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Kitoh H, Kaneko H, Kitamura A, Sawamura K. Femoral lengthening with enzyme replacement therapy in an adolescent patient with prenatal benign hypophosphatasia: A case report. J Orthop Sci 2023; 28:1487-1491. [PMID: 34391614 DOI: 10.1016/j.jos.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/24/2021] [Accepted: 07/07/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Hiroshi Kitoh
- Department of Orthopaedic Surgery, Aichi Children's Health and Medical Center, Obu, 474-8710, Japan; Department of Comprehensive Pediatric Medicine, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan.
| | - Hiroshi Kaneko
- Department of Orthopaedic Surgery, Aichi Children's Health and Medical Center, Obu, 474-8710, Japan
| | - Akiko Kitamura
- Department of Orthopaedic Surgery, Aichi Children's Health and Medical Center, Obu, 474-8710, Japan
| | - Kenta Sawamura
- Department of Orthopaedic Surgery, Aichi Children's Health and Medical Center, Obu, 474-8710, Japan
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Hypophosphatasia: A Unique Disorder of Bone Mineralization. Int J Mol Sci 2021; 22:ijms22094303. [PMID: 33919113 PMCID: PMC8122659 DOI: 10.3390/ijms22094303] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 12/25/2022] Open
Abstract
Hypophosphatasia (HPP) is a rare genetic disease characterized by a decrease in the activity of tissue non-specific alkaline phosphatase (TNSALP). TNSALP is encoded by the ALPL gene, which is abundantly expressed in the skeleton, liver, kidney, and developing teeth. HPP exhibits high clinical variability largely due to the high allelic heterogeneity of the ALPL gene. HPP is characterized by multisystemic complications, although the most common clinical manifestations are those that occur in the skeleton, muscles, and teeth. These complications are mainly due to the accumulation of inorganic pyrophosphate (PPi) and pyridoxal-5′-phosphate (PLP). It has been observed that the prevalence of mild forms of the disease is more than 40 times the prevalence of severe forms. Patients with HPP present at least one mutation in the ALPL gene. However, it is known that there are other causes that lead to decreased alkaline phosphatase (ALP) levels without mutations in the ALPL gene. Although the phenotype can be correlated with the genotype in HPP, the prediction of the phenotype from the genotype cannot be made with complete certainty. The availability of a specific enzyme replacement therapy for HPP undoubtedly represents an advance in therapeutic strategy, especially in severe forms of the disease in pediatric patients.
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Matsushita M, Mishima K, Nagata T, Kamiya Y, Imagama S, Kitoh H. Asfotase alfa has a limited effect in improving the bowed limbs in perinatal benign hypophosphatasia: A case report. Clin Pediatr Endocrinol 2021; 30:53-56. [PMID: 33446953 PMCID: PMC7783131 DOI: 10.1297/cpe.30.53] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/27/2020] [Indexed: 01/04/2023] Open
Abstract
Hypophosphatasia (HPP) is a rare skeletal dysplasia characterized by impaired bone
mineralization, caused by loss-of-function mutations in the tissue-nonspecific alkaline
phosphatase (TNSALP) gene. Enzyme replacement therapy (ERT) by
administration of asfotase alfa was reported to improve the survival rate, bone
mineralization, and short stature in the severe form of HPP. However, the effect of
asfotase alfa in improving the skeletal phenotypes for the mild form of HPP has not been
elucidated. We report a case with perinatal benign HPP who had compound heterozygous
mutations of p.F327L and p.R30X in the TNSALP gene. No hypomineralization
was seen in the radiographs from the neonatal period, but bowing of the femurs and ulnares
bilaterally was persistent. ERT was administered during the age of 7.8 to 10.8 yr,
although there was an interruption in the treatment for one year. The bowed femurs and
ulnares were not improved by the treatment with asfotase alfa at the age of 10.8 yr. Bone
mineral density of the lumbar spine was between –0.5 and –1.0 of the z-score, and the
patient’s height was about –2.0 SD during the treatment. Asfotase alfa might have a
limited effect in improving the bowed limbs in perinatal benign hypophosphatasia.
