Primary hypomagnesemia with secondary hypocalcemia, diarrhea and insensitivity to parathyroid hormone

TRPM6

TRPM6 is a bifunctional protein comprising a TRP cation channel segment covalently linked to an α-type serine/threonine protein kinase. TRPM6 is expressed in the intestinal and renal epithelial cells. Loss-of-function mutations in the human TRPM6 gene give rise to hypomagnesemia with secondary hypocalcemia (HSH), suggesting that the TRPM6 channel kinase plays a central role in systemic Mg(2+) homeostasis. In contrast, Trpm6 null mice show a delay in prenatal development, neural tube defects, and prenatal death. Possible functions of TRPM6 in prenatal and adult organisms will be discussed in this chapter.

The association of bone mineral density and parathyroid hormone with serum magnesium in adult patients with sickle-cell anaemia

INTRODUCTION

Bone disorders including osteopenia and osteoporosis are a frequent cause of morbidity in sickle-cell disease (SCD). Magnesium (Mg) regulates some biological processes important in bone remodelling. We aimed to investigate whether serum Mg levels (sMg) may have an impact on bone mineral density (BMD) in sickle-cell anaemia (SCA).

MATERIAL AND METHODS

Sixty adults with SCA in steady-state and 20 age- and race-matched healthy blood donors were included in the study. The BMD was evaluated with respect to minerals and biochemical indices of bone metabolism. Multivariate analysis was performed to determine the factors influencing BMD.

RESULTS

The mean sMg concentration was 0.64 ±0.06 (reference range 0.7-1.2 mmol/l) for 34% of the population, and 0.86 ±0.08 mmol/l for 66%. There were significant differences between Mg groups and controls in BMD, phosphorus (PO(4)), parathyroid hormone (PTH) (p = 0.011, p = 0.011 and p = 0.0001 respectively) and osteocalcin (OC) (p = 0.030) levels. The sMg was found to be associated positively with serum calcium (Ca), PTH and OC (r = 0.585; r = 0.436; r = 0.351 respectively, all at p < 0.05), and negatively with PO(4) (r = -0.312; p < 0.05). Multivariate analysis demonstrated that only PTH (p < 0.05) was an independent factor for BMD. Moreover, it identified sMg, OC, and CTX as independent factors for PTH (all p < 0.05).

CONCLUSIONS

These results indicate that serum Mg may be a co-contributing factor in causing low BMD. However, other possible aetiologies including decreased PTH and increased bone turnover certainly play a role. Based on the present data, it is prudent to monitor sMg routinely in this patient population and treat the condition whenever possible.

Identification of E. dysenterica laxative peptide: a novel strategy in the treatment of chronic constipation and irritable bowel syndrome

Plants have contributed over the years to the discovery of various pharmacological products. Amongst the enormous diversity of herbs with remarkable medicinal use and further pharmacological potential, here in this report we evaluated pulp extracts from Eugenia dysenterica fruits and further identified the active principle involved in such laxative activity in rats. For protein isolation, fruits were macerated with an extraction solution following precipitation with (NH(4))(2)SO(4) (100%). After dialysis, the peptide was applied onto a reversed-phase semi-preparative HPLC column, and the major fraction was eluted with 26% and 66% acetonitrile. The evaluation of molecular masses by MALDI-TOF and Tris/Tricine SDS-PAGE of HPLC fractions showed the presence of a major peptide with approximately 7 kDa. The N-terminal amino acid peptide sequence was determined and showed no similarity to other proteins deposited in the Data Bank. Peptide from E. dysenterica was able to enhance rats' intestinal motility by approximately 20.8%, probably being responsible for laxative activity. Moreover, these proteins were non-toxic to mammals, as observed in histopathology and hemolytic analyses. In conclusion, results here reported indicate that, in the near future, proteins synthesized by E. dysenterica fruits could be utilized in the development of novel biotechnological pharmaceutics with laxative properties for use in chronic constipation and irritable bowel syndrome treatment.

Prevalence of hypovitaminosis D in early infantile hypocalcemia

AIM

To further define the pathogenesis of infantile hypocalcemia, the prevailing vitamin D status, and treatment outcomes.

METHODS AND RESULTS

Of the 23 infants admitted with infantile hypocalcemia, 21 had biochemical evidence of hypocalcemia and hyperphosphatemia and the other two had isolated hypocalcemia. The majority of these infants had relatively low serum intact parathyroid hormone responses against the backdrop of hypocalcemia. Thirteen (56.5%) of these infants had low 25-hydroxyvitamin D (25-OHD) levels, of whom 69% were Hispanic and 23% were African American. Infantile serum vitamin D status reflected that of the mother in all the 16 instances in which it was measured. Treatment with calcitriol hastened recovery from hypocalcemia in our series.

