Calcium

Most abundant mineral

Total= 1kg (22 500mmol)

99% in the bone

0.1% in ECF = 22.5mmol

= 9 mmol in plasma + 16 mmol in intracellular

In bone:

Calcium moves between bone and ECF

~500 mmol/24 hours

In kidneys:

Filtered in kidney = 240mmol/24h

Reabsorbed in the tubules = 234 mmol/24h

Excretion in urine = 6 mmol/24h

In GIT:

Calcium in food: 25mmol/25h

Calcium in GIT secretion: 6mmol/24h

Calcium excretion in faeces: 19mmol/24 hours

GIT reabsorb calcium in secretion + food

Calcium loss:

0.3mmol (skin) + 19mmol (faeces) + 6 mmol (urine) = 25mmol

Calcium requirement: 12.5mmol/24 hours

Function of calcium

Structural

• Bone

• Teeth
Neuromuscular
• Control of excitability

• Release of neurotransmitter

• Initiate muscle contraction

Enzymic
• Co-factor for coagulation factors
Signalling
• Intracellular second messenger

Bone
• Osteoid (collagenous matrix) + calcium salt ( hydroxyapatite)

• Remodelling = Resorption (osteoclast) + Formation (osteoblast)

• Formation = Osteoid synthesis + calcium + phosphate (hydroxyapatite)

• Phosphate: released from pyrophosphate

• Mediated by alkaline phosphatase

• Alkaline phosphatase released by osteoblast

• Bone is a reservoir: calcium, phosphate, magnesium, sodium

Plasma calcium
Distribution of calcium in plasma

Total calcium: 2.25-2.6 mmol/L

= diffusible 54% + non diffusible 46%

= (free 47% + complexed 7%) + non diffusible 46%

Non diffusible: protein bound

Free: physiologically active

maintained by homeostatic mechanism

Complexed: with citrate and phosphate, bicarbonate, lactate

Alkalosis: Increased calcium binding to albumin

Increased calcium complex

-> reduced physiologically active calcium (total calcium still normal)

-> clinical sign of hypocalcaemia

Acidosis : Calcium has to compete with H+ for albumin

Reduced calcium binding to albumin

Reduced calcium complex

-> increased physiologically active calcium

-> signs of hypercalcaemia

Plasma albumin:

Affect total calcium concentration (regardless ionized calcium concentration)

Corrected calcium corrected for hypoalbuminaemia

= Total calcium (measured) + (Normal albumin , assumed to be 4.4 which is normal - Patient's albumin) x 0.8

Analytical technique:

• Total calcium

• Measurement include protein bound and ionized calcium

• Easier to measure

• Affected by albumin level

• Although calcium binds to other protein, only albumin is clinically significant

• Thus, eg; hypogammaglobulinemia unlikely to alter total calcium level

• Ionized calcium can be measure too

Method for total calcium measurement:

• Colorimetric analysis with metallochromic indicator

◦Metallochromic indicator or dyes bind calcium and forms color complex

◦Ca ions are released when exposed to acids

◦Released ion binds to chelating agent eg: arsenzo III

◦Measure absorbance at 650nm

◦Concentration of Ca-dye complex determined from Beer's Law

• Atomic absorption spectrometry (AAS)

◦reference method

• Indirect potentiometry

◦ISE method

◦Add acid to Ca to release from albumin

◦Total calcium measured voltametrically

◦Ionized calcium: direct measurement (no need acid treatment)

Calcium-Regulating Hormones
• Parathyroid hormone

• Calcitriol

• Calcitonin (minimal)

Parathyroid hormone
• Polypeptide hormone

• Synthesised from larger precursor (inactive)

• Forms active PTH in the plasma

• Synthesised in the Parathyroid glands chief cells

• Half-life: 3-4 min

• Metabolised in the liver and kidneys

Stimulation of PTH release

• Reduced ionised Ca

• Mild hypomagnesemia

• Low calcitriol

Inhibition of PTH release

• Hypercalcaemia

• Severe hypomagnesemia

• Increased calcitriol

PTH not affected by phosphate concentration

In the absence of adequate calcitriol, there is resistance to the calcium mobilizing effect of PTH

Action of PTH

• Increase Ca, reduce phosphate

• Bone

◦Mobilize calcium from bone

◦Osteoclast cause bone resorption

• Kidneys

◦Increase reabsorption of filtered calcium

‣ Increase bone resorption causing increased ca

‣ Despite increased reabsorption, may still cause hypercalciuria

◦Decreasing reabsorption of phosphate

‣ Causing phosphaturia, reduced plasma phosphate

◦Decrease reabsorption of bicarbonate

‣ Causing acidosis

◦Stimulate formation of calcitriol

‣ Increase calcium and phosphate absorption from the gut

‣ Increase ostoclastic resorption (in high concentration)

