Improving diagnosis of tumor-induced osteomalacia with gallium-68 DOTATATE PET/CT

Context: Tumor-induced osteomalacia (TIO) is a rarely diagnosed disorder presenting with bone pain, fractures, muscle weakness, and moderate-to-severe hypophosphatemia resulting from fibroblast growth factor 23-mediated renal phosphate wasting. Tumors secreting fibroblast growth factor 23 are often small and difficult to find with conventional imaging. Objective: We studied the utility of 68Ga-DOTA-octreotate (DOTATATE) somatostatin receptor positron emission tomography (PET)/computed tomography (CT) imaging in the diagnosis of TIO. Design and Setting: A multicenter case series was conducted at tertiary referral hospitals. Patients and Methods: Six patients with TIO diagnosed between 2003 and 2012 in Australia were referred for DOTATATE PET imaging. We reviewed the clinical history, biochemistry, imaging characteristics, histopathology, and clinical outcome of each patient. Results: Each case demonstrated delayed diagnosis despite severe symptoms. DOTATATE PET/CT imaging demonstrated high uptake and localized the tumor with confidence in each case. After surgical excision, there was resolution of clinical symptoms and serum phosphate, except in one patient who demonstrated residual disease on PET/CT. All tumors demonstrated high somatostatin receptor subtype 2 cell surface receptor expression using immunohistochemistry. Conclusions: In patients with TIO, DOTATATE PET/CT can successfully localize phosphaturic mesenchymal tumors and may be a practical first step in functional imaging for this disorder. Serum phosphate should be measured routinely in patients with unexplained muscle weakness, bone pain, or stress fractures to allow earlier diagnosis of TIO. - See more at: http://press.endocrine.org/doi/abs/10.1210/jc.2012-3642#sthash.eXD0CopL.dpuf

Audiologic findings in patients with hypophosphatemic rickets/osteomalacia

This paper is a review of the connection between sensorineural hearing loss and rickets.

Audiologic findings in patients with hypophosphatemic rickets/osteomalacia

This paper is a review of the connection between sensorineural hearing loss and rickets.

Oncogenic osteomalacia: loss of hypophosphatemia might be the key to avoid misdiagnosis

A osteomalacia oncogênica é um diagnóstico clínico desafiador, caracterizado pela perda renal de fosfato e baixos níveis de 1,25-di-hidroxivitamina D3, ocorrendo na presença de um tumor produtor de altos níveis de fator de crescimento de fibroblasto 23. No entanto, é possível que se trate muito mais de uma falha de diagnóstico clínico do que propriamente uma doença rara. Os autores relatam o caso de um homem de 42 anos com histórico de fraqueza muscular progressiva por cinco anos e restrição à cadeira de rodas, sem diagnóstico. Seus exames laboratoriais evidenciavam baixos níveis de fósforo. A remoção cirúrgica de um hemangiopericitoma detectado previamente em cavidade nasal levou à resolução completa dos sintomas. Os autores enfatizam que, mesmo com a etiologia já evidenciada, o paciente consultou diversos clínicos no decorrer dos cinco anos até que fossem instituídos o diagnóstico e o tratamento adequados. Arq Bras Endocrinol Metab. 2012;56(8):570-3

Oncogenic osteomalacia: loss of hypophosphatemia might be the key to avoid misdiagnosis

Diagnosing oncogenic osteomalacia is still a challenge. The disorder is characterized by osteomalacia caused by renal phosphate wasting and low serum concentration of 1,25-dihydroxyvitamin D3 occurring in the presence of a tumor that produces high levels of fibroblast growth factor 23. However, it is possible that the disease is much more misdiagnosed than rare. We present the case of a 42-year-old man with a long-term history of undiagnosed progressive muscle weakness. His laboratory results mainly showed low serum phosphate. Surgical removal of a nasal hemangiopericytoma that had been diagnosed five years earlier, brought him to a symptom-free condition. Even though knowing the underlying etiology would explain his osteomalacia, the patient sought medical help from countless physicians for five consecutive years, and only after adequate treatment a rewarding outcome was achieved.

