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van Velsen EFS, Geeraedts TEA, Bosman A, Zillikens MC. Thermal Ablation for Treating Tumor-induced Osteomalacia in a Patient With IV Phosphate Dependency. JCEM Case Rep 2023; 1:luad086. [PMID: 37908985 PMCID: PMC10580436 DOI: 10.1210/jcemcr/luad086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Indexed: 11/02/2023]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome associated with tumors secreting fibroblast growth factor 23 that can be cured with complete surgical resection of the tumor. However, when these tumors are at difficult locations, less invasive modalities such as thermal ablation (TA) might be a good alternative. A 40-year-old woman was seen for a second opinion because of severe hypophosphatemia with complaints of fatigue, myalgia, and muscle weakness for which she needed IV phosphate for 15 to 18 hours per day in addition to oral alfacalcidol and phosphate. Initial laboratory results revealed hypophosphatemia (0.59 mmol/L [1.83 mg/dL]; reference range, 0.90-1.50 mmol/L [8.40-10.2 mg/dL]), increased fibroblast growth factor 23 levels (137 RU/mL; reference range, <125 RU/mL), and a reduced TmP-GFR (0.47 mmol/L; reference range, 0.8-1.4 mmol/L). Gallium-positron emission tomography/computed tomography (CT) showed moderately increased uptake at thoracic vertebra (Th) 8 and mildly increased uptake at Th7, suggestive of TIO. Complete tumor removal would have required resection of at least 1 vertebral body. Therefore, CT-guided TA was performed at Th8. No complications were observed, and in the months after, treatment with IV phosphate could be discontinued, indicating a satisfying result from the procedure. This extreme TIO case demonstrates that CT-guided TA can be an alternative to extensive or risky classical surgery.
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Affiliation(s)
- Evert F S van Velsen
- Department of Internal Medicine, Erasmus University Medical Center, 3015 CE, Rotterdam, The Netherlands
- Erasmus MC Bone Center, Erasmus University Medical Center, 3015 CE, Rotterdam, The Netherlands
| | - Tychon E A Geeraedts
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, 3015 CE, Rotterdam, The Netherlands
| | - Ariadne Bosman
- Department of Internal Medicine, Erasmus University Medical Center, 3015 CE, Rotterdam, The Netherlands
- Erasmus MC Bone Center, Erasmus University Medical Center, 3015 CE, Rotterdam, The Netherlands
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus University Medical Center, 3015 CE, Rotterdam, The Netherlands
- Erasmus MC Bone Center, Erasmus University Medical Center, 3015 CE, Rotterdam, The Netherlands
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Guo Y, Zhou YH, Wu XP, Tang CY, Wang M, Mo ZH, Shepherd JA, Ng BK, Fan B, Zhou HD. Changes in Bone Mineral Density Following Conventional Oral Phosphonate Treatment of Hypophosphatemic Osteomalacia: A Non-Randomized Controlled Study. Int J Gen Med 2021; 14:7925-7931. [PMID: 34795510 PMCID: PMC8593346 DOI: 10.2147/ijgm.s332534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/20/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose There are limited clinical studies aimed at solving the problem of the efficiency of conventional treatment with oral phosphate and calcitriol in adults with hypophosphatemic osteomalacia (HO). In addition, there still had no good non-hazardous markers to evaluate the severity of bone loss of osteomalacia before and after treatment. Therefore, the purpose of this study was to assess the efficacy of conventional treatment with a self-blended phosphate supplementation and calcitriol on patients with HO and whether bone mineral density (BMD) can be helpful for monitoring the efficacy. Patients and Methods A total of 21 HO patients and 105 healthy controls were enrolled. All patients were tested for serum biomarkers and BMD of the lumbar spine (L1-L4), femoral neck, and total left hip. After three years of treatment, 11 of 21 HO patients were recalled for BMD measurement. According to the administration of drugs, HO patients with calcium and calcitriol were divided into three phosphate treatment groups: patients in group A (n = 3) received continuous phosphate supplementation, patients in group B (n = 5) received intermittent phosphate supplementation and patients in group C (n = 3) received no phosphate supplementation. Results The diagnoses of 21 HO patients were 5 cases of hereditary