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Introduction. Hypercalcemia is infrequent in pediatrics, of diverse etiology, and with multiorgan morbidity. Objective. Describe the etiology, biochemistry, clinical, and treatment in pediatric patients with hypercalcemia. Population and methods. Retrospective and descriptive study of a cohort of patients with hypercalcemia between 2008 and 2022. They were classified into three groups (G): hypercalcemia of iatrogenic cause (G1), parathyroid hormone (PTH) independent (G2), or PTH-dependent (G3). Results. One hundred forty-seven patients were included; 57% were male, with a median age of 3.7 years, median calcemia of 11.8 mg/dl, and mean phosphatemia of 4.9 mg/dl. Symptoms were present in 29% of patients, and 28.6% required additional treatments to those of the first line. In G1, 76 patients (51.7%) were included; in G2, 58 (39.4%), and in G3, 13 (8.8%). Median calcemia was lower in G1 vs. G2 and G3 (11.6 mg/dl, 12.6 mg/dl, and 12.3 mg/dl), and mean phosphatemia was lower in G3 vs. G1 and G2 (3.7 mg/dl, 5.3 mg/dl, and 4.9 mg/dl). Most of the patients with hypercalcemia were asymptomatic and did not require additional treatments. The percentage of symptomatic patients and the percentage requiring additional treatment were lower in G1 than in the other two groups. Conclusions. Iatrogenesis was the most frequent cause, presenting lower calcemia, while PTH-dependent causes presented the lowest phosphatemia. PTH-independent causes represented a diagnostic and therapeutic challenge due to lacking a characteristic biochemical profile.

Introducción. La hipercalcemia es infrecuente en pediatría, de etiología diversa y con morbilidad multiorgánica. Objetivo. Describir etiología, bioquímica, clínica y tratamiento en pacientes pediátricos con hipercalcemia. Población y métodos. Estudio retrospectivo y descriptivo de una cohorte de pacientes con hipercalcemia entre 2008 y 2022. Se clasificaron en tres grupos (G): hipercalcemia de causa iatrogénica (G1), paratohormona (PTH) independiente (G2) o PTH dependiente (G3). Resultados. Se incluyeron 147 pacientes; el 57 % eran varones, edad mediana de 3,7 años, calcemia mediana 11,8 mg/dl y fosfatemia media 4,9 mg/dl. El 29,9 % de los pacientes fueron sintomáticos y el 28,6 % requirió tratamientos adicionales a los de la primera línea. En G1 se incluyeron 76 pacientes (51,7 %); en G2, 58 (39,4 %), y en G3, 13 (8,8 %). La calcemia mediana fue menor en G1 vs. G2 y G3 (11,6 mg/dl, 12,6 mg/dl y 12,3 mg/dl). La fosfatemia media fue menor en G3 vs. G1 y G2 (3,7 mg/dl, 5,3 mg/dl y 4,9 mg/dl). La mayoría de los pacientes con hipercalcemia fueron asintomáticos sin requerimientos de tratamientos adicionales. El porcentaje de pacientes sintomáticos y el de requerimiento de tratamientos adicionales fue menor en G1 que en los otros dos grupos. Conclusiones. La iatrogenia fue la causa más frecuente, y se presentó con calcemias más bajas; mientras que las causas PTH dependientes presentaron las fosfatemias más bajas. Las causas PTH independientes representaron un desafío diagnóstico y terapéutico por la falta de un perfil bioquímico característico.

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There are many factors involved in the incidence of Alzheimer's disease that, in combination, impede or hinder normal neuronal functions. Little is currently known about calcium regulation before and during the disease. Internal instability of calcium levels is associated with increased vascular risk, a prevalent condition in a high number of individuals already compromised by Alzheimer's disease. This review provides a reevaluation of the molecular mechanism of the sarcoendoplasmic reticulum calcium ATPase (SERC-A) in the disease and discusses salient aspects of voltage-gated calcium channel function; in these way new alternatives could be open for its treatment. These regulation mechanisms are clinically relevant since the irregular functions of SERC+A has been implicated in pathologies of brain function.

Hay muchos factores implicados en la incidencia de la enfermedad de Alzheimer que, en combinación, terminan por impedir o dificultar las funciones neuronales normales. Actualmente, poco se conoce sobre la regulación del calcio, antes de la enfermedad y durante la misma. La inestabilidad interna de los niveles de calcio se asocia a un mayor riesgo vascular, condición prevalente en un gran número de individuos ya comprometidos por la enfermedad de Alzheimer. Esta revisión proporciona una reevaluación de los mecanismos moleculares de la ATPasa dependiente de Ca2+ del retículo sarcoendoplásmico (SERC-A) en la enfermedad y analiza los aspectos más destacados de la función de los canales de calcio dependientes de voltaje; de esta manera, se podrán abrir nuevas alternativas de tratamiento. Estos mecanismos de regulación son clínicamente relevantes, ya que se ha implicado la función irregular de SERC-A en diversas alteraciones de la función cerebral.

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Hay muchos factores implicados en la incidencia de la enfermedad de Alzheimer que, en combinación, terminan por impedir o dificultar las funciones neuronales normales. Actualmente, poco se conoce sobre la regulación del calcio, antes de la enfermedad y durante la misma. La inestabilidad interna de los niveles de calcio se asocia a un mayor riesgo vascular, condición prevalente en un gran número de individuos ya comprometidos por la enfermedad de Alzheimer. Esta revisión proporciona una reevaluación de los mecanismos moleculares de la ATPasa dependiente de Ca2+ del retículo sarcoendoplásmico (SERC-A) en la enfermedad y analiza los aspectos más destacados de la función de los canales de calcio dependientes de voltaje; de esta manera, se podrán abrir nuevas alternativas de tratamiento. Estos mecanismos de regulación son clínicamente relevantes, ya que se ha implicado la función irregular de SERC-A en diversas alteraciones de la función cerebral.

