Lecture 9, Calcium and Bone Metabolism

7/21/2019 Lecture 9, Calcium and Bone Metabolism

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CALCIUM AND BONECALCIUM AND BONE

METABOLISMMETABOLISM

LECTURE 8LECTURE 8


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ParatParathyrhyroidoidglandsglands

Four pFour pea-sized glandsea-sized glands

located posterior to thelocated posterior to thethyroid lobes.thyroid lobes.

They secrete PTH , thatThey secrete PTH , thatplays a major role inplays a major role in

bonebone remoderemodelllingling andandcalciumcalciumhomeostasis.homeostasis.


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CalciumCalciumCalcium ions play a critical role in intracellularCalcium ions play a critical role in intracellular

and extracellular eventsand extracellular events

Roles of calciumRoles of calcium::

Skeletal strengthSkeletal strength

euromuscular conductioneuromuscular conduction

Excitation! contraction coupling"Excitation! contraction coupling"


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Role of #T$Role of #T$ #T$ prevents serum calcium from falling#T$ prevents serum calcium from falling

%y stimulating calcium movement from:%y stimulating calcium movement from: &ntestinal lumen&ntestinal lumen

renal tu%ular lumenrenal tu%ular lumen 'one fluid compartment'one fluid compartment

into the %loodinto the %lood

(irect(irecteffects oneffects on %one and kidney%one and kidney &ndirect&ndirect effects oneffects on intestineintestine)mediated %y)mediated %y

vitamin (*vitamin (*


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Cellular effects of +itamin (Cellular effects of +itamin (

Stimulates calcium and phosphate a%sor%tion fromStimulates calcium and phosphate a%sor%tion fromthe intestinethe intestine

Regulates %one resor%tion and formationRegulates %one resor%tion and formation

(ecreases calcium rea%sor%tion in the distal renal(ecreases calcium rea%sor%tion in the distal renal

tu%ulestu%ules

Represses the transcription and secretion of #T$Represses the transcription and secretion of #T$


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Role of calcitoninRole of calcitonin

#revents a%normal increase in serum Ca and#revents a%normal increase in serum Ca and

phosphate concentrationphosphate concentration (ecreases %one resor%tion(ecreases %one resor%tion inhi%its renal tu%ular calcium rea%sor%tioninhi%its renal tu%ular calcium rea%sor%tion Uncertain effect on vit ( meta%olism and intestinalUncertain effect on vit ( meta%olism and intestinal

a%sorption of calciuma%sorption of calcium ,ay %e considered as a counteregulator of #T$,ay %e considered as a counteregulator of #T$


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#-T$.L./&C-L C.(&T&.S#-T$.L./&C-L C.(&T&.S

$0#ERC-LCE,&-$0#ERC-LCE,&-

$0#.C-LCE,&-$0#.C-LCE,&-

.STE.#.R.S&S.STE.#.R.S&S


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$0#ERC-LCE,&-$0#ERC-LCE,&-


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Causes:Causes:,alignancy:,alignancy:

,ultiple myeloma,ultiple myeloma

'ony metastases'ony metastases

LymphomaLymphoma


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Causes:Causes:Increased bone resorbtion:Increased bone resorbtion:

HyperparatiroidismHyperparatiroidism

Hypercalcemia in parathyroid cancersHypercalcemia in parathyroid cancers

HyperthyroidismHyperthyroidism

PheochromocytomaPheochromocytoma

ImmobilizationImmobilization

Vitamina into!icationVitamina into!ication

ddison"s diseaseddison"s disease


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Causes:Causes:Increased renal reabsorption or decreased renal elimination:Increased renal reabsorption or decreased renal elimination:

Rha%domyolysisRha%domyolysis

Thiazide diureticsThiazide diuretics

#enal $ailure#enal $ailure

Heart $ailureHeart $ailure

%ithium carbonate%ithium carbonate


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Causes:Causes:Increased intestinal absorbtion:Increased intestinal absorbtion:

Vitamina & into!icationVitamina & into!ication

'arcoidosis and other granulomatous diseases'arcoidosis and other granulomatous diseases

TuberculosisTuberculosis

%ymphomas%ymphomas

I&'I&'


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$yperparathyroidism$yperparathyroidism

Increased autonomous production of PTH-Increased autonomous production of PTH-primary hyperparathyroidismprimary hyperparathyroidism

