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Bhadada SK, Pal R, Dhiman V, Alonso N, Ralston SH, Kaur S, Gupta R. Adult hypophosphatasia with a novel ALPL mutation: Report of an Indian kindred. Bone Rep 2020; 12:100247. [PMID: 32025537 PMCID: PMC6997823 DOI: 10.1016/j.bonr.2020.100247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/03/2020] [Accepted: 01/21/2020] [Indexed: 01/25/2023] Open
Abstract
Hypophosphatasia is an inborn error in metabolism characterized by low serum alkaline phosphatase (ALP) activity resulting from deactivating mutations in TNSALP (also known as ALPL), the gene that encodes the ‘tissue-specific’ isoenzyme of ALP. The disease exhibits significant clinical heterogeneity that spans from death in utero to only dental complications in adult life. Herein, we report a 47-year-old woman presenting with fracture of shaft of left femur. She had been complaining of pain in both of her thighs for the past 3 years. In addition, she gave a history of premature loss of teeth. Review of old radiographs revealed pseudo-fractures involving the lateral cortices of the femora on both sides. Biochemical panel revealed hyperphosphatemia, persistently low total alkaline phosphatase (ALP) and low-normal bone turnover markers. Screening of her siblings revealed low ALP in her younger sister and brother who were otherwise free from any major dento-arthro-osseous complaints. Sanger sequencing showed a novel, heterozygous, missense mutation in exon 5 at position 311 (c.311a > g;p.104 Asn > Ser) of ALPL gene in the three members. The patient underwent open reduction and intramedullary nailing of left femur along with prophylactic nailing on right side. This case report represents the first genetically confirmed kindred of adult hypophosphatasia from the Indian subcontinent.
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Affiliation(s)
- Sanjay K Bhadada
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India-160012
| | - Rimesh Pal
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India-160012
| | - Vandana Dhiman
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India-160012
| | - Nerea Alonso
- Rheumatology and Bone Disease Unit, Centre for Genomic and Experimental Medicine, IGMM, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU
| | - Stuart H Ralston
- Rheumatology and Bone Disease Unit, Centre for Genomic and Experimental Medicine, IGMM, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU
| | - Simran Kaur
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India-160012
| | - Rajat Gupta
- Department of Diabetes and Endocrinology, Alchemist Hospital, Panchkula 134112, India
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Michigami T, Ohata Y, Fujiwara M, Mochizuki H, Adachi M, Kitaoka T, Kubota T, Sawai H, Namba N, Hasegawa K, Fujiwara I, Ozono K. Clinical Practice Guidelines for Hypophosphatasia. Clin Pediatr Endocrinol 2020; 29:9-24. [PMID: 32029969 PMCID: PMC6958520 DOI: 10.1297/cpe.29.9] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 08/16/2019] [Indexed: 12/17/2022] Open
Abstract
Hypophosphatasia (HPP) is a rare bone disease caused by inactivating mutations in the
ALPL gene, which encodes tissue-nonspecific alkaline phosphatase
(TNSALP). Patients with HPP have varied clinical manifestations and are classified based
on the age of onset and severity. Recently, enzyme replacement therapy using bone-targeted
recombinant alkaline phosphatase (ALP) has been developed, leading to improvement in the
prognosis of patients with life-threatening HPP. Considering these recent advances,
clinical practice guidelines have been generated to provide physicians with guides for
standard medical care for HPP and to support their clinical decisions. A task force was
convened for this purpose, and twenty-one clinical questions (CQs) were formulated,
addressing the issues of clinical manifestations and diagnosis (7 CQs) and those of
management and treatment (14 CQs). A systematic literature search was conducted using
PubMed/MEDLINE, and evidence-based recommendations were developed. The guidelines have
been modified according to the evaluations and suggestions from the Clinical Guideline
Committee of The Japanese Society for Pediatric Endocrinology (JSPE) and public comments
obtained from the members of the JSPE and a Japanese HPP patient group, and then approved
by the Board of Councils of the JSPE. We anticipate that the guidelines will be revised
regularly and updated.
