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Arcidiacono GP, Camozzi V, Zaninotto M, Tripepi G, Fusaro M, Torres MO, Zanchetta F, Cannito M, Cecchinato A, Diogo M, Peleg Falb M, Plebani M, Simioni P, Sella S, Giannini S. Tubular phosphate transport: a comparison between different methods of urine sample collection in FGF23-dependent hypophosphatemic syndromes. Clin Chem Lab Med 2024; 62:1126-1132. [PMID: 38295343 DOI: 10.1515/cclm-2023-1292] [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: 11/14/2023] [Accepted: 01/23/2024] [Indexed: 02/02/2024]
Abstract
OBJECTIVES Tubular maximum phosphate reabsorption per glomerular filtration rate (TmP/GFR) is used to evaluate renal phosphate reabsorption and it is a useful tool for the differential diagnosis of hypophosphatemic syndromes. TmP/GFR is typically calculated from fasting plasma and second morning void urine samples, obtained 2 h after the first void (TmP/GFR 2 h). The purpose of this study was to evaluate if TmP/GFR calculated from 24 h urine collection (TmP/GFR 24 h) can be used as an alternative for TmP/GFR 2 h in patients with urine phosphate wasting. METHODS We enrolled adult patients with X-linked hypophosphatemia (XLH) or tumor-induced osteomalacia (TIO). All patients underwent blood and urine sample collections, to calculate TmP/GFR 24 h and TmP/GFR 2 h. RESULTS Twenty patients (17 XLH and 3 TIO), aged 24-78 years, were included. All patients had low TmP/GFR 2 h (0.35 mmol/L, IQR 0.24-0.47 mmol/L) and TmP/GFR 24 h (0.31 mmol/L, IQR 0.22-0.43 mmol/L). The concordance correlation coefficient between TmP/GFR 2 h and TmP/GFR 24 h was 0.86 (95 % CI: 0.69-0.93), with a systematic bias of 0.05 mmol/L (95 % limits of agreement: -0.10 to 0.20). Furthermore, in 70 % (i.e., 14 patients out of 20) and 80 % (i.e., 16 patients out of 20) of cases the difference between TmP/GFR 2 h and TmP/GFR 24 h was within ±30 % and ±35 %, respectively. CONCLUSIONS Despite TmP/GFR 2 and 24 h show a relatively suboptimal agreement, the difference between the two parameters appears to be small and not clinically significant in the setting of adult patients with FGF23-dependent urine phosphate wasting and secondary hypophosphatemia.
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Affiliation(s)
| | - Valentina Camozzi
- Department of Medicine, Endocrinology Unit, University of Padova, Padova, Italy
| | - Martina Zaninotto
- Department of Medicine, Laboratory Medicine Unit, University of Padova, Padova, Italy
| | - Giovanni Tripepi
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Clinical Epidemiology of Renal Diseases and Hypertension, Ospedali Riuniti, Reggio Calabria, Italy
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy
| | | | - Francesca Zanchetta
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Michele Cannito
- Department of Medicine, Endocrinology Unit, University of Padova, Padova, Italy
| | - Alberta Cecchinato
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Martin Diogo
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Mor Peleg Falb
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Mario Plebani
- Department of Medicine, Laboratory Medicine Unit, University of Padova, Padova, Italy
| | - Paolo Simioni
- Department of Medicine, General Medicine and Thrombotic and Hemorrhagic Diseases Unit, University of Padova, Padova, Italy
| | - Stefania Sella
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
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Takashi Y, Kawanami D, Fukumoto S. Recent advances in fibroblast growth factor 23-related hypophosphatemic disorders. Curr Opin Endocrinol Diabetes Obes 2024:01266029-990000000-00093. [PMID: 38687287 DOI: 10.1097/med.0000000000000866] [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] [Indexed: 05/02/2024]
Abstract
PURPOSE OF REVIEW Fibroblast growth factor 23 (FGF23) is a hormone to reduce blood phosphate concentration. Excessive actions of FGF23 induce FGF23-related hypophosphatemic disorders, such as X-linked hypophosphatemic rickets (XLH) and tumor-induced osteomalacia (TIO). We will summarize recent advances in the diagnosis and treatment of FGF23-related hypophosphatemic disorders. RECENT FINDINGS The measurement of blood FGF23 is useful to make a diagnosis of FGF23-related hypophosphatemic disorders. It was reported that many patients with FGF23-related hypophosphatemic disorders, especially TIO, were misdiagnosed, therefore, it is necessary to enhance the awareness of these diseases. A novel method to inhibit excessive actions of FGF23 by a human monoclonal antibody for FGF23, burosumab, has been approved in several countries. In more long-term observation than clinical trials, burosumab has also been shown to improve biochemical abnormalities and symptoms of rickets/osteomalacia. Following these advances, several registries and consensus recommendations on FGF23-related hypophosphatemic disorders, especially XLH, have been established in each country or region. SUMMARY Further long-term effects of burosumab and the precise mechanism of FGF23 overproduction in patients with FGF23-related hypophosphatemic disorders need to be clarified in the future studies.
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Affiliation(s)
- Yuichi Takashi
- Department of Endocrinology and Diabetes, Fukuoka University School of Medicine
| | - Daiji Kawanami
- Department of Endocrinology and Diabetes, Fukuoka University School of Medicine
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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.
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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
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Gun ZH, Osamor C, Taylor J, Li X, Szymczuk V, Boyce AM. Serum Phosphorus as a Driver of Skeletal Morbidity in Fibrous Dysplasia. J Clin Endocrinol Metab 2024; 109:1334-1340. [PMID: 37975816 PMCID: PMC11031212 DOI: 10.1210/clinem/dgad671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/19/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023]
Abstract
CONTEXT Fibrous dysplasia (FD) results in fractures, pain, and deformities. Abnormal osteoprogenitor cells overproduce FGF23, leading to hyperphosphaturia in most patients and frank hypophosphatemia in a subset. Studies suggest hypophosphatemia is associated with increased FD-related morbidity. However, the relationship between phosphorus and skeletal complications has not been investigated, and the optimal therapeutic target has not been determined. OBJECTIVE Characterize the impact of serum phosphorus on FD-related morbidity and identify levels associated with increased skeletal complications. METHODS Natural history study with 240 subjects at a clinical research center who had ≥1 fasting phosphorus level, determined as age- and sex-adjusted Z-scores. Subjects were categorized based on frank hypophosphatemia (Z-score ≤ -2; n = 48); low-normophosphatemia (> -2 to ≤ -1; n = 66); and high-normophosphatemia (> -1 to ≤ 2; n = 125). Main outcomes were fractures, orthopedic surgeries, and scoliosis. RESULTS Subjects with frank and low-normophosphatemia had increased fracture and surgery rates vs high-normophosphatemia. The prevalence of moderate to severe scoliosis was similarly higher in the frank and low-normophosphatemia groups. In a subanalysis of patients matched for Skeletal Burden Score ≥35, fracture and surgery rates remained higher in the frank hypophosphatemia group, suggesting association between phosphorus and skeletal complications is not explained by differences in FD burden alone. CONCLUSION Both frank hypophosphatemia and low-normophosphatemia are associated with increased FD-related complications. This supports FGF23-mediated hypophosphatemia as a driver of skeletal morbidity, which may impact a larger proportion of the FD/McCune-Albright syndrome population than previously recognized. These findings enable clinicians to identify at-risk patients and will inform development of prospective studies to determine optimal therapeutic targets.
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Affiliation(s)
- Zubeyir Hasan Gun
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
- Pediatric Endocrinology Inter-Institute Training Program, National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Charles Osamor
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
| | - Jocelyn Taylor
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
| | - Xiaobai Li
- Biostatistics and Clinical Epidemiology Service, NIH Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Vivian Szymczuk
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
- Pediatric Endocrinology Inter-Institute Training Program, National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Alison M Boyce
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
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Wagner E, Bertholet-Thomas A, Romier M, Loin L, Lemoine S, Vignot E, Flammier S, Garnier C, De-Mul A, Feutrier C, Juillard S, Thivichon-Prince B, Lienhart G, Bacchetta J. X-linked hypophosphatemia: The value of feedback focus groups to assess patient and caregiver needs. Eur J Med Genet 2024; 68:104912. [PMID: 38296036 DOI: 10.1016/j.ejmg.2024.104912] [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: 04/20/2023] [Revised: 11/22/2023] [Accepted: 01/20/2024] [Indexed: 02/09/2024]
Abstract
X-linked hypophosphatemia (XLH) is a rare, multi-systemic, invalidating disease requiring a multi-disciplinary approach. No specific action in XLH, neither for the patients' specific needs nor for the methodology for the evaluation of these were found. Thus, to identify the needs of XLH patients and their caregivers, we organised focus groups in our reference centre with a view to build educational sessions. Focus groups including either XLH children, XLH adults, or caregivers ran in parallel. Each group was led by a person trained in therapeutic education (nurse, paediatric nephrologist) with another healthcare provider specialised in XLH (rheumatologist, nephrologist). One additional person with knowledge of XLH (clinical research associate, paediatric resident) took minutes. The duration of each session was 1.5h; XLH patients/caregivers were asked to answer age-adapted "open questions" on their daily life and quality of life. At the end, a global restitution was made. The needs identified were later grouped and analysed, which allowed us to build the educational sessions. The XLH children group included 5 children, the XLH adults group included 10 adults, and the caregivers group included 6 parents or partners. Major needs were identified: knowledge of XLH, treatment, dental care and adapted physical activity, with additional questions on socio-professional adaptations and financial support in adults. Partner patients were also identified to co-build the support programme. The study allowed us to identify the needs of XLH patients and their caregivers using the focus group method and then, using these needs, to build educational sessions and a therapeutic education programme for XLH patients.