Advanced prostate cancer as a cause of oncogenic osteomalacia: an underdiagnosed condition

Tumor-induced osteomalacia (TIO) is a paraneoplastic bone mineral disturbance related to fibroblast growth factor 23 (FGF23) overproduction by the tumor, usually from mesenchymal origin. Such condition leads to high phosphate renal wasting and, consequently, to cumbersome symptoms as weakness, bone pain, and fractures. Case report. We report a case of an advanced castration-refractory prostate cancer patient, which developed severe hypophosphatemia with elevated phosphate excretion fraction. TIO was suspected, and increased levels of FGF23 reinforced such diagnosis. The patient died 4 months after being diagnosed with TIO. This case suggests that TIO has a dismal prognosis in prostate cancer patients. The clinical oncology community must be aware about such disturbance that can be present in those patients with weakness, bone pain, and hypophosphatemia.

Cloning and characterization of FGF23 as a causative factor of tumor-induced osteomalacia

Tumor-induced osteomalacia (TIO) is one of the paraneoplastic diseases characterized by hypophosphatemia caused by renal phosphate wasting. Because removal of responsible tumors normalizes phosphate metabolism, an unidentified humoral phosphaturic factor is believed to be responsible for this syndrome. To identify the causative factor of TIO, we obtained cDNA clones that were abundantly expressed only in a tumor causing TIO and constructed tumor-specific cDNA contigs. Based on the sequence of one major contig, we cloned 2,270-bp cDNA, which turned out to encode fibroblast growth factor 23 (FGF23). Administration of recombinant FGF23 decreased serum phosphate in mice within 12 h. When Chinese hamster ovary cells stably expressing FGF23 were s.c. implanted into nude mice, hypophosphatemia with increased renal phosphate clearance was observed. In addition, a high level of serum alkaline phosphatase, low 1,25-dihydroxyvitamin D, deformity of bone, and impairment of body weight gain became evident. Histological examination showed marked increase of osteoid and widening of growth plate. Thus, continuous production of FGF23 reproduced clinical, biochemical, and histological features of TIO in vivo. Analyses for recombinant FGF23 products produced by Chinese hamster ovary cells indicated proteolytic cleavage of FGF23 at the RXXR motif. Recent genetic study indicates that missense mutations in this RXXR motif of FGF23 are responsible for autosomal dominant hypophosphatemic rickets, another hypophosphatemic disease with similar features to TIO. We conclude that overproduction of FGF23 causes TIO, whereas mutations in the FGF23 gene result in autosomal dominant hypophosphatemic rickets possibly by preventing proteolytic cleavage and enhancing biological activity of FGF23.

Elucidating the links between UV radiation and vitamin D synthesis : using an in vitro model

Ultraviolet radiation (UV) is the carcinogen that causes the most common malignancy in humans – skin cancer. However, moderate UV exposure is essential for producing vitaminDin our skin. VitaminDincreases the absorption of calcium from the diet, and adequate calcium is necessary for the building and maintenance of bones. Thus, low levels of vitamin D can cause osteomalacia and rickets and contribute to osteoporosis. Emerging evidence also suggests vitamin D may protect against falls, internal cancers, psychiatric conditions, autoimmune diseases and cardiovascular diseases. Since the dominant source of vitamin D is sunlight exposure, there is a need to understand what is a “balanced” level of sun exposure to maintain an adequate level of vitamin D but minimise the risks of eye damage, skin damage and skin cancer resulting from excessive UV exposure. There are many steps in the pathway from incoming solar UV to the eventual vitamin D status of humans (measured as 25-hydroxyvitamin D in the blood), and our knowledge about many of these steps is currently incomplete. This project begins by investigating the levels of UV available for synthesising vitamin D, and how these levels vary across seasons, latitudes and times of the day. The thesis then covers experiments conducted with an in vitro model, which was developed to study several aspects of vitamin D synthesis. Results from the model suggest the relationship between UV dose and vitamin D is not linear. This is an important input into public health messages regarding ‘safe’ UV exposure: larger doses of UV, beyond a certain limit, may not continue to produce vitamin D; however, they will increase the risk of skin cancers and eye damage. The model also showed that, when given identical doses of UV, the amount of vitamin D produced was impacted by temperature. In humans, a temperature-dependent reaction must occur in the top layers of human skin, prior to vitamin D entering the bloodstream. The hypothesis will be raised that cooler temperatures (occurring in winter and at high latitudes) may reduce vitamin D production in humans. Finally, the model has also been used to study the wavelengths of UV thought to be responsible for producing vitamin D. It appears that vitamin D production is limited to a small range of UV wavelengths, which may be narrower than previously thought. Together, these results suggest that further research is needed into the ability of humans to synthesise vitamin D from sunlight. In particular, more information is needed about the dose-response relationship in humans and to investigate the proposed impact of temperature. Having an accurate action spectrum will also be essential for measuring the available levels of vitamin D-effective UV. As this research continues, it will contribute to the scientific evidence-base needed for devising a public health message that will balance the risks of excessive UV exposure with maintaining adequate vitamin D.

