2 Calcium homeostasis: Parathyroid Hormone, Calcitonin and Vitamin D3
3 Physiological importance of Calcium Calcium salts in bone provide structural integrity of the skeletonCalcium ions in extracellular and cellular fluids is essential to normal function of a host of biochemical processesNeuoromuscular excitabilityBlood coagulationHormonal secretionEnzymatic regulation
4 Regulation of Calcium Concentration The important role that calcium plays in so many processes dictates that its concentration, both extracellularly and intracellularly, be maintained within a very narrow range.This is achieved by an elaborate system of controls
5 Regulation of Intracellular Calcium Concentration Control of cellular calcium homeostasis is as carefully maintained as in extracellular fluids[Ca2+]cyt is approximately 1/1000th of extracellular concentrationStored in mitochondria and ER“pump-leak” transport systems control [Ca2+]cytCalcium leaks into cytosolic compartment and is actively pumped into storage sites in organelles to shift it away from cytosolic pools.
6 Extracellular Calcium When extracellular calcium falls below normal, the nervous system becomes progressively more excitable because of increase permeability of neuronal membranes to sodium.Hyperexcitability causes tetanic contractionsHypercalcemic tetany [Ca2+]cyt
7 Extracellular Calcium Three definable fractions of calcium in serum:Ionized calcium 50%Protein-bound calcium 40%90% bound to albuminRemainder bound to globulinsCalcium complexed to serum constituents 10%Citrate and phosphate
8 Extracellular Calcium Binding of calcium to albumin is pH dependentAcute alkalosis increases calcium binding to protein and decreases ionized calciumPatients who develop acute respiratory alkalosis have increased neural excitability and are prone to seizures due to low ionized calcium in the extracellular fluid which results in increased permeability to sodium ions
9 Calcium and phosphorous Calcium is tightly regulated with Phosphorous in the body.Phosphorous is an essential mineral necessary for ATP, cAMP second messenger systems, and other roles
11 Calcium in blood and bone Ca2+ normally ranges from mg/dL in the plasma.The active free ionized Ca2+ is only about 48% 46% is bound to protein in a non-diffusible state while 6% is complexed to salt.Only free, ionized Ca2+ is biologically active.
13 Phosphorous in blood and bone PO4 normal plasma concentration is mg/dL. 87% is diffusible, with 35% complexed to different ions and 52% ionized.13% is in a non-diffusible protein bound state % is found in bone.The rest is in ATP, cAMP, and proteins
14 Calcium and bone99% of Calcium is found in the bone. Most is found in hydroxyapatite crystals. Very little Ca2+ can be released from the bone– though it is the major reservoir of Ca2+ in the body.
15 Structure of bonesHaversian canals within lamellae
16 Calcium turnover in bones 80% of bone is mass consists of cortical bone– for example: dense concentric layers of appendicular skeleton (long bones)20% of bone mass consists of trabecular bone– bridges of bone spicules of the axial skeleton (skull, ribs, vertebrae, pelvis)Trabecular bone has five times greater surface area, though comprises lesser mass.Because of greater accessibility trabecular bone is more important to calcium turnover
17 Bones99% of the Calcium in our bodies is found in our bones which serve as a reservoir for Ca++ storage.10% of total adult bone mass turns over each year during remodeling processDuring growth rate of bone formation exceeds resporption and skeletal mass increases.Linear growth occurs at epiphyseal plates.Increase in width occurs at periosteumOnce adult bone mass is achieved equal rates of formation and resorption maintain bone mass until age of about 30 years when rate of resportion begins to exceed formation and bone mass slowly decreases.
18 Bone cell typesThere are three types of bone cells: Osteoblasts are the differentiated bone forming cells and secrete bone matrix on which Ca++ and PO precipitate.Osteocytes, the mature bone cells are enclosed in bone matrix.Osteoclasts is a large multinucleated cell derived from monocytes whose function is to resorb bone. Inorganic bone is composed of hydroxyapatite and organic matrix is composed primarily of collagen.
19 Bone formation Active osteoblasts synthesize and extrude collagen Collagen fibrils form arrays of an organic matrix called the osetoid.Calcium phosphate is deposited in the osteoid and becomes mineralizedMineralization is combination of CaP04, OH-, and H3CO3– hydroxyapatite.
20 Mineralization Requires adequate Calcium and phosphate Dependent on Vitamin DAlkaline phosphatase and osteocalcin play roles in bone formationTheir plasma levels are indicators of osteoblast activity.
21 CanaliculiWithin each bone unit is a minute fluid-containing channel called the canaliculi.Canaliculi traverse the mineralized bone.Interior osteocytes remain connected to surface cells via syncytial cell processes.This process permits transfer of calcium from enormous surface area of the interior to extracellular fluid.
