Clinical Chemistry 45:8(B)

1347–1352 (1999) Beckman Conference

Hormonal Control of Calcium Homeostasis

Gregory R. Mundy* and Theresa A. Guise

Calcium homeostasis in the extracellular fluid is tightly relatively constant at 150 mg per day, the net calcium
controlled and defended physiologically. Hypercalce- absorption is ;150 mg per day for a healthy adult in
mia always represents considerable underlying pathol- normal calcium balance. Calcium absorbed from the gut
ogy and occurs when the hormonal control of calcium enters the blood and is filtered by the kidney. The
homeostasis is overwhelmed. The major hormones that majority of filtered calcium (.98%) is reabsorbed in the
are responsible for normal calcium homeostasis are proximal renal tubules; thus, only 150 mg per day is
parathyroid hormone and 1,25-dihydroxyvitamin D; excreted in healthy individuals (4 ).
these hormones control extracellular fluid calcium on a The skeleton is the major body storage site for calcium.
chronic basis. Over- or underproduction of these hor- A healthy adult contains ;1–1.3 kg of calcium, and 99% of
mones or the tumor peptide, parathyroid hormone- this is in the form of hydroxyapatite in the skeleton (5 ).
related peptide, are the major causes of aberrant extra- The remaining 1% is contained in the ECF and soft tissues.
cellular fluid calcium concentrations. These hormonal Additionally, ,1% of the skeletal content of calcium is in
defense mechanisms are reviewed here. bone fluid and exchanges freely with the ECF.
© 1999 American Association for Clinical Chemistry Although the hormonal control of calcium fluxes is
central to understanding of normal calcium homeostasis,
Control of Calcium Homeostasis Parfitt and co-workers (6 –11 ) have also emphasized the
The extracellular fluid (or plasma) calcium concentration importance of physico-chemical exchanges of calcium
is tightly controlled by a complex homeostatic mechanism between the bone fluid and the ECF. The bone fluid is rich
involving fluxes of calcium between the extracellular fluid in calcium because it is in equilibrium with the mineral
(ECF)1 and the kidney, bone, and gut. These fluxes are phase of bone at the bone surface. The exchanges between
carefully regulated by three major hormones: parathyroid the bone fluid and the ECF may be important in deter-
hormone (PTH), calcitonin, and 1,25-dihydroxyvitamin D mining the set point (mean concentration of serum cal-
[1,25(OH)2D3]. Important cellular functions are depen- cium at steady state) and error correction (by which
dent on the maintenance of the extracellular calcium serum calcium is returned to the set point and corrected
concentration within a narrow range (1 ). Disturbances of by oscillations in the ionized calcium concentrations
this tightly regulated homeostatic system leads to disor- about this mean). The relative importance of this ex-
ders of calcium metabolism that have predictable effects, change mechanism has been underappreciated.
which can be ascribed to effects on these cellular func- Neuman showed almost 40 years ago that there is a
tions. special bone fluid that is analogous to the cerebrospinal
The approximate fluxes of calcium into and out of the fluid. This bone fluid is separated from the ECF by a
ECF that occur during each 24-h period are shown in Fig. “bone membrane”, which is probably composed of the
1. Usually, bone mineral accretion equals skeletal mineral bone lining cells that cover bone surfaces in a continuum
resorption, and calcium content in the urine approximates (10, 12–14 ). This bone membrane functions to keep cal-
that of net intestinal absorption. An average Western diet cium in the ECF and out of the bone (the ECF is super-
provides a calcium intake of ;1 g of elemental calcium saturated with calcium compared with both the bone fluid
per day. Typically, ;30% (300 mg) is absorbed, the and the crystalline surface of bone). The hormonal mech-
majority across the small intestine and a small percentage anisms that might control calcium fluxes across the bone
in the colon (2, 3 ). Because gut secretion of calcium is membrane are unknown at present, as are any possible
influences on these fluxes by disease states such as the

University of Texas Health Science Center, Medicine/Endocrinology, 7703

1
Floyd Curl Dr., San Antonio, TX 78284-7877. Nonstandard abbreviations: ECF, extracellular fluid; PTH, parathyroid
*Author for correspondence. Fax 210-567-6693; e-mail mundy@uthscsa.edu. hormone; 1,25(OH)2D3, 1,25-dihydroxyvitamin D; and PTH-rP, PTH-related
Received March 15, 1999; accepted June 2, 1999. protein.

