PHYSIOLOGY OF CALCIUM AND VITAMIN D METABOLISM

MARKERS OF BONE FORMATION AND BONE

RESORPTION

BY DR. MOHAMMED ABDUL NAVEED

2ND YR ORTHOPAEDIC PG
GANDHI MEDICAL COLLEGE
BONE COMPOSITION
CALCIUM
 Calcium is essential for normal cell function and physiological
processes such as blood coagulation, nerve conduction and
muscle contraction.
 The main sources of calcium are dairy products, green
vegetables and soya (or fortified foods).
 The recommended daily intake for adults is 800–1000 mg and
1200  mg during pregnancy and lactation. Children need less,
about 200–400 mg per day.
 About 50% of the dietary calcium is absorbed (mainly in the
upper gut) but much of that is secreted back into the bowel and
only about 200 mg enters the circulation.
 The normal concentration in plasma and extracellular fluid is
(8.8–10.4 mg/dL). Much of this is bound to albumin as well as
other proteins; about half is ionized and effective in cell
metabolism and the regulation of calcium homoeostasis.
 PHOSPHORUS
 Phosphorus is needed for many important metabolic processes,
including energy transport and intracellular cell signalling.
 It is abundantly available in the diet and is absorbed in the
small intestine, more or less in proportion to the amount
ingested;
 Absorption is reduced in the presence of antacids such as
aluminium hydroxide, which binds phosphorus in the gut.
 Phosphate excretion is extremely efficient, but 90% is
reabsorbed in the proximal tubules. Plasma concentration –
almost entirely in the form of ionized inorganic phosphate
(Pi) – is normally maintained at (2.8–4.0 mg/dL).
 The solubility product of calcium and phosphate is held at
a fairly constant level; any increase in the one will cause the
other to fall.
 HORMONE REGULATION
 REGULATORS OF  REGULATORS OF
CALCIUM PHOSPHORUS

 VIT D3  VIT D3
 PTH  PTH

 CALCITONIN  FGF23
VITAMIN D
 There are two main forms: vitamin D2 (ergocalciferol),
which s synthetic, and vitamin D3 (cholecalciferol),
which is naturally occurring.
VITAMIN D METABOLISM
 The active vitamin D
metabolites are derived
either from the diet or by
conversion of precursors
when the skin is exposed
to sunlight. The inactive
‘vitamin’ is hydroxylated,
first in the liver and then
in the kidney, to form the
active metabolites 25-
HCC and 1,25-DHCC.
VITAMIN D
 Although the concentration of active metabolites can be
measured in serum samples, the best indicator of
vitamin D status is 25-OHD concentration (serum
1,25-(OH)2D has a half-life of only 15 hours and is
therefore not as good an indicator). Generally, 25-OHD
levels of >50 nmol/L are considered sufficient.
PARATHYROID HORMONE (PTH)

 PTH is produced by the parathyroid glands.

 (PTH) is the major regulator of extracellular calcium
concentration.
 Secretion is regulated by plasma ionized calcium.

 This regulation is mediated by the calcium-sensing

receptor (CaSR), which is activated by decreased ionized
calcium, leading to suppression of PTH secretion.
 CALCITONIN
 Secreted by parafollicular or C cells
 distributed throughout thyroid gland
 Normal serum concentration

 Men:<8.8 pg/mL

 Women:<5.8 pg/mL

 Level Increases when serum Ca

concentration>2.25mmol/L
FGF23(PHOPHATURIC HORMONE)

 FGF23 is produced by osteocytes, and acts to lower serum Pi

by promoting renal Pi excretion through suppression of renal
tubular Pi reabsorption.
 FGF23 levels are influenced by dietary Pi intake, and by
calcitriol levels; the latter reduces serum Pi by increasing Pi
excretion via stimulation of FGF23 release, leading to a
reciprocal increase in serum calcium.
 Altered circulating levels of FGF23, which can be readily
measured, are associated with a variety of genetic and acquired
disorders. In many of these cases, the clinical manifestations
reflect reduced skel-etal mineralization as a result of a reduction
in the calcium × phosphate product due to excess FGF23
activity, giving a clinical picture of hypophospha-temia and
vitamin D-resistant osteomalacia .
BONE REMODELLING CYCLE
 BONE REMODELLING =BONE RESORPTION
+BONE FORMATION.

 Bone formation and resorption continue as a lifelong

process contributing to bone growth and modelling.
 These two processes are carefully which serves to
maintain bone integrity.
 They are also activated during repair following injury,
for example after a fracture.
BONE REMODELLING CYCLE
 BONE RESORPTION