There are many factors involved in the incidence of Alzheimer's disease that, in combination, impede or hinder normal neuronal functions. Little is currently known about calcium regulation before and during the disease. Internal instability of calcium levels is associated with increased vascular risk, a prevalent condition in a high number of individuals already compromised by Alzheimer's disease. This review provides a reevaluation of the molecular mechanism of the sarcoendoplasmic reticulum calcium ATPase (SERC-A) in the disease and discusses salient aspects of voltage-gated calcium channel function; in these way new alternatives could be open for its treatment. These regulation mechanisms are clinically relevant since the irregular functions of SERC+A has been implicated in pathologies of brain function.

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In this study we evaluated the effects of the prepartum anionic diet on the electrolyte balance and calcemia of high producing dairy cows in the first days of lactation, and investigated the impact on the frequency of subclinical hypocalcemia (SCH). Sixty healthy Holstein cows, producing 30 kg of milk/day, handled in intensive system (compost barn), were distributed in groups (n=15) according to lactation order: first, second, third, and fourth to sixth. In the last three weeks before calving they received a diet with negative DCAD (-6mEq/100g DM) and high chloride content. After calving, they received a diet with positive DCAD (18mEq/100g DM). Urine pH was measured before calving. Serum Na+, Cl-, K+, and total Ca concentrations, and the strong ion difference (SID3) were determined in samples taken soon after calving (0h), 24, 48, 72 and 96h after. The frequencies of SCH were determined considering the critical value of 2.125mmol/L (8.5mg/dL). Two-way repeated measures ANOVA and chi-square test were used for comparisons. The cows eliminated acidic urine before calving. Na+, K+, Cl-, and SID3 values did not differ between groups. Na+ and K+ did not vary between days; Cl- was elevated at calving and decreased until 72h; and SID3 was reduced at calving and increased up to 48h. The Ca levels were reduced until 24h and increased up to 72h. Cows of third and fourth to sixth lactations presented lower values up to 24h. SCH was observed in almost half of the cows (43.3% to 55%) until 48h. The maintenance of hypocalcemia for three or more consecutive days occurred in 53.3% of third and fourth to sixth lactations cows. Ingestion of a high chloride prepartum anionic diet led to hyperchloremic acidosis and this imbalance was reversed on the second postpartum day. The induced effects on electrolyte and acid-base balances were not able to prevent the occurrence of SCH in the first days of lactation.(AU)

Os objetivos do estudo foram avaliar os efeitos que a dieta aniônica pré-parto provoca sobre o equilíbrio eletrolítico e sobre a calcemia de vacas leiteiras de alta produção nos primeiros dias de lactação, e verificar o impacto sobre a frequência da hipocalcemia subclínica (HSC). Sessenta fêmeas hígidas HPB, com produção de 30 kg de leite/dia, manejadas em sistema intensivo (compost barn), foram distribuídas por grupos (n=15) de acordo com a ordem de lactação: primeira, segunda, terceira e quarta a sexta. Nas três semanas pré-parto receberam dieta com DCAD negativa (-6mEq/100g MS) e teor de cloreto elevado. Após o parto receberam dieta com DCAD positiva (18mEq/100g MS). O pH da urina foi mensurado antes do parto. As concentrações séricas de Na+, Cl-, K+ e Ca total e a diferença de íons fortes (SID3) foram determinadas em amostras colhidas ao parto (0h), 24, 48, 72 e 96h após. As frequências de HSC foram determinadas considerando-se o valor crítico de 2,125mmol/L (8,5mg/dL). ANOVA de medidas repetidas e teste de qui-quadrado foram empregados para as comparações. As vacas eliminavam urina ácida antes do parto. Os valores de Na+, K+, Cl- e SID3 não diferiram entre os grupos. Na+ e K+ não variaram entre os dias; Cl- era elevado ao parto e diminuiu até 72h; e SID3 era reduzida ao parto e aumentou até 48h. A calcemia era reduzida até 24h e se elevou até 72h. Vacas de terceira e de quarta a sexta lactações apresentaram valores mais baixos até 24h. A HSC foi observada em quase metade das vacas (43,3% a 55%) até 48h. A manutenção de hipocalcemia por três ou mais dias seguidos ocorreu em 53,3% das vacas de terceira e de quarta a sexta lactações. A ingestão de dieta aniônica pré-parto com alto teor de cloreto provocou acidose hiperclorêmica e este desequilíbrio se reverteu no segundo dia pós-parto. Os efeitos induzidos sobre os equilíbrios eletrolítico e ácido base não foram capazes de prevenir a ocorrência de HSC nos primeiros dias da lactação.(AU)

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In this study we evaluated the effects of the prepartum anionic diet on the electrolyte balance and calcemia of high producing dairy cows in the first days of lactation, and investigated the impact on the frequency of subclinical hypocalcemia (SCH). Sixty healthy Holstein cows, producing 30 kg of milk/day, handled in intensive system (compost barn), were distributed in groups (n=15) according to lactation order: first, second, third, and fourth to sixth. In the last three weeks before calving they received a diet with negative DCAD (-6mEq/100g DM) and high chloride content. After calving, they received a diet with positive DCAD (18mEq/100g DM). Urine pH was measured before calving. Serum Na+, Cl-, K+, and total Ca concentrations, and the strong ion difference (SID3) were determined in samples taken soon after calving (0h), 24, 48, 72 and 96h after. The frequencies of SCH were determined considering the critical value of 2.125mmol/L (8.5mg/dL). Two-way repeated measures ANOVA and chi-square test were used for comparisons. The cows eliminated acidic urine before calving. Na+, K+, Cl-, and SID3 values did not differ between groups. Na+ and K+ did not vary between days; Cl- was elevated at calving and decreased until 72h; and SID3 was reduced at calving and increased up to 48h. The Ca levels were reduced until 24h and increased up to 72h. Cows of third and fourth to sixth lactations presented lower values up to 24h. SCH was observed in almost half of the cows (43.3% to 55%) until 48h. The maintenance of hypocalcemia for three or more consecutive days occurred in 53.3% of third and fourth to sixth lactations cows. Ingestion of a high chloride prepartum anionic diet led to hyperchloremic acidosis and this imbalance was reversed on the second postpartum day. The induced effects on electrolyte and acid-base balances were not able to prevent the occurrence of SCH in the first days of lactation.(AU)

