DR.

CYRIL JACOB KURIAN

Calcium
Sources
Milk Egg, fish, vegetables Cereals

Daily requirements
Adult : 500mg/day Children : 1200mg/day Pregnancy and lactation : 1500mg/day

Absorption of Calcium part of Occurs in the first and second

duodenum Absorption requires a carrier protein, helped by Calcium dependent ATPase Factors increasing absorption
Vitamin D which induces synthesis of the carrier protein Calbindin in the intestinal epithelial cells Parathyroid hormone increases calcium transport from intestinal cells Acidity favors calcium absorption Amino acids, especially lysine and arginine


Factors decreasing Calcium absorption
Phytic acid present in cereals Oxalates present in some leafy vegetables In malabsorption syndromes causing steatorrhoea, fatty acid is not absorbed, causing formation of insoluble salts of fatty acid High phosphate content will cause precipitation as calcium phosphate

Functions of Calcium
1. 2. 3. 4. Activation of enzymes Contraction of muscle fibres Transmission of nerve impulses Calcium- calmodulin complex regulates microfilament mediated processes such as degranulation of secretary vesicles, endocytosis, cell motility etc.

Functions of Calcium
5. Secretion of hormones such as insulin, parathyroid hormone etc. from the endocrine cells. 6. Calcium and cAMP are second messengers of different hormones. E.g. glucagon 7. Permeability of serum through capillaries is decreased by calcium 8. Calcium is known as factor IV in blood coagulation cascade


9. In myocardium, calcium prolongs systole 10. Bulk of calcium is used for bone and teeth formation

Blood levels of Calcium

Normal blood level of calcium is 9-11mg/dl

Factors Regulating Blood Calcium Levels

Effects on
Blood Calcium Intestine

Vitamin D
Increased Increased

Parathormone
Much increased

Calcitonin
Decreased

Increased (indirectly)

Bone Kidney

Increases Demineralization bone formation Increased calcium reabsorption and increased phosphate excretion
Rickets Tetany

Opposes demineralizaton Increased phosphate excretion

Deficiency manifestation


Other factors affecting serum calcium include
Phosphorus Serum proteins Acid and alkali Renal threshold, etc.

Blood calcium more than 11mg/dl Major cause is hyperparathyroidism caused by a parathyroid adenoma or an ectopic parathormone secreting tumor. Clinical signs include osteoporosis, punched out areas on X-ray, pathological fractures, polyuria, bilateral recurrent renal calculi, ectopic calcification in arterial walls, muscle tissues etc., anorexia, muscle wealness and short QT interval on ECG.

Hypercalcemia

Hypocalcemia
Serum calcium <8.8mg/dl is hypocalcemia When s.Ca <8.5mg/dl, there will be mild tremors. When s.Ca <7.5mg/dl, life threatening tetany occurs Tetany may be due to accidental surgical removal of parathyroid glands or by autoimmune disease. In tetany, increased neuromuscular irritability results in carpopedal spasm, laryngeal spasm etc. Clinical signs are Chovsteks sign (tapping over 5th cranial nerve causes facial contraction) and Trousseau's sign (inflation of BP cuff causes carpopedal spasm).

Pseudohypoparathyroid ism X-linked dominant condition

Although PTH level is normal, there is abnormal end organ response to PTH. This leads to hypocalcemia and hyperphosphatemia Shortening of 4th and 5th metacarpal and metatarsal bones may be associated

Renal Tubular Acidosis

+

Defective H production in the renal tubules Kidney cannot lower urinary pH below 5 Excess urinary loss of bicarbonate, sodium, potassium, calcium, magnesium and phosphates. Serum calcium and bicarbonate levels are lowered. Bone changes are similar to rickets, so often called Renal Rickets.

Fanconi's Syndrome
Glucosuria and aminoaciduria are associated with hypercalciuria and hyperphosphturia. Consequently, serum calcium levels are lowered.

Phosphorus
Mainly an intracellular ion Functions of phosphate ions are:
1. 2. 3. Formation of bones and teeth Production of high energy phosphate compounds like ATP,GTP,CTP,creatine phosphate etc. Synthesis of nucleside co-enzymes likesuch as NAD and NADP DNA and RNA synthesis ,where phosphodiester linkages form the backbone of the structure

4.


5. Formation of phosphate esters like glucose-6-phosphate, phosphoproteins and phospholipids 6. Activation of enzymes 7. Phosphate buffer system in blood

Serum phosphate level is 3-4mg/dl in normal adults and 5-6mg/dl in children Requirement is 500mg/day Surces include milk, cereals, nuts and meat

Magnesium ion Mainly an intracellular

Requirement
400mg/day Men 300mg/day Women

Sources
Cereals, beans, leafy vegetables and fish

Normal serum magnesium level is 1.8 - 2.2 mg/dl


Functions of Magnesium:
Activator of enzymes Lowers neuromuscular irritability Improves glucose tolerance