hypophosphatemic rickets, 4 cases of Fanconi syndrome with the features of renal tubular acidosis and vitamin D deficiency, and 12 cases of hereditary vitamin D abnormality. The average initial serum phosphorus level of the patient group was approximately 50% lower than that of the control group. Lower BMD was significantly observed in the HO group than the control group at the lumbar spine and total hip. Continuous treatment with the phosphate supplement could increase BMD in the lumbar spine and total hip by 33.4-52.3% and in the femoral neck increased by 43.2-79.3% compared with baseline, and the effect appears to be continued once treatment is discontinued. Conclusion These findings suggest that conventional therapy can improve bone mineral defects in patients with HO, especially in the femoral neck. Detection of BMD in HO patients is a good tool to assess the extent of bone defects and the therapeutic effect. Trial Registration Chinese Clinical Trial Registry, ChiCTR-OOC-16010095. Registered 7 December 2016. Retrospectively registered.
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Affiliation(s)
- Yue Guo
- National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory of Metabolic Bone Diseases, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, People's Republic of China.,Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People's Republic of China
| | - Ying-Hui Zhou
- National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory of Metabolic Bone Diseases, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, People's Republic of China
| | - Xian-Ping Wu
- National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory of Metabolic Bone Diseases, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, People's Republic of China
| | - Chen-Yi Tang
- National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory of Metabolic Bone Diseases, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, People's Republic of China
| | - Min Wang
- Department of Endocrinology, Xiangya Hospital of Central South University, Changsha, 410008, People's Republic of China
| | - Zhao-Hui Mo
- Department of Endocrinology, The Third Xiangya Hospital of Central South University, Changsha, 410013, People's Republic of China
| | - John A Shepherd
- Department of Radiology & Biomedical Imaging, University of California at San Francisco, San Francisco, CA, 94143, USA
| | - Bennett K Ng
- Department of Radiology & Biomedical Imaging, University of California at San Francisco, San Francisco, CA, 94143, USA
| | - Bo Fan
- Department of Radiology & Biomedical Imaging, University of California at San Francisco, San Francisco, CA, 94143, USA
| | - Hou-De Zhou
- National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory of Metabolic Bone Diseases, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, People's Republic of China
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Rao M, Dadey L, Glowa T, Veldkamp P. Fanconi Syndrome Leading to Hypophosphatemic Osteomalacia Related to Tenofovir Use. Infect Dis Rep 2021; 13:448-453. [PMID: 34073672 PMCID: PMC8162330 DOI: 10.3390/idr13020044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/13/2021] [Accepted: 05/13/2021] [Indexed: 01/01/2023] Open
Abstract
Tenofovir disoproxil fumarate (TDF) is used worldwide to treat and prevent Human Immunodeficiency Virus (HIV) infection. Fanconi syndrome is a complication of TDF use and is characterized by inadequate reabsorption of glucose, phosphate and protein in the proximal tubule of the kidney which may eventually lead to osteomalacia manifested by symptoms of pain, muscular weakness and difficulty ambulating. We present a patient with severe osteomalacia due to progressive and unrecognized Fanconi's syndrome, who responded rapidly to TDF withdrawal, oral phosphate repletion and calcitriol. With the widespread use of TDF-containing antiviral regimens, it is critically important that physicians adhere to screening recommendations to detect early Fanconi syndrome, and recognize symptoms of osteomalacia as a serious complication.
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Affiliation(s)
- Mana Rao
- Essen Medical Associates Bronx, New York, NY 10453, USA
- Correspondence:
| | - Liam Dadey
- Parkview Health, Fort Wayne, IN 46805, USA;
| | - Thomas Glowa
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (T.G.); (P.V.)
| | - Peter Veldkamp
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (T.G.); (P.V.)