Os objetivos do estudo foram avaliar os efeitos que a dieta aniônica pré-parto provoca sobre o equilíbrio eletrolítico e sobre a calcemia de vacas leiteiras de alta produção nos primeiros dias de lactação, e verificar o impacto sobre a frequência da hipocalcemia subclínica (HSC). Sessenta fêmeas hígidas HPB, com produção de 30 kg de leite/dia, manejadas em sistema intensivo (compost barn), foram distribuídas por grupos (n=15) de acordo com a ordem de lactação: primeira, segunda, terceira e quarta a sexta. Nas três semanas pré-parto receberam dieta com DCAD negativa (-6mEq/100g MS) e teor de cloreto elevado. Após o parto receberam dieta com DCAD positiva (18mEq/100g MS). O pH da urina foi mensurado antes do parto. As concentrações séricas de Na+, Cl-, K+ e Ca total e a diferença de íons fortes (SID3) foram determinadas em amostras colhidas ao parto (0h), 24, 48, 72 e 96h após. As frequências de HSC foram determinadas considerando-se o valor crítico de 2,125mmol/L (8,5mg/dL). ANOVA de medidas repetidas e teste de qui-quadrado foram empregados para as comparações. As vacas eliminavam urina ácida antes do parto. Os valores de Na+, K+, Cl- e SID3 não diferiram entre os grupos. Na+ e K+ não variaram entre os dias; Cl- era elevado ao parto e diminuiu até 72h; e SID3 era reduzida ao parto e aumentou até 48h. A calcemia era reduzida até 24h e se elevou até 72h. Vacas de terceira e de quarta a sexta lactações apresentaram valores mais baixos até 24h. A HSC foi observada em quase metade das vacas (43,3% a 55%) até 48h. A manutenção de hipocalcemia por três ou mais dias seguidos ocorreu em 53,3% das vacas de terceira e de quarta a sexta lactações. A ingestão de dieta aniônica pré-parto com alto teor de cloreto provocou acidose hiperclorêmica e este desequilíbrio se reverteu no segundo dia pós-parto. Os efeitos induzidos sobre os equilíbrios eletrolítico e ácido base não foram capazes de prevenir a ocorrência de HSC nos primeiros dias da lactação.(AU)

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OBJECTIVE: To evaluate calcium metabolism and bone mineral density (BMD) in new users of depot medroxyprogesterone acetate (DMPA) in the first year of use. METHODS: This prospective, non-randomized study, conducted at the University of Campinas, São Paulo, Brazil, was carried out between February 2011 and February 2013. Women aged from 18 to 40 with a body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) <30 and with no known history of disease or medication use who chose to use DMPA were paired by age (±1 year) and BMI (±1) with women commencing the use of a copper intrauterine device (IUD). The primary outcomes were BMD measured by dual-energy X-ray absorptiometry and calcium metabolism markers; other variables were body composition and lifestyle habits. Repeated measures analysis of variance (ANOVA) and multiple regression analyses were used to evaluate associations. RESULTS: Twenty-seven women using DMPA and 24 using IUD were evaluated, with a mean age of 29.7 years and 28.6 years, respectively. The DMPA group presented with a 3.6% (P<0.001) loss of lumbar spine BMD, a 2.1% (P=0.100) loss of femoral neck BMD and higher phosphorus (P=0.014) concentrations at 12 months compared to the IUD group. The decreases in BMD were associated with the use of DMPA, while total mass and coffee intake were found to be protective factors. CONCLUSION: Changes in calcium metabolism and a decrease in BMD were found in the DMPA group at 12 months.

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AIM: To detect differences in the pattern of serum calcium tests ordering before and after the implementation of a decision algorithm. METHODS: We studied patients admitted to an internal medicine ward of a university hospital on April 2013 and April 2016. Patients were classified as critical or non-critical on the day when each test was performed. Adequacy of ordering was defined according to adherence to a decision algorithm implemented in 2014. RESULTS: Total and ionised calcium tests per patient-day of hospitalisation significantly decreased after the algorithm implementation; and duplication of tests (total and ionised calcium measured in the same blood sample) was reduced by 49%. Overall adequacy of ionised calcium determinations increased by 23% (P=0.0001) due to the increase in the adequacy of ionised calcium ordering in non-critical conditions. CONCLUSIONS: A decision algorithm can be a useful educational tool to improve adequacy of the process of ordering serum calcium tests.

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ABSTRACT Objective: To characterize the calcium influx pathways implicated in the sustained elevation of endothelial intracellular calcium concentration, required for the synthesis and release of relaxing factors. Methods: We evaluated the effect of the newly synthesized pyrazole derivatives, described as selective inhibitors for ORAI (BTP2/Pyr2 and Pyr6) and TRPC3 (Pyr3 and Pyr10) channels, upon endothelium- and extracellular calcium-dependent relaxations stimulated by acetylcholine and thapsigargin, in pre-constricted rat thoracic aortic rings. Results: Acetylcholine and thapsigargin responses were completely reverted by Pyr2 and Pyr6 (1 to 3μM). Pyr3 (0.3 to 3μM) caused a rapid reversal of acetylcholine (6.2±0.08mg.s−1) and thapsigargin (3.9±0.25mg.s−1) relaxations, whereas the more selective TRPC3 blocker Pyr10 (1 to 3μM) had no effect. The recently described TRPC4/5 selective blocker, ML204 (1 to 3μM), reverted completely acetylcholine relaxations, but minimally thapsigargin induced ones. Noteworthy, relaxations elicited by GSK1016790A (TRPV4 agonist) were unaffected by pyrazole compounds or ML204. After Pyr2 and Pyr6 pre-incubation, acetylcholine and thapsigargin evoked transient relaxations similar in magnitude and kinetics to those observed in the absence of extracellular calcium. Sodium nitroprusside relaxations as well as phenylephrine-induced contractions (denuded aorta) were not affected by any of pyrazole compounds (1 to 3μM). Conclusion: These observations revealed a previously unrecognized complexity in rat aorta endothelial calcium influx pathways, which result in production and release of nitric oxide. Pharmacologically distinguishable pathways mediate acetylcholine (ORAI/TRPC other than TRPC3/TRPC4 calcium-permeable channels) and thapsigargin (TRPC4 not required) induced calcium influx.

