Abnormal Calcium Research Articles

SAT224 Nonsurgical Hypoparathyroidism: 40 Years After Diagnosis

Abstract Disclosure: L.I. Kaplan: None. A. Yuen: None. P.D. Greenberg: None. Background: The majority of cases of hypoparathyroidism occur after neck surgery. The most common nonsurgical cause is autoimmune, either in isolation or part of Autoimmune Polyglandular Syndrome Type 1. Hypomagnesemia is a functional cause. Hypoparathyroidism can occur as part of genetic syndromes that include congenital anomalies, short stature and developmental delay. Non-syndromic genetic etiologies including Autosomal Dominant Hypocalcemia type 1 (ADH1), a gain of function mutation in the calcium sensing receptor (CaSR) that can present in infancy, childhood or adulthood with hypocalcemia (50% symptomatic), hypercalcuria (10%) and basal ganglia calcification (35%). For ADH1, targeted therapies are being developed. Clinical Case: A 90-year-old male was diagnosed with hypoparathyroidism at age 50 when he presented with hand cramping and was found to have hypocalcemia with low PTH. He was started on calcitriol and calcium supplementation. Many years later he started following at our endocrine clinic. Past medical history includes prostate cancer treated with radiation and androgen deprivation therapy, HTN, and pre-diabetes. He has no history of neck surgery, other endocrinopathies, candidiasis, vitiligo or congenital anomalies. He has no family history of hypocalcemia and has two children without calcium abnormalities. His DEXA shows stable +T scores in LS spine and bilateral hips. He has not had brain imaging. Nephrocalcinosis was not reported on renal ultrasound. More than 10 years ago, he presented with severe hypercalcemia, acute renal failure (Ca 13.5 mg/dl, Cr 6.0mg/dl, Phos 5.5mg/dl) and ureteral stones after taking over the counter calcium supplements in excess. He underwent stone removal with return to baseline renal function. Subsequently, he underwent knee replacement surgeries and required IV calcium until he was able to swallow pills. Since this time, he has been managed on calcitriol, calcium carbonate, vitamin D3, and chlorthalidone with close follow up for adjustment of regimen to target Ca 8.0-8.5 mg/dl. He has not had a recurrence of severe hypercalcemia, hyperphosphatemia or nephrolithiasis. He feels well and lives at home with his wife. Lab values over the past 10 years are as follows: Ca 8.1-10.6 mg/dl (8.5-10.5), Alb 4.0-4.6 g/dl (3.5-5.4), Phos 4.3-5.5 mg/dl (2.8-4.5), Mg 1.7-1.9 mg/dl (1.3-2.1), K 3.7-4.4 mEq/L (3.6-5.2), Cr 1.0-1.5 mg/dl (0.5-1.3), PTH 0.00-1.4 pg/ml (10-55), 25 OH Vit D 18-58 ng/ml (32-100), 1,25 OH Vit D3 25.5-37.2 pg/ml (19.9-79.3), 24hr Urine Ca 162- 384 mg/24 hrs (50-400). Clinical lessons: Chronic hypoparathyroidism can be well managed with close follow up and frequent lab monitoring. This patient should be referred for genetic testing, particularly to look for ADH1 mutation in the CaSR gene as targeted treatments are being developed. His children should be tested for any mutations found in him. Presentation: Saturday, June 17, 2023

GNAQ/GNA11 Mosaicism Is Associated with Abnormal Serum Calcium Indices and Microvascular Neurocalcification

Mosaic mutations in genes GNAQ or GNA11 lead to a spectrum of diseases including Sturge-Weber syndrome and phakomatosis pigmentovascularis with dermal melanocytosis. The pathognomonic finding of localized "tramlining" on plain skull radiography, representing medium-sized neurovascular calcification and associated with postnatal neurological deterioration, led us to study calcium metabolism in a cohort of 42 children. In this study, we find that 74% of patients had at least one abnormal measurement of calcium metabolism, the commonest being moderately low serum ionized calcium (41%) or high parathyroid hormone (17%). Lower levels of ionized calcium even within the normal range were significantly associated with seizures, and with specific antiepileptics despite normal vitamin D levels. Successive measurements documented substantial intrapersonal fluctuation in indices over time, and DEXA scans were normal in patients with hypocalcemia. Neurohistology from epilepsy surgery in five patients revealed not only intravascular, but perivascular and intraparenchymal mineral deposition and intraparenchymal microvascular disease in addition to previously reported findings. Neuroradiology review clearly demonstrated progressive calcium deposition in individuals over time. These findings and those of the adjoining paper suggest that calcium deposition in the brain of patients with GNAQ/GNA11 mosaicism may not be a nonspecific sign of damage as was previously thought, but may instead reflect the central postnatal pathological process in this disease spectrum.

Elderly-onset calcinosis of hyperphosphataemic familial tumoural calcinosis/hyperostosis-hyperphosphataemia syndrome: the role of comorbid scleroderma.

