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Calcium,magnesium,phosphate and chloride imbalances


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Calcium,magnesium,phosphate and chloride imbalances
Their treatment,my main reference is Eric strong's lectures in youtube,and some of the websites.Hope everyone finding Serum electrolytes find atleast some use of it .
Thank you

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Calcium,magnesium,phosphate and chloride imbalances

  1. 1. Ca+2 Mg+2 PO4 -2 andCl-
  2. 2. • Most of the calcium in the body is stored in the bones as hydroxyapatite (Ca₁₀(PO₄)₆(OH)₂). • Calcium in the plasma : 45% free ionized form  45% bound to proteins (predominantly albumin)  10% complexed with anions (eg: citrate ,sulfate,phosphate) Normal serum Ca+29-11mg/dl. Physiologically active Typically measured in routine blood tests
  3. 3. In addition to its regulation by serum Ca+2,PTH is also regulated by serum acid –base status. ↓SERUM pH ↑PTH ↑urinary excretion of Phosphate ↑buffering of H+ions excreted in the distal tubule ↑serum pH
  4. 4. Hypercalcemia
  5. 5. PTH excess Hormone Independe nt Bone Resorption Vitamin D excess Excessive Dietary intake of Ca+2 Thiaz ides Rare Miscellaneous Mechanisms Hyperparathyroidi sm Osteolytic bone metastase s ↑intake of Vitamin D Milk-Alkali Syndrome (↑intake of CaCO3) Adrenal Crisis PTHrP –secreting malignancy Paget’s disease Ectopic Calcitriol Production Severe Rhabdo. Complicated by AKI Lithium Hyperthyr oidism Theophylline Toxicity Familial Hypocalciuric hypercalcemia Immobiliz ation
  6. 6. Clinical manifestations • Stones , bones,groans and psychiatric overtones (moans). • Other symptoms include : Constipation Anorexia Nausea Weakness lethargy There are no reliable physical findings of hypercalcemia.
  7. 7. • Short QT interval • Additional findings are: Dehydration Renal Insufficiency Nephrogenic Diabetes insipidus Type 1 Renal tubular acidosis
  8. 8. Diagnostic Evaluation • Step1: correct calcium for low albumin • Step2:Perform thorough Physical examination and obtain Chest X-ray. • Step3 : Measure PTH.
  9. 9. Elevated calcidiol Bone mets, rare causes Ectopic productio n of Calcitriol malignancy Excessive dietary intake of calcium or Vitamin D None of 3 are eleva ted PTHrP elevated Elevated calcitriol with normal calcidiol 10Hyperpa rathyroidi sm High or High- normal Low or low - normal
  10. 10. Hypocalcemia
  11. 11. etiology •Hypoparathyroidism: • s/p thyroidectomy or other neck surgery • s/p I131 therapy for graves disease or thyroid cancer • Autoimmune hypoparathyroidism • Infiltration of parathyroids • Hypomagnesemia • Genetic /congenital
  12. 12. • Vitamin D deficiency • Low dietary intake of Ca+2 • Miscellaneous  Osteoblastic bone metastases • Pancreatitis • Hungry bones syndrome • Multiple Transfusions • Acute Respiratory Alkalosis • Hyperphosphatemia • Bisphosphonates
  13. 13. Symptoms • Perioral paresthesias • Muscle stiffness ,spasms and cramps • Shortness of breath (diaphragmatic spasms) • Diaphoresis • EKG finding –long QT interval • Other severe symptoms –seizures, hypotension, emotional lability , psychosis.
  14. 14. Signs • Chvostek’s sign:Facial spasm elicited by tapping on the ipsilateral facial nerve anterior to the ear. • Trousseau’s sign- Carpopedal spasm induced by inflation of a BP cuff above SBP for 3 minutes.
  15. 15. Diagnostic evaluation • Step1 :correct calcium for low albumin • Step 2: Measure PTH , creatinine , phosphate , magnesium , calcidiol and calcitriol
  16. 16. Treatment • Oral calcium(1500-2000mg elemental calcium daily in divided doses) • IV calcium • Vitamin D • Magnesium Should be reserved for the pts with severe symptoms- seizures ,tetany, prolonged QT ,abrupt decrease <7.5mg/dl Although common to give as a slow bolus(ie. over 10-20 min)this improves calcium levels only transiently. Magnesium sulfate IV (1- 2gm)with frequent monitoring Pts with moderate def. – 600- 800units/day Pts with severe malabsorption- 10000- 50000units/day.
  17. 17. Phosphate • Serum phosphate level Reference range in adults, 2.5-4.5 mg/dL • in children, 3-6 mg/dL • hemolysis or hyperlipidemia of the serum sample may lead to falsely elevated phosphorus levels
  18. 18. • Most of the phosphate in the body is also stored in the bones as hydroxyapatite. • Most of the remainder of the body’s phosphate is intracellular ,as component of phospholipids in cell membranes ,DNA,RNA and ATP and ADP.
