hypocalcemia
DESCRIPTION
Cairan & elektrolitKoreksi MetabolikMetabolismeKedokteranTRANSCRIPT
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HYPOCALCEMIHYPOCALCEMIAA
Jeffri Indra Setiawan, MDJeffri Indra Setiawan, MD
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NILAI NORMAL NILAI NORMAL CALCIUMCALCIUM
Calcium, plasma: 4.5 - 5.5 meq/L ; Calcium, plasma: 4.5 - 5.5 meq/L ;
9 - 10.5 mg/dL (2.2 - 2.6 mmol/L 9 - 10.5 mg/dL (2.2 - 2.6 mmol/L ))
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REGULATION OF THE SERUM REGULATION OF THE SERUM CALCIUMCALCIUM (Figure 5.1)(Figure 5.1)
Vitamin D Liver 25 OHD Kidney 1,25 diOHD
PTH
Serum calcium Bone resorption
Renal tubular Calcium reabsorption
Gut Calcium reabsorption
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CAUSES OF CAUSES OF HYPOCALCEMIAHYPOCALCEMIA
HypoalbuminemiaHypoalbuminemiaDisturbance in parathroid systemDisturbance in parathroid system
HypoparathyroidismHypoparathyroidismSurgicalSurgicalInfiltrativeInfiltrativeIdiopathicIdiopathic
PseudohypoparathyroidismPseudohypoparathyroidismHypomagnesiaHypomagnesiaDisturbances in vitamin D systemDisturbances in vitamin D system
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Lanjutan …Lanjutan …
Decreased intake-nutritionalDecreased intake-nutritionalDecreased absorption-malabsorptionDecreased absorption-malabsorptionDecreased production of 25(OH)D-Decreased production of 25(OH)D-liver deseaseliver deseaseIncreased metabolism of 25(OH)DIncreased metabolism of 25(OH)D
PhenobarbitalPhenobarbitalPhenytoinPhenytoinAlcoholAlcoholGlutethimideGlutethimide
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Lanjutan …Lanjutan …Accelerated loss of 25(OH)DAccelerated loss of 25(OH)D
Nephrotic syndromeNephrotic syndrome
Disturbances of enterohepatic Disturbances of enterohepatic circulationcirculation
Decreased production of 1,25(OH)2DDecreased production of 1,25(OH)2D
HereditaryHereditary
Renal deseaseRenal desease
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Lanjutan …Lanjutan …
Removal of calcium from serumRemoval of calcium from serumHyperphosphatemiaHyperphosphatemia
LaxativesLaxativesPhosphate enemasPhosphate enemasCytotoxic treatment of leukimias Cytotoxic treatment of leukimias
and lymphomasand lymphomasRhabdomyolysis Rhabdomyolysis
Osteoblastic metastases Osteoblastic metastases Acute pancreatitisAcute pancreatitis
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Sign & symtompsSign & symtomps1.Psychiatric1.Psychiatric2.Neuromuscular2.Neuromuscular
a. Tetanya. Tetanyb. seizuresb. seizuresc. Intellectual impairmentc. Intellectual impairmentd. Extrapyramidal disordersd. Extrapyramidal disorderse. Myopathye. Myopathy
3.Ectodermal3.Ectodermal4.Ocular cataracts4.Ocular cataracts5.Dental5.Dental6.Cardiovascular6.Cardiovascular
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Diagnostic evaluation of the Diagnostic evaluation of the patient with hypocalcemiapatient with hypocalcemia
Fig.5.3Fig.5.3 Measure serum albumin levelMeasure serum albumin level
Hypoalbuminemia Hypoalbuminemia HypoalbuminemiaHypoalbuminemiaaccounts for hypocalcemia accounts for hypocalcemia for hypocalcemiafor hypocalcemia
Measure magnesium levelMeasure magnesium level
HypomagnesemiaHypomagnesemia Magnesium level normalMagnesium level normal<0,8 mEq/L<0,8 mEq/L
Evaluate serum phosphate and Evaluate serum phosphate and draw PTH leveldraw PTH level
Elevated PTH Elevated PTH Low PTH and high PO4 Low PTH and high PO4
Low serum PO4 Low serum PO4 Normal or high PO4 Normal or high PO4 Hypoparathyroid Hypoparathyroid
Vitamin D deficiency Vitamin D deficiency Pseudohypoparathyroidism Pseudohypoparathyroidism
Confirm with clinical picture,Confirm with clinical picture, measurement of vitamin D metabolites,measurement of vitamin D metabolites, and/or response to PTH infusionand/or response to PTH infusion
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Diagnostic evaluation of the Diagnostic evaluation of the patient with hypocalcemiapatient with hypocalcemia
Fig.5.3Fig.5.3
Measure serum albumin levelMeasure serum albumin level
Hypoalbuminemia Hypoalbuminemia HypoalbuminemiaHypoalbuminemiaaccounts for hypocalcemia accounts for hypocalcemia for hypocalcemiafor hypocalcemia
