Original Study

Acomparison of total calcium, corrected calcium,

and ionized calciumconcentrations as indicators
of calciumhomeostasis among hypoalbuminemic
dogs requiring intensive care
Claire R. Sharp, BSc, BVMS; Marie E. Kerl, DVM, DACVIM, DACVECC and F.A. Mann, DVM, MS,
DACVS, DACVECC
Abstract
Objective (1) To evaluate whether total calcium (tCa) correlates with ionized calcium (iCa) in
hypoalbuminemic dogs; (2) to evaluate whether calcium adjusted for albumin (Alb), or total protein (TP),
or both accurately predict iCa concentrations and hence can be used to monitor calcium homeostasis in
critically ill hypoalbuminemic dogs; and (3) to evaluate factors associated with any potential discrepancy in
calcium classication between corrected total and ionized values.
Design Prospective observational clinical study.
Setting Small animal intensive care unit in a veterinary medical teaching hospital.
Animals Twenty-eight client-owned dogs with hypoalbuminemia.
Interventions None.
Measurements and Main Results iCa was determined using ion-specic electrode methodology, on
heparinized plasma. The tCa concentration was adjusted for Alb and TP using published equations. In total
29% (8/28) of the hypoalbuminemic, critically ill dogs in this study were hypocalcemic at intensive care unit
admission, as determined by iCa measurement. Corrected calcium values failed to accurately classify calcium
status in 67.9% and 64.3% of cases, according to whether the Alb-adjusted or TP-adjusted values, respectively,
were used. The sensitivity and specicity of the tCa to evaluate hypocalcemia was 100% and 47%, respectively.
The sensitivity and specicity of the correction formulae were 37.5% and 79% for the Alb-adjusted values and
37.5% and 74% for TP-adjusted values. tCa overestimated the presence of hypocalcemia and underestimated
the presence of normocalcemia, while corrected calcium values overestimated the presence of normocalcemia
and underestimated the presence of hypocalcemia.
Conclusions Calcium homeostasis in hypoalbuminemic critically ill dogs should be evaluated by iCa
concentrations rather than tCa or calcium adjusted for Alb or TP. Given that tCa has 100% sensitivity for
detecting hypocalcemia in this population it is recommended that all hypoalbuminemic and critically ill
patients with low tCa should be evaluated with an iCa measurement.
(J Vet Emerg Crit Care 2009; 19(6): 571578) doi: 10.1111/j.1476-4431.2009.00485.x
Keywords: clinical pathology, critical care, electrolytes, small animal
Introduction
Aberrations in calcium homeostasis, notably hypo-
calcemia, are common in critically ill humans and
dogs.
13
Hypocalcemia, of clinical and prognostic sig-
nicance, has been documented in dogs with acute
renal failure
4
and diabetic ketoacidosis.
5
However,
hypocalcemia often goes unrecognized in critically ill,
hypoalbuminemic humans because it is assumed that
the total calcium (tCa) concentration is falsely low sub-
sequent to low albumin (Alb) concentrations, since a
proportion of serum calcium is bound to protein, par-
ticularly Alb.
6,7
In dogs, 34% of total body calcium is
Research presented in part at the University of Missouri Phi Zeta Research
Day March 2006 and the 12th International Veterinary Emergency and
Critical Care Symposium, San Antonio, TX, 2006.
Dr. Kerl discloses that she has received support from Heska Corporation.
The authors report no conicts of interest.
Grant Support: This study was supported by a grant from the Pi Chapter
of Phi Zeta in the College of Veterinary Medicine at the University of
Missouri.
Address correspondence and reprint requests to
Dr. Claire R. Sharp, BSc, BVMS, Cummings School of Veterinary Medicine
at Tufts University, 200 Westboro Rd, North Grafton, MA 01536.
Email: claire.sharp@tufts.edu
From the Department of Veterinary and Medicine and Surgery, University
of Missouri, Columbia, MO 65211.
