A calcium homeostasis model: orchestration of fast acting PTH and calcitonin with slow calcitriol

Significant role of 1,25-dihydroxyvitamin D on serum calcium levels after total thyroidectomy: a prospective cohort study

Introduction

Although active vitamin D (VD) has been used both preoperatively and postoperatively to prevent hypocalcemia risk in patients undergoing total thyroidectomy, the role of 1,25-dihydroxyvitamin D (1,25(OH)2D) has not been examined. This study comprehensively investigated the effects of 1,25(OH)2D on calcium (Ca) concentrations after total thyroidectomy.

Methods

Serum Ca, parathyroid hormone (PTH), and 1,25(OH)2D levels were measured in 82 patients with thyroid disease before and after surgery.

Results

Serum Ca, PTH, and 1,25(OH)2D levels decreased significantly on the morning of the first postoperative day. Notably, the decrease in 1,25(OH)2D concentration was significantly lower than that of PTH concentration (10.5 ± 33.4% vs. 52.1 ± 30.1%, p<0.0001), with 28% of patients showing increases in 1,25(OH)2D. The only factor predicting a postoperative 1,25(OH)2D decrease was a high preoperative 1,25(OH)2D concentration. Postoperative 1,25(OH)2D concentrations, as well as the magnitude and rate of decrease from preoperative levels, showed strong positive correlations with preoperative 1,25(OH)2D concentrations (p<0.0001 for all three variables) but not with PTH concentrations. These findings suggest that 1,25(OH)2D concentrations after thyroidectomy were more strongly dependent on preoperative concentrations than on the effect of PTH decrease and were relatively preserved, possibly preventing sudden severe postoperative hypocalcemia. A high 1,25(OH)2D level was the most important preoperative factor for hypocalcemia (<2 mmol/L; p<0.05) on the first postoperative day; however, only PTH decrease was statistically significant (p<0.001) when intraoperative factors were added. In the PTH >10 pg/mL group, the decrease in 1,25(OH)2D levels was significantly associated with postoperative hypocalcemia (p<0.05). Similarly, in the PTH levels >15 pg/mL group, a decrease in 1,25(OH)2D concentration was a significant factor, and the amount of PTH decrease was no longer significant.

Conclusion

1,25(OH)2D plays an important role in preventing sudden, severe hypocalcemia due to decreased PTH levels after total thyroidectomy, whereas high preoperative 1,25(OH)2D levels are a significant risk factor for postoperative hypocalcemia. Optimizing preoperative protocols to adjust Ca, PTH, and 1,25(OH)2D levels to improve the management of patients undergoing total thyroidectomy and to prevent extreme intraoperative PTH decreases may reduce the risk of hypocalcemia.

Pharmacokinetic Estimation Models-based Approach to Predict Clinical Implications for CYP Induction by Calcitriol in Human Cryopreserved Hepatocytes and HepaRG Cells

Calcitriol, a vitamin D₃ metabolite, is approved for various indications because it is the bioactive form of vitamin D in the body. The purpose of this study was to predict the clinical significance of cytochrome P450 (CYP) induction by calcitriol using in vitro human cryopreserved hepatocytes, HepaRG experimental systems, and various pharmacokinetic estimation models. CYP2B6, 3A4, 2C8, and 2C9 mRNA levels increased in a concentration-dependent manner in the presence of calcitriol in human cryopreserved hepatocytes and HepaRG cells. Using the half maximal effective concentration (EC₅₀) and maximum induction effect (E_max) obtained from the in vitro study, a basic kinetic model was applied, suggesting clinical relevance. In addition, a static mechanistic model showed the improbability of a clinically significant effect; however, the calculated area under the plasma concentration-time curve ratio (AUCR) was marginal for CYP3A4 in HepaRG cells. To clarify the effect of CYP3A4 in vivo, physiologically based pharmacokinetic (PBPK) modeling was applied as a dynamic mechanistic model, revealing a low clinically significant effect of CYP3A4 induction by calcitriol. Therefore, we conclude that CYP induction by calcitriol treatment would not be clinically significant under typical clinical conditions.

