Comprehensive Physiology Wiley Online Library

Kidney and Bone: Physiological and Pathophysiological Relationships

Full Article on Wiley Online Library



Abstract

The sections in this article are:

1 Chemical and Cellular Composition of Bone
1.1 Extracellular Constituents of Bone
1.2 Bone Cells
2 Development and Structure of Bone
2.1 Endochondral Ossification
2.2 Intramembranous Ossification
3 Skeletal Growth and Modeling
3.1 Principles of Skeletal Growth
3.2 Skeletal Modeling
3.3 Epiphyseal Closure
3.4 Bone Cell Function and Skeletal Growth and Modeling
4 Bone Turnover and the Remodeling Cycle
4.1 Skeletal Remodeling
4.2 Cellular Control of Bone Remodeling
5 Fracture Healing
6 Bone Cell Function and Fracture Repair
7 Interrelationships of Kidney and Bone in Normal Physiology
7.1 General Considerations
7.2 Overall Calcium Balance
7.3 Hormonal Control of Mineral Ion Homeostasis
7.4 Role of the Parathyroid Glands in the Calcium Homeostatic System
7.5 Bone Cell Function and Ionic Homeostasis
7.6 Aspects of Renal Function Essential for Normal Skeletal Structure and Function and Ionic Homeostasis
8 Metabolic Bone Disease
8.1 Osteitis Fibrosa
8.2 Osteomalacia
8.3 Osteoporosis
9 Laboratory Evaluation of Metabolic Bone Disease
9.1 Direct Assays of Calcium‐Regulating Hormones in Blood
9.2 Clinical Assessment of the Function of Target Organs for Calcium‐Regulating Hormones
10 Abnormalities in Renal Function Leading to Skeletal Disease
10.1 Abnormalities in Renal Calcium Handling
10.2 Abnormalities in Renal Phosphate Handling
10.3 Hypo‐ and Hypermagnesemia Due to Renal Causes
10.4 Renal Tubular Acidosis
10.5 Primary Abnormalities in Vitamin D Metabolism
10.6 Renal Resistance to PTH: Pseudohypoparathyroidism
10.7 Chronic Renal Insufficiency
10.8 Pathophysiology of Renal Osteodystrophy
11 Disorders Affecting the Homeostatic Mechanisms Linking Kidney and Bone
11.1 Primary Hyperparathyroidism
11.2 Humoral Hypercalcemia of Malignancy
11.3 Hypoparathyroidism
11.4 Deficient Quantities and Action of Vitamin D
11.5 Hypervitaminosis D
11.6 Sarcoidosis and Other Granulomatous Diseases
12 Other Hormonal Abnormalities and Drugs Affecting Both Bone and Kidney
12.1 Calcitonin
12.2 Growth Hormone
12.3 Estrogen
12.4 Glucocorticoids
12.5 Insulin
12.6 Thyroid Hormones
13 Miscellaneous Associations Between Bone and Kidney
13.1 Disorders Affecting Both Kidney and Bone
13.2 Pharmacological Agents Affecting Both Kidney and Bone
14 Effects of Bone Disease on the Kidney
Figure 1. Figure 1.

Collagen fibrils show characteristic striated appearance with 640 Å repeat, which results from staggered arrangement of individual collagen molecules (arrows). Holes between end of one molecule and beginning of the next may represent a site where mineral ions are initially deposited during mineralization. Each collagen molecule in turn is made up of three intertwined polypeptide chains, each in α‐helical configuration (shown schematically at bottom left and on right).

From Tanzer 551
Figure 2. Figure 2.

Electron micrograph of osteoblast (upper right) showing abundant endoplasmic reticulum and Golgi apparatus (G), which is actively synthesizing and secreting collagen to form unmineralized osteoid overlying mineralized bone in lower left.

From Cooper 157
Figure 3. Figure 3.

Electron micrograph of osteocyte encased within lacuna in mineralized bone. Thin cytoplasmic processes (P) extend into narrow canaliculi within bone and maintain contact with nearby osteocytes or bone surface.

From Cooper 157
Figure 4. Figure 4.

A: electron micrograph of osteoclast engulfing spicule of mineralized bone (dark area, lower right). Ruffled cell border becomes closely apposed to bone surface and digests bone through process involving secretion of hydrogen ions and digestive enzymes. × 10,800. B: light micrograph showing several multinucleated osteoclasts in deep Howship's lacuna. × 300.

