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Pfau K, Lengyel I, Ossewaarde-van Norel J, van Leeuwen R, Risseeuw S, Leftheriotis G, Scholl HPN, Feltgen N, Holz FG, Pfau M. Pseudoxanthoma elasticum - Genetics, pathophysiology, and clinical presentation. Prog Retin Eye Res 2024; 102:101274. [PMID: 38815804 DOI: 10.1016/j.preteyeres.2024.101274] [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: 02/04/2024] [Revised: 05/17/2024] [Accepted: 05/20/2024] [Indexed: 06/01/2024]
Abstract
Pseudoxanthoma elasticum (PXE) is an autosomal-recessively inherited multisystem disease. Mutations in the ABCC6-gene are causative, coding for a transmembrane transporter mainly expressed in hepatocytes, which promotes the efflux of adenosine triphosphate (ATP). This results in low levels of plasma inorganic pyrophosphate (PPi), a critical anti-mineralization factor. The clinical phenotype of PXE is characterized by the effects of elastic fiber calcification in the skin, the cardiovascular system, and the eyes. In the eyes, calcification of Bruch's membrane results in clinically visible lesions, including peau d'orange, angioid streaks, and comet tail lesions. Frequently, patients must be treated for secondary macular neovascularization. No effective therapy is available for treating the cause of PXE, but several promising approaches are emerging. Finding appropriate outcome measures remains a significant challenge for clinical trials in this slowly progressive disease. This review article provides an in-depth summary of the current understanding of PXE and its multi-systemic manifestations. The article offers a detailed overview of the ocular manifestations, including their morphological and functional consequences, as well as potential complications. Lastly, previous and future clinical trials of causative treatments for PXE are discussed.
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Affiliation(s)
- Kristina Pfau
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland; Department of Ophthalmology, University Hospital Bonn, Bonn, Germany.
| | - Imre Lengyel
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom; Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | | | - Redmer van Leeuwen
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Sara Risseeuw
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Georges Leftheriotis
- University Hospital Nice, Vascular Physiology and Medicine Unit, 06000, Nice, France
| | | | - Nicolas Feltgen
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland
| | - Frank G Holz
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
| | - Maximilian Pfau
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland; Institute of Molecular and Clinical Ophthalmology Basel, Basel, Basel-Stadt, Switzerland
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Foster BL, Boyce AM, Millán JL, Kramer K, Ferreira CR, Somerman MJ, Wright JT. Inherited phosphate and pyrophosphate disorders: New insights and novel therapies changing the oral health landscape. J Am Dent Assoc 2024:S0002-8177(24)00370-2. [PMID: 39127957 DOI: 10.1016/j.adaj.2024.05.016] [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: 03/25/2024] [Revised: 05/20/2024] [Accepted: 05/28/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND Mineral metabolism is critical for proper development of hard tissues of the skeleton and dentition. The dentoalveolar complex includes the following 4 mineralized tissues: enamel, dentin, cementum, and alveolar bone. Developmental processes of these tissues are affected by inherited disorders that disrupt phosphate and pyrophosphate homeostasis, although manifestations are distinct from those in the skeleton. TYPES OF STUDIES REVIEWED The authors discuss original data from experiments and comparative analyses and review articles describing effects of inherited phosphate and pyrophosphate disorders on dental tissues. A particular emphasis is placed on how new therapeutic approaches for these conditions may affect oral health and dental treatments of affected patients. RESULTS Disorders of phosphate and pyrophosphate metabolism can lead to reduced mineralization (hypomineralization) or inappropriate (ectopic) calcification of soft tissues. Disruptions in phosphate levels in X-linked hypophosphatemia and hyperphosphatemic familial tumoral calcinosis and disruptions in pyrophosphate levels in hypophosphatasia and generalized arterial calcification of infancy contribute to dental mineralization defects. Traditionally, there have been few options to ameliorate dental health problems arising from these conditions. New antibody and enzyme replacement therapies bring possibilities to improve oral health in affected patients. PRACTICAL IMPLICATIONS Research over the past 2 decades has exponentially expanded the understanding of mineral metabolism, and has led to novel treatments for mineralization disorders. Newly implemented and emerging therapeutic strategies affect the dentoalveolar complex and interact with aspects of oral health care that must be considered for dental treatment, clinical trial design, and coordination of multidisciplinary care teams.