CONCLUSIONS

Relative hypoparathyroidism is the etiology in the majority of cases of late onset and early infantile hypocalcemia. We identified vitamin D deficiency in a significant percentage of infants with hypocalcemia, especially Hispanics and African Americans. Maternal 25-OHD concentrations should be ascertained if the infant has low 25-OHD levels.

Hypocalcaemia and chronic alcohol intoxication: transient hypoparathyroidism secondary to magnesium deficiency

The authors report the observation of an alcoholic patient admitted for tetanic manifestations, in whom severe hypocalcaemia associated with hyperphosphatemia were suggestive of hypoparathyroidism. Administration of magnesium supplementation alone improved the clinical features and led to the correction of the calcium abnormalities. The mechanisms of hypomagnesemia in alcohol intoxication are reviewed as well as the links with hypocalcaemia.

A case of alcoholic dementia with hypomagnesemia and hypocalcemia

A 47-year-old man with chronic alcoholism was admitted to a psychiatric institution because of his mental symptoms and abnormal behavior. He had dementia, emotional disturbances, muscle cramps (tetanic fits), and impairment of abstract thinking and psychomotor function. The biochemical examination of his blood revealed hypomagnesemia, hypocalcemia and a low level of serum parathyroid hormone. The administration of Ca lactate improved hypocalcemia and muscle cramps, but not the other symptoms. An addition of Mg sulfate did not change the clinical condition and the serum electrolyte level. From these findings a relation of chronic alcohol intake to the imbalance of serum electrolytes as well as a low level of serum parathyroid hormone was discussed, and a pathogenetic mechanism of dementia observed in this case was speculated.

Primary hypomagnesaemia. A case report and literature review

A case of primary hypomagnesaemia with secondary hypocalcaemia in an Arab girl of consanguineous parents is reported. She presented at the age of 3 weeks with generalised convulsions, was treated with magnesium supplements and followed up for 5 years during which she showed normal physical and psychomotor development. In view of the striking male preponderance among the reported cases and the presence of parental consanguinity in a few, the inheritance is discussed and genetic heterogeneity is suggested.

Skeletal adenylate cyclase: effect of Mg2+, Ca2+, and PTH

Plasma membranes were prepared from mineralized guinea pig bone in order to study Mg2+ and Ca2+ modulation of skeletal adenylate cyclase. Plasma membrane preparation was accomplished by crushing the bone in liquid N2 and subsequent multiple washings in buffer containing EGTA to remove all Ca2+ prior to adenylate cyclase assay. Skeletal adenylate cyclase was found to be dependent on GTP and Mg2+ and responsive to bovine 1-34 PTH. Ca2+ caused a competitive inhibition of Mg2+ -activated skeletal adenylate cyclase. The apparent KaMg was 1.9 +/- 0.3 in the presence of 0.2 microM Ca2+ but increased to a mean of 7.2 +/- 1.3 in the presence of 5.0 microM Ca2+. Analysis of the Ca2+ inhibition curves at concentrations from .05 microM-1.0 mM were consistent with the presence of two Ca2+ inhibition sites, one with an apparent Ki of 1-2 microM and the other with an apparent Ki of approximately 500 microM. Lowering the Mg2+ concentration increased the contribution of the high affinity Ca2+ binding site to the overall Ca2+ inhibition, and raising the Mg2+ concentration had the opposite effect. While bPTH 1-34 enhanced adenylate cyclase activity, it did not increase the affinity of Mg2+ for skeletal adenylate cyclase nor did it alter the KiCa or the pattern of Ca2+ inhibition. These data may explain the skeletal resistance to PTH during Mg deficiency.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypocitraturia in patients with gastrointestinal malabsorption

We measured serum and urinary citrate, oxalate, calcium, and magnesium in 22 normal subjects and in 16 patients with malabsorption. The patients had subnormal levels of serum citrate and magnesium during fasting, subnormal 24-hour levels of urinary citrate, magnesium, and calcium, and excessive levels of urinary oxalate. Daily citrate excretion averaged only 15 per cent of normal. The hypocitraturia in the patients resulted from a subnormal filtered load of citrate and abnormally high net tubular reabsorption of the anion. An oral citrate supplement raised both the serum concentration and the filtered load of citrate to normal fasting values, but net tubular reabsorption remained abnormally high and urinary excretion abnormally low. Intramuscular magnesium sulfate, which corrected the hypomagnesemia and hypomagnesuria, had no effect on serum citrate or its filtered load. Nevertheless the injection restored net tubular reabsorption of citrate to normal and partially improved the hypocitraturia. Full correction of the hypocitraturia was achieved by combined treatment with oral citrate and intramuscular magnesium sulfate. Hypocitraturia may contribute to the formation of oxalate stones in these patients, and therefore our treatment may help to prevent this complication.

