Hypocalcemia: a sometimes overlooked cause of heart failure in the elderly

Delayed onset of non-cardiogenic pulmonary oedema following amlodipine overdose

Amlodipine, a widely used antihypertensive medication, can cause serious complications in overdose, including hypotension, bradycardia, non-cardiogenic pulmonary oedema (NCPO) and death. This report describes a young adult woman who ingested 100 mg of amlodipine in a polypharmacy suicide attempt. Although she initially stabilised, she unexpectedly developed delayed NCPO 3 days post ingestion, requiring intubation and intensive care unit readmission. She recovered fully with supportive care and was discharged in good health. This case highlights the importance of prolonged monitoring and vigilance in managing long-acting calcium channel blocker overdoses, even when the initial clinical response appears satisfactory.

Serum total calcium levels as a non-linear predictor of in-hospital mortality in heart failure patients: insights from a retrospective cohort study

BACKGROUND

Calcium is pivotal in the regulation of bodily homeostasis, with numerous studies highlighting its link to cardiovascular disease in the adult population. However, the relationship between serum calcium levels and the prognosis of heart failure (HF) patients is not clear. This study explored the association between serum total calcium (STC) and in-hospital mortality in patients with HF.

METHODS

Clinical data of 1,176 patients with HF were obtained from the Multiparametric Intelligent Monitoring in Intensive Care III (MIMIC-III) database. The patients were categorized into STC quartiles, and baseline characteristics were comprehensively analyzed. Univariate and multivariate analyses were employed to identify factors associated with in-hospital mortality. To explore the non-linear relationship between STC and mortality, a two-piecewise linear regression model was applied. Subgroup analyses were conducted to identify potential confounding variables.

RESULTS

In this cohort, 159 (13.53%) patients experienced in-hospital mortality. Significant differences in various parameters were observed among STC quartiles. Univariate analysis identified numerous factors associated with mortality. Multivariate analysis confirmed STC as an independent predictor of in-hospital mortality, with a negative association persisting even after adjusting for confounding factors (odds ratio [OR]: 0.49, 95%CI: 0.32-0.76; P = 0.0016). Non-linear analysis revealed an inflection point at 8.41 mg/dL, below which the risk of in-hospital death significantly increased (OR: 0.26, 95%CI: 0.12-0.55; P = 0.0005). Subgroup analyses indicated a pronounced inverse association in patients without atrial fibrillation or chronic obstructive pulmonary disease, as well as those with a left ventricular ejection fraction ≤ 50%.

CONCLUSION

This study identified STC as an independent predictor of in-hospital mortality in HF patients, with a non-linear relationship.

Renal Function Is Associated with Changes in Bone Mineral Density in Postmenopausal Osteoporotic Women Treated with Denosumab: Data From a Retrospective Cohort Study

Background/Objectives: Renal function influences bone metabolism, as kidney failure can increase the risk of fractures. Denosumab is an approved osteoporosis treatment, but its efficacy in relation to renal function has not yet been studied in real-life scenarios. This study aimed to investigate the denosumab-induced change in bone mineral density (BMD) according to kidney function. Methods: A retrospective analysis was conducted at the outpatient clinic in postmenopausal women receiving denosumab (60 mg subcutaneously administered every 6 months). The glomerular filtration rate (eGFR) was measured by the 2021 CKD-EPI equation and patients were stratified for eGFR categories. BMD was measured by dual-energy X-ray absorptiometry. Results: 128 women (mean age 70.3 ± 9.4 years) were recruited. The mean denosumab treatment duration was 3.9 ± 1.4 years and all the participants had improved BMD values. In stepwise multiple regression analysis-after controlling for age, BMI, and treatment duration-the eGFR value (ß = -0.11, SE 0.04, p = 0.01) was independently associated with the lumbar spine BMD change. The same association remained when the eGFR categories were considered (ß = 3.564, SE 1.29, p = 0.007). In addition, after controlling for BMI and the duration of denosumab treatment, age (ß = -0.7915, SE 0.37, p = 0.03) and eGFR (ß = -0.3257, SE 0.1567, p = 0.04) were found to be associated with femoral neck BMD change. The association remained when considering eGFR categories (ß = 8.7339, SE 4.29, p = 0.04). Conclusions: This retrospective study suggests that eGFR is associated with denosumab efficacy in postmenopausal women treated for osteoporosis.

