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Dudde F, Fildebrandt D, Smeets R, Gosau M, Amling M, Beikler T, Barvencik F. Role of PLP-Level as a predictive marker for oral health status in adult hypophosphatasia. Clin Oral Investig 2024; 28:419. [PMID: 38976034 PMCID: PMC11230944 DOI: 10.1007/s00784-024-05809-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Accepted: 06/28/2024] [Indexed: 07/09/2024]
Abstract
AIM The aim of this study was to investigate the role of pyridoxal-5-phosphate (PLP) level on the oral health status as a predictive marker in patients with hypophosphatasia (HPP). MATERIALS AND METHODS Throughout a systematic retrospective assessment both bone metabolism and oral health status were analyzed. The oral health status was assessed by the decayed/missing/filled teeth index (DMFT), clinical attachment level (CAL), probing pocket depth (PPD), and the periodontal screening index (PSI). RESULTS A total of 48 HPP patients (81.3% female) with a mean age of 42.21 years was included in this retrospective study. The study population was divided into two groups using the mean PLP level (87 µg/l) as a cut-off. Patients with a PLP level ≥ 87 µg/l (n = 14) showed a significantly poorer oral health status regarding DMFT index, CAL, PPD and PSI compared to patients with a PLP level < 87 µg/l (n = 34). No significant group differences for tooth loss were found. CONCLUSION The results of the present study indicate that the PLP level is a suitable diagnostic predictor for the oral health status in HPP patients. HPP patients with PLP levels ≥ 70 µg/l should be included into a regular dental preventive program. CLINICAL RELEVANCE The oral health status in HPP and its correlation with laboratory parameters (i.e. PLP) has been understudied. For clinical practice, the findings of the present study clearly demonstrated that high PLP levels correlate with a worse oral health status in HPP patients. Therefore, these patients should receive an intensive dental treatment and/or inclusion in a strict maintenance program in a specialized dental practice/university hospital with a PLP level ≥ 70 µg/l.
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Affiliation(s)
- Florian Dudde
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529, Hamburg, Germany
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dominik Fildebrandt
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralf Smeets
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Oral and Maxillofacial Surgery, Division of Regenerative Orofacial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Gosau
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529, Hamburg, Germany
| | - Thomas Beikler
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529, Hamburg, Germany.
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Lehane F, Malaise O, Von Frenckell C, Otto B, Docampo E, Ribbens C. Hypophosphatasia Presenting as a Chronic Diffuse Pain Syndrome with Extra-Articular Calcifications. J Clin Med 2024; 13:2263. [PMID: 38673536 PMCID: PMC11051522 DOI: 10.3390/jcm13082263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Hypophosphatasia is a rare genetic disease characterized by abnormal alkaline phosphatase activity and deficiency of bone and teeth mineralization. Hypophosphatasia is well known in pediatrics with typical presentations in children, but mild forms can also be present in adults and are difficult to detect. We present the case of a 50-year-old woman referred for pain management, with a previous diagnosis of fibromyalgia. The association of clinical features (diffuse pain syndrome, early dental loosening, personal history of two fractures with osteoporosis, and family history of osteoporosis) with radiographic (heterotopic calcifications of the yellow and interspinous lumbar ligaments) and biological (low levels of total alkaline phosphatase) indices was suggestive of hypophosphatasia, which was confirmed by genetic analysis. We review and discuss the association between hypophosphatasia, musculoskeletal pain, and calcium pyrophosphate deposition and the importance of raising the diagnosis of adult-onset hypophosphatasia when facing these two rheumatologic entities.
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Affiliation(s)
- Florence Lehane
- Rheumatology Department, University Hospital of Liège, 4000 Liège, Belgium (C.R.)
| | - Olivier Malaise
- Rheumatology Department, University Hospital of Liège, 4000 Liège, Belgium (C.R.)
| | | | - Bernard Otto
- Radiology Department, University Hospital of Liège, 4000 Liège, Belgium
| | - Elisa Docampo
- Rheumatology Department, University Hospital of Liège, 4000 Liège, Belgium (C.R.)
| | - Clio Ribbens
- Rheumatology Department, University Hospital of Liège, 4000 Liège, Belgium (C.R.)
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Alsarraf F, Ali DS, Almonaei K, Al-Alwani H, Khan AA, Brandi ML. Hypophosphatasia: presentation and response to asfotase alfa. Osteoporos Int 2024; 35:717-725. [PMID: 37993691 DOI: 10.1007/s00198-023-06943-z] [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: 05/28/2023] [Accepted: 10/04/2023] [Indexed: 11/24/2023]
Abstract
Hypophosphatasia (HPP) is a rare bone disease with limited scientific evidence on the tolerability and safety of its novel treatment, Asfotase Alfa (AA). We report 7 HPP patients' heterogenous presentations and the significant improvement in various clinical outcomes attained with AA shedding light on this highly effective and safe therapy. INTRODUCTION Hypophosphatasia (HPP) is a rare inherited metabolic bone disorder characterized by a deficiency in the tissue non-specific alkaline phosphatase (TNSALP) due to loss of function mutation in the ALPL gene. HPP is associated with impaired skeletal mineralization due to elevations in inorganic pyrophosphate and altered phosphate : pyrophosphate ratio. Asfotase alfa (AA) "enzyme replacement" was approved for treatment of HPP in 2015. We present 7 patients with HPP, 5 with pediatric-onset, and 2 with adult-onset, who have been treated with AA and describe the efficacy and safety in these patients. METHODS 7 patients (4 females, 3 males) aged 19-68 years with HPP were included in this study. Diagnosis of HPP was confirmed by DNA analysis. AA was administered in doses of 6mg/kg/week with a mean follow-up of 6 months (SD= 5). RESULTS Subjective improvement in muscle strength, muscle pain, walking ability, and walking distance with a reduction in the use of gait aids was seen "with AA in HPP patients." Muscle strength and pain improved by up to 70% from baseline as quantified subjectively by patients. Walking distance improved by up to 100%. Patients also reported improved cognition, mood, and energy levels, with up to 90% improvement in mood and 75% improvement in energy levels. 4 out of 6 patients first noted clinical signs of improvement after 3 months of being on therapy. 1 out of the 7 patients sustained a toe fracture 10 months from being on AA. AA was well-tolerated with injection site reactions being the most reported adverse effect. CONCLUSION HPP treatment with AA in individuals with both pediatric and adult-onset forms resulted in significant subjective improvement in musculoskeletal and cognitive manifestations in addition to patients' quality of life. The drug was well tolerated in 6 patients. 1 patient discontinued therapy because of minor adverse effects with myalgias.
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Affiliation(s)
- F Alsarraf
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada.
| | - D S Ali
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
| | - K Almonaei
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - H Al-Alwani
- Department of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - A A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
| | - M L Brandi
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy
- Donatello Bone Clinic, Villa Donatello Hospital, Florence, Italy
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Kinsman D, Hu J, Zhang Z, Li G. New Empirical Bayes Models to Jointly Analyze Multiple RNA-Sequencing Data in a Hypophosphatasia Disease Study. Genes (Basel) 2024; 15:407. [PMID: 38674342 PMCID: PMC11049189 DOI: 10.3390/genes15040407] [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: 02/23/2024] [Revised: 03/17/2024] [Accepted: 03/18/2024] [Indexed: 04/28/2024] Open
Abstract
Hypophosphatasia is a rare inherited metabolic disorder caused by the deficiency of tissue-nonspecific alkaline phosphatase. More severe and early onset cases present symptoms of muscle weakness, diminished motor coordination, and epileptic seizures. These neurological manifestations are poorly characterized. Thus, it is urgent to discover novel differentially expressed genes for investigating the genetic mechanisms underlying the neurological manifestations of hypophosphatasia. RNA-sequencing data offer a high-resolution and highly accurate transcript profile. In this study, we apply an empirical Bayes model to RNA-sequencing data acquired from the spinal cord and neocortex tissues of a mouse model, individually, to more accurately estimate the genetic effects without bias. More importantly, we further develop two integration methods, weighted gene approach and weighted Z method, to incorporate two RNA-sequencing data into a model for enhancing the effects of genetic markers in the diagnostics of hypophosphatasia disease. The simulation and real data analysis have demonstrated the effectiveness of our proposed integration methods, which can maximize genetic signals identified from the spinal cord and neocortex tissues, minimize the prediction error, and largely improve the prediction accuracy in risk prediction.
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Affiliation(s)
- Dawson Kinsman
- Department of Mathematics and Statistics, University of Michigan-Dearborn, Dearborn, MI 48128, USA;
| | - Jian Hu
- Manufacturing Systems Engineering, University of Michigan-Dearborn, Dearborn, MI 48128, USA;
| | - Zhi Zhang
- Department of Natural Sciences, University of Michigan-Dearborn, Dearborn, MI 48128, USA;
| | - Gengxin Li
- Department of Mathematics and Statistics, University of Michigan-Dearborn, Dearborn, MI 48128, USA;
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Dattagupta A, Petak S. A Case of Hypophosphatasia With Normal Alkaline Phosphatase Levels. AACE Clin Case Rep 2024; 10:38-40. [PMID: 38523854 PMCID: PMC10958627 DOI: 10.1016/j.aace.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/17/2023] [Accepted: 11/17/2023] [Indexed: 03/26/2024] Open
Abstract
Background/Objective Hypophosphatasia (HPP) is a rare disease associated with low serum alkaline phosphatase (ALP) activity. Here, we present a case of a patient with normal serum ALP levels diagnosed with HPP. Case Report A 36-year-old woman presented with progressive fatigue, weakness, and joint pain. She had been evaluated in the past for genetic disorders due to these symptoms and was found to have a history of several total ALP levels within normal limits but elevated vitamin B6 levels. She also reported having loose teeth and "gray gums" during her childhood. Bone-specific ALP was tested for suspicion of HPP and returned at 4.4 μ/L (reference range, 5.3-19.5 μg/L), which prompted genetic testing. Genetic testing confirmed a positive pathogenetic variant of the ALPL gene, the c.542C>T (p.Ser181Leu) variant. She started asfotase alfa treatment to improve her symptoms. Discussion HPP was diagnosed based on clinical suspicion supported by laboratory findings, which can cause it to be underdiagnosed or misdiagnosed. Current literature reports that a low total ALP level is the main biochemical marker of HPP and the only level needed to diagnose the disease. However, bone-specific ALP, a common marker used for bone turnover, has not been required to be tested. Conclusion This case highlights a patient with normal total ALP, but low bone-specific ALP diagnosed with HPP confirmed by genetic testing. This case warrants future investigation into the diagnostic approach to HPP and the diagnostic utility between ALP and bone-specific ALP.
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Affiliation(s)
- Antara Dattagupta
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Houston Methodist Hospital, Houston, Texas
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Steven Petak
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Houston Methodist Hospital, Houston, Texas
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González-Cejudo T, Villa-Suárez JM, Ferrer-Millán M, Andújar-Vera F, Contreras-Bolívar V, Andreo-López MC, Gómez-Vida JM, Martínez-Heredia L, González-Salvatierra S, de Haro Muñoz T, García-Fontana C, Muñoz-Torres M, García-Fontana B. Mild hypophosphatasia may be twice as prevalent as previously estimated: an effective clinical algorithm to detect undiagnosed cases. Clin Chem Lab Med 2024; 62:128-137. [PMID: 37440753 DOI: 10.1515/cclm-2023-0427] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES Since the prevalence of hypophosphatasia (HPP), a rare genetic disease, seems to be underestimated in clinical practice, in this study, a new diagnostic algorithm to identify missed cases of HPP was developed and implemented. METHODS Analytical determinations recorded in the Clinical Analysis Unit of the Hospital Universitario Clínico San Cecilio in the period June 2018 - December 2020 were reviewed. A new clinical algorithm to detect HPP-misdiagnosed cases was used including the following steps: confirmation of persistent hypophosphatasemia, exclusion of secondary causes of hypophosphatasemia, determination of serum pyridoxal-5'-phosphate (PLP) and genetic study of ALPL gene. RESULTS Twenty-four subjects were selected to participate in the study and genetic testing was carried out in 20 of them following clinical algorithm criteria. Eighty percent of patients was misdiagnosed with HPP following the current standard clinical practice. Extrapolating these results to the current Spanish population means that there could be up to 27,177 cases of undiagnosed HPP in Spain. In addition, we found a substantial proportion of HPP patients affected by other comorbidities, such as autoimmune diseases (∼40 %). CONCLUSIONS This new algorithm was effective in detecting previously undiagnosed cases of HPP, which appears to be twice as prevalent as previously estimated for the European population. In the near future, our algorithm could be globally applied routinely in clinical practice to minimize the underdiagnosis of HPP. Additionally, some relevant findings, such as the high prevalence of autoimmune diseases in HPP-affected patients, should be investigated to better characterize this disorder.