 Bone resorption is carried out by the osteoclasts under

the influence of stromal cells (including osteoblasts) and
both local and systemic activators.
 Though it has long been known that parathyroid
hormone (PTH) promotes bone resorption, osteoclasts
have no receptor for PTH. The hormone acts indirectly
through its effect on 1,25- (OH)2D3 and osteoblasts.
 Proliferation of osteoclastic progenitor cells requires the
presence of an osteoclast differentiating factor produced
by the stromal osteoblasts after stimulation by, for
example, PTH, glucocorticoids or pro-inflammatory
cytokines.
BONE FORMATION
 carried out by teams of osteoblasts,
 which are recruited to a bone surface and

 secrete osteoid, composed of type I collagen fibrils, which becomes

deposited on the adjacent bone surface.
 Bone mineral, hydroxyapatite crystals, subsequently become
deposited in spaces between collagen fibrils.
 Whereas osteoid is rapidly mineralized following its synthesis, a
process of secondary mineralization takes place after bone formation
is complete.
 Skeletal maturity also influences the degree of collagen cross-link
formation, a process whereby adjacent type I collagen fibrils undergo
fur-ther protein binding to enhance tensile strength. The amino acid
sequence where these cross-links occur, termed N-terminal
telopeptide, are largely specific to bone, and their level in plasma
following release into the circulation following bone resorption
forms the basis of clinical measurement of bone turnover.
BONE FORMATION
 Like bone resorption, bone formation is regulated by a
combination of systemic and locally produced factors
acting to promote osteoblast differentiation.
 most important local factors in regulating osteoblast
differentiation are the bone morphoge-netic proteins
(BMPs) and the Wnt signalling system, both of which
comprise complex systems of multiple ligands, cell
surface receptors, intracellular signalling pathways and
endogenous inhibitors.
BONE REMODELLING
 Osteoblast and osteoclast activity are coordinated during
bone remodelling.
 This process, which determines the internal architecture of
bone, occurs not only during growth but throughout life.
 Bone remodelling serves several crucial purposes: ‘old bone’
is continually replaced by ‘new bone’ and in this way the
skeleton is protected from the excess accumulation of fatigue
damage and the risk of stress failure;
 Bone turnover is sensitive to the demands of function, and
trabec-ulae are fashioned in accordance with the stresses
imposed upon the bone, the thicker and stronger trabeculae
following the trajectories of compressive stress and the finer
trabeculae lying in the planes of tensile stress.
 BONE TURNOVER
 It is a coupled process of bone formation and bone
resorption
 Takes place throughout the life at different rates

 Before 30yrs bone formation exceeds resorption

 At 30 yrs the skeletal mass is at its peak and both

processes are matched
 Later resorption goes on increasing for the rest of the life

 The annual rate of bone turnover in healthy adults has

been esti-mated as 4% for cortical bone and 25% for
trabecular bone.
BIOCHEMICAL MARKERS OF BONE FORMATION AND
RESORPTION AND THEIR UTILITY IN ORTHOPAEDICS

 Chemicals in serum and urine can serve as markers for

monitoring bone loss, bone reformation, and the
effectiveness of therapy in patients with osteoporosis.
HISTORY
• More than 50 years ago, Fuller Albright,the father
of metabolic bone diseases, noted that postmenopausal
women were losing excessive amounts of calcium in
their urine.
• He is credited with introducing the use of
biochemical markers into the clinical arena.
FORMATION MARKERS(SERUM)

 Total ALP
 Bone ALP

 Osteocalcin (OC)

 C-terminal propeptide of protocollagen type I (PICP)

 N-terminal propeptide of protocollagen type I (PINP)

RESORPTION MARKERS(SERUM)

 Tartrate resistant acid phosphatase (TRAP)

 C-terminal telopeptide of collagen type I(ICTP)

 N-terminal telopeptide of collagen type I (NTX)

 β-CrossLaps (β-CTX)
URINE MARKERS
 Urinary excretion of calcium
 Hydroxyproline

 Pirydinolin (Pir)

 Deoxypirydinolin (Dpir)

 C-terminal telopeptide of collagen type I (ICTP)

 N-terminal telopeptide of collagen type I (NTX)

 α-CrossLaps (α-CTX)
FORMATION MARKERS
ALKALINE POHOSPHATASE

 Alkaline phosphatase activity is derived from various

tissues such as the liver, bone, placenta, etc.
 Bone and liver isoforms are the most common (90%).

 Both are found in the same proportion in the healthy

individual .
 Normal range: 20 – 140 IU/L
SERUM OSTEOCALCIN
 Osteocalcin is a small protein (49 amino acids) .
 Synthesized by mature osteoblasts , odontoblasts , and
hypertrophic chondrocytes .
 Major advantages –

considered a specific marker of osteoblast

function as its levels correlate with the bone formation
rate.
PRO COLLAGEN TYPE 1
 Procollagen type 1 contains N- and C-terminal
extensions, which are removed by specific proteases
during conversion of procollagen to collagen.
 Antibodies are used to detect the P1CP and P1NP by
ELISA or radioimmunoassay.
 Measurement of P1NP appears to be a more sensitive
marker of bone formation rate in osteoporosis.
 Because type I collagen is the main product of synthesis
of the osteoblast, the amino-termina carboxy propeptides
would, theoretically, be the ideal marker of bone
formation.
RESORPTION MARKERS
 Historically, urinary calcium was the first test used to
assess bone resorption.
 However, the fact that it is influenced by various factors,
such as calcium intake, intestinal absorption and renal
threshold of excretion of calcium, makes its
determination a test with low sensitivity and specificity,
and is currently unused.
CARBOXYTERMINAL (ICTP, CTX) AND AMINO-
TERMINAL (NTX) TELOPEPTIDES OF COLLAGEN
 They have shown a significant correlation with BMD in
postmenopausal women.
 considered the most clinically useful markers of bone
resorption currently available.