Aluminium in Fisch und Fischereierzeugnissen

Recent reports associating aluminium with several skeletal (osteomalacia) and neurological disorders (encephalopathy and Alzheimer’s disease) in humans suggest that exposure to aluminium may pose a hazard to health. This requires the examination of aluminiumcontent in different foodstuffs. Therefore, an analytical method for the determination of aluminium in fish and fishery products, especially in fishery products packaged in aluminium cans, was developed using graphite furnace atomic absorption spectrometry. Fillets of lean and fatty fish showed aluminium levels lower than 1mg/kg wet weight, muscle of crustacean, molluscan and shellfish had apparently higher aluminium levels (up to 20 mg/kg wet weight). The aluminium content in some aluminum-canned herring was much higher than the content found in herring caught in the North Sea. These results indicate that aluminium is taken up by the herring fillets in aluminium cans, presumably through the slight and slow dissolution of aluminium from the can wall, due to some defects in the protective lacquer layer. A comparison of the aluminium levels measured in canned herring with the average aluminium-intake (normally between 3 and 5 mg/day) or with the provisional tolerable daily intake of 1mg/kg body weight per day (WHO 1989) indicated, that the aluminium content of the edible part of aquatic food does not play a significant role. High consumption of fish fillets does not pose any health risk.

Contrôle de l'expression de la protéine PHEX et rôle de PHEX et FGF23 dans la minéralisation par les cellules MC3T3

PHEX est une protéine importante dans le processus de minéralisation osseuse. Des mutations ou la délétion d’une partie de ce gène causent l’hypophosphatémie liée au chromosome X (XLH). Cette maladie est caractérisée par une hypophosphatémie, accompagnée de défauts de minéralisation, de rachitisme et de lésions ostéomalaciques. Avec l’hypophosphatémie, les taux circulants de vitamine D devraient être augmentés, ce qui n’est pas le cas d’où une régulation anormale de la production de vitamine D a lieu. Cependant, malgré le fait que cette protéine soit une peptidase, aucun substrat physiologique n’a encore été répertorié pour PHEX. PHEX est une protéine membranaire de type II de la famille M13 des métalloendopeptidases à zinc possédant un court domaine N-terminal cytosolique, un segment transmembrannaire d’environ 20 acides aminés et une large portion C-terminale extracellulaire où se trouve le site actif de l’enzyme. PHEX est exprimée de façon majoritaire dans les os et dans les dents et elle apparaît à l’initiation de la minéralisation. Les patients souffrant de XLH et la souris Hyp, qui est un modèle animal de la maladie humaine, montrent des quantités importantes de la protéine FGF23. De plus, FGF23 est impliqué dans une autre maladie reliée au métabolisme du phosphate, l’hypophosphatémie rachitique autosomale dominante (ADHR) où des mutations de FGF23 causent sensiblement les mêmes symptômes que XLH. FGF23 est produit principalement par les ostéoblastes et les ostéocytes. FGF23 cause une hypophosphatémie par la diminution de l’expression du cotransporteur NaPi de type II, responsable de la réabsorption du phosphate rénal. L’hypothèse proposée dans la littérature serait que PHEX activerait ou inactiverait des peptides importants pour la minéralisation osseuse. Plus spécifiquement, l’activation ou l’inactivation de ces peptides aurait pour rôle de réguler les quantités de FGF23. Selon l’hypothèse mentionnée précédemment, la régulation de PHEX pourrait donc avoir un effet sur la minéralisation. Une quantité croissante de données sur la régulation de PHEX sont maintenant disponibles. Par exemple, la vitamine D diminue l’expression de PHEX tandis que les glucocorticoïdes et l’hormone de croissance augmentent son expression. Dans une première étude, nous avons voulu déterminer si un peptide relié à la minéralisation osseuse, le PTHrP1-34, pouvait réguler l’expression de PHEX. Nous avons déterminé que le PTHrP1-34 peut réguler de façon négative l’expression de PHEX dans les cellules UMR-106, une lignée cellulaire ostéoblastique. Cette régulation passe par la voie de l’AMPc/protéine kinase A. De plus, cette diminution d’expression est également observée au jour 7 dans des cultures primaires d’ostéoblastes de rat en minéralisation. Par la suite, nous avons étudié un mutant de PHEX, le mutant E4Q retrouvé chez un patient souffrant de XLH, où la mutation se retrouve dans le domaine cytosolique de PHEX. Cette mutation n’interfère pas avec le site catalytique de l’enzyme puisque ce mutant de PHEX peut tout aussi bien cliver un substrat synthétique que la protéine sauvage. Il a été déterminé que cette mutation annule un motif di-acide. Nous avons démontré que ce motif di-acide est responsable de la liaison de PHEX à COPII, responsable de la formation de vésicules de sécrétion. De plus, il semblerait que ce motif soit important, probablement par son interaction avec COPII, à l’incorporation de PHEX dans des vésicules de calcification, lesdites vésicules étant importantes dans le processus de minéralisation. Finalement, des essais de compétitions ont démontré que la minéralisation pouvait être perturbée lorsque l’on surexprimait la queue cytosolique sauvage de PHEX, contrairement à la queue mutée. Ceci suggère possiblement que l’interaction avec COPII menant à l’incorporation de PHEX dans les vésicules de calcification ou d’autres protéines comprenant de tels motifs pourrait être importante pour la minéralisation. Finalement, la dernière étude porte sur la protéine FGF23. Nous avons démontré, par la surexpression de FGF23 dans la lignée MC3T3 d’ostéoblastes de souris, que cette surexpression a un effet sur la sénescence de ces cellules. En effet, des essais de sénescence ont montré l’augmentation de celle-ci lorsque FGF23 est surexprimé. Par contre, la prolifération n’est pas altérée. De plus, il semblerait que la différenciation soit plus rapide, tel qu’observé par une minéralisation survenant plus tôt, mais n’étant pas plus importante. Bref, la surexpression de FGF23 semblerait faire en sorte que les ostéoblastes se différencient plus rapidement et passent donc à un état de sénescence prématuré comparativement aux cellules sauvages. Ceci est en accord avec la littérature où KLOTHO, un cofacteur de FGF23 permettant sa liaison avec une plus grande affinité sur son récepteur, lorsqu’inactivé démontre un phénotype similaire au vieillissement incluant un phénotype de sénescence.