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Affiliation(s)
- Trinidad González-Cejudo
- Clinical Analysis Unit, University Hospital Clínico San Cecilio, Granada, Spain
- Department of Medicine, University of Granada, Granada, Spain
| | | | - María Ferrer-Millán
- Instituto de Investigación Biosanitaria de Granada (ibs. GRANADA), Granada, Spain
| | - Francisco Andújar-Vera
- Department of Computer Science and Artificial Intelligence, University of Granada, Granada, Spain
- CIBER on Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
- Andalusian Research Institute in Data Science and Computational Intelligence (DaSCI Institute), Granada, Spain
| | - Victoria Contreras-Bolívar
- Instituto de Investigación Biosanitaria de Granada (ibs. GRANADA), Granada, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, Granada, Spain
| | | | | | | | - Sheila González-Salvatierra
- Instituto de Investigación Biosanitaria de Granada (ibs. GRANADA), Granada, Spain
- Department of Biochemistry and Molecular Biology II, Faculty of Pharmacy, University of Granada, Granada, Spain
| | - Tomás de Haro Muñoz
- Clinical Analysis Unit, University Hospital Clínico San Cecilio, Granada, Spain
| | - Cristina García-Fontana
- Instituto de Investigación Biosanitaria de Granada (ibs. GRANADA), Granada, Spain
- CIBER on Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, Granada, Spain
| | - Manuel Muñoz-Torres
- Department of Medicine, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (ibs. GRANADA), Granada, Spain
- CIBER on Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, Granada, Spain
| | - Beatriz García-Fontana
- Instituto de Investigación Biosanitaria de Granada (ibs. GRANADA), Granada, Spain
- CIBER on Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
- Department of Cell Biology, University of Granada, Granada, Spain
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Hidaka N, Murata H, Tachikawa K, Osaki K, Sekiyama T, Kinoshita Y, Kato H, Hoshino Y, Kimura S, Sunouchi T, Watanabe S, Nangaku M, Makita N, Michigami T, Ito N. The Effect of Asfotase Alfa on Plasma and Urine Pyrophosphate Levels and Pseudofractures in a Patient With Adult-Onset Hypophosphatasia. JBMR Plus 2023; 7:e10842. [PMID: 38130758 PMCID: PMC10731098 DOI: 10.1002/jbm4.10842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/07/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023] Open
Abstract
Hypophosphatasia (HPP) is an inherited disease caused by variants of the ALPL gene encoding tissue-nonspecific alkaline phosphatase. Adult-onset HPP (adult HPP), known as a mild form of HPP, develops symptoms involving osteomalacia after the age of 18 years. Asfotase alfa (AA) is a modulated recombinant human alkaline phosphatase (ALP) that has been established as a first-line therapy for severe forms of HPP, such as perinatal and infantile forms. We described a 64-year-old female who presented with pseudofractures in bilateral femur diaphyses and impaired mobility. Low serum ALP activity and a high concentration of urine phosphoethanolamine indicated the diagnosis of HPP, which was confirmed by the identification of a homozygous variant in the ALPL gene (c.319G > A; p.Val107Ile). An in vitro transfection experiment to measure the ALP activity of this novel variant protein was performed, resulting in 40% of the residual enzymatic activity compared with the wild type. AA was initiated to facilitate the union of pseudofracture and to improve mobility. After 6 months, radiographic images revealed the disappearance of fracture lines, and improvement of ambulatory ability was confirmed by the 6-minute walk test (525 to 606 m). The EQ-5D-5L index was also improved (0.757 to 0.895). Within a follow-up period, the levels of urine pyrophosphate corrected by urine creatinine (uPPi/Cre) declined in parallel with the level of plasma PPi (plasma PPi: 6.34 to 1.04 μM, uPPi/Cre: 226.8 to 75.4 nmol/mg). The beneficial effect of AA on pseudofracture healing in adult HPP was presented, although the application of AA should be restricted to patients exhibiting relatively severe manifestations. In addition, a novel pathogenic variant of the ALPL gene was identified with the supportive result of functional analysis. Furthermore, when monitoring patients with HPP treated with AA, uPPi/Cre might be a convenient substitute for plasma PPi, which requires immediate filtration after blood sampling. © 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)
- Naoko Hidaka
- Division of Nephrology and EndocrinologyThe University of Tokyo HospitalTokyoJapan
- Osteoporosis CenterThe University of Tokyo HospitalTokyoJapan
| | - Hiroaki Murata
- Department of Orthopaedic Surgery, Panasonic Health Insurance OrganizationMatsushita Memorial HospitalOsakaJapan
| | - Kanako Tachikawa
- Department of Bone and Mineral Research, Research InstituteOsaka Women's and Children's HospitalOsakaJapan
| | - Keiichi Osaki
- Department of Rehabilitation, Panasonic Health Insurance OrganizationMatsushita Memorial HospitalOsakaJapan
| | - Takashi Sekiyama
- Department of Rehabilitation, Panasonic Health Insurance OrganizationMatsushita Memorial HospitalOsakaJapan
| | - Yuka Kinoshita
- Division of Nephrology and EndocrinologyThe University of Tokyo HospitalTokyoJapan
- Osteoporosis CenterThe University of Tokyo HospitalTokyoJapan
| | - Hajime Kato
- Division of Nephrology and EndocrinologyThe University of Tokyo HospitalTokyoJapan
- Osteoporosis CenterThe University of Tokyo HospitalTokyoJapan
| | - Yoshitomo Hoshino
- Division of Nephrology and EndocrinologyThe University of Tokyo HospitalTokyoJapan
- Osteoporosis CenterThe University of Tokyo HospitalTokyoJapan
| | - Soichiro Kimura
- Division of Nephrology and EndocrinologyThe University of Tokyo HospitalTokyoJapan
- Osteoporosis CenterThe University of Tokyo HospitalTokyoJapan
| | - Takashi Sunouchi
- Division of Nephrology and EndocrinologyThe University of Tokyo HospitalTokyoJapan
- Osteoporosis CenterThe University of Tokyo HospitalTokyoJapan
| | - So Watanabe
- Osteoporosis CenterThe University of Tokyo HospitalTokyoJapan
- Department of Geriatric Medicine, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Masaomi Nangaku
- Division of Nephrology and EndocrinologyThe University of Tokyo HospitalTokyoJapan
| | - Noriko Makita
- Division of Nephrology and EndocrinologyThe University of Tokyo HospitalTokyoJapan
- Osteoporosis CenterThe University of Tokyo HospitalTokyoJapan
| | - Toshimi Michigami
- Department of Bone and Mineral Research, Research InstituteOsaka Women's and Children's HospitalOsakaJapan
| | - Nobuaki Ito
- Division of Nephrology and EndocrinologyThe University of Tokyo HospitalTokyoJapan
- Osteoporosis CenterThe University of Tokyo HospitalTokyoJapan
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Kim SM, Korkmaz F, Sims S, Ryu V, Yuen T, Zaidi M. Musculoskeletal and neurocognitive clinical significance of adult hypophosphatasia. Osteoporos Sarcopenia 2023; 9:115-120. [PMID: 38374822 PMCID: PMC10874721 DOI: 10.1016/j.afos.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/03/2023] [Accepted: 12/12/2023] [Indexed: 02/21/2024] Open
Abstract
Hypophosphatasia (HPP), also called Rathbun disease, is a rare genetic disorder that is caused by the loss-of-function mutation in the ALPL gene encoding tissue non-specific alkaline phosphatase. Doctor Rathbun first described the case of a 3-week-old infant who presented with severe osteopenia, rickets, and multiple radiographic fractures, and died shortly after of epileptic seizure and respiratory distress. The term "hypophosphatasia" was coined as the patients' alkaline phosphatase levels were significantly low. Since then, our understanding of HPP has evolved, and now we appreciate causative genetic mutation and the broad spectrum of clinical presentation depending on the age of onset, severity, and skeletal involvement: perinatal, infantile, childhood, adult and odontohypophosphatasia. The new development of enzyme replacement with asfostase alfa has saved the lives of severe form of hypophosphatasia. However, it is still unclear and remains challenging how to manage adult HPP that often presents with mild and non-specific symptoms such as muscle pain, joint stiffness, fatigue, anxiety, or low bone mass, which are common in the general population and not necessarily attributed to HPP. In this review, we will present 3 unique cases of adult HPP and discuss the pathophysiology, clinical presentation particularly neuromuscular and neurocognitive symptoms and management of adult HPP.
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Affiliation(s)
- Se-Min Kim
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Funda Korkmaz
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steve Sims
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vitaly Ryu
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tony Yuen
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mone Zaidi
- Center for Translational Medicine and Pharmacological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Kuehn K, Hahn A, Seefried L. Impact of Restricted Phosphorus, Calcium-adjusted Diet on Musculoskeletal and Mental Health in Hypophosphatasia. J Endocr Soc 2023; 8:bvad150. [PMID: 38111621 PMCID: PMC10726311 DOI: 10.1210/jendso/bvad150] [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: 09/12/2023] [Indexed: 12/20/2023] Open
Abstract
Context Impairments in musculoskeletal and mental health are common in adults with Hypophosphatasia (HPP). Restricted phosphorus intake has been suggested to positively affect symptoms in HPP, but there is a lack of interventional evidence. Objective This work aimed to evaluate the effect of a phosphorus-restricted, calcium-adjusted diet on musculoskeletal and mental health in HPP. Methods A prospective, noncontrolled, single-center interventional study (NuSTEPS II) was conducted among outpatients at the Osteology Department, University of Wuerzburg, Germany. A total of 26 adults with an established HPP diagnosis received a standardized diet with a defined daily intake of phosphorus (1160-1240 mg/d) and calcium (870-930 mg/d) over 8 weeks. Main outcome measures were functional testing and patient-reported outcome measures. Results At 8 weeks, significant improvements were observed in usual gait speed (P = .028) and the chair-rise test (P = .019), while no significant changes were seen in the 6-minute walk test (P = .468) and the timed up-and-go test (P = .230). Pain was not significantly reduced according to the visual analog scale (VAS) (P = .061), pain subscale of the 36-Item Short-Form Health Survey (SF-36) (P = .346), and Pain Disability Index (P = .686). Further, there was a significant improvement in the SF-36 vitality subscale (P = .022) while all other subscales as well as the Lower Extremity Functional Scale (P = .670) and the Fatigue Assessment Scale (P = .392) did not change significantly. Adjustments of mineral intake were not associated with relevant alterations regarding the intake of energy and energy-supplying nutrients or body composition. Conclusion Adjusting phosphorus and calcium intake may positively affect individual symptoms in adults with HPP, but overall clinical effectiveness regarding major issues like pain and endurance appears limited.
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Affiliation(s)
- Katinka Kuehn
- Faculty of Natural Science, Institute of Food Science and Human Nutrition, Leibniz University Hannover, 30167 Hanover, Germany
| | - Andreas Hahn
- Faculty of Natural Science, Institute of Food Science and Human Nutrition, Leibniz University Hannover, 30167 Hanover, Germany
| | - Lothar Seefried
- Clinical Trial Unit, Orthopedic Institute, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany
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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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Injean P, Tan J, Lee S, Downey C. Could Some Patients With Fibromyalgia Potentially Have Hypophosphatasia? A Retrospective Single-Center Study. ACR Open Rheumatol 2023; 5:524-528. [PMID: 37661663 PMCID: PMC10570664 DOI: 10.1002/acr2.11591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 09/05/2023] Open
Abstract
OBJECTIVE Hypophosphatasia (HPP) is a rare disease characterized by incomplete or defective bone mineralization due to a mutation in the alkaline phosphatase (ALP) gene causing low levels of ALP. Disease presentation is heterogeneous and can present as a chronic pain syndrome like fibromyalgia (FM). Our objective was to determine if there are any potential patients with HPP in the group of patients who were diagnosed with FM. Antiresorptive therapy use can trigger atypical femur fractures in patients with HPP. METHODS We performed a retrospective chart review of all patients 18 years or older at a single academic center who were diagnosed with FM and had either a low or a normal ALP level. The following characteristics were reviewed: biological sex; age; history of fractures; diagnosis of osteoporosis, osteopenia, osteoarthritis, and chondrocalcinosis; genetic testing; vitamin B6 level testing; and medications. RESULTS Six hundred eleven patients with FM were identified. Two hundred had at least one low ALP level, and 57 had at least three consecutively low measurements of ALP, 44% of which had a history of fractures. No patients had vitamin B6 levels checked. None of the patients had previous genetic testing for HPP or underwent testing for zinc or magnesium levels. CONCLUSION The percentage of patients with FM who were found to have consistently low ALP levels was 9.3%. None had vitamin B6 level or genetic testing, suggesting that the diagnosis was not suspected. It is important to diagnose HPP given the availability of enzyme replacement therapy to prevent complications from HPP such as fractures. Our data support screening for this condition as a part of the initial workup of FM.
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Affiliation(s)
- Patil Injean
- Cedars Sinai Medical CenterLos AngelesCalifornia
| | - John Tan
- Huckleberry LabsIrvineCalifornia
| | - Sandy Lee
- University of Southern CaliforniaLos Angeles
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Calmarza P, Lapresta C, Martínez García M, Ochoa J, Sienes Bailo P, Acha Pérez J, Beltrán Audera J, González-Roca E. Musculoskeletal pain and muscular weakness as the main symptoms of adult hypophosphatasia in a Spanish cohort: clinical characterization and identification of a new ALPL gene variant. J Bone Miner Metab 2023; 41:654-665. [PMID: 37351650 DOI: 10.1007/s00774-023-01440-z] [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: 01/04/2023] [Accepted: 05/15/2023] [Indexed: 06/24/2023]
Abstract
INTRODUCTION Hypophosphatasia (HPP) is a rare inherited disorder, caused by mutations in the alkaline phosphatase (ALPL) gene, which encodes for the tissue non-specific alkaline phosphatase (TNSALP) isoform of alkaline phosphatase (ALP). Adult HPP is one of the mild forms that presents with unspecific signs such as osteopenia, osteomalacia and muscle involvement. Our purpose was to identify and characterize possibly misdiagnosed adult HPP patients at a clinical and biochemical level. MATERIAL AND METHODS At the laboratory of Miguel Servet University Hospital we retrospectively reviewed serum ALP levels in adults over a 48-month period. The clinical records of individuals with consistently low ALP levels were reviewed to exclude secondary causes. Those with persistent hypophosphatasemia were screened for symptoms of HPP. The study participants were evaluated at biochemical and genetic levels. RESULTS We identified 705 ALP determinations (out of 384,000 processed) in 589 patients below the reference range (30 U/l). Only 21 patients with clinical signs and symptoms of HPP were selected for genetic testing. Finally, only 12 patients participated in the study, 83.3% of whom (10/12) harbored a pathogenic or likely pathogenic variant in a heterozygous state. The major symptoms of our cohort were the presence of musculoskeletal pain (100% of patients) and muscular weakness (83.3% patients). CONCLUSION Mild HPP patients presenting with diffuse symptoms such as musculoskeletal pain may be undiagnosed or misdiagnosed as osteoporosis patients by routine diagnosis. It is important to identify these individuals, to avoid inappropriate treatment with antiresorptive drugs.
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Affiliation(s)
- Pilar Calmarza
- Clinical Biochemistry Department, IIS Aragón, Miguel Servet University Hospital, Network Research Center in Cardiovascular Diseases (CIBERCV), University of Zaragoza, 50009, Zaragoza, Spain.
| | - Carlos Lapresta
- Preventive Medicine Department, Miguel Servet University Hospital, 50009, Zaragoza, Spain
| | | | - José Ochoa
- Occupational Risk Prevention Service, MAS Prevention, Zaragoza, Spain
| | - Paula Sienes Bailo
- Clinical Biochemistry Department, Miguel Servet University Hospital, 50009, Zaragoza, Spain
| | - Javier Acha Pérez
- Endocrinology Department, Miguel Servet University Hospital, 50009, Zaragoza, Spain
| | - Jesús Beltrán Audera
- Rheumatology department, Miguel Servet University Hospital, 50009, Zaragoza, Spain
| | - Eva González-Roca
- Molecular Biology Core Lab/Immunology Department, CDB. Hospital Clínic, Barcelona, Spain
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13
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Rauf MA, Kotecha J, Moss K. Reducing diagnostic delay in hypophosphatasia: a case series of 14 patients presenting to general rheumatology. Osteoporos Int 2023; 34:1647-1652. [PMID: 37118032 PMCID: PMC10427523 DOI: 10.1007/s00198-023-06749-z] [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: 11/06/2022] [Accepted: 04/05/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVES Hypophosphatasia (HPP) is a rare genetic metabolic bone disease that can cause chronic pain and fractures. Its hallmark is a persistently low serum ALP. HPP is now recognised by many osteoporosis specialists, but other specialists, such as rheumatologists and primary care physicians, may be less aware of this condition, causing diagnostic delay and possible harm to these patients. Our objective was to highlight features that can reduce this delay. METHODS We retrospectively analysed 14 patients that presented with musculoskeletal pain to general rheumatology clinic at St. George's Hospital and were subsequently diagnosed with HPP. RESULTS Median diagnostic delay was 13 years. All patients had an ALP below reference range for age and gender, with lowest mean ALP of 16 IU/L. All but one patient were women with median age of 51 years. Most common presentation was peripheral joint pain in 85.7% of patients. This was due to early-onset CPPD (calcium pyrophosphate deposition disease) in 71.4% of patients, osteoarthritis in 50%, or bursitis in 50%. Axial pain was reported in 64% of patients due to osteoarthritis or spinal stenosis. Fifty percent of patients had a history of long bone pain. Fifty percent had previous fracture(s). A total of 28.6% of patients had psoriatic arthritis, of which 1 patient had spondyloarthropathy, and 4 patients also had enthesitis. CONCLUSION Patients with HPP can present to rheumatology with musculoskeletal pain, and if a persistently low ALP is confirmed, this may reduce the diagnostic delay of this rare disease. Similar to other rheumatologic patients, musculoskeletal pain in HPP was noted in peripheral joints and in the spine with almost a third of patients having psoriatic arthritis. Pain was also noted in the long bones, a feature consistent with metabolic bone disease. The diagnosis of HPP was also more likely in those patients with a personal or family history of dental disease or arthritis.
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Affiliation(s)
- Muhammad A. Rauf
- Department of Medicine, St. George’s University of London, Cranmer Terrace, London, SW17 0RE UK
| | - Jalpa Kotecha
- Weston Education Centre, King’s College Hospital, London, UK
| | - Katie Moss
- Department of Rheumatology, St. George’s University Hospitals NHS Foundation Trust, London, UK
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14
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Reis FS, Lazaretti-Castro M. Hypophosphatasia: from birth to adulthood. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2023; 67:e000626. [PMID: 37249457 PMCID: PMC10665056 DOI: 10.20945/2359-3997000000626] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/12/2022] [Indexed: 05/31/2023]
Abstract
Hypophosphatasia (HPP) is an inherited disease caused by a low activity of tissue-nonspecific alkaline phosphatase, a hydrolase that removes phosphate groups from many molecules. Decreased alkaline phosphatase activity leads to the accumulation of three main metabolites, i.e., pyridoxal 5´-phosphate (PLP), inorganic pyrophosphate (PPi), and phosphoethanolamine. Impairment in PLP dephosphorylation induces seizures, while PPi accumulation inhibits bone mineralization. Clinically, HPP has a wide spectrum of presentations, ranging from neonatal death to an apparent lack of symptoms. This disease is classified into six subtypes according to the age at onset of first signs or symptoms. The clinical manifestations of the disease include rickets-like bone changes, bone demineralization, fragility fractures, reduced muscular strength, chest deformity, pulmonary hypoplasia, nephrolithiasis, nephrocalcinosis, and chondrocalcinosis. Treatment of HPP consists of enzyme replacement therapy. Before this therapy was approved, treatment was palliative and associated with high morbidity and mortality. Asfotase alfa has changed the prognosis of the disease by reducing bone deformity and improving bone mineralization, lung function, and muscle weakness, among other benefits. In adults, teriparatide and anti-sclerostin antibody have been used off-label in selected cases, demonstrating benefit in accelerating fracture healing and in concomitant treatment of osteoporosis. This review summarizes the main aspects of HPP and identifies the particularities of the disease in adult patients.
