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Residency Exam > Calcium Disorders (Panopto Video Link) > Flashcards

Calcium Disorders (Panopto Video Link) Flashcards

1
Q

What is the total amount of calcium in the body?

A

1 kg

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2
Q

Of the 1 kg of calcium in the body, how much is in bone?

A

990 g

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3
Q

What are 3 roles of extracellular calcium?

A
  1. Nerve tissue excitation
  2. Muscle contractility
  3. Cofactor for several enzyme systems and the blood clotting cascade
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4
Q

What are 3 roles of extracellular calcium?

A
  1. Nerve tissue excitation
  2. Muscle contractility
  3. Cofactor for several enzyme systems and the blood clotting cascade
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5
Q

What are 3 roles of extracellular calcium?

A
  1. Nerve tissue excitation
  2. Muscle contractility
  3. Cofactor for several enzyme systems and the blood clotting cascade
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6
Q

What are 3 roles of extracellular calcium?

A
  1. Nerve tissue excitation
  2. Muscle contractility
  3. Cofactor for several enzyme systems and the blood clotting cascade
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7
Q

What percentage of serum calcium is protein-bound?

A

40%

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8
Q

What percentage of serum calcium is in its free form (and is physiologically active)?

A

47%

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9
Q

Other than free calcium or protein-bound calcium, what forms may serum calcium take?

A

The remainder is mostly complexes with phosphate or citrate

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10
Q

How is calcium corrected for albumin?

A

Add 0.02 mmol/L to the serum calcium for every g/L albumin is below 37, (or subtract 0.02 mmol/L for every g/L above 37)

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11
Q

How does alkalosis affect calcium?

A

Alkalosis causes an increase in the binding of calcium and lowers ionised (free) calcium

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12
Q

How does acidosis affect calcium?

A

Acidosis causes a decrease in the binding of calcium and increases ionised (free) calcium

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13
Q

What is the magnitude to which pH affects serum calcium?

A

A shift of 0.1 pH unit produces a change in ionised calcium of ~0.04 to 0.05 mmol/L

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14
Q

What is the magnitude to which pH affects serum calcium?

A

A shift of 0.1 pH unit produces a change in ionised calcium of ~0.04 to 0.05 mmol/L

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15
Q

What are 3 hormones involved in calcium homeostasis?

A
  1. Parathyroid hormone
  2. Activated Vitamin D
  3. Calcitonin
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16
Q

What are the 3 organs involved in calcium homeostasis?

A
  1. Bone
  2. Kidney
  3. Small intestine
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17
Q

If you have a decreased serum calcium, how does this affect parathyroid hormone release?

A

Parathyroid hormone release will be increased to compensate.

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18
Q

What is the half-life of parathyroid hormone?

A

Minutes

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19
Q

What is the principal regulator of calcium concentration in the extracellular fluid?

A

Parathyroid hormone

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20
Q

What is the effect of parathyroid hormone on serum electrolytes?

A

Parathyroid hormone increases serum calcium and decreases serum phosphate

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21
Q

What 3 organs does parathyroid hormone act on to maintain calcium homeostasis?

A
  1. Small intestine
  2. Kidney
  3. Bone
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22
Q

How does parathyroid hormone affect calcium homeostasis via the intestine?

A

By increasing intestinal absorption of calcium

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23
Q

How does parathyroid hormone affect calcium homeostasis via the kidneys?

A

By increasing reabsorption of calcium and increasing phosphate excretion

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24
Q

How does parathyroid hormone affect calcium homeostasis via the bones?

A

By increasing calcium movement into the extracellular fluid via increased bone resorption

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25
Q

What 3 organs does colecalciferol act on to maintain calcium homeostasis?

A
  1. Gastrointestinal tract
  2. Bone
  3. Kidney
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26
Q

How does colecalciferol affect calcium homeostasis via the gastrointestinal tract?

A

By increasing absorption of calcium

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27
Q

How does colecalciferol affect calcium homeostasis via the kidneys?