Review: Regulation of gastrointestinal and renal transport of calcium and phosphorus in ruminants

In comparison to monogastric animals, ruminants show some peculiarities in respect to the regulation of mineral homeostasis, which can be regarded as a concerted interplay between gastrointestinal absorption, renal excretion and bone mobilisation to maintain physiological Ca and phosphate (Pi) concentrations in serum. Intestinal absorption of Ca or Pi is mediated by two general mechanisms: paracellular, passive transport dominates when luminal Ca or Pi concentrations are high and transcellular. The contribution of active transport becomes more important when dietary Ca or Pi supply is restricted or the demand increased. Both pathways are modulated directly by dietary interventions, influenced by age and regulated by endocrine factors such as 1,25-dihydroxyvitamin D3. Similar transport processes are observed in the kidney. After filtration, Ca and Pi are resorbed along the nephron. However, as urinary Ca and Pi excretion is very low in ruminants, the regulation of these renal pathways differs from that described for monogastric species, too. Furthermore, salivary secretion, as part of endogenous Pi recycling, and bone mobilisation participate in the maintenance of Ca and Pi homeostasis in ruminants. Saliva contains large amounts of Pi for buffering rumen pH and to ensure optimal conditions for the rumen microbiome. The skeleton is a major reservoir of Ca and Pi to compensate for discrepancies between demand and uptake. But alterations of the regulation of mineral homeostasis induced by other dietary factors such as a low protein diet were observed in growing ruminants. In addition, metabolic changes, for example, at the onset of lactation have pronounced effects on gastrointestinal mineral transport processes in some ruminant species. As disturbances of mineral homeostasis do not only increase the risk of the animals to develop other diseases, but are also associated with protein and energy metabolism, further research is needed to improve our knowledge of its complex regulation.

An In Silico Model for the Prediction of Changes in Mineral Density in Cortical Bone Remodeling

An in silico model for the estimation of volumetric bone mineral density (vBMD) changes at a cortical bone site subjected to mechanobiological bone remodeling is proposed in this manuscript. Mechanisms of cell differentiation, receptor-ligand binding, mechanical signaling, and resorption or deposition of bone matrix were considered, therefore providing a comprehensive description of mechanobiological bone remodeling in the bone microenvironment and enabling the analysis of temporal evolution of disease or therapy scenarios. The proposed model is composed by five modules, namely, bone cells populations, mechanobiology, volume fractions and porosity, mineral density, and structural stiffness. The model is an extension of other models found in the literature because equations for the obtaining of cortical vBMD and the binding of parathyroid hormone (PTH) to parathyroid hormone 1 receptor are included. The proposed model showed a satisfactory agreement with the solutions of other in silico models found in the literature. Simulations of walking and running exercise routines were performed for the evaluation of model capability regarding the control of the numerical error and prediction of vBMD. The computational method used to solve the case study controlled the relative numerical error by less than 1 × 10-7 for approximately 1.7 × 106 time steps. The predicted values correlate with the concept of increasing BMD by vigorous physical activity; however, they contrast with the specific effect of physical activities on cortical vBMD.

Use of a Systems Pharmacology Model Based Approach Toward Dose Optimization of Parathyroid Hormone Therapy in Hypoparathyroidism

We present an application of a quantitative systems pharmacology (QSP) model to support a regulatory decision, specifically in assessing the adequacy of the proposed dosing regimen. On January 23, 2015, the US Food and Drug Administration (FDA) approved Natpara (human parathyroid hormone (PTH)) to control hypocalcemia in patients with hypoparathyroidism. Clinical trial results indicated that although once-daily PTH reduced calcium and vitamin D dose requirement while maintaining the normocalcemia, the regimen was not adequate to control hypercalciuria. We hypothesized that the lack of control on urinary calcium excretion was due to the short half-life of PTH. The QSP model-based simulations indicated that a more frequent dosing regimen may provide better control on hypercalciuria while maintaining normocalcemia. A postmarketing trial was recommended to assess pharmacokinetics (PKs) and pharmacodynamics (PDs) of PTH dose and dosing regimen. Although other modeling approaches may be feasible, in this specific case, QSP model-based simulations fulfilled the information gap to support recommendations of this postmarketing trial.

