Hypocalcemia In Patients Research Articles

Predicting cure and hypocalcemia by intraoperative parathyroid hormone decline in normohormonal primary hyperparathyroidism: A multi-institutional validation study

BackgroundNormohormonal primary hyperparathyroidism is characterized by hypercalcemia and inappropriately normal parathyroid hormone levels. We previously reported that intraoperative parathyroid hormone decline of 50–70% for normohormonal and 75–88% for classic primary hyperparathyroidism during parathyroidectomy was predictive of (1) cure and (2) avoidance of hypocalcemia in a single-institution study (derivation cohort). We sought to externally validate these findings. MethodsWe performed a multi-institutional retrospective cohort study of patients undergoing parathyroidectomy for primary hyperparathyroidism from 2002 to 2019 (validation cohort). Primary outcomes were biochemical cure (calcium <10.3 mg/dL) and postoperative hypocalcemia (≤8.8 mg/dL) ≥6 months postoperatively. Test characteristics of the previously derived thresholds were evaluated in this cohort. ResultsA total of 163 (16%) of 1,037 patients had normohormonal primary hyperparathyroidism. Cure rates were similar for normohormonal and classic primary hyperparathyroidism (94% vs 92%, P = .41). In patients who were cured, the median intraoperative parathyroid hormone decrease was lower in normohormonal compared with classic primary hyperparathyroidism (56.8 vs 73.3%, P < .0001). Rates of hypocalcemia were similar for normohormonal and classic primary hyperparathyroidism (14.6% vs 11.9%, P = .44), but increasing percent intraoperative parathyroid hormone decrease beyond 65% disproportionately correlated with hypocalcemia in patients with normohormonal primary hyperparathyroidism. When intraoperative parathyroid hormone thresholds from the derivation cohort were applied, positive predictive values for cure were 97% and 94% for normohormonal and classic primary hyperparathyroidism, respectively; negative predictive values for hypocalcemia were 89% for both groups. For both cohorts combined, a minimal intraoperative parathyroid hormone of 50% provided similar cure rates between groups (95.4% vs 93.8%, P = .42), whereas intraoperative parathyroid hormone exceeding 65% correlated with a greater risk of hypocalcemia in normohormonal compared with classic primary hyperparathyroidism (13.4% vs 6.9%, P = .02). ConclusionThis multi-institutional study externally validated that intraoperative parathyroid hormone decrease of 50–65% predicts cure and hypocalcemia in patients with normohormonal primary hyperparathyroidism.

Ratios of calcium to citrate administration in blood transfusion for traumatic hemorrhage: A retrospective cohort study.

Massive transfusion with citrated blood products causes hypocalcemia, which is associated with mortality. Recognition of this problem has led to increased calcium administration; however, the optimal dosing is still unknown. This retrospective, single-center study included level 1 trauma patients in 2019 and 2020 who underwent an operation within 12 h of arrival and received a transfusion. Preoperative and intraoperative administrations were totaled to calculate the ratio of administered calcium to the number of blood transfusions for each patient. The citrate content of each blood component was estimated to calculate a second ratio, the ratio of administered calcium to administered citrate. Receiver Operating Characteristic (ROC) curves were performed on both ratios to determine the optimal cutoff values for predicting severe hypocalcemia (ionized calcium <0.9 mmol/L) and hypercalcemia (>1.35 mmol/L) at the end of the intraoperative period. A total of 506 trauma activations were included, receiving a mean of 17.4 citrated blood products and 16.3 mmol of calcium (equivalent to 2400 mg of calcium chloride). No ratio was statistically significant in differentiating severely hypocalcemic patients from the rest. A calcium to blood ratio of 0.903 mmol of administered calcium per citrated blood product differentiated hypercalcemic patients from the rest. Quantifying received calcium and citrated blood products was insufficient to predict severe hypocalcemia, suggesting other contributions to hypocalcemia. We demonstrated an upper-limit ratio for calcium administration in traumatic hemorrhage; however, further studies are required to determine what calcium dosing regimen results in the best outcomes.

Role of Postoperative Intact Parathyroid Hormone Levels in Predicting Hypocalcaemia after Thyroidectomy.

