1
|
Baroncelli GI, Comberiati P, Aversa T, Baronio F, Cassio A, Chiarito M, Cosci o di Coscio M, De Sanctis L, Di Iorgi N, Faienza MF, Fintini D, Franceschi R, Kalapurackal M, Longhi S, Mariani M, Pitea M, Secco A, Tessaris D, Vierucci F, Wasniewska M, Weber G, Mora S. Diagnosis, treatment, and management of rickets: a position statement from the Bone and Mineral Metabolism Group of the Italian Society of Pediatric Endocrinology and Diabetology. Front Endocrinol (Lausanne) 2024; 15:1383681. [PMID: 38706696 PMCID: PMC11066174 DOI: 10.3389/fendo.2024.1383681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/03/2024] [Indexed: 05/07/2024] Open
Abstract
Rickets results from impaired mineralization of growing bone due to alterations in calcium and phosphate homeostasis. Clinical signs of rickets are related to the age of the patient, the duration of the disease, and the underlying disorder. The most common signs of rickets are swelling of the wrists, knees or ankles, bowing of the legs (knock-knees, outward bowing, or both) and inability to walk. However, clinical features alone cannot differentiate between the various forms of rickets. Rickets includes a heterogeneous group of acquired and inherited diseases. Nutritional rickets is due to a deficiency of vitamin D, dietary calcium or phosphate. Mutations in genes responsible for vitamin D metabolism or function, the production or breakdown of fibroblast growth factor 23, renal phosphate regulation, or bone mineralization can lead to the hereditary form of rickets. This position paper reviews the relevant literature and presents the expertise of the Bone and Mineral Metabolism Group of the Italian Society of Pediatric Endocrinology and Diabetology (SIEDP). The aim of this document is to provide practical guidance to specialists and healthcare professionals on the main criteria for diagnosis, treatment, and management of patients with rickets. The various forms of rickets are discussed, and detailed references for the discussion of each form are provided. Algorithms to guide the diagnostic approach and recommendations to manage patients with rare forms of hereditary rickets are proposed.
Collapse
Affiliation(s)
- Giampiero I. Baroncelli
- Pediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
| | - Pasquale Comberiati
- Pediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
- Department of Clinical and Experimental Medicine, Section of Paediatrics, University of Pisa, Pisa, Italy
| | - Tommaso Aversa
- Department of Human Pathology of Adulthood and Childhood, University of Messina, Messina, Italy
- Pediatric Unit, University Hospital “G. Martino”, Messina, Italy
| | - Federico Baronio
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessandra Cassio
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Mariangela Chiarito
- Pediatric Unit, Department of Precision and Regenerative Medicine and Ionian Area, University “A. Moro” of Bari, Bari, Italy
| | - Mirna Cosci o di Coscio
- Pediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
| | - Luisa De Sanctis
- Division of Pediatric Endocrinology, Department of Public Health and Pediatrics, University of Turin, Regina Margherita Children’s Hospital, Turin, Italy
| | - Natascia Di Iorgi
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Maria Felicia Faienza
- Pediatric Unit, Department of Precision and Regenerative Medicine and Ionian Area, University “A. Moro” of Bari, Bari, Italy
| | - Danilo Fintini
- Endocrinology and Diabetology Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Roberto Franceschi
- Department of Pediatrics, Santa Chiara Hospital of Trento, APSS, Trento, Italy
| | - Mila Kalapurackal
- Department of Pediatrics, Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University (PMU), Bolzano, Italy
| | - Silvia Longhi
- Department of Pediatrics, Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University (PMU), Bolzano, Italy
| | - Michela Mariani
- Endocrinology and Diabetology Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Marco Pitea