Measure magnesium Measure magnesium levellevel
HypomagnesemiaHypomagnesemia Magnesium level Magnesium level normalnormal
<0,8 mEq/L<0,8 mEq/LEvaluate serum phosphate Evaluate serum phosphate
andanddraw PTH leveldraw PTH level
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Lanjutan …Lanjutan …Evaluate serum phosphate and Evaluate serum phosphate and draw PTH leveldraw PTH level
Elevated PTHElevated PTH Low PTH and high PO4 Low PTH and high PO4
Low serum POLow serum PO44 Normal or high PO Normal or high PO44 Hypoparathyroid Hypoparathyroid
Vitamin D deficiency Vitamin D deficiency Pseudohypoparathyroidism Pseudohypoparathyroidism
Confirm with clinical picture,Confirm with clinical picture, measurement of vitamin D metabolites,measurement of vitamin D metabolites, and/or response to PTH infusionand/or response to PTH infusion
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Therapeutic Approach Therapeutic Approach 1.Acute hypocalcemia1.Acute hypocalcemia
Calcium Gluconate 10gr 20-30 ml 1xCalcium Gluconate 10gr 20-30 ml 1x(Per 10 ml(Per 10 ml90 mg kalsium)90 mg kalsium)
2.Chronic hypocalcemia 2.Chronic hypocalcemia Increasing Intestinal Absorption of Increasing Intestinal Absorption of CalciumCalcium- Vitamin D Therapy- Vitamin D Therapy- Increasing Calcium Intake- Increasing Calcium Intake
(calcium Lactate tablet)(calcium Lactate tablet)3. Tx underlying Desase3. Tx underlying Desase
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HYPERCALCEMIAHYPERCALCEMIA
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Causes of Hypercalcemia Causes of Hypercalcemia HyperparathyroidismHyperparathyroidism
AdenomaAdenoma
HyperplasiaHyperplasia
Multiple endocrine neoplasia Multiple endocrine neoplasia syndromesyndrome
FamilialFamilial
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Lanjutan …Lanjutan …
Malignancy asociatedMalignancy asociated
Metastatic resorption of boneMetastatic resorption of bone
Secretion of PTH-like substanceSecretion of PTH-like substance
Osteoclast activation factorOsteoclast activation factor
ProstaglandinsProstaglandins
Hormonal therapy of breast cancerHormonal therapy of breast cancer
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Lanjutan …Lanjutan …Granulomatosus disordersGranulomatosus disorders
SarcoidosisSarcoidosis
BeryliosisBeryliosis
TuberculosisTuberculosis
HistoplasmosisHistoplasmosis
CoccidioidomycosisCoccidioidomycosis
Paget’s diseasePaget’s disease
Addison’s diseaseAddison’s disease
ThyrotoxicosisThyrotoxicosis
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Lanjutan …Lanjutan …
Vitamin D intoxicationVitamin D intoxicationMilk-alkali syndromeMilk-alkali syndromeImmobilization Immobilization ThiazidesThiazidesRecovery from acute renal failureRecovery from acute renal failurePostrenal transplantPostrenal transplant
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Sign & SymtompsSign & Symtomps1.Sign & symtomps associated 1.Sign & symtomps associated
with hypercalcemia include ;with hypercalcemia include ; AnorexiaAnorexia Nausea & VomitingNausea & Vomiting ConstipationConstipation Polyuria, nocturia, and Polyuria, nocturia, and
polydipsiapolydipsia HypertensionHypertension
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Lanjutan …Lanjutan …
Confusion, stupor, and comaConfusion, stupor, and coma Acute and chronic renal Acute and chronic renal
insufficiencyinsufficiency NephrolithiasisNephrolithiasis Metastatic calcificationMetastatic calcification Peptic ulcer disease, pancreatitisPeptic ulcer disease, pancreatitis Electrocsrdiogrsphic changesElectrocsrdiogrsphic changes
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2. 2. Signs & symptoms associated with Signs & symptoms associated with underlying disease processes underlying disease processes includeinclude
a.Hyperparathyroidism; anemia, a.Hyperparathyroidism; anemia, myopathy, hyperchloremic acidosis, myopathy, hyperchloremic acidosis, hypophosphatemia, bone disease, hypophosphatemia, bone disease, pseudogoutpseudogout
b.Sarcoides; disturbances on chest x-b.Sarcoides; disturbances on chest x-rays, lymphadenopathyrays, lymphadenopathy
