Bone Metabolism Flashcards

1
Q

How is bone mass normally maintained?

What regulates this?

A

Balance between activity of:
• Osteoblasts which produce matrix and bone mineralization
• Osteoclasts which break it down (degrade the matrix and cause resorption)

Process is tightly regulated by local endocrine factors
•	Hormones
•	Vitamins 
•	Stress
•	Inflammation
•	Growth factors
•	cytokines
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2
Q

What factors affect formation and resorption by osteoblasts/clasts?

A
•	Glucocorticoids
o	Inhibits osteoblasts 
•	Estrogen 
o	Inhibits osteoclasts and stimulates osteoblasts
•	Thyroid hormones
o	Stimulates osteoclasts
•	Growth hormone nd IGF1 
o	Stimulates osteoblasts
•	Calcitonin 
o	Inhibits osteoclasts
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3
Q

What things can shift bone turnover to favour resorption?

A
  • Decrease in sex hormones
  • Drugs- glucocorticoids
  • Hyperparathyroidism
  • Cushings Syndrome
  • Kidney disease
  • GIT absorptive issues
  • Genetic causes- affect enzymes that regulate bone metabolism
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4
Q

What is the leading cause of osteoporosis?

Who is it most common in?

A
  • It is the most common bone disease
  • Leading cause is a drop in oestrogen in women and testosterone in men
  • Most common in post-menopausal Caucasian women
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5
Q

What is Osteoporosis?

A
  • Systemic condition characterized by low bone mass and deterioration in bone microarchitecture
  • Leads to increased bone fragility and increased fracture risk
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6
Q

Where is the bodies calcium usually stored?

Why is this clinically important?

A
  • 99% is stored in the bone as ca hydroxyapatite
  • 1% is dissolved in blood and ECF
  • Bound to plasma proteins, small organic molecules (Phosphate) and free ions
  • This means that If the body needs calcium, it needs to come from this store
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7
Q

Why is calcium homeostasis important?

A
  • It is essential for key cellular processes
  • Heart and muscle contraction
  • Nerve conduction
  • Exocytosis
  • Activity of enzymes
  • There is a tight control of extra and intracellular calcium levels via transporters, pumps and binding proteins
  • If there is a dietary deficit in calcium it will be resorbed from the bone
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8
Q

What are the clinical consequences of high or low blood calcium?

A
  • Hypercalcaemia
  • Fractures due to excessive resorption of bones making them prone to break after minor trauma
  • Formation of renal stones
  • Proximal myopathy
  • Pancreatitis
  • Mental changes
  • Usually due to primary hyperparathyroidism
  • Hypocalcaemia
  • Paraesthesia
  • Cramps
  • Tetany
  • Agitation
  • Seizures
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9
Q

What are the key players in calcium homeostasis, and how do they interact?

A

Parathyroid hormone
• Fast acting
• Responsible for the minute to minute control of serum calcium concentration
• Calcitriol
• Slow acting and maintains day to day control of serum calcium concentration

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10
Q

What are the main target organs in calcium homeostasis?

A
  • Intestine
  • Kidney
  • Bone
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11
Q
Parathyroid hormone:
What is its role?
Where is it produced/Secreted?
What regulates this ?
What does it target and what are the effects?
A

Role:
• The most important regulator of blood calcium and phosphate
• Primary hormone regulating bone metabolism/remodelling

Produced and secreted:
• Parathyroid gland
• Synthesized as a preprohormone

Regulation:
• Secretion is dependent on serum calcium
• Calcium binds to a Calcium sensing receptor (CaR)
• This is a GPCR expressed on many cells
• Signalling cascade leads to SUPPRESSION of PTH secretion and cell proliferation
• Inhibited by - high plasma Ca
• Stimulated by- low plasma ca

Targets:
• Bone
• Causes resorption via increased osteoclast activity
• Increased calcium mobilisation
• Kidney
• Increased calcium reabsorption
• Decreased calcium excretion in urine
• Increased production of active vitamin D
o This acts on the small intestine to increase calcium absorption from the diet

Effect:
• Increased blood calcium

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12
Q

What is the Ca/PTH axis feedback loop?

What is the clinical significance of this?

A
  • PTH is the principal modulator of plasma ca levels
  • ECF Ca levels are the primary determinant of PTH secretion
  • Comparing calcium and PTH levels can show where there is a problem in the axis
  • Examples
  • Low calcium with low PTH = PTH not responding ? Hypoparathyroidism
  • High Calcium with High PTH = Gland producing too much PTH ? Hyperparathyroidism
  • Low calcium with high PTH = response is correct- need to evaluate for non parathyroid problem
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13
Q

Calcitonin
Where is it produced/Secreted?
What regulates this ?
What does it target and what are the effects?