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Abstract
Chronic heavy metal exposure and the health hazards that ensue are important public-health problems. We highlight the occurrence of hypophosphataemic osteomalacia due to chronic cadmium exposure in the silver industry in India. Three silversmiths presented similarly with clinical, biochemical and radiological evidence of hypophosphataemic osteomalacia. Considering their occupation, their blood samples were screened for heavy metals and were found to have toxic levels of cadmium. They were initiated on neutral phosphate and calcitriol. On follow-up, they reported significant reduction in severity of symptoms. It is essential to maintain a high index of suspicion in diagnosing this condition. A thorough knowledge of the occupational background of patients, as well as ambient conditions at the workplace is of utmost importance in contemplating the possibility of such rare occurrences. Moreover, regulatory agencies and policy makers ought to survey the silver industry and ensure that the metals used are within permissible safe limits of exposure.
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Affiliation(s)
- J Paul
- Department of Endocrinology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - K E Cherian
- Department of Endocrinology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - N Thomas
- Department of Endocrinology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - T V Paul
- Department of Endocrinology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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Zhu S, Yang YH, Gao RW, Li R, Zou YZ, Feng L, Zhang B. Clinical features of hypophosphatemic osteomalacia induced by long-term low-dose adefovir dipivoxil. Drug Des Devel Ther 2017; 12:41-45. [PMID: 29343941 PMCID: PMC5747959 DOI: 10.2147/dddt.s140988] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective To investigate the predictors of hypophosphatemic osteomalacia induced by adefovir dipivoxil (ADV) and to monitor for early detection. Patients and methods Hospitalized patients who were diagnosed with ADV-related hypo-phosphatemic osteomalacia were recruited and retrospectively analyzed in our hospital from January 2012 to December 2016. A telephone interview was conducted at 1, 3, 6, 9, 12, and 24 months after cessation of ADV. Results In the 8 patients enrolled in the study, the hypophosphatemic osteomalacia symptoms developed at an average of 5.14 (4–7) years since ADV treatment (10 mg/d). The average alkaline phosphatase (ALP) level was 279.50 (137–548) U/L, which was significantly higher than the normal level (45–125 U/L). The serum phosphorus level was an average of 0.59 (0.43–0.69) mmol/L, which was lower than the normal range (2.06–2.60 mmol/L). Serum calcium levels of the enrolled patients remained within normal limits. Reduced estimated glomerular filtration rate (eGFR <29 mL/min/1.73 m2) was seen in 4 cases. The clinical manifestations were mainly progressive systemic bone and joint pain, frequent fractures, trouble in walking, height reduction (4–6 cm), and so on. After cessation of ADV, symptoms like bone pain resolved gradually. Serum phosphorus level restored to normal in 4.5 months after the withdrawal of ADV. However, in 4 patients, renal function failed to return to normal in 24 months. Conclusion More attention should be paid to the duration of ADV treatment. The level of serum phosphorus and ALP, as well as renal function, should be monitored for early detection of potential adverse drug reactions.
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Affiliation(s)
- Sheng Zhu
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yu-Hui Yang
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Rong-Wei Gao
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Ran Li
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yu-Zhen Zou
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Lei Feng
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Bo Zhang
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Abstract
RATIONALE Hypophosphatemic osteomalacia (HO) is a metabolic bone disease, exhibiting different etiologies such as genetic mutation, tumor induction, dysimmunity, or renal disease. Sjogren's syndrome (SS) is a connective tissue disorder commonly involving exocrine glands; however kidney involvement is also encountered, leading to abnormal phosphorus metabolism, even HO. PATIENT CONCERNS A 47-year-old female patient presented progressively worsening pain in the chest wall, back and bilateral lower extremities as well as muscle weakness was referred to our department. DIAGNOSES, INTERVENTIONS AND OUTCOMES Due to the laboratory test results, radiographic findings and pathologic results, she was diagnosed with adult-onset HO associated with SS. She was then treated with alkalinization, steroids, neutral phosphate, calcium supplements together with activated vitamin D. So far, she recovered uneventfully with relieved pain and increased serum phosphorus level. LESSONS HO may be secondary to renal tubular acidosis of SS patients, and it might be a diagnostic challenge when the kidney involvement in SS is latent and precede the typical sicca symptoms.