Increased PTH production as response toIncreased PTH production as response toprolonged hypocalcemia -prolonged hypocalcemia - secondarysecondaryhyperparathyroidismhyperparathyroidism (feedback control is(feedback control ismaintained)maintained)

Autonomous secondary hyperparathyroidism -Autonomous secondary hyperparathyroidism -tertiary hyperparathyroidismtertiary hyperparathyroidism


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#athology#athology 812 single adenoma812 single adenoma

342 parathyroid hyperplasia342 parathyroid hyperplasia

isolatedisolated

associated with other endocrine abnormalities:associated with other endocrine abnormalities:

ultiple endocrine neoplasia (!"# types I and II)ultiple endocrine neoplasia (!"# types I and II)

$% parathyroid carcinoma$% parathyroid carcinoma


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,E,E

,E &,E & ,E &&a,E &&a ,E &&%,E &&%An autosomalAn autosomal

dominant conditiondominant condition

&haracteri'ed by:&haracteri'ed by:

ParathyroidParathyroid

tumourstumours

hyperplasiahyperplasia

Anterior pituitaryAnterior pituitary

adenomaadenoma

PancreaticPancreatic

neuroendocrineneuroendocrine

tumourstumours

An autosomalAn autosomal

dominant conditiondominant condition

&omprises:&omprises:

amilialamilial

medullary thyroidmedullary thyroid

carcinomacarcinoma

PheocromocytomPheocromocytom

aa

ParathyroidParathyroid

tumourstumours

de*ned by thede*ned by the

association of:association of:

edullary thyroidedullary thyroid

carcinomacarcinoma

PheochromocytomaPheochromocytoma

ultiple mucosalultiple mucosalneuromasneuromas

HyperparathyroidismHyperparathyroidism

(parathyroid(parathyroid

hyperplasia)hyperplasia)


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Skin and tongue neuromas in ,E syndromeSkin and tongue neuromas in ,E syndrome


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Clinical featuresClinical features ,ost patients are asymptomatic,ost patients are asymptomatic

5eatures of hypercalcemia5eatures of hypercalcemia

Target organ damage:Target organ damage: 'one'one

6idneys6idneys 7oints7oints /astrointestinal/astrointestinal

6id6id '' // t . h.th


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6idneys6idneys 'one'one /astro!/astro!intestinalintestinal

.ther.ther

+enal calculi+enal calculi

"efrocalcinos"efrocalcinos

is- lessis- less

fre,uentfre,uent

+enal+enal

impairment-impairment-

*nal stage*nal stage

IncreasedIncreasedosteoclast actiityosteoclast actiity

and decreasedand decreasedosteoblast actiityosteoblast actiity

.steoporosis-.steoporosis-a/ects all sites#a/ects all sites#but predominantbut predominant

loss is inloss is inperipheral corticalperipheral corticalbonebone

.steitis *brosa.steitis *brosacystica - less thancystica - less than

$0% of patients$0% of patients&linical:&linical:

-bone painbone pain

-pathologicpathologicfracturesfractures

-bonebonedeformationdeformation

-norexia-norexia

+omiting+omiting

ConstipationConstipation

-%dominal pain-%dominal pain

&ntestinal calculi&ntestinal calculi

#ancreatitis#ancreatitis

,uscle eakness,uscle eakness

Lethargy9 fatigue9Lethargy9 fatigue9depression9 difficultydepression9 difficultyin concentration andin concentration andpersonality changespersonality changes

-rticular-rticularmanifestationsmanifestations)pseudogout*)pseudogout*

(ental(entalmanifestationsmanifestations

)dental cavities*)dental cavities*

Salivary duct calculiSalivary duct calculi


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1one deformation2pinal compression


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2aliary duct calculi


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ultiple caities# edentations3


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Radiologic findingsRadiologic findings

Su%periostal resorption of cortical %one9 %est seenSu%periostal resorption of cortical %one9 %est seen:: in high! resolution films of the phalanges orin high! resolution films of the phalanges or in the skull9 creating ain the skull9 creating a salsalt!t!andand!!pepperpepper;;appearenceappearence

.steoporosis.steoporosis! predominant loss of cortical %onepredominant loss of cortical %one

! the mass and the mechanical strength of the tra%ecular %one arethe mass and the mechanical strength of the tra%ecular %one arerelatively maintainedrelatively maintained