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Tchernychev B, Nitschke Y, Chu D, Sullivan C, Flaman L, O’Brien K, Howe J, Cheng Z, Thompson D, Ortiz D, Rutsch F, Sabbagh Y. Inhibition of Vascular Smooth Muscle Cell Proliferation by ENPP1: The Role of CD73 and the Adenosine Signaling Axis. Cells 2024; 13:1128. [PMID: 38994980 PMCID: PMC11240470 DOI: 10.3390/cells13131128] [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: 04/24/2024] [Revised: 06/24/2024] [Accepted: 06/28/2024] [Indexed: 07/13/2024] Open
Abstract
The Ectonucleotide Pyrophosphatase/Phosphodiesterase 1 (ENPP1) ectoenzyme regulates vascular intimal proliferation and mineralization of bone and soft tissues. ENPP1 variants cause Generalized Arterial Calcification of Infancy (GACI), a rare genetic disorder characterized by ectopic calcification, intimal proliferation, and stenosis of large- and medium-sized arteries. ENPP1 hydrolyzes extracellular ATP to pyrophosphate (PPi) and AMP. AMP is the precursor of adenosine, which has been implicated in the control of neointimal formation. Herein, we demonstrate that an ENPP1-Fc recombinant therapeutic inhibits proliferation of vascular smooth muscle cells (VSMCs) in vitro and in vivo. Addition of ENPP1 and ATP to cultured VSMCs generated AMP, which was metabolized to adenosine. It also significantly decreased cell proliferation. AMP or adenosine alone inhibited VSMC growth. Inhibition of ecto-5'-nucleotidase CD73 decreased adenosine accumulation and suppressed the anti-proliferative effects of ENPP1/ATP. Addition of AMP increased cAMP synthesis and phosphorylation of VASP at Ser157. This AMP-mediated cAMP increase was abrogated by CD73 inhibitors or by A2aR and A2bR antagonists. Ligation of the carotid artery promoted neointimal hyperplasia in wild-type mice, which was exacerbated in ENPP1-deficient ttw/ttw mice. Prophylactic or therapeutic treatments with ENPP1 significantly reduced intimal hyperplasia not only in ttw/ttw but also in wild-type mice. These findings provide the first insight into the mechanism of the anti-proliferative effect of ENPP1 and broaden its potential therapeutic applications beyond enzyme replacement therapy.
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Affiliation(s)
- Boris Tchernychev
- Research and Development, Inozyme Pharma, 321 Summer St, Suite 400, Boston, MA 02201, USA; (B.T.); (D.C.); (C.S.); (L.F.); (K.O.); (J.H.); (Z.C.); (D.T.); (D.O.); (Y.S.)
| | - Yvonne Nitschke
- Department of General Pediatrics, Münster University Children’s Hospital, 48149 Münster, Germany;
- INTEC Network of Ectopic Calcification, Center for Medical Genetics Ghent, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Di Chu
- Research and Development, Inozyme Pharma, 321 Summer St, Suite 400, Boston, MA 02201, USA; (B.T.); (D.C.); (C.S.); (L.F.); (K.O.); (J.H.); (Z.C.); (D.T.); (D.O.); (Y.S.)
| | - Caitlin Sullivan
- Research and Development, Inozyme Pharma, 321 Summer St, Suite 400, Boston, MA 02201, USA; (B.T.); (D.C.); (C.S.); (L.F.); (K.O.); (J.H.); (Z.C.); (D.T.); (D.O.); (Y.S.)
