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Bohns FR, Akhtar R, Chuang YJ, Chen PY. Bone quality in zebrafish vertebrae improves after alendronate administration in a glucocorticoid-induced osteoporosis model. J Mech Behav Biomed Mater 2024; 154:106521. [PMID: 38555661 DOI: 10.1016/j.jmbbm.2024.106521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 03/15/2024] [Accepted: 03/21/2024] [Indexed: 04/02/2024]
Abstract
Glucocorticoid-induced osteoporosis (GIOP) changes the microarchitecture of bones and often leads to the reduction of bone-mineral density (BMD) and increased fracture rates. Zebrafish has been used as an alternative model for GIOP, however, the interaction of GIOP, and its treatment, with zebrafish bone morphometrics and mechanical properties, remains a challenge. Thus, this study aimed to evaluate the effects of prednisolone and alendronate on the properties of zebrafish vertebrae. Adult 7-month-old zebrafish were distributed into four groups: control (CTRL), prednisolone-only (PN), alendronate-only (ALN), and the sequential use of both medicines (PN + ALN). Fish skeletons were scanned via micro-tomography (n = 3) to obtain vertebra morphometrics (e.g., BMD). Bone morphology was assessed using scanning electron microscopy (n = 4) and the biomechanical behaviour with nanoindentation technique (n = 3). The BMD decreased in PN (426.08 ± 18.58 mg/cm3) and ALN (398.23 ± 10.20 mg/cm3) groups compared to the CTRL (490.43 ± 41.96 mg/cm3) (p < 0.001); however, administering the medicines in sequence recovered the values to healthy levels (495.43 ± 22.06 mg/cm3) (p > 0.05). The bone layered structures remain preserved in all groups. The vertebrae of the groups that received ALN and PN + ALN, displayed higher modulus of elasticity (27.27 ± 1.59 GPa and 25.68 ± 2.07 GPa, respectively) than the CTRL (22.74 ± 1.60 GP) (p < 0.001). ALN alone increased the hardness of zebrafish vertebrae to the highest value among the treatments (1.32 ± 0.13 GPa) (p < 0.001). Conversely, PN + ALN (1.25 ± 0.11 GPa) showed unaltered hardness from the CTRL (1.18 ± 0.13 GPa), but significantly higher than the PN group (1.08 ± 0.12 GPa) (p < 0.001). ALN administered after GIOP development, rescued osteoporotic condition by recovering the BMD and bone hardness in zebrafish vertebrae.
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Affiliation(s)
- Fabio Rocha Bohns
- Department of Materials Science and Engineering, National Tsing Hua University, Hsinchu, Taiwan; Department of Mechanical, Materials and Aerospace Engineering, University of Liverpool, Liverpool, UK; International Intercollegiate Ph.D. Program, National Tsing Hua University, Hsinchu, Taiwan
| | - Riaz Akhtar
- Department of Mechanical, Materials and Aerospace Engineering, University of Liverpool, Liverpool, UK
| | - Yung-Jen Chuang
- School of Medicine, National Tsing Hua University, Hsinchu, Taiwan
| | - Po-Yu Chen
- Department of Materials Science and Engineering, National Tsing Hua University, Hsinchu, Taiwan.
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Larid G, Vix J, Preuss P, Robin F, Tison A, Delaveau C, Krajewski F, Bouvard B, Chu Miow Lin D, Guggenbuhl P, Maugars Y, Saraux A, Debiais F. Detection of hypophosphatasia in hospitalised adults in rheumatology and internal medicine departments: a multicentre study over 10 years. RMD Open 2024; 10:e004316. [PMID: 38580346 PMCID: PMC11002352 DOI: 10.1136/rmdopen-2024-004316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 03/15/2024] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION Hypophosphatasia (HPP) is a rare genetic disease caused by loss-of-function mutations in the ALPL gene encoding the tissue non-specific alkaline phosphatase (ALP). Mild HPP is usually misdiagnosed in adult age. While an elevated serum ALP value draws more attention than a low value, low serum ALP should be better recognised and may lead to HPP detection. METHODS Patients were selected from the records of the biochemistry department of six University Hospitals in France. Patients were hospitalised in the departments of rheumatology and internal medicine between 2007 and 2017. RESULTS 56 321 hospitalised patients had at least 2 serum ALP dosages and 664 of these patients had at least 2 low serum ALP≤35 UI/L. Among these 664 patients, 482 (72.6%) had fluctuating low values (mean age 62.9 years; 60% of women) and 182 patients (27.4%) had persistent low values below 35 IU/L (mean age 53.4 years; 67% of women). Among patients with persistent hypophosphatasaemia treated with bisphosphonates, 70.8% never had ALP measurement before treatment and 20.8% were treated despite an abnormal decrease of ALP. Genetic testing was performed in 18 patients and was positive in 11. Genetic diagnosis of HPP was at least 6.0% in persistent hypophosphatasaemia and at least 15.9% in patients with at least three symptoms suggestive of HPP. CONCLUSION In this 10-year retrospective study, 0.32% of adult patients hospitalised in the rheumatology and internal medicine departments had persistently low serum ALP, and among them, 6% had genetically proven HPP. Reported hypophosphatasaemia represented only 3.6% of hospitalised patients.
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Affiliation(s)
- Guillaume Larid
- Department of Rheumatology, CHU Poitiers, Poitiers, France
- LITEC, Poitiers University, Poitiers, France
| | - Justine Vix
- Department of Rheumatology, CHU Poitiers, Poitiers, France
| | | | | | | | | | | | | | - Delphine Chu Miow Lin
- Department of Rheumatology, CHU de Tours, Tours, France
- Université de Tours, Tours, France
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Brandi ML, Khan AA, Rush ET, Ali DS, Al-Alwani H, Almonaei K, Alsarraf F, Bacrot S, Dahir KM, Dandurand K, Deal C, Ferrari SL, Giusti F, Guyatt G, Hatcher E, Ing SW, Javaid MK, Khan S, Kocijan R, Lewiecki EM, Linglart A, M'Hiri I, Marini F, Nunes ME, Rockman-Greenberg C, Seefried L, Simmons JH, Starling SR, Ward LM, Yao L, Brignardello-Petersen R, Roux C. The challenge of hypophosphatasia diagnosis in adults: results from the HPP International Working Group Literature Surveillance. Osteoporos Int 2024; 35:439-449. [PMID: 37982856 DOI: 10.1007/s00198-023-06859-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 11/21/2023]
Abstract
Hypophosphatasia (HPP) is an inborn error of metabolism caused by reduced or absent activity of the tissue non-specific alkaline phosphatase (TNSALP) enzyme, resulting from pathogenic variants in the ALPL gene. Clinical presentation of HPP is highly variable, including lethal and severe forms in neonates and infants, a benign perinatal form, mild forms manifesting in adulthood, and odonto-HPP. Diagnosis of HPP remains a challenge in adults, as signs and symptoms may be mild and non-specific. Disease presentation varies widely; there are no universal signs or symptoms, and the disease often remains underdiagnosed or misdiagnosed, particularly by clinicians who are not familiar with this rare disorder. The absence of diagnosis or a delayed diagnosis may prevent optimal management for patients with this condition. Formal guidelines for the diagnosis of adults with HPP do not exist, complicating efforts for consistent diagnosis. To address this issue, the HPP International Working Group selected 119 papers that explicitly address the diagnosis of HPP in adults through a Medline, Medline In-Process, and Embase search for the terms "hypophosphatasia" and "HPP," and evaluated the pooled prevalence of 17 diagnostic characteristics, initially selected by a group of HPP clinical experts, in eligible studies and in patients included in these studies. Six diagnostic findings showed a pooled prevalence value over 50% and were considered for inclusion as major diagnostic criteria. Based on these results and according to discussion and consideration among members of the Working Group, we finally defined four major diagnostic criteria and five minor diagnostic criteria for HPP in adults. Authors suggested the integrated use of the identified major and minor diagnostic criteria, which either includes two major criteria, or one major criterion and two minor criteria, for the diagnosis of HPP in adults.
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Affiliation(s)
- Maria Luisa Brandi
- F.I.R.M.O. Italian Foundation for the Research On Bone Diseases, Florence, Italy.