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Affiliation(s)
- Guohua Shen
- Department of Nuclear Medicine, West China Hospital of Sichuan University
| | - Yuwei Zhang
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Shuang Hu
- Department of Nuclear Medicine, West China Hospital of Sichuan University
| | - Bin Liu
- Department of Nuclear Medicine, West China Hospital of Sichuan University
| | - Anren Kuang
- Department of Nuclear Medicine, West China Hospital of Sichuan University
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Abstract
BACKGROUND In this paper, we explore nephrogenic hypophosphatemic osteomalacia associated with low-dose adefovir dipivoxil (ADV) therapy. METHODS Five patients who were treated with ADV for >2 years were included in this study. The metabolic index of phosphate and calcium, renal tubular function, renal function and pathological changes of the patients were investigated. RESULTS Two male and three female patients were studied. All of the patients presented with a reduced serum phosphate level (0.38-0.60 mmol/L) accompanied with hyperphosphaturia at 10.9-23.8 mmol/24 h. The serum potassium level was also reduced or at lower range (2.56-3.54 mmol/L), but the 24-h urinary potassium was relatively increased. Urinalysis also demonstrated increased excretion of glucose in four patients. Urine protein electrophoresis showed low-to-moderate molecular weight protein. Three patients manifested urine acidification function impairment. Four patients had accompanying renal insufficiency. Three patients had difficulty walking and presented with a reduction in height (2.5-14 cm). Renal biopsy revealed that most of the glomeruli were normal accompanied by mild interstitial fibrosis with inflammatory cell infiltration. ADV treatment was subsequently ceased. Patients were treated with regular phosphate supplementation, citrate acid potassium and calcium bicarbonate. After 6-month treatment, the bone pain was significantly alleviated. Serum creatinine of one patient returned to normal levels and two patients who had difficulty walking were able to walk independently. CONCLUSIONS The current study showed long-term and low-dose ADV treatment in a Chinese population may lead to proximal tubular impairment, metabolic acidosis, hypophosphatemia, hypokalemia, metabolic bone disease, renal osteopathia and renal functional damage.
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Affiliation(s)
- Yaowen Xu
- Department of Nephrology , Ruijin Hospital, Shanghai Jiaotong University School of Medicine , Shanghai , China
| | - Pingyan Shen
- Department of Nephrology , Ruijin Hospital, Shanghai Jiaotong University School of Medicine , Shanghai , China
| | - Xiaoxia Pan
- Department of Nephrology , Ruijin Hospital, Shanghai Jiaotong University School of Medicine , Shanghai , China
| | - Nan Chen
- Department of Nephrology , Ruijin Hospital, Shanghai Jiaotong University School of Medicine , Shanghai , China
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Wu C, Zhang H, Qian Y, Wang L, Gu X, Dai Z. Hypophosphatemic osteomalacia and renal Fanconi syndrome induced by low-dose adefovir dipivoxil: a case report and literature review suggesting ethnic predisposition. J Clin Pharm Ther 2013; 38:321-6. [PMID: 23590583 DOI: 10.1111/jcpt.12050] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 01/28/2013] [Indexed: 01/18/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Adefovir dipivoxil (ADV) is one of the commonly used antiviral agents in the treatment of chronic hepatitis B (CHB) infection. Safety of a daily dose of 10 mg ADV is advocated by the registration trials. We report a case of severe hypophosphatemic osteomalacia and renal Fanconi syndrome induced by low-dose ADV in a CHB-related cirrhosis patient, and discuss the case through a thorough review of other cases reported in the literature. CASE SUMMARY A 48-yr-old Chinese man with CHB-related cirrhosis developed severe progressive generalized bone pain and muscle weakness after receiving ADV 10 mg daily for 54 months. The laboratory