A

By increasing reabsorption of calcium within the distal tubule

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28
Q

Describe the effects of the kidneys on calcium

A

The glomerulus filters out calcium that is not bound to protein

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29
Q

How does colecalciferol affect calcium homeostasis via the bones?

A

By increasing calcium mobilisation from the bones

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30
Q

What is the site of calcitonin release in response to hypercalcaemia?

A

Parafollicular cells of the thyroid gland

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31
Q

What are 2 activities of calcitonin in maintaining calcium homeostasis?

A
  1. Decreased osteoclast activity
  2. Stimulate calciuresis from the distal tubule
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32
Q

Describe the effects of the kidneys on calcium

A

The glomerulus filters out calcium that is not bound to protein

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33
Q

Describe the reabsorption of calcium in the kidney

A

It is primarily reabsorbed in the proximal tubule, followed by the ascending loop of Henle, followed by the distal nephron.

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34
Q

Describe the reabsorption of calcium in the kidney

A

It is primarily reabsorbed in the proximal tubule, followed by the ascending loop of Henle, followed by the distal nephron.

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35
Q

Which two hormones increase calcium absorption during calcium deficient states?

A

Parathyroid hormone and colecalciferol

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36
Q

Which other electrolyte is the reabsorption of calcium similar to?

A

Sodium

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37
Q

What are 5 miscellaneous hormones involved in calcium homeostasis?

A
  1. Prostaglandins that mobilise calcium
  2. Growth factors (growth hormone, somatomedins)
  3. Thyroid hormones (decrease skeletal mass)
  4. Gonadal hormones which help maintain bone mass
  5. Adrenocortical hormones
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38
Q

Why does furosemide have a calciuretic effect?

A

As a significant portion of calcium is reabsorbed in the loop of Henle

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39
Q

What are 5 miscellaneous hormones involved in calcium homeostasis?

A
  1. Prostaglandins that mobilise calcium
  2. Growth factors (growth hormone, somatomedins)
  3. Thyroid hormones (decrease skeletal mass)
  4. Gonadal hormones which help maintain bone mass
  5. Adrenocortical hormones
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40
Q

What are 5 miscellaneous hormones involved in calcium homeostasis?

A
  1. Prostaglandins that mobilise calcium
  2. Growth factors (growth hormone, somatomedins)
  3. Thyroid hormones (decrease skeletal mass)
  4. Gonadal hormones which help maintain bone mass
  5. Adrenocortical hormones
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41
Q

What are 5 miscellaneous hormones involved in calcium homeostasis?

A
  1. Prostaglandins that mobilise calcium
  2. Growth factors (growth hormone, somatomedins)
  3. Thyroid hormones (decrease skeletal mass)
  4. Gonadal hormones which help maintain bone mass
  5. Adrenocortical hormones
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42
Q

What are 5 miscellaneous hormones involved in calcium homeostasis?

A
  1. Prostaglandins that mobilise calcium
  2. Growth factors (growth hormone, somatomedins)
  3. Thyroid hormones (decrease skeletal mass)
  4. Gonadal hormones which help maintain bone mass
  5. Adrenocortical hormones
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43
Q

What are 5 miscellaneous hormones involved in calcium homeostasis?

A
  1. Prostaglandins that mobilise calcium
  2. Growth factors (growth hormone, somatomedins)
  3. Thyroid hormones (decrease skeletal mass)
  4. Gonadal hormones which help maintain bone mass
  5. Adrenocortical hormones
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44
Q

Describe the effect of prostaglandins on calcium

A

Prostaglandins promote calcium mobilisation

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45
Q

What are 2 growth factors involved in calcium homeostasis?

A
  1. Growth hormone
  2. Somatomedins
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46
Q

What are 2 growth factors involved in calcium homeostasis?

A
  1. Growth hormone
  2. Somatomedins
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47
Q

How do thyroid hormones affect skeletal mass?