A 73-year-old woman with type 2 diabetes mellitus was referred to our department for glycaemic control. Physical examination revealed two subcutaneous hard masses around the left shoulder and the right hip joint. The patient could not fully extend her fingers because of skin sclerosis in both hands. Laboratory studies showed hyperphosphataemia and a high ratio of renal tubular maximum reabsorption of phosphate to glomerular filtration rate. There were no abnormalities in serum calcium, creatinine, alkaline phosphatase, and intact parathyroid hormone levels, whereas serum fibroblast growth factor 23 was low. Hyperphosphataemic familial tumoural calcinosis/hyperostosis-hyperphosphataemia syndrome (HFTC/HHS) was diagnosed using whole genome sequencing that revealed a novel frameshift beyond the 584th threonine located in the lectin domain of UDP-N-acetyl-alpha-D-galactosamine:polypeptide N-acetylgalactosaminyltransferase 3 associated with a duplication of the 1748th thymine in the coding region of the corresponding gene. Furthermore, anti-nuclear, anti-centromere, and anti-cardiolipin antibodies were positive, implying that comorbid limited type scleroderma might play a role in tumoural calcinosis (TC) development. A low phosphate diet was prescribed with phosphate-lowering medications, including aluminium hydroxide, acetazolamide, and sevelamer hydrochloride. The patient displayed a decrease in serum phosphate levels from 6.5 to 5.5 mg/dL 10 months after the initiation of treatment, but her TC had not improved during treatment for more than 1 year. This case was interesting because the patient with HFTC/HHS exhibited TC despite being over her 60s, and subsequent scleroderma might contribute to the specific clinical course. When HFTC/HHS presents with elderly-onset TC, the involvement of comorbidities in exacerbating TC should be considered. HFTC/HHS occurs on an autosomal recessive basis, but its clinical course and manifestations differ significantly throughout the cases. HFTC/HHS may be undiagnosed until later in life because of its rarity, unfamiliarity, and phenotype diversity; therefore, HFTC/HHS should be included in the differential diagnosis of elderly patients with unexplained hyperphosphataemia or ectopic calcinosis. Comorbidities, including rheumatologic disorders, may contribute to developing HFTC/HHS-associated calcinosis.

Generation and characterization of human induced pluripotent stem cell line METUi002-A from a patient with primary familial brain calcification (PFBC) carrying a heterozygous mutation (c.687dupT (p.Val230CysfsTer28)) in the SLC20A2 gene

Primary familial brain calcification (PFBC) is a rare neurological condition characterized by abnormal calcification commonly in basal ganglia and multiple other brain regions, leading to neuropsychiatric, cognitive, and motor symptoms. SLC20A2, one of the known causative genes for PFBC, contains the highest number of variants directly associated with the disease. Here, we established an iPSC line (METUi002-A) from the peripheral blood mononuclear cells of a clinically diagnosed PFBC patient carrying a SLC20A2 mutation (c.687dupT) using the integration-free Sendai reprogramming. METUi002-A can serve as a valuable tool to generate cellular models to investigate the mechanistic effects of this mutation in PFBC.

171 Abnormal calcium signaling in cystic fibrosis neutrophils is inversely correlated with FEV1 and can be corrected with the Orai1 antagonist ELD607

171 Abnormal calcium signaling in cystic fibrosis neutrophils is inversely correlated with FEV1 and can be corrected with the Orai1 antagonist ELD607

P13 Calciphylaxis as a rare skin manifestation in a patient with an inflammatory myositis

