[Multiple enterolithiasis, coexisting with bladder and gallbladder lithiasis, associated with colon adenocarcinoma]. / Enterolitiasis múltiple, coexistiendo con litiasis biliar y vesical, asociada a adenocarcinoma de colon.

Enteroliths are calculi primarily formed in the intestine. Enterolithiasis is a rare condition frequently associated with intestinal stasis. Usually it causes no symptoms in most cases, but it can be an important diagnostic clue in patients presenting intestinal occlusive symptoms. We report a case of multiple enterolithiasis, very infrequent pathology, coexisting with bladder and gall bladder lithiasis in a patient with colon adenocarcinoma. Diagnosis was made by X-rays and CT images. Calculi were analysed by several methods: chemical, infrared spectroscopy, stereoscopic microscopy and atomic emission spectroscopy; they showed that caluli are made up of organic material and whilokita (calcium and magnesium ortophosphate). No risk factors for lithogenesis were found in this patient excluding the intestinal stasis caused by intestinal narrowing as a result of adenocarcinoma. Genetic factors are suggested as main contributors to hyperlithogenesis observed in this patient. The physiopathological conditions were studied in depth and literature about this subject reviewed.

Bone specific binding sites for 1,25(OH)2D3 in magnesium deficiency.

It has been reported that some hypoparathyroid patients with magnesium deficiency showed altered responses to vitamin D treatment. In the same way, in vitro bone studies have demonstrated the existence of a decrease in the 1,25-dihydroxyvitamin D3-induced resorption in bone as a result of magnesium deficiency. These findings suggest some kind of alteration in the 1,25(OH)2D3 in bone in magnesium deficiency. In the present work, using a binding assay based on the 1,25(OH)2D3 and 3H-1,25(OH)2D3 competition for the hormone binding sites in rat calvaria homogenates, a significant decrease in the number of 1,25(OH)2D3 specific binding sites has been found in calvaria incubated in magnesium-deficient medium compared to magnesium-replete ones. Alterations in the hormone-receptor affinity were not found. These results suggest that an alteration in the 1,25(OH)2D3 action on magnesium-deficient bone could be due, at least in part, to a decrease in the number of available vitamin D receptors in bone cells.

Effects of 24,25(OH)2D3, 1,25(OH)2D3 and 25(OH)D3 on alkaline and tartrate-resistant acid phosphatase activities in fetal rat calvaria.

The aim of this work was to evaluate the effects of 24,25-dihydroxyvitamin D3, 24,25(OH)2D3, on alkaline phosphatase (AP) and tartrate-resistant acid phosphatase (TRAP) activities in fetal rat calvaria cultures. These actions were compared with those of 1,25-dihydroxyvitamin D3, 1,25(OH)2D3, and 25-hydroxyvitamin D3, 25(OH)D3, in similar experimental conditions. At 10 min, 30 min and at 24 h incubation time, 1,25(OH)2D3 (10(-10)M) and 25(OH)D3 (10(-7) M) produced a significant increase in AP and TRAP activities compared to control group (without vitamin D metabolites). However, 24,25(OH)2D3 (10(-7) M) only produced effects on phosphatase activities similar to those produced by 1,25(OH)2D3 and 25(OH)D3, after 24 h incubation time. These findings suggest that 1,25(OH)2D3 and 25(OH)2D3 could carry out actions in minutes (nongenomic mechanism), while 24,25(OH)2D3 needs longer periods of time to perform its biological actions (genomic mechanism).

Mitochondrial alkaline phosphatase as an intracellular signal in the synthesis of 1,25(OH)2D3 and 24,25(OH)2D3 in LLC-PK1 cells.

