Dr E.Faraji MD,Internist,Endocrinologist
2/19/2025
1
Dr E.Faraji
MD,Internist,Endocrinologist
Tabriz University of Medical Sciences
Nothing to Declare
H
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B
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99% in Bone
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1% Exchangeable
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50% Bound
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50% Ionized
•
Strong Extra- to Intracellular Gradiant (10,000:1)
•
Calcium Channels
•
Intracellular portion 99% Bound
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C
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R
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PTH
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1,25(OH)2 VitD3
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Calcium
•
P
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P
T
H
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Acute or Chronic reduction of
IONIZED Ca
below normal physiologic
range
•
8.5 – 10.5 mg/dl Total ca.
•
Ionized Ca below 1.2mM/l
•
Total Ca influenced by albumin,PH,FFA level,lipid infusions
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9
s
/
s
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Acuteness
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Severity
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JCEM 2016
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JCEM 2016
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f
E
t
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g
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PTH Related
•
PTH Unrelated
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P
T
H
r
e
l
a
t
e
d
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Bilezikian :Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism
14
P
T
H
U
n
r
e
l
a
t
e
d
2/19/2025
Bilezikian : Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism:
15
P
T
H
r
e
l
a
t
e
d
2/19/2025
16
Postsurgica
l
-Autoimmune-Congenital
Hypomagnesemia
Pseudohypoparathyroidism
G
e
n
e
t
i
c
E
t
i
o
l
o
g
y
2/19/2025
JCEM
17
2/19/2025
Review of Hypoparathyroidism :Ejigayehu G. Abate
1
18
2/19/2025
Review of Hypoparathyroidism :Ejigayehu G. Abate
19
P
o
s
t
s
u
r
g
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c
a
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H
y
p
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p
a
r
a
t
h
y
r
o
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d
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s
m
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Neck Surgery
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Thyroidectomy (38%)
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Parathyroidectomy(21%)
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RLND
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Any Neck surgery(5%)
•
75% all hypoparas
2/19/2025
Powers J, Joy K, Ruscio A, Lagast H. Prevalence and incidence of hypoparathyroidism in the United States using a large claims database. J Bone Miner Res
(2013)
20
T
h
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r
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h
y
r
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d
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s
m
•
Depends on
•
the center
•
type of intervention
•
surgical expertise.
•
Transient postsurgical hypoparathyroidism lasting˂6 months
25.4 – 83%
of patients worldwide after neck surgery
•
Permenant postsurgical hypoparathyroidism, defined as lasting more
than 6 months
0.12– 4.6%
of cases
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JCEM 2016
21
R
i
s
k
F
a
c
t
o
r
s
2/19/2025
Postsurgical Hypoparathyroidism: A Systematic Review
KASSIANI KAKAVA
22
R
i
s
k
F
a
c
t
o
r
s
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M
o
r
b
i
d
i
t
y
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Q
o
L
I am not the person I was before
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G
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T
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Resolve S/S Hypocalcemia
•
Maintain sCa at 8-9mg/dl
•
U/Ca normal
•
Phosphate in Normal range
•
P*Ca not more than 55
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Consider and avoid complications of treatment
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T
r
e
a
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E
m
e
r
g
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g
T
r
e
a
t
m
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n
t
s
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PTH(1-34)
•
PTH(1-84)
•
Not routinely recommended
•
Only in those who cannot be controlled with conventional treatmen
•
Replace
•
24w
•
134pt
•
rhPTH vs Placebo
2/19/2025
Mannstadt M, et al. Efficacy and safety of recombinant human parathyroid hormone (1-84) in hypoparathyroidism (
REPLACE
): a double-blind, placebo-controlled,
randomised, phase 3 study. Lancet Diabetes Endocrinol(2013) 1
28
53% able to reduce Ca .VitD by more than50%
43% completely stopped VitD and reduce Ca
2/19/2025
JCEM2016 Management of Hypoparathyroidism: SummaryStatement and GuidelinesMaria Luisa Brandi,
29
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o
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p
l
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c
a
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o
n
s
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f
T
r
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m
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Undertreatment
•
Overtreatment
•
Hyperphosphatemia
•
Hypercaciuria
•
Nephrocalcinosis
•
Nephrolithiasis
•
Renal failure
Patients are often not satisfied
2/19/2025
30
2/19/2025
JCEM2016 Management of Hypoparathyroidism: SummaryStatement and GuidelinesMaria Luisa Brandi,
31
S
u
m
m
e
r
y
a
n
d
K
e
y
m
e
s
s
a
g
e
s
•
Treaetment of
Acute /Severe
hypocalcemia is an
Emergency.
•
Postsurgical HypoPT is the most common form of HypoPT.
•
Training
dedicated
thyroid surgeons is of utmost importance.
•
Careful selection of
Pt
and the Best
surgical level.
•
Preoperative provisions
are important.
•
Intra/Postoperative PTH,Ca,P levels are valuable
predictive
factors.
•
Meticulous attention to
morbidities
of HypoPT.
•
Close attention to the
complications of Treatment
•
All medical activities should be
Patient Oriented
2/19/2025
32
2/19/2025
33
Dr. E. Faraji, a renowned Internist and Endocrinologist at Tabriz University of Medical Sciences, discusses hypocalcemic disorders, calcium regulation in the body, PTH actions, and the classification of etiology. The content includes detailed information on hypocalcemia, its symptoms, and severity, as well as insights into PTH-related and unrelated conditions. Images supplement the text, providing a visual aid to enhance understanding.