Abstract Introduction Calciphylaxis is a rare but severe vascular complication that can occur in patients with inflammatory myositis. It is characterised by an abnormal deposition of calcium in small and medium sized vessels which can then lead to occlusion and tissue ischemia. It is also known as calcific uremic arteriolopathy, primarily associated with end-stage renal disease, but can also manifest in other clinical settings, including myositis. Myositis encompasses various autoimmune disorders such as polymyositis and dermatomyositis. The exact mechanisms underlying the development of calciphylaxis in myositis are not entirely understood. However, chronic inflammation associated with myositis can trigger this condition. Case description A 70-year-old woman presented to the emergency department in April 2021 with one month history of persistent shortness of breath on exertion and fatigue. A thorough investigation was carried out with auto-immune profile being negative and the radiological appearances were consistent with cryptogenic organizing pneumonia (COP). Treatment was initiated promptly with corticosteroids. Further HRCTs were done to assess the patient’s progress, and revealed a general improvement of the peri bronchial distribution of lung infiltrates. In June 2021, she was diagnosed with acute diverticulitis with localized perforation and was managed conservatively. In October 2021, she contracted COVID-19. She recovered well but presented in December 2021 with a 3-week history of increasing breathlessness, symmetrical arm weakness and rash over her lower limbs. A creatine kinase (CK) was sent which came back with a high value of 3907 IU/L. She was then referred to the rheumatology team. Further investigations revealed a cytoplasmic ANA stain but negative myositis antibody profile, an increase in Troponin T, and pericardial effusion. MRI of the upper limbs showed acute proximal upper limb myositis, worse on the left. Subsequent muscle biopsy showed a necrotizing myopathy. The rash on her calves was initially described as a livedo-like rash, though with skin breakdown, necrotic and ulcerated areas. A skin biopsy was reported as non-uremic calciphylaxis. She was treated for myositis with corticosteroids and intravenous immunoglobulins (chosen due to concerns regarding infection given the diverticular perforation). Her leg ulcers were regularly dressed with light compression and treated with antibiotics. These measures improved her muscle strength, CK and troponin. Leg ulcers were slow to heal but did improve over a period of ten months. Regarding her abdominal perforation, she had two surgeries but developed small bowel obstruction in December 2022. Despite surgical intervention, her condition deteriorated and, unfortunately, she passed away. Discussion The co-occurrence of calciphylaxis and myositis poses several interesting questions for medical professionals. The pathogenesis of calciphylaxis in end-stage renal disease is thought to be related to abnormalities in calcium and phosphate metabolism. However, in myositis it is unclear. Chronic inflammation and tissue damage associated with myositis likely play a role in the initiation of the calcification process. Patients with myositis-associated calciphylaxis typically present with painful skin lesions which often start as small, purplish, or mottled patches that progress to necrotic ulcers. These lesions most commonly occur in the lower extremities but can also involve the abdomen, buttocks, or upper extremities. The ulcers are often non-healing and prone to secondary infection leading to a considerable risk of complications. The condition is associated with significant morbidity and mortality. Calciphylaxis in the context of myositis poses diagnostic and treatment challenges given the rarity of the condition. Differentiating it from other causes of tissue necrosis and skin ulcerations requires careful evaluation of clinical history, laboratory tests, imaging, and skin biopsies. This case involved a multidisciplinary approach including dermatologists, rheumatologists, vascular, pain management and wound care specialists. Treatment strategies aim to address wound care, pain management, secondary infection control, controlling inflammation in myositis, optimising renal function and potentially interventions targeting calcium and phosphate metabolism. Overall, calciphylaxis in myositis presents a significant clinical challenge that requires early recognition, prompt diagnosis, and a multidisciplinary treatment approach for managing this complex condition and improving patient outcomes. This condition requires further research to better understand the pathogenesis and outcomes with different treatments. Key learning points The most important learning point in this case for us was the multidisciplinary team required approach to manage this rare condition. Collaboration among rheumatology, dermatology, vascular and wound care specialties helped us to optimise treatment strategies for this condition. Identifying and addressing the underlying causes of calciphylaxis is essential. In myositis, autoimmune processes should be managed appropriately. Proper wound care is crucial to prevent infection and promote wound healing. Wound care specialists can provide guidance on appropriate dressings and techniques to optimise wound healing. Calciphylaxis-associated pain can be severe and may need involvement of pain management team for monitoring and adjustment of medications. Calciphylaxis can be a rare skin manifestation of inflammatory myositis.

Could long-term dialysis vintage and abnormal calcium, phosphorus and iPTH control accelerate aging among the maintenance hemodialysis population?

Objective Aging is a complex process of physiological dysregulation of the body system and is common in hemodialysis patients. However, limited studies have investigated the links between dialysis vintage, calcium, phosphorus, and iPTH control and aging. The purpose of the current study was to examine these associations. Methods During 2020, a cross-sectional study was conducted in 3025 hemodialysis patients from 27 centers in Anhui Province, China. Biological age was calculated by a formula using chronological age and clinical indicators. The absence of the target range for serum phosphorus (0.87–1.45 mmol/L), corrected calcium (2.1–2.5 mmol/L) and iPTH (130–585 pg/mL) were identified as abnormal calcium, phosphorus, and iPTH control. Results A total of 1131 hemodialysis patients were included, 59.2% of whom were males (669/1131). The mean (standard deviation) of actual age and biological age were 56.07 (12.79) years and 66.94 (25.88), respectively. The median of dialysis vintage was 4.3 years. After adjusting for the confounders, linear regression models showed patients with abnormal calcium, phosphorus, and iPTH control and on hemodialysis for less than 4.3 years (B = 0.211, p = .002) or on hemodialysis for 4.3 years or more (B = 0.302, p < .001), patients with normal calcium, phosphorus, and iPTH control and on hemodialysis for 4.3 years or more (B = 0.087, p = .013) had a higher biological age. Conclusion Our findings support the hypothesis that long-term hemodialysis and abnormal calcium, phosphorus, and iPTH control may accelerate aging in the hemodialysis population. Further studies are warrant to verify the significance of maintaining normal calcium-phosphorus metabolism in aging.

