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Prevention of estrogen deficiency-related bone loss with human parathyroid hormone-(1-34): a randomized controlled trial.

CONTEXT: Short-term intermittent administration of parathyroid hormone (PTH) prevents bone loss from the spine in women treated with a gonadotropin-releasing hormone (GnRH) analog. However, the effects of a longer period of PTH administration on bone mass in estrogen-deficient women, particularly on the hip and on cortical bone of the total body, are unknown. OBJECTIVE: To determine whether more prolonged PTH administration can prevent estrogen deficiency bone loss from the hip, spine, and total body in young women with endometriosis receiving GnRH analog (nafarelin acetate) therapy. DESIGN: Randomized controlled trial. SETTING: General Clinical Research Center of a tertiary care, university-affiliated hospital. PATIENTS: Forty-three women between the ages of 21 and 45 years with symptomatic endometriosis. INTERVENTION: Nafarelin alone (200 microg intranasally twice daily) or nafarelin plus human parathyroid hormone-(1-34) (hPTH-[1-34]) (40 microg subcutaneously daily). MAIN OUTCOME MEASURES: The primary end points were bone mineral density (BMD) of the anterior-posterior and lateral spine, femoral neck, trochanter, radial shaft, and total body at 12 months of treatment. RESULTS: In the women who received nafarelin alone, the mean (SEM) BMDs of the anterior-posterior spine, lateral spine, femoral neck, trochanter, and total body were 4.9% (0.6%) (P<.001), 4.9% (0.8%) (P<.001), 4.7% (1.1%) (P<.001), 4.3% (0.9%) (P<.001), and 2.0% (0.6%) (P= .003) lower than at baseline after 12 months of therapy. In contrast, coadministration of hPTH-(1-34) increased BMD of the anterior-posterior spine by 2.1% (1.1%) (P=.09) and lateral spine by 7.5% (1.9%) (P=.002) and prevented bone loss from the femoral neck, trochanter, and total body, despite severe estrogen deficiency. Radial shaft BMD did not change significantly in either group. Serum bone-specific alkaline phosphatase and osteocalcin concentrations and urinary excretion of hydroxyproline and deoxypyridinoline increased 2-fold to 3-fold during the first 6 to 9 months of therapy in the women who received nafarelin plus hPTH-(1-34) and then declined. Changes in urinary deoxypyridinolone excretion were strongly predictive (r= 0.85) of changes in spinal BMD in the women who received nafarelin plus hPTH-(1-34). CONCLUSIONS: Parathyroid hormone prevents bone loss from the proximal femur and total body and increases lumbar spinal BMD in young women with GnRH analog-induced estrogen deficiency.

Adult↗

Effect of parathyroid hormone on vitamin D metabolism in osteopetrosis.

Indices of vitamin D metabolism were studied before and after infusion of bovine parathyroid hormone extract in three children with osteopetrosis. Basal serum concentrations of calcium, alkaline phosphatase, and 25-hydroxyvitamin D tended to be low. Serum immunoreactive parathyroid hormone levels were in the upper normal range in two patients. A marked increase in urinary cyclic adenosine 3':5'-monophosphate (cAMP) in all patients was solely due to an increase in the nephrogenous cAMP. The basal concentration of 1,25-dihydroxyvitamin D was clearly more than the upper limit of normal range in all three patients and increased after parathyroid extract infusion in one patient. The basal serum levels of 24,25-dihydroxyvitamin D were within normal limits and tended to decrease after parathyroid extract infusion in two of the patients. Parathyroid hormone and 1,25-dihydroxyvitamin D act in concert to increase calcium resorption from bone, and the increased serum levels of both these factors may reflect lack, or unresponsiveness, of target cells in bone.

Child↗

Purification of human parathyroid hormone: recent studies and further observations.

