???? ?????????

1
????? ???????????

• ?"? ???? ???
• ???? ????????? ????? ???????
• ??"? ????????

2
?????? ?????

• ???? ?? 70
• Ca - 8mg/dl
• ???? ????? ????? ????? ???????????????.
• ?????? ?????? ??????.
• ?????? ?? ???? ????? ??????.
• Alb-4, ALP-156

• ???? ?? 60
• Ca 6.4mg/dl
• ??????? ? ?.?.?. ???? ????? ????? ????? ???
  ?????? ????.
• ?????? ?? ????? ????? ??????. ???? ?????? ?????
  ??????.
• Alb 3mg/dl

• ?? ?????? ??? ??????
• ?? ???????

3
Calcium homeostasis
4
Pathogenesis of hypocalcemia

1. Failure to secrete PTH.
2. Failure to respond to PTH.
3. Deficiency of vitamin D.
4. Failure to respond to vitamin D.

5
Etiology of hypocalcemia

• PTH deficiency (hypoparathyroidism)
• Surgical
• Radiation
• Idiopathic
• Functional (low Mg)
• PTH resistance
• Pseudohypoparathyroidism
• Renal failure
• Drugs

• Vitamin D deficiency
• Vitamin D deficiency
• Renal failure
• Heredetary type 1 vitamin D dependant rickets
• Vitamin D resistance
• Heredetary type 2 vitamin D dependant rickets
• Others

6
Etiology of hypocalcemia

• Low PTH levels (hypoparathyroidism)
• PT destruction
• post-surgery
• Radiation
• autoimmune

• High PTH levels (secondary hyperparathyroidism)
• Vitamin D deficiency
• Renal failure
• Vitamin D resistance
• PTH resistance
• Pseudohypoparathyroidism
• hypomagnesemia
• Drugs

7
Hypocalcemia clinical features

• Mild (Ca 8-8.8mg/dl)
• usually asymptomatic.
• Moderate (Ca 7-8mg/dl)
• Chvosteks sign, Trousseaus sign
• Severe (Ca lt 7mg/dl)
• acute signs of neuromuscular irritability
• calcifications of basal ganglia.
• subcapsular cataract
• Papilledema
• abnormal dentition.

8
Hypocalcemic symptoms of increased neuromuscular
irritability

• Chvosteks sign, Trousseaus sign.
• Parasthesia, muscle cramps.
• Tetany
• Seizures
• Prolonged QT on ECG.
• Laryngospasm, bronchospasm.

9
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10
Chvosteks and Trousseaus signs
11
Prolonged QT
12
Hypocalcemia - treatment

• Acute depends on symptoms I.v.calcium
  gluconate correct hypomagnesemia if diagnosed.
• Persistent oral treatment calcium vitamin
  D vitamin D2 1-a- D3. (1a
  hydroxycholecalciferol) calcitriol.

13
Etiology of hypocalcemia

• Low PTH levels (hypoparathyroidism)
• PT destruction
• post-surgery
• Radiation
• autoimmune

• High PTH levels (secondary hyperparathyroidism)
• Vitamin D deficiency
• Renal failure
• Vitamin D resistance
• PTH resistance
• Pseudohypoparathyroidism
• hypomagnesemia
• Drugs

14
PTH deficiency -Hypoparathyroidism

• Post surgical
• Autoimmune
• Laboratory
• Calcium ?
• Phosphate ?
• PTH ?

15
Post surgical hypoparathyroidism

• The most common cause of hypoparathyroidism in
  adults.
• Presumptive diagnosis for hypocalcemia for any
  patients with a surgical scar on the neck.
• Total thyroidectomy for cancer.
• Causes Edema, hemorrhage to PT glands.
  Destruction of blood supply.
• Presenting symptoms tetany 1-2 post op.
• Usually transient (more than 50), reversible.

16
PTH deficiency Idiopathic hypoparathyroidism

• Isolated orpart of polyglandular endocrinopathy
  type I.
• Addison disease
• Hypogonadism
• Autoimmune thyroid
• D.M. type 1
• Mucocutaneus candidiasis
• Aqcuired age 2-10.
• Circulating parathyroid antibodies common.
• Women gt men

17
????? 1

• ???? ?? 60
• Ca 6.5mg/dl
• Phosphate 6.1mg/dl (2.5-4.5)
• ??????? ? ?.?.?. ???? ????? ????? ????? ???
  ?????? ????.
• ?????? ?? ????? ????? ??????. ???? ?????? ?????
  ??????.
• Alb 3mg/dl
• Corrected Ca 6.50.87.3mg/dl

