Determination of Serum

Calcium and Phosphorus

2nd Year Medical Students
Clinical Biochemistry Lab
02/03/2015
Introduction
Calcium is one of the most important divalent ions in our body
It is important for:
The transmission of nerve impulses
Maintaining normal muscle contractility
Certain enzymatic reactions as a cofactor
The coagulation of blood
Release of hormones (exocytosis)
Calcium Distribution
About 99% of calcium in our body is part of the bones
The remaining 1% is mostly in blood and other ECF and this found as
several forms:
45% as free or ionized calcium (physiologically active fraction)
40% as protein-bound calcium, mostly albumin
15% is bound to other anions as phosphate, citrate and bicarbonate
The serum total calcium concentration is tightly controlled at around
2.15-2.55 mmol/L
The serum ionized calcium is about 1.16-1.32 mmol/L
Calcium Homeostasis
Control of Plasma Calcium
Calcium homeostasis follow a general rule that EC
concentrations are controlled rather than the total body
content and the effectiveness of this depends on:
An adequate supply of calcium and vitamin D
Normal functioning of :
Intestine
Parathyroid gland
Kidneys
If any of these is impaired, calcium leaves bones by passive
diffusion and plasma concentration is maintained at the
expense of bone calcification
Regulation of Calcium level

Any change in serum protein concentration alter the concentration of

both protein bound and total calcium

Changes in pH also affects calcium-protein binding

Acidosis decreases calcium binding leading to an increase of free calcium (H+
compete with calcium for binding) and also increases calcium solubility
leading to increase in the release of calcium from bones

PTH , vitamin D and calcitonin are known to regulate calcium

homeostasis by altering their secretions in response to the changes of
ionized calcium level
Regulation of Calcium level
PTH
Secreted in response to a decrease in ionized calcium
In the bones, activates bone resorption releasing calcium and HPO4 into ECF
In the kidneys, PTH conserves Calcium by increasing its reabsorption (while
increasing HPO4 excretion) and also stimulates renal production of active
vitamin D
Vitamin D promotes intestinal absorption and renal reabsorption of
calcium and HPO4 and enhances PTH effect on bone resorption
Calcitonin, originating from thyroid gland, is secreted in response to
an increase in calcium and exerts its calcium lowering effect by
inhibiting the action of both PTH and vitamin D
Regulation of Calcium level
Hypocalcemia
• Hypocalcemia occur in the following cases:
• Primary hypoparathyroidism (glandular aplasia, destruction or surgical
removal)
• Pseudohypoparathyroidism (PTH target tissue response is decreased)
• Sever Hypomagnesaemia (inhibits PTH secretion or impair its action on the
bone , and possibly vit D resistance)
• Malabsorption states
• Drugs like loop diuretics
• Acute pancreatitis
• Chronic kidney disease
• Rhabdommyolysis (phosphate releases and complexes with calcium)
Hypercalcemia
• Due to the following reasons:
• Primary Hyperparathyroidism (adenoma or glandular hyperplasia)- this is the
leading cause
• Malignancy is the second leading cause , bony metastases like lung, breast
and kidney tumors
• Thyrotoxicosis (high bone turnover rate)
• Vitamin D toxicity
• Drugs like Thiazide diuretics (reduce renal calcium excretion)
Determination of Serum
phosphorous
Clinical Biochemistry Lab
2nd Year Medical Students
2/3/2015
Introduction
• Practically, all body phosphorus is present as phosphate
• Phosphate is the major intracellular anion
• Approximately 80% of which is found in the bony skeleton and 20% is
distributed in the soft tissues and muscles
• Blood phosphorous classified into:
• Organic phosphate (ATP)
• Inorganic phosphate as mono- and divalent anions
• Phosphate esters of lipids (phospholipids)
Physiological Importance of Phosphate
• Functions of phosphate:
• An important intracellular buffer
• As a component of phospholipids and nucleic acids
• Has a central role in metabolic pathways including glycolysis and oxidative
phosphorylation
• Also has a role in the optimal function of leucocytes like chemotaxis and
phagocytosis
• The most important energy reservoirs are ATP and creatine phosphate
Regulation
• The daily phosphate intake is about 30 mmol
• Protein-rich food is a major source of phosphate intake, as are nuts and
cereals
• The output is largely renal with more than 90% being excreted by this
route
• GI loss accounts for only 10% of the phosphate excretion
• It is regulated by:
• PTH which increases its renal excretion
• Vitamin D which increases both its absorption from GIT and renal
reabsorption
• Growth hormone which decreases renal excretion of phosphate
• Acid-base state (acidosis causes shifting of phosphate out of the cells)
Clinical Significance
Normal serum level in adults is 0.8-1.8 mmol/L
Although the concentration of all blood phosphate compounds is about 12 mg/dL
(3.9 mmol/L), only about 3-4 mg/dL is inorganic phosphate
Hyperphosphatemia
• Occur in the following cases:
• Artefact due to in vitro hemolysis or old blood sample
• Acute or chronic kidney disease
• Increased tissue breakdown
• Acidaemia (metabolic or respiratory acidosis)
• Diabetic ketoacidosis
• Hypoparathyroidism
• Excess vitamin D intake
• Sever infections, intensive exercise, and neoplastic disorders (increased
breakdown of cells)
Hypophosphatemia
• Can be seen in the following cases:
• Cellular redistribution ( intravenous glucose, alkalemia, insulin administration)
• Malabsorption states
• Long term parenteral nutrition without phosphate supplementation
• Liver disease
• Hyperparathyroidism (increased excretion)
• Vitamin D deficiency (decreased absorption)