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Wang LKP, Shanmugasundaram M, Cooney E, Lee PDK. Siblings with vitamin D-dependent rickets type 1A: Importance of genetic testing and a review of genotype-phenotype correlations. Am J Med Genet A 2024:e63780. [PMID: 38822637 DOI: 10.1002/ajmg.a.63780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/09/2024] [Accepted: 05/18/2024] [Indexed: 06/03/2024]
Abstract
Vitamin D-dependent rickets type 1A (VDDR1A) is a rare condition caused by biallelic pathogenic variants in CYP27B1, which encodes 25-hydroxyvitamin D3-1-α-hydroxylase. Inadequate activity of this enzyme results in deficient 1α-hydroxylation of inactive 25-hydroxyvitamin D to biologically active 1,25-dihydroxyvitamin D, with consequent adverse effects on calcium and phosphate metabolism. A female child was clinically diagnosed at 18 months old with hypophosphatemic rickets based on phenotype and biochemical testing, with neither parent affected. A subsequent affected male sibling led to the reconsideration of the diagnosis. Exome sequencing showed a homozygous CYP27B1 c.1040T>A (p.Ile347Asn) variant for both children. No variants were found in genes associated with hypophosphatemic rickets. A review of published cases of VDDR1A with homozygous CYP27B1 variants indicates variable clinical presentation, lack of genotype-phenotype correlation, and low serum phosphate at diagnosis in most cases. These findings emphasize the clinical importance of molecular testing as part of the diagnostic evaluation for cases of non-nutritional rickets.
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Affiliation(s)
| | | | - Erin Cooney
- Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas, USA
| | - Phillip D K Lee
- Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas, USA
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Méaux MN, Harambat J, Rothenbuhler A, Léger J, Kamenicky P, Soskin S, Boyer O, Boros E, D'Anella P, Mignot B, Gebhart M, Vic P, Richard N, Thivichon-Prince B, Francou B, Linglart A, Bacchetta J, Molin A. Genotype-phenotype Description of Vitamin D-dependent Rickets 1A: CYP27B1 p.(Ala129Thr) Variant Induces a Milder Disease. J Clin Endocrinol Metab 2023; 108:812-826. [PMID: 36321535 DOI: 10.1210/clinem/dgac639] [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: 07/22/2022] [Revised: 10/26/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Vitamin D-dependent rickets type 1A (VDDR1A) is a rare genetic disease associated with loss-of-function variations in the gene encoding the vitamin D-activating enzyme 1α-hydroxylase (CYP27B1). Phenotype-genotype correlation is unclear. Long-term outcome data are lacking. The objective of this study was to describe characteristics and outcomes to search for a phenotype-genotype correlation. METHODS We retrospectively collected clinical data, genetic features, and outcomes from 24 genetically confirmed cases from 10 French centers; results are presented as median (min-max). RESULTS Clinical symptoms at diagnosis (age, 1.5 [0.5-8.7] years) were mainly bone and neurological abnormalities, and laboratory data showed hypocalcemia (1.97 [1.40-2.40] mmol/L), hypophosphatemia (-3.4 [-13.4 to (-)0.2] SD score for age), low 25OHD and low 1,25(OH)2D3, secondary hyperparathyroidism with PTH at 6.6 (1.3-13.7) times the upper limit for normal (ULN; PTH expressed as ULN to homogenize data presentation), and increased alkaline phosphatase (1968 [521-7000] IU/L). Bone radiographs were abnormal in 83% of patients. We identified 17 variations (11 missense, 3 frameshift, 2 truncating, and 1 acceptor splice site variations) in 19 families (homozygous state in 58% [11/19]). The partial loss-of-function variation p.(Ala129Thr) was associated with a milder phenotype: older age at diagnosis, higher serum calcium (2.26 vs 1.85 mmol/L), lower PTH (4.7 vs 7.5 ULN), and lower alkaline phosphatase (759 vs 2082 IU/L). Patients were treated with alfacalcidol. Clinical (skeletal, neurological), biochemical, and radiological outcomes were satisfactory, and complications occurred if there was bad adherence. CONCLUSION Overall, our findings highlight good outcomes under substitutive treatment and the need of a closer follow-up of eyes, teeth, kidneys, and blood pressure in VDDR1A.
