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Sviridonova MA. [Syndrome of hypocalсiuric hypercalcemia. Is it rare? Two clinical cases in an outpatient clinic]. PROBLEMY ENDOKRINOLOGII 2022; 68:24-31. [PMID: 36337015 DOI: 10.14341/probl13125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/17/2022] [Accepted: 06/17/2022] [Indexed: 11/09/2022]
Abstract
Hypocalciuric hypercalcemia syndrome (familial hypocalciuric hypercalcemia, FHH) is an inherited condition based on dysfunction of the calcium receptor or its associated partner proteins. Recent evidence suggests that the prevalence of this condition may be comparable to that of primary hyperparathyroidism. Clinical manifestations of FHH are usually absent; however the classic symptoms of hypercalcemia may be present in some cases. Timely differential diagnosis of FHH avoids unnecessary and expensive instrumental examination, as well as ineffective treatment. The clinical cases presented in this publication demonstrate the unjustified difficulties in this issue and the necessity to raise the awareness of physicians about the familial hypocalciuric hypercalcemia.
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Disorders of the Calcium Sensing Signaling Pathway: From Familial Hypocalciuric Hypercalcemia (FHH) to Life Threatening Conditions in Infancy. J Clin Med 2022; 11:jcm11092595. [PMID: 35566721 PMCID: PMC9100033 DOI: 10.3390/jcm11092595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/29/2022] [Accepted: 05/01/2022] [Indexed: 11/23/2022] Open
Abstract
Familial hypocalciuric hypercalcemia (FHH) is a mostly benign condition of elevated calcium and PTH levels based on a hyposensitive calcium sensing receptor (CaSR) in FHH 1 or its downstream regulatory pathway in FHH2 and FHH3. In children, adolescents and young adults with FHH the main challenge is to distinguish the condition from primary hyperparathyroidism and thereby to avoid unnecessary treatments including parathyroidectomy. However, inheritance of FHH may result in neonatal hyperparathyroidism (NHPT) or neonatal severe hyperparathyroidism (NSHPT), conditions with high morbidity, and in the latter even high mortality. This review focuses on the genetic and pathophysiological framework that leads to the severe neonatal form, gives recommendations for counselling and summarizes treatment options.
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Gorvin CM. Genetic causes of neonatal and infantile hypercalcaemia. Pediatr Nephrol 2022; 37:289-301. [PMID: 33990852 PMCID: PMC8816529 DOI: 10.1007/s00467-021-05082-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/25/2021] [Accepted: 04/06/2021] [Indexed: 12/02/2022]
Abstract
The causes of hypercalcaemia in the neonate and infant are varied, and often distinct from those in older children and adults. Hypercalcaemia presents clinically with a range of symptoms including failure to thrive, poor feeding, constipation, polyuria, irritability, lethargy, seizures and hypotonia. When hypercalcaemia is suspected, an accurate diagnosis will require an evaluation of potential causes (e.g. family history) and assessment for physical features (such as dysmorphology, or subcutaneous fat deposits), as well as biochemical measurements, including total and ionised serum calcium, serum phosphate, creatinine and albumin, intact parathyroid hormone (PTH), vitamin D metabolites and urinary calcium, phosphate and creatinine. The causes of neonatal hypercalcaemia can be classified into high or low PTH disorders. Disorders associated with high serum PTH include neonatal severe hyperparathyroidism, familial hypocalciuric hypercalcaemia and Jansen's metaphyseal chondrodysplasia. Conditions associated with low serum PTH include idiopathic infantile hypercalcaemia, Williams-Beuren syndrome and inborn errors of metabolism, including hypophosphatasia. Maternal hypocalcaemia and dietary factors and several rare endocrine disorders can also influence neonatal serum calcium levels. This review will focus on the common causes of hypercalcaemia in neonates and young infants, considering maternal, dietary, and genetic causes of calcium dysregulation. The clinical presentation and treatment of patients with these disorders will be discussed.
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Affiliation(s)
- Caroline M. Gorvin
- Institute of Metabolism and Systems Research and Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, B15 2TT UK ,Centre of Membrane Proteins and Receptors (COMPARE), Universities of Birmingham and Nottingham, Birmingham, B15 2TT UK
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Bernardor J, Flammier S, Salles JP, Amouroux C, Castanet M, Lienhardt A, Martinerie L, Damgov I, Linglart A, Bacchetta J. Off-label use of cinacalcet in pediatric primary hyperparathyroidism: A French multicenter experience. Front Pediatr 2022; 10:926986. [PMID: 36090548 PMCID: PMC9449487 DOI: 10.3389/fped.2022.926986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 07/11/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cinacalcet is a calcimimetic approved in adults with primary hyperparathyroidism (PHPT). Few cases reports described its use in pediatric HPT, with challenges related to the risk of hypocalcemia, increased QT interval and drug interactions. In this study, we report the French experience in this setting. METHODS We retrospectively analyzed data from 18 pediatric patients from 7 tertiary centers who received cinacalcet for PHPT. The results are presented as median (interquartile range). RESULTS At a median age of 10.8 (2.0-14.4) years, 18 patients received cinacalcet for primary HPT (N = 13 inactive CASR mutation, N = 1 CDC73 mutation, N = 1 multiple endocrine neoplasia type 1, N=3 unknown etiology). Cinacalcet was introduced at an estimated glomerular filtration rate (eGFR) of 120 (111-130) mL/min/1.73 m2, plasma calcium of 3.04 (2.96-3.14) mmol/L, plasma phosphate of 1.1 (1.0-1.3) mmol/L, age-standardized (z score) phosphate of -3.0 (-3.5;-1.9), total ALP of 212 (164-245) UI/L, 25-OHD of 37 (20-46) ng/L, age-standardized (z score) ALP of -2.4 (-3.7;-1.4), PTH of 75 (59-123) ng/L corresponding to 1.2 (1.0-2.3)-time the upper limit for normal (ULN). The starting daily dose of cinacalcet was 0.7 (0.6-1.0) mg/kg, with a maximum dose of 1.0 (0.9-1.4) mg/kg per day. With a follow-up of 2.2 (1.3-4.3) years on cinacalcet therapy, PTH and calcium significantly decreased to 37 (34-54) ng/L, corresponding to 0.8 (0.5-0.8) ULN (p = 0.01), and 2.66 (2.55-2.90) mmol/L (p = 0.002), respectively. In contrast, eGFR, 25-OHD, ALP and phosphate and urinary calcium levels remained stable. Nephrocalcinosis was not reported but one patient displayed nephrolithiasis. Cinacalcet was progressively withdrawn in three patients; no side effects were reported. CONCLUSIONS Cinacalcet in pediatric HPT can control hypercalcemia and PTH without significant side effects.