- Donatello Bone Clinic, Villa Donatello Hospital, Florence, Italy.
| | - Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Eric T Rush
- Division of Clinical Genetics, Children's Mercy Kansas City and Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
- Division of Endocrinology, Metabolism, Osteoporosis, and Genetics, Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Dalal S Ali
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Hatim Al-Alwani
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Khulod Almonaei
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Farah Alsarraf
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Severine Bacrot
- Department of Genetics, Centre Hospitalier de Versailles, Hôpital André Mignot, Versailles, France
| | - Kathryn M Dahir
- Division of Endocrinology and Metabolism, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karel Dandurand
- Department of Medicine, Endocrinology and Metabolism, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Chad Deal
- Center for Osteoporosis and Metabolic Bone Disease, Department of Rheumatology, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Serge Livio Ferrari
- Division of Bone Diseases, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Francesca Giusti
- Donatello Bone Clinic, Villa Donatello Hospital, Florence, Italy
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Erin Hatcher
- Neuromuscular Clinic, McMaster University Medical Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Steven W Ing
- Division of Endocrinology, Diabetes, & Metabolism, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah Khan
- Bone Research and Education Centre, Oakville, ON, Canada
| | - Roland Kocijan
- Trauma Centre Meidling, Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA, 1St Medical Department Hanusch Hospital, 1140, Vienna, Austria
| | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - Agnes Linglart
- APHP, Bicêtre Paris-Sud, University Paris Sud, Paris-Saclay, Le Kremlin Bicêtre, Paris, France
| | - Iman M'Hiri
- Bone Research and Education Centre, Oakville, ON, Canada
| | - Francesca Marini
- F.I.R.M.O. Italian Foundation for the Research On Bone Diseases, Florence, Italy
| | - Mark E Nunes
- Division of Medical Genetics and Metabolism, Valley Children's HealthCare, Madera, CA, USA
| | | | - Lothar Seefried
- Musculoskeletal Center Würzburg, University of Würzburg, Würzburg, Germany
| | - Jill H Simmons
- Division of Endocrinology and Metabolism, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan R Starling
- Division of Clinical Genetics, Children's Mercy Kansas City and Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Leanne M Ward
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Christian Roux
- INSERM CRESS UMR 1153, Paris, France
- Université Paris-Cité, Department of Rheumatology, APHP-Centre, Cochin Hospital, Paris, France
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Charles JF, Malabanan AO, Krolczyk S, Dahir KM. Rare Causes of Musculoskeletal Pain: Thinking beyond Common Rheumatologic Diseases. Case Rep Rheumatol 2024; 2024:6540026. [PMID: 38283708 PMCID: PMC10810688 DOI: 10.1155/2024/6540026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 01/06/2024] [Accepted: 01/09/2024] [Indexed: 01/30/2024] Open
Abstract
Objectives Rare metabolic bone diseases can present with symptoms mimicking more common rheumatological conditions including spondyloarthritis, osteoarthritis, and fibromyalgia. Increasing awareness of these rare diseases within the rheumatology community is vital to ensure that affected patients are diagnosed and appropriately treated. The literature includes several reports of tumour-induced osteomalacia initially diagnosed as rheumatic disease, but other rare diseases such as X-linked hypophosphatemia (XLH) and hypophosphatasia (HPP) also deserve attention. Here, we describe two cases of adult patients incorrectly diagnosed with ankylosing spondylitis and osteoarthritis who, upon referral to a metabolic bone disease specialist, were subsequently diagnosed with XLH and HPP, respectively, profoundly altering their management. Methods The cases were collected from Brigham and Women's Hospital, Boston, MA, USA, and Vanderbilt University Medical Center, Nashville, TN, USA. Results Details of the patients' respective medical and family histories are presented, and the clinical and biochemical investigations undertaken to reach the correct diagnoses are described. Conclusion Rheumatologists should be encouraged to think beyond common rheumatological diseases when faced with symptoms such as bone pain, muscle pain, and stiffness, especially when accompanied by manifestations including atraumatic fractures, poor dentition, and hearing loss. In cases where one of these rare diseases is suspected, referral to a metabolic bone disease specialist for confirmation of diagnosis is encouraged as effective treatment options have recently become available.
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Affiliation(s)
- Julia F. Charles
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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5
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Rush E, Brandi ML, Khan A, Ali DS, Al-Alwani H, Almonaei K, Alsarraf F, Bacrot S, Dahir KM, Dandurand K, Deal C, Ferrari SL, Giusti F, Guyatt G, Hatcher E, Ing SW, Javaid MK, Khan S, Kocijan R, Lewiecki EM, Linglart A, M'Hiri I, Marini F, Nunes ME, Rockman-Greenberg C, Roux C, Seefried L, Starling SR, Ward L, Yao L, Brignardello-Petersen R, Simmons JH. Proposed diagnostic criteria for the diagnosis of hypophosphatasia in children and adolescents: results from the HPP International Working Group. Osteoporos Int 2024; 35:1-10. [PMID: 37982855 PMCID: PMC10786745 DOI: 10.1007/s00198-023-06843-2] [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] [Received: 12/30/2022] [Accepted: 06/23/2023] [Indexed: 11/21/2023]
Abstract
Hypophosphatasia (HPP) is a rare inborn error of metabolism that presents variably in both age of onset and severity. HPP is caused by pathogenic variants in the ALPL gene, resulting in low activity of tissue nonspecific alkaline phosphatase (TNSALP). Patients with HPP tend have a similar pattern of elevation of natural substrates that can be used to aid in diagnosis. No formal diagnostic guidelines currently exist for the diagnosis of this condition in children, adolescents, or adults. The International HPP Working Group is a comprised of a multidisciplinary team of experts from Europe and North America who have expertise in the diagnosis and management of patients with HPP. This group reviewed 93 papers through a Medline, Medline In-Process, and Embase search for the terms "HPP" and "hypophosphatasia" between 2005 and 2020 and that explicitly address either the diagnosis of HPP in children, clinical manifestations of HPP in children, or both. Two reviewers independently evaluated each full-text publication for eligibility and studies were included if they were narrative reviews or case series/reports that concerned diagnosis of pediatric HPP or included clinical aspects of patients diagnosed with HPP. This review focused on 15 initial clinical manifestations that were selected by a group of clinical experts.The highest agreement in included literature was for pathogenic or likely pathogenic ALPL variant, elevation of natural substrates, and early loss of primary teeth. The highest prevalence was similar, including these same three parameters and including decreased bone mineral density. Additional parameters had less agreement and were less prevalent. These were organized into three major and six minor criteria, with diagnosis of HPP being made when two major or one major and two minor criteria are present.
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Affiliation(s)
- Eric Rush
- Division of Clinical Genetics, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, USA.
- Department of Pediatrics, University of Missouri - Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, USA.
- Division of Endocrinology, Metabolism, Osteoporosis, and Genetics, Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, KS, USA.
| | - Maria Luisa Brandi
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy
- Donatello Bone Clinic, Villa Donatello Hospital, Florence, Italy
| | - Aliya Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Dalal S Ali
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Hatim Al-Alwani
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Khulod Almonaei
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Farah Alsarraf
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Severine Bacrot
- Department of Genetics, Centre Hospitalier de Versailles, Hôpital André Mignot, Versailles, France
| | - Kathryn M Dahir
- Division of Endocrinology and Metabolism, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karel Dandurand
- Department of Medicine, Endocrinology and Metabolism, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Chad Deal
- Center for Osteoporosis and Metabolic Bone Disease, Department of Rheumatology, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Serge Livio Ferrari
- Division of Bone Diseases, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Francesca Giusti
- Donatello Bone Clinic, Villa Donatello Hospital, Florence, Italy
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Erin Hatcher
- Neuromuscular Clinic, McMaster University Medical Centre, Hamilton Health Sciences, Hamilton, Canada
| | - Steven W Ing
- Division of Endocrinology, Diabetes, & Metabolism, Ohio State University Wexner Medical Center, Columbus, USA
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah Khan
- Bone Research and Education Centre, Oakville, ON, Canada
| | - Roland Kocijan
- 1st Medical Department, Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA, Trauma Centre Meidling, Hanusch Hospital, 1140, Vienna, Austria
| | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - Agnes Linglart
- APHP, Bicêtre Paris-Sud, University Paris Sud, Paris-Saclay, Le Kremlin Bicêtre, Paris, France
| | - Iman M'Hiri
- Bone Research and Education Centre, Oakville, ON, Canada
| | - Francesca Marini
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy
| | - Mark E Nunes
- Division of Medical Genetics and Metabolism, Valley Children's HealthCare, Madera, CA, USA
| | | | - Christian Roux
- Rheumatology Department, Hospital Pasteur 2 CHU, 06000, Nice, France
- Inserm, CNRS, iBV, Université Côte d'Azur, 06000, Nice, France
| | - Lothar Seefried
- Musculoskeletal Center Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - Susan R Starling
- Division of Clinical Genetics, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, USA
| | - Leanne Ward
- Children's Hospital of Eastern Ontario, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | | | - Jill H Simmons
- Division of Endocrinology and Metabolism, Vanderbilt University Medical Center, Nashville, TN, USA
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Kim SM, Korkmaz F, Sims S, Ryu V, Yuen T, Zaidi M. Musculoskeletal and neurocognitive clinical significance of adult hypophosphatasia. Osteoporos Sarcopenia 2023; 9:115-120. [PMID: 38374822 PMCID: PMC10874721 DOI: 10.1016/j.afos.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/03/2023] [Accepted: 12/12/2023] [Indexed: 02/21/2024] Open
Abstract
Hypophosphatasia (HPP), also called Rathbun disease, is a rare genetic disorder that is caused by the loss-of-function mutation in the ALPL gene encoding tissue non-specific alkaline phosphatase. Doctor Rathbun first described the case of a 3-week-old infant who presented with severe osteopenia, rickets, and multiple radiographic fractures, and died shortly after of epileptic seizure and respiratory distress. The term "hypophosphatasia" was coined as the patients' alkaline phosphatase levels were significantly low. Since then, our understanding of HPP has evolved, and now we appreciate causative genetic mutation and the broad spectrum of clinical presentation depending on the age of onset, severity, and skeletal involvement: perinatal, infantile, childhood, adult and odontohypophosphatasia. The new development of enzyme replacement with asfostase alfa has saved the lives of severe form of hypophosphatasia. However, it is still unclear and remains challenging how to manage adult HPP that often presents with mild and non-specific symptoms such as muscle pain, joint stiffness, fatigue, anxiety, or low bone mass, which are common in the general population and not necessarily attributed to HPP. In this review, we will present 3 unique cases of adult HPP and discuss the pathophysiology, clinical presentation particularly neuromuscular and neurocognitive symptoms and management of adult HPP.
