization

Diagnostic evaluation of the Diagnostic evaluation of the patient with hypercalcemiapatient with hypercalcemia

Fig.5.2Fig.5.2

Hypercalcemia Hypercalcemia Do : PTH LevelDo : PTH Level

Low or undetectable PTHLow or undetectable PTH Elevated PTHElevated PTHDoDo/History : Vit D Intoxication/History : Vit D Intoxication DoDo/Chest x-ray/Chest x-ray

Milk-Alkali syndromeMilk-Alkali syndrome IVPIVPUrinalysisUrinalysisAbdomonal flat plateAbdomonal flat plate

Chest X-ray:Chest X-ray: Sarcoidosis,Sarcoidosis, MalignancyMalignancy Negative Negative Positif for Positif for

malignancymalignancyIVP : MalignancyIVP : Malignancy

in Presense ofin Presense ofT3/T4 : ThyrotoxicosisT3/T4 : Thyrotoxicosis GI symptomsGI symptoms

Do/Upper GI/lower GIDo/Upper GI/lower GI

Lanjutan …Lanjutan …Negative Negative Positive forPositive for

malignancymalignancyin Presense ofin Presense ofGI symptomsGI symptomsDo/Upper GI/lower GIDo/Upper GI/lower GI

Bone surveyBone survey Negative Negative Positive forPositive forAndAnd Metastatic malignancyMetastatic malignancy malignancymalignancyalkalinealkaline Paget’s diseasePaget’s diseasephosphatasephosphatase

Surgery forSurgery forHyperparathyroidismHyperparathyroidism

NegativeNegative

Venous LocalizationVenous Localization

Therapeutic Approach Therapeutic Approach 1. Acute hypercalcemia1. Acute hypercalcemia

- Begin with volume Expansion- Begin with volume ExpansionSaline and Furosemide :Saline and Furosemide :- initial priming saline infusion of 1 - initial priming saline infusion of 1 to 2 liters over 1 hour should be to 2 liters over 1 hour should be given. Diuretics are then begun as given. Diuretics are then begun as follows :follows :a. Begin with a priming dose of 1 to a. Begin with a priming dose of 1 to 2 liters saline IV over 1 hour2 liters saline IV over 1 hourb. Give furosemide 40 to 80 mg IV b. Give furosemide 40 to 80 mg IV and repeat every 2 to 3 hoursand repeat every 2 to 3 hours


c. Measure urine volume every hour c. Measure urine volume every hour and urine sodium-potassium and urine sodium-potassium concentration every 4 to 6 hours concentration every 4 to 6 hours

d. Replace urine volume with saline d. Replace urine volume with saline and added potassium chlorideand added potassium chloride

e. If hypercalcemia is prolonged, add e. If hypercalcemia is prolonged, add magnesium (15 mg per hour)magnesium (15 mg per hour)

Lanjutan …Lanjutan …2. 2. Chronic hypercalcemia Chronic hypercalcemia

a. Steroidesa. Steroides1. Sarcoidosis1. Sarcoidosis2. Multiple myeloma2. Multiple myeloma3. Breast cancer (50%)3. Breast cancer (50%)4. Vitamin D intoxication4. Vitamin D intoxication

b. Oral phosphateb. Oral phosphate1. Hyperparathyroidism (nonsurgical 1. Hyperparathyroidism (nonsurgical

candidates)candidates)2. Most malignancies2. Most malignancies

c. Mithramycin : If oral phosphate is c. Mithramycin : If oral phosphate is ineffective or ineffective or

serum phosphate is elevatedserum phosphate is elevated3. Tx Underlying Desease3. Tx Underlying Desease

THANK YOUTHANK YOU

HYPOCALCEMIA

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