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Affiliation(s)
- Estelle Wagner
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières OSCAR et ORKID, Filières Européennes Bond et ERKNet, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France.
| | - Aurélia Bertholet-Thomas
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières OSCAR et ORKID, Filières Européennes Bond et ERKNet, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France; INSERM 1033, LYOS, Prévention des Maladies Osseuses, Lyon, France
| | - Mélanie Romier
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières OSCAR et ORKID, Filières Européennes Bond et ERKNet, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| | - Laure Loin
- Transversal Unit of Therapeutic Patient Education of Department of Rhône, Hospices Civils de Lyon, Lyon, France
| | - Sandrine Lemoine
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières OSCAR et ORKID, Filières Européennes Bond et ERKNet, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France; Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Emmanuelle Vignot
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières OSCAR et ORKID, Filières Européennes Bond et ERKNet, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France; Rheumatology, Edouard Herriot Hospital, Lyon, France
| | - Sacha Flammier
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières OSCAR et ORKID, Filières Européennes Bond et ERKNet, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| | - Charlotte Garnier
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières OSCAR et ORKID, Filières Européennes Bond et ERKNet, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| | - Aurélie De-Mul
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières OSCAR et ORKID, Filières Européennes Bond et ERKNet, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| | - Corinne Feutrier
- Transversal Unit of Therapeutic Patient Education of Department of Rhône, Hospices Civils de Lyon, Lyon, France
| | - Sandrine Juillard
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières OSCAR et ORKID, Filières Européennes Bond et ERKNet, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| | - Béatrice Thivichon-Prince
- Centre de Compétence Maladies Rares Orales et dentaires, Pôle d'odontologie de Lyon, Hospices Civils de Lyon, Lyon, France
| | - Guillemette Lienhart
- Centre de Compétence Maladies Rares Orales et dentaires, Pôle d'odontologie de Lyon, Hospices Civils de Lyon, Lyon, France
| | - Justine Bacchetta
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières OSCAR et ORKID, Filières Européennes Bond et ERKNet, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France; INSERM 1033, LYOS, Prévention des Maladies Osseuses, Lyon, France; Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France.
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Kastelic MS, Roman-González A, De Paula Colares Neto G, De Paula FJA, Reza-Albarrán AA, Morales LR, Tormo S, Meza-Martínez AI. Latin-American consensus on the transition into adult life of patients with X-linked hypophosphatemia. Endocrine 2024; 84:76-91. [PMID: 38117452 PMCID: PMC10987342 DOI: 10.1007/s12020-023-03624-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: 08/05/2023] [Accepted: 11/22/2023] [Indexed: 12/21/2023]
Abstract
INTRODUCTION X-linked hypophosphatemia is an orphan disease of genetic origin and multisystem involvement. It is characterized by a mutation of the PHEX gene which results in excess FGF23 production, with abnormal renal and intestinal phosphorus metabolism, hypophosphatemia and osteomalacia secondary to chronic renal excretion of phosphate. Clinical manifestations include hypophosphatemic rickets leading to growth abnormalities and osteomalacia, myopathy, bone pain and dental abscesses. The transition of these patients to adult life continues to pose challenges to health systems, medical practitioners, patients and families. For this reason, the aim of this consensus is to provide a set of recommendations to facilitate this process and ensure adequate management and follow-up, as well as the quality of life for patients with X-linked hypophosphatemia as they transition to adult life. MATERIALS AND METHODS Eight Latin American experts on the subject participated in the consensus and two of them were appointed as coordinators. The consensus work was done in accordance with the nominal group technique in 6 phases: (1) question standardization, (2) definition of the maximum number of choices, (3) production of individual solutions or answers, (4) individual question review, (5) analysis and synthesis of the information and (6) synchronic meetings for clarification and voting. An agreement was determined to exist with 80% votes in favor in three voting cycles. RESULTS AND DISCUSSION Transition to adult life in patients with hypophosphatemia is a complex process that requires a comprehensive approach, taking into consideration medical interventions and associated care, but also the psychosocial components of adult life and the participation of multiple stakeholders to ensure a successful process. The consensus proposes a total of 33 recommendations based on the evidence and the knowledge and experience of the experts. The goal of the recommendations is to optimize the management of these patients during their transition to adulthood, bearing in mind the need for multidisciplinary management, as well as the most relevant medical and psychosocial factors in the region.
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Affiliation(s)
- Maria Sofia Kastelic
- Pediatric Endocrinology department, Hospital Nacional Profesor Alejandro Posadas, Buenos Aires, Argentina
| | - Alejandro Roman-González
- Endocrinology department, Hospital Universitario San Vicente Fundación, Medellín, Colombia.
- Universidad de Antioquia, Medellin, Colombia.
| | | | - Francisco J A De Paula
- Department of Internal Medicine, Faculdade de Medicina de Ribeirão Preto-USP, Ribeirão Preto, Brasil
| | - Alfredo Adolfo Reza-Albarrán
- Department of endocrinology and metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Lilian Reyes Morales
- Chief of the Department of Pediatric Nephrology of the National Institute of Pediatrics, Ciudad de México, México
| | - Silvina Tormo
- Department of endocrinology and metabolism, Hospital Nacional Posadas. El Palomar, Buenos Aires, Argentina
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Pott V, Tietze H, Kanzelmeyer N, von der Born J, Baumann U, Mindermann C, Suhlrie A, Drube J, Melk A, Das AM, Schnabel D, Haffner D, Leifheit-Nestler M. LMS-Based Pediatric Reference Values for Parameters of Phosphate Homeostasis in the HARP Cohort. J Clin Endocrinol Metab 2024; 109:668-679. [PMID: 37850343 DOI: 10.1210/clinem/dgad597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 10/19/2023]
Abstract
CONTEXT The assessment of phosphate homeostasis in children is challenging due to the marked changes in laboratory parameters during growth and development, and the lack of adequate reference values. OBJECTIVE To develop Lambda-Mu-Sigma (LMS)-based continuous pediatric reference percentiles for 7 key laboratory parameters of phosphate homeostasis. METHODS This cross-sectional, single-center study, the HAnnover Reference values for Pediatrics (HARP) study, included 455 children aged 0.1-18 years (254 boys) from outpatient hospital clinics and a secondary school program. Main outcome measures were LMS-based continuous reference percentiles for serum phosphate, plasma intact fibroblast growth factor 23 (iFGF23), and its cofactor soluble Klotho (sKlotho), tubular maximum phosphate reabsorption per glomerular filtration rate (TmP/GFR), fractional tubular reabsorption of phosphate (TRP), and urinary calcium/creatinine (Ca/Crea) and phosphate/creatinine (Pi/Crea) ratios. RESULTS LMS-based percentiles and z-scores were established for 7 key laboratory parameters of phosphate homeostasis, which were all found to be age-dependent. Serum phosphate, TmP/GFR, and sKlotho associated with sex. Serum phosphate, TmP/GFR, and urinary Ca/Crea and Pi/Crea levels were highest in infancy and declined until age 18 years, while phosphate and TmP/GFR values reached adult levels earlier in girls compared to boys. iFGF23 concentrations are highest in infancy and fall to a stable plateau by 4 years of age, while sKlotho peaks during adolescence. CONCLUSION This is the first report of LMS-based continuous pediatric reference percentiles for key laboratory parameters of phosphate homeostasis that allow calculation of standardized patient z-scores to facilitate test result interpretation in children and adolescents.
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Affiliation(s)
- Veronika Pott
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Pediatric Research Center, Hannover Medical School, 30625 Hannover, Germany
| | - Helene Tietze
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Pediatric Research Center, Hannover Medical School, 30625 Hannover, Germany
| | - Nele Kanzelmeyer
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Pediatric Research Center, Hannover Medical School, 30625 Hannover, Germany
| | - Jeannine von der Born
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Pediatric Research Center, Hannover Medical School, 30625 Hannover, Germany
| | - Ulrich Baumann
- Department of Pediatric Pneumology, Allergy and Neonatology, Hannover Medical School, 30625 Hannover, Germany
| | - Charlotte Mindermann
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Pediatric Research Center, Hannover Medical School, 30625 Hannover, Germany
| | - Adriana Suhlrie
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Pediatric Research Center, Hannover Medical School, 30625 Hannover, Germany
| | - Jens Drube
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Pediatric Research Center, Hannover Medical School, 30625 Hannover, Germany
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Pediatric Research Center, Hannover Medical School, 30625 Hannover, Germany
| | - Anibh M Das
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Pediatric Research Center, Hannover Medical School, 30625 Hannover, Germany
| | - Dirk Schnabel
- Center for Chronically Sick Children, Pediatric Endocrinology, University Medicine, Charité Berlin, 13353 Berlin, Germany
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Pediatric Research Center, Hannover Medical School, 30625 Hannover, Germany
| | - Maren Leifheit-Nestler
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Pediatric Research Center, Hannover Medical School, 30625 Hannover, Germany
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Biasucci G, Donini V, Cannalire G. Rickets Types and Treatment with Vitamin D and Analogues. Nutrients 2024; 16:416. [PMID: 38337700 PMCID: PMC10857029 DOI: 10.3390/nu16030416] [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: 12/21/2023] [Revised: 01/15/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
The definition of "Vitamin D" encompasses a group of fat-soluble steroid compounds of different origins with similar chemical structures and the same biological effects. Vitamin D deficiency and/or a defect in the process of its synthesis or transport predispose individuals to several types of rickets. In addition to cholecalciferol, ergocalciferol, and vitamins D3 and D2, there are also active metabolites for the treatment of this condition which are commercially available. Calcitriol and aphacalcidiol are active metabolites that do not require the renal activation step, which is required with calcifediol, or hepatic activation. The purpose of this review is to summarize current approaches to the treatment of rickets for generalist physicians, focusing on the best vitamin D form to be used in each type, or, in the case of X-linked hypophosphatemic rickets (XLH), on both conventional and innovative monoclonal antibody treatments.
