Hypocalcemia and Hypercalcemia

1. HYPERCALCEMIA & HYPOCALCEMIA
MODERATOR
 DR. RAKESH RANJAN
 ASSISTANT PROFESSOR PEDIATRIC
DEPARTMENT
 SHRI KRISHNA MEDICAL
COLLEGE,MUZZAFARPUR
PRESENTER
 DR. JAIKISHAN
AND
DR. AMANATULLAH
PG- DNB(1ST YEAR)
PEDIATRIC DEPARTMENT
SKMC, MUZZAFARPUR

2. CALCIUM HOMEOSTASIS
 It involves interaction of GIT absorption , Bone resorption and Renal excretion .
 PTH and Vit D are principle regulators of Calcium Homeostasis.
 Normal Serum Calcium level is 9-11 mg /dL.
 Calcitonin & PTH-related peptide are important primary regulator in fetus.
 PTH is an 84 amino acid chain , but its biologic activity resides in the first 34 residues.

3. Most (99%) body calcium is stored in the bone and is in constant
equilibrium with serum calcium .
Approx 1-2% of body calcium exist in ECF for physiological function
like –
Blood Coagulation
Cellular Communication
Exocytosis and Endocytosis
Muscle contraction
Neuromuscular transmission

4.  Most of the filtered Calcium is Reabsorbed in the
proximal convulted tubule (approx 70% ) ,
Ascending Loop of Henle (20%) & the Distal
convulted tubule and Collecting Duct (5-10%) .

5. Role of Calcium Sensing receptor
The body senses calcium levels using calcium sensing
receptors present in parathyroid gland and kidney.
The Calcium sensing receptor is GPCR
Plasma calcium exists in 3 different forms –
50 % as biologically active ionized form
45% bounded to plasma protein (mainly albumin)
5% complexed to phosphate

7. Metabolic acidosis leads to increased ionized calcium
from reduced protein binding
Alkalosis has opposite effect .
Corrected Calcium can be calculated by
Corrected Ca = ( 4 – Plasma albumin in g/dL ) x 0.8
+ Measured Serum Calcium
[ for every 1g/dL drop in Serum Albumin below 4g/dL,
measured Sr. calcium decreased by 0.8 mg/dL ]

9. HYPERCALCEMIA
 Defined as Serum Calcium levels > 11mg/dL.
 Hypercalcemia is often asymptomatic although it can cause
symptoms at levels 12mg/dL

10. Causes of Hypercalcemia
Hypercalcemia is uncommon in children as compared to Hypocalcemia .
➢ 1) Neonates
Neonatal primary hyperparathyroidism
Secondary hyperparathyroidism
Excessive supplementation of Calcium
William’s Syndrome
Familial Hypocalcemic Hypercalcemia

11. ➢ Older Children
Hyperparathyroidism – Parathyroid Adenoma
MEN-1
Malignancies - Non Hodgkin or Hodgkin Lymphoma
- Ewing’s Sarcoma
- Neuroblastoma
Granulomatous disease - Sarcoidosis
TB
Wegener disease .
Others - Vit D or Vit A intoxication
- Thiazide diuretic
- Milk-Alkali Syndrome

12. Symptoms and Signs of Hypercalcemia
Common Symptoms are –
Polyuria
Polydipsia
Poor weight gain
Failure to thrive
Easy Fatigability
Irritability
Confusion
Pain abdomen
Constipation

13.  Severe Hypercalcemia inhibits neuromuscular and myocardial
depolarization causing arrhythmia and neuromuscular weakness.
Severe acute abdominal pain could be a clue to suspect
pancreatitis
 Severe Calcium >14 mg/dL may result in encephalopathy .
 Bone related symptoms are Bone pain and Fractures
 CVS effect – Prolong PR interval
Short QT interval
Widened QRS complex

15. Treatment of Hypercalcemia
 Treatment is required for symptomatic hypercalcemia and
asymptomatic hypercalcemia with serum calcium > 15 mg/dL .
A) For increasing Calcium elimination
Twice maintenance fluid ( Isotonic Fluid )
Loop Diuretics – I.V Furosemide 1-2 mg/kg/day
in case of renal or cardiac disease only
Hemodialysis

16. b) Reducing Bone absorption – Bisphosphonates
Pamidronate (0.5-1 mg/kg)
as an infusion over 4-6 hrs
Calcitonin – 4 units /kg IM/S.C
q 12 hourly
c) Reducing calcium absorption – Steroids (1-2 mg/kg/day –
20-40 mg/day )
d) Surgical intervention may be needed in patients with
hyperparathyroidism, particularly with recurrent renal stones .