From Teitelbaum 556. Reproduced from Holtrop et al. 275, Journal of Cell Biology, 1974, 60: 346–355, by copyright permission of the Rockefeller University Press
Figure 5. Figure 5.

Primary ossification center in human radius.

From Ogden 418
Figure 6. Figure 6.

Light micrograph of epiphyseal growth plate, illustrating resting (R), proliferating (P), and hypertrophic (H) chondrocytes, as well as zones of provisional calcification (PC) and ossification (O).

From McKibbin 387
Figure 7. Figure 7.

Various representations of trabecular bone. A: digested specimen of trabecular bone, is shown schematically in B. Note that it is made up of interconnecting plates and rods of bone. C: a representative section through portion of B, illustrating origin of usual histological appearance of trabecular bone (D).

From Bullough 102
Figure 8. Figure 8.

A: Schematic representation of change in contour of end of a long bone (1) as it enlarges (2). B: demonstration of sequential addition of bone on outside surface of the diaphysis and inside surface of metaphysis as well as removal of bone from inside diaphysis and outside metaphysis that accomplishes this end.

From Enlow 190
Figure 9. Figure 9.

X‐ray films of playing (right) and nonplaying (left) arms of a professional tennis player. Note increased cortical area in the playing arm, which can result from greater cortical thickness and/or diameter.

From Jones et al. 295
Figure 10. Figure 10.

Several photographs of Robert Wadlow, later known as the “Alton giant”, who developed growth hormone excess at an early age, increasing in weight from 9 pounds at birth to 62 pounds at 1 year of age. He continued to grow throughout his life, reaching a height of 8 feet 11 inches and weight of 475 pounds shortly before his death at 22 years from cellulitis of the feet.

From Daughaday 163
Figure 11. Figure 11.

Schematic of events involved in remodeling cycle in cortical bone. Multinucleated osteoclasts (1) comprise the cutting cone that escavates bone. During subsequent reversal phase (2), osteoclasts disappear and osteoblasts differentiate from mesenchymal precursors, which then lay down new bone (3) to fill in all missing bone except for narrow central canal.

From Albright and Skinner 13
Figure 12. Figure 12.

Steps involved in fracture healing. During inflammatory phase, tissue response similar to that in other injured tissues takes place, with formation of hematoma and fibrin clot and mobilization of inflammatory cells. There is subsequent formation of trabecular bone by osteogenic cells arising either from intact periosteum or from mesenchymal precursors (reparative phase). This trabecular bone is then remodeled over a period of months to form cortical bone in this example of long bone fracture.

From Brand 70
Figure 13. Figure 13.

Example of calcium balance in hypothetical normal individual. Details of calcium fluxes in intestine, kidney, and bone are given in text. ECF, extracellular fluid.

From Brown 91
Figure 14. Figure 14.

Overall hormonal control of calcium homeostasis. Decreases in extracellular ionized calcium concentration stimulate parathyroid hormone (PTH) release, which, in concert with 1,25(OH)2D, modifies calcium and phosphate handling by kidney, intestine, and bone to restore calcium and phosphate concentrations toward normal in the extracellular fluid (ECF). Further details are given in text.

From Brown and LeBoff 93, with permission of S. Karger AG, Basel
Figure 15. Figure 15.

Homeostatic responses to hypophosphatemia in normal individual. Enhanced formation of 1,25(OH)2D increases efficiency of calcium and phosphate absorption from intestine and mobilizes these two ions from bone. Resulting increase in extracellular fluid (ECF) calcium suppresses parathyroid hormone (PTH) release, enhancing renal calcium clearance and reducing phosphate clearance to restore phosphate concentration toward normal while preventing hypercalcemia.

Figure 16. Figure 16.

Inverse, sigmoidal relationship between extracellular ionized calcium concentration and parathyroid hormone (PTH) release in normal human parathyroid tissue. a: data from four separate preparations of human parathyroid cells expressed as percent of maximal PTH release as a function of ionized calcium concentration in vitro. “Set‐point” refers to calcium concentration producing half‐maximal inhibition of PTH release. b: the four parameters that may be used to define such sigmoidal curves.

