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Kamenický P, Briot K, Munns CF, Linglart A. X-linked hypophosphataemia. Lancet 2024; 404:887-901. [PMID: 39181153 DOI: 10.1016/s0140-6736(24)01305-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 08/27/2024]
Abstract
X-linked hypophosphataemia is a genetic disease caused by defects in the phosphate regulating endopeptidase homolog X-linked (PHEX) gene and is characterised by X-linked dominant inheritance. The main consequence of PHEX deficiency is increased production of the phosphaturic hormone fibroblast growth factor 23 (FGF23) in osteoblasts and osteocytes. Chronic exposure to circulating FGF23 is responsible for renal phosphate wasting and decreased synthesis of calcitriol, which decreases intestinal phosphate absorption. These mechanisms result in lifelong hypophosphataemia, impaired growth plate and bone matrix mineralisation, and diverse manifestations in affected children and adults, including some debilitating morbidities and possibly increased mortality. Important progress has been made in disease knowledge and management over the past decade; in particular, targeting FGF23 is a therapeutic approach that has substantially improved outcomes. However, patients affected by this complex disease need lifelong care and innovative treatment strategies, such as gene repair of PHEX, are necessary to further limit the disease burden.
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Affiliation(s)
- Peter Kamenický
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France; Centre de Référence des Maladies du Métabolisme du Calcium et du Phosphate, Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France.
| | - Karine Briot
- Centre de Référence des Maladies du Métabolisme du Calcium et du Phosphate, Service de Rhumatologie, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Craig F Munns
- Department of Endocrinology and Diabetes, Queensland Children's Hospital and Child Health Research Centre and Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Agnès Linglart
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France; Service d'Endocrinologie et du Diabète de l'Enfant, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France
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Sorsby M, Almardini S, Alayyat A, Hughes A, Venkat S, Rahman M, Baker J, Rana R, Rosen V, Liu ES. The role of GDF5 in regulating enthesopathy development in the Hyp mouse model of XLH. J Bone Miner Res 2024; 39:1162-1173. [PMID: 38836497 PMCID: PMC11337578 DOI: 10.1093/jbmr/zjae086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/25/2024] [Accepted: 06/04/2024] [Indexed: 06/06/2024]
Abstract
X-linked hypophosphatemia (XLH) is caused by mutations in PHEX, leading to rickets and osteomalacia. Adults affected with XLH develop a mineralization of the bone-tendon attachment site (enthesis), called enthesopathy, which causes significant pain and impaired movement. Entheses in mice with XLH (Hyp) have enhanced bone morphogenetic protein (BMP) and Indian hedgehog (IHH) signaling. Treatment of Hyp mice with the BMP signaling blocker palovarotene attenuated BMP/IHH signaling in Hyp entheses, thus indicating that BMP signaling plays a pathogenic role in enthesopathy development and that IHH signaling is activated by BMP signaling in entheses. It was previously shown that mRNA expression of growth/differentiation factor 5 (Gdf5) is enhanced in Hyp entheses at P14. Thus, to determine a role for GDF5 in enthesopathy development, Gdf5 was deleted globally in Hyp mice and conditionally in Scx + cells of Hyp mice. In both murine models, BMP/IHH signaling was similarly decreased in Hyp entheses, leading to decreased enthesopathy. BMP/IHH signaling remained unaffected in WT entheses with decreased Gdf5 expression. Moreover, deletion of Gdf5 in Hyp entheses starting at P30, after enthesopathy has developed, partially reversed enthesopathy. Taken together, these results demonstrate that while GDF5 is not essential for modulating BMP/IHH signaling in WT entheses, inappropriate GDF5 activity in Scx + cells contributes to XLH enthesopathy development. As such, inhibition of GDF5 signaling may be beneficial for the treatment of XLH enthesopathy.
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Affiliation(s)
- Melissa Sorsby
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Shaza Almardini
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Ahmad Alayyat
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Ashleigh Hughes
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Shreya Venkat
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Mansoor Rahman
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Jiana Baker
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Rakshya Rana
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Vicki Rosen
- Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA 02115, United States
| | - Eva S Liu
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA 02115, United States
- Harvard Medical School, Boston, MA 02115, United States
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Insogna KL, Sullivan R, Parziale S, Deng Y, Carrano D, Simpson C, Dufour S, Carpenter T, Petersen KF. Effect of Burosumab on Muscle Function and Strength, and Rates of ATP Synthesis in Skeletal Muscle in Adults With XLH. J Clin Endocrinol Metab 2024; 109:e1061-e1071. [PMID: 37930769 DOI: 10.1210/clinem/dgad642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/05/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
CONTEXT In clinical trials, burosumab ameliorates symptoms of pain, fatigue, and stiffness and improves performance on certain muscle function studies in patients with X-linked hypophosphatemia (XLH). OBJECTIVE This work aimed to determine if burosumab increases adenosine triphosphate (ATP) synthesis in skeletal muscle of treatment-naive adults with XLH, and if so, whether that correlates with improved muscle function. METHODS Ten untreated, symptomatic adults with XLH had ATP synthesis rates measured in the right calf using the 31P magnetic resonance spectroscopy saturation transfer technique. Baseline muscle function tests and symptoms of pain, fatigue, stiffness, and lower-extremity joint pain were quantified. All participants were treated with burosumab, 1 mg/kg every 4 weeks for 12 weeks. ATP synthesis rates and muscle function tests were repeated 2 weeks ("peak") and 4 weeks ("trough") after the third dose of burosumab. RESULTS All symptoms improved with treatment. Performance on the 6-Minute Walk Test (6MWT) and Sit to Stand (STS) tests also improved. Muscle strength and ATP synthesis rates did not change over the 3 months of the study. When individuals whose performances on the 6MWT and STS test were at or better than the median outcome for those tests were compared to those whose outcomes were below the median, no difference was observed in the rate of change in ATP synthesis. Intracellular muscle concentrations of phosphate were normal. CONCLUSION The improvement in the 6MWT and STS test without changes in muscle strength or ATP synthesis rates suggests that reductions in pain, fatigue, and stiffness may partly explain the improved performance. Intracellular phosphate in skeletal muscle is insulated from hypophosphatemia in XLH.
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Affiliation(s)
- Karl L Insogna
- Department of Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, CT 06520-8020, USA
| | - Rebecca Sullivan
- Department of Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, CT 06520-8020, USA
| | - Stephen Parziale
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT 06510, USA
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT 06510, USA
| | - Diana Carrano
- Rehabilitation Supervisor, Yale New Haven Hospital, New Haven, CT 06510, USA
| | - Christine Simpson
- Department of Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, CT 06520-8020, USA
| | - Sylvie Dufour
- Department of Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, CT 06520-8020, USA
| | - Thomas Carpenter
- Department of Pediatrics, Section of Endocrinology, Yale School of Medicine, New Haven, CT 06510, USA
| | - Kitt Falk Petersen
- Department of Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, CT 06520-8020, USA
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Ferreira CR, Carpenter TO, Braddock DT. ENPP1 in Blood and Bone: Skeletal and Soft Tissue Diseases Induced by ENPP1 Deficiency. ANNUAL REVIEW OF PATHOLOGY 2024; 19:507-540. [PMID: 37871131 PMCID: PMC11062289 DOI: 10.1146/annurev-pathmechdis-051222-121126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
The enzyme ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) codes for a type 2 transmembrane glycoprotein that hydrolyzes extracellular ATP to generate pyrophosphate (PPi) and adenosine monophosphate, thereby contributing to downstream purinergic signaling pathways. The clinical phenotypes induced by ENPP1 deficiency are seemingly contradictory and include early-onset osteoporosis in middle-aged adults and life-threatening vascular calcifications in the large arteries of infants with generalized arterial calcification of infancy. The progressive overmineralization of soft tissue and concurrent undermineralization of skeleton also occur in the general medical population, where it is referred to as paradoxical mineralization to highlight the confusing pathophysiology. This review summarizes the clinical presentation and pathophysiology of paradoxical mineralization unveiled by ENPP1 deficiency and the bench-to-bedside development of a novel ENPP1 biologics designed to treat mineralization disorders in the rare disease and general medical population.
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Affiliation(s)
- Carlos R Ferreira
- Metabolic Medicine Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Thomas O Carpenter
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Demetrios T Braddock
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA;
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Herrou J, Fechtenbaum J, Rothenbuhler A, Kamenický P, Roux C, Linglart A, Briot K. Development of Spinal Enthesopathies in Adults With X-linked Hypophosphatemia. J Clin Endocrinol Metab 2023; 108:e1524-e1531. [PMID: 37390471 DOI: 10.1210/clinem/dgad383] [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: 04/12/2023] [Revised: 06/09/2023] [Accepted: 06/26/2023] [Indexed: 07/02/2023]
Abstract
CONTEXT Musculoskeletal complications are the main manifestations in adults with X-linked hypophosphatemia (XLH). Enthesopathy significantly impairs quality of life. OBJECTIVE To identify the risk factors associated with the development and progression of spinal enthesopathies in adults with XLH. DESIGN AND SETTING We conducted a retrospective study in the French Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism. PATIENTS Adults XLH patients with 2 EOS® imaging performed at least 2 years apart at the same center between June 2011 and March 2022. The progression of enthesopathies was defined as a new enthesopathy at least 1 intervertebral level in patients with or without presence of enthesopathy at baseline. MAIN OUTCOME MEASURES Demographic, treatment, PHEX mutation with the progression of enthesopathies. RESULTS Fifty-one patients (66.7% of women, mean age 42.1 ± 13.4 years) underwent 2 EOS imaging with an average interval of 5.7 (± 2.31) years.Progression of spinal enthesopathies was observed in 27 (52.9%) patients. In univariate analysis, patients with a progression of spinal enthesopathies were significantly older (P < .0005), were significantly older at treatment initiation (P = .02), presented with dental complications (P = .03), received less frequently treatment during childhood with phosphate and/or vitamin D analogs (P = .06), and presented more frequently with hip osteoarthritis (P = .002) at baseline. In multivariate analysis, none of these factors was associated with a progression of spinal enthesopathies. CONCLUSION This study confirms the high proportion of patients with a progression of spinal enthesopathies. Age seems to be the main factor associated with progression.
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Affiliation(s)
- Julia Herrou
- Department of Rheumatology, INSERM UMR 1153, Université de Paris-Cité, APHP Centre, Cochin Hospital, 75014 Paris, France
- Department of Rheumatology, APHP Centre, Cochin Hospital, 75014 Paris, France
| | - Jacques Fechtenbaum
- Department of Rheumatology, APHP Centre, Cochin Hospital, 75014 Paris, France
| | - Anya Rothenbuhler
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
- Department of Endocrinology and Diabetes for Children, APHP, Bicêtre Paris Saclay Hospital, 94270 Le Kremlin Bicêtre, France
- APHP, Plateforme d'expertise Paris Saclay maladies rares, Bicêtre Paris Saclay Hospital, 94270 Le Kremlin Bicêtre, France
| | - Peter Kamenický
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
- Université Paris-Saclay, INSERM UMR-S 1185, Physiologie et Physiopathologie Endocriniennes, 94270 Le Kremlin-Bicêtre, France
| | - Christian Roux
- Department of Rheumatology, INSERM UMR 1153, Université de Paris-Cité, APHP Centre, Cochin Hospital, 75014 Paris, France
- Department of Rheumatology, APHP Centre, Cochin Hospital, 75014 Paris, France
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
| | - Agnès Linglart
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
- Department of Endocrinology and Diabetes for Children, APHP, Bicêtre Paris Saclay Hospital, 94270 Le Kremlin Bicêtre, France
- APHP, Plateforme d'expertise Paris Saclay maladies rares, Bicêtre Paris Saclay Hospital, 94270 Le Kremlin Bicêtre, France
| | - Karine Briot
- Department of Rheumatology, INSERM UMR 1153, Université de Paris-Cité, APHP Centre, Cochin Hospital, 75014 Paris, France
- Department of Rheumatology, APHP Centre, Cochin Hospital, 75014 Paris, France
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
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Grimbly C, Graf D, Ward LM, Alexander RT. X-linked hypophosphatemia, fibroblast growth factor 23 signaling, and craniosynostosis. Exp Biol Med (Maywood) 2023; 248:2175-2182. [PMID: 38230523 PMCID: PMC10800125 DOI: 10.1177/15353702231222023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024] Open
Abstract
This review summarizes the current knowledge of fibroblast growth factor 23 signaling in bone and its role in the disease pathology of X-linked hypophosphatemia. Craniosynostosis is an under-recognized complication of X-linked hypophosphatemia. The clinical implications and potential cellular mechanisms invoked by increased fibroblast growth factor 23 signaling causing craniosynostosis are reviewed. Knowledge gaps are identified and provide direction for future clinical and basic science studies.