Journal of Veterinary Emergency and Critical Care 19(6) 2009, pp 571578
doi:10.1111/j.1476-4431.2009.00485.x
& Veterinary Emergency and Critical Care Society 2009 571
protein bound.
8
Given the potential adverse sequelae of
hypocalcemia in critical illness, the ability to accurately
predict an individuals calcium status is important to
help guide patient management.
Traditionally, assessment of an animals calcium sta-
tus has been based on evaluation of the tCa concentra-
tion. The tCa concentration has been assumed to be
directly proportional to ionized calcium (iCa), which is
the biologically active form of calcium and the gold
standard for determination of calcium status,
9
but the
validity of this assumption in a variety of clinical sit-
uations has not been established in veterinary patients.
It has been suggested that tCa can be corrected or ad-
justed relative to the Alb or total protein (TP) concen-
tration in order to improve diagnostic interpretation,
particularly in patients with hypoalbuminemia or hy-
poproteinemia when iCa measurement is not avail-
able.
10,11
The two most commonly used formulae for
adjustment of tCa for Alb and TP, respectively, are
listed in Table 1. Correction for Alb rather than TP is
preferred in veterinary medicine because of the
stronger relationship between serum Alb and tCa con-
centrations.
9,10
It has been assumed that tCa concentrations that
correct into the normal reference interval suggest nor-
mal serum iCa whereas failure to correct into the
reference interval suggests abnormal serum iCa con-
centrations.
9
The forumulae were calculated based on
regression analysis in 209 dogs that found a positive
linear relationship between tCa and Alb (r 50.575;
Po0.001; r
2
50.33), and between tCa and TP (r 50.411;
Po0.001).
10
However, the ubiquitous use of these
formulae to adjust tCa values for hypoalbuminemia
has been questioned since they were established in a
relatively small population of dogs and were not con-
rmed by iCa measurements given development before
routine use of ion-selective electrodes to measure iCa.
In 2 veterinary studies that investigated the relationship
between corrected tCa and iCa, correction of tCa con-
centration for Alb did not improve the correlation be-
tween total and iCa concentrations in dogs.
12,13
Despite
this, veterinarians continue to use the correction for-
mulae in dogs to diagnose primary disorders of calcium
metabolism.
Human studies have concluded that tCa- and Alb-
adjusted calcium cannot be used in an intensive care
setting to diagnose hypocalcemia in critically ill pa-
tients and should be replaced by measurement of
iCa.
6,7,14,15
A large study that evaluated the ability of
tCa or adjusted-calcium values to predict iCa concen-
trations in a heterogeneous population of dogs, con-
cluded that adjusted and measured tCa concentrations
are unreliable for predicting iCa status in dogs.
12
To the
knowledge of the authors, this question has not been
researched specically in critically ill small animals.
The objectives of this study were (1) to evaluate
whether tCa correlates with iCa in hypoalbuminemic
dogs; (2) to evaluate whether calcium adjusted for Alb
and TP accurately predicts iCa concentrations and
hence can be used to monitor calcium homeostasis in
critically ill hypoalbuminemic dogs; and (3) to evaluate
factors associated with any potential discrepancy in
calcium classication between corrected total and ion-
ized values.
We hypothesized that hypoalbuminemic, skeletally
mature dogs with abnormally low tCa would have cor-
responding ionized hypocalcemia underestimated by
calcium concentrations mathematically adjusted ac-
cording to concentrations of Alb and TP.
Materials and Methods
This study was designed as a prospective, single-
center, observational study utilizing hypoalbuminemic,
skeletally mature dogs, requiring intensive care treat-
ment in a veterinary medical teaching hospital. Hypo-
albuminemic patients were identied on admission to
the intensive care unit (ICU) by the principal investi-
gator. Patient enrollment was limited to times when the
principal investigator was available, to ensure consis-
tency of sample processing. The total number of pa-
tients included was limited by availability of funding.