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Affiliation(s)
- Julie Bernardor
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières de Santé Maladies Rares OSCAR, ORKID et ERKNet, Service de Néphrologie Rhumatologie et Dermatologie Pédiatriques, Hôpital Femme Mère Enfant, Bron, France.,INSERM UMR S1033 Research Unit, Lyon, France.,Service de Néphrologie Pédiatrique, CHU de Nice, Hôpital Archet, Nice, France.,Faculté de Médecine, Université Côte d'Azur, Nice, France
| | - Sacha Flammier
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières de Santé Maladies Rares OSCAR, ORKID et ERKNet, Service de Néphrologie Rhumatologie et Dermatologie Pédiatriques, Hôpital Femme Mère Enfant, Bron, France
| | - Jean-Pierre Salles
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Unité d'Endocrinologie, Génétique et Pathologies Osseuses, Filières Santé Maladies Rares OSCAR et BOND, Hôpital des Enfants, Toulouse, France
| | - Cyril Amouroux
- Service d'Endrocrinologie et Néphrologie Pédiatrique, Filière de Santé Maladies Rares OSCAR, Hôpital Arnaud de Villeneuve - CHU Montpellier, Université de Montpellier, Montpellier, France
| | - Mireille Castanet
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Département de Pédiatrie, Filière Santé Maladies Rares OSCAR, CHU Rouen, Rouen, France
| | | | - Laetitia Martinerie
- Service d'Endocrinologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement (CRMERCD), Hôpital Robert Debré, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Ivan Damgov
- Center for Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany.,Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Agnès Linglart
- AP-HP, Centre de référence des maladies rares du métabolisme du calcium et du phosphate, Plateforme d'expertise maladies rares Paris Saclay, filière OSCAR, EndoRare and BOND ERN, Hôpital de Bicêtre Paris Saclay, Le Kremlin-Bicêtre, France.,Université Paris-Saclay, AP-HP, Service d'endocrinologie et diabète de l'enfant, Service de médecine des adolescents, Hôpital de Bicêtre Paris Saclay, INSERM U1185, Le Kremlin-Bicêtre, France
| | - Justine Bacchetta
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières de Santé Maladies Rares OSCAR, ORKID et ERKNet, Service de Néphrologie Rhumatologie et Dermatologie Pédiatriques, Hôpital Femme Mère Enfant, Bron, France.,INSERM UMR S1033 Research Unit, Lyon, France.,Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France
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5
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Kurian R, Madegowda Chandrashekar G, Antony MA, Chandra L, Kant R. Severe Symptomatic Hypercalcemia in a Patient With Familial Hypocalciuric Hypercalcemia. Cureus 2021; 13:e20057. [PMID: 34993031 PMCID: PMC8720036 DOI: 10.7759/cureus.20057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 11/05/2022] Open
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6
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Diao J, DeBono A, Josephs TM, Bourke JE, Capuano B, Gregory KJ, Leach K. Therapeutic Opportunities of Targeting Allosteric Binding Sites on the Calcium-Sensing Receptor. ACS Pharmacol Transl Sci 2021; 4:666-679. [PMID: 33860192 DOI: 10.1021/acsptsci.1c00046] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Indexed: 01/24/2023]
Abstract
The CaSR is a class C G protein-coupled receptor (GPCR) that acts as a multimodal chemosensor to maintain diverse homeostatic functions. The CaSR is a clinical therapeutic target in hyperparathyroidism and has emerged as a putative target in several other diseases. These include hyper- and hypocalcaemia caused either by mutations in the CASR gene or in genes that regulate CaSR signaling and expression, and more recently in asthma. The development of CaSR-targeting drugs is complicated by the fact that the CaSR possesses many different binding sites for endogenous and exogenous agonists and allosteric modulators. Binding sites for endogenous and exogenous ligands are located throughout the large CaSR protein and are interconnected in ways that we do not yet fully understand. This review summarizes our current understanding of CaSR physiology, signaling, and structure and how the many different binding sites of the CaSR may be targeted to treat disease.
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Affiliation(s)
- Jiayin Diao
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Aaron DeBono
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia.,Medicinal Chemistry, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Tracy M Josephs
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Jane E Bourke
- Department of Pharmacology, Biomedicine Discovery Institute, Monash University, 9 Ancora Imparo Way, Clayton, Victoria 3800, Australia
| | - Ben Capuano
- Medicinal Chemistry, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Karen J Gregory
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia.,Department of Pharmacology, Biomedicine Discovery Institute, Monash University, 9 Ancora Imparo Way, Clayton, Victoria 3800, Australia
| | - Katie Leach
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia.,Department of Pharmacology, Biomedicine Discovery Institute, Monash University, 9 Ancora Imparo Way, Clayton, Victoria 3800, Australia
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7
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Tőke J, Czirják G, Enyedi P, Tóth M. Rare diseases caused by abnormal calcium sensing and signalling. Endocrine 2021; 71:611-617. [PMID: 33528764 PMCID: PMC8016752 DOI: 10.1007/s12020-021-02620-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 01/08/2021] [Indexed: 12/20/2022]
Abstract
The calcium-sensing receptor (CaSR) provides the major mechanism for the detection of extracellular calcium concentration in several cell types, via the induction of G-protein-coupled signalling. Accordingly, CaSR plays a pivotal role in calcium homeostasis, and the CaSR gene defects are related to diseases characterized by serum calcium level changes. Activating mutations of the CaSR gene cause enhanced sensitivity to extracellular calcium concentration resulting in autosomal dominant hypocalcemia or Bartter-syndrome type V. Inactivating CaSR gene mutations lead to resistance to extracellular calcium. In these cases, familial hypocalciuric hypercalcaemia (FHH1) or neonatal severe hyperparathyroidism (NSHPT) can develop. FHH2 and FHH3 are associated with mutations of genes of partner proteins of calcium signal transduction. The common polymorphisms of the CaSR gene have been reported not to affect the calcium homeostasis itself; however, they may be associated with the increased risk of malignancies.
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Affiliation(s)
- Judit Tőke
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Gábor Czirják
- Department of Physiology, Semmelweis University, Budapest, Hungary
| | - Péter Enyedi
- Department of Physiology, Semmelweis University, Budapest, Hungary
| | - Miklós Tóth
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary.
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8
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Leach K, Hannan FM, Josephs TM, Keller AN, Møller TC, Ward DT, Kallay E, Mason RS, Thakker RV, Riccardi D, Conigrave AD, Bräuner-Osborne H. International Union of Basic and Clinical Pharmacology. CVIII. Calcium-Sensing Receptor Nomenclature, Pharmacology, and Function. Pharmacol Rev 2020; 72:558-604. [PMID: 32467152 PMCID: PMC7116503 DOI: 10.1124/pr.119.018531] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The calcium-sensing receptor (CaSR) is a class C G protein-coupled receptor that responds to multiple endogenous agonists and allosteric modulators, including divalent and trivalent cations, L-amino acids, γ-glutamyl peptides, polyamines, polycationic peptides, and protons. The CaSR plays a critical role in extracellular calcium (Ca2+ o) homeostasis, as demonstrated by the many naturally occurring mutations in the CaSR or its signaling partners that cause Ca2+ o homeostasis disorders. However, CaSR tissue expression in mammals is broad and includes tissues unrelated to Ca2+ o homeostasis, in which it, for example, regulates the secretion of digestive hormones, airway constriction, cardiovascular effects, cellular differentiation, and proliferation. Thus, although the CaSR is targeted clinically by the positive allosteric modulators (PAMs) cinacalcet, evocalcet, and etelcalcetide in hyperparathyroidism, it is also a putative therapeutic target in diabetes, asthma, cardiovascular disease, and cancer. The CaSR is somewhat unique in possessing multiple ligand binding sites, including at least five putative sites for the "orthosteric" agonist Ca2+ o, an allosteric site for endogenous L-amino acids, two further allosteric sites for small molecules and the peptide PAM, etelcalcetide, and additional sites for other cations and anions. The CaSR is promiscuous in its G protein-coupling preferences, and signals via Gq/11, Gi/o, potentially G12/13, and even Gs in some cell types. Not surprisingly, the CaSR is subject to biased agonism, in which distinct ligands preferentially stimulate a subset of the CaSR's possible signaling responses, to the exclusion of others. The CaSR thus serves as a model receptor to study natural bias and allostery. SIGNIFICANCE STATEMENT: The calcium-sensing receptor (CaSR) is a complex G protein-coupled receptor that possesses multiple orthosteric and allosteric binding sites, is subject to biased signaling via several different G proteins, and has numerous (patho)physiological roles. Understanding the complexities of CaSR structure, function, and biology will aid future drug discovery efforts seeking to target this receptor for a diversity of diseases. This review summarizes what is known to date regarding key structural, pharmacological, and physiological features of the CaSR.