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Affiliation(s)
- Toshimi Michigami
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka Prefectural Hospital Organization, Osaka, Japan.,Task Force for Hypophosphatasia Guidelines
| | - Yasuhisa Ohata
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan.,Task Force for Hypophosphatasia Guidelines
| | - Makoto Fujiwara
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan.,Task Force for Hypophosphatasia Guidelines
| | - Hiroshi Mochizuki
- Division of Endocrinology and Metabolism, Saitama Children's Medical Center, Saitama, Japan.,Task Force for Hypophosphatasia Guidelines
| | - Masanori Adachi
- Department of Endocrinology and Metabolism, Kanagawa Children's Medical Center, Kanagawa, Japan.,Task Force for Hypophosphatasia Guidelines
| | - Taichi Kitaoka
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan.,Task Force for Hypophosphatasia Guidelines
| | - Takuo Kubota
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan.,Task Force for Hypophosphatasia Guidelines
| | - Hideaki Sawai
- Department of Obstetrics and Gynecology, Hyogo College of Medicine, Hyogo, Japan.,Task Force for Hypophosphatasia Guidelines
| | - Noriyuki Namba
- Division of Pediatrics and Perinatology, Tottori University Faculty of Medicine, Tottori, Japan.,Task Force for Hypophosphatasia Guidelines
| | - Kosei Hasegawa
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan.,Task Force for Hypophosphatasia Guidelines
| | - Ikuma Fujiwara
- Department of Pediatrics, Sendai City Hospital, Miyagi, Japan.,Task Force for Hypophosphatasia Guidelines
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan.,Task Force for Hypophosphatasia Guidelines
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Fujisawa Y, Kitaoka T, Ono H, Nakashima S, Ozono K, Ogata T. Case Report: Efficacy of Reduced Doses of Asfotase Alfa Replacement Therapy in an Infant With Hypophosphatasia Who Lacked Severe Clinical Symptoms. Front Endocrinol (Lausanne) 2020; 11:590455. [PMID: 33391183 PMCID: PMC7775725 DOI: 10.3389/fendo.2020.590455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 11/12/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Hypophosphatasia is a rare bone disease characterized by impaired bone mineralization and low alkaline phosphatase activity. Here, we describe the course of bone-targeted enzyme replacement therapy with asfotase alpha for a female infant patient with hypophosphatasia who lacked apparent severe clinical symptoms. CASE PRESENTATION The patient exhibited low serum alkaline phosphatase (60 U/L; age-matched reference range, 520-1,580) in a routine laboratory test at birth. Further examinations revealed skeletal demineralization and rachitic changes, as well as elevated levels of serum calcium (2.80 mmol/L; reference range, 2.25-2.75 mmol/L) and ionic phosphate (3.17 mmol/L; reference range, 1.62-2.48 mmol/L), which are typical features in patients with hypophosphatasia. Sequencing analysis of the tissue-nonspecific alkaline phosphatase (TNSALP) gene identified two pathogenic mutations: c.406C>T, p.Arg136Cys and c.979T>C, p.Phe327Leu. Thus, the patient was diagnosed with hypophosphatasia. At the age of 37 days, she began enzyme replacement therapy using asfotase alpha at the standard dose of 6 mg/kg/week. Initial therapy from the age of 37 days to the age of 58 days substantially improved rickets signs in the patient; it also provided immediate normalization of serum calcium and ionic phosphate levels. However, serum ionic phosphate returned to a high level (2.72 mmol/L), which was presumed to be a side effect of asfotase alpha. Thus, the patient's asfotase alfa treatment was reduced to 2 mg/kg/week, which allowed her to maintain normal or near normal skeletal features thereafter, along with lowered serum ionic phosphate levels. Because the patient exhibited slight distal metaphyseal demineralization in the knee at the age of 2 years and 6 months, her asfotase alfa treatment was increased to 2.4 mg/kg/week. No signs of deterioration in bone mineralization were observed thereafter. At the age of 3 years, the patient's motor and psychological development both appeared normal, compared with children of similar age. CONCLUSION This is the first report in which reduced doses of asfotase alfa were administered to an infant patient with hypophosphatasia who lacked apparent severe clinical symptoms. The results demonstrate the potential feasibility of a tailored therapeutic option based on clinical severity in patients with hypophosphatasia.
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Affiliation(s)
- Yasuko Fujisawa
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Japan
- *Correspondence: Yasuko Fujisawa,
| | - Taichi Kitaoka
- Department of Pediatrics, Faculty of Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hiroyuki Ono
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shinichi Nakashima
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Keiichi Ozono
- Department of Pediatrics, Faculty of Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Tsutomu Ogata
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Japan
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54
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Hypophosphatasie – eine klinisch und genetisch variable Erkrankung. MED GENET-BERLIN 2019. [DOI: 10.1007/s11825-019-00271-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Zusammenfassung
Die Hypophosphatasie (HPP) ist eine erbliche metabolische Multisystemerkrankung, deren klinische Hauptcharakteristika Mineralisierungsstörungen von Knochen und Zähnen sowie Muskel- und Gelenkschmerzen sind. Die klinische Symptomatik ist vom Erkrankungsalter abhängig und gestaltet sich sowohl interindividuell als auch intrafamiliär sehr variabel. Es werden sechs Unterformen der HPP abgegrenzt, wobei die Übergänge fließend sind. Sie reichen von der schweren perinatalen Form, die früher aufgrund fehlender Skelettmineralisierung meist tödlich war, bis hin zur adulten Form mit typischen Symptomen wie Frakturheilungsstörungen oder Stressfrakturen. Unspezifische Symptome wie Muskelschmerzen und -schwäche, Migräne oder Depressionen können ebenfalls Teil der HPP sein. Während schwere Formen mit einer Prävalenz zwischen 1/100.000 und 1/300.000 selten sind, kommen milde Formen der HPP deutlich häufiger vor. Perinatale und frühkindliche Formen sind meist autosomal-rezessiv vererbt, hingegen werden später auftretende Formen autosomal-rezessiv oder -dominant vererbt. Ursache der HPP ist eine reduzierte oder fehlende Aktivität der gewebeunspezifischen alkalischen Phosphatase (AP), welche durch das ALPL-Gen kodiert wird. Laborchemisch lassen sich im Serum eine alters- und geschlechtsspezifisch erniedrigte AP-Aktivität und eine konsekutive Erhöhung der AP-Substrate, z. B. des Pyridoxal-5-Phosphats (PLP), feststellen. Seit der Erstbeschreibung der Erkrankung 1948 haben sich die Diagnostik und Therapie der HPP dramatisch verbessert. Vor 4 Jahren ist eine Enzymersatztherapie mit Asfotase alfa (Strensiq®) für schwer betroffene HPP-Patienten mit Beginn der Erkrankung vor dem 18. Lebensjahr zugelassen worden. Dieser Artikel gibt einen Überblick über das breite klinische Spektrum der HPP, pathophysiologische Hintergründe, die laborchemische und molekulargenetische Diagnostik sowie gegenwärtige Therapieoptionen und deren Behandlungsindikationen.