Baseline patient characteristics and
clinical parameters
Baseline laboratory tests (CBC and biochemistry) were
ordered by the patients primary service as part of their
routine clinical care and provided prospective identi-
cation of hypoalbuminemia. Patient characteristics such
as age, gender, breed, admitting specialty, admitting
diagnosis, preexistent chronic diseases, cause of hypo-
albuminemia (if known), and hospital course were re-
corded. Each patient contributed only once to the data
pool. No treatment interventions were performed or
evaluated as part of this study.
Table1: Commonly used formulas for adjusting total calcium
(tCa) for albumin and total protein (TP) in dogs
Parameter
adjusted for Formula for adjusted calcium (mg/dL)
Albumin (g/dL) tCa (mg/dL) albumin (g/dL)13.5
Albumin (g/L) tCa (mmol/L) [0.025 albumin (g/L)]10.0875
TP (g/dL) tCa (mg/dL) [0.4 TP (g/dL)]13.3
TP (g/L) tCa (mmol/L) [0.1 TP (g/L)]10.825
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00485.x 572
C.R. Sharp et al.
Criteria for inclusion
Skeletally mature dogs admitted to the small animal
ICU with either hypoalbuminemia (dened as Alb con-
centration 29 g/L [2.9 g/dL]); or hypoproteinemia
(dened as TP concentration 52 g/L [5.2 g/dL]) were
included.
Criteria for exclusion
Dogs who received blood products, calcium, vitamin D,
furosemide, or heparin in the 24 hours before the lab-
oratory measurements were excluded from analysis.
Laboratory data and analytical methods
Following identication of hypoalbuminemic, adult
dogs, iCa concentration was measured by the princi-
pal investigator on the original blood sample. tCa, Alb,
and TP were analyzed in heparinized plasma tubes
a
with a chemistry analyzer
b
using standard methodol-
ogy. tCa was determined colorimetrically using the se-
lective ligand arsenazo III. The normal reference
interval for tCa, determined by our laboratory, is 2.3
2.825 mmol/L (9.211.3 mg/dL). Alb was measured us-
ing the bromcresol green dye-binding method and TP
was determined by the biuret method using a modi-
cation of the procedure described by Weichselbaum.
16
The normal reference intervals determined by our lab-
oratory for Alb and TP are 2940 g/L (2.94.0 g/dL)
and 5274 g/L (5.27.4 g/dL), respectively. iCa concen-
tration and pH was determined by ion-selective elec-
trode potentiometry using a point-of-care, handheld
analyzer.
c
The normal reference intervals determined
by our laboratory for iCa and pH are 1.121.32 mmol/L
and 7.37.43, respectively.
Ionized hypocalcemia was dened as an iCa concen-
tration of o1.12 mmol/L (o4.5 mg/dL). Total hypo-
calcemia was dened as a tCa concentration of
o9.2 mg/dL. Ionized hypercalcemia was dened as
an iCa concentration of 41.32 mmol/L (45.3 mg/dL).
Total hypercalcemia was dened as a tCa concentration
of 411.3 mg/dL. The cut-off values to dene abnormal
were dictated by the upper and lower limits of the ref-
erence ranges for our clinical pathology laboratory.
References intervals for our laboratory had been previ-
ously determined by the 95% condence intervals for
measured iCa using 25 healthy adult dogs owned by
hospital employees. Dogs that establish these intervals
were deemed healthy on the basis of a normal physical
examination, CBC, and biochemistry panel.
Statistical analyses
Mean and standard deviation were determined for Alb,
TP, tCa, iCa, and pH. Upon correction of calcium
status according to the formulae in Table 1, dogs
were classied as hypocalcemic, normocalcemic, or
hypercalcemic. The 2 published methods of adjusted
calcium were analyzed individually for sensitivity,
specicity, percentage false negatives, and percentage
false positives for predicting true hypocalcemia or hy-
percalcemia according to the measured iCa concentra-
tion. The predicted calcium concentration was assigned
to be either a true positive (TP), true negative (TN),
false positive (FP), or false negative (FN) for identifying
patients with either hypocalcemia or hypercalcemia.
Overall accuracy for each adjustment formula was also
evaluated.
