Treatment of Abnormal Ionized Calcium Levels

Hypocalcemia Management

The American Journal of Kidney Diseases recommends initiating calcium gluconate infusion at 1-2 mg elemental calcium per kg body weight per hour if ionized calcium falls below normal (<0.9 mmol/L or <3.6 mg/dL) 1, 2
A 10-mL ampule of 10% calcium gluconate contains 90 mg of elemental calcium 2
Ionized calcium should be monitored every 4-6 hours for the first 48-72 hours after parathyroidectomy, then twice daily until stable 1, 3
Calcium infusion should be gradually reduced when ionized calcium reaches normal range (1.15-1.36 mmol/L) and remains stable 1
The American Journal of Kidney Diseases suggests transitioning to oral calcium carbonate 1-2 g three times daily, plus calcitriol up to 2 g/day when oral intake is possible 1, 4

For adynamic bone disease in Stage 5 CKD, the American Journal of Kidney Diseases recommends allowing plasma PTH levels to rise to increase bone turnover 4, 6
This can be accomplished by decreasing doses of calcium-based phosphate binders and vitamin D or eliminating such therapy 4, 6
Lowering dialysate calcium (1.0-2.0 mEq/L) has been suggested but remains experimental 7
Parathyroidectomy is recommended for severe hyperparathyroidism (persistent intact PTH >800 pg/mL) with hypercalcemia and/or hyperphosphatemia refractory to medical therapy 1, 4
Effective surgical options include subtotal parathyroidectomy or total parathyroidectomy with parathyroid tissue autotransplantation 1
After parathyroidectomy, phosphate binders may need to be discontinued or reduced based on serum phosphorus levels 1, 3