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55
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Hepp N, Frederiksen AL, Dunø M, Jørgensen NR, Langdahl B, Vedtofte P, Hove HB, Hindsø K, Jensen JEB. Multiple Fractures and Impaired Bone Fracture Healing in a Patient with Pycnodysostosis and Hypophosphatasia. Calcif Tissue Int 2019; 105:681-686. [PMID: 31489468 DOI: 10.1007/s00223-019-00605-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 08/21/2019] [Indexed: 02/07/2023]
Abstract
Pycnodysostosis (PYCD) is a rare recessive inherited skeletal disease, characterized by short stature, brittle bones, and recurrent fractures, caused by variants in the Cathepsin K encoding gene that leads to impaired osteoclast-mediated bone resorption. Hypophosphatasia (HPP) is a dominant or recessive inherited condition representing a heterogeneous phenotype with dental symptoms, recurrent fractures, and musculoskeletal problems. The disease results from mutation(s) in the tissue non-specific alkaline phosphate encoding gene with reduced activity of alkaline phosphatase and secondarily defective mineralization of bone and teeth. Here, we present the first report of a patient with the coexistence of PYCD and HPP. This patient presented typical clinical findings of PYCD, including short stature, maxillary hypoplasia, and sleep apnoea. However, the burden of disease was caused by over 30 fractures, whereupon most showed delayed healing and non-union. Biochemical analysis revealed suppressed bone resorption and low bone formation capacity. We suggest that the coexistence of impaired bone resorption and mineralization may explain the severe bone phenotype with poor fracture healing.
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Affiliation(s)
- Nicola Hepp
- Department of Endocrinology, Hvidovre University Hospital Copenhagen, Kettegård Alle 30, 2650, Hvidovre, Denmark.
| | - Anja Lisbeth Frederiksen
- Department of Clinical Genetics, Odense University Hospital, Winsløws Vej 4, 5000, Odense C, Denmark
- Department of Clinical Research, Faculty of Health, University of Southern Denmark, Winsløwparken 19. 3, 5000, Odense C, Denmark
| | - Morten Dunø
- Department of Clinical Genetics, University Hospital Copenhagen Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Niklas Rye Jørgensen
- Department of Clinical Biochemistry, Rigshospitalet, Valdemar Hansens Vej 13, 2600, Glostrup, Denmark
- OPEN, Odense Patient Data Explorative Network, Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, J.B.Winsløws Vej 9, 5000, Odense C, Denmark
| | - Bente Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, G317, 8200, Aarhus N, Denmark
| | - Poul Vedtofte
- Department of Oral and Maxillofacial Surgery, University Hospital Copenhagen Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Hanne B Hove
- Center for Rare Diseases, Department of Pediatrics, University Hospital Copenhagen, Juliane Maries Vej 6, 2100, Copenhagen, Denmark
| | - Klaus Hindsø
- Paediatric Section, Department of Orthopedic Surgery, University Hospital Copenhagen Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jens-Erik Beck Jensen
- Department of Endocrinology, Hvidovre University Hospital Copenhagen, Kettegård Alle 30, 2650, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
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56
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Rolvien T, Schmidt T, Schmidt FN, von Kroge S, Busse B, Amling M, Barvencik F. Recovery of bone mineralization and quality during asfotase alfa treatment in an adult patient with infantile-onset hypophosphatasia. Bone 2019; 127:67-74. [PMID: 31152801 DOI: 10.1016/j.bone.2019.05.036] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/24/2019] [Accepted: 05/28/2019] [Indexed: 10/26/2022]
Abstract
Hypophosphatasia (HPP) is a hereditary musculoskeletal disorder characterized by low serum alkaline phosphatase (ALP) activity leading to poor bone mineralization. On a micro-morphological level, this may not only be reflected by an enrichment of osteoid but also a degradation of bone quality. Asfotase alfa is an enzyme replacement therapy that was recently demonstrated to improve bone mineralization as well as clinical status (e.g. growth, muscle strength and quality of life). However, the underlying changes of bone quality parameters on asfotase alfa treatment are currently not known. In the present study, we report a 24-year-old woman with genetically confirmed infantile-onset HPP and recurrent fractures. While the initiated asfotase alfa treatment was followed by rapid clinical improvements (i.e., disappearance of bone marrow edema, increase of muscle strength), the BMD assessed by DXA at the hip and spine increased moderately at two years follow-up. A detailed skeletal assessment using high-resolution peripheral quantitative computed tomography (HR-pQCT) and a high-resolution analysis of two consecutive iliac crest bone biopsies revealed only minor improvements of bone microarchitecture but a remarkable reduction of osteoid parameters. Furthermore, the high mineralization heterogeneity at baseline assessed by quantitative backscattered electron imaging (qBEI) decreased after 2 year of asfotase alfa treatment. Finally, we found an increase in mineral maturation reflected by higher mineral-to-matrix and carbonate-to-phosphate ratios using Fourier transform infrared spectroscopy (FTIR) imaging as well as increased local mechanical properties using reference point indentation (RPI). Taken together, our findings provide evidence for an improvement of bone quality indices beyond the mere reduction of osteoid indices and thereby contribute to the understanding of fracture risk reduction in HPP patients on asfotase alfa treatment.