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Affiliation(s)
- Katie Leach
- Drug Discovery Biology, Monash Institute of Pharmaceutical Science, Monash University, Parkville, Australia (K.L., T.M.J., A.N.K.); Nuffield Department of Women's & Reproductive Health (F.M.H.) and Academic Endocrine Unit, Radcliffe Department of Clinical Medicine (F.M.H., R.V.T.), University of Oxford, Oxford, United Kingdom; Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (T.C.M., H.B.-O.); Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom (D.T.W.); Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria (E.K.); Physiology, School of Medical Sciences and Bosch Institute (R.S.M.) and School of Life & Environmental Sciences, Charles Perkins Centre (A.D.C.), University of Sydney, Sydney, Australia; and School of Biosciences, Cardiff University, Cardiff, United Kingdom (D.R.)
| | - Fadil M Hannan
- Drug Discovery Biology, Monash Institute of Pharmaceutical Science, Monash University, Parkville, Australia (K.L., T.M.J., A.N.K.); Nuffield Department of Women's & Reproductive Health (F.M.H.) and Academic Endocrine Unit, Radcliffe Department of Clinical Medicine (F.M.H., R.V.T.), University of Oxford, Oxford, United Kingdom; Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (T.C.M., H.B.-O.); Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom (D.T.W.); Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria (E.K.); Physiology, School of Medical Sciences and Bosch Institute (R.S.M.) and School of Life & Environmental Sciences, Charles Perkins Centre (A.D.C.), University of Sydney, Sydney, Australia; and School of Biosciences, Cardiff University, Cardiff, United Kingdom (D.R.)
| | - Tracy M Josephs
- Drug Discovery Biology, Monash Institute of Pharmaceutical Science, Monash University, Parkville, Australia (K.L., T.M.J., A.N.K.); Nuffield Department of Women's & Reproductive Health (F.M.H.) and Academic Endocrine Unit, Radcliffe Department of Clinical Medicine (F.M.H., R.V.T.), University of Oxford, Oxford, United Kingdom; Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (T.C.M., H.B.-O.); Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom (D.T.W.); Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria (E.K.); Physiology, School of Medical Sciences and Bosch Institute (R.S.M.) and School of Life & Environmental Sciences, Charles Perkins Centre (A.D.C.), University of Sydney, Sydney, Australia; and School of Biosciences, Cardiff University, Cardiff, United Kingdom (D.R.)
| | - Andrew N Keller
- Drug Discovery Biology, Monash Institute of Pharmaceutical Science, Monash University, Parkville, Australia (K.L., T.M.J., A.N.K.); Nuffield Department of Women's & Reproductive Health (F.M.H.) and Academic Endocrine Unit, Radcliffe Department of Clinical Medicine (F.M.H., R.V.T.), University of Oxford, Oxford, United Kingdom; Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (T.C.M., H.B.-O.); Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom (D.T.W.); Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria (E.K.); Physiology, School of Medical Sciences and Bosch Institute (R.S.M.) and School of Life & Environmental Sciences, Charles Perkins Centre (A.D.C.), University of Sydney, Sydney, Australia; and School of Biosciences, Cardiff University, Cardiff, United Kingdom (D.R.)
| | - Thor C Møller
- Drug Discovery Biology, Monash Institute of Pharmaceutical Science, Monash University, Parkville, Australia (K.L., T.M.J., A.N.K.); Nuffield Department of Women's & Reproductive Health (F.M.H.) and Academic Endocrine Unit, Radcliffe Department of Clinical Medicine (F.M.H., R.V.T.), University of Oxford, Oxford, United Kingdom; Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (T.C.M., H.B.-O.); Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom (D.T.W.); Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria (E.K.); Physiology, School of Medical Sciences and Bosch Institute (R.S.M.) and School of Life & Environmental Sciences, Charles Perkins Centre (A.D.C.), University of Sydney, Sydney, Australia; and School of Biosciences, Cardiff University, Cardiff, United Kingdom (D.R.)
| | - Donald T Ward
- Drug Discovery Biology, Monash Institute of Pharmaceutical Science, Monash University, Parkville, Australia (K.L., T.M.J., A.N.K.); Nuffield Department of Women's & Reproductive Health (F.M.H.) and Academic Endocrine Unit, Radcliffe Department of Clinical Medicine (F.M.H., R.V.T.), University of Oxford, Oxford, United Kingdom; Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (T.C.M., H.B.-O.); Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom (D.T.W.); Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria (E.K.); Physiology, School of Medical Sciences and Bosch Institute (R.S.M.) and School of Life & Environmental Sciences, Charles Perkins Centre (A.D.C.), University of Sydney, Sydney, Australia; and School of Biosciences, Cardiff University, Cardiff, United Kingdom (D.R.)
| | - Enikö Kallay
- Drug Discovery Biology, Monash Institute of Pharmaceutical Science, Monash University, Parkville, Australia (K.L., T.M.J., A.N.K.); Nuffield Department of Women's & Reproductive Health (F.M.H.) and Academic Endocrine Unit, Radcliffe Department of Clinical Medicine (F.M.H., R.V.T.), University of Oxford, Oxford, United Kingdom; Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (T.C.M., H.B.-O.); Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom (D.T.W.); Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria (E.K.); Physiology, School of Medical Sciences and Bosch Institute (R.S.M.) and School of Life & Environmental Sciences, Charles Perkins Centre (A.D.C.), University of Sydney, Sydney, Australia; and School of Biosciences, Cardiff University, Cardiff, United Kingdom (D.R.)
| | - Rebecca S Mason
- Drug Discovery Biology, Monash Institute of Pharmaceutical Science, Monash University, Parkville, Australia (K.L., T.M.J., A.N.K.); Nuffield Department of Women's & Reproductive Health (F.M.H.) and Academic Endocrine Unit, Radcliffe Department of Clinical Medicine (F.M.H., R.V.T.), University of Oxford, Oxford, United Kingdom; Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (T.C.M., H.B.-O.); Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom (D.T.W.); Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria (E.K.); Physiology, School of Medical Sciences and Bosch Institute (R.S.M.) and School of Life & Environmental Sciences, Charles Perkins Centre (A.D.C.), University of Sydney, Sydney, Australia; and School of Biosciences, Cardiff University, Cardiff, United Kingdom (D.R.)
| | - Rajesh V Thakker
- Drug Discovery Biology, Monash Institute of Pharmaceutical Science, Monash University, Parkville, Australia (K.L., T.M.J., A.N.K.); Nuffield Department of Women's & Reproductive Health (F.M.H.) and Academic Endocrine Unit, Radcliffe Department of Clinical Medicine (F.M.H., R.V.T.), University of Oxford, Oxford, United Kingdom; Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (T.C.M., H.B.-O.); Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom (D.T.W.); Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria (E.K.); Physiology, School of Medical Sciences and Bosch Institute (R.S.M.) and School of Life & Environmental Sciences, Charles Perkins Centre (A.D.C.), University of Sydney, Sydney, Australia; and School of Biosciences, Cardiff University, Cardiff, United Kingdom (D.R.)
| | - Daniela Riccardi
- Drug Discovery Biology, Monash Institute of Pharmaceutical Science, Monash University, Parkville, Australia (K.L., T.M.J., A.N.K.); Nuffield Department of Women's & Reproductive Health (F.M.H.) and Academic Endocrine Unit, Radcliffe Department of Clinical Medicine (F.M.H., R.V.T.), University of Oxford, Oxford, United Kingdom; Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (T.C.M., H.B.-O.); Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom (D.T.W.); Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria (E.K.); Physiology, School of Medical Sciences and Bosch Institute (R.S.M.) and School of Life & Environmental Sciences, Charles Perkins Centre (A.D.C.), University of Sydney, Sydney, Australia; and School of Biosciences, Cardiff University, Cardiff, United Kingdom (D.R.)
| | - Arthur D Conigrave
- Drug Discovery Biology, Monash Institute of Pharmaceutical Science, Monash University, Parkville, Australia (K.L., T.M.J., A.N.K.); Nuffield Department of Women's & Reproductive Health (F.M.H.) and Academic Endocrine Unit, Radcliffe Department of Clinical Medicine (F.M.H., R.V.T.), University of Oxford, Oxford, United Kingdom; Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (T.C.M., H.B.-O.); Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom (D.T.W.); Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria (E.K.); Physiology, School of Medical Sciences and Bosch Institute (R.S.M.) and School of Life & Environmental Sciences, Charles Perkins Centre (A.D.C.), University of Sydney, Sydney, Australia; and School of Biosciences, Cardiff University, Cardiff, United Kingdom (D.R.)
| | - Hans Bräuner-Osborne
- Drug Discovery Biology, Monash Institute of Pharmaceutical Science, Monash University, Parkville, Australia (K.L., T.M.J., A.N.K.); Nuffield Department of Women's & Reproductive Health (F.M.H.) and Academic Endocrine Unit, Radcliffe Department of Clinical Medicine (F.M.H., R.V.T.), University of Oxford, Oxford, United Kingdom; Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (T.C.M., H.B.-O.); Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom (D.T.W.); Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria (E.K.); Physiology, School of Medical Sciences and Bosch Institute (R.S.M.) and School of Life & Environmental Sciences, Charles Perkins Centre (A.D.C.), University of Sydney, Sydney, Australia; and School of Biosciences, Cardiff University, Cardiff, United Kingdom (D.R.)
