Total serum calcium = 8.5 10.

5 mg/dl

Ionized serum calcium = 4.5 5.2 mg/dl
Serum calcium
99 % of total body calcium Bone

1 % in ICF, ECF, Cell membrane
1 gm/kg body weight
Calcium distribution
Calcium weight
50%
40% 10%
Ionized Protein bound
Complexed
with minerals
10%
Ionized Protein bound
Complexed
with minerals
10%
Ionized Protein bound
Complexed
with minerals
Alkalosis
Acidosis
Total calcium 7.0
Serum albumin 2.5

Corrected Serum Calcium = 7.0 + { ( 4- 2.5) x 0.8 }
= 7.0 + 1.2
= 8.2
50%
40% 10%
Ionized Protein bound
50%
10%
Normal
Hypoalbuminemia
PTH
Decrease calcium excretion
Vit. D3
1,25 (OH)2 Vit. D
Increase calcium absorption
Vit. D3
1,25 (OH)2 Vit. D
Calcium functions:

1- Blood coagulation


2- Muscle contraction



3- Neuromuscular transmission



4- Skeletal growth

PTH
Decrease calcium excretion
Vit. D3
1,25 (OH)2 Vit. D
Increase calcium absorption
Vit. D3
1,25 (OH)2 Vit. D
Causes of hypocalcemia:
1- Hypoparathyroidism - Post irradiation
- Infiltration
- Surgical removal
- Pseudo hypoparathyroidism ( resistance to PTH)
- familial
2- Vitamin D deficiency - Poor intake
- Inadequate exposure to UV rays
- Malabsorption
- Increased metabolism by drugs eg. Phenytoin
- Renal failure
3- Renal failure
4- Acute pancreatitis
5- Transfusion of citrated blood
6- Hyperphophatemia
Hypercalcemia
Total serum calcium > 10.5 mg/dl
PTH
Decrease calcium excretion
Vit. D3
1,25 (OH)2 Vit. D
Increase calcium absorption
Vit. D3
1,25 (OH)2 Vit. D
Causes of hypercalcemia
PTH related causes
Primary Hyperparathyroidism
Adenoma > 90 %
Tertiary Hyperparathyroidism
In renal failure due to prolonged stimulation
M E N
Multiple Endocrinal Neoplasm
Type 1 Type 2
Parathyroid
Pituitary
Pancreas
Parathyroid
Medullary thyroid carcinoma

Pheochromocytoma
Malignancy
(mediated by PTHrP) lung, breast, and renal
Vitamin D intoxication
Vitamin D
(mediated by cytokines) multiple myeloma
Granulomatous disease sarcoidosis
Hodgkins lymphoma
OTHERS
Drugs Thiazide diuretics
Thyrotoxicosis
Familial Idiopathic
Clinical Manifestations of Hypercalcemia
stones - Renal stones, Polyuria, dehydration
bones - In primary hyperparathyroidism
- Subperiosteal resorption
- Brown tumors of long bones
abdominal moans Vomitting, peptic ulcer, pancreatitis
psychic groans coma, convulsions
Neuromuscular Muscle weakeness
Cardiovascular Short QT, Vascular calcification
Others Corneal calcification, keratitis
Causes of hypercalcemia
PTH related causes
Primary Hyperparathyroidism
Adenoma > 90 %
Tertiary Hyperparathyroidism
In renal failure due to prolonged stimulation
M E N
Multiple Endocrinal Neoplasm
Type 1 Type 2
Parathyroid
Pituitary
Pancreas
Parathyroid
Medullary thyroid carcinoma

Pheochromocytoma
Malignancy
(mediated by PTHrP) lung, breast, and renal
Vitamin D intoxication
Vitamin D
(mediated by cytokines) multiple myeloma
Granulomatous disease sarcoidosis
Hodgkins lymphoma
OTHERS
Drugs Thiazide diuretics
Thyrotoxicosis
Familial Idiopathic
Diagnosis

Serum Calcium, PO
4

24 hr urine Ca excretion

Intact PTH (10-60pg/ml)
Serum PTHrP

Isotope scan of parathyroid glands
99m
Tc sestamibi scans to predict the
location of abnormal gland



PTH
Decrease calcium excretion
Vit. D3
1,25 (OH)2 Vit. D
Increase calcium absorption
Vit. D3
1,25 (OH)2 Vit. D
Treatment of hypercalcemia
Surgical removal of parathyroid adenoma
Measures to decrease serum calcium
1- IV saline + Frusemide (lasix) Increase calcium excretion
2- Calcitonin Inhibits osteoclasts funcions
3- Bisphosphonate : pamidronate Inhibits osteoclasts funcions
4- Corticosteroids used in sarcoidosis, Vit. D toxication, lymphoma
5- Dialysis In renal failure
Thank you