| | - Lisa Flaman
- Research and Development, Inozyme Pharma, 321 Summer St, Suite 400, Boston, MA 02201, USA; (B.T.); (D.C.); (C.S.); (L.F.); (K.O.); (J.H.); (Z.C.); (D.T.); (D.O.); (Y.S.)
| | - Kevin O’Brien
- Research and Development, Inozyme Pharma, 321 Summer St, Suite 400, Boston, MA 02201, USA; (B.T.); (D.C.); (C.S.); (L.F.); (K.O.); (J.H.); (Z.C.); (D.T.); (D.O.); (Y.S.)
| | - Jennifer Howe
- Research and Development, Inozyme Pharma, 321 Summer St, Suite 400, Boston, MA 02201, USA; (B.T.); (D.C.); (C.S.); (L.F.); (K.O.); (J.H.); (Z.C.); (D.T.); (D.O.); (Y.S.)
| | - Zhiliang Cheng
- Research and Development, Inozyme Pharma, 321 Summer St, Suite 400, Boston, MA 02201, USA; (B.T.); (D.C.); (C.S.); (L.F.); (K.O.); (J.H.); (Z.C.); (D.T.); (D.O.); (Y.S.)
| | - David Thompson
- Research and Development, Inozyme Pharma, 321 Summer St, Suite 400, Boston, MA 02201, USA; (B.T.); (D.C.); (C.S.); (L.F.); (K.O.); (J.H.); (Z.C.); (D.T.); (D.O.); (Y.S.)
| | - Daniel Ortiz
- Research and Development, Inozyme Pharma, 321 Summer St, Suite 400, Boston, MA 02201, USA; (B.T.); (D.C.); (C.S.); (L.F.); (K.O.); (J.H.); (Z.C.); (D.T.); (D.O.); (Y.S.)
| | - Frank Rutsch
- Department of General Pediatrics, Münster University Children’s Hospital, 48149 Münster, Germany;
- INTEC Network of Ectopic Calcification, Center for Medical Genetics Ghent, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Yves Sabbagh
- Research and Development, Inozyme Pharma, 321 Summer St, Suite 400, Boston, MA 02201, USA; (B.T.); (D.C.); (C.S.); (L.F.); (K.O.); (J.H.); (Z.C.); (D.T.); (D.O.); (Y.S.)
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4
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Parolin M, Partigiani NB, Benetti E, Longo G, Vidal E. The use of burosumab to treat autosomal-recessive hypophosphatemic rickets type 2: rationale and a first clinical experience. J Nephrol 2024; 37:1371-1374. [PMID: 38308754 DOI: 10.1007/s40620-023-01884-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/26/2023] [Indexed: 02/05/2024]
Affiliation(s)
- Mattia Parolin
- Pediatric Nephrology, Dialysis and Transplant Unit, Department for Woman's and Child's Health, University-Hospital of Padova, Via Giustiniani 3, 35128, Padua, Italy
| | - Nicola Bertazza Partigiani
- Pediatric Nephrology, Dialysis and Transplant Unit, Department for Woman's and Child's Health, University-Hospital of Padova, Via Giustiniani 3, 35128, Padua, Italy
| | - Elisa Benetti
- Pediatric Nephrology, Dialysis and Transplant Unit, Department for Woman's and Child's Health, University-Hospital of Padova, Via Giustiniani 3, 35128, Padua, Italy
| | - Germana Longo
- Pediatric Nephrology, Dialysis and Transplant Unit, Department for Woman's and Child's Health, University-Hospital of Padova, Via Giustiniani 3, 35128, Padua, Italy
| | - Enrico Vidal
- Pediatric Nephrology, Dialysis and Transplant Unit, Department for Woman's and Child's Health, University-Hospital of Padova, Via Giustiniani 3, 35128, Padua, Italy.
- Department of Medicine (DMED), University of Udine, Udine, Italy.