In previous works we have found a mitochondrial alkaline phosphatase (AP) activity in LLC-PK1. The aim of this work has been to study the possible involvement of mitochondrial AP activity in the synthesis of 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) and 24,25-dihydroxyvitamin D3 (24,25(OH)2D3) from the substrate 25(OH)D3. Renal phenotype LLC-PK1 cells were incubated with 25(OH)D3 as substrate and treated with or without 1,25(OH)2D3, forskolin, 12-myristate-13-acetate (PMA) and 1,25(OH)2D3 in conjunction with PMA. Incubation of LLC-PK1 cells with forskolin (adenylate cyclase activator) not only stimulated the 1-hydroxylase and inhibited the 24-hydroxylase activities but also increased the mitochondrial AP activity. The addition of 1,25(OH)2D3, the main activator of 24-hydroxylase, produced a decrease of mitochondrial AP activity, a decrease of 1,25(OH)2D3 synthesis and an increase of the 24,25(OH)2D3 synthesis. Incubation with PMA, a potent activator of protein kinase C, did not produce any changes in mitochondrial AP activity, but an inhibition of 1,25(OH)2D3 and an activation of 24,25(OH)2D3 synthesis were found. Moreover, incubation of LLC-PK1 cells with PMA in conjunction with 1,25(OH)2D3 produced an additive effect in the decrease of 1,25(OH)2D3 and an increase of 24,25(OH)2D3 synthesis remaining mitochondrial AP activity as cells treated only with 1,25(OH)2D3. Our results suggest that mitochondrial AP activity could be involved as an intracellular signal in the regulation of 25(OH)D3 metabolism to the synthesis of 1,25(OH)2D3 and 24,25(OH)2D3 in renal phenotype LLC-PK1 cells through cAMP protein kinase system.

Biochemical markers of bone remodeling and bone sialoprotein in ankylosing spondylitis.

The aim of this work was to determine bone mineral density (BMD) in a group of patients with ankylosing spondylitis (AS) and to study alterations in bone remodeling in these patients. Eighteen patients (16 males and two females) with AS, mean age 44.7, range 21-75, and 18 age- and sex-matched healthy controls were studied. BMD was evaluated by dual energy X-ray absorptiometry. The following biochemical markers of bone remodeling were studied: formation - serum amino and carboxyterminal propeptides of procollagen I (PINP and PICP); resorption - urinary total and free deoxypyridinoline and pyridinoline (TDpyr, FDpyr, TPyr and FPyr), crosslinked aminoterminal telopeptides of collagen I (NTX), carboxyterminal telopeptide of collagen I (CTX) and serum bone sialoprotein (BSP). Receiver operating characteristic (ROC) curves of markers were also performed. We found a decrease of bone mass and an increase in TPyr, FPyr, TDpyr, FDpyr, NTX and BSP in AS, but no significant differences were found in PICP, PINP and CTX. FDpyr, FPyr and TPyr showed the highest discrimination between patients and controls according to the results of the ROC curves. TPyr/TDpyr was higher in AS than in controls. We found osteopenia, with a normal formation and a significant increase in bone resorption in AS. FDpyr, FPyr and TPyr seem to present the best sensitivity for the study of alterations of bone resorption in this pathology, although NTX, TDpyr and BSP also show significant differences. The elevation in the ratio TPyr/TDpyr in AS compared to controls indicates that in AS there is a type I-collagen degradation in tissues different from bone.

A variation in Bone Alkaline Phosphatase levels that correlates positively with bone loss and normal levels of aminoterminal propeptide of collagen I in girls with anorexia nervosa.