RESUMO Objetivo: Caracterizar as vias do influxo de cálcio envolvidas no aumento sustentado da concentração intracelular de cálcio na célula endotelial, essencial para a síntese e a liberação de fatores relaxantes. Métodos: Analisamos o efeito de derivados pirazólicos sintetizados recentemente, descritos como inibidores seletivos para canais ORAI (BTP2/Pyr2 e Pyr6) e TRPC3 (Pyr3 e Pyr10), nos relaxamentos dependentes de endotélio e cálcio extracelular, produzidos por acetilcolina e tapsigargina, em anéis pré-contraídos da aorta torácica de rato. Resultados: As respostas de acetilcolina e tapsigargina foram completamente revertidas por Pyr2 e Pyr6 (1 a 3μM). Pyr3 (0,3 a 3μM) produziu reversão rápida dos relaxamentos de acetilcolina (6,2±0,08mg.s−1) e tapsigargina (3,9±0,25mg.s−1), enquanto o bloqueador mais seletivo para TRPC3, Pyr10 (1 a 3μM), não apresentou efeito. ML204 (1 a 3μM), bloqueador seletivo de TRPC4, descrito há pouco tempo, reverteu os relaxamentos induzidos por acetilcolina de forma completa, mas afetou minimamente aqueles produzidos por tapsigargina. Os derivados pirazólicos ou ML204 não afetaram os relaxamentos estimulados com GSK1016790A (TRPV4-agonista). Ainda, após pré-incubação com Pyr2 e Pyr6, acetilcolina e tapsigargina provocaram relaxamentos transitórios semelhantes em magnitude e cinética àqueles observados na ausência de cálcio extracelular. Os relaxamentos do nitroprussiato de sódio e as contrações induzidas pela fenilefrina (aorta sem endotélio) não foram afetados pelos compostos pirazólicos (1 a 3μM). Conclusão: Essas observações revelaram uma complexidade desconhecida das vias de influxo de cálcio no endotélio da aorta de rato, que resultam na produção e na liberação de óxido nítrico. Vias distinguíveis farmacologicamente medeiam o influxo estimulado por acetilcolina (ORAI TRPC, diferentes de TRPC3 TRPC4) e tapsigargina (TRPC4 não requerido).

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Pseudohypoparathyroidism (PHP) is a group of rare genetic disorders that share organ targeted resistance to the action of parathyroid hormone (PTH) as a common feature. Biochemically, they may present with hypocalcemia, hyperphosphatemia and elevated PTH. Some forms present with a specific phenotype: short stature, round facies, short neck, obesity, brachydactyly and subcutaneous calcifications, called Albrigth's Hereditary Osteodystrophy (AHO). This spectrum of disorders are caused by several alterations in the gene coding for the alpha subunit of the G protein (GNAS): an ubiquitous signaling protein that mediates the action of numerous hormones such as PTH, TSH, gonadotropins, and ACTH, among others. According to their inheritance with maternal or paternal imprinting, they may manifest in a diversity of clinical forms. Although most commonly diagnosed during childhood, PHP may manifest clinically during adolescence or early adulthood. We report two late presenting cases of pseudohypoparathyroidism. A 21-year-old female with biochemical abnormalities characteristic of pseudohypoparathyroidism who was misdiagnosed as epilepsy and a 13-year-old boy with the classic AHO phenotype but without alterations in phospho-calcium metabolism, compatible with pseudopseudohypoparathyrodism.

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Abstract Tumoral calcinosis is an uncommon type of extraosseous calcification characterized by large rubbery or cystic masses containing calcium-phosphate deposits. The condition prevails in the periarticular tissue with preservation of osteoarticular structures. Elevated calcium-phosphorus products and severe secondary hyperparathyroidism are present in most patients with uremic tumoral calcionosis (UTC). Case report of an obese secondary to chronic glomerulonephritis, undergoing continuous ambulatory peritoneal dialysis (CAPD) reported the appearance of painless tumors in the medial surface of fifth finger and left arm. Tumoral calcinosis was confirmed by left biceps biopsy. Poor adherence to CAPD. The patient was transferred to the "tidal" modality of peritoneal dialysis and after was treated by hemodialysis, despite the persistence of severe hyperparathyroidism progressive reduction of UTC until near to its complete disappearance. Nowadays, one year after patient received deceased-donor kidney transplantation, he presents with an improvement in secondary hyperparathyroidism. UTC should be included in the elucidation of periarticular calcification of every patient on dialysis. Relevant laboratory findings such as secondary hyperparathyroidism and elevated calcium- phosphorus products in the presence of periarticular calcification should draw attention to the diagnosis of UTC.

Resumo A calcinose tumoral é um tipo raro de calcificação extraóssea caracterizada por grandes massas císticas e elásticas contendo depósitos de fosfato de cálcio. A condição é mais prevalente no tecido periarticular e preserva estruturas osteoarticulares. A elevação do produtos cálcio-fósforo e o hiperparatireoidismo secundário grave estão presentes na maioria dos pacientes com calcinose tumoral urêmica (UTC). O relato de caso em questão refere-se a um homem de 22 anos, branco, obeso, com doença renal crônica secundária à glomerulonefrite crônica, em diálise peritoneal ambulatorial contínua (CAPD), que apresentou aparecimento de tumores indolores na face medial do quinto quirodáctilio e braço esquerdo. A calcinose tumoral foi confirmada por biópsia do bíceps esquerdo. O paciente apresentava baixa adesão à CAPD. Foi transferido para a modalidade de diálise peritoneal e depois iniciou tratamento por hemodiálise. Apesar da persistência do hiperparatireoidismo grave, houve redução progressiva da UTC, com resolução próxima do seu desaparecimento completo. Há 1 ano o paciente foi submetido a transplante renal, doador falecido, e apresentou melhora do hiperparatiroidismo secundário. A UTC deve ser incluída na elucidação de calcificação periarticular de pacientes em diálise. Os achados laboratoriais relevantes, tais como hiperparatiroidismo secundário e elevação dos produtos cálcio-fósforo na presença de calcificação periarticular, devem chamar a atenção para o diagnóstico da UTC.

