Download - Shaila Sukthankar
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Shaila Sukthankar
Hypocalcaemia
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Ca – Daily Requirements
Age/ sex Ca (mg)
1-3 350
4-6 450
7-10 550
11-18 M 1000
11-18 F 800
19 + 700
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Ca – Dietary Sources (NDC)
Milk – 100 ml =120mg Cheese – 15gm = 110mg Yoghurt pot – 80gm = 160mg Other sources
– Fish– Meat– Bread– Cereal– Broccoli
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Hypocalcaemia - Causes
Failure of secretion or actions of PTH Disorders of vitamin D CaSR disorders Dietary Ca deficiency (CMPI) Malabsorption of Ca – coeliac disease, short
gut, tufting enteropathy
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Hypocalcaemia – Clinical Features
Neuromuscular excitability Paraesthesia (tingling sensation) around mouth,
fingers and toes Muscle cramps, carpopedal spasms Tetany Seizures – focal or generalised Laryngospasm, stridor and apneas (neonates) Cardiac rhythm disturbances (prolonged QT interval) Chvostek’s and Trousseau’s signs – latent
hypocalcemia
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Hypocalcaemia - Investigations
Ca and Pi PTH Vit D (25 hydroxy and 1,25 dihydroxy levels) Mg Urinary Ca/ Cr ratio
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Hypocalcaemia - Approach
Low PTH– Hypoparathyroidism
Primary/ secondary Normal/ low normal PTH
– Mg deficiency– CaSR activating mutation
High PTH– Vit D deficiency– VDDR– Pseudohypoparathyroidism – types 1, 2
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Severe Symptomatic:• IV 10% Calcium Gluconate @ 0.11 mmol/kg (0.5 mls/kg – max 20 mls) over 10 minutes• Continuous IV infusion of Calcium Gluconate
@ 0.1 mmol/kg (Max 8.8 mmols) over 24 hours
Severe Asymptomatic:
Oral Calcium Supplements @ 0.2 mmol/kg (Max 10 mmols or 400 mg Ca) 4 x a day
Treatment of Hypocalcaemia
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• Aim to keep serum Ca between 2.0 to 2.2 mmol/l• Oral Calcium supplements• Active preparations of Vitamin D
• 1,25-dihydroxyvitamin D (Calcitriol)• 1‑α‑hydroxyvitamin D (Alfacalcidiol) @ 50
nanograms/kg (Max ~2 micrograms/day)• Monitoring
• Urine Ca/Cr (<0.7)• Renal Ultrasound Scan
Treatment of Hypoparathyroidism
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Case 1 - Presentation
TM 8 years Episodic palpitations, sweating and pallor TIA at 4 years age Referred to cardiology at RMCH – marginal
prolonged QTc Incidental hypocalcaemia Father has h/o kidney stones
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Case 1 - Investigations
Ca 1.6 mmol/ l, Pi 2.6 mmol/ l, ALP 237 Vit D 23 ng/ ml PTH 6 (normal 10 -70) Urinary ca/ cr ratio 0.6 initially
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Case 1 - Treatment
1 - alpha calcidol started initially at 0.5 mcg daily
Ca/ Cr ratio rose to 0.9 – 1.2 when Ca levels were 1.9 mmol/ l
Diagnosis – Activating mutation of the CaSR
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CaSR
Present on the membrane of parathyroid cells
Calciostat – regulates PTH sensitivity and response to Ca levels in serum
Set at a “trigger” point to alter PTH secretion as guided by Ca level
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CaSR mutations and effect on PTH
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Case 1 – Learning Points
In the face of hypocalcaemia, PTH value is important
Urinary Ca/ Cr ratio monitoring is important to detect hypercalciuria – particularly after treatment is started
In the long term, over-treatment can lead to nephrocalcinosis
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Case 2 - Presentation
1 week old baby girl Frequent short seizures at home for 2 days Asian origin Breast fed exclusively Well in between seizure episodes Apyrexial, no focus of infection Mum had IDDM, on insulin (brief hypoglycaemia in
neonatal period)
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Case 2 - Investigations
All inflammatory markers normal U/E, blood gas and sugar normal Head scan normal Ca 1.6, Pi 2.7, ALP 400 PTH 15 (10 – 70) Urinary ca/ cr ratio 0.4 Vit D 26 Mg 0.49
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Case 2 - Treatment
Oral calcium supplements Oral magnesium supplements ABIDEC drops
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Ca – Role of Mg
Always measure serum magnesium in a hypocalcaemic child
Hypomagnesemia impairs PTH secretion
It also causes resistance to the actions of PTH at the level of kidney and bone
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Case 2 – Learning Points
Hypomagnesaemia may cause relative insensitivity of parathyroid gland to hypocalcaemia
Optimum treatment requires adequate correction of low magnesium
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Case 3 - Presentation
2 month old infant girl Consanguinity, Somalian origin Gastroenteritis Breast fed No seizures No fever Wide open AF and open PF
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Case 3 - Investigations
Ca 1.6, Pi 1.8, ALP 650 PTH 434 Vit D 0.6 ng/ml Mild metabolic acidosis
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Case 3 - Treatment
Oral Ca supplements until serum Ca over 2.0 Cholecalciferol 3,000 Units daily for 6 weeks ABIDEC advised for 6 – 12 months Maternal assessment After treatment with oral Calcium supplements and
vit D– PTH 400– Ca 2.0– Pi 0.4– 25 OH vit D 55ng/ml
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Case 3 – Learning Points
Increased awareness of vit D deficiency in breast fed infants – especially of Asian and African origin
Routine/ opportunistic supplementation for breast fed infants with MV drops
Maternal evaluation – likely vit D and iron deficiency Sibling screening as indicated – for incidental vit D
deficiency/ rickets When PTH persistently high after initial treatment,
check 1,25 dihydroxy levels too
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An Approach to a Child Serum [Ca] <2.1 mmol/l An Approach to a Child Serum [Ca] <2.1 mmol/l with with normal serum Albumin & Mg Concentrationsnormal serum Albumin & Mg Concentrations
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Urine Ca/Cr
>0.56 mmol/mmol
<0.56 mmol/mmol
Hypocalcaemic hypercalciuriaHypocalcaemic hypercalciuria
Serum PSerum P
Low High
Vitamin D related causes
Serum 25 OH DSerum 25 OH D
Serum 1, 25 (OH)2 DSerum 1, 25 (OH)2 D
VDDR Type IVDDR Type I
VDDR Type IIVDDR Type II
LowNormal
Low High
Serum PTHSerum PTH
Low High
Vit D DeficiencyVit D Deficiency
Hypo-para-thyroidismHypo-para-thyroidism
Pseudo-hypo-para-thyroidismPseudo-hypo-para-thyroidism
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Picture quiz
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Autoimmune Polyglandular Endocrinopathy type 1
Mucocutaneous candidosis
Alopecia Brittle, dystrophic nails Intestinal malabsorption Autoimmune hepatitis Keratoconjunctivitis Asplenia
Parathyroid Thyroid Adrenals Gonads Pancreatic islet cells Gastric parietal cells
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Thank You!
Questions???