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Endocrine Physiology

lecture 5
Dale Buchanan Hales, PhD
Department of Physiology & Biophysics



Calcium homeostasis:
Parathyroid Hormone, Calcitonin
and Vitamin D3
Physiological importance of
Calcium
Calcium salts in bone provide structural integrity
of the skeleton
Calcium ions in extracellular and cellular fluids is
essential to normal function of a host of
biochemical processes
Neuoromuscular excitability
Blood coagulation
Hormonal secretion
Enzymatic regulation
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
Control of cellular calcium homeostasis is as
carefully maintained as in extracellular fluids
[Ca
2+
]
cyt
is approximately 1/1000
th
of extracellular
concentration
Stored in mitochondria and ER
pump-leak transport systems control [Ca
2+
]
cyt

Calcium leaks into cytosolic compartment and is
actively pumped into storage sites in organelles to shift
it away from cytosolic pools.
Regulation of Intracellular
Calcium Concentration
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
contractions
Hypercalcemic tetany [Ca
2+
]
cyt

Three definable fractions of calcium in
serum:
Ionized calcium 50%
Protein-bound calcium 40%
90% bound to albumin
Remainder bound to globulins
Calcium complexed to serum constituents 10%
Citrate and phosphate

Extracellular Calcium
Binding of calcium to albumin is pH dependent
Acute alkalosis increases calcium binding to
protein and decreases ionized calcium
Patients 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
Extracellular Calcium
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
Calcium turnover
Calcium in blood and bone
Ca
2+
normally ranges from 8.5-10 mg/dL in
the plasma.
The active free ionized Ca
2+
is only about
48% 46% is bound to protein in a non-
diffusible state while 6% is complexed to
salt.
Only free, ionized Ca
2+
is biologically
active.
Phosphate Turnover
Phosphorous in blood and bone
PO
4
normal plasma concentration is 3.0-4.5
mg/dL. 87% is diffusible, with 35%
complexed to different ions and 52%
ionized.
13% is in a non-diffusible protein bound
state. 85-90% is found in bone.
The rest is in ATP, cAMP, and proteins
Calcium and bone
99% of Calcium is found in the bone. Most
is found in hydroxyapatite crystals. Very
little Ca
2+
can be released from the bone
though it is the major reservoir of Ca
2+
in
the body.
Structure of bones
Haversian canals within lamellae
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
Bones
99% 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 process
During growth rate of bone formation exceeds resporption
and skeletal mass increases.
Linear growth occurs at epiphyseal plates.
Increase in width occurs at periosteum
Once 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.
Bone cell types
There 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.

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 mineralized
Mineralization is combination of CaP0
4
,
OH
-
, and H
3
CO
3

hydroxyapatite.
Mineralization
Requires adequate Calcium and phosphate
Dependent on Vitamin D
Alkaline phosphatase and osteocalcin play
roles in bone formation
Their plasma levels are indicators of
osteoblast activity.

Canaliculi
Within 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.
Bones
cells
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. CaPO
4
precipitates
out of solution id its solubility is exceeded. The
solubility is defined by the equilibrium equation:
Ksp = [Ca
2+
]
3
[PO
4
3-
]
2
.
In the absence of hormonal regulation plasma Ca
++

is maintained at 6-7 mg/dL by this equilibrium.

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 crystals
Happens quickly.
Bone resorption
Does not merely extract calcium, it destroys
entire matrix of bone and diminishes bone
mass.
Cell responsible for resorption is the
osteoclast.

Bone remodeling
Endocrine 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.
Osteoclasts and Ca++ resorption
Calcium, bones and osteoporosis
The total bone mass of humans peaks at 25-
35 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.
Reduced bone density and mass: osteoporosis
Susceptibility to fracture.
Earlier in life for women than men but eventually
both genders succumb.
Reduced risk:
Calcium in the diet
habitual exercise
avoidance of smoking and alcohol intake
avoid drinking carbonated soft drinks

Calcium, bones and osteoporosis
Vertebrae of 40- vs. 92-year-old
women
Note the marked loss of trabeculae with preservation of cortex.
Hormonal
control of
bones
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.
Vitamin D
Vitamin 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 .

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
Vitamin 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.
Synthesis of Vitamin D
PTH 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.
Synthesis of Vitamin D
The 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.
Synthesis of Vitamin D
25-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 PO
4
stimulate 1a-hydroxylase activity
Synthesis of Vitamin D
Synthesis of
Vitamin D
Vitamin D
Vitamin 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.
Vitamin D action
The main action of 1,25-(OH)
2
-D is to stimulate
absorption of Ca
2+
from the intestine.
1,25-(OH)
2
-D induces the production of calcium
binding proteins which sequester Ca
2+
, buffer high
Ca
2+
concentrations that arise during initial
absorption and allow Ca
2+
to be absorbed against a
high Ca
2+
gradient
Vitamin D promotes intestinal
calcium absorption
Vitamin D acts via steroid hormone like
receptor to increase transcriptional and
translational activity
One gene product is calcium-binding
protein (CaBP)
CaBP facilitates calcium uptake by
intestinal cells
Clinical correlate
Vitamin D-dependent rickets type II
Mutation in 1,25-(OH)2-D receptor
Disorder characterized by impaired
intestinal calcium absorption
Results in rickets or osteomalacia despite
increased levels of 1,25-(OH)2-D in
circulation
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.