c.Systemic manifestation of c.Systemic manifestation of malignancy malignancy
d.Thyrotoxicosis d.Thyrotoxicosis
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Diagnostic evaluation of the Diagnostic evaluation of the
patient with hypercalcemiapatient with hypercalcemia Fig.5.2Fig.5.2
Hypercalcemia Hypercalcemia
Do : PTH level
Low or undetectable PTH Elevated PTHDo : History : Vitamin D intoxication Do : Chest x-ray Milk-alkali syndrome IVP
Urinalysis Abdominal flat plateChest x-ray :
Sarcoidosis,
malignancy
IVP : Malignancy
T3/T4 : Thyrotoxicosis
Bone surveyAnd Metastatic malignancyalkaline Paget’s diseasephosphatase
Negative Positive for malignancy
in presense of GI symptoms Do: Upper GI/Lower GI
Negative Positive for malignancy
Surgery for
hyperparathyroidism
Negative
Venous localization
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Diagnostic evaluation of the Diagnostic evaluation of the patient with hypercalcemiapatient with hypercalcemia
Fig.5.2Fig.5.2
Hypercalcemia Hypercalcemia Do : PTH LevelDo : PTH Level
Low or undetectable PTHLow or undetectable PTH Elevated PTHElevated PTHDoDo/History : Vit D Intoxication/History : Vit D Intoxication DoDo/Chest x-ray/Chest x-ray
Milk-Alkali syndromeMilk-Alkali syndrome IVPIVPUrinalysisUrinalysisAbdomonal flat plateAbdomonal flat plate
Chest X-ray:Chest X-ray: Sarcoidosis,Sarcoidosis, MalignancyMalignancy Negative Negative Positif for Positif for
malignancymalignancyIVP : MalignancyIVP : Malignancy
in Presense ofin Presense ofT3/T4 : ThyrotoxicosisT3/T4 : Thyrotoxicosis GI symptomsGI symptoms
Do/Upper GI/lower GIDo/Upper GI/lower GI
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Lanjutan …Lanjutan …Negative Negative Positive forPositive for
malignancymalignancyin Presense ofin Presense ofGI symptomsGI symptomsDo/Upper GI/lower GIDo/Upper GI/lower GI
Bone surveyBone survey Negative Negative Positive forPositive forAndAnd Metastatic malignancyMetastatic malignancy malignancymalignancyalkalinealkaline Paget’s diseasePaget’s diseasephosphatasephosphatase
Surgery forSurgery forHyperparathyroidismHyperparathyroidism
NegativeNegative
Venous LocalizationVenous Localization
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Therapeutic Approach Therapeutic Approach 1. Acute hypercalcemia1. Acute hypercalcemia
- Begin with volume Expansion- Begin with volume ExpansionSaline and Furosemide :Saline and Furosemide :- initial priming saline infusion of 1 - initial priming saline infusion of 1 to 2 liters over 1 hour should be to 2 liters over 1 hour should be given. Diuretics are then begun as given. Diuretics are then begun as follows :follows :a. Begin with a priming dose of 1 to a. Begin with a priming dose of 1 to 2 liters saline IV over 1 hour2 liters saline IV over 1 hourb. Give furosemide 40 to 80 mg IV b. Give furosemide 40 to 80 mg IV and repeat every 2 to 3 hoursand repeat every 2 to 3 hours
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Lanjutan …Lanjutan …
c. Measure urine volume every hour c. Measure urine volume every hour and urine sodium-potassium and urine sodium-potassium concentration every 4 to 6 hours concentration every 4 to 6 hours
d. Replace urine volume with saline d. Replace urine volume with saline and added potassium chlorideand added potassium chloride
e. If hypercalcemia is prolonged, add e. If hypercalcemia is prolonged, add magnesium (15 mg per hour)magnesium (15 mg per hour)
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Lanjutan …Lanjutan …2. 2. Chronic hypercalcemia Chronic hypercalcemia
a. Steroidesa. Steroides1. Sarcoidosis1. Sarcoidosis2. Multiple myeloma2. Multiple myeloma3. Breast cancer (50%)3. Breast cancer (50%)4. Vitamin D intoxication4. Vitamin D intoxication
b. Oral phosphateb. Oral phosphate1. Hyperparathyroidism (nonsurgical 1. Hyperparathyroidism (nonsurgical
candidates)candidates)2. Most malignancies2. Most malignancies
c. Mithramycin : If oral phosphate is c. Mithramycin : If oral phosphate is ineffective or ineffective or
serum phosphate is elevatedserum phosphate is elevated3. Tx Underlying Desease3. Tx Underlying Desease
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THANK YOUTHANK YOU