Calcium Metabolism: Moderators Prof Deepak Rai DR Mahesha K Presenter: DR Nabeel Shams

CALCIUM METABOLISM
MODERATORS
PROF DEEPAK RAI
DR MAHESHA K
PRESENTER: DR NABEEL SHAMS

INTRODUCTION
 Calcium -most abundant mineral in the
human body.
 1.5%- total body weight.
 Along with phosphorous it forms the

principal contituents of the bone.
 Normal serum level 9-11mg/dl

 Calcium is an divalent cation with multiple
roles in vertebrate physiology
 They can be grouped as either structural or

metabolic
SOURCE OF CALCIUM
SOURCE OF CALCIUM
1.Dietary source
 Whole milk 10%
 Low fat milk 18%
 Cheese 27%
 Other dairy products 17%
 Vegetables 7%(Spinach, Turnip, Cabbage, Soya beans)
2. From bones- Resorption


 DISTRIBUTION OF CALCIUM
 1) calcium in plasma
 2) calcium in bones
CALCIUM IN PLASMA

 About 41% combined - plasma proteins
nondiffusible form
 About 9% combined- anionic substances of the

plasma and interstitial fluids (citrate and
phosphate, for instance)
 Remaining 50%- both diffusible through the

capillary membrane and ionized
 The ionised calcium concentration in serum is
approximately 5mg/dl.
 It is the ionised fraction that is biologically

active and is closely regulated
DISTRIBUTION OF THE PLASMA
CALCIUM
CALCIUM IN BONES
i) Rapidly exchangeable calcium
ii) slowly exchangeable calcium

 i) The rapidly exchangeable calcium-
maintains the plasma calcium level
ii) The slowly exchangeable calcium-

bone remodelling
DAILY REQUIREMENTS OF CALCIUM
MEN 400 mg
WOMEN 400mg
PREGNANT WOMEN 1000mg

 ABSORBTION AND EXCRETION
 Calcium ions-poorly absorbed from the
intestines
 Vitamin D promotes calcium absorption from

the intestines
 Majority of absorbtion takes place from the

1st and 2nd psrt of deudenum
• About 35% of injested calcium is usually
absorbed and the remaining is excreted in
faeces
In contrast the absorbtion of phoshate from
the intestines occurs very easily
About 10% of the injested calcium is excreted
in urine
98-99% -reabsorbed from renal tubules

Majorityof reabsorbtion-distal convoluted tubules and proximal part of
collecting duct
Thebone contains a type of exchangeable calcium that is always in

equilibrium with calcum ions in the extra cellular fluid
The exchangeable calcium provides an buffering mechanism to maintain the

calcium ion concentration
Parathormone and Vit D play a major
role
 FACTORS AFFECTNG CALCIUM ABSORBTION
 Factors causing increased absorbtion
 a) Vit D
 b) PTH
 c) Acidity
 d) Amino acids
Factors causing decreased absorbtion
a)Phytic acid ( present in cereals)
b)Oxalates( leafy vegetables- formation of

insoluble calcium oxalates)
c) Malabsorbtion syndromes
d) Phosphate: optimum ratio of calcium to

phosphorus alowing maximum absorbtion is 1:2 to
2:1
 REGULATION OF THE BLOOD CALCIUM LEVEL
 Calcium metabolism is mainly regulated by
 Parathormone
 1,25 dihydroxycholecalciferol(calcitriol)
 Calcitonin
 PARATHORMONE
 Parathhormone secreted by chief cells of the
parathyroid gland
 The pricipal regulator of PTH secretion is the

