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DISORDERS OF CALCIUM
  METABOLISM


Dr Shamim Akram
10
13
ETIOLOGIES OF HYPERCALCEMIA

Increased GI Absorption                                  Decreased Bone
         Milk-alkali syndrome                            Mineralization
         Elevated calcitriol
                    Vitamin D excess                             Elevated PTH
                              Excessive dietary intake           Aluminum toxicity
                              Granuomatous diseases
                    Elevated PTH
                    Hypophosphatemia                     Decreased Urinary Excretion

Increased Loss From Bone                                         Thiazide diuretics
         Increased net bone resorption                           Elevated calcitriol
                  Elevated PTH
                            Hyperparathyroidism                  Elevated PTH
                  Malignancy
                            Osteolytic metastases

         Increased bone turnover
                  Paget’s disease of bone
                  Hyperthyroidism
15



                         CAUSES
           Approx. 80% of all cases are caused by
          Malignancy or Primary Hyperpathyroidism

•   V   Vitamins                    T   Thiazide,
•   I   Immobilization                   other drugs - Lithium
•   T   Thyrotoxicosis              R   Rabdomyolysis
•   A   Addison’s disease           A   AIDS
•   M   Milk-alkali syndrome        P   Paget’s disease,
•   I   Inflammatory disorders           Parental nutrition,
                                         Pheochromocytoma,
•   N   Neoplastic related               Parathyroid disease
        disease
• S     Sarcoidosis
17
SIGNS AND SYMPTOMS
 Bones, stones, abdominal groans, and
 psychic moans.
 • Malaise, fatigue, headaches, diffuse
   aches and pains, constipation.
 • Patients are often dehydrated
 • Lethargy and psychosis when
   hypercalcemia is severe.
 • Calcifications in
   skin, cornea, conjunctiva, and kidneys.

                                             18
CLINICAL
1.   Renal ; , stone, nephrocalcinosis
2.   GI ;, Constipation, PU, Pancratitis
3.   Neuro ; Weakness, Drowsiness, Apnea
4.   Cardio ; Short QT <0.3 ,Broad T, Heart
     Block, Vent arrhythmia,Asystole, Sense
     to digoxin
5.    Musculo ; Cramp, Bone
     pain, Pathologic Fx
6.   Others ; Band Keratopathy

                                          19
20
DIAGNOSIS
 Detailed history and physical examination…
 PTH level
 Vitamin D level
 Serum calcium levels
 Urine evaluation
 Ultrasound
 X-RAYS,MRI,CT scan
 PET(Positron Emission Tomography
MANAGEMENT HYPERCALCEMIA
   General
     Hydration  2-4L/day Keep urine output > 1-2
      ml/kg/hr onset 12-24 hr
     Lasix 10-20 mg iv. q 6-12 hr * only after
      adequate hydration *
     Mobilization
     Dialysis




                                                    22
MANAGEMENT HYPERCALCEMIA

   Specific
     Calcitonin

     Bishosphonates

     Galliumnitrite
     Plicamycin, Mithramycin

     Hydrocortisone




                                   23
ETIOLOGIES OF HYPOCALCEMIA
Decreased GI Absorption
  Poor dietary intake of calcium
  Impaired absorption of calcium
          Vitamin D deficiency
                                                   Increased Urinary Excretion
                Poor dietary intake of vitamin D
                Malabsorption syndromes               Low PTH
          Decreased conversion of vit. D to                 thyroidectomy
  calcitriol
                Liver failure                               I131 treatment
                Renal failure                               Autoimmune hypoparathyroidism
                Low PTH
                                                      PTH resistance
                Hyperphosphatemia
                                                      Vitamin D deficiency / low calcitriol
Decreased Bone Resorption/Increased
  Mineralization
  Low PTH
  PTH resistance pseudohypoparathyroidism)
  Vitamin D deficiency / low calcitriol
  Hungry bones syndrome
  Osteoblastic metastases
SYMPTOMS AND SIGNS OF HYPOCALCEMIA

 Neuromuscular irritability
 Paresthesias

 Laryngospasm / Bronchospasm

 Tetany

 Seizures

 Chvostek sign

 Trousseau sign

 Prolonged QTc time on ECG
Trousseau sign:
    (very uncomfortable and painful)


   A blood pressure cuff is
    inflated to a pressure
    above the patients
    systolic level.
   Pressure is continued for
    several minutes.
   Carpopedal spasm:
    * flexion at the wrist
    * flexion at the MP joints
    * extension of the IP joints
    * adduction
    thumbs/fingers
   Long QT interval with
    normal T waves
   Prolongation of the ST
    segment with little shift
    from the baseline
TREATMENT HYPOCALCEMIA

    Symptomatic hypocalcemia needs IV calcium and
     continuous monitoring for arrhythmias.
    Once serum Ca is in safe range ( >7 mg/dl) IV Ca
     can be stopped, and oral Ca started.
    Oral Ca and vit D are initiated as soon as possible
     when patient is tolerating oral feed.
    Active form of vit D is preferred in treatment of
     HPH and hyperphosphatemia because both
     impair activation of 25 OH vit D by one alpha
     hydroxylase.
    Diet, no specific diet is required but adequate Ca
     and vit D intake is recommended.
Thank   you