- Pediatric Endocrinology Unit, Department of Pediatrics, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Andrea Secco
- Pediatric and Pediatric Emergency Unit, Children Hospital, Azienda Ospedaliera SS Antonio e Biagio e C. Arrigo, Alessandria, Italy
| | - Daniele Tessaris
- Division of Pediatric Endocrinology, Department of Public Health and Pediatrics, University of Turin, Regina Margherita Children’s Hospital, Turin, Italy
| | | | - Malgorzata Wasniewska
- Department of Human Pathology of Adulthood and Childhood, University of Messina, Messina, Italy
| | - Giovanna Weber
- Pediatric Endocrinology Unit, Department of Pediatrics, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Stefano Mora
- Laboratory of Pediatric Endocrinology, Department of Pediatrics, IRCCS Ospedale San Raffaele, Milan, Italy
| |
Collapse
|
2
|
Cherian KE, Paul TV. Inherited fibroblast growth factor 23 excess. Best Pract Res Clin Endocrinol Metab 2024; 38:101844. [PMID: 38044258 DOI: 10.1016/j.beem.2023.101844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Syndromes of inherited fibroblast growth factor 23 (FGF-23) excess encompass a wide spectrum that includes X-linked hypophosphataemia (XLH), autosomal dominant and recessive forms of rickets as well as various syndromic conditions namely fibrous dysplasia/McCune Albright syndrome, osteoglophonic dysplasia, Jansen's chondrodysplasia and cutaneous skeletal hypophosphataemia syndrome. A careful attention to patient symptomatology, family history and clinical features, supported by appropriate laboratory tests will help in making a diagnosis. A genetic screen may be done to confirm the diagnosis. While phosphate supplements and calcitriol continue to be the cornerstone of treatment, in recent times burosumab, the monoclonal antibody against FGF-23 has been approved for the treatment of children and adults with XLH. While health-related outcomes may be improved by ensuring adherence and compliance to prescribed treatment with a smooth transition to adult care, bony deformities may persist in some, and this would warrant surgical correction.
Collapse
|
3
|
Chinoy A, Padidela R. Refractory Rickets. Indian J Pediatr 2023; 90:574-581. [PMID: 37074534 DOI: 10.1007/s12098-023-04538-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/12/2023] [Indexed: 04/20/2023]
Abstract
Nutritional rickets, caused by vitamin D and/or calcium deficiency is by far the most common cause of rickets. In resource-limited settings, it is therefore not uncommon to treat rickets with vitamin D and calcium. If rickets fails to heal and/or if there is a family history of rickets, then refractory rickets should be considered as a differential diagnosis. Chronic low serum phosphate is the pathological hallmark of all forms of rickets as its low concentration in extracellular space leads to the failure of apoptosis of hypertrophic chondrocytes leading to defective mineralisation of the growth plate. Parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF23) control serum phosphate concentration by facilitating the excretion of phosphate in the urine through their action on the proximal renal tubules. An increase in PTH, as seen in nutritional rickets and genetic disorders of vitamin D-dependent rickets (VDDRs), leads to chronic low serum phosphate, causing rickets. Genetic conditions leading to an increase in FGF23 concentration cause chronic low serum phosphate concentration and rickets. Genetic conditions and syndromes associated with proximal renal tubulopathies can also lead to chronic low serum phosphate concentration by excess phosphate leak in urine, causing rickets.In this review, authors discuss an approach to the differential diagnosis and management of refractory rickets.
Collapse
Affiliation(s)
- Amish Chinoy
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, M13 9WL, UK
- Faculty of Biology Medicine and Health, University of Manchester, Manchester, M13 9PL, UK
| | - Raja Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, M13 9WL, UK.
- Faculty of Biology Medicine and Health, University of Manchester, Manchester, M13 9PL, UK.