Sensitivity was used to indicate what percent of the
population with abnormal iCa concentrations (hypo-
calcemia or hypercalcemia) the published method was
successfully able to detect. Percentage (%) sensitiv-
ity5TP/(TP1FN) 100. Specicity dened what per-
centage of dogs with normal iCa concentrations were
correctly detected by the correction method. Percentage
(%) specicity 5TN/(TN1FP) 100. False positives
reect the percentage of dogs incorrectly labeled as hy-
pocalcemic or hypercalcemic. Percentage false posi-
tives 5FP/(FP1TN) 100. False negatives indicated
the percentage of dogs with abnormal iCa concentra-
tions that were not predicted as abnormal. Percentage
false negatives 5FN/(FN1TP) 100. Accuracy was
calculated as a percentage, dening the total number
of patients whose iCa status was classied correctly
versus those classied incorrectly.
Results
A total of 28 critically ill, hypoalbuminemic dogs were
enrolled in this study. There were 11 spayed females, 6
sexually intact females, 9 neutered males, and 2 sexu-
ally intact males. A variety of breeds were represented
including 3 Shetland sheepdogs, 3 Labrador Retrievers,
3 mixed breed dogs, 2 Toy Poodles, 2 Golden Retriev-
ers, 2 Dachshunds, 2 Yorkshire Terriers, 2 Australian
Shepherds, and 1 each of German Shepherd, Corgi,
Great Dane, Pug, Cavalier King Charles Spaniel, Stan-
dard Poodle, American Eskimo, English Mastiff, and
Rat Terrier. Mean age was 6.3 years (range 9 mo to
15.5 y). Most patients (17/28; [60%]) were admitted to
the hospital through the emergency and critical care
service. Other admitting specialties were internal med-
icine (n 58), oncology (n 52), and neurology (n 51).
Subsequently, 6 patients were transferred to the soft
tissue surgery service and underwent surgery.
Primary body systems affected and admitting diag-
noses are listed in Table 2. The mean length of ICU stay
was 3.3 days, while the median was 2 days (range
o6 h14 d). Twenty of 28 (71.5%) dogs survived to dis-
charge, 6 of 28 (21.5%) dogs were euthanized, and 2 of
28 (7%) died. One of the dogs that died presented to the
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00485.x 573
Calcium measurement in hypoalbuminemic dogs
emergency service in severe maldistributive shock as-
sociated with gastric dilatation and volvulus. Surgery,
involving a radical partial gastrectomy, partial splenec-
tomy, and incisional gastropexy was undertaken and
the patient was admitted to the ICU immediately post-
operatively. This patient had the lowest Alb (6 g/L
[0.6 g/dL]) and lowest iCa (0.88 mmol/L) of the dogs
enrolled in this study, and died shortly after ICU ad-
mission due to progressive hypotension that was un-
responsive to uid resuscitation and vasopressor
support. The ionized hypocalcemia was not specically
treated. Use of correction formulae in this patient
would have inappropriately predicted normocalcemia
(calcium adjusted for Alb 52.55 mmol/L [10.2 mg/dL];
calcium adjusted for TP52.51 mmol/L [10.04 mg/dL]),
while the presence of hypocalcemia was appropriately
detected by low tCa (1.82 mmol/L [7.3 mg/dL]). The
other patient that died was admitted to the ICU
after having a cystotomy performed by the referring
veterinarian for urolithiasis; a diagnosis of severe pan-
creatitis and remaining urethral calculi was made at the
time of admission. The dog was moderately hypo-
albuminemic (Alb 518 g/L [1.8 g/dL]) and had a nor-
mal iCa (1.13 mmol/L) but was predicted to be
hypocalcemic on the basis of low tCa (1.82 mmol/L
[7.3 mg/dL]) and low adjusted calcium (calcium
adjusted for Alb 52.25 mmol/L [9.0 mg/dL]; calcium
adjusted for TP52.24 mmol/L [8.96 mg/dL]). This
patient died 5 days later associated with postoperative
hypotension when an exploratory celiotomy was
performed to debride a pancreatic abscess. Of the 6
patients that were euthanatized, 3 were normocalcemic
based on their iCa (1.21, 1.21, and 1.15 mmol/L), 2 had
mild ionized hypocalcemia associated with pancreatitis
(iCa 51.08 mmol/L) in 1 patient and septic peritonitis
secondary to ruptured pyometra (iCa 51.11 mmol/L)
in the other; while another had a severe ionized hypo-
calcemia (iCa 50.91 mmol/L) and acute hepatic failure.