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Affiliation(s)
- Masaki Matsushita
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenichi Mishima
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tadashi Nagata
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasunari Kamiya
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Kitoh
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Orthopaedic Surgery, Aichi Children's Health and Medical Center, Aichi, Japan
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Abstract
PURPOSE OF REVIEW The goal of this review is to give an overview of diagnosis and up-to-date management of major pediatric metabolic bone diseases that are associated with bone fragility, including nutritional rickets, hypophosphatemic rickets, osteogenesis imperfecta, Ehlers--Danlos syndrome, Marfan's syndrome, hypophosphatasia, osteopetrosis and skeletal fluorosis. RECENT FINDINGS During the past decade, a number of advanced treatment options have been introduced and shown to be an effective treatment in many metabolic bone disorders, such as burosumab for hypophosphatemic rickets and asfotase alfa for hypophosphatasia. On the other hand, other disorders, such as nutritional rickets and skeletal fluorosis continue to be underrecognized in many regions of the world. Genetic disorders of collagen-elastin, such as osteogenesis imperfecta, Ehlers--Danlos syndrome and Marfan's syndrome are also associated with skeletal fragility, which can be misdiagnosed as caused by non-accidental trauma/child abuse. SUMMARY It is essential to provide early and accurate diagnosis and treatment for pediatric patients with metabolic bone disorders in order to maintain growth and development as well as prevent fractures and metabolic complications.
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Michigami T, Tachikawa K, Yamazaki M, Kawai M, Kubota T, Ozono K. Hypophosphatasia in Japan: ALPL Mutation Analysis in 98 Unrelated Patients. Calcif Tissue Int 2020; 106:221-231. [PMID: 31707452 DOI: 10.1007/s00223-019-00626-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 10/24/2019] [Indexed: 12/19/2022]
Abstract
Hypophosphatasia (HPP) is highly variable in clinical expression and is generally classified into six subtypes. Although it would be beneficial to be able to predict the clinical course from the ALPL genotype, studies on this issue are limited. Here, we aimed to clarify the features of Japanese HPP and the relationships between genotype and clinical manifestations. We analyzed 98 unrelated Japanese patients to investigate the percentage of each clinical form, frequently detected mutations, and the relationship between the genotype and phenotype. Some of the identified mutants were characterized by transfection experiments. Perinatal severe form was the most frequent (45.9%), followed by perinatal benign form (22.4%). Among the 196 alleles, p.Leu520ArgfsX86 (c.1559delT) was detected in 89 alleles, and p.Phe327Leu (c.979T>C) was identified in 23 alleles. All of the homozygotes for p.Leu520ArgfsX86 were classified into perinatal severe form, and patients carrying p.Phe327Leu in one of the alleles were classified into perinatal benign or odonto HPP. Twenty of the 22 patients with perinatal benign HPP were compound heterozygous for p.Phe327Leu and another mutation. Most patients with odonto HPP were found to be monoallelic heterozygotes for dominant-negative mutations or compound heterozygotes with mutants having residual activity. The high prevalence of p.Leu520ArgfsX86 and p.Phe327Leu mutations might underlie the high rate of perinatal severe and perinatal benign forms, respectively, in Japanese HPP. Although ALPL genotyping would be beneficial for predicting the clinical course to an extent, the observed phenotypical variability among patients sharing the same genotypes suggests the presence of modifiers.
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Affiliation(s)
- Toshimi Michigami
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka Prefectural Hospital Organization, 840 Murodo-cho, Izumi, 594-1101, Osaka, Japan.
| | - Kanako Tachikawa
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka Prefectural Hospital Organization, 840 Murodo-cho, Izumi, 594-1101, Osaka, Japan
| | - Miwa Yamazaki
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka Prefectural Hospital Organization, 840 Murodo-cho, Izumi, 594-1101, Osaka, Japan
| | - Masanobu Kawai
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka Prefectural Hospital Organization, 840 Murodo-cho, Izumi, 594-1101, Osaka, Japan
| | - Takuo Kubota
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, 565-0871, Osaka, Japan
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, 565-0871, Osaka, Japan
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Offiah AC, Vockley J, Munns CF, Murotsuki J. Differential diagnosis of perinatal hypophosphatasia: radiologic perspectives. Pediatr Radiol 2019; 49:3-22. [PMID: 30284005 PMCID: PMC6313373 DOI: 10.1007/s00247-018-4239-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 06/25/2018] [Accepted: 08/14/2018] [Indexed: 01/13/2023]
Abstract
Perinatal hypophosphatasia (HPP) is a rare, potentially life-threatening, inherited, systemic metabolic bone disease that can be difficult to recognize in utero and postnatally. Diagnosis is challenging because of the large number of skeletal dysplasias with overlapping clinical features. This review focuses on the role of fetal and neonatal imaging modalities in the differential diagnosis of perinatal HPP from other skeletal dysplasias (e.g., osteogenesis imperfecta, campomelic dysplasia, achondrogenesis subtypes, hypochondrogenesis, cleidocranial dysplasia). Perinatal HPP is associated with a broad spectrum of imaging findings that are characteristic of but do not occur in all cases of HPP and are not unique to HPP, such as shortening, bowing and angulation of the long bones, and slender, poorly ossified ribs and metaphyseal lucencies. Conversely, absent ossification of whole bones is characteristic of severe lethal HPP and is associated with very few other conditions. Certain features may help distinguish HPP from other skeletal dysplasias, such as sites of angulation of long bones, patterns of hypomineralization, and metaphyseal characteristics. In utero recognition of HPP allows for the assembly and preparation of a multidisciplinary care team before delivery and provides additional time to devise treatment strategies.