To determine the sensitivity and specificity of intact parathyroid hormone (iPTH) levels in predicting hypocalcaemia after thyroidectomy. A descriptive cross-sectional study. Place and Duration of the Study: Department of General Surgery, Shifa International Hospital and Shifa Foundation, Islamabad, from May 2021 to 2022. The sample size was calculated to be 205 with consecutive non-probability sampling. Serum iPTH levels and serum calcium levels were measured postoperatively at 6 hours and 24 hours and recorded in a proforma for analysis. After collection, the data were entered and analysed using SPSS version 24.0. Among 205 patients, 157 (76.6%) were females and 48 (23.4%) were males. At 6 hours postoperatively, 121 (59%) patients had normal iPTH levels and 123 (60%) patients had normal serum calcium levels (p = 0.15). At 24-hour, 130 (63.4%) patients had normal iPTH levels and 92 (44.9%) patients had normal serum calcium levels (p = 0.001). Overall, 8 (3.9%) patients developed symptomatic hypocalcaemia (p = <0.001). The sensitivity and specificity of iPTH levels at ≤15 pg/ml were 100% and 70%, respectively, but at 24 pg/ml cut-off level, the specificity increased to 90% with sensitivity of 100%. Low serum iPTH levels at 6 hours after surgery can predict hypocalcaemia in patients undergoing thyroidectomy, even if serum calcium levels appear normal at that time. Parathyroid hormone, Serum calcium, Hypocalcaemia, Total thyroidectomy, Calcium homeostasis.

Identification of novel risk factors for postoperative severe hypocalcemia in patients with primary hyperparathyroidism undergoing parathyroidectomy: a case control study

BackgroundPatients with primary hyperparathyroidism (PHPT) are at risk for severe hypocalcemia (SH) following parathyroidectomy (PTX), but limited data exist on the predictors of SH. We aimed to identify risk factors for early postoperative SH after PTX in patients with PHPT and to evaluate the predictive value of clinical parameters.MethodsA retrospective review of patients with PHPT who underwent PTX between January 2010 and December 2022 was performed. A total of 46 patients were included in the study, with 15 (32.6%) experiencing postoperative SH, 19 (41.3%) having calculi in the ureter or kidney, and 37 (80.4%) having osteoporosis. Patients were divided into SH and non-SH groups based on postoperative serum calcium levels. Preoperative biochemical indicators, bone turnover markers, and renal function parameters were analyzed and correlated with postoperative SH.ResultsStatistically significant (P < 0.05) differences were found in preoperative serum calcium (serum Ca), intact parathyroid hormone, serum phosphorus (serum P), serum Ca/P, percentage decrease of serum Ca, total procollagen type 1 intact N-terminal propeptide, osteocalcin (OC), and alkaline phosphatase levels between the two groups. Multivariate analysis showed that serum P (odds ratio [OR] = 0.989; 95% confidence interval [95% CI] = 0.981–0.996; P = 0.003), serum Ca (OR = 0.007; 95% CI = 0.001–0.415; P = 0.017), serum Ca/P (OR = 0.135; 95% CI = 0.019–0.947; P = 0.044) and OC levels (OR = 1.012; 95% CI = 1.001–1.024; P = 0.036) were predictors of early postoperative SH. The receiver operating characteristic curve analysis revealed that serum P (area under the curve [AUC] = 0.859, P < 0.001), serum Ca/P (AUC = 0.735, P = 0.010) and OC (AUC = 0.729, P = 0.013) had high sensitivity and specificity.ConclusionPreoperative serum P, serum Ca/P and osteocalcin levels may identify patients with PHPT at risk for early postoperative SH after PTX.

Severe hypocalcemia in the emergency department: a retrospective cohort study of prevalence, etiology, treatment and outcome.