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Affiliation(s)
- Fernanda Salles Reis
- Departamento de Medicina, Disciplina de Endocrinologia, Universidade Federal de São Paulo (Unifesp), São Paulo, Brasil
| | - Marise Lazaretti-Castro
- Departamento de Medicina, Disciplina de Endocrinologia, Universidade Federal de São Paulo (Unifesp), São Paulo, Brasil,
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Schmidt FN, Schmidt C, Delsmann J, Amling M, Barvencik F. Radial HR-pQCT and Finite Element Analysis in HPP Patients are Superior in Identifying Susceptibility to Fracture-Associated Skeletal Affections Compared to DXA and Laboratory Tests. Calcif Tissue Int 2023; 112:691-703. [PMID: 37147467 DOI: 10.1007/s00223-023-01082-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/05/2023] [Indexed: 05/07/2023]
Abstract
Hypophosphatasia (HPP) is an inborn disease that causes a rare form of osteomalacia, a mineralization disorder affecting mineralized tissues. Identification of patients at high risk for fractures or other skeletal manifestations (such as insufficiency fractures or excessive bone marrow edema) by bone densitometry and laboratory tests remains clinically challenging. Therefore, we examined two cohorts of patients with variants in the ALPL gene grouped by bone manifestations. These groups were compared by means of bone microarchitecture using high-resolution peripheral quantitative computed tomography (HR-pQCT) and simulated mechanical performance utilizing finite element analysis (FEA). Whereas the incidence of skeletal manifestations among the patients could not be determined by dual energy X-ray absorptiometry (DXA) or laboratory assessment, HR-pQCT evaluation showed a distinct pattern of HPP patients with such manifestations. Specifically, these patients had a pronounced loss of trabecular bone mineral density, increased trabecular spacing, and decreased ultimate force at the distal radius. Interestingly, the derived results indicate that the non-weight-bearing radius is superior to the weight-bearing tibia in identifying deteriorated skeletal patterns. Overall, the assessment by HR-pQCT appears to be of high clinical relevance due to the improved identification of HPP patients with an increased risk for fractures or other skeletal manifestations, especially at the distal radius.
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Affiliation(s)
- Felix N Schmidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Constantin Schmidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Julian Delsmann
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany.
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16
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Riancho JA. Diagnostic Approach to Patients with Low Serum Alkaline Phosphatase. Calcif Tissue Int 2023; 112:289-296. [PMID: 36348061 DOI: 10.1007/s00223-022-01039-y] [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: 08/29/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Increased serum levels of alkaline phosphatase (ALP) are widely recognized as a biochemical marker of many disorders affecting the liver or bone. However, the approach for patients with low ALP phosphatase is not well-established. Low serum ALP is an epiphenomenon of many severe acute injuries and diseases. Persistently low serum ALP may be secondary to drug therapy (including antiresorptives) or a variety of acquired disorders, such as malnutrition, vitamin and mineral deficiencies, endocrine disorders, etc. Hypophosphatasia, due to pathogenic variants of the ALPL gene, which encodes tissue non-specific ALP, is the most common genetic cause of low serum ALP. Marked bone hypomineralization is frequent in severe pediatric-onset cases. However, adult forms of hypophosphatasia usually present with milder manifestations, such as skeletal pain, chondrocalcinosis, calcific periarthritis, dental problems, and stress fractures. The diagnostic approach to these patients is discussed. Measuring several ALP substrates, such as pyrophosphate, pyridoxal phosphate, or phosphoethanolamine, may help to establish enzyme deficiency. Gene analysis showing a pathogenic variant in ALPL may confirm the diagnosis. However, a substantial proportion of patients show normal results after sequencing ALPL exons. It is still unknown if those patients carry unidentified mutations in regulatory regions of ALPL, epigenetic changes, or abnormalities in other genes.
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Affiliation(s)
- Jose A Riancho
- Departamento de Medicina y Psiquiatría, Universidad de Cantabria, Servicio de Medicina Interna, Hospital UM Valdecilla-IDIVAL, Av Valdecilla sn, 39008, Santander, Spain.
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Wölfel EM, von Kroge S, Matthies L, Koehne T, Petz K, Beikler T, Schmid-Herrmann CU, Kahl-Nieke B, Tsiakas K, Santer R, Muschol NM, Herrmann J, Busse B, Amling M, Rolvien T, Jandl NM, Barvencik F. Effects of Infantile Hypophosphatasia on Human Dental Tissue. Calcif Tissue Int 2023; 112:308-319. [PMID: 36414794 PMCID: PMC9968273 DOI: 10.1007/s00223-022-01041-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/02/2022] [Indexed: 11/23/2022]
Abstract
Hypophosphatasia (HPP) is an inherited, systemic disorder, caused by loss-of-function variants of the ALPL gene encoding the enzyme tissue non-specific alkaline phosphatase (TNSALP). HPP is characterized by low serum TNSALP concentrations associated with defective bone mineralization and increased fracture risk. Dental manifestations have been reported as the exclusive feature (odontohypophosphatasia) and in combination with skeletal complications. Enzyme replacement therapy (asfotase alfa) has been shown to improve respiratory insufficiency and skeletal complications in HPP patients, while its effects on dental status have been understudied to date. In this study, quantitative backscattered electron imaging (qBEI) and histological analysis were performed on teeth from two patients with infantile HPP before and during asfotase alfa treatment and compared to matched healthy control teeth. qBEI and histological methods revealed varying mineralization patterns in cementum and dentin with lower mineralization in HPP. Furthermore, a significantly higher repair cementum thickness was observed in HPP compared to control teeth. Comparison before and during treatment showed minor improvements in mineralization and histological parameters in the patient when normalized to matched control teeth. HPP induces heterogeneous effects on mineralization and morphology of the dental status. Short treatment with asfotase alfa slightly affects mineralization in cementum and dentin. Despite HPP being a rare disease, its mild form occurs at higher prevalence. This study is of high clinical relevance as it expands our knowledge of HPP and dental involvement. Furthermore, it contributes to the understanding of dental tissue treatment, which has hardly been studied so far.
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Affiliation(s)
- Eva Maria Wölfel
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529, Hamburg, Germany
- Interdisciplinary Competence Center for Interface Research (ICCIR), Lottestr. 55A, Hamburg, Germany
| | - Simon von Kroge
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529, Hamburg, Germany
| | - Levi Matthies
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Till Koehne
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529, Hamburg, Germany
- Department of Orthodontics, Center for Dental and Oral Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Karin Petz
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Thomas Beikler
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Carmen Ulrike Schmid-Herrmann
- Department of Orthodontics, Center for Dental and Oral Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Bärbel Kahl-Nieke
- Department of Orthodontics, Center for Dental and Oral Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Konstantinos Tsiakas
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - René Santer
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Nicole Maria Muschol
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Jochen Herrmann
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Section of Pediatric Radiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Björn Busse
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529, Hamburg, Germany
- Interdisciplinary Competence Center for Interface Research (ICCIR), Lottestr. 55A, Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529, Hamburg, Germany
| | - Tim Rolvien
- Division of Orthopaedics, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Nico Maximilian Jandl
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529, Hamburg, Germany
- Division of Orthopaedics, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529, Hamburg, Germany.
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Ng E, Ashkar C, Seeman E, Schneider HG, Nguyen H, Ebeling PR, Sztal-Mazer S. A low serum alkaline phosphatase may signal hypophosphatasia in osteoporosis clinic patients. Osteoporos Int 2023; 34:327-337. [PMID: 36434431 DOI: 10.1007/s00198-022-06597-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022]
Abstract
UNLABELLED Low serum alkaline phosphatase (ALP) was found in 9% of patients attending an osteoporosis clinic, 0.6% of hospital patients, and 2/22 with an atypical femoral fracture. Hypophosphatasia was diagnosed in 3% of osteoporosis clinic patients with low ALP. Low ALP is a screening tool for hypophosphatasia, a condition potentially aggravated by antiresorptive therapy. INTRODUCTION Hypophosphatasia (HPP) is an inherited disorder associated with impaired primary mineralisation of osteoid (osteomalacia). HPP may be misdiagnosed as osteoporosis, a reduction in the volume of normally mineralized bone. Both illnesses may result in fragility fractures, although stress and atypical fractures are more common in HPP. Antiresorptive therapy, first-line treatment for osteoporosis, is relatively contraindicated in HPP. Misdiagnosis and mistreatment can be avoided by recognising a low serum alkaline phosphatase (ALP). Our aim was to determine the prevalence of a low ALP (< 30 IU/L) in patients attending an osteoporosis clinic, in a hospital-wide setting, and in a group of patients with atypical femoral fractures (AFF). METHODS This was a retrospective study of patients attending an osteoporosis clinic at a tertiary hospital during 8 years (2012-2020). Patients were categorised into those with a transiently low ALP, those with low ALP on ≥ 2 occasions but not the majority of measurements, and those with a persistently low ALP. ALP levels were also assessed in hospital-wide records and a group of patients with AFF. RESULTS Of 1839 patients attending an osteoporosis clinic, 168 (9%) had ≥ 1 low ALP, 50 (2.7%) had low ALP for ≥ 2 months, and seven (0.4%) had persistently low ALP levels. HPP was diagnosed in five patients, four of whom had persistently low ALP levels. The prevalence of HPP was 0.3% in the osteoporosis clinic and 3% in patients with ≥ 1 low ALP. Low ALP occurred in 0.6% of all hospital patients and 2/22 with AFF. CONCLUSION Persistently low ALP in osteoporosis clinic attendees is easy to identify and signals the possibility of hypophosphatasia, a condition that may be mistaken for osteoporosis and incorrectly treated with antiresorptive therapy.
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Affiliation(s)
- Elisabeth Ng
- Department of Endocrinology & Diabetes, Alfred Health, Melbourne, Australia.
- Department of Endocrinology, Monash Health, Clayton, Australia.
| | - Claudia Ashkar
- Department of Endocrinology & Diabetes, Alfred Health, Melbourne, Australia
| | - Ego Seeman
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology, Austin Health, Melbourne, Australia
| | - Hans G Schneider
- Department of Endocrinology & Diabetes, Alfred Health, Melbourne, Australia
- Clinical Biochemistry Unit, Alfred Pathology Service, Alfred Health, Melbourne, Australia
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
| | - Hanh Nguyen
- Department of Endocrinology, Monash Health, Clayton, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Australia
| | - Peter R Ebeling
- Department of Endocrinology, Monash Health, Clayton, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Australia
| | - Shoshana Sztal-Mazer
- Department of Endocrinology & Diabetes, Alfred Health, Melbourne, Australia
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
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Mizuno H, Sawa N, Sekine A, Inoue N, Oba Y, Ikuma D, Yamanouchi M, Hasegawa E, Suwabe T, Suzuki H, Hoshino J, Ubara Y. A Bone Histomorphometric Analysis of Hypophosphatasia-related Osteoporosis after Teriparatide Treatment. Intern Med 2023; 62:75-79. [PMID: 35650135 PMCID: PMC9876712 DOI: 10.2169/internalmedicine.9624-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
A 79-year-old man was admitted with a compression fracture of the first lumbar vertebra. His alkaline phosphatase (ALP) level was 35 IU/L, and his dual energy X-ray absorptiometry T score was -3.7 standard deviations, indicating osteoporosis. A genetic analysis showed a mutation of the alkaline phosphatase biomineralization-associated gene encoding tissue-nonspecific alkaline phosphatase. Hypophosphatasia-related osteoporosis was diagnosed. Alendronate, teriparatide, and minodronate were administered in that order. The ALP level increased during teriparatide use. A bone biopsy performed after three years of teriparatide treatment showed that cancellous bone was adynamic. In cortical bone, tetracycline double-labeling indicates enhanced bone formation. Teriparatide may thus be a viable treatment option even in patients with hypophosphatasia.
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Affiliation(s)
- Hiroki Mizuno
- Nephrology Center + the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Naoki Sawa
- Nephrology Center + the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Akinari Sekine
- Nephrology Center + the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Noriko Inoue
- Nephrology Center + the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Yuki Oba
- Nephrology Center + the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Daisuke Ikuma
- Nephrology Center + the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Masayuki Yamanouchi
- Nephrology Center + the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Eiko Hasegawa
- Nephrology Center + the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Tatsuya Suwabe
- Nephrology Center + the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Hisanori Suzuki
- Department of Endocrinology and and Metabolism, Toranomon Hospital, Japan
| | - Junichi Hoshino
- Nephrology Center + the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Yoshifumi Ubara
- Nephrology Center + the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
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20
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Dahir KM, Kishnani PS, Martos-Moreno GÁ, Linglart A, Petryk A, Rockman-Greenberg C, Martel SE, Ozono K, Högler W, Seefried L. Impact of muscular symptoms and/or pain on disease characteristics, disability, and quality of life in adult patients with hypophosphatasia: A cross-sectional analysis from the Global HPP Registry. Front Endocrinol (Lausanne) 2023; 14:1138599. [PMID: 37051203 PMCID: PMC10083387 DOI: 10.3389/fendo.2023.1138599] [Citation(s) in RCA: 5] [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: 01/05/2023] [Accepted: 03/03/2023] [Indexed: 03/28/2023] Open
Abstract
INTRODUCTION Hypophosphatasia (HPP) manifests in adults as fractures/pseudofractures, pain, muscle weakness, and other functional impairments. Better phenotypic disease characterization is needed to help recognize disability and treat patients with HPP. METHODS Baseline/pretreatment demographic, clinical characteristic, and patient-reported disability/health-related quality-of-life (HRQoL) data from adults (≥18 y) in the Global HPP Registry (NCT02306720) were stratified by presence of overt skeletal manifestations (skeletal group) versus muscular/pain manifestations without skeletal manifestations (muscular/pain group) and summarized descriptively. Disability was measured using the Health Assessment Questionnaire-Disability Index (HAQ-DI), and HRQoL using the 36-item Short Form Health Survey (SF-36v2). RESULTS Of 468 adults, 300 were classified into the skeletal group and 73 into the muscular/pain group. The skeletal group had a higher median age at baseline (50.1 vs 44.4 y; P=0.047) but a lower median age at first HPP manifestation (12.3 vs 22.1 y; P=0.0473), with more signs and symptoms (median, 4 vs 3; P<0.0001) and involved body systems (median, 3 vs 2; P<0.0001) than the muscular/pain group. More patients in the skeletal group required any use of mobility aids (22.6% vs 3.5%, respectively; P=0.001). Six-Minute Walk test distances walked were similar between groups. SF-36v2 and HAQ-DI scores were similar between groups for physical component summary (n=238; mean [SD]: 40.2 [11.0] vs 43.6 [11.2]; P=0.056), mental component summary (n=238; mean [SD]: 43.6 [11.3] vs 43.8 [11.8]; P=0.902), and HAQ-DI (n=239; median [minimum, maximum]: 0.4 [0.0, 2.7] vs 0.3 [0.0, 2.1]; P=0.22). CONCLUSION Adults with HPP experience similar QoL impairment regardless of skeletal involvement. REGISTRATION https://clinicaltrials.gov/ct2/show/NCT02306720 and https://www.encepp.eu/encepp/viewResource.htm?id=47907, identifier NCT02306720; EUPAS13514.