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Affiliation(s)
- Marie-Noëlle Méaux
- CHU de Bordeaux, Service de Néphrologie Pédiatrique, Centre de Référence des Maladies Rénales Rares Sorare, 33 000 Bordeaux, France
- CHU de Lyon, Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, 69 500 Bron, France
- INSERM, UMR 1033, Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 69 008 Lyon, France
| | - Jérôme Harambat
- CHU de Bordeaux, Service de Néphrologie Pédiatrique, Centre de Référence des Maladies Rénales Rares Sorare, 33 000 Bordeaux, France
| | - Anya Rothenbuhler
- Centre de Référence des Maladies Rares du Calcium et du Phosphate, filière OSCAR, France
- Assistance Publique-Hôpitaux de Paris, Université Paris Saclay, INSERM, Service d'Endocrinologie et Diabète de l'enfant, Unité Physiologie et Physiopathologie Endocrinienne, Hôpital Bicêtre Paris Saclay, 94270 Le Kremlin-Bicêtre, France
| | - Juliane Léger
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert Debré, Endocrinologie Diabétologie Pédiatrique, 75 019 Paris, France
| | - Peter Kamenicky
- Assistance Publique-Hôpitaux de Paris, Hôpital Kremlin Bicêtre, Service d'Endocrinologie et de Biologie de la Reproduction, 94270 Le Kremlin-Bicêtre, France
| | - Sylvie Soskin
- CHU de Strasbourg, Service d'Endocrinologie Pédiatrique, 69 091 Strasbourg, France
| | - Olivia Boyer
- Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, CRMR MARHEA, Institut Imagine, Université Paris Cité, 75015 Paris, France
| | - Emese Boros
- Hôpital Universitaire des enfants Reine Fabiola, Service d'Endocrinologie Pédiatrique, 1020 Bruxelles, Belgique
| | | | - Brigitte Mignot
- CHU de Besançon, Service d'Endocrinologie Pédiatrique, 25000 Besançon, France
| | - Maite Gebhart
- CHU de Besançon, Service d'Endocrinologie Pédiatrique, 25000 Besançon, France
| | - Philippe Vic
- CH de Cornouailles, Service de Pédiatrie, 29000 Quimper, France
| | - Nicolas Richard
- CHU de Caen, Service de Génétique, EA7450 Biotargen, 14033 Caen, France
| | | | - Bruno Francou
- Assistance Publique-Hôpitaux de Paris, Hôpital Kremlin-Bicêtre, Laboratoire de génétique moléculaire, 94270 Le Kremlin-Bicêtre, France
| | - Agnès Linglart
- Centre de Référence des Maladies Rares du Calcium et du Phosphate, filière OSCAR, France
- Assistance Publique-Hôpitaux de Paris, Université Paris Saclay, INSERM, Service d'Endocrinologie et Diabète de l'enfant, Unité Physiologie et Physiopathologie Endocrinienne, Hôpital Bicêtre Paris Saclay, 94270 Le Kremlin-Bicêtre, France
| | - Justine Bacchetta
- CHU de Lyon, Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, 69 500 Bron, France
- INSERM, UMR 1033, Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 69 008 Lyon, France
- Centre de Référence des Maladies Rares du Calcium et du Phosphate, filière OSCAR, France
- Centre de Référence des Maladies Rénales Rares Néphrogones, filière ORKID, France
| | - Arnaud Molin
- Centre de Référence des Maladies Rares du Calcium et du Phosphate, filière OSCAR, France
- CHU de Caen, Service de Génétique, EA7450 Biotargen, 14033 Caen, France
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Cannalire G, Pilloni S, Esposito S, Biasucci G, Di Franco A, Street ME. Alkaline phosphatase in clinical practice in childhood: Focus on rickets. Front Endocrinol (Lausanne) 2023; 14:1111445. [PMID: 36817604 PMCID: PMC9931734 DOI: 10.3389/fendo.2023.1111445] [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: 11/29/2022] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
Serum alkaline phosphatase (ALP) and its isoenzymes reflect bone metabolism: ALP increases the ratio of inorganic phosphate to pyrophosphate systemically and facilitates mineralization as well as reduces extracellular pyrophosphate concentration, an inhibitor of mineral formation. On the contrary, low ALP activity is associated with reduction of bone turnover. ALP includes four isoenzymes depending on the site of tissue expression: intestinal ALP, placental ALP, germ cell ALP and tissue nonspecific ALP or liver/bone/kidney ALP. The bone isoenzyme (B-ALP) is involved in bone calcification and is a marker of bone turnover as a result of osteoblastic activity. ALP and its isoenzymes are crucial in the diagnostic process of all the forms of rickets.The most common cause of rickets is vitamin D nutritional deficiency. The aim of this review is to update on the role played by ALP serum concentrations as a relevant marker in thediagnosis and treatment of rickets. Indeed, the diagnosis of rickets is based on its clinical, radiological and laboratory characteristics. An elevated ALP level is one of the markers for the diagnosis of rickets in children, though it is also associated with bone formation process. ALP is also useful for the differentiation between rickets and other disorders that can mimic rickets because of their clinical and laboratory characteristics, and, together with other biochemical markers, is crucial for the differential diagnosis of the different forms of rickets. Age, severity and duration of rickets may also modulate ALP elevation. Finally, ALP measurements are useful in clinical and therapeutic follow-up.