ASSESSMENT OF VITAMIN D AND CALCIUM LEVELS IN TYPE 2 DIABETES MELLITUS

Diabetes mellitus is an endocrinological condition marked by poor carbohydrate metabolism. T2DM is increasing both domestically and globally. Vitamin D and calcium have a significant role in intermediate metabolic processes, which include enzyme activity, electrical gradients, and the functioning of cells. T2DM was shown to be correlated with abnormal calcium and vitamin D levels. The objective of the current study is to assess the calcium and vitamin D levels in 200 patients, of whom 100 were T2DM patients and 100 were healthy, non-diabetic controls. 12 hours of entire night fasting, a volume of 5 ml of blood was drawn completely aseptically from the antecubital vein to measure glycated hemoglobin, fasting plasma glucose (FPG), postprandial plasma glucose (PPPG), serum 25 hydroxy (OH) Vitamin D (25[OH]D) and calcium. There was a statistically significant difference between the type 2 diabetes and non-diabetic groups for the following measurements: FPG (P 0.001), PPPG (P 0.001), serum vitamin D (P 0.001), and calcium (P 0.001). Comparing T2DM patients to the control group, lower calcium and vitamin D levels were found. This study found that Type 2 diabetes patients had much lower vitamin D and calcium levels, which may play a key role in the disease's propensity to develop early in vulnerable people.

SACE and IL-2R as serum biomarkers for evaluation of multi-organ involvement and prognosis of sarcoidosis

BackgroundSerum biomarkers in the evaluation of organ involvement and prognostic monitoring of sarcoidosis have not been determined. The purpose of this study was to identify common biomarkers that could be used to assess organ involvement and monitor outcomes in sarcoidosis patients.MethodsFrom Mar 2013 to Sep 2021, patients with newly diagnosed pulmonary sarcoidosis were enrolled in this study in Shanghai Pulmonary Hospital. The information from medical records was retrospectively collected including diagnosis, organ involvement, laboratory tests and follow up data. Differences of continuous variables between groups were analyzed by unpaired Student’s t-test. Multivariate logistic regression model was performed to identify potential independent factors associated with multiple organ involvement.ResultsA total of 832 patients were included in the study. There were 339 (40.7%) patients with single organ pulmonary involvement, while 493 (59.3%) patients had two to seven organs involved. Among the routine serum tests, only the serum angiotensin converting enzyme (SACE) level was an independent factor of multiple organ involvement. Compared to those patients without involvement, SACE levels were higher in patients with extra-thoracic lymph node, skin, or spleen involvement as well as abnormal calcium metabolism. Interleukin-2 receptor (IL-2R) levels were higher in patients with extra-thoracic lymph node, spleen involvement and abnormal calcium metabolism than in those without it. The mean levels of SACE and IL-2R showed upward trends paralleling the increase on number of organs involved. In follow up, SACE and IL-2R levels were both decreased in an improved patient group, while there was no obvious difference was noticed before and after treatment in patients with persistent disease.ConclusionSACE and IL-2R were useful as serum biomarkers in the initial evaluation of organ involvement as well as monitoring prognosis in sarcoidosis.

Contributed Session I: Foveal RGCs develop abnormal calcium clearance weeks after photoreceptor ablation.

Vision restoration therapies aim to restore light sensitivity to the retina following photoreceptor (PR) degeneration. Physiological changes in retinal ganglion cells (RGCs) have been reported in rodent models of PR loss but this has not been investigated in primates. By expressing both a calcium indicator (GCaMP6s) and an optogenetic actuator (ChrimsonR) in foveal RGCs of a macaque, we reactivate RGCs and assess activity in the weeks and years following PR loss. Cones were ablated with an ultrafast laser delivered through an adaptive optics scanning light ophthalmoscope (AOSLO). A 0.5 s optogenetic stimulus (1 mW, 640 nm) was delivered to the deafferented RGCs, and GCaMP fluorescence was recorded for 90 s. The calcium response was collected with AOSLO over 10 weeks and the signal decay was fitted with an exponential model. Optogenetic responses in RGCs persisted over 2 years following PR ablation. The mean time to peak calcium response was stable in deafferented RGCs over the 10 weeks (paired t-test, p<0.001), while the mean decay constant of the calcium response decreased 2.1 fold (2.5±0.5 s to 1.2±0.2 s SD) in the 8 weeks post PR ablation. The presence of optogenetic responses 2 years after PR loss and the stable rise time is promising for vision restoration therapies with RGCs. However, the 2-fold reduction in the decay constant of the calcium response suggests that restored activity may be impacted by physiological changes in the inner retina weeks after PR loss.