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Affiliation(s)
- Kathryn M. Dahir
- Division of Endocrinology and Metabolism, Vanderbilt University Medical Center, Nashville, TN, United States
- *Correspondence: Kathryn M. Dahir,
| | - Priya S. Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | - Gabriel Ángel Martos-Moreno
- Departments of Pediatrics and Pediatric Endocrinology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
- Department of Pediatrics, Universidad Autónoma de Madrid, Madrid, Spain
- Centro de Investigación Biomédica en Red Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain
| | - Agnès Linglart
- Department of Endocrinology and Childhood Diabetes, Paris Saclay University, AP-HP and INSERM, Paris, France
| | - Anna Petryk
- Department of Global Medical Affairs, Alexion, AstraZeneca Rare Disease, Boston, MA, United States
| | - Cheryl Rockman-Greenberg
- Department of Pediatrics & Child Health and Biochemistry & Medical Genetics, University of Manitoba, Winnipeg, MB, Canada
| | - Samantha E. Martel
- Department of Epidemiology, Alexion, AstraZeneca Rare Disease, Boston, MA, United States
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University, Suita, Osaka, Japan
| | - Wolfgang Högler
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Lothar Seefried
- Orthopedic Department, University of Würzburg, Würzburg, Germany
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Ross J, Bowden MR, Yu C, Diaz-Thomas A. Transition of young adults with metabolic bone diseases to adult care. Front Endocrinol (Lausanne) 2023; 14:1137976. [PMID: 37008909 PMCID: PMC10064010 DOI: 10.3389/fendo.2023.1137976] [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: 01/05/2023] [Accepted: 03/06/2023] [Indexed: 03/19/2023] Open
Abstract
As more accurate diagnostic tools and targeted therapies become increasingly available for pediatric metabolic bone diseases, affected children have a better prognosis and significantly longer lifespan. With this potential for fulfilling lives as adults comes the need for dedicated transition and intentional care of these patients as adults. Much work has gone into improving the transitions of medically fragile children into adulthood, encompassing endocrinologic conditions like type 1 diabetes mellitus and congenital adrenal hyperplasia. However, there are gaps in the literature regarding similar guidance concerning metabolic bone conditions. This article intends to provide a brief review of research and guidelines for transitions of care more generally, followed by a more detailed treatment of bone disorders specifically. Considerations for such transitions include final adult height, fertility, fetal risk, heritability, and access to appropriately identified specialists. A nutrient-dense diet, optimal mobility, and adequate vitamin D stores are protective factors for these conditions. Primary bone disorders include hypophosphatasia, X-linked hypophosphatemic rickets, and osteogenesis imperfecta. Metabolic bone disease can also develop secondarily as a sequela of such diverse exposures as hypogonadism, a history of eating disorder, and cancer treatment. This article synthesizes research by experts of these specific disorders to describe what is known in this field of transition medicine for metabolic bone diseases as well as unanswered questions. The long-term objective is to develop and implement strategies for successful transitions for all patients affected by these various conditions.
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Affiliation(s)
- Jordan Ross
- Division of Pediatric Endocrinology, University of Tennessee Health Science Center, Memphis, TN, United States
- *Correspondence: Jordan Ross,
| | - Michelle R. Bowden
- Division of General Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
- Le Bonheur Children’s Hospital, Memphis, TN, United States
| | - Christine Yu
- Endocrinology Division, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Alicia Diaz-Thomas
- Division of Pediatric Endocrinology, University of Tennessee Health Science Center, Memphis, TN, United States
- Le Bonheur Children’s Hospital, Memphis, TN, United States
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22
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Sadhukhan S, Mehta P, Rajender S, Gupta SK, Chattopadhyay N. Proposing a clinical algorithm for better diagnosis of hypophosphatasia in resource-limiting situations. Osteoporos Int 2022; 33:2479-2493. [PMID: 35776147 DOI: 10.1007/s00198-022-06480-1] [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: 01/07/2022] [Accepted: 06/16/2022] [Indexed: 10/17/2022]
Abstract
Early diagnosis of hypophosphatasia (HPP) is challenging. Here, we propose to broaden the diagnostic criteria of HPP by reviewing published data on BMD and fractures in HPP patients. Non-osteoporotic fractures and higher than normal lumbar BMD were recurrent in HPP patients and could be included as diagnostic criteria. HPP is a genetic disorder caused by autosomal recessive or dominant loss-of-function mutations in the ALPL gene that encodes for tissue-nonspecific alkaline phosphatase (TNSALP). Expressive genetic heterogeneity and varying severity of TNSALP deficiency lead to a wide-ranging presentation of skeletal diseases at different ages that coupled with HPP's rarity and limitation of biochemical and mutational studies present serious hurdles to early diagnosis and management of HPP. To widen the scope of HPP diagnosis, we assessed the possibility of areal bone mineral density (BMD) as an additional clinical feature of this disease. PubMed, Web of Science, and ScienceDirect were searched with the following keywords: ("Hypophosphatasia OR HPP") AND ("Bone Mineral Density OR BMD") AND "Human". Studies and case reports of subjects with age ≥ 18 years and having BMD data were included. We pooled data from 25 publications comprising 356 subjects (90 males, 266 females). Only four studies had a control group. Biochemical hallmarks, pyridoxal 5'-phosphate (PLP) and phosphoethanolamine (PEA), were reported in fifteen and six studies, respectively. Twenty studies reported genetic data, nineteen studies reported non-vertebral fractures, all studies reported lumbar spine (LS) BMD, and nineteen reported non-vertebral BMD. Higher than normal and normal BMD at LS were reported in three and two studies, respectively. There was marked heterogeneity in BMD at the non-vertebral sites. Higher than normal or normal LS BMD in an adult with minimal or insufficient fractures, pseudofractures, non-healing fractures, fragility fractures, and stress fractures may be included in the diagnostic protocol of HPP. However, genetic testing is recommended for a definitive diagnosis.
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Affiliation(s)
- Sreyanko Sadhukhan
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Lucknow, India
- Academy of Scientific and Innovative Research, Ghaziabad, 201002, India
| | - Poonam Mehta
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Lucknow, India
- Academy of Scientific and Innovative Research, Ghaziabad, 201002, India
| | - Singh Rajender
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Lucknow, India
- Academy of Scientific and Innovative Research, Ghaziabad, 201002, India
| | - Sushil Kumar Gupta
- Department of Endocrinology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, India
| | - Naibedya Chattopadhyay
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Lucknow, India.
- Academy of Scientific and Innovative Research, Ghaziabad, 201002, India.
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Hepp N, Frederiksen AL, Duno M, Jørgensen NR, Jensen JEB. Biochemical and clinical manifestations in adults with hypophosphatasia: a national cross-sectional study. Osteoporos Int 2022; 33:2595-2605. [PMID: 35986118 DOI: 10.1007/s00198-022-06536-2] [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: 01/06/2022] [Accepted: 08/15/2022] [Indexed: 11/24/2022]
Abstract
UNLABELLED Hypophosphatasia (HPP) is a rare disease affecting bone mineralization. Adults with HPP have an increased occurrence of low-energy fractures, which cannot be explained by reduced bone mass assessed by dual energy X-ray absorptiometry. The bone phenotype in adults with HPP requires further studies investigating bone strength and bone structural parameters. INTRODUCTION Hypophosphatasia (HPP) is a rare inherited disorder of bone and mineral metabolism, characterized by broad-ranging clinical manifestations and severity. However, studies investigating the clinical spectrum in adults with HPP compared to a control group are scarce. The aim of this study was to evaluate biochemical and clinical characteristics as well as bone health in a Danish cohort of adults with HPP. METHODS We conducted a cross-sectional study assessing biochemical parameters, fracture prevalence, bone mineral density (BMD), bone turnover markers, physical performance and pain characteristics in 40 adults with HPP and 40 sex-, age-, BMI- and menopausal status-matched healthy controls. RESULTS Patients with HPP had a significantly higher prevalence of non-vertebral, low-energy fractures (p = < 0.001). BMD at the lumbar spine, total hip, femoral neck, forearm and whole body did not differ between the groups. Low levels of the bone-specific alkaline phosphatase correlated significantly with higher BMD at the lumbar spine and femoral neck in both groups. The bone formation marker N-terminal propeptide of type 1 procollagen was significantly lower in patients with HPP than healthy controls (p = 0.006). Adults with HPP had significantly reduced walking capability (p = < 0.001) and lower body strength (p = < 0.001). Chronic pain was significantly more prevalent in adults with HPP than the control group (p = 0.029). CONCLUSIONS The increased occurrence of low-energy fractures in adults with HPP is not explained by low BMD. Adults with HPP have reduced physical performance when compared with healthy controls.
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Affiliation(s)
- Nicola Hepp
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark.
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200, Copenhagen, Denmark.
| | - Anja Lisbeth Frederiksen
- Department of Clinical Genetics, Aalborg University Hospital, Ladegaardsgade 5, 9000, Aalborg C, Denmark
- Department of Clinical Research, Aalborg University, Fredrik Bajers Vej 7K, 9220, Aalborg Ø, Denmark
| | - Morten Duno
- Department of Clinical Genetics, University Hospital Copenhagen Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Niklas Rye Jørgensen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200, Copenhagen, Denmark
- Department of Clinical Biochemistry, Rigshospitalet, Valdemar Hansens Vej 13, 2600, Glostrup, Denmark
| | - Jens-Erik Beck Jensen
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200, Copenhagen, Denmark
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24
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Okawa R, Nakano K. Dental manifestation and management of hypophosphatasia. JAPANESE DENTAL SCIENCE REVIEW 2022; 58:208-216. [PMID: 35814738 PMCID: PMC9260292 DOI: 10.1016/j.jdsr.2022.06.002] [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] [Received: 02/28/2022] [Revised: 06/22/2022] [Accepted: 06/26/2022] [Indexed: 11/24/2022] Open
Abstract
Hypophosphatasia is an inherited metabolic disorder characterized by defective mineralization of bones and teeth with a wide variety of manifestations, ranging from stillbirth to dental symptoms alone. Recently, the prognosis of severe hypophosphatasia patients has been greatly improved by the introduction of enzyme replacement therapy. The typical dental manifestation is early exfoliation of primary teeth due to disturbed cementum formation, so dentures are recommended to ensure that important oral functions are acquired. Some studies have shown that enzyme replacement therapy improves dental mineralization, resulting in the stabilization of periodontal tissues and better growth of tooth roots. A nationwide Japanese survey revealed the common genetic and dental manifestations of patients with mild hypophosphatasia, which markedly differ from those of the severe forms. There may be many undiagnosed mild patients, so dentists should contribute to the early diagnosis by screening possible cases based on the typical finding of early exfoliation of primary teeth. Early diagnosis is important for patients to receive early intervention in both medical and dental fields. The establishment of fundamental dental therapy to solve the dental problems is still underway and is eagerly anticipated.
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Shajani-Yi Z, Ayala-Lopez N, Black M, Dahir KM. Urine phosphoethanolamine is a specific biomarker for hypophosphatasia in adults. Bone 2022; 163:116504. [PMID: 35878747 DOI: 10.1016/j.bone.2022.116504] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/04/2022] [Accepted: 07/19/2022] [Indexed: 11/02/2022]
Abstract
OBJECTIVES We investigated the utility of urine phosphoethanolamine (PEA) as a marker to aid in diagnosing and/or confirming hypophosphatasia (HPP) in adults and for monitoring patients on enzyme replacement therapy (ERT). METHODS Data was collected from seventy-eight adults who were referred to the Vanderbilt Program for Metabolic Bone Disease for evaluation of a possible or confirmatory HPP diagnosis between July 2014 through December 2019. Fifty-nine patients were diagnosed with HPP and nineteen were excluded from a diagnosis of HPP. The urine PEA results of those patients with a confirmed diagnosis of HPP and those patients with a diagnosis of HPP excluded were captured and compared to other laboratory and clinical parameters consistent with HPP, including alkaline phosphatase (ALP) activity, plasma pyridoxal 5'-phosphate (PLP), the presence of musculoskeletal abnormalities, and genetic testing for pathogenic mutations in ALPL. RESULTS Initial urine PEA values in patients in our HPP cohort and not on ERT were significantly higher (median = 150.0 nmol/mg creatinine, IQR = 82.0-202.0) compared patients in our HPP negative group (median 18.0 nmol/mg creatinine, IQR = 14.0-30.0, p < 0.0001) and higher than patients on ERT (median 65.0 nmol/mg creatinine, IQR = 45.3-79.8). Patients who began ERT had a decline in urine PEA levels after treatment with a mean decrease of 68.1 %. Plasma ALP levels were significantly lower in the group of patients with HPP and not on ERT group (median = 24.0 U/L, IQR = 15.0-29.50) compared to the patients without HPP (median = 45.50 U/L, IQR = 34.0-62.0;) and plasma PLP levels were significantly higher in the HPP non-ERT group (median = 284.0 nmol/L, IQR = 141.0-469.4) compared to the patients without HPP (median = 97.5 nmol/L, IQR = 43.7-206.0;). The area under the curve (AUC) of urine PEA, ALP, and PLP to distinguish between HPP and non-HPP patients is 0.968, 0.927 and 0.781, respectively, in our cohort. Urine PEA had 100 % specificity (95 % CI of 83.2 % to 100.0 %) for diagnosing HPP at a value >53.50 nmol/mg creatinine with a sensitivity of 88.4 %; 95%CI 75.5 to 94.9 %. ALP had a 100 % specificity (95 % CI of 82.4 % to 100.0 %) for diagnosing HPP at a value <30.5 U/L with a sensitivity of 77.2 %; (95%CI 64.8 to 86.2 %). PLP had a 100 % specificity (95 % CI of 81.6 % to 100.0 %) for diagnosing HPP at a value >436 nmol/L with a sensitivity of 26.9 %; (95%CI 16.8 to 40.3 %). The most common pathogenic or likely pathogenic mutations in our cohort were c.1250A>G (p.Asn417Ser), c.1133A>T (p.Asp378Val), c.881A>C (p.Asp294Ala), c.1171C>T (p.Arg391Cys), and c.571G>A, (p.Glu191Lys). CONCLUSIONS Urine PEA is a promising diagnostic and confirmatory marker for HPP in patients undergoing investigation for HPP. Urine PEA also has potential use as a marker to monitor ERT compliance. Future studies are necessary to evaluate the association between PEA levels and clinical outcomes.
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Affiliation(s)
- Zahra Shajani-Yi
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Nadia Ayala-Lopez
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Margo Black
- Division of Endocrinology, Program for Metabolic Bone Disorders, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kathryn McCrystal Dahir
- Division of Endocrinology, Program for Metabolic Bone Disorders, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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Sinha P, Gabor R, Haupt‐Harrington R, Deering L, Steiner RD. Dental manifestations in adult hypophosphatasia and their correlation with biomarkers. JIMD Rep 2022; 63:434-445. [PMID: 36101824 PMCID: PMC9458606 DOI: 10.1002/jmd2.12307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 05/02/2022] [Accepted: 05/24/2022] [Indexed: 11/18/2022] Open
Abstract
Hypophosphatasia (HPP) is a genetic condition with broad clinical manifestations caused by alkaline phosphatase (ALP) deficiency. Adults with HPP exhibit a wide spectrum of signs and symptoms. Dental manifestations including premature tooth loss are common. Much of the published literature reporting dental manifestations consists of case reports and series of symptomatic patients, likely biased towards more severe dental manifestations. The objective of this study was to systematically explore the dental manifestations among adults with HPP by conducting a comprehensive dental evaluation. To minimize bias, the study explored dental manifestations in an unselected cohort of adults with HPP. Participants were identified searching electronic health record (EHR) data from a rural health system to discover adults with persistent ALP deficiency. Heterozygotes with pathogenic (P), likely pathogenic (LP), or uncertain variants (VUS) in ALPL and at least one elevated ALP substrate were defined as adults with HPP and underwent genetic, dental, oral radiographic, and biomarker evaluation. Twenty‐seven participants completed the study. Premature tooth loss was present in 63% (17/27); 19% (5/27) were missing eight or more teeth. Statistically significant associations were found between premature permanent tooth loss and HPP biomarkers ALP (p = 0.049) and bone‐specific ALP (p = 0.006). Serum ALP (ρ = −0.43, p = 0.037) and bone‐specific ALP (ρ = −0.57, p = 0.004) were negatively correlated with number of teeth lost prematurely. As noted with tooth loss, periodontal breakdown was associated with bone‐specific ALP. An inverse association between periodontal breakdown and bone‐specific ALP was observed (p = 0.014). These findings suggest a role for ALP in maintenance of dentition.