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Affiliation(s)
- Giacomo Biasucci
- Pediatrics and Neonatology Unit, University of Parma, Gugliemo da Saliceto Hospital, 29121 Piacenza, Italy;
- Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy
| | - Valentina Donini
- Unit of Pediatrics, Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy;
| | - Giuseppe Cannalire
- Pediatrics and Neonatology Unit, University of Parma, Gugliemo da Saliceto Hospital, 29121 Piacenza, Italy;
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9
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Park E, Kang HG. X-linked hypophosphatemic rickets: from diagnosis to management. Clin Exp Pediatr 2024; 67:17-25. [PMID: 37321578 PMCID: PMC10764665 DOI: 10.3345/cep.2022.01459] [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: 12/18/2022] [Revised: 02/02/2023] [Accepted: 03/28/2023] [Indexed: 06/17/2023] Open
Abstract
X-linked hypophosphatemia (XLH), the most common cause of hypophosphatemic rickets, affects one in every 20,000 people. Although conventional therapy for XLH was introduced approximately 4 decades ago, the temporary replacement of oral phosphate salts and activated vitamin D cannot completely control chronic hypophosphatemia, leaving patients with incomplete healing and residual skeletal deformity as well as at risk of endocrine abnormalities and adverse drug reactions. However, understanding the pathophysiology has led to the development of a targeted therapy, burosumab, a fibroblast growth factor-23 inhibitor that was recently approved in Korea for the treatment of XLH. This review provides insight into the diagnosis, evaluation, treatment, and recommended follow-up for a typical case of XLH and reviews its pathophysiology.
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Affiliation(s)
- Eujin Park
- Department of Pediatrics, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Departments of Pediatrics, Seoul National University Children’s Hospital, Seoul, Korea
- Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
- Wide River Institute of Immunology, Seoul National University, Hongcheon, Korea
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10
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Lira Dos Santos EJ, Nakajima K, Po J, Hanai A, Zhukouskaya V, Biosse Duplan M, Linglart A, Shimada T, Chaussain C, Bardet C. Dental impact of anti-fibroblast growth factor 23 therapy in X-linked hypophosphatemia. Int J Oral Sci 2023; 15:53. [PMID: 38052774 DOI: 10.1038/s41368-023-00259-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 11/03/2023] [Accepted: 11/05/2023] [Indexed: 12/07/2023] Open
Abstract
Elevated fibroblast growth factor 23 (FGF23) in X-linked hypophosphatemia (XLH) results in rickets and phosphate wasting, manifesting by severe bone and dental abnormalities. Burosumab, a FGF23-neutralizing antibody, an alternative to conventional treatment (phosphorus and active vitamin D analogs), showed significant improvement in the long bone phenotype. Here, we examined whether FGF23 antibody (FGF23-mAb) also improved the dentoalveolar features associated with XLH. Four-week-old male Hyp mice were injected weekly with 4 or 16 mg·kg-1 of FGF23-mAb for 2 months and compared to wild-type (WT) and vehicle (PBS) treated Hyp mice (n = 3-7 mice). Micro-CT analyses showed that both doses of FGF23-mAb restored dentin/cementum volume and corrected the enlarged pulp volume in Hyp mice, the higher concentration resulting in a rescue similar to WT levels. FGF23-mAb treatment also improved alveolar bone volume fraction and mineral density compared to vehicle-treated ones. Histology revealed improved mineralization of the dentoalveolar tissues, with a decreased amount of osteoid, predentin and cementoid. Better periodontal ligament attachment was also observed, evidenced by restoration of the acellular cementum. These preclinical data were consistent with the retrospective analysis of two patients with XLH showing that burosumab treatment improved oral features. Taken together, our data show that the dentoalveolar tissues are greatly improved by FGF23-mAb treatment, heralding its benefit in clinics for dental abnormalities.
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Affiliation(s)
- Elis J Lira Dos Santos
- Université Paris Cité, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France
| | - Kenta Nakajima
- R&D Division, Kyowa Kirin, Co., Ltd, 3-6-6 Asahi-machi, Machida-shi, Tokyo, Japan
| | - Julien Po
- Université Paris Cité, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France
| | - Ayako Hanai
- R&D Division, Kyowa Kirin, Co., Ltd, 3-6-6 Asahi-machi, Machida-shi, Tokyo, Japan
| | - Volha Zhukouskaya
- Université Paris Cité, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France
| | - Martin Biosse Duplan
- Université Paris Cité, Institut Imagine, INSERM UMR 1163, Paris, France
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Dental Medicine Department, Bretonneau Hospital, GHN-Université Paris Cité, Paris, France
| | - Agnès Linglart
- Paris-Saclay University, AP-HP, INSERM U1185, DMU SEA, Endocrinology and Diabetes for Children, Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR filière, EndoRare, and BOND ERNs, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Takashi Shimada
- Medical Affairs Department, Kyowa Kirin, Co., Ltd, 1-9-2 Otemachi, Chiyoda-ku, Tokyo, Japan
| | - Catherine Chaussain
- Université Paris Cité, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Dental Medicine Department, Bretonneau Hospital, GHN-Université Paris Cité, Paris, France
| | - Claire Bardet
- Université Paris Cité, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France.
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11
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Seefried L, Alzahrani A, Arango Sancho P, Bacchetta J, Crowley R, Emma F, Gibbins J, Grandone A, Javaid MK, Mindler G, Raimann A, Rothenbuhler A, Tucker I, Zeitlin L, Linglart A. XLH Matters 2022: Insights and recommendations to improve outcomes for people living with X-linked hypophosphataemia (XLH). Orphanet J Rare Dis 2023; 18:333. [PMID: 37885021 PMCID: PMC10604503 DOI: 10.1186/s13023-023-02883-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Affiliation(s)
- Lothar Seefried
- Orthopedic Institute, König-Ludwig Haus, University of Würzburg, Würzburg, Germany
| | - Ali Alzahrani
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Pedro Arango Sancho
- Department of Pediatric Nephrology, Hospital Sant Joan de Déu, Barcelona, Spain
- Department of Onco-Nephrology, Pediatric Cancer Center, Barcelona, Spain
| | - Justine Bacchetta
- Pediatric Nephrology, Reference Center for Rare Diseases of Calcium and Phosphate, Filières OSCAR et ORKID, INSERM1033, Hospices Civils de Lyon, Lyon, France
| | - Rachel Crowley
- St Vincent's University Hospital and Rare Disease Clinical Trial Network, University College Dublin, Dublin, Ireland
| | - Francesco Emma
- Division of Nephrology, Children's Hospital Bambino Gesù-IRCCS, Rome, Italy
| | | | - Anna Grandone
- Department of Woman, Child, General and Specialized Surgery, University of Campania L. Vanvitelli, Naples, Italy
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Gabriel Mindler
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | | | - Anya Rothenbuhler
- APHP, Endocrinology and Diabetology for Children, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France
- APHP, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Filière OSCAR, Paris, France
- APHP, Platform of Expertise for Rare Disorders Paris Saclay, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Ian Tucker
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Leonid Zeitlin
- Pediatric Bone Clinic, Orthopedic Department, Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Tel Aviv-Yafo, Israel
| | - Agnès Linglart
- APHP, Endocrinology and Diabetology for Children, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France.
- APHP, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Filière OSCAR, Paris, France.
- APHP, Platform of Expertise for Rare Disorders Paris Saclay, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France.
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12
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Kocijan R, Mindler GT, Hartmann MA, Kraus DA, Raimann A, Zwerina J. Dissociation of clinical, laboratory, and bone biopsy findings in adult X-linked hypophosphatemia: a case report. Wien Med Wochenschr 2023; 173:339-345. [PMID: 36695943 DOI: 10.1007/s10354-022-01000-6] [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: 10/28/2022] [Accepted: 12/15/2022] [Indexed: 01/26/2023]
Abstract
X‑linked hypophosphatemia (XLH) is a phosphate wasting disorder. Typical serum constellations include low serum phosphate as well as high alkaline phosphatase (ALP) and fibroblast growth factor 23 (FGF-23 ) levels. Adult XLH patients usually suffer from (pseudo)fractures, enthesopathies, impaired mobility, and osteoarthritis. We report the case of a middle-aged woman with clinically mild disease, relatively balanced laboratory values, but bone non-healing of the femur post-surgery. Transiliac bone biopsy revealed pronounced osteomalacia and severe deterioration of bone microstructure. Due to the lack of XLH-typical symptoms, the patient was not substituted with calcitriol and phosphate in adulthood. Thus, laboratory findings and radiological examinations do not necessarily reflect bone metabolism in XLH. Bone biopsies should be considered in unclear cases or prior to surgery in adults with XLH.
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Affiliation(s)
- Roland Kocijan
- 1st Medical Department Hanusch Hospital, Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA; Trauma Centre Meidling, Heinrich-Collin-Straße 30, 1140, Vienna, Austria.
- Vienna Bone and Growth Center, Vienna, Austria.
- School of medicine, Metabolic bone diseases unit, Sigmund Freud University Vienna, Vienna, Austria.
| | - Gabriel Tilmann Mindler
- Vienna Bone and Growth Center, Vienna, Austria
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
| | - Markus Alexander Hartmann
- 1st Medical Department Hanusch Hospital, Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA; Trauma Centre Meidling, Heinrich-Collin-Straße 30, 1140, Vienna, Austria
| | - Danial Arian Kraus
- 1st Medical Department Hanusch Hospital, Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA; Trauma Centre Meidling, Heinrich-Collin-Straße 30, 1140, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Adalbert Raimann
- Vienna Bone and Growth Center, Vienna, Austria
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Pulmonology, Allergology and Endocrinology, Medical University Vienna, Vienna, Austria
| | - Jochen Zwerina
- 1st Medical Department Hanusch Hospital, Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA; Trauma Centre Meidling, Heinrich-Collin-Straße 30, 1140, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
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13
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Danielewicz A, Wójciak M, Sowa I, Kusz M, Wessely-Szponder J, Dresler S, Latalski M. Metabolic Imbalances and Bone Remodeling Agents in Adolescent Idiopathic Scoliosis: A Study in Postmenarcheal Girls. Int J Mol Sci 2023; 24:13286. [PMID: 37686090 PMCID: PMC10487495 DOI: 10.3390/ijms241713286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/21/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
The causes and mechanisms underlying adolescent idiopathic scoliosis (AIS) remain unclear, and the available information regarding metabolic imbalances in AIS is still insufficient. This investigation aimed to evaluate the concentrations of specific bone remodeling-related agents in postmenarcheal girls diagnosed with AIS. The study encompassed thirty-six scoliosis patients and eighteen age-matched healthy individuals assigned to the control group. The patients underwent clinical and radiological examinations to assess the degree of the spinal deformity, type of curvature, and skeletal maturity. Blood and urine samples were collected from all participants and serological markers were measured using an enzyme-linked immunosorbent assay. Our study results demonstrated that the balance of phosphate-calcium and parathormone levels seems normal in individuals with AIS. Furthermore, no statistically significant differences were observed in the content of Klotho protein, osteocalcin, osteoprotegerin, C-terminal telopeptide of type I collagen (CTX), sclerostin, and alkaline phosphatase. Nevertheless, the serum levels of vitamin D (25-OH-D) were lowered, while N-terminal propeptide of type I procollagen (PINP), and fibroblast growth factor-23 (FGF23) were increased in the AIS group, with p-values of 0.044, 0.001, and 0.022, respectively. This finding indicates the potential involvement of these factors in the progression of AIS, which necessitates further studies to uncover the fundamental mechanisms underlying idiopathic scoliosis.