Variable setpoint as a relaxing component in physiological control

Setpoints in physiology have been a puzzle for decades, and especially the notion of fixed or variable setpoints have received much attention. In this paper, we show how previously presented homeostatic controller motifs, extended with saturable signaling kinetics, can be described as variable setpoint controllers. The benefit of a variable setpoint controller is that an observed change in the concentration of the regulated biochemical species (the controlled variable) is fully characterized, and is not considered a deviation from a fixed setpoint. The variation in this biochemical species originate from variation in the disturbances (the perturbation), and thereby in the biochemical species representing the controller (the manipulated variable). Thus, we define an operational space which is spanned out by the combined high and low levels of the variations in (1) the controlled variable, (2) the manipulated variable, and (3) the perturbation. From this operational space, we investigate whether and how it imposes constraints on the different motif parameters, in order for the motif to represent a mathematical model of the regulatory system. Further analysis of the controller's ability to compensate for disturbances reveals that a variable setpoint represents a relaxing component for the controller, in that the necessary control action is reduced compared to that of a fixed setpoint controller. Such a relaxing component might serve as an important property from an evolutionary point of view. Finally, we illustrate the principles using the renal sodium and aldosterone regulatory system, where we model the variation in plasma sodium as a function of salt intake. We show that the experimentally observed variations in plasma sodium can be interpreted as a variable setpoint regulatory system.

Coupling between phosphate and calcium homeostasis: a mathematical model

We developed a mathematical model of calcium (Ca) and phosphate (PO₄) homeostasis in the rat to elucidate the hormonal mechanisms that underlie the regulation of Ca and PO₄ balance. The model represents the exchanges of Ca and PO₄ between the intestine, plasma, kidneys, bone, and the intracellular compartment, and the formation of Ca-PO₄-fetuin-A complexes. It accounts for the regulation of these fluxes by parathyroid hormone (PTH), vitamin D₃, fibroblast growth factor 23, and Ca²⁺-sensing receptors. Our results suggest that the Ca and PO₄ homeostatic systems are robust enough to handle small perturbations in the production rate of either PTH or vitamin D₃ The model predicts that large perturbations in PTH or vitamin D₃ synthesis have a greater impact on the plasma concentration of Ca²⁺ ([Ca²⁺]_p) than on that of PO₄ ([PO₄]_p); due to negative feedback loops, [PO₄]_p does not consistently increase when the production rate of PTH or vitamin D₃ is decreased. Our results also suggest that, following a large PO₄ infusion, the rapidly exchangeable pool in bone acts as a fast, transient storage PO₄ compartment (on the order of minutes), whereas the intracellular pool is able to store greater amounts of PO₄ over several hours. Moreover, a large PO₄ infusion rapidly lowers [Ca²⁺]_p owing to the formation of CaPO₄ complexes. A large Ca infusion, however, has a small impact on [PO₄]_p, since a significant fraction of Ca binds to albumin. This mathematical model is the first to include all major regulatory factors of Ca and PO₄ homeostasis.

A model of calcium homeostasis in the rat

We developed a model of calcium homeostasis in the rat to better understand the impact of dysfunctions such as primary hyperparathyroidism and vitamin D deficiency on calcium balance. The model accounts for the regulation of calcium intestinal uptake, bone resorption, and renal reabsorption by parathyroid hormone (PTH), vitamin D₃, and Ca²⁺ itself. It is the first such model to incorporate recent findings regarding the role of the calcium-sensing receptor (CaSR) in the kidney, the presence of a rapidly exchangeable pool in bone, and the delayed response of vitamin D₃ synthesis. Accounting for two (fast and slow) calcium storage compartments in bone allows the model to properly predict the effects of bisphophonates on the plasma levels of Ca²⁺ ([Ca²⁺]_p), PTH, and vitamin D₃ Our model also suggests that Ca²⁺ exchange rates between plasma and the fast pool vary with both sex and age, allowing [Ca²⁺]_p to remain constant in spite of sex- and age-based hormonal and other differences. Our results suggest that the inconstant hypercalciuria that is observed in primary hyperparathyroidism can be attributed in part to counterbalancing effects of PTH and CaSR in the kidney. Our model also correctly predicts that calcimimetic agents such as cinacalcet bring down [Ca²⁺]_p to within its normal range in primary hyperparathyroidism. In addition, the model provides a simulation of CYP24A1 inactivation that leads to a situation reminiscent of infantile hypercalcemia. In summary, our model of calcium handling can be used to decipher the complex regulation of calcium homeostasis.