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Background: Knowledge about the variability in the request of calcium-phosphate metabolism laboratory tests in primary care is important to design strategies to improve health system efficiency. Aim: To compare the inter-practice variability in calcium-phosphate metabolism laboratory tests requested by general practitioners from diverse regions across Spain. Material and Methods: One hundred and forty one clinical laboratories were invited to participate in an observational cross-sectional study. They informed the number of serum calcium, phosphate, parathyroid hormone and 25-hydroxyvitamin D requested by general practitioners. Appropriateness indicators were calculated as number of test requests per 1,000 inhabitants and ratio of related tests requests. The differences according to hospital setting, region and type of management were analyzed. Results: We recruited 76 laboratories (17,679,195 inhabitants). General practitioners requested 3,260,894 calcium-phosphate metabolism tests. The rate of request ranged from 2.97 per 1,000 inhabitants for 25-hydroxyvitamin D to 98.89 per 1,000 inhabitants for calcium. The rates of request for calcium, phosphate, parathyroid hormone in some areas were 30, 100 and 340 times higher than in other areas. Parathyroid hormone and 25-hydroxyvitamin D were highly requested in private management areas. There were also differences in phosphate, parathyroid hormone and 25-hydroxyvitamin D requesting between regions across Spain. Conclusions: The high variability observed is difficult to explain by differences in patient case mix between regions. Depending on the area, calcium could be under requested to detect primary hyperparathyroidism.

Objetivo: Conocer la variabilidad en la solicitud de pruebas de laboratorio en atención primaria es importante para diseñar estrategias que mejoren la eficiencia del sistema de salud. La propuesta de este estudio fue comparar la variabilidad en la solicitud de pruebas para la evaluación del metabolismo fosfocálcico por médicos de atención primaria de diversas regiones de España. Material y Método: Se invitó a participar a 141 laboratorios clínicos de diversas regiones españolas. Completaron una encuesta con el número de determinaciones de calcio, fósforo, hormona paratiroidea y 25-hidroxivitamina D solicitadas por médicos de atención primaria de sus áreas. Se calcularon las tasas en relación a la población y se construyeron indicadores de adecuación. Los resultados se compararon por características del hospital, región y tipo de gestión. Resultados: Obtuvimos los datos de 76 laboratorios (17.679.195 habitantes). Los médicos de atención primaria solicitaron 3.260.894 pruebas de metabolismo fosfocálcico. La tasa de solicitud varió de 2,97 por 1.000 habitantes de 25-hidroxivitamin D a 98,89 por 1.000 habitantes de calcio. Las tasas de calcio, fósforo, hormona paratiroidea en algunas áreas fue 30, 100 y 340 veces más alta respecto a otras. Hormona paratiroidea y 25-hidroxivitamina D fueron más solicitadas significativamente en hospitales con gestión privada. También hubo diferencias en fósforo, hormona paratiroidea y 25-hidroxivitamina D solicitas entre distintas regiones de España. Discusión: La alta variabilidad observada es difícil de explicar por las diferencias de las características de los pacientes. Dependiendo de la región podría haber una infra solicitud para la detección del hiperparatiroidismo primario.

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The present study aimed to evaluate the effect of dietary cation-anion difference (DCAD) on ruminal fermentation, total apparent digestibility, blood and renal metabolism of lactating dairy cows. Sixteen Holstein cows were distributed in four contemporary 4×4 Latin Square designs, which consisted of four periods of 21 days and four treatments according to DCAD: +290; +192; +98 and -71 milliequivalent (mEq)/kg dry matter (DM). Ruminal pH and concentrations of acetic and butyric acid increased linearly according to the increase of DCAD. Similarly, NDF total apparent digestibility linearly increased by 6.38% when DCAD increased from -71 to 290 mEq/kg DM [Y=65.90 (SE=2.37)+0.0167 (SE=0.0068)×DCAD (mEq/kg DM)]. Blood pH was also increased according to DCAD, which resulted in reduction of serum concentrations of Na, K and ionic calcium (iCa). To maintain the blood acid-base homeostasis, renal metabolism played an important role in controlling serum concentrations of Na and K, since the Na and K urinary excretion increased linearly by 89.69% and 46.06%, respectively, from -71 to 290 mEq/kg DM. Changes in acid-base balance of biological fluids may directly affect the mineral composition of milk, as milk concentrations of Na, K, iCa and chlorides were reduced according to blood pH increased. Thus, it can be concluded that the increase of DCAD raises the pH of ruminal fluid, NDF total apparent digestibility, and blood pH, and decreases the milk concentration of cationic minerals, as well as the efficiency of Na utilization to milk production.