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Affiliation(s)
- Tim Rolvien
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Tobias Schmidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Felix N Schmidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simon von Kroge
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Björn Busse
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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57
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Rauch F, Bardai G, Rockman-Greenberg C. ALPL mutations in adults with rheumatologic disorders and low serum alkaline phosphatase activity. J Bone Miner Metab 2019; 37:893-899. [PMID: 30719581 DOI: 10.1007/s00774-019-00991-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/22/2019] [Indexed: 12/18/2022]
Abstract
Tissue-nonspecific alkaline phosphatase (ALP), encoded by ALPL, is important for bone homeostasis and interacts with collagen type I. In the present study, we sequenced ALPL and a panel of collagen type I-related genes in 24 adults (age 22-80 years; 20 female) with persistently low serum ALP (< 40 U/L) and a range of rheumatologic symptoms. We found heterozygous pathogenic or likely pathogenic variants in ALPL in 14 (58%) of these individuals. In addition, 7 study participants had potentially damaging heterozygous variants of uncertain significance in genes related to collagen type I. Patients who were positive for ALPL variants had similar age and serum ALP levels to patients in whom no ALPL variants were detected, but had higher serum pyridoxal-5-phosphate concentrations (median 214 nmol/L vs. 64 nmol/L; p = 0.02; U test). In summary, heterozygous ALPL variants are frequent in individuals with rheumatologic symptoms and low ALP serum activity. It is possible that variants in genes that are involved in collagen type I production have a modifying effect on the clinical consequences of such ALPL variants.
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Affiliation(s)
- Frank Rauch
- Shriners Hospital for Children, McGill University, 1003 Decarie, Montreal, QC, H4A 0A9, Canada.
| | - Ghalib Bardai
- Shriners Hospital for Children, McGill University, 1003 Decarie, Montreal, QC, H4A 0A9, Canada
| | - Cheryl Rockman-Greenberg
- Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada
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58
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Schmidt T, Rolvien T, Linke C, Jandl NM, Oheim R, Amling M, Barvencik F. Outcome of Teriparatide Treatment on Fracture Healing Complications and Symptomatic Bone Marrow Edema in Four Adult Patients With Hypophosphatasia. JBMR Plus 2019; 3:e10215. [PMID: 31485555 PMCID: PMC6715780 DOI: 10.1002/jbm4.10215] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/23/2019] [Accepted: 06/24/2019] [Indexed: 12/12/2022] Open
Abstract
The response to teriparatide has been described in very few cases of hypophosphatasia (HPP). In this cross‐sectional study, we report the prevalence of symptomatic bone marrow edema (BME) and fracture healing complications in a large cohort of childhood and adult HPP patients and discuss the results of teriparatide treatment in four cases. From 2016 to 2018, 51 patients with a diagnosis of HPP were seen at our institution. The diagnosis of HPP was established by low serum alkaline phosphatase (ALP), elevated serum pyridoxal‐5‐phosphate (PLP), at least one typical clinical symptom of HPP and supported by ALPL mutation analysis. In this study cohort, 28 (56%) and 14 (27%) patients had a history of fracture or a history of BME, respectively. Four patients, including middle‐aged to elderly women and men who all presented with persistent symptomatic BME or fracture healing complications, were treated with teriparatide. DXA was performed prior to treatment and laboratory values were measured on a regular basis during treatment. Treatment with teriparatide showed variable effects in terms of clinical and biochemical response. Although all four patients displayed a temporary increase in ALP activity, only two patients with a mild form of adult HPP and moderately increased PLP levels showed definite clinical and radiological improvement after teriparatide treatment. In conclusion, fracture healing complications and BME occur frequently in HPP patients. Teriparatide shows variable clinical and biochemical effects depending on the severity of the disease. PLP levels and the number of ALPL alleles might be good parameters to predict treatment outcomes. © 2019 The Authors. JBMR Plus Published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research
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Affiliation(s)
- Tobias Schmidt
- Department of Osteology and Biomechanics University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Tim Rolvien
- Department of Osteology and Biomechanics University Medical Center Hamburg-Eppendorf Hamburg Germany.,Department of Orthopedics University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Carolin Linke
- Department of Osteology and Biomechanics University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Nico Maximilian Jandl
- Department of Osteology and Biomechanics University Medical Center Hamburg-Eppendorf Hamburg Germany.,Department of Orthopedics University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Ralf Oheim
- Department of Osteology and Biomechanics University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Michael Amling
- Department of Osteology and Biomechanics University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics University Medical Center Hamburg-Eppendorf Hamburg Germany
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59
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Rassie K, Dray M, Michigami T, Cundy T. Bisphosphonate Use and Fractures in Adults with Hypophosphatasia. JBMR Plus 2019; 3:e10223. [PMID: 31687651 PMCID: PMC6820463 DOI: 10.1002/jbm4.10223] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 06/24/2019] [Accepted: 07/15/2019] [Indexed: 02/06/2023] Open
Abstract
Adults with hypophosphatasia (HPP) may suffer femoral fractures resembling the atypical femoral fractures that can occur with long‐term bisphosphonate treatment, and there is an emerging consensus that bisphosphonates should not be used in adults with HPP and low bone mass. However, the spectrum of HPP in adults is wide: ranging from the severely affected—who commonly have osteomalacia—through to the minimally affected. The former typically have biallelic and the latter, heterozygous ALPL mutations. We have reviewed reports of fractures in adults with genetically proven HPP which suggest that the risk of fracture is at least 200‐fold greater in those with biallelic mutations. We also discuss two cases of postmenopausal women with heterozygous ALPL mutations. One had fractures and severe osteoporosis, but histology revealed no evidence of osteomalacia. The second had taken alendronate for 8 years, but despite profound suppression of bone turnover, histology again revealed no evidence of osteomalacia. The management of adults with HPP who have coexisting osteoporosis is challenging. More data are clearly needed, but we suggest that the risks of bisphosphonate therapy may be relatively low in patients who have heterozygous mutations and no histological evidence of osteomalacia. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Kate Rassie
- Department of Endocrinology Greenlane Clinical Centre Auckland New Zealand
| | - Michael Dray
- Department of Pathology Waikato Hospital Hamilton New Zealand
| | - Toshimi Michigami
- Department of Bone & Mineral Research Osaka Women's & Children's Hospital Isumi Japan
| | - Tim Cundy
- Department of Endocrinology Greenlane Clinical Centre Auckland New Zealand.,Department of Medicine, Faculty of Medical & Health Sciences University of Auckland Auckland New Zealand
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Rolvien T, Krause M, Zustin J, Yastrebov O, Oheim R, Barvencik F, Frosch KH, Amling M. Intra-articular osteoid osteoma accompanied by extensive bone marrow edema. A clinical and micro-morphological analysis. J Bone Oncol 2019; 18:100256. [PMID: 31497501 PMCID: PMC6722254 DOI: 10.1016/j.jbo.2019.100256] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 12/18/2022] Open
Abstract
A series of patients with intra-articular osteoid osteoma (OO) is demonstrated. Extensive and persistent bone marrow edema syndrome masked the correct diagnosis. No consistent patterns of impaired bone mineral status could be confirmed in these patients. Nidus specimens displayed significantly higher mineralization heterogeneity determined by qBEI.
