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The use of calcium carbonate (CaCO3) to bind phosphorus (P) in chronic hemodialysis patients has been a popular tactic in the past decade. Nonetheless, problems with hypercalcemia decrease its usefulness, particularly in patients treated with calcitriol. A P binder not containing calcium (Ca) would be of value in these circumstances. In short-term studies, we showed that magnesium carbonate (MgCO3) was well-tolerated and controlled P and Mg levels when given in conjunction with a dialysate Mg of 0.6 mg/dl. We, therefore, performed a prospective, randomized, crossover study to evaluate if the chronic use of MgCO3 would allow a reduction in the dose of CaCO3 and yet achieve acceptable levels of Ca, P, and Mg. We also assessed whether the lower dose of CaCO3 would facilitate the use of larger doses of calcitriol. The two phases were MgCO3 plus half the usual dose of CaCO3 and CaCO3 alone given in the usual dose. It was found that MgCO3 (dose, 465 +/- 52 mg/day elemental Mg) allowed a decrease in the amount of elemental Ca ingested from 2.9 +/- 0.4 to 1.2 +/- 0.2 g/day (P < 0.0001). The Ca, P, Mg levels were the same in the two phases. The maximum dose of i.v. calcitriol without causing hypercalcemia was 1.5 +/- 0.3 micrograms/treatment during the MgCO3 phase and 0.8 +/- micrograms/treatment during the Ca phase (P < 0.02). If these studies are confirmed, the use of MgCO3 and a dialysate Mg of 0.6 mg/dl may be considered in selected patients who develop hypercalcemia during treatment with i.v. calcitriol and CaCO3.

The active metabolite of vitamin D, calcitriol (1 alpha,25-(OH)2D3), suppresses parathyroid hormone (PTH) gene transcription. Although 1 alpha,25-(OH)2D3 is effective in suppressing secondary hyperparathyroidism (SH) in uremic patients, the mandatory use of large amounts of calcium salts to control serum phosphorus may preclude, in some patients, the use of ideal therapeutic doses of 1 alpha,25-(OH)2D3 because of hypercalcemia. We have studied a new analog of calcitriol, 19-nor-1 alpha,25-(OH)2D2, that possesses low calcemic and phosphatemic activity. Uremic rats received vehicle, 1 alpha,25-(OH)2D3 (2.0, 4.0, or 8.0 ng/rat) or 19-nor-1,25-(OH)2D2 (8.0, 25 or 75 ng/rat) intraperitoneally (IP) every other day for a period of 8 days. Pretreatment and posttreatment values of intact PTH were measured. The normal values for rat intact-PTH were 22 +/- 4.2 pg/mL and for ionized calcium (ICa) 4.77 +/- .07 mg/dL. The only dose of 1 alpha,25-(OH)2D3 that achieved a significantly, suppressed PTH (P < 0.01) was the 8.0 ng/rat. PTH decreased from 202 +/- 31 to 90 +/- 20 pg/mL. However, ICa increased from 4.81 +/- 0.08 to 5.08 mg/dL from uremic control (P < 0.02). Conversely, all doses of 19-nor-1,25-(OH)2D2 were effective in suppressing PTH, and none produced an elevation in ICa that was significantly different from that of vehicle-treated uremic rats. The maximum effect was achieved with the 75 ng/rat dose, which decreased PTH from 193 +/- 49 to 53 +/- 16 pg/mL (a decrease in 72.5%).(ABSTRACT TRUNCATED AT 250 WORDS)

The separate and combined effects of weight-bearing exercise and hormone replacement therapy (HRT) on bone mineral density (BMD) were studied in 32 women, 60 to 72 years of age. HRT consisted of continuous conjugated estrogens 0.625 mg/day and trimonthly medroxyprogesterone acetate 5 mg/day for 13 days. Exercise consisted of 2 months of low-intensity exercise followed by 9 months of more vigorous weight-bearing exercise approximately 45 minutes/day, > or = 3 days/week, at 65-85% of maximal heart rate. Lumbar spine and proximal femur BMD were significantly increased in response to exercise and to HRT, and total body BMD was significantly increased in response to HRT; neither exercise nor HRT had an effect on wrist BMD. The combination of exercise + HRT resulted in increased BMD at all sites except the wrist, with effects being additive for the lumbar spine and Ward's triangle and synergistic for the total body. Based on reductions in serum osteocalcin levels, it appears that increases in BMD in response to HRT and exercise + HRT were due to decreased bone turnover. The lack of change in serum osteocalcin and IGF-I in response to exercise alone suggests that increases in BMD were due to decreased bone resorption and not increased formation. Results indicate that weight-bearing exercise + HRT may be effective in preventing and/or treating osteoporosis. It is likely that the additive effects of weight-bearing exercise and HRT on bone mineral accretion, coupled with other adaptations to the exercise (i.e., increased strength and functional capacity), could effectively reduce the incidence of falls and osteoporotic fractures.

It has been suggested that magnesium carbonate (MgCO3) may be an effective and safe alternative to calcium carbonate in binding phosphorus in dialysis patients. In these studies, the concentration of magnesium in the dialysate was either very low or zero. To date, only patients undergoing conventional dialysis have been reported. The primary purpose of the present study was to determine the fluxes of magnesium using dialysate magnesium concentrations of 0 mg/dL, 0.6 mg/dL, and 1.8 mg/dL in eight patients undergoing high-efficiency hemodialysis. The net removal of magnesium was 486 +/- 44 mg, 306 +/- 69 mg, and 56 +/- 50 mg, with the use of dialysate magnesium concentrations of 0 mg/dL, 0.6 mg/dL, and 1.8 mg/dL, respectively (P = 0.001). Plasma magnesium levels significantly decreased from 3.3 +/- 0.2 mg/dL to 1.6 +/- 0.2 mg/dL and from 3.4 +/- 0.3 mg/dL to 2.1 +/- 0.2 mg/dL during the dialysis sessions using 0 mg/dL and 0.6 mg/dL magnesium dialysates, respectively. Plasma magnesium remained unchanged when 1.8 mg/dL dialysate magnesium was used. A significant independent correlation was found between the total magnesium removed and both the dialysate concentration used (P < 0.001) and the predialysis plasma magnesium level (P < 0.001). The measured magnesium removal exceeded the estimated predialysis extracellular fluid (ECF) magnesium pool with the use of magnesium-free dialysate. This was not found with dialysate magnesium concentrations of either 0.6 mg/dL or 1.8 mg/dL. A secondary purpose of the study was to determine the acute clinical tolerance of the low and magnesium-free dialysates.(ABSTRACT TRUNCATED AT 250 WORDS)