| |
Collapse
|
4
|
Rickets, elevated fibroblast growth factor-23 and mild anemia: Answers. Pediatr Nephrol 2021; 36:2301-2304. [PMID: 33646398 DOI: 10.1007/s00467-021-05012-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/05/2021] [Accepted: 02/10/2021] [Indexed: 11/27/2022]
|
5
|
Liu C, Li X, Zhao Z, Chi Y, Cui L, Zhang Q, Ping F, Chai X, Jiang Y, Wang O, Li M, Xing X, Xia W. Iron deficiency plays essential roles in the trigger, treatment, and prognosis of autosomal dominant hypophosphatemic rickets. Osteoporos Int 2021; 32:737-745. [PMID: 32995940 DOI: 10.1007/s00198-020-05649-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 09/17/2020] [Indexed: 12/19/2022]
Abstract
UNLABELLED By analyzing iron status of 14 ADHR patients, we found that iron deficiency was an important trigger of ADHR. Correcting iron deficiency significantly improved patients' symptoms. Meanwhile, patients' serum phosphate showed positive correlations with iron metabolism parameters and hemoglobin-related parameters, suggesting the necessity of monitoring and correcting the iron status in ADHR. INTRODUCTION Autosomal dominant hypophosphatemic rickets (ADHR) is unique for its incomplete penetrance, variety of disease onsets, and waxing and waning phenotypes. Iron deficiency is a trigger of ADHR. This study aimed to clarify the role of iron deficiency in ADHR. METHODS Data of clinical manifestations and laboratory examinations were collected from patients among eight kindreds with ADHR. Multiple regression and Pearson's correlation tests were performed to test the relationships of serum phosphate levels and other laboratory variables during the patients' follow-ups. RESULTS Among 23 ADHR patients with fibroblast growth factor 23 (FGF23) mutations, 14 patients presented with obvious symptoms. Ten patients had iron deficiency at the onset of ADHR, coinciding with menarche, menorrhagia, pregnancy, and chronic gastrointestinal bleeding. Two patients who did not have their iron status tested presented with symptoms after abortion and pregnancy in one patient each, which suggested that they also had iron deficiency at onset. Patients were treated with ferrous succinate tablets, vitamin C, and neutral phosphate and calcitriol. With correction of the iron status, the patients' symptoms showed notable improvement, with increased serum phosphate levels. Two patients' FGF23 levels also declined to the normal range. There were strong correlations between serum phosphate and serum iron levels (r = 0.7689, p < 0.0001), serum ferritin levels (r = 0.5312, p = 0.002), iron saturation (r = 0.7907, p < 0.0001), and transferrin saturation (r = 0.7875, p < 0.001). We also examined the relationships between serum phosphate levels and hemoglobin-related indices, which were significant (hemoglobin: r = 0.71, p < 0.0001; MCV: r = 0.7589, p < 0.0001; MCH: r = 0.8218, p < 0.0001; and MCHC: r = 0.7751, p < 0.0001). Longitudinal data of six patients' follow-up also showed synchronous changes in serum phosphate with serum iron levels. CONCLUSIONS Iron deficiency plays an important role in triggering ADHR. Monitoring and correcting the iron status are helpful for diagnosing and treating ADHR. Iron metabolism parameters and hemoglobin-related parameters are positively correlated with serum phosphate levels in patients with ADHR and iron deficiency, and these might serve as good indicators of prognosis of ADHR.
Collapse
Affiliation(s)
- C Liu
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - X Li
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Z Zhao
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Y Chi
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - L Cui
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Q Zhang
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - F Ping
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - X Chai
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Y Jiang
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - O Wang
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - M Li
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - X Xing
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - W Xia
- Department of Endocrinology, NHC Key Laboratory of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
| |
Collapse
|
6
|
Liu AQ, Zhang LS, Guo H, Wu ML, Li TY, Xuan K, Wei KW. Long-term dental intervention and laboratory examination in a patient with Vitamin D-dependent rickets type I: A case report. Medicine (Baltimore) 2020; 99:e22508. [PMID: 33031289 PMCID: PMC7544169 DOI: 10.1097/md.0000000000022508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Vitamin D-dependent rickets type I (VDDR-I) is a rare form of rickets, which is an autosomal recessive disease caused by 1α-hydroxylase enzyme deficiency. However, long-term dental management and microscopic morphology of teeth remain largely unclear. PATIENT CONCERNS We report the case of a 10-year-old Chinese boy complaining of yellowish-brown teeth with extensive caries. DIAGNOSES Clinical and laboratory examinations were performed, and VDDR-I was confirmed. Scanning electron microscopy confirmed amelogenesis imperfecta. INTERVENTIONS The patient had been taking drugs intervention for VDDR-I from the age of 3 years. The decayed teeth were treated, and metal-preformed crowns were placed to prevent further impairment. Sequence tooth extraction and remineralization therapy were also performed. OUTCOMES After 3 years of follow-up, the patient exhibited normal tooth replacement and an acceptable oral hygiene status. However, the new erupted teeth had amelogenesis imperfecta. LESSONS This case is the first to confirm amelogenesis imperfecta in a patient with VDDR-I that was not prevented by drug intervention. Importantly, it provides evidence that long-term dental intervention in patients with VDDR-I can result in an acceptable oral hygiene status. Therefore, early and long-term dental intervention is necessary in VDDR-I patients.