A

Produced:
• Thyroid C cells (main source)
• Also in other tissues (lung, intestine and mammary gland)

Targets:
•	Kidney
•	Increases excretion of calcium
•	Bone
•	Increases deposition in bone by inhibiting osteoclasts
•	Prevents resorption
•	Intestine
•	Decreases uptake

Aim:
• Decrease blood calcium levels

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14
Q

Vitamin D2/D3
What are the different forms?
Where is it produced?
Solubility/trasnport?

A

Vitamin D2 = ergocalcigerol
• Sourced from plan and yeast

Vitamin D3 = Cholecalciferol
• Most is produced by the skin in photochemical synthesis
• Exposure of the precursor to UV radiation
• Some is ingested in small amounts in fish

Activity:
• In the D2 or D3 form it is a pro-hormone with little significant biological activity
• Needs to be metabolised to an active form

  • Lipid soluble steroid hormone
  • Transported in the blood by transcalciferin
  • Vitamin D binding protein
  • Long half life - 5-12 hours
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15
Q

Calcitriol:
How is it synthesized?
What are its actions?
Solubility/binding?

A
  • Vitamin D3 must be metabolised within the body to become the active form - calcitriol
  • Liver forms the intermediate form - Calcidiol
  • Kidney transforms this into the active form calcitriol under the stimulation of PTH
  • The lipid soluble hormone Binds to intracellular Vitamin D receptors
  • Effects gene expression to cause protein synthesis
Acts on
•	Bone:
•	Regulates bone remodeling
•	Gut
•	Inreases calcium and phosphate absorption
•	Muscle
•	Increases growth , strength and contraction
•	Increases immune function
•	Decreases inflammation
•	Epithelial cells
•	Increases differentiation
•	Decreases proliferation
•	Causes apoptosis
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16
Q

What happens to calcium absorption when there is a vitamin D deficiency?

A
  • It is not efficiently absorbed

* Calcitriol controls synthesis of genes and increases expression of proteins that promote transcellular transport of ca

17
Q

What happens when blood Calcium levels fall?

A

PTH
• Low calcium causes stimulation of PTH secretion
• PTH acts directly on bone to induce osteoclastic resorption from bone
• PTH increases synthesis of Calcitriol by the kidney
• PTH increases reabsorption of calcium from the glomerular filtrate preventing loss in the urine

Calcitriol
• Calcitriol increases intestinal absorption of calcium
• Calcitriol can stimulate osteoclasts indirectly by stimulating osteoblasts to release factors that stimulate differentiation
• Not as potent as PTH
• Slow acting
• Role in normal bone remodeling

18
Q

What do PTH , calcitriol and calcitonin do In the case of normal calcium levels?

A

PTH
• Inhibition of PTH synthesis
• Decrease in PTH levels
• Less mobilization of calcium from the bones

Calcitriol
• Enhances absorption of Ca and phosphorus from the small intestine
• This helps to maintain a proper balance that assists Calcitonin to mineralize the bone matrix

Calcitonin
• Reduces osteoclastic bone resorption and allows excess calcium to deposit in bones
• Decreases PTH synthesis

19
Q

How common is Vitamin D deficiency?
What are the effects of a mild/Moderate deficiency?
What are the effects of a severe deficiency?

A
  • More than 40% of the world is vitamin D deficient
  • 1 in 5 children
  • Can be due to :
  • Reduced intake
  • Age related factors
  • Decreased sun exposure
  • Sunscreen use
  • Decline in renal function
  • Mild to moderate deficiency
  • Decreased calcium absorption resulting in decreased serum calcium
  • Increased PTH causing increased tubular resorption of calcium and bone resorption
  • Decreased bone density
  • High bone turnover
  • Increased fracture risk in older people

• Severe Vitamin D deficiency
• <15 nM
• Blood calcium below normal
• Can cause secondary hyperparathyroidism
o PTH also causes phosphorus loss via the urine leading to a decreased serum phosphate
o This imbalance causes a defect in bone mineralization
• Children get rickets
• Adults get Osteomalacia

20
Q
Phosphorus-
How abundant is it?
Where is it stored?
What do cells use it for?
Dietary sources?
A
  • It is the most abundant mineral after calcium
  • The bulk is stored in bone (85%) as mineralized hydroxyapatite ECM giving the bone strength
  • Every cell contains phosphate anions
  • Complexed to proteins or lipids
  • Nucleic acids in DNA and RNA
  • Needed for energy production
  • Used as a chemical buffer in serum and urine
  • Most unprocessed food has it
21
Q

How is phosphate balance maintained- ie ?