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Affiliation(s)
- Priya Sinha
- Marshfield Clinic Health System Marshfield Dental Center Marshfield Wisconsin USA
| | - Rachel Gabor
- Marshfield Clinic Research Institute Research Computing and Analytics Marshfield Wisconsin USA
| | - Rachael Haupt‐Harrington
- Marshfield Clinic Health System, Marshfield Clinic Research Institute Medical Genetics Marshfield Wisconsin
| | - Leila Deering
- Marshfield Clinic Research Institute Research Computing and Analytics Marshfield Wisconsin USA
| | - Robert D. Steiner
- Marshfield Clinic Health System, Marshfield Clinic Research Institute Medical Genetics Marshfield Wisconsin
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin
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Dahir KM, Seefried L, Kishnani PS, Petryk A, Högler W, Linglart A, Martos-Moreno GÁ, Ozono K, Fang S, Rockman-Greenberg C. Clinical profiles of treated and untreated adults with hypophosphatasia in the Global HPP Registry. Orphanet J Rare Dis 2022; 17:277. [PMID: 35854311 PMCID: PMC9295501 DOI: 10.1186/s13023-022-02393-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 06/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background The clinical signs and symptoms of hypophosphatasia (HPP) can manifest during any stage of life. The age at which a patient’s symptoms are reported can impact access to targeted treatment with enzyme replacement therapy (asfotase alfa), as this treatment is indicated for patients with pediatric-onset HPP in most countries. As such, many patients reported to have adult-onset HPP typically do not receive treatment. Comparison of the disease in treated and untreated adult patients is confounded by the approved indication. To avoid this confounding factor, a comparison between baseline disease manifestations prominent among treated versus untreated adult patients was limited to those with pediatric-onset HPP using data collected from the Global HPP Registry. The hypothesis was that treated adults will have a greater disease burden at baseline than untreated adults. The analysis of disease manifestations in adults with adult-onset HPP was conducted separately. Results A total of 398 adults with HPP were included; 213 with pediatric-onset (114 treated, 99 untreated) and 141 with adult-onset HPP (2 treated and 139 untreated). The treated, pediatric-onset patients were more likely to have a history of pain (prevalence ratio [PR]: 1.3, 95% confidence interval [CI] 1.1, 1.4), skeletal (PR: 1.3, 95% CI 1.1, 1.6), constitutional/metabolic (PR: 1.7, 95% CI 1.3, 2.0), muscular (PR: 1.8, 95% CI 1.4, 2.1) and neurological (PR: 1.7, 95% CI 1.1, 2.3) manifestations of HPP, and also had poorer measures for health-related quality of life, pain, and disability compared with untreated pediatric-onset patients. In patients with adult-onset HPP, the most frequent signs and symptoms were chronic bone pain (52.5%), dental manifestations (42.6%), fatigue (23.4%), recurrent fractures or pseudofractures (22.0%), and generalized body pain (22.0%). Conclusions Along with the more classical skeletal signs and symptoms, pain, muscular, and constitutional/metabolic manifestations are common in adults with HPP, regardless of age of disease onset, highlighting a full spectrum of HPP manifestations.
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Affiliation(s)
- Kathryn M Dahir
- Program for Metabolic Bone Disorders at Vanderbilt, Endocrinology and Diabetes, Vanderbilt University Medical Center, 8210 Medical Center East, 1215 21st Avenue South, Nashville, TN, 37232-8148, USA.
| | | | | | - Anna Petryk
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | - Wolfgang Högler
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Agnès Linglart
- DMU 3 SEA, Service d'endocrinologie et Diabète de L'enfant, filière OSCAR, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, Paris-Saclay University, AP-HP, INSERM, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Gabriel Ángel Martos-Moreno
- Departments of Pediatrics and Pediatric Endocrinology Hospital Infantil, CIBERobn, ISCIII, Universitario Niño Jesús, IIS La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Shona Fang
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
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Hepp N, Folkestad L, Møllebæk S, Frederiksen AL, Duno M, Jørgensen NR, Hermann AP, Jensen JEB. Bone-microarchitecture and bone-strength in a sample of adults with hypophosphatasia and a matched reference population assessed by HR-pQCT and impact microindentation. Bone 2022; 160:116420. [PMID: 35421614 DOI: 10.1016/j.bone.2022.116420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/03/2022] [Accepted: 04/07/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Hypophosphatasia (HPP) is an autosomal recessive or dominate disease affecting bone mineralization, and adults with HPP are in risk to develop metatarsal stress fractures and femoral pseudofractures. Given to the scarce data on the bone quality and its association to the fracture risk in adults with HPP, this study aimed to evaluate bone turnover, bone strength and structure in adults with HPP. METHODS In this cross-sectional study, we included 14 adults with genetically verified HPP and 14 sex-, age-, BMI-, and menopausal status-matched reference individuals. We analyzed bone turnover markers, and measured bone material strength index (BMSi) by impact microindentation. Bone geometry, volumetric density and bone microarchitecture as well as failure load at the distal radius and tibia were evaluated using a second-generation high-resolution peripheral quantitative computed tomography system. RESULTS Bone turnover markers did not differ between patients with HPP and reference individuals. BMSi did not differ between the groups (67.90 [63.75-76.00] vs 65.45 [58.43-69.55], p = 0.149). Parameters of bone geometry and volumetric density did not differ between adults with HPP and the reference group. Patients with HPP had a tendency toward higher trabecular separation (0.664 [0.613-0.724] mm vs 0.620 [0.578-0.659] mm, p = 0.054) and inhomogeneity of trabecular network (0.253 [0.235-0.283] mm vs 0.229 [0.208-0.252] mm, p = 0.056) as well as lower trabecular bone volume fraction (18.8 [16.4-22.7] % vs 22.8 [20.6-24.7] %, p = 0.054) at the distal radius. In addition, compound heterozygous adults with HPP had a significantly higher cortical porosity at the distal radius than reference individuals (1.5 [0.9-2.2] % vs 0.7 [0.6-0.7] %, p = 0.041). CONCLUSIONS BMSi is not reduced in adults with HPP. Increased cortical porosity may contribute to the occurrence of femoral pseudofractures in compound heterozygous adults with HPP. However, further studies investigating larger cohorts of adults with HPP using methods of bone histomorphometry are recommended to adequately assess the bone quality in adults with HPP.
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Affiliation(s)
- Nicola Hepp
- Dept. of Endocrinology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark; Dept. of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200 Copenhagen, Denmark.
| | - Lars Folkestad
- Dept. of Endocrinology and Metabolism, Odense University Hospital, Kløvervænget 6, 5000 Odense C, Denmark; Dept. of Clinical Research, University of Southern Denmark, Winsløwparken 19, 5000 Odense C, Denmark
| | - Simone Møllebæk
- Dept. of Endocrinology and Metabolism, Odense University Hospital, Kløvervænget 6, 5000 Odense C, Denmark
| | - Anja Lisbeth Frederiksen
- Dept. of Clinical Genetics, Aalborg University Hospital, Ladegaardsgade 5, 9000 Aalborg C, Denmark; Dept. of Clinical Research, Aalborg University, Fredrik Bajers Vej 7K, 9220 Aalborg Ø, Denmark
| | - Morten Duno
- Dept. of Clinical Genetics, University Hospital Copenhagen Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Niklas Rye Jørgensen
- Dept. of Clinical Biochemistry, Rigshospitalet, Valdemar Hansens Vej 13, 2600 Glostrup, Denmark; Dept. of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200 Copenhagen, Denmark
| | - Anne Pernille Hermann
- Dept. of Endocrinology and Metabolism, Odense University Hospital, Kløvervænget 6, 5000 Odense C, Denmark
| | - Jens-Erik Beck Jensen
- Dept. of Endocrinology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark; Dept. of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200 Copenhagen, Denmark
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Davies EH, Matthews C, Merlet A, Zimmermann M. Time to See the Difference: Video Capture for Patient-Centered Clinical Trials. THE PATIENT 2022; 15:389-397. [PMID: 34993934 PMCID: PMC8736327 DOI: 10.1007/s40271-021-00569-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 12/12/2021] [Indexed: 11/25/2022]
Abstract
Developing therapeutics for the treatment of rare diseases usually requires a strong understanding of the natural history of the disease. Often, it also requires the creation of novel assessment tools and clinical trial endpoints. In diseases where mobility is impacted, the use of video to capture the impact of the disease and the assessment of specific parameters, such as gait and stride length, can help design sensitive endpoints. Video as an assessment tool also allows the use of historical videos or videos filmed by non-experts outside of clinical settings. Given the increased use of telemedicine, the use of video may be a useful addition to clinical trial assessments. Two cases are presented: (1) the use of video in the development of asfotase alfa (Strensiq®) in hypophosphatasia is detailed as an example of the utility of this type of assessment in rare diseases; and (2) a home-setting video tool that was developed and validated (SARAhome) from a commonly used clinical scale (Scale for the Assessment and Rating of Ataxia [SARA]), allowing patients to record their own severity of ataxia. While there are certain limitations associated with video assessment, advancing technologies such as automated analysis and machine learning provide a tremendous opportunity for automated analysis of video recordings, reducing the bias associated with human assessment.
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Affiliation(s)
- Elin Haf Davies
- Aparito, Wrexham, Wales, UK. .,Chair at Metabolic Support UK, University College London, London, UK.
| | | | - Adeline Merlet
- Global Regulatory Affairs, AstraZeneca Rare Disease, Alexion, Zurich, Switzerland
| | - Martine Zimmermann
- Global Regulatory Affairs, AstraZeneca Rare Disease, Alexion Europe SAS, Paris, France
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30
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Salles Rosa Neto N, Englert D, McAlister WH, Mumm S, Mills D, Veis DJ, Burshell A, Boyde A, Whyte MP. Periarticular calcifications containing giant pseudo-crystals of francolite in skeletal fluorosis from 1,1-difluoroethane "huffing". Bone 2022; 160:116421. [PMID: 35429657 DOI: 10.1016/j.bone.2022.116421] [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: 02/21/2022] [Revised: 04/03/2022] [Accepted: 04/08/2022] [Indexed: 01/28/2023]
Abstract
Inhalant use disorder is a psychiatric condition characterized by repeated deliberate inhalation from among a broad range of household and industrial chemical products with the intention of producing psychoactive effects. In addition to acute intoxication, prolonged inhalation of fluorinated compounds can cause skeletal fluorosis (SF). We report a young woman referred for hypophosphatasemia and carrying a heterozygous ALPL gene variant (c.457T>C, p.Trp153Arg) associated with hypophosphatasia, the heritable metabolic bone disease featuring impaired skeletal mineralization, who instead suffered from SF. Manifestations of her SF included recurrent articular pain, axial osteosclerosis, elevated bone mineral density, maxillary exostoses, and multifocal periarticular calcifications. SF was suspected when a long history was discovered of 'huffing' a computer cleaner containing 1,1-difluoroethane. Investigation revealed markedly elevated serum and urine levels of F-. Histopathology and imaging techniques including backscattered electron mode scanning electron microscopy, X-ray microtomography, energy dispersive and wavelength dispersive X-ray emission microanalysis, and polarized light microscopy revealed that her periarticular calcifications were dystrophic deposition of giant pseudo-crystals of francolite, a carbonate-rich fluorapatite. Identifying unusual circumstances of F- exposure is key for diagnosing non-endemic SF. Increased awareness of the disorder can be lifesaving.
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Affiliation(s)
- Nilton Salles Rosa Neto
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
| | - Daniel Englert
- Endocrinology Department, Ochsner Medical Center, New Orleans, LA 70121, USA.
| | - William H McAlister
- Pediatric Radiology Section, Mallinckrodt Institute of Radiology at St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Steven Mumm
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
| | - David Mills
- Dental Physical Sciences, Dental Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, E1 4NS, UK.
| | - Deborah J Veis
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
| | - Alan Burshell
- Endocrinology Department, Ochsner Medical Center, New Orleans, LA 70121, USA.
| | - Alan Boyde
- Dental Physical Sciences, Dental Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, E1 4NS, UK.
| | - Michael P Whyte
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
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31
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Tornero C, Navarro-Compán V, Buño A, Heath KE, Díaz-Almirón M, Balsa A, Tenorio JA, Quer J, Aguado P. Biochemical algorithm to identify individuals with ALPL variants among subjects with persistent hypophosphatasaemia. Orphanet J Rare Dis 2022; 17:98. [PMID: 35241128 PMCID: PMC8896389 DOI: 10.1186/s13023-022-02253-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 02/13/2022] [Indexed: 11/11/2022] Open
Abstract
Background Hypophosphatasia (HPP) is a rare and underdiagnosed condition characterized by deficient bone and teeth mineralization. The aim of this study was first, to evaluate the diagnostic utility of employing alkaline phosphatase (ALP) threshold levels to identify adults with variants in ALPL among individuals with persistently low ALP levels and second, to determine the value of also including its substrates (serum pyridoxal-5′-phosphate—PLP—and urinary phosphoetanolamine-PEA) for this purpose in order to create a biochemical algorithm that could facilitate the diagnostic work-up of HPP.
Results The study population comprised 77 subjects with persistent hypophosphatasaemia. They were divided into two groups according to the presence (+GT) or absence (−GT) of pathogenic ALPL variants: 40 +GT and 37 −GT. Diagnostic utility measures were calculated for different ALP thresholds and Receiver Operating Characteristic (ROC) curves were employed to determine PLP and PEA optimal cut-off levels to predict the presence of variants. The optimal threshold for ALP was 25 IU/L; for PLP, 180 nmol/L and for PEA, 30 µmol/g creatinine. Biochemical predictive models were assessed using binary logistic regression analysis and bootstrapping machine learning technique and results were then validated. For ALP < 25 UI/L (model 1), the area under curve (AUC) and the 95% confidence intervals (CI) was 0.68 (95% CI 0.63–0.72) and it improved to 0.87 (95% CI 0.8–0.9), when PEA or PLP threshold levels were added (models 2 and 3), reaching 0.94 (0.91–0.97) when both substrates were included (model 4). The internal validation showed that the addition of serum PLP threshold levels to the model just including ALP improved significantly sensitivity (S) and negative predictive value (NPV) − 100%, respectively- with an accuracy (AC) of 93% in comparison to the inclusion of urinary PEA (S: 71%; NPV 75% and AC: 79%) and similar diagnostic utility measures as those observed in model 3 were detected when both substrates were added. Conclusions In this study, we propose a biochemical predictive model based on the threshold levels of the main biochemical markers of HPP (ALP < 25 IU/L and PLP > 180 nmol/L) that when combined, seem to be very useful to identify individuals with ALPL variants. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02253-5.
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Affiliation(s)
- C Tornero
- Department of Rheumatology, La Paz University Hospital, IdiPaz, Paseo de La Castellana, 261, 28046, Madrid, Spain. .,Skeletal Dysplasia Multidisciplinary Unit (UMDE) and ERN-BOND, La Paz University Hospital, Madrid, Spain.
| | - V Navarro-Compán
- Department of Rheumatology, La Paz University Hospital, IdiPaz, Paseo de La Castellana, 261, 28046, Madrid, Spain
| | - A Buño
- Department of Clinical Biochemistry, La Paz University Hospital, Madrid, Spain
| | - K E Heath
- Skeletal Dysplasia Multidisciplinary Unit (UMDE) and ERN-BOND, La Paz University Hospital, Madrid, Spain.,Institute of Medical and Molecular Genetics (INGEMM), La Paz University Hospital, IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain.,CIBERER (Centro de Investigación Biomédica en Red de Enfermedades Raras), ISCIII, Madrid, Spain
| | - M Díaz-Almirón
- Department of Biostatistics, La Paz University Hospital, Madrid, Spain
| | - A Balsa
- Department of Rheumatology, La Paz University Hospital, IdiPaz, Paseo de La Castellana, 261, 28046, Madrid, Spain
| | - J A Tenorio
- Institute of Medical and Molecular Genetics (INGEMM), La Paz University Hospital, IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain.,CIBERER (Centro de Investigación Biomédica en Red de Enfermedades Raras), ISCIII, Madrid, Spain
| | - J Quer
- Masters in Telecommunications and Big Data, Telecommunications Engineering Degree, ICAI, Madrid, Spain
| | - P Aguado
- Department of Rheumatology, La Paz University Hospital, IdiPaz, Paseo de La Castellana, 261, 28046, Madrid, Spain.,Skeletal Dysplasia Multidisciplinary Unit (UMDE) and ERN-BOND, La Paz University Hospital, Madrid, Spain
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32
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Siami H, Parsamanesh N, Besharati Kivi S. Young woman with hypophosphatasia: A case report. Clin Case Rep 2022; 10:e05633. [PMID: 35356190 PMCID: PMC8958189 DOI: 10.1002/ccr3.5633] [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] [Received: 01/26/2022] [Revised: 02/23/2022] [Accepted: 03/09/2022] [Indexed: 11/11/2022] Open
Abstract
Hypophosphatasia is a rare inherited disease defined by teeth and bone mineralization impairment leading to depletion of tissue non‐specific alkaline phosphatase. We define a young woman diagnosed with hypophosphatasia (after several times alkaline phosphatase levels were low) was discovered following femoral fracture. A 30‐year‐old woman who presented for a history of early permanent teeth loss during the last 5 years and HPP‐like symptoms in family history and bone radiograph verified bowing, deficient mineralization, and symmetrical subtrochanteric stress fractures of femurs was referred to our clinic for further management. Blood test findings defined raised phosphorus levels on two occasions at 6.2 and 5.7 mg/dl and insufficient 25‐hydroxy vitamin D level. HPP early diagnosis and adequate treatment, depending on the clinical symptoms along with laboratory tests, could be effective in decreasing the suffering of the disease and side effects.
