Ionised Calcium

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1) In which conditions do we get a low ionic calcium level?

We get a low ionic calcium level in the following conditions:
• Hypoparathyroidism, which is an underactive parathyroid gland
• Inherited resistance to parathyroid hormone
• Malabsorption of calcium
• A vitamin D deficiency
• Osteomalacia or rickets, in which there is softening of the bones (in many cases due to a vitamin D deficiency)
• A magnesium deficiency
• High phosphorus levels
• Acute pancreatitis, which is an inflammation of the pancreas
• Kidney failure
• Malnutrition
• Alcoholism
 

2) In which conditions do we get a high ionic calcium level?

• Hyperparathyroidism, which is an overactive parathyroid gland. 
• A sedentary lifestyle or lack of mobility
•  Milk-alkali syndrome, in which there is high levels of calcium in the body due to consuming too much milk, antacids, or calcium carbonate over
    time.      
• Multiple myeloma, which is cancer of the plasma cells (a type of white blood cell that produces antibodies).
• Paget’s disease,it is a disorder which results in deformity due to abnormal bone destruction and growth.
• Sarcoidosis,that is an inflammatory disease that affects the eyes, skin, and other organs.
• Tuberculosis.
• A kidney transplant.
• The use of drugs such as thiazide diuretics.
• Some kinds of tumors.
• An overdose of vitamin D.

3) Which are the drugs which may affect the levels of ionised calcium?

• calcium salts
• hydralazine
• lithium
• thyroxine
• thiazide diuretics


4) Why is ionized calcium important?

The ionized calcium present in blood plasma is found to be a co-factor for two of the enzymes (blood-clotting factors)which are involved in the production of fibrin by the clotting cascade, hence calcium is essential for the process of blood coagulation.


5) How is ionized calcium calculated?

Various nomograms and formulae have been developed to estimate ionized calcium, which is done by correcting total calcium for total protein, albumin, globulins, and pH. The most widely used of these is the Payne et al. formula: Adjusted calcium (mmol/L) = Total calcium (mmol/L) + 0.02 [40 – serum albumin (g/L)].


6) When do you need ionized calcium?

The clinician may order an ionized calcium test if the patient has any signs of numbness around the mouth or in hands and feet, or if there are muscle spasms in the same areas. These are symptoms of low free calcium levels. An ionized calcium test is difficult to perform as compared to a serum calcium test.


7) Why does calcium need to be corrected for albumin?

Hypoalbuminemia: Calcium correction — Calcium in serum is bound to proteins, mainly albumin. As a result of which, the total serum calcium concentration in patients with low or high serum albumin levels may not accurately reflect the physiologically important ionized (or free) calcium concentration.


8) How is high ionized calcium treated?

• Calcitonin (Miacalcin). This hormone from salmon is known to control calcium levels in the blood. 
• Calcimimetics. This type of drug may help control overactive parathyroid glands. 
• Bisphosphonates.
• Denosumab (Prolia, Xgeva).
• Prednisone.
• IV fluids and diuretics.


9) Which are the foods that may block calcium absorption?

Other components in food: phytic acid and oxalic acid, which are found naturally in some plants, bind to calcium and can inhibit its absorption. Foods with high levels of oxalic acid are- spinach, collard greens, sweet potatoes, rhubarb, and beans.

10) What are the symptoms of hypercalcemia?

• Loss of appetite.
• Nausea and vomiting.
• Constipation and abdominal pain.
• The need to drink more fluids and pass urine more frequently
• Tiredness, weakness, or muscle pain.
• Confusion, disorientation, and difficulty in thinking.
• Headaches.
• Depression


11) What is the importance of estimation of ionised calcium in newborns?

Newborns, particularly the premature and low birth weight infants, often are monitored during the first few days of life for neonatal hypocalcemia using the test for ionized calcium. This may occur because of an immature parathyroid gland and may not always cause symptoms. The condition can resolve itself or may require treatment with supplemental calcium, which is given orally or intravenously.


12) Should a patient be worried if the clinician orders for the ionic calcium test instead of a total calcium test?

No. Measurement of total calcium is usually sufficient for screening purposes. The total calcium test is more easily performed than the ionized calcium test since it does not require special handling of the blood sample.

The ionized calcium test requires specialized handling and urgent delivery of the blood sample to the laboratory for prompt analysis. The necessary handling and delivery is difficult to achieve outside the setting of a hospital.

In most of the cases, total calcium is a good substitute for free calcium since the free and bound forms are usually each about half of the total.

The direct measurement of ionized calcium is particularly significant during surgery as well as in severely ill patients, when changes in total calcium may not reliably tell how abnormal the ionized calcium level is.

13) How is the calcium level in bone estimated?

Blood and urine calcium measurements cannot estimate the amount of calcium in the bones. A test that is similar to an X-ray, called a bone density or "Dexa" scan, is used for this purpose.

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