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7 Implication of the PTH1R in the Pathogenesis of Secondary Hyperparathyroidism and Adynamic Osteopathy
P.A. Ureña Torres et al.
regulate its own production. In addition, the PTH1R down-regulation in bone cells
accentuates the negative calcium balance by impeding the resorptive and hypercalcemic action of PTH.
As regards of the adynamic osteopathy, a CKD-MBD complication that has
long times been recognized, numerous contributing factors have been proposed
including age, race, diabetes, excessive calcium and phosphate loading, calcitriol
deficiency and excess as well, accumulation of PTH fragments that antagonize
PTH1R, high serum osteoprotegerin (OPG) levels, decreased circulating bone
morphogenetic proteins, high leptin, decreased PTH pulsatility, and PTH1R downregulation in bone cells [53, 55, 59–64]. The skeletal PTH1R down-regulation is
certainly one of the major players as it has been related to the skeletal resistance to
the resorptive and hypercalcemic action of PTH. For these reasons, and to overcome the reduced number of PTH1R in uremic bone cells, it is actually recommended to maintain a serum PTH concentration above two times the upper limit of
normal values in CKD patients (KDIGO) . In case of very low serum PTH
levels, the scarce PTH1R number that could be stimulated by such a low PTH
would be insufficient to maintain a normal bone turnover rate [66, 67]. In addition,
as vitamin D down-regulates the PTH1R in osteoblast cells [66, 68], it is likely that
this phenomenon is implicated in the cases of adynamic osteopathy observed in
uremic children treated by peritoneal dialysis and high doses of active vitamin D
The anabolic effect of PTH on bone is mediated, at least partly, by downregulating SOST gene expression and the resulting amount of sclerostin production
by osteocyte and osteoblast cells, which frees the Wnt signaling pathway [72, 73].
Consequently, sclerostin over-expression reduces PTH-associated bone gain in
experimental animals . PTH, through the PTH1R, has also sclerostinindependent bone anabolic activities, which are mediated by Wnt10b produced by
T-cell . Accordingly, dysregulation of the osteocyte Wnt/β-catenin signaling
pathway, the major skeletal anabolic principle of the postnatal skeleton, seems to be
also involved in the pathophysiology of CKD-MBD .
Diseases Associated with PTH1R Mutations
Constitutively activating mutations of the PTH1R have been described in subjects
with Jansen’s disease, an autosomal dominant methaphyseal chondrodysplasia
characterized by dwarfism, severe cartilage conjugation, hypercalcemia, and hypophosphatemia in the presence of paradoxically low PTH and PTHrP . In contrast, inhibiting mutations of the PTH1R have also been identified in lethal forms of
autosomal recessive chondrodysplasia characterized by a premature endochondral
ossification . These activating and inhibiting mutations illustrate the crucial role
played by this PTH1R in the development of endochondral bone, where it slows
down PTHrP-induced differentiation of pre-hypertrophic chondrocytes in hypertrophic chondrocytes .
8 The Parathyroid Type I Receptor and Vitamin D in Chronic Kidney Disease
Vitamin D Regulates Renal and Bone PTH1R
Vitamin D deficiency is associated with up-regulation of the renal and skeletal
PTH1R in subjects with normal renal function. However, daily and intermittent
administration of calcitriol, for the treatment of SHPT in uremic children, inhibits
PTH1R expression and function in bone cells . As previously mentioned in this
chapter, PTH1R down-regulation in bone cells plays a central role in the skeletal
resistance to PTH action and the development of a low bone turnover disease in
CKD [54, 66, 69, 70].
PTH and vitamin D (1,25(OH)2D3) stimulate calcium reabsorption in the renal
distal convoluted tubules (DCT), and vitamin D further stimulates this phenomenon
by increasing PTH-stimulated calcium transport by DCT cells. It has now been
shown that vitamin D exerts this effect by considerably increasing the PTH1R
mRNA expression in DCT cells. This up-regulation is specific since 1,25(OH)2D3
does not change mRNA expression for other genes including the adrenergic receptor and the sodium-hydrogen exchanger (Na+/H+). Of note, the inactive vitamin D
form, 25(OH)D3 did not have any effect on the PTH1R mRNA expression level
. Vitamin A, through the retinoid X receptor (RXR), and the vitamin D/VDR
complex, may also modulate PTH1R expression. In combination with the putative
RXR ligand, 9-cis-retinoic acid, 1,25(OH)2D3 increases PTH1R mRNA expression
by fourfold in DCT cells, however, 9-cis-retinoic acid alone did not have any effect.