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Calcium Metabolism

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  • 2. DISORDERS OF CALCIUM METABOLISM Dr Shamim Akram
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  • 14. ETIOLOGIES OF HYPERCALCEMIA Increased GI Absorption Decreased Bone Milk-alkali syndrome Mineralization Elevated calcitriol Vitamin D excess Elevated PTH Excessive dietary intake Aluminum toxicity Granuomatous diseases Elevated PTH Hypophosphatemia Decreased Urinary Excretion Increased Loss From Bone Thiazide diuretics Increased net bone resorption Elevated calcitriol Elevated PTH Hyperparathyroidism Elevated PTH Malignancy Osteolytic metastases Increased bone turnover Paget’s disease of bone Hyperthyroidism
  • 15. 15 CAUSES Approx. 80% of all cases are caused by Malignancy or Primary Hyperpathyroidism • V Vitamins  T Thiazide, • I Immobilization other drugs - Lithium • T Thyrotoxicosis  R Rabdomyolysis • A Addison’s disease  A AIDS • M Milk-alkali syndrome  P Paget’s disease, • I Inflammatory disorders Parental nutrition, Pheochromocytoma, • N Neoplastic related Parathyroid disease disease • S Sarcoidosis
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  • 18. SIGNS AND SYMPTOMS  Bones, stones, abdominal groans, and psychic moans. • Malaise, fatigue, headaches, diffuse aches and pains, constipation. • Patients are often dehydrated • Lethargy and psychosis when hypercalcemia is severe. • Calcifications in skin, cornea, conjunctiva, and kidneys. 18
  • 19. CLINICAL 1. Renal ; , stone, nephrocalcinosis 2. GI ;, Constipation, PU, Pancratitis 3. Neuro ; Weakness, Drowsiness, Apnea 4. Cardio ; Short QT <0.3 ,Broad T, Heart Block, Vent arrhythmia,Asystole, Sense to digoxin 5. Musculo ; Cramp, Bone pain, Pathologic Fx 6. Others ; Band Keratopathy 19
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  • 21. DIAGNOSIS  Detailed history and physical examination…  PTH level  Vitamin D level  Serum calcium levels  Urine evaluation  Ultrasound  X-RAYS,MRI,CT scan  PET(Positron Emission Tomography
  • 22. MANAGEMENT HYPERCALCEMIA  General  Hydration 2-4L/day Keep urine output > 1-2 ml/kg/hr onset 12-24 hr  Lasix 10-20 mg iv. q 6-12 hr * only after adequate hydration *  Mobilization  Dialysis 22
  • 23. MANAGEMENT HYPERCALCEMIA  Specific  Calcitonin  Bishosphonates  Galliumnitrite  Plicamycin, Mithramycin  Hydrocortisone 23
  • 24. ETIOLOGIES OF HYPOCALCEMIA Decreased GI Absorption Poor dietary intake of calcium Impaired absorption of calcium Vitamin D deficiency Increased Urinary Excretion Poor dietary intake of vitamin D Malabsorption syndromes Low PTH Decreased conversion of vit. D to thyroidectomy calcitriol Liver failure I131 treatment Renal failure Autoimmune hypoparathyroidism Low PTH PTH resistance Hyperphosphatemia Vitamin D deficiency / low calcitriol Decreased Bone Resorption/Increased Mineralization Low PTH PTH resistance pseudohypoparathyroidism) Vitamin D deficiency / low calcitriol Hungry bones syndrome Osteoblastic metastases
  • 25. SYMPTOMS AND SIGNS OF HYPOCALCEMIA  Neuromuscular irritability  Paresthesias  Laryngospasm / Bronchospasm  Tetany  Seizures  Chvostek sign  Trousseau sign  Prolonged QTc time on ECG
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  • 28. Trousseau sign: (very uncomfortable and painful)  A blood pressure cuff is inflated to a pressure above the patients systolic level.  Pressure is continued for several minutes.  Carpopedal spasm: * flexion at the wrist * flexion at the MP joints * extension of the IP joints * adduction thumbs/fingers
  • 29. Long QT interval with normal T waves  Prolongation of the ST segment with little shift from the baseline
  • 30. TREATMENT HYPOCALCEMIA  Symptomatic hypocalcemia needs IV calcium and continuous monitoring for arrhythmias.  Once serum Ca is in safe range ( >7 mg/dl) IV Ca can be stopped, and oral Ca started.  Oral Ca and vit D are initiated as soon as possible when patient is tolerating oral feed.  Active form of vit D is preferred in treatment of HPH and hyperphosphatemia because both impair activation of 25 OH vit D by one alpha hydroxylase.  Diet, no specific diet is required but adequate Ca and vit D intake is recommended.
  • 31. Thank you