?? ???????
18
????? 1

• PTH 5pg/ml (12-72)
• Diagnosis hypoparathyroidism post surgical.
• Treatment acute - intravenous calcium
  persistent - 1-a- D3
  calcium

19
Etiology of hypocalcemia

• Low PTH levels (hypoparathyroidism)
• PT destruction
• post-surgery
• Radiation
• autoimmune

• High PTH levels (secondary hyperparathyroidism)
• Vitamin D deficiency
• Renal failure
• Vitamin D resistance
• PTH resistance
• Pseudohypoparathyroidism
• hypomagnesemia
• Drugs

20
Secondary causes of hyperparathyridism
Vitamin D ?
Calcium ?
Phsophate ?
PTH ?
21
Etiology of hypocalcemia

• Low PTH levels (hypoparathyroidism)
• PT destruction
• post-surgery
• Radiation
• autoimmune

• High PTH levels (secondary hyperparathyroidism)
• Vitamin D deficiency
• Renal failure
• Vitamin D resistance
• PTH resistance
• Pseudohypoparathyroidism
• hypomagnesemia
• Drugs

22
Vitamin D metabolism
23
Vitamin D Metabolism

• Normal vitamin D gt20ng/dl
• Vitamin D deficiency lt8ng/dl

24
Vitamin D deficiency - etiology

• 25 (OH)D deficiency
• Cutaneus
• Clothes
• Sunscreens
• Melanin
• Latitude
• season
• Dietary absence
• Malabsorption

• Impaired 25 hydroxylation
• liver diseases-severe
• Impaired 1alpha hydroxylation
• 1.renal failure
• 2.enzyme mutations I)
• 3.oncogenic osteomalacia
• Target organ resistance
• receptor mutation (II)

25
25 (OH)D deficiency - etiology

• ????? ???? ?? ?????? D ????
• ????? ?????? ??????? - ?? ????, ??? ????, ????
  ????
• ???? ??????
• ????? ??? ???? ?????? (??? ??? ???)
• ?????? ????
• ?????
• ???
• ?????? ?????????? ??? ????? ???? IBD , ?????
• ???? ?????? D ????? ????? ??? ????, ??? ?????,
  ????? ????????

26
??? ?????? D - ??? ????

• ??????? ????? ?????? ??? ??? 20-80.
• NEJM 3/98, Thomas -
• Boston, 290 medical inpatients 57
• high risk diet, winter, housebound
• also in low risk agelt65 42
• multivitamins - 46
• ?????? ????? ?????? ???? ???????? 60-83
• ????? 24-35.

27
Clinical features of vitamin D deficiency

• 1. ?????? ?????? - ??????????.
• 2. ????????? ?? ???????? ????? ?????
  ?????? ????? ?????? proximal.
• ???? ?????, ???? ?????.
• 3. ????????? ?? ??????????.
• 4. ????? ????? ????? ???????????
• ????????????
• ??????????????, ?????

28
25(OH)D deficiency - laboratory

• 25(OH)Vitamin D ?
• Calcium ?
• P ?
• PTH ? - bone kidneys intestine
• ALP ?

29
????? 2

• ???? ?? 70.
• Ca - 8mg/dl.
• ???? ????? ????? ????? ???????????????.
• ?????? ?? ???? ????? ??????.
• Alb-4, P 2.1mg/dl (2.5-4.5),
• ALP-180 (45-115).
• GGT 15 normal
• Normal kidney function.
• PTH 258pg/ml (12-72)

?? ?????? ?????? ??????
30
????? 2

• PTH 238pg/ml (12-72)
• 25(OH)D3 5ng/dl (20-46)
• Diagnosis secondary hyperparathyroidism vitamin
  D deficiency
• Treatment ?

31
????? 2

• ???? ?? 70 ?? ?????????? ?? ??? ??? ?????? D
• ?????? ?? ???? ????? ??????.
• ????? ?????? ?? ???? ?????? D ?????? 2000
  ?????? ????
• ????? ????? ??????? ????? ??????? ?????.

32
Etiology of hypocalcemia

• Low PTH levels (hypoparathyroidism)
• PT destruction
• post-surgery
• Radiation
• autoimmune

• High PTH levels (secondary hyperparathyroidism)
• Vitamin D deficiency
• Renal failure
• Vitamin D resistance
• PTH resistance
• Pseudohypoparathyroidism
• hypomagnesemia
• Drugs

33
Hypocalcemia in chronic renal failure

1. 1,25(OH)2D ?
2. Phosphate ?
3. PTH ? bone resistance to PTH actions reduced
   VDR and CaSR on PT gland

34
Evaluation of hypocalcemia
35
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