A

Thyroid hormones decrease skeletal mass

48
Q

Describe the expected neuromuscular effects of hypocalcaemia at a level of 1.0 mmol/L

A

Laryngospasm and suffocation at a serum calcium concentration of 1.0 mmol/L

49
Q

How do thyroid hormones affect skeletal mass?

A

Thyroid hormones decrease skeletal mass

50
Q

Which is more common: hypercalcaemia or hypocalcaemia?

A

Hypercalcaemia

51
Q

How do gonadal hormones affect bone mass?

A

Gonadal hormones help maintain bone mass

52
Q

Which is more common: hypercalcaemia or hypocalcaemia?

A

Hypercalcaemia

53
Q

What are 4 principal causes of hypocalcaemia?

A
  1. Chronic renal failure
  2. Hereditary and acquired hypoparathyroidism
  3. Vitamin D deficiency
  4. Hypomagnesaemia
54
Q

When is treatment of hypercalcaemia typically indicated?

A

When calcium concentrations are above 3.0 mmol/L, or if the patient is symptomatic

55
Q

What are 5 signs of neuromuscular hyper-excitability secondary to hypocalcaemia?

A
  1. Tetany
  2. Chvostek sign
  3. Tousseau sign
  4. Carpopedal spasm
  5. Muscle cramps
56
Q

Muscle spasms, tetany and/or what other symptom are expected at a serum calcium concentration of 1.5 mmol/L?

A

Tremors

57
Q

Describe the expected neuromuscular effects of hypocalcaemia at a level of 1.0 mmol/L

A

Laryngospasm and suffocation at a serum calcium concentration of 1.0 mmol/L

58
Q

Describe the typical aetiologies of hypercalcaemia

A

Approximately 80% of all cases are caused by malignancy or primary hyperparathyroidism

59
Q

What is the mechanism by which hypocalcaemia leads to neuromuscular excitability?

A

With less calcium, sodium channels open more easily

60
Q

Describe the ECG changes typically seen in hypocalcaemia

A

Hypocalcaemia causes QTc prolongation primarily by prolonging the ST segment. The T wave is typically left unchanged.

61
Q

What are 4 signs of hypocalcaemia that may present before levels reach 2.8 mmol/L?

A
  1. Polyuria/polydipsia
  2. Dyspepsia (due to calcium-regulated release of gastrin
  3. Depression
  4. Mild cognitive impairment
62
Q

What is the mechanism by which hypocalcaemia causes dyspepsia?

A

Due to calcium-regulated release of gastrin

63
Q

What are 4 symptoms of hypercalcaemia that typically appear between levels of 2.8 and 3.5 mmol/L?

A
  1. Muscle weakness
  2. Constipation
  3. Anorexia/nausea
  4. Fatigue
64
Q

What are 7 potential complications of hypercalcaemia which typically occur with concentrations above 3.5 mmol/L?

A
  1. Abdominal pain
  2. Vomiting
  3. Dehydration
  4. Lethargy
  5. Cardiac arrhythmias, shortened QT interval
  6. Coma
  7. Pancreatitis
65
Q

When is treatment of hypercalcaemia typically indicated?

A

When calcium concentrations are above 3.0 mmol/L, or if the patient is symptomatic

66
Q

Describe the typical aetiologies of hypercalcaemia

A

Approximately 80% of all cases are caused by malignancy or primary hyperparathyroidism

67
Q

A mnemonic for the aetiologies of hypercalcaemia is VITAMINS TRAP, what does this stand for?

Vitamins
Immobilisation
T
A
M
I
N
Sarcoidosis
T
R
A
P

A

VITAMINS TRAP:
Vitamins
Immobilisation
Thyrotoxicosis
Addison’s disease
Milk-alkaline syndrome
Inflammatory disorders
Neoplastic related disease
Sarcoidosis
Thiazides/other drugs (lithium)
Rhabdomyolysis
AIDS
Paget’s disease, parenteral nutrition, pheochromocytoma, parathyroid disease

68
Q

What is typically the most common symptom of hypercalcaemia?