Likewise, the putative ligand for the retinoic acid receptor (RAR), all-trans-retinoic
acid, either alone or in combination with 1,25(OH)2D3, increases PTH1R mRNA
expression in DCT cells. Altogether, these findings indicate that 1,25(OH)2D3 upregulates the PTH1R in renal cells in a manner consistent with VDR/RXR heterodimers binding to a VDRE in the promoter region and trans-activating the PTH1R
Other Factors Regulating PTH1R
Extremely and continuously high levels of circulating PTH down-regulate renal and
bone PTH1R . Thus, it was thought that parathyroidectomy could correct such
a down-regulation; however, several experimental animal models have not been
able to demonstrate any improvement of skeletal PTH1R expression by parathyroidectomy, in particular in cases of CKD . Nevertheless, blocking calcium
channels with verapamil in uremic rats normalized intracellular calcium concentration and returned PTH1R expression to normal levels in cardiomyocytes; despite of
the marked elevation of serum PTH levels .
PTHrP can also down-regulate renal PTH1R as shown in rats over-producing
PTHrP by bearing the Walker carcinoma tumor . This regulation is tissuespecific and pamidronate, which partially corrected hypercalcemia and high circulating PTH levels in this model, also normalized the PTH1R mRNA expression in
P.A. Ureña Torres et al.
the kidney but not in tumors . Breast cancer cells express both PTHrP and
PTH1R and the PTH1R expression can be modulated by substrates present in the
extracellular matrix as well as by hydrocortisone , supporting the active participation of stromal collagen composition in the regulation of PTHrP production and
probably carcinogenesis . In choriocarcinoma JAR cells, the PTH1R is upregulated by epidermal growth factor (EGF), estradiol (E2) and dexamethasone, but
active vitamin D (1,25-dihydroxyvitamin D) down-regulated PTH1R in the same
cells and may act as an anti-proliferative agent .
Glucocorticosteroids and transforming growth factor beta (TGFβ) have distinct
tissular effects; they up-regulate the PTH1R expression in osteoblastic cells whereas
the same compounds down-regulate PTH1R expression in renal cells .
The renin-angiotensin-aldosterone system plays a crucial role in systemic blood
pressure control as well as regulating renal blood flow and glomerular filtration rate.
In addition, increased plasma aldosterone concentration, as well as the aldosterone
to renin ratio, has been shown to be independently associated with circulating PTH
levels. And, exclusively in patients with high circulating PTH levels, plasma aldosterone levels are independently associated with an increased risk of cardiovascular
mortality . In CKD, angiotensin II participates in the pathogenesis of kidney
damage, and PTHrP, a known vasodilator and proliferating agent, is up-regulated by
angiotensin II in renal tubules, glomeruli and renal vessels in case of renal injury
. The PTH1R mRNA expression is also increased by angiotensin II in these renal
structures. The blockage of angiotensin II action by AT1 (antagonists of type 1
angiotensin receptor), but not by AT2 antagonists, significantly reduced angiotensin
II-induced renal PTHrP and PTH1R overexpression and decreased tubular damage
and renal fibrosis [84–87]. Locally produced PTHrP exerts its vasodilating action by
binding and activating the PTH1R in vascular smooth muscle cells (VSMC). In
these cells, angiotensin II also stimulates PTHrP production, which is followed by a
rapid desensitization of PTHrP-related cAMP response due to PTH1R down-regulation. Contrarily to bone cells where the PTH1R down-regulation and desensitization
are mediated by a protein kinase pathway, in VSMC the activation of this signaling
pathway does not seem to be involved, which suggests that such diversity in the
PTH1R regulatory mechanisms provides a means for restricting the length and duration of the cellular response to PTH and PTHrP in a tissular specific manner .