Osteoid osteoma (OO) is a benign bone tumor producing non-mineralized bone matrix (i.e., osteoid). While peritumoral edema is commonly found in OO, extensive bone marrow edema has been reported less frequently. Furthermore, the micro-morphological characteristics of the nidus and its central calcification remain unclear. In this study, a consecutive series of four patients suffering from extensive bone marrow edema triggered by intra-articular osteoid osteoma underwent clinical examination, magnetic resonance imaging (MRI) and computed tomography (CT) as well as dual-energy X-ray absorptiometry (DXA) and laboratory bone turnover analyses. The obtained resection specimens were processed by undecalcified histology and were subsequently analyzed by light microscopy and quantitative backscattered electron imaging (qBEI). We report an entity of intra-articular osteoid osteoma in the knee and foot, in which an extensive and persistent bone marrow edema syndrome masked the correct diagnosis. While metabolic bone diseases were excluded in all cases, the reassessment of the patients’ clinical history including pain characteristics (nocturnal, aspirin sensitivity) led us to perform additional CT, where the tumor was diagnosed. The micro-morphological analysis of the OO biopsies revealed that the nidus was surrounded by hyperosteoidosis, while central mineralization was detected in all cases. This mineralized area showed a significantly higher mineralization heterogeneity than the surrounding trabecular bone and more disorganized collagen fibers detected by qBEI and polarized light microscopy, respectively. Taken together, our results indicate that osteoid osteoma should be considered when persistent and extensive, peri-articular bone marrow edema is diagnosed. The central calcification that is found inside the nidus in conventional imaging was mirrored by bone matrix with a heterogeneous mineralization pattern.
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Affiliation(s)
- Tim Rolvien
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Corresponding author at: Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529 Hamburg, Germany.
| | - Matthias Krause
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jozef Zustin
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Pathologisch-Anatomisches Institut Regensburg, Regensburg, Germany
| | - Oleg Yastrebov
- Department of Foot Surgery, Agaplesion Diakonieklinikum, Hamburg, Germany
| | - Ralf Oheim
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Corresponding author.
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Martins L, de Almeida AB, Dos Santos EJL, Foster BL, Machado RA, Kantovitz KR, Coletta RD, Nociti FH. A novel combination of biallelic ALPL mutations associated with adult hypophosphatasia: A phenotype-genotype association and computational analysis study. Bone 2019; 125:128-139. [PMID: 31077853 DOI: 10.1016/j.bone.2019.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/28/2019] [Accepted: 05/07/2019] [Indexed: 02/07/2023]
Abstract
Hypophosphatasia (HPP) is an inherited metabolic disorder that causes defective skeletal and dental mineralization. HPP exhibits a markedly heterogeneous range of clinical manifestations caused by dysfunction of the tissue-nonspecific isozyme of alkaline phosphatase (TNSALP), resulting from loss-of-function mutations in the ALPL gene. HPP has been associated with predominantly missense mutations in ALPL, and a number of compound heterozygous genotypes have been identified. Here, we describe a case of a subject with adult-onset HPP caused by a novel combination of missense mutations p.Gly473Ser and p.Ala487Val, resulting in chronic musculoskeletal pain, myopathy, persistent fatigue, vomiting, and an uncommon dental phenotype of short-rooted permanent teeth. Pedigree and biochemical analysis indicated that severity of symptoms was correlated with levels of residual ALP activity, and co-segregated with the p.Gly473Ser missense mutation. Bioinformatic analysis to predict the structural and functional impact of each of the point mutations in the TNSALP molecule, and its potential contribution to the clinical symptoms, revealed that the affected Gly473 residue is localized in the homodimer interface and predicted to have a dominant negative effect. The affected Ala487 residue was predicted to bind to Tyr479, which is closely located the N-terminal α-helix of TNSALP monomer 2, suggesting that both changes may impair dimer stability and catalytic functions. In conclusion, these findings assist in defining genotype-phenotype associations for HPP, and further define specific sites within the TNSALP molecule potentially related to neuromuscular manifestations in adult HPP, allowing for a better understanding of HPP pathophysiology.