From Brown 87, with permission of S. Karger AG, Basel
Figure 17. Figure 17.

Comparison of relationship between extracellular calcium concentration and parathyroid hormone (PTH) release in normal human parathyroid cells (△), cells prepared from adenomas (□), and cells from tissue showing uremic secondary hyperplasia (◯).

From Brown and LeBoff 93, with permission of S. Karger AG, Basel
Figure 18. Figure 18.

Reabsorption of calcium by different segments of nephron, shown as percent of filtered load of calcium remaining in tubular fluid.

From Sutton and Dirks 541
Figure 19. Figure 19.

Calcium excretion as function of serum calcium concentration in normal subjects [solid line ± 2 SD (dotted lines)], hypoparathyroid individuals (△), and patients with primary hyperparathyroidism (•).

From Peacock et al. 437
Figure 20. Figure 20.

Relationship between serum levels of 1,25(OH)2D3 and 24,25(OH)2D3 and serum phosphorous concentration in thyropara‐thyroidectomized rats receiving diets containing varying amounts of calcium and phosphorus. Note inverse dependence of radioactive 1,25(OH)2D3 formed from tritiated 25(OH)D3 on serum phosphorous concentration.

From Tanaka and DeLuca 550
Figure 21. Figure 21.

Origins and fates of parathyroid hormone (PTH 1–84) and its principal fragments. PTH 1–84 is secreted by parathyroid glands and is metabolized to carboxy‐terminal (C‐term.) fragments by liver and kidney. Parathyroid glands also secrete C‐term. fragments. N‐terminal (N‐term.) fragments presumably are formed by processes that yield C‐term. fragments but are difficult to demonstrate in circulation of normal subjects. PTH 1–84 is cleared by liver, by glomerular filtration, and by peritubular uptake in kidney. N‐term. fragments may be cleared by glomerular filtration, peritubular uptake, and bone. C‐term. fragments are cleared only by glomerular filtration. ECF, extracellular fluid.

From Brown 89, in Divalent Ion Homeostasis, Churchill Livingstone, 1983, by permission
Figure 22. Figure 22.

Undecalcified histological section showing osteitis fibrosa in uremic bone. Osteoclasts (black arrow) and osteoblasts (white arrow) are plentiful, and osteoid (arrowhead) and peritrabecular fibrosis (F) are also abundant. × 180.

From Teitelbaum 555, in Divalent Ion Homeostasis, Churchill Livingstone, 1983, by permission
Figure 23. Figure 23.

Undecalcified section of osteomalacic bone from uremic patient showing osteomalacia with many thick osteoid seams (dark areas). × 180.

From Teitelbaum 555, in Divalent Ion Homeostasis, Churchill Livingstone, 1983, by permission
Figure 24. Figure 24.

Midsagittal sections through digested lumbar vertebrae of a young (upper) and an elderly (lower) woman.

From Avioli 33
Figure 25. Figure 25.

Relationship between urinary calcium‐to‐creatinine clearance ratio and creatinine clearance in subjects with familial hypocalciuric hypercalcemia (•) and typical primary hyperparathyroidism (◯).

From reference Aurbach et al. 31
Figure 26. Figure 26.

Marked growth retardation and bowing of lower extremities in two related boys with X‐linked hypophosphatemic rickets.

From Harrison and Harrison 254
Figure 27. Figure 27.

Circulating levels of 1,25(OH)2D3 in normal subjects (•) and in patients with vitamin D‐resistant rickets (VDRR) (▴) and vitamin D‐dependent rickets (VDDR) (▪).

Reprinted from Scriver et al. 496, by permission of The New England Journal of Medicine, 299: 976–980, 1978
Figure 28. Figure 28.

Characteristic appearance of mother and daughter with pseudohypoparathyroidism.

From Aurbach et al. 31
Figure 29. Figure 29.

Reduced levels of Gs activity in subjects with pseudohypoparathyroidism and Albright's hereditary osteodystrophy (+AHO). Gs activity is measured by its ability to activate adenylate cyclase in membranes of mutant mouse cells deficient in Gs. In contrast to subjects with AHO, those with pseudohypoparathyroidism without these phenotypic features have levels of Gs activity similar to those of normal controls.

From Aurbach et al. 31
Figure 30. Figure 30.