‣ Promotes bone mineralization (in low concentration)

Analytical technique

• Sandwich Immunoassay, detection via IRMA (radioactive-labelled) or CMIA (chemiluminescent-labelled)

• Cons: lack of specificity, may detect inactive fragments

Calcitriol

• Is a vitamin D, steroid hormone

• 7 dehydrocholesterol in skin + sunlight -> precalciferol

• Precalciferol to liver and hydroxylated (25-hydroxylation) to cholecalciferol

• Cholecalciferol to kidney and hydroxylated (1α-hydroxylation) to 1,25-

dihydrocalciferol

Stimulation of calcitriol synthesis

• high PTH

• Low phosphate

• Low calcium

• Calcitonin

• Oestrogen

• Cytokines

• Interferon

Inhibition of calcitriol synthesis

• low PTH

• High phosphate

• High FGF32

• High calcitriol

• Leptin

• Ascorbic acids

When Calcitriol synthsis is inhibited, Cholecalciferol will be hydroxylated into

• 24,25-dihydrocalciferol

• 1,24,25-dihydrocalciferol

These are inactive form of calcitriol

Action of calcitriol

• Synthesise calbindin D (Ca carrier protein) to increase GIT calcium and phosphate absorption

• Bind to osteoblast to release ALP (ALP release phosphate from pyrophosphate for bone mineralization)

• Stimulate osteoblast to release osteocalcin to increase bone mineralization

• Increase bone resorption (at high level)

• Enhance effect of PTH in renal tubules (for reabsorption of Ca)

• Others: Reduce osteoporosis, anti-tumour growth activity

Analytical methods

• HUKM: detect 25-hydrocalciferol via sandwich immunoassay (RIA or CMIA)

◦Longer half-life (2-3 weeks)

◦Reduced fluctuation with sunlight and dietary intake

◦Larger concentration

◦Easier to measure

• Reference method: Dual mass spectometry

Calcitonin

• Peptide hormone

• Produced from C-cell of the thyroid

Action

• Inhibit bone resorption

• Increase calcium uptake from the gut

-> increase calcium without loss of mineral from bone

Analytical method

• Sandwich Immunoassay, detection via IRMA (radioactive-labelled) or CMIA (chemiluminescent-labelled)

Fibroblast growth factor 23 (FGF23)

• Produced by osteocytes

• Causes increase phosphate loss

Stimulation of FGF23 synthesis

• High calcitriol

• High phosphate

Action

• inhibit Na-Po4 cotransporter -> reduced reabsorption of Na and PO4

• Inhibit 1α-hydoxylase -> reduced calcitriol -> reduced GIT absorption of calcium and phosphate

FGF23 Mutation

• Hypophosphatemia + osteomalacia

Calcium Homeostasis

Low Calcium stimulates PTH secretion

Increase bone resorption

Increase calcitriol ️ increase gut reabsorption of calcium and phosphate

️increase bone mineralization

Increase reabsorption of calcium from kidney ️ hypercalciuria

Decrease phosphate reabsorption in kidney ️phosphaturia

Phosphate homeostasis

Hypophosphatemia

increase calcitriol release ️ stimulate calcium absorption from the gut ️ excess calcium excreted in urine

️ ️stimulate phosphate absorption from the gut

inhibit FGF23 release

loss of inhibition of Na-Po4 cotransporter in the kidneys

increase PO4 reabsorption

Disorder of Calcium, Phosphate and Magnesium Metabolism

Hypercalcaemia

Causes Clinical Features

• most common is

◦Primary hyperthyroidism

◦Malignancy

• usually asymptomatic

Malignant Disease

• usually symptomatic

️Metastatic

️no relationship between bone metastasis with severity/presence of hypercalcaemia

️can be due to humoral factors eg: growth factors, prostaglandins and osteoclast-activating
cytokines

️Non-metastic ️ due to secretion of PTH-related peptide (PTHrP)

Primary hyperparathyrodism

• 1 in 1000

• occur at any age

• most common in postmenopausal women

• Commonly due to

◦Parathyroid adenoma, may be due to MEN

◦Diffuse parathyroid hyperplasia

◦Parathyroid carcinoma, rare

• Complications

◦osteoporosis

◦renal impairment

◦renal calculi

• Diagnosis

◦to localize tumour (adenoma is usually not palpable)

