HYPOCALCEMI

A
Jeffri Indra Setiawan, MD

NILAI NORMAL
CALCIUM

Calcium, plasma: 4.5 - 5.5 meq/L ;

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

REGULATION OF THE SERUM

CALCIUM
(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
HYPOCALCEMIA

Hypoalbuminemia
Disturbance in parathroid system
Hypoparathyroidism
Surgical
Infiltrative
Idiopathic
Pseudohypoparathyroidism
Hypomagnesia
Disturbances in vitamin D system

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Decreased intake-nutritional
Decreased absorption-malabsorption
Decreased production of 25(OH)D-liver
desease
Increased metabolism of 25(OH)D
Phenobarbital
Phenytoin
Alcohol
Glutethimide

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Accelerated loss of 25(OH)D
Nephrotic syndrome
Disturbances of enterohepatic
circulation
Decreased production of 1,25(OH)2D
Hereditary
Renal desease

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Removal of calcium from serum
Hyperphosphatemia
Laxatives
Phosphate enemas
Cytotoxic treatment of leukimias
and lymphomas
Rhabdomyolysis
Osteoblastic metastases
Acute pancreatitis

Sign & symtomps

1.Psychiatric
2.Neuromuscular
a. Tetany
b. seizures
c. Intellectual impairment
d. Extrapyramidal disorders
e. Myopathy
3.Ectodermal
4.Ocular cataracts
5.Dental
6.Cardiovascular

Diagnostic evaluation of the

patient with hypocalcemia

Fig.5.3
Measure serum albumin level

Hypoalbuminemia
accounts for hypocalcemia

Hypoalbuminemia
for hypocalcemia
Measure magnesium level

Hypomagnesemia
<0,8 mEq/L

Magnesium level normal

Evaluate serum phosphate and
draw PTH level

Elevated PTH
Low serum PO4
Vitamin D deficiency

Normal or high PO4

Pseudohypoparathyroidism

Confirm with clinical picture,

measurement of vitamin D metabolites,
and/or response to PTH infusion

Low PTH and high PO4

Hypoparathyroid

Diagnostic evaluation of the

patient with hypocalcemia

Fig.5.3

Measure serum albumin level

Hypoalbuminemia
Hypoalbuminemia
accounts for hypocalcemia for hypocalcemia
Measure magnesium level
Hypomagnesemia
Magnesium level normal
<0,8 mEq/L
Evaluate serum phosphate and
draw PTH level

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Evaluate serum phosphate and
draw PTH level
Elevated PTH

Low PTH and high PO4

Low serum PO4 Normal or high PO4

Hypoparathyroid
Vitamin D deficiency
Pseudohypoparathyroidism
Confirm with clinical picture,
measurement of vitamin D metabolites,
and/or response to PTH infusion

Therapeutic Approach

1.Acute hypocalcemia
Calcium Gluconate 10gr 20-30 ml 1x
(Per 10 ml90 mg kalsium)
2.Chronic hypocalcemia
Increasing Intestinal Absorption of
Calcium
- Vitamin D Therapy
- Increasing Calcium Intake
(calcium Lactate tablet)
3. Tx underlying Desase

HYPERCALCEMIA

Causes of Hypercalcemia
Hyperparathyroidism
Adenoma
Hyperplasia
Multiple endocrine neoplasia
syndrome
Familial

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Malignancy asociated
Metastatic resorption of bone
Secretion of PTH-like substance
Osteoclast activation factor
Prostaglandins
Hormonal therapy of breast cancer

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Granulomatosus disorders
Sarcoidosis
Beryliosis
Tuberculosis
Histoplasmosis
Coccidioidomycosis
Pagets disease
Addisons disease
Thyrotoxicosis

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Vitamin D intoxication
Milk-alkali syndrome
Immobilization
Thiazides
Recovery from acute renal failure
Postrenal transplant

Sign & Symtomps

1.Sign & symtomps associated
with hypercalcemia include ;
Anorexia
Nausea & Vomiting
Constipation
Polyuria, nocturia, and
polydipsia
Hypertension

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Confusion,

stupor, and coma

Acute and chronic renal
insufficiency
Nephrolithiasis
Metastatic calcification
Peptic ulcer disease, pancreatitis
Electrocsrdiogrsphic changes

2. Signs & symptoms associated with

underlying disease processes include

a.Hyperparathyroidism; anemia,
myopathy, hyperchloremic acidosis,
hypophosphatemia, bone disease,
pseudogout
b.Sarcoides; disturbances on chest xrays, lymphadenopathy
c.Systemic manifestation of
malignancy
d.Thyrotoxicosis

Diagnostic evaluation of the

patient with hypercalcemia

Fig.5.2

Hypercalcemia
Do : PTH level
Low or undetectable PTH
Do : History : Vitamin D intoxication
Chest x-ray
Milk-alkali syndrome

Elevated PTH
Do :
IVP
Urinalysis
Abdominal flat plate

Chest x-ray :
Sarcoidosis,
malignancy

Negative

IVP : Malignancy
T3/T4 : Thyrotoxicosis
Bone survey
And
alkaline
phosphatase

Metastatic malignancy
Pagets disease

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

patient with hypercalcemia

Fig.5.2

Hypercalcemia
Do : PTH Level

Low or undetectable PTH

Elevated PTH
Do/History : Vit D Intoxication Do/Chest x-ray
Milk-Alkali syndrome
IVP
Urinalysis
Abdomonal flat plate
Chest X-ray: Sarcoidosis,
Malignancy
Negative
Positif for
malignancy
IVP : Malignancy
in Presense of
T3/T4 : Thyrotoxicosis
GI symptoms
Do/Upper GI/lower GI

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Negative

Positive for
malignancy

in Presense of
GI symptoms
Do/Upper GI/lower GI

Bone survey
And
alkaline
phosphatase

Negative
Metastatic malignancy
Pagets disease

Surgery for
Hyperparathyroidism
Negative
Venous Localization

Positive for
malignancy

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

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c. Measure urine volume every hour
and urine sodium-potassium
concentration every 4 to 6 hours
d. Replace urine volume with saline
and added potassium chloride
e. If hypercalcemia is prolonged, add
magnesium (15 mg per hour)

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2. Chronic hypercalcemia

a. Steroides
1. Sarcoidosis
2. Multiple myeloma
3. Breast cancer (50%)
4. Vitamin D intoxication
b. Oral phosphate
1. Hyperparathyroidism (nonsurgical
candidates)
2. Most malignancies
c. Mithramycin : If oral phosphate is ineffective
or
serum phosphate is elevated
3. Tx Underlying Desease

THANK YOU