The aim of this study was to evaluate the prevalence of severe hypocalcemia in patients attending the emergency department. Symptoms, causes, treatment, and outcome of severe hypocalcemia as well as course of calcium concentrations were assessed. This retrospective case series included all adult patients with measurements of serum calcium concentrations presenting to the emergency department of the Bürgerspital Solothurn between January 01 in 2017 and December 31 in 2020. Medical record reviews were performed of all patients with severe hypocalcemia, defined by a serum calcium concentration < 1.9mmol/L, to assess clinical presentation and management. 1265 (3.95%) patients had a serum calcium concentration of < 2.1mmol/L of which 139 (11%) had severe hypocalcemia of < 1.9mmol/L. 113 patients had at least one measurement of albumin. Of these, 43 (3.4%) had an albumin-corrected serum calcium < 1.9mmol/L defining true, severe hypocalcemia. Hypocalcemia was identified and documented in 35% of all cases. The mean serum calcium concentration was 1.74 ± 0.14mmol/L. Calcium concentrations in malignancy-related hypocalcemia were similar to non-malignancy-related hypocalcemia. The main symptoms attributed to hypocalcemia were cardiac and neurologic. 12% of patients with severe hypocalcemia received intravenous and 23% oral calcium replacement. Active malignancy was the main cause of severe hypocalcemia in 28%, while in most cases, the main cause remained unclear. 41.9% of severely hypocalcemic patients reattended the emergency department for another episode of hypocalcemia within 1 year. Hypocalcemia is common in patients attending the emergency department, however, appears to be neglected frequently. The disorder is often a manifestation of severe disease, triggered by multiple causes. Calcium replacement was administered in less than half of the patients with severe hypocalcemia in this study. Due to frequent readmissions to the emergency department and a high mortality, increased awareness of the disorder and careful follow-up are desirable.

#1250 Measurement of ionized calcium with a point-of-care ionometer during treatment with etelcalcetide

Abstract Background and Aims Etelcalcetide is an intravenous calcimimetic indicated for the treatment of mineral and bone disorders in hemodialysis patients by lowering parathyroid hormone (PTH), calcium and phosphorus. The assessment of ionized calcium versus total calcium has not yet been studied during treatment with etelcalcetide, and there are no real data on the occurrence of hypocalcemia as measured by ionized calcium in the pre- and post-hemodialysis period during treatment with etelcalcetide. The aim of this study was to describe the time course of ionized and total serum calcium levels during chronic treatment with etelcalcetide and to assess the occurrence of hypocalcemia in patients treated with etelcalcetide by measuring ionized calcium levels. Method This was an observational, non-interventional, prospective, single-arm phase IV study. A total of 20 chronic hemodialysis patients (15 men and 5 women) aged 55.9 ± 18.2 years undergoing dialysis for 5.5 ± 4.3 years in two hemodialysis centers of the University Medical Centre Ljubljana were enrolled in the study between January 2020 and March 2021. All patients received etelcalcetide as a bolus injection into the venous line of the dialysis circuit three times a week, immediately after each hemodialysis session. Ionized calcium levels were determined using a point-of-care ionometer (GEM Premier 3000) before starting treatment with etelcalcetide prior to dialysis, then during treatment in the first week before and after dialysis, then once a week until the maintenance phase was reached and at least once a month thereafter. Hypocalcemia was defined by a pre-dialysis ionized calcium concentration below 0.90 mmol/L. The corrected total calcium values was measured prior to dialysis at least once a month according to routine clinical practice. The data of all these patients were included in the analysis, except for one, who underwent a kidney transplantation after receiving only 4 doses of etelcalcetide. Results We demonstrated that both corrected total calcium and ionized calcium before dialysis decreased over time during treatment with etelcalcetide. Of 240 measurements of ionized calcium with a point-of-care ionometer at the bedside, the concentration of ionized calcium was below 0.90 mmol/L three times in two patients (0.81, 0.84, 0.85). In one patient, we increased a calcium level in the dialysate from 1.50 to 1.75 mmol/L and in the other from 1.25 to 1.50 mmol/L. In addition, we observed 2 further measurements of ionized calcium of 0.90 mmol/L and 18 measurements between 0.91 and 0.96 mmol/L. However, this corresponds to 1.25% of hypocalcemias with ionized calcium below 0.90 mmol/L and 8.3% of those with calcium between 0.90 and 0.96 mmol/L. As calcium concentration in the bath increased, the pre-dialysis calcium concentrations also appeared to increase. At the beginning of the study, the calcium concentration in the dialysate was 1.5 mmol/L in 16 of 20 patients. 2 patients were treated with a calcium concentration in the dialysate of 1.75 mmol/L and 2 others with 1.25 mmol/L. The proportion of patients using higher dialysate calcium concentration was higher at the end of the study, as two patients switched to 1.75 mmol/L, and one from 1.25 to 1.50 mmol/L. This probably indicates a co-intervention triggered by a reduction in serum calcium levels prior to dialysis during treatment with etelcalcetide. Visual comparisons of the time course of ionized and corrected calcium concentrations before dialysis during chronic treatment with etelcalcetide in 19 patients showed a good correlation between point-of-care ionized calcium and routinely measured total calcium. Conclusion A point-of-care ionometer for the determination of ionized calcium at the bedside has the potential to guide etelcalcetide therapy by optimizing serum calcium levels and also to prevent potentially threatening hypocalcemia.