Conclusions and Perspectives
Although several PTH receptors have been identified in vertebrates, but PTH1R
appears to be the principal mediator of PTH actions and regulator of mineral and
bone metabolism. PTH1R expression is down-regulated in bone and kidney at early
stages of CKD and represent a determinant factor for the development of SHPT and
CKD-MBD. The mechanisms responsible for this down-regulation remain largely
elusive. From a clinical point of view, the identification of these mechanisms and
mode of action represents an important challenge to improve uremic SHPT
8 The Parathyroid Type I Receptor and Vitamin D in Chronic Kidney Disease
prevention. Use of supra-physiological doses of active vitamin D analogs to treat
uremic SHPT may contribute to the development of low bone turnover disease,
adynamic osteopathy, and longitudinal growth retardation in uremic children,
through the down-regulation of the skeletal PTH1R. PTH1R gene polymorphisms
or mutations might explain some cases of severe osteoporosis and renal osteodystrophy in CKD subjects with inappropriately low serum PTH levels and severe
clinical and histological manifestations of bone loss. Finally, the accumulation of
truncated PTH fragments in CKD may compete with the bioactive whole (1–84)
PTH and act as inhibitors of the PTH1R, favoring then favor the skeletal resistance
to PTH hypercalcemic action.
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Vitamin D and Klotho in Chronic Kidney
Hirotaka Komaba and Beate Lanske
Abstract Klotho, originally identified as an aging suppressor, forms a complex
with the fibroblast growth factor (FGF) receptor and functions as an obligatory coreceptor for FGF23, a bone-derived hormone that regulates phosphate and vitamin
D metabolism. The identification and characterization of the klotho-FGF23 axis has
considerably advanced our understanding of chronic kidney disease-mineral and
bone disorder (CKD-MBD). By acting as a co-factor for FGFR in FGF23 signaling,
klotho plays a central role in the pathogenesis of disturbances of phosphate and
vitamin D metabolism in CKD. Klotho also exists as a soluble circulating protein,
which is produced by cleavage of the extracellular region. Although the detailed
mechanism remains to be determined, soluble klotho has been shown to possess
multiple functions. Accumulating data suggest that both transmembrane and soluble
form of klotho is deficient in patients with CKD and such klotho deficiency contributes to the pathogenesis of secondary hyperparathyroidism, vascular calcification,
left ventricular hypertrophy, and worsening of kidney injury. In this chapter, we
present recent insights into the role of the klotho-FGF23 axis in the altered metabolism of phosphate and vitamin D in CKD. We also discuss the reported multifunctional roles of soluble klotho and their potential involvement in the pathophysiology
Keywords FGF23 • Klotho • Vitamin D • CKD-MBD • Secondary
H. Komaba, MD, PhD (*)
Division of Nephrology, Endocrinology and Metabolism, Tokai University School of
Medicine, Shimo-Kasuya, Isehara, Japan
B. Lanske, MD
Department of Oral Medicine, Infection & Immunity, Harvard School of Dental Medicine,
Boston, MA, USA
© Springer International Publishing Switzerland 2016
P.A. Ureña Torres et al. (eds.), Vitamin D in Chronic Kidney Disease,
H. Komaba and B. Lanske
Klotho was originally identified by Kuro-o and co-workers while attempting to create a rodent model of hypertension when the transgene accidentally generated a
phenotype resembling premature-aging syndromes. Mice homozygous for the
transgene (kl/kl mice) develop complex phenotypes resembling human aging,
including growth arrest, soft-tissue calcifications, osteopenia, generalized tissue
atrophy, and short life-span .
The klotho gene encodes a single-pass transmembrane protein and is expressed
primarily in the kidney, the parathyroid gland, and the choroid plexus in the brain.
The principal function of klotho is to regulate phosphate and vitamin D metabolism
through acting as a co-receptor for bone-derived fibroblast growth factor 23 (FGF23)
[2, 3]. Loss of klotho hampers the binding of FGF23 to FGF receptors (FGFRs) and
results in severe hyperphosphatemia and hypervitaminosis D, which is considered
to explain the most part of the premature-aging features in kl/kl mice [4–7]. Beside
its physiological roles, accumulating evidences have demonstrated the critical role
of klotho-FGF23 axis in the pathogenesis of chronic kidney disease-mineral and
bone disorder (CKD-MBD) .
In this chapter, we present recent insights into the role of klotho and FGF23 in
the altered metabolism of phosphate and vitamin D in CKD. We also discuss the
reported multifunctional roles of soluble form klotho and their potential involvement in the pathophysiology of CKD-MBD.