Hypocalcemia as a cause of reversible heart failure: A case report and review of the literature

Introduction

In both pediatric and adult populations, hypocalcemia-induced heart failure is an extremely rare presentation. The aim of the current study is to report a case of reversible heart failure caused by severe hypocalcemia resulting from hypoparathyroidism, which was resolved by correcting the serum calcium level.

Case report

A 29-year-old female presented with orthopnea, dyspnea on mild exertion, and bilateral lower limb swelling. She had a positive Trousseau's sign. Vital signs were stable except for tachycardia. On chest auscultation, there were bilateral basal fine inspiratory crackles. She was immediately treated as a case of pulmonary edema with intravenous furosemide and oxygen therapy. Subsequent treatment for correcting the hypocalcemia was then initiated.

Discussion

Hypocalcemia has been proven to influence cardiac function, resulting in lower cardiac contractility as determined by decreased left ventricular work index, stroke index, and cardiac index. In rare circumstances, the clinical, biochemical (elevation of cardiac enzymes), electrocardiographic, and echocardiographic data may lead to an incorrect diagnosis of an acute ischemic attack.

Conclusion

Hypocalcemia as a possible factor leading to heart failure should be considered in the differential diagnosis of all individuals with congestive heart failure.

An evolutionary machine learning for pulmonary hypertension animal model from arterial blood gas analysis

Pulmonary hypertension (PH) is a rare and fatal condition that leads to right heart failure and death. The pathophysiology of PH and potential therapeutic approaches are yet unknown. PH animal models' development and proper evaluation are critical to PH research. This work presents an effective analysis technology for PH from arterial blood gas analysis utilizing an evolutionary kernel extreme learning machine with multiple strategies integrated slime mould algorithm (MSSMA). In MSSMA, two efficient bee-foraging learning operators are added to the original slime mould algorithm, ensuring a suitable trade-off between intensity and diversity. The proposed MSSMA is evaluated on thirty IEEE benchmarks and the statistical results show that the search performance of the MSSMA is significantly improved. The MSSMA is utilised to develop a kernel extreme learning machine (MSSMA-KELM) on PH from arterial blood gas analysis. Comprehensively, the proposed MSSMA-KELM can be used as an effective analysis technology for PH from arterial Blood gas analysis with an accuracy of 93.31%, Matthews coefficient of 90.13%, Sensitivity of 91.12%, and Specificity of 90.73%. MSSMA-KELM can be treated as an effective approach for evaluating mouse PH models.

Prognosis assessment model based on low serum calcium in patients with acute pulmonary thromboembolism

Background and objective

The pulmonary embolism severity index (PESI) and simplified PESI (sPESI) are recommended to recognize patients with acute pulmonary thromboembolism (PTE) with low prognosis risk, which is of great significance for treatment. This study aims to verify the influence of hypocalcaemia on the prognosis of patients with PTE and to establish a new prognosis assessment model.

Methods

This is an observational, multicentre study enrolling patients with PTE from February 2010 to June 2020 across 12 Chinese hospitals. Variables in PESI, serum calcium levels and patient survival status as of 5 July 2020 were collected. The area under the curve of the receiver operating characteristic curve, sensitivity, specificity and Youden index were used to evaluate model performance.

Results

In the cohort of 4196 patients with PTE, independent associations existed between hypocalcaemia and mid‐ and long‐term mortalities (p <0.05). By including hypocalcaemia, the new 30‐day death risk prediction rule, Peking Union Medical College Hospital rule (PUMCH rule), showed significantly higher specificity (0.622 [0.582, 0.661]; p <0.001) than the PESI (0.514 [0.473, 0.554]) and sPESI (0.484 [0.444, 0.525]) and similar sensitivity (0.963 [0.810, 0.999]; p = 0.161) with PESI (0.889 [0.708, 0.976]) and sPESI (0.963 [0.810, 0.999]) in the internal validation cohort. Well‐performing predictive validity was also verified on a constructed external validation cohort.

Conclusion

Hypocalcaemia is independently associated with mid‐ and long‐term PTE mortalities. The PUMCH rule showed significantly higher specificity than the PESI and sPESI and similar sensitivity, which may be used as a prognostic assessment tool for patients with acute PTE.

Currently, pulmonary embolism severity index (PESI) and simplified PESI (sPESI) are recommended to recognize pulmonary thromboembolism (PTE) patients with low prognosis risk. In this multicentre research, a new prognosis assessment model including hypocalcaemia, which is confirmed to be independently associated with mid‐ and long‐term PTE mortalities, showed significantly higher specificity with PESI and sPESI and similar sensitivity.