Colestase crônica em crianças e em adolescentes : avaliação nutricional, avaliação neurológica e níveis plasmáticos de vitaminas D e E

A colestase crônica na infância e na adolescência interfere diretamente no cres-cimento e no desenvolvimento do indivíduo e produz conseqüências clínicas relacionadas com a má absorção das vitaminas lipossolúveis da dieta. A vitamina E exerce um importante papel na estrutura e na função dos sistemas nervoso e musculoesquelético. A vitamina D tem reconhecida influência sobre a fisiopatologia da osteopenia colestática que se manifesta como osteoporose, raquitismo ou osteomalácia. A realização de dosagens plasmáticas dessas vitami-nas é essencial para detectar precocemente suas deficiências, bem como para monitorizar uma adequada suplementação. Essas dosagens não são realizadas de rotina no nosso meio. Os objetivos do presente estudo foram verificar os níveis plasmáticos de vitami-nas D e E em uma amostra de crianças e adolescentes com colestase crônica; verificar o esta-do nutricional e a ingestão de macro e micronutrientes desses pacientes; verificar o uso de su-plemento de vitaminas, o tempo de colestase; e realizar avaliação neurológica para estabelecer eventual relação com os níveis plasmáticos de vitamina E. A amostra constou de 22 crianças e adolescentes com colestase crônica que con-sultavam no ambulatório ou estiveram internadas na Unidade de Gastroenterologia Pediátrica do Hospital de Clínicas de Porto Alegre no período de dezembro de 2000 a abril de 2002. Como controles, participaram 17 crianças eutróficas e normais do ponto de vista gastroentero-lógico com faixa etária correspondente. Foram realizadas avaliação nutricional e avaliação neurológica. Foi pesquisado o tempo de colestase e o uso de suplemento de vitaminas lipossolúveis. A técnica utilizada para as dosagens da vitamina E foi a cromatografia líquida de alta precisão (HPLC) e as dosagens plasmáticas de vitamina D pela técnica de radioimunoensaio. A prevalência de desnutrição variou entre 23,8% a 63,0% considerando as diferentes medidas e padrões utilizados. O inquérito alimentar realizado demonstrou uma ingestão calórica média de 89,33 ± 27,4% em relação ao recomendado para idade com uma distribui-ção dos macronutrientes em relação às calorias ingeridas dentro dos valores de referência para o grupo em questão, havendo, porém, uma pobre ingestão de micronutrientes como ferro e zinco. O exame neurológico foi alterado em 43% dos pacientes colestáticos, em que foram constatadas vinte alterações neurológicas em nove pacientes. Não obtivemos resultados con-fiáveis para os níveis plasmáticos de vitamina E, apesar de realizar 3 etapas para validação. O valor médio de vitamina D entre os pacientes foi de 13,7 ± 8,39 ng/ml, enquanto que no grupo controle foi de 25,58 ± 16,73 ng/ml (P = 0,007), havendo uma prevalência de hipovitaminose D entre esses pacientes de 36%. Não foi observada relação entre estado nutricional, tempo de colestase ou uso de suplemento oral de vitaminas lipossolúveis e os níveis plasmáticos refe-ridos. Concluímos que a média de níveis plasmáticos de vitamina D nas crianças e nos adolescentes colestáticos do estudo foi significativamente menor do que nos controles nor-mais sem relação significativa com estado nutricional, tempo de colestase ou uso de suple-mento de vitaminas. As alterações neurológicas foram freqüentes e a prevalência de desnutri-ção nos pacientes foi semelhante à encontrada na literatura. A ingesta calórica foi deficiente havendo porém, um equilíbrio dos macronutrientes e ingestão insuficiente de ferro e zinco.