results showed severe hypophosphatemia and features of proximal renal tubule dysfunction. Imaging studies were consistent with osteomalacia. After discontinuation of ADV, his symptoms resolved, laboratory abnormalities normalized and imaging studies showed improvement. In addition to our case, 12 other patients have been reported to have developed hypophosphatemic osteomalacia induced by low-dose ADV. Most of the reported cases were of subjects of East-Asian ethnicity. After discontinuation or reduction of ADV, serum phosphate level increased and clinical symptoms significantly improved in all cases. WHAT IS NEW AND CONCLUSION Hypophosphatemic osteomalacia and renal Fanconi syndrome can be associated with low-dose ADV. Clinicians treating CHB patients with ADV 10 mg daily over long periods of time should be aware of this infrequent but serious complication.
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Affiliation(s)
- C Wu
- Department of Endocrinology, The Second Affiliated Hospital of Wenzhou Medical College, Wenzhou
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Abstract
Oncogenic osteomalacia is a rare association between mesenchymal tumors and hypophosphatemic rickets. It is more of a biochemical entity than a clinical one. The pathophysiology of the tumor is not clear. However, it has been seen that the clinical and biochemical parameters become normal if the lesion responsible for producing the osteomalacia is excised. For a clinical diagnosis a high index of suspicion is necessary. We present three such cases where in one the oncogenic osteomalacia reversed while in rest it did not. We present this case report to sensitize about the entity.
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Affiliation(s)
- Ish K Dhammi
- Department of Orthopedics, UCMS and GTB Hospital, Delhi, India
| | - Anil K Jain
- Department of Orthopedics, UCMS and GTB Hospital, Delhi, India
| | - Ajay Pal Singh
- Department of Orthopedics, UCMS and GTB Hospital, Delhi, India,Address for correspondence: Dr. Ajay Pal Singh, Residential Complex, D-13. UCMS and GTB Hospital, Dilshad Garden, New Delhi, India. E-mail:
| | - Puneet Mishra
- Department of Orthopedics, UCMS and GTB Hospital, Delhi, India
| | - Saurabh Jain
- Department of Orthopedics, UCMS and GTB Hospital, Delhi, India
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Suzuki E, Yamada M, Ariyasu D, Izawa M, Miyamoto J, Koto S, Hasegawa Y. Patients with Hypophosphatemic Osteomalacia Need Continuous Treatment during Adulthood. Clin Pediatr Endocrinol 2009; 18:29-33. [PMID: 24790377 PMCID: PMC4004881 DOI: 10.1297/cpe.18.29] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Accepted: 11/13/2008] [Indexed: 11/15/2022] Open
Abstract
The treatment for hypophosphatemic rickets in children includes phosphate and
vitamin D preparations. In children, this regimen significantly improves symptoms, while a
treatment for adult patients has not been established. We therefore investigated the
clinical courses of 15 adult patients who discontinued therapy when final height was
achieved in order to assess the necessity of treatment in adulthood. Thirteen patients
developed symptomatic complications, including bone fractures. Among the 13, the 10
patients who restarted therapy all showed clinical improvement, and no side effects of
treatment were observed. This study shows that there are some patients with
hypophosphatemic osteomalacia who need continuous treatment during adulthood.
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Affiliation(s)
- Eri Suzuki
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Makoto Yamada
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Daisuke Ariyasu
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Masako Izawa
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Junko Miyamoto
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Shinobu Koto
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Yukihiro Hasegawa
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
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