23 Control of bone formation and resorption Bone resorption of Ca++ by two mechanims: osteocytic osteolysis is a rapid and transient effect and osteoclasitc resorption which is slow and sustained.Both are stimulated by PTH. CaPO4 precipitates out of solution id its solubility is exceeded. The solubility is defined by the equilibrium equation: Ksp = [Ca2+]3[PO43-]2.In the absence of hormonal regulation plasma Ca++ is maintained at 6-7 mg/dL by this equilibrium.
24 Osteocytic osteolysis Transfer of calcium from canaliculi to extracellular fluid via activity of osteocytes.Does not decrease bone mass.Removes calcium from most recently formed crystalsHappens quickly.
25 Bone resorptionDoes not merely extract calcium, it destroys entire matrix of bone and diminishes bone mass.Cell responsible for resorption is the osteoclast.
26 Bone remodelingEndocrine signals to resting osteoblasts generate paracrine signals to osteoclasts and precursors.Osteoclasts resorb and area of mineralized bone.Local macrophages clean up debris.Process reverses when osteoblasts and precursors are recruited to site and generate new matrix.New matrix is minearilzed.New bone replaces previously resorbed bone.
28 Calcium, bones and osteoporosis The total bone mass of humans peaks at years of age.Men have more bone mass than women.A gradual decline occurs in both genders with aging, but women undergo an accelerated loss of bone due to increased resorption during perimenopause.Bone resorption exceeds formation.
29 Calcium, bones and osteoporosis Reduced bone density and mass: osteoporosisSusceptibility to fracture.Earlier in life for women than men but eventually both genders succumb.Reduced risk:Calcium in the diethabitual exerciseavoidance of smoking and alcohol intakeavoid drinking carbonated soft drinks
30 Vertebrae of 40- vs. 92-year-old women Note the marked loss of trabeculae with preservation of cortex.
32 Hormonal control of Ca2+ Three principal hormones regulate Ca++ and three organs that function in Ca++ homeostasis.Parathyroid hormone (PTH), 1,25-dihydroxy Vitamin D3 (Vitamin D3), and Calcitonin, regulate Ca++ resorption, reabsorption, absorption and excretion from the bone, kidney and intestine. In addition, many other hormones effect bone formation and resorption.
33 Vitamin DVitamin D, after its activation to the hormone 1,25-dihydroxy Vitamin D3 is a principal regulator of Ca++.Vitamin D increases Ca++ absorption from the intestine and Ca++ resorption from the bone .
34 Synthesis of Vitamin D Humans acquire vitamin D from two sources. Vitamin D is produced in the skin by ultraviolet radiation and ingested in the diet.Vitamin D is not a classic hormone because it is not produce and secreted by an endocrine “gland.” Nor is it a true “vitamin” since it can be synthesized de novo.Vitamin D is a true hormone that acts on distant target cells to evoke responses after binding to high affinity receptors
35 Synthesis of Vitamin DVitamin D3 synthesis occurs in keratinocytes in the skin.7-dehydrocholesterol is photoconverted to previtamin D3, then spontaneously converts to vitamin D3.Previtamin D3 will become degraded by over exposure to UV light and thus is not overproduced.Also 1,25-dihydroxy-D (the end product of vitamin D synthesis) feeds back to inhibit its production.
36 Synthesis of Vitamin DPTH stimulates vitamin D synthesis. In the winter or if exposure to sunlight is limited (indoor jobs!), then dietary vitamin D is essential.Vitamin D itself is inactive, it requires modification to the active metabolite, 1,25-dihydroxy-D.The first hydroxylation reaction takes place in the liver yielding 25-hydroxy D.Then 25-hydroxy D is transported to the kidney where the second hydroxylation reaction takes place.
37 Synthesis of Vitamin DThe mitochondrial P450 enzyme 1a-hydroxylase converts it to 1,25-dihydroxy-D, the most potent metabolite of Vitamin D.The 1a-hydroxylase enzyme is the point of regulation of D synthesis.Feedback regulation by 1,25-dihydroxy D inhibits this enzyme.PTH stimulates 1a-hydroxylase and increases 1,25-dihydroxy D.
38 Synthesis of Vitamin D25-OH-D3 is also hydroxylated in the 24 position which inactivates it.If excess 1,25-(OH)2-D is produced, it can also by 24-hydroxylated to remove it.Phosphate inhibits 1a-hydroxylase and decreased levels of PO4 stimulate 1a-hydroxylase activity
40 Vitamin DVitamin D is a lipid soluble hormone that binds to a typical nuclear receptor, analogous to steroid hormones.Because it is lipid soluble, it travels in the blood bound to hydroxylated a-globulin.There are many target genes for Vitamin D.