Diagnóstico da deficiência de fósforo em bovinos pelos exames histológicos e microrradiográficos de costelas

The objective of the present study was to show the efficiency of histologic and microradiographic techniques performed on rib bone samples as a mean of diagnosing the phosphorus status of cattle raised on phosphorus deficient pastures and receiving different mineral supplements. The rib samples were obtained from cattle of different ages which died from disease that was clinically and epidemiologically diagnosed as botulism. Ten out of 24 juvenile and adult animals studied exibited alterations of osteomalacia, while the others without those alterations served as controls. It is suggested that the method could be useful to improve the diagnosis of phosphorus deficiency of cattle in Brazil.

Advances in sickle cell disease treatment: From drug discovery until the patient monitoring

Sickle Cell Disease (SCD) is one of the most prevalent hematological diseases in the world. Despite the immense progress in molecular knowledge about SCD in last years few therapeutical sources are currently available. Nowadays the treatment is performed mainly with drugs such as hydroxyurea or other fetal hemoglobin inducers and chelating agents. This review summarizes current knowledge about the treatment and the advancements in drug design in order to discover more effective and safe drugs. Patient monitoring methods in SCD are also discussed. © 2011 Bentham Science Publishers Ltd.

Enzyme replacement prevents enamel defects in hypophosphatasia mice

Hypophosphatasia (HPP) is the inborn error of metabolism characterized by deficiency of alkaline phosphatase activity, leading to rickets or osteomalacia and to dental defects. HPP occurs from loss-of-function mutations within the gene that encodes the tissue-nonspecific isozyme of alkaline phosphatase (TNAP). TNAP knockout (Alpl-/-, aka Akp2-/-) mice closely phenocopy infantile HPP, including the rickets, vitamin B6-responsive seizures, improper dentin mineralization, and lack of acellular cementum. Here, we report that lack of TNAP in Alpl-/- mice also causes severe enamel defects, which are preventable by enzyme replacement with mineral-targeted TNAP (ENB-0040). Immunohistochemistry was used to map the spatiotemporal expression of TNAP in the tissues of the developing enamel organ of healthy mouse molars and incisors. We found strong, stage-specific expression of TNAP in ameloblasts. In the Alpl-/- mice, histological, mu CT, and scanning electron microscopy analysis showed reduced mineralization and disrupted organization of the rods and inter-rod structures in enamel of both the molars and incisors. All of these abnormalities were prevented in mice receiving from birth daily subcutaneous injections of mineral-targeting, human TNAP at 8.2?mg/kg/day for up to 44 days. These data reveal an important role for TNAP in enamel mineralization and demonstrate the efficacy of mineral-targeted TNAP to prevent enamel defects in HPP. (C) 2012 American Society for Bone and Mineral Research.