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VanSickle JS, Srivastava T, Alon US. Use of calcimimetics in children with normal kidney function. Pediatr Nephrol 2019; 34:413-422. [PMID: 29552709 DOI: 10.1007/s00467-018-3935-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 11/26/2022]
Abstract
The calcium-sensing receptor (CaSR) plays an important role in the homeostasis of serum ionized calcium by regulating parathyroid hormone (PTH) secretion and tubular calcium handling. Calcimimetics, which act by allosteric modulation of the CaSR, mimic hypercalcemia resulting in suppression of PTH release and increase in calciuria. Mostly used in children to treat secondary hyperparathyroidism associated with advanced renal failure, we have shown that calcimimetics can also be successfully used in children with bone and mineral disorders in which elevated PTH plays a detrimental role in skeletal pathophysiology in the face of normal kidney function. The current review briefly discusses the role of the CaSR and calcimimetics in calcium homeostasis, and then addresses the potential applications of calcimimetics in children with normal kidney function with disorders in which suppression of PTH is beneficial.
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Affiliation(s)
- Judith Sebestyen VanSickle
- Bone and Mineral Disorders Clinic, Division of Nephrology, Children's Mercy Hospital, University of Missouri at Kansas City, 2401Gillham Road, Kansas City, MO, 64108, USA
| | - Tarak Srivastava
- Bone and Mineral Disorders Clinic, Division of Nephrology, Children's Mercy Hospital, University of Missouri at Kansas City, 2401Gillham Road, Kansas City, MO, 64108, USA
- Renal Research Laboratory, Research and Development, Kansas City VA Medical Center, Kansas City, MO, 64128, USA
| | - Uri S Alon
- Bone and Mineral Disorders Clinic, Division of Nephrology, Children's Mercy Hospital, University of Missouri at Kansas City, 2401Gillham Road, Kansas City, MO, 64108, USA.
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10
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Arenas Morales AJ, DeFreitas MJ, Katsoufis CP, Seeherunvong W, Chandar J, Zilleruelo G, Freundlich M, Abitbol CL. Cinacalcet as rescue therapy for refractory hyperparathyroidism in young children with advanced chronic kidney disease. Pediatr Nephrol 2019; 34:129-135. [PMID: 30203374 DOI: 10.1007/s00467-018-4055-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 08/10/2018] [Accepted: 08/13/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Studies in the use of the calcimimetic, cinacalcet, in pediatric chronic kidney disease (CKD) are few and limited to older children with secondary hyperparathyroidism (sHPT), a major morbid complication contributing to poor growth, bone deformities, and cardiovascular disease. Our objectives were to determine a safe and effective dosing regimen of cinacalcet in the treatment of infants and young children with sHPT that was refractory to standard care and to examine their growth during treatment. METHODS Ten young pediatric patients with advanced CKD were studied retrospectively during 11 courses of treatment with cinacalcet. All had severe sHPT with intact parathyroid hormone (iPTH) levels ≥ 500 pg/ml and were refractory to standard therapy with phosphate binders and active vitamin D analogs at high doses for > 30 days. The cinacalcet dose was advanced by 50% every 2-4 weeks to achieve a decline in the iPTH to a goal of 150-300 pg/ml. Linear growth was assessed at 6-month intervals by change in z-scores (△SDS) for length before and during cinacalcet therapy. RESULTS Median age at initiation of cinacalcet was 18 months (IQR 6, 36) with an average starting dose of 0.7 ± 0.2 mg/kg/day. Median effective dose required to reach iPTH goal of 150-300 pg/ml was 2.8 mg/kg/day (IQR 2.0, 3.1), and time to goal was 112 days (IQR 56, 259) with a median overall decline in iPTH of 82% from baseline by 6 months (p < 0.0001). No subject experienced a clinical adverse event, although 4 had biochemical asymptomatic hypocalcemia. Linear growth improved significantly during cinacalcet therapy (△SDS - 0.62 ± 1.2 versus + 0.91 ± 1.4; p < 0.005). By multiple regression analysis, the primary determinants of growth were concurrent treatment with growth hormone and age < 2 years (R2 = 89.6%; p < 0.001). A shorter treatment time required to achieve iPTH goals also was associated with improved growth (r = - 0.75; p < 0.01). CONCLUSIONS Cinacalcet may be used effectively and safely in infants and small children with refractory sHPT in advanced CKD using a cautious dosing regimen. Cinacalcet successfully brings iPTH to target level and supports growth when other treatments have been ineffective.
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Affiliation(s)
- Aura J Arenas Morales
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960, Miami, FL, 33130, USA
| | - Marissa J DeFreitas
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960, Miami, FL, 33130, USA
| | - Chryso P Katsoufis
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960, Miami, FL, 33130, USA
| | - Wacharee Seeherunvong
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960, Miami, FL, 33130, USA
| | - Jayanthi Chandar
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960, Miami, FL, 33130, USA
| | - Gaston Zilleruelo
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960, Miami, FL, 33130, USA
| | - Michael Freundlich
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960, Miami, FL, 33130, USA
| | - Carolyn L Abitbol
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960, Miami, FL, 33130, USA.
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11
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Hannan FM, Olesen MK, Thakker RV. Calcimimetic and calcilytic therapies for inherited disorders of the calcium-sensing receptor signalling pathway. Br J Pharmacol 2018; 175:4083-4094. [PMID: 29127708 PMCID: PMC6177618 DOI: 10.1111/bph.14086] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/24/2017] [Accepted: 10/30/2017] [Indexed: 12/15/2022] Open
Abstract
The calcium-sensing receptor (CaS receptor) plays a pivotal role in extracellular calcium homeostasis, and germline loss-of-function and gain-of-function mutations cause familial hypocalciuric hypercalcaemia (FHH) and autosomal dominant hypocalcaemia (ADH), respectively. CaS receptor signal transduction in the parathyroid glands is probably regulated by G-protein subunit α11 (Gα11 ) and adaptor-related protein complex-2 σ-subunit (AP2σ), and recent studies have identified germline mutations of these proteins as a cause of FHH and/or ADH. Calcimimetics and calcilytics are positive and negative allosteric modulators of the CaS receptor that have potential efficacy for symptomatic forms of FHH and ADH. Cellular studies have demonstrated that these compounds correct signalling and/or trafficking defects caused by mutant CaS receptor, Gα11 or AP2σ proteins. Moreover, mouse model studies indicate that calcilytics can rectify the hypocalcaemia and hypercalciuria associated with ADH, and patient-based studies reveal calcimimetics to ameliorate symptomatic hypercalcaemia caused by FHH. Thus, calcimimetics and calcilytics represent targeted therapies for inherited disorders of the CaS receptor signalling pathway. LINKED ARTICLES This article is part of a themed section on Molecular Pharmacology of GPCRs. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v175.21/issuetoc.
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Affiliation(s)
- Fadil M Hannan
- Department of Musculoskeletal Biology, Institute of Ageing and Chronic DiseaseUniversity of LiverpoolLiverpoolUK
- Academic Endocrine Unit, Radcliffe Department of MedicineUniversity of OxfordOxfordUK
| | - Mie K Olesen
- Department of Musculoskeletal Biology, Institute of Ageing and Chronic DiseaseUniversity of LiverpoolLiverpoolUK
- Academic Endocrine Unit, Radcliffe Department of MedicineUniversity of OxfordOxfordUK
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of MedicineUniversity of OxfordOxfordUK
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12
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Auron A, Alon US. Hypercalcemia: a consultant's approach. Pediatr Nephrol 2018; 33:1475-1488. [PMID: 28879535 DOI: 10.1007/s00467-017-3788-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 07/24/2017] [Accepted: 08/11/2017] [Indexed: 12/11/2022]
Abstract
Due to their daily involvement in mineral metabolism, nephrologists are often asked to consult on children with hypercalcemia. This might become even more pertinent when the hypercalcemia is associated with acute kidney injury and/or hypercalciuria and renal calcifications. The best way to assess the severity of hypercalcemia is by measurement of plasma ionized calcium, and if not available by adjusting serum total calcium to albumin concentration. The differential diagnosis of the possible etiologies of the disturbance in the mineral homeostasis starts with the assessment of serum parathyroid hormone concentration, followed by that of vitamin D metabolites in search of both genetic and acquired etiologies. Several tools are available to acutely treat hypercalcemia with the current main components being fluids, loop diuretics, and antiresorptive agents. This review will address the pathophysiologic mechanisms, clinical manifestations, and treatment modalities involved in hypercalcemia.