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Affiliation(s)
- Chelsey Grimbly
- Department of Pediatrics, Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB T6G 2R7, Canada
- Women & Children’s Health Research Institute, University of Alberta, Edmonton, AB T6G 2R7, Canada
| | - Daniel Graf
- Women & Children’s Health Research Institute, University of Alberta, Edmonton, AB T6G 2R7, Canada
- Department of Dentistry and Dental Hygiene, University of Alberta, Edmonton, AB T6G 2R7, Canada
| | - Leanne M Ward
- Division of Endocrinology and Metabolism, Department of Pediatrics Faculty of Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON K1H 8L1, Canada
| | - R Todd Alexander
- Department of Pediatrics, Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB T6G 2R7, Canada
- Women & Children’s Health Research Institute, University of Alberta, Edmonton, AB T6G 2R7, Canada
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Macica CM, Tommasini SM. Biomechanical Impact of Phosphate Wasting on Articular Cartilage Using the Murine Hyp Model of X-linked hypophosphatemia. JBMR Plus 2023; 7:e10796. [PMID: 37808393 PMCID: PMC10556269 DOI: 10.1002/jbm4.10796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/05/2023] [Accepted: 06/19/2023] [Indexed: 10/10/2023] Open
Abstract
Degenerative osteoarthritis (OA) is recognized as an early-onset comorbidity of X-linked hypophosphatemia (XLH), contributing to pain and stiffness and limiting range of motion and activities of daily living. Here, we extend prior findings describing biochemical and cellular changes of articular cartilage (AC) in the phosphate-wasting environment of XLH to determine the impact of these changes on the biomechanical properties of AC in compression and potential role in the etiology of OA. We hypothesize that despite increased proteoglycan biosynthesis, disruption of the mineralized zone of AC impacts the mechanical properties of cartilage that function to accommodate loads and that therapeutic restoration of this zone will improve the mechanical properties of AC. Data were compared between three groups: wild type (WT), Hyp, and Hyp mice treated with calcitriol and oral phosphate. EPIC microCT confirmed AC mineral deficits and responsiveness to therapy. MicroCT of the Hyp subchondral bone plate revealed that treatment improved trabecular bone volume (BV/TV) but remained significantly lower than WT mice in other trabecular microstructures (p < 0.05). Microindentation AC studies revealed that, compared with WT mice, the mean stiffness of tibial AC was significantly lower in untreated Hyp mice (2.65 ± 0.95 versus 0.87 ± 0.33 N/mm, p < 0.001) and improved with therapy (2.15 + 0.38 N/mm) to within WT values. Stress relaxation of AC under compressive loading displayed similar biphasic relaxation time constants (Taufast and Tauslow) between controls and Hyp mice, although Tauslow trended toward slowed relaxation times. In addition, Taufast and Tauslow times correlated with peak load in WT mice (r = 0.80; r = 0.78, respectively), whereas correlation coefficient values for Hyp mice (r = 0.46; r = 0.21) improved with treatment (r = 0.71; r = 0.56). These data provide rationale for therapies that both preserve AC stiffness and recovery from compression. The Hyp mouse also provides unique insight into determinants of structural stiffness and the viscoelastic properties of AC in the progression of OA. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Carolyn M Macica
- Connecticut Children's Research InstituteHartfordCTUSA
- Department of PharmacologyYale University School of MedicineNew HavenCTUSA
| | - Steven M Tommasini
- Department of Orthopaedics and RehabilitationYale University School of MedicineNew HavenCTUSA
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Kato H, Braddock DT, Ito N. Genetics of Diffuse Idiopathic Skeletal Hyperostosis and Ossification of the Spinal Ligaments. Curr Osteoporos Rep 2023; 21:552-566. [PMID: 37530996 PMCID: PMC10543536 DOI: 10.1007/s11914-023-00814-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 08/03/2023]
Abstract
PURPOSE OF REVIEW The study aims to provide updated information on the genetic factors associated with the diagnoses 'Diffuse Idiopathic Skeletal Hyperostosis' (DISH), 'Ossification of the Posterior Longitudinal Ligament' (OPLL), and in patients with spinal ligament ossification. RECENT FINDINGS Recent studies have advanced our knowledge of genetic factors associated with DISH, OPLL, and other spinal ossification (ossification of the anterior longitudinal ligament [OALL] and the yellow ligament [OYL]). Several case studies of individuals afflicted with monogenic disorders, such as X-linked hypophosphatemia (XLH), demonstrate the strong association of fibroblast growth factor 23-related hypophosphatemia with OPLL, suggesting that pathogenic variants in PHEX, ENPP1, and DMP1 are associated with FGF23-phosphate wasting phenotype and strong genetic factors placing patients at risk for OPLL. Moreover, emerging evidence demonstrates that heterozygous and compound heterozygous ENPP1 pathogenic variants inducing 'Autosomal Recessive Hypophosphatemic Rickets Type 2' (ARHR2) also place patients at risk for DISH and OPLL, possibly due to the loss of inhibitory plasma pyrophosphate (PPi) which suppresses ectopic calcification and enthesis mineralization. Our findings emphasize the importance of genetic and plasma biomarker screening in the clinical evaluation of DISH and OPLL patients, with plasma PPi constituting an important new biomarker for the identification of DISH and OPLL patients whose disease course may be responsive to ENPP1 enzyme therapy, now in clinical trials for rare calcification disorders.
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Affiliation(s)
- Hajime Kato
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan.
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan.
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Rana R, Baker JT, Sorsby M, Jagga S, Venkat S, Almardini S, Liu ES. Impaired 1,25-dihydroxyvitamin D3 action underlies enthesopathy development in the Hyp mouse model of X-linked hypophosphatemia. JCI Insight 2023; 8:e163259. [PMID: 37490334 PMCID: PMC10544216 DOI: 10.1172/jci.insight.163259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/20/2023] [Indexed: 07/27/2023] Open
Abstract
X-linked hypophosphatemia (XLH) is characterized by high serum fibroblast growth factor 23 (FGF23) levels, resulting in impaired 1,25-dihydroxyvitamin D3 (1,25D) production. Adults with XLH develop a painful mineralization of the tendon-bone attachment site (enthesis), called enthesopathy. Treatment of mice with XLH (Hyp) with 1,25D or an anti-FGF23 Ab, both of which increase 1,25D signaling, prevents enthesopathy. Therefore, we undertook studies to determine a role for impaired 1,25D action in enthesopathy development. Entheses from mice lacking vitamin D 1α-hydroxylase (Cyp27b1) (C-/-) had a similar enthesopathy to Hyp mice, whereas deletion of Fgf23 in Hyp mice prevented enthesopathy, and deletion of both Cyp27b1 and Fgf23 in mice resulted in enthesopathy, demonstrating that the impaired 1,25D action due to high FGF23 levels underlies XLH enthesopathy development. Like Hyp mice, enthesopathy in C-/- mice was observed by P14 and was prevented, but not reversed, with 1,25D therapy. Deletion of the vitamin D receptor in scleraxis-expressing cells resulted in enthesopathy, indicating that 1,25D acted directly on enthesis cells to regulate enthesopathy development. These results show that 1,25D signaling was necessary for normal postnatal enthesis maturation and played a role in XLH enthesopathy development. Optimizing 1,25D replacement in pediatric patients with XLH is necessary to prevent enthesopathy.
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Affiliation(s)
- Rakshya Rana
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jiana T. Baker
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Melissa Sorsby
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Supriya Jagga
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Shreya Venkat
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Shaza Almardini
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Eva S. Liu
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Buss DJ, Rechav K, Reznikov N, McKee MD. Mineral tessellation in mouse enthesis fibrocartilage, Achilles tendon, and Hyp calcifying enthesopathy: A shared 3D mineralization pattern. Bone 2023:116818. [PMID: 37295663 DOI: 10.1016/j.bone.2023.116818] [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: 04/06/2023] [Revised: 05/17/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
The hallmark of enthesis architecture is the 3D compositional and structural gradient encompassing four tissue zones - tendon/ligament, uncalcified fibrocartilage, calcified fibrocartilage and bone. This functional gradient accommodates the large stiffness differential between calcified bone and uncalcified tendon/ligament. Here we analyze in 3D the organization of the mouse Achilles enthesis and mineralizing Achilles tendon in comparison to lamellar bone. We use correlative, multiscale high-resolution volume imaging methods including μCT with submicrometer resolution and FIB-SEM tomography (both with deep learning-based image segmentation), and TEM and SEM imaging, to describe ultrastructural features of physiologic, age-related and aberrant mineral patterning. We applied these approaches to murine wildtype (WT) Achilles enthesis tissues to describe in normal calcifying fibrocartilage a crossfibrillar mineral tessellation pattern similar to that observed in lamellar bone, but with greater variance in mineral tesselle morphology and size. We also examined Achilles enthesis structure in Hyp mice, a murine model for the inherited osteomalacic disease X-linked hypophosphatemia (XLH) with calcifying enthesopathy. In Achilles enthesis fibrocartilage of Hyp mice, we show defective crossfibrillar mineral tessellation similar to that which occurs in Hyp lamellar bone. At the cellular level in fibrocartilage, unlike in bone where enlarged osteocyte mineral lacunae are found as peri-osteocytic lesions, mineral lacunar volumes for fibrochondrocytes did not differ between WT and Hyp mice. While both WT and Hyp aged mice demonstrate Achilles tendon midsubstance ectopic mineralization, a consistently defective mineralization pattern was observed in Hyp mice. Strong immunostaining for osteopontin was observed at all mineralization sites examined in both WT and Hyp mice. Taken together, this new 3D ultrastructural information describes details of common mineralization trajectories for enthesis, tendon and bone, which in Hyp/XLH are defective.
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Affiliation(s)
- Daniel J Buss
- Department of Anatomy and Cell Biology, School of Biomedical Sciences, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Katya Rechav
- Electron Microscopy Unit, Weizmann Institute of Science, Rehovot, Israel
| | - Natalie Reznikov
- Department of Anatomy and Cell Biology, School of Biomedical Sciences, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada; Department of Bioengineering, Faculty of Engineering, McGill University, Montreal, Quebec, Canada; Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Marc D McKee
- Department of Anatomy and Cell Biology, School of Biomedical Sciences, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada; Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec, Canada.
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Insights into the Molecular and Hormonal Regulation of Complications of X-Linked Hypophosphatemia. ENDOCRINES 2023. [DOI: 10.3390/endocrines4010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Abstract
X-linked hypophosphatemia (XLH) is characterized by mutations in the PHEX gene, leading to elevated serum levels of FGF23, decreased production of 1,25 dihydroxyvitamin D3 (1,25D), and hypophosphatemia. Those affected with XLH manifest impaired growth and skeletal and dentoalveolar mineralization as well as increased mineralization of the tendon–bone attachment site (enthesopathy), all of which lead to decreased quality of life. Many molecular and murine studies have detailed the role of mineral ions and hormones in regulating complications of XLH, including how they modulate growth and growth plate maturation, bone mineralization and structure, osteocyte-mediated mineral matrix resorption and canalicular organization, and enthesopathy development. While these studies have provided insight into the molecular underpinnings of these skeletal processes, current therapies available for XLH do not fully prevent or treat these complications. Therefore, further investigations are needed to determine the molecular pathophysiology underlying the complications of XLH.
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12
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Kato H, Okawa R, Ogasawara T, Hoshino Y, Hidaka N, Koga M, Kinoshita Y, Kobayashi H, Taniguchi Y, Fukumoto S, Nangaku M, Makita N, Hoshi K, Nakano K, Ito N. Effect of conventional treatment on dental complications and ectopic ossifications among 30 adults with XLH. J Clin Endocrinol Metab 2022; 108:1405-1414. [PMID: 36524341 DOI: 10.1210/clinem/dgac732] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/29/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
CONTEXT Conventional treatment of XLH was reported to prevent dental complications, but whether the preventive effect was different among different types of teeth, including anterior teeth and molar teeth, is uncertain. Evidence of the preventive effect of conventional treatment on ectopic ossifications is also limited. OBJECTIVE To compare dental complications and ectopic ossifications among XLH adults with early (< 5 years old) or late (≥5 years old) conventional treatment. METHODS This retrospective observational study included a total of 30 adults with XLH using orthopantomograms, spinal computed tomography scans and X-rays of hip/knee joints. Dental complications, including decayed, missing filled (DMF) index and devitalized tooth, apical periodontitis, and periodontitis, were evaluated. The index of ossification of the anterior/posterior longitudinal ligament and yellow ligament (OA/OP/OY index) and the sum of the OA/OP/OY index (OS index) were utilized to evaluate the severity of spinal ligament ossification. The severity of the hip/knee osteophytes was evaluated by the Kellgren-Lawrence (KL) classification. RESULTS The number of sound teeth was significantly lower, and the DMF index was significantly higher in patients with late treatment. The severity of dental complications in the anterior tooth and molar tooth, OA/OP/OY/OS index, and KL grade were not significantly different among patients with early treatment and those with late treatment. CONCLUSION Early treatment could prevent dental complications but did not prevent ectopic ossification in adult patients with XLH. The difference in the preventive effect was not observed among different types of teeth.
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Affiliation(s)
- Hajime Kato
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Rena Okawa
- Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Osaka, Japan
| | - Toru Ogasawara
- Department of Oral and Maxillofacial Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshitomo Hoshino
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Naoko Hidaka
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Minae Koga
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuka Kinoshita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroshi Kobayashi
- Department of Orthopedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuki Taniguchi
- Department of Orthopedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Noriko Makita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazuto Hoshi
- Department of Oral and Maxillofacial Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazuhiko Nakano
- Department of Pediatric Dentistry, Osaka University Graduate School of Dentistry, Osaka, Japan
| | - Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
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13
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Bai X, Levental M, Karaplis AC. Burosumab Treatment for Autosomal Recessive Hypophosphatemic Rickets Type 1 (ARHR1). J Clin Endocrinol Metab 2022; 107:2777-2783. [PMID: 35896139 PMCID: PMC9516063 DOI: 10.1210/clinem/dgac433] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Autosomal recessive hypophosphatemic rickets (ARHR) are rare, heritable renal phosphate-wasting disorders that arise from overexpression of the bone-derived phosphaturic hormone fibroblast growth factor 23 (FGF23) leading to impaired bone mineralization (rickets and osteomalacia). Inactivating mutations of Dentin matrix protein 1 (DMP1) give rise to ARHR type 1 (ARHR1). Short stature, prominent bowing of the legs, fractures/pseudofractures, and severe enthesopathy are prominent in this patient population. Traditionally, treatment consists of oral phosphate replacement and the addition of calcitriol but this approach is limited by modest efficacy and potential renal and gastrointestinal side effects. OBJECTIVE The advent of burosumab (Crysvita), a fully humanized monoclonal antibody to FGF23 for the treatment of X-linked hypophosphatemia and tumor-induced osteomalacia, offers a unique opportunity to evaluate its safety and efficacy in patients with ARHR1. RESULTS Monthly administration of burosumab to 2 brothers afflicted with the disorder resulted in normalization of serum phosphate, healing of pseudofracture, diminished fatigue, less bone pain, and reduced incapacity arising from the extensive enthesopathy and soft tissue fibrosis/calcification that characterizes this disorder. No adverse effects were reported following burosumab administration. CONCLUSION The present report highlights the beneficial biochemical and clinical outcomes associated with the use of burosumab in patients with ARHR1.
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Affiliation(s)
- Xiuying Bai
- Lady Davis Institute for Medical Research, CIUSSS de Centre-Ouest-de-l’île-de-Montréal, Jewish General Hospital, McGill University, Montréal, Quebec, H3T 1E2, Canada
| | - Mark Levental
- Department of Radiology, CIUSSS de Centre-Ouest-de-l’île-de-Montréal, Jewish General Hospital, McGill University, Montréal, Quebec, H3T 1E2, Canada
| | - Andrew C Karaplis
- Correspondence: Andrew C. Karaplis, MD, PhD, Lady Davis Institute for Medical Research, 3755 Cote Steve Catherine, Montreal, QC, H3T 1E2, Canada.
