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
 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
concentration
• Stored in mitochondria and ER
• “pump-leak” transport systems control [Ca2+]cyt
– Calcium leaks into cytosolic compartment and is
actively pumped into storage sites in organelles to shift
it away from cytosolic pools.
 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 [Ca2+]cyt
 Extracellular Calcium
• 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
 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
• Ca2+ normally ranges from 8.5-10 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.
Phosphate Turnover
 Phosphorous in blood and bone

• PO4 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 Ca2+ 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 osteoid.
• Calcium phosphate is deposited in the
osteoid and becomes mineralized
• Mineralization is combination of CaP0 4,
OH-, and H3CO3– 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. 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.
 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.
Calcium, bones and osteoporosis
• 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
 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
 Synthesis of Vitamin D
• 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 1-hydroxylase
converts it to 1,25-dihydroxy-D, the most potent
metabolite of Vitamin D.
• The 1-hydroxylase enzyme is the point of
regulation of D synthesis.
• Feedback regulation by 1,25-dihydroxy D inhibits
this enzyme.
• PTH stimulates 1-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 1-hydroxylase and decreased
levels of PO4 stimulate 1-hydroxylase activity
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 -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 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
 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
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.
Calcium regulates PTH
 Regulation of PTH
• PTH 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 Ca 2+ via
generation of inositol phosphates and decrease in
cAMP which prevents exocytosis of PTH from
secretory granules.
 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 Ca 2+ and
PO4, no direct control of PTH is exerted by
phosphate levels.
 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 Jansen’s

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 “Jansen’s 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
• Bihormonal—concomitant decrease in
1,25-(OH)2-D
 Hypoparathyroidism

• 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
 Pseudohypoparathyroidism

• PTH-resistant hypoparathyroidism
– Due to defect in PTH receptor-adenylate
cyclase complex
• Mutation in Gs 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.
 Calcitonin

• 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 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.
 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.
 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