During the isolation of human parathyroid hormone there is an extensive loss of immuno-assayble hormone over the successive extraction steps, due in part to the presence of fragments that are soluble in 4% trichloroacetic acid. These fragments are derived from both the amino- and carboxyl-terminal regions of the hormone. The hormonal fractions precipitated with trichloroacetic acid were further purified by gel filtration and ion-exchange chromatography. At the final ion-exchange purification step, some preparations of the hormone eluted in multiple fractions. When the various components were characterized separately by immunoassay, amino acid composition, enzymic cleavage and partial sequence analysis, they were found to be closely comparable, although the most acidic fraction contained a blocked terminal amino group. Extraction of a number of batches of tissue permitted revision of the amino acid composition of human parathyroid hormone. Biosynthetic studies with labelled amino acids confirmed the absence of tyrosine and the presence of phenylalanine and threonine and localized these residues to definite regions of the molecule.

Amino Acid Sequence↗

International collaborative study of N.I.B.S.C. research standard for human parathyroid hormone for immunoassay.

The use of a Research Standard for human parathyroid hormone (PTH) in a collaborative study of 17 laboratories in ten countries is described. Results of the study showed that the Research Standard was not distinguishable by immunoreactive criteria from the other preparations and laboratory working standards of human PTH included in the study. It was, however, shown to be distinguishable from the International Reference Preparation for Parathyroid Hormone, Bovine, for Immunoassay by immunoreactive criteria and by heterogeneity of estimates in terms of bovine PTH. The Research Standard had appropriate biological activities in three different in-vitro bioassay systems and appeared to be stable under conditions of accelerated degradation. This material in ampoules coded 75/549 is now available internationally as N.I.B.S.C. Research Standard for human PTH for immunoassay.

Drug Stability↗

Direct effect of parathyroid hormone on rat uterine contraction.

Synthetic bovine parathyroid hormone containing the 1-34 NH2 terminal amino acids [bPTH-(1-34)] is capable of inhibiting stimulated uterine contraction. The purpose of the present investigation is to determine whether the inhibitory action of bPTH-(1-34) is a direct action of the hormone fragment. The effect of different synthetic preparations of bPTH-(1-34), salmon calcitonin, corticotropin-inhibiting peptide and bovine serum albumin on oxytocin-stimulated uterine contraction was determined. In addition, the effects of atropine, propranolol, phentolamine, pyrilamine, cimetidine and the prostaglandin synthetase inhibitor indomethacin on the inhibitory action of bPTH-(1-34) on uterine contraction was determined. Both synthetic preparations of bPTH-(1-34) inhibited oxytocin-initiated contractions similarly. Salmon calcitonin, corticotropin-inhibiting peptide, and bovine serum albumin did not alter oxytocin-stimulated uterine contractions. The salmon calcitonin also did not alter the ability of bPTH-(1-34) to exert its inhibitory effect on uterine contraction. Cholinergic, alpha and beta adrenergic, histaminergic (H1 and H2) and prostaglandin synthetase inhibitors did not alter the action of bPTH-(1-34). These results suggest that the action of bPTH-(1-34) is 1) not due to the presence of a contaminant in the synthetic hormone preparation and 2) that the effect could be due to a direct action effect of the hormone fragment on uterine tissue.

Adrenocorticotropic Hormone↗

Relationships between parathyroid hormone, 25-hydroxyvitamin D, and bone mineral density in elderly men.

This study aimed to determine the relationships between parathyroid hormone, vitamin D status and bone mineral density (BMD) in healthy older men. Subjects [n = 133, mean age (SD) 69.5 (3.1), range 65-76 years] were recruited from two general practices in Cambridge. Blood samples were drawn for measurement of intact parathyroid hormone (1-84, hPTH) and total 25-hydroxyvitamin D. Bone mineral density at the hip and spine was measured by dual-energy X-ray absorptiometry (DEXA). After adjusting for age and body mass index (BMI), PTH was negatively correlated with trochanteric (r = -0.24, p = 0.007), intertrochanteric (r = -0.29, p = 0.001), and Ward's Triangle BMD (r = -0.15, p = 0.087). By analysis of variance, controlling for age and BMI, PTH showed a relatively consistent downward trend with increasing tertiles of bone mineral density, especially at the hip. These results suggest a role of parathyroid hormone in determining hip bone mineral density in a community-based sample of healthy elderly men.