Evaluation of Hypocalcemia Following Total Laryngectomy With and Without Thyroidectomy.

Hypoparathyroidism and associated hypocalcemia are well-established complications following laryngectomy. This study further characterizes the rates of hypocalcemia in patients undergoing total laryngectomy (TL) with and without thyroidectomy and hemithyroidectomy. Retrospective cohort study. TriNetX. We queried TriNetX, a deidentified patient database, to identify patients who underwent TL with and without thyroidectomy and hemithyroidectomy. Rates of hypocalcemia, low parathyroid hormone (PTH), calcium, and calcitriol supplementation were compared between groups with multivariable repeated measures logistic regression. We identified 870 patients in the TL without thyroidectomy cohort, 158 patients in the hemithyroidectomy cohort, and 123 in the total thyroidectomy cohort. Rates of hypocalcemia differed between patients receiving total thyroidectomy versus TL alone for 0 to 1 month (odds ratio [OR]: 2.88 [1.95-4.26]) 1 to 6 months (OR: 5.08 [2.29-11.3]), and 6 to 12 months (OR: 2.63 [1.003-6.88]) postoperatively, with adjustment for age at laryngectomy, race, ethnicity, and gender. Results were similar among those who received calcium supplementation. The rate of low PTH levels differed in these groups for 0 to 1 month (OR: 5.13 [3.10-8.51]), 1 to 6 months (OR: 3.47 [1.46-8.22]), and 6 to 12 months (OR: 3.63 [1.40-9.38]) following surgery. Rates of postoperative calcium supplementation were increased for patients receiving total thyroidectomy versus TL for 1 to 6 months (OR: 2.44 [1.62-3.68]), and 6 to 12 months following surgery (OR: 1.79 [1.18-2.72]). Patients undergoing TL with total thyroidectomy have a higher risk of postoperative hypocalcemia compared to patients receiving TL alone. Risk of parathyroid injury in these patients may warrant further emphasis on PTH measurement after surgery and a multidisciplinary approach to management.

Ionized hypocalcemia as a prognostic factor of early mortality in traumatic brain injury

ABSTRACT Traumatic brain injury (TBI) is a common neurological condition. It can affect mental, physical, and cognitive functions and is a common cause of mortality. Electrolytes imbalance is common in those patients. Effective therapy of electrolytes abnormalities improves neurological outcome and reduces mortality. Therefore, we studied the predictive significance of ionized hypocalcemia for early mortality in TBI patients. Patients and method This observational study in the intensive care units of the Ain Shams University hospitals was done on sixty adult patients with TBI of both sexes, divided into two groups: group A (ionized hypocalcemic patients), and group B (normocalcemic patients). On admission, medical history, physical examination including neurological evaluation, and appropriate investigations were performed. Ionized calcium was measured at the start of the 28-day study and then every five days after that. Results There was no statistically significant difference between the two groups for demographic data, brain injury type, or the number of intubated patients (p > 0.05). There was a statistically significant difference for diffuse axonal damage, subdural hemorrhage, cerebral edema, GCS, and mean blood pressure (p < 0.001). Serum ionized calcium in group A was significantly lower than in group B on the day of admission and day five (p < 0.001). On the day of admission, there was a significant difference in serum sodium (p < 0.05). In both groups, there was a significant difference in the ICU stay as regards survivors (p < 0.001). There was a statistically significant difference in 28-day mortality between the two groups (p = 0.001). Conclusion In TBI patients, ionized hypocalcemia on admission and on day five, hypernatremia and disturbed conscious level are strongly linked to greater fatality rates.

Predictive factors of early postoperative hypocalcemia in patients with secondary hyperparathyroidism undergoing parathyroidectomy

Predictive factors of early postoperative hypocalcemia in patients with secondary hyperparathyroidism undergoing parathyroidectomy

A prospective cross-sectional study on hypocalcemia after total thyroidectomy in patients with Graves' disease: insights on secondary hyperparathyroidism.