A

Nocturia

69
Q

What are the gastrointestinal symptoms of hypercalcaemia?

A

Anorexia/nausea/vomiting
Constipation
Acute pancreatitis (rarely)

70
Q

What are 3 symptoms of hypercalcaemia related to the cardiovascular system?

A
  1. Hypertension
  2. Arrhythmias
  3. ECG abnormalities
71
Q

What are 3 symptoms of hypercalcaemia related to the renal system?

A
  1. Polyuria
  2. Polydipsia
  3. Nephrocalcinosis (rarely)
72
Q

What are 6 symptoms of hypercalcaemia related to the central nervous system?

A
  1. Cognitive difficulties
  2. Apathy
  3. Drowsiness
  4. Obtundation
  5. Seizures
  6. Coma
73
Q

What are 4 neuromuscular symptoms of hypercalcaemia?

A
  1. Weakness
  2. Myalgia
  3. Arthralgias
  4. Hyporeflexia
74
Q

What ECG changes may be seen in extreme hypercalcaemia?

A

Ventricular irritability and VF arrest

75
Q

What is a rhyming phrase for the symptoms of hypercalcaemia?

A

Moans (central nervous system), bones (bone pain), groans (gastrointestinal disturbances) and stones (nephrolithiasis)

76
Q

What are 6 significant complications of hypercalcaemia?

A
  1. Cardiac arrhythmia
  2. Hypertension
  3. Pancreatitis
  4. Peptic ulcer disease
  5. Nephrolithiasis
  6. Accelerated vascular calcification
77
Q

What ECG changes may be seen in extreme hypercalcaemia?

A

Ventricular irritability and VF arrest

78
Q

What is an ECG change which may be seen in severe hypercalcaemia?

A

Osborn waves (J waves)

79
Q

What ECG changes may be seen in extreme hypercalcaemia?

A

Ventricular irritability and VF arrest

80
Q

What ECG changes may be seen in extreme hypercalcaemia?

A

Ventricular irritability and VF arrest

81
Q

If a patient has hypercalcaemia and hyperparathyroidism, what is this indicative of?

A

Primary hyperparathyroidism

82
Q

If a patient has hypercalcaemia in the absence of hyperparathyroidism, what is this indicative of?

A

Hypercalcaemia of malignancy

83
Q

If a patient has hypocalcaemia and hypoparathyroidism, what is this indicative of?

A

Primary hypoparathyroidism

84
Q

If calcium is high, parathyroid hormone is high, and phosphate is low, what is this indicative of?

A

Primary hyperparathyroidism

85
Q

What accounts for the majority of hypercalcaemia cases?

A

Malignancy

86
Q

If calcium is low/normal, parathyroid hormone is high, and phosphate is high/normal, what is this indicative of?

A

Secondary hyperparathyroidism

87
Q

If calcium is high, parathyroid hormone is very high, and phosphate is high, what is this indicative of?

A

Tertiary hyperparathyroidism

88
Q

Describe the effects of isotonic saline administration in hypercalcaemia

A

Sodium interferes with the resorption of calcium in the proximal tubule, and loading with normal saline produces calciuresis

89
Q

If calcium is high, parathyroid hormone is very high, and phosphate is high, what is this indicative of?

A

Tertiary hyperparathyroidism

90
Q

What is the cause of secondary hyperparathyroidism?

A

Renal impairment

91
Q

What is the cause of secondary hyperparathyroidism?

A

Renal impairment

92
Q

What is the cause of secondary hyperparathyroidism?

A

Renal impairment

93
Q

Why is calcium expected to be low/normal and phosphate high/normal in renal impairment?

A

The kidney is not producing calcitriol effectively, leading to low calcium, and the kidney is unable to excrete phosphate

94
Q

What is the mechanism by which tertiary hyperparathyroidism occurs?