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Affiliation(s)
- Se-Min Kim
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Funda Korkmaz
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steve Sims
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vitaly Ryu
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tony Yuen
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mone Zaidi
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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7
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Rauf MA, Kotecha J, Moss K. Reducing diagnostic delay in hypophosphatasia: a case series of 14 patients presenting to general rheumatology. Osteoporos Int 2023; 34:1647-1652. [PMID: 37118032 PMCID: PMC10427523 DOI: 10.1007/s00198-023-06749-z] [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] [Received: 11/06/2022] [Accepted: 04/05/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVES Hypophosphatasia (HPP) is a rare genetic metabolic bone disease that can cause chronic pain and fractures. Its hallmark is a persistently low serum ALP. HPP is now recognised by many osteoporosis specialists, but other specialists, such as rheumatologists and primary care physicians, may be less aware of this condition, causing diagnostic delay and possible harm to these patients. Our objective was to highlight features that can reduce this delay. METHODS We retrospectively analysed 14 patients that presented with musculoskeletal pain to general rheumatology clinic at St. George's Hospital and were subsequently diagnosed with HPP. RESULTS Median diagnostic delay was 13 years. All patients had an ALP below reference range for age and gender, with lowest mean ALP of 16 IU/L. All but one patient were women with median age of 51 years. Most common presentation was peripheral joint pain in 85.7% of patients. This was due to early-onset CPPD (calcium pyrophosphate deposition disease) in 71.4% of patients, osteoarthritis in 50%, or bursitis in 50%. Axial pain was reported in 64% of patients due to osteoarthritis or spinal stenosis. Fifty percent of patients had a history of long bone pain. Fifty percent had previous fracture(s). A total of 28.6% of patients had psoriatic arthritis, of which 1 patient had spondyloarthropathy, and 4 patients also had enthesitis. CONCLUSION Patients with HPP can present to rheumatology with musculoskeletal pain, and if a persistently low ALP is confirmed, this may reduce the diagnostic delay of this rare disease. Similar to other rheumatologic patients, musculoskeletal pain in HPP was noted in peripheral joints and in the spine with almost a third of patients having psoriatic arthritis. Pain was also noted in the long bones, a feature consistent with metabolic bone disease. The diagnosis of HPP was also more likely in those patients with a personal or family history of dental disease or arthritis.
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Affiliation(s)
- Muhammad A. Rauf
- Department of Medicine, St. George’s University of London, Cranmer Terrace, London, SW17 0RE UK
| | - Jalpa Kotecha
- Weston Education Centre, King’s College Hospital, London, UK
| | - Katie Moss
- Department of Rheumatology, St. George’s University Hospitals NHS Foundation Trust, London, UK
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8
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Schmidt FN, Schmidt C, Delsmann J, Amling M, Barvencik F. Radial HR-pQCT and Finite Element Analysis in HPP Patients are Superior in Identifying Susceptibility to Fracture-Associated Skeletal Affections Compared to DXA and Laboratory Tests. Calcif Tissue Int 2023; 112:691-703. [PMID: 37147467 DOI: 10.1007/s00223-023-01082-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/05/2023] [Indexed: 05/07/2023]
Abstract
Hypophosphatasia (HPP) is an inborn disease that causes a rare form of osteomalacia, a mineralization disorder affecting mineralized tissues. Identification of patients at high risk for fractures or other skeletal manifestations (such as insufficiency fractures or excessive bone marrow edema) by bone densitometry and laboratory tests remains clinically challenging. Therefore, we examined two cohorts of patients with variants in the ALPL gene grouped by bone manifestations. These groups were compared by means of bone microarchitecture using high-resolution peripheral quantitative computed tomography (HR-pQCT) and simulated mechanical performance utilizing finite element analysis (FEA). Whereas the incidence of skeletal manifestations among the patients could not be determined by dual energy X-ray absorptiometry (DXA) or laboratory assessment, HR-pQCT evaluation showed a distinct pattern of HPP patients with such manifestations. Specifically, these patients had a pronounced loss of trabecular bone mineral density, increased trabecular spacing, and decreased ultimate force at the distal radius. Interestingly, the derived results indicate that the non-weight-bearing radius is superior to the weight-bearing tibia in identifying deteriorated skeletal patterns. Overall, the assessment by HR-pQCT appears to be of high clinical relevance due to the improved identification of HPP patients with an increased risk for fractures or other skeletal manifestations, especially at the distal radius.
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Affiliation(s)
- Felix N Schmidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Constantin Schmidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Julian Delsmann
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany.
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Li X, Ren N, Wang Z, Wang Y, Hu Y, Hu W, Gu J, Hong W, Zhang Z, Wang C. Clinical and Genetic Characteristics of Hypophosphatasia in Chinese Adults. Genes (Basel) 2023; 14:genes14040922. [PMID: 37107680 PMCID: PMC10137706 DOI: 10.3390/genes14040922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/06/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Hypophosphatasia (HPP) is an inherited disease caused by ALPL mutation, resulting in decreased alkaline phosphatase (ALP) activity and damage to bone and tooth mineralization. The clinical symptoms of adult HPP are variable, making diagnosis challenging. This study aims to clarify the clinical and genetic characteristics of HPP in Chinese adults. There were 19 patients, including 1 with childhood-onset and 18 with adult-onset HPP. The median age was 62 (32-74) years and 16 female patients were involved. Common symptoms included musculoskeletal symptoms (12/19), dental problems (8/19), fractures (7/19), and fatigue (6/19). Nine patients (47.4%) were misdiagnosed with osteoporosis and six received anti-resorptive treatment. The average serum ALP level was 29.1 (14-53) U/L and 94.7% (18/19) of patients had ALP levels below 40 U/L. Genetic analysis found 14 ALPL mutations, including three novel mutations-c.511C>G (p.His171Ala), c.782C>A (p.Pro261Gln), and 1399A>G (p.Met467Val). The symptoms of two patients with compound heterozygous mutations were more severe than those with heterozygous mutations. Our study summarized the clinical characteristics of adult HPP patients in the Chinese population, expanded the spectrum of pathogenic mutations, and deepened clinicians' understanding of this neglected disease.
