Physiology and pathophysiology of the extracellular calcium-sensing receptor

The system governing extracellular calcium (Ca2+ (o)) homeostasis maintains near constancy of Ca2+ (o) so as to ensure continual availability of calcium ions for their numerous intracellular and extracellular roles. In contrast to the intracellular ionized calcium concentration (Ca2+ (i)), which varies substantially during intracellular signaling via this key second messenger, Ca2+ (o) remains nearly invariant. Yet there must be a mechanism that senses small changes in Ca2+ (o) so as to set into motion the homeostatic responses that return Ca2+ (o) to its normal level. The recent identification and molecular cloning of the mechanism through which parathyroid cells and a number of other cell types sense Ca2+ (o), a G protein-coupled Ca2+ (o)-sensing receptor (CaR), has proven unequivocally that extracellular calcium ions serve in an informational capacity. The CaR permits Ca2+ (o) to function in a hormone-like role as an extracellular first messenger through which parathyroid, kidney, and other cells communicate with one another via the CaR. The identification of inherited human hypercalcemic and hypocalcemic disorders arising from inactivating and activating mutations of the CaR, respectively, has provided additional proof of the essential, nonredundant role of the CaR in mineral ion homeostasis. Moreover, CaR-active drugs are currently in clinical trials for the treatment of primary and uremic hyperparathyroidism, disorders in which there are acquired, tissue-specific reductions in CaR expression and, in turn, defective Ca2+ (o)-sensing by pathological parathyroid cells. No doubt further studies of Ca2+ (o)- sensing by the CaR will reveal additional functions of Ca2+ (o), not only as a systemic "hormone" but also in local, paracrine, and autocrine signaling through this novel Ca2+ (o)-sensing receptor. Am J Med. 1999;106:238-253. (C) 1999 by Excerpta Medica, Inc.