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Affiliation(s)
- Haleh Siami
- School of Medicine Islamic Azad University of Medical Science Tehran Iran
| | - Negin Parsamanesh
- Zanjan Metabolic Diseases Research Center Zanjan University of Medical Science Zanjan Iran
| | - Shahin Besharati Kivi
- Zanjan Metabolic Diseases Research Center Zanjan University of Medical Science Zanjan Iran
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33
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Held CM, Guebelin A, Krebs A, Sass JO, Wurm M, Lausch E, van der Werf-Grohmann N, Schwab KO. Screening for hypophosphatasia: does biochemistry lead the way? J Pediatr Endocrinol Metab 2022; 35:169-178. [PMID: 34551461 DOI: 10.1515/jpem-2021-0104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 08/16/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Patients with childhood hypophosphatasia (HPP) often have unspecific symptoms. It was our aim to identify patients with mild forms of HPP by laboratory data screening for decreased alkaline phosphatase (AP) within a pediatric population. METHODS We conducted a retrospective hospital-based data screening for AP activity below the following limits: Girls: ≤12 years: <125 U/L; >12 years: <50 U/L Boys: ≤14 years: <125 U/L; >14 years: <70 U/L. Screening positive patients with otherwise unexplained hypophosphatasemia were invited for further diagnostics: Re-test of AP activity, pyridoxal 5'-phosphate (PLP) in hemolyzed whole blood, phosphoethanolamine (PEA) in serum and urine, and inorganic pyrophosphate in urine. Sequencing of the ALPL gene was performed in patients with clinical and/or laboratory abnormalities suspicious for HPP. RESULTS We assessed a total of 14,913 samples of 6,731 patients and identified 393 screening-positive patients. The majority of patients were excluded due to known underlying diseases causing AP depression. Of the 30 patients who participated in the study, three had a decrease in AP activity in combination with an increase in PLP and PEA. A heterozygous ALPL mutation was detected in each of them: One patient with a short stature was diagnosed with childhood-HPP and started with enzyme replacement therapy. The remaining two are considered as mutation carriers without osseous manifestation of the disease. CONCLUSIONS A diagnostic algorithm based on decreased AP is able to identify patients with ALPL mutation after exclusion of the differential diagnoses of hypophosphatasemia and with additional evidence of increased AP substrates.
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Affiliation(s)
- Corinna Melanie Held
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Anic Guebelin
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Andreas Krebs
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Jörn Oliver Sass
- Department of Natural Sciences, Institute for Functional Gene Analytics (IFGA), Research Group Inborn Errors of Metabolism, Bonn-Rhein-Sieg University of Applied Science, Rheinbach, Germany
| | - Michael Wurm
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Ekkehart Lausch
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Natascha van der Werf-Grohmann
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Karl Otfried Schwab
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Centre, University of Freiburg, Freiburg, Germany
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Rush ET, Johnson B, Aradhya S, Beltran D, Bristow SL, Eisenbeis S, Guerra NE, Krolczyk S, Miller N, Morales A, Ramesan P, Sarafrazi S, Truty R, Dahir K. Molecular Diagnoses of X-Linked and Other Genetic Hypophosphatemias: Results From a Sponsored Genetic Testing Program. J Bone Miner Res 2022; 37:202-214. [PMID: 34633109 PMCID: PMC9298723 DOI: 10.1002/jbmr.4454] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 09/27/2021] [Accepted: 10/02/2021] [Indexed: 12/20/2022]
Abstract
X-linked hypophosphatemia (XLH), a dominant disorder caused by pathogenic variants in the PHEX gene, affects both sexes of all ages and results in elevated serum fibroblast growth factor 23 (FGF23) and below-normal serum phosphate. In XLH, rickets, osteomalacia, short stature, and lower limb deformity may be present with muscle pain and/or weakness/fatigue, bone pain, joint pain/stiffness, hearing difficulty, enthesopathy, osteoarthritis, and dental abscesses. Invitae and Ultragenyx collaborated to provide a no-charge sponsored testing program using a 13-gene next-generation sequencing panel to confirm clinical XLH or aid diagnosis of suspected XLH/other genetic hypophosphatemia. Individuals aged ≥6 months with clinical XLH or suspected genetic hypophosphatemia were eligible. Of 831 unrelated individuals tested between February 2019 and June 2020 in this cross-sectional study, 519 (62.5%) individuals had a pathogenic or likely pathogenic variant in PHEX (PHEX-positive). Among the 312 PHEX-negative individuals, 38 received molecular diagnoses in other genes, including ALPL, CYP27B1, ENPP1, and FGF23; the remaining 274 did not have a molecular diagnosis. Among 319 patients with a provider-reported clinical diagnosis of XLH, 88.7% (n = 283) had a reportable PHEX variant; 81.5% (n = 260) were PHEX-positive. The most common variant among PHEX-positive individuals was an allele with both the gain of exons 13-15 and c.*231A>G (3'UTR variant) (n = 66/519). Importantly, over 80% of copy number variants would have been missed by traditional microarray analysis. A positive molecular diagnosis in 41 probands (4.9%; 29 PHEX positive, 12 non-PHEX positive) resulted in at least one family member receiving family testing. Additional clinical or family member information resulted in variant(s) of uncertain significance (VUS) reclassification to pathogenic/likely pathogenic (P/LP) in 48 individuals, highlighting the importance of segregation and clinical data. In one of the largest XLH genetic studies to date, 65 novel PHEX variants were identified and a high XLH diagnostic yield demonstrated broad insight into the genetic basis of XLH. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Eric T Rush
- Children's Mercy Kansas City, Kansas City, MO, USA.,Department of Pediatrics, University of Missouri - Kansas City School of Medicine, Kansas City, MO, USA.,Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | | | | | | | | | | - Norma E Guerra
- Department of Pediatric Nephrology, Hospital General del Centro Médico Nacional «La Raza», Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | | | | | | | | | | | | | - Kathryn Dahir
- Program for Metabolic Bone Disorders, Vanderbilt University Medical Center (VUMC), Nashville, TN, USA
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35
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Sanabria-de la Torre R, Martínez-Heredia L, González-Salvatierra S, Andújar-Vera F, Iglesias-Baena I, Villa-Suárez JM, Contreras-Bolívar V, Corbacho-Soto M, Martínez-Navajas G, Real PJ, García-Fontana C, Muñoz-Torres M, García-Fontana B. Characterization of Genetic Variants of Uncertain Significance for the ALPL Gene in Patients With Adult Hypophosphatasia. Front Endocrinol (Lausanne) 2022; 13:863940. [PMID: 35498405 PMCID: PMC9047899 DOI: 10.3389/fendo.2022.863940] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/14/2022] [Indexed: 11/29/2022] Open
Abstract
Hypophosphatasia (HPP) a rare disease caused by mutations in the ALPL gene encoding for the tissue-nonspecific alkaline phosphatase protein (TNSALP), has been identified as a potentially under-diagnosed condition worldwide which may have higher prevalence than currently established. This is largely due to the overlapping of its symptomatology with that of other more frequent pathologies. Although HPP is usually associated with deficient bone mineralization, the high genetic variability of ALPL results in high clinical heterogeneity, which makes it difficult to establish a specific HPP symptomatology. In the present study, three variants of ALPL gene with uncertain significance and no previously described (p.Del Glu23_Lys24, p.Pro292Leu and p.His379Asn) were identified in heterozygosis in patients diagnosed with HPP. These variants were characterized at phenotypic, functional and structural levels. All genetic variants showed significantly lower in vitro ALP activity than the wild-type (WT) genotype (p-value <0.001). Structurally, p.His379Asn variant resulted in the loss of two Zn2+ binding sites in the protein dimer which may greatly affect ALP activity. In summary, we identified three novel ALPL gene mutations associated with adult HPP. The correct identification and characterization of new variants and the subsequent study of their phenotype will allow the establishment of genotype-phenotype relationships that facilitate the management of the disease as well as making it possible to individualize treatment for each specific patient. This would allow the therapeutic approach to HPP to be personalized according to the unique genetic characteristics and clinical manifestations of each patient.
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Affiliation(s)
- Raquel Sanabria-de la Torre
- Department of Medicine, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
| | - Luis Martínez-Heredia
- Department of Medicine, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
| | - Sheila González-Salvatierra
- Department of Medicine, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
| | - Francisco Andújar-Vera
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Department of Computer Science and Artificial Intelligence, University of Granada, Granada, Spain
- Andalusian Research Institute in Data Science and Computational Intelligence (DaSCI Institute), Granada, Spain
| | | | - Juan Miguel Villa-Suárez
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Clinical Analysis Unit, University Hospital Clínico San Cecilio, Granada, Spain
| | - Victoria Contreras-Bolívar
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, Granada, Spain
| | | | - Gonzalo Martínez-Navajas
- Gene Regulation, Stem Cells and Development Lab, Pfizer-University of Granada-Junta de Andalucía Centre for Genomics and Oncological Research (GENYO), Granada, Spain
- Department of Biochemistry and Molecular Biology I, Faculty of Science, University of Granada, Granada, Spain
| | - Pedro J. Real
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Gene Regulation, Stem Cells and Development Lab, Pfizer-University of Granada-Junta de Andalucía Centre for Genomics and Oncological Research (GENYO), Granada, Spain
- Department of Biochemistry and Molecular Biology I, Faculty of Science, University of Granada, Granada, Spain
| | - Cristina García-Fontana
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, Granada, Spain
- Biomedical Research Network in Fragility and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
- *Correspondence: Cristina García-Fontana, ; Manuel Muñoz-Torres,
| | - Manuel Muñoz-Torres
- Department of Medicine, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, Granada, Spain
- Biomedical Research Network in Fragility and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
- *Correspondence: Cristina García-Fontana, ; Manuel Muñoz-Torres,
| | - Beatriz García-Fontana
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, Granada, Spain
- Biomedical Research Network in Fragility and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
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Santurtún M, Mediavilla-Martinez E, Vega AI, Gallego N, Heath KE, Tenorio JA, Lapunzina P, Riancho-Zarrabeitia L, Riancho JA. Pain and health-related quality of life in patients with hypophosphatasemia with and without ALPL gene mutations. Front Endocrinol (Lausanne) 2022; 13:965476. [PMID: 36072928 PMCID: PMC9442670 DOI: 10.3389/fendo.2022.965476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/26/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Low serum alkaline phosphatase levels are the hallmark of hypophosphatasia, a disorder due to pathogenic variants of the ALPL gene. However, some patients do not carry ALPL variants and the cause of low alkaline phosphatase remains unknown. We aimed to determine health-related quality of life in adults with low alkaline phosphatase and explore the differences between patients with and without ALPL mutations. METHODS We studied 35 adult patients with persistently low alkaline phosphatase unrelated to secondary acquired causes who had ALPL sequenced, and 35 controls of similar age. Three questionnaires about body pain (Brief Pain Inventory, BPI), physical disability (Health Assessment Questionnaire Disability Index, HAQ-DI), and health-related quality of life (36-item Short-Form Health Survey, SF-36) were delivered by telephone interviews. RESULTS The mean BPI intensity and interference scores were higher in the patient group (p=0.04 and 0.004, respectively). All domains of the HAQ instrument tended to score better in the control group, with significant differences in the "reach" score (p=0.037) and the overall mean score (0.23 vs 0.09; p=0.029). Patients scored worse than controls in several SF-36 dimensions (Role physical, p=0.039; Bodily pain p=0.046; Role emotional, p=0.025). Patients with and without pathogenic variants scored similarly across all tests, without between-group significant differences. CONCLUSIONS Patients with persistently low levels of alkaline phosphatase have significantly worse scores in body pain and other health-related quality of life dimensions, without differences between patients with and without pathogenic variants identified in ALPL gene. This is consistent with the latter ones carrying mutations in regulatory regions.
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Affiliation(s)
- Maite Santurtún
- Departamento de Enfermería, Hospital Padre Meni, Universidad de Cantabria, Santander, Spain
| | | | - Ana I. Vega
- Servicio de Genética, Hospital UM Valdecila, Santander, Spain
| | - Natalia Gallego
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Instituto de Genética Médica y Molecular, Hospital U Lapaz, Instituto de Investigación Sanitaria La Paz (IDIPAZ), Madrid, Spain
- ERN-ITHACA, Brussels, Belgium
| | - Karen E. Heath
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Instituto de Genética Médica y Molecular, Hospital U Lapaz, Instituto de Investigación Sanitaria La Paz (IDIPAZ), Madrid, Spain
- ERN-ITHACA, Brussels, Belgium
| | - Jair A. Tenorio
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Instituto de Genética Médica y Molecular, Hospital U Lapaz, Instituto de Investigación Sanitaria La Paz (IDIPAZ), Madrid, Spain
- ERN-ITHACA, Brussels, Belgium
| | - Pablo Lapunzina
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Instituto de Genética Médica y Molecular, Hospital U Lapaz, Instituto de Investigación Sanitaria La Paz (IDIPAZ), Madrid, Spain
- ERN-ITHACA, Brussels, Belgium
| | - Leyre Riancho-Zarrabeitia
- Servicio de Reumatología, Hospital U Sierrallana Torrelavega, Instituto de Investigación Sanitaria Valdecilla (IDIVAL), Santander, Spain
| | - José A. Riancho
- Departamento de Medicina y Psiquiatría, Servicio de Medicina Interna, Hospital Valdecilla, Instituto de Investigación Sanitaria Valdecilla (IDIVAL), Universidad de Cantabria, Santander, Spain
- *Correspondence: José A. Riancho,
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Endocrinology of bone mineralization: an update. ANNALES D'ENDOCRINOLOGIE 2021; 83:46-53. [PMID: 34921812 DOI: 10.1016/j.ando.2021.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 12/01/2021] [Indexed: 11/20/2022]
Abstract
Throughout the world, millions of people suffer from fragilizing osteopathies such as osteomalacia and osteoporosis.Osteomalacia is a rare disorder, corresponding to mineralization abnormalities in adult bone, as opposed to rickets in children. Renal phosphate loss and hypophosphatasia are the main causes of vitamin-resistant osteomalacia. Diagnosis is based on clinical history, phosphocalcic metabolism assessment and, if necessary, molecular characterization, and must be rapid in order to initiate the most appropriate treatment and consider new treatments such as burosumab if necessary.Osteoporosis is characterized by reduced bone mass and strength, which increases the risk of fragility fracture. Fracture-related burden is expected to increase over the coming decades linked to the aging of population and a treatment gap. In order to reduce this treatment gap, it is important to develop two strategies: improvement of screening and of treatment. Systematic screening using the FRAX® fracture risk assessment tool could be useful to increase anti-osteoporosis medical treatment and reduce fracture rates. The question of treatment sequencing in osteoporosis is another challenge, notably after denosumab cessation, complicated by a decrease in bone mineral density and increased risk of fracture. New treatments are also available, including romosozumab, a humanized monoclonal antibody which promotes bone formation and inhibits bone resorption by inhibiting sclerostin. Romosozumab is approved in several countries, including France, for treating severe osteoporosis in postmenopausal women at high risk of fracture and free of cardiovascular comorbidity.Endocrinologists need to be aware of these fragilizing osteopathies in order to improve both diagnosis and treatment.
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Abstract
Hypophosphatasia (HPP) is an inherited metabolic disease caused by loss-of-function mutations in the tissue non-specific alkaline phosphatase (TNAP) gene. Reduced activity of TNAP leads to the accumulation of its substrates, mainly inorganic pyrophosphate and pyridoxal-5′-phosphate, metabolic aberrations that largely explain the musculoskeletal and systemic features of the disease. More than 400 ALPL mutations, mostly missense, are reported to date, transmitted by either autosomal dominant or recessive mode. Severe disease is rare, with incidence ranging from 1:100,000 to 1:300,000 live births, while the estimated prevalence of the less severe adult form is estimated to be between 1:3100 to 1:508, in different countries in Europe. Presentation largely varies, ranging from death in utero to asymptomatic adults. In infants and children, clinical features include skeletal, respiratory and neurologic complications, while recurrent, poorly healing fractures, muscle weakness and arthropathy are common in adults. Persistently low serum alkaline phosphatase is the cardinal biochemical feature of the disease. Management requires a dedicated multidisciplinary team. In mild cases, treatment is usually symptomatic. Severe cases, with life-threating or debilitating complications, can be successfully treated with enzyme replacement therapy with asfotase alfa.