ECF ionised calcium concentration
 The regulation of PTH is mediated by calcium

sensing receptor( CASR)
 Plasma PTH concentrations exhibit diurnal
variation
 They are stable during the afternoon and
evening
 They rise around 50% around 2:00 am and
subsequently fall below 50% of the afternoon

values by 9:00am
 Parathyroid hormone binds to cell surface
receptors in its target tissues
 The two principal target tissues are bone and

kidney where it activates adenylate cyclase
and phospholipase C
 ACTIONS OF PARATHORMONE
 On bone
 - stimulates osteoclastic activity hence
enhances the resorption of calcium from the
bones
 Resorption of calcium- two phases

 a) Rapid phase
 b) Slow phase
 Rapid phase- occurs within minutes
 causes increased permeability
of osteoclasts and osteoblasts for calcium
 Slow phase- Occurs by activation of

osteoclasts
 When the osteoclasts get activated they
release proteolytic enzymes and acids leading
to digestion of the organic matrix
 On kidneys-
 a) Reduces proximal tubular resorbtion of

phosphate
 b) Increases the distal tubular reabsorption of

calcium
 c) Formation of 1,25-dihydroxycholecalciferol
from 25-hydroxycholecalciferol
 On GI tract

 PTH increases the absorption indirectly by
forming 1,25-dihydrocholecalciferol in the
kidneys
 PTH causes activation of Vit D

 Parathormone-controls extracellular calcium
and phosphate concentrations
 Excess activity- hypercalcemia
 Reduced activity- hypocalcemia


HYPERCALCEMIA
CLASSIFICATIO OF CAUSES
 1. Parathyroid related
 a) Primary hyper parathyroidism
 b) Lithium therapy
 c) Familial hpercalciuric calciuria
 2. Malingnancy related
 3. Vit D realted
 4. Associated with high bone turnover
 5. Associated with renal failure

CLINICAL FINDINGS
 Mild hypercalcemia often asymptomatic
 Symptoms occur if calcium >12mg/dl
 They include- constipation, polyuria, nausea

vomiting, peptic ulcer desease, weakness,
lethargy
TREATMENT
 Forced calciuresis
 In case of dehydration 0.9% saline

rapidly(250ml/hr)
 Bisphosphonates for hypercalcemia of

malignancy
 HYPOCALCIMEA
CAUSES
 A)Decreased intake or absorption
 B)Increased loss
 C)Endocrine desease
 D)Others
CLINICAL FINDINGS
 Primarily affects the neuromuscular and

cardiovascular systems
 A) Cardiovascular changes:
 Dilatation of the heart
 Prolonged duration of the ST segment and
QT interval
 Arrythmias
 B) Neuromuscular changes:
 Hyper reflexia and convulsions
 Carpopedal spasm
 Laryngeal stridor
 Physical findings- Chovstek sign and
Trousseaus sign
TREATMENT
In severe symptomatic hypocalcimea-

10mg/kg of 10% calcium gluconate in
one litre of Dextrose infusion over 4-5 hours
In asymtomatic Hypcalcimea- Oral calcium 1-

2gm and vit d preparations
Parathyroid hormone increases:
 Resorption of calcium from the bones
 Resorption of calcium from the renal tubules
 Absorbtion of calcium from the GI tract

 CONTROLOF PARATHYROID
SECRETION BY CALCIUM IONS
 The solid curve shows the acute effect when
the calcium concentration is changed over a
period of a few hours

 the calcium ion concentration changes over a
period of many weeks is shown by the dashed
line.
 1,25-DIHYDROXYCHOLECALCIFEROL
 Vitamin D- calcium absorption from the
intestinal tract
 vitamin D must first be converted the final

active product, 1,25-dihydroxycholecalciferol
ACTIVATION OF VIT D3
EFFECTS OF VIT D ON CALCIUM
METABOLISM
 Promotes intestinal calcium absorption
 Promotes phosphate absorption by the

intestines
 Decreases renal calcium and phosphate

excretion
 CALCITONIN
 Secreted by parafollicular in the thyroid gland
 Plasma level of calcitonin is 1-2 mg/dl
 Degraded and excerted by liver and kidney