To investigate the parathyroid function and calcium (Ca) levels in the secondary hyperparathyroidism (SHPT) state in patients with Graves' disease. We examined 31 consecutive patients with Graves' disease without chronic kidney disease, who were treated with total thyroidectomy. The patients were divided into a normal parathyroid hormone (PTH) group (NPTH group; n = 19) with a PTH level ≤ 65pg/mL, and a secondary hyperparathyroidism group (SHPT group; n = 12), with a PTH level > 65pg/mL. The PTH and Ca-related parameters were examined and the risk factors for postoperative hypocalcemia were analyzed. The preoperative Ca level was significantly lower (2.24 ± 0.06 vs. 2.31 ± 0.07mmol/L, p < 0.05) in the SHPT group than in the NPTH group. The reduction in PTH, 1,25-dihydroxyvitamin D (1,25(OH)2D), and Ca levels from the preoperative day to the next morning was significantly greater in the SHPT group than in the NPTH group (p < 0.05). When intraoperative factors were included, the decrease in the PTH level alone was significant. SHPT was a significant factor in determining the extent of PTH reduction. Hyperfunctioning parathyroid glands in the SHPT state were more susceptible to postoperative PTH reduction, which, combined with low preoperative Ca levels, increased the risk of postoperative hypocalcemia in patients with Graves' disease.

Investigating Potential Correlations between Calcium Metabolism Biomarkers and Periprocedural Clinical Events in Major Cardiovascular Surgeries: An Exploratory Study.

Background: There is emerging but conflicting evidence regarding the association between calcium biomarkers, more specifically ionized calcium and the prognosis of intensive care unit (ICU) postoperative cardiac patients. Methods: Our study investigated the relationship between ionized calcium, vitamin D, and periprocedural clinical events such as cardiac, neurologic and renal complications, major bleeding, vasoactive-inotropic score (VIS), and length of ICU and hospitalization. Results: Our study included 83 consecutive subjects undergoing elective major cardiac surgery requiring cardiopulmonary bypass. The mean age of the participants was 64.9 ± 8.5 years. The majority of procedures comprised isolated CABG (N = 26, 31.3%), aortic valve procedures (N = 26, 31.3%), and mitral valve procedures (N = 12, 14.5%). A difference in calcium levels across all time points (p < 0.001) was observed, with preoperative calcium being directly associated with intraoperative VIS (r = 0.26, p = 0.016). On day 1, calcium levels were inversely associated with the duration of mechanical ventilation (r = -0.30, p = 0.007) and the length of hospital stay (r = -0.22, p = 0.049). At discharge, calcium was inversely associated with length of hospital stay (r = -0.22, p = 0.044). All calcium levels tended to be lower in those who died during the 1-year follow-up (p = 0.054). Preoperative vitamin D levels were significantly higher in those who experienced AKI during hospitalization (median 17.5, IQR 14.5-17.7, versus median 15.3, IQR 15.6-20.5, p = 0.048) Conclusion: Fluctuations in calcium levels and vitamin D may be associated with the clinical course of patients undergoing cardiac surgery. In our study, hypocalcemic patients exhibited a greater severity of illness, as evidenced by elevated VIS scores, and experienced prolonged mechanical ventilation time and hospital stays. Additional larger-scale studies are required to gain a deeper understanding of their impact on cardiac performance and the process of weaning from cardiopulmonary bypass, as well as to distinguish between causal and associative relationships.

Recurrent severe hypocalcemia following chemotherapy regimen changes in advanced breast cancer: two case reports

BackgroundAs an oncologic emergency related to abnormalities in calcium metabolism, hypercalcemia associated with paraneoplastic syndrome and bone metastases is well known. Meanwhile, the incidence of hypocalcemia is low, except in cases associated with bone-modifying agents used for bone metastases. Hypocalcemia induced by bone-modifying agents typically occurs early after the initial administration, and its incidence can be significantly reduced by preventive administration of calcium and vitamin D3 supplements.Case reportWe report two cases of recurrent severe hypocalcemia occurring during chemotherapy for metastatic breast cancer with multiple bone metastases.Case 1: A 35-year-old Japanese woman developed metastases in the bone, liver, and ovaries during postoperative endocrine therapy for invasive lobular carcinoma of the breast. She underwent chemotherapy and treatment with denosumab. She experienced recurrent episodes of severe hypocalcemia subsequent to a change in the chemotherapy regimen. Case 2: A 65-year-old Japanese woman encountered multiple bone metastases after postoperative anti-human epidermal growth factor receptor 2 therapy and during endocrine therapy for invasive ductal carcinoma of the breast. She underwent anti-human epidermal growth factor receptor 2 therapy and treatment with denosumab. She experienced recurrent severe hypocalcemia subsequent to a change in the chemotherapy regimen to letrozole + lapatinib, trastuzumab emtansine, and lapatinib + capecitabine.ConclusionsWe observed two cases of recurrent severe hypocalcemia in patients with advanced breast cancer and bone metastases after modifications to their therapy regimens. These cases differed from the typical hypocalcemia induced by bone-modifying agents. It is possible that antitumor drugs affect calcium and bone metabolism associated with bone metastases. While these cases are rare, it is crucial for oncologists to be aware of hypocalcemia not only at the initiation of bone-modifying agents but also throughout the entire antitumor therapy, as hypocalcemia can lead to fatal outcomes.