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Affiliation(s)
- Ari Auron
- Bone and Mineral Disorders Clinic, Division of Pediatric Nephrology, Children's Mercy Hospital, University of Missouri at Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Uri S Alon
- Bone and Mineral Disorders Clinic, Division of Pediatric Nephrology, Children's Mercy Hospital, University of Missouri at Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, 64108, USA.
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13
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Nicolescu RC, Lombet J, Cavalier E. Vitamin D-Resistant Rickets and Cinacalcet-One More Favorable Experience. Front Pediatr 2018; 6:376. [PMID: 30555810 PMCID: PMC6282023 DOI: 10.3389/fped.2018.00376] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/15/2018] [Indexed: 11/29/2022] Open
Abstract
Hereditary vitamin D-resistant rickets (HVDRR) is an autosomal recessive disorder characterized by early onset of severe rickets, with a complete triad of clinical, biochemical and skeletal abnormalities. Homozygous or heterozygous mutations in the vitamin D receptor (VDR) gene leading to complete or partial target organ resistance to the action of 1α, 25-dihydroxyvitamin D3 (the active form of vitamin D) are responsible for HVDRR. Theoretically the therapeutic goal is to overcome this tissue resistance, and to normalize calcium and phosphate homeostasis. Practically, the treatment could be oriented to correct the secondary hyperparathyroidism to avoid long-term negative impact on bone health. The conventional therapeutic strategy (high-dose calcium plus active vitamin D metabolites) gives variable responses in magnitude and duration. We report a case of HVDRR with heterozygous mutation in the VDR gene, neonatal alopecia, and a severe clinical phenotype diagnosed at the age of 30 months who showed unsatisfactory response to traditional therapy. The short-term responsiveness to cinacalcet was encouraging, with adequate correction of phosphate-calcium homeostasis and significant improvement of clinical and radiological status at 6 months of treatment.
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Affiliation(s)
- Ramona C Nicolescu
- Division of Endocrinology and Diabetes, Department of Pediatrics, Centre Hospitalier Regional Citadelle, University of Liège, Liège, Belgium
| | - Jacques Lombet
- Division of Nephrology, Department of Pediatrics, University Hospital Center of Liège, Liège, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, University Hospital Center of Liège, University of Liège, Liège, Belgium
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14
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Srivastava T, Jafri S, Truog WE, Sebestyen VanSickle J, Manimtim WM, Alon US. Successful Reversal of Furosemide-Induced Secondary Hyperparathyroidism With Cinacalcet. Pediatrics 2017; 140:peds.2016-3789. [PMID: 29192005 DOI: 10.1542/peds.2016-3789] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2017] [Indexed: 11/24/2022] Open
Abstract
Secondary hyperparathyroidism (SHPT) is a rare complication of furosemide therapy that can occur in patients treated with the loop diuretic for a long period of time. We report a 6-month-old 28-weeks premature infant treated chronically with furosemide for his bronchopulmonary dysplasia, who developed hypocalcemia and severe SHPT, adversely affecting his bones. Discontinuation of the loop diuretic and the addition of supplemental calcium and calcitriol only partially reversed the SHPT, bringing serum parathyroid hormone level down from 553 to 238 pg/mL. After introduction of the calcimimetic Cinacalcet, we observed a sustained normalization of parathyroid hormone concentration at 27 to 63 pg/mL and, with that correction, of all biochemical abnormalities and healing of the bone disease. No adverse effects were noted. We conclude that in cases of SHPT due to furosemide in which traditional treatment fails, there may be room to consider the addition of a calcimimetic agent.
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Affiliation(s)
| | - Shahryar Jafri
- Sections of Nephrology, Bone and Mineral Disorder Clinic, and
| | - William E Truog
- Neonatology, The Children's Mercy Hospitals and Clinics, University of Missouri at Kansas City, Kansas City, Missouri
| | | | - Winston M Manimtim
- Neonatology, The Children's Mercy Hospitals and Clinics, University of Missouri at Kansas City, Kansas City, Missouri
| | - Uri S Alon
- Sections of Nephrology, Bone and Mineral Disorder Clinic, and
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15
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Sethi BK, Nagesh VS, Kelwade J, Parekh H, Dukle V. Utility of Cinacalcet in Familial Hypocalciuric Hypercalcemia. Indian J Endocrinol Metab 2017; 21:362-363. [PMID: 28459040 PMCID: PMC5367245 DOI: 10.4103/2230-8210.202034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Bipin Kumar Sethi
- Department of Endocrinology, CARE Hospital, Banjara Hills, Hyderabad, Telangana, India
| | - V. Sri Nagesh
- Department of Endocrinology, CARE Hospital, Banjara Hills, Hyderabad, Telangana, India
| | - Jayant Kelwade
- Department of Endocrinology, CARE Hospital, Banjara Hills, Hyderabad, Telangana, India
| | - Harsh Parekh
- Department of Endocrinology, CARE Hospital, Banjara Hills, Hyderabad, Telangana, India
| | - Vaibhav Dukle
- Department of Endocrinology, CARE Hospital, Banjara Hills, Hyderabad, Telangana, India
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16
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Mayr B, Schnabel D, Dörr HG, Schöfl C. GENETICS IN ENDOCRINOLOGY: Gain and loss of function mutations of the calcium-sensing receptor and associated proteins: current treatment concepts. Eur J Endocrinol 2016; 174:R189-208. [PMID: 26646938 DOI: 10.1530/eje-15-1028] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 12/08/2015] [Indexed: 12/26/2022]
Abstract
The calcium-sensing receptor (CASR) is the main calcium sensor in the maintenance of calcium metabolism. Mutations of the CASR, the G protein alpha 11 (GNA11) and the adaptor-related protein complex 2 sigma 1 subunit (AP2S1) genes can shift the set point for calcium sensing causing hyper- or hypo-calcemic disorders. Therapeutic concepts for these rare diseases range from general therapies of hyper- and hypo-calcemic conditions to more pathophysiology oriented approaches such as parathyroid hormone (PTH) substitution and allosteric CASR modulators. Cinacalcet is a calcimimetic that enhances receptor function and has gained approval for the treatment of hyperparathyroidism. Calcilytics in turn attenuate CASR activity and are currently under investigation for the treatment of various diseases. We conducted a literature search for reports about treatment of patients harboring inactivating or activating CASR, GNA11 or AP2S1 mutants and about in vitro effects of allosteric CASR modulators on mutated CASR. The therapeutic concepts for patients with familial hypocalciuric hypercalcemia (FHH), neonatal hyperparathyroidism (NHPT), neonatal severe hyperparathyroidism (NSHPT) and autosomal dominant hypocalcemia (ADH) are reviewed. FHH is usually benign, but symptomatic patients benefit from cinacalcet. In NSHPT patients pamidronate effectively lowers serum calcium, but most patients require parathyroidectomy. In some patients cinacalcet can obviate the need for surgery, particularly in heterozygous NHPT. Symptomatic ADH patients respond to vitamin D and calcium supplementation but this may increase calciuria and renal complications. PTH treatment can reduce relative hypercalciuria. None of the currently available therapies for ADH, however, prevent tissue calcifications and complications, which may become possible with calcilytics that correct the underlying pathophysiologic defect.