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Affiliation(s)
- Xiang Li
- Shanghai Clinical Research Center of Bone Disease & Department of Osteoporosis and Bone Diseases, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China
| | - Na Ren
- Shanghai Clinical Research Center of Bone Disease & Department of Osteoporosis and Bone Diseases, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China
| | - Ziyuan Wang
- Shanghai Clinical Research Center of Bone Disease & Department of Osteoporosis and Bone Diseases, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China
| | - Ya Wang
- Shanghai Clinical Research Center of Bone Disease & Department of Osteoporosis and Bone Diseases, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China
| | - Yunqiu Hu
- Shanghai Clinical Research Center of Bone Disease & Department of Osteoporosis and Bone Diseases, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China
| | - Weiwei Hu
- Shanghai Clinical Research Center of Bone Disease & Department of Osteoporosis and Bone Diseases, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China
| | - Jiemei Gu
- Shanghai Clinical Research Center of Bone Disease & Department of Osteoporosis and Bone Diseases, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China
| | - Wei Hong
- Department of Osteoporosis & Shanghai Key Laboratory of Clinical Geriatric Medicine, Huadong Hospital, Fudan University, Shanghai 200040, China
| | - Zhenlin Zhang
- Clinical Research Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China
| | - Chun Wang
- Shanghai Clinical Research Center of Bone Disease & Department of Osteoporosis and Bone Diseases, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China
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Ross J, Bowden MR, Yu C, Diaz-Thomas A. Transition of young adults with metabolic bone diseases to adult care. Front Endocrinol (Lausanne) 2023; 14:1137976. [PMID: 37008909 PMCID: PMC10064010 DOI: 10.3389/fendo.2023.1137976] [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] [Received: 01/05/2023] [Accepted: 03/06/2023] [Indexed: 03/19/2023] Open
Abstract
As more accurate diagnostic tools and targeted therapies become increasingly available for pediatric metabolic bone diseases, affected children have a better prognosis and significantly longer lifespan. With this potential for fulfilling lives as adults comes the need for dedicated transition and intentional care of these patients as adults. Much work has gone into improving the transitions of medically fragile children into adulthood, encompassing endocrinologic conditions like type 1 diabetes mellitus and congenital adrenal hyperplasia. However, there are gaps in the literature regarding similar guidance concerning metabolic bone conditions. This article intends to provide a brief review of research and guidelines for transitions of care more generally, followed by a more detailed treatment of bone disorders specifically. Considerations for such transitions include final adult height, fertility, fetal risk, heritability, and access to appropriately identified specialists. A nutrient-dense diet, optimal mobility, and adequate vitamin D stores are protective factors for these conditions. Primary bone disorders include hypophosphatasia, X-linked hypophosphatemic rickets, and osteogenesis imperfecta. Metabolic bone disease can also develop secondarily as a sequela of such diverse exposures as hypogonadism, a history of eating disorder, and cancer treatment. This article synthesizes research by experts of these specific disorders to describe what is known in this field of transition medicine for metabolic bone diseases as well as unanswered questions. The long-term objective is to develop and implement strategies for successful transitions for all patients affected by these various conditions.
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Affiliation(s)
- Jordan Ross
- Division of Pediatric Endocrinology, University of Tennessee Health Science Center, Memphis, TN, United States
- *Correspondence: Jordan Ross,
| | - Michelle R. Bowden
- Division of General Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
- Le Bonheur Children’s Hospital, Memphis, TN, United States
| | - Christine Yu
- Endocrinology Division, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Alicia Diaz-Thomas
- Division of Pediatric Endocrinology, University of Tennessee Health Science Center, Memphis, TN, United States
- Le Bonheur Children’s Hospital, Memphis, TN, United States
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Feurstein J, Behanova M, Haschka J, Roetzer K, Uyanik G, Hadzimuratovic B, Witsch-Baumgartner M, Schett G, Zwerina J, Kocijan R. Identifying adult hypophosphatasia in the rheumatology unit. Orphanet J Rare Dis 2022; 17:435. [PMID: 36514157 PMCID: PMC9749273 DOI: 10.1186/s13023-022-02572-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 11/20/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The most frequent manifestation in adult hypophosphatasia (HPP) is musculoskeletal pain. The unspecific nature of its clinical presentation may prevent correct diagnosis. The aim of the study was to assess the prevalence of ALPL mutations in adult patients treated in rheumatological outpatient facilities with evident musculoskeletal symptoms typical for HPP. METHODS Over a period of 10 years 9,522 patients were screened in the rheumatology outpatient clinic of the Hanusch hospital Vienna. Serum ALP levels ≤ 40 U/L were found in 524 patients. After screening for secondary causes, 73 patients were invited for clinical evaluation. Genetic testing was performed in 23 patients with suspected HPP. Logistic regression models with Firth penalisation were used to estimate the unadjusted and BMI-adjusted association of each clinical factor with HPP. RESULTS Mutations in the ALPL gene were observed in 57% of genetically screened patients. Arthralgia, fractures, and pain were the leading symptoms in individuals with ALPL mutation. Chondrocalcinosis (OR 29.12; 95% CI 2.02-1593.52) and dental disease (OR 8.33; 95% CI 0.93-143.40) were associated with ALPL mutation, independent of BMI. Onset of symptoms in patients with ALPL mutation was at 35.1 (14.3) years, with a mean duration from symptoms to diagnosis of 14.4 (8.1) years. Bone mineral density (BMD) and trabecular bone score (TBS) as well as bone turnover markers were not indicative for HPP or ALPL mutation. CONCLUSION HPP can mimic rheumatologic diseases. Thus, HPP should be considered as a possible diagnosis in adult patients presenting with musculoskeletal pain of unknown origin in rheumatology outpatient clinics. In patients with persistently low ALP serum levels and unclear musculoskeletal pain, HPP as the underlying cause has to be considered.
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Affiliation(s)
- Julia Feurstein
- grid.413662.40000 0000 8987 0344Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1St Medical Department, Hanusch Hospital, Heinrich-Collin-Strasse 30, 1140 Vienna, Austria ,grid.413662.40000 0000 8987 03441St Medical Department, Hanusch Hospital Vienna, Vienna, Austria
| | - Martina Behanova
- grid.413662.40000 0000 8987 0344Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1St Medical Department, Hanusch Hospital, Heinrich-Collin-Strasse 30, 1140 Vienna, Austria
| | - Judith Haschka
- grid.413662.40000 0000 8987 0344Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1St Medical Department, Hanusch Hospital, Heinrich-Collin-Strasse 30, 1140 Vienna, Austria ,grid.413662.40000 0000 8987 03441St Medical Department, Hanusch Hospital Vienna, Vienna, Austria ,Vienna Bone and Growth Centre, Vienna, Austria
| | - Katharina Roetzer
- grid.413662.40000 0000 8987 0344Centre for Medical Genetics, Hanusch Hospital Vienna, Vienna, Austria ,grid.263618.80000 0004 0367 8888Medical Faculty of Genetics, Sigmund Freud University, Vienna, Austria
| | - Gökhan Uyanik
- grid.413662.40000 0000 8987 0344Centre for Medical Genetics, Hanusch Hospital Vienna, Vienna, Austria ,grid.263618.80000 0004 0367 8888Medical Faculty of Genetics, Sigmund Freud University, Vienna, Austria
| | - Benjamin Hadzimuratovic
- grid.413662.40000 0000 8987 03441St Medical Department, Hanusch Hospital Vienna, Vienna, Austria
| | - Martina Witsch-Baumgartner
- grid.5361.10000 0000 8853 2677Division Human Genetics, Department of Medical Genetics, Molecular and Clinical Pharmacology, Medical University Innsbruck, Innsbruck, Austria
| | - Georg Schett
- grid.5330.50000 0001 2107 3311Department of Internal Medicine 3, The University Clinic of Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Jochen Zwerina
- grid.413662.40000 0000 8987 0344Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1St Medical Department, Hanusch Hospital, Heinrich-Collin-Strasse 30, 1140 Vienna, Austria ,grid.413662.40000 0000 8987 03441St Medical Department, Hanusch Hospital Vienna, Vienna, Austria ,Vienna Bone and Growth Centre, Vienna, Austria
| | - Roland Kocijan
- grid.413662.40000 0000 8987 0344Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1St Medical Department, Hanusch Hospital, Heinrich-Collin-Strasse 30, 1140 Vienna, Austria ,grid.413662.40000 0000 8987 03441St Medical Department, Hanusch Hospital Vienna, Vienna, Austria ,Vienna Bone and Growth Centre, Vienna, Austria ,grid.263618.80000 0004 0367 8888Medical Faculty of Bone Diseases, Sigmund Freud University, Vienna, Austria
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12
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Zhu R, Xu Y, Wang Z, Li H, Song M, Wan H, Yang H, Zhang X, Chai Y, Yu B. Higher serum apolipoprotein B level will reduce the bone mineral density and increase the risk of osteopenia or osteoporosis in adults. Front Cell Dev Biol 2022; 10:1054365. [PMID: 36568987 PMCID: PMC9780286 DOI: 10.3389/fcell.2022.1054365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/18/2022] [Indexed: 12/13/2022] Open
Abstract
Objective: There is very limited evidence in the NHANES database linking serum apolipoprotein B and lumbar bone mineral density (BMD) in adults aged 20-59 years. There are few studies associating apolipoprotein B concentrations with BMD, and there is some debate about the association between obesity and BMD. Therefore, the purpose of this study was to determine the association between serum apolipoprotein B concentrations and lumbar spine BMD in adults aged 20-59 years and to predict its association with risk of osteopenia or osteoporosis. Methods: A cross-sectional study of the entire US ambulatory population was conducted using data from the National Health and Nutrition Examination Survey (NHANES) database. Weighted multiple regression equation models were used to assess the association between serum apolipoprotein B and lumbar BMD. A logistic weighted regression model was used to assess the association between serum apolipoprotein B concentrations and risk of osteopenia or osteoporosis. Subsequent stratified analyses were performed to refine the primary population of association. Results: Our study showed a significant negative association between serum apolipoprotein B concentration and lumbar BMD and a significant positive association with the risk of osteoporosis or osteopenia in the total population. After stratifying by sex, age and race, we concluded differently. The association of serum apolipoprotein B concentration with lumbar spine BMD and risk of osteopenia or osteoporosis was significant in male, but not in female. After stratification by age, the negative association between serum apolipoprotein B concentrations and lumbar BMD and the positive association with risk of osteopenia or osteoporosis was more significant in the 30-39 and 50-59 years age groups. When stratified by race, serum apolipoprotein B concentrations were significantly negatively associated with lumbar BMD and positively associated with risk of osteopenia or osteoporosis in Mexican American and non-Hispanic black populations. Thus, these findings suggest that these associations are influenced by sex, age, and race, respectively. Conclusion: Our results suggest that the association between serum apolipoprotein B levels and the risk of lumbar BMD and osteopenia or osteoporosis varies by sex, age, and race. In men, elevated serum apolipoprotein B levels were negative for bone quality. Elevated serum apolipoprotein B levels in the age groups 30-39 and 50-59 years also had a negative effect on bone quality. In the Mexican American and Non-Hispanic Black populations, elevated serum apolipoprotein B levels also had a significant negative effect on bone quality.