Anorexia nervosa (AN) is a very extended pathology among adolescent girls nowadays. These patients show a high degree of osteopenia; hence, study of their bone remodelling is of great interest. Serum bone alkaline phosphatase (bAP) and aminoterminal propeptide of procollagen I (PINP) provide good sensitivity in the analysis of bone alterations in postmenopausal osteoporosis. The aim of this study was to compare the usefulness of bAP and PINP in the study of bone remodelling in AN, and their possible correlation with the degree of osteopenia in this pathology. In order to help in the interpretation of the results, levels of the beta-isomer of urinary carboxyterminal propeptide of collagen I (beta-CTX) have also been included. Serum bAP (IRMA) Tandem R-Ostase, Hybritech), PINP (RIA, Orion Diagnostica) and CTX (CrossLaps ELISA, Osteometer) were determined in 41 girls with AN, aged 18.5+/-2.2 years (mean+/-SD) and in 31 healthy control women, aged 19+/-2.3 years. Bone mineral density (BMD) in lumbar spine was measured by DEXA in the AN group. We found that 41 of the 43 patients had BMD z-scores under -2. No significant differences were found in the levels of serum bAP nor in PINP and beta-CTX levels between controls and patients, although values in the AN group were highly variable. All the BMD z-score values were negative, and their absolute value correlates positively with bAP (P = 0.0279) and almost with beta-CTX (P = 0.0921) but not with PINP (P = 0.4627). Bone AP correlates with PINP in control girls (P = 0.017), but not in the AN group (P = 0.3573). Patients with AN were divided into three groups according to their levels of bAP: low (I), normal (II) or high (III). Patients with the highest bAP levels also presented the highest increase in bone resorption, according to their beta-CTX levels, and the highest degree of osteopenia. However, values of PINP were similar in the three groups of patients. The bAP/beta-CTX ratios in subgroups I, II and III of AN patients were 0.035, 0.065 and 0.073, a finding that suggests that bAP is not indicating the real degree of bone mineralization in these patients, because it is a contradiction that the formation/resorption ratio should be higher in the patients who have the highest bone loss. These results could suggest that bone loss in AN is produced by an increase in bone resorption (beta-CTX), without variations in bone matrix formation (PINP); bAP levels are a good marker in the follow-up of osteopenia degree, but not a real indicator of bone mineralization, a similar situation to that of osteomalacia.

Aminoterminal propeptide of type I collagen and bone alkaline phosphatase in the study of bone metastases associated with prostatic carcinoma.

The aim of this work was to evaluate the usefulness of serum aminoterminal propeptide of type I collagen (PINP) in the early detection of bone metastases associated with prostatic carcinoma. The results were compared with those of bone isoenzyme of alkaline phosphatase (bAP). Levels of total alkaline phosphatase (TAP) and prostatic specific antigen (PSA), related to the existence of bone metastases, are also evaluated. Fifty-five male patients aged 70-80 years were studied. Nine presented a benign prostatic hyperplasia (BPH) and the rest clinically confirmed prostatic cancer. Cancer patients were classified in accordance with the staging grouping of the International Union Against Cancer/American Joint Committee on Cancer TNM 1992 Revision: stage 0 or BPH (n=9), I (n=6), II (n=12), III (n=18) and IV (n=10). According to this classification, patients of groups BPH, I, II and III have no evidence of metastases. Those of stage IV present any type of metastases. In the case of this work, all patients of group IV presented bone metastases. Some patients of group BPH, I and II were untreated. The rest of the patients were under treatment (radical prostatectomy, telecobaltotherapy or hormonal therapy) for a period of between 6 months and 15 years. Serum PSA (Quimioluminiscence, IMMULITE), PINP (RIA, Orion Diagnostica), bAP (IRMA, Tamdem R-Ostase, Hybritech), and TAP (autoanalyzer) were determined. We found the following sensitivities and specificities (relating the presence of bone metastases to values higher than the upper limit of normality and, in the case of PSA, to values higher than 100 microg/L): (1) PINP: 100% (10/10) and 87% (39/45), (2) bAP: 90% (9/10) and 82% (37/45), (3) TAP: 60% (6/10) and 93% (42/45), (4) PSA: 40% (4/10) and 100% (45/45). These results suggest that PINP and bAP are adequate biochemical markers of bone formation to be used in the detection of bone metastases in prostatic carcinoma, improving the sensitivity and specificity of TAP and PSA. With respect to PINP, bAP presents the disadvantage of its cross-reactivity with liver isoenzyme.

Urinary alpha and beta C-telopeptides of collagen I: clinical implications in bone remodeling in patients with anorexia nervosa.