Die Expression und Regulation der CYP3A in menschlicher Haut

In Leber und Dünndarm bauen CYP3A-Enzyme eine Vielzahl von Fremdstoffen ab, die in den Körper gelangt sind. Zudem aber sind diese Enzyme auch in anderen Organen, wie der Haut exprimiert. Doch weder die genaue Zusammensetzung der CYP3A-Isozyme noch deren physiologische Rolle in der Haut sind bisher bekannt. Basierend auf begrenzten in vitro-Daten ist eine Rolle der CYP3A in der kutanen Vitamin D-Synthese denkbar. Auf der anderen Seite könnten die kutanen CYP3A auch lokal oder systemisch verabreichte Medikamente in der Haut verstoffwechseln und so zur Entstehung immunologischer und nicht-immunologischer unerwünschter Arzneimittelwirkungen beitragen, von denen sich bis zu 45 % in der Haut manifestieren.rnDie Arbeitshypothese dieses Projekts war, dass die CYP3A die kutane Synthese von Vitamin D regulieren. In dieser Funktion wurden sie zur Vermeidung von Vitamin D-Mangel-Erkrankungen wie Rachitis oder Osteomalazie in Europäern negativ selektiert. rnDie Expression und Regulation der CYP3A wurde in Hautbiopsien, einer Zelllinie epidermalen Ursprungs und primären Hautzellen wie auch in transgenen Mäusen untersucht. Die metabolische Aktivität der CYP3A gegenüber den kutanen Vitamin D-Vorstufen wurde mit Hilfe rekombinant exprimierter Enzyme untersucht. CYP3A5-mRNA war die häufigste der CYP3A in humanen Hautproben und überstieg die von CYP3A4 um das Dreifache, die von CYP3A7 um das 130-Fache. Damit entsprach diese 1,3 %, 0,01 % bzw. 0,01 % der jeweiligen hepatischen Genexpression. Die Expression von CYP3A43 war zu vernachlässigen. CYP3A5 zeigte eine bimodale Expression sowohl auf mRNA- als auch auf Proteinebene. So zeigten Träger der Wildtyp-Allels *1 eine 3,3-fach höhere mRNA- und 1,8-fach höhere Proteinmenge als homozygote Träger des Nullallels *3. CYP3A4/7- und CYP3A5-Protein wurde v. a. in den Keratinozyten der Epidermis und den Talgdrüsen, also den Bereichen der kutanen Vitamin D-Synthese lokalisiert. Die CYP3A5-Expression wurde ferner in der Haut transgener Mäusen gezeigt, die das Reportergen Luziferase unter Kontrolle des humanen CYP3A5-Promoters exprimieren. Verglichen mit der Leber war die kutane Expression des Vitamin D-Rezeptors (VDR) 100-fach höher, die der Xenosensoren CAR und PXR vergleichbar bzw. zu vernachlässigen. Dementsprechend erhöhte die Behandlung mit 1,25-Dihydroxyvitamin D, dem aktiven Vitamin D-Hormon, und dessen Vorstufen außer 7-Dehydrocholesterol, jedoch nicht der PXR-Ligand Rifampicin, die Expression der CYP3A. Wie in Zwei-Hybrid-Experimenten gezeigt, wurden die Effekte des 1,25-Dihydroxyvitamin D und dessen Vorstufen alleinig durch VDR vermittelt. Die Effektstärke hingegen war abhängig von Zellspender, Zellpassage und Zelltypus. Alle drei CYP3A-Isozyme metabolisieren Vitamin D zu einem oder mehreren unbekannten Metaboliten, jedoch nicht zu 25-Hydroxyvitamin D, dem direkten Vorläufer des aktiven Vitamin D. rnZusammengefasst legen die Daten nahe, dass die kutanen CYP3A, allen voran CYP3A5, die Vitamin D-Homöostase durch VDR-vermittelte Induktion des Abbaus von Vitamin D-Vorstufen regulieren. Dies zusammen mit Sequenzdaten liefert starke Indizien für Vitamin D als treibende Kraft der Selektion des CYP3A-Lokus in Europäern. Der Einfluss der CYP3A-Expression auf selektiv wirksame, klinisch relevante Knochenveränderungen wie Rachitis oder Osteomalazie müssen folgen.rn