Calcium for GPs

8/3/2019 Calcium for GPs

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HYPERCALCAEMIAHYPOCALCAEMIA

Zahir Mughal


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Introduction

The Royal College of General Practitioners

GP curriculum and hypercalcaemia

Curriculum statement 12: Care of people with cancer and palliative

carerequires GPs in training to have knowledge of various palliative careemergencies and their appropriate management. This includes the

diagnosis and management of hypercalcaemia in cancer and palliative care

settings.

Curriculum statement 15.6: Metabolic problemsincludes recognition

and management of parathyroid disease within its knowledge base as acommon and/or important disease


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Ca2+ Metabolism

99% of calcium is locked up in bones

Hydroxyapatite crystals (CaPO4) make up 65% of weight of bone

Of the remaining 1%:

45% is bound to albumin

10% bound to other proteins and organic anions

45% free this is what is biologically active

Calcium balance

Postive calcium balance - children and during pregnancy and

lactation


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Overview of Calcium Homeostasis

Low serum Ca2+

PTH releaseVitamin D activation

High serum Ca2+

Increase serum

Ca2+ by acting on

-kidney

-bone

-intestine

Calcitonin release

Calcium levels

restored to normal

Decrease serum

Ca2+ by acting on

-kidney

-bone

-intestine

-vefeedback


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Interpreting Lab results

1. Total calcium

2. Serum albumin

3. Serum phosphate4. Corrected calcium.

. The total calcium can vary due to the binding ofcalcium to albumin.

.The most relevant parameter, and that to which

the reference ranges apply to, is the corrected


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Hypercalcaemia


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Hypercalcaemia

Mild: 2.653.0 mmol/l

Moderate: 3.03.4 mmol/l

Severe: greater than 3.4 mmol/l


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Hypercalcaemia

bones, stones, psychic groans, abdominal moans

Renal: polyuria, polydipsia, nephrocalcinosis

Gastro-intestinal: anorexia, nausea, vomiting, constipation, abdominal pain

Central nervous system: confusion, lethargy, depression

Other: generalized aches and pains, pruritis, sore eyes, corneal calcification


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Investigation of the asymptomaticpatient who has hypercalcaemia


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Summary: Hypercalcaemia

The commonest cause in the community is a

parathyroid adenoma causing primary

hyperparathyroidism (90% of cases).

Common causes in hospital practice is excesstherapeutic vitamin D (or vitamin D derivatives)

and malignancy.

Severe hypercalcaemia can be a medicalemergency requiring hospital admission.


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Hypocalcaemia


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Hypocalcaemia

This is a low plasma calcium i.e. less than 2.3

mmol/l.


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Hypocalcaemia

Causes:

Vitamin D deficiency

Chronic renal disease (end-stage)

hypomagnesemia

pancreatitis

hypoparathyroidism.

Dietary lack of Calcium is rare but binding of calcium

by phytate in chapati flour may be important in Asian

people


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Hypocalcaemia

Mood changes (e.g. depression)

Convulsions

Paraesthesia and numbness of hands and feet

Skeletal muscle spasms, tetany

Cardiac arrhythmias

Bone pain and fragile


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Hypocalcaemia

In hospital practice, hypocalcaemia is most

commonly seen in subjects with dietary vitamin D

deficiency or as a transient event after total

thyroidectomy.


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Investigation of hypocalcaemia


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Treatment of Hypocalcaemia

Patients with symptomatic hypocalcaemia or

those with corrected serum levels of 1875

mmol/L or less

Treated with parenteral calcium until the symptoms

cease or the calcium concentration rises above this

point

Chronic asymptomatic mild hypocalcaemia

Calcium homeostasis can be restored with oral calcium

and vitamin D.

Oral calcium carbonate is often the most commonl

Calcium for GPs

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