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Affiliation(s)
- Bernhard Mayr
- Division of Endocrinology and DiabetesDepartment of Medicine I, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, GermanyCenter for Chronic Sick ChildrenPediatric Endocrinology and Diabetes, Charité University Medicine Berlin, Berlin, GermanyDivision of Paediatric Endocrinology and DiabetesDepartment of Paediatrics, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Dirk Schnabel
- Division of Endocrinology and DiabetesDepartment of Medicine I, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, GermanyCenter for Chronic Sick ChildrenPediatric Endocrinology and Diabetes, Charité University Medicine Berlin, Berlin, GermanyDivision of Paediatric Endocrinology and DiabetesDepartment of Paediatrics, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Helmuth-Günther Dörr
- Division of Endocrinology and DiabetesDepartment of Medicine I, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, GermanyCenter for Chronic Sick ChildrenPediatric Endocrinology and Diabetes, Charité University Medicine Berlin, Berlin, GermanyDivision of Paediatric Endocrinology and DiabetesDepartment of Paediatrics, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Christof Schöfl
- Division of Endocrinology and DiabetesDepartment of Medicine I, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, GermanyCenter for Chronic Sick ChildrenPediatric Endocrinology and Diabetes, Charité University Medicine Berlin, Berlin, GermanyDivision of Paediatric Endocrinology and DiabetesDepartment of Paediatrics, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
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17
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Srivastava T, Krudys J, Mardis NJ, Sebestyen-VanSickle J, Alon US. Cinacalcet as adjunctive therapy in pseudohypoparathyroidism type 1b. Pediatr Nephrol 2016; 31:795-800. [PMID: 26628282 DOI: 10.1007/s00467-015-3271-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Revised: 11/01/2015] [Accepted: 11/03/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND In patients with pseudohypoparathyroidism type 1b (PHP1b) due to a tissue-specific imprinting defect in the G-protein α-subunit, skeletal disorders can arise from the bones being sensitive to parathyroid hormone (PTH) while the kidneys remain resistant to this hormone. CASE-DIAGNOSIS/TREATMENT We report a 4.8-year-old girl with PHP1b who presented with an abnormal gait, severe skeletal changes and elevated levels of serum PTH (2844 pg/ml), phosphate (7.2 mg/dl) and bone turnover markers. Traditional treatment with calcium and calcitriol failed to suppress PTH secretion, which was still elevated at 2877 pg/ml after 14 months of therapy, nor did it correct the other clinical, biochemical and radiographic abnormalities. The addition of cinacalcet to the treatment regimen over the subsequent 32 months resulted in normalization of serum PTH (58 ng/ml), phosphate (4.9 mg/dl) and bone turnover markers, and resolution of the radiographic changes, with no adverse effects noted. CONCLUSIONS Due to its ease of administration, we recommend the addition of cinacalcet into the armamentarium of medications available to treat children with PHP1b.
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Affiliation(s)
- Tarak Srivastava
- Bone and Mineral Disorder Clinic, Section of Nephrology, The Children's Mercy Hospitals and Clinics, University of Missouri at Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
- Renal Research Laboratory, Research and Development, Kansas City VA Medical Center, Kansas City, MO, 64128, USA
| | - Jeffrey Krudys
- Bone and Mineral Disorder Clinic, Section of Nephrology, The Children's Mercy Hospitals and Clinics, University of Missouri at Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Neil J Mardis
- Department of Radiology, The Children's Mercy Hospitals and Clinics, University of Missouri at Kansas City, Kansas City, MO, 64108, USA
| | - Judith Sebestyen-VanSickle
- Bone and Mineral Disorder Clinic, Section of Nephrology, The Children's Mercy Hospitals and Clinics, University of Missouri at Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Uri S Alon
- Bone and Mineral Disorder Clinic, Section of Nephrology, The Children's Mercy Hospitals and Clinics, University of Missouri at Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA.
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18
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Abstract
The extracellular calcium-sensing receptor, CaSR, is a member of the G protein-coupled receptor superfamily and has a critical role in modulating Ca(2+) homeostasis via its role in the parathyroid glands and kidneys. New evidence suggests that CaSR expression in cartilage and bone also directly regulates skeletal homeostasis. This Review discusses the role of CaSR in chondrocytes, through which CaSR contributes to the development of the cartilaginous growth plate, as well as in osteoblasts and osteoclasts, through which CaSR has effects on skeletal development and bone turnover in young and mature animals. The interaction of skeletal CaSR activation with parathyroid hormone (PTH), which is secreted by the parathyroid gland, can lead to net bone formation in trabecular bone or net bone resorption in cortical bone. Allosteric modulators of CaSR are beneficial in some clinical conditions, with effects that are mediated by the ability of these agents to alter levels of PTH and improve Ca(2+) homeostasis. However, further insights into the action of CaSR in bone cells might lead to CaSR-based drugs that maximize not only the effects of the receptor on the parathyroid glands and kidneys but also on bone.
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Affiliation(s)
- David Goltzman
- Department of Medicine, McGill University, 687 Pine Avenue West, Montreal, QC H3A 1A1, Canada
| | - Geoffrey N Hendy
- Department of Medicine, McGill University, 687 Pine Avenue West, Montreal, QC H3A 1A1, Canada
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19
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Rodríguez M, Goodman WG, Liakopoulos V, Messa P, Wiecek A, Cunningham J. The Use of Calcimimetics for the Treatment of Secondary Hyperparathyroidism: A 10 Year Evidence Review. Semin Dial 2015; 28:497-507. [DOI: 10.1111/sdi.12357] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Mariano Rodríguez
- Servicio de Nefrologia; IMIBIC; Hospital Universitario Reina Sofia; Córdoba Spain
| | | | - Vassilios Liakopoulos
- Division of Nephrology and Hypertension; 1st Department of Internal Medicine; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Piergiorgio Messa
- Division of Nephrology and Dialysis; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Università di Milano; Milan Italy
| | - Andrzej Wiecek
- Department of Nephrology, Endocrinology and Metabolic Diseases; Medical University of Silesia; Katowice Poland
| | - John Cunningham
- Centre for Nephrology; UCL Medical School; Royal Free Campus; London United Kingdom
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20
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Sarav M, Sprague SM. Cinacalcet hydrochloride for the treatment of hyperparathyroidism. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.940311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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21
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Atay Z, Bereket A, Haliloglu B, Abali S, Ozdogan T, Altuncu E, Canaff L, Vilaça T, Wong BYL, Cole DEC, Hendy GN, Turan S. Novel homozygous inactivating mutation of the calcium-sensing receptor gene (CASR) in neonatal severe hyperparathyroidism-lack of effect of cinacalcet. Bone 2014; 64:102-7. [PMID: 24735972 DOI: 10.1016/j.bone.2014.04.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 03/21/2014] [Accepted: 04/07/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND NSHPT is a life-threatening disorder caused by homozygous inactivating calcium-sensing receptor (CASR) mutations. In some cases, the CaSR allosteric activator, cinacalcet, may reduce serum PTH and calcium levels, but surgery is the treatment of choice. OBJECTIVE To describe a case of NSHPT unresponsive to cinacalcet. PATIENT AND RESULTS A 23-day-old girl was admitted with hypercalcemia, hypotonia, bell-shaped chest and respiratory distress. The parents were first-degree cousins once removed. Serum Ca was 4.75 mmol/l (N: 2.10-2.62), P: 0.83 mmol/l (1.55-2.64), PTH: 1096 pg/ml (9-52) and urinary Ca/Cr ratio: 0.5mg/mg. First, calcitonin was given (10 IU/kg × 4/day), and then 2 days later, pamidronate (0.5mg/kg) for 2 days. Doses of cinacalcet were given daily from day 28 of life starting at 30 mg/m2 and increasing to 90 mg/m2 on day 43. On day 33, 6 days after pamidronate, serum Ca levels had fallen to 2.5 mmol/l but, thereafter, rose to 5 mmol/l despite the cinacalcet. Total parathyroidectomy was performed at day 45. Hungry bone disease after surgery required daily Ca replacement and calcitriol for 18 days. At 3 months, the girl was mildly hypercalcemic, with no supplementation, and at 6 months, she developed hypocalcemia and has since been maintained on Ca and calcitriol. By CASR mutation analysis, the infant was homozygous and both parents heterozygous for a deletion-frameshift mutation. CONCLUSION The predicted nonfunctional CaSR is consistent with lack of response to cinacalcet, but total parathyroidectomy was successful. An empiric trial of the drug and/or prompt mutation testing should help minimize the period of unnecessary pharmacotherapy.
