Hypocalcemia

This has come up many times in the exam:

• Question 7.2 from the second paper of 2018 (also included management of hypocalcemia, which was new)
• Question 7.1 from the first paper of 2014 (guess that the post-op patient's problems are all due to parathyroid surgery)
• Question 9 from the second paper of 2013 (list four causes)
• Question 25.1 from the second paper of 2010 (the parathyroid surgery patient again - identical to Question 7.1 from the first paper of 2014)
• Question 25 from the second paper of 2006 (list five causes and three clinical manifestations)

Oh's Manual has dedicated a small paragraph to hypocalcemia, which is inadequate for CICM SAQ preparation. As the SAQs generally trend towards the "list six kinds of something" questions, the following summary is in the form of easily memorised lists. It has been derived largely from two good articles from the BMJ, one by Cooper and Gittoes (2008) and the other by Hannan and Thakker (2013). Both are too long even for the casual reader; the time-poor exam candidate may wish to limit themselves to the excellent summary from LITFL.

Causes of hypocalcemia

The causes of hypocalcemia can be divided into those which are caused by a low parathyroid hormone, and those which feature a normal parathyroid hormone level.

Causes of Hypocalcemia

Low  Parathyroid Hormone Primary hypoparathyroidism (i.e. destruction of the parathyroid glands) Surgical: post-operative hypoparathyroidism Autoimmune Storage disease, eg. haemochromatosis or Wilsons'\ HIV infection Dysregulation of PTH secretion Congenital Hypomagnesemia Sepsis

High or normal Parathyroid hormone Vitamin D deficiency "True" deficiency (i.e. malabsorption or inadequate UV light) Insufficient synthesis (eg. renal failure) Altered protein binding Alkalosis PTH resistance Hypomagnesemia Chelation or depletion Hyperphosphataemia Tumour lysis syndrome (which causes hyperphosphataemia) Acute pancreatitis Depletion in coagulopathy Consumption by osteoclastic bone metastases Drugs Phenytoin Fluoride toxicity Foscarnet EDTA Citrate Phosphate Bisphosphonates

Question 9 from the second paper of 2013 asked specifically for four causes of ionised  hypocalcemia, which may have led some of the candidates to discuss situations where ionised calcium is low in the presence of a normal total calcium. Of course, that would be a very short list. Ionised hypocalcemia in isolation is rare. It is seen in only one scenario: citrate toxicity. When citrate is used to chelate calcium, the total calcium is normal, but the ionised fraction is low. This is because measurement instruments which detect calcium will also measure citrate-calcium complexes in the serum, but the electrode which measures ionised calcium will only measure the free fraction, which decreases with citrate chelation.

Investigations for hypocalcemia

If one goes by the table above, parathyroid hormone measurement is central to the diagnosis. However, other tests are also helpful. The following list of tests needs to be regurgitated if the college ever ask to "suggest a list of investigations":

• PTH
• Serum 25-hydroxyvitamin D
• Magnesium level
• Phosphate level
• Urea and creatinine
• Amylase and lipase

Serum PTH helps discriminate where the disorder is coming from. Low parathyroid levels are the opposite of what is supposed to happen in hypocalcemia: PTH is supposed to be secreted in response to hypocalcemia, to increase bone resorption and decrease renal excretion (among other things). Ergo, if the patient is hypocalcemic and the PTH is low, something is horribly wrong with the way the PTH is being excreted. This could be due to a number of causes. For instance, there may have been some sort of surgical destruction of the parathyroid glands, as in the favoured CICM SAQ. Alternatively, PTH secretion may have been suppressed,  as in sepsis where the parathyroid glands are suppressed by inflammatory cytokines, or in the case of low magnesium levels (the serum magnesium needs to be below 0.4mmol/L). Lastly, the secretion of PTH may be dysregulated by some sort orf congential mutation of the PTH regulatory pathway.

A raised PTH is a normal reaction to low calcium, which assures you that the parathyroid glands are intact and functioning normally. The question then is, why is the calcium still low?

Serum 25-hydroxyvitamin D  should be the next investigation. Vitamin D deficiency is a very common cause of hypocalcemia. In turn, the commonest causes of Vitamin D deficiency are renal failure, dietary deficiency and lack of UV light. For this reason, urea and creatinine should be tested. Realistically, in the ICU you will be aware of renal function long before the vitamin D levels are available.

Hypomagnesemia can cause both depressed PTH secretion and impaired tissue response to PTH; the sustained level required for this effect is below 0.4mmol/L

Hyperphosphataemia can be associated with low calcium; generally speaking primary hypoparathyroid disorders are associated with a raised serum phosphate. In turn, secondary hyperparathyroidism (eg. in Vitamin D deficiency) are associated with a low phosphate. High phosphate will also chelate calcium, forming insoluble calcium phosphate, but because it is insoluble it is not measurable by normal means and therefore is unlikely to show up in the tests.

Clinical features of hypocalcemia

Clinical Manifestations of Hypocalcemia

Mild hypocalcemia Generalised myalgia Twitching, fasciculations QT prolongation Chvostek’s sign Confusion, delirium, psychosis

Severe hypocalcemia Carpopedal spasm (Trousseau’s sign) Tetany and seizures Papilloedema, raised intracranial pressure Cardiac arrhythmias, esp. Torsades Hypotension

Management of hypocalcemia

Replace the calcium, you would think. How much more complicated does it need to be? Well. Surprisingly the college examiners were able to stretch this simple task into a paragraph of management recommendations, in their model answer to Question 7.2 from the second paper of 2018. In response, following a time-honoured Deranged Physiology tradition, the author had to go a step further and bury the simplicity of giving calcium under a ton of potentially unnecessary detail. The bulk of this comes from  Cooper and Gittoes (2008):

Acute replacement

• IV replacement of calcium salt
• Calcium chloride or gluconate, doesn't matter
• Ensure magnesium and phosphate are replaced at the same time 

Medium term replacement

• Oral calcium replacement
  • In their model answer to Question 7.2 from the second paper of 2018, the college specifically recommend calcium citrate, "Not Ca carbonate",   in spite of the fact that the citrate appears to have lower oral bioavailability (Wang et al, 2014). According to UpToDate, both choices are available in exactly the same dose of elemental calcium. One possible reason for this (otherwise unexplainable) preference is the need for normal gastric pH to dissolve calcium carbonate tables, i.e. it is to be taken with food whereas calcium citrate is more suitable to an otherwise fasted post-operative patient. 
• Vitamin D replacement
• With intact parathyroid function:
  • Cholecalciferol (which is then converted to calcitriol in the kidney, provided parathyroid function is normal)
• With impaired parathyroid function:
  •  Calcitriol, the hormonally active version of Vitamin D (without PTH around the oral cholecalciferol supplements will not be effective)
• Both drugs will have positive effects:
  • Improve gut absorption
  • Improve release of calcium from bone
  • Decrease renal excretion

So, what might one do if in spite of ongoing calcium infusion the ionised calcium keeps dropping? That would probably be the "recalcitrant hypoCa" described by the examiners  in their model answer to Question 7.2 from the second paper of 2018. "Recalcitrant hypoCa" is actually a real phenomenon which tends to occur in patients who have previously had gastric bypass procedures (Moore et al, 2013), as the patient in this question has done. It has no scientific definition, but some authors (eg. Ballal et al, 2017) seem to characterise it as a hypocalcemia which fails to respond to either vitamin D supplementation or intravenous calcium. There are some treatment options open to these people:

• Thiazide diuretics (which increase the renal reabsorption of calcium)
• recombinant PTH