Klotho as a Co-receptor for FGF23
The major function of klotho to regulate mineral metabolism has been uncovered by
the identification of FGF23 as a regulator of phosphate and vitamin D metabolism
[2, 3]. The Fgf23 gene was first cloned in mice as a new member of the FGF family
 and subsequently identified as a causative humoral factor for autosomal dominant hypophosphatemic rickets/osteomalacia (ADHR)  and tumor-induced
osteomalacia (TIO) . FGF23 induces urinary phosphate excretion by suppressing the expression of the sodium-phosphate cotransporter . FGF23 also suppresses 1,25(OH)2D via inhibition of the 1α-hydroxylase (CYP27B1) that converts
25-hydroxyvitamin D [25(OH)D] to 1,25(OH)2D and stimulation of the
24-hydroxylase (CYP24) that converts 1,25(OH)2D to inactive metabolites in the
proximal tubule of the kidney . Depletion of FGF23 has been shown to induce
hyperphosphatemia, excessive levels of 1,25(OH)2D, soft tissue calcification, and
short life-span , which are also observed in klotho-deficient (kl/kl) mice .
The strikingly similar phenotypes between Fgf23-null and klotho-deficient mice
implicate that the premature aging-like features may be partly regulated through a
common signaling pathway involving both FGF23 and klotho. This speculation led
to the identification of klotho as a co-factor for FGF23 and its receptor interactions
[2, 3]. FGF23 has been shown to bind to multiple FGFRs, including FGFR1c,
FGFR3c, and FGFR4 . Among these FGFRs, FGFR1c is likely to be the
Vitamin D and Klotho in Chronic Kidney Disease
physiologically relevant target for FGF23, because klotho-dependent FGF23 signaling defined by upregulation of the gene early growth-responsive 1 (Egr-1) is
enhanced only through interaction with FGFR1c but not with other FGFRs .
Structural analysis of FGF23 protein found that the N-terminal region of FGF23
binds to and activates FGFR whereas the C-terminal region of FGF23 is necessary
for the interaction with klotho .
The functional importance of klotho as a co-receptor for FGF23 has been evidenced in several in vivo studies. Genetic inactivation of klotho in either Hyp mice,
a murine homolog of X-linked hypophosphatemic rickets (XLH) , or FGF23
transgenic mice  has been shown to reverse the phenotype to the one identical
to Fgf23-null mice. Furthermore, an exogenous injection of bioactive FGF23 into
either klotho knockout mice or Fgf23/klotho double knockout mice did not produce
any obvious changes in phosphate and vitamin D metabolism . These observations strongly support the in vivo importance of klotho in FGF23 action, although it
remains to be determined why FGF23-mediated phosphate and vitamin D metabolism takes place in the proximal tubules, despite the predominant expression of
klotho in the distal tubular epithelial cells. One previous study has detected robust
induction of phosphorylated ERK1 (a marker of FGF23 bioactivity) only within
klotho-expressing distal tubules following FGF23 injection , suggesting that
FGF23-mediated signaling might be initiated in the distal tubule. However, a recent
study has shown that proximal tubular cells also express klotho and that FGF23
directly downregulates NaPi-2a in the proximal tubule through activation of ERK1/2
and serum/glucocorticoid-regulated kinase-1 (SGK1) . Furthermore, the targeted deletion of klotho in the distal tubule yielded only minor phenotypes compared to klotho-deficient mice . Collectively, these data suggest interdependency
between proximal and distal tubular cells for mediating FGF23 action but further
research is needed to confirm this possibility.
Given the critical role of klotho in regulating phosphate and vitamin D metabolism,
the premature-aging phenotype of klotho-deficient mice has been explained by its dramatic changes in mineral metabolism. Indeed, it has been shown that low phosphate
diet  and vitamin D-deficient diet  both rescue several aging-like phenotypes in
klotho-deficient mice, together with restoration of mineral disturbance. Furthermore,
genetic ablation of Cyp27b1  or NaPi2a  has also been shown to attenuate the
premature aging-phenotype of klotho-deficient mice. These data have provided compelling evidence that the premature aging syndrome caused by klotho deficiency is due
to retention of phosphate, calcium, and/or 1,25(OH)2D, but still cannot completely
eliminate the possibility of unique functions of klotho as discussed below.
The Role of Klotho-FGF23 Axis in CKD-MBD
The identification and characterization of klotho-FGF23 axis has reshaped our
understandings of the pathogenesis of CKD-MBD . In patients with CKD, circulating FGF23 levels increase progressively as kidney function declines [21, 22],
presumably to maintain neutral phosphate balance by promoting urinary phosphate