Fragments derived from degradation of type I collagen C-telopeptide (CTX) can be nonisomerized (alpha) or beta-isomerized (beta) depending on the age of bone; i.e., mainly the alpha form is derived from new bone and the beta form from old bone. We have studied 41 female patients with anorexia nervosa (AN), aged 18.5 +/- 2.2 years (range 16-24 years), and with an evolution time between 1.5 and 11 years, and 31 healthy control females (C), with a mean age of 19 +/- 2.3 years (range 16-24 years). The AN patients showed a significant decrease in bone mass, with a mean Z-score of bone mineral density (BMD) of -3.2 +/- 0.8 (range -0.9 to -5.4). The aim of our study was to determine the levels of urinary alpha- and beta-CTX markers of bone resorption, the alpha/beta ratio (alpha/beta), and the level of bone alkaline phosphatase (bAP), a biochemical marker of bone formation, in order to relate them to the degree of osteopenia and the status of bone remodeling. Statistical analysis was by the Mann-Whitney test. The degree of osteopenia correlated with bAP levels (p = 0.0027) but not with the other parameters. Patients with AN were divided into three groups according to their levels of bAP: high (H), normal (N) or low (L). We found that BMD was significantly lower, and alpha- and beta-CTX were significantly higher, in groups H and N than in group L. Bone AP correlated significantly with alpha-CTX (p = 0.0042) and alpha/beta (0.0095) in the controls, but not with beta-CTX, while in AN patients bAP correlated with beta-CTX (p = 0.0000) and with alpha-CTX (p = 0.022) but not with the alpha/beta ratio. The ratio CTX/bAP (resorption/formation) was similar in AN patients and controls. It is concluded that: (1) patients with AN have a high degree of osteopenia which correlated with bAP levels; (2) urinary CTX fragments found in AN patients seem to come mainly from old bone (beta-CTX), while CTX found in healthy adolescent control females come from new bone (alpha-CTX). For this reason, alpha-CTX is more suitable than beta-CTX for measuring bone resorption in controls and beta-CTX is more suitable in patients with AN; (3) the resorption/formation ratio (CTX/bAP) was similar in AN patients and controls. From points (2) and (3) it is possible to suggest that, although bAP reflects bone formation in control females, this marker does not reflect effective bone mineralization in AN patients, a similar feature to that of patients with osteomalacia.

Biochemical markers of bone formation in the study of postmenopausal osteoporosis.

A comparative study was performed on the sensitivity of the determination of the available biochemical markers of bone formation--total and bone alkaline phosphatase (TAP and bAP, respectively), osteocalcin (BGP), procollagen I aminoterminal propeptide (PINP) and procollagen I carboxyterminal propeptide (PICP)--in the study of postmenopausal osteoporosis. The comparison between PINP and PICP, due to the recent development of the amino-terminal assay, is of special interest. The study included 26 untreated osteoporotic postmenopausal women, age 59 +/- 6 years (range 46-69 years) and 17 healty control postmenopausal women, age 56 +/- 7 years (range 48-70 years). We found a significant increase in the levels of bAP (p = 0.0021), BGP (p = 0.041), PINP (p = 0.0001) and PCIP (p = 0.0073), but not in the levels of TAP (p = 0.3389), in osteoporotic patients with respect to the control group. Serum PINP and bAP showed the highest diagnostic accuracy among the markers of bone formation studies, as can be deduced from the receiver operating characteristics (ROC) curves. In spite of their similar origin (amino-terminal and carboxy-terminal release from a procollagen molecule), the results obtained by measuring levels of PINP are significantly better than those found with PICP.

[Alkaptonuria, prostatic calculi, and ectopic ureter]. / Alcaptonuria, litiasis prostática y uréter ectópico.

Alkaptonuria is an uncommon tyrosine metabolism disorder. Deficit of homogentisic acid oxidase leads to the elimination of large amounts of homogentisic acid in the urine with accumulation of homogentisic acid oxidized pigment in the connective tissue (ochronosis). The ultimate evolution of ochronosis is degenerative arthritis. The clinical case reported is a 57-year old male diagnosed with alkaptonuria in an early stage of the connective tissue disease who comes to the clinic due to a lower urinary obstructive syndrome secondary to benign prostate hyperplasia but is diagnosed with giant prostate lithiasis. The patient undergoes retropubic adenomectomy with lithiasis removal and re-implantation of ectopic ureter from a dual left excretory system. Clinical evolution is completely successful. The rarity of the case calls for circulation and revision of the clinical and therapeutical aspects of this entity.