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Hurley MM, Coffin JD, Doetschman T, Valera C, Clarke K, Xiao L. FGF receptor inhibitor BGJ398 partially rescues osteoarthritis-like phenotype in older high molecular weight FGF2 transgenic mice via multiple mechanisms. Sci Rep 2022; 12:15968. [PMID: 36153352 PMCID: PMC9509331 DOI: 10.1038/s41598-022-20269-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
We have used Basic Fibroblast Growth Factor (FGF2) transgenic mice as experimental models for human X-linked hypophosphatemia (XLH)-related degenerative osteoarthritis (OA) to investigate the pathogenesis of the disease and to test potential pharmacotherapies for treatment. This study tested the efficacy of BJG398, a small molecule fibroblast growth factor receptor tyrosine kinase (FGFRTK) inhibitor, to rescue the knee joint osteoarthritis phenotype in High Molecular Weight fibroblast growth factor 2 transgenic (HMWTgFGF2) mice. BJG398 was administered in vivo to 8-month-old female HMWTgFGF2 mice for six weeks. Histomorphometry, immunohistochemistry and micro-CT were used to examine the knee joints in BGJ398-treated and control mice. We assessed: Fibroblast Growth Factor 23 (FGF23) expression and FGFR1 activity; Matrix metalloproteinase 13 (MMP13) and Aggrecanase2 (ADAMTS5) expression; then signaling by SMAD1/5/8-pSMAD6, pERK1/2 and Runt-related transcription factor 2 (RUNX2). Using PrimePCR arrays, we identified a contributing role for major target genes in the TGFB/BMP2 signaling pathway that were regulated by BGJ398. BGJ398 inhibited HMWFGF2/FGF23-induced increase in bone morphogenic protein receptor-1, bone morphogenic protein-2 and 4 and Serine peptidase inhibitor, clade E, member 1. The results from Micro-CT and histology show BGJ398 treatment rescued the OA changes in subchondral bone and knee articular cartilage of HMWTgFGF2 mice. The gene expression and signal transduction results provide convincing evidence that HMWFGF2 generates OA through FGFRTK with characteristic downstream signaling that defines OA, namely: increased FGF23-FGFR1 activity with BMP-BMPR, activation of pSMAD1/5/8-RUNX2 and pERK signaling pathways, then upregulation of MMP13 and ADAMTS5 to degrade matrix. BGJ398 treatment effectively reversed these OA molecular phenotypes, providing further evidence that the OA generated by HMWFGF2 in the transgenic mice is FGFR-mediated and phenocopies the OA found in the Hyp mouse homolog of XLH with a spontaneous mutation in the Phex (phosphate regulating endopeptidase on the X chromosome) gene and human XLH-OA. Overall, the results obtained here explain how the pleotropic effects of FGF2 emanate from the different functions of HMW protein isoforms for cartilage and bone homeostasis, and the pathogenesis of XLH-degenerative osteoarthropathy. BGJ398 inhibits HMWFGF2-induced osteoarthritis via multiple mechanisms. These results provided important scientific evidence for the potential application of BGJ398 as a therapeutic agent for osteoarthritis in XLH.
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Affiliation(s)
- Marja M Hurley
- Department of Medicine, School of Medicine, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030-3023, USA.
| | - J Douglas Coffin
- Department BMED, SB 271, The University of Montana, Missoula, MT, 59812, USA
| | - Thomas Doetschman
- Department of Cellular and Molecular Medicine, University of Arizona College of Medicine, Tucson, AZ, 85724, USA
| | - Christina Valera
- Department of Medicine, School of Medicine, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030-3023, USA
| | - Kai Clarke
- Department of Medicine, School of Medicine, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030-3023, USA
| | - Liping Xiao
- Department of Medicine, School of Medicine, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030-3023, USA
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15
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Macica CM, Luo J, Tommasini SM. The Enthesopathy of XLH Is a Mechanical Adaptation to Osteomalacia: Biomechanical Evidence from Hyp Mice. Calcif Tissue Int 2022; 111:313-322. [PMID: 35618776 DOI: 10.1007/s00223-022-00989-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 05/06/2022] [Indexed: 11/02/2022]
Abstract
A major comorbidity of X-linked hypophosphatemia (XLH) is fibrocartilaginous tendinous insertion site mineralization resulting in painful enthesophytes that contribute to the adult clinical picture and significantly impact physical function. Enthesophytes in Hyp mice, a murine model of XLH are the result of a hyperplastic expansion of resident alkaline phosphatase, Sox9-positive mineralizing fibrochondrocytes. Here, we hypothesized hyperplasia as a compensatory physical adaptation to aberrant mechanical stresses at the level of the entheses interface inserting into pathologically soft bone. To test this hypothesis, we examined the Achilles insertion of the triceps surae developed under normal and impaired loading conditions in Hyp and WT mice. Tensile stiffness, ultimate strength, and maximum strain were measured and compared. Biomechanical testing revealed that under normal loading conditions, despite inserting into a soft bone matrix, both the enthesophyte development (9 weeks) and progression (6-8 months) of Hyp mice were equivalent to the mechanical properties of WT mice. Unloading the insertion during development significantly reduced alkaline phosphatase, Sox9-positive fibrochondrocytes. In WT mice, this correlated with a decrease in stiffness and ultimate strength relative to the control limb, confirming the critical role of mechanical loading in the development of the enthesis. Most significantly, in response to unloading, maximum strain was increased in tensile tests only in the setting of subchondral osteomalacia of Hyp mice. These data suggest that mineralizing fibrochondrocyte expansion in XLH occurs as a compensatory adaptation to the soft bone matrix.
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Affiliation(s)
- Carolyn M Macica
- Department of Medical Sciences, Frank H. Netter, M.D., School of Medicine at Quinnipiac University, North Haven, CT, 06518, USA.
- , 275, Mt Carmel Ave, Hamden, CT, 06518, USA.
| | - Jack Luo
- Department of Medical Sciences, Frank H. Netter, M.D., School of Medicine at Quinnipiac University, North Haven, CT, 06518, USA
| | - Steven M Tommasini
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, 06510, USA
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16
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Kanamalla K, Fuchs R, Herzog C, Steigbigel KD, Macica CM. An Evidence-based Physical Therapy Prescription for Adults With X-linked Hypophosphatemia. J Endocr Soc 2022; 6:bvac094. [PMID: 35795809 PMCID: PMC9249973 DOI: 10.1210/jendso/bvac094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Indexed: 11/23/2022] Open
Abstract
Context X-linked hypophosphatemia (XLH) is a rare and progressive metabolic phosphate-wasting disorder characterized by lifelong musculoskeletal comorbidities. Despite considerable physical disability, there are currently no disease-specific physical therapy (PT) recommendations for XLH designed to improve engagement and confidence in performing activities of daily living (ADL). Objective The objective of this patient-centered study was to develop an evidence-based PT program to address gaps in the management of adult XLH without imposing unintended harm. Methods Creation of the program was informed by a prior controlled clinical study to evaluate the physical and functional effect of XLH on adulthood, and guided by the physical presentation of participants, subjective data and patient goals acquired at intake, and by performance on multiple active range of motion (ROM) movements from the standing position. A weekly standardized interview process was used to assess progression of physical and functional abilities, gains and concerns, and to obtain timely feedback to inform future exercise modifications. Outcomes were evaluated using validated functional tools and subjective data obtained throughout the study. Results A remote 12-week PT program was created based on collected data. Open and closed kinetic-chain exercises were developed and implemented. Functional improvements were documented, and weekly surveys indicated improved abilities and confidence to engage in ADL. Minimal improvements were observed in active upper and lower extremity ROM, reflective of substantial bony restrictions characteristic of XLH. Conclusion This study represents the first disease-specific PT recommendations for XLH to mitigate the unique physical challenges of the adult disorder that can be modified to adapt to the current progression status of the adult disorder.
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Affiliation(s)
- Karthik Kanamalla
- Quinnipiac University, Frank H. Netter MD School of Medicine, Department of Medical Sciences, North Haven, Connecticut 06518, USA
| | - Rebekah Fuchs
- Quinnipiac University, School of Health Sciences, Department of Physical Therapy, North Haven, Connecticut 06518, USA
| | - Casey Herzog
- Quinnipiac University, School of Health Sciences, Department of Physical Therapy, North Haven, Connecticut 06518, USA
| | - Keith D Steigbigel
- Quinnipiac University, Frank H. Netter MD School of Medicine, Department of Medical Sciences, North Haven, Connecticut 06518, USA
| | - Carolyn M Macica
- Quinnipiac University, Frank H. Netter MD School of Medicine, Department of Medical Sciences, North Haven, Connecticut 06518, USA
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17
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Kato H, Ansh AJ, Lester ER, Kinoshita Y, Hidaka N, Hoshino Y, Koga M, Taniguchi Y, Uchida T, Yamaguchi H, Niida Y, Nakazato M, Nangaku M, Makita N, Takamura T, Saito T, Braddock DT, Ito N. Identification of ENPP1 Haploinsufficiency in Patients With Diffuse Idiopathic Skeletal Hyperostosis and Early-Onset Osteoporosis. J Bone Miner Res 2022; 37:1125-1135. [PMID: 35340077 PMCID: PMC9177665 DOI: 10.1002/jbmr.4550] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 11/10/2022]
Abstract
Homozygous ENPP1 mutations are associated with autosomal recessive hypophosphatemic rickets type 2 (ARHR2), severe ossification of the spinal ligaments, and generalized arterial calcification of infancy type 1. There are a limited number of reports on phenotypes associated with heterozygous ENPP1 mutations. Here, we report a series of three probands and their families with heterozygous and compound heterozygous ENPP1 mutations. The first case (case 1) was a 47-year-old male, diagnosed with early-onset osteoporosis and low-normal serum phosphate levels, which invoked suspicion for hypophosphatemic rickets. The second and third cases were 77- and 54-year-old females who both presented with severe spinal ligament ossification and the presumptive diagnosis of diffuse idiopathic skeletal hyperostosis (DISH). Upon workup, fibroblast growth factor 23 (FGF23) was noted to be relatively high in case 2 and serum phosphorous was low-normal in case 3, and the diagnoses of X-linked hypophosphatemic rickets (XLH) and ARHR2 were considered. Genetic testing for genes related to congenital hypophosphatemic rickets was therefore performed, revealing heterozygous ENPP1 variants in cases 1 and 2 (case 1, c.536A>G, p.Asn179Ser; case 2, c.1352A>G, p.Tyr451Cys) and compound heterozygous ENPP1 variants in case 3 constituting the same variants present in cases 1 and 2 (c.536A>G, p.Asn179Ser and c.1352A>G, p.Tyr451Cys). Several in silico tools predicted the two variants to be pathogeneic, a finding confirmed by in vitro biochemical analysis demonstrating that the p.Asn179Ser and p.Tyr451Cys ENPP1 variants possessed a catalytic velocity of 45% and 30% compared with that of wild-type ENPP1, respectively. Both variants were therefore categorized as pathogenic loss-of-function mutations. Our findings suggest that ENPP1 mutational status should be evaluated in patients presenting with the diagnosis of idiopathic DISH, ossification of the posterior longitudinal ligament (OPLL), and early-onset osteoporosis. © 2022 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Hajime Kato
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis center, The University of Tokyo Hospital, Tokyo, Japan
| | - Anenya J. Ansh
- Department of Pathology, Yale University, New Haven, CT, USA
| | - Ethan R. Lester
- Department of Pathology, Yale University, New Haven, CT, USA
| | - Yuka Kinoshita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis center, The University of Tokyo Hospital, Tokyo, Japan
| | - Naoko Hidaka
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis center, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshitomo Hoshino
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis center, The University of Tokyo Hospital, Tokyo, Japan
| | - Minae Koga
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis center, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuki Taniguchi
- Department of Orthopedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Taisuke Uchida
- Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Hideki Yamaguchi
- Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yo Niida
- Division of Genomic Medicine, Department of Advanced Medicine, Medical Research Institute, Kanazawa Medical University, Ishikawa, Japan
| | - Masamitsu Nakazato
- Division of Neurology, Respirology, Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Noriko Makita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis center, The University of Tokyo Hospital, Tokyo, Japan
| | - Toshinari Takamura
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Ishikawa, Japan
| | - Taku Saito
- Osteoporosis center, The University of Tokyo Hospital, Tokyo, Japan
- Department of Orthopedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis center, The University of Tokyo Hospital, Tokyo, Japan
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18
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Trombetti A, Al-Daghri N, Brandi ML, Cannata-Andía JB, Cavalier E, Chandran M, Chaussain C, Cipullo L, Cooper C, Haffner D, Harvengt P, Harvey NC, Javaid MK, Jiwa F, Kanis JA, Laslop A, Laurent MR, Linglart A, Marques A, Mindler GT, Minisola S, Yerro MCP, Rosa MM, Seefried L, Vlaskovska M, Zanchetta MB, Rizzoli R. Interdisciplinary management of FGF23-related phosphate wasting syndromes: a Consensus Statement on the evaluation, diagnosis and care of patients with X-linked hypophosphataemia. Nat Rev Endocrinol 2022; 18:366-384. [PMID: 35484227 DOI: 10.1038/s41574-022-00662-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 12/17/2022]
Abstract
X-linked hypophosphataemia (XLH) is the most frequent cause of hypophosphataemia-associated rickets of genetic origin and is associated with high levels of the phosphaturic hormone fibroblast growth factor 23 (FGF23). In addition to rickets and osteomalacia, patients with XLH have a heavy disease burden with enthesopathies, osteoarthritis, pseudofractures and dental complications, all of which contribute to reduced quality of life. This Consensus Statement presents the outcomes of a working group of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases, and provides robust clinical evidence on management in XLH, with an emphasis on patients' experiences and needs. During growth, conventional treatment with phosphate supplements and active vitamin D metabolites (such as calcitriol) improves growth, ameliorates leg deformities and dental manifestations, and reduces pain. The continuation of conventional treatment in symptom-free adults is still debated. A novel therapeutic approach is the monoclonal anti-FGF23 antibody burosumab. Although promising, further studies are required to clarify its long-term efficacy, particularly in adults. Given the diversity of symptoms and complications, an interdisciplinary approach to management is of paramount importance. The focus of treatment should be not only on the physical manifestations and challenges associated with XLH and other FGF23-mediated hypophosphataemia syndromes, but also on the major psychological and social impact of the disease.