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Ferrante EA, Cudrici CD, Rashidi M, Fu YP, Huffstutler R, Carney K, Chen MY, St Hilaire C, Smith K, Bagheri H, Katz JD, Ferreira CR, Gahl WA, Boehm M, Brofferio A. Pilot study to evaluate the safety and effectiveness of etidronate treatment for arterial calcification due to deficiency of CD73 (ACDC). Vasc Med 2024; 29:245-255. [PMID: 38568107 DOI: 10.1177/1358863x241235669] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
BACKGROUND Arterial calcification due to deficiency of CD73 (ACDC; OMIM 211800) is a rare genetic disease resulting in calcium deposits in arteries and small joints causing claudication, resting pain, severe joint pain, and deformities. Currently, there are no standard treatments for ACDC. Our previous work identified etidronate as a potential targeted ACDC treatment, using in vitro and in vivo disease models with patient-derived cells. In this study, we test the safety and effectiveness of etidronate in attenuating the progression of lower-extremity arterial calcification and vascular blood flow based on the computed tomography (CT) calcium score and ankle-brachial index (ABI). METHODS Seven adult patients with a confirmed genetic diagnosis of ACDC were enrolled in an open-label, nonrandomized, single-arm pilot study for etidronate treatment. They took etidronate daily for 14 days every 3 months and were examined at the NIH Clinical Center bi-annually for 3 years. They received a baseline evaluation as well as yearly follow up after treatment. Study visits included imaging studies, exercise tolerance tests with ABIs, clinical blood and urine testing, and full dental exams. RESULTS Etidronate treatment appeared to have slowed the progression of further vascular calcification in lower extremities as measured by CT but did not have an effect in reversing vascular and/or periarticular joint calcifications in our small ACDC cohort. CONCLUSIONS Etidronate was found to be safe and well tolerated by our patients and, despite the small sample size, appeared to show an effect in slowing the progression of calcification in our ACDC patient cohort.(ClinicalTrials.gov Identifier NCT01585402).
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Affiliation(s)
- Elisa A Ferrante
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Cornelia D Cudrici
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mahmood Rashidi
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Yi-Ping Fu
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rebecca Huffstutler
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Katherine Carney
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Marcus Y Chen
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Cynthia St Hilaire
- Departments of Medicine and Bioengineering, Vascular Medicine Institute, University of Pittsburg, PA, USA
| | - Kevin Smith
- Clinical Center Nursing Department, Hatfield Clinical Center at the National Institutes of Health, Bethesda, MD, USA
| | - Hadi Bagheri
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - James D Katz
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Carlos R Ferreira
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - William A Gahl
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Manfred Boehm
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Alessandra Brofferio
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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6
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Baroncelli GI, Comberiati P, Aversa T, Baronio F, Cassio A, Chiarito M, Cosci o di Coscio M, De Sanctis L, Di Iorgi N, Faienza MF, Fintini D, Franceschi R, Kalapurackal M, Longhi S, Mariani M, Pitea M, Secco A, Tessaris D, Vierucci F, Wasniewska M, Weber G, Mora S. Diagnosis, treatment, and management of rickets: a position statement from the Bone and Mineral Metabolism Group of the Italian Society of Pediatric Endocrinology and Diabetology. Front Endocrinol (Lausanne) 2024; 15:1383681. [PMID: 38706696 PMCID: PMC11066174 DOI: 10.3389/fendo.2024.1383681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/03/2024] [Indexed: 05/07/2024] Open
Abstract
Rickets results from impaired mineralization of growing bone due to alterations in calcium and phosphate homeostasis. Clinical signs of rickets are related to the age of the patient, the duration of the disease, and the underlying disorder. The most common signs of rickets are swelling of the wrists, knees or ankles, bowing of the legs (knock-knees, outward bowing, or both) and inability to walk. However, clinical features alone cannot differentiate between the various forms of rickets. Rickets includes a heterogeneous group of acquired and inherited diseases. Nutritional rickets is due to a deficiency of vitamin D, dietary calcium or phosphate. Mutations in genes responsible for vitamin D metabolism or function, the production or breakdown of fibroblast growth factor 23, renal phosphate regulation, or bone mineralization can lead to the hereditary form of rickets. This position paper reviews the relevant literature and presents the expertise of the Bone and Mineral Metabolism Group of the Italian Society of Pediatric Endocrinology and Diabetology (SIEDP). The aim of this document is to provide practical guidance to specialists and healthcare professionals on the main criteria for diagnosis, treatment, and management of patients with rickets. The various forms of rickets are discussed, and detailed references for the discussion of each form are provided. Algorithms to guide the diagnostic approach and recommendations to manage patients with rare forms of hereditary rickets are proposed.