In brief: Severe hypocalcemia with denosumab (Prolia) in chronic kidney disease.

The FDA is requiring a boxed warning in the label of denosumab (Prolia – Amgen), a monoclonal antibody that inhibits osteoclasts, about an increased risk of severe hypocalcemia in patients with advanced chronic kidney disease (CKD; eGFR &lt;30 mL/min/1.73 m2), particularly those on dialysis. FDA-approved indications for Prolia are listed in Table 1.

Association between preoperative cholecalciferol therapy and hypocalcemia after parathyroidectomy in patients with primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a endocrine disorder characterized by excessive secretion of parathyroid hormone (PTH) from parathyroid gland tumors. Parathyroidectomy (PTE) is the main treatment for PHPT, but it can lead to hypocalcemia in up to 46% of cases. Hypocalcemia is associated with seizures and life-threatening cardiac arrhythmias, and vitamin D deficiency can exacerbate PHPT severity and contribute to «hungry bones syndrome,» resulting in severe and persistent postoperative hypocalcemia. To evaluate the association and determine the strength of the relationship between preoperative cholecalciferol therapy and the occurrence of hypocalcemia within 1-3 days after PTE in patients with PHPT. The study was conducted at the Endocrinology Research Centre, during the periods of 1993-2010 and 2017-2020. The inclusion criteria consisted of patients diagnosed with PHPT who required PTE, had a serum 25-hydroxyvitamin D (25(OH)D) level below 20 ng/mL, and a serum total calcium level below 3 mmol/L. The exclusion criterion was the use of medications that affect calcium-phosphorus metabolism, including cinacalcet, denosumab, or bisphosphonates, either as monotherapy or as part of combination therapy. There were 117 patients, including 110 (94%) females and 7 (6%) males. The median age and interquartile range were 58 [49; 65] years. Among the participants, 21 (18%) received cholecalciferol supplementation for a duration of 2 weeks to 2 months prior to PTE, aiming to address vitamin D deficiency. The remaining 96 (82%) participants did not receive -cholecalciferol supplementation. Both groups, i.e., participants receiving cholecalciferol and those who did not, were similar in terms of anthropometric factors (sex and age at the time of surgery), preoperative clinical characteristics (BMD decrease), and laboratory parameters (PTH, total calcium, phosphorus, ALP, OC, CTX-1, and 25(OH)D levels). The occurrence of postoperative hypocalcemia was significantly lower in participants who received cholecalciferol supplementation (10% vs. 63%, p&lt;0,001, FET2). Cholecalciferol intake showed a negative association with hypocalcemia development (RR=0,15, 95% CI (0,03; 0,51)). Preoperative cholecalciferol supplementation for 2 weeks to 2 months before PTE reduces the risk of postoperative hypocalcemia in patients with PHPT by 2-33 times.

Denosumab-induced hypocalcemia in patients with solid tumors and renal dysfunction: a multicenter, retrospective, observational study