‣ 99mTc-Sestamibi scanning

‣ Measurement of PTH via selective jugular cannulation

◦Measurement of PTH to confirm sucessful resection

◦Lab investigations:

• Treatment:

◦Definitive: surgical removal

◦Indication for surgery

‣ Symptomatic patients

‣ Ca >2.85mmol/L

‣ Evidence of decrease bone density

‣ eGFR <60mL/min/1.73m2

‣ Young patient <50yo

◦Asymptomatic: reassessment of complications, high fluid intake

Secondary Hyperparathyroidism

• Resistance to the metabolic actions of PTH

• Eg: Renal failure, Vitamin D deficiency, pseudohypoparathyroidism

• Renal failure

◦Reduced GFR ️decrease PO4 excreation

◦Reduced calcitriol ️ reduced action of PTH for bone resorption ️ hypocalcaemia

️ reduced GIT absorption of calcium ️ hypocalcaemia

◦Reduced renal excreation of PTH, increased secretion of PTH

increased PTH level

Parathyroid gland hyperplasia (chronic parathyroid stimulation)

initially low calcium, hyperphosphatemia

severe hyperparathyrodism cause hypercalcaemia and hyperphosphatemia

➡ ➡

Tertiary Hyperparathyroidism

• Autonomous hyperparathyroidism

• Due to chronic parathyroid stimulation

• Renal failure causing inability to correct hypocalcaemia ️chronic PTH stimulation ️PTH hyperplasia
️Autonomous PTH secretion

• Transplanted kidney causing normal calcitriol production ️ PTH effect manifested as hypercalcaemia

Thyrotoxicosis

• d/t increased osteoclastic activity ️ osteoporosis and hypercalcaemia

➡

Excessive Vitamin D

▶
• increased GIT absorption of calcium

• Enhanced bone resorption

• Hypercalciuria
▶
• Symptoms: weakness, irritability, nausea, vomiting, diarrhea, soft tissue calcification

• Synptoms may persists for years d/t adipose tissue storage of Vit D

• Dx; measurement of 25(OH)D

• Rx: steroid

Granulomatous disorders

• eg: Sarcoidosis, Tuberculosis, Coccidiodomycosis, silicone-induced granuloma

➡
• Due to:

◦1α-hydroxylation of 25-hydroxycholecalciferol by macrophages in the sarcoid granuloma

◦increased sensitivity to Vit D

Milk-alkali Syndrome

• ingestion of milk/antacid

• Alkali increases calcium reabsorption

• Symptoms: Hypercalcaemia, hypocalciuria, alkalosis, azotemia, soft tissue calcification

Thiazide diuretic

• Increase calcium reabsorption

Lithium therapy

• Increased PTH secretion

Acute Adrenal Failure

• d/t sudden fall in cortisol causing plasma volume contraction

Immobilization

• Bone resorption without bone formation ️ hypercalciuria

Familial Hypocalciuric Hypercalcaemia

• autosomal dominant

• mutation in the CaSR gene ️ increase in PTH

• asymptomatic, benign

• present throughout life

• DX: relative hypocalciuria to the degree of hypercalcaemia

◦Familial Hypocalciuric Hypercalcaemia : Calcium clearance: Creatinine clearance = <0.01

◦Primary Hyperparathyroidism : >0.02

Investigation

HYPOCALCAEMIA
CLINICAL FEATURES

• Behavioural disturbance

• Stupor

• Numbness and paraesthesia

• Carpopedal spasm

• Tetany, convulsion

• Laryngeal spasm

• Respiratory arrest

• Cataracts (chronic hypocalcaemia)

• Basal ganglia calcifications (chronic hypocalcaemia)

• Positive Trosseau sign

• Positive Chvostek sign

• Prolonged QT

• Low voltage T wave (repolarization)

CAUSES OF HYPOCALCAEMIA

Associated with low PTH

• Post surgical removal thyroid/parathyroid

• Low Mg++

• Hypoparathyroidism

• Hungry bone syndrome

• Inherited disorders

Associated with high PTH level

• ESRF

• Vitamin D deficiency

◦Dietary

◦Malabsorption

◦Inadequate exposure to UV light

• Disorder of Vitamin D metabolism

◦ESRF

◦Lithium therapy

◦1α-hydroxylase deficiency

◦Vitamin D resistance

• Pseudohypoparathyroidism

• Acute pancreatitis

• Hyperphosphatemia

• Massive transfusion with citrated blood

• Acute rhabdomyolysis

Artefactual

• Blood collected from EDTA tube

Others

• Critically ill patients with sepsis, burns and acute renal failure

• Drugs: Heparin, glucagon, protamine (transient)