(ental x!ray ! loss of lamina dura of the teeth(ental x!ray ! loss of lamina dura of the teeth

#lain a%dominal radiograph for renal stones )for prognostic reasons*#lain a%dominal radiograph for renal stones )for prognostic reasons*


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Bone resorptionBone resorption


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ormal %one $yperparathyroid


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Bone resorption in the skullBone resorption in the skull


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'one resorption in the skull'one resorption in the skull


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Loss of lamina dura of theLoss of lamina dura of the

teethteeth


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"oninasie methods to estimate bone"oninasie methods to estimate bone

mineral density:mineral density:

- 45A (dual-energy 6- ray- 45A (dual-energy 6- ray

absorptiometry)absorptiometry)

- 5- ray- 5- ray

- bone scanning- bone scanning


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#articular clinical forms#articular clinical forms

#regnancy#regnancy ChildrenChildren ElderlyElderly

2pontaneous2pontaneous

abortionabortion

Increased riskIncreased risk

of perinatalof perinataldeathdeath

- intense bone- intense bone

modi*cationsmodi*cations

- decreaseddecreasedperformance in schoolperformance in school

-personality changespersonality changes

ainly neurologicalainly neurological

symptomssymptoms

- lethargy- lethargy

- confusion#- confusion#

depressiondepression

-dyspepsia# nausea#-dyspepsia# nausea#dehydrationdehydration


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La%oratory findingsLa%oratory findings

Hypercalcemia - both total and ioni'ed calcium areHypercalcemia - both total and ioni'ed calcium areeleatedeleated

2erum phosphorus leel is: low-normal or low2erum phosphorus leel is: low-normal or low

HyperchloremiaHyperchloremia metabolic acidosismetabolic acidosis

!leation of the alkaline phosphatase leel!leation of the alkaline phosphatase leel

HypomagnesemiaHypomagnesemia


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&maging studies&maging studies

77Tc- sestamibi scanning77Tc- sestamibi scanning

"oninasie:"oninasie:

- &T- &T

- +I- +I

- 8ltrasound- 8ltrasound


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#arathyroid adenoma#arathyroid adenoma


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#arathyroid adenoma#arathyroid adenoma


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#arathyroid adenoma


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TreatmentTreatment

3"SUR/ER0 )parathyroidectomy*3"SUR/ER0 )parathyroidectomy* Removal of the adenomaRemoval of the adenoma &f there is parathyroid hyperplasia! < = gland are removed9 leaving a&f there is parathyroid hyperplasia! < = gland are removed9 leaving a

remnant tissue sufficient to prevent hypocalcemiaremnant tissue sufficient to prevent hypocalcemia

The recurence rate of hypercalcemia is high in pacients ith parathyroidThe recurence rate of hypercalcemia is high in pacients ith parathyroid

hyperplasia )especially in those ith one of the ,E syndromes*hyperplasia )especially in those ith one of the ,E syndromes* &n such cases the remnant parathyroid can %e removed from the neck&n such cases the remnant parathyroid can %e removed from the neck

and implanted in forearm musclesand implanted in forearm muscles

Complications:Complications:

(amage to the recurent laryngeal nerve(amage to the recurent laryngeal nerve &nadvertent removal or devitali>ation of all parathyroid tissue9 producing&nadvertent removal or devitali>ation of all parathyroid tissue9 producing

permanent hypoparathyroidism"permanent hypoparathyroidism"


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TreatmentTreatment

&ndications for surgery:&ndications for surgery:! serum Ca markedly elevated )?339@! 3@mgAdl*! serum Ca markedly elevated )?339@! 3@mgAdl*

! previous episode of life!threatening hypercalcemia! previous episode of life!threatening hypercalcemia

! creatinine clearance BD2 than normal! creatinine clearance BD2 than normal! renal lithiasis! renal lithiasis

! urinary calcium markedly elevated! urinary calcium markedly elevated)?4DDmgA@4h*)?4DDmgA@4h*

! %one mass is su%stantially reduced! %one mass is su%stantially reduced

! young pacient )B1D years*! young pacient )B1D years*


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TreatmentTreatment@" ,edical treatment in@" ,edical treatment in

hyperparathyroidism:hyperparathyroidism:

! prior to surgery! prior to surgery

! inopera%le cases or refusal of surgery! inopera%le cases or refusal of surgery

! parathyroid crisis! parathyroid crisis

! tumoral hypercalcemia! tumoral hypercalcemia


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$ypercalcemia treatement$ypercalcemia treatement&nitial management:&nitial management: +igourous rehydratation:+igourous rehydratation:

Saline

Restore renal functionRestore renal function

Chronic therapyChronic therapy

&ntravenous %isphosphonates )pammidronate or >oledronic acid*! inhi%it osteoclast&ntravenous %isphosphonates )pammidronate or >oledronic acid*! inhi%it osteoclast%one resorption%one resorption normalisation of Ca levelsnormalisation of Ca levels

Calcitonin! synthetic salmon calcitonin )antiresorptive agent*Calcitonin! synthetic salmon calcitonin )antiresorptive agent*

/lucocorticoids in high doses:/lucocorticoids in high doses:

(ecrease renal Ca elimination(ecrease renal Ca elimination &nhi%it a series of osteolithic factors&nhi%it a series of osteolithic factors -re the first line of treatment for hypercalcemia in patients ith multiple mieloma9-re the first line of treatment for hypercalcemia in patients ith multiple mieloma9

lymphoma9 sarcoidosis or intoxication ith vitamin (A -"lymphoma9 sarcoidosis or intoxication ith vitamin (A -"


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$0#.C-LCE,&-$0#.C-LCE,&-


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CausesCauses

$ypoparathyroidism$ypoparathyroidism (ecreased vit ((ecreased vit (levelslevels

(iminished Ca release(iminished Ca releasefrom %onefrom %one

Circulating CaCirculating Cacomplexioncomplexion

(estruction of parathyroid(estruction of parathyroidglands:glands:

-utoimmune-utoimmunesurgicalsurgicalRadiationRadiation&nfiltration&nfiltrationfailure of parathyroidfailure of parathyroiddevelopment )(i/eorgedevelopment )(i/eorgesyndrome*syndrome*deposition of metals )iron9deposition of metals )iron9copper9 aluminium*copper9 aluminium*

Resistance to #T$ action:Resistance to #T$ action:pseudohypoparathyroidismpseudohypoparathyroidismrenal insufficencyrenal insufficencymedications that %lockmedications that %lockosteoclastic %one resorptionosteoclastic %one resorption)calcitonin9 %isphosphonates)calcitonin9 %isphosphonates**

+itamin (+itamin (deficiencydeficiency

-cute-cute

pancreatitispancreatitis

-cute systemic-cute systemicillnessillness

$ereditary$ereditaryvitamin (!vitamin (!

dependent ricketsdependent rickets)type 3 and @*)type 3 and @*

.steomalacia.steomalacia

&nhi%ition of %one&nhi%ition of %oneresorptionresorption

&ncreased uptake&ncreased uptakeof calcium intoof calcium into%one: osteo%lastic%one: osteo%lasticmetastases9 hungrymetastases9 hungry%one syndrome%one syndrome

&ncreased al%umin&ncreased al%uminin alcalosisin alcalosis

-cute pancreatitis-cute pancreatitis)a%normal #T$ and)a%normal #T$ and

vitamin (vitamin (meta%olism*meta%olism*

#hosphate infusion#hosphate infusion

Rapid tumor lysisRapid tumor lysisCrush inFury ithCrush inFury ithmyonecrosismyonecrosis

,ultiple %lood,ultiple %loodtransfusion!transfusion!complexing %y citratecomplexing %y citrate


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Clinical featuresClinical featuresNeuromuscular manifestationsNeuromuscular manifestations Other manifestationsOther manifestations

ParesthesiasParesthesiasNumness an! tin"lin" aroun! the mouth# in theNumness an! tin"lin" aroun! the mouth# in thefin"er tips# in the feetfin"er tips# in the feet

Tetan$Tetan$

The tetan$ attack e"ins %ith pro!romalThe tetan$ attack e"ins %ith pro!romalparesthesias follo%e! $ spasms of the muscles ofparesthesias follo%e! $ spasms of the muscles ofthe e&tremities an! facethe e&tremities an! face

'$per(entilation'$per(entilation

Patients ma$ h$per(entilatePatients ma$ h$per(entilate h$pocapniah$pocapnia alkalosisalkalosis