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Affiliation(s)
- Luciane Martins
- Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, University of Campinas - UNICAMP, Piracicaba, SP, Brazil
| | - Amanda Bandeira de Almeida
- Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, University of Campinas - UNICAMP, Piracicaba, SP, Brazil
| | - Elis Janaína Lira Dos Santos
- Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, University of Campinas - UNICAMP, Piracicaba, SP, Brazil
| | - Brian L Foster
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - Renato Assis Machado
- Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas - UNICAMP, Piracicaba, SP, Brazil
| | - Kamila Rosamilia Kantovitz
- Department of Pediatric Dentistry, Piracicaba Dental School, University of Campinas - UNICAMP, Piracicaba, SP, Brazil; Department of Dental Materials, São Leopoldo Mandic School of Dentistry and Research Center, Campinas, SP, Brazil
| | - Ricardo D Coletta
- Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas - UNICAMP, Piracicaba, SP, Brazil
| | - Francisco H Nociti
- Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, University of Campinas - UNICAMP, Piracicaba, SP, Brazil.
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Colazo JM, Hu JR, Dahir KM, Simmons JH. Neurological symptoms in Hypophosphatasia. Osteoporos Int 2019; 30:469-480. [PMID: 30215116 DOI: 10.1007/s00198-018-4691-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 08/26/2018] [Indexed: 12/27/2022]
Abstract
UNLABELLED Hypophosphatasia (HPP) typically manifests with fractures, tooth loss, and muscle pain. Although mental health diagnoses and neurological symptoms have not been previously well documented in HPP, they occur commonly. The recognition of non-traditional symptoms may improve patient satisfaction, preempt costly evaluation and misdiagnosis, and lead to further treatment options. INTRODUCTION Hypophosphatasia (HPP) is an inborn error of metabolism due to deficiency of tissue non-specific alkaline phosphatase (TNSALP). It is traditionally characterized by rickets in children and osteomalacia in adults, along with fractures, tooth loss, and muscle pain. Neurological symptoms and mental health diagnoses have not been widely reported, and we therefore report their prevalence in a cohort of patients with HPP. METHODS A retrospective chart review was performed on a series of 82 HPP patients. Patient charts were reviewed to identify the possible presence and onset of 13 common neurological symptoms. RESULTS Median age was 36 years (2 to 79). Seventeen had adult onset HPP (> 18 years) and 65 had pediatric onset HPP (< 18 years). Median time from symptom onset to HPP diagnosis was 8 years (0 to 67). Seventy-four percent had a family history of bone disease, while 17% had a family history of neurologic disease. Bone problems occurred in 89%, dental problems in 77%, and muscle problems in 66%. Fatigue occurred in 66%, headache in 61%, sleep disturbance in 51%, gait change in 44%, vertigo in 43%, depression in 39%, anxiety in 35%, neuropathy in 35%, and hearing loss in 33%. CONCLUSIONS The extra-skeletal manifestations of HPP, specifically neurological symptoms, have not been previously well documented. However, mental health diagnoses and neurological symptoms such as headache and sleep disturbance occur commonly in patients with HPP. The recognition of non-traditional symptoms in HPP may improve patient satisfaction, preempt costly evaluation and misdiagnosis, and may lead to further treatment options.
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Affiliation(s)
- J M Colazo
- Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
- Medical Scientist Training Program, Vanderbilt University School of Medicine, Nashville, TN, 37232, USA
| | - J R Hu
- Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - K M Dahir
- Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - J H Simmons
- Department of Pediatrics, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
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Galeano-Valle F, Vengoechea J, Galindo RJ. A rare mutation in hypophosphatasia: a case report of adult form and review of the literature. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2019; 63:89-93. [PMID: 30864637 PMCID: PMC10118836 DOI: 10.20945/2359-3997000000108] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 12/11/2018] [Indexed: 11/23/2022]
Abstract
Hypophosphatasia is a rare inborn error of metabolism characterized by low serum alkaline phosphatase activity due to loss-of-function mutations in the gene encoding the tissue-nonspecific isoenzyme of alkaline phosphatase (TNSALP). Extracellular accumulation of TNSALP substrates leads to dento-osseous and arthritic complications featuring tooth loss, rickets or osteomalacia, and calcific arthopathies. Mild hypophosphatasia usually has autosomal dominant inheritance, severe cases are either autosomal recessive or due to a dominant negative effect. Clinical manifestations of hypophosphatasia are extremely variable, ranging from life threatening to asymptomatic clinical presentations. The clinical presentation of the adult-onset hypophosphatasia is highly variable. Fractures, joint complications of chondrocalcinosis, calcifying polyarthritis and multiple pains may reveal minor forms of the disease in adults. It is important to recognize the disease to provide the best supportive treatment and to prevent the use of anti-resorption drugs in these patients. Bone-targeted enzyme-replacement therapy (asfotase alfa) was approved in 2015 to treat pediatric-onset hypophosphatasia. We present a case of a 41-year-old male diagnosed with adult form of hypophosphatasia with a rare ALPL mutation that has been previously described only once and review the literature on the adult form of the disease and its genetic mechanism.