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Affiliation(s)
- Andrea Trombetti
- Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- Division of Geriatrics, Department of Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Nasser Al-Daghri
- Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | | | - Jorge B Cannata-Andía
- Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
- Universidad de Oviedo, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
- Retic REDinREN-RICORS, 2040-ISCIII, Madrid, Spain
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liege, CHU de Liège, Liège, Belgium
| | - Manju Chandran
- Complicated Metabolic Bone Disorders Clinic, Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Catherine Chaussain
- Université de Paris, Institut des maladies musculo-squelettiques, URP2496, UFR Odontologie, Montrouge, France
- AP-HP, FHU DDS-Net, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphore, Service médecine bucco-dentaire, Hôpital Bretonneau, GH Paris Nord Université de Paris, Paris, France
| | - Lucia Cipullo
- Patient representative with XLH, Geneva, Switzerland
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Dieter Haffner
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Pol Harvengt
- XLH Belgium, Belgian association of patients with XLH (a member of the International XLH Alliance), Waterloo, Belgium
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Famida Jiwa
- Chair of the Committee of Patients Societies at the International Osteoporosis Foundation, Osteoporosis Canada, Toronto, Canada
| | - John A Kanis
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - Andrea Laslop
- Scientific Office, Federal Office for Safety in Health Care, Vienna, Austria
| | - Michaël R Laurent
- Centre for Metabolic Bone Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Agnès Linglart
- Paris-Saclay University, INSERM U1185, Le Kremlin-Bicêtre, France
- AP-HP, endocrinology and diabetes for children, Reference centre for rare diseases of calcium and phosphate metabolism, OSCAR network, Platform of expertise for rare diseases of Paris Saclay Hospital, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Andréa Marques
- Rheumatology Department, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
- Health Sciences Research Unit: Nursing (UICiSA:E), Nursing School of Coimbra, Coimbra, Portugal
| | - Gabriel T Mindler
- Department of Paediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, 'Sapienza', Rome University, Rome, Italy
| | | | - Mario Miguel Rosa
- Departamento de Neurociências, Laboratório de Farmacologia Clínica E Terapêutica Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Lothar Seefried
- Orthopedic Department, University of Würzburg, Würzburg, Germany
| | - Mila Vlaskovska
- Medical Faculty, Department of Pharmacology, Medical University Sofia, Sofia, Bulgaria
| | - María Belén Zanchetta
- Instituto de Investigaciones Metabólicas (IDIM), Universidad del Salvador, Buenos Aires, Argentina
| | - René Rizzoli
- Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
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Ferreira CR, Ansh AJ, Nester C, O’Brien C, Stabach PR, Murtada SI, Lester ER, Khursigara G, Molloy L, Carpenter TO, Braddock DT. Musculoskeletal Comorbidities and Quality of Life in ENPP1-Deficient Adults and the Response of Enthesopathy to Enzyme Replacement Therapy in Murine Models. J Bone Miner Res 2022; 37:494-504. [PMID: 34882836 PMCID: PMC9667476 DOI: 10.1002/jbmr.4487] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 11/04/2021] [Accepted: 12/05/2021] [Indexed: 12/20/2022]
Abstract
Ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) deficiency leads to cardiovascular calcification in infancy, fibroblast growth factor 23 (FGF23)-mediated hypophosphatemic rickets in childhood, and osteomalacia in adulthood. Excessive enthesis mineralization and cervical spine fusion have been previously reported in patients with biallelic ENPP1 deficiency, but their effect on quality of life is unknown. We describe additional musculoskeletal complications in patients with ENPP1 deficiency, namely osteoarthritis and interosseous membrane ossification, and for the first time evaluate health-related quality of life (HRQoL) in patients with this disease, both subjectively via narrative report, and objectively via the Brief Pain Inventory-Short Form, and a Patient Reported Outcome Measurement Information System Physical Function (PROMIS PF) short form. Residual pain, similar in magnitude to that identified in adult patients with X-linked hypophosphatemia, was experienced by the majority of patients despite use of analgesic medications. Impairment in physical function varied from mild to severe. To assess murine ENPP1 deficiency for the presence of enthesopathy, and for the potential response to enzyme replacement therapy, we maintained Enpp1asj/asj mice on regular chow for 23 weeks and treated cohorts with either vehicle or a long-acting form of recombinant ENPP1. Enpp1asj/asj mice treated with vehicle exhibited robust calcification throughout their Achilles tendons, whereas two-thirds of those treated with ENPP1 enzyme replacement exhibited complete or partial suppression of the Achilles tendon calcification. Our combined results document that musculoskeletal complications are a significant source of morbidity in biallelic ENPP1 deficiency, a phenotype which is closely recapitulated in Enpp1asj/asj mice. Finally, we show that a long-acting form of recombinant ENPP1 prevents the development of enthesis calcification at the relatively modest dose of 0.3 mg/kg per week, suggesting that suppression of enthesopathy may be attainable upon dose escalation. © 2021 American Society for Bone and Mineral Research (ASBMR). This article has been contributed to by US Government employees and their work is in the public domain in the USA.
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Affiliation(s)
- Carlos R. Ferreira
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Anenya Jai Ansh
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | | | | | - Paul R. Stabach
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Sae-Il Murtada
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Ethan R. Lester
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | | | | | - Thomas O. Carpenter
- Department of Pediatrics (Endocrinology), Yale University School of Medicine, New Haven, CT, USA
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20
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Growth and mechanobiology of the tendon-bone enthesis. Semin Cell Dev Biol 2022; 123:64-73. [PMID: 34362655 PMCID: PMC8810906 DOI: 10.1016/j.semcdb.2021.07.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/17/2021] [Accepted: 07/20/2021] [Indexed: 12/15/2022]
Abstract
Tendons are cable-like connective tissues that transfer both active and passive forces generated by skeletal muscle to bone. In the mature skeleton, the tendon-bone enthesis is an interfacial zone of transitional tissue located between two mechanically dissimilar tissues: compliant, fibrous tendon to rigid, dense mineralized bone. In this review, we focus on emerging areas in enthesis development related to its structure, function, and mechanobiology, as well as highlight established and emerging signaling pathways and physiological processes that influence the formation and adaptation of this important transitional tissue.
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21
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Herrou J, Picaud AS, Lassalle L, Pacot L, Chaussain C, Merzoug V, Hervé A, Gadion M, Rothenbuhler A, Kamenický P, Roux C, Linglart A, Duplan MB, Briot K. Prevalence of Enthesopathies in Adults With X-linked Hypophosphatemia: Analysis of Risk Factors. J Clin Endocrinol Metab 2022; 107:e224-e235. [PMID: 34406383 DOI: 10.1210/clinem/dgab580] [Citation(s) in RCA: 7] [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: 05/10/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Enthesopathies are the determinant of a poor quality of life in adults with X-linked hypophosphatemia (XLH). OBJECTIVE To describe the prevalence of patients with enthesopathies and to identify the risk factors of having enthesopathies. METHODS Retrospective study in the French Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism between June 2011 and December 2020. Adult XLH patients with full body X-rays performed using the EOS® low-dose radiation system and clinical data collected from medical records. The main outcome measures were demographics, PHEX mutation, conventional treatment, and dental disease with the presence of enthesopathies. RESULTS Of the 114 patients included (68% women, mean age 42.2 ± 14.3 years), PHEX mutation was found in 105 patients (94.6%), 86 (77.5%) had been treated during childhood. Enthesopathies (spine and/or pelvis) were present in 67% of the patients (n = 76). Patients with enthesopathies were significantly older (P = .001) and more frequently reported dental disease collected from medical records (P = .03). There was no correlation between the PHEX mutations and the presence of enthesopathies. Sixty-two patients had a radiographic dental examination in a reference center. Severe dental disease (number of missing teeth, number of teeth endodontically treated, alveolar bone loss, and proportion of patients with 5 abscesses or more) was significantly higher in patients with enthesopathies. CONCLUSION Adult XLH patients have a high prevalence of enthesopathies in symptomatic adults patients with XLH seen in a reference center. Age and severe dental disease were significantly associated with the presence of enthesopathies.
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Affiliation(s)
- Julia Herrou
- INSERM UMR 1153, Université de Paris, APHP Centre, Paris, France
- APHP Centre, Department of Rheumatology, Cochin Hospital, Paris, France
| | - Axelle Salcion Picaud
- APHP Centre, Department of Rheumatology, Cochin Hospital, Paris, France
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
| | - Louis Lassalle
- APHP, Department of Radiology, Cochin Hospital, Paris, France
| | - Laurence Pacot
- APHP, Department of Genetics, Cochin Hospital, Paris, France
| | - Catherine Chaussain
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
- Université de Paris, Medical and Dental Schools, Paris, France
- APHP, Department of Odontology, Bretonneau Hospital, HUPNVS, Paris, France
| | - Valérie Merzoug
- APHP, Department of Pediatric Radiology, Bicêtre Paris Saclay Hospital, Le Kremlin Bicêtre, France
| | - Agathe Hervé
- APHP, Department of Odontology, Bretonneau Hospital, HUPNVS, Paris, France
| | - Margaux Gadion
- APHP, Department of Odontology, Bretonneau Hospital, HUPNVS, Paris, France
| | - Anya Rothenbuhler
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
- APHP, Department of Endocrinology and Diabetes for Children, Bicêtre Paris Saclay Hospital, Le Kremlin Bicêtre, France
- APHP, Plateforme d'expertise Paris Saclay maladies rares, Bicêtre Paris Saclay Hospital, Le Kremlin Bicêtre, France
| | - Peter Kamenický
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre,France
| | - Christian Roux
- INSERM UMR 1153, Université de Paris, APHP Centre, Paris, France
- APHP Centre, Department of Rheumatology, Cochin Hospital, Paris, France
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
| | - Agnès Linglart
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
- APHP, Department of Endocrinology and Diabetes for Children, Bicêtre Paris Saclay Hospital, Le Kremlin Bicêtre, France
- APHP, Plateforme d'expertise Paris Saclay maladies rares, Bicêtre Paris Saclay Hospital, Le Kremlin Bicêtre, France
| | - Martin Biosse Duplan
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
- Université de Paris, Medical and Dental Schools, Paris, France
- APHP, Department of Odontology, Bretonneau Hospital, HUPNVS, Paris, France
| | - Karine Briot
- INSERM UMR 1153, Université de Paris, APHP Centre, Paris, France
- APHP Centre, Department of Rheumatology, Cochin Hospital, Paris, France
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
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22
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Salcion A, Herrou J, Briot K. Adult rheumatologic features, treatment and complications of X-linked hypophosphatemia. Arch Pediatr 2021; 28:606-611. [PMID: 34625379 DOI: 10.1016/j.arcped.2021.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
X-linked hypophosphatemia (XLH) is a rare genetic phosphate disorder caused mainly by PHEX mutations. Unlike for children, knowledge of the disease's manifestations in adults is limited. Musculoskeletal symptoms are the main feature of the disease in young adults associated with a heavy burden on patients' life. They include fractures and pseudofractures, pain, joint stiffness, osteoarthritis, enthesopathies, and muscle weakness, eventually leading to impaired quality of life. Conventional treatment with phosphate supplements and vitamin D analogs is indicated in symptomatic patients. Appropriate rehabilitation is also a key to the management of the disease to improve physical function and decrease pain, stiffness, and fatigue. Regarding the incidence and consequences of musculoskeletal features in XLH, all patients should be assessed by a bone disease specialist and, if necessary, managed by a multidisciplinary team.
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Affiliation(s)
- Axelle Salcion
- Department of Rheumatology, Reference Center for Rare Disorders for Calcium and Phosphate Metabolism, Cochin Hospital, Paris, France
| | - Julia Herrou
- Department of Rheumatology, Reference Center for Rare Disorders for Calcium and Phosphate Metabolism, Cochin Hospital, Paris, France; INSERM U1153, Paris, France
| | - Karine Briot
- Department of Rheumatology, Reference Center for Rare Disorders for Calcium and Phosphate Metabolism, Cochin Hospital, Paris, France; INSERM U1153, Paris, France.
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Abstract
X-linked hypophosphatemia (XLH) is the most common form of inheritable rickets. The disease is caused principally by PHEX mutations leading to increased concentrations of circulating intact FGF23, hence renal phosphate wasting, hypophosphatemia, and decreased circulating levels of 1,25(OH)2 vitamin D. The chronic hypophosphatemia leads to rickets and osteomalacia through a combination of mechanisms, including a lack of endochondral ossification and impaired mineralization. Imaging has a major role in determining the diagnosis of rickets and its cause, detecting complications as early as possible, and helping in treatment monitoring.
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Kato H, Koga M, Kinoshita Y, Taniguchi Y, Kobayashi H, Fukumoto S, Nangaku M, Makita N, Ito N. Incidence of Complications in 25 Adult Patients With X-linked Hypophosphatemia. J Clin Endocrinol Metab 2021; 106:e3682-e3692. [PMID: 33912912 DOI: 10.1210/clinem/dgab282] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Indexed: 12/20/2022]
Abstract
CONTEXT Adults with X-linked hypophosphatemia (XLH) present complications other than osteomalacia. OBJECTIVE To describe the incidence and severity of comorbidities in adults with XLH. METHODS This observational retrospective study included a total of 25 adults with XLH with thorough investigations, including spinal computed tomography scans, x-rays of hip/knee joints and Achilles tendons, abdominal ultrasounds, and audiograms. The index of ossification of the anterior/posterior longitudinal ligament and yellow ligament (OA/OP/OY index) and the sum of OA/OP/OY index (OS index) were utilized to evaluate the severity of spinal ligament ossification. The Kellgren-Lawrence (KL) classification was adopted to evaluate the severity of the hip/knee osteophytes. RESULTS The participants consisted of 13 male patients and 12 female patients from 21 families, with a median age of 43 (range, 18-72) years. In all, 20 patients (80%) showed spinal ligament ossification. The median OA/OP/OY/OS indices were 2 (0-22), 0 (0-15), 6 (0-13), and 12 (0-41), respectively. Hip/knee osteophytes were reported in 24 (96%) and 17 cases (68%). The median KL grade was 3 in the hip joint and 2 in the knee joint, and 18 cases (72%) developed enthesopathy in the Achilles tendon. Nephrocalcinosis and hearing impairment were observed in 18 (72%) and 8 (32%) cases. CONCLUSION This study revealed a high prevalence and severity of ectopic ossification and disclosed the incidence of nephrocalcinosis and hearing impairment in adults with XLH. In cases with severe spinal ligament ossification or noticeable osteophytes around the hip/knee joints, undiagnosed XLH should be considered as a possible underlying condition.
