Ectopic Calcification as Abnormal Biomineralization

Abstract:  Vascular calcification is observed frequently in hemodialysis patients. The guidelines for kidney disease outcomes quality initiative recommend a strict control of serum calcium and phosphorus concentrations. Calcium–phosphorus product in extracellular fluids is almost at an oversaturation level in dialysis patients and in healthy individuals as well, but crystallization of hydroxyapatite does not occur in healthy individuals. Presumably, some systemic mechanism that has yet to be defined works to block the formation of hydroxyapatite crystals in healthy individuals, whereas in dialysis patients this defense mechanism is disrupted in hard tissues, leading to progressive biomineralization. Matrix vesicles released from specialized mesenchymal cells such as osteoblasts, play a central role in disrupting the putative defense mechanism against calcification. Matrix vesicles are internally in a highly favorable environment for progressive calcification, and essentially a nidus for hydroxyapatite crystal nucleation and its external growth through disruption of the defense mechanism. Osteoblastic cells release matrix vesicles that form initial crystal hydroxyapatite by condensation of phosphate and calcium, referred to as matrix vesicle calcification. Hydroxyapatite crystals break through vesicular membranes to reach a nearby collagen fiber network and form a continuous layer of calcified bone matrix. Thereafter follows the formation of additive bone matrix by osteoblasts and the advance of the calcification front. Therefore, ectopic calcification arises mechanistically from: (i) disruption of a systemic defense mechanism against calcification; and (ii) appearance of osteoblast‐like cells in hard tissues that normally are localized in soft tissues. Abnormal accumulation of calcium/inorganic phosphate in dialysis patients is accounted for by the former disruption of systemic defense mechanism against calcification, and arterial calcification in dialysis patients by the latter osteoblast‐like cells transformed from tunica media or vascular smooth‐muscle cells.