Aged↗

Relaxant mechanisms of parathyroid hormone in rat mesenteric artery.

The effects of parathyroid hormone (PTH) on tension and intracellular Ca level ([Ca ] ) were examined in ring preparations of rat mesenteric artery using isometric tension recording and the fura-2 method, respectively. The PTH (30 n ) elicited relaxation in arterial rings precontracted by phenylephrine regardless of the presence or absence of endothelium. In the endothelium-denuded arterial rings precontracted by 3 micro M of phenylephrine or 60 m of potassium chloride (KCl), PTH-related protein and PTH produced concentration-dependent relaxation to the same extent, but inhibited contraction induced by phenylephrine more effectively than that induced by KCl. Phenylephrine-induced tonic contraction was changed to a phasic one with decreased peak tension in the presence of PTH. Similar changes were observed with extracellular Ca removal or methoxyverapamil plus SK&F96365, respective of voltage-gated and receptor-operated Ca channel inhibitors. Phenylephrine evoked a concentration-dependent contraction concomitant with an increase in [Ca ]. PTH reduced both responses to the same extent. In a Ca -free solution, PTH inhibited a phasic contraction and a transient increase in [Ca ] in response to phenylephrine but not caffeine. Reverse transcriptase-polymerase chain reaction showed that PTH and PTH receptors were expressed in the rat mesenteric artery. In this tissue, PTH increased cyclic adenosine monophosphate (cAMP) levels. These results suggest that the inhibitory effect of PTH on alpha -adrenoceptor-mediated contraction results from the inhibition of Ca influx through receptor-operated and voltage-gated Ca channels, and Ca release from Ca stores, probably via increased cAMP in the rat mesenteric artery.

Animals↗

Role of protein kinase C on the acute desensitization of renal cortical adenylate cyclase to parathyroid hormone.

The mechanisms of adenylate cyclase desensitization to parathyroid hormone are still unclear. Current evidence suggest that the signal generated after PTH binding to receptors results in activation of adenylate cyclase and stimulation of phospholipase C with subsequent activation of protein kinase C. Recent studies have suggested a role of protein kinase C on the regulation of the PTH-dependent receptor-adenylate cyclase system in cultured cells. Therefore, the present studies were conducted to examine the role of protein kinase C on the desensitization of canine renal cortical adenylate cyclase after an acute exposure in vivo to PTH. A group of normal dogs were treated with a single intravenous injection of 1 microgram/k of syn bPTH (1-34) or Nle bPTH (3-34). Ten minutes later, animals were subjected to bilateral nephrectomy and the kidney cortex processed for preparations of basolateral membranes for determinations of adenylate cyclase activity, as well as membrane and cytosolic fractions for analysis of protein kinase C activity. Animals not treated with PTH were used as controls. PTH administration in vivo resulted in a 46.9 +/- 9.3% decrease in maximal adenylate cyclase activity in vitro in response to syn bPTH (1-34) (P < 0.001). Likewise, PTH binding as measured with 125I-Nle8,18,Tyr34-bPTH (1-34)NH2 showed a 40 +/- 3% decrease. This alterations were associated with a marked translocation of protein kinase C from the cytosol to the membrane. Thus, protein kinase C activity in membrane fractions increased from 160.6 +/- 44.8 pmol Pi/min in controls to 500.4 +/- 123 in PTH treated dogs (P < 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Adenylyl Cyclases↗

Parathyroid hormone, vitamin D, and cardiovascular disease in chronic renal failure.

