Hypocalcemia <7.5 mg/dl: early predictive marker for multisystem organ failure in severe acute necrotizing pancreatitis, proposed by the study analyzing post-ERCP pancreatitis

Early prediction of organ failure by combined markers in patients with acute pancreatitis

BACKGROUND

Several biological markers and clinical scoring systems have been used to predict the course of acute pancreatitis. Because organ failure is the most severe complication of the disease, prognostic markers and their combinations that would predict organ failure on hospital admission were sought.

METHODS

Some 351 consecutive patients with acute pancreatitis were studied. Blood samples were taken within 12 h of admission. This case-control study included all 33 patients with organ failure and 99 matched controls without organ failure. Measurements included 19 prognostic markers and Acute Physiology And Chronic Health Evaluation (APACHE) II score.

RESULTS

Plasma interleukin 10, serum glucose and serum calcium were identified as independent predictors of organ failure by logistic regression analysis. Calcium level correlated with clinical onset of organ failure. The combination of interleukin 10 (more than 50 pg/ml) or calcium (less than 1.65 mmol/l) was a significantly better predictor than any single marker or APACHE II score, with a sensitivity of 88 per cent, specificity 93 per cent and diagnostic odds ratio 94.

CONCLUSION

Organ failure in acute pancreatitis can be predicted with high accuracy at hospital admission using a combination of plasma interleukin 10 and serum calcium measurements.

Assessment and management of patients with abnormal calcium

Calcium is essential for homeostasis, and normocalcemia should be maintained strictly during the perioperative period. The biochemistry of calcium equilibrium results from the calcium-sensing receptors on the parathyroid glands, which detect changes in calcium concentrations and initiate the proper response. Asymptomatic hypercalcemia is a common metabolic derangement that is often discovered on routine serum screening. The most common etiologies are primary hyperparathyroidism and cancer. Increasingly, parathyroidectomy is the preferred therapy for primary hyperparathyroidism. Severe hypercalcemia ("hypercalcemic crisis") should be managed aggressively with a combination of intravenous fluids, steroids, bisphosphonates, and calcitonin. Some of these patients may require an urgent parathyroidectomy for calcium control. Hypocalcemia needs to be verified, as many cases of hypocalcemia are the artifact of hypoalbuminemia. Severe hypocalcemia occurs after subtotal or total parathyroidectomy with auto transplantation as well as after massive resuscitation or blood transfusion. Strategies aimed at correcting calcium concentrations depend on the severity of symptomatology. If symptoms are mild, oral calcium supplementation can be given; otherwise, intravenous calcium should be administered.