Chronic kidney disease mineral bone disorder in childhood and young adulthood: a ‘growing’ understanding

Chronic kidney disease (CKD) mineral and bone disorder (MBD) comprises a triad of biochemical abnormalities (of calcium, phosphate, parathyroid hormone and vitamin D), bone abnormalities (turnover, mineralization and growth) and extra-skeletal calcification. Mineral dysregulation leads to bone demineralization causing bone pain and an increased fracture risk compared to healthy peers. Vascular calcification, with hydroxyapatite deposition in the vessel wall, is a part of the CKD-MBD spectrum and, in turn, leads to vascular stiffness, left ventricular hypertrophy and a very high cardiovascular mortality risk. While the growing bone requires calcium, excess calcium can deposit in the vessels, such that the intake of calcium, calcium- containing medications and high calcium dialysate need to be carefully regulated. Normal physiological bone mineralization continues into the third decade of life, many years beyond the rapid growth in childhood and adolescence, implying that skeletal calcium requirements are much higher in younger people compared to the elderly. Much of the research into the link between bone (de)mineralization and vascular calcification in CKD has been performed in older adults and these data must not be extrapolated to children or younger adults. In this article, we explore the physiological changes in bone turnover and mineralization in children and young adults, the pathophysiology of mineral bone disease in CKD and a potential link between bone demineralization and vascular calcification.Graphical abstractA higher resolution version of the Graphical abstract is available as Supplementary information

Added value of arterial enhancement fraction derived from dual-energy computed tomography for preoperative diagnosis of cervical lymph node metastasis in papillary thyroid cancer: initial results.

To explore the added value of arterial enhancement fraction (AEF) derived from dual-energy computed tomography CT (DECT) to conventional image features for diagnosing cervical lymph node (LN) metastasis in papillary thyroid cancer (PTC). A total of 273 cervical LNs (153 non-metastatic and 120 metastatic) were recruited from 92 patients with PTC. Qualitative image features of LNs were assessed. Both single-energy CT (SECT)-derived AEF (AEFS) and DECT-derived AEF (AEFD) were calculated. Correlation between AEFD and AEFS was determined using Pearson's correlation coefficient. Multivariate logistic regression analysis with the forward variable selection method was used to build three models (conventional features, conventional features + AEFS, and conventional features + AEFD). Diagnostic performances were evaluated using receiver operating characteristic (ROC) curve analyses. Abnormal enhancement, calcification, and cystic change were chosen to build model 1 and the model provided moderate diagnostic performance with an area under the ROC curve (AUC) of 0.675. Metastatic LNs demonstrated both significantly higher AEFD (1.14 vs 0.48; p < 0.001) and AEFS (1.08 vs 0.38; p < 0.001) than non-metastatic LNs. AEFD correlated well with AEFS (r = 0.802; p < 0.001), and exhibited comparable performance with AEFS (AUC, 0.867 vs 0.852; p = 0.628). Combining CT image features with AEFS (model 2) and AEFD (model 3) could significantly improve diagnostic performances (AUC, 0.865 vs 0.675; AUC, 0.883 vs 0.675; both p < 0.001). AEFD correlated well with AEFS, and exhibited comparable performance with AEFS. Integrating qualitative CT image features with both AEFS and AEFD could further improve the ability in diagnosing cervical LN metastasis in PTC. Arterial enhancement fraction (AEF) values, especially AEF derived from dual-energy computed tomography, can help to diagnose cervical lymph node metastasis in patients with papillary thyroid cancer, and complement conventional CT image features for improved clinical decision making. • Metastatic cervical lymph nodes (LNs) demonstrated significantly higher arterial enhancement fraction (AEF) derived from dual-energy computed tomography (DECT) and single-energy CT (SECT)-derived AEF (AEFS) than non-metastatic LNs in patients with papillary thyroid cancer. • DECT-derived AEF (AEFD) correlated significantly with AEFS, and exhibited comparable performance with AEFS. • Integrating qualitative CT images features with both AEFS and AEFD could further improve the differential ability.

Ryanodine receptor inhibition with acute dantrolene treatment reduces arrhythmia susceptibility in human hearts.

Ryanodine receptor 2 (RyR2) hyperactivity is observed in structural heart diseases that are a result of ischemia or heart failure. It causes abnormal calcium handling and calcium leaks that cause metabolic, electrical, and mechanical dysfunction, which can trigger arrhythmias. Here, we tested the antiarrhythmic potential of dantrolene (RyR inhibitor) in human hearts. Human hearts not used in transplantation were obtained, and right ventricular outflow tract (RVOT) wedges and left ventricular (LV) slices were prepared. Pseudo-ECGs were recorded to determine premature ventricular contraction (PVC) incidences. Optical mapping was performed to determine arrhythmogenic substrates. After baseline optical recordings, tissues were treated with 1) isoproterenol (250 nM), 2) caffeine (200 mM), and 3) dantrolene (2 or 10 mM). Optical recordings were obtained after each treatment. Isoproterenol and caffeine treatment increased PVC incidence, whereas dantrolene reduced the PVC burden. Isoproterenol shortened action potential duration (APD) in the RV, RVOT, and LV regions and shortened calcium transient duration (CaTD) in the LV. Caffeine further shortened APD in the RV, did not modulate APD in the RVOT, and prolonged APD in the LV. In addition, in the LV, CaTD prolongation was also observed. More importantly, adding dantrolene did not alter APD in the RV or RVOT regions but produced a trend toward APD prolongation and significant CaTD prolongation in the LV, restoring these parameters to baseline values. In conclusions, dantrolene treatment suppresses triggers and reverses arrhythmogenic substrates in the human heart and could be a novel antiarrhythmic therapy in patients with structural heart disease.NEW & NOTEWORTHY Ryanodine receptor 2 hyperactivity is observed in structural heart diseases caused by ischemia or heart failure. It causes abnormal calcium leaks, which can trigger arrhythmias. To prevent arrhythmias, we applied dantrolene in human hearts ex vivo. Isoproterenol and caffeine treatment increased PVC incidence, whereas dantrolene reduced the PVC burden. Dantrolene treatment suppresses triggers and reverses arrhythmogenic substrates and could be a novel antiarrhythmic therapy in patients with structural heart disease.