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Presentation Transcript
Dr E.Faraji MD,Internist,Endocrinologist Tabriz University of Medical Sciences Nothing to Declare 2/19/2025 1
HYPOCALCEMIC HYPOCALCEMIC DISORDERS DISORDERS 2/19/2025 2
Calcium in the Body Calcium in the Body 99% in Bone 1% Exchangeable 50% Bound 50% Ionized Strong Extra- to Intracellular Gradiant (10,000:1) Calcium Channels Intracellular portion 99% Bound 2/19/2025 williams 3
2/19/2025 williams 4
Calcium Regulators Calcium Regulators PTH 1,25(OH)2 VitD3 Calcium P 2/19/2025 5
PTH PTH 2/19/2025 williams 6
PTH Actions PTH Actions on Calcium Homeostasis on Calcium Homeostasis 2/19/2025 7
PTH PTH Ca Ca Curve Curve 2/19/2025 williams 8
Hypocalcemia Hypocalcemia Acute or Chronic reduction of IONIZED Ca below normal physiologic range 8.5 10.5 mg/dl Total ca. Ionized Ca below 1.2mM/l Total Ca influenced by albumin,PH,FFA level,lipid infusions 2/19/2025 9
s/s s/s Acuteness Severity 2/19/2025 10
2/19/2025 JCEM 2016 11
2/19/2025 JCEM 2016 12
Classification of Etiology Classification of Etiology PTH Related PTH Unrelated 2/19/2025 13
PTH related PTH related 2/19/2025 Bilezikian :Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism 14
PTH Unrelated PTH Unrelated 2/19/2025 Bilezikian : Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism: 15
PTH related PTH related Postsurgical-Autoimmune-Congenital PTH Hypomagnesemia Secretion Resistance Pseudohypoparathyroidism 2/19/2025 16
Genetic Etiology Genetic Etiology 2/19/2025 JCEM 17
2/19/2025 18 Review of Hypoparathyroidism :Ejigayehu G. Abate 1
Review of Hypoparathyroidism :Ejigayehu G. Abate 2/19/2025 19
Postsurgical Postsurgical Hypoparathyroidism Hypoparathyroidism Neck Surgery Thyroidectomy (38%) Parathyroidectomy(21%) RLND Any Neck surgery(5%) 75% all hypoparas Powers J, Joy K, Ruscio A, Lagast H. Prevalence and incidence of hypoparathyroidism in the United States using a large claims database. J Bone Miner Res (2013) 2/19/2025 20
The incidence of postsurgical The incidence of postsurgical hypoparathyroidism hypoparathyroidism Depends on the center type of intervention surgical expertise. Transient postsurgical hypoparathyroidism lasting 6 months 25.4 83% of patients worldwide after neck surgery Permenant postsurgical hypoparathyroidism, defined as lasting more than 6 months 0.12 4.6% of cases 2/19/2025 JCEM 2016 21
Risk Factors Risk Factors Postsurgical Hypoparathyroidism: A Systematic Review KASSIANI KAKAVA 2/19/2025 22
Risk Factors Risk Factors 2/19/2025 23
Morbidity Morbidity 2/19/2025 24
QoL QoL I am not the person I was before 2/19/2025 25
Goals of Treatment Goals of Treatment Resolve S/S Hypocalcemia Maintain sCa at 8-9mg/dl U/Ca normal Phosphate in Normal range P*Ca not more than 55 Consider and avoid complications of treatment 2/19/2025 26
Treatment Treatment 2/19/2025 27
Emerging Treatments Emerging Treatments PTH(1-34) PTH(1-84) Not routinely recommended Only in those who cannot be controlled with conventional treatmen Replace 24w 134pt rhPTH vs Placebo 43% completely stopped VitD and reduce Ca 53% able to reduce Ca .VitD by more than50% Mannstadt M, et al. Efficacy and safety of recombinant human parathyroid hormone (1-84) in hypoparathyroidism (REPLACE): a double-blind, placebo-controlled, randomised, phase 3 study. Lancet Diabetes Endocrinol(2013) 1 2/19/2025 28
2/19/2025 JCEM2016 Management of Hypoparathyroidism: SummaryStatement and GuidelinesMaria Luisa Brandi, 29
Complications of Treatment Complications of Treatment Undertreatment Overtreatment Hyperphosphatemia Hypercaciuria Nephrocalcinosis Nephrolithiasis Renal failure Patients are often not satisfied 2/19/2025 30
JCEM2016 Management of Hypoparathyroidism: SummaryStatement and GuidelinesMaria Luisa Brandi, 2/19/2025 31
Summery and Key messages Summery and Key messages Treaetment of Acute /Severe hypocalcemia is an Emergency. Postsurgical HypoPT is the most common form of HypoPT. Training dedicated thyroid surgeons is of utmost importance. Careful selection of Pt and the Best surgical level. Preoperative provisions are important. Intra/Postoperative PTH,Ca,P levels are valuable predictive factors. Meticulous attention to morbidities of HypoPT. Close attention to the complications of Treatment All medical activities should be Patient Oriented 2/19/2025 32
2/19/2025 33