A control engineering model of calcium regulation

CONTEXT

A control engineering perspective provides a framework for representing important mechanistic details of the calcium (Ca) regulatory system efficiently. The resulting model facilitates the testing of hypotheses about mechanisms underlying the emergence of known Ca-related pathologies.

OBJECTIVE

The objective of this work is to develop a comprehensive computational model that will enable quantitative understanding of plasma Ca regulation under normal and pathological conditions.

DESIGN

Ca regulation is represented as an engineering control system where physiological subprocesses are mapped onto corresponding block components (sensor, controller, actuator, and process), and underlying mechanisms are represented by differential equations. The resulting model is validated with clinical observations of induced hypo- or hypercalcemia in healthy subjects, and its applicability is demonstrated by comparing model predictions of Ca-related pathologies to corresponding clinical data.

RESULTS

Our model accurately predicts clinical responses to induced hypo- and hypercalcemia in healthy subjects within a framework that facilitates the representation of Ca-related pathologies in terms of control system component defects. The model also enables a deeper understanding of the emergence of pathologies and the testing of hypotheses about related features of Ca regulation-for example, why primary hyperparathyroidism and hypoparathyroidism arise from "controller defects."

CONCLUSIONS

The control engineering framework provides an efficient means of organizing the subprocesses constituting Ca regulation, thereby facilitating a fundamental understanding of this complex process. The resulting validated model's predictions are consistent with clinically observed short- and long-term dynamic characteristics of the Ca regulatory system in both healthy and diseased patients. The model also enables simulation of currently infeasible clinical tests and generates predictions of physiological variables that are currently not measurable.

Effects of 1,25-dihydroxyvitamin D3 on calcium and phosphorus homeostasis in sheep fed diets either adequate or restricted in calcium content

It was the aim of the present study to collect basic data on calcium (Ca) and phosphorus (P) homoeostasis in sheep. Two series of experiments were carried out to investigate the effects of 1,25-dihydroxyvitammin D(3) (calcitriol) in supraphysiological dosage in combination with varying alimentary Ca supply. In the first series, blood samples were collected over 72 h to determine the concentrations of total Ca (Ca), ionized Ca (Ca(2+)), inorganic phosphate (P(i)), and the bone resorption marker CrossLaps (CL). In the second series, measurements were carried out over 12h. In addition, urine samples were collected to calculate the fractional excretions (FE) of Ca and P(i). Changes in plasma macromineral concentrations (P<0.01) as well as in CL (P<0.001) and endogenous calcitriol (P<0.05) were observed in the alimentary Ca-restricted animals, indicating that the reduction of daily Ca intake challenged the animals' macromineral homeostatic mechanisms. However, the Ca-restricted diet had an effect on neither FE of Ca nor on FE of P(i). The treatment resulted in peak serum calcitriol concentrations between 1,900 and 2,500 pg/mL, and supraphysiological concentrations were maintained for the next 48 h. Irrespective of dietary Ca, calcitriol had hypercalcemic and hyperphosphatemic effects. An increase in CL was revealed only in the Ca-restricted, calcitriol-treated sheep (P<0.01), reflecting a remarkable enhancement of Ca mobilization from the bone by calcitriol exclusively in this group. From these data, it can be concluded that the sheep can be a suitable animal model for studying catabolic effects of Ca deficiency and calcitriol on bone metabolism.

Age-related increases in parathyroid hormone may be antecedent to both osteoporosis and dementia

BACKGROUND

Numerous studies have reported that age-induced increased parathyroid hormone plasma levels are associated with cognitive decline and dementia. Little is known about the correlation that may exist between neurological processing speed, cognition and bone density in cases of hyperparathyroidism. Thus, we decided to determine if parathyroid hormone levels correlate to processing speed and/or bone density.