Hypoparathroidism

• Can be

◦Inherited : DiGeorge, thymic aplasia

◦Acquired: idiopathic, autoimmune, surgery, haemochromatosis, infiltrative condition

• low PTH ️ low calcium high phosphate

• usually have low calcitriol too ️ low GIT reabsorption

Pseudohypoparathyroidism (Albright's Osteodystrophy)

• ineffective PTH

• Two types

➡ ➡
◦Type 1: PTH binds to receptor ️ defective activation of adenyl cyclase ️ no cAMP formed

◦Type 2: PTH binds to receptor adenyl cyclase formed ️ cAMP formed ️ response is blocked

➡
• Clinical features

◦Extraosseous calcifications

◦Rounded face

◦Short stature

◦Shortening of 4th and 5th metacarpals/ metatarsals

◦Learning difficulty

◦Extrapyramidal symptoms : choreoathetotic movement, dystonia

◦Increased ICP, papilloedema

◦Lenticular cataracts

• Lab investigations

◦High PTH
➡
◦Low calcium

◦PTH infusion:

‣ Type 1: low cAMP

➡ ➡
‣ Type 2 or normal people : high cAMP

Hypomagnesemia
• causes deficiency of PTH and impaired responsiveness to PTH

Vitamin D Deficiency
• Can be due to inadequate intake, inadequate synthesis (enzyme x cukup, malabsorption
• Causes

◦Adults: Osteomalacia

◦Childrens: Rickets

• Low vit D ️low calcitriol ️ reduced calcium and phosphate absorption from GIT hypocalcaemia
secondary hyperparathyroidism hypophosphatemia increased ALP

• Lab ix:

◦Hypocalcaemia

◦Hypophosphatemia

◦Increased ALP

◦High PTH

Impaired Vitamin D Metabolism

• Phenobarbital treatment, phenytoin

◦Induce hepatic microsomal hydroxylating enzymes alter vitamin D metabolism in the liver

◦Directly inhibit intestinal calcium absorption

• Chronic liver disease, Primary Biliary Cirrhosis

◦Hypocalcaemia, metabolic bone disease

◦Mechanism:

‣ Malabsorption of vit D

‣ Decreased 25-hydroxylation in the liver

‣ Decreased synthesis of vitamin d binding protein

Hungry Bone Syndrome

• Hyperparathyroidism increased bone resorption hypercalcaemia

surgical removal of parathyroid

➡ ➡
️

rapid intake of calcium by the bone

️
⬇
hypocalcaemia (often severe and symptomatic)

• must be anticipated, give calcium and vit D before surgery

HYPERPHOSPHATEMIA

CLINICAL FEATURES
• No direct symptoms

• If chronic, enhanced mineralization

◦Inhibit 1α-hydroxylation in the kidneys

◦Phosphate + Calcium = Ectopic calcifications

• Most common in ESRF supplemented with vitamin D

MECHANISM
• Increased extracellular load due to transcellular shift

eg: acidosis

• Increased tubular reabsorption

eg: hypoparathyroidism, pseudohypoparathyroidism

• Increased extracellular load

Eg: rhabdomyolysis. Intravascular hemolysis, leukaemia,

lymphoma, cytotoxic therapy, tumour lysis syndrome

• secondary to increased vitamin D

Eg: granulomatous disease ie: Sarcoidosis

MANAGEMENT
• Treat underlying cause

• Phosphate binder

◦Usually calcium salt eg: CaCO3

◦Reduce GIT absorption

Phosphate pyramid

HYPOPHOSPHATEMIA

CLINICAL FEATURES
• Symptomatic only in severe cases (<0.3mmol/L)