A

After a prolonged period of secondary hyperparathyroidism, the homeostatic mechanisms controlling parathyroid hormone become distorted, and parathyroid hormone production increases, leading to an increase in calcium, while the kidneys can still not excrete phosphate effectively

95
Q

What accounts for the majority of hypercalcaemia cases?

A

Malignancy

96
Q

What are 3 aetiologies of hypercalcaemia in malignancy?

A
  1. Increased bone resorption (osteoclast activity)
  2. Parathyroid hormone-related substance secreted by tumours
  3. Direct erosion by tumour cells
97
Q

What are 6 solid tumour cancers associated with hypercalcaemia?

A
  1. Breast cancer
  2. Lung
  3. Pancreas
  4. Kidney
  5. Ovary
  6. Prostate
98
Q

What are 6 of the common treatment options for hypercalcaemia?

A
  1. Hydration
  2. Furosemide
  3. Bisphosphonates
  4. Calcitonin
  5. Denosumab
  6. Parathyroidectomy
99
Q

What are 2 haematological cancers associated with hypercalcaemia?

A
  1. Myeloma
  2. Lymphosarcoma
100
Q

What are 6 of the common treatment options for hypercalcaemia?

A
  1. Hydration
  2. Furosemide
  3. Bisphosphonates
  4. Calcitonin
  5. Denosumab
  6. Parathyroidectomy
101
Q

What are 6 of the common treatment options for hypercalcaemia?

A
  1. Hydration
  2. Furosemide
  3. Bisphosphonates
  4. Calcitonin
  5. Denosumab
  6. Parathyroidectomy
102
Q

What are 6 of the common treatment options for hypercalcaemia?

A
  1. Hydration
  2. Furosemide
  3. Bisphosphonates
  4. Calcitonin
  5. Denosumab
  6. Parathyroidectomy
103
Q

What are 4 relatively uncommon treatments for hypercalcaemia?

A
  1. Gallium nitrate
  2. Steroids
  3. Phosphate
  4. Dialysis
104
Q

What is the first step in the management of severe hypercalcaemia?

A

Hydration with isotonic saline

105
Q

Describe the effects of isotonic saline administration in hypercalcaemia

A

Sodium interferes with the resorption of calcium in the proximal tubule, and loading with normal saline produces calciuresis

106
Q

What does the rate of intravenous saline administration for hypercalcaemia depend on?

A

The severity of the hypercalcaemia and the tolerability and tolerance of the cardiovascular system for volume expansion

107
Q

What is the mechanism by which loop diuretics can be used to treat hypercalcaemia?

A

Loop diuretics facilitate urinary excretion of calcium by inhibiting calcium reabsorption in the thick ascending limb of the loop of Henle.

108
Q

What is a benefit of loop diuretics in the treatment of hypercalcaemia?

A

They guard against fluid overload

109
Q

What is a complication of loop diuretics in the treatment of hypercalcaemia?

A

The potential for electrolyte disturbances

110
Q

Describe the effects of thiazide diuretics on calcium

A

Thiazides lead to increased sodium/water reabsorption secondary to volume depletion, leading to increased passive calcium reabsorption

111
Q

What is the mechanism by which pamidronate is effective for hypercalcaemia?

A

It inhibits osteoclast function

112
Q

What is the usual dosage of pamidronate for hypercalcaemia?

A

60 mg to 90 mg IV stat

113
Q

Describe the effectiveness of pamidronate in hypercalcaemia

A

70 to 100% of patients will have decreased calcium within 24 hours, and 66% will have normal serum calcium within 7 days

114
Q

What are 3 adverse effects associated with pamidronate?

A
  1. Mild transient increase in temperature (<2oC)
  2. Transient leukopaenia
  3. Small reduction in serum phosphate level
115
Q

What is the primary pathway of excretion of pamidronate?

A

Via the kidneys (dose reduction may be required in impairment)

Residency Exam (22 decks)

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