METHODS

The recruited subjects that met the inclusion criteria (n = 92, age-matched, age 18-90 years, mean = 58.85, SD = 15.47) were evaluated for plasma parathyroid hormone levels and these levels were statistically correlated with event-related P300 potentials. Groups were compared for age, bone density and P300 latency. One-tailed tests were used to ascertain the statistical significance of the correlations. The study groups were categorized and analyzed for differences of parathyroid hormone levels: parathyroid hormone levels <30 (n = 30, mean = 22.7 +/- 5.6 SD) and PTH levels >30 (n = 62, mean = 62.4 +/- 28.3 SD, p <or= 02).

RESULTS

Patients with parathyroid hormone levels <30 showed statistically significantly less P300 latency (P300 = 332.7 +/- 4.8 SE) relative to those with parathyroid hormone levels >30, which demonstrated greater P300 latency (P300 = 345.7 +/- 3.6 SE, p = .02). Participants with parathyroid hormone values <30 (n = 26) were found to have statistically significantly higher bone density (M = -1.25 +/- .31 SE) than those with parathyroid hormone values >30 (n = 48, M = -1.85 +/- .19 SE, p = .04).

CONCLUSION

Our findings of a statistically lower bone density and prolonged P300 in patients with high parathyroid hormone levels may suggest that increased parathyroid hormone levels coupled with prolonged P300 latency may become putative biological markers of both dementia and osteoporosis and warrant intensive investigation.

Motivations and methods for analyzing pulsatile hormone secretion

Endocrine glands communicate with remote target cells via a mixture of continuous and intermittent signal exchange. Continuous signaling allows slowly varying control, whereas intermittency permits large rapid adjustments. The control systems that mediate such homeostatic corrections operate in a species-, gender-, age-, and context-selective fashion. Significant progress has been made in understanding mechanisms of adaptive interglandular signaling in vivo. Principal goals are to understand the physiological origins, significance, and mechanisms of pulsatile hormone secretion. Key analytical issues are: 1) to quantify the number, size, shape, and uniformity of pulses, nonpulsatile (basal) secretion, and elimination kinetics; 2) to evaluate regulation of the axis as a whole; and 3) to reconstruct dose-response interactions without disrupting hormone connections. This review will focus on the motivations driving and the methodologies used for such analyses.

The circadian rhythm of osteoprotegerin and its association with parathyroid hormone secretion

BACKGROUND

Osteoclast resorptive activity, which is known to demonstrate circadian rhythmicity, is regulated by various endocrine hormones and cytokines. PTH suppresses osteoprotegerin (OPG), a regulator of osteoclast activity that has recently been shown to have a circadian rhythm in healthy controls. We studied the differences in the relationship between PTH, OPG, and type I collagen C-telopeptide (betaCTX) over a 24-h period in premenopausal women, elderly postmenopausal women, and elderly men.

METHODS

Hourly peripheral venous blood samples were obtained from 18 healthy non-osteoporotic volunteers: premenopausal women (n = 6; mean age, 30.2 +/- 2.2 yr), postmenopausal women (n = 6; mean age, 68.2 +/- 2.6 yr), and elderly men (n = 6; mean age, 68.2 +/- 2.3 yr). Plasma PTH (1-84), OPG, betaCTX, and calcium were measured on all samples. Cosinor analysis was performed to analyze the circadian rhythm parameters. Cross-correlation analysis was used to determine the relationship between the time series of the variables.

RESULTS

The 24-h mean PTH, OPG, and betaCTX concentrations were significantly higher in postmenopausal women as compared with premenopausal women and elderly men (P < 0.001). Significant circadian rhythms were observed for PTH (P < 0.05), OPG (P < 0.05), and betaCTX (P < 0.001) in all subjects. PTH secretion was characterized by two peaks in premenopausal women and elderly men and by a sustained increase in PTH concentration in postmenopausal women. OPG secretion was circadian with a daytime increase and nocturnal decrease, and a greater percent decrease in OPG secretion was observed in the postmenopausal women between 1600 and 2400 h. OPG secretion was inversely related to PTH (r = -0.4) and betaCTX (r = -0.6) secretion over a 24-h period.

CONCLUSION

This report confirms a circadian rhythm for circulating OPG. The nocturnal decline in circulating OPG is greater in postmenopausal women as compared with premenopausal women and elderly men. Altered PTH secretion may contribute to the OPG secretory pattern in postmenopausal women resulting in increased nocturnal bone resorption.