EFFECTS OF CALCITONIN
 On bones- stimulates osteoblastic activity
 On kidney – inhibits the resorption of calcium

from renal tubules
 On intestine: prevents the absorption of

calcium
RELATION OF EXTRA CELLULAR
CALCIUM WITH BONE
 Bone is composed – a) organic matrix

b)calcium salts
 Organic matrix- composed 95% of collagen
fibers and the rest ground substance
 Bone salts are deposited in the organic matrix

which are primarily calcium and phosphate
ORGANIC MATRIX OF BONE
 -95% are collagen fibres, They give tensile

strength to the bone
 -The rest is homogenous gelatinous medium

called ground substance
BONE SALTS
 COMPOSED PRINCIPALLY OF CALCIUM AND

PHOSPHATE
CELL TYPES OF BONES
 OSTEOBLASTS
 OSTEOCYTES
 OSTEOCLASTS
OSSIFICATION AND CALCIFICATION
 Conversion of cartilage into bone –
ossification
 Ossification carried out by osteoblasts which

lay down the matrix
 Calcium is deposited in the matrix-

calcification
USES OF CALCIUM
 a) Bone and teeth formation
 b) Neuronal activity
 c) Skeletal muscle activity
 d) Cardiac activity
 e) Smooth muscle activity
 f) Secretory activity of the glands
 g) Cell division and growth
 h) Coagulation of blood

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CALCIUM METABOLISM

PRESENTER: DR NABEEL SHAMS

 1.5%- total body weight.

 Along with phosphorous it forms the

 Normal serum level 9-11mg/dl

 They can be grouped as either structural or

 Low fat milk 18%

 Other dairy products 17%

 Vegetables 7%(Spinach, Turnip, Cabbage, Soya beans)

2. From bones- Resorption

 About 9% combined- anionic substances of the

 Remaining 50%- both diffusible through the

 It is the ionised fraction that is biologically

i) Rapidly exchangeable calcium

ii) slowly exchangeable calcium

ii) The slowly exchangeable calcium-

PREGNANT WOMEN 1000mg

 Vitamin D promotes calcium absorption from

 Majority of absorbtion takes place from the

98-99% -reabsorbed from renal tubules

Thebone contains a type of exchangeable calcium that is always in

The exchangeable calcium provides an buffering mechanism to maintain the

b)Oxalates( leafy vegetables- formation of

d) Phosphate: optimum ratio of calcium to

 The pricipal regulator of PTH secretion is the

 The regulation of PTH is mediated by calcium

subsequently fall below 50% of the afternoon

 The two principal target tissues are bone and

 Resorption of calcium- two phases

 Slow phase- Occurs by activation of

 a) Reduces proximal tubular resorbtion of

 b) Increases the distal tubular reabsorption of

 PTH causes activation of Vit D

 Excess activity- hypercalcemia

 Reduced activity- hypocalcemia

 Mild hypercalcemia often asymptomatic

 Symptoms occur if calcium >12mg/dl

 They include- constipation, polyuria, nausea

 In case of dehydration 0.9% saline

 Bisphosphonates for hypercalcemia of

 A)Decreased intake or absorption

 Primarily affects the neuromuscular and

In severe symptomatic hypocalcimea-

In asymtomatic Hypcalcimea- Oral calcium 1-

 Resorption of calcium from the bones

 Resorption of calcium from the renal tubules

 Absorbtion of calcium from the GI tract

 vitamin D must first be converted the final

 Promotes phosphate absorption by the

 Decreases renal calcium and phosphate

 Plasma level of calcitonin is 1-2 mg/dl

 Degraded and excerted by liver and kidney

 On kidney – inhibits the resorption of calcium

 On intestine: prevents the absorption of

 Bone is composed – a) organic matrix

 Bone salts are deposited in the organic matrix

 -95% are collagen fibres, They give tensile

 -The rest is homogenous gelatinous medium

 COMPOSED PRINCIPALLY OF CALCIUM AND