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DISORDERS OF MINERAL
METABOLISMXu, Mingtong
Department of Endocrinology, The Second Affiliated Hospital of Sun Yat-
Sen University
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Introduction:
Mineral Metabolism Clinical Disorders Hyperparathyroidism Hypoparathyroidism Osteoporosis
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Introduction: Mineral Metabolism
Calcium ions phosphate ionsExtracellular Con. total in serum 2.510-3M 1.010-3M free 1.210-3M 0.8510-3M Function bone mineral bone mineral blood coagulation membrane excitability
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Introduction: Mineral Metabolism
Calcium ions phosphate ionsIntracellular Con. 10-7M 1-210-7M Function signal for: structural role neuronal activation high energy bonds hormone secretion regulation of proteins muscle contraction by phosphorylation
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Calcium and Phosphate Homeostasis
Parathyroid Hormone (PTH)
Calcitonin
Vitamin D
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Calcium and Phosphate Homeostasis
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Parathyroid Hormone BONE
1. Activate osteoclasts 2. Osteoclast development 3. Proteases to digest matrix 4. Inhibit collagen synthesis 5. Inhibit osteoblast development 6. Stimulate osteoblasts via release of
matrix growth factors 7. Stimulate osteoblasts via IGF I
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Parathyroid Hormone
KIDNEY 1. Stimulate calcium reabsorption 2. Inhibit phosphate and bicarbonate
reabsorption
3. Stimulate synthesis of 1,25(OH)2D3 in the proximal tubule by activating 25(OH) 2D3
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Parathyroid Hormone
INTESTINE
Stimulate calcium absorption
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Calcitonin BONE
Stimulate osteoblasts Inhibit osteoclast
KIDNEY Inhibit calcium and
phosphate reabsorption INTSTINE
Inhibit calcium absorption
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Vitamin D
INTSTINE Stimulate calcium absorption
BONE Stimulate osteoclast and osteoblasts
KIDNEY Stimulate calcium and phosphate
reabsorption
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CLINICAL DISORDERHypercalcemic Disorder
Parathyroid-Dependent Hypercalcemia
Primary Hyperparathyroidism
Familial Hypocalciuric Hypercalcemia
Lithium-induced Hypercalcemia
Parathyroid-Independent Hypercalcemia
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HYPERCALCEMIA DISORDER
Parathyroid-Independent Hypercalcemia Hypercalcemia of Malignancy Vitamin D Intoxication Sarcoidosis and Other Granulomatous Hyperthyroidism Vitamin A Intoxication Adrenal Insufficiency Thiazide Diuretics Milk-alkali Syndrome Renal failure
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CLINICAL DISORDER
Hypocalcemic Disorder
Parathyroid-Related Disorder
Vitamin D-Related Disorder
Neoplasms
Neonatal Hypocalcemic
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CLINICAL DISORDER Hyperphosphatemia
Impaired Renal Phosphate Excretion Increased Extracellular Phosphate
Hypophosphatemia Reduced Renal Tubular Phosphate Reabsorption Impaired Intestine Phosphate Absorption Shifts of Extracellular Phosphate into Cells/ Bone
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HYPERPARATHYROIDISM
Primary Hyperparathyroidism
Primary abnormality of the parathyroid glands leads to inappropriate secretion of PTH.
Secondary Hyperparathyroidism
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PRIMARY HYPERPARATHYROIDISM
ETIOLOGY Parathyroid Adenoma 75-80% Primary Parathyroid Hyperplasia 20%, all glands Parathyroid carcinoma 1-2% Multiple Endocrine Neoplasia (MEN I) parathyroid, anterior pituitary and pancreatic islet Multiple Endocrine Neoplasia (MEN II) medullary carcinoma of thyroid, pheochromocytoma and parathyroid
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PRIMARY HYPERPARATHYROIDISM
CLINICAL MANIFESTATION relative benign, asymtomatic women are affected often between age of 15 and 65
Hypercalcemia Bone Kidney
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HYPERCALCEMIA Nuropsychiatric symptoms: weakness,
fatigue, apathy, difficulty in concentrating, depression, dementia, psychosis, coma, irritability, memory loss, emotional lability
Neuromuscular symptoms: symmetrical proximal weakness, gait disturbance, muscle atrophy
Hypertension
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HYPERCALCEMIA
Gastrointestinal symptoms: anorexia, nausea, vomiting, constipation, abdominal pain, peptic ulcer, acute and chronic pancreatitis
Ectopic calcification: conjunctival calcification, band
keratopathy
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Skeletal InvolvementBone pain and tendernessPathologic fractureDeformityRadiographic feature: generalized demineralization of bone, subperiosteal resorption, brown tumors, pathologic fracture, skull: mottled,groundglass;
dental erosion
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骨质疏松时骨折好发部位
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骨皮质变薄
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纤维囊性骨炎
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棕 色 瘤
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棕 色 瘤