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Masi L, Marini F, Franceschelli F, Leoncini G, Cianferotti L, Cioppi F, Giusti F, Marcucci G, Gronchi G, Brandi ML. Polymorphic variants of alkaline phosphatase gene correlate with clinical signs of adult hypophosphatasia? Osteoporos Int 2021; 32:2461-2472. [PMID: 34097127 PMCID: PMC8608776 DOI: 10.1007/s00198-021-05893-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 02/15/2021] [Indexed: 11/28/2022]
Abstract
UNLABELLED We analyzed polymorphism of the ALPL gene in patients with low serum levels of tissue-nonspecific alkaline phosphatase (TNAP). The presence of three or more of the less frequent alleles of ALPL polymorphisms was associated with significantly lower TNAP serum level and higher frequencies of metatarsal fractures, which may help confirm a clinical suspicion of adult hypophosphatasia. INTRODUCTION Alkaline phosphatases (ALPs) are membrane-bound enzymes that hydrolyze monophosphate esters at a high pH (pH 8-10). Inorganic pyrophosphate, pyridoxal 5-phosphate, the activated form of vitamin B6 (PLP), and phosphoethanolamine (PEA), are natural substrates of ALPs. Hypophosphatasia (HPP, OMIM 146300, 241500, 241510) is a heterogeneous rare metabolic bone disease caused by loss-of-function mutations in the tissue-nonspecific alkaline phosphatase gene (ALPL; MIM 171760) with a deficiency of TNAP. Clinical presentation of HPP in adults demonstrated a wide range of manifestations, many of which are nonspecific. In the present study, we screened the polymorphic genetic variants of ALPL in 56 subjects presenting low serum levels of TNAP and/or other clinical signs of adult HPP in order to evaluate a possible role of polymorphic variants in the diagnosis and management of HPP in adults. METHODS Genomic DNA was extracted from peripheral blood and ALPL gene was sequenced by PCR-based Sanger technique. RESULTS Fourteen different polymorphic variants were found in the study population. A lower serum level of TNAP and higher frequencies of metatarsal fractures were observed in patients bearing three or more of the minor frequency alleles (MFAs) of the ALPL polymorphic variants. The presence of some MFAs, mostly as a contemporary presence of three or more of them, was found to be mainly represented in patients having both a significantly lower level of TNAP and a higher level of vitamin B6. CONCLUSION The genetic analysis and presence of some polymorphic variants may be an instrument to confirm clinical and biochemical data, consider adult HPP, and help clinicians be cautious in the administration of anti-reabsorption drugs.
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Affiliation(s)
- L Masi
- University Hospital of Florence, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy
| | - F Marini
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - F Franceschelli
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - G Leoncini
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - L Cianferotti
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - F Cioppi
- University Hospital of Florence, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy
| | - F Giusti
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - G Marcucci
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - G Gronchi
- Deparment of Neuroscience, Psychology Drug Research and Child's Health, University of Florence, Florence, Italy
| | - M L Brandi
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy.
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Kinoshita Y, Mohamed FF, Amadeu de Oliveira F, Narisawa S, Miyake K, Foster BL, Millán JL. Gene Therapy Using Adeno-Associated Virus Serotype 8 Encoding TNAP-D 10 Improves the Skeletal and Dentoalveolar Phenotypes in Alpl -/- Mice. J Bone Miner Res 2021; 36:1835-1849. [PMID: 34076297 PMCID: PMC8446309 DOI: 10.1002/jbmr.4382] [Citation(s) in RCA: 12] [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: 03/08/2021] [Revised: 05/25/2021] [Accepted: 05/28/2021] [Indexed: 12/26/2022]
Abstract
Hypophosphatasia (HPP) is caused by loss-of-function mutations in the ALPL gene that encodes tissue-nonspecific alkaline phosphatase (TNAP), whose deficiency results in the accumulation of extracellular inorganic pyrophosphate (PPi ), a potent mineralization inhibitor. Skeletal and dental hypomineralization characterizes HPP, with disease severity varying from life-threatening perinatal or infantile forms to milder forms that manifest in adulthood or only affect the dentition. Enzyme replacement therapy (ERT) using mineral-targeted recombinant TNAP (Strensiq/asfotase alfa) markedly improves the life span, skeletal phenotype, motor function, and quality of life of patients with HPP, though limitations of ERT include frequent injections due to a short elimination half-life of 2.28 days and injection site reactions. We tested the efficacy of a single intramuscular administration of adeno-associated virus 8 (AAV8) encoding TNAP-D10 to increase the life span and improve the skeletal and dentoalveolar phenotypes in TNAP knockout (Alpl-/- ) mice, a murine model for severe infantile HPP. Alpl-/- mice received 3 × 1011 vector genomes/body of AAV8-TNAP-D10 within 5 days postnatal (dpn). AAV8-TNAP-D10 elevated serum ALP activity and suppressed plasma PPi . Treatment extended life span of Alpl-/- mice, and no ectopic calcifications were observed in the kidneys, aorta, coronary arteries, or brain in the 70 dpn observational window. Treated Alpl-/- mice did not show signs of rickets, including bowing of long bones, enlargement of epiphyses, or fractures. Bone microstructure of treated Alpl-/- mice was similar to wild type, with a few persistent small cortical and trabecular defects. Histology showed no measurable osteoid accumulation but reduced bone volume fraction in treated Alpl-/- mice versus controls. Treated Alpl-/- mice featured normal molar and incisor dentoalveolar tissues, with the exceptions of slightly reduced molar enamel and alveolar bone density. Histology showed the presence of cementum and normal periodontal ligament attachment. These results support gene therapy as a promising alternative to ERT for the treatment of HPP. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Yuka Kinoshita
- Sanford Children's Health Research Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Fatma F Mohamed
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - Flavia Amadeu de Oliveira
- Sanford Children's Health Research Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Sonoko Narisawa
- Sanford Children's Health Research Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Koichi Miyake
- Department of Biochemistry and Molecular Biology, Nippon Medical School, Tokyo, Japan
| | - Brian L Foster
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - José Luis Millán
- Sanford Children's Health Research Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
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Garcia-Carretero R, Olid-Velilla M, Perez-Torrella D, Torres-Pacho N, Darnaude-Ortiz MT, Bustamate-Zuloeta AD, Tenorio JA. Predictive modeling of hypophosphatasia based on a case series of adult patients with persistent hypophosphatasemia. Osteoporos Int 2021; 32:1815-1824. [PMID: 33619648 DOI: 10.1007/s00198-021-05885-8] [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: 09/29/2020] [Accepted: 02/09/2021] [Indexed: 10/22/2022]
Abstract
UNLABELLED Approximately half of individuals with hypophosphatasemia (low levels of serum alkaline phosphatase) have hypophosphatasia, a rare genetic disease in which patients may have stress fractures, bone and joint pain, or premature tooth loss. We developed a predictive model based on specific biomarkers of this disease to better diagnose this condition. INTRODUCTION Hypophosphatasemia is a condition in which low levels of alkaline phosphatase (ALP) are detected in the serum. Some individuals presenting with this condition may have a rare genetic disease called hypophosphatasia (HPP), which involves mineralization of the bone and teeth. Lack of awareness of HPP and its nonspecific symptoms make this genetic disease difficult to diagnose. We developed a predictive model based on biomarkers of HPP such as ALP and pyridoxal 5'-phosphate (PLP), because clinical manifestations sometimes are not recognized as symptoms of HPP. METHODS We assessed 325,000 ALP results between 2010 and 2015 to identify individuals suspected of having HPP. We performed univariate and multivariate analyses to characterize the relationship between hypophosphatasemia and HPP. Using several machine learning algorithms, we developed several models based on biomarkers and compared their performance to determine the best model. RESULTS The final cohort included 45 patients who underwent a genetic test. Half (23 patients) showed a mutation of the ALPL gene that encodes the tissue-nonspecific ALP enzyme. ALP (odds ratio [OR] 0.61, 95% confidence interval [CI] 0.3-0.8, p = 0.01) and PLP (OR 1.06, 95% CI 1.01-1.15, p = 0.04) were the only variables significantly associated with the presence of HPP. Support vector machines and logistic regression were the machine learning algorithms that provided the best predictive models in terms of classification (area under the curve 0.936 and 0.844, respectively). CONCLUSIONS Given the high probability of a misdiagnosis, its nonspecific symptoms, and a lack of awareness of serum ALP levels, it is difficult to make a clinical diagnosis of HPP. Predictive models based on biomarkers are necessary to achieve a proper diagnosis. Our proposed machine learning approaches achieved reasonable performance compared to traditional statistical methods used in biomedicine, increasing the likelihood of properly diagnosing such a rare disease as HPP.
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Affiliation(s)
- R Garcia-Carretero
- Department of Internal Medicine, Mostoles University Hospital, Rey Juan Carlos University, Madrid, Spain.
| | - M Olid-Velilla
- Department of Internal Medicine, Mostoles University Hospital, Madrid, Spain
| | - D Perez-Torrella
- Department of Laboratory of Clinical Analysis, Mostoles University Hospital, Madrid, Spain
| | - N Torres-Pacho
- Department of Internal Medicine, Mostoles University Hospital, Madrid, Spain
| | - M-T Darnaude-Ortiz
- Department of Clinical Genetics, Mostoles University Hospital, Madrid, Spain
| | | | - J-A Tenorio
- Institute of Medical and Molecular Genetics (INGEMM), La Paz University Hospital, Madrid, Spain
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The Occurrence and Burden of Hypophosphatasia in an Ambulatory Care Endocrinology Practice. Endocr Pract 2021; 27:1189-1192. [PMID: 34265454 DOI: 10.1016/j.eprac.2021.07.005] [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: 04/27/2021] [Revised: 07/02/2021] [Accepted: 07/07/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Hypophosphatasia (HPP) is an inherited disease resulting from loss-of-function mutations in the ALPL gene encoding tissue-nonspecific alkaline phosphatase. The presentation and severity of the disease are highly variable, ranging from perinatal onset with high mortality rates to adult identification with low mortality rates and symptoms ranging from minimal to severe. Moderate forms of HPP typically manifest during middle age and are often undiagnosed. The objective of this study was to determine the occurrence and burden of HPP in an ambulatory care endocrinology practice. METHODS Potential subjects were identified with a computerized text search of patient electronic medical records. Search terms included serum alkaline phosphatase (ALP) levels of ≤40 U/L. Records of patients with at least 2 low ALP levels were reviewed manually to identify potential patients with a history consistent with hypophosphatasia. RESULTS In total, 315 patients with ALP levels ≤40 U/L were identified from an estimated 20 000 patient records. Fifty-six patients with a single low level were excluded from further review. The remaining 259 patients were reviewed, 10 of whom had histories consistent with HPP. None of the identified 10 patients was currently being treated or had previously been treated for HPP. Information about these patients was shared with their respective providers, along with the recommendation to proceed with further evaluation to confirm the diagnosis of HPP. CONCLUSION Hypophosphatasia is an uncommon condition with variable presentation, often resulting in a missed diagnosis. Surveillance of practices by identifying patients with low ALP levels is a rational screening approach to identifying potential patients with HPP.
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Hepp N, Frederiksen AL, Duno M, Præst Holm J, Rye Jørgensen N, Beck Jensen JE. Biochemical, clinical and genetic characteristics in adults with persistent hypophosphatasaemia; Data from an endocrinological outpatient clinic in Denmark. Bone Rep 2021; 15:101101. [PMID: 34258332 PMCID: PMC8256181 DOI: 10.1016/j.bonr.2021.101101] [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: 04/19/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 12/18/2022] Open
Abstract
Background Hypophosphatasia (HPP) is an inborn disease caused by pathogenic variants in ALPL. Low levels of alkaline phosphatase (ALP) are a biochemical hallmark of the disease. Scarce knowledge about the prevalence of HPP in Scandinavia exists, and the variable clinical presentations make diagnostics challenging. The aim of this study was to investigate the prevalence of ALPL variants as well as the clinical and biochemical features among adults with endocrinological diagnoses and persistent hypophosphatasaemia. Methods A biochemical database containing ALP measurements of 26,121 individuals was reviewed to identify adults above 18 years of age with persistently low levels of ALP beneath range (≤ 35 ± 2.7 U/L). ALPL genetic testing, biochemical evaluations and assessment of clinical features by a systematic questionnaire among included patients, were performed. Results Among 24 participants, thirteen subjects (54.2%) revealed a disease-causing variant in ALPL and reported mild clinical features of HPP, of which musculoskeletal pain was the most frequently reported (n = 9). The variant c. 571G > A; p.(Glu191Lys) was identified in six subjects, and an unreported missense variant (c.1019A > C; p.(His340Pro)) as well as a deletion of exon 2 were detected by genetic screening. Biochemical analyses showed no significant differences in ALP (p = 0.059), the bone specific alkaline phosphatase (BALP) (p = 0.056) and pyridoxal-5′-phosphate (PLP) (p = 0.085) between patients with an ALPL variant and negative genetic screening. Patients with a variant in ALPL had significantly higher PLP levels than healthy controls (p = 0.002). We observed normal ALP activity in some patients classified as mild HPP, and slightly increased levels of PLP in two subjects with normal genetic screening and four healthy controls. Among 51 patients with persistent hypophosphatasaemia, fifteen subjects (29.4%) received antiresorptive treatment. Two patients with unrecognized HPP were treated with bisphosphonates and did not show complications due to the treatment. Conclusions Pathogenic variants in ALPL are common among patients with endocrinological diagnoses and low ALP. Regarding diagnostics, genetic testing is necessary to identify mild HPP due to fluctuating biochemical findings. Antiresorptive treatment is a frequent reason for hypophosphatasaemia and effects of these agents in adults with a variant in ALPL and osteoporosis remain unclear and require further studies. Mild HPP is overlooked among adults with endocrinological diagnoses. Biochemical hallmarks of HPP can fluctuate to normal among mild forms. Genetic screening of ALPL including MLPA is necessary to identify mild HPP. Musculoskeletal pain is the most common symptom in adult HPP. Effects of bisphosphonates in mild HPP need further studies.
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Affiliation(s)
- Nicola Hepp
- Dept. of Endocrinology, Hvidovre University Hospital Copenhagen, Kettegaard Alle 30, 2650 Hvidovre, Denmark
| | - Anja Lisbeth Frederiksen
- Dept. of Clinical Genetics, Aalborg University Hospital, Ladegaardsgade 5, 9000 Aalborg C, Denmark.,Dept. of Clinical Research, Aalborg University, Fredrik Bajers Vej 7K, 9220 Aalborg Ø, Denmark
| | - Morten Duno
- Dept. of Clinical Genetics, University Hospital Copenhagen Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jakob Præst Holm
- Department of Endocrinology, Copenhagen University Hospital Herlev, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Niklas Rye Jørgensen
- Dept. of Clinical Biochemistry, Rigshospitalet, Valdemar Hansens Vej 13, 2600 Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200 Copenhagen, Denmark
| | - Jens-Erik Beck Jensen
- Dept. of Endocrinology, Hvidovre University Hospital Copenhagen, Kettegaard Alle 30, 2650 Hvidovre, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200 Copenhagen, Denmark
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Pan WJ, Pradhan R, Pelto R, Seefried L. Pharmacokinetics of Asfotase Alfa in Adult Patients With Pediatric-Onset Hypophosphatasia. J Clin Pharmacol 2021; 61:1334-1343. [PMID: 33822385 PMCID: PMC8518624 DOI: 10.1002/jcph.1870] [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] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/01/2021] [Indexed: 11/24/2022]
Abstract
Hypophosphatasia is a rare metabolic disease resulting from variant(s) in the gene‐encoding tissue‐nonspecific isozyme of alkaline phosphatase. In this 13‐week, phase 2a, multicenter, randomized, open‐label, dose‐response study (ClinicalTrials.gov: NCT02797821), the pharmacokinetics of asfotase alfa, an enzyme replacement therapy approved for the treatment of hypophosphatasia, was assessed in adult patients with pediatric‐onset hypophosphatasia. In total, 27 adults were randomly assigned 1:1:1 to a single subcutaneous dose of asfotase alfa (0.5, 2.0, or 3.0 mg/kg) during week 1. From week 3 to week 9, patients received 0.5, 2.0, or 3.0 mg/kg subcutaneously 3 times per week (equivalent to 1.5, 6.0, or 9.0 mg/kg/wk, respectively). Noncompartmental analysis revealed exposure (maximum concentration in the dosing interval and area under the concentration‐time curve from time 0 to infinity) to asfotase alfa increased between single‐ and multiple‐dose administration and with increasing doses; however, extensive interindividual variability was observed in the concentration‐time profiles within each dose cohort. Median terminal elimination half‐life was ≈5 days following multiple‐dose administration, with steady state achieved by approximately day 29. Dose‐normalized exposure data indicated that asfotase alfa activity was approximately dose‐proportional within the studied dose range. Additionally, dose‐normalized exposure was comparable across body mass index categories of <25, ≥25 to <30, and ≥30 kg/m2, indicating that asfotase alfa dosing bioavailability was consistent in these patients, including those who were obese. These data, together with previously published pharmacodynamic results in this study population, support the use of asfotase alfa at the recommended dose of 6 mg/kg/wk in adults with pediatric‐onset hypophosphatasia.