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Affiliation(s)
- Zeynep Atay
- Department of Pediatric Endocrinology, Marmara University, Pendik, Istanbul 34899, Turkey.
| | - Abdullah Bereket
- Department of Pediatric Endocrinology, Marmara University, Pendik, Istanbul 34899, Turkey
| | - Belma Haliloglu
- Department of Pediatric Endocrinology, Marmara University, Pendik, Istanbul 34899, Turkey
| | - Saygin Abali
- Department of Pediatric Endocrinology, Marmara University, Pendik, Istanbul 34899, Turkey
| | - Tutku Ozdogan
- Department of Neonatology, Marmara University, Pendik, Istanbul 34899, Turkey
| | - Emel Altuncu
- Department of Neonatology, Marmara University, Pendik, Istanbul 34899, Turkey
| | - Lucie Canaff
- Department of Medicine, Physiology and Human Genetics, McGill University, Montreal, Quebec H3A 0G4, Canada; Calcium Research Laboratory and Hormones and Cancer Research Unit, Royal Victoria Hospital, Montreal, Quebec H3A 1A1, Canada
| | - Tatiane Vilaça
- Department of Medicine, Physiology and Human Genetics, McGill University, Montreal, Quebec H3A 0G4, Canada; Department of Medicine, Physiology and Human Genetics, McGill University, Montreal, Quebec H3A 0G4, Canada
| | - Betty Y L Wong
- Departments of Laboratory Medicine and Pathobiology, Medicine, and Genetics, University of Toronto, Toronto, Ontario M5G IL5, Canada
| | - David E C Cole
- Departments of Laboratory Medicine and Pathobiology, Medicine, and Genetics, University of Toronto, Toronto, Ontario M5G IL5, Canada
| | - Geoffrey N Hendy
- Department of Medicine, Physiology and Human Genetics, McGill University, Montreal, Quebec H3A 0G4, Canada; Calcium Research Laboratory and Hormones and Cancer Research Unit, Royal Victoria Hospital, Montreal, Quebec H3A 1A1, Canada
| | - Serap Turan
- Department of Pediatric Endocrinology, Marmara University, Pendik, Istanbul 34899, Turkey
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22
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Nakamura A, Hotsubo T, Kobayashi K, Mochizuki H, Ishizu K, Tajima T. Loss-of-function and gain-of-function mutations of calcium-sensing receptor: functional analysis and the effect of allosteric modulators NPS R-568 and NPS 2143. J Clin Endocrinol Metab 2013; 98:E1692-701. [PMID: 23966241 DOI: 10.1210/jc.2013-1974] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Activating mutations in the calcium-sensing receptor (CASR) gene cause autosomal dominant hypoparathyroidism, and heterozygous inactivating CASR mutations cause familial hypocalciuric hypercalcemia. Recently, there has been a focus on the use of allosteric modulators to restore the functional activity of mutant CASRs. In this study, the effect of allosteric modulators NPS R-568 and NPS 2143 on CASR mutants was studied in vitro. METHODS DNA sequence analysis of the CASR gene was undertaken in autosomal dominant hypoparathyroidism and familial hypocalciuric hypercalcemia Japanese patients, and the functional consequences for the Gi-MAPK pathway and cell surface expression of CASR were determined. Furthermore, we studied the effect of NPS R-568 and NPS 2143 on the signal transduction activity and cell surface expression of each mutant CASR. RESULTS We identified 3 activating mutations (S122C, P569H, and I839T) and 2 inactivating mutations (A110T and R172G) in patients. The activating and inactivating mutations caused leftward and rightward shifts, respectively, in the dose-response curves of the signaling pathway. NPS R-568 rescued the signal transduction capacity of 2 inactivating mutants without increasing cell surface expression levels. NPS 2143 suppressed the enhanced activity of the activating mutants without altering cell surface expression levels, although A843E, which is a constitutively active mutant, was suppressed to a lesser degree. CONCLUSIONS We have identified 4 novel mutations of CASR. Moreover, our results indicate that allosteric modulators can restore the activity of the loss- and gain-of-function mutant CASRs, identified in this study.
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Affiliation(s)
- Akie Nakamura
- Department of Pediatrics, Hokkaido University School of Medicine, Sapporo 060-8635, Japan.
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23
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Nemeth EF, Shoback D. Calcimimetic and calcilytic drugs for treating bone and mineral-related disorders. Best Pract Res Clin Endocrinol Metab 2013; 27:373-84. [PMID: 23856266 DOI: 10.1016/j.beem.2013.02.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The calcium-sensing receptor (CaSR) plays a pivotal role in regulating systemic Ca(2+) homeostasis and is a target for drugs designed to treat certain disorders of bone and mineral metabolism. Calcimimetics are agonists or positive allosteric modulators of the CaSR; they inhibit parathyroid hormone (PTH) secretion and stimulate renal Ca(2+) excretion. The first calcimimetic drug is cinacalcet, a positive allosteric modulator of the CaSR that is approved for treating secondary hyperparathyroidism (HPT) in patients on renal replacement therapy and for some forms of primary HPT characterized by clinically significant hypercalcemia. Cinacalcet is also being investigated as a therapy for other hypercalcemic conditions and certain hypophosphatemic disorders. Calcilytics are CaSR inhibitors that stimulate the secretion of PTH and decrease renal excretion of Ca(2+). Although calcilytics have failed thus far as anabolic therapies for osteoporosis, they are currently being evaluated as novel therapies for new indications involving hypocalcemia and/or hypercalciuria.
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Affiliation(s)
- Edward F Nemeth
- MetisMedica, 13 Poplar Plains Road, Toronto, ON M4V 2M7, Canada.
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24
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Srivastava T, Alon US. Cinacalcet as adjunctive therapy for hereditary 1,25-dihydroxyvitamin D-resistant rickets. J Bone Miner Res 2013; 28:992-6. [PMID: 23212715 DOI: 10.1002/jbmr.1838] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 11/05/2012] [Accepted: 11/26/2012] [Indexed: 01/01/2023]
Abstract
Secondary hyperparathyroidism from inadequate calcium absorption in the gut, is the underlying pathophysiology for rachitic changes in hereditary vitamin D-resistant rickets (HVDRR). We describe a novel use of Cinacalcet to treat a child with HVDRR in whom conventional modes of therapy had to be discontinued. Cinacalcet therapy with high-dose oral calcium effectively normalized the metabolic abnormalities and bone condition. The relative ease of administration of the calcimimetic as a once- or twice-daily oral preparation, compared with traditional intravenous calcium administration, should encourage its move to the frontline of treatment of the disorder.
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Affiliation(s)
- Tarak Srivastava
- Section of Nephrology, Bone and Mineral Disorder Clinic, Children's Mercy Hospitals and Clinics, University of Missouri at Kansas City, Kansas City, MO 64108, USA
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25
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García Soblechero E, Ferrer Castillo MT, Jiménez Crespo B, Domínguez Quintero ML, González Fuentes C. Neonatal hypercalcemia due to a homozygous mutation in the calcium-sensing receptor: failure of cinacalcet. Neonatology 2013; 104:104-8. [PMID: 23817301 DOI: 10.1159/000350540] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 03/01/2013] [Indexed: 11/19/2022]
Abstract
A neonate affected by a novel inactivating mutation in the calcium-sensing receptor (CASR) gene is presented. This mutation is homozygously inherited and has not been previously described. A deletion in exon 5 (c.1392_1404del13) of the gene causes a loss of function of the receptor, which results in neonatal severe hyperparathyroidism and an ensuing extreme hypercalcemia. In a case of homozygosis of the CASR gene, the use of cinacalcet is the second reported calcimimetic treatment attempt and the first treatment attempt prior to surgery. However, because of the type of mutation, parathyroid surgery was necessary at 4 months of age after therapeutic failure. Because there are multiple mutations that affect the CASR gene in different ways, treatment with cinacalcet as an alternative to surgery may be valuable in homozygous cases that are caused by different mutations than the reported case.
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26
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Tundidor Rengel D, Torres Grajales JL, Oriola J, Ferrer J, Webb SM. Cinacalcet for management of hypercalcemia secondary to calcium-sensing receptor mutation. ENDOCRINOLOGIA Y NUTRICION : ORGANO DE LA SOCIEDAD ESPANOLA DE ENDOCRINOLOGIA Y NUTRICION 2013; 60:40-41. [PMID: 22464540 DOI: 10.1016/j.endonu.2012.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 01/06/2012] [Accepted: 01/09/2012] [Indexed: 05/31/2023]
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27
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Breitwieser GE. Minireview: the intimate link between calcium sensing receptor trafficking and signaling: implications for disorders of calcium homeostasis. Mol Endocrinol 2012; 26:1482-95. [PMID: 22745192 DOI: 10.1210/me.2011-1370] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The calcium-sensing receptor (CaSR) regulates organismal Ca(2+) homeostasis. Dysregulation of CaSR expression or mutations in the CASR gene cause disorders of Ca(2+) homeostasis and contribute to the progression or severity of cancers and cardiovascular disease. This brief review highlights recent findings that define the CaSR life cycle, which controls the cellular abundance of CaSR and CaSR signaling. A novel mechanism, termed agonist-driven insertional signaling (ADIS), contributes to the unique hallmarks of CaSR signaling, including the high degree of cooperativity and the lack of functional desensitization. Agonist-mediated activation of plasma membrane-localized CaSR increases the rate of insertion of CaSR at the plasma membrane without altering the constitutive endocytosis rate, thereby acutely increasing the maximum signaling response. Prolonged CaSR signaling requires a large intracellular ADIS-mobilizable pool of CaSR, which is maintained by signaling-mediated increases in biosynthesis. This model provides a rational framework for characterizing the defects caused by CaSR mutations and the altered functional expression of wild-type CaSR in disease states. Mechanistic dissection of ADIS of CaSR should lead to optimized pharmacological approaches to normalize CaSR signaling in disorders of Ca(2+) homeostasis.