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La enfermedad mineral ósea (EMO) es un término amplio que incluye a las alteraciones séricas del calcio, fósforo, vitamina D, paratohormona, anormalidades en el crecimiento, mineralización ósea y/o a las calcificaciones extraesqueléticas que acompañan al paciente con enfermedad renal crónica (ERC). Está presente en casi la totalidad de pacientes en diálisis y con el trasplante renal puede no siempre mejorar. Se han identificado nuevos factores y hormonas; como klotho y factor de crecimiento de fibroblastos-23 (FGF-23) que interactúan con la vitamina D y con la paratohormona en el manejo renal del calcio y fósforo. Ciertos reportes indican que son marcadores precoces del desarrollo de EMO, incluso cuando la función renal está levemente disminuida y los niveles de paratohormona son normales. La EMO ha sido asociada con mayor mortalidad, principalmente por su vinculación con la calcificación vascular. Este proceso conlleva a un incremento de eventos cardiovasculares que constituyen la principal causa de morbimortalidad en pacientes con ERC, sobre todo aquellos que se encuentran en diálisis, independientemente de la modalidad que los pacientes sigan. La forma de presentación de la EMO puede ser de alto o bajo recambio. Aunque no está completamente definido qué es lo que determina que se exprese una en particular, se ha encontrado que la enfermedad de bajo recambio se relaciona con malnutrición, uso inadecuado de calcitriol y diálisis ineficiente. El conocimiento de la EMO es relevante por su asociación con las complicaciones mencionadas y porque constituye un parámetro para evaluar la terapia instalada.

Mineral Bone Disorder (MBD) is a broad term that includes abnormal serum calcium, phosphorus, vitamin D, parathyroid hormone, growth abnormalities, bone mineralization and/or extraskeletal calcifications in patients with chronic kidney disease (CKD ). It is present in almost all patients on dialysis and may not always improve with a kidney transplant. New factors and hormones have been identified, such as Klotho and fibroblast growth factor-23 (FGF-23) that interact with vitamin D and the parathyroid hormone in the renal management of calcium and phosphorus. Some reports indicate that they are early markers of the development of MBD, even when kidney function is slightly decreased and parathyroid hormone levels are normal. MBD has been associated with higher mortality, mainly because of its link with vascular calcification. This process leads to an increase in cardiovascular events which are the leading cause of morbidity and mortality in CKD patients, especially those who are on dialysis, regardless of the modality that the patients follow. The presentation of the BMD can be of high or low turnover. Although it is not completely defined what determines that a particular form of presentation is expressed, it has been found that the low turnover disease is related to malnutrition, inappropriate use of calcitriol and inefficient dialysis. Knowledge of BMD is relevant for its association with the complications mentioned above and because it constitutes a parameter for assessing the instituted therapy.

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Introduction: Familial Hypomagnesaemia with hypercalciuria and nephrocalcinosis, with severe ocular impairment secondary to claudin-19 mutation, is a rare recessive autossomic disorder. Its spectrum includes renal Mg2+ wasting, medullary nephrocalcinosis and progressive chronic renal failure in young people. Objective: To report a case of kidney transplantation father to daughter in a familial occurrence of severe bilateral nephrocalcinosis associated with ocular impairment in a non-consanguineous Brazilian family, in which two daughters had nephrocalcinosis and severe retinopathy. Methods: The index case, a 19 years-old female, had long-lasting past medical history of recurrent urinary tract infections, and the abdominal X-ray revealed bilateral multiple renal calcifications as well as ureteral lithiasis, and she was under haemodialysis. She had the diagnosis of retinitis pigmentosa in the early neonatal period. The other daughter (13 years-old) had also nephrocalcinosis with preserved kidney function, retinopathy with severe visual impairment, and in addition, she exhibited hypomagnesaemia = 0.5 mg/dL and hypercalciuria. The other family members (mother, father and son) had no clinical disease manifestation. Mutation analysis at claudin-19 revealed two heterozygous missense mutations (P28L and G20D) in both affected daughters. The other family members exhibited mutant monoallelic status. In despite of that, the index case underwent intrafamilial living donor kidney transplantation (father). Conclusion: In conclusion, the disease was characterized by an autosomal recessive compound heterozygous status and, after five years of donation the renal graft function remained stable without recurrence of metabolic disturbances or nephrocalcinosis. Besides, donor single kidney Mg2+ and Ca2+ homeostasis associated to monoallelic status did not affect the safety and the usual living donor post-transplant clinical course. .

Introdução: Hipomagnesemia familiar com hipercalciúria e nefrocalcinose, com grave envolvimento ocular, por mutação no gene da claudina-19, é uma doença rara autossômica recessiva. Seu espectro inclui perda renal de magnésio, nefrocalcinose medular e doença renal progressiva em crianças e adolescentes. Objetivo: Relatar um caso de transplante renal pai para filha em uma ocorrência familiar de nefrocalcinose bilateral grave associada com comprometimento ocular em uma família brasileira não consangüínea, na qual duas filhas apresentavam nefrocalcinose e retinopatia severa. Métodos: O caso índice, uma mulher de 19 anos de idade, tinha longa história pregressa de infecção urinária de repetição, o raio-X abdominal revelava calcificações renais múltiplas bilaterais, bem como litíase ureteral, e estava sob hemodiálise. Havia um diagnóstico prévio de retinite pigmentosa no período neonatal precoce. A outra filha (13 anos de idade) também apresentava nefrocalcinose com função renal preservada, retinopatia com grave deficiência visual, e além disso, ela exibia hipomagnesemia = 0,5 mg/dL e hipercalciúria. Os outros membros da família (mãe, pai e filho) não tinham nenhuma manifestação clínica da doença. A análise mutacional no gene da claudin-19 revelou duas mutações heterozigotas (P28L e G20D) em ambas as filhas afetadas. Os outros membros da família apresentavam estado mutante monoalélico. Apesar disso, o caso índice foi submetido a transplante de rim com doador vivo intrafamiliar (pai). Conclusão: Em conclusão, a doença foi caracterizada por um estado heterozigoto recessivo composto autossômico e após cinco anos de doação a função do enxerto ...