See relatedEditorial

Case report: Denosumab-associated acute heart failure in patients with cardiorenal insufficiency

Denosumab is a pivotal treatment for postmenopausal women with osteoporosis. Although its clinical use is generally well tolerated by patients, denosumab in patients with renal insufficiency may increase the risk of hypocalcemia. Thus, we have to consider the population of denosumab in the treatment of osteoporosis and preventive measures for related complications. In a patient with cardiorenal insufficiency, we reported a case of denosumab-induced hypocalcemia complicated by acute left heart failure due to delayed administration of active vitamin D and calcium supplements. The patient's symptoms did not improve after anti-heart failure treatment. However, after adequate calcium and vitamin D supplementation subsequently, the patient's symptoms of heart failure were rapidly relieved, and the serum calcium level returned to normal within three weeks. Therefore, our case showed that the application of denosumab in patients requires assessment of cardiac and renal function, timely calcium and vitamin D supplementation, and enhanced monitoring of serum calcium levels to prevent acute left heart failure induced by denosumab-related hypocalcemia.

Tetany Exacerbating Heart Failure: A Case Report

Tetany is characterized by numbness and stiffness in the hands and feet caused by hypocalcemia, hypomagnesemia, and hyperventilatory alkalosis, primarily at peripheral neuromuscular junctions. Although hypocalcemia is common in critically ill patients, its diagnosis of hypocalcemia is complicated and sometimes overlooked. We encountered an 82-year-old woman with tetany that exacerbated heart failure. Pain and respiratory failure due to tetany are conditions that can lead to exacerbation of heart failure. Chronic renal failure is frequently associated with chronic heart failure, and regular follow-up of calcium, phosphorus, and magnesium levels is necessary for such patients.

Association between serum calcium and prognosis in patients with acute pulmonary embolism and the optimization of pulmonary embolism severity index

Introduction

Calcium is an important coagulation factor and hypocalcemia is related to progression and poor prognosis of many cardiopulmonary diseases. However, influence of hypocalcemia on pulmonary thromboembolism (PTE) prognosis has never been reported. This study aimed to explore its prognostic value and optimize the pulmonary embolism severity index (PESI), the widely used prognosis assessment model, based on the value.

Methods

PTE patients’ variables in PESI and other related clinical characteristics including admission serum calcium were collected. Associations between these variables and PTE mortality were assessed by logistic regression and cox analysis. Variables significantly associated with 30-day PTE mortality were included to develop a new prognosis prediction rule and then its validity was compared with PESI and simplified PESI (sPESI).

Results

496 PTE patients were included and 49.48% patients had hypocalcemia (serum calcium ≤ 2.13 mmol/L) in admission, showing higher 7-day (P = 0.021), 14-day (P = 0.002), 30-day (13.03% vs 4.98%, P = 0.002) mortalities than patients without hypocalcemia. Adjusting for variables in PESI, hypocalcemia was further revealed to be an independent predictor of 30-day mortality (P = 0.014).

The optimal prediction rule contained hypocalcemia and 5 variables in PESI and sPESI, showing higher predictive validity [sensitivity (Sen): 0.930, specificity (Spec): 0.390, area under curve (AUC): 0.800] than PESI (Sen: 0.814, Spec: 0.367, AUC: 0.716) and sPESI (Sen: 0.907, Spec: 0.216, AUC: 0.703).

Conclusions

Hypocalcemia is an independent predictor of the mortality following acute PTE. Based on hypocalcemia, the optimal prediction rule showed higher validity than PESI and sPESI.