Similar to the discovery of the VDR in nonclassical target tissues, the expression of 1 alpha-hydroxylase activity in immune cells, in the hematopoietic system, in tissues at early stages in development, in keratinocytes, and in the liver raises numerous questions about the physiological role of endogenous 1,25(OH)2D3 production. Extrarenal sources are regulated independently from the renal enzyme. The tight control of nonrenal 1 alpha-hydroxylase by physiological levels of calcitriol under normal circumstances and the total absence of regulation in several pathological states are consistent with 1,25(OH)2D3 synthesis having a local role rather than contributing to systemic calcitriol homeostasis. The simultaneous expression of vitamin D receptors, constitutive 1 alpha-hydroxylase, and inducible 24-hydroxylase activity in the same cell or in cells of the nearby environment suggests that they constitute a means for an in situ regulation of the response to vitamin D. Experimental evidence indicates that tissue-specific vitamin D microendocrine systems participate in transmural calcium transport, in normalizing serum calcitriol in chronic renal failure, in the control of hematopoiesis, in the modulation of the immune response, and in cellular growth and differentiation in a variety of cell types. A complete understanding of the physiological relevance of extrarenal calcitriol synthesis awaits cloning of the 1 alpha-hydroxylase and characterization of the molecular mechanisms modulating its expression.

The past 20 years has witnessed a dramatic improvement in our understanding of the factors involved in the pathogenesis of secondary hyperparathyroidism in chronic renal insufficiency. The major causes are retention of phosphorus, relatively low levels of serum calcium, and decreased 1,25-(OH)2D3 (calcitriol) levels. Abnormalities in vitamin D metabolism are responsible for a series of events that result in a state of abnormal calcium-regulated parathyroid hormone (PTH) secretion. In patients with a moderate degree of renal insufficiency, phosphate restriction suppresses PTH secretion by increasing serum calcitriol. However, studies in patients and dogs with advanced renal insufficiency have clearly demonstrated that phosphate per se, independent of the levels of calcitriol or ionized calcium, has an important effect on the secretion of PTH. In addition, low levels of calcitriol, characteristically seen in patients with advanced renal insufficiency, may affect the response of the parathyroid glands to serum ionized calcium. A shift in the set-point for calcium-regulated PTH secretion requires a much higher concentration of serum calcium to suppress the release of PTH. Studies evaluating the administration of intravenous calcitriol have clearly demonstrated that the parathyroid glands become more sensitive to calcium and the suppression of PTH secretion can be achieved with physiologic levels of ionized calcium. In addition, the number of calcitriol receptors in the parathyroid glands of patients and experimental animals with advanced renal failure is low. Investigators have shown that the administration of calcitriol to normal rats increases the mRNA of the vitamin D receptor. Thus, calcitriol upregulates the number of its own receptor.(ABSTRACT TRUNCATED AT 250 WORDS)

Previous studies from our laboratory have shown that anephric patients have very low, but detectable, levels of 1,25(OH)2D3 (calcitriol) that can be increased to normal by administration of large doses of 25(OH)D3. The report of 1 alpha-hydroxylase activity in pig liver with an affinity for substrate significantly lower than that of the renal enzyme, led us to use the rat as an experimental model to further clarify the need of supraphysiological levels of 25(OH)D3 to correct calcitriol deficiency in chronic uremia. We have measured 1,25(OH)2D3 production by rat liver. Cytosol free liver homogenates (CFH) from normal rats were incubated with 25(OH)D3 and the production of 1,25(OH)2D3 was measured using the thymus radioreceptor assay after solid phase C18 extraction and HPLC purification of the samples. 1,25(OH)2D3 production was linear up to 30 minutes and a CFH protein concentration up to 20 mg. Saturability was attained for a substrate concentration of approximately 60 microM. Ketoconazole, a cytochrome P450 inhibitor, blocked calcitriol production in a dose dependent fashion. Total inhibition of the liver 1 alpha-hydroxylase was achieved with 180 microM ketoconazole. We next compared the kinetics of the 1 alpha-hydroxylases of normal and uremic rat livers. Maximal velocities were not statistically different (139.6 +/- 22.3 pg/mg/min for normals and 217.1 +/- 73.3 pg/mg/min for uremic rats). However, the apparent Km was 35.9 +/- 3.2 microM for uremic animals, significantly higher (P < or = 0.001) than that of normal rats (16.6 +/- 0.7 microM).(ABSTRACT TRUNCATED AT 250 WORDS)

1,25-dihydroxyvitamin D3 has been used with success in the treatment of secondary hyperparathyroidism associated with chronic renal failure. However, frequently 1,25-(OH)2D3 induces hypercalcemia, especially in those patients ingesting large doses of calcium carbonate, precluding the administration of therapeutic doses of 1,25-(OH)2D3. In addition, control of serum phosphorus is a persistent problem in patients maintained on chronic hemodialysis and 1,25-(OH)2D3 treatment can aggravate the hyperphosphatemia. Thus, ideally an analog of 1,25-(OH)2D3 that can suppress PTH with minor effects on calcium (Ca) and phosphate (PO4) metabolism would be an ideal tool to control secondary hyperparathyroidism. We have shown that 22-oxa-1,25-(OH)2D3 (OCT), an analog of 1,25-(OH)2D3 with little calcemic activity, can suppress PTH mRNA in normal rats and in cultured bovine parathyroid cells with equipotency to 1,25-(OH)2D3. To further characterize the differential effects of 1,25-(OH)2D3 and OCT on Ca and PO4 metabolism we performed several experiments in intact and parathyroidectomized (PTX) rats. In metabolic studies in four groups of normal rats 1,25-(OH)2D3 treatment (8 ng/day) significantly increased the intestinal Ca absorption from 15.2 +/- 2.68% to 30.5 +/- 2.85% (P < 0.01), while the same dose of OCT had no effect. A dose of 200 ng/day of OCT increased intestinal Ca absorption similarly to the 8 ng/day dose of 1,25-(OH)2D3, from 10.6 +/- 2.49% to 24.8 +/- 2.35% (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