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Affiliation(s)
- Hajime Kato
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Minae Koga
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Yuka Kinoshita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Yuki Taniguchi
- Department of Orthopedic Surgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Hiroshi Kobayashi
- Department of Orthopedic Surgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima 770-8503, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Noriko Makita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
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25
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Abstract
PURPOSE OF REVIEW X-Linked hypophosphatemia (XLH) is the most common genetic cause of rickets. This review describes advances in the management of XLH using burosumab which was FDA approved for treating children with XLH in 2018. RECENT FINDINGS Elevated FGF23 in XLH leads to systemic hypophosphatemia and several musculoskeletal manifestations, including rachitic bone deformities, impaired growth, dental abscesses, insufficiency fractures, osteoarthritis, and enthesopathy, with lifelong consequences for physical function and quality of life. Burosumab treatment has demonstrated clinical improvement of rickets and growth in children, including during a randomized controlled trial compared with conventional therapy. Burosumab also improved pseudofracture healing in adults. Burosumab led to greater improvement in rickets and growth than conventional therapy. However, many questions remain regarding the impact of burosumab on several outcomes, including final height, nephrocalcinosis, dental disease, enthesopathy, and surgical interventions.
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Affiliation(s)
- Erik A Imel
- Department of Medicine, Indiana University School of Medicine, 1120 West Michigan Street, CL 365, Indianapolis, IN, 46202-5111, USA.
- Department of Pediatrics, Indiana University School of Medicine, 1120 West Michigan Street, CL 365, Indianapolis, IN, 46202-5111, USA.
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26
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Koumakis E, Cormier C, Roux C, Briot K. The Causes of Hypo- and Hyperphosphatemia in Humans. Calcif Tissue Int 2021; 108:41-73. [PMID: 32285168 DOI: 10.1007/s00223-020-00664-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/20/2020] [Indexed: 12/11/2022]
Abstract
Phosphate homeostasis involves several major organs that are the skeleton, the intestine, the kidney, and parathyroid glands. Major regulators of phosphate homeostasis are parathormone, fibroblast growth factor 23, 1,25-dihydroxyvitamin D, which respond to variations of serum phosphate levels and act to increase or decrease intestinal absorption and renal tubular reabsorption, through the modulation of expression of transcellular transporters at the intestinal and/or renal tubular level. Any acquired or genetic dysfunction in these major organs or regulators may induce hypo- or hyperphosphatemia. The causes of hypo- and hyperphosphatemia are numerous. This review develops the main causes of acquired and genetic hypo- and hyperphosphatemia.
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Affiliation(s)
- Eugénie Koumakis
- Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Reference Center for Rare Genetic Bone Disorders, OSCAR Filière, Rheumatology Department, Cochin Hospital, AP-HP Centre-Paris University, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France.
| | - Catherine Cormier
- Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Reference Center for Rare Genetic Bone Disorders, OSCAR Filière, Rheumatology Department, Cochin Hospital, AP-HP Centre-Paris University, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Christian Roux
- Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Reference Center for Rare Genetic Bone Disorders, OSCAR Filière, Rheumatology Department, Cochin Hospital, AP-HP Centre-Paris University, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Karine Briot
- Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Reference Center for Rare Genetic Bone Disorders, OSCAR Filière, Rheumatology Department, Cochin Hospital, AP-HP Centre-Paris University, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
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27
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Abstract
Great strides over the past few decades have increased our understanding of the pathophysiology of hypophosphatemic disorders. Phosphate is critically important to a variety of physiologic processes, including skeletal growth, development and mineralization, as well as DNA, RNA, phospholipids, and signaling pathways. Consequently, hypophosphatemic disorders have effects on multiple systems, and may cause a variety of nonspecific signs and symptoms. The acute effects of hypophosphatemia include neuromuscular symptoms and compromise. However, the dominant effects of chronic hypophosphatemia are the effects on musculoskeletal function including rickets, osteomalacia and impaired growth during childhood. While the most common causes of chronic hypophosphatemia in children are congenital, some acquired conditions also result in hypophosphatemia during childhood through a variety of mechanisms. Improved understanding of the pathophysiology of these congenital conditions has led to novel therapeutic approaches. This article will review the pathophysiologic causes of congenital hypophosphatemia, their clinical consequences and medical therapy.
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Affiliation(s)
- Erik Allen Imel
- Division of Endocrinology, Departments of Medicine and Pediatrics, Indiana University School of Medicine, 1120 West Michigan Street, Gatch Building Room 365, Indianapolis, IN, 46112, USA.
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28
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Athonvarangkul D, Insogna KL. New Therapies for Hypophosphatemia-Related to FGF23 Excess. Calcif Tissue Int 2021; 108:143-157. [PMID: 32504139 DOI: 10.1007/s00223-020-00705-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/12/2020] [Indexed: 12/12/2022]
Abstract
FGF23 is a hormone produced by osteocytes in response to an elevation in the concentration of extracellular phosphate. Excess production of FGF23 by bone cells, or rarely by tumors, is the hormonal basis for several musculoskeletal syndromes characterized by hypophosphatemia due to renal phosphate wasting. FGF23-dependent chronic hypophosphatemia causes rickets and osteomalacia, as well as other skeletal complications. Genetic disorders of FGF23-mediated hypophosphatemia include X-linked hypophosphatemia (XLH), autosomal dominant hypophosphatemic rickets (ADHR), autosomal recessive hypophosphatemic rickets (ARHR), fibrous dysplasia of bone, McCune-Albright syndrome, and epidermal nevus syndrome (ENS), also known as cutaneous skeletal hypophosphatemia syndrome (CSHS). The principle acquired form of FGF23-mediated hypophosphatemia is tumor-induced osteomalacia (TIO). This review summarizes current knowledge about the pathophysiology and clinical presentation of the most common FGF23-mediated conditions, with a focus on new treatment modalities. For many decades, calcitriol and phosphate supplements were the mainstay of therapy. Recently, burosumab, a monoclonal blocking antibody to FGF23, has been approved for treatment of XLH in children and adults, and an active comparator trial in children has shown good efficacy and safety for this drug. The remainder of FGF23-mediated hypophosphatemic disorders continue to be treated with phosphate and calcitriol, although ongoing trials with burosumab for treatment of tumor-induced osteomalacia show early promise. Burosumab may be an effective treatment for the remainder of FGF23-mediated disorders, but clinical trials to support that possibility are at present not available.
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Affiliation(s)
- Diana Athonvarangkul
- Department of Medicine Section of Endocrinology, Yale School of Medicine, PO Box 802080, New Haven, CT, 06520, USA.
| | - Karl L Insogna
- Department of Medicine Section of Endocrinology, Yale School of Medicine, PO Box 802080, New Haven, CT, 06520, USA
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29
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Dahir K, Roberts MS, Krolczyk S, Simmons JH. X-Linked Hypophosphatemia: A New Era in Management. J Endocr Soc 2020; 4:bvaa151. [PMID: 33204932 PMCID: PMC7649833 DOI: 10.1210/jendso/bvaa151] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/07/2020] [Indexed: 01/29/2023] Open
Abstract
X-linked hypophosphatemia (XLH) is a rare, hereditary, progressive musculoskeletal disease that often causes pain and short stature, as well as decreased physical function, mobility, and quality of life. Hypophosphatemia in XLH is caused by loss of function mutations in the phosphate-regulating endopeptidase homolog X-linked (PHEX) gene, resulting in excess levels of the phosphate-regulating hormone fibroblast growth factor 23 (FGF23), which leads to renal phosphate wasting and decreased serum 1,25-dihydroxyvitamin D production. Historically, treatment options were limited to oral phosphate and active vitamin D analogues (conventional management) dosed several times daily in an attempt to improve skeletal mineralization by increasing serum phosphorus. The recent approval of burosumab, a fully human monoclonal antibody to FGF23, has provided a new, targeted treatment option for patients with XLH. This review summarizes our current understanding of XLH, the safety and efficacy of conventional management and burosumab, existing recommendations for managing patients, and unanswered questions in the field.
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Affiliation(s)
- Kathryn Dahir
- Endocrinology and Diabetes, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Jill H Simmons
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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30
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Boro H, Singh Naik S, Singh C, Khatiwada S, Khadgawat R. X-Linked Hypophosphatemic Rickets Manifesting as Sclerotic Bone Disease and Enthesopathy. Cureus 2020; 12:e10874. [PMID: 33178527 PMCID: PMC7652373 DOI: 10.7759/cureus.10874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
X-linked hypophosphatemic (XLH) rickets is a genetic disease caused due to the inactivation of the PHEX gene (phosphate regulating gene with homology to endopeptidase on the X chromosome). The usual presentation is with rickets and osteomalacia, and dental abscesses leading to premature loss of teeth. However, enthesopathy and sclerotic bone disease in XLH have also been reported in a few case reports. In this report, we describe the case of a 23-year-old female patient who presented to us with severe bone deformities, proximal myopathy, truncal weakness, and recent onset of pain and stiffness around the joints. She was diagnosed with XLH and was found to have severe enthesopathy along with heterotopic ossification.
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31
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Robinson ME, AlQuorain H, Murshed M, Rauch F. Mineralized tissues in hypophosphatemic rickets. Pediatr Nephrol 2020; 35:1843-1854. [PMID: 31392510 DOI: 10.1007/s00467-019-04290-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/03/2019] [Accepted: 06/06/2019] [Indexed: 12/19/2022]
Abstract
Hypophosphatemic rickets is caused by renal phosphate wasting that is most commonly due to X-linked dominant mutations in PHEX. PHEX mutations cause hypophosphatemia indirectly, through the increased expression of fibroblast growth factor 23 (FGF23) by osteocytes. FGF23 decreases renal phosphate reabsorption and thereby increases phosphate excretion. The lack of phosphate leads to a mineralization defect at the level of growth plates (rickets), bone tissue (osteomalacia), and teeth, where the defect facilitates the formation of abscesses. The bone tissue immediately adjacent to osteocytes often remains unmineralized ("periosteocytic lesions"), highlighting the osteocyte defect in this disorder. Common clinical features of XLH include deformities of the lower extremities, short stature, enthesopathies, dental abscesses, as well as skull abnormalities such as craniosynostosis and Chiari I malformation. For the past four decades, XLH has been treated by oral phosphate supplementation and calcitriol, which improves rickets and osteomalacia and the dental manifestations, but often does not resolve all aspects of the mineralization defects. A newer treatment approach using inactivating FGF23 antibodies leads to more stable control of serum inorganic phosphorus levels and seems to heal rickets more reliably. However, the long-term benefits of FGF23 antibody treatment remain to be elucidated.
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Affiliation(s)
- Marie-Eve Robinson
- Shriners Hospital for Children and McGill University, 1003 Boulevard Decarie, Montreal, Québec, H4A 0A9, Canada
| | - Haitham AlQuorain
- Shriners Hospital for Children and McGill University, 1003 Boulevard Decarie, Montreal, Québec, H4A 0A9, Canada
| | - Monzur Murshed
- Shriners Hospital for Children and McGill University, 1003 Boulevard Decarie, Montreal, Québec, H4A 0A9, Canada
| | - Frank Rauch
- Shriners Hospital for Children and McGill University, 1003 Boulevard Decarie, Montreal, Québec, H4A 0A9, Canada.
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32
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Faraji-Bellée CA, Cauliez A, Salmon B, Fogel O, Zhukouskaya V, Benoit A, Schinke T, Roux C, Linglart A, Miceli-Richard C, Chaussain C, Briot K, Bardet C. Development of Enthesopathies and Joint Structural Damage in a Murine Model of X-Linked Hypophosphatemia. Front Cell Dev Biol 2020; 8:854. [PMID: 33072734 PMCID: PMC7536578 DOI: 10.3389/fcell.2020.00854] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022] Open
Abstract
X-linked hypophosphatemia (XLH) is characterized by rickets and osteomalacia, caused by inactivating mutations in the Phosphate-regulating endopeptidase homolog X-linked (PHEX) gene. With aging, adult patients develop paradoxical heterotopic calcifications of tendons and ligaments at their insertion sites (enthesophytes), and joint alterations. Understanding the progression of this structural damage that severely affects patients’ quality of life will help to improve the management of XLH. Here, we characterized the occurrence of enthesophytes and joint alterations through a 12 month in vivo micro-CT follow-up in the Hyp mouse, a murine model of XLH (n = 5 mice per group). Similar to adult patients with XLH, Hyp mice developed calcaneal enthesophytes, hip joint alterations, erosions of the sacroiliac joints and periarticular calcifications. These lesions were already present at month 3 and gradually worsened over time. In sharp contrast, no abnormalities were observed in control mice at early time points. Histological analyses confirmed the presence of bone erosions, calcifications and expansion of mineralizing enthesis fibrocartilage in Hyp mice and their absence in controls and suggested that new bone formation is driven by altered mechanical strain. Interestingly, despite a strong deformation of the curvature, none of the Hyp mice displayed enthesophyte at the spine. Peripheral enthesophytes and joint alterations develop at the early stages of the disease and gradually worsen overtime. Overall, our findings highlight the relevance of this preclinical model to test new therapies aiming to prevent bone and joint complications in XLH.