Impact of Changes in Serum Calcium Levels on In-Hospital Mortality

Background and objectives: Calcium concentration is strictly regulated at both the cellular and systemic level, and changes in serum calcium levels can alter various physiological functions in various organs. This study aimed to assess the association between changes in calcium levels during hospitalization and mortality. Materials and Methods: We searched our patient database to identify all adult patients admitted to our hospital from January 1st, 2009 to December 31st, 2013. Patients with ≥2 serum calcium measurements during the hospitalization were included. The serum calcium changes during the hospitalization, defined as the absolute difference between the maximum and the minimum calcium levels, were categorized into five groups: 0–0.4, 0.5–0.9, 1.0–1.4, 1.5–1.9, and ≥2.0 mg/dL. Multivariable logistic regression was performed to assess the independent association between calcium changes and in-hospital mortality, using the change in calcium category of 0–0.4 mg/dL as the reference group. Results: Of 9868 patients included in analysis, 540 (5.4%) died during hospitalization. The in-hospital mortality progressively increased with higher calcium changes, from 3.4% in the group of 0–0.4 mg/dL to 14.5% in the group of ≥2.0 mg/dL (p < 0.001). When adjusted for age, sex, race, principal diagnosis, comorbidity, kidney function, acute kidney injury, number of measurements of serum calcium, and hospital length of stay, the serum calcium changes of 1.0–1.4, 1.5–1.9, and ≥2.0 mg/dL were significantly associated with increased in-hospital mortality with odds ratio (OR) of 1.55 (95% confidence interval (CI) 1.15–2.10), 1.90 (95% CI 1.32–2.74), and 3.23 (95% CI 2.39–4.38), respectively. The association remained statistically significant when further adjusted for either the lowest or highest serum calcium. Conclusion: Larger serum calcium changes in hospitalized patients were progressively associated with increased in-hospital mortality.

Diuretic Activity of a Novel Peripherally-Restricted Orally-Active Kappa Opioid Receptor Agonist

Kappa-opioid agonists (KOAs) enhance cardiac performance, as well as reduce infarct size and prevent deleterious cardiac remodeling following myocardial infarction. Additionally, KOAs promote diuresis; however, there has been limited development of KOAs as a class due to the promotion of untoward central nervous system (CNS)-mediated side effects. Our laboratory has developed a peripherally-restricted, orally-active, KOA (JT09) for the treatment of pain and cardiovascular disease. Peripherally-restricted KOAs possess a limited side-effect profile and demonstrate potential in preventing heart failure. The aim of this study was to assess the diuretic activity of lead compound JT09 relative to vehicle control and Tolvaptan through single oral administration to adult male Sprague–Dawley rats. JT09-administered rats demonstrated significantly increased urine output relative to vehicle control. However, the effect persisted for 8 h, whereas Tolvaptan-administered rats demonstrated diuretic activity for 24 h. Relative to Tolvaptan, urine output was significantly reduced in JT09 administered animals at all-time points, suggesting that the overall diuretic effect of JT09 is less profound than Tolvaptan. Additionally, JT09-administered rats demonstrated alterations in clinical chemistry; reduced urine specific gravity; and increased urine pH relative to vehicle control. The following study establishes a preliminary diuretic profile for JT09.

Incidence of hypocalcemia and hypercalcemia in hospitalized patients: Is it changing?

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Disorders of calcium metabolism are frequently encountered in clinical practice.

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Hypocalcemia accounted for 27.72% and hypercalcemia for 4.74% of inpatients.

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Incidence of hypo- and hypercalcemia changed over time.

Disorders of calcium metabolism are frequently encountered in routine clinical practice. However limited data are available on the epidemiology of hypocalcemia and hypercalcemia in hospitalized patients. Our aim was to evaluate the frequency of hypocalcemia and hypercalcemia in hospitalized patients.

This is a retrospective study based on the laboratory results of all hospitalized subjects (n = 12,334) whose calcemia was determined between January 1st, 2011 and December 31st, 2014. Measurements of serum calcium were carried out by a single centralized laboratory. Hypocalcemia was defined as serum calcium levels <8.2 mg/dl and hypercalcemia as serum calcium levels >10.4 mg/dl. Albumin correction was applied to adjust serum calcium values.

Overall, hypocalcemia accounted for 27.72% (n = 3420) and hypercalcemia for 4.74% (n = 585) of the 12,334 inpatients. The highest prevalence of hypocalcemia was found in patients over 65 yr. (n = 2097, 61.31%) vs. younger subjects, while the highest prevalence of hypercalcemia was observed in patients aged 0–18 yr. (n = 380, 64.95%). Hypocalcemia was more often encountered in males (n = 1952, 57.07%) while no gender differences were found regarding hypercalcemia. Incidence of hypocalcemia changed over time varying from 35.42% (n = 1061) in 2011 to 21.93% (n = 672) in 2014 (r = −0.98; p = 0.01). Differently, incidence of hypercalcemia did not significantly increase significantly from 3.47% (n = 104) in 2011 to 6.92% (n = 211) in 2014 (r = 0.94; p = 0.052).

Despite increased awareness about electrolytes disturbance, physicians should consider calcium levels because of life-threatening consequences associated to hypo- and hypercalcemia. Patient’s gender and age could be associated to a different risk of calcium disturbance in hospitalized patients.