BACKGROUND: Parathyroid hormone and vitamin D have been shown to influence cardiac and vascular growth and function experimentally in human subjects with normal renal function. Because of the increased prevalence of hyperparathyroidism and altered vitamin D status in chronic renal failure, these alterations have been considered to contribute to the increased prevalence of cardiovascular disease and hypertension seen in this patient population. Methods and Results. In this article, we review experimental and clinical literature on the cardiovascular effects of parathyroid hormone and vitamin D and relate them to the development of cardiac and vascular dysfunction in uremia, such as: cardiomyopathy, myocardial hypertrophy, and fibrosis, as well as to myocardial ischemia; uremic glucose intolerance, dyslipidemia, and atherosclerosis; hypertension; and vascular and cardiac calcifications. CONCLUSIONS: The hyperparathyroid state and altered vitamin D status found in uremia contribute to the cardiovascular pathology seen clinically in uremia and also to the excess mortality from cardiovascular causes found in this patient group. The therapeutic implications of these observations are also discussed.

Cardiovascular Diseases↗

Stabilized NMR structure of human parathyroid hormone(1-34).

The structure of the biologically-active N-terminal region of human parathyroid hormone, PTH(1-34), was investigated in the presence of 10% trifluoroethanol using two-dimensional proton NMR spectroscopy, distance geometry and dynamic simulated annealing. Complete assignments of all backbone and side chain hydrogens were made with the aid of totally correlated spectroscopy (TOCSY) experiments, providing through-bond 1H-1H connectivities, and NOESY providing through-space and sequential backbone connectivities. Distance and angle constraints were used in the distance geometry algorithm DIANA II to generate a family of structures satisfying all inputs. The lowest energy structures were further refined using the dynamic-simulated-annealing protocol XPLOR 3. The major structural features evident in 10% trifluoroethanol are two segments of alpha-helix extending from residues Glu4 to Lys14/His14 and Ser17 to Asp30. A short length of unordered structure joined the two spans of helix. The structures of the N-terminal regions (4-13/14) agreed closely with the structure found in human parathyroid-hormone-related protein (PTHrP)(1-34) obtained earlier by Ray, Barden and Kemp [19]. However, PTHrP(16-19) exhibited a reverse turn which is incorporated in an extended helix in PTH. The consequent interactions between several hydrophobic residues in the C-terminal region in PTHrP are absent in PTH. Moreover, the turn in PTHrP(22-25) at the start of the C-terminal helix is present as a more standard loop of helix in PTH. Comparisons between the structures of the two hormones has enabled the probable location and structure of the PTH receptor-binding site to be placed in the segment of amphiphilic alpha-helix (24-31).

Amino Acid Sequence↗

Parathyroid hormone receptors in control of proximal tubule function.

Parathyroid hormone action on renal proximal tubule function involves phospholipase C/protein kinase C as well as adenylate cyclase/protein kinase A mediated regulatory pathways. Tissue culture experiments suggest that low concentrations of PTH affect preferentially the phospholipase C/protein kinase C pathway. In vivo, both regulatory cascades are probably involved in the regulation of proximal tubule function. It is not clear at present whether the two intracellular pathways are linked to one or two PTH receptors. A polarized distribution of PTH receptor(s) involving different second messengers appears possible in proximal tubule epithelial cells. High-affinity (Kd 10(-11)-10(-12) M) PTH receptors in the range of circulating PTH concentrations in vivo remain to be identified. Structural and functional characterization of PTH receptors as well as of the PTH-sensitive intracellular mediators and transport systems form the basis for a better understanding of PTH-dependent regulation of proximal tubule function.

Absorption↗

Immediate and medium-term results of intraoperative parathyroid hormone monitoring during video-assisted parathyroidectomy.