BackgroundBone metastases are frequently observed in advanced cancer, and bone modifying agents are used to prevent or treat skeletal-related events. Zoledronic acid is contraindicated in patients with severe renal impairment (Ccr < 30 mL/min), but it is not completely known whether denosumab can be used in them. We aimed to determine the association between renal function and hypocalcemia development during denosumab treatment.MethodsWe included patients with solid cancer and bone metastases who started denosumab treatment between April 2017 and March 2019. They were classified into four groups based on creatinine clearance (Ccr; mL/min): normal (Ccr ≥ 80), mild (50 ≤ Ccr ˂80), moderate (30 ≤ Ccr ˂50), and severe (Ccr ˂30). Hypocalcemia was evaluated using the Common Terminology Criteria for Adverse Events (v5.0) based on the albumin-adjusted serum calcium levels; its incidence (stratified by renal function) and risk factors were investigated using a Chi-square test and logistic regression analysis.ResultsOf 524 patients (age: 69 ± 11 years; 303 men), 153 had a normal renal function and 222, 117, and 32 had mild, moderate, and severe renal dysfunction. The albumin-adjusted serum calcium level was higher than the measured (total) calcium level in most patients. The incidence of grade ≥ 1 hypocalcemia was 32.0% in the normal group and 37.4%, 29.9%, and 62.5% in the mild, moderate, and severe renal dysfunction groups, respectively. It was, therefore, higher in the severe renal dysfunction groups than in the normal group (P = 0.002). The incidence of grade ≥ 3 hypocalcemia did not differ significantly among the groups. Pre-treatment low serum calcium levels and severe renal dysfunction were risk factors for hypocalcemia.ConclusionsEvaluating denosumab-induced hypocalcemia required albumin adjustment, and its incidence was high among patients with severe renal dysfunction. Reduced serum calcium levels and severely impaired renal function were associated with an elevated hypocalcemia risk.

A Study of Incidence and Management of Postoperative Hypocalcemia in Patients Undergoing Near-Total and Total Thyroidectomy.

To study the incidence and management of postoperative hypocalcemia in participants undergoing near-total (NTT) and total thyroidectomy (TT) at a tertiary health care center. This is an observational prospective study. Patients posted for NTT and TT in our institute and meeting the inclusion criteria were included. A total of 45 participants were enrolled. The serum calcium was measured on postoperative day 2, at the time of discharge and on 3months follow-up. A combination of injectable and oral calcium supplements with or without vitamin D sachet was used for the treatment of hypocalcemia. Hypocalcemia was observed in 49% cases. Women were observed to develop hypocalcemia at a higher rate than men. Incidence of hypocalcemia was more in TT patients than NTT patients. Cases with malignant pathology were more susceptible to develop hypocalcemia than those with benign pathology. Operated TT with concomitant neck dissection were at higher risk for development of hypocalcemia. There was no significant association between age and incidence of hypocalcemia. Serum calcium measured on postoperative day 2 was a reliable indicator of risk of hypocalcemia. The early measurement of serum calcium level is a reliable indicator of the risk of hypocalcemia. Standardized treatment of hypocalcemic patients with calcium and vitamin D supplements can reduce the incidence and morbidity associated with postoperative hypocalcemia.

Association of Hypocalcemia with In-Hospital Outcomes in Patients with Heart Failure

Objective: To determine the association of hypocalcemia with in-hospital outcomes in terms of in-hospital mortality in patients with heart failure. Methodology: This descriptive Study was done at department of Cardiology, LUMHS, Jamshoro, from March 2022 to March 2023. Patients aged 18 to 80 years old both genders, patients who were present with heart failure were included. Baseline investigations, including serum calcium levels, were performed, with hypocalcemia defined as serum calcium levels &lt;8.7mg/dL. Patients were then categorized based on the presence or absence of hypocalcemia and assessed for in-hospital mortality. Data analysis was conducted using SPSS version 24.0. Results: The mean age of the patients was 63.84 years with a standard deviation of 15.55 years and mean serum calcium level was 8.80 mg/dL. Among the patients, 69.4% were male and 30.6% were female. Among patients of heart failure, the in-Hospital mortality was 18.3%. The overall frequency of hypocalcemia in patients with heart failure was 19.40%. Among patients how died during hospital stay, 2.6% had hypocalcemia, while 16.8% were died without hypocalcemia, the p-value 0.316 indicated that the association of hypocalcemia was statistically insignificant (p-0.316). The P-values for gender and diabetes mellitus were significant (&lt;0.05), indicating a correlation between these factors and hypocalcemia, while age and hypertension showed insignificant associations with hypocalcemia (&gt;0.05).

Decreased level of pre-operative vitamin D in a patient who is undergoing a total thyroidectomy is an early indicator of post-operative hypocalcemia.