1347
1348 Mundy and Guise: Hormonal Control of Calcium Homeostasis

linked receptor is mutated in the disorders of familial

hypocalciuric hypercalcemia (17 ), neonatal severe hyper-
parathyroidism, and autosomal dominant hypocalcemia
(18, 19 ). Synthesis of PTH is likely maximal under normal
physiologic conditions because parathyroid cells exposed
to hypercalcemic conditions in vitro display a decrease in
mRNA for PTH, whereas those exposed to hypocalcemic
conditions do not show such an increase (20 ). Active
vitamin D metabolites decrease PTH synthesis in vitro
and in vivo (21, 22 ) as well.
The biological actions of PTH include (a) stimulation of
osteoclastic bone resorption and release of calcium and
phosphate from bone, (b) stimulation of calcium reabsorp-
tion and inhibition of phosphate reabsorption from the
renal tubules, and (c) stimulation of renal production of
1,25(OH)2D3, which increases intestinal absorption of cal-
cium and phosphate. The amino-terminal end of the PTH
molecule binds to the PTH receptor to elicit these biologic
Fig. 1. Calcium homeostasis in a healthy adult over 24 h. responses. The PTH receptor has recently been cloned and
found to be a member of the large family of receptors that
hypercalcemia of malignancy or primary hyperparathy- contain a seven transmembrane-spanning domain and
roidism. However, it is possible that these fluxes buffer work through activation of G-proteins (23 ).
fluctuations in ECF calcium caused by, for example, PTH metabolism is complex and produces several
dietary calcium loads or calcium entry from bone destruc- fragments of varying biological and immunological reac-
tion caused by malignancy. For example, these fluxes may tivity. The intact and biologically active peptide has a
be important in determining set point. They could also be half-life in the circulation of ,4 min (24 ). Intact PTH is
important in returning plasma calcium to the steeping cleared rapidly by kidney and liver (25–27 ). Hepatic
(error correction) after a calcium load. Kupffer cells take up intact PTH and degrade it into very
small peptides as well as cleave it into discrete fragments
Hormonal Effects on Calcium Homeostasis that are released into the circulation (28 –30 ). The released
Blood ionized calcium concentrations are remarkably carboxy-terminal fragments circulate considerably longer
stable in healthy individuals because of the homeostatic than the intact hormone, mainly because they are cleared
system involving the actions of the three calciotropic exclusively by glomerular filtration (28, 31, 32 ). The com-
hormones on the target organs of bone, gut, and kidney, plex metabolism and circulating heterogeneity of PTH are
and possibly also on fluxes between the bone canalicular likely reasons for the difficulty encountered in developing
fluid and the ECF mentioned above. Normal calcium good PTH assays. Highly sensitive and specific immuno-
homeostasis is primarily dependent on the interactions of radiometric assays for intact PTH are now widely avail-
PTH, 1,25(OH)2D3, and calcitonin on these organs to able (33 ).
maintain the ionized calcium concentration within a very The tumor peptide PTH-related protein (PTH-rP) was
narrow range. Other factors also influence calcium fluxes, first discovered with in vitro bioassays for PTH in tumors
although current evidence suggests that only these three derived from lung, breast, and kidney (34 –36 ). This factor
hormones are under negative feedback control. is now known to be expressed by many squamous cell
carcinomas and has also been described in T-cell lympho-
pth and pth-related peptide mas that present with humoral hypercalcemia (37 ). It is a
PTH is an 84-amino acid peptide that is synthesized by 141-amino acid peptide and shares considerable homol-
the chief cells of the parathyroid gland. Secretion of PTH ogy with PTH in the first 13 amino acids. It binds to and
is highly dependent on the ionized calcium concentration activates the PTH receptor, and this is presumably the
and represents a simple negative feedback loop. The reason it mimics the biological effects of PTH on bone,
serum PTH concentration decreases as the serum calcium kidney, and the gut. It stimulates osteoclastic bone resorp-
concentration increases, although PTH secretion is not tion and promotes renal tubular calcium reabsorption in
entirely suppressible (15 ). However, there is a relatively similar concentrations to that of native PTH (38 ). In some
narrow range of regulation of PTH secretion by extracel- models of hypercalcemia associated with increased PTH-
lular calcium, with little further effect when total cor- rP, hypercalcemia can be reversed by passive inoculation
rected serum calcium is .2.9 mmol/L (11.5 mg/dL) or with neutralizing antibodies to PTH-rP (39 ). It is now
,2.1 mmol/L (8.5 mg/dL). The calcium-sensing receptor known that PTH-rP is produced by ;50% of primary
that mediates this negative feedback has recently been breast cancers and its production may be enhanced at the
cloned from bovine parathyroid cells (16 ). This G-protein- bone site by bone-derived factors such as transforming
 Clinical Chemistry 45, No. 8(B), 1999 1349