New biochemical markers of bone resorption in the study of postmenopausal osteoporosis.

We performed a comparative study on the sensitivity of the determination of several biochemical markers of bone resorption: urinary calcium/creatinine, free pyridinolines (F-Pyr), free deoxypyridinoline (F-Dpyr), carboxyterminal telopeptide of collagen I (CTX) and aminoterminal crosslinked telopeptides of collagen I (NTX) in the study of postmenopausal osteoporosis. The study included 19 untreated osteoporotic postmenopausal women, aged 59 +/- 6 years, range 46-70 and 16 healthy control postmenopausal women, aged 56 +/- 7 years, range 48-70 years. The following bone markers were determined in 2-h fasting urine samples: calcium/creatinine (atomic absorptiometry), F-Pyr (ELISA, Metra), F-Dpyr (ELISA, Metra), CTX (Crosslaps, Cis bio International) and NTX (ELISA, Osteomark, OSTEX). Values of all markers were expressed as urinary creatinine (Cr) ratios. We found a significant increase in all the studied biochemical markers of bone resorption in osteoporotic patients with respect to control women. Areas under receiver operating characteristic (ROC) curves corresponding to F-Pyr/Cr, Calcium/ Cr, NTX/Cr, CTX/Cr and F-Dpyr/Cr were 74%, 75%, 93.4%, 95.7% and 96% respectively. There were no significant differences among the areas of the ROC curves corresponding to NTX, CTX and F-Dpyr, but areas under urinary calcium and F-Pyr were significantly lower. Among the biochemical markers of bone resorption studied, F-Dpyr, CTX and NTX presented the best discrimination between osteoporotic and control women. F-Dpyr/Cr sensitivity was 79% with a specificity of 100%, CTX/Cr sensitivity was also 79% with a specificity of 100% and NTX/Cr sensitivity was 52% with a specificity of 100%.

Possible alterations of the in vivo 1,25(OH)2D3 synthesis and its tissue distribution in magnesium-deficient rats.

In a previous work we showed that a decrease in the free intracellular magnesium produced alterations in the kinetic behaviour of 1 alpha-hydroxylase which reduced the synthesis rate of 1,25(OH)2D3. This in vitro result strongly supports that magnesium deficiency could also induce in vivo failure of the renal enzyme and then a decrease of 1,25(OH)2D3 serum levels. In the present work we have tested the effect of magnesium deficiency on the in vivo transformation of the substrate 3H-25(OH)D3 to 3H-1,25(OH)2D3 as well as the distribution of synthesized hormone among its different target tissues. We found that magnesium deficiency produced a decrease of both the in vivo synthesis of 3H-1,25(OH)2D3 and the binding of the radioactive hormone to bone tissue. These results may explain the different criteria present in the scientific literature concerning the relationships between magnesium status and vitamin D metabolism.

Possible involvement of a magnesium dependent mitochondrial alkaline phosphatase in the regulation of the 25-hydroxyvitamin D3-1 alpha-and 25-hydroxyvitamin D3-24R-hydroxylases in LLC-PK1 cells.