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Affiliation(s)
- Anna Danielewicz
- Paediatric Orthopaedic Department, Medical University of Lublin, Gębali 6, 20-093 Lublin, Poland;
| | - Magdalena Wójciak
- Department of Analytical Chemistry, Medical University of Lublin, Chodźki 4a, 20-093 Lublin, Poland; (M.W.); (I.S.); (S.D.)
| | - Ireneusz Sowa
- Department of Analytical Chemistry, Medical University of Lublin, Chodźki 4a, 20-093 Lublin, Poland; (M.W.); (I.S.); (S.D.)
| | - Monika Kusz
- Department of Pediatric Nephrology, Childrens’ University Hospital in Lublin, Gębali 6, 20-093 Lublin, Poland;
| | - Joanna Wessely-Szponder
- Sub-Department of Pathophysiology, Department of Preclinical Veterinary Sciences, Faculty of Veterinary Medicine, University of Life Sciences, 20-033 Lublin, Poland;
| | - Sławomir Dresler
- Department of Analytical Chemistry, Medical University of Lublin, Chodźki 4a, 20-093 Lublin, Poland; (M.W.); (I.S.); (S.D.)
| | - Michał Latalski
- Paediatric Orthopaedic Department, Medical University of Lublin, Gębali 6, 20-093 Lublin, Poland;
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14
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Kim KJ, Song JE, Kim JH, Hong N, Kim SG, Lee J, Rhee Y. Elevated morbidity and mortality in patients with chronic idiopathic hypophosphatemia: a nationwide cohort study. Front Endocrinol (Lausanne) 2023; 14:1229750. [PMID: 37635983 PMCID: PMC10448510 DOI: 10.3389/fendo.2023.1229750] [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: 05/26/2023] [Accepted: 07/26/2023] [Indexed: 08/29/2023] Open
Abstract
Background Chronic idiopathic hypophosphatemia (CIH) induced by X-linked hypophosphatemic rickets or tumor-induced osteomalacia is a rare inherited or acquired disorder. However, due to its rarity, little is known about the epidemiology and natural course of CIH. Therefore, we aimed to identify the prevalence and long-term health outcomes of CIH patients. Methods Using the Korean Health Insurance Review and Assessment claims database, we evaluated the incidence of hypophosphatemia initially diagnosed from 2003 to 2018. After excluding secondary conditions that could change serum phosphorus levels, we identified 154 patients (76 men and 78 women) with non-secondary and non-renal hypophosphatemia. These hypophosphatemic patients were compared at a ratio of 1:10 with age-, sex-, and index-year-matched controls (n = 1,540). Results In the distribution of age at diagnosis, a large peak was observed in patients aged 1-4 years and small peaks were observed in ages from 40-70 years. The age-standardized incidence rate showed non-statistically significant trend from 0.24 per 1,000,000 persons in 2003 to 0.30 in 2018. Hypophosphatemic patients had a higher risk of any complication (adjusted hazard ratio [aHR], 2.17; 95% confidence interval [CI], 1.67-2.69) including cardiovascular outcomes, chronic kidney disease, hyperparathyroidism, osteoporotic fractures, periodontitis, and depression. Hypophosphatemic patients also had higher risks of mortality and hospitalization than the controls (aHR, 3.26; 95% CI, 1.83-5.81; and aHR, 2.49; 95% CI, 1.97-3.16, respectively). Conclusion This first nationwide study of CIH in South Korea found a bimodal age distribution and no sex differences among patients. Hypophosphatemic patients had higher risks of complications, mortality, and hospitalization compared to age- and sex-matched controls.
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Affiliation(s)
- Kyoung Jin Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ji Eun Song
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ji Hyun Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Namki Hong
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sin Gon Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yumie Rhee
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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15
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Pecoraro C, Fioretti T, Perruno A, Klain A, Cioffi D, Ambrosio A, Passaro D, Annicchiarico Petruzzelli L, Di Domenico C, de Girolamo D, Vallone S, Cattaneo F, Ammendola R, Esposito G. De Novo Large Deletions in the PHEX Gene Caused X-Linked Hypophosphataemic Rickets in Two Italian Female Infants Successfully Treated with Burosumab. Diagnostics (Basel) 2023; 13:2552. [PMID: 37568915 PMCID: PMC10417872 DOI: 10.3390/diagnostics13152552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
Pathogenic variants in the PHEX gene cause rare and severe X-linked dominant hypophosphataemia (XLH), a form of heritable hypophosphatemic rickets (HR) characterized by renal phosphate wasting and elevated fibroblast growth factor 23 (FGF23) levels. Burosumab, the approved human monoclonal anti-FGF23 antibody, is the treatment of choice for XLH. The genetic and phenotypic heterogeneity of HR often delays XLH diagnoses, with critical effects on disease course and therapy. We herein report the clinical and genetic features of two Italian female infants with sporadic HR who successfully responded to burosumab. Their diagnoses were based on clinical and laboratory findings and physical examinations. Next-generation sequencing (NGS) of the genes associated with inherited HR and multiple ligation probe amplification (MLPA) analysis of the PHEX and FGF23 genes were performed. While a conventional analysis of the NGS data did not reveal pathogenic or likely pathogenic small nucleotide variants (SNVs) in the known HR-related genes, a quantitative analysis identified two different heterozygous de novo large intragenic deletions in PHEX, and this was confirmed by MLPA. Our molecular data indicated that deletions in the PHEX gene can be the cause of a significant fraction of XLH; hence, their presence should be evaluated in SNV-negative female patients. Our patients successfully responded to burosumab, demonstrating the efficacy of this drug in the treatment of XLH. In conclusion, the execution of a phenotype-oriented genetic test, guided by known types of variants, including the rarest ones, was crucial to reach the definitive diagnoses and ensure our patients of long-term therapy administration.
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Affiliation(s)
- Carmine Pecoraro
- Paediatric Nephrology, Dialysis and Renal Transplantation Unit, Santobono Pausilipon Children’s Hospital, 80129 Naples, Italy;
| | - Tiziana Fioretti
- CEINGE—Advanced Biotechnologies Franco Salvatore, 80145 Naples, Italy; (T.F.); (A.A.); (D.P.); (C.D.D.); (D.d.G.)
| | - Assunta Perruno
- Primary Care Pediatrician, ASL NA2 North, 80027 Naples, Italy;
| | - Antonella Klain
- Pediatric Endocrinology Unit, Santobono Pausilipon Children’s Hospital, 80129 Naples, Italy; (A.K.); (D.C.)
| | - Daniela Cioffi
- Pediatric Endocrinology Unit, Santobono Pausilipon Children’s Hospital, 80129 Naples, Italy; (A.K.); (D.C.)
| | - Adelaide Ambrosio
- CEINGE—Advanced Biotechnologies Franco Salvatore, 80145 Naples, Italy; (T.F.); (A.A.); (D.P.); (C.D.D.); (D.d.G.)
| | - Diego Passaro
- CEINGE—Advanced Biotechnologies Franco Salvatore, 80145 Naples, Italy; (T.F.); (A.A.); (D.P.); (C.D.D.); (D.d.G.)
| | - Luigi Annicchiarico Petruzzelli
- Paediatric Nephrology, Dialysis and Renal Transplantation Unit, Santobono Pausilipon Children’s Hospital, 80129 Naples, Italy;
| | - Carmela Di Domenico
- CEINGE—Advanced Biotechnologies Franco Salvatore, 80145 Naples, Italy; (T.F.); (A.A.); (D.P.); (C.D.D.); (D.d.G.)
| | - Domenico de Girolamo
- CEINGE—Advanced Biotechnologies Franco Salvatore, 80145 Naples, Italy; (T.F.); (A.A.); (D.P.); (C.D.D.); (D.d.G.)
| | - Sabrina Vallone
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, 80131 Naples, Italy; (S.V.); (F.C.); (R.A.)
| | - Fabio Cattaneo
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, 80131 Naples, Italy; (S.V.); (F.C.); (R.A.)
| | - Rosario Ammendola
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, 80131 Naples, Italy; (S.V.); (F.C.); (R.A.)
| | - Gabriella Esposito
- CEINGE—Advanced Biotechnologies Franco Salvatore, 80145 Naples, Italy; (T.F.); (A.A.); (D.P.); (C.D.D.); (D.d.G.)
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, 80131 Naples, Italy; (S.V.); (F.C.); (R.A.)
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16
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Seefried L, Duplan MB, Briot K, Collins MT, Evans R, Florenzano P, Hawkins N, Javaid MK, Lachmann R, Ward LM. Anticipated effects of burosumab treatment on long-term clinical sequelae in XLH: expert perspectives. Front Endocrinol (Lausanne) 2023; 14:1211426. [PMID: 37547321 PMCID: PMC10400326 DOI: 10.3389/fendo.2023.1211426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/27/2023] [Indexed: 08/08/2023] Open
Abstract
X-linked hypophosphatemia (XLH) is a rare, progressive, genetic disease with multisystem impact that typically begins to manifest in early childhood. Two treatment options exist: oral phosphate in combination with active vitamin D ("conventional therapy") and a fully human monoclonal anti-FGF23 antibody, burosumab. The clinical benefit of conventional therapy in adults is limited, and poor tolerance and complications are common. Burosumab was first approved as a treatment for XLH in 2018 and its disease-modifying benefits in clinical trials in children suggest burosumab treatment could also alter the disease course in adults. Without long-term clinical data on multiple XLH-related sequelae available, the results of an elicitation exercise are reported, in which eight global experts in XLH posited how long-term treatment with burosumab is anticipated to impact the life course of clinical sequelae in adults with XLH. Based on their clinical experiences, the available evidence and their disease understanding, the experts agreed that some long-term benefits of using burosumab are likely in adults with XLH even if they have a misaligned skeleton from childhood. Burosumab treatment is anticipated to reduce the incidence of fractures and halt the progression of clinical sequelae associated with conventional therapy. While the trajectories for established dental abscesses are not expected to improve with burosumab treatment, dental abscess development may be prevented. Starting treatment with burosumab in childhood to increase the likelihood of an aligned skeleton and continuation into and throughout adulthood to maintain euphosphatemia may optimize patient outcomes, although future real-world investigation is required to support this hypothesis.