growth factor-b (TGFb) (32, 40, 41 ). RIAs have been de- many years such as those on the vascular system, what
veloped for PTH-rP, although these assays have not the signal transduction pathway that is connected to this
shown a perfect relationship between the presence and receptor is, and finally whether this receptor is related to
severity of hypercalcemia and expression of the protein the anabolic response of PTH. Early studies suggest the
(35, 42, 43 ). receptor is not as responsive to PTH-rP as it is to PTH and
It is now clear that PTH-rP has a pathophysiological that it may mediate its effects through cAMP and intra-
role not just in hypercalcemia but also in local osteolysis. cellular calcium signal transduction pathways (51 ).
Immunohistochemistry has been used to demonstrate that
there is increased expression of PTH-rP in bone sites calcitonin
compared with either soft tissue metastases or primary Calcitonin is a 32-amino acid peptide that is synthesized
tumors in patients with carcinoma of the breast (32 ). This and secreted by the parafollicular cells of the thyroid
has been shown experimentally by inoculation of the gland. The ionized calcium concentration is the most
human breast cancer cell line MDA-MB-231 into the left important regulator of calcitonin secretion (52 ). Increases
cardiac ventricles of nude mice. Osteolytic lesions caused in ionized calcium produce an increase in calcitonin
by metastasis occur over the following 4 – 6 weeks, and secretion, and conversely, a fall in the ambient calcium
there is an increase in PTH-rP expression in the tumor concentration inhibits calcitonin secretion. Gastrointesti-
cells that metastasize to bone. When tumor-bearing nude nal peptide hormones, gastrin in particular, are potent
mice are treated with neutralizing antibodies to PTH-rP, calcitonin secretogogues. This likely is responsible for
not only is there a decrease in the development of the increased calcitonin secretion after meals, but the physi-
osteolytic bone lesions, but there is also a decrease in the ologic relevance of this observation remains unclear.
tumor burden in bone (40 ). Pentagastrin, a gastrin analog, is used as a provocative
The physiological role of the PTH-rP remains unclear. stimulus to determine the capacity of a patient to secrete
It probably has no regulatory effect on calcium homeosta- calcitonin (53 ).
sis under physiological conditions. It is produced in The precise biological role of calcitonin in the overall
healthy skin cells as well as in amniotic cells, and it may schema of calcium homeostasis is uncertain. Calcitonin
have effects on epithelial cell replication and on smooth directly inhibits osteoclastic bone resorption (54 ), and the
muscle contraction during labor (44 ). It is also expressed effect is rapid, occurring within minutes of administra-
by lactating breast tissue and is present in large amounts tion. This inhibition is accompanied by the production of
in breast milk. However, most recent interest has focused cAMP (55 ) as well as an increase in cytosolic calcium (56 )
on its potential local effects in cartilage differentiation. in the osteoclast and leads to contraction of the osteoclast
PTH-rP knockout experiments performed by introducing cell membrane (57 ). These effects are transient and likely
the null-mutation into the germ line of mice have shown have little role in calcium homeostasis chronically, al-
that the mice have died before birth of an abnormality of though they may be important in short-term control of
the rib cage that causes impaired respiration (45 ). These calcium loads. Clinical observations support the notion
abnormalities are caused by an enhanced cartilage cell that calcitonin has little chronic effect because neither
differentiation and normal ossification in the rib cage. calcitonin-deficient patients (athyroid) nor patients with
Thus, PTH-rP is a naturally occurring and essential inhib- medullary thyroid cancer and excess calcitonin produc-
itor of cartilage cell differentiation, and its absence leads tion experience alterations in calcium homeostasis. The
to abnormalities at the growth plate. Overexpression calcitonin receptor has been cloned (58 ) and is structur-
experiments using transgenic mice in which PTH-rP ex- ally similar to the PTH receptor in that it also has seven
pression is targeted to cartilage cells by use of the type II transmembrane domains. Calcitonin is metabolized in
collagen promoter show a marked delay in endochondral minutes in the circulation, predominantly in the kidney
ossification (46 ) and also demonstrate cartilage abnormal- (1 ). The calcitonin receptor is related structurally to the
ities (46 ). Its effects on cartilage cells seem to be mediated PTH/PTH-rP and secretin receptors (58 ). The calcitonin
by Indian hedgehog protein produced by prehypertropic receptor exists in several isoforms, and its expression
cartilage cells in the growth plate (47, 48 ). seems to be influenced by ambient concentrations of
Two PTH receptors have been identified. The more calcitonin itself. This may be the reason for down-regula-
recently described receptor is a G-protein-coupled recep- tion of the receptor and the escape phenomenon that
tor that shares 51% amino acid homology with the well- occurs in the continued presence of calcitonin (59 ).
known PTH/PTH-rP receptor, but PTH appears to be the
major and possibly only active ligand (49 –51 ). The im- vitamin d metabolites
portance of this second PTH receptor is not clear, and The steroid hormone 1,25(OH)2D3 is the major biologi-
there are many important questions that need to be cally active metabolite of the vitamin D sterol family. The
addressed. These include the effects of PTH-rP on this vitamin D precursor (previtamin D3) is either ingested in
receptor and whether these are identical to those of PTH, the diet or synthesized in the skin from 7-dehydrocholes-
whether this receptor can explain some of the controver- terol through exposure to sunlight (60 ). Hydroxylation
sial non-bone effects of PTH that have been described for occurs in the liver at the C-25 position to form 25-
1350 Mundy and Guise: Hormonal Control of Calcium Homeostasis