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Affiliation(s)
- RunJiu Zhu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuan Xu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - ZhaoFu Wang
- Department of Orthopaedics, People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan, China
| | - Hui Li
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - MingRui Song
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - HaoYang Wan
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hong Yang
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China,Department of Respiratory and Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xin Zhang
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China,Department of Orthopaedics & Traumatology, Wuyi Hospital of Traditional Chinese Medicine, Jiangmen, China
| | - Yu Chai
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China,*Correspondence: Bin Yu, ; Yu Chai,
| | - Bin Yu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China,*Correspondence: Bin Yu, ; Yu Chai,
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13
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Sadhukhan S, Mehta P, Rajender S, Gupta SK, Chattopadhyay N. Proposing a clinical algorithm for better diagnosis of hypophosphatasia in resource-limiting situations. Osteoporos Int 2022; 33:2479-2493. [PMID: 35776147 DOI: 10.1007/s00198-022-06480-1] [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] [Received: 01/07/2022] [Accepted: 06/16/2022] [Indexed: 10/17/2022]
Abstract
Early diagnosis of hypophosphatasia (HPP) is challenging. Here, we propose to broaden the diagnostic criteria of HPP by reviewing published data on BMD and fractures in HPP patients. Non-osteoporotic fractures and higher than normal lumbar BMD were recurrent in HPP patients and could be included as diagnostic criteria. HPP is a genetic disorder caused by autosomal recessive or dominant loss-of-function mutations in the ALPL gene that encodes for tissue-nonspecific alkaline phosphatase (TNSALP). Expressive genetic heterogeneity and varying severity of TNSALP deficiency lead to a wide-ranging presentation of skeletal diseases at different ages that coupled with HPP's rarity and limitation of biochemical and mutational studies present serious hurdles to early diagnosis and management of HPP. To widen the scope of HPP diagnosis, we assessed the possibility of areal bone mineral density (BMD) as an additional clinical feature of this disease. PubMed, Web of Science, and ScienceDirect were searched with the following keywords: ("Hypophosphatasia OR HPP") AND ("Bone Mineral Density OR BMD") AND "Human". Studies and case reports of subjects with age ≥ 18 years and having BMD data were included. We pooled data from 25 publications comprising 356 subjects (90 males, 266 females). Only four studies had a control group. Biochemical hallmarks, pyridoxal 5'-phosphate (PLP) and phosphoethanolamine (PEA), were reported in fifteen and six studies, respectively. Twenty studies reported genetic data, nineteen studies reported non-vertebral fractures, all studies reported lumbar spine (LS) BMD, and nineteen reported non-vertebral BMD. Higher than normal and normal BMD at LS were reported in three and two studies, respectively. There was marked heterogeneity in BMD at the non-vertebral sites. Higher than normal or normal LS BMD in an adult with minimal or insufficient fractures, pseudofractures, non-healing fractures, fragility fractures, and stress fractures may be included in the diagnostic protocol of HPP. However, genetic testing is recommended for a definitive diagnosis.
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Affiliation(s)
- Sreyanko Sadhukhan
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Lucknow, India
- Academy of Scientific and Innovative Research, Ghaziabad, 201002, India
| | - Poonam Mehta
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Lucknow, India
- Academy of Scientific and Innovative Research, Ghaziabad, 201002, India
| | - Singh Rajender
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Lucknow, India
- Academy of Scientific and Innovative Research, Ghaziabad, 201002, India
| | - Sushil Kumar Gupta
- Department of Endocrinology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, India
| | - Naibedya Chattopadhyay
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Lucknow, India.
- Academy of Scientific and Innovative Research, Ghaziabad, 201002, India.
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14
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Hepp N, Frederiksen AL, Duno M, Jørgensen NR, Jensen JEB. Biochemical and clinical manifestations in adults with hypophosphatasia: a national cross-sectional study. Osteoporos Int 2022; 33:2595-2605. [PMID: 35986118 DOI: 10.1007/s00198-022-06536-2] [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] [Received: 01/06/2022] [Accepted: 08/15/2022] [Indexed: 11/24/2022]
Abstract
UNLABELLED Hypophosphatasia (HPP) is a rare disease affecting bone mineralization. Adults with HPP have an increased occurrence of low-energy fractures, which cannot be explained by reduced bone mass assessed by dual energy X-ray absorptiometry. The bone phenotype in adults with HPP requires further studies investigating bone strength and bone structural parameters. INTRODUCTION Hypophosphatasia (HPP) is a rare inherited disorder of bone and mineral metabolism, characterized by broad-ranging clinical manifestations and severity. However, studies investigating the clinical spectrum in adults with HPP compared to a control group are scarce. The aim of this study was to evaluate biochemical and clinical characteristics as well as bone health in a Danish cohort of adults with HPP. METHODS We conducted a cross-sectional study assessing biochemical parameters, fracture prevalence, bone mineral density (BMD), bone turnover markers, physical performance and pain characteristics in 40 adults with HPP and 40 sex-, age-, BMI- and menopausal status-matched healthy controls. RESULTS Patients with HPP had a significantly higher prevalence of non-vertebral, low-energy fractures (p = < 0.001). BMD at the lumbar spine, total hip, femoral neck, forearm and whole body did not differ between the groups. Low levels of the bone-specific alkaline phosphatase correlated significantly with higher BMD at the lumbar spine and femoral neck in both groups. The bone formation marker N-terminal propeptide of type 1 procollagen was significantly lower in patients with HPP than healthy controls (p = 0.006). Adults with HPP had significantly reduced walking capability (p = < 0.001) and lower body strength (p = < 0.001). Chronic pain was significantly more prevalent in adults with HPP than the control group (p = 0.029). CONCLUSIONS The increased occurrence of low-energy fractures in adults with HPP is not explained by low BMD. Adults with HPP have reduced physical performance when compared with healthy controls.
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Affiliation(s)
- Nicola Hepp
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark.
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200, Copenhagen, Denmark.
| | - Anja Lisbeth Frederiksen
- Department of Clinical Genetics, Aalborg University Hospital, Ladegaardsgade 5, 9000, Aalborg C, Denmark
- Department of Clinical Research, Aalborg University, Fredrik Bajers Vej 7K, 9220, Aalborg Ø, Denmark
| | - Morten Duno
- Department of Clinical Genetics, University Hospital Copenhagen Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Niklas Rye Jørgensen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200, Copenhagen, Denmark
- Department of Clinical Biochemistry, Rigshospitalet, Valdemar Hansens Vej 13, 2600, Glostrup, Denmark
| | - Jens-Erik Beck Jensen
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200, Copenhagen, Denmark
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Khanjee N, Maalouf NM. Romosozumab-aqqg in the Treatment of Osteoporosis in a Patient With Hypophosphatasia. J Endocr Soc 2022; 6:bvac159. [DOI: 10.1210/jendso/bvac159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract
Hypophosphatasia is a rare, inherited condition that causes osteomalacia and recurrent fractures. Therapeutic options for osteoporosis in patients with hypophosphatasia are limited because of concerns for a greater likelihood of atypical femoral fractures with antiresorptive agents. We report here the case of a patient with hypophosphatasia and osteoporosis who was treated with romosozumab-aqqg (Romo). An 81-year-old woman presented for management of osteoporosis with multiple fractures. She experienced a decline in bone mineral density over 20 years despite sequential osteoporosis treatment with oral bisphosphonates, hormone replacement therapy, teriparatide, and denosumab. Hypophosphatasia was suspected because of low serum alkaline phosphatase levels and was confirmed by genetic testing. After diagnosing hypophosphatasia, bone mineral density continued to decline and a trial of Romo was begun. After 1 year of Romo therapy, bone mineral density improved by 21%, and 10% at the lumbar spine and total hip, respectively. These changes were substantially greater than what she had experienced with prior teriparatide therapy. Blood alkaline phosphatase remained low on Romo. To our knowledge, this is the first report of a patient with hypophosphatasia and osteoporosis treated with Romo. In our patient, Romo did not significantly impact serum alkaline phosphatase, but improved bone mineral density significantly. In conclusion, Romo is a potential treatment option for osteoporosis in patients with hypophosphatasia for whom limited alternatives exist.