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Affiliation(s)
- Lothar Seefried
- Orthopedic Department, University of Würzburg, Würzburg, Germany
| | - Martin Biosse Duplan
- Service de Médecine Bucco-Dentaire, Hôpital Bretonneau, AP-HP, Paris, France
- UFR d’Odontologie, Université de Paris, Paris, France
- Institut Imagine, INSERM, Paris, France
| | - Karine Briot
- Department of Rheumatology, Hôpital Cochin, Université de Paris-Cité, Paris, France
| | - Michael T. Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, United States
| | - Rachel Evans
- Health Economics, Visible Analytics, Oxford, United Kingdom
| | - Pablo Florenzano
- Department of Endocrinology, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Endocrinology, Centro Traslacional en Endocrinologia (CETREN-UC), Santiago, Chile
| | - Neil Hawkins
- Health Economics, Visible Analytics, Oxford, United Kingdom
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Robin Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Leanne M. Ward
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
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17
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董 沙, 车 若, 郑 必, 张 爱, 王 春, 白 咪, 陈 颖. [Value of serum fibroblast growth factor 23 in diagnosis of hypophosphatemic rickets in children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:705-710. [PMID: 37529952 PMCID: PMC10414175 DOI: 10.7499/j.issn.1008-8830.2303016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/02/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVES To study the value of serum fibroblast growth factor 23 (FGF23) in the diagnosis of hypophosphatemic rickets in children. METHODS A total of 28 children who were diagnosed with hypophosphatemic rickets in Children's Hospital of Nanjing Medical University from January 2016 to June 2021 were included as the rickets group. Forty healthy children, matched for sex and age, who attended the Department of Child Healthcare of the hospital were included as the healthy control group. The serum level of FGF23 was compared between the two groups, and the correlations of the serum FGF23 level with clinical characteristics and laboratory test results were analyzed. The value of serum FGF23 in the diagnosis of hypophosphatemic rickets was assessed. RESULTS The rickets group had a significantly higher serum level of FGF23 than the healthy control group (P<0.05). In the rickets group, the serum FGF23 level was positively correlated with the serum alkaline phosphatase level (rs=0.38, P<0.05) and was negatively correlated with maximum renal tubular phosphorus uptake/glomerular filtration rate (rs=-0.64, P<0.05), while it was not correlated with age, height Z-score, sex, and parathyroid hormone (P>0.05). Serum FGF23 had a sensitivity of 0.821, a specificity of 0.925, an optimal cut-off value of 55.77 pg/mL, and an area under the curve of 0.874 in the diagnosis of hypophosphatemic rickets (P<0.05). CONCLUSIONS Serum FGF23 is of valuable in the diagnosis of hypophosphatemic rickets in children, which providing a theoretical basis for early diagnosis of this disease in clinical practice.
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Affiliation(s)
| | | | - 必霞 郑
- 南京医科大学附属儿童医院儿科学重点实验室,江苏南京210000
| | | | - 春莉 王
- 南京医科大学附属儿童医院儿科学重点实验室,江苏南京210000
| | - 咪 白
- 南京医科大学附属儿童医院儿科学重点实验室,江苏南京210000
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18
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Münch J, Goodyer PR, Wagner CA. Tubular Diseases and Stones Seen From Pediatric and Adult Nephrology Perspectives. Semin Nephrol 2023; 43:151437. [PMID: 37968178 DOI: 10.1016/j.semnephrol.2023.151437] [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] [Indexed: 11/17/2023]
Abstract
The tubular system of the kidneys is a complex series of morphologic and functional units orchestrating the content of tubular fluid as it flows along the nephron and collecting ducts. Renal tubules maintain body water, regulate electrolytes and acid-base balance, reabsorb precious organic solutes, and eliminate specific metabolites, toxins, and drugs. In addition, decisive mechanisms to adjust blood pressure are governed by the renal tubules. Genetic as well as acquired disorders of these tubular functions may cause serious diseases that manifest both in childhood and adulthood. This article addresses a selection of tubulopathies and the underlying pathomechanisms, while highlighting the important differences in pediatric and adult nephrology care. These range from rare monogenic conditions such as nephrogenic diabetes insipidus, cystinosis, and Bartter syndrome that present in childhood, to the genetic and acquired tubular pathologies causing hypertension or nephrolithiasis that are more prevalent in adults. Both pediatric and adult nephrologists must be aware of these conditions and the age-dependent manifestations that warrant close interaction between the two subspecialties.
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Affiliation(s)
- Johannes Münch
- Institute of Physiology, University of Zurich, Zurich, Switzerland; Institute of Human Genetics, University of Zurich, Zurich, Switzerland; National Center of Competence in Research, NCCR Kidney.CH, Switzerland
| | - Paul R Goodyer
- McGill University Health Centre, Montreal, Quebec, Canada
| | - Carsten A Wagner
- Institute of Physiology, University of Zurich, Zurich, Switzerland; National Center of Competence in Research, NCCR Kidney.CH, Switzerland.
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19
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Soto Barros J, Sanchez SI, Cabral K, Beggs AH, Agrawal PB, Genetti CA, Brownstein CA, Carpenter TO. X-linked hypophosphatemia in 4 generations due to an exon 13-15 duplication in PHEX, in the absence of the c.*231A>G variant. Bone 2023; 172:116763. [PMID: 37059315 PMCID: PMC10198939 DOI: 10.1016/j.bone.2023.116763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/30/2023] [Accepted: 04/05/2023] [Indexed: 04/16/2023]
Abstract
X-linked hypophosphatemia is the most common cause of inherited rickets, due to inactivating variants of PHEX. More than 800 variants have been described to date and one which consists of a single base change in the 3' untranslated region (UTR) (c.*231A>G) is reported as prevalent in North America. Recently an exon 13-15 duplication has been found to occur in concert with the c.*231A>G variant, and thus it is unclear whether the pathogenicity is solely a function of the UTR variant. We present a family with XLH who harbors the exon 13-15 duplication but does not carry the 3'UTR variant, providing evidence that the duplication itself is the pathogenic variant when these two variants are found in cis.
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Affiliation(s)
- Julio Soto Barros
- Department of Pediatrics, Faculty of Medicine, University of Concepcion, Concepcion, Chile; Las Higueras Hospital, Talcahuano, Chile; Yale Center for X-Linked Hypophosphatemia, Department of Pediatrics (Endocrinology), Yale University, New Haven, CT 06519, United States of America
| | - Sabrina I Sanchez
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA 02115, United States of America
| | - Kristin Cabral
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA 02115, United States of America
| | - Alan H Beggs
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA 02115, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA 02115, United States of America
| | - Pankaj B Agrawal
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA 02115, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA 02115, United States of America; Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine and Holtz Children's Hospital, Jackson Health System, Miami, FL 33136, United States of America
| | - Casie A Genetti
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA 02115, United States of America
| | - Catherine A Brownstein
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA 02115, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA 02115, United States of America
| | - Thomas O Carpenter
- Yale Center for X-Linked Hypophosphatemia, Department of Pediatrics (Endocrinology), Yale University, New Haven, CT 06519, United States of America.
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20
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Li Z, Wen X, Li N, Zhong C, Chen L, Zhang F, Zhang G, Lyu A, Liu J. The roles of hepatokine and osteokine in liver-bone crosstalk: Advance in basic and clinical aspects. Front Endocrinol (Lausanne) 2023; 14:1149233. [PMID: 37091847 PMCID: PMC10117885 DOI: 10.3389/fendo.2023.1149233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/22/2023] [Indexed: 04/08/2023] Open
Abstract
Both the liver and bone are important secretory organs in the endocrine system. By secreting organ factors (hepatokines), the liver regulates the activity of other organs. Similarly, bone-derived factors, osteokines, are created during bone metabolism and act in an endocrine manner. Generally, the dysregulation of hepatokines is frequently accompanied by changes in bone mass, and osteokines can also disrupt liver metabolism. The crosstalk between the liver and bone, particularly the function and mechanism of hepatokines and osteokines, has increasingly gained notoriety as a topic of interest in recent years. Here, based on preclinical and clinical evidence, we summarize the potential roles of hepatokines and osteokines in liver-bone interaction, discuss the current shortcomings and contradictions, and make recommendations for future research.