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Bowden SA, Foster BL. Alkaline Phosphatase Replacement Therapy for Hypophosphatasia in Development and Practice. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1148:279-322. [PMID: 31482504 DOI: 10.1007/978-981-13-7709-9_13] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Hypophosphatasia (HPP) is an inherited disorder that affects bone and tooth mineralization characterized by low serum alkaline phosphatase. HPP is caused by loss-of-function mutations in the ALPL gene encoding the protein, tissue-nonspecific alkaline phosphatase (TNSALP). TNSALP is expressed by mineralizing cells of the skeleton and dentition and is associated with the mineralization process. Generalized reduction of activity of the TNSALP leads to accumulation of its substrates, including inorganic pyrophosphate (PPi) that inhibits physiological mineralization. This leads to defective skeletal mineralization, with manifestations including rickets, osteomalacia, fractures, and bone pain, all of which can result in multi-systemic complications with significant morbidity, as well as mortality in severe cases. Dental manifestations are nearly universal among affected individuals and feature most prominently premature loss of deciduous teeth. Management of HPP has been limited to supportive care until the introduction of a TNSALP enzyme replacement therapy (ERT), asfotase alfa (AA). AA ERT has proven to be transformative, improving survival in severely affected infants and increasing overall quality of life in children and adults with HPP. This chapter provides an overview of TNSALP expression and functions, summarizes HPP clinical types and pathologies, discusses early attempts at therapies for HPP, summarizes development of HPP mouse models, reviews design and validation of AA ERT, and provides up-to-date accounts of AA ERT efficacy in clinical trials and case reports, including therapeutic response, adverse effects, limitations, and potential future directions in therapy.
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Affiliation(s)
- S A Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH, USA.
| | - B L Foster
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
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Abstract
PURPOSE OF REVIEW Hypophosphatasia (HPP) is a rare genetic disorder caused by mutations of the ALPL gene. ALPL encodes the tissue-non-specific isoenzyme of alkaline phosphatase (TNSALP). Consequently, bone mineralization is decreased leading to fractures, arthralgia, and extra-skeletal manifestations including tissue calcification, respiratory failure, and neurological complications. This review summarizes the most important clinical findings, diagnosis, and treatment options for HPP. RECENT FINDINGS Asfotase alfa is a recombinant human alkaline phosphatase, used as treatment for the underlying cause of HPP. Asfotase alfa enhances the survival in life-threatening HPP and improves bone mineralization, muscle strength, and pulmonary function. However, discontinuation of asfotase alfa leads to reappearance of bone hypomineralization. Due to its varied manifestations, HPP often mimics rheumatological and other bone diseases, thereby delaying its diagnosis. Asfotase alfa, a recombinant alkaline phosphatase, is available for the long-term enzyme replacement therapy in patients with pediatric-onset HPP to treat the bone manifestations of the disease.
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López-Delgado L, Riancho-Zarrabeitia L, García-Unzueta MT, Tenorio JA, García-Hoyos M, Lapunzina P, Valero C, Riancho JA. Abnormal bone turnover in individuals with low serum alkaline phosphatase. Osteoporos Int 2018; 29:2147-2150. [PMID: 29947871 DOI: 10.1007/s00198-018-4571-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/08/2018] [Indexed: 10/14/2022]
Abstract
The clinical spectrum of hypophosphatasia (HPP) is broad and variable within families. Along severe infantile forms, adult forms with mild manifestations may be incidentally discovered by the presence of low alkaline phosphatase (ALP) activity in serum. However, it is still unclear whether individuals with persistently low levels of ALP, in the absence of overt manifestations of HPP, have subclinical abnormalities of bone remodeling or bone mass. The aim of this study was to obtain a better understanding of the skeletal phenotype of adults with low ALP by analyzing bone mineral density (BMD), bone microarchitecture (trabecular bone score, TBS), and bone turnover markers (P1NP and ß-crosslaps). We studied 42 individuals with persistently low serum ALP. They showed lower levels of P1NP (31.4 ± 13.7 versus 48.9 ± 24.4 ng/ml; p = 0.0002) and ß-crosslaps (0.21 ± 0.17 versus 0.34 ± 0.22 ng/ml, p = 0.0015) than individuals in the control group. There were no significant differences in BMD, bone mineral content, or TBS. These data suggest that individuals with hypophosphatasemia have an overall reduction of bone turnover, even in the absence of overt manifestations of HPP or low BMD. We evaluated bone mineral density (BMD), bone microarchitecture, and bone turnover markers in patients with low serum levels of alkaline phosphatase. Our results show that these patients have low bone remodeling even in the absence of BMD abnormalities, thus supporting the recommendation of avoiding antiresorptives such as bisphosphonates in these subjects.
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Affiliation(s)
- L López-Delgado
- Service of Internal Medicine, Hospital U.M. Valdecilla, University of Cantabria, IDIVAL, Av Valdecilla SN, 39008, Santander, Spain
| | | | - M T García-Unzueta
- Service of Clinical Biochemistry, Hospital U.M. Valdecilla, University of Cantabria, IDIVAL, Santander, Spain
| | - J A Tenorio
- Institute of Medical and Molecular Genetics (INGEMM), Hospital Universitario La Paz. IdiPAZ, Universidad Autónoma de Madrid and CIBERER, ISCIII, Madrid, Spain
| | - M García-Hoyos
- Service of Internal Medicine, Hospital U.M. Valdecilla, University of Cantabria, IDIVAL, Av Valdecilla SN, 39008, Santander, Spain
| | - P Lapunzina
- Institute of Medical and Molecular Genetics (INGEMM), Hospital Universitario La Paz. IdiPAZ, Universidad Autónoma de Madrid and CIBERER, ISCIII, Madrid, Spain
| | - C Valero
- Service of Internal Medicine, Hospital U.M. Valdecilla, University of Cantabria, IDIVAL, Av Valdecilla SN, 39008, Santander, Spain
| | - J A Riancho
- Service of Internal Medicine, Hospital U.M. Valdecilla, University of Cantabria, IDIVAL, Av Valdecilla SN, 39008, Santander, Spain.
