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Introduction

Parathyroid hormone (PTH) is produced by the parathyroid glands; it increases blood Ca through binding to and activation of the type 1 PTH receptor (PTH1R) in the 2 major target organs, bone and kidney. The PTH gene is ancient, as orthologs have been identified in teleost fish [3], which split from tetrapods about 500 million years ago. Remarkably, these PTH species fully activate the human PTH1R [4] and lead to an increase in bone mass when administered to rats [5]. However, the function of PTH in fish is unknown. Another evolutionarily conserved ligand, PTH-related peptide also binds and activates the same receptor but has different functions. It is expressed in most tissues and acts in an autocrine/paracrine manner. Parathyroid glands have not been identified in aquatic vertebrates and might have evolved during the water-to-land transition.

The amino-terminus of PTH, which is conserved among vertebrates, exhibits all known biological actions of PTH. The carboxyl-terminal region of PTH does not bind the PTH1R but has biological actions in some assays. The biological significance of the C-terminal region of PTH is unclear, and a C-terminal PTH receptor has yet not been identified [6].

Biochemistry and Metabolism

PTH is initially produced as preproPTH, a 115-amino acid precursor peptide, that later matures intracellularly into full-length PTH containing 84 amino acids. PTH is stored in secretory granules in parathyroid cells and is released when serum calcium is low. This circulating PTH comprises full-length PTH(1–84) peptides as well as several forms of truncated, mostly carboxyl-terminal fragments, the majority being PTH (34–84) and PTH (37–84) [7, 8]. These fragments cannot bind and activate the classic PTH1R.

While the plasma half-life of intact PTH (1–84) is only a few minutes, renal clearance of PTH fragments is slower. Therefore, under normocalcemic conditions, up to 80% of circulating PTH is inactive fragments, while only about 20% is intact, biologically active PTH (1–84) [9]. PTH fragments are produced by the parathyroid glands. These glands contain proteolytic enzymes such as cathepsins B and D, and therefore release fragments together with intact PTH (1–84) [10]. Under hypocalcemic conditions, the percentage of intact PTH (1–84) released in the circulation increases, and under hypercalcemic conditions, it decreases. Fragments are also formed by proteolytic cleavage of intact PTH (1–84) in the periphery, mainly in the Kupffer cells of the liver.

The fact that circulating PTH mainly comprises biologically inactive fragments makes the measurement of plasma PTH challenging. The first-generation PTH assays, reported in 1963, were radioimmunoassays [11] which, for the first time, enabled the measurement of PTH, but their utility was limited as they detected not only intact PTH (1–84) but also circulating fragments.

The introduction of an improved double antibody immunoassay in 1987, the intact PTH assay, greatly improved the accuracy and clinical utility [12]. This sandwich assay uses a carboxyl-terminal capture antibody linked to a solid phase, and an amino-terminal detection antibody, which made this assay more specific and, for example, able to distinguish primary hyperparathyroidism from hypercalcemia of malignancy.

A “third generation” “whole PTH” or “biointact PTH” assay [13], which uses an amino-terminal detection antibody specific to the extreme amino-terminus PTH (1–6) did not prove to be superior, but studies are limited [14].

In summary, currently used PTH assays are second-generation assays, which can be relied on to make the diagnosis of hyper- and hypoparathyroidism.