hydroxyvitamin D, the substrate for the more potent

Table 1. Defenses against hypocalcemia and
metabolite, 1,25(OH)2D3. 25-Hydroxyvitamin D is hy-
hypercalcemia.
droxylated at the C-1 position in the kidney by 1@-
Protection against decreased plasma calcium (e.g., caused by
hydroxylase, a complex cytochrome P450 mitochondrial dietary or hormonal deficiency)
enzyme system located in the proximal nephron (61 ), to Glomerular filtration: filtered load of calcium decreases
form 1,25(OH)2D3 (62– 64 ). The renal 1@-hydroxylation of Calciotropic hormones (PTH, 1,25(OH)2D3, and calcitonin)
25-hydroxyvitamin D is the major recognized control Effects on bone and kidney: hypocalcemia stimulates PTH
point in vitamin D metabolism, responding to ambient release, which increases plasma calcium by effects on renal
phosphate concentrations, circulating PTH concentra- tubules and osteoclasts
tions, and calcium concentrations. PTH and phosphate Effects on gut (adaptation): increased fractional absorption of
dietary calcium, mediated by 1,25(OH)2D3
depletion act independently to increase 1,25(OH)2D3 pro-
duction, PTH being the more potent stimulus. Protection against increases in plasma calcium (caused by bone
1,25(OH)2D3 also acts via its receptor to inhibit renal destruction or large dietary calcium load)
1@-hydroxylase activity. Nephrectomy abolishes the 1@- Glomerular filtration: filtered load of calcium increases
hydroxylase activity. The only other known important Calciotropic hormones
extrarenal sites of 1,25(OH)2D3 production are in the PTH; but no further decrease in secretion if plasma calcium
.2.9 mmol/L (11.5 mg/dL)
placenta and granulomatous tissue (65– 67 ). The half-life Calcitonin; but no long-term efficacy
of 1,25(OH)2D3 in the circulation is ;5 h in humans. 1,25(OH)2D3; but gut effects are slow and limited
Fifteen percent is excreted as urinary metabolites and 50%
as fecal metabolites (4 ).
1,25(OH)2D3 increases plasma calcium and phosphate
concentrations by increasing the absorption of calcium is responsible for the mediation of its effects on gene
and phosphate from the gastrointestinal tract (64 ). It also expression (72 ).
increases bone resorption (68 ) and enhances the effects of
PTH in the nephron to promote renal tubular calcium Defenses against Hypercalcemia and Hypocalcemia
reabsorption. It is a powerful differentiation agent for The usual physiologic defenses against hypercalcemia
committed osteoclast precursors (69, 70 ), causing their and hypocalcemia are listed in Table 1. The majority of
maturation to form multinucleated cells that are capable these defense mechanisms are mediated through the
of resorbing bone. By these actions, 1,25(OH)2D3 provides hormonal actions of PTH and 1,25(OH)2D3.
a supply of calcium and phosphate available at bone A fall in ionized calcium concentration is immediately
surfaces for the formation of normal mineralized bone. sensed by the parathyroid glands, which respond with an