Abstract P3135: In Vivo Dissection Of CaMKII-Mediated Arrhythmias In CPVT

Background: Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited arrhythmia syndrome of the structurally intact heart manifesting life-threatening bursts of ventricular tachycardias due to dominant gain-of-function mutations in the ryanodine receptor type 2 (RyR2) and β-adrenergic (β-AR) stimulation. Both protein kinase A (PKA) and Ca 2+ - calmodulin-dependent protein kinase II (CaMKII) can phosphorylate RyR2 channels, but only the latter can initiate the arrhythmogenic phenotype in CPVT. Whether through L-type Ca 2+ channel (LTCC)-mediated Ca 2+ increase or the Epac2-nitric oxide pathway, the exact mechanism by which β-AR-mediated CaMKII activation unmasks lethal arrhythmias in CPVT remains unresolved. Aim: To gain mechanistic insight and ablate ventricular arrhythmias in a mouse model of CPVT by selectively disrupting integral components of β-AR signaling. Methods: By utilizing either direct adeno-associated virus (AAV) delivery or the CRISPR/Cas9-AAV-based somatic mutagenesis (CASAAV) system, we selectively expressed a mutant LTCC β 2 -subunit, ablated the small GTPase Rad, or disrupted other components of the β-AR pathway in the hearts of mice with the pathogenic RyR2 mutation R4650I as a model of CPVT. The effects of disruption of LTCC regulation were determined by high-speed Ca 2+ imaging of isolated ventricular cardiomyocytes or whole animal electrophysiological (EP) testing for ventricular arrhythmia incidence in vivo . Results &amp; Conclusions: Our data demonstrate that abnormal RyR2-mediated calcium release events are induced by hyperactivated LTCCs in vitro , even in the absence of adrenergic stimulation, with increased arrhythmia incidence in vivo . These results suggest that β-AR stimulation leads to pathogenic RyR2 Ca 2+ leak through LTCC-mediated contribution to CaMKII hyperactivity. Alternative mechanisms of CaMKII activation that mediate arrhythmia induction in CPVT require additional future investigation.

Abstract P1038: Role Of Hypomorphic Notch1 Mutations In Cardiomyocyte Signaling And Function In Hypoplastic Left Heart Syndrome

Background: Congenital heart disease (CHD) affects is the most common birth defect and affects 1% of births in the United States. Hypoplastic left heart syndrome (HLHS) a complex CHD where left sided structures are malformed during embryonic development. Compound heterozygous mutations in NOTCH1, a developmental transmembrane protein have been implicated HLHS patients. However, the effect of hypomorphic NOTCH1 expression on cardiomyocyte development has not been fully characterized. Methods: Using HLHS patient derived induced pluripotent stem cells (iPSCs) with a compound heterozygous NOTCH1 expression and CRISPR-Cas9 gene editing technology we developed multiple iPSCs clones with hypomorphic NOTCH1 expression. We characterized expression of NOTCH1 downstream signaling molecules using transcriptomics of iPSCs and CMs. We further characterized mitochondrial structure, ATP production and sarcomere architecture of the resulting CMs. Lastly, we characterized calcium transients and contractility of the NOTCH1 hypomorphic CMs. Results: iPSC-CMs with hypomorphic NOTCH1 expression showed reduced pluripotency and decreased differentiation into cardiomyocytes. Transcriptomics studies showed that hypomorphic clones increasingly differentiated into fibroblasts and smooth muscle cells as compared to wild-type (WT) cells. Multiple signaling pathways associated mitochondrial function, sarcomeric organization, and cardiomyocyte development were dysregulated. Live cell imaging showed abnormal sarcomeric architecture and mitochondrial hyperfission as compared to WT cells. ATP production was also decreased as compared to WT. Lastly, calcium transients in hypomorphic CMs showed a decrease in time to peak and upslope which consequently lead to decreased contractility and relaxation rates of hypomorphic NOTCH1 CMs. Conclusion: Hypomorphic expression of NOTCH1 seen in HLHS affects multiple aspects of CM cytoskeletal architecture during CM development. Consequently, NOTCH1 hypomorphic iPSC-CMs have abnormal calcium transients and decreased contractility, likely contributing to the higher incidence of arrhythmia and heart failure seen in HLHS patients.

