1. HYPOCALCEMIA GROUP MEMBERS: - CHRISTINE ALPHONSO - SATRUPA SINGH

2. DEFINITION  Hypocalcemia can be defined as an electrolyte imbalance indicated by a low level of calcium in the blood.  The normal adult value for calcium is 4.5-5.5 mEq/L.  Calcium is important for healthy bones and teeth, as well as for normal muscle and nerve function.  Normal blood calcium levels are maintained through the actions of parathyroid hormone (PTH), your kidneys and intestines.

3. ETIOLOGY Cause are:  Vitamin D deficiency & Dependency  Chronic Renal Failure  Magnesium deficiency  Alcohol  Leukemia (certain types) or blood disorders  Tumor lysis syndrome, occurs when your body breaks down tumor cells rapidly after chemotherapy  Drugs such as diuretics, estrogens replacement therapy, fluorides, glucose, insulin, excessive laxative use, and magnesium  Hypoparathyroidism  Pseudohypoparathyroidism

4. PATHOPHYSIOLOGY  In plasma fraction for normal physiologic processes, ionized calcium is the necessary. In the neuromuscular system, ionized calcium facilitates nerve conduction, muscle contraction, and muscle relaxation. Calcium is necessary for bone mineralization and is an important cofactor for hormonal secretion in endocrine organs. At the cellular level, calcium is an important regulator of ion transport and membrane integrity.  Calcium turnover is estimated to be 10-20 mEq/day. Approximately 500 mg of calcium is removed from the bones daily and replaced by an equal amount. Normally, the amount of calcium absorbed by the intestines is matched by urinary calcium excretion. Despite these enormous fluxes of calcium, the levels of ionized calcium remain stable because of the rigid control maintained by parathyroid hormone (PTH), vitamin D, and calcitonin through complex feedback loops. These compounds act primarily at bone, renal, and GI sites. Calcium levels are also affected by magnesium and phosphorus.

5. PATHOPHYSIOLOGY CONT’D  Decrease in ionized calcium can be defined as patients presenting with a decrease in total serum calcium whom may not have "true" hypocalcemia. A reduction in total serum calcium can result from a decrease in albumin secondary to liver disease, nephrotic syndrome, or malnutrition.  Hypocalcemia causes neuromuscular irritability and tetany. Alkalemia induces tetany due to a decrease in ionized calcium, whereas acidemia is protective. This pathophysiology is important in patients with renal failure who have hypocalcemia because rapid correction of acidemia or development of alkalemia may trigger tetany.

6. CLINICAL MANIFESTATIONS  No symptoms is seen if you have long-standing low blood calcium levels  Neuromuscular irritability: nerves and muscles may spasm or twitch that are directly related to blood calcium levels  Muscle cramps in your legs or your arms  Sensory symptoms consisting of paresthesias of the lips, tongue, fingers and feet  Depression (Mild)  Confused or disoriented (Severely low)  Your heart muscle may contract irregularly due to the electrolyte disturbance.

7. CLINICAL MANIFESTATIONS CONT’D  Dry and scaly skin, brittle nails, and coarse hair  Candida infections occasionally occur in hypocalcemia however, commonly occur in patients with idiopathic hypoparathyroidism.  Cataracts occasionally occur with long-standing hypocalcemia thus are not reversible by correction of serum Ca.

8. EPIDEMIOLOGY  Since hypocalcemia is a multifactorial diagnosis, it is difficult to estimate the incidence and prevalence.  Ionized calcium typically remains normal, however quite common in ill patients are decreases in total serum calcium.  In renal failure the use of prophylactic calcium has reduced the incidence of renal osteodystrophy  Autoimmune polyglandular syndrome is extremely rare with perhaps 0.04 cases/1000 patients/year  This may occur at any age  Genetic predisposition in pseudohypoparathyroidism, genetic hypoparathyroidism, and vitamin D receptor abnormalities

9. DIAGNOSIS  First step in evaluation of hypocalcemia is to exclude factitious cases  This is done by measuring the serum albumin levels.  Since low serum albumin levels can cause a reduction in the total, but not the ionized, fraction of serum calcium.

10. DIFFERENTIAL DIAGNOSIS  Acute Kidney Injury  Acute Pancreatitis  Hydrofluoric Acid Burns  Hyperparathyroidism  Hyperphosphatemia  Hypomagnesemia  Hypoparathyroidism  Metabolic Alkalosis

11. TREATMENT/MANAGEMENT  Intake of adequate calcium if your blood test results indicate hypocalcemia.  Calcium, in any form, needs vitamin D to be absorbed. Take 400-800 mg of Vitamin D with your calcium supplements per day; to ensure that the calcium you take is being absorbed.  To increase your dietary intake of calcium, choose your foods wisely:  Dark & green vegetables  Sardines and salmon (with bones)  Red beans  Dairy products contain the most calcium (Milk or yogurt)  Many cereals, orange juices, and other foods are fortified with calcium. Read the labels of your food items carefully.  If you do not take in enough calcium during hypocalcemia, especially if you have taken steroids for your disease that may cause "bone thinning," you are at risk for long term complications of bone loss (osteoporosis). You may be at a higher risk for fractures, curved spine, and loss of height.

12. REFERENCE  Suneja, M. (1994 - 2015). Hypocalcemia. Retrieved September 19, 2015, from http://emedicine.medscape.com/article/241893-overview#a5: http://emedicine.medscape.com/article/241893-overview#a5  Hypocalcemia. (n.d.). Retrieved September 19, 2015, from https://www.clinicalkey.com: https://www.clinicalkey.com/topics/endocrinology/hypocalcemia.html#180595  Hypocalcemia Low Calcium. (2002 - 2015). Retrieved September 20, 2015, from http://chemocare.com: http://chemocare.com/chemotherapy/side- effects/hypocalcemia-low-calcium.aspx  Lewis, J. L. (2013, March). Hypocalcemia. Retrieved September 20, 2015, from http://www.msdmanuals.com: http://www.msdmanuals.com/professional/endocrine-and-metabolic- disorders/electrolyte-disorders/hypocalcemia