We previously showed that OCT, an analog of 1,25-(OH)2D3 with little calcemic activity, can decrease PTH mRNA levels in normal rats and inhibit PTH secretion in cultured bovine parathyroid cells with the same potency as 1,25-(OH)2D3 and that in normal rats fed a normal calcium diet, administration of OCT (500 ng) for 5 days did not increase plasma Ca. Thus, to determine if PTH suppression by OCT contributes to its lack of calcemic activity and to further characterize the effects of OCT on Ca metabolism, we performed several studies in parathyroidectomized (PTX) rats. PTX rats, maintained on a normal diet (0.9% Ca), received daily injections of vehicle, 1,25-(OH)2D3 (200 ng/day), or OCT (200 ng/day) for 6 days. Plasma Ca was measured daily. Plasma Ca in control rats stayed between 6.60 and 7.40 mg/dl, whereas Ca increased to 12.9 +/- 0.42 mg/dl in 1,25-(OH)2D3-treated rats and to 9.53 +/- 0.35 mg/dl in OCT-treated rats after 6 days. With a Ca-deficient diet, control rats maintained a plasma Ca between 4.25 and 4.60 mg/dl, but Ca increased to 13.7 +/- 0.24 mg/dl with 1,25-(OH)2D3 and to 7.29 +/- 0.17 mg/dl with OCT. Since the elevation in Ca by OCT was similar with both diets, OCT appears to act primarily on bone. PTX rats were infused with PTH (1.84 micrograms/kg/day) via an Alzet pump to achieve normal plasma Ca and then treated daily with either vehicle or OCT (200 ng/day). After 6 days, OCT increased serum Ca to 10.7 +/- 0.21 mg/dl over a control value of 8.58 +/- 0.29 mg/dl.(ABSTRACT TRUNCATED AT 250 WORDS)

Parathyroid hormone-related peptide (PTHrP) has substantial homology with both human and rat parathyroid hormone (66% and 73%, respectively) in the first 15 amino acids. PTHrP (1-34) stimulates cyclic adenosine monophosphate (cAMP) release in bone and kidney, and these effects are felt to occur through interaction with the parathyroid hormone (PTH) receptor. Differences in the biologic potency between rat PTH(1-34) and human PTH(1-34)--and between PTHrP and PTH--have been described in a variety of experimental systems. In this study, we compared the bioactivity of these three amino-terminal synthetic fragments on the stimulation of cAMP formation in an isolated perfused rat femur preparation. Dose-response experiments demonstrated that PTHrP(1-34) was more potent in stimulating cAMP release than human PTH(1-34), whereas PTHrP(1-34) and rat PTH(1-34) were equipotent. Despite the fact that the extraction of immunoreactive rat PTH(1-34) and human PTH(1-34) was the same, rat PTH(1-34) was more potent in stimulating adenylate cyclase activity than human PTH(1-34). These data show that the isolated perfused rat femur preparation is an effective method for evaluation of the effects of PTH and PTHrP. Despite significant structural differences in the binding domain between rat PTH(1-34) and PTHrP(1-34), the effects of rat PTH(1-34) and PTHrP(1-34) are similar. Because the structure of rat PTHrP(1-34) and human PTHrP(1-34) are identical, and because it is desirable to utilize homologous systems to study the potency and effects of test peptides, it would appear that rat PTH(1-34) is the most appropriate peptide for comparison with PTHrP in rat-based experimental systems.

Control of phosphorus accumulation in chronic renal insufficiency is crucial to the prevention of secondary hyperparathyroidism and metastatic calcification. In early renal failure, calcitriol levels are normal and parathyroid hormone levels are elevated. The phosphorus levels are maintained in the normal range by the phosphaturia induced by hyperparathyroidism. In this situation, dietary phosphorus restriction increases calcitriol levels and suppresses parathyroid hormone secretion. As renal failure progresses into late stages, hyperphosphatemia is evident along with low levels of calcitriol and worsening hyperparathyroidism. Phosphorus restriction will not affect calcitriol concentrations, yet parathyroid levels may decline. During long-term dialysis, urinary excretion of phosphorus is usually minimal. Therefore, phosphorus balance is determined primarily by the net amount absorbed by the bowel and the quantity removed during dialytic therapy. Given an adequate diet, no form of conventional dialysis is able to fully compensate for the gastrointestinal absorption of phosphorus. Hence, compounds that bind phosphorus in the bowel are often necessary. With the realization that the use of phosphorus binders containing aluminum leads to aluminum accumulation and its sequelae: osteomalacia, dementia, myopathy, and anemia, other phosphorus binders have been evaluated. Calcium carbonate has been investigated the most thoroughly and is in wide use. It is inexpensive and contains a high percent of elemental calcium. However, it is only modestly potent in the binding of phosphorus, and large doses are often necessary to attain satisfactory control of phosphorus. This may lead to hypercalcemia. One approach to this problem is to decrease the concentration of calcium in the dialysate. Alternatively, a more effective phosphorus binder may be used. Calcium acetate has been shown in acute studies to have twice the binding capacity of phosphorus per calcium absorbed than calcium carbonate. Whether use of this compound decreases the incidence of hypercalcemia is unproven. Calcium citrate increases the gastrointestinal absorption of aluminum and offers no advantage over calcium carbonate. Other compounds, such as calcium ketoacids and calcium alginate, have not been extensively studied and are not generally available. The use of phosphorus binders containing magnesium in conjunction with a dialysate low in magnesium may be efficacious. Large doses of magnesium will cause diarrhea and thus limit its use as a single agent. Reasons for failure to control hyperphosphatemia include poor compliance, improper prescription of binders, poor dissolution rates seen with some generic brands of calcium carbonate, and the presence of severe hyperparathyroidism. Optimal control of serum phosphorus in dialysis patients should always be viewed in the context of adequate nutrition and protein intake.