All 3 of the hypocalcemic patients that were euthanized
were inappropriately corrected into the reference inter-
val with the application of both the Alb- and TP-based
correction formulae.
The mean (SD) TP concentration was 50g/L (10g/L)
(5.0g/dL [1.0g/dL]) (range 1465g/L [1.46.5g/dL]). The
mean Alb concentration was 22g/L (0.5g/L) (2.2g/dL
[0.5g/dL]) (range 629g/L [0.62.9g/dL]). Mean tCa was
2.18mmol/L (0.3mmol/L) (8.7mg/dL [1.2mg/dL])
(range 1.62.8mmol/L [6.411.2mg/dL]). Mean iCa was
1.16mmol/L (0.12mmol/L) (range 0.881.49mmol/L).
Mean pH was 7.36 (0.06). Only 1 patient was alkalemic,
due to a respiratory alkalosis (pH57.465, PvCO
2
5
27.8mmHg, HCO
3
520.0mmol/L), and this patient
was normocalcemic (iCa51.23mmol/L).
In total, 19 of the 28 dogs (68%) were normocalcemic,
8 (29%) were hypocalcemic, and 1 (3%) was hyper-
calcemic as determined by iCa. Using tCa as an
indicator of calcium status resulted in a marked over-
estimation of hypocalcemia (classied 18/28 [64%]
patients as hypocalcemic) and a marked underestima-
tion of normocalcemia (classied only 10/28 [36%] as
normocalcemic).
Using tCa adjusted for Alb as an indicator of calcium
status resulted in a mild underestimation of hypo-
calcemia (classied only 6/28 [21%] as hypocalcemic)
and a mild overestimation in the number of patients
classied as normocalcemic (classied 20/28 [71%] as
normocalcemic) and hypercalcemic (classied 2/28
[7%] as hypercalcemic).
As with the Alb-adjusted formula, using tCa adjusted
for TP as an indicator of calcium status resulted in a
mild underestimation of hypocalcemia (classied only
7/28 [25%] as hypocalcemic), and a mild overestima-
tion in the number of patients classied as hyper-
calcemic (classied 2/28 [7%] as hypercalcemic). The
classication of patients as normocalcemic, hypo-
calcemic, or hypocalcemic by the different methodolo-
gies is demonstrated in Table 3.
The sensitivity, specicity, percentage of false posi-
tives, and percentage of false negatives of the tCa and
Ca adjusted for Alb and TP, for predicting true hypo-
calcemia according to the measured iCa is reported in
Table2: Primary body system affected and primary denitive
diagnosis at admission to the intensive care unit in 28 adult,
hypoalbuminemic, critically ill dogs whose calcium status was
evaluated
Body system
affected Denitive diagnosis
Number
of dogs
Endocrine Diabetic ketoacidosis 3
Diabetes mellitus 1
Gastrointestinal Acute gastroenteritis 2
Pancreatitis 2
Pancreatic abscess 1
Hepatic Congenital portosystemic shunt 2
Acute hepatic failure 1
Sepsis Source of sepsis included: 1
Ruptured pyometra 1
Bladder rupture with urinary tact infection 1
Cutaneous infection at amputation site
Trauma Motor vehicle accident 1
Gunshot trauma 1
Neoplasia Acute lymphoblastic leukemia 1
Multicentric lymphoma 1
Thyroid adenoma 1
Vascular Pulmonary thromboembolism 1
Neuromuscular Cervical spondylopathy 1
Peripheral neuropathy 1
Genitourinary Urinary tract infection 3
Dystocia 1
Renal Protein losing nephropathy 1
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00485.x 574
C.R. Sharp et al.