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Affiliation(s)
- Carole-Anne Faraji-Bellée
- Université de Paris, Laboratory Orofacial Pathologies, Imaging and Biotherapies UR 2496, Dental School, Montrouge, France
| | - Axelle Cauliez
- Université de Paris, Laboratory Orofacial Pathologies, Imaging and Biotherapies UR 2496, Dental School, Montrouge, France
| | - Benjamin Salmon
- Université de Paris, Laboratory Orofacial Pathologies, Imaging and Biotherapies UR 2496, Dental School, Montrouge, France.,APHP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Dental Medicine Department, Bretonneau Hospital, Paris, France
| | - Olivier Fogel
- Department of Rheumatology, Cochin Hospital, Université de Paris, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, and Reference Center for Rare Genetic Bone Diseases, Cochin Hospital, Paris, France
| | - Volha Zhukouskaya
- Université de Paris, Laboratory Orofacial Pathologies, Imaging and Biotherapies UR 2496, Dental School, Montrouge, France.,APHP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR and Platform of Expertise for Rare Diseases Paris-Sud, Bicêtre Paris-Sud Hospital, Le Kremlin Bicêtre, France
| | - Aurélie Benoit
- Université de Paris, URB2I, UR 4462, Dental School, Montrouge, France
| | - Thorsten Schinke
- Department of Osteology and Biomechanics, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Christian Roux
- Department of Rheumatology, Cochin Hospital, Université de Paris, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, and Reference Center for Rare Genetic Bone Diseases, Cochin Hospital, Paris, France
| | - Agnès Linglart
- APHP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR and Platform of Expertise for Rare Diseases Paris-Sud, Bicêtre Paris-Sud Hospital, Le Kremlin Bicêtre, France.,APHP, Department of Endocrinology and Diabetology for Children, Bicêtre Paris Sud Hospital, Le Kremlin-Bicêtre, France.,Paris Sud - Paris Saclay University, Faculté de Médecine, Le Kremlin - Bicêtre, France
| | - Corinne Miceli-Richard
- Department of Rheumatology, Cochin Hospital, Université de Paris, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, and Reference Center for Rare Genetic Bone Diseases, Cochin Hospital, Paris, France
| | - Catherine Chaussain
- Université de Paris, Laboratory Orofacial Pathologies, Imaging and Biotherapies UR 2496, Dental School, Montrouge, France.,APHP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Dental Medicine Department, Bretonneau Hospital, Paris, France.,APHP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR and Platform of Expertise for Rare Diseases Paris-Sud, Bicêtre Paris-Sud Hospital, Le Kremlin Bicêtre, France
| | - Karine Briot
- Department of Rheumatology, Cochin Hospital, Université de Paris, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, and Reference Center for Rare Genetic Bone Diseases, Cochin Hospital, Paris, France.,APHP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filière OSCAR and Platform of Expertise for Rare Diseases Paris-Sud, Bicêtre Paris-Sud Hospital, Le Kremlin Bicêtre, France
| | - Claire Bardet
- Université de Paris, Laboratory Orofacial Pathologies, Imaging and Biotherapies UR 2496, Dental School, Montrouge, France
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Imel EA. Enthesopathy, Osteoarthritis, and Mobility in X-linked Hypophosphatemia1. J Clin Endocrinol Metab 2020; 105:5831333. [PMID: 32374835 PMCID: PMC7271761 DOI: 10.1210/clinem/dgaa242] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 04/30/2020] [Indexed: 01/21/2023]
Affiliation(s)
- Erik A Imel
- Department of Medicine and Pediatrics, Division of Endocrinology, Indiana University School of Medicine, Riley Hospital for Children, Indiana Center for Musculoskeletal Health, Indianapolis, Indiana
- Correspondence: Erik A. Imel, MD, Department of Medicine and Pediatrics, Division of Endocrinology, Indiana University School of Medicine, Riley Hospital for Children, Indiana Center for Musculoskeletal Health, Gatch Clinical Building Room 365, 1120 West Michigan Street, Indianapolis, Indiana 46202. E-mail:
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Hughes M, Macica C, Meriano C, Doyle M. Giving Credence to the Experience of X-Linked Hypophosphatemia in Adulthood: An Interprofessional Mixed-Methods Study. J Patient Cent Res Rev 2020; 7:176-188. [PMID: 32377551 DOI: 10.17294/2330-0698.1727] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Purpose X-linked hypophosphatemia (XLH) is a rare X-linked dominant metabolic bone disease, often diagnosed in childhood but causing increasing physical debilitation and pain in adulthood. Physical comorbidities of XLH in adulthood include pervasive and early-onset degenerative arthritis, mineralizing enthesophytes and osteophytes, osteomalacia and pseudofracture, dental abscesses, and hearing loss. Methods This mixed-methods analysis included physical findings, diagnostic imaging, occupational and physical therapy assessments, and semi-structured interviews by social work to understand the functional outcomes and lived experience of XLH in adulthood, through connections between qualitative data obtained by social work and occupational therapy with the quantitative findings from other disciplines. Results Three primary themes of chronic pain, fear of falling, and lack of credence given by health care providers emerged from qualitative data and could be correlated with physical findings from functional outcome assessments These concerns contrasted with resilience, adaption, and compensation demonstrated by participants. Conclusions While new treatments may ease the burden of disease for adults with XLH, further research, increased provider awareness and education, and further development of standards of care are needed to promote accurate and adequate assessment and intervention for adults with XLH.
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Affiliation(s)
- Melissa Hughes
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT
| | - Carolyn Macica
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT
| | - Catherine Meriano
- Occupational Therapy, School of Health Sciences, Quinnipiac University, North Haven, CT
| | - Maya Doyle
- Social Work, School of Health Sciences, Quinnipiac University, North Haven, CT
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Steele A, Gonzalez R, Garbalosa JC, Steigbigel K, Grgurich T, Parisi EJ, Feinn RS, Tommasini SM, Macica CM. Osteoarthritis, Osteophytes, and Enthesophytes Affect Biomechanical Function in Adults With X-linked Hypophosphatemia. J Clin Endocrinol Metab 2020; 105:5734494. [PMID: 32047911 PMCID: PMC8416779 DOI: 10.1210/clinem/dgaa064] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/06/2020] [Indexed: 12/17/2022]
Abstract
CONTEXT X-Linked hypophosphatemia (XLH) is a lifelong metabolic disease with musculoskeletal comorbidities that dominate the adult clinical presentation. OBJECTIVE The adult XLH disorder has yet to be quantified on the basis of the physical and functional limitations that can affect activities of daily living. Our goal was to report the impact of the musculoskeletal manifestations on physical function. DESIGN AND SETTING Musculoskeletal function was evaluated by validated questionnaires and in an interdisciplinary clinical space where participants underwent full-body radiologic imaging, goniometric range of motion (ROM) measurements, general performance tests, and kinematic gait analysis. PATIENTS Nine adults younger than 60 years with a diagnosis of XLH and self-reported musculoskeletal disability, but able to independently ambulate, were selected to participate. Passive ROM and gait analysis were also performed on age-approximated controls to account for differences between individual laboratory instrumentation. RESULTS Enthesophytes, degenerative arthritis, and osteophytes were found to be consistently bilateral and diffusely present at the spine and synovial joints across participants, with predominance at weight-bearing joints. Passive ROM in adults with XLH was decreased at the cervical spine, hip, knee, and ankle compared to controls. Gait analysis relative to controls revealed increased step width, markedly increased lateral trunk sway, and physical restriction at the hip, knees, and ankle joints that translated into limitations through the gait cycle. CONCLUSIONS The functional impact of XLH musculoskeletal comorbidities supports the necessity for creating an interprofessional health-care team with the goal of establishing a longitudinal plan of care that considers the manifestations of XLH across the lifespan.
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Affiliation(s)
- Amy Steele
- Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut
| | - Ramon Gonzalez
- Department of Diagnostic Imaging, School of Health Sciences at Quinnipiac University, North Haven, Connecticut
| | - Juan C Garbalosa
- Department of Physical Therapy, School of Health Sciences at Quinnipiac University, North Haven, Connecticut
| | - Keith Steigbigel
- Department of Physical Therapy, School of Health Sciences at Quinnipiac University, North Haven, Connecticut
| | - Tania Grgurich
- Department of Diagnostic Imaging, School of Health Sciences at Quinnipiac University, North Haven, Connecticut
| | - Erika J Parisi
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Richard S Feinn
- Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut
| | - Steven M Tommasini
- Department of Orthopaedics, Yale University School of Medicine at Quinnipiac University, New Haven, Connecticut
| | - Carolyn M Macica
- Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut
- Correspondence and Reprint Requests: Carolyn M. Macica, PhD, Department of Medical Sciences, Frank H. Netter MD School of Medicine, Quinnipiac University, NH-MED, 275 Mt Carmel Avenue, Hamden, CT 06518. E-mail:
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Lecoq AL, Brandi ML, Linglart A, Kamenický P. Management of X-linked hypophosphatemia in adults. Metabolism 2020; 103S:154049. [PMID: 31863781 DOI: 10.1016/j.metabol.2019.154049] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/23/2019] [Accepted: 11/25/2019] [Indexed: 11/27/2022]
Abstract
X-linked hypophosphatemia (XLH) is caused by mutations in the PHEX gene which result in Fibroblast Growth Factor-23 (FG-F23) excess and phosphate wasting. Clinically, XLH children present with rickets, bone deformities and short stature. In adulthood, patients may still be symptomatic with bone and joint pain, osteomalacia-related fractures or pseudofractures, precocious osteoarthrosis, enthesopathy, muscle weakness and severe dental anomalies. Besides these musculoskeletal and dental manifestations, adult XLH patients are also prone to secondary and tertiary hyperparathyroidism, cardiovascular and metabolic disorders. Pathophysiology of hyperparathyroidism is only partially understood but FGF23 excess and deficient production of calcitriol likely contributes to its development. Similarly, the pathophysiological mechanisms of potential cardiovascular and metabolic involvements are not clear, but FGF-23 excess may play an essential role. Treatment should be considered in symptomatic patients, patients undergoing orthopedic or dental surgery and women during pregnancy and lactation. Treatment with oral phosphate salts and active vitamin D analogs has incomplete efficacy and potential risks. Burosumab, a recombinant human monoclonal antibody against FGF-23, has proven its efficacy in phase 2 and phase 3 clinical trials in adult patients with XLH, but currently its position as first line or second line treatment differ among the countries.
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Affiliation(s)
- Anne-Lise Lecoq
- AP-HP, Department of Endocrinology and Reproductive Diseases, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, filière OSCAR, and Platform of Expertise for Rare Disorders, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, University Hospital of Florence, Florence, Italy
| | - Agnès Linglart
- AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, filière OSCAR, and Platform of Expertise for Rare Disorders, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France; Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France
| | - Peter Kamenický
- AP-HP, Department of Endocrinology and Reproductive Diseases, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, filière OSCAR, and Platform of Expertise for Rare Disorders, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France; Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France.
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37
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Bacchetta J, Bardet C, Prié D. Physiology of FGF23 and overview of genetic diseases associated with renal phosphate wasting. Metabolism 2020; 103S:153865. [PMID: 30664852 DOI: 10.1016/j.metabol.2019.01.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/08/2019] [Accepted: 01/16/2019] [Indexed: 12/31/2022]
Abstract
Phosphate is a cornerstone of several physiological pathways including skeletal development, bone mineralization, membrane composition, nucleotide structure, maintenance of plasma pH, and cellular signaling. The kidneys have a key role in phosphate homeostasis with three hormones having important functions in renal phosphate handling or intestinal absorption: parathyroid hormone (PTH), fibroblast growth factor 23 (FGF23), and 1-25-dihydroxyvitamin D (1,25(OH)2D). FGF23 is mainly synthesized by osteocytes; it is a direct phosphaturic factor that also inhibits 1,25(OH)2D and PTH. In addition to crucial effects on phosphate and calcium metabolism, FGF23 also has 'off-target' effects notably on the cardiovascular, immune and central nervous systems. Genetic diseases may affect the FGF23 pathway, resulting in either increased FGF23 levels leading to hypophosphatemia (such as in X-linked hypophosphatemia) or defective secretion/action of intact FGF23 inducing hyperphosphatemia (such as in familial tumoral calcinosis). The aim of this review is to provide an overview of FGF23 physiology and pathophysiology in X-linked hypophosphatemia, with a focus on FGF23-associated genetic diseases.
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Affiliation(s)
- Justine Bacchetta
- Reference Center for Rare Renal Disorders, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Department of Pediatric Nephrology, Rheumatology and Dermatology, Femme Mère Enfant Hospital, Bron Cedex, France; Lyon-Est Medical School, Lyon 1 University, Lyon, France; INSERM 1033, LYOS, Bone Disorders Prevention, Lyon, France.
| | - Claire Bardet
- Paris Descartes University, EA2496, Faculty of Dental Surgery, Montrouge, France
| | - Dominique Prié
- Paris Descartes University of Medicine, Necker-Enfants Malades Institute, INSERM U1151, France; Functional Exploration Department, Necker-Enfants Malades Hospital, AP-HP, Paris, France
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38
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Xiao L, Williams D, Hurley MM. Inhibition of FGFR Signaling Partially Rescues Osteoarthritis in Mice Overexpressing High Molecular Weight FGF2 Isoforms. Endocrinology 2020; 161:5696655. [PMID: 31901095 PMCID: PMC6959088 DOI: 10.1210/endocr/bqz016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 01/02/2020] [Indexed: 12/29/2022]
Abstract
Fibroblast growth factor 2 (FGF2) and fibroblast growth factor receptors (FGFRs) are key regulatory factors in osteoarthritis (OA). HMWTg mice overexpress the high molecular weight FGF2 isoforms (HMWFGF2) in osteoblast lineage and phenocopy both Hyp mice (which overexpress the HMWFGF2 isoforms in osteoblasts and osteocytes) and humans with X-linked hypophosphatemia (XLH). We previously reported that, similar to Hyp mice and XLH subjects who develop OA, HMWTg mice also develop an OA phenotype associated with increased degradative enzymes and increased FGFR1 compared with VectorTg mice. Therefore, in this study, we examined whether in vivo treatment with the FGFR tyrosine kinase inhibitor NVP-BGJ398 (BGJ) would modulate development of the OA phenotype in knee joints of HMWTg mice. VectorTg and HMWTg mice (21 days of age) were treated with vehicle or BGJ for 13 weeks. Micro-computed tomography images revealed irregular shape and thinning of the subchondral bone with decreased trabecular number and thickness within the epiphyses of vehicle-treated HMWTg knees, which was partially rescued following BGJ treatment. Articular cartilage thickness was decreased in vehicle-treated HMWTg mice, and was restored to the cartilage thickness of VectorTg mice in the BGJ-treated HMWTg group. Increased OA degradative enzymes present in HMWTg vehicle-treated joints decreased after BGJ treatment. OA in HMWTg mice was associated with increased Wnt signaling that was rescued by BGJ treatment. This study demonstrates that overexpression of the HMWFGF2 isoforms in preosteoblasts results in osteoarthropathy that can be partially rescued by FGFR inhibitor via reduction in activated Wnt signaling.