%orsen h$pocalcemia )increase! in!in" of ionic Ca to%orsen h$pocalcemia )increase! in!in" of ionic Ca to

plasma proteins*plasma proteins*

A!rener"ic s$mptomsA!rener"ic s$mptoms

An&iet$# tach$car!ia# s%eatin"# pallorAn&iet$# tach$car!ia# s%eatin"# pallor

Con(ulsionsCon(ulsionsMuch more common in $oun"+ t%o t$pes,Much more common in $oun"+ t%o t$pes,

-enerali.e! form of tetan$+-enerali.e! form of tetan$+

T$pical epileptiform sei.ure )%ith EE- chan"es*T$pical epileptiform sei.ure )%ith EE- chan"es*

Latent tetan$ si"ns )Ch(ostek/s si"n# Trousseau/s si"n*Latent tetan$ si"ns )Ch(ostek/s si"n# Trousseau/s si"n*

E&trap$rami!al si"ns )classic parkinsonism* 0 in patientsE&trap$rami!al si"ns )classic parkinsonism* 0 in patients%ith chronic h$pocalcemia%ith chronic h$pocalcemia

Posterior lenticular cataractPosterior lenticular cataractPro!uces total opacit$ of thePro!uces total opacit$ of thelens )in opposition to senilelens )in opposition to senilecataract %hich islimite! to acataract %hich islimite! to ase"ment of the lens *+ treatin"se"ment of the lens *+ treatin"h$pocalcemia halts theh$pocalcemia halts thepro"ressionpro"ression

Car!iac manifestationsCar!iac manifestations

Prolon"ation of 1T# resistanceProlon"ation of 1T# resistanceto !i"italis# h$potension#to !i"italis# h$potension#refractor$ C'2 %ithrefractor$ C'2 %ithcar!iome"al$car!iome"al$

Dental manifestationsDental manifestations

Anormalities in enamelAnormalities in enamelformationformation

Dela$e! 3 asent !ental eruptionDela$e! 3 asent !ental eruption

Anormal root formationAnormal root formation

Malasorption s$n!romeMalasorption s$n!rome

Steatorrhea in lon"4stan!in"Steatorrhea in lon"4stan!in"untreate! !iseaseuntreate! !isease


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TrousseauGs signTrousseauGs sign


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La%oratory findingsLa%oratory findings


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La%oratory findingsLa%oratory findings $$yypocalcemiapocalcemia)B39D mmolAl*)B39D mmolAl*

$$yyperperphphososphphoremiaoremia)?39D mmolAl*)?39D mmolAl*

,agnesiu,agnesiumm levels! normalA lolevels! normalA lo

#T$ level:#T$ level: Lo in true hypoparathyroidismLo in true hypoparathyroidism

Elevated in pseudo!hypoparathyroidismElevated in pseudo!hypoparathyroidism

ormal in pseudo!pseudo!hypoparathyroidismormal in pseudo!pseudo!hypoparathyroidism


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$ypoparathyroidism$ypoparathyroidismCausesCauses:: Surgical removal of the parathyroid glands ! the most commonSurgical removal of the parathyroid glands ! the most common

cause )surgery of the neck*"cause )surgery of the neck*"

Hdiopathic hypoparathyroidism! polyglandular endocrinopathiesHdiopathic hypoparathyroidism! polyglandular endocrinopathies)adrenal insufficiency*)adrenal insufficiency*

5amilial hypoparathyroidism! uncommon5amilial hypoparathyroidism! uncommon

(i/eorge syndrome:(i/eorge syndrome: (ysmorphia(ysmorphia

Cardiac deffectsCardiac deffects &mmune defficiency&mmune defficiency $ypoparathyroidism$ypoparathyroidism


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#seudohypoparathyroidism#seudohypoparathyroidism &t is a herita%le disorder&t is a herita%le disorder

Target organs unresponsive to #T$Target organs unresponsive to #T$

Caracteri>ed %y:Caracteri>ed %y: $ypocalcemia$ypocalcemia $yperphosphoremia$yperphosphoremia Elevated #T$ levelsElevated #T$ levels

Characteristic somatic phenotype knon asCharacteristic somatic phenotype knon as Alri"ht/sAlri"ht/shere!itar$ osteo!$stroph$here!itar$ osteo!$stroph$


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#seudo!pseudo!#seudo!pseudo!hypoparathyroidismhypoparathyroidism