42 Vitamin D actionThe main action of 1,25-(OH)2-D is to stimulate absorption of Ca2+ from the intestine.1,25-(OH)2-D induces the production of calcium binding proteins which sequester Ca2+, buffer high Ca2+ concentrations that arise during initial absorption and allow Ca2+ to be absorbed against a high Ca2+ gradient
43 Vitamin D promotes intestinal calcium absorption Vitamin D acts via steroid hormone like receptor to increase transcriptional and translational activityOne gene product is calcium-binding protein (CaBP)CaBP facilitates calcium uptake by intestinal cells
44 Clinical correlate Vitamin D-dependent rickets type II Mutation in 1,25-(OH)2-D receptorDisorder characterized by impaired intestinal calcium absorptionResults in rickets or osteomalacia despite increased levels of 1,25-(OH)2-D in circulation
45 Vitamin D Actions on Bones Another important target for 1,25-(OH)2-D is the bone.Osteoblasts, but not osteoclasts have vitamin D receptors.1,25-(OH)2-D acts on osteoblasts which produce a paracrine signal that activates osteoclasts to resorb Ca++ from the bone matrix.1,25-(OH)2-D also stimulates osteocytic osteolysis.
46 Vitamin D and BonesProper bone formation is stimulated by 1,25-(OH)2-D.In its absence, excess osteoid accumulates from lack of 1,25-(OH)2-D repression of osteoblastic collagen synthesis.Inadequate supply of vitamin D results in rickets, a disease of bone deformation
47 Parathyroid HormonePTH is synthesized and secreted by the parathyroid gland which lie posterior to the thyroid glands.The blood supply to the parathyroid glands is from the thyroid arteries.The Chief Cells in the parathyroid gland are the principal site of PTH synthesis.
48 Synthesis of PTH PTH is translated as a pre-prohormone. Cleavage of leader and pro-sequences yield a biologically active peptide of 84 aa.Cleavage of C-terminal end yields a biologically inactive peptide.
49 Regulation of PTH The dominant regulator of PTH is plasma Ca2+. Secretion of PTH is inversely related to [Ca2+].Maximum secretion of PTH occurs at plasma Ca2+ below 3.5 mg/dL.At Ca2+ above 5.5 mg/dL, PTH secretion is maximally inhibited.
51 Regulation of PTHPTH secretion responds to small alterations in plasma Ca2+ within seconds.A unique calcium receptor within the parathyroid cell plasma membrane senses changes in the extracellular fluid concentration of Ca2+.This is a typical G-protein coupled receptor that activates phospholipase C and inhibits adenylate cyclase—result is increase in intracellular Ca2+ via generation of inositol phosphates and decrease in cAMP which prevents exocytosis of PTH from secretory granules.
52 Regulation of PTH When Ca2+ falls, cAMP rises and PTH is secreted. 1,25-(OH)2-D inhibits PTH gene expression, providing another level of feedback control of PTH.Despite close connection between Ca2+ and PO4, no direct control of PTH is exerted by phosphate levels.
54 PTH actionThe overall action of PTH is to increase plasma Ca++ levels and decrease plasma phosphate levels.PTH acts directly on the bones to stimulate Ca++ resorption and kidney to stimulate Ca++ reabsorption in the distal tubule of the kidney and to inhibit reabosorptioin of phosphate (thereby stimulating its excretion).PTH also acts indirectly on intestine by stimulating 1,25-(OH)2-D synthesis.
56 Primary Hyperparathyroidism Calcium homeostatic loss due to excessive PTH secretionDue to excess PTH secreted from adenomatous or hyperplastic parathyroid tissueHypercalcemia results from combined effects of PTH-induced bone resorption, intestinal calcium absorption and renal tubular reabsorptionPathophysiology related to both PTH excess and concomitant excessive production of 1,25-(OH)2-D.