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Affiliation(s)
- Liping Xiao
- Department of Medicine, Division of Endocrinology and Metabolism, School of Medicine, UConn Health, Farmington, CT
| | - Donyell Williams
- Department of Medicine, Division of Endocrinology and Metabolism, School of Medicine, UConn Health, Farmington, CT
| | - Marja M Hurley
- Department of Medicine, Division of Endocrinology and Metabolism, School of Medicine, UConn Health, Farmington, CT
- Correspondence: Marja Hurley, MD, Department of Medicine MC-3023, UConn Health, 263 Farmington Avenue, Farmington, CT 06030-3105. E-mail:
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39
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King HE, Tommasini SM, Rodriguez-Navarro AB, Mercado BQ, Skinner HCW. Correlative vibrational spectroscopy and 2D X-ray diffraction to probe the mineralization of bone in phosphate-deficient mice. J Appl Crystallogr 2019; 52:960-971. [PMID: 31636517 PMCID: PMC6782074 DOI: 10.1107/s1600576719009361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 06/29/2019] [Indexed: 11/18/2022] Open
Abstract
Bone crystallite chemistry and structure change during bone maturation. However, these properties of bone can also be affected by limited uptake of the chemical constituents of the mineral by the animal. This makes probing the effect of bone-mineralization-related diseases a complicated task. Here it is shown that the combination of vibrational spectroscopy with two-dimensional X-ray diffraction can provide unparalleled information on the changes in bone chemistry and structure associated with different bone pathologies (phosphate deficiency) and/or health conditions (pregnancy, lactation). Using a synergistic analytical approach, it was possible to trace the effect that changes in the remodelling regime have on the bone mineral chemistry and structure in normal and mineral-deficient (hypophosphatemic) mice. The results indicate that hypophosphatemic mice have increased bone remodelling, increased carbonate content and decreased crystallinity of the bone mineral, as well as increased misalignment of crystallites within the bone tissue. Pregnant and lactating mice that are normal and hypophosphatemic showed changes in the chemistry and misalignment of the apatite crystals that can be related to changes in remodelling rates associated with different calcium demand during pregnancy and lactation.
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Affiliation(s)
- Helen E King
- Department of Earth Sciences, Utrecht University, Princetonlaan 8a, Utrecht 3584 CB, The Netherlands
- Department of Geology and Geophysics, Yale University, 210 Whitney Avenue, New Haven, Connecticut CT-06511, USA
| | - Steven M Tommasini
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 330 Cedar Street, New Haven, Connecticut CT-06510, USA
| | | | - Brandon Q Mercado
- Department of Chemistry, Yale University, 225 Prospect Street, New Haven, Connecticut CT-06511, USA
| | - H Catherine W Skinner
- Department of Geology and Geophysics, Yale University, 210 Whitney Avenue, New Haven, Connecticut CT-06511, USA
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Abstract
Fibroblast growth factor 23 (FGF23), one of the endocrine fibroblast growth factors, is a principal regulator in the maintenance of serum phosphorus concentration. Binding to its cofactor αKlotho and a fibroblast growth factor receptor is essential for its activity. Its regulation and interaction with other factors in the bone-parathyroid-kidney axis is complex. FGF23 reduces serum phosphorus concentration through decreased reabsorption of phosphorus in the kidney and by decreasing 1,25 dihydroxyvitamin D (1,25(OH)2D) concentrations. Various FGF23-mediated disorders of renal phosphate wasting share similar clinical and biochemical features. The most common of these is X-linked hypophosphatemia (XLH). Additional disorders of FGF23 excess include autosomal dominant hypophosphatemic rickets, autosomal recessive hypophosphatemic rickets, fibrous dysplasia, and tumor-induced osteomalacia. Treatment is challenging, requiring careful monitoring and titration of dosages to optimize effectiveness and to balance side effects. Conventional therapy for XLH and other disorders of FGF23-mediated hypophosphatemia involves multiple daily doses of oral phosphate salts and active vitamin D analogs, such as calcitriol or alfacalcidol. Additional treatments may be used to help address side effects of conventional therapy such as thiazides to address hypercalciuria or nephrocalcinosis, and calcimimetics to manage hyperparathyroidism. The recent development and approval of an anti-FGF23 antibody, burosumab, for use in XLH provides a novel treatment option.
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Affiliation(s)
- Anisha Gohil
- Indiana University School of Medicine, Riley Hospital for Children, Fellow, Endocrinology and Diabetes, 705 Riley Hospital Drive, Room 5960, Indianapolis, IN 46202, USA, E-mail:
| | - Erik A Imel
- Indiana University School of Medicine, Riley Hospital for Children, Associate Professor of Medicine and Pediatrics, 1120 West Michigan Street, CL 459, Indianapolis, IN 46202, USA
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41
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Haffner D, Emma F, Eastwood DM, Duplan MB, Bacchetta J, Schnabel D, Wicart P, Bockenhauer D, Santos F, Levtchenko E, Harvengt P, Kirchhoff M, Di Rocco F, Chaussain C, Brandi ML, Savendahl L, Briot K, Kamenicky P, Rejnmark L, Linglart A. Clinical practice recommendations for the diagnosis and management of X-linked hypophosphataemia. Nat Rev Nephrol 2019; 15:435-455. [PMID: 31068690 PMCID: PMC7136170 DOI: 10.1038/s41581-019-0152-5] [Citation(s) in RCA: 272] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
X-linked hypophosphataemia (XLH) is the most common cause of inherited phosphate wasting and is associated with severe complications such as rickets, lower limb deformities, pain, poor mineralization of the teeth and disproportionate short stature in children as well as hyperparathyroidism, osteomalacia, enthesopathies, osteoarthritis and pseudofractures in adults. The characteristics and severity of XLH vary between patients. Because of its rarity, the diagnosis and specific treatment of XLH are frequently delayed, which has a detrimental effect on patient outcomes. In this Evidence-Based Guideline, we recommend that the diagnosis of XLH is based on signs of rickets and/or osteomalacia in association with hypophosphataemia and renal phosphate wasting in the absence of vitamin D or calcium deficiency. Whenever possible, the diagnosis should be confirmed by molecular genetic analysis or measurement of levels of fibroblast growth factor 23 (FGF23) before treatment. Owing to the multisystemic nature of the disease, patients should be seen regularly by multidisciplinary teams organized by a metabolic bone disease expert. In this article, we summarize the current evidence and provide recommendations on features of the disease, including new treatment modalities, to improve knowledge and provide guidance for diagnosis and multidisciplinary care.
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Affiliation(s)
- Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany.
- Center for Congenital Kidney Diseases, Center for Rare Diseases, Hannover Medical School, Hannover, Germany.
| | - Francesco Emma
- Department of Pediatric Subspecialties, Division of Nephrology, Children's Hospital Bambino Gesù - IRCCS, Rome, Italy
| | - Deborah M Eastwood
- Department of Orthopaedics, Great Ormond St Hospital for Children, Orthopaedics, London, UK
- The Catterall Unit Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK
| | - Martin Biosse Duplan
- Dental School, Université Paris Descartes Sorbonne Paris Cité, Montrouge, France
- APHP, Department of Odontology, Bretonneau Hospital, Paris, France
- APHP, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, and Filière OSCAR, Paris, France
| | - Justine Bacchetta
- Department of Pediatric Nephrology, Rheumatology and Dermatology, University Children's Hospital, Lyon, France
| | - Dirk Schnabel
- Center for Chronic Sick Children, Pediatric Endocrinology, Charitè, University Medicine, Berlin, Germany
| | - Philippe Wicart
- APHP, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, and Filière OSCAR, Paris, France
- APHP, Department of Pediatric Orthopedic Surgery, Necker - Enfants Malades University Hospital, Paris, France
- Paris Descartes University, Paris, France
| | - Detlef Bockenhauer
- University College London, Centre for Nephrology and Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Fernando Santos
- Hospital Universitario Central de Asturias (HUCA), University of Oviedo, Oviedo, Spain
| | - Elena Levtchenko
- Department of Pediatric Nephrology and Development and Regeneration, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Pol Harvengt
- RVRH-XLH, French Patient Association for XLH, Suresnes, France
| | - Martha Kirchhoff
- Phosphatdiabetes e.V., German Patient Association for XLH, Lippstadt, Germany
| | - Federico Di Rocco
- Pediatric Neurosurgery, Hôpital Femme Mère Enfant, Centre de Référence Craniosténoses, Université de Lyon, Lyon, France
| | - Catherine Chaussain
- Dental School, Université Paris Descartes Sorbonne Paris Cité, Montrouge, France
- APHP, Department of Odontology, Bretonneau Hospital, Paris, France
- APHP, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, and Filière OSCAR, Paris, France
| | - Maria Louisa Brandi
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Lars Savendahl
- Pediatric Endocrinology Unit, Karolinska University Hospital, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Karine Briot
- APHP, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, and Filière OSCAR, Paris, France
- Paris Descartes University, Paris, France
- APHP, Department of Rheumatology, Cochin Hospital, Paris, France
- INSERM UMR-1153, Paris, France
| | - Peter Kamenicky
- APHP, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, and Filière OSCAR, Paris, France
- APHP, Department of Endocrinology and Reproductive Diseases, Bicêtre Paris-Sud Hospital, Paris, France
- INSERM U1185, Bicêtre Paris-Sud, Paris-Sud - Paris Saclay University, Le Kremlin-Bicêtre, France
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Agnès Linglart
- APHP, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, and Filière OSCAR, Paris, France
- INSERM U1185, Bicêtre Paris-Sud, Paris-Sud - Paris Saclay University, Le Kremlin-Bicêtre, France
- APHP, Platform of Expertise of Paris-Sud for Rare Diseases and Filière OSCAR, Bicêtre Paris-Sud Hospital (HUPS), Le Kremlin-Bicêtre, France
- APHP, Endocrinology and Diabetes for Children, Bicêtre Paris-Sud Hospital, Le Kremlin-Bicêtre, France
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42
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Emma F, Cappa M, Antoniazzi F, Bianchi ML, Chiodini I, Eller Vainicher C, Di Iorgi N, Maghnie M, Cassio A, Balsamo A, Baronio F, de Sanctis L, Tessaris D, Baroncelli GI, Mora S, Brandi ML, Weber G, D'Ausilio A, Lanati EP. X-linked hypophosphatemic rickets: an Italian experts' opinion survey. Ital J Pediatr 2019; 45:67. [PMID: 31151476 PMCID: PMC6545008 DOI: 10.1186/s13052-019-0654-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/26/2019] [Indexed: 01/24/2023] Open
Abstract
Background X-linked hypophosphatemic rickets (XLH) is the first cause of inherited hypophosphatemia and is caused by mutation in the PHEX gene, resulting in excessive expression of the phosphaturic factor FGF23. Symptoms are mainly related to rickets in children and osteomalacia in adults and cause several complications that can be highly invalidating. Due to its rarity, XLH is poorly known and diagnosis is frequently delayed. Conventional treatment is based on oral phosphate salts supplementation and activated vitamin D analogs, which however, cannot cure the disease in most cases. Objective Due to the low prevalence of XLH, an experts’ opinion survey was conducted across Italian centers to collect data on XLH and on its management. Methods A questionnaire was developed by a group of experts to collect data on XLH epidemiology, diagnosis and treatment in Italy. Results Data from 10 Italian centers (nine of which pediatric) on 175 patients, followed between 1998 and 2017, were included in the survey. Most patients were followed since childhood and 63 children became adults during the investigated period. The diagnosis was made before the age of 1 and between 1 and 5 years in 11 and 50% of cases, respectively. Clinically apparent bone deformities were present in 95% of patients. These were ranked moderate/severe in 75% of subjects and caused growth stunting in 67% of patients. Other frequent complications included bone pain (40%), dental abscesses (33%), and dental malpositions (53%). Treatment protocols varied substantially among centers. Nephrocalcinosis was observed in 34% of patients. Tertiary hyperparathyroidism developed in 6% of patients. Conclusions XLH remains a severe condition with significant morbidities.
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Affiliation(s)
- F Emma
- Division of Nephrology, Department of Pediatric Subspecialties, Children's Hospital Bambino Gesù, IRCCS, Piazza Sant'Onofrio 4, 00165, Rome, Italy.
| | - M Cappa
- Endocrinology Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - F Antoniazzi
- Department of Surgery, Dentistry, Pediatrics and Gynecology, Pediatric Division, University of Verona, Borgo Roma Hospital, Verona, Italy
| | - M L Bianchi
- Experimental Laboratory for Children's Bone Metabolism Research, Bone Metabolism Unit, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - I Chiodini
- Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Dept. of Clinical Sciences & Community Health, University of Milan, Milan, Italy
| | - C Eller Vainicher
- Unit of Endocrinology, IRCCS Cà Granda Foundation, Maggiore Policlinico Hospital, Milan, Italy
| | - N Di Iorgi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Department of General and Specialist Pediatric Sciences, Pediatric Clinic, IRCCS Giannina Gaslini Institute, University of Genova, Genova, Italy
| | - M Maghnie
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Department of General and Specialist Pediatric Sciences, Pediatric Clinic, IRCCS Giannina Gaslini Institute, University of Genova, Genova, Italy
| | - A Cassio
- Department of Medical & Surgical Sciences, Pediatric Unit, S. Orsola Malpighi University Hospital, Bologna, Italy
| | - A Balsamo
- Department of Medical & Surgical Sciences, Pediatric Unit, S. Orsola Malpighi University Hospital, Bologna, Italy
| | - F Baronio
- Department of Medical & Surgical Sciences, Pediatric Unit, S. Orsola Malpighi University Hospital, Bologna, Italy
| | - L de Sanctis
- Department of Public Health and Pediatric Sciences, University of Torino - Regina Margherita Children Hospital, Torino, Italy
| | - D Tessaris
- Department of Public Health and Pediatric Sciences, University of Torino - Regina Margherita Children Hospital, Torino, Italy
| | - G I Baroncelli
- Pediatric Unit, Department of Obstetrics, Gynecology and Pediatrics, University Hospital of Pisa, Pisa, Italy
| | - S Mora
- Department of Pediatrics, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - M L Brandi
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - G Weber
- Department of Pediatrics, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
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43
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Beck-Nielsen SS, Mughal Z, Haffner D, Nilsson O, Levtchenko E, Ariceta G, de Lucas Collantes C, Schnabel D, Jandhyala R, Mäkitie O. FGF23 and its role in X-linked hypophosphatemia-related morbidity. Orphanet J Rare Dis 2019; 14:58. [PMID: 30808384 PMCID: PMC6390548 DOI: 10.1186/s13023-019-1014-8] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/30/2019] [Indexed: 12/29/2022] Open
Abstract
Background X-linked hypophosphatemia (XLH) is an inherited disease of phosphate metabolism in which inactivating mutations of the Phosphate Regulating Endopeptidase Homolog, X-Linked (PHEX) gene lead to local and systemic effects including impaired growth, rickets, osteomalacia, bone abnormalities, bone pain, spontaneous dental abscesses, hearing difficulties, enthesopathy, osteoarthritis, and muscular dysfunction. Patients with XLH present with elevated levels of fibroblast growth factor 23 (FGF23), which is thought to mediate many of the aforementioned manifestations of the disease. Elevated FGF23 has also been observed in many other diseases of hypophosphatemia, and a range of animal models have been developed to study these diseases, yet the role of FGF23 in the pathophysiology of XLH is incompletely understood. Methods The role of FGF23 in the pathophysiology of XLH is here reviewed by describing what is known about phenotypes associated with various PHEX mutations, animal models of XLH, and non-nutritional diseases of hypophosphatemia, and by presenting molecular pathways that have been proposed to contribute to manifestations of XLH. Results The pathophysiology of XLH is complex, involving a range of molecular pathways that variously contribute to different manifestations of the disease. Hypophosphatemia due to elevated FGF23 is the most obvious contributor, however localised fluctuations in tissue non-specific alkaline phosphatase (TNAP), pyrophosphate, calcitriol and direct effects of FGF23 have been observed to be associated with certain manifestations. Conclusions By describing what is known about these pathways, this review highlights key areas for future research that would contribute to the understanding and clinical treatment of non-nutritional diseases of hypophosphatemia, particularly XLH.