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Affiliation(s)
- Giampiero I. Baroncelli
- Pediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
| | - Pasquale Comberiati
- Pediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
- Department of Clinical and Experimental Medicine, Section of Paediatrics, University of Pisa, Pisa, Italy
| | - Tommaso Aversa
- Department of Human Pathology of Adulthood and Childhood, University of Messina, Messina, Italy
- Pediatric Unit, University Hospital “G. Martino”, Messina, Italy
| | - Federico Baronio
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessandra Cassio
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Mariangela Chiarito
- Pediatric Unit, Department of Precision and Regenerative Medicine and Ionian Area, University “A. Moro” of Bari, Bari, Italy
| | - Mirna Cosci o di Coscio
- Pediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
| | - Luisa De Sanctis
- Division of Pediatric Endocrinology, Department of Public Health and Pediatrics, University of Turin, Regina Margherita Children’s Hospital, Turin, Italy
| | - Natascia Di Iorgi
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Maria Felicia Faienza
- Pediatric Unit, Department of Precision and Regenerative Medicine and Ionian Area, University “A. Moro” of Bari, Bari, Italy
| | - Danilo Fintini
- Endocrinology and Diabetology Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Roberto Franceschi
- Department of Pediatrics, Santa Chiara Hospital of Trento, APSS, Trento, Italy
| | - Mila Kalapurackal
- Department of Pediatrics, Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University (PMU), Bolzano, Italy
| | - Silvia Longhi
- Department of Pediatrics, Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University (PMU), Bolzano, Italy
| | - Michela Mariani
- Endocrinology and Diabetology Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Marco Pitea
- Pediatric Endocrinology Unit, Department of Pediatrics, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Andrea Secco
- Pediatric and Pediatric Emergency Unit, Children Hospital, Azienda Ospedaliera SS Antonio e Biagio e C. Arrigo, Alessandria, Italy
| | - Daniele Tessaris
- Division of Pediatric Endocrinology, Department of Public Health and Pediatrics, University of Turin, Regina Margherita Children’s Hospital, Turin, Italy
| | | | - Malgorzata Wasniewska
- Department of Human Pathology of Adulthood and Childhood, University of Messina, Messina, Italy
| | - Giovanna Weber
- Pediatric Endocrinology Unit, Department of Pediatrics, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Stefano Mora
- Laboratory of Pediatric Endocrinology, Department of Pediatrics, IRCCS Ospedale San Raffaele, Milan, Italy
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Liu T, Wang W, Liu Z, Pei G, Wang C, Jiang Y, Pang C. A previously healthy 3-year-old female with hypertension, proteinuria, and hypercalciuria. Pediatr Nephrol 2024; 39:1301-1313. [PMID: 38165475 PMCID: PMC10899356 DOI: 10.1007/s00467-023-06230-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 01/03/2024]
Abstract
A 3-year-old female patient with no significant medical history presented to her pediatrician with foamy urine. Initial testing revealed moderate proteinuria on qualitative testing, although she was incidentally noted to have severe hypertension (240/200 mmHg). Physical examination of the carotid and femoral areas revealed significant systolic