Table 4. The overall accuracy of each of the calcium
parameters is also displayed in Table 4.
Discussion
Ionized hypocalcemia is a common electrolyte abnor-
mality among critically ill humans with reported prev-
alence up to 88%.
2
Ionized hypocalcemia often goes
unrecognized in the ICU setting due to a tendency to
base evaluation of calcium status on tCa, and tCa ad-
justed for concentrations of Alb and TP, rather than di-
rect measurement of iCa. Many critically ill patients are
hypoproteinemic and hypoalbuminemic owing to a va-
riety of factors such as a decrease in serum protein
concentrations in response to inammation (Alb is a
negative acute phase protein), dilution with intrave-
nous uid therapy, and increased loss associated with
concurrent protein-losing disease. In these patients it is
commonly assumed that the tCa is falsely low subse-
quent to hypoalbuminemia, because about 50% of
serum calcium is typically bound to Alb.
6,7
These
long-held assumptions have recently come under scru-
tiny in both human and veterinary medicine.
Human studies have concluded that tCa- and Alb-
adjusted calcium cannot be used in an intensive care
setting to reliably monitor the calcium status of criti-
cally ill patients and should be replaced by measure-
ment of iCa.
6,7,14,15
The conclusions from these studies
regarding the diagnostic discordance between adjusted
calcium and iCa are similar to those of our study, in that
they demonstrate the overestimation of normocalcemia
and underestimation of hypocalcemia by adjusted cal-
cium values when compared with iCa measurements.
Recognition of true ionized hypocalcemia in critically ill
patients is vital because hypocalcemia can lead to se-
rious neurologic and cardiovascular complications.
6
A
limited number of veterinary studies have also docu-
mented a lack of correlation between corrected calcium
and iCa
12,13
; however, no such evaluations have been
previously performed solely in hypoalbuminemic, crit-
ically ill dogs.
There is evidence in a broader population that ad-
justed and measured tCa concentrations are unreliable
for predicting iCa status in dogs.
12,13
The largest vet-
erinary study evaluating usefulness of calcium correc-
tion formulae investigated a large population of sick
dogs (n 51633 dogs total) including 490 dogs with
chronic renal failure. While this study did not speci-
cally evaluate critically ill dogs, it did include a large
number of presumably critically ill dogs based on di-
agnoses of sepsis (or at least diseases associated with
sepsis such as pyometra, uterine rupture, mastitis, pyo-
thorax, and parvovirus), septic shock, pancreatitis, heat
prostration, and trauma (eg, hit by a vehicle, gunshot
wounds). In that study, diagnostic discordance (ie, the
percentage of dogs with incorrect identication of cal-
cium status) was 27% when tCa was used to predict iCa
status; tCa slightly overestimated normocalcemia and
underestimated hypocalcemia. Adjusting the tCa for
Alb or TP also resulted in an underestimation of the
prevalence of hypocalcemia; while overestimating the
prevalence of hypercalcemia. The use of an adjustment
equation increased the degree of diagnostic discor-
dance to approximately 37% across all dogs. The diag-
nostic discordance associated with use of an adjustment
equation, increased even further in dogs with chronic
Table3: Percentage of patients classied as normo-, hypo-, and hypercalcemic according to the different methods used to classify
calcium status
Method of determining calcium status
Classication of patients calcium status
Normocalcemia Hypocalcemia Hypercalcemia
iCa 19/28 (68%) 8/28 (29%) 1/28 (3%)
tCa 10/28 (36%) 18/28 (64%) 0/28 (0%)
Alb-adjusted Ca 20/28 (71%) 6/28 (21%) 2/28 (7%)
TP-adjusted Ca 19/28 (68%) 7/28 (25%) 2/28 (7%)
iCa, ionized calcium; tCa, total calcium; Alb, albumin; TP, total protein.