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Affiliation(s)
- Giuseppe Cannalire
- Pediatrics and Neonatology Unit, University of Parma, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Simone Pilloni
- Unit of Pediatrics, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Susanna Esposito
- Unit of Pediatrics, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Giacomo Biasucci
- Pediatrics and Neonatology Unit, University of Parma, Guglielmo da Saliceto Hospital, Piacenza, Italy
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- *Correspondence: Giacomo Biasucci,
| | - Anna Di Franco
- Department of Laboratory Medicine, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Maria Elisabeth Street
- Unit of Pediatrics, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Yi C, Xu J, He J, Zhang X, Zhang X, Huang J. Lifelong deformities in an adult caused by vitamin D‑dependent rickets type 1A: A case report. Exp Ther Med 2022; 24:762. [PMID: 36561972 PMCID: PMC9748631 DOI: 10.3892/etm.2022.11698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
Vitamin D-dependent rickets (VDDR) type 1A is a rare autosomal recessive disorder caused by cytochrome P450 family 27 subfamily B member 1 (CYP27B1) mutations and can lead to deficiencies in 1α-hydroxylase activity. The present study describes the case of a 39-year-old male patient who presented with rickets and deformities of limbs. Blood biochemical analysis revealed hypocalcemia and high serum parathyroid hormone (PTH) levels. Whole-exome Sanger sequencing using peripheral venous blood of this patient and his parents revealed exon1 c.182T>C, a novel mutation. Through physical examination, laboratory tests, imaging including lower limbs and lumbar spine X-ray and pelvis CT scan, and genetic testing, the patient was diagnosed with VDDR-1A. Following 1 month of treatment with 0.5 µg 1,25-dihydroxy-vitamin D3 twice daily and 0.6 g calcium carbonate once daily, follow-up examinations revealed that the patient's PTH and serum calcium levels had returned to normal. As the patient was diagnosed in his adulthood and missed the optimal treatment period, he developed irreversible deformities. If VDDR-1A can be diagnosed during infancy and childhood, skeletal deformities may be prevented. Therefore, the present report supports the proposal of early genetic sequencing in children with calcium deficiencies for the early diagnosis of rare diseases such as VDDR-1A, -1B and -2A and hereditary hypophosphatemic rickets. Since VDDR-1A diagnosed in adults is rare, the present case may provide clinicians with further insights into the characteristics of this rare disease.
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Affiliation(s)
- Caihong Yi
- Department of Rheumatology and Immunology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310006, P.R. China
| | - Juan Xu
- Department of Endocrinology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310006, P.R. China
| | - Jiangping He
- Department of Rheumatology and Immunology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310006, P.R. China
| | - Xiaofang Zhang
- Department of Rheumatology and Immunology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310006, P.R. China
| | - Xianfeng Zhang
- Department of Endocrinology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310006, P.R. China,Correspondence to: Dr Jiao Huang, Department of Rheumatology and Immunology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, 261 Huansha Road, Hangzhou, Zhejiang 310006, P.R. China
| | - Jiao Huang
- Department of Rheumatology and Immunology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310006, P.R. China,Correspondence to: Dr Jiao Huang, Department of Rheumatology and Immunology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, 261 Huansha Road, Hangzhou, Zhejiang 310006, P.R. China
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Haffner D, Leifheit-Nestler M, Grund A, Schnabel D. Rickets guidance: part I-diagnostic workup. Pediatr Nephrol 2022; 37:2013-2036. [PMID: 34910242 PMCID: PMC9307538 DOI: 10.1007/s00467-021-05328-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/30/2021] [Accepted: 10/01/2021] [Indexed: 01/22/2023]
Abstract
Rickets is a disease of the growing child arising from alterations in calcium and phosphate homeostasis resulting in impaired apoptosis of hypertrophic chondrocytes in the growth plate. Its symptoms depend on the patients' age, duration of disease, and underlying disorder. Common features include thickened wrists and ankles due to widened metaphyses, growth failure, bone pain, muscle weakness, waddling gait, and leg bowing. Affected infants often show delayed closure of the fontanelles, frontal bossing, and craniotabes. The diagnosis of rickets is based on the presence of these typical clinical symptoms and radiological findings on X-rays of the wrist or knee, showing metaphyseal fraying and widening of growth plates, in conjunction with elevated serum levels of alkaline phosphatase. Nutritional rickets due to vitamin D deficiency and/or dietary calcium deficiency is the most common cause of rickets. Currently, more than 20 acquired or hereditary causes of rickets are known. The latter are due to mutations in genes involved in vitamin D metabolism or action, renal phosphate reabsorption, or synthesis, or degradation of the phosphaturic hormone fibroblast growth factor 23 (FGF23). There is a substantial overlap in the clinical features between the various entities, requiring a thorough workup using biochemical analyses and, if necessary, genetic tests. Part I of this review focuses on the etiology, pathophysiology and clinical findings of rickets followed by the presentation of a diagnostic approach for correct diagnosis. Part II focuses on the management of rickets, including new therapeutic approaches based on recent clinical practice guidelines.