Whether 24,25-dihydroxyvitamin D3 has effects on increase in PTH secretion. PTH increases osteoclastic bone
bone metabolism has been a controversial issue for years. resorption, releasing calcium and phosphate from bone
Many people have believed it to be biologically inert. into the ECF. PTH also causes increased renal tubular
However, recent studies in null-mutant mice in which the reabsorption of calcium as well as inhibition of phosphate
25-hydroxyvitamin D 24-hydroxylase gene is deleted reabsorption. PTH stimulates synthesis of 1,25(OH)2D3,
throw doubt on this notion (71 ). Although the heterozy- which further increases absorption of calcium and phos-
gotes are apparently normal, approximately one-half of phate from the gut. If these mechanisms are intact,
the homozygotes die before weaning, apparently because the extracellular calcium concentrations should return to
of hypercalcemia associated with nephrocalcinosis. Al- normal.
though the bone histology is normal in the first generation In the converse situation, a rise in ionized calcium
of homozygotes, the second generation show an accumu-
concentration causes a decrease in PTH secretion from the
lation of osteoid tissue at sites of intramembranous ossi-
parathyroid glands. Thus, renal tubular calcium reabsorp-
fication, such as in the calvaria, clavicle, mandible, and
tion and osteoclastic bone resorption are decreased. Syn-
periosteal surface of long bones. These studies suggest
thesis of 1,25(OH)2D3 is also decreased, which in turn
that 24,25-dihydroxyvitamin D3 may play an important
role in normal intramembranous bone formation. decreases absorption of dietary calcium and phosphate.
Recently, there have been further clarifications of the Thus, a healthy individual responds to increases in ion-
receptor mechanisms and response elements in target ized calcium with an increase in renal calcium excretion
genes for 1,25-dihydroxyvitamin D. The gene that has and a decrease in intestinal absorption of calcium.
been used most frequently for studying transcriptional In general, these hormonal responses are more effec-
effects of the vitamin D receptor is the osteocalcin gene, tive in protecting against hypocalcemia than hypercalce-
which has provided a wealth of information. It is appar- mia. Perturbations in these mechanisms as exemplified by
ent that the vitamin D receptor functions as a transcrip- excessive increases in bone resorption, deficiencies or
tion factor (like other members of the steroid hormone excesses of PTH or 1,25(OH)2D3, and defects in renal
superfamily) and causes effects on target genes by form- capacity to handle calcium and phosphate will lead to
ing a heterodimer with the retinoic acid receptor, and this either hypercalcemia or hypocalcemia.
 Clinical Chemistry 45, No. 8(B), 1999 1351

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