Objective: To investigate the viability of utilizing preoperative serum vitamin D levels as a predictor of postoperative transient hypocalcemia in patients who were undergoing total thyroidectomy in our population. Study Design: Prospective Observational study. Setting: Shifa International Hospital Islamabad, Pakistan. Period: 1st July 2020 to 30th June 2022. Material &amp; Methods: All the data was collected prospectively. Patients are divided into two groups depending on the pre- operative vitamin D levels. The preoperative vitamin D levels are checked on day of admission before the surgery. After the surgery, their post-operative serum calcium levels are checked at 6 hours, 24 hours and 48 hours. Intact PTH levels are also checked after the surgery and correlation of transient hypocalcemia with intact PTH levels is also checked. Results: Our results strongly predict that serum Vitamin D levels and intact parathyroid hormone (PTH) levels are diagnostic indicators of transient hypocalcemia in post thyroidectomy patients. Conclusion: Our study shows: Pre-operative vitamin D is an early indicator of hypocalcemia in post-thyroidectomy patients. Serum intact parathyroid hormone levels is an early indicator of hypocalcemia in post-thyroidectomy patients.

Frequency of Hypocalcemia among Patients with Moderate to Severe Chronic Plaque Psoriasis

Psoriasis is a common skin problem. It is associated with many risk factors including hypocalcemia. It is important to determine serum calcium levels among psoriatic patients that may help in proper management. Objective: To determine frequency of hypocalcemia in patients of moderate to severe chronic plaque psoriasis. Methods: It was a cross-sectional study that had involved 90 patients of both genders aged between 22-70 years having chronic plaque psoriasis. The patients were evaluated for level of calcium in serum and hypocalcemia was labeled if albumin corrected serum calcium was &lt;8.9 mg/dl. A prior written informed consent was taken from each patient. Results: The mean age of the patients was 40.7 ±1 3.9 years. There were 51 (56.7%) male and 39 (43.3%) female patients with a male to female ratio of 1.3:1. The mean duration of disease was 9.2 ± 4.4 years while the mean serum calcium was 8.89 ± 0.79 mg/dl. 59 (65.6%) patients had moderate while 31 (34.4%) patients had severe disease. Hypocalcemia was observed in 35 (38.9%) patients and it was significantly higher in patients with severe disease as compared to moderate disease (58.1% vs. 28.8%; p-value=0.007). Conclusions: In this study a substantial proportion of patients with chronic plaque psoriasis had hypocalcemia suggesting potential role of serum calcium in the pathogenesis of psoriasis. Hypocalcemia may also indicate severity of disease. This study advocates routine screening a correction of serum calcium levels among such patients as it leads to timely identification and appropriate management of the disease.

Reducing the risk of denosumab-induced hypocalcemia in patients with advanced chronic kidney disease: a quality improvement initiative.

There is an increased risk of hypocalcemia with denosumab in advanced chronic kidney disease (CKD). We aimed to reduce the proportion of patients with advanced CKD who experienced denosumab-induced hypocalcemia at our center. We conducted a quality improvement (QI) project of patients with CKD stage 3b or less (i.e., estimated glomerular filtration rate <45 mL/min/1.73m2 including dialysis) who were part of the Osteoporosis and Bone Disease Program at St. Joseph's Health Care London (Canada) between December 2020 and January 2023. Our intervention was a clinical care pathway which optimized CKD mineral and bone disorder (CKD-MBD) and 25-hydroxyvitamin levels; provided calcium and vitamin D prophylaxis; promoted multidisciplinary communication between bone and kidney specialists; and carefully monitored calcium post-denosumab injection. Our primary outcome measure was the proportion of patients with hypocalcemia (defined by albumin-corrected serum calcium <1.9mmol/L) at 60 days. Process measures included the appropriate provision of calcium and vitamin D prophylaxis. Balance measures included the development of hypercalcemia and hyperphosphatemia following prophylaxis. We used plan-do-see-act cycles to study four tests of change and presented results using descriptive statistics and run charts. There were 6 patients with advanced CKD treated with denosumab prior to the implementation of our care pathway (March 2015-October 2020; 83% receiving dialysis). At the time of their denosumab injection, 83% were using 500-1000 mg of calcium, and 83% used 1000-2000 IU of vitamin D3. Fifty percent developed denosumab-induced hypocalcemia. Following the implementation of our care pathway, 15 patients (40% receiving dialysis) were treated with denosumab. Ninety-three percent received calcium at a daily dose of 350 to 2250 mg and 87% received 1000-2000 IU of vitamin D3. Thirteen percent developed denosumab-induced hypocalcemia. There was no hypercalcemia or hyperphosphatemia. A clinical care pathway focused on the safe provision of denosumab in advanced CKD reduced the risk of hypocalcemia in patients treated in our hospital. Similar pathways could be adopted and tested in other centers.