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Affiliation(s)
- Amaka C Offiah
- Academic Unit of Child Health, Sheffield Children's NHS Foundation Trust, University of Sheffield, Western Bank, Sheffield, S10 2TH, UK.
| | - Jerry Vockley
- School of Medicine and Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Craig F Munns
- The Children's Hospital at Westmead, Westmead, NSW, Australia
- Sydney Medical School, The University of Sydney, University of Sydney NSW, Sydney, Australia
| | - Jun Murotsuki
- Aoba Ward, Miyagi Children's Hospital, Sendai, Miyagi Prefecture, Japan
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Abstract
Hypophosphatasia (HPP) is a rare inherited disorder primarily affecting bone and dental mineralization. Although there is a continuum in the severity of the disease, clinical forms may be arbitrarily distinguished on the basis of age at onset and the presence or absence of bone symptoms: perinatal, infantile, juvenile, adult, prenatal benign, and odontological. Severe forms (perinatal and infantile) are autosomally recessively inherited while less severe forms may be autosomally recessively or dominantly inherited. Genetic counseling is complicated by the coexistence of the two modes of inheritance, the incomplete penetrance of the dominant forms, the markedly variable expression of the disease, including intra-familial expression, and the existence of a benign prenatal form that may sometimes be difficult to distinguish from the severe prenatal form. The disease is due to loss-of-function mutations in the Alkaline Phosphatase-Liver (ALPL) gene encoding the tissue nonspecific alkaline phosphatase (TNSALP). The great variety of missence mutations and the dominant negative effect of some mutations largely explain the clinical heterogeneity. Directed mutagenesis studies allowed further elucidation of the cellular pathophysiology of HPP, classification of the alleles in terms of their severity and dominant negative effect, and molecular explanations of the dominant inheritance mode. Genetics significantly contributed to show that there are in fact two HPPs, rare, severe and recessive HPP, and mild recessive or mild dominant HPP, which is markedly more frequent and probably under-diagnosed. The prevalence of the severe forms of HPP has been estimated to be 1/300,000 in France and Northern Europe while the prevalence of the moderate forms of HPP may reach 1/6,370.
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Affiliation(s)
- E Mornet
- Service de biologie, unité de génétique constitutionnelle, centre hospitalier de Versailles, Le Chesnay, France.
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Abstract
We review here clinical, pathophysiological, diagnostic, genetic and molecular aspects of Hypophosphatasia (HPP), a rare inherited metabolic disorder. The clinical presentation is a continuum ranging from a prenatal lethal form with no skeletal mineralization to a mild form with late adult onset presenting with nonpathognomonic symptoms. The prevalence of severe forms is low, whereas less severe forms are more frequently observed. The disease is caused by loss-of-function mutations in the ALPL gene encoding the Tissue Nonspecific Alkaline Phosphatase (TNSALP), a central regulator of mineralization. Severe forms are recessively inherited, whereas moderate forms are either recessively or dominantly inherited, and the more severe the disease is, the more often it is subject to recessive inheritance. The diagnosis is based on a constantly low alkaline phosphatase (AP) activity in serum and genetic testing that identifies ALPL mutations. More than 340 mutations have been identified and are responsible for the extraordinary clinical heterogeneity. A clear but imperfect genotype-phenotype correlation has been observed, suggesting that other genetic or environmental factors modulate the phenotype. Enzyme replacement therapy is now available for HPP, and other approaches, such as gene therapy, are currently being investigated.
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Affiliation(s)
- Etienne Mornet
- Unité de Génétique Constitutionnelle, Service de Biologie, Centre Hospitalier de Versailles, 177 rue de Versailles, 78150 Le Chesnay, France.
