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7 Implication of the PTH1R in the Pathogenesis of Secondary Hyperparathyroidism and Adynamic Osteopathy

7 Implication of the PTH1R in the Pathogenesis of Secondary Hyperparathyroidism and Adynamic Osteopathy

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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) [65]. 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

derivatives [69–71].

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 [73]. PTH, through the PTH1R, has also sclerostinindependent bone anabolic activities, which are mediated by Wnt10b produced by

T-cell [74]. 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 [72].


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 [75]. In contrast, inhibiting mutations of the PTH1R have also been identified in lethal forms of

autosomal recessive chondrodysplasia characterized by a premature endochondral

ossification [76]. 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 [13].

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 [68]. 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

[77]. 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

gene [77].


Other Factors Regulating PTH1R

Extremely and continuously high levels of circulating PTH down-regulate renal and

bone PTH1R [78]. 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 [57]. 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 [56].

PTHrP can also down-regulate renal PTH1R as shown in rats over-producing

PTHrP by bearing the Walker carcinoma tumor [79]. 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 [79]. 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 [80], supporting the active participation of stromal collagen composition in the regulation of PTHrP production and

probably carcinogenesis [80]. 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 [81].

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 [78].

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 [82]. 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

[83]. 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 [88].


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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factor for human mesangial cells: implications for diabetic nephropathy. J Cell Physiol.


88. Okano K, Wu S, Huang X, et al. Parathyroid hormone (PTH)/PTH-related protein (PTHrP)

receptor and its messenger ribonucleic acid in rat aortic vascular smooth muscle cells and

UMR osteoblast-like cells: cell-specific regulation by angiotensin-II and PTHrP. Endocrinology.


Chapter 9

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

e-mail: Hirotaka_Komaba@hsdm.harvard.edu

B. Lanske, MD

Department of Oral Medicine, Infection & Immunity, Harvard School of Dental Medicine,

Boston, MA, USA

e-mail: beate_lanske@hsdm.harvard.edu

© Springer International Publishing Switzerland 2016

P.A. Ureña Torres et al. (eds.), Vitamin D in Chronic Kidney Disease,

DOI 10.1007/978-3-319-32507-1_9




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 [1].

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) [8].

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

[9] and subsequently identified as a causative humoral factor for autosomal dominant hypophosphatemic rickets/osteomalacia (ADHR) [10] and tumor-induced

osteomalacia (TIO) [11]. FGF23 induces urinary phosphate excretion by suppressing the expression of the sodium-phosphate cotransporter [12]. 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 [12]. Depletion of FGF23 has been shown to induce

hyperphosphatemia, excessive levels of 1,25(OH)2D, soft tissue calcification, and

short life-span [13], which are also observed in klotho-deficient (kl/kl) mice [1].

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 [3]. 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 [2].

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 [14].

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) [15], or FGF23

transgenic mice [16] 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 [17]. 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 [18], 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) [19]. Furthermore, the targeted deletion of klotho in the distal tubule yielded only minor phenotypes compared to klotho-deficient mice [20]. 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 [4] and vitamin D-deficient diet [5] both rescue several aging-like phenotypes in

klotho-deficient mice, together with restoration of mineral disturbance. Furthermore,

genetic ablation of Cyp27b1 [6] or NaPi2a [7] 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 [8]. 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

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