The determination of circulating biologically active PTH in the rat has been difficult due at least in part to the inability to develop an antibody suitable for RIA of rat PTH. However, since the amino acid sequence of the rat PTH molecule has been deduced by molecular techniques, corresponding synthetic peptides have made it possible to produce such an antibody. A total of 12 roosters were immunized with synthetic rat PTH-(1-34), and one animal, RD1, developed a sensitive antibody against this amino-terminal region of the rat PTH molecule. To further increase the sensitivity of the RIA, we utilized an analog of rat PTH, Tyr1 rat PTH-(2-34), as the radioligand, which can be iodinated to high specific activity (450 microCi/micrograms). The iodinated peptide was purified by HPLC using a C18 Nova Pak HPLC column and a 20-60% acetonitrile gradient in 0.1% TFA. Synthetic rat PTH-(1-34) was used as the standard. To validate the RIA, we measured PTH under a variety of metabolic conditions. Normal values for PTH were 55.6 +/- 3.9 pg/ml (n = 26). Levels in parathyroidectomized (PTX) rats (n = 9) were undetectable, but renal insufficiency and vitamin D deficiency increased PTH to 587.4 +/- 141.3 pg/ml (n = 73) and 1662.0 +/- 137.8 (n = 27), respectively. Intraperitoneal (IP) administration of ethylenediaminetetraacetic acid (EDTA), 200 mg/kg, was used to decrease ionized calcium (ICa) from 4.75 +/- 0.07 to 3.55 +/- 0.10 mg/dl, which increased PTH from 51.3 +/- 5.9 to 109.3 +/- 13.4 pg/ml (n = 12).(ABSTRACT TRUNCATED AT 250 WORDS)

We have previously reported low serum levels of 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3] and increased 1,25-(OH)2D3 production after the administration of 25-hydryoxyvitamin D (25OHD) to anephric humans. Since normal alveolar macrophages are known to synthesize 1,25-(OH)2D3 when stimulated with gamma-interferon or lipopolysaccharide, we determined whether macrophages derived from peripheral blood monocytes could be an extrarenal source of 1,25-(OH)2D3. Our results demonstrated that macrophages from normal individuals synthesize 1,25-(OH)2D3. The apparent Km for 25OHD3 was 6.6 +/- 0.5 nM and the maximum velocity was 47.4 +/- 13.7 fmol 1,25-(OH)2D3/h.microgram DNA. The activity of this enzyme was reduced 37.2 +/- 3.1% by physiological concentrations (96 pmol/L) of 1,25-(OH)2D3 in the incubation medium. Normal macrophages further hydroxylated 1,25-(OH)2D3 to more polar metabolites, and this catabolic activity was significantly enhanced by physiological concentrations of 1,25-(OH)2D3. In chronic renal failure, peripheral macrophages exhibited an enhanced 1 alpha-hydroxylase activity (8.2 +/- 0.8 vs. 4.2 +/- 0.5 fmol 1,25-(OH)2D3/microgram DNA.h in controls) and a decreased capacity to degrade 1,25-(OH)2D3. Exogenous 1,25-(OH)2D3, in physiological concentrations, reduced 1,25-(OH)2D3 synthesis to a degree (23.6 +/- 8.5%) comparable to that observed in normal cells. 1,25-(OH)2D3 production by macrophages did not correlate with the severity of hyperparathyroidism. Moreover, human PTH-(1-34) in supraphysiological concentrations (20,000 and 100,000 ng/L) did not stimulate the 1 alpha-hydroxylase activity of macrophages from either normal or uremic subjects. These results demonstrate that 1) normal peripheral macrophages metabolize 25OHD3 and 1,25-(OH)2D3; 2) macrophages in uremia display higher rates of 1,25-(OH)2D3 synthesis and lower rates of catabolism than normal macrophages; and 3) 1,25-(OH)2D3 deficiency, but not hyperparathyroidism, may play a role in the stimulation of 1,25-(OH)2D3 production by macrophages in chronic renal failure.

Previous studies from our laboratories have suggested that zinc depletion reduces the circulating level of 1,25-dihydroxycholecalciferol-1,25-(OH)2D-in phosphorus-depleted rats. Since calcitriol synthesis is in part dependent on renal function, we studied vitamin D metabolites, parathyroid hormone response, and mineral balance in animals with different zinc nutritional and renal functional status. Twenty-three male Lewis rats were pair fed with zinc-replete or zinc-deplete diets for 2 weeks. Thereafter, half of each paired group underwent nephrectomy, while half had sham operations. After a 4-week observation period, the zinc-depleted animals had lower plasma zinc levels, and nephrectomized animals had higher plasma creatinine concentrations than respective controls at sacrifice. Plasma calcium and phosphorus concentrations were similar in all four groups at sacrifice. The 25-hydroxycholecalciferol and parathyroid hormone concentrations were similar in groups with renal insufficiency, regardless of the zinc nutritional status. The mean plasma 1,25-(OH)2D concentration was 20 +/- 4 pg/ml in the zinc-replete/sham-control group. In the zinc-replete nephrectomized animals, the mean plasma 1,25-(OH)2D concentration was increased by 133% to 56 +/- 6 pg/ml, as compared with zinc-deplete nephrectomized group. There was a significant effect of renal function, zinc nutritional status, and the interaction of these factors in accounting for differences in mean 1,25-(OH)2D levels. Zinc-deplete groups had consistent negative net zinc balance. However, there was no consistent effect of zinc nutritional status on external calcium or phosphorus balance when nephrectomized groups of different zinc nutritional status were compared.(ABSTRACT TRUNCATED AT 250 WORDS)

OCT, a non-calcemic analogue of 1,25(OH)2D3 has been found to have a more potent activity than that of 1,25(OH)2D3 regarding cell differentiation and immunopotentiation activity, and to prolong the average life span of MRL/l mice. Recently, we found that OCT effectively suppressed the secretion and synthesis of PTH without inducing hypercalcemia. In primary cultures of bovine parathyroid cells, OCT was capable of suppressing PTH release in a dose-dependent manner. OCT was also active in vivo, and, like 1,25(OH)2D3, decreased the pre-pro(PTH) mRNA levels. In a group of rats with CRF, daily administration of OCT, 8 ng i.p. for 2 weeks returned PTH levels to normal without changes in serum calcium. Preliminary results in dogs with CRF indicated that after the administration of OCT 5 micrograms i.v., N-terminal PTH decreased by 76% without changes in Ca. In conclusion, OCT may provide a unique contribution to the treatment of secondary hyperparathyroidism.

Under normal circumstances extrarenal sources of calcitriol probably constitutes a microendocrine system involved in cell differentiation and local intercellular communication with no influence on systemic calcium homeostasis. Under pathological conditions such as chronic renal failure, extrarenal sources have the potential to normalize serum calcitriol after adequate stimulation (such as, 25(OH)D administration). Extrarenal 1,25-(OH)2D3 synthesis is controlled by physiological levels of calcitriol. However, in sarcoidosis and other granulomatous diseases, 1,25-(OH)2D3 production by macrophages is deregulated, causing severe alterations in systemic calcium homeostasis.