Factors that may contribute to development of secondary hyperparathyroidism in renal failure. Reduced functional renal mass, hyperphosphatemia and/or intracellular phosphate elevation, and perhaps acidosis contribute to decreased levels of 1,25(OH)2D. The latter decreases release of calcium from bone and reduces intestinal calcium absorption, resulting in hypocalcemia, which stimulates parathyroid hormone (PTH) secretion and parathyroid cellular hyperplasia. Low levels of 1,25(OH)2D per se as well as decrease in level of receptor for 1,25−(OH)2D in parathyroid cells (not shown) probably also directly stimulate parathyroid function.

From Brown and LeBoff 93, with permission of S. Karger AG, Basel
Figure 31. Figure 31.

Comparison of epiphyseal growth plate of normal (A) and rachitic (B) rat tibia. Note thin, uniform layer of unmineralized cartilage in normal rat (wavy vertical line in middle) between metaphyseal spongiosa (left) and center of ossification in the epiphyseal cartilage (right). In rachitic rat there is failure of mineralization of growth plate, with a broad irregular zone of chondro‐osteoid separating metaphysis from center of ossification.

From Harrison and Harrison 256
Figure 32. Figure 32.

Appearance of two siblings, aged 7 and 3 years, with vitamin D‐dependent rickets type 2. Note total alopecia and skeletal deformities of rickets.

Courtesy of J. F. Rosen
Figure 33. Figure 33.

Temporal changes in serum calcium, 25(OH)D3, and 1,25(OH)2D3 concentrations in patient with sarcoidosis. Note that usual increase in 25(OH)D3 during summer months is accompanied by inappropriate increase in 1,25(OH)2D3, which then leads to hypercalcemia.

From Papapoulos et al. 428


Figure 1.

Collagen fibrils show characteristic striated appearance with 640 Å repeat, which results from staggered arrangement of individual collagen molecules (arrows). Holes between end of one molecule and beginning of the next may represent a site where mineral ions are initially deposited during mineralization. Each collagen molecule in turn is made up of three intertwined polypeptide chains, each in α‐helical configuration (shown schematically at bottom left and on right).

From Tanzer 551


Figure 2.

Electron micrograph of osteoblast (upper right) showing abundant endoplasmic reticulum and Golgi apparatus (G), which is actively synthesizing and secreting collagen to form unmineralized osteoid overlying mineralized bone in lower left.

From Cooper 157


Figure 3.

Electron micrograph of osteocyte encased within lacuna in mineralized bone. Thin cytoplasmic processes (P) extend into narrow canaliculi within bone and maintain contact with nearby osteocytes or bone surface.

From Cooper 157


Figure 4.

A: electron micrograph of osteoclast engulfing spicule of mineralized bone (dark area, lower right). Ruffled cell border becomes closely apposed to bone surface and digests bone through process involving secretion of hydrogen ions and digestive enzymes. × 10,800. B: light micrograph showing several multinucleated osteoclasts in deep Howship's lacuna. × 300.

From Teitelbaum 556. Reproduced from Holtrop et al. 275, Journal of Cell Biology, 1974, 60: 346–355, by copyright permission of the Rockefeller University Press


Figure 5.

Primary ossification center in human radius.

From Ogden 418


Figure 6.

Light micrograph of epiphyseal growth plate, illustrating resting (R), proliferating (P), and hypertrophic (H) chondrocytes, as well as zones of provisional calcification (PC) and ossification (O).

From McKibbin 387


Figure 7.

Various representations of trabecular bone. A: digested specimen of trabecular bone, is shown schematically in B. Note that it is made up of interconnecting plates and rods of bone. C: a representative section through portion of B, illustrating origin of usual histological appearance of trabecular bone (D).

From Bullough 102


Figure 8.

A: Schematic representation of change in contour of end of a long bone (1) as it enlarges (2). B: demonstration of sequential addition of bone on outside surface of the diaphysis and inside surface of metaphysis as well as removal of bone from inside diaphysis and outside metaphysis that accomplishes this end.

From Enlow 190


Figure 9.

X‐ray films of playing (right) and nonplaying (left) arms of a professional tennis player. Note increased cortical area in the playing arm, which can result from greater cortical thickness and/or diameter.

From Jones et al. 295


Figure 10.