57 Hypercalcemia of Malignancy Underlying cause is generally excessive bone resorption by one of three mechanisms1,25-(OH)2-D synthesis by lymphomasLocal osteolytic hypercalcemia20% of all hypercalcemia of malignancyHumoral hypercalcemia of malignancyOver-expression of PTH-related protein (PTHrP)
58 PTHrPThree forms of PTHrP identified, all about twice the size of native PTHMarked structural homology with PTHPTHrP and PTH bind to the same receptorPTHrP reproduce full spectrum of PTH activities
59 PTH receptor defectRare disease known as Jansen’s metaphyseal chondrodysplasiaCharacterized by hypercalcemia, hypophosphotemia, short-limbed dwarfismDue to activating mutation of PTH receptorRescue of PTH receptor knock-out with targeted expression of “Jansen’s transgene”
60 HypoparathyroidismHypocalcemia occurs when there is inadequate response of the Vitamin D-PTH axis to hypocalcemic stimuliHypocalcemia is often multifactorialHypocalcemia is invariably associated with hypoparathyroidismBihormonal—concomitant decrease in 1,25-(OH)2-D
61 Hypoparathyroidism PTH-deficient hypoparathyroidism Reduced or absent synthesis of PTHOften due to inadvertent removal of excessive parathyroid tissue during thyroid or parathyroid surgeryPTH-ineffective hypoparathyroidismSynthesis of biologically inactive PTH
62 Pseudohypoparathyroidism PTH-resistant hypoparathyroidismDue to defect in PTH receptor-adenylate cyclase complexMutation in Gas subunitPatients are also resistant to TSH, glucagon and gonadotropins
65 Calcitonin Calcitonin acts to decrease plasma Ca++ levels. While PTH and vitamin D act to increase plasma Ca++-- only calcitonin causes a decrease in plasma Ca++.Calcitonin is synthesized and secreted by the parafollicular cells of the thyroid gland.They are distinct from thyroid follicular cells by their large size, pale cytoplasm, and small secretory granules.
66 CalcitoninThe major stimulus of calcitonin secretion is a rise in plasma Ca++ levelsCalcitonin is a physiological antagonist to PTH with regard to Ca++ homeostasis
67 Calcitonin The target cell for calcitonin is the osteoclast. Calcitonin acts via increased cAMP concentrations to inhibit osteoclast motility and cell shape and inactivates them.The major effect of calcitonin administration is a rapid fall in Ca2+ caused by inhibition of bone resorption.
68 CalcitoninRole of calcitonin in normal Ca2+ control is not understood—may be more important in control of bone remodeling.Used clinically in treatment of hypercalcelmia and in certain bone diseases in which sustained reduction of osteoclastic resorption is therapeutically advantageous.Chronic excess of calcitonin does not produce hypocalcemia and removal of parafollicular cells does not cause hypercalcemia. PTH and Vitamin D3 regulation dominate.May be more important in regulating bone remodeling than in Ca2+ homeostasis.
69 Nutrition and CalciumHeaney RP, Refferty K Am J. Clin Nutr :343-7Excess calciuria associated with consumption of carbonated beverages is confined to caffeinated beverages.Acidulant type (phosphoric vs. citric acid) has no acute effect.The skeletal effects of carbonated beverage consumption are due primarily to milk displacement.
70 Nutrition and Calcium See Nutrition 2000 Vol 16 (7/8) in particular: Calvo MS “Dietary considerations to prevent loss of bone and renal function”“overall trend in food consumption in the US is to drink less milk and more carbonated soft drinks.”“High phosphorus intake relative to low calcium intake”Changes in calcium homeostasis and PTH regulation that promote bone loss in children and post-menopausal women.High sodium associated with fast-food consumption competes for renal reabsorption of calcium and PTH secretion.
71 Nutrition and Calcium See Nutrition 2000 Vol 16 (7/8) in particular: Harland BF “Caffeine and Nutrition”Caffeine is most popular drug consumed world-wide.75% comes from coffeeDeleterious effects associated with pregnancy and osteoporosis.Low birth-rate and spontaneous abortion with excessive consumptionFor every 6 oz cup of coffee consumed there was a net loss of 4.6 mg of calciumHowever, if you add milk to your coffee, you can replace the calcium that is lost.
72 Ill effects of soft drinks Intake of carbonated beverages has been associated with increased excretion and loss of calcium25 years ago teenagers drank twice as much milk as soda pop. Today they drink more than twice as much soda pop as milk.Another significant consideration is obesity and increased risk for diabetes.For complete consideration of ill effects of soft drinks on health and environment see:
73 Excessive sodium intake Excessive intake of sodium may cause renal hypercalciuria by impairing calcium reabsorption resulting in compensatory increase in PTH secretion.Stimulation of intestinal calcium absorption by PTH-induced 1,25-(OH)2-D production compensates for excessive calcium excretionPost-menopausal women at greater risk for bone loss due to excessive sodium intake due to impaired vitamin D synthesis which accompanies estrogen deficiency.
74 Exercise and CalciumNormal bone function requires weight-bearing exerciseTotal bed-rest causes bone loss and negative calcium balanceMajor impediment to long-term space travel