A

Renal cotransporter:
• There are sodium- phosphate co transporters in the proximal renal tubular cells
• If there is low dietary phosphate intake there is an increase in expression of transporters leading to increased renal phosphate absorption
• In excess intake the opposite occurs and there is less transporters expression and more phosphate is excreted in urine

FGF-23
• FGF 23 = 23 fibroblast growth factor (phosphaturic hormone)
• Secreted from bone
• Works on the kidney
• Secreted in response to HIGH dietary intake or serum phosphate levels
• It works on the Sodium phosphate cotransporter to decrease expression of transporters
• Causes:
• Inhibition of phosphate reabsorption (Similar to PTH)
• Increased excretion of phosphate (Similar to PTH)
• Decreases calcitriol synthesis resulting in decreased gut phosphate absorption (Opposite to PTH)
• Aim:
• To decrease serum phosphate level

22
Q

What happens if the FGF-23 is excessively elevated?

What causes it?

A
  • Phosphate levels will become too decreased
  • Linked to rare forms of hereditary hypophosphataemic rickets and osteomalacia
  • Most often found in chronic kidney disease
  • Decreased glomerular filtration
  • Decreased kidney phosphate excretion
  • Increased FGF 23 secretion from bone
  • Decreased calcitriol through inhibition of hydroxylase in the kidney
  • Low blood calcium
  • Secondary hyperparathyroidism
23
Q

Very broadly what are the effects of the following on ca and phosphate levels?
PTH
Calcitriol

A

PTH :
• Increases Calcium
• Decreases Phosphate

Calcitriol
• Increases Calcium
• Increases Phosphate

24
Q

What are some causes of hypercalcaemia?

What is the reference range?

A
> 2.6
•	Hyperparathyroidism 
•	Primary, secondary, tertiary
•	Increased absorption of calcium
•	Malignancy
•	Vitamin D intoxication
•	Thiazide diuretics
•	Renal insufficiency
•	Thyrotoxicosis
•	Familial hypocalciuric hypercalcaemia
•	Sarcoidosis
25
What are the effects of Hypercalcaemia?
* Neurological: * Confusion * Lethargy * Headaches * Depression * Coma * Abdominal: * Nausea and vomiting * Abdominal pain * Polyuria, polydipsia * Pancreatitis * Kidney stones * Other: * Dehydration * Bradycardia * Renal failure * Muscle fatigue
26
What are some causes of hypocalcaemia | What is the range?
``` < 2.25 • Osteomalacia : vitamin D deficiency • Chronic renal failure • Hypoparathyroidism • Alkalosis • Hypomagnesaemia • Acute pancreatitis • Alcoholism • Chronic diarrhoea • Hyperventilation • Malabsorption ```
27
What are some effects of hypocalcaemia?
* Cardiovascular: * Long QT intervals * Hypotension * Heart failure * Neuromuscular * Cramps / spasms * Tetany * Bronchospasms * Neurological: * Irritability * Seizures /Convulsions * Hyperreflexia * Positive chvostek sign * Positive trousseau sign * Parathesias * Abdominal * Intestinal cramps * laryngospasm
28
What are some causes of hyperphosphataemia?
• Increase absorption of phosphate o Excess use of some laxatives and enemas o Excess Vit D • Shift of phosphates from cells into blood o High levels of cell destruction –metastatic tumour cell lysis during chemotherapy • Inadequate excretion of phosphate o Renal failure o Hypoparathyroidism
29
What are the clinical manifestations of hyperphosphataemia?
* Neuromuscular: * Muscle cramping / Muscle twitching * Tetany * Hyperreflexia * Hypotension * Neurological: * Confusion * Paraesthesia * Seizures * Coma * Other: * Soft tissue calcification – Aching, stiff joints * Alkalosis * Itching skin * Cardiac dysrhythmias
30
What are some causes of hypophosphataemia?
* Inadequate absorption of phosphate * Chronic diarrhoea * Vomiting * Malabsorption * Misuse of phosphate-binding antacids * Chronic alcoholism * Vit D deficiency * Shift of phosphate from blood into cells * Respiratory Alkalosis * Insulin administration * Adrenalin administration * Excessive phosphate excretion * Increased diuresis * Hyperparathyroidism * Other: * Severe burns * Severe sepsis
31
Magnesium: What is its role in the body? Where is it stored? Where is it sourced from?
``` Role: • Nerve and muscle function • Neurotransmission • Bone structure • Constituent of several enzymes ``` Stored: • 50% is stored in the bone and muscle • 1/3 is bound to protieins ``` Dietary source: • Green vegetables • Cereal • Nuts • Dairy products ```
32
What are some causes of Hypermagnesaemia?
* Increased absorption of Mg: * Excessive use of Mg-containing antacids * Excessive infusion of Mg * Decreased excretion of Mg: * Renal failure * Metabolic acidosis
33
What are the clinical manifestations of hypermagnesaemia?
* Neuromuscular: * Decrease in deep tendon reflexes - Hyporeflexia * Muscular weakness * Paraesthesia * Paralytic ileus * Other: * Platelet aggregation * Hypotension * Dysrhythmia * Respiratory depression * Drowsiness and lethargy * Flushed skin and sweating * Cardiac arrest