  19. 19. • The small fraction of phosphate that is in the serum exists as circulating phospholipids and inorganic phosphate. • Inorganic phosphate consists of HPO4 -2 and H2PO4 -1 in a 4:1 ratio at pH 7.40 which is physiologically active and what is typically measured in routine blood tests.
  20. 20. Hypophosphatemia
  21. 21. Etiology ↓GI absorption: ↓Intake of dietary Phosphate(only seen in malnourished alcoholic)  Malabsorption  Phosphate binders (eg. Calcium acetate,Al+3 and Mg+2 containing antacids)
  22. 22. • ↑Urinary Excretion: •Vitamin D deficiency •Hyperparathyroidism •Variety of rare genetic disorder •Fanconi syndrome(proximal tubule dysfunction • Internal Redistribution: –Refeeding syndrome –Hungry bones syndrome –Acute respiratory alkalosis
  23. 23. MECHANISM EARLY MANIFESTATIONS (serum phosphate 1-2 mg/dl) LATE MANIFESTATIONS (serum phosphate <1mg/dl) Dysfunctional bone metabolism ↓bone mineralization Bone pain Rickets(children) Osteomalacia (adults) ↓ Intracellular ATP ↓Myocardial contractility Proximal muscle weakness ↑RBC rigidity Encephalopathy Heart failure Rhabdomyolysis Hemolysis Seizures , coma ↓RBC 2,3DPG ↑affinity of Hb for O2 Systemic ischemia
  24. 24. Diagnostic evaluation • The first step is measurement of 24hr urine phosphate excretion , and/ or fractional excretion of phosphate.(FE PO4)
  25. 25. Patients with uncorrectable ,ongoing urinary loss of phosphate will require ongoing oral phosphate repletion even after serum phosphate is normalized
  26. 26. Hyperphosphatemia
  27. 27. Hyperphosphatemia symptoms • Altered mental status • Delirium • Obtundation • Coma • Convulsions and seizures • Muscle cramping or tetany • Neuromuscular hyperexcitability (ie, Chvostek and Trousseau signs) • Paresthesias (particularly perioral and distal extremities)
  28. 28. Diagnostic evaluation • The cause of the clinically relevant hyperphosphatemia is rarely a diagnostic mystery. • Pseudohyperphosphatemia should be identified • When uncertain as to the etiology , it is best to start by working up the likely concurrent calcium disorder.
  29. 29. Acuity Renal function Treatment Acute intact For mild hyperphosphatemia ,therapy is unnecessary Will usually resolve within 6- 12hrs. IF degree is Life threatening Consider normal saline +/- acetazolamide impaired Consider Hemodialysis
  30. 30. Acuity Renal function Treatment Chronic Intact For Vitamin D excess and Hypoparathyroidism treatment of the underlying condition is usually sufficient For Familial tumoral calcinosis ,treatment requires low phosphate diet and phosphate binders impaired low phosphate diet and phosphate binders
  31. 31. Magnesium • needed for more than 300 biochemical reactions in the body. It helps to maintain – normal nerve and muscle function – supports a healthy immune system, – keeps the heart beat steady, and helps bones remain strong. – It also helps regulate blood glucose levels and – aid in the production of energy and protein.
  32. 32. • ~50% of Mg is stored in bone • ~49% is in the intracellular space • Of the remaining 1%: • ~20%bound to albumin • ~10% complexed with anions • ~70% Unbound(ie. Biologically active) • Serum Mg correlates poorly with total body Mg content. • Average daily intake: 360mg
  33. 33. Hypomagnesemia
  34. 34. Etiology • ↓GI uptake: –Poor dietary intake(particularly common in alcoholics) –Proton pump Inhibitors –Primary intestinal Hypomagnesemia –Excessive GI losses: –Chronic diarrhea
  35. 35. • Renal losses : • Medications:Loop and Thiazide diuretics • Amphotericin B • Aminoglycosides • Electrolyte abnormalitiesHypercalcemia Hypokalemia • Transient renal tubular dysfunction • Familial Renal Mg wasting syndromes • Miscellaneous Pancreatitis •Hungry bones syndrome
  36. 36. Symptoms/Signs : – Tetany (seizures in children/neonates) – Hypokalemia – Hypoparathyroidism hypocalcemia (<1.2mg/dL) – Vitamin D deficiency (due to low calcitriol) – EKG changes: widened QRS, peaked T-waves, PR interval prolongation, – Ventricular arrhythmias (especially during ischemia or bypass), like TORSADE de POINTES.