Abstract P1121: Substrate Rigidity And Mybpc3 Genotype Regulate Development Of Hypertrophic Cardiomyopathy Structural And Functional Phenotypes In Human Ipsc-derived Micro-heart Muscle Arrays

Introduction: We hypothesized that mechanical loading is a key factor in the early stages of hypertrophic remodeling associated with pathogenesis of hypertrophic cardiomyopathy (HCM). We tested this hypothesis in vitro with human induced pluripotent stem cell derived cardiomyocytes (hiPSC-CM) bearing heterozygous loss-of-function mutations in Myosin Binding Protein C (MYBPC3). Cardiomyocytes were cultured in engineered micro-heart muscle arrays that were loaded by changing substrate rigidity. Methods: Isogenic control and MYBPC3 +/- hiPSC-CM were seeded into dogbone-shaped molds to form micro-heart muscle atop silicone rubber substrates with rigidity levels ranging from levels of embryonic (0.4 kPa) to fibrotic adult heart (114 kPa). Spontaneously contracting micro-tissues formed within 48 hours. 10 days after formation, tissues were monitored for action potentials (voltage sensitive dye, BeRST-1), Ca 2+ transients (GCaMP6f reporter), and contractility (substrate deflection). Cell and tissue architecture were assessed in 8 μm cryosections, and RNA transcription via qRT-PCR. Results: MYBPC3 +/- and control cardiomyocytes had similar physiology and morphology in 2D monolayers. However, MYBPC3 +/- tissues exhibited marked changes in Ca 2+ handling, which were exacerbated when substrate stiffness increased to the level of healthy heart muscle (15 kPa). This was concurrent with hypertrophy of MYBPC3 +/- cardiomyocytes at 15 kPa. MYBPC3 +/- tissue Ca 2+ handling abnormalities were linked to enhanced Ca 2+ intake rather than SERCA deficiency or excessive myofilament buffering. MYBPC3 +/- tissues exhibited mis-regulation of cardiac troponins on the RNA and protein localization levels, which may underlie the observed structural and physiological changes. Conclusions: Changes in the rigidity of the substrate, mimicking changes in heart muscle caused by blood pressure, pushed hiPSC-cardiac micro-tissues with MYBPC3 mutations to recapitulate key structural and electrophysiological characteristics of HCM. In contrast, control tissues exhibited hypertrophy and abnormal calcium handling, but only at extreme values of substrate stiffness. This suggests that HCM mutations may exaggerate load-dependent hypertrophic remodeling.

Inflammation and gut dysbiosis as drivers of CKD-MBD.

Two decades ago, Kidney Disease: Improving Global Outcomes coined the term chronic kidney disease-mineral and bone disorder (CKD-MBD) to describe the syndrome of biochemical, bone and extra-skeletal calcification abnormalities that occur in patients with CKD. CKD-MBD is a prevalent complication and contributes to the excessively high burden of fractures and cardiovascular disease, loss of quality of life and premature mortality in patients with CKD. Thus far, therapy has focused primarily on phosphate retention, abnormal vitamin D metabolism and parathyroid hormone disturbances, but these strategies have largely proved unsuccessful, thus calling for paradigm-shifting concepts and innovative therapeutic approaches. Interorgan crosstalk is increasingly acknowledged to have an important role in health and disease. Accordingly, mounting evidence suggests a role for both the immune system and the gut microbiome in bone and vascular biology. Gut dysbiosis, compromised gut epithelial barrier and immune cell dysfunction are prominent features of the uraemic milieu. These alterations might contribute to the inflammatory state observed in CKD and could have a central role in the pathogenesis of CKD-MBD. The emerging fields of osteoimmunology and osteomicrobiology add another level of complexity to the pathogenesis ofCKD-MBD, but also create novel therapeutic opportunities.

Regulation of specific abnormal calcium signals in the hippocampal CA1 and primary cortex M1 alleviates the progression of temporal lobe epilepsy.