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Objetivos: Relatar um caso clínico de tuberculose de apresentação não usual.Descrição do caso: Uma lactente de oito meses, sem infecção pelo vírus de imunodeficiência humana (HIV), filha de mãe seropositiva para HIV e com tuberculose pulmonar, foi internada por febre com 15 dias de evolução, sem outra sintomatologia. A radiografia de tórax revelou múltiplos focos de hipotransparência bilateralmente e a prova de tuberculina 8 mm. A doente não havia recebido a vacina BCG. Realizou broncofibroscopia que evidenciou compressão extrínseca da árvore traqueobrônquica, causada por múltiplas adenopatias, confirmadas por ressonância magnética nuclear do mediastino. Na ecografia abdominal foram encontrados aspectos sugestivos de nefrocalcinose. Os estudos do metabolismo cálcio-fósforo e da função renal não revelaram alterações. Iniciou terapêutica antibacilar tripla e corticoterapia. Foi isolado Mycobacterium tuberculosis no lavado bronco-alveolar. Verificou-se boa evolução clínica, tendo alta com 27 dias de terapêutica antibacilar.Conclusões: Este caso clínico destaca-se pela forma incomum de apresentação da tuberculose, com a presença de nefrocalcinose. As perturbações do metabolismo do cálcio associadas à tuberculose são raras, mas têm implicação no seguimento e no prognóstico.

Aims: To report a case of tuberculosis with unusual presentation.Case description: An eight months old infant without infection by the human immunodeficiency virus (HIV), born of an HIV-positive mother with pulmonary tuberculosis, was hospitalized for fever lasting 15 days, with no other symptoms. Chest radiography revealed multiple bilateral nodular opacities and the tuberculin test was 8 mm. The patient had not received BCG vaccination. Bronchoscopy showed extrinsic compression of the tracheobronchial tree, caused by multiple adenopathies, confirmed by nuclear magnetic resonance imaging of the mediastinum. Abdominal ultrasound was suggestive of nephrocalcinosis. Phospho-calcium metabolism and renal function studies showed no alterations. Triple antituberculous therapy and corticosteroid were started. Mycobacterium tuberculosis was isolated in bronchoalveolar lavage. There was good clinical outcome and the patient was discharged with 27 days of antituberculosis therapy.Conclusions : This case stands out for its unusual presentation , with the presence of nephrocalcinosis. Disturbances of calcium metabolism associated with tuberculosis are rare, but have implications for the follow-up and prognosis.

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A Hipocalcemia Não Puerperal (HNP) é uma condição rara e pouco compreendida. Não há estudos que expliquem a sua relação com a ingestão de pastagens de inverno como base da alimentação volumosa. Os objetivos deste trabalho foram descrever aspectos clínicos de dois casos naturais de HNP, e estudar o balanço mineral e eletrolítico de vacas leiteiras de alta e de média produção alimentadas em pastagem de inverno em diferentes estágios de evolução. Foram acompanhados dois casos de HNP em vacas leiteiras, mantidas em pastagens de aveia ou de azevém no município de Francisco Beltrão, PR. De três propriedades localizadas no mesmo município, foram selecionadas vacas lactantes hígidas de alta produção da raça Holandesa (n=11) e de média produção das raças Holandesa (n=8) e Jersey (n=9), mantidas em pastagem mista de aveia e azevém, de junho a outubro de 2011, e complementadas com silagem de milho. Amostras de sangue, de urina e dos alimentos ingeridos foram colhidas antes do ingresso na pastagem (maio), e nos estágios inicial (junho), intermediário (julho) e final (setembro) do ciclo de maturação da forragem. Foram determinadas as concentrações séricas e urinárias de Ca, P, Mg, Na+, K+, Cl- e creatinina e calculada as excreções fracionadas. Nas amostras de alimento foram determinadas a matéria seca (MS) e as concentrações de Ca, P, Mg, Na, K, Cl e S, e calculou-se a diferença entre cátions e ânions da dieta (DCAD) nos diferentes momentos. Com base nas evidências pode-se afirmar que vacas leiteiras em lactação mantidas em pastagem de aveia e/ou de azevém nos meses de inverno podem desenvolver hipocalcemia e exibir sinais clínicos e resposta ao tratamento similares aos da hipocalcemia puerperal clássica, mesmo não sendo recém paridas. A ingestão de aveia e azevém, substituindo parcialmente a silagem de milho como volumoso da dieta, não provoca desequilíbrio eletrolítico e não interfere com a calcemia, a fosfatemia ou a magnesemia de vacas lactantes de alta e de média produção. A utilização das forrageiras de inverno como a única ou principal fonte de volumoso da dieta parece ser o fator desencadeante da doença e pode estar relacionada com o excesso de cátions ingeridos devido à elevada concentração de K, principalmente, quando a planta é jovem.(AU)

Non-parturient hypocalcaemia (NPH) is a rare and poor understood condition. There are no studies that explain its relationship with winter pasture intake. The aim of this study was to describe clinical aspects of two natural cases of NPH, and to study the mineral and electrolyte balance of high and medium producing dairy cows feeded with winter pasture in different growing stages. Two cases of NPH in lactating dairy cows, grazing in oat grass and perennial ryegrass in Francisco Beltrão, PR, Brazil, were described. Healthy lactating high producing Holstein cows (n=11) and medium producing Holstein (n=8) and Jersey (n=9) cows were selected from three farms located in the same municipality. They were maintained in a mixing pasture of oats and perennial ryegrass from June to October, and supplemented with corn silage. Blood, urine and ingested food samples were collected before treatment started (May), and during initial (June), intermediate (July) and final stages (September) of the grass maturation cycle. Serum and urinary concentrations of Ca, P, Mg, Na+, K+, Cl- and creatinine were determined, and their fractional excretion were calculated. Dry matter and Ca, P, Mg, Na, K, Cl and S concentrations were determined in food samples, and the dietary cation-anion difference was calculated. Based on clinical evidence we can assure that lactating dairy cows maintained in oat and perennial ryegrass pastures during the winter months can develop hypocalcaemia, showing signs and responding to treatment similar to classic puerperal hypocalcaemia, even in non-parturient period. Partial substitution of corn silage to oat and perennial ryegrass pasture did not cause electrolyte imbalances and did not interfere with the calcemia, phosphatemia or magnesemia of high and medium producing lactating dairy cows. Using winter forage as the only or main source of roughage in the diet can be the triggering factor for the disease, which can be related to excessive cation intake due to increased K concentration, especially during early stages of pasture growing.(AU)