Table4: Sensitivity, specicity, percent false positive, percent false negative, and accuracy for total calcium (tCa) and calcium
adjusted for albumin (Alb) and total protein (TP) for predicting hypocalcemia
Sensitivity
n
Specicity
n
False positive
n
False negative
n
Accuracy
n
tCa 100 47 0 54 60.7
tCa adjusted for Alb 37.5 79 21 62.5 67.9
tCa adjusted for TP 37.5 74 26 62.5 64.3
n
All values are percentages.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00485.x 575
Calcium measurement in hypoalbuminemic dogs
renal failure to 55%. Overall, the data obtained from
this study suggested that tCa was a better predictor of
iCa status, compared with adjusted Ca; however, the
diagnostic discordance indicated that tCa alone was an
unacceptable predictor of iCa status.
12
The ndings of
our study are consistent with this previous veterinary
study and the human literature
15
in that the corrected
calcium values overestimate the presence of norm-
ocalcemia and underestimate the presence of hypo-
calcemia. The ndings of our study differ from the
other veterinary study in that tCa underestimated
the presence of normocalcemia and overestimated hy-
pocalcemia in our dogs.
Signicant differences were also noted between
these 2 studies when evaluating the sensitivity and
specicity of tCa and corrected calcium for predicting
hypocalcemia. The study by Schenck and Chew
12
doc-
umented a higher sensitivity (Se 582% for Alb adjust-
ment; 83% for TP adjustment) and similar specicity
(Sp582% for Alb adjustment; 80% for TP adjustment)
of the adjustment formulas for predicting hypo-
calcemia. That study also documented a much lower
sensitivity (Se 567%) and higher specicity (Sp593%)
of tCa for predicting hypocalcemia.
iCa measurement is the gold standard for determi-
nation of calcium status because the active form of cal-
cium is that which is not bound to Alb or complexed to
other ions.
9
Reliable methods for directly measuring
iCa have long been available in clinical pathology di-
agnostic laboratories. Modern instrumentation uses
potentiometric methods with calcium ion-specic elec-
trodes that minimize interference by other ions, protein,
hemolysis, and lipemia.
17
More recently, reliable point-
of-care analyzers, have become available in veterinary
medicine. These analyzers provide rapid results using a
relatively small volume of blood.
3,1821
A high incidence of ionized hypocalcemia has
been found in human patients with a variety of
critical illnesses
2224
such as sepsis,
25,26
pancreatitis,
27,28
rhabdomyolysis,
29
severe burns,
30,31
and meningococcal
disease.
32
Multiple studies have also found signicantly
higher mortality in hypocalcemic, compared with norm-
ocalcemic, critically ill human patients.
33,34
The incidence
of hypocalcemia is less well understood in critically ill
veterinary patients, but hypocalcemia has been docu-
mented in endotoxic horses,
35
a dog,
21
and experimental
animal models of endotoxemia.
36,37
To the knowledge of
the authors, the only investigation of the incidence of ion-
ized hypocalcemia specically in critically ill dogs evalu-
ated 141 dogs upon admission to a small animal ICU.
1
This study documented an incidence of ionized hypo-
calcemia of 16%. Additionally, the presence of ionized
hypocalcemia was found to predict a longer duration of
both ICU and hospital stay in those dogs not previously
treated with intravenous uids or blood products, but was
not associated with decreased survival. In contrast, ion-
ized hypocalcemia has been found to be associated with
increased mortality in dogs with acute renal failure
4
and
diabetic ketoacidosis,
5
cats with pancreatitis,
38
and horses
with colic.
35
In this study, 26% of critically ill, hypo-
albuminemic dogs had ionized hypocalcemia. While this
study was not designed nor powered to evaluate the
effects of ionized hypocalcemia on mortality, animals with
ionized hypocalcemia were subjectively more likely to die
or be euthanatized. The mortality rate in normocalcemic
patients was 21%, compared with 37.5% mortality in the
patients with ionized hypocalcemia.
The etiology of hypocalcemia in critical illness is un-
known but suspected to be multifactorial.