Tartrate-resistant acid phosphatase(TRAP)

 Is a lysosomal enzyme not only involved in osteoclast
bone degradation but is also present in other tissues.
 It is poorly specific, and together with the
methodological difficulty in identifying it, currently
makes it of little use.
CLINICAL UTILITY OF BIOMARKERS IN
OSTEOPOROSIS

 assessment of therapeutic response.

 Predicting risk of fracture and bone loss and their
correlation with BMD.
 Prediction of bone mass.
 DISEASE WITH MARKERS

Disease S. Ca S. PO4 S.PTH S. ALP Recent biomarker

Osteoporosis N N N N/high Cathepsin K

C- telopeptide

Rickets/Osetmalacia Low low high high Osteocalcin

Paget’s disease N N N high --------

LIMITATIONS ON THE USE OF MARKERS
 However, one cannot ignore the fact that markers of
bone turnover show a marked variability, both analytical
and biological.
 The causes of variability : age, sex, ethnicity, fracture
repair, renal and hepatic function, other associated
diseases, and so on.
 It is important to determine the time of sample collection
according to the circadian rhythm of each marker.
 Some markers in particular are heavily influenced by
food, as is the case with serum CTX.
 APPLIED
PHYSIOLOGY
 METABOLIC BONE DISEASES

 OSTEOPOROSIS(MOST COMMON)
 RICKETS

 OSTEOMALACIA

 HYPERPARATHYROIDISM

 RENAL OSTEODYSTROPHY(CHRONIC KIDNEY

DISEASE-BONE MINERAL DISEASE)
 PAGETS DISEASE(OSTEITITS DEFORMANS)

 OSTEOPETROSIS(MARBLE BONE DISEASE)

 HYPERCALCAEMIA OF MALIGNANCY
 RICKETS &
OSTEOMALACIA
 Rickets is defective mineralization of bones
before epiphysial closure in immature mammals
due to deficiency or impaired metabolism
of vitamin D, phosphorus or calcium ,potentially
leading to fractures and deformity.
 Osteomalacia is a similar condition occurring in
adults, generally due to a deficiency of vitamin
D but occurs after epiphyseal closure.
 RICKETS &
OSTEOMALACIA
• Lab investigations include :
• S. ALP ↑
• Ca low in Vitamin D deficiency
• Phosphate may be normal or low
• PTH may ↑
 OSTEOPOROSIS
 DEF-Osteoporosis as a clinical disorder is characterized
by an abnormally low bone mass and defects in bone
structure, a combination which renders the bone
unusually fragile and at greater than normal risk of
fracture in a person of that age, sex and race.
 OSTEOPOROSI
S
 Common in developed countries
 Associated with advanced age
 Associated with increased risk of fractures (hip,
vertebrae, forearm)
 Exercise & nutrition play an important role in
attaining adequate skeletal mass
 During early adult life bone formation = bone
resorption
 Aging increases bone resorption
 OSTEOPOROSIS
• Pathophysiology
 Inadequate bone formation during
growth
 Pathophysiological process
impairing osteoblastic bone
formation
 Increase in bone resorption
 FACTORS INVOLVED IN CAUSATION
OF OSTEOPOROSIS
 Hormones
 Poor diet
 Genetic factors
 Cytokines
 Prostaglandins
 Growth factors
Low physical activity and low exposure to
sunlight
OSTEOPOROSIS
-
• Risk Factors
 Early menopause
 family history
 Sedentary life
 Low calcium intake
 Cigarette smoking
 Excessive alcohol
 Excessive caffeine
 steroid therapy
 CLINICAL
PRESENTATIONS
 Back pain
 Fractures
Investigations
 Routine X-rays
 Bone scan
 Investigations for secondary causes
 OSTEOPOROSIS
(MANAGEMENT)
 Exercise
 Calcium
 Vit D
 Bisphosponates
 Oestrogen replacement
 Androgens
 PAGETS
DISEASE
 Disease of bone remodelling
 osteoclast mediated bone resorption followed by
new bone formation
 Cause unknown ?virus (paramyxovirus)
 More common in caucasian
PAGETS DISEASE
(INVESTIGATIONS)

 ↑ markers of bone formation

 ↑ ↑ Serum alk phosphatase
 Urinary hydroxy proline and pyridinoline cross links
 X-rays
 cortical thikening
 osteolytic, & osteiosclerotic
 bone scan
 RENAL
OSTEODYSTROPHY
• Associated with CRF
a) ↓excretion of PO4 ---> ↑ PO4
b) Inability of kidney to synthesise 1,25 (OH)2D (↓ renal
mass & ↑ PO4)
c) ↓ intestinal absorption of Ca ---> hypocalcemia
• Results in hyper parathyroidism
• LAB INVESTIGATIONS:
 ↑ PO4
 HYPOCALCEMIA
 ↑ PTH
 ↓1,25 (OH)2 D
 ↑ ALP
 Mg ↑
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