Impact of admission serum calcium levels on mortality in hospitalized patients

OBJECTIVES

To assess the relationship between admission serum calcium levels and in-hospital mortality in all hospitalized patients.

METHODS

All adult hospitalized patients who had admission serum calcium levels available between years 2009 and 2013 were enrolled. Admission serum calcium was categorized based on its distribution into six groups (<7.9, 7.9 to <8.4, 8.4 to <9.0, 9.0 to <9.6, 9.6 to <10.1, and ≥10.1 mg/dL). The odds ratio (OR) of in-hospital mortality by admission serum calcium, using the calcium category of 9.6-10.1 mg/dL as the reference group, was obtained by logistic regression analysis.

RESULTS

18,437 patients were studied. The lowest incidence of in-hospital mortality was associated with admission serum calcium within 9.6 to <10.1 mg/dL. A higher in-hospital mortality rate was observed in patients with serum calcium <9.6 and ≥10.1 mg/dL. Also, 38% and 33% of patients with admission serum calcium <7.9 and ≥10.1 mg/dL were on calcium supplements before admission, respectively. After adjusting for potential confounders, both serum calcium <8.4 and ≥10.1 mg/dL were associated with an increased risk of in-hospital mortality with ORs of 2.86 [95% confidence interval (CI) 1.98-4.17], 1.74 (95% CI 1.21-2.53), and 1.69 (95% CI 1.10-2.59) when serum calcium were within <7.9, 7.9 to <8.4, and ≥10.1 mg/dL, respectively.

CONCLUSION

Hypocalcemia and hypercalcemia on admission were associated with in-hospital mortality. Highest mortality risk is observed in patients with admission hypocalcemia (<7.9 mg/dL). One-third of patients with hypercalcemia on admission were on calcium supplements.

Admission calcium levels and risk of acute kidney injury in hospitalised patients

BACKGROUND

The risk of acute kidney injury (AKI) development among hospitalised patients with elevated calcium levels on admission remains unclear. The aim of this study was to assess the risk of AKI in hospitalised patients stratified by various admission serum calcium levels.

METHODS

This is a single-centre retrospective study conducted at a tertiary referral hospital. All hospitalised adult patients who had admission calcium levels available between 2009 and 2013 were enrolled. Admission calcium was categorised based on its distribution into six groups (≤7.9, 8.0-8.4, 8.5-8.9, 9.0-9.4, 9.5-9.9, and ≥10.0 mg/dL). The primary outcome was hospital-acquired AKI. Logistic regression analysis was performed to obtain the odds ratio of AKI for various admission calcium strata using calcium levels of 8.0-8.4 mg/dL (lowest incidence of AKI) as the reference group.

RESULTS

A total of 12 784 patients were studied. Hospital-acquired AKI occurred in 1779 (13.9%) patients. The incidence of AKI among patients with admission calcium ≤7.9, 8.0-8.4, 8.5-8.9, 9.0-9.4, 9.5-9.9 and ≥10 mg/dL was 14.7%, 11.7%, 11.8%, 14.6%, 15.8% and 17.3%, respectively. After adjusting for potential confounders, admission calcium levels ≤7.9, 9.0-9.4, 9.5-9.9 and ≥10 mg/dL were associated with increased risk of AKI with odds ratios of 1.36 (95%CI 1.08-1.72), 1.29 (95%CI 1.08-1.56), 1.38 (95%CI 1.14-1.68) and 1.51 (95%CI 1.19-1.91), respectively.

CONCLUSION

Admission hypocalcaemia and hypercalcaemia are associated with an increased risk for hospital acquired AKI. Patients with admission hypercalcaemia (≥10 mg/dL) carry a 1.51-fold risk for AKI development during hospitalisation.

Hypocalcaemia as a Reversible Cause of Acute Heart Failure in a Long-Term Survivor of Childhood Cancer

Hypocalcaemia is known for its neuromuscular symptoms, which are rapidly alleviated by intravenous supplementation. Calcium is also essential for both cardiac cell excitability and contraction. We present a case of acute heart failure due to hypocalcaemia in a young male with a complex medical history.