Temporal lobe epilepsy is a multifactorial neurological dysfunction syndrome that is refractory, resistant to antiepileptic drugs, and has a high recurrence rate. The pathogenesis of temporal lobe epilepsy is complex and is not fully understood. Intracellular calcium dynamics have been implicated in temporal lobe epilepsy. However, the effect of fluctuating calcium activity in CA1 pyramidal neurons on temporal lobe epilepsy is unknown, and no longitudinal studies have investigated calcium activity in pyramidal neurons in the hippocampal CA1 and primary motor cortex M1 of freely moving mice. In this study, we used a multi-channel fiber photometry system to continuously record calcium signals in CA1 and M1 during the temporal lobe epilepsy process. We found that calcium signals varied according to the grade of temporal lobe epilepsy episodes. In particular, cortical spreading depression, which has recently been frequently used to represent the continuously and substantially increased calcium signals, was found to correspond to complex and severe behavioral characteristics of temporal lobe epilepsy ranging from grade II to grade V. However, vigorous calcium oscillations and highly synchronized calcium signals in CA1 and M1 were strongly related to convulsive motor seizures. Chemogenetic inhibition of pyramidal neurons in CA1 significantly attenuated the amplitudes of the calcium signals corresponding to grade I episodes. In addition, the latency of cortical spreading depression was prolonged, and the above-mentioned abnormal calcium signals in CA1 and M1 were also significantly reduced. Intriguingly, it was possible to rescue the altered intracellular calcium dynamics. Via simultaneous analysis of calcium signals and epileptic behaviors, we found that the progression of temporal lobe epilepsy was alleviated when specific calcium signals were reduced, and that the end-point behaviors of temporal lobe epilepsy were improved. Our results indicate that the calcium dynamic between CA1 and M1 may reflect specific epileptic behaviors corresponding to different grades. Furthermore, the selective regulation of abnormal calcium signals in CA1 pyramidal neurons appears to effectively alleviate temporal lobe epilepsy, thereby providing a potential molecular mechanism for a new temporal lobe epilepsy diagnosis and treatment strategy.

Changes in urinary exosomal protein CALM1 may serve as an early noninvasive biomarker for diagnosing diabetic kidney disease

BackgroundThe risk of the development and progression of diabetic kidney disease (DKD) was increased by abnormal calcium release. However, it is still unknown whether calcium signal pathway-related proteins are changed in urinary exosomes. This study aims to explore the changes in urinary exosomal proteins, which may provide novel biomarkers for diagnosing DKD. MethodsUrinary exosomes were isolated from 132 participants by size exclusion chromatography method and 72 participants were tested by LC-MS/MS (Discovery phase). Correlation and multivariate logistics analysis were applied to evaluate selected urinary proteins. Western blot and ELISA were used to validate the selected protein (Validation phase: n = 60). The diagnostic performance of the selected biomarker was evaluated by receiver operating characteristic curve analyses between the discovery and validation phases. ResultsSixteen calcium signal pathway-related proteins were identified, however, only Calmodulin-1(CALM1) was continuously increased. Different expression of CALM1 was found in patients with different level of estimated glomerular filtration rate (eGFR) in two cohorts. The level of CALM1 was correlated with eGFR and serum creatinine levels in two cohorts. Multivariate analysis revealed that serum albumin (ALB) levels and CALM1 were independent risk factors for DKD. A diagnostic model based on CALM1 and serum ALB levels that could significantly distinguish DKD was established and validated. ConclusionsSignificant changes in calcium signal pathway-related urinary exosomal proteins were observed. The CALM1 may serve as an early noninvasive biomarker for diagnosing DKD.

Fahr's syndrome as a manifestation of autoimmune polyendocrine syndrome-1 and its unusual association with neuromyelitis optica spectrum disorder.

Fahr's syndrome, also known as bilateral striopallidodendate calcinosis, is a rare inherited neurodegenerative illness characterized by abnormal calcium deposition in several areas of the brain, resulting in a wide range of neuropsychological symptoms. Fahr's syndrome, secondary to autoimmune polyendocrine syndrome type 1, which includes adrenal insufficiency and mucocutaneous candidiasis in addition to hypoparathyroidism, is exceedingly rare. No case report has been documented to date to show the co-occurrence of Fahr's syndrome and neuromyelitis optica spectrum disorder. Here, we discuss the case of a 30-year-old man with a previous history of seizures and symptoms of ectodermal dystrophy presented with seizures, left-sided hemiparesis, dysarthria, and other characteristics indicative of severe hypocalcemia. The neuroimaging findings strongly suggested Fahr's syndrome, with radiographic evidence of Neuromyelitis optica spectrum disorder as longitudinal extensive transverse myelitis in the cervical spinal cord, high titers of serum aquaporin-4 antibodies, and demyelinating neuropathy on nerve conduction studies. This distinct neuropsychological presentation and neuroimaging findings led to the diagnosis of Fahr's syndrome as a result of hypoparathyroidism caused by autoimmune polyendocrine syndrome type 1 with cooccurrence of neuromyelitis optica spectrum disorder. The patient's clinical symptoms improved considerably after he was treated based on a provisional diagnosis. The clinical importance of our case is significant for both neuropsychiatrists and endocrinologists, as autoimmune polyendocrine syndrome should be considered as the etiology of Fahr's syndrome. This case report also aims to report this unusual association of Neuromyelitis optica spectrum disorder with Fahr's syndrome to give the future prospective to know whether this association is incidental or there is a missing link between these two different disorders.