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Hypocalcemia
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- 2. HYPOCALCEMIA : • Adecrease in the serum calcium <8.5mg/dl or ionized calcium <3.4-4mg/dl is termed as hypocalcemia. • Calcium in the blood is partly bound to plasma protein(approx.45%),notably albumin • Regulated by vitD ,phosphorous and PTH.
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- 4. ROLE OF Mg •Hypomagnesemia impairs PTH secretion • Measure serum magnesium in hypocalcemic patients always. • It also causes the resistance of the cations of PTH at the level of kidney and bone.
- 5. Etiology • Hypocalcemia withsecondary hyperparathyroidism: • -Vit D deficiency or impaired1,25(oh)2D production. • -Parathyroid hormone resistance • syndrome(pseudohypoparathyroidis m) • Hypocalcemia with Hypoparathyroidism Parathyroid agenesis Isolated DiGeorge’s syndrome Parathyroid destruction Surgical Radiation Infiltration by metastases or systemic diseases Autoimmune Reduced parathyroid function Hypomagnesemia
- 6. Contd.. -Most common causeis hypoalbuminemia -Drugs (calcium chelators, bisphosphonates, phenytoin) -Chronic kidney disease/ severe sepsis -Acute pancreatitis -Acidosis/Alkalosis
- 7. Clinical features • Paraesthesia(tinglingsensation)perioral,fingers and toes • Muscle cramps,carpopedal spasms • Tetany,seizures (focal or generalized) • Cardiac rhythm disturbances, prolonged QT interval • Chvostek’s sign and trousseau’s sign • Altered mental status.
- 9. Investigations • S.calcium andphosphate levels • S.albumin • Corrected s.calcium=serum calcium+0.8*(normal albumin-pt albumin) • S.creat (For renal disease) • PTH levels in serum • Parathyroid antibodies(idiopathic hypoparathyroidism) • Vit D serum level • Magnesium level • ECG
- 10. Management of Hypocalcemia •severely symptomatic: requires rapid correction by IV calcium • Asymptomatic patients treated with oral supplements of vit D with calcium. • In case of hypomagnesemia Mg++ therapy given • calcium gluconate usually 1 to 2 ampules (90-180 mg of elemental calcium/10 ml) diluted in 50 to 100 mL of 5% dextrose is infused over 10-20 minutes. This can be repeated until the patient's symptoms have cleared.
- 11. • Rapid administrationcould result in arrhythmias so intravenous administration should be carefully monitored. • Refractory hypocalcemia: continuous infusion of elemental calcium.
- 12. HYPOPARATHYROIDISM • It resultsfrom a deficiency in or absence of PTH. • It is characterized by Hypocalcemia and hyperphosphatemia and is often associated with chronic tetany. • Hypoparathyroidism usually results from the accidental removal of or damage to several parathyroid glands during thyroidectomy . • Transient hypoparathyroidism is common after subtotal thyroidectomy.. • PSEUDOHYPOPARATHYROIDISM: Biological active PTH is produced in this inherited disorder but there is an end organ resistance to its effects
- 13. • MECHANISM: • Whenextracellular Ca2+ is decreased there is decreased Ca2+ binding to the receptor, which stimulates PTH secretion.
- 14. CAUSES • IATROGENIC: Total thyroidectomy,surgery in the treatment of thyroid, laryngeal or other neck malignancy. • AUTOIMMUNE • Infiltration of the parathyroid gland(granulomatous,iron overload,metastases) • Congenital (Di George syndrome) • Radiation induceddestruction of parathyroid glands • Hungry bone syndrome(post parathyroidectomy) • HIV infection
- 15. Clinical Feautures • Musclespasm/cramping • Spasm of facial muscles • Convulsions, cataract • hair loss, dry skin, malformed nails • Papilledema, psychiatric manifestations.
- 16. LABS • PTH: Primary hypoparathyroidism:serum PTH & serum calcium decreased Pseudohypoparathyroidism: serum PTH increased Secondary hypoparathyroidism: serum PTH reduced &serum calcium level increased • Plasma calcium • 25-hydroxy vit D measurement to exclude vit D deficiency • Serum Magnesium • Serum phosphorous • Urine calcium
- 17. Treatment • Aim tokeep serum Ca2+ between 8.0-8.5mg/dL(2.0-2.1mmol/L) • Surgical implantation • Acute hypoparathyroidism –IV calcium with oral calcitriol supplementation • Oral calcium supplements. • Active preparations of of Vit D -1,25-dihydroxyvitamin D(calcitriol) -alfacalcidiol@ 50nanograms/kg(max 2 micrograms/day).