Low serum calcium is associated with left ventricular systolic dysfunction in a Chinese population with coronary artery disease

Whether serum calcium is associated with heart systolic function in patients with established coronary artery disease (CAD) and acute myocardial infarction (AMI) remains to be elucidated. This study is aimed to assess the association between serum calcium and left ventricular systolic dysfunction in a Chinese population of CAD. The cross-sectional study included 5938 CAD patients with and without AMI in China. The factors associated with AMI and left ventricular ejection fraction (LVEF) were evaluated. The data showed that AMI patients had lower serum calcium levels (2.11 ± 0.13 vs 2.20 ± 0.10 mmol/l, P < 0.001) than those without AMI. Multiple logistic regression analysis exhibited that serum calcium (OR: 0.000, 95% CI: 0.000–0.001) was one of the independent factors correlated with AMI. CAD patients with and without AMI when LVEF <50% had lower serum calcium levels than those when LVEF ≥50% respectively. Serum calcium was independently associated with LVEF and LVEF <50% in CAD patients with and without AMI respectively using multivariate analysis. The independent association between serum calcium and LVEF still existed among CAD patients when LVEF ≥50%. Serum calcium levels are significantly decreased following AMI. Low serum calcium is independently correlated with left ventricular systolic dysfunction in CAD patients with and without AMI.

Calcium Disorders in the Emergency Department: Independent Risk Factors for Mortality

Background

Calcium disorders are common in both intensive care units and in patients with chronic kidney disease and are associated with increased morbidity and mortality. It is unknown whether calcium abnormalities in unselected emergency department admissions have an impact on in-hospital mortality.

Methods

This cross-sectional analysis included all admissions to the Emergency Department at the Inselspital Bern, Switzerland from 2010 to 2011. For hyper- and hypocalcaemic patients with a Mann-Whitney U-test, the differences between subgroups divided by age, length of hospital stay, creatinine, sodium, chloride, phosphate, potassium and magnesium were compared. Associations between calcium disorders and 28-day in-hospital mortality were assessed using the Cox proportional hazard regression model.

Results

8,270 patients with calcium measurements were included in our study. Overall 264 (3.2%) patients died. 150 patients (6.13%) with hypocalcaemia and 7 patients with hypercalcaemia (6.19%) died, in contrast to 104 normocalcaemic patients (1.82%). In univariate analysis, calcium serum levels were associated with sex, mortality and pre-existing diuretic therapy (all p<0.05). In multivariate Cox regression analysis, hypocalcaemia and hypercalcaemia were independent risk factors for mortality (HR 2.00 and HR 1.88, respectively; both p<0.01).

Conclusion

Both hypocalcaemia and hypercalcaemia are associated with increased 28-day in-hospital mortality in unselected emergency department admissions.

Predictive value of ionized calcium in critically ill patients: an analysis of a large clinical database MIMIC II

BACKGROUND AND OBJECTIVE

Ionized calcium (iCa) has been investigated for its association with mortality in intensive care unit (ICU) patients in many studies. However, these studies are small in sample size and the results are conflicting. The present study aimed to establish the association of iCa with mortality by using a large clinical database.

METHODS

Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC II) database was used for analysis. Patients older than 15 years were eligible, and patients without iCa measured during their ICU stay were excluded. Demographic data and clinical characteristics were extracted and compared between survivors and non-survivors. iCa measure on ICU admission was defined as Ca0; Camax was the maximum iCa during ICU stay; Camin was the minimum value of iCa during the ICU stay; Camean was the arithmetic mean iCa during ICU stay.

MAIN RESULTS

A total of 15409 ICU admissions satisfied our inclusion criteria and were included in our analysis. The prevalence of hypocalcemia on ICU entry was 62.06%. Ca0 was significantly lower in non-survivors than in survivors (1.11 ± 0.14 vs 1.13 ± 0.10 mmol/l, p<0.001). In multivariate analysis, moderate hypocalcemia in Ca0 was significantly associated with increased risk of death (OR: 1.943; 95% CI: 1.340-2.817), and mild hypercalcemia was associated with lower mortality (OR: 0.553, 95% CI: 0.400-0.767). While moderate and mild hypocalcemia in Camean is associated with increased risk of death (OR: 1.153, 95% CI: 1.006-1.322 and OR: 2.520, 95% CI: 1.485-4.278), hypercalcemia in Camean is not significantly associated with ICU mortality.

CONCLUSION

The relationship between Ca0 and clinical outcome follows an "U" shaped curve with the nadir at the normal range, extending slightly to hypercalcemia. Mild hypercalcemia in Ca0 is protective, whereas moderate and mild hypocalcemia in Camean is associated with increased risk of death.