Skeletal defectsSkeletal defects

o la%oratory a%normalitieso la%oratory a%normalities


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Skeletal !efects5 Alri"ht/sSkeletal !efects5 Alri"ht/s

here!itar$ osteo!$stroph$here!itar$ osteo!$stroph$

Short statureShort stature

Round faceRound face

Short neckShort neck

'rachydactyly )short digits*'rachydactyly )short digits*

Shortened metatarsals! most often the fourth and fifthShortened metatarsals! most often the fourth and fifth

Su%cutaneous ossificationsSu%cutaneous ossifications

Reduced intelligenceReduced intelligence

Con!itionCon!ition ClinicalClinical PT'PT' CaCa PP 6it D6it D -enetic-enetic


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Con!ition Clinicalaspectaspect

PT' Ca P 6it D -enetic

'$poparath$roi!ism'$poparath$roi!ism NN LL LL '' LL NN

Pseu!oh$poPTPseu!oh$poPT

t$pe 7at$pe 7a

SkeletalSkeletal!efects!efects

'' LL '' LL -enetic-enetic!efect from!efect from

mothermother


t$pe 7t$pe 7

NN '' LL '' LL -enetic-enetic!efect from!efect from

mothermother


t$pe 8t$pe 8 NN

''

LL

''

LL

99

Pseu!opseu!oh$poPseu!opseu!oh$poparath$roi!ismparath$roi!ism

SkeletalSkeletal!efects!efects

NN NN NN NN -enetic-enetic!efect from!efect from

fatherfather


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#seudohypoparathyroidism I clinical features#seudohypoparathyroidism I clinical features


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#seudohypoparathyroidism#seudohypoparathyroidism


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Calcifications in the %rain! CT imageCalcifications in the %rain! CT image


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$ypocalcemia treatment$ypocalcemia treatment


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Acute h$pocalcemia treatmentAcute h$pocalcemia treatment -im: to prevent laryngeal stridor and convulsions-im: to prevent laryngeal stridor and convulsions #atent airay is assured#atent airay is assured

&ntravenous calcium gluconate 3D!@DmL )JDmg calciumA3Dml*9 given sloly&ntravenous calcium gluconate 3D!@DmL )JDmg calciumA3Dml*9 given sloly)maximum 3DmLAmin*)maximum 3DmLAmin*

#lasma calcium levels checked regularly and the infusion rate adFustedK target#lasma calcium levels checked regularly and the infusion rate adFustedK target

level: "1!JmgAdLlevel: "1!JmgAdL Caution in pacients taking digitalis )EC/ monitoring reMuired* Caution in pacients taking digitalis )EC/ monitoring reMuired*

+itamin ( should %e initiated as soon as possi%leK+itamin ( should %e initiated as soon as possi%leK

Nhen possi%le9 oral calcium is given )@DDmg every @ hoursK gradually increasing toNhen possi%le9 oral calcium is given )@DDmg every @ hoursK gradually increasing to1DDmg every @ hours*K if serum calcium level falls %elo "1mgAdL9 intravenous1DDmg every @ hours*K if serum calcium level falls %elo "1mgAdL9 intravenous

administration is restartedadministration is restarted -nticonvulsive agents )pheno%ar%ital* may %e helpful in patients ith convulsionsK-nticonvulsive agents )pheno%ar%ital* may %e helpful in patients ith convulsionsK

#henothia>ine drugs )chlorproma>ine* should %e avoided I they may induce severe#henothia>ine drugs )chlorproma>ine* should %e avoided I they may induce severedyskinesiadyskinesia


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Chronic h$pocalcemia treatmentChronic h$pocalcemia treatment

.ral calcium in a dose of 3"1 !


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OSTEOPO:OSISOSTEOPO:OSIS


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-symptomatic reduction in the Muantity of %one-symptomatic reduction in the Muantity of %one

&ts presence is not usually appreciated until minimal&ts presence is not usually appreciated until minimaltrauma causes a fractureKtrauma causes a fractureK

,ost common sites of osteoporotic fractures:,ost common sites of osteoporotic fractures: #roximal femur#roximal femur (istal radius )CollesG fracture*(istal radius )CollesG fracture*

+erte%ral+erte%ral $umerus$umerus Ri%sRi%s #elvis#elvis

$ypogonadism$ypogonadism #remature menopause#remature menopause

, l h di, l h di


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,ale hypogonadism,ale hypogonadism