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Affiliation(s)
- Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany. .,Hannover Medical School, Pediatric Research Center, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Maren Leifheit-Nestler
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany ,Hannover Medical School, Pediatric Research Center, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Andrea Grund
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany ,Hannover Medical School, Pediatric Research Center, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Dirk Schnabel
- Center for Chronically Sick Children, Pediatric Endocrinology, University Medicine, Charitè Berlin, Germany
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Lin Y, Guan Z, Mei H, Zhang W, Zhou Z, Su L, Cheng J, Zheng R, Liang C, Cai Y, Yin X, Wu D, Liu L, Zeng C. Clinical characteristics and long-term outcomes of 12 children with vitamin D-dependent rickets type 1A: A retrospective study. Front Pediatr 2022; 10:1007219. [PMID: 36405822 PMCID: PMC9671943 DOI: 10.3389/fped.2022.1007219] [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: 07/30/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022] Open
Abstract
PURPOSE Vitamin D-dependent rickets type 1A (VDDR1A) is a rare autosomal recessive disorder caused by deficiency of the CYP27B1 gene. This study aims to investigate the phenotypic and genotypic features of VDDR1A children in southern China and evaluate the long-term therapeutic effects. METHODS Twelve children from southern China with VDDR1A were enrolled in this study. Their clinical, radiological, biochemical, and molecular findings were analyzed retrospectively. The rickets severity score (RSS), biochemical parameters, and height standard deviation score (HtSDS) were used to evaluate clinical outcomes. RESULTS Six males and six females were included in this VDDR1A cohort. The age of onset was from 6 months to 1.8 years, and the age at diagnosis was 2.1 ± 0.8 years. The most common clinical symptoms at diagnosis were delayed walking (10/12) and severe growth retardation (9/12). HtSDS at diagnosis was negatively associated with age (p < 0.05). All patients presented with hypocalcemia, hypophosphatemia, increased serum alkaline phosphatase and parathyroid hormone, and high RSS at diagnosis. Two allelic variants of the CYP27B1 gene were identified in all patients, including nine different variants, four known and five novel, with c.1319_1325dupCCCACCC(p.Phe443Profs*24) being the most frequent. All patients were treated with calcitriol and calcium after diagnosis, and all patients but one were followed-up from 6 months to 15.6 years. HtSDS, RSS, and biochemical parameters were found to be improved during the first few years of the treatment. However, only five patients had good compliance. Although RSS and biochemical parameters were significantly improved, the HtSDS change was not significant from the time of diagnosis to the last visit, and seven patients remained of a short stature (HtSDS < -2). CONCLUSION Our study extends the mutational spectrum of VDDR1A and finds a hotspot variant of the CYP27B1 gene in southern China. The results reconfirm the importance of early diagnosis and treatment compliance and reveal the challenge of height improvement in VDDR1A patients.
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Affiliation(s)
- Yunting Lin
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Zhihong Guan
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Huifen Mei
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Wen Zhang
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Zhizi Zhou
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Ling Su
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Jing Cheng
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Ruidan Zheng
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Cuili Liang
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Yanna Cai
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Xi Yin
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Dongyan Wu
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Li Liu
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Chunhua Zeng
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
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