Several photographs of Robert Wadlow, later known as the “Alton giant”, who developed growth hormone excess at an early age, increasing in weight from 9 pounds at birth to 62 pounds at 1 year of age. He continued to grow throughout his life, reaching a height of 8 feet 11 inches and weight of 475 pounds shortly before his death at 22 years from cellulitis of the feet.

From Daughaday 163


Figure 11.

Schematic of events involved in remodeling cycle in cortical bone. Multinucleated osteoclasts (1) comprise the cutting cone that escavates bone. During subsequent reversal phase (2), osteoclasts disappear and osteoblasts differentiate from mesenchymal precursors, which then lay down new bone (3) to fill in all missing bone except for narrow central canal.

From Albright and Skinner 13


Figure 12.

Steps involved in fracture healing. During inflammatory phase, tissue response similar to that in other injured tissues takes place, with formation of hematoma and fibrin clot and mobilization of inflammatory cells. There is subsequent formation of trabecular bone by osteogenic cells arising either from intact periosteum or from mesenchymal precursors (reparative phase). This trabecular bone is then remodeled over a period of months to form cortical bone in this example of long bone fracture.

From Brand 70


Figure 13.

Example of calcium balance in hypothetical normal individual. Details of calcium fluxes in intestine, kidney, and bone are given in text. ECF, extracellular fluid.

From Brown 91


Figure 14.

Overall hormonal control of calcium homeostasis. Decreases in extracellular ionized calcium concentration stimulate parathyroid hormone (PTH) release, which, in concert with 1,25(OH)2D, modifies calcium and phosphate handling by kidney, intestine, and bone to restore calcium and phosphate concentrations toward normal in the extracellular fluid (ECF). Further details are given in text.

From Brown and LeBoff 93, with permission of S. Karger AG, Basel


Figure 15.

Homeostatic responses to hypophosphatemia in normal individual. Enhanced formation of 1,25(OH)2D increases efficiency of calcium and phosphate absorption from intestine and mobilizes these two ions from bone. Resulting increase in extracellular fluid (ECF) calcium suppresses parathyroid hormone (PTH) release, enhancing renal calcium clearance and reducing phosphate clearance to restore phosphate concentration toward normal while preventing hypercalcemia.



Figure 16.

Inverse, sigmoidal relationship between extracellular ionized calcium concentration and parathyroid hormone (PTH) release in normal human parathyroid tissue. a: data from four separate preparations of human parathyroid cells expressed as percent of maximal PTH release as a function of ionized calcium concentration in vitro. “Set‐point” refers to calcium concentration producing half‐maximal inhibition of PTH release. b: the four parameters that may be used to define such sigmoidal curves.

From Brown 87, with permission of S. Karger AG, Basel


Figure 17.

Comparison of relationship between extracellular calcium concentration and parathyroid hormone (PTH) release in normal human parathyroid cells (△), cells prepared from adenomas (□), and cells from tissue showing uremic secondary hyperplasia (◯).

From Brown and LeBoff 93, with permission of S. Karger AG, Basel


Figure 18.

Reabsorption of calcium by different segments of nephron, shown as percent of filtered load of calcium remaining in tubular fluid.

From Sutton and Dirks 541


Figure 19.

Calcium excretion as function of serum calcium concentration in normal subjects [solid line ± 2 SD (dotted lines)], hypoparathyroid individuals (△), and patients with primary hyperparathyroidism (•).

From Peacock et al. 437


Figure 20.

Relationship between serum levels of 1,25(OH)2D3 and 24,25(OH)2D3 and serum phosphorous concentration in thyropara‐thyroidectomized rats receiving diets containing varying amounts of calcium and phosphorus. Note inverse dependence of radioactive 1,25(OH)2D3 formed from tritiated 25(OH)D3 on serum phosphorous concentration.

From Tanaka and DeLuca 550


Figure 21.

Origins and fates of parathyroid hormone (PTH 1–84) and its principal fragments. PTH 1–84 is secreted by parathyroid glands and is metabolized to carboxy‐terminal (C‐term.) fragments by liver and kidney. Parathyroid glands also secrete C‐term. fragments. N‐terminal (N‐term.) fragments presumably are formed by processes that yield C‐term. fragments but are difficult to demonstrate in circulation of normal subjects. PTH 1–84 is cleared by liver, by glomerular filtration, and by peritubular uptake in kidney. N‐term. fragments may be cleared by glomerular filtration, peritubular uptake, and bone. C‐term. fragments are cleared only by glomerular filtration. ECF, extracellular fluid.