HYPOTHESIS: Using an intraoperative parathyroid hormone (IOPTH) assay during video-assisted parathyroidectomy by lateral approach is useful in patients with sporadic primary hyperparathyroidism, and the medium-term results of surgery are excellent. DESIGN: Retrospective study of patients with sporadic primary hyperparathyroidism following video-assisted parathyroidectomy by lateral approach with IOPTH measurement. PATIENTS: Of 394 patients with sporadic primary hyperparathyroidism, 200 (67%) were eligible for video-assisted parathyroidectomy by lateral approach: patients in whom a single enlarged gland was clearly localized by ultrasonography, sestamibi scintigraphy, or both. MAIN OUTCOME MEASURES: An IOPTH assay was used in 198 patients. Intraoperative parathyroid hormone was measured at induction, skin incision, ablation, and 5 and 15 minutes after ablation. RESULTS: The immediate results of the IOPTH assay were true positive in 187 cases (94.4%), true negative in 8 cases (4%), false negative in 2 cases (1%), and false positive in 1 case (0.5%). The overall accuracy of the IOPTH assay was 98.5%. All patients were normocalcemic postoperatively. The median follow-up was 20.5 months in 150 reviewed: 149 patients (99.4%) were normocalcemic, 17 patients (11.3%) had an elevated PTH level with normocalcemia, and 1 patient (0.6%) had recurrent primary hyperparathyroidism. CONCLUSIONS: In our experience, IOPTH monitoring during video-assisted parathyroidectomy by lateral approach is useful in detecting multiple gland disease not suspected by preoperative localization studies. Overall, IOPTH monitoring predicts medium-term normocalcemia with a success rate of 98.5% in patients with sporadic primary hyperparathyroidism.

Adult↗

Short-term effects of synthetic human parathyroid hormone-(1--34) administration on bone mineral metabolism in osteoporotic patients.

Since studies in animals and humans have shown that parathyroid hormone can stimulate bone formation and increase trabecular bone, and patients with primary and secondary hyperparathyroidism may exhibit osteosclerosis, we evaluated the effect of short-term administration of human parathyroid hormone, hPTH-(1--34), in patients with osteoporosis. Six patients with osteoporosis underwent detailed studies including blood and urinary measurements of calcium, phosphate, and magnesium; 47Ca kinetic studies; and 18-d balance studies before and during the short-term administration (3--4 wk) of a daily subcutaneous injection of hPTH fragment 1--34 given as 450 or 750 U/dose. The mean fasting plasma calcium values rose slightly after hPTH-(1--34) administration, primarily in the high-dose group. There was no difference in the mean fasting plasma inorganic phosphate levels. The mean daily urinary excretion of calcium and phosphate was significantly increased in patients given the higher dose. In patients given 750 U, net intestinal calcium absorption increased, phosphate absorption increased, calcium balance improved, and phosphate balance improved. In patients given 450 U, calcium balance and phosphate balance worsened. 47Ca kinetic studies showed a minimal increase in bone accretion rate, a decrease in the mean transit time of calcium in the exchangeable pools, and a decrease in the exchangeable-pool size. In all six patients there was an increased renal clearance of 47Ca as a result of hPTH-(1--34) administration. These studies indicate that low doses of parathyroid hormone may promote bone formation, whereas higher doses clearly have an adverse effect on the skeleton.

Aged↗

High- and low-flux acetate-free biofiltration: experimental assessment of calcium mass balance and intact parathyroid hormone behaviour.

We studied total calcium mass balance and plasma intact parathyroid hormone behaviour in 10 uraemic patients who underwent acetate-free biofiltration carried out in accordance with six different dialytic schedules, where either a polyacrylonitrile or a polysulphone membrane was used. Schedules 1 and 2 involved a reinfusion flow rate of 33.3 ml/min with a dialysate calcium concentration (DCa) of 1.75 and 2 mmol/l respectively; in schedule 3, 4, 5 and 6 reinfusion flow rate amounted to 50 ml/min and DCa was respectively of 1.75, 2, 2.25 and 2.5 mmol/l. Dehydration remained unchanged in all schedules: 700 g/h. Finally high- and low-flux acetate-free biofiltration are able to induce different Ca mass balance which may suit different therapeutic contexts. Ca mass balance was either positive or negative depending on reinfusion flow rate and DCa. With a reinfusion flow rate of 33.3 ml/min a DCa of at least 2 mmol/l was necessary to obtain a positive mass balance, while with a reinfusion flow rate of 50 ml/min DCa had to equal 2.25 mmol/l. In high-flux acetate-free biofiltration, the estimation of predialytic Ca2+ and DCa values, using a simple formula, allows prediction of the mass balance that will be attained. At the end of acetate-free biofiltration, intact parathyroid hormone always decreased when a polyacrylonitrile membrane was employed while it increased, in the presence of negative Ca mass balance with a polysulphone membrane.