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Affiliation(s)
- Naveed Khanjee
- Department of Internal Medicine, Division of Endocrinology, University of Texas Southwestern Medical Center , Dallas, TX 75390-8885 , USA
| | - Naim M Maalouf
- Department of Internal Medicine, Division of Endocrinology, University of Texas Southwestern Medical Center , Dallas, TX 75390-8885 , USA
- The Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center , Dallas, TX 75390-8885 , USA
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16
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Hepp N, Folkestad L, Møllebæk S, Frederiksen AL, Duno M, Jørgensen NR, Hermann AP, Jensen JEB. Bone-microarchitecture and bone-strength in a sample of adults with hypophosphatasia and a matched reference population assessed by HR-pQCT and impact microindentation. Bone 2022; 160:116420. [PMID: 35421614 DOI: 10.1016/j.bone.2022.116420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/03/2022] [Accepted: 04/07/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Hypophosphatasia (HPP) is an autosomal recessive or dominate disease affecting bone mineralization, and adults with HPP are in risk to develop metatarsal stress fractures and femoral pseudofractures. Given to the scarce data on the bone quality and its association to the fracture risk in adults with HPP, this study aimed to evaluate bone turnover, bone strength and structure in adults with HPP. METHODS In this cross-sectional study, we included 14 adults with genetically verified HPP and 14 sex-, age-, BMI-, and menopausal status-matched reference individuals. We analyzed bone turnover markers, and measured bone material strength index (BMSi) by impact microindentation. Bone geometry, volumetric density and bone microarchitecture as well as failure load at the distal radius and tibia were evaluated using a second-generation high-resolution peripheral quantitative computed tomography system. RESULTS Bone turnover markers did not differ between patients with HPP and reference individuals. BMSi did not differ between the groups (67.90 [63.75-76.00] vs 65.45 [58.43-69.55], p = 0.149). Parameters of bone geometry and volumetric density did not differ between adults with HPP and the reference group. Patients with HPP had a tendency toward higher trabecular separation (0.664 [0.613-0.724] mm vs 0.620 [0.578-0.659] mm, p = 0.054) and inhomogeneity of trabecular network (0.253 [0.235-0.283] mm vs 0.229 [0.208-0.252] mm, p = 0.056) as well as lower trabecular bone volume fraction (18.8 [16.4-22.7] % vs 22.8 [20.6-24.7] %, p = 0.054) at the distal radius. In addition, compound heterozygous adults with HPP had a significantly higher cortical porosity at the distal radius than reference individuals (1.5 [0.9-2.2] % vs 0.7 [0.6-0.7] %, p = 0.041). CONCLUSIONS BMSi is not reduced in adults with HPP. Increased cortical porosity may contribute to the occurrence of femoral pseudofractures in compound heterozygous adults with HPP. However, further studies investigating larger cohorts of adults with HPP using methods of bone histomorphometry are recommended to adequately assess the bone quality in adults with HPP.
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Affiliation(s)
- Nicola Hepp
- Dept. of Endocrinology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark; Dept. of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200 Copenhagen, Denmark.
| | - Lars Folkestad
- Dept. of Endocrinology and Metabolism, Odense University Hospital, Kløvervænget 6, 5000 Odense C, Denmark; Dept. of Clinical Research, University of Southern Denmark, Winsløwparken 19, 5000 Odense C, Denmark
| | - Simone Møllebæk
- Dept. of Endocrinology and Metabolism, Odense University Hospital, Kløvervænget 6, 5000 Odense C, Denmark
| | - Anja Lisbeth Frederiksen
- Dept. of Clinical Genetics, Aalborg University Hospital, Ladegaardsgade 5, 9000 Aalborg C, Denmark; Dept. of Clinical Research, Aalborg University, Fredrik Bajers Vej 7K, 9220 Aalborg Ø, Denmark
| | - Morten Duno
- Dept. of Clinical Genetics, University Hospital Copenhagen Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Niklas Rye Jørgensen
- Dept. of Clinical Biochemistry, Rigshospitalet, Valdemar Hansens Vej 13, 2600 Glostrup, Denmark; Dept. of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200 Copenhagen, Denmark
| | - Anne Pernille Hermann
- Dept. of Endocrinology and Metabolism, Odense University Hospital, Kløvervænget 6, 5000 Odense C, Denmark
| | - Jens-Erik Beck Jensen
- Dept. of Endocrinology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark; Dept. of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200 Copenhagen, Denmark
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Salles Rosa Neto N, Englert D, McAlister WH, Mumm S, Mills D, Veis DJ, Burshell A, Boyde A, Whyte MP. Periarticular calcifications containing giant pseudo-crystals of francolite in skeletal fluorosis from 1,1-difluoroethane "huffing". Bone 2022; 160:116421. [PMID: 35429657 DOI: 10.1016/j.bone.2022.116421] [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] [Received: 02/21/2022] [Revised: 04/03/2022] [Accepted: 04/08/2022] [Indexed: 01/28/2023]
Abstract
Inhalant use disorder is a psychiatric condition characterized by repeated deliberate inhalation from among a broad range of household and industrial chemical products with the intention of producing psychoactive effects. In addition to acute intoxication, prolonged inhalation of fluorinated compounds can cause skeletal fluorosis (SF). We report a young woman referred for hypophosphatasemia and carrying a heterozygous ALPL gene variant (c.457T>C, p.Trp153Arg) associated with hypophosphatasia, the heritable metabolic bone disease featuring impaired skeletal mineralization, who instead suffered from SF. Manifestations of her SF included recurrent articular pain, axial osteosclerosis, elevated bone mineral density, maxillary exostoses, and multifocal periarticular calcifications. SF was suspected when a long history was discovered of 'huffing' a computer cleaner containing 1,1-difluoroethane. Investigation revealed markedly elevated serum and urine levels of F-. Histopathology and imaging techniques including backscattered electron mode scanning electron microscopy, X-ray microtomography, energy dispersive and wavelength dispersive X-ray emission microanalysis, and polarized light microscopy revealed that her periarticular calcifications were dystrophic deposition of giant pseudo-crystals of francolite, a carbonate-rich fluorapatite. Identifying unusual circumstances of F- exposure is key for diagnosing non-endemic SF. Increased awareness of the disorder can be lifesaving.
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Affiliation(s)
- Nilton Salles Rosa Neto
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
| | - Daniel Englert
- Endocrinology Department, Ochsner Medical Center, New Orleans, LA 70121, USA.
| | - William H McAlister
- Pediatric Radiology Section, Mallinckrodt Institute of Radiology at St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Steven Mumm
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
| | - David Mills
- Dental Physical Sciences, Dental Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, E1 4NS, UK.
| | - Deborah J Veis
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
| | - Alan Burshell
- Endocrinology Department, Ochsner Medical Center, New Orleans, LA 70121, USA.
| | - Alan Boyde
- Dental Physical Sciences, Dental Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, E1 4NS, UK.
| | - Michael P Whyte
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
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18
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Michałus I, Gawlik A, Wieczorek-Szukała K, Lewiński A. The Clinical Picture of Patients Suffering from Hypophosphatasia—A Rare Metabolic Disease of Many Faces. Diagnostics (Basel) 2022; 12:diagnostics12040865. [PMID: 35453912 PMCID: PMC9031194 DOI: 10.3390/diagnostics12040865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/22/2022] [Accepted: 03/29/2022] [Indexed: 11/16/2022] Open
Abstract
Hypophosphatasia (HPP) is a rare, and usually diagnosed with delay, genetic disease caused by a mutation in the alkaline phosphatase liver/bone/kidney type (ALPL) gene. Low activity of the alkaline phosphatase (ALP) impairs the hydroxyapatite formation, reducing skeletal mineralization. The aim of the study was to present patients diagnosed with HPP. The data from the history and medical records of patients were analyzed. In the study group, one patient was diagnosed with perinatal type of HPP, three were diagnosed with infant variant, eight were diagnosed with children variant, two were diagnosed with odontohypophosphatasia, and two were diagnosed with the adult type of the disease. The most frequently presented symptoms included premature loss of teeth in 11/16 (68.75%) patients, bone deformities in 10/16 (62.5%) patients, chronic bone pain in 9/16 (56.25%) patients, and fractures in 8/16 (50%) patients. Reduction in bone mineral density in at least one examined projection has been found in 11/14 patients. Conclusions: The correct diagnosis of HPP is difficult due to the variety of types and clinical symptoms, as well as the very rare occurrence of this disease. Both lower and upper reference values of the determined biochemical parameters may be important in HPP diagnostics.