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Affiliation(s)
- Zhanghao Li
- Law Sau Fai Institute for Advancing Translational Medicine in Bone and Joint Diseases (TMBJ), School of Chinese Medicine, Hong Kong Baptist University (HKBU), Hong Kong, Hong Kong SAR, China
| | - Xiaoxin Wen
- Department of Anatomy, Jinzhou Medical University, Jinzhou, China
| | - Nanxi Li
- Law Sau Fai Institute for Advancing Translational Medicine in Bone and Joint Diseases (TMBJ), School of Chinese Medicine, Hong Kong Baptist University (HKBU), Hong Kong, Hong Kong SAR, China
| | - Chuanxin Zhong
- Law Sau Fai Institute for Advancing Translational Medicine in Bone and Joint Diseases (TMBJ), School of Chinese Medicine, Hong Kong Baptist University (HKBU), Hong Kong, Hong Kong SAR, China
| | - Li Chen
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing, China
| | - Feng Zhang
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing, China
| | - Ge Zhang
- Law Sau Fai Institute for Advancing Translational Medicine in Bone and Joint Diseases (TMBJ), School of Chinese Medicine, Hong Kong Baptist University (HKBU), Hong Kong, Hong Kong SAR, China
| | - Aiping Lyu
- Law Sau Fai Institute for Advancing Translational Medicine in Bone and Joint Diseases (TMBJ), School of Chinese Medicine, Hong Kong Baptist University (HKBU), Hong Kong, Hong Kong SAR, China
- Guangdong-Hong Kong-Macau Joint Lab on Chinese Medicine and Immune Disease Research, Guangzhou, China
- *Correspondence: Jin Liu, ; Aiping Lyu,
| | - Jin Liu
- Law Sau Fai Institute for Advancing Translational Medicine in Bone and Joint Diseases (TMBJ), School of Chinese Medicine, Hong Kong Baptist University (HKBU), Hong Kong, Hong Kong SAR, China
- Guangdong-Hong Kong-Macau Joint Lab on Chinese Medicine and Immune Disease Research, Guangzhou, China
- *Correspondence: Jin Liu, ; Aiping Lyu,
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21
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Ramos P, Larson B, Ashrafzadeh-Kian S, Ito N, Kato H, Bornhorst JA, Algeciras-Schimnich A. Intact Fibroblast Growth Factor 23 Concentrations in Hypophosphatemic Disorders. Endocr Pract 2023; 29:193-198. [PMID: 36627024 DOI: 10.1016/j.eprac.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/23/2022] [Accepted: 01/03/2023] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Evaluation of circulating fibroblast growth factor 23 (FGF23) concentrations plays a key role in the differential diagnosis of patients presenting with hypophosphatemia. FGF23 concentrations obtained by different immunoassays are not comparable and subsequently, differences in the clinical performance of the assays might arise. In this study, we evaluated the clinical performance of the Medfrontier FGF23 Intact immunoassay (MedFrontier, Minaris Medical Co, Ltd, Tokyo, Japan) in clinically relevant hypophosphatemic conditions. METHODS Intact FGF23 (iFGF23) was measured in serum samples from 61 patients with FGF23-dependent hypophosphatemia (42-tumor induced osteomalacia [TIO] and 19-X-linked hypophosphatemia [XLH]); 8 patients with FGF23-independent hypophosphatemia (6-Fanconi Syndrome and 2-Vitamin D dependent rickets); 10 normophosphatemic patients; 15 chronic kidney disease (CKD) stage-2/3 and 20 CKD stage-4/5 patients; and a healthy control population. Disease-specific differences in measured iFGF23 concentrations and FGF23 concentration association with phosphate concentrations were reported. RESULTS iFGF23 concentrations were significantly elevated in 90% and 84% of TIO and XLH hypophosphatemia patients as compared to healthy controls (both TIO and XLH, P = .0001). There was no significant correlation between iFGF23 and phosphate concentrations (P = .74 and P = .86) for TIO and XLH, respectively. Patients with CKD showed a significant increase in serum iFGF23 as the estimated glomerular filtration rate decreased (ρ = -0.79, P ≤ 0.0001). CONCLUSIONS This study evaluated the clinical performance of the MedFrontier iFGF23 assay in a large cohort of XLH and TIO Caucasian and Asian patients. The clinical sensitivity of this iFGF23 assay is appropriate for clinical use.
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Affiliation(s)
- Paola Ramos
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Bethany Larson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | | | - Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan; Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Hajime Kato
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan; Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Joshua A Bornhorst
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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22
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The Possible Outcomes of Poor Adherence to Conventional Treatment in Patients with X-Linked Hypophosphatemic Rickets/Osteomalacia. ENDOCRINES 2023. [DOI: 10.3390/endocrines4010010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
X-linked hypophosphatemic rickets/osteomalacia is an inherited disease caused by the loss of function in PHEX. Elevated plasma FGF23 in patients with XLH leads to hypophosphatemia. The conventional treatment for XLH, consisting of oral phosphate and active vitamin D, is often poorly adhered to for various reasons, such as the requirement to take multiple daily doses of phosphate. Burosumab, an anti-FGF23 antibody, is a new drug that directly targets the mechanism underlying XLH. We report herein three adult patients with poor adherence to the conventional treatment. In Patient 1, adherence was poor throughout childhood and adolescence. The treatment of Patients 2 and 3 became insufficient after adolescence. All of the patients suffered from gait disturbance caused by pain, fractures, and lower extremity deformities early in life. We prescribed burosumab for the latter two patients, and their symptoms, which were unaffected by resuming conventional treatment, dramatically improved with burosumab. Maintaining adherence to the conventional treatment is crucial but challenging for patients with XLH. Starting burosumab therapy from childhood or adolescence in pediatric patients with poor adherence may help prevent the early onset of complications.
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23
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Walker EYX, Lindsay TAJ, Allgrove J, Marlais M, Bockenhauer D, Hayes W. Burosumab in management of X-linked hypophosphataemia: a retrospective cohort study of growth and serum phosphate levels. Arch Dis Child 2023; 108:379-384. [PMID: 36717209 DOI: 10.1136/archdischild-2022-324962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/09/2023] [Indexed: 02/01/2023]
Abstract
BACKGROUND Burosumab, an antifibroblast growth factor 23 monoclonal antibody, improves rickets severity, symptoms and growth in children with X-linked hypophosphataemia (XLH) followed up to 64 weeks in clinical trials. International dosing guidance recommends targeting normal serum phosphate concentration; however, some children may not achieve this despite maximal dosing. This study compares clinical outcomes in children with XLH on long-term burosumab treatment who achieved normal phosphate versus those who did not. METHODS Single-centre retrospective review of a large paediatric cohort with XLH treated with burosumab. We evaluated growth and biochemical markers of bone health in those who did compared with those who did not achieve normal plasma phosphate concentration. RESULTS Fifty-five children with XLH with median age of 11.7 (IQR 6.8-15.5) years were included. 27 (49%) had low plasma phosphate concentration, and 27 (49%) had normal phosphate after a median burosumab treatment duration of 3.3 (IQR 2.6-3.7) years. 1 (2%) did not have a recent phosphate level recorded. No difference in growth was found between normal and abnormal phosphate groups (p=0.9). CONCLUSIONS Young children with XLH experience sustained growth on long-term burosumab treatment, although without normal plasma phosphate concentration in many. Consideration should be made to changing burosumab dosing recommendations to target normalisation of alkaline phosphatase, as opposed to plasma phosphate concentration.
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Affiliation(s)
- Emma Yi Xiu Walker
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Jeremy Allgrove
- Department of Endocrinology, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
| | - Matko Marlais
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Institute of Child Health, University College London, London, UK
| | - Detlef Bockenhauer
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Department of Renal Medicine, University College London, London, UK
| | - Wesley Hayes
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK .,Institute of Child Health, University College London, London, UK
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24
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Akta C, Wenzel-Schwarz F, Stauffer A, Kranzl A, Raimann A, Kocijan R, Ganger R, Mindler GT. The ankle in XLH: Reduced motion, power and quality of life. Front Endocrinol (Lausanne) 2023; 14:1111104. [PMID: 37033213 PMCID: PMC10073673 DOI: 10.3389/fendo.2023.1111104] [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: 11/29/2022] [Accepted: 02/23/2023] [Indexed: 04/11/2023] Open
Abstract
BACKGROUND X-linked hypophosphatemia (OMIM 307800) is a rare bone disease caused by a phosphate-wasting condition with lifelong clinical consequences. Those affected suffer from bone pain, complex skeletal deformities, impaired mobility and a reduced quality of life. Early osteoarthritis and reduced range of motion of the lower limbs are known pathologies in XLH patients. However, XLH-specific data on the affected compartments such as the ankle joint through the evaluation of radiographic and gait analysis data is still lacking. PATIENTS AND METHODS In this cross-sectional study, patients with genetically verified XLH, age ≥ 16 - 50 years and a complete record of gait analysis and or radiographic analysis data were included. Clinical examination, radiological and gait analysis data were compared to norms using the dataset of our gait laboratory registry. Radiographic analysis included tibial deformity analysis and assessment of osteoarthritis and enthesopathies. Western Ontario and McMaster Universities Arthritis Index (WOMAC), SF36v2, American Orthopedic Foot and Ankle Society score (AOFAS) and the Foot and Ankle Outcome Score (FAOS) were used. Twentythree participants with 46 limbs were eligible for the study. RESULTS A total of 23 patients (n=46 feet) met the inclusion criteria. Patients with XLH had significantly reduced gait quality, ankle power and plantar flexion (p < 0.001) compared to a historic gait laboratory control group. Ankle valgus deformity was detected in 22 % and ankle varus deformity in 30 % of the patients. The subtalar joint (59.1%) as well as the anterior tibiotalar joint (31.1%) were the main localizations of moderate to severe joint space narrowing. Ankle power was decreased in moderate and severe subtalar joint space narrowing (p < 0.05) compared to normal subtalar joint space narrowing. No lateral or medial ligament instability of the ankle joint was found in clinical examination. Tibial procurvatum deformity led to lower ankle power (p < 0.05). CONCLUSIONS This study showed structural and functional changes of the ankle in patients with XLH. Subtalar ankle osteoarthritis, patient reported outcome scores and clinical ankle restriction resulted in lower gait quality and ankle power.