Vitamin D and Bones
Proper 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
Parathyroid Hormone
PTH 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.
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.
Regulation of PTH
The dominant regulator of PTH is plasma
Ca
2+
.
Secretion of PTH is inversely related to
[Ca
2+
].
Maximum secretion of PTH occurs at
plasma Ca
2+
below 3.5 mg/dL.
At Ca
2+
above 5.5 mg/dL, PTH secretion is
maximally inhibited.

Calcium regulates PTH
PTH secretion responds to small alterations in
plasma Ca
2+
within seconds.
A unique calcium receptor within the parathyroid
cell plasma membrane senses changes in the
extracellular fluid concentration of Ca
2+
.
This is a typical G-protein coupled receptor that
activates phospholipase C and inhibits adenylate
cyclaseresult is increase in intracellular Ca
2+
via
generation of inositol phosphates and decrease in
cAMP which prevents exocytosis of PTH from
secretory granules.
Regulation of PTH
When Ca
2+
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 Ca
2+
and
PO
4
, no direct control of PTH is exerted by
phosphate levels.

Regulation of PTH
Calcium
regulates
PTH
secretion
PTH action
The 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.
Calcium vs. PTH
Primary Hyperparathyroidism
Calcium homeostatic loss due to excessive PTH
secretion
Due to excess PTH secreted from adenomatous or
hyperplastic parathyroid tissue
Hypercalcemia results from combined effects of
PTH-induced bone resorption, intestinal calcium
absorption and renal tubular reabsorption
Pathophysiology related to both PTH excess and
concomitant excessive production of 1,25-(OH)2-D.
Hypercalcemia of Malignancy
Underlying cause is generally excessive bone
resorption by one of three mechanisms
1,25-(OH)2-D synthesis by lymphomas
Local osteolytic hypercalcemia
20% of all hypercalcemia of malignancy
Humoral hypercalcemia of malignancy
Over-expression of PTH-related protein (PTHrP)
PTHrP
Three forms of PTHrP identified, all about
twice the size of native PTH
Marked structural homology with PTH
PTHrP and PTH bind to the same receptor
PTHrP reproduce full spectrum of PTH
activities
PTH receptor defect
Rare disease known as Jansens
metaphyseal chondrodysplasia
Characterized by hypercalcemia,
hypophosphotemia, short-limbed dwarfism
Due to activating mutation of PTH receptor
Rescue of PTH receptor knock-out with
targeted expression of Jansens transgene
Hypoparathyroidism
Hypocalcemia occurs when there is
inadequate response of the Vitamin D-PTH
axis to hypocalcemic stimuli
Hypocalcemia is often multifactorial
Hypocalcemia is invariably associated with
hypoparathyroidism
Bihormonalconcomitant decrease in 1,25-
(OH)2-D
PTH-deficient hypoparathyroidism
Reduced or absent synthesis of PTH
Often due to inadvertent removal of excessive
parathyroid tissue during thyroid or parathyroid
surgery
PTH-ineffective hypoparathyroidism
Synthesis of biologically inactive PTH
Hypoparathyroidism
Pseudohypoparathyroidism
PTH-resistant hypoparathyroidism
Due to defect in PTH receptor-adenylate
cyclase complex
Mutation in Gas subunit
Patients are also resistant to TSH, glucagon
and gonadotropins
Calcium homeostasis
PTH,
Calcium &
Phosphate
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.
The major stimulus of calcitonin secretion
is a rise in plasma Ca
++
levels
Calcitonin is a physiological antagonist to
PTH with regard to Ca
++
homeostasis
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 Ca
2+
caused
by inhibition of bone resorption.
Calcitonin
Role of calcitonin in normal Ca
2+
control is not
understoodmay 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 Ca
2+
homeostasis.
Calcitonin
Nutrition and Calcium
Heaney RP, Refferty K Am J. Clin Nutr
200174:343-7
Excess 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.
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.



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 coffee
Deleterious effects associated with pregnancy and
osteoporosis.
Low birth-rate and spontaneous abortion with excessive
consumption
For every 6 oz cup of coffee consumed there was a net loss of
4.6 mg of calcium
However, if you add milk to your coffee, you can replace the
calcium that is lost.
Ill effects of soft drinks
Intake of carbonated beverages has been
associated with increased excretion and loss of
calcium
25 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:
http://www.saveharry.com/bythenumbers.html
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 excretion
Post-menopausal women at greater risk for bone
loss due to excessive sodium intake due to
impaired vitamin D synthesis which accompanies
estrogen deficiency.

Exercise and Calcium
Normal bone function requires weight-
bearing exercise
Total bed-rest causes bone loss and negative
calcium balance
Major impediment to long-term space travel