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A Hipocalcemia Não Puerperal (HNP) é uma condição rara e pouco compreendida. Não há estudos que expliquem a sua relação com a ingestão de pastagens de inverno como base da alimentação volumosa. Os objetivos deste trabalho foram descrever aspectos clínicos de dois casos naturais de HNP, e estudar o balanço mineral e eletrolítico de vacas leiteiras de alta e de média produção alimentadas em pastagem de inverno em diferentes estágios de evolução. Foram acompanhados dois casos de HNP em vacas leiteiras, mantidas em pastagens de aveia ou de azevém no município de Francisco Beltrão, PR. De três propriedades localizadas no mesmo município, foram selecionadas vacas lactantes hígidas de alta produção da raça Holandesa (n=11) e de média produção das raças Holandesa (n=8) e Jersey (n=9), mantidas em pastagem mista de aveia e azevém, de junho a outubro de 2011, e complementadas com silagem de milho. Amostras de sangue, de urina e dos alimentos ingeridos foram colhidas antes do ingresso na pastagem (maio), e nos estágios inicial (junho), intermediário (julho) e final (setembro) do ciclo de maturação da forragem. Foram determinadas as concentrações séricas e urinárias de Ca, P, Mg, Na+, K+, Cl- e creatinina e calculada as excreções fracionadas. Nas amostras de alimento foram determinadas a matéria seca (MS) e as concentrações de Ca, P, Mg, Na, K, Cl e S, e calculou-se a diferença entre cátions e ânions da dieta (DCAD) nos diferentes momentos. Com base nas evidências pode-se afirmar que vacas leiteiras em lactação mantidas em pastagem de aveia e/ou de azevém nos meses de inverno podem desenvolver hipocalcemia e exibir sinais clínicos e resposta ao tratamento similares aos da hipocalcemia puerperal clássica, mesmo não sendo recém paridas...

Non-parturient hypocalcaemia (NPH) is a rare and poor understood condition. There are no studies that explain its relationship with winter pasture intake. The aim of this study was to describe clinical aspects of two natural cases of NPH, and to study the mineral and electrolyte balance of high and medium producing dairy cows feeded with winter pasture in different growing stages. Two cases of NPH in lactating dairy cows, grazing in oat grass and perennial ryegrass in Francisco Beltrão, PR, Brazil, were described. Healthy lactating high producing Holstein cows (n=11) and medium producing Holstein (n=8) and Jersey (n=9) cows were selected from three farms located in the same municipality. They were maintained in a mixing pasture of oats and perennial ryegrass from June to October, and supplemented with corn silage. Blood, urine and ingested food samples were collected before treatment started (May), and during initial (June), intermediate (July) and final stages (September) of the grass maturation cycle. Serum and urinary concentrations of Ca, P, Mg, Na+, K+, Cl- and creatinine were determined, and their fractional excretion were calculated. Dry matter and Ca, P, Mg, Na, K, Cl and S concentrations were determined in food samples, and the dietary cation-anion difference was calculated. Based on clinical evidence we can assure that lactating dairy cows maintained in oat and perennial ryegrass pastures during the winter months can develop hypocalcaemia, showing signs and responding to treatment similar to classic puerperal hypocalcaemia, even in non-parturient period. Partial substitution of corn silage to oat and perennial ryegrass pasture did not cause electrolyte imbalances and did not interfere with the calcemia, phosphatemia or magnesemia of high and medium producing lactating dairy cows...

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Among the different feed additives studied in poultry production, clinoptilolite, an aluminosilicate capable of adsorbing harmful substances and of improving live performance and egg and meat quality, was evaluated. The objective of the present study was to evaluate the influence of dietary clinoptilolite and calcium levels on the performance and egg quality of layers. In total, 576 layers were distributed according to a completely randomized experimental design in a 3 x 4 factorial arrangement (three calcium levels - 2.5, 3.1, or 3.7% and four clinoptilolite levels - 0.0, 0.15, 0.25, or 0.50%), with 12 treatments of six replicates of eight birds each. The experiment included four 28-d cycles. The experimental diets were based on corn and soybean meal. Results were submitted to analysis of variance and means were compared by the test of Tukey at 5% significance level using SISVAR statistical package. There was a significant interaction between the evaluated factors for egg production and feed conversion ratio per dozen eggs and egg mass. The lowest calcium level resulted in worse performance and eggshell quality. Clinoptilolite levels affected albumen and yolk content. It was concluded that up to 0.50% inclusion of clinoptilolite in layer diets does not benefit layer performance or eggshell quality. Although the inclusion of only 2.5% calcium in layer diets is not recommended, it is possible to add 3.1% because it promoted similar results as the recommended level of 3.7%.

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Among the different feed additives studied in poultry production, clinoptilolite, an aluminosilicate capable of adsorbing harmful substances and of improving live performance and egg and meat quality, was evaluated. The objective of the present study was to evaluate the influence of dietary clinoptilolite and calcium levels on the performance and egg quality of layers. In total, 576 layers were distributed according to a completely randomized experimental design in a 3 x 4 factorial arrangement (three calcium levels - 2.5, 3.1, or 3.7% and four clinoptilolite levels - 0.0, 0.15, 0.25, or 0.50%), with 12 treatments of six replicates of eight birds each. The experiment included four 28-d cycles. The experimental diets were based on corn and soybean meal. Results were submitted to analysis of variance and means were compared by the test of Tukey at 5% significance level using SISVAR statistical package. There was a significant interaction between the evaluated factors for egg production and feed conversion ratio per dozen eggs and egg mass. The lowest calcium level resulted in worse performance and eggshell quality. Clinoptilolite levels affected albumen and yolk content. It was concluded that up to 0.50% inclusion of clinoptilolite in layer diets does not benefit layer performance or eggshell quality. Although the inclusion of only 2.5% calcium in layer diets is not recommended, it is possible to add 3.1% because it promoted similar results as the recommended level of 3.7%.(AU)

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