It has been demonstrated that dephosphorylation of the ferredoxin component of the mitochondrial 25-hydroxyvitamin D3-1-hydroxylase, as a result of a PTH-cAMP mediated activation, involves a protein phosphatase activity. However, the nature and properties of this phosphatase are uncertain. It has been proved that alkaline phosphatase, a magnesium dependent enzyme, could dephosphorylate in vitro the ferredoxin component of the 25-hydroxyvitamin D3-1-hydroxylase. Moreover, some evidence of mitochondrial localization of some alkaline phosphatases has been published. Although the existence of a levamisole inhibitable alkaline phosphatase activity has been described in renal cells, its role remains to be elucidated. In the present work, the existence of an alkaline phosphatase in mitochondrial membrane preparations from LLC-PK1 cells has been described. This alkaline phosphatase is magnesium dependent and levamisole inhibitable. Preparations of mitochondrial membrane from LLC-PK1 cells also showed 25-hydroxyvitamin D3-1-hydroxylase (1-hydroxylase) and 25-hydroxyvitamin D3-24R-hydroxylase (24-hydroxylase) activities being both enzymes responsive to the 8Br-cAMP mediated regulation. The 8Br-cAMP not only stimulated the 1-hydroxylase and inhibited the 24-hydroxylase activities but also increased the mitochondrial alkaline phosphatase activity. In the same way, the levamisole (specific inhibitor of some alkaline phosphatases) inhibited the mitochondrial alkaline phosphatase and also the 1-hydroxylase activity. In addition, the inhibition of mitochondrial alkaline phosphatase by levamisole avoids the effect of 8Br-cAMP on the 1-hydroxylase and 24-hydroxylase activities. On the other hand, the mitochondrial alkaline phosphatase and the 1-hydroxylase activities showed similar behaviour with respect to the magnesium concentrations in the incubation medium. Taking these results together it could be possible to suggest the implication of the Mg(2+)-dependent mitochondrial alkaline phosphatase activity found in LLC-PK1 cells in the regulation of the 1,25(OH)2D3 and 24,25(OH)2D3 synthesis.

Parathyroid hormone related peptide (1-34) and 1,25-dihydroxyvitamin D, have no additive effects on bone tartrate resistant acid phosphatase activity in fetal rat calvaria cultures.

Parathyroid hormone related peptide (PTHrP) and 1,25-dihydroxyvitamin D are known to be resorptive agents which could contribute to the development of hypercalcemia in humoral hypercalcemia of malignancy (HHM) syndrome in Walker 256 tumor bearing rats. In order to clarify some aspects about the relative contribution of these factors to bone resorption, we have determined the effects produced by PTHrP (1-34) and/or 1,25(OH)2D3 on tartrate resistant acid phosphatase (TRAP), a biochemical marker of bone resorption, in fetal rat calvaria cultures. At the same time, bovine parathyroid hormone (PTH) (1-34) was used as a control in the experiments in order to compare its effects with those produced by the other two agonists. In the present work, 10(-7) M PTH (1-34), 10(-7) M PTHrP (1-34) and 10(-8) M or 10(-10) M 1,25(OH)2D3 produced a significant increase in TRAP activity, when these agonists were added to the calvaria culture. Surprisingly, and in spite of the different ways of action of PTH, PTHrP and 1,25(OH)2D3, their actions are not additive in our experiment. The results of the present work suggest that any of the two implicated factors PTHrP or 1,25(OH)2D3 could be individually responsible for the high rate of bone resorption that takes place in HHM syndrome in Walker 256 carcinosarcoma bearing rats, although other different agents, like TGF, could also be implicated.

[Nephrolithiasis and bone involvement in primary hyperparathyroidism. The relative role of vitamin D]. / Nefrolitiasis y participación ósea en el hiperparatiroidismo primario. Papel relativo de la vitamina D.

In order to analyze the role of 1,25(OH)2 D3 in bone and renal presentation forms of primary hyperparathyroidism (PHP), 61 patients, whose diagnosis had been confirmed surgically, were studied. An increase in serum 1,25(OH)2 D3 levels was found in PHP when compared to normal controls (49.1 +/- 2.8 pg/ml vs 34.1 +/- 1.4 pg/ml) (p less than 0.5). This increase directly correlates with serum alkaline phosphatase and creatinine clearance and inversely correlates with age. When patients were divided into two groups: A (n = 35) and B (n = 26) according to normal or increased 1,25(OH)2 D3 respectively, no difference was found in the clinical presentation forms of PHP. However, higher values of the biochemical parameters and bone remodeling markers were found in group B than in group A. This suggests the role of 1,25(OH)2 D3 as a modulator of metabolic activity in PHP and its possible therapeutic character in the clinical control of asymptomatic forms.