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Affiliation(s)
| | - Zulf Mughal
- Royal Manchester Children's Hospital, Manchester, UK
| | | | - Ola Nilsson
- Karolinska Institutet, Stockholm, Sweden and Örebro University, Örebro, Sweden
| | | | - Gema Ariceta
- Hospital Universitario Materno-Infantil Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Dirk Schnabel
- University Children's Hospital of Berlin, Berlin, Germany
| | | | - Outi Mäkitie
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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44
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Weber TJ, Quarles LD. Molecular Control of Phosphorus Homeostasis and Precision Treatment of Hypophosphatemic Disorders. ACTA ACUST UNITED AC 2019; 5:75-85. [PMID: 31871877 DOI: 10.1007/s40610-019-0118-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose of Review Serum phosphorus is maintained in a narrow range by balancing dietary phosphate absorption, influx and efflux of phosphorus from bone and intracellular stores, and renal reabsorption of filtered phosphate. Acute hypophosphatemia, typically caused by transient increases in cellular uptake, can lead to severe complications such as cardiopulmonary dysfunction and rhabdomyolysis that can warrant parenteral phosphate repletion. Chronic hypophosphatemia, however, generally represents true phosphate deficiency and may result in long-term metabolic and skeletal complications, particularly in children due to the critical importance of phosphorus to skeletal mineralization and longitudinal growth. Recent Findings In addition to the well characterized roles of vitamin D and parathyroid hormone (PTH), a new bone-kidney axis has been discovered that regulates phosphate homeostasis through the bone-derived hormone Fibroblast Growth Factor 23 (FGF23) and its phosphaturic actions that are mediated by activation of fibroblast growth factor receptors (FGFRs) complexed with α-Klotho in renal tubules. Chronic hypophosphatemia can now be classified as FGF23 dependent or independent. Summary In cases of FGF23 dependent hypophosphatemia, traditional non-specific treatments with elemental phosphorus and 1,25(OH)2 vitamin D (calcitriol) can now be replaced with a targeted approach by using an FGF-23 blocking antibody (Burosumab).
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Affiliation(s)
- Thomas J Weber
- Department of Medicine, Division of Endocrinology, Metabolism and Nutrition, 303 Baker House, DUMC 3470, Duke University Medical Center, Durham, NC 27710
| | - L Darryl Quarles
- Department of Medicine, Division of Nephrology 956 Court Ave, Suite B266, University of Tennessee Health Sciences Center, Memphis, TN 38163
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45
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Mills ES, Iorio L, Feinn RS, Duignan KM, Macica CM. Joint replacement in X-linked hypophosphatemia. J Orthop 2018; 16:55-60. [PMID: 30662239 DOI: 10.1016/j.jor.2018.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 12/02/2018] [Indexed: 10/27/2022] Open
Abstract
X-linked hypophosphatemia (XLH) is associated with a pervasive, severe degenerative osteoarthritis. We conducted a retrospective chart review/patient survey using the Knee or Hip Osteoarthritis Outcome Score Physical Function Short Form. Fourteen total knee arthroplasties and 7 total hip arthroplasties among 11 patients were included. The mean KOOS-PS score was 31.4 ± 9.7 with a mean follow up of 6.9 years. Mean HOOS-PS score was 14.8 ± 12.9 at a mean follow up of 7.6 years. One knee failed due to aseptic loosening and one hip was revised due to polyethylene wear. In conclusion, total joint arthroplasty is beneficial in XLH.
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Affiliation(s)
- Emily S Mills
- Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, Hamden, CT, 06518, USA
| | - Louis Iorio
- Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, Hamden, CT, 06518, USA
| | - Richard S Feinn
- Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, Hamden, CT, 06518, USA
| | - Kevin M Duignan
- Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, Hamden, CT, 06518, USA
| | - Carolyn M Macica
- Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, Hamden, CT, 06518, USA
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46
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Marcucci G, Masi L, Ferrarì S, Haffner D, Javaid MK, Kamenický P, Reginster JY, Rizzoli R, Brandi ML. Phosphate wasting disorders in adults. Osteoporos Int 2018; 29:2369-2387. [PMID: 30014155 DOI: 10.1007/s00198-018-4618-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 06/19/2018] [Indexed: 12/14/2022]
Abstract
A cause of hypophosphatemia is phosphate wasting disorders. Knowledge concerning mechanisms involved in phosphate wasting disorders has greatly increased in the last decade by the identification of phosphatonins, among them FGF-23. FGF-23 is a primarily bone derived factor decreasing renal tubular reabsorption of phosphate and the synthesis of calcitriol. Currently, pharmacological treatment of these disorders offers limited efficacy and is potentially associated to gastrointestinal, renal, and parathyroid complications; therefore, efforts have been directed toward newer pharmacological strategies that target the FGF-23 pathway. This review focuses on phosphate metabolism, its main regulators, and phosphate wasting disorders in adults, highlighting the main issues related to diagnosis and current and new potential treatments.
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Affiliation(s)
- G Marcucci
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - L Masi
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - S Ferrarì
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - D Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - M K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - P Kamenický
- Service d'Endocrinologie et des Maladies de la Reproduction, Centre de référence des Maladies Rares du métabolisme du calcium et du phosphore, Hopital de Bicêtre - AP-HP, 94275, Le Kremlin-Bicêtre, France
| | - J-Y Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - R Rizzoli
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - M L Brandi
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy.
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47
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Imel EA, White KE. Pharmacological management of X-linked hypophosphataemia. Br J Clin Pharmacol 2018; 85:1188-1198. [PMID: 30207609 DOI: 10.1111/bcp.13763] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/05/2018] [Accepted: 09/05/2018] [Indexed: 12/25/2022] Open
Abstract
The most common heritable disorder of renal phosphate wasting, X-linked hypophosphataemia (XLH), was discovered to be caused by inactivating mutations in the phosphate regulating gene with homology to endopeptidases on the X-chromosome (PHEX) gene in 1995. Although the exact molecular mechanisms by which PHEX mutations cause disturbed phosphate handling in XLH remain unknown, focus for novel therapies has more recently been based upon the finding that the bone-produced phosphaturic hormone fibroblast growth factor-23 is elevated in XLH patient plasma. Previous treatment strategies for XLH were based upon phosphate repletion plus active vitamin D analogues, which are difficult to manage, fail to address the primary pathogenesis of the disease, and can have deleterious side effects. A novel therapy for XLH directly targeting fibroblast growth factor-23 via a humanized monoclonal antibody (burosumab-twza/CRYSVITA, henceforth referred to just as burosumab) has emerged as an effective, and recently approved, pharmacological treatment for both children and adults. This review will provide an overview of the clinical manifestations of XLH, the molecular pathophysiology, and summarize its current treatment.
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Affiliation(s)
- Erik A Imel
- Department of Medicine, Division of Endocrinology and Metabolism, Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Pediatrics, Section of Endocrinology and Diabetology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kenneth E White
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
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48
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Amenta E, King HE, Petermann H, Uskoković V, Tommasini SM, Macica CM. Vibrational spectroscopic analysis of hydroxyapatite in HYP mice and individuals with X-linked hypophosphatemia. Ther Adv Chronic Dis 2018; 9:268-281. [PMID: 30719271 PMCID: PMC6348532 DOI: 10.1177/2040622318804753] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 07/20/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND X-linked hypophosphatemia (XLH) is the most common form of familial phosphate-wasting disorders, due to an inactivating mutation in the phosphate-regulating neutral endopeptidase, X-linked gene. Persistent osteomalacia, enthesophytes, osteophytes, degenerative arthritis and dental abscesses/periodontal disease dominate the adult disorder. However, the impact of insufficient phosphate on hydroxyapatite composition, the major inorganic component of bone and teeth, is unknown in individuals with XLH. METHODS Using Raman spectroscopy, the carbonate (CO3 2-) to phosphate (PO4 3-) ion ratio was measured in HYP and wild-type mice and in primary and permanent teeth from XLH individuals and unaffected controls. RESULTS There was a significant difference in carbonate ion substitution between the HYP and wild-type femoral cortical bone (0.36 ± 0.08 versus 0.24 ± 0.04; p < 0.001). Carbonate ion substitution levels were also higher in permanent XLH teeth compared with unaffected individuals (0.39 ± 0.12 versus 0.23 ± 0.04; p < 0.001), but not in primary teeth (0.29 ± 0.11 versus 0.26 ± 0.02; p = 0.29). Complementary Fourier transform infrared analyses demonstrated higher relative intensities of the four major vibrational bands originating from the carbonate anion in XLH teeth compared with unaffected controls. CONCLUSION Ionic substitution within the crystal lattice is a common feature of hydroxyapatite and one that confers the physiological properties of bone that impact mechanical strength and the process of bone remodeling. Our data demonstrating anionic substitution in human dentin from individuals with XLH validate the use of dentin as a proxy for bone and to better understand the molecular adaptations that occur in the biochemical milieu of XLH.
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Affiliation(s)
- Eva Amenta
- Department of Medical Sciences, Frank H. Netter, M.D., School of Medicine at Quinnipiac University, North Haven, CT, USA
| | - Helen E. King
- Department of Earth Sciences, Utrecht University, Utrecht, The Netherlands
| | - Holger Petermann
- Department of Geology and Geophysics, Yale University, New Haven, CT, USA
| | - Vuk Uskoković
- Department of Biomedical and Pharmaceutical Sciences, School of Pharmacy, Chapman University, Irvine, CA, USA
| | - Steven M. Tommasini
- Department of Orthopaedics and Rehabilitation, Yale University, New Haven, CT, USA
| | - Carolyn M. Macica
- Frank H. Netter MD School of Medicine, Quinnipiac University, 275 Mt. Carmel Avenue, NH-MED MNH-311H, Hamden, CT 06518, USA
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Abstract
Our understanding of the regulation of phosphate balance has benefited tremendously from the molecular identification and characterization of genetic defects leading to a number of rare inherited or acquired disorders affecting phosphate homeostasis. The identification of the key phosphate-regulating hormone, fibroblast growth factor 23 (FGF23), as well as other molecules that control its production, such as the glycosyltransferase GALNT3, the endopeptidase PHEX, and the matrix protein DMP1, and molecules that function as downstream effectors of FGF23 such as the longevity factor Klotho and the phosphate transporters NPT2a and NPT2c, has permitted us to understand the complex interplay that exists between the kidneys, bone, parathyroid, and gut. Such insights from genetic disorders have allowed not only the design of potent targeted treatment of FGF23-dependent hypophosphatemic conditions, but also provide clinically relevant observations related to the dysregulation of mineral ion homeostasis in health and disease.
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Affiliation(s)
- Marta Christov
- Division of Nephrology, Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - Harald Jüppner
- Endocrine Unit and Pediatric Nephrology Unit, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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50
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Lin B, Srikanth P, Castle AC, Nigwekar S, Malhotra R, Galloway JL, Sykes DB, Rajagopal J. Modulating Cell Fate as a Therapeutic Strategy. Cell Stem Cell 2018; 23:329-341. [PMID: 29910150 PMCID: PMC6128730 DOI: 10.1016/j.stem.2018.05.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In injured tissues, regeneration is often associated with cell fate plasticity, in that cells deviate from their normal lineage paths. It is becoming increasingly clear that this plasticity often creates alternative strategies to restore damaged or lost cells. Alternatively, cell fate plasticity is also part and parcel of pathologic tissue transformations that accompany disease. In this Perspective, we summarize a few illustrative examples of physiologic and aberrant cellular plasticity. Then, we speculate on how one could enhance endogenous plasticity to promote regeneration and reverse pathologic plasticity, perhaps inspiring interest in a new class of therapies targeting cell fate modulation.
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Affiliation(s)
- Brian Lin
- Center for Regenerative Medicine, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA; Harvard Stem Cell Institute, Cambridge, MA 02138, USA
| | - Priya Srikanth
- Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Pathways Program, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Alison C Castle
- Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Pathways Program, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Sagar Nigwekar
- Pathways Program, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Rajeev Malhotra
- Pathways Program, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jenna L Galloway
- Center for Regenerative Medicine, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA; Harvard Stem Cell Institute, Cambridge, MA 02138, USA; Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - David B Sykes
- Center for Regenerative Medicine, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA; Harvard Stem Cell Institute, Cambridge, MA 02138, USA
| | - Jayaraj Rajagopal
- Center for Regenerative Medicine, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, USA; Harvard Stem Cell Institute, Cambridge, MA 02138, USA; Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Pathways Program, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Pediatric Pulmonary Medicine, Massachusetts General Hospital for Children, Boston, MA 02114, USA.
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