  37. 37. Treatment • Abrupt increases in serum Mg (as seen during IV administration )inhibit Mg reabsorption in the loop of henle and lead to transient Mg wasting ,limiting the utility of the IV route. • In the absence of symptoms ,arrhythmias ,or concurrent hypokalemia oral repletion is usually preserved. • Treat underlying disease (PPI, diuretics, alcohol, uncontrolled diabetes)
  38. 38. • In the presence of symptoms ,arrhythmias , and/or hypokalemia , IV Mg can be given ,usually 1-2gms at a time . • Although it is common practice to give IV Mg relatively quickly (ie.,<15min/gram),this speed is usually not necessary. • Avoid replacement in patients with reduced GFR
  39. 39. Hypermagnesemia
  40. 40. etiology • Renal failure • Excessive Mg intake – Magnesium citrate – Overdose of Epsom salts • Excessive IV Mg infusion (eg: ecclampsia) • Magnesium containing enemas • Miscellaneous –Tumor lysis syndrome
  41. 41. Clinical manifestations Cardiovascular Bradycardia Conduction block Hypotension Neuromuscular Decreased reflexes Muscle weakness Drowsiness , coma Parasympathetic blockade- Cutaneous flushing Dry mouth Dilated pupils Urinary retention
  42. 42. Chloride Cl-
  43. 43. • Chloride - the major anion of extracellular fluid • Chloride accounts for two-thirds of all serum anions. –Chloride moves passively with Na+ or against HCO3 - to maintain neutral electrical charge –Chloride usually follows Na (if one is abnormal, so is the other)
  44. 44. Functions –- not completely known, –it maintains cellular integrity by: •hydration •osmotic pressure •electrical neutrality & other functions • Chloride is secreted by the stomach's mucosa as hydrochloric acid.
  45. 45. • Normal range: 98-106 mmol/L • Critical values: < 70 or >120 mmol/L • Chloride daily requirements for adults are 80-120 mEq/d as NaCL • CSF – 120-132 mEq/L
  46. 46. Hypochloremia
  47. 47. • Total body chloride depletion Extrarenal: –Inadequate NaCl intake –Vomiting –Small bowel fistulas • Renal: • Diuretic abusers • Salt-losing nephropathy • Interstitial nephritis • Adrenal insufficiency
  48. 48. • Dilutional :(decreased chloride concentration) • Increased effective circulatory blood volume • Hypertonic infusions • Pathologic water drinkers • Intrinsic renal diseases
  49. 49. Symptoms • Excess fluid loss or dehydration (diarrhea, vomiting) • Muscle hypertonicity (Spasticity) • Tetany • Shallow, depressed breathing • Muscle weakness • Sweating • High fever • Weight loss
  50. 50. diagnosis • Serum chloride levels < 98 mEq/L confirm the diagnosis. • Serum pH is above 7.45 • Serum carbon dioxide levels > 32 mEq/L. • Serum osmolarity < 280mOsm/L • Arterial blood gas analysis for identifying any acid base imbalance. • Sometimes, a chloride test can be done.This finds out how much chloride is excreted in the urine.
  51. 51. Treatment • Electrolyte replacement therapy • IV administration of normal (0.9 NaCl) or half strength saline (0.45 NaCl). • Ammonium chloride (an acidifying agent) – This is for treating the metabolic alkalosis. Dosage depends up on the serum chloride level and weight of the patient. This is contraindicated in cases of impaired renal or liver functions.
  52. 52. • Oral or intravenous KCl (10- 40mEq PO). IV should not exceed 20 mEq/hr. • Dietary modifications –Consume sodium and potassium rich diet, as hypochloremia causes deficiency of these nutrients.
  53. 53. Hyperchloremia
  54. 54. Causes of hyperchloremia may include • Loss of body fluids from prolonged vomiting, diarrhea, sweating or high fever (dehydration). • High levels of blood sodium. • Kidney failure, or kidney disorders • Diabetes insipidus or diabetic coma • Drugs such as: androgens, corticosteroids, estrogens, and certain diuretics.
  55. 55. Symptoms/signs • Excess fluid loss or dehydration (diarrhea, vomiting) • High blood sugar • Kussmaul’s breathing (deep and rapid breathing) • Dyspnea • Intense thirst • Weakness • Tachypnea • Hypertension • Pitting edema • Diminished cognitive ability • Possible coma
  56. 56. Hyperchloremia Diagnosis • Serum chloride levels > 106 mEq/L confirm the diagnosis. • Serum pH is under 7.35 • Serum carbon dioxide levels < 22 mEq/L. • Sometimes, a chloride test can be done .
  57. 57. Treatment • Sodium bicarbonate I.V infusion – This is to raise the bicarbonate level in blood and for permitting renal excretion of chloride anion, as chloride and bicarbonate compete to combine with sodium. • Lactated Ringer’s solution – This is administered in cases of hyperchloremia. In liver, this gets converted to bicarbonate, thereby increasing the base bicarbonate for correcting the acidosis caused. • Low sodium diet – The excess chloride ions may combine with sodium to form hypernatremia.