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骨 质 疏 松
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Renal Manifestation
Calcium nephrolithiasis recurrent , severe
NephrocalcinosisFunction abnormalities
impaired concentrating ability renal failure
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LABORATORY TEST
Serum Ca P ALP Urine Ca /+ P
PTH Radiography: bone, kindeyLocalization: ultrasonography, CT, MRI, 99Tc-sestamibi
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DIAGNOSIS
Serum Ca
Urine Ca
PTH
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MANAGEMENTSurgical TreatmentTherapy for Severs Hypercalcemia Serum calcium3.75mmol/L Disturbances of nervous system and
gastrointestinal function: fatigue, lethargy, confusion, coma, anorexia, nausea, constipation, abdominal pain
Polyuria,nocturia and polydipsia
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Therapy for Severs Hypercalcemia
Rehadration 2-4L/d 0.9%NaCl
Bisphosphonates Diuretic Calcitonin Dialysis Glucocorticoid
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HYPOPARATHYROIDISM
Parathyroid disease PTH
Pseudohypoparathyroidism:
resistance to the PTH PTH
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HYPOPARATHYROIDISM
ETIOLOGY 1. Congenital of Inherited Parathyroid
disorders
2. Impaired PTH Secretion
3. Postsurgical Hypoparathyroidism
4. Infiltrative Disorders
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HYPOPARATHYROIDISM
CLINICAL MANIFESTATION1. Neuromuscular irritability perioral paresthesia tingling of the fingers and toes spontaneous or latent tetany Chovestek’ sign Trousseau’s sign
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CLINICAL MANIFESTATION
2. Cardiovescular disorders EKG: QT intervals ventricular arrhythmias3. Calcification of basal ganglia
extrapyramidal disorders4. Cataract5. Defects in mineralization of new bone
and calcification of teeth
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LABORATORY TEST
Serum total calcium 2mmol/L free calcium protein-bound component
Serum free calcium can be affected by variety of factors: hypoalbuminemia, alkalosis etc. Serum phosphate Urine Ca, P PTH
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DIAGNOSIS
Serum Ca Urine Ca PTH
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TREATMENT
Acute Hypocalcemia
1. 10% calcium gluconate 10-20ml iv
2. Sedative
3. Magnesium replacement
4. Monitoring of calcium level
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TREATMENTChronic Hypocalcemia
1. Dietary2. Exogenous calcium replacement 1-1.5g daily3. Vitamin D4. Monitoring of calcium level
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OSTEOPOROSIS
A disease characterized by low bone
mass and microarchitectural
deterioration of bone tissue, leading
to enhanced bone fragility and a
consequent increase in fracture risk.
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OSTEOPOROSIS
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OSTEOPOROSIS Primary osteoporosis
Type I osteoporosis
(postmenopaused osteoporosis)
vertebral fracture
Type II osteoporosis (senile osteoporosis)
hip fracture
Secondary osteoporosis
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PATHOGENESIS
Primary osteoporosis 1. Fail to achieve optimal peak bone
mass; 2. Bone loss caused by increased bone
resorption; 3. Inadequate replacement of lost bone
as a result of decreased bone formation.
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PATHOGENESIS Secondary osteoporosis
1. Endocrine disorders 2. Hematopoietic disorder 3. Connective tissue disorders 4. Drug-induced disorders 5. Immobilization 6. Renal disease 7. Nutritional and gastrointestinal
disorders
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CLINICAL FEATURES
Vertebral crush fracture back pain, height loss, kyphosis, impairment of chest wall function
Hip fracture femoral neck, the base of greater
trochanterColles fracture
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LABORATORY TEST
Biochemical measurements 1. Markers of bone resorption
fasting urinary calcium excretion
urinary hydroxyproline excretion
urine pyridinoline or deoxypyridinoline
Tartrate-resistant acid phosphatase
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LABORATORY TEST
Biochemical measurements 2. Markers of bone formation
alkaline phosphatase
osteocalcin
amino- and carboxy-terminal extension peptides of procollagen
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LABORATORY TEST
Bone densitometry
dual-energy X-ray absorptiometry
Bone biopsy
Radiographs and Bone scans
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DIAGNOSIS Category DefinitionNormal A value for BMD/BMC1SD of the young adult reference mean.Low bone mass A value for BMD/BMC1SD and 2.5 (osteopenia) SD lower than the young adult mean.Osteoporosis A value for BMD/BMC 2.5SD lower than the young adult mean.Severe A value for BMD/BMC 2.5SD lowerOsteoporosis than the young adult mean in the presence of one or more fragility fractures.
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TREATMENT
1. Nutrition and calcium replacement2. Exercise and lifestyle3. Hormone replacement therapy4. Bisphosphonates5. Calcitonin6. Estrogen analogues