In conclusion, a number vitamin D analogues have been developed that have very low calcemic activity but retain several other properties of 1,25-(OH)2D3, including the ability to differentiate leukemia and skin cells, to enhance the immune response, and to suppress parathyroid hormone levels. Although the mechanism of this selective activity is not yet clear, these analogues may provide new insights into the differences in action of 1,25-(OH)2D3 in various target tissues. Most importantly, the selective action of these analogues may be exploited for the treatment of diseases such as leukemia, psoriasis and hyperparathyroidism.

It is currently believed that the two chronic acidemic disorders exert disparate effects on urinary calcium excretion: chronic metabolic acidosis induces consistent hypercalciuria, but no appreciable change or even a decrease in calcium excretion is reported to attend chronic respiratory acidosis. Whereas the effect of metabolic acidosis is well documented, little work has been carried out in chronic hypercapnia. In fact, most of the studies on chronic respiratory acidosis were short in duration, had employed only mild hypercapnia, or had failed to control carefully the prevailing metabolic conditions. We have carried out balance observations in nine dogs exposed to a 10% CO2 atmosphere in an environmental chamber for a period of two weeks. Chronic respiratory acidosis led to a significant increase in urinary calcium excretion from a mean control value of 0.4 +/- 0.1 mmol/day to 0.6 +/- 0.1 mmol/day during both week 1 and 2 of hypercapnia (P less than 0.05). Hypercalciuria occurred even though filtered load of calcium fell. Mean fractional excretion of calcium increased significantly during each week of hypercapnia averaging 0.60 +/- 0.12% during control, 1.05 +/- 0.13% during week 1, and 1.26 +/- 0.17% during week 2 of hypercapnic exposure (P less than 0.05). There were no changes in plasma levels of immunoreactive parathyroid hormone or 1,25-dihydroxyvitamin D3. These findings suggest that chronic respiratory acidosis, just like chronic metabolic acidosis, augments urinary calcium excretion by a direct depressive effect on the tubular reabsorption of calcium.

We examined the effects of high concentrations of glucose on PTH secretion from cultured bovine parathyroid cells. Increasing medium concentration of glucose caused suppression of PTH secretion. A significant suppression of PTH secretion was found within 48 hours of incubation with as little as 15 mM glucose. The addition of choline chloride to the medium did not suppress PTH secretion, although the osmolality was the same as that of the medium containing 50 mM glucose. When cells previously exposed to 50 mM glucose were reincubated in the medium containing 5 mM glucose for another 48 hours, a complete recovery of PTH secretion was observed. In the cells exposed to 50 mM glucose, the magnitude of the response of PTH secretion to 10(-6) M isoproterenol was blunted. Acid-urea gel electrophoresis revealed that the pattern of intact PTH and fragments secreted from cells exposed to high concentration of glucose was similar to that from control cells. Removal of insulin from the medium resulted in a suppression of PTH secretion similar to changes observed with high concentrations of glucose. The suppressive effects of high concentrations of glucose and lack of insulin were additive. However, we cannot exclude from the present studies whether the suppressive effects of the lack of insulin on PTH secretion was secondary to the fact that insulin may be required for the maintenance of parathyroid cells. The present studies demonstrate that glucose directly modulates PTH secretion in primary parathyroid cell culture.

In the present studies, we used fluoride and pertussis toxin, potent modulators of guanine nucleotide binding proteins (G proteins), to examine the role of G proteins, cytosolic calcium ([Ca]i) and cAMP in the regulation of PTH secretion from dispersed bovine parathyroid cells. NaF suppressed PTH secretion and cAMP content and increased [Ca]i levels in a dose-dependent manner. Prior removal of extracellular calcium with EGTA completely blocked the NaF-induced increase in [Ca]i, but did not prevent the NaF-induced inhibition of PTH secretion and cAMP content. Pretreatment with 10(-5) M verapamil or 10(-4) M diltiazem blocked neither the NaF-induced suppression of PTH secretion and cAMP content nor the increase in [Ca]i. Manganese chloride (10(-4) M) significantly inhibited the NaF-induced increase in [Ca]i, but did not block the NaF-induced suppression of PTH secretion and cAMP content. Pertussis toxin blocked neither the NaF-induced increase in [Ca]i nor suppression of PTH secretion and cAMP content. Our data suggest that (1) NaF might stimulate a calcium channel resulting in the increase in [Ca]i by acting on a G protein in a manner resistant to the inhibition by pertussis toxin; (2) the NaF-induced increase in [Ca]i is not directly linked to the suppression of PTH secretion, and (3) the NaF-induced suppression of PTH secretion might be explained at least in part by the decrease in cell cAMP content.

Current evidence suggests that administration of 1,25(OH)2D3 to patients with chronic renal insufficiency results in suppression of secondary hyperparathyroidism only if hypercalcemia occurs. However, since the parathyroid glands possess specific receptors for 1,25(OH)2D3 and a calcium binding protein, there is considerable interest in a possible direct effect of 1,25(OH)2D3 on parathyroid hormone (PTH) secretion independent of changes in serum calcium. Recent findings indicate substantial degradation of 1,25(OH)2D3 in the intestine, therefore, it is possible that while oral administration of the vitamin D metabolite increases intestinal calcium absorption, the delivery of 1,25(OH)2D3 to peripheral target organs may be limited. We therefore compared the effects of orally or intravenously administered 1,25(OH)2D3 on the plasma levels of 1,25(OH)2D3 and the effects of these two modes of treatment on PTH secretion. Whereas oral administration of 1,25(OH)2D3 in doses adequate to maintain serum calcium at the upper limits of normal did not alter PTH levels, a marked suppression (70.1 +/- 3.2%) of PTH levels was seen in all 20 patients given intravenous 1,25(OH)2D3. Temporal studies suggested a 20.1 +/- 5.2% decrease in PTH without a significant change in serum calcium with intravenous 1,25(OH)2D3. In five patients the serum calcium was increased by the oral administration of calcium carbonate, the decrement in serum i-PTH was only 25 +/- 6.65% when compared with 73.5 +/- 5.08% (P less than 0.001) obtained by the administration of intravenous 1,25(OH)2D3. Thus, a similar serum calcium achieved by intravenous 1,25(OH)2D3 rather than calcium carbonate has a greater suppressive effect in the release of PTH. These studies indicate that 1,25(OH)2D3 administered intravenously rather than orally may result in a greater delivery of the vitamin D metabolite to peripheral target tissues other than the intestine and allow a greater expression of biological effects of 1,25(OH)2D3 in peripheral tissues. The use of intravenous 1,25(OH)2D3 thus provides a simple and extremely effective way to suppress secondary hyperparathyroidism in dialysis patients.