Influence of magnesium on the secretion and action of parathyroid hormone

The interactions of serum levels of magnesium and parathyroid hormone (PTH) have been studied in a patient with hypomagnesemia and hypocalcemia following intestinal bypass surgery for obesity. When serum magnesium was low serum PTH was not stimulated by hypocalcemia. With correction of magnesium deficiency hypocalcemia was associated with elevation of serum PTH levels. Infusion of exogenous PTH induced a clearly detectable renal response in the presence of hypomagnesemia but the response was diminished when serum magnesium was elevated. In this patient it appears that hypomagnesemia suppressed parathyroid gland activity, leaving the renal action of PTH intact.

Functional hypoparathyroidism and parathyroid hormone end-organ resistance in human magnesium deficiency

Hypocalcaemia is a well-recognized manifestation of magnesium deficiency. We have studied seventeen patients with this syndrome in an attempt to determine the pathogenesis of the hypocalcaemia. Mean initial serum calcium concentration was 5-6 mg/dl and mean initial serum magnesium concentration was 0-75 mg/dl. Serum immunoreactive parathyroid hormone (IPTH) was measured in sixteen patients in the untreated state. Despite severe hypocalcaemia, serum IPTH was either undetectable (less than 150 pg/ml) or normal (less than 550 pg/ml) in all but two patients. Serial measurements made during the initial 4 days of magnesium therapy in four patients showed an increase in serum IPTH within 24h, but a delayed increase in serum calcium, which required approximately 4 days to reach normal values. The effect of the rapid normalization of serum magnesium on serum IPTH and serum calcium concentration was studied in three patients. Within 1 min after 144-300 mg of elemental magnesium was administered i.v., serum IPTH had risen from undetectable to 3600 pg/ml and 1725 pg/ml in two patients and from 425 pg/ml to 937 pg/ml in the third. Serum calcium concentrations were unchanged after 30-60 min. These data provide evidence for impaired parathyroid gland function in most of the magnesium deficient patients. The rapidity with which serum IPTH rose in response to magnesium therapy indicates that this may reflect a defect in parathyroid hormone (PTH) secretion rather than its biosynthesis. The failure of serum calcium concentration to increase during the initial days of magnesium repletion, at a time when serum IPTH concentrations were normal or elevated, suggests end-organ resistance to PTH in these patients. The renal response to PTH was examined in two magnesium deficient patients by measurement of urinary cyclic AMP excretion following administration of parathyroid extract. In both patients there was a minimal increase in urinary cyclic AMP concentrations. In contrast, when the hepatic response to glucagon was tested on the same patients by measurement of plasma cyclic AMP concentrations following administration of glucagon, normal increases were observed. These results suggest that adenylate cyclase systems of various organs may be affected differentially by a state of magnesium deficiency. It is suggested that magnesium deficiency may result in defective cyclic AMP generation in the parathyroid glands and in the PTH target organs. This could be the principal mechanism operative in both impaired PTH secretion and end-organ resistance to PTH which together contribute to the development of hypocalcaemia.

Studies on mechanisms of hypocalcemia of magnesium depletion

Studies were carried out to evaluate the mechanism of hypocalcemia in magnesium depletion. Day old chicks fed a magnesium deficient diet developed marked hypocalcemia, with a direct relation between serum calcium (y) and magnesium (x): y = 2.68 x + 4.24, r = 0.84 (both in mg/100 ml). Injections of parathyroid extract that increased serum calcium 2-3 mg/100 ml in normals had no effect in Mg-depleted birds. Very large dietary supplements of calcium or vitamin D(3) increased mean serum calcium only from 5.3 to 7.7 and 7.8 mg/100 ml, respectively, while a normal magnesium diet for 3 days increased calcium from 5.3 to 9.9 mg/100 ml despite absence of dietary calcium. Intestinal calcium transport, studied in vitro, and the calcium concentration of the carcass was significantly increased in magnesium-depleted chicks, making it unlikely that reduced intestinal absorption of calcium caused the hypocalcemia. In magnesium-deficient chicks, the bone content of magnesium was decreased by 74%, the calcium content was unchanged, and the cortical thickness of bone was markedly increased. After 3 days of magnesium-repletion, cortical thickness was reduced with increased endosteal resorption. There was an increase in unmineralized osteoid tissue in the magnesium-depleted chicks. Parathyroid gland size and histology did not differ in magnesium-depleted and control birds. The results suggest that hypocalcemia develops due to altered equilibrium of calcium between extracellular fluid and bone, favoring increased net movement into the latter. Failure of parathyroid gland function could also exist, and unresponsiveness to parathyroid hormone (PTH) may also contribute to the hypocalcemia. However, failure of PTH action is probably due to the presence of excess osteoid tissue rather than a primary event leading to hypocalcemia.