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Affiliation(s)
- Celine Akta
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
- Medical Faculty of Bone Diseases, Sigmund Freud University, Vienna, Austria
| | - Florian Wenzel-Schwarz
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Alexandra Stauffer
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Andreas Kranzl
- Vienna Bone and Growth Center, Vienna, Austria
- Laboratory for Gait and Movement Analysis, Orthopaedic Hospital Speising, Vienna, Austria
| | - Adalbert Raimann
- Vienna Bone and Growth Center, Vienna, Austria
- Comprehensive Center for Pediatrics, Department of Pediatrics and Adolescent Medicine, Division of Pediatric Pulmonology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria
| | - Roland Kocijan
- Vienna Bone and Growth Center, Vienna, Austria
- Medical Faculty of Bone Diseases, Sigmund Freud University, Vienna, Austria
- 1st Medical Department, Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, Hanusch Hospital, Vienna, Austria
| | - Rudolf Ganger
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Gabriel T. Mindler
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
- *Correspondence: Gabriel T. Mindler,
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Doulgeraki A, Laurent MR. Editorial: Rickets and osteomalacia, from genes to nutrition. Front Endocrinol (Lausanne) 2023; 14:1141888. [PMID: 36742385 PMCID: PMC9893633 DOI: 10.3389/fendo.2023.1141888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 01/20/2023] Open
Affiliation(s)
- Artemis Doulgeraki
- Department of Bone and Mineral Metabolism, Institute of Child Health, Agia Sophia Children’s Hospital, Athens, Greece
- *Correspondence: Artemis Doulgeraki,
| | - Michaël R. Laurent
- Centre for Metabolic Bone Diseases, University Hospitals Leuven, Leuven, Belgium
- Geriatrics Department, Imelda Hospital, Bonheiden, Belgium
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26
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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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Kritmetapak K, Kumar R. Phosphatonins: From Discovery to Therapeutics. Endocr Pract 2023; 29:69-79. [PMID: 36210014 DOI: 10.1016/j.eprac.2022.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Phosphate is crucial for cell signaling, energy metabolism, nucleotide synthesis, and bone mineralization. The gut-bone-parathyroid-kidney axis is influenced by parathyroid hormone, 1,25-dihydroxyvitamin D, and phosphatonins, especially fibroblast growth factor 23 (FGF23). These hormones facilitate maintenance of phosphate homeostasis. This review summarizes current knowledge regarding the phosphate homeostasis, phosphatonin pathophysiology, and clinical implications of FGF23-related hypophosphatemic disorders, with specific focus on burosumab treatment. METHOD A focused literature search of PubMed was conducted. RESULTS Phosphatonins including FGF23, secreted frizzled-related protein 4, matrix extracellular phosphoglycoprotein, and fibroblast growth factor 7 play a pathogenic role in several hypophosphatemic disorders. Excess FGF23 inhibits sodium-dependent phosphate cotransporters (NaPi-2a and NaPi-2c), resulting in hyperphosphaturia and hypophosphatemia. Additionally, FGF23 suppresses 1,25-dihydroxyvitamin D synthesis in the proximal renal tubule, and thus, it indirectly inhibits intestinal phosphate absorption. Disorders of FGF23-related hypophosphatemia include X-linked hypophosphatemia (XLH), autosomal dominant hypophosphatemic rickets, autosomal recessive hypophosphatemic rickets, fibrous dysplasia/McCune-Albright syndrome, and tumor-induced osteomalacia (TIO). Complications of conventional therapy with oral phosphate and vitamin D analogs comprise gastrointestinal distress, hypercalcemia, nephrocalcinosis, and secondary/tertiary hyperparathyroidism. In both children and adults with XLH and TIO, the anti-FGF23 antibody burosumab exhibits a favorable safety profile and is associated with healing of rickets in affected children and improvement of osteomalacia in both children and adults. CONCLUSION The treatment paradigm for XLH and TIO is changing based on data from recent clinical trials. Research suggest that burosumab is effective and safe for pediatric and adult patients with XLH or TIO.
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Affiliation(s)
| | - Rajiv Kumar
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota.
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Kato H, Okawa R, Ogasawara T, Hoshino Y, Hidaka N, Koga M, Kinoshita Y, Kobayashi H, Taniguchi Y, Fukumoto S, Nangaku M, Makita N, Hoshi K, Nakano K, Ito N. Effect of conventional treatment on dental complications and ectopic ossifications among 30 adults with XLH. J Clin Endocrinol Metab 2022; 108:1405-1414. [PMID: 36524341 DOI: 10.1210/clinem/dgac732] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/29/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
CONTEXT Conventional treatment of XLH was reported to prevent dental complications, but whether the preventive effect was different among different types of teeth, including anterior teeth and molar teeth, is uncertain. Evidence of the preventive effect of conventional treatment on ectopic ossifications is also limited. OBJECTIVE To compare dental complications and ectopic ossifications among XLH adults with early (< 5 years old) or late (≥5 years old) conventional treatment. METHODS This retrospective observational study included a total of 30 adults with XLH using orthopantomograms, spinal computed tomography scans and X-rays of hip/knee joints. Dental complications, including decayed, missing filled (DMF) index and devitalized tooth, apical periodontitis, and periodontitis, were evaluated. The index of ossification of the anterior/posterior longitudinal ligament and yellow ligament (OA/OP/OY index) and the sum of the OA/OP/OY index (OS index) were utilized to evaluate the severity of spinal ligament ossification. The severity of the hip/knee osteophytes was evaluated by the Kellgren-Lawrence (KL) classification. RESULTS The number of sound teeth was significantly lower, and the DMF index was significantly higher in patients with late treatment. The severity of dental complications in the anterior tooth and molar tooth, OA/OP/OY/OS index, and KL grade were not significantly different among patients with early treatment and those with late treatment. CONCLUSION Early treatment could prevent dental complications but did not prevent ectopic ossification in adult patients with XLH. The difference in the preventive effect was not observed among different types of teeth.
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Affiliation(s)
- Hajime Kato
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Rena Okawa
- Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Osaka, Japan
| | - Toru Ogasawara
- Department of Oral and Maxillofacial Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshitomo Hoshino
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Naoko Hidaka
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Minae Koga
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuka Kinoshita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroshi Kobayashi
- Department of Orthopedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuki Taniguchi
- Department of Orthopedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Noriko Makita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazuto Hoshi
- Department of Oral and Maxillofacial Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazuhiko Nakano
- Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Osaka, Japan
| | - Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
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Osteomalacia Is Not a Single Disease. Int J Mol Sci 2022; 23:ijms232314896. [PMID: 36499221 PMCID: PMC9740398 DOI: 10.3390/ijms232314896] [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: 10/09/2022] [Revised: 11/18/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Among bone-material qualities, mineralization is pivotal in conferring stiffness and toughness to the bone. Osteomalacia, a disease ensuing from inadequate mineralization of the skeleton, is caused by different processes leading to decreased available mineral (calcium and/or phosphate) or enzymatic alterations. Vitamin D deficiency, which remains the major cause of altered mineralization leading to inadequate intestinal calcium and phosphate absorption, may be also associated with other conditions primarily responsible for abnormal mineralization. Given the reality of widespread vitamin D inadequacy, a full biochemical assessment of mineral metabolism is always necessary to rule out or confirm other conditions. Both too-high or too-low serum alkaline phosphatase (ALP) levels are important for diagnosis. Osteomalacic syndrome is reversible, at least in part, by specific treatment. Osteomalacia and bone mineralization themselves constitute largely unexplored fields of research. The true prevalence of the different forms of osteomalacia and the recovery after proper therapy have yet to be determined in the real world. Although non-invasive techniques to assess bone mineralization are not available in clinical practice, the systematic assessment of bone quality could help in refining the diagnosis and guiding the treatment. This review summarizes what is known of osteomalacia recent therapeutic developments and highlights the future issues of research in this field.
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Ertl DA, Le Lorier J, Gleiss A, Trabado S, Bensignor C, Audrain C, Zhukouskaya V, Coutant R, Berkenou J, Rothenbuhler A, Haeusler G, Linglart A. Growth pattern in children with X-linked hypophosphatemia treated with burosumab and growth hormone. Orphanet J Rare Dis 2022; 17:412. [PMID: 36371259 PMCID: PMC9652849 DOI: 10.1186/s13023-022-02562-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/23/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND X-linked hypophosphatemia (XLH) is characterized by increased serum concentrations of fibroblast growth factor 23 (FGF23), hypophosphatemia and insufficient endogenous synthesis of calcitriol. Beside rickets, odonto- and osteomalacia, disproportionate short stature is seen in most affected individuals. Vitamin D analogs and phosphate supplements, i.e., conventional therapy, can improve growth especially when started early in life. Recombinant human growth hormone (rhGH) therapy in XLH children with short stature has positive effects, although few reports are available. Newly available treatment (burosumab) targeting increased FGF23 signaling leads to minimal improvement of growth in XLH children. So far, we lack data on the growth of XLH children treated with concomitant rhGH and burosumab therapies. RESULTS Thirty-six patients received burosumab for at least 1 year after switching from conventional therapy. Of these, 23 received burosumab alone, while the others continued rhGH therapy after switching to burosumab. Children treated with burosumab alone showed a minimal change in height SDS after 1 year (mean ± SD 0.0 ± 0.3 prepubertal vs. 0.1 ± 0.3 pubertal participants). In contrast, rhGH clearly improved height during the first year of treatment before initiating burosumab (mean ± SD of height gain 1.0 ± 0.4); patients continued to gain height during the year of combined burosumab and rhGH therapies (mean ± SD height gain 0.2 ± 0.1). As expected, phosphate serum levels normalized upon burosumab therapy. No change in serum calcium levels, urinary calcium excretion, or 25-OHD levels was seen, though 1,25-(OH)2D increased dramatically under burosumab therapy. CONCLUSION To our knowledge, this is the first study on growth under concomitant rhGH and burosumab treatments. We did not observe any safety issue in this cohort of patients which is one of the largest in Europe. Our data suggest that continuing treatment with rhGH after switching from conventional therapy to burosumab, if the height prognosis is compromised, might be beneficial for the final height.