Acetates↗

Comparison of the effects of parathyroid hormone (PTH) and recombinant PTH-related protein on bicarbonate excretion by the isolated perfused rat kidney.

The isolated perfused rat kidney was used to study the effects of amino-terminal fragments of human parathyroid hormone, hPTH(1-34), bovine parathyroid hormone, bPTH(1-84) and of PTH-related proteins, PTHrP(1-34), PTHrP(1-84), PTHrP(1-108) and PTHrP(1-141) on urinary bicarbonate excretion. PTHrP(1-34) (7 nmol/l), bPTH(1-84) (5.5 nmol/l) and hPTH(1-34) (7 nmol/l) had similar effects in increasing bicarbonate excretion with respect to the control. At lower concentrations (0.7 nmol/l) all PTHrP components, but not hPTH(1-34) or bPTH(1-84) increased bicarbonate excretion significantly. Infusions of PTHrP(1-108) and PTHrP(1-141) at 0.7 nmol/l, while associated with a rise in urinary bicarbonate concentration and excretion during the early stages of perfusion, produced a sharp decline in bicarbonate concentration and excretion in the latter part of perfusion. The different peptides produced no significant differences in glomerular filtration rate, fractional excretion of sodium or urine volume. The absence of substantial differences between the effects of hPTH(1-34) and PTHrP(1-34) are as noted in previous studies. The differences between PTHrP(1-108)/PTHrP(1-141) and PTHrP(1-34) demonstrated here are consistent with (1) the clinical manifestations of acidosis in hyperparathyroidism and alkalosis in humoral hypercalcaemia of malignancy, and (2) an independent action of a component of PTHrP beyond amino acids 1-34.

Animals↗

[A new technic to evaluate the sensitivity of the renal parathyroid hormone receptor in man].

We propose a simplified assessment of response to parathyroid hormone which could replace the traditional Ellsworth Howard test for the differential diagnosis of pseudohypoparathyroidism in man. We have demonstrated that bovine parathyroid hormone in normal and hypoparathyroid subject increases plasma cAMP except in pseudohypoparathyroid subjects. It is an efficient, reliable method without any collection of urine samples.

Child, Preschool↗

Measurement of human serum parathyroid hormone in disorders of calcium metabolism and during administration of certain gut hormones.

A sensitive radio-immunoassay for parathyroid hormone (PTH) using the commercially available antisera AS 211/32 and AS 211/41 has been established. The lower limit of sensitivity of the assay is 0,25 ng/ml. Seventy-nine per cent of normal subjects have PTH levels in the measurable range, with a mean of 0,49 ng/ml (SD +/- 0,26 ng/ml). Only 1 of 9 patients with proven primary hyperparathyroidism had a normal serum PTH value. The mean serum PTH value in this group was 3,0 +/- 0,26 ng/ml, which differed significantly from that in the normal group (P < 0,001). The serum PTH level of 33 patients on chronic haemodialysis was uniformly raised, while in 8 patients with hypoparathyroidism PTH levels were undetectable. Patients with malignant disease presented a mixed picture, with raised, normal or undetectable PTH levels. We investigated a possible relationship between the gut hormones, gastrin, secretin and cholecystokinin-pancreozymin (CCK-PK) and PTH secretion in human volunteers. No effect was found, although the investigations were conducted over relatively short time periods.

Adolescent↗

Aluminum absorption and distribution: effect of parathyroid hormone.

In rats, gastrointestinal aluminum absorption and tissue distribution were altered by parathyroid hormone; the resultant tissue concentrations were similar to those observed in dialysis patients with a fatal encephalopathy. In dialysis patients, serum aluminum and endogenous parathyroid hormone concentrations are significantly correlated. These data suggest that aluminum toxicity in dialysis patients results from oral aluminum ingestion in the presence of hyperparathyroidism.

Aluminum↗