Studies were performed on 12 patients with idiopathic hypercalciuria to evaluate the hypothesis that the acid load accompanying potassium acid phosphate would adversely affect renal calcium reabsorption and citrate excretion compared to the neutral form of the phosphate salt. During acute clearance studies, neutral phosphate (NP) led to a fall in FECa (2.2 +/- 0.6% to 0.8 +/- 0.1%, P less than 0.02) and no change in titratable acidity (TA) or net acid excretion (NAE). Acid phosphate (AP) did not reduce FECa acutely, and led to a rise in TA (22 +/- 4 to 62 +/- 6 muEq/min, P less than 0.02) and NAE (46 +/- 6 to 6 89 +/- 7 muEq/min, P less than 0.02). During chronic administration, AP resulted in higher urinary calcium excretion in both absorptive (187 +/- 29 vs. 141 +/- 18 mg/day, P less than 0.02) and renal hypercalciuric patients (233 +/- 24 vs. 173 +/- 190.02 mg/day, P less than 0.02). Also, TA and NAE were higher following AP, whereas citrate excretion was lower (375.4 +/- 64.6 vs. 633.4 +/- 28.8 mg/day, P less than 0.01). These data suggest that the reported ineffectiveness of AP in the therapy of nephrolithiasis may be related to the deleterious effects of the acid load on calcium and citrate metabolism.

Traditionally, phosphate binders containing aluminum have been used effectively to control serum phosphorus levels in patients with chronic renal failure. In these patients, however, absorption and accumulation of aluminum in plasma and tissues can lead to debilitating pathologic conditions, including aluminum-related osteodystrophy. An alternative therapeutic approach using calcium carbonate as a phosphate binder has been proven to be effective. In a recent study of 20 patients on chronic hemodialysis, the efficacy of calcium carbonate therapy was demonstrated. Serum phosphorus levels in these patients were 4.8 +/- 0.13 mg/dL with the use of aluminum-containing phosphate binders, 7.3 +/- 0.26 mg/dL when phosphate binders were discontinued, and 4.8 +/- 0.17 mg/dL with the use of calcium carbonate (Os-CaL 500) therapy. The total amount of aluminum ingested for all 20 patients combined went from 112 g/d at the beginning of the study to 22 g/d at the end of the study. The amounts of calcium carbonate administered varied because of large variations in dietary phosphorus intake between patients. In addition, the individual distribution of phosphorus intake during the day dictated the dosing schedule. There were no adverse side effects associated with calcium carbonate therapy. A few patients ingesting large amounts of calcium carbonate to control their extremely high phosphorus levels developed hypercalcemia. However, this effect was reversible after discontinuation of calcium carbonate therapy.

WR-2721 [S-2-(3-aminopropylamino)ethylphosphorothioic acid] is a chemoprotective and radioprotective agent that has been shown to lower serum calcium in dogs and in humans. This is secondary both to impaired release of Ca2+ from bone and diminished secretion of parathyroid hormone (PTH) from parathyroid glands. Because cAMP plays a role in the regulation of PTH secretion and WR-2721 has been shown to lower cAMP levels in radiated mouse spleen, we investigated the effects of WR-2721 on cAMP production in dispersed bovine parathyroid cells. Additionally, we studied the adenylate cyclase in plasma membranes from normal bovine parathyroid glands after exposure to WR-2721. With parathyroid cells incubated at 0.5 mM Ca2+, addition of WR-2721 in concentrations ranging from 0.02 to 2.0 mM resulted in a progressive decrease in intracellular cAMP (42-50%, respectively). In plasma membranes of bovine parathyroid cells a dose-dependent decrease in adenylate cyclase activity was noted. Inhibition of the cyclase was seen over a wide range of Mg2+ concentrations (2.5-40 mM). WR-2721 inhibited both basal and NaF, Gpp(NH)p, forskolin, and pertussin toxin-stimulated adenylate cyclase. These data suggest that WR-2721 inhibits the activity of parathyroid adenylate cyclase.

An assessment of free and total calcium measurements was made in 691 patients with suspected hypercalcemia or disorders often associated with hypercalcemia. In 18.9% of the 1049 specimens analyzed from nine different patient groups, a different impression of hypercalcemia was obtained depending on whether the free or total calcium was considered. Analysis of the ratio of free to total calcium indicated that there are two main factors which influence the distribution of calcium in the serum of hypercalcemic patients: the concentrations of albumin and parathyroid hormone. A lowered albumin concentration accounted for the altered distribution of calcium in patients with malignancies and partially accounted for the altered distribution in patients postrenal transplantation. In patients with confirmed primary hyperparathyroidism a higher ratio of free to total calcium was found, which could not be explained by alterations in protein, albumin, pH, or CO2 content but was related to parathyroid hormone concentration. Free calcium appears to be a slightly better indicator of elevated calcium states than total calcium. Measurements of free calcium should be particularly useful in patients with altered albumin concentration, with multiple myeloma in whom a calcium-binding protein could be present, after renal transplantation, and with suspected hyperparathyroidism and normal or slightly elevated total calcium values.

Recent studies suggest that the uptake of immunoreactive parathyroid hormone (iPTH) displays different characteristics in liver, kidney, and bone. Using the isolated perfused canine bone, we have characterized the uptake of two synthetic analogs of PTH, bovine PTH-(3-34) [bPTH-3(3-34)] and [Nle8,Nle18,Tyr34]bPTH-(3-34) amide, which had previously been shown to inhibit PTH-stimulated adenylate cyclase activity in renal membranes. During the infusion of synthetic bPTH-(1-34) (3 ng/ml), extraction of iPTH by isolated perfused bone averaged 37 +/- 1%, and cAMP production rose from 6.2 +/- 2.0 to 21 +/- 3 pmol/min. Extraction of bPTH-(3-34) was similar (35 +/- 2%), but cAMP levels did not increase over baseline with PTH concentrations as high as 100 ng/ml. Simultaneous infusion of bPTH-(1-34) and bPTH-(3-34) at molar ratios of 1:2 led to a 50% inhibition of PTH-stimulated cAMP increases. The extraction by bone of the more potent in vitro inhibitor of renal cortical adenylate cyclase [Nle8,Nle18,Tyr34]bPTH-(3-34) NH2 (3 ng/ml) averaged 39 +/- 2%. In contrast, cAMP production rose from a baseline of 5.6 +/- 0.5 to 12.5 +/- 2.0 pmol/min, demonstrating agonist activity for the analog. These studies show that [Nle3,Nle18,Tyr34]bPTH-(3-34) NH2 has agonist properties in isolated perfused bone, and unsubstituted bPTh-(3-34) inhibits PTH-stimulated cAMP release by perfused bone.