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Affiliation(s)
- Diana-Alexandra Ertl
- grid.413784.d0000 0001 2181 7253AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR and Platform of Expertise for Rare Diseases Paris-Sud, Bicêtre Paris-Saclay Hospital, 78 Rue du Général Leclerc, 94270 Le Kremlin Bicêtre, France ,grid.460789.40000 0004 4910 6535University Paris Saclay, Le Kremlin-Bicêtre, France ,grid.50550.350000 0001 2175 4109AP-HP, Department of Endocrinology and Diabetology for Children and Department of Adolescent Medicine, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France ,grid.22937.3d0000 0000 9259 8492Department of Pediatrics and Adolescent Medicine, Division of Pulmonology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria ,Vienna Bone and Growth Center, Vienna, Austria
| | - Justin Le Lorier
- grid.413784.d0000 0001 2181 7253AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR and Platform of Expertise for Rare Diseases Paris-Sud, Bicêtre Paris-Saclay Hospital, 78 Rue du Général Leclerc, 94270 Le Kremlin Bicêtre, France ,grid.460789.40000 0004 4910 6535University Paris Saclay, Le Kremlin-Bicêtre, France ,grid.50550.350000 0001 2175 4109AP-HP, Department of Endocrinology and Diabetology for Children and Department of Adolescent Medicine, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Andreas Gleiss
- grid.22937.3d0000 0000 9259 8492Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Séverine Trabado
- grid.7429.80000000121866389Department of Molecular Genetics, Pharmacogenetics and Hormonology, Inserm U1185 and University Paris Saclay, AP-HP Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | | | - Christelle Audrain
- grid.413784.d0000 0001 2181 7253AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR and Platform of Expertise for Rare Diseases Paris-Sud, Bicêtre Paris-Saclay Hospital, 78 Rue du Général Leclerc, 94270 Le Kremlin Bicêtre, France ,grid.460789.40000 0004 4910 6535University Paris Saclay, Le Kremlin-Bicêtre, France
| | - Volha Zhukouskaya
- grid.413784.d0000 0001 2181 7253AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR and Platform of Expertise for Rare Diseases Paris-Sud, Bicêtre Paris-Saclay Hospital, 78 Rue du Général Leclerc, 94270 Le Kremlin Bicêtre, France ,grid.508487.60000 0004 7885 7602Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, Platforme d´Imaginerie du Vivant (PIV), University Paris Cite, Montrouge, France ,grid.508487.60000 0004 7885 7602AP-HP Cochin Hospital, Department of Diabetology, University Paris Cite, Paris, France
| | - Régis Coutant
- grid.411147.60000 0004 0472 0283Department of Pediatric Endocrinology and Diabetes, CHU Angers, Anger, France
| | - Jugurtha Berkenou
- grid.413784.d0000 0001 2181 7253AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR and Platform of Expertise for Rare Diseases Paris-Sud, Bicêtre Paris-Saclay Hospital, 78 Rue du Général Leclerc, 94270 Le Kremlin Bicêtre, France ,grid.460789.40000 0004 4910 6535University Paris Saclay, Le Kremlin-Bicêtre, France
| | - Anya Rothenbuhler
- grid.413784.d0000 0001 2181 7253AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR and Platform of Expertise for Rare Diseases Paris-Sud, Bicêtre Paris-Saclay Hospital, 78 Rue du Général Leclerc, 94270 Le Kremlin Bicêtre, France ,grid.460789.40000 0004 4910 6535University Paris Saclay, Le Kremlin-Bicêtre, France ,grid.50550.350000 0001 2175 4109AP-HP, Department of Endocrinology and Diabetology for Children and Department of Adolescent Medicine, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Gabriele Haeusler
- grid.22937.3d0000 0000 9259 8492Department of Pediatrics and Adolescent Medicine, Division of Pulmonology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria ,Vienna Bone and Growth Center, Vienna, Austria
| | - Agnès Linglart
- grid.413784.d0000 0001 2181 7253AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR and Platform of Expertise for Rare Diseases Paris-Sud, Bicêtre Paris-Saclay Hospital, 78 Rue du Général Leclerc, 94270 Le Kremlin Bicêtre, France ,grid.460789.40000 0004 4910 6535University Paris Saclay, Le Kremlin-Bicêtre, France ,grid.50550.350000 0001 2175 4109AP-HP, Department of Endocrinology and Diabetology for Children and Department of Adolescent Medicine, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
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Treatment of X-Linked Hypophosphatemia in Children. ENDOCRINES 2022. [DOI: 10.3390/endocrines3030042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The conventional treatment for X-linked hypophosphatemia (XLH), consisting of phosphorus supplementation and a biologically active form of vitamin D (alfacalcidol or calcitriol), is used to treat rickets and leg deformities and promote growth. However, patients’ adult height often remains less than −2 SD. Moreover, adverse events, such as renal calcification and hyperparathyroidism, may occur. The main pathology in XLH is caused by excessive production of fibroblast growth factor 23 (FGF23). Several studies have demonstrated that treatment with burosumab, a blocking neutralizing antibody against FGF23, is better than conventional therapy for severe XLH and has no serious, short-term side effects. Thus, treatment with burosumab may be an option for severe XLH. The present article reviews the conventional and burosumab therapies. In addition to the fact that the long-term efficacy of antibody-based treatment has not been demonstrated, there are other, unresolved issues concerning the burosumab treatment of XLH.
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X-Linked Hypophosphatemia Transition and Team Management. ENDOCRINES 2022. [DOI: 10.3390/endocrines3030032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
X-linked hypophosphatemia (XLH) is the most common form of inherited disorders that are characterized by renal phosphate wasting, but it is a rare chronic disease. XLH presents in multisystemic organs, not only in childhood, but also in adulthood. Multidisciplinary team management is necessary for the care of patients with XLH. Although XLH has often been perceived as a childhood disease, recent studies have demonstrated that it is a long-term and progressive disease throughout adulthood. In the past 20 years, the importance of the transition from pediatric care to adult care for patient outcomes in adulthood in many pediatric onset diseases has been increasingly recognized. This review describes transitional care and team management for patients with XLH.
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Adult Presentation of X-Linked Hypophosphatemia. ENDOCRINES 2022. [DOI: 10.3390/endocrines3030030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Adult X-linked hypophosphatemia (XLH) patients present with specific symptoms, including enthesopathies (e.g., ossification of longitudinal ligaments (OPLL), osteophytes around large joints, and enthesopathy in the Achilles tendons), early osteoarthritis, the development of severe secondary and tertiary hyperparathyroidism (SHPT/THPT), and the subsequent progression of chronic kidney disease (CKD). In addition, these patients exhibit the typical phenotypes of osteomalacia, such as pseudofracture and fracture in weight-bearing bones, odontitis, and tooth abscesses. The mechanism underlying enthesopathy development is unknown; however, a common underlying mechanism among XLH and autosomal recessive hypophosphatemic rickets (ARHR1/2) due to mutations in PHEX, DMP1, and ENPP1 is assumed. Clarification of the pathogenesis and drug discovery for this complication is an urgent issue, as many adult XLH patients suffer subsequent debilitating nervous symptoms or impingement syndrome, and existing treatments are ineffective. Severe SHPT and THPT are associated with conventional therapy, including active vitamin D and phosphate supplementation, and complicated and careful adjustment of dosages by experienced clinicians is required to avoid SHPT/THPT. Burosumab is a very effective therapy without risk for the development of SHPT/THPT. However, indications for this drug should be carefully considered, along with cost-effectiveness, guidelines or recommendations, and the health care system of each country.
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Thrailkill KM, Kalaitzoglou E, Fowlkes JL. Emerging therapies for the treatment of rare pediatric bone disorders. Front Pediatr 2022; 10:1012816. [PMID: 36304528 PMCID: PMC9592743 DOI: 10.3389/fped.2022.1012816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 09/09/2022] [Indexed: 11/24/2022] Open
Abstract
In recent years, new therapies for the treatment of rare pediatric bone disorders have emerged, guided by an increasing understanding of the genetic and molecular etiology of these diseases. Herein, we review three such disorders, impacted by debilitating deficits in bone mineralization or cartilage ossification, as well as the novel disease-modifying drugs that are now available to treat these conditions. Specifically, we discuss asfotase alfa, burosumab-twza, and vosoritide, for the treatment of hypophosphatasia, X-linked hypophosphatemia and achondroplasia, respectively. For each skeletal disorder, an overview of the clinical phenotype and natural history of disease is provided, along with a discussion of the clinical pharmacology, mechanism of action and FDA indication for the relevant medication. In each case, a brief review of clinical trial data supporting drug development for each medication is provided. Additionally, guidance as to drug dosing and long-term monitoring of adverse events and pediatric efficacy is presented, to aid the clinician seeking to utilize these novel therapies in their practice, or to become familiar with the healthcare expectations for children receiving these medications through specialized multidisciplinary clinics. The availability of these targeted therapies now significantly augments treatment options for conditions in which past therapy has relied upon less specific, symptomatic medical and orthopedic care.
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Affiliation(s)
- Kathryn M Thrailkill
- Department of Pediatrics, University of Kentucky Barnstable Brown Diabetes Center, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Evangelia Kalaitzoglou
- Department of Pediatrics, University of Kentucky Barnstable Brown Diabetes Center, University of Kentucky College of Medicine, Lexington, KY, United States
| | - John L Fowlkes
- Department of Pediatrics, University of Kentucky Barnstable Brown Diabetes Center, University of Kentucky College of Medicine, Lexington, KY, United States
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Xu T, Tao X, Zhang Z, Yue H. Clinical and genetic characteristics of 29 Chinese patients with X-linked hypophosphatemia. Front Endocrinol (Lausanne) 2022; 13:956646. [PMID: 36060934 PMCID: PMC9437435 DOI: 10.3389/fendo.2022.956646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/02/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The aim of this study was to fully describe the clinical and genetic characteristics, including clinical manifestations, intact fibroblast growth factor 23 (iFGF23) levels, and presence of PHEX gene mutations, of 22 and 7 patients with familial and sporadic X-linked dominant hypophosphatemia (XLH), respectively. METHODS Demographic data, clinical features, biochemical indicators, and imaging data of 29 patients were collected. All 22 exons and exon-intron boundaries of the PHEX gene were amplified by polymerase chain reaction (PCR) and directly sequenced. The serum level of iFGF23 was measured in 15 of the patients. RESULTS Twenty-nine patients (male/female: 13:16, juvenile/adult: 15:14) with XLH were included. The main symptoms were bowed lower extremities (89.7%), abnormal gait (89.7%), and short stature/growth retardation (78.6%). Hypophosphatemia with a high alkaline phosphatase level was the main biochemical feature and the median value of serum iFGF23 was 55.7 pg/ml (reference range: 16.1-42.2 pg/ml). Eight novel mutations in the PHEX gene were identified by Sanger sequencing, including two missense mutations (p. Gln682Leu and p. Phe312Ser), two deletions (c.350_356del and c.755_761del), one insertion (c.1985_1986insTGAC), and three splice mutations (c.1700+5G>C, c.1966-1G>T, and c.350-14_350-1del). Additionally, the recurrence rate after the first orthopedic surgery was 77.8% (7/9), and five of them had their first surgery before puberty. CONCLUSION Our study expanded the clinical phenotypes and gene mutation spectrum of XLH and provided a reference for the optimal timing of orthopedic surgeries.
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Affiliation(s)
| | | | | | - Hua Yue
- *Correspondence: Hua Yue, ; Zhenlin Zhang,
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