18. HYPOCALCEMIA
DEFINITION
Defined as serum calcium level less than
8.5 mg /dL

19. Causes of Hypocalcemia
1) Neonatal
a) Maternal disorder
Diabetes mellitus
Toximia of pregnancy
Vit D deficiency
Use of anti-convulsants
High intake of alkali or
magnesium sulfate
Hyperparathyroidism

20. (B) Neonatal Disorder :
LBW : Prematurity, IUGR , Peripartum asphyxia , sepsis ,
critical illness hyperbilirubinemia , phototherapy
exchange transfusions , hypomagnesemia ,hypermagnesemia
acute/chronic renal failure , hypoparathyroidism
Vit D deficiency or resistance .
2)Hypoparathyroidism
a) Congenital
1) Transient Neonatal
2) Congenital Hypoparathyroidism
3) Insensitivity to PTH
4) CaSR activating mutation

21. (B) Acquired :
1) Autoimmune polygandular syndrome type 1 (AIRE Gene mutation)
2) Activating antibodies to the CaSR
3) Hypomagnesemia / Hypermagnesemia
3) VIT D Deficiency
4) Other Causes like –
1) Calcium deficiency due to Nutritional Deprivation , Hypercalcemia
2) Disorders of magnesium Homeostasis
3) Hyperphosphatemia – a) renal failure
b) phosphate administration

22. Clinical Manifestation
➢ The Symptoms of Hypocalcemia are related to disturbance in nerve and muscle conduction as
hypocalcemia causes neuromuscular excitability .
Muscular pain and Cramps ( early manifestations)
➢ Numbness, Stiffness and Tingling of hand and feet .
➢ Uncommon symptoms – Stridor secondary to laryngeal spasm and apnea in infants .

23. Chvostek and Trousseau signs can be
elicited in Hypocalcemia

24.  ECG reveals prolonged QTc interval ( > 0.4 s ) and
QoTc ( > 0.2 s )

25. Investigation
Basic investigation in hypocalcemia
1) Serum Calcium level is low and Phosphorus level is elevated
2) Serum Calcium , Phosphate , Alkaline phosphatase .
3) Serum Vit D , Parathyroid hormone , X ray Wrist or Knee
4) Serum albumin , Serum Creatinine , Serum Magnesium
5) Urine Calcium / Creatinine ratio .

26. Treatment
Depends on severity of symptoms and underlying etiology of hypocalcemia
- I/V Calcium required in case of Seizure , Laryngospasm , Tetany , Cardiovascular compromise
- 10 % Calcium Gluconate ( 1ml contains 9.3 mg of elemental calcium )
- I/V dose – 0.5-1 ml/kg (max 2 ml/kg )
Calcium Gluconate diluted with Ns or 5% dextrose ( 1:10 dilution ) over 20 min
- Not more than 5 mg of elemental calcium per minute
- Additionally 1,25 dihydroxycholecalciferol should be given
initial dose – 0.25 μg / 24 hr
maintenance dose – 0.01 – 0.10 μg / kg / 24 hr
maximum dose – 1 – 2 μg / 24 hr

27. - I/V calcium should be always infused under cardiac monitoring
- Once the acute symptoms are subsided discontinue I/V Supplementation
- For those children who don’t need urgent correction of serum calcium , oral calcium
supplementation can be administered upto 400 mg / kg /day .
- Magnesium deficiencies must be considered In patients with unexplained
hypocalcemia
- Concentration of serum Mg < 1.5 mg/dL are abnormal