Collapse
Affiliation(s)
- An-Qi Liu
- State Key Laboratory of Military Stomatology and National Clinical Research Center for Oral Diseases and Shaanxi Clinical Research Center for Oral Diseases, Department of Preventive Dentistry, School of Stomatology
| | - Li-Shu Zhang
- State Key Laboratory of Military Stomatology and National Clinical Research Center for Oral Diseases and Shaanxi Clinical Research Center for Oral Diseases, Department of Preventive Dentistry, School of Stomatology
| | - Hao Guo
- State Key Laboratory of Military Stomatology and National Clinical Research Center for Oral Diseases and Shaanxi Clinical Research Center for Oral Diseases, Department of Preventive Dentistry, School of Stomatology
| | - Mei-Ling Wu
- State Key Laboratory of Military Stomatology and National Clinical Research Center for Oral Diseases and Shaanxi Clinical Research Center for Oral Diseases, Department of Preventive Dentistry, School of Stomatology
| | - Tian-Yi Li
- State Key Laboratory of Military Stomatology and National Clinical Research Center for Oral Diseases and Shaanxi Clinical Research Center for Oral Diseases, Department of Preventive Dentistry, School of Stomatology
| | - Kun Xuan
- State Key Laboratory of Military Stomatology and National Clinical Research Center for Oral Diseases and Shaanxi Clinical Research Center for Oral Diseases, Department of Preventive Dentistry, School of Stomatology
| | - Ke-Wen Wei
- Department of Dentistry, Hospital of Tangdu, Fourth Military Medical University, Xi’an, Shaanxi Province, China
| |
Collapse
|
7
|
Saraff V, Nadar R, Högler W. New Developments in the Treatment of X-Linked Hypophosphataemia: Implications for Clinical Management. Paediatr Drugs 2020; 22:113-121. [PMID: 31965544 PMCID: PMC7083817 DOI: 10.1007/s40272-020-00381-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
X-linked hypophosphataemia (XLH) is due to mutations in phosphate-regulating gene with homologies to endopeptidases on the X chromosome (PHEX) and represents the most common heritable form of rickets. In this condition, the hormone fibroblast growth factor 23 (FGF23) is produced in excessive amounts for still unknown reasons, and causes renal phosphate wasting and suppression of 1,25-dihydroxyvitamin D, leading to low serum phosphate concentrations. Prolonged hypophosphataemia decreases apoptosis of hypertrophic chondrocytes in growth plates (causing rickets) and decreases mineralisation of existing bone (causing osteomalacia). In contrast to historical conventional treatment with oral phosphate supplements and active vitamin D for the last 50 years, the new anti-FGF23 antibody treatment (burosumab) targets the primary pathology by blocking FGF23, thereby restoring phosphate homeostasis. In this review, we describe the changes in treatment monitoring, treatment targets and long-term treatment goals, including future opportunities and challenges in the treatment of XLH in children.
Collapse
Affiliation(s)
- Vrinda Saraff
- Department of Endocrinology and Diabetes, Birmingham Women’s and Children’s Hospital NHS Trust, Birmingham, UK ,grid.6572.60000 0004 1936 7486Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ruchi Nadar
- Department of Endocrinology and Diabetes, Birmingham Women’s and Children’s Hospital NHS Trust, Birmingham, UK
| | - Wolfgang Högler
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK. .,Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Kepler Universitätsklinikum, Krankenhausstrasse 26-30, 4020, Linz, Austria.
| |
Collapse
|