Lo estrogensAamenorrheaLo estrogensAamenorrhea HyperprolactinemiaHyperprolactinemiaanore!ia ner(osaanore!ia ner(osa

athletic amenorrheaathletic amenorrhea

Endocrine disordersEndocrine disorders )ushing"s syndrome)ushing"s syndrome*H de$iciency*H de$iciency

hyperparathyroidismhyperparathyroidism

acromegaly +ith hypogonadismacromegaly +ith hypogonadism

hyperthyroidismhyperthyroidism

/& disorders/& disorders alabsorptionalabsorption

*astrectomy*astrectomy

(rugs(rugs Systemic corticoids )?< months*Systemic corticoids )?< months*

Chemotherapy )gonadal damage*Chemotherapy )gonadal damage*-nticonvulsivants-nticonvulsivants-romatase inhi%itors for %reast cancer-romatase inhi%itors for %reast cancer

utritionalutritional calcium or vitamin ( deficitcalcium or vitamin ( deficitsmoking9 alcohol9 coffesmoking9 alcohol9 cofferestrictive dietsrestrictive diets

/enetic/enetic

.ther.ther &mmo%ili>ation&mmo%ili>ationincreased phisical activityincreased phisical activity


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,easurement of %one mass,easurement of %one mass

The most accurate and used method isThe most accurate and used method isdual energy O!ray a%sorptiometry )(EO-*9dual energy O!ray a%sorptiometry )(EO-*9ith the loest radiation exposure"ith the loest radiation exposure"

,easurements of spine and hip %one,easurements of spine and hip %onemass are the %est predictors of fracturemass are the %est predictors of fractureriskrisk

Reading a %one densitometryReading a %one densitometry


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Reading a %one densitometryReading a %one densitometryreportreport

T! score: compares patientGs %one mass toT! score: compares patientGs %one mass toyoung normal su%Fects %one massyoung normal su%Fects %one mass

P! score: compares patientGs %one mass toP! score: compares patientGs %one mass toage! matched normal su%Fects"age! matched normal su%Fects"

',( )%one mineral density*: the actual',( )%one mineral density*: the actual%one density value expressed in gAcm@%one density value expressed in gAcm@


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T scoreT score

? !3? !3 ormalormal

!3 to !@"1!3 to !@"1 .steopenia.steopenia

B!@"1B!@"1 .steoporosis.steoporosis


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Clinical manifestationsClinical manifestations

$eight loss! due to verte%ral compression$eight loss! due to verte%ral compressionfracturesfractures

Spinal deformity! kyphosisSpinal deformity! kyphosis

#ain appears in 3A< of pacients ith verte%ral#ain appears in 3A< of pacients ith verte%ralfracturesfractures


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6yphosis due to osteoporosis6yphosis due to osteoporosis


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5actors influencing fracture risk5actors influencing fracture risk Skeletal factors:Skeletal factors:

'one age'one age 'one si>e'one si>e

'one mineral density and Muality'one mineral density and Muality Extrinsic factors )falling risk*:Extrinsic factors )falling risk*:

&mpaired vision&mpaired vision

(iminished muscle strenght(iminished muscle strenght europathyeuropathy #resence of small animals in household#resence of small animals in household


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TreatmentTreatment

#revention ! for all ages:#revention ! for all ages:

Regular physical activity of reasona%le intensityRegular physical activity of reasona%le intensity

-deMuate nutrient intake-deMuate nutrient intake Correct calcium intakeCorrect calcium intake

Treatment of hypogonadism )hormone replacement*Treatment of hypogonadism )hormone replacement*


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TreatmentTreatment -ntiresor%tive agents:-ntiresor%tive agents:

CalciumCalcium +itamin ( and calcitriol+itamin ( and calcitriol

EstrogenEstrogen

CalcitoninCalcitonin 'isphosphonates'isphosphonates

'one! forming agents:'one! forming agents:

5luoride5luoride -ndrogens-ndrogens #arathyroid hormone#arathyroid hormone


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5ollo!up5ollo!up

#eriodic height measurements#eriodic height measurements

-nnual evaluation of ',(-nnual evaluation of ',(

'iannual la% tests )%one turnover'iannual la% tests )%one turnovermarkers*markers*

Documents

Lecture 9, Calcium and Bone Metabolism