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Affiliation(s)
- Izabela Michałus
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital-Research Institute, 93-338 Lodz, Poland;
| | - Aneta Gawlik
- Department of Pediatrics and Pediatric Endocrinology, Faculty of Medical Sciences, Medical University of Silesia, 40-759 Katowice, Poland;
| | | | - Andrzej Lewiński
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital-Research Institute, 93-338 Lodz, Poland;
- Department of Endocrinology and Metabolic Diseases, Medical University of Lodz, 90-419 Lodz, Poland;
- Correspondence:
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19
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Yang L, Hou A, Zhang X, Zhang J, Wang S, Dong J, Zhang S, Jiang H, Kuang H. TMT‐based proteomics analysis to screen potential biomarkers of Achyranthis Bidentatae Radix for osteoporosis in rats. Biomed Chromatogr 2022; 36:e5339. [DOI: 10.1002/bmc.5339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/10/2022] [Accepted: 01/14/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Liu Yang
- Key Laboratory of Basic and Application Research of Beiyao Heilongjiang University of Chinese Medicine, Ministry of Education Harbin China
| | - Ajiao Hou
- Key Laboratory of Basic and Application Research of Beiyao Heilongjiang University of Chinese Medicine, Ministry of Education Harbin China
| | - Xiaojuan Zhang
- Key Laboratory of Basic and Application Research of Beiyao Heilongjiang University of Chinese Medicine, Ministry of Education Harbin China
| | - Jiaxu Zhang
- Key Laboratory of Basic and Application Research of Beiyao Heilongjiang University of Chinese Medicine, Ministry of Education Harbin China
| | - Song Wang
- Key Laboratory of Basic and Application Research of Beiyao Heilongjiang University of Chinese Medicine, Ministry of Education Harbin China
| | - Jiaojiao Dong
- Key Laboratory of Basic and Application Research of Beiyao Heilongjiang University of Chinese Medicine, Ministry of Education Harbin China
| | - Shihao Zhang
- Key Laboratory of Basic and Application Research of Beiyao Heilongjiang University of Chinese Medicine, Ministry of Education Harbin China
| | - Hai Jiang
- Key Laboratory of Basic and Application Research of Beiyao Heilongjiang University of Chinese Medicine, Ministry of Education Harbin China
| | - Haixue Kuang
- Key Laboratory of Basic and Application Research of Beiyao Heilongjiang University of Chinese Medicine, Ministry of Education Harbin China
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Seefried L, Rak D, Petryk A, Genest F. Bone turnover and mineral metabolism in adult patients with hypophosphatasia treated with asfotase alfa. Osteoporos Int 2021; 32:2505-2513. [PMID: 34215909 PMCID: PMC8608777 DOI: 10.1007/s00198-021-06025-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/31/2021] [Indexed: 11/04/2022]
Abstract
UNLABELLED There is limited understanding of how asfotase alfa affects mineral metabolism and bone turnover in adults with pediatric-onset hypophosphatasia. This study showed that adults with hypophosphatasia treated with asfotase alfa experienced significant changes in biochemical markers of bone and mineral metabolism, possibly reflecting enhanced bone remodeling of previously osteomalacic bone. INTRODUCTION Hypophosphatasia (HPP), due to a tissue nonspecific alkaline phosphatase (TNSALP) deficiency, can cause impaired bone mineralization and turnover. Although HPP may be treated with asfotase alfa, an enzyme replacement therapy, limited data are available on how treatment with asfotase alfa affects mineral metabolism and bone turnover in adults with HPP. METHODS ALP substrates, bone turnover and mineral metabolism markers, and bone mineral density (BMD) data from EmPATHY, a single-center, observational study of adults (≥ 18 years) with pediatric-onset HPP treated with asfotase alfa (NCT03418389), were collected during routine clinical care and analyzed from baseline through 24 months of treatment. RESULTS Data from 21 patients showed significantly increased ALP activity and reduced urine phosphoethanolamine (PEA)/creatinine (Cr) ratios after baseline through 24 months of asfotase alfa treatment. There were significant transient increases in parathyroid hormone 1-84 (PTH), osteocalcin, and procollagen type 1 N-propeptide (P1NP) levels at 3 and 6 months and in tartrate-resistant acid phosphatase 5b (TRAP5b) levels at 3 months, with a significant decrease in N-terminal telopeptide of type 1 collagen (NTX) levels at 24 months. Lumbar spine BMD T scores continuously increased during treatment. CONCLUSION Significant changes in bone turnover and mineral metabolism markers after asfotase alfa treatment suggest that treatment-mediated mineralization may enable remodeling and bone turnover on previously unmineralized surfaces. Urine PEA/Cr ratios may be a useful parameter in monitoring treatment during routine care.
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Affiliation(s)
- L Seefried
- Orthopedic Clinic König-Ludwig-Haus, Julius-Maximilians-Universität Würzburg, Brettreichstr. 11, 97070, Würzburg, Germany.
| | - D Rak
- Orthopedic Clinic König-Ludwig-Haus, Julius-Maximilians-Universität Würzburg, Brettreichstr. 11, 97070, Würzburg, Germany
| | - A Petryk
- Alexion Pharmaceuticals, Inc., Boston, MA, USA
| | - F Genest
- Orthopedic Clinic König-Ludwig-Haus, Julius-Maximilians-Universität Würzburg, Brettreichstr. 11, 97070, Würzburg, Germany
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Abstract
Hypophosphatasia (HPP) is an inherited metabolic disease caused by loss-of-function mutations in the tissue non-specific alkaline phosphatase (TNAP) gene. Reduced activity of TNAP leads to the accumulation of its substrates, mainly inorganic pyrophosphate and pyridoxal-5′-phosphate, metabolic aberrations that largely explain the musculoskeletal and systemic features of the disease. More than 400 ALPL mutations, mostly missense, are reported to date, transmitted by either autosomal dominant or recessive mode. Severe disease is rare, with incidence ranging from 1:100,000 to 1:300,000 live births, while the estimated prevalence of the less severe adult form is estimated to be between 1:3100 to 1:508, in different countries in Europe. Presentation largely varies, ranging from death in utero to asymptomatic adults. In infants and children, clinical features include skeletal, respiratory and neurologic complications, while recurrent, poorly healing fractures, muscle weakness and arthropathy are common in adults. Persistently low serum alkaline phosphatase is the cardinal biochemical feature of the disease. Management requires a dedicated multidisciplinary team. In mild cases, treatment is usually symptomatic. Severe cases, with life-threating or debilitating complications, can be successfully treated with enzyme replacement therapy with asfotase alfa.
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22
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Kato M, Michigami T, Tachikawa K, Kato M, Yabe I, Shimizu T, Asaka T, Kitagawa Y, Atsumi T. Novel mutation in the ALPL gene with a dominant negative effect in a Japanese family. J Bone Miner Metab 2021; 39:804-809. [PMID: 33821301 DOI: 10.1007/s00774-021-01219-0] [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] [Received: 10/23/2020] [Accepted: 02/25/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Hypophosphatasia (HPP) is caused by mutations in the ALPL gene encoding tissue nonspecific alkaline phosphatase (TNSALP) and inherited in either an autosomal recessive or autosomal dominant manner. It is characterized clinically by defective mineralization of bone, dental problems, and low serum ALP levels. In the current report, we demonstrate a novel mutation in the ALPL gene (c.244G > A p.Gly82Arg) in a Japanese family with low serum ALP levels. MATERIALS AND METHODS The ALPL gene analysis using hybridization capture-based next-generation sequencing was performed. The expression plasmids of the wild type and mutated TNSALP were introduced into COS-7 cells. The enzymatic activity of ALP in the cell lysates was measured using p-nitrophenylphosphate as a substrate. RESULTS TNSALP with the novel ALPL mutation (c.244G > A p.Gly82Arg) completely lost its enzymatic activity and suppressed that of wild-type TNSALP, corroborating its dominant negative effect. The diagnosis of autosomal dominant HPP was confirmed in three members of the family. CONCLUSION Our approach would help to avoid the inappropriate use of bone resorption inhibitors for currently mis- or under-diagnosed HPP, given that the presence of further, yet undetected mutations of the ALPL gene are plausible.