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Ikeue R, Nakamura-Takahashi A, Nitahara-Kasahara Y, Watanabe A, Muramatsu T, Sato T, Okada T. Bone-Targeted Alkaline Phosphatase Treatment of Mandibular Bone and Teeth in Lethal Hypophosphatasia via an scAAV8 Vector. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2018; 10:361-370. [PMID: 30202773 PMCID: PMC6129726 DOI: 10.1016/j.omtm.2018.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 08/13/2018] [Indexed: 12/16/2022]
Abstract
Hypophosphatasia is an inherited disease caused by mutations in the gene encoding tissue-nonspecific alkaline phosphatase (TNALP), the major symptom of which is hypomineralization of the bones and teeth. We had recently demonstrated that TNALP-deficient (Akp2−/−) mice, which mimic the phenotype of the severe infantile form of hypophosphatasia, can be treated by intramuscular injection of a self-complementary (sc) type 8 recombinant adeno-associated virus (rAAV8) vector expressing bone-targeted TNALP with deca-aspartates at the C terminus (TNALP-D10) via the muscle creatine kinase (MCK) promoter. In this study, we focused on the efficacy of this scAAV8-MCK-TNALP-D10 treatment on the mandibular bone and teeth in neonatal Akp2−/− mice. Upon scAAV8-MCK-TNALP-D10 injection, an improvement of mandibular growth was observed by X-ray analysis. Micro-computed tomography analysis revealed progressive mineralization of the molar root in the treated Akp2−/− mice, and morphometric parameters of the alveolar bone were improved. These results suggest that the mandibular bones and teeth of hypophosphatasia were effectively treated by muscle directed rAAV-mediated TNALP-D10 transduction. Our strategy would be promising for future hypophosphatasia gene therapy because it induces dentoalveolar mineralization and reduces the risk of tooth exfoliation.
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Affiliation(s)
- Ryo Ikeue
- Department of Fixed Prosthodontics, Tokyo Dental College, Tokyo, Japan
| | - Aki Nakamura-Takahashi
- Department of Pharmacology, Tokyo Dental College, Tokyo, Japan.,Department of Biochemistry and Molecular Biology, Nippon Medical School, Tokyo, Japan
| | | | - Atsushi Watanabe
- Department of Biochemistry and Molecular Biology, Nippon Medical School, Tokyo, Japan.,Division of Clinical Genetics, Nippon Medical School Hospital, Tokyo, Japan
| | - Takashi Muramatsu
- Department of Operative Dentistry, Tokyo Dental College, Tokyo, Japan
| | - Toru Sato
- Department of Fixed Prosthodontics, Tokyo Dental College, Tokyo, Japan
| | - Takashi Okada
- Department of Biochemistry and Molecular Biology, Nippon Medical School, Tokyo, Japan
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Daniel AB, Saraff V, Shaw NJ, Yates R, Mughal MZ, Padidela R. Healthcare resource utilization in the management of hypophosphatasia in three patients displaying a spectrum of manifestations. Orphanet J Rare Dis 2018; 13:142. [PMID: 30115096 PMCID: PMC6097329 DOI: 10.1186/s13023-018-0869-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/03/2018] [Indexed: 01/09/2023] Open
Abstract
Background Hypophosphatasia (HPP) is a rare, heterogeneous disease caused by low tissue-nonspecific alkaline phosphatase activity and associated with a range of signs and symptoms, including bone mineralization defects, respiratory problems, seizures, premature tooth loss, and fractures. Data from patients with HPP and their healthcare resource utilization are lacking. We evaluated healthcare utilization for 3 patients with differing severities of HPP. Results Patient 1 had perinatal HPP (received enzyme replacement therapy asfotase alfa under a compassionate use program), Patient 2 had infantile HPP, and Patient 3 had childhood HPP. Healthcare resources used in the National Health Service, England, were identified from coded activities in the hospital database and detailed medical records. These data showed that healthcare utilization was directly related to disease severity. Patient 1 had respiratory complications necessitating prolonged admission for ventilation from birth. Over 2.5 years, this patient was hospitalized 725 days, with visits from 16 specialists. Patient 2 had HPP-associated signs and symptoms starting in infancy, was treated for craniosynostosis, experienced multiple fractures, and required outpatient management for > 18 years. Patient 3 developed signs and symptoms of HPP in childhood and received outpatient and day case treatment for dental, orthopedic, and cardiovascular problems over 24 years. Healthcare utilization varied with severity and complexity of disease manifestations between these patients. Conclusions With the recent approval of asfotase alfa for HPP, data from this analysis may help mobilize multidisciplinary healthcare resources for management of HPP by elucidating healthcare resource needs of patients who show a spectrum of clinical manifestations of HPP.
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Affiliation(s)
- Anjali B Daniel
- Department of Paediatric Endocrinology & Metabolic Bone Diseases, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Vrinda Saraff
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Nick J Shaw
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Robert Yates
- Department of Paediatric Intensive Care Unit, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - M Zulf Mughal
- Department of Paediatric Endocrinology & Metabolic Bone Diseases, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Raja Padidela
- Department of Paediatric Endocrinology & Metabolic Bone Diseases, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK. .,Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
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Stress and Insufficiency Fractures. Clin Rev Bone Miner Metab 2017. [DOI: 10.1007/s12018-017-9239-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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