◦Proximal weakness

◦Anorexia

◦Dizziness

◦Myopathy

◦Dysphagia

◦Ileus

◦Respiratory failure d/t respiratory muscle weakness

◦Impairment of cardiac contractility due to ATP

depletion

◦Metabolic encephalopathy

MECHANISMS
• Shift in PO4 from extracellular fluid into cells

◦acute respiratory alkalosis,

◦salicylate poisoning

◦alcohol withdrawal

◦heatstroke

◦hepatic coma

◦increase insulin during glucose administration

◦recovery from DKA

◦refeeding in malnourished patients

• Increased urinary excretion

◦Usually secondary to hyperparathyroidism

◦Renal tubular defects eg: Fanconi's syndrome, Familial Hypophosphatemia

◦X-linked vitamin D-resistant rickets

◦Aldosteronisms

◦Glucocorticoid and Mineralocorticoid administration

◦Diuretic therapy

• Increase urinary loss

◦Osmotic diuresis

◦Acute volume expansion

◦Malignant neoplasm eg leukaemia and lymphoma

• Decrease intake/absorption

◦Vomiting

◦Diarrhea

◦Phosphate binding antacids

◦Malabsorption

◦Vitamin D deficiency ->reduce calcitriol for absorption

◦Steatorrhea

• Oncogenic hypophosphatemia with osteomalacia

◦Hyperphosphaturia via activation of FGF23

MANAGEMENT
• Give PO4 (enteral or IV)

◦Dont give in oliguric and hypercalcaemic

MAGNESIUM

• Normal: 0.7-1.0 mmol/L

• Daily intake: 8 mmol/24 hours

• Some bind to albumin

ACTION
• Co-factor for enzymes

• Maintenence of ribosome, nucleic acid, proteins

• affect permeability of excitable membranes

HYPERMAGNESEMIA

DEFINITION

• Se Mg2++ >0.9mmol/L

CLINICAL FEATURES

• 2.5-5.0 mmol/L : affect cardiac conduction, bradycardia,

respiratory depression, depressed mental status

• >7.5 mmol/L : Respiratory paralysis and cardiac arrest

• 3.0-4.0 mmol/L: Induced hypermagnesemia in

bronchospasm and eclampsia

CAUSES

• Renal insuffiuciency

• Bowel disorder

MANAGEMENT

• IV Calcium

• Dialysis

HYPOMAGNESEMIA

DEFINITION

• Se Mg <0.5mmol/L

CLINICAL FEATURES

• Usually associated with hypocalcaemia

• Hypomagnesemia causes low PTH ️ hypocalcaemia

◦Neuromuscular excitability: Carpopedal spasm, seizure, muscular weakness

◦Depression, psychosis

◦Metabolic abnormalities: Carbohydrate intolerence, hyperinsulinism

◦Cardiac arrhythmia

MECHANISM

• Loss of Mg fro GIT

◦Diarrhoea

◦Malabsorption

◦Steatorrhea

◦Bowel resection

◦IEM ; primary intestinal hypomagnesemia

• Urinary loss

◦Thiazide and loop diuretics

➡
◦Na resorption in kidneys: via Na-dependent magnesium efflux pathway in kidney

◦Volume expansion

◦Hypercalcemia and hypercalciuria

◦Nephrotoxic drugs

◦Diabetes mellitus: Glycosuria and osmotic diuresis

• Others:

◦Alcoholism

◦Sustained and extensive stress

BIOCHEMICAL MARKERS OF BONE REMODELLING

• Starts with bone resorption by osteoclast ️ formation of new bone by osteoblast

• Resorption > formation = Net bone loss ️ osteoporotic fracture

DIAGNOSTIC PROCEDURE TO MONITOR BONE TURNOVER

• Imaging technique

➡
• Bone biopsy

• Biochemical markers of bone turnover

➡
Imaging technique

Eg: bone density measurement

• Pros:

◦Non-invasive

• Cons:

◦ Difficult to detect early stages/ acute changes

◦Does not define abnormal distribution of bone loss

Bone biopsy

• Pros:

◦Define the distribution of bone mass

• Cons:

◦Invasive

◦Cannot provide ideas of the long and slowly developing process

Biochemical markers

• Conventional markers: less sensitive

◦Osteopotosis: Calcium and PTH will be normal due to minute changes over time

• Bone turnover markers:

◦Pros:

‣ More sensitive to subtle changes

‣ Noninvasive

‣ Can detect and monitor progression

BONE TURNOVER MARKERS

BONE RESORPTION MARKERS

• Bone tissue:

◦Organic matrix (osteoid)

◦Bone mineral

◦Bone cells

• Bone resorption markers

◦quantify:

‣ Constituent of bone matrix : calcium

‣ Collagen degradation products : hydrpoxyproline, pyridinium cross-links, telopeptides

‣ Cellular products from mineralized matrix degradation : TRAP

‣ Others: cathepsin K

‣ Bone metaboplism regulator: RANK, RANKL,osteoprotegerin

◦Has a diurnal rhythm, highest in the morning

BONE FORMATION MARKERS

• ALP

• Products of bone matrix synthesis

◦Osteocalcin

◦Procollagen Type 1 N-terminal and C-Terminal peptides