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Affiliation(s)
- Wei-Jian Pan
- Alexion Pharmaceuticals, Inc., Boston, Massachusetts, USA
| | | | - Ryan Pelto
- Alexion Pharmaceuticals, Inc., Boston, Massachusetts, USA
| | - Lothar Seefried
- Orthopedic Department, University of Würzburg, Würzburg, Bavaria, Germany
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Papadopoulou A, Bountouvi E, Sideri V, Moutsatsou P, Skarakis NS, Doulgeraki A, Karachaliou FE. Parietal aplasia and hypophosphatasia in a child harboring a novel mutation in RUNX2 and a likely pathogenic variant in TNSALP. Bone 2021; 146:115904. [PMID: 33647526 DOI: 10.1016/j.bone.2021.115904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/03/2021] [Accepted: 02/23/2021] [Indexed: 11/30/2022]
Abstract
Cleidocranial dysplasia is a dominantly inherited skeletal dysplasia resulting from inherited or spontaneous mutations of Runt-related transcription factor 2 gene (RUNX2). It represents a clinical continuum typically characterized by wide calvarial sutures, clavicular hypoplasia and dental abnormalities. CDD has been rarely associated with skeletal and biochemical features that mimic hypophosphatasia. We report clinical, biochemical and molecular profile of a 3-year-old female with CCD, presented in utero with large cranial defects. She displayed severe parietal dysplasia, wide cranial sutures, clavicular abnormalities and biochemical features of hypophospatasia (HHP). She was preliminary diagnosed with benign perinatal HHP, harboring a likely pathogenic heterozygous TNSALP variant (p.Ser181Leu) inherited by the mother, who also displayed low levels of ALP. Asfotase alfa was introduced for a six-month-period with rather positive impact on cranial ossification. Nevertheless, focal skeletal disease (cranium and clavicles) and absence of clinical symptoms in the mother, carrier of the same genetic variant, posed diagnosis into question and further genetic analysis detected the novel spontaneous frameshift mutation c.1191delC (p.Phe398Leufs*86) in RUNX2 gene, establishing the CCD diagnosis. Although genotype-phenotype correlations are difficult, p.Phe398Leufs*86 appears to be associated with a severe cranial phenotype and absence of parietal bones, similarly to other adjacent frameshift/splicing mutations. The TNSALP variant (p.Ser181Leu) may contributed to patient's final phenotype, as well as to maternal low ALP levels. However, since low ALP levels have been also reported in few CCD patients with no alterations in TNSALP gene, studies to elucidate RUNX2 and TNSALP interactions could shed more light on differential diagnosis between CCD and HHP, CCD appropriate therapy and genetic counselling. ACCESSION NUMBER: (SUB8185506).
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Affiliation(s)
- Anna Papadopoulou
- Third Department of Pediatrics, National & Kapodistrian University of Athens, University General Hospital "Attikon", Medical School, Athens, Greece; Department of Clinical Biochemistry, National & Kapodistrian University of Athens, University General Hospital "Attikon", Medical School, Athens, Greece.
| | - Evangelia Bountouvi
- Third Department of Pediatrics, National & Kapodistrian University of Athens, University General Hospital "Attikon", Medical School, Athens, Greece
| | - Vassiliki Sideri
- Third Department of Pediatrics, National & Kapodistrian University of Athens, University General Hospital "Attikon", Medical School, Athens, Greece
| | - Paraskevi Moutsatsou
- Department of Clinical Biochemistry, National & Kapodistrian University of Athens, University General Hospital "Attikon", Medical School, Athens, Greece
| | - Nikitas Spyridon Skarakis
- Department of Clinical Biochemistry, National & Kapodistrian University of Athens, University General Hospital "Attikon", Medical School, Athens, Greece; Department of Endocrinology and Diabetes Center, "G. Gennimatas", General Hospital of Athens, Athens, Greece
| | - Artemis Doulgeraki
- Department of Bone and Mineral Metabolism, Institute of Child Health, Athens, Greece
| | - Fotini Eleni Karachaliou
- Third Department of Pediatrics, National & Kapodistrian University of Athens, University General Hospital "Attikon", Medical School, Athens, Greece
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Kishnani PS, Del Angel G, Zhou S, Rush ET. Investigation of ALPL variant states and clinical outcomes: An analysis of adults and adolescents with hypophosphatasia treated with asfotase alfa. Mol Genet Metab 2021; 133:113-121. [PMID: 33814268 DOI: 10.1016/j.ymgme.2021.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/03/2021] [Accepted: 03/14/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hypophosphatasia (HPP), a rare metabolic disease, can be inherited in an autosomal recessive (biallelic) or an autosomal dominant (monoallelic) manner. Most of the severe, early-onset, frequently lethal HPP in infants is acquired through recessive inheritance; less severe, later-onset, typically nonlethal HPP phenotypes are acquired through either dominant or recessive inheritance. HPP's variable clinical presentation arises from >400 identified ALPL pathogenic variants with likely variable penetrance, especially with autosomal dominant inheritance. This post hoc analysis investigated the relationship between ALPL variant state (biallelic and monoallelic) and clinical outcomes with asfotase alfa in HPP. METHODS Data were pooled from two phase 2, randomized, open-label studies in adolescents and adults with HPP; one study evaluated the efficacy and safety of different doses of asfotase alfa (n = 25), and the other assessed the pharmacodynamics and safety of asfotase alfa (n = 19). Patients were grouped by ALPL variant state (biallelic or monoallelic). Available data from both studies included ALPL pathogenic variant state, Baseline characteristics, HPP-specific medical history, and Baseline TNSALP substrate levels (inorganic pyrophosphate [PPi] and pyridoxal 5'-phosphate [PLP]) concentrations). Clinical outcomes over 5 years of treatment were available from only the efficacy and safety study. RESULTS In total, 44 patients with known variant status were included in the pooled analysis (biallelic, n = 30; monoallelic, n = 14). The most common pathogenic variant was c.571G > A (p.Glu191Lys) in biallelic patients (allele frequency: 19/60) and c.1133A > T (p.Asp378Val) in monoallelic patients (allele frequency: 7/28). Median (min, max) Baseline PPi concentrations were significantly higher in patients with a biallelic vs monoallelic variant state (5.3 [2.2, 12.1] vs 4.3 [3.5, 7.4] μM; P = 0.0113), as were Baseline PLP concentrations (221.4 [62.4, 1590.0] vs 75.1 [28.8, 577.0] ng/mL; P= 0.0022). HPP-specific medical history was generally similar between biallelic and monoallelic patients in terms of incidence and type of manifestations; notable exceptions included fractures, which were more common among monoallelic patients, and delayed walking and bone deformities such as abnormally shaped chest and head and bowing of arms or legs, which were more common among biallelic patients. Data from the efficacy and safety study (n = 19) showed that median PPi and PLP concentrations were normalized over 5 years of treatment in patients with both variant states. Median % predicted distance walked on the 6-Minute Walk Test remained within the normal range for monoallelic patients over 4 years of treatment, and improved from below normal (<84%) to normal in biallelic patients. CONCLUSIONS Although patients with biallelic variants had significantly higher Baseline PPi and PLP levels than monoallelic variants, both groups generally showed similar pretreatment Baseline clinical characteristics. Treatment with asfotase alfa for up to 5 years normalized TNSALP substrate concentrations and improved functional outcomes, with no clear differences between biallelic and monoallelic variant states. This study suggests that patients with HPP have significant disease burden, regardless of ALPL variant state.
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Affiliation(s)
- Priya S Kishnani
- Department of Pediatrics, Duke University Medical Center, 2351 Erwin Road, Durham, NC, USA.
| | | | - Shanggen Zhou
- Covance, Inc., 206 Carnegie Center Dr, Princeton, NJ, USA.
| | - Eric T Rush
- Children's Mercy Hospital Kansas City, 2401 Gillham Rd, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA; University of Kansas School of Medicine, Kansas City, KS, USA.
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Fenn JS, Lorde N, Ward JM, Borovickova I. Hypophosphatasia. J Clin Pathol 2021; 74:635-640. [PMID: 33931563 DOI: 10.1136/jclinpath-2021-207426] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 11/04/2022]
Abstract
Hypophosphatasia (HPP) is a group of inherited disorders characterised by the impaired mineralisation of bones and/or teeth and low serum alkaline phosphatase (ALP) activity. It is caused by a mutation in the ALPL gene encoding the tissue-non-specific isoenzyme of ALP (TNSALP) resulting in a loss of function. The disease is highly heterogenous in its clinical expression ranging from stillbirth without mineralised bone to the mild form of late adult onset with symptoms and signs such as musculoskeletal pain, arthropathy, lower-extremity fractures, premature loss of teeth or an incidental finding of reduced serum ALP activity. A classification based on the age at diagnosis and the presence or absence of bone symptoms was historically used: perinatal, prenatal benign, infantile, childhood, adult and odontohypophosphatasia. These subtypes are known to have overlapping signs and complications. Three forms of HPP distinguishable by their genetic characteristics have been described: severe, moderate and mild. Severe forms of HPP (perinatal and infantile severe) are recessively inherited, whereas moderate HPP may be dominantly or recessively inherited. The biochemical hallmark of HPP is persistently low serum ALP for age and increase in natural substrates of TNSALP, pyridoxal 5'-phosphate and phosphoethanolamine supported by radiological findings. The diagnosis is confirmed by ALPL sequencing. A multidisciplinary team of experts is essential for the effective management. Calcium restriction is recommended in infants/children to manage hypercalcaemia. A targeted enzyme replacement therapy for HPP has become available and correct diagnosis is crucial to allow early treatment.
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Affiliation(s)
- Jonathan Samuel Fenn
- Black Country Pathology Services, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Nathan Lorde
- Department of Clinical Chemistry, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Martin Ward
- Department of Radiology, McGill University Health Center, Montreal, Québec, Canada
| | - Ingrid Borovickova
- Department of Biochemical Genetics, Children's Health Ireland at Temple Street, Dublin, Ireland
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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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Karakostas P, Dolscheid-Pommerich R, Hass MD, Weber N, Brossart P, Schäfer VS. [Prevalence of hypophosphatasia in adult patients in rheumatology]. Z Rheumatol 2021; 81:513-519. [PMID: 33852075 PMCID: PMC9338116 DOI: 10.1007/s00393-021-00994-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 11/29/2022]
Abstract
Hintergrund Die Hypophosphatasie (HPP) ist eine genetische Erkrankung, die durch eine oder mehrere Mutationen im Gen für alkalische Phosphatase (ALP) verursacht wird, verantwortlich für die Kodierung der gewebespezifischen ALP und für den Mineralisierungsprozess. Ziel der Arbeit Bestimmung der Prävalenz der HPP bei rheumatologischen Patienten. Material und Methoden Retrospektive Analyse der Krankenakten aller erwachsener Patienten mit pathologisch erniedrigten gesamt ALP-Werten (<35 U/l), die zwischen Januar 2017 und Juni 2019 in der Rheumatologie der Medizinischen Klinik III am Universitätsklinikum Bonn behandelt wurden. Die Analyse wurde in Bezug auf klinische Zeichen sowie auf die Ergebnisse der Gentests für HPP untersucht. Ergebnisse Bei 60 von 2289 Patienten (2,62 %) zeigten sich pathologisch niedrige ALP-Werte, bei 30 von ihnen (1,31 %) wurden persistierend niedrige ALP-Werte festgestellt. Bei 19 dieser 30 Patienten wurde ein Gentest für ALP-Genmutationen durchgeführt. Sieben der 19 Patienten (36,84 %) hatten HPP-Zeichen (Insuffizienzfrakturen oder schlechter Zahnstatus seit der Kindheit), alle mit pathologischer ALP-Mutation. Drei dieser Patienten (15,78 %) hatten jeweils eine Insuffizienzfraktur mit normwertiger Knochendichtemessung in der Vorgeschichte. Insgesamt 13 von 19 Patienten wiesen (68,42 %) Mutationen im ALP-Gen auf. Interessanterweise wurde keine Assoziation mit einer Chondrokalzinose festgestellt. Diskussion Die HPP scheint eine unterdiagnostizierte Erkrankung mit einem höheren Anteil betroffener Patienten, welche in der Rheumatologie vorstellig werden, zu sein. Daher sollten zukünftige Studien darauf abzielen, ein Diagnostikprotokoll in der klinischen Praxis zu entwickeln.
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Affiliation(s)
- P Karakostas
- Klinik für Innere Medizin III, Onkologie, Hämatologie, Rheumatologie und Klinische Immunologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland.
| | - R Dolscheid-Pommerich
- Institut für Klinische Chemie und Klinische Pharmakologie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - M D Hass
- Zentrum für Blutgerinnungsstörungen und Transfusionsmedizin Bonn, Bonn, Deutschland
| | - N Weber
- Klinik für Innere Medizin III, Onkologie, Hämatologie, Rheumatologie und Klinische Immunologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
| | - P Brossart
- Klinik für Innere Medizin III, Onkologie, Hämatologie, Rheumatologie und Klinische Immunologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
| | - V S Schäfer
- Klinik für Innere Medizin III, Onkologie, Hämatologie, Rheumatologie und Klinische Immunologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
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Vieira LHR, Peixoto KC, Flósi CL, de Farias MLF, Madeira M. Active search of adult patients with persistently low serum alkaline phosphatase levels for the diagnosis of hypophosphatasia. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:289-294. [PMID: 33844893 PMCID: PMC10065342 DOI: 10.20945/2359-3997000000347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective Alkaline phosphatase (ALP) is the main laboratory marker of hypophosphatasia (HPP), a rare disease unknown to most physicians. The prevalence of HPP has been widely discussed in the literature due to the diverse phenotypes of HPP. The purpose of this study was to search for patients with hypophosphatasemia based on previous biochemistry tests and reevaluate them to confirm the diagnosis of HPP. Methods A total of 289,247 biochemical tests for ALP in adults were performed from 2015 to 2019 in two tertiary hospitals in Rio de Janeiro were reviewed (Clementino Fraga Filho University Hospital - HUCFF - and Bonsucesso Federal Hospital - BFH). Results A total of 1,049 patients were identified with ALP levels below 40 U/L, and 410 patients had hypophosphatasemia confirmed by at least two exams. After the active search of medical reports and/or interviews based on structured questionnaires, 398 subjects were excluded due to secondary causes of reduced ALP. The remaining 12 patients were invited to attend the medical consultation at HUCFF, accompanied by at least one first-degree relative. None of the patients or their relatives had a history or clinical manifestations consistent with HPP. Serum ALP was within reference values in all relatives, but persistently low in further laboratory evaluation in all the 12 patients, in whom secondary causes were ruled out. Thus, we cannot exclude the possibility that they might carry the mutations associated with HPP. Conclusion Further image evaluations and genetic testing would be appropriate to confirm this asymptomatic adult form of HPP.
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Affiliation(s)
- Lucio Henrique Rocha Vieira
- Divisão de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil,
| | - Kleison Cordeiro Peixoto
- Laboratório de Bioquímica, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, RJ, Brasil
| | - Caroline Leal Flósi
- Divisão de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Maria Lucia Fleiuss de Farias
- Divisão de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Miguel Madeira
- Divisão de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
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