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Affiliation(s)
- Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N15W7, Kita-Ku, Sapporo, 060-8638, Japan.
| | - Toshimi Michigami
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka Prefectural Hospital Organization, Osaka, Japan
| | - Kanako Tachikawa
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka Prefectural Hospital Organization, Osaka, Japan
| | - Momoko Kato
- The Division of Clinical Genetics, Hokkaido University Hospital, Sapporo, Japan
| | - Ichiro Yabe
- The Division of Clinical Genetics, Hokkaido University Hospital, Sapporo, Japan
| | - Tomohiro Shimizu
- Department of Orthopedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takuya Asaka
- Oral Diagnosis and Medicine, Hokkaido University, Sapporo, Japan
| | | | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N15W7, Kita-Ku, Sapporo, 060-8638, Japan
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23
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Fenn JS, Lorde N, Ward JM, Borovickova I. Hypophosphatasia. J Clin Pathol 2021; 74:635-640. [PMID: 33931563 DOI: 10.1136/jclinpath-2021-207426] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 11/04/2022]
Abstract
Hypophosphatasia (HPP) is a group of inherited disorders characterised by the impaired mineralisation of bones and/or teeth and low serum alkaline phosphatase (ALP) activity. It is caused by a mutation in the ALPL gene encoding the tissue-non-specific isoenzyme of ALP (TNSALP) resulting in a loss of function. The disease is highly heterogenous in its clinical expression ranging from stillbirth without mineralised bone to the mild form of late adult onset with symptoms and signs such as musculoskeletal pain, arthropathy, lower-extremity fractures, premature loss of teeth or an incidental finding of reduced serum ALP activity. A classification based on the age at diagnosis and the presence or absence of bone symptoms was historically used: perinatal, prenatal benign, infantile, childhood, adult and odontohypophosphatasia. These subtypes are known to have overlapping signs and complications. Three forms of HPP distinguishable by their genetic characteristics have been described: severe, moderate and mild. Severe forms of HPP (perinatal and infantile severe) are recessively inherited, whereas moderate HPP may be dominantly or recessively inherited. The biochemical hallmark of HPP is persistently low serum ALP for age and increase in natural substrates of TNSALP, pyridoxal 5'-phosphate and phosphoethanolamine supported by radiological findings. The diagnosis is confirmed by ALPL sequencing. A multidisciplinary team of experts is essential for the effective management. Calcium restriction is recommended in infants/children to manage hypercalcaemia. A targeted enzyme replacement therapy for HPP has become available and correct diagnosis is crucial to allow early treatment.
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Affiliation(s)
- Jonathan Samuel Fenn
- Black Country Pathology Services, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Nathan Lorde
- Department of Clinical Chemistry, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Martin Ward
- Department of Radiology, McGill University Health Center, Montreal, Québec, Canada
| | - Ingrid Borovickova
- Department of Biochemical Genetics, Children's Health Ireland at Temple Street, Dublin, Ireland
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Hypophosphatasia: A Unique Disorder of Bone Mineralization. Int J Mol Sci 2021; 22:ijms22094303. [PMID: 33919113 PMCID: PMC8122659 DOI: 10.3390/ijms22094303] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 12/25/2022] Open
Abstract
Hypophosphatasia (HPP) is a rare genetic disease characterized by a decrease in the activity of tissue non-specific alkaline phosphatase (TNSALP). TNSALP is encoded by the ALPL gene, which is abundantly expressed in the skeleton, liver, kidney, and developing teeth. HPP exhibits high clinical variability largely due to the high allelic heterogeneity of the ALPL gene. HPP is characterized by multisystemic complications, although the most common clinical manifestations are those that occur in the skeleton, muscles, and teeth. These complications are mainly due to the accumulation of inorganic pyrophosphate (PPi) and pyridoxal-5′-phosphate (PLP). It has been observed that the prevalence of mild forms of the disease is more than 40 times the prevalence of severe forms. Patients with HPP present at least one mutation in the ALPL gene. However, it is known that there are other causes that lead to decreased alkaline phosphatase (ALP) levels without mutations in the ALPL gene. Although the phenotype can be correlated with the genotype in HPP, the prediction of the phenotype from the genotype cannot be made with complete certainty. The availability of a specific enzyme replacement therapy for HPP undoubtedly represents an advance in therapeutic strategy, especially in severe forms of the disease in pediatric patients.
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Abstract
Delineating the genetic background and the underlying pathophysiology of rare skeletal dysplasias enables a broader understanding of these disorders as well as novel perspectives regarding differential diagnosis and targeted development of therapeutic approaches. Hypophosphatasia (HPP) due to genetically determined Alkaline Phosphatase deficiency exemplifies this development. While an enzyme replacement therapy could be established for severe HPP with the prevailing bone manifestation, the clinical impact of not immediately bone-related manifestations just being successively understood. Correspondingly, the elucidation of the pathophysiology underlying renal phosphate wasting expanded our knowledge regarding phosphate metabolism and bone health and facilitated the development of an anti-FGF-23 Antibody for targeted treatment of X‑linked Hypophosphatemia (XLH). Evolutions regarding the nosology of osteogenesis imperfecta (OI) along with the identification of further causative genes also detected in the context of genetically determined osteoporosis illustrate the pathophysiologic interrelation between monogenetic bone dysplasias and multifactorial osteoporosis. While current therapeutic strategies for OI follow osteoporosis treatment, the expanding knowledge about OI forms the fundament for establishing improved treatment strategies-for both OI and osteoporosis. Similar developments are emerging regarding rare skeletal disorders like Achondroplasia, Fibrodysplasia ossificans progressive and Morbus Morquio (Mukopolysaccharidosis Type IV).
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Affiliation(s)
- Lothar Seefried
- Orthopädisches Zentrum für Muskuloskeletale Forschung, Universität Würzburg, Brettreichstr. 11, 97074, Würzburg, Deutschland.
| | - Franz Jakob
- Orthopädisches Zentrum für Muskuloskeletale Forschung, Universität Würzburg, Brettreichstr. 11, 97074, Würzburg, Deutschland
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26
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Polyzos SA, Tournis S, Goulas A, Kollia P, Whyte MP. Adult hypophosphatasia treated with reduced frequency of teriparatide dosing. JOURNAL OF MUSCULOSKELETAL & NEURONAL INTERACTIONS 2021; 21:584-589. [PMID: 34854399 PMCID: PMC8672398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We report a 41-year-old man diagnosed with the adult form of hypophosphatasia (HPP) and treated for 4 years with less frequent than conventional daily doses of teriparatide (TPTD). He presented with a history of three low-energy fractures and low bone mineral density (BMD) ineffectively treated with bisphosphonate. We identified within ALPL, the gene that encodes the homodimeric "tissue-nonspecific" isoenzyme of alkaline phosphatase (ALP) and underlies HPP, a heterozygous missense mutation (c.455 G>A→R135H). Characteristic painful periarticular calcification removed at a shoulder did not recur. However, access to medical treatment with asfotase alfa (AA) was denied. After he sustained a low-energy metatarsal fracture, we administered TPTD subcutaneously "off-label" at 20 μg/d. An elbow fracture occurred two months later. Five months afterwards, due to his limited number of approved TPTD doses, TPTD treatment was extended using alternate-day dosing. Although his serum ALP activity did not increase (33-48 U/l; reference range 40-120) with 4 years of TPTD treatment, his BMD improved 15% in the lumbar spine and 6% in the femoral neck with no further fractures. Our experience represents success overcoming two prescription deadlocks; AA was denied for adult HPP, and TPTD was not to be administered daily for more than two years.
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Affiliation(s)
- Stergios A. Polyzos
- First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece,Corresponding author: Stergios A. Polyzos, MD, MSc, PhD, First Laboratory of Pharmacology, School of Medicine, Campus of Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece E-mail:
| | - Symeon Tournis
- Laboratory for the Research of Musculoskeletal System “Th. Garofalidis”, Medical School, National and Kapodistrian University of Athens, KAT Hospital, Greece
| | - Antonis Goulas
- First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagoula Kollia
- Department of Genetics and Biotechnology, Faculty of Biology, National and Kapodistrian University of Athens, Greece
| | - Michael P. Whyte
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children, St. Louis, MO, USA, Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO, USA
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