These studies examine the metabolism of highly purified bovine parathyroid hormone [bPTH-(1--84)] by fetal rat calvaria. Enzymatically dispersed bone cells and intact (minced) calvaria were incubated with bPTH-(1--84) and the incubation medium was analyzed for degradation of PTH by polyacrylamide gel electrophoresis. Eluates of gel slices were assayed for immunoreactive PTH (iPTH) in carboxy- and amino-terminal RIAs. Both bone preparations metabolized bPTH-(1--84). The intact hormone progessively decreased with time and carboxy-terminal iPTH fragments were evident by 5 min of incubation. In the isolated cell preparations, intact hormone was completely degraded at submaximal doses of PTH (5 X 10(-9) M), as assessed by cAMP production. Degradation was incomplete in intact calvarial preparations at all doses studied. Intact calvaria were less sensitive to PTH with regard to cAMP production. No amino-terminal fragments were detected in the medium with either cell preparation. Oxidized (biologically inactive) bPTH-(1--84) was not metabolized in these systems. These findings contrast with studies in liver and kidney preparations, where oxidized bPTH has been shown to be degraded. These findings contrast with studies in liver and kidney preparations, where oxidized bPTH has been shown to be degraded. These data suggest that biological activity may be necessary for the metabolism of intact bPTH-(1--84) by bone cells and that skeletal tissue may contribute to the immunoheterogeneity of circulating PTH in the rat.

Severe hypocalcemia secondary to magnesium depletion has been described in numerous patients with gastrointestinal disorders. The development of profound hypomagnesemia in chronic renal disease is a rare finding. We studied three patients with advanced renal failure and magnesium depletion. Severe hypocalcemia also was present in these patients. Despite hyperplasia of the parathyroid glands, the levels of immunoreactive parathyroid hormone (PTH) in blood were inappropriately low for the degree of renal insufficiency. After the administration of magnesium there was a significant increase in the levels of circulating i-PTH in serum with a concomitant improvement in the hypocalcemia.

Hypoparathyroidism was diagnosed in nine members of a kindred of three generations. This study investigated why these persons were asymptomatic and without developmental abnormalities, in contrast to the common presentation of idiopathic hypoparathyroidism. In the hypocalcemic subjects, serum calcium level was 7.4 +/- 0.8 mg/dl (mean +/- SD) and ionized serum calcium level was 3.48 +/- 0.21 mg/dl. Immunoreactive parathyroid hormone values were inappropriately low. Injection of EDTA in one patient lowered ionized calcium levels, but immunoreactive parathyroid hormone values did not rise. Serum levels of 1,25-dihydroxyvitamin D and other vitamin D metabolites were normal or elevated and substantially higher than in other hypoparathyroid states. The normally observed positive correlation between the fasting urinary calcium/creatinine ratio and serum 1,25-dihydroxyvitamin D that reflects the dependence of net bone resorption on 1,25-dihydroxyvitamin D was upheld in hypoparathyroid patients. It is proposed that the subjects with familial hypoparathyroidism in this kindred had moderate asymptomatic hypocalcemia without developmental abnormalities because normal or elevated serum 1,25-dihydroxyvitamin D levels enhanced intestinal calcium absorption. This may represent one point in the spectrum of idiopathic hypoparathyroidism. Alternately, both the moderate degree of hypocalcemia and the normal serum calcitriol values could have been related to mild, partial hypoparathyroidism, which could have been inherited in this kindred.

Secondary hyperparathyroidism is a universal complication of chronic renal failure. It has been proposed that the markedly elevated levels of immunoreactive parathyroid hormone (i-PTH) in uremia may represent a "uremic toxin" responsible for many of the abnormalities of the uremic state. Plasma i-PTH consists of a mixture of intact hormone, a single-chain polypeptide of 84 amino acids, and smaller molecular weight hormonal fragments from both the carboxy- and amino-terminal portion of the PTH molecule. The hormonal fragments arise from metabolism of intact PTH by peripheral organs as well as from secretion of fragments from the parathyroid glands. The structural requirements for the known biological actions of PTH reside in the amino-terminal portion of the PTH molecule. Carboxy-terminal fragments, biologically inactive at least in terms of adenylate cyclase activation, hypercalcemia, or phosphaturia, depend on the kidney for their removal from plasma, and thus accumulate in the circulation in chronic renal failure. It is unknown at the present time if other biological effects of these carboxy-terminal fragments may contribute to some of the biochemical alterations observed in uremia. The most significant consequence of increased PTH levels in uremia is the development of bone disease characterized by osteitis fibrosa. In addition, it would appear that PTH plays an important role in some of the abnormal electroencephalographic patterns observed in uremia. This may be due to a potential role of PTH in increasing calcium content of brain. Parathyroid hormone also has been implicated as a pathogenetic factor in many other alterations present in uremia, i.e., peripheral neuropathy, carbohydrate intolerance, hyperlipidemia, and other alterations. Unfortunately, outstanding clinical research is lacking in this field and conclusive experimental data are practically nonexistent. Further studies are necessary if one is to accept the concept of PTH being a significant "uremic toxin."

The effects of continuous ambulatory peritoneal dialysis on parathyroid hormone (PTH) and mineral metabolism were evaluated in ten patients. Utilizing a PTH radioimmunoassay, which measures both intact hormone and carboxyl-terminal PTH fragments, it was found that the mean clearance of immunoreactive parathyroid hormone was 1.5 +/- 0.73 ml/min (SEM) yielding a daily net removal of 13.6 +/- 3.2% of estimated total extracellular parathyroid hormone. Gel electrophoresis of the dialysate revealed the presence of both intact parathyroid hormone and fragments in a similar pattern to that of peripheral plasma. Normal levels of 25-(OH) vitamin D and vitamin D binding protein were observed prior to the initiation of continuous ambulatory peritoneal dialysis and following 6 months of treatment. Timed dialysate collections (N = 93) demonstrated a daily calcium influx of only 9.9 +/- 9.7 mg. The daily removal of phosphorus was 308.4 +/- 15.5 mg. Despite elevated serum magnesium levels in all patients, the net daily removal was inadequate (31.2 +/- 15.5 mg). It was concluded that: (1) Unlike chronic hemodialysis, continuous ambulatory peritoneal dialysis removes significant amounts of parathyroid hormone. (2) Normal 25-(OH) vitamin D and vitamin D binding protein levels are maintained with continuous ambulatory peritoneal dialysis despite large protein losses. (3) Substantial amounts of phosphorus are removed with continuous ambulatory peritoneal dialysis but not to an extent that precludes use of phosphorus binders. (4) Dialysate containing lower magnesium and possibly higher calcium concentrations should be made available to improve mineral homeostasis.

