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calcium balance (hypercalcemia (clinical manifestations (renal (AKI…

- - - - primary hyperparathyroidism (high Ca, low phos, high/normal PTH, increased urine Ca excretion)
        
        adenoma
        
        hyperplasia
        
        carcinoma
        
        genetic (e.g. MEN)
        
        radiation
        
        symptoms: can be asymptomatic, osteoporosis, renal stones
        
        tx: surgical removal, calcimimetics (cinacalcet)
      - familial hypercacemic hypocalciuria (FHH) (high calcium, high PTH, decreased urine Ca excretion)
        
        loss of function mutation of the CaSR
        
        higher serum Ca is needed to suppress PTH
        
        tx: no tx necessary
      - tertiary hyperparathyroidism (occurs in pts with CKD)
      - lithium (high calcium, high PTH, looks like primary hyperparathyroidism until lithium removed)
        
        shifts set point for PTH inhibition (requires greater serum Ca to inhibit PTH)
    - - malignancies
        
        usually severe
        
        tumor usually apparent
        
        mechanisms
        
        lytic bone lesions (e.g. myeloma, metastases)
        
        production of PTH-related protein (e.g. solid tumors, leukemias)
        
        increased production of active vitamin D (e.g. lymphomas) leadings to increased intestinal Ca reabsorption
        
        ectopic PTH secretion (e.g. small cell lung cancer)
      - granulomas (producing 1,25-(OH)2 vit D)
        
        sarcoidosis
        
        infections
        
        TB
        
        histoplasmosis
        
        coccidiomycosis
      - milk-alkali or calcium-alkali syndrome
        
        ingestion of large amounts of milk or CaCO3
        
        triad of hypercalcemia, AKI (volume depletion), and metabolic alkalosis
      - thiazides
        
        state of volume depletion, calcium follows sodium and bicarb reabsoprtion
      - vitamin D intoxication
      - vitamin A intoxication
      - immobilization
      - Paget's disease of the bone + immobilization
      - thyrotoxicosis/hyperthyroidism
  - - - altered sensorium
      - coma
    - - weakness
    - - constipation, nausea, vomiting
      - increased gastrin --> PUD
    - - AKI (volume depletion, vasoconstriction, tissue deposition)
      - nephrogenic DI (decreased AQP2 channels)
      - stones
    - - short QT
      - elevated ST
  - - - IV NS at high rate
    - - calcitonin (short-lived)
      - bisphosphonates (for most cases, esp malignancy)
      - steroids (for sarcoidosis and lymphomas)
      - donusumab (for malignancy)
      - calcimimetics (for primary or tertiary hyperparathyroidism)
- - - - vitamin D deficiency or resistance (low calcium, low phos)
        
        not enough UV light
        
        liver disease
        
        kidney disease
        
        decreased oral intake / malabsorption
      - chronic kidney disease (CKD)
        
        high serum phos, low vitamin D, mild hypocalcemia, secondary hyperparathyroidism
      - resistance to PTH action (pseudohypoparathyroidism)
        
        Albright Hereditary Osteodystrophy
      - massive transfusion (citrate binds calcium)
      - extravascular deposition
        
        hyperphosphatemia (phosphorous can bind calcium in the blood in CKD and deposit it elsewhere)
        
        acute pancreatitis (exposes fatty tissue in pancreas to the blood, binding calcium)
        
        osteoblastic metastasis (prostate cancer)
    - - surgical removal of parathyroid gland
        
        hypoparathyroidism
        
        low Ca, high phos, normal Mg, low PTH
      - hungry bone syndrome
      - primary (autoimmune) hypoparathyroidism
      - hereditary (polyglandular syndrome, Di-George's syndrome)
      - hypomagnesemia
      - sepsis or acute severe illness (cytokine suppression of PTH action)
    - - Ca chelators (EDTA, citrate)
      - bisphosphonates
      - denosumab
      - cisplatin
      - cinacalcet (primary/tertiary hyperparathyroidism - acts at site of CaSR making it more sensitive to calcium)
  - - - perioral numbness
      - muscle cramps
      - tetany (if serum Ca < 7 mg/dl)
      - laryngismus stridulus, bronchospasm
      - seizures
      - Trousseau's sign (blood pressure cuff, hypercontractility) and Chvostek's sign (facial nerve, also present in hypomagnesemia)
    - - anxiety
      - depression
      - psychosis
    - - prolonged QT
      - VT/torsade de pointe
      - CHF
      - hypotension
  - - - symptomatic or acute severe hypocalcemia (< 7.5): IV calcium
      - asymptomatic: oral Ca and vit D
    - - hypoparathyroidism: calcium + vitamine D (1,25-OH)
      - hypomagnesemia: replace Mg
      - vitamin D def: replace vit D
      - liver disease: calcidiol (25-OH vit D)
      - renal disease: lower phos, supplement with Ca and vit D