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Sheikh Z, Ali S, Hussain A, Mohan S, Thyagarajan M. A Newborn with No Bones: Neonatal Hypophosphatasia with Respiratory Distress. J Pediatr 2017; 188:306. [PMID: 28662950 DOI: 10.1016/j.jpeds.2017.05.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 05/22/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Zishan Sheikh
- Birmingham Children's Hospital Birmingham, United Kingdom
| | - Sana Ali
- Birmingham Children's Hospital Birmingham, United Kingdom
| | - Adam Hussain
- Birmingham Children's Hospital Birmingham, United Kingdom
| | - Shyam Mohan
- Birmingham Children's Hospital Birmingham, United Kingdom
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Porntaveetus T, Srichomthong C, Suphapeetiporn K, Shotelersuk V. Monoallelic FGFR3
and Biallelic ALPL
mutations in a Thai girl with hypochondroplasia and hypophosphatasia. Am J Med Genet A 2017; 173:2747-2752. [DOI: 10.1002/ajmg.a.38370] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 06/16/2017] [Accepted: 06/25/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Thantrira Porntaveetus
- Craniofacial Genetics and Stem Cells Research Group, Faculty of Dentistry, Department of Physiology; Chulalongkorn University; Bangkok Thailand
| | - Chalurmpon Srichomthong
- Center of Excellence for Medical Genetics, Faculty of Medicine, Department of Pediatrics; Chulalongkorn University; Bangkok Thailand
- Excellence Center for Medical Genetics, King Chulalongkorn Memorial Hospital; The Thai Red Cross Society; Bangkok Thailand
| | - Kanya Suphapeetiporn
- Center of Excellence for Medical Genetics, Faculty of Medicine, Department of Pediatrics; Chulalongkorn University; Bangkok Thailand
- Excellence Center for Medical Genetics, King Chulalongkorn Memorial Hospital; The Thai Red Cross Society; Bangkok Thailand
| | - Vorasuk Shotelersuk
- Center of Excellence for Medical Genetics, Faculty of Medicine, Department of Pediatrics; Chulalongkorn University; Bangkok Thailand
- Excellence Center for Medical Genetics, King Chulalongkorn Memorial Hospital; The Thai Red Cross Society; Bangkok Thailand
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12
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Meah F, Basit A, Emanuele N, Emanuele MA. Hypophosphatasia: Review of Bone Mineral Metabolism, Pathophysiology, Clinical Presentation, Diagnosis, and Treatment. Clin Rev Bone Miner Metab 2017. [DOI: 10.1007/s12018-016-9225-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Hypophosphatasia is a rare disorder due to a mutation in the ALPL gene encoding the alkaline phosphatase (ALP) leading to a diminished activity of the enzyme in bone, liver, and kidney. Hypophosphatasia is a heterogeneous disease, ranging from extreme life-threatening forms revealed at birth in young infants presenting with severely impaired bone mineralization, seizures, and hypercalcemia, to young adults with premature exfoliation of their teeth without any other symptom. We will review the challenges of the clinical, biochemical, radiological, and genetic diagnosis. Schematically, the diagnosis relies on low ALP levels and, in most cases, on the genetic defect in the ALPL gene. An enzyme replacement therapy is now developed for hypophosphatasia; early results in the severe form of the disease are extremely encouraging. However, multidisciplinary care remains the core of treatment of hypophosphatasia encompassing nutritional support, adjustment of calcium and phosphate intake, monitoring of vitamin D levels, careful and personalized physical therapy, and regular dental monitoring and care.
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Affiliation(s)
- Agnès Linglart
- Department of Pediatric Endocrinology and Diabetology for Children, APHP, Bicêtre Paris Sud, Le Kremlin Bicêtre, 94270, France.
- APHP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism and Plateforme d'Expertise Paris Sud Maladies Rares, Le Kremlin Bicêtre, 94270, France.
| | - Martin Biosse-Duplan
- APHP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism and Plateforme d'Expertise Paris Sud Maladies Rares, Le Kremlin Bicêtre, 94270, France
- Department of Odontology, APHP, Bretonneau Paris Nord Val de Seine, Paris, 75018, France
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Bianchi ML. Hypophosphatasia: an overview of the disease and its treatment. Osteoporos Int 2015; 26:2743-57. [PMID: 26245849 DOI: 10.1007/s00198-015-3272-1] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 07/28/2015] [Indexed: 11/30/2022]
Abstract
This review presents the current knowledge on hypophosphatasia, a rare genetic disease of very variable severity (from lethal to mild) and clinical presentation, caused by defective production of tissue-non-specific alkaline phosphatase (TNSALP). Hypophosphatasia can affect babies in utero as well as infants, children, and adults. The article first presents the genetics of TNSALP and its many known mutations underlying the disease. Then, it presents the epidemiology, classification, and clinical presentation of the six different forms of the disease (perinatal lethal, prenatal benign, infantile, childhood, adult, and odontohypophosphatasia) as well as the essential diagnostic clues. The last section on treatment presents a survey of the therapeutic approaches, up to the ongoing phase 2 studies of enzyme replacement therapy.
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Affiliation(s)
- M L Bianchi
- Experimental Laboratory for Children's Bone Metabolism Research, Bone Metabolism Unit, Istituto Auxologico Italiano IRCCS, via L. Ariosto 13, 20145, Milano, Italy.
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