From Brown 89, in Divalent Ion Homeostasis, Churchill Livingstone, 1983, by permission


Figure 22.

Undecalcified histological section showing osteitis fibrosa in uremic bone. Osteoclasts (black arrow) and osteoblasts (white arrow) are plentiful, and osteoid (arrowhead) and peritrabecular fibrosis (F) are also abundant. × 180.

From Teitelbaum 555, in Divalent Ion Homeostasis, Churchill Livingstone, 1983, by permission


Figure 23.

Undecalcified section of osteomalacic bone from uremic patient showing osteomalacia with many thick osteoid seams (dark areas). × 180.

From Teitelbaum 555, in Divalent Ion Homeostasis, Churchill Livingstone, 1983, by permission


Figure 24.

Midsagittal sections through digested lumbar vertebrae of a young (upper) and an elderly (lower) woman.

From Avioli 33


Figure 25.

Relationship between urinary calcium‐to‐creatinine clearance ratio and creatinine clearance in subjects with familial hypocalciuric hypercalcemia (•) and typical primary hyperparathyroidism (◯).

From reference Aurbach et al. 31


Figure 26.

Marked growth retardation and bowing of lower extremities in two related boys with X‐linked hypophosphatemic rickets.

From Harrison and Harrison 254


Figure 27.

Circulating levels of 1,25(OH)2D3 in normal subjects (•) and in patients with vitamin D‐resistant rickets (VDRR) (▴) and vitamin D‐dependent rickets (VDDR) (▪).

Reprinted from Scriver et al. 496, by permission of The New England Journal of Medicine, 299: 976–980, 1978


Figure 28.

Characteristic appearance of mother and daughter with pseudohypoparathyroidism.

From Aurbach et al. 31


Figure 29.

Reduced levels of Gs activity in subjects with pseudohypoparathyroidism and Albright's hereditary osteodystrophy (+AHO). Gs activity is measured by its ability to activate adenylate cyclase in membranes of mutant mouse cells deficient in Gs. In contrast to subjects with AHO, those with pseudohypoparathyroidism without these phenotypic features have levels of Gs activity similar to those of normal controls.

From Aurbach et al. 31


Figure 30.

Factors that may contribute to development of secondary hyperparathyroidism in renal failure. Reduced functional renal mass, hyperphosphatemia and/or intracellular phosphate elevation, and perhaps acidosis contribute to decreased levels of 1,25(OH)2D. The latter decreases release of calcium from bone and reduces intestinal calcium absorption, resulting in hypocalcemia, which stimulates parathyroid hormone (PTH) secretion and parathyroid cellular hyperplasia. Low levels of 1,25(OH)2D per se as well as decrease in level of receptor for 1,25−(OH)2D in parathyroid cells (not shown) probably also directly stimulate parathyroid function.

From Brown and LeBoff 93, with permission of S. Karger AG, Basel


Figure 31.

Comparison of epiphyseal growth plate of normal (A) and rachitic (B) rat tibia. Note thin, uniform layer of unmineralized cartilage in normal rat (wavy vertical line in middle) between metaphyseal spongiosa (left) and center of ossification in the epiphyseal cartilage (right). In rachitic rat there is failure of mineralization of growth plate, with a broad irregular zone of chondro‐osteoid separating metaphysis from center of ossification.

From Harrison and Harrison 256


Figure 32.

Appearance of two siblings, aged 7 and 3 years, with vitamin D‐dependent rickets type 2. Note total alopecia and skeletal deformities of rickets.

Courtesy of J. F. Rosen


Figure 33.

Temporal changes in serum calcium, 25(OH)D3, and 1,25(OH)2D3 concentrations in patient with sarcoidosis. Note that usual increase in 25(OH)D3 during summer months is accompanied by inappropriate increase in 1,25(OH)2D3, which then leads to hypercalcemia.

From Papapoulos et al. 428
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Edward M. Brown. Kidney and Bone: Physiological and Pathophysiological Relationships. Compr Physiol 2011, Supplement 25: Handbook of Physiology, Renal Physiology: 1841-1916. First published in print 1992. doi: 10.1002/cphy.cp080239