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Hello and welcome. I am Dr George Lundberg and this is At Large at Medscape.

How is your calcium? Is it good or bad? Does it help you or hurt you? Where is it? Evaluating calcium in humans is a lot like evaluating a piece of real estate: It is all about location, location, location.

First, the good places: More than 99% is in teeth, bones, or blood and intra- and extracellular fluid.

Then, the bad places: soft tissues; kidneys and urinary tract; artery and vein walls; tumors; female breasts; or as part of resolving necrosis or cellular degeneration.

How does it get there? Calcium in, calcium out. Calcium in: maybe a supplement of 1000 mg/day orally for an adult. Calcium out: via urine and feces, with the retained calcium being managed by spectacular metabolic homeostasis. It is a very delicate balance.

One of the ways that calcium appears in seemingly unwanted locations is called "dystrophic calcification," and its presence seems relatively inert.

Can you move calcium around in the body? Maybe not moving individual calcium moieties from place to place, but can you regulate how much of what kind of calcium is in any one place at any one time?

Like the Blind Man and the Elephant: Point of View Matters

The nutritionists would say: This is all about diet.

The endocrinologists would say...a lot; they really know this field.

The imagers would say: I love calcium; it gives me so many fun things to look at, measure, and analyze to try to predict importance.

The urologists would say: I can take care of your stones. We will flush them out or pluck them out or shake them into small pieces with the lithotripter. And by the way, here is your $30,000 bill.

The mammographers and breast surgeons would say: If I did not have calcium flecks to find in the mammogram, I might have a really hard time justifying biopsies.

The procedural interventionists would say: Send me your calcified arteries; I have a stent for you.

Big pharma would say: We have lots of drugs.

The outlier chelationists would say: We can give you some IV infusions to get rid of all that bad stuff.

As a pathologist, I have cut—or, more accurately, sawed—a whole lot of bones, healthy and diseased. It is really good to have a lot of calcium as hydroxyapatite there, in the bone. I have cut up a lot of kidneys destroyed by stones obstructing the urinary tract. Calcium can be really bad to have there. I have longitudinally opened or perpendicularly transected many hundreds of large and small arteries; many normal, many diseased by narrowing; many occluded by atherosclerotic plaque, intraplaque hemorrhage, cholesterol, thrombus (acute, evolving, organized, or recanalized), and calcified; sometimes very thick, hard, brittle, even rigid; and especially in arteries of hearts, brains, necks, chests, bellies, legs. Bad.

But which came first: the chicken or the egg? Was the vascular wall calcium an instigating progenitor, a fellow traveler as simple dystrophy, a part of the inflammatory pathogenesis, or a culminating bony add-on for advanced atherosclerosis? Those are really good questions.

Here's the new stuff. A large volume of alternative literature has been hyping vitamin K2 as active in preventing or treating arterial calcification for years. But serious science now seems to be backing that up. The relationship of vitamin D, vitamin K2, and calcium may hold a real key to a better understanding of harmful arterial calcification. Check it out; keep an open mind; stay tuned.

That is my opinion. I am Dr George Lundberg, at large for Medscape.

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