Lithium chloride administration to growing rats, which resulted in circulating lithium levels of 1.4 meq/liter, was attended by significant suppression of bone mineralization and organic matrix synthesis as assessed by tetracycline labeling and histological quantitation of osteoid, respectively. These effects of lithium were not associated with changes in animal behavior, nor were there any significant differences in blood levels of calcium, phosphorus, alkaline phosphatase, creatinine, pH, or parathyroid hormone. The data suggest that lithium inhibition of bone mineralization is secondary to suppression of osteoid formation.

Both adults and children receiving total parenteral nutrition (TPN) have been found to have low serum levels of 1,25(OH)2-vitamin D [1,25(OH)2D]. Many of these were subsequently found to have inadvertently received large quantities of aluminum in the TPN solution. Since aluminum administration to dogs is associated with a fall in serum 1,25(OH)2D levels, the present study was designed to prospectively follow serum levels of this sterol while patients received a TPN solution low in aluminum. Nine children received a TPN solution comparable to that previously administered to children who demonstrated low serum levels of 1,25(OH)2D, except for a moderately reduced phosphorus and markedly reduced aluminum content. Serum was obtained during the first and fourth weeks of TPN treatment and analyzed for 1,25(OH)2D, 25-hydroxyvitamin D [25(OH)D], immunoreactive parathyroid hormone (iPTH), calcium, and phosphorus. Results revealed normal or high serum levels of 1,25(OH)2D and normal levels of iPTH, calcium, phosphorus, and 25(OH)D. Thus, low aluminum-containing TPN does not produce a fall in serum 1,25(OH)2D, providing evidence that aluminum may have been a factor in causing the reduced serum 1,25(OH)2D in those children previously receiving TPN.

The plasma disappearance rate (metabolic clearance rate) of administered intact parathyroid hormone (intact PTH) was analyzed in awake dogs with indwelling hepatic and renal vein catheters. The metabolic clearance rate (MCR) of intact PTH was found to be very rapid, 21.6 +/- 3.1 ml/min per kg in 11 normal dogs. The liver accounted for the greatest fraction of the MCR of intact PTH (61 +/- 4%) by virtue of an arterial minus venous (a - v) difference across the liver of 45 +/- 3%. The renal uptake of intact PTH accounted for 31 +/- 3% of the MCR of intact PTH. The renal a - v difference for intact PTH of 29 +/- 2% was significantly greater than the filtration fraction indicating renal uptake of intact PTH at sites independent of glomerular filtration. Together, the hepatic and renal clearances of intact PTH accounted for all but a small fraction of the MCR of intact PTH. The MCR of intact PTH, rendered biologically inactive by oxidation, was markedly decreased to 8.8 +/- 1 ml/min per kg. The a - v difference of oxidized intact PTH was reduced both in the liver and kidney. These data suggested that the high uptake rates of intact PTH are dependent, at least in part, upon sites recognizing only biologically active PTH. Chronic renal failure (CRF) decreased the MCR of intact PTH to 11.3 +/- 1.3 ml/min per kg (n = 10). Both the hepatic and renal a - v differences of intact PTH were reduced in dogs with CRF. This resulted in reductions in the hepatic and renal clearances of intact PTH. These studies identify the liver as a major extrarenal site of PTH metabolism affected by CRF. They suggest that CRF impairs the function of the major uptake sites involved in intact PTH metabolism.

The mean +/- SEM of the cord, 48-hr, and 7-day values for serum calcium, magnesium, human calcitonin (HCT), parathyroid hormone (PTH), and 25-hydroxy-vitamin D (25-OHD) for premature and term infants can be seen in Table 1. Mean cord calcium concentrations were similar for term and premature infants. Serum calcium concentrations fell in both term and premature infants at 48 hr, but decreased more in the premature infants (from 10.23 +/- 0.30 to 8.74 +/- 0.19 mg/dl) than in the term infants (from 10.5 +/- 0.26 to 9.6 +/- 0.23 mg/dl). Serum calcium values increased from 48 hr to 7 days in both groups, and there was no significant difference between term and premature infants' serum calcium concentrations (10.6 +/- 0.28 and 10.12 +/- 0.3 mg/dl, respectively) at that time. There was no significant difference between term and premature cord serum magnesium concentrations. Serum magnesium concentrations increased similarly by 48 hr in both groups and remained at these concentrations at 7 days of life. Serum HCT concentrations were elevated above normal adult levels (71.9 +/- 6.6 pg/ml, 81% less than 100 pg/ml, n = 63) in both premature and term cord sera, but premature cord concentrations (146 +/- 24 pg/ml) were significantly higher than term cord concentration (91 +/- 21 pg/ml). Both term and premature infants displayed a 2-3-fold increase in serum HCT by 48 hr and a partial fall by 7 days to concentrations still above those seen in cord sera (Fig. 1). Nine of 10 premature and 9 of 10 term infants had undetectable PTH concentrations in cord sera. In two premature infants, PTH serum concenttration remained undetectable at 48 hr. However, the majority of both premature and term infants had elevated levels of PTH at 48 hr. The mean PTH concentrations were lower but still elevated at 7 days with the suggestion of higher concentrations in premature infants (Fig 2). There were no significant differences in serum 25-OHD concentrations between term and premature sera at birth or at 7 days. There was a weakly positive correlation between 25-OHD and cord calcium (r = 0.45, P less than 0.05), and a negative correlation between cord calcium and 48-hr PTH (r = -0.53, P less than 0.01). Calcium and magnesium were significantly positively correlated in 48-hr (r = 0.83) and 7-day (r = 0.84) sera in premature infants but not in term infants. Cord 25-OHD and cord HCT levels were significantly positively correlated (r = 0.80, P less than 0.01) in the term infants but not the premature infants.