3,25
Potential
mechanisms of low iCa concentrations in critically ill pa-
tients include translocation of calcium ions (into cells,
tissues, or third spaces)
37,3941
; altered function of the
parathyroid gland (secondary hypoparathyroidism has
been documented in humans with sepsis)
25,42
; disruption
of vitamin D homeostasis
25
; calciuria
23,43
; chelation of
calcium
44
; decreased bone turnover and hence attenuated
bone resorption of calcium
23,43
; metabolic and respira-
tory alkaloses
45,46
; and severe hypomagnesemia.
4751
In-
creased circulating concentrations of pro-inammatory
cytokines
23,44
and procalcitonin have also been proposed
to contribute.
3,7,52
A relative postoperative hypocalcemia
(ie, when compared with preoperative baseline values)
has also been reported in both human and veterinary
medicine. However, while statistically signicant, the de-
crease in iCa concentrations associated with anesthesia
and surgery do not appear to be clinically signicant, and
the measured values remain within reference ranges in
otherwise healthy patients anesthetized for elective pro-
cedures.
53,54
Of the 8 patients in this study with hypo-
calcemia, some had underlying diseases known to
predispose to hypocalcemia such as diabetic ketoacido-
sis, acute renal failure, and pancreatitis; these diseases
have known mechanisms of inducing hypocalcemia. The
underlying diseases in the remaining hypocalcemic pa-
tients included sepsis associated with ruptured pyome-
tra, gastric dilatation-volvulus, systemic histoplasmosis,
pericardial effusion, hepatic failure, and dystocia. The
mechanisms of hypocalcemia in these patients are less
precisely dened.
Limitations of this study include the relatively small
sample size, inconsistent collection of anaerobic blood
samples, use of heparinized plasma for all biochemical
measurements, and lack of fasting blood samples. It is
well established that proper sample handling is neces-
sary for accurate measurement of iCa. It is recom-
mended that samples are collected and processed
anaerobically because mixing serum/plasma and air
results in loss of carbon dioxide and an associated
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00485.x 576
C.R. Sharp et al.
increase in pH leading to decreased iCa concen-
trations.
55
The analysis of serum is recommended
because it eliminates the potential interference of the
anticoagulant. The amount and type of heparin used to
anticoagulate a sample will affect iCa measurements,
however, because we used samples anticoagulated with
a xed amount of lithium heparin (full green top tubes)
the inuence of the anticoagulant was assumed to be
standardized. Fasting blood samples are also recom-
mended for evaluation of calcium status because the
effects of dietary calcium on iCa concentration has not
been evaluated
9
; however, a study in normal dogs
found that an overnight fast did not result in any sig-
nicant changes in iCa.
53
Despite the potential for these
variables to interfere with our results, attempts were
made to minimize inaccuracies caused by improper
methodology, such as by ensuring appropriate heparin
dilution (all lithium heparin blood tubes were lled to
the limit allowed by the tube vacuum) and rapid mea-
surement of iCa following collection (o30 min from
collection). Another potential limitation is that the
ranges for tCa and iCa in normal dogs are relatively
wide and vary among laboratories and analyzers. All of
the measurements in this study were evaluated using
the same methodology; however, these results might
not apply when different sampling technologies are
utilized.
56
Conclusions and Clinical Relevance
Calcium homeostasis in hypoalbuminemic critically ill
dogs should be evaluated by iCa concentrations rather
than the use of tCa or calcium adjusted for Alb or TP.
Using tCa as an indicator of calcium status resulted in
overestimation of hypocalcemia and underestimation
of normocalcemia, while using tCa adjusted for Alb or
TP resulted in overestimation of normocalcemia and
underestimation of hypocalcemia. Given that tCa
has 100% sensitivity for detecting hypocalcemia it is
recommended that all hypoalbuminemic, critically ill
patients with low tCa should be evaluated with an
iCa measurement in order to determine which of these
patients have true hypocalcemia.
Footnotes
a
MonoJect, Tyco healthcare Group LP, Manseld, MA.
b
AU400, Olympus, Tokyo, Japan.
c
i-STAT, Abbott Laboratories, Abbott Park, IL.
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