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Affiliation(s)
- Gerda E Breitwieser
- Weis Center for Research, Geisinger Clinic, Danville, Pennsylvania 17822-2604, USA.
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28
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Wilhelm-Bals A, Parvex P, Magdelaine C, Girardin E. Successful use of bisphosphonate and calcimimetic in neonatal severe primary hyperparathyroidism. Pediatrics 2012; 129:e812-6. [PMID: 22331334 DOI: 10.1542/peds.2011-0128] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Neonatal primary hyperparathyroidism (NPHT) is associated with an inactivating homozygous mutation of the calcium sensing receptor (CaSR). The CaSR is expressed most abundantly in the parathyroid glands and the kidney and regulates calcium homeostasis through its ability to modulate parathormone secretion and renal calcium reabsorption. NPHT leads to life threatening hypercalcemia, nephrocalcinosis, bone demineralization, and neurologic disabilities. Surgery is the treatment of choice. While waiting for surgery, bisphosphonates offer a good alternative to deal with hypercalcemia. Cinacalcet is a class II calcimimetic that increases CaSR affinity for calcium, leading to parathormone suppression and increased calcium renal excretion. At present, there is little evidence as to whether cinacalcet could improve the function of mutant CaSR in NPHT. We report a case of NPHT, treated successfully with bisphosphonates and cinacalcet after surgery failure. To our knowledge, it is the first time cinacalcet has been used for NPHT.
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Affiliation(s)
- Alexandra Wilhelm-Bals
- Division of Pediatric Nephrology, Department of Pediatrics, Children Hospital, Geneva, Switzerland.
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29
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Familial hypocalciuric hypercalcemia: new mutation in the CASR gene converting valine 697 to methionine. Eur J Pediatr 2012; 171:147-50. [PMID: 21643651 DOI: 10.1007/s00431-011-1504-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 05/24/2011] [Indexed: 10/18/2022]
Abstract
Familial hypocalciuric hypercalcemia is an uncommon cause of hypercalcemia that arises from mutations in the calcium-sensing receptor gene. Inactivation of this receptor leads to a decreased receptor sensitivity to calcium, determining that higher concentrations of calcium are needed to inhibit the release of parathormone in the parathyroid glands. Patients usually are asymptomatic. Diagnosis is usually made casually after a routine blood analysis. The syndrome is characterized by mild or moderate hypercalcemia, hypocalciuria, and normal or slightly increased levels of parathormone. The degree of hypercalcemia depends on the type of mutation. The accurate diagnosis is important since it is a benign disorder that does not require medical or surgical treatment. We report a 9-year-old female with persistent hypercalcemia in several routine blood analyses, who was diagnosed with familial hypocalciuric hypercalcemia after genetic studies were performed. A new mutation determining a nucleotide change c.2089G>A in the calcium-sensing receptor gene (exon 7) was detected. This mutation was also found in the patient's mother and brother.
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30
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Rasmussen AQ, Jørgensen NR, Schwarz P. Clinical and biochemical outcomes of cinacalcet treatment of familial hypocalciuric hypercalcemia: a case series. J Med Case Rep 2011; 5:564. [PMID: 22142470 PMCID: PMC3287106 DOI: 10.1186/1752-1947-5-564] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 12/05/2011] [Indexed: 11/10/2022] Open
Abstract
Introduction Familial hypocalciuric hypercalcemia is a rare benign autosomal-dominant genetic disease with high penetrance. In most cases, patients with familial hypocalciuric hypercalcemia experience unspecific physical discomfort or asymptomatic disease. These patients are typically characterized by mild to moderately increased blood ionized calcium and a normal to slightly elevated serum parathyroid hormone. Case presentation Four female patients with familial hypocalciuric hypercalcemia with inactivating mutations in the CaSR gene were included in the treatment study. Three patients were related: two were siblings and one was the daughter of one of these. The ages of the related patients were 51 years, 57 years and 35 years. All three patients were carriers of the same mutation. The fourth patient, unrelated to the others, was 53 years old, and a carrier of a novel and previously unknown mutation leading to familial hypocalciuric hypercalcemia. All four patients were Caucasians of Danish nationality. Biochemically, all patients had elevated blood ionized calcium, serum parathyroid hormone, serum magnesium and total serum calcium, except one, whose serum parathyroid hormone was within the normal range prior to treatment. All patients were treated with cinacalcet in a dosage of 30 mg to 60 mg per day. Conclusion Three months after the initiation of cinacalcet treatment, all our patients experiencing clinical signs of hypercalcemia had improved in self -reported well-being and in biochemical parameters. None of our patients suffered adverse events to cinacalcet treatment. Biochemical markers of calcium homeostasis were improved and remained stable during the observation period of 12 months (two patients), 24 and 36 months, in both the symptomatic and the asymptomatic patients.
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Affiliation(s)
- Anne Qvist Rasmussen
- Research Centre of Ageing and Osteoporosis, Department of Medicine, Glostrup University Hospital, Glostrup, Denmark.
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31
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Reh CMS, Hendy GN, Cole DEC, Jeandron DD. Neonatal hyperparathyroidism with a heterozygous calcium-sensing receptor (CASR) R185Q mutation: clinical benefit from cinacalcet. J Clin Endocrinol Metab 2011; 96:E707-12. [PMID: 21289269 DOI: 10.1210/jc.2010-1306] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
UNLABELLED Neonatal hyperparathyroidism can be caused by a heterozygous inactivating mutation in the calcium-sensing receptor. Calcimimetics, allosteric activators of the calcium-sensing receptor, may provide an effective means of reducing PTH secretion in such patients. OBJECTIVE/PATIENT: The objective of the study was to identify the molecular defect and to monitor the postnatal course of a 1-wk-old infant with elevated blood ionized calcium, serum PTH, and alkaline phosphatase and low calcium excretion. The parents were normocalcemic. METHODS CASR gene mutation analysis was performed on genomic DNA of the proband and her parents. The infant was treated initially with pamidronate and then cinacalcet. RESULTS A heterozygous mutation (R185Q, CGA > CAA) in exon 4 of the CASR gene was identified in the proband. The CASR gene of both parents was normal. At 1 wk of age, iv fluids and furosemide were initiated, but hypercalcemia, hyperparathyroidism, and low calcium excretion persisted. At 2 wk of age, a single iv dose of pamidronate resulted in hypocalcemia and further increase in PTH levels, but hypercalcemia recurred within 1 wk. At 3 wk of age, a single oral dose of cinacalcet resulted in decreased PTH levels at 2 h; blood-ionized calcium reached a nadir at 10 h. Three days later daily cinacalcet was initiated, resulting in normalization of ionized calcium. The suppression of serum PTH and reduction in total serum calcium was maintained long term. CONCLUSIONS In neonatal hyperparathyroidism secondary to presumed de novo heterozygous CASR mutation, treatment with cinacalcet decreases PTH secretion and serum calcium levels and mitigates the need for parathyroidectomy.
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Affiliation(s)
- Christina M S Reh
- The Center for Endocrinology, Diabetes, and Metabolism at Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California 90027, USA
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Henley C, Yang Y, Davis J, Lu JYL, Morony S, Fan W, Florio M, Sun B, Shatzen E, Pretorius JK, Richards WG, St. Jean DJ, Fotsch C, Reagan JD. Discovery of a Calcimimetic with Differential Effects on Parathyroid Hormone and Calcitonin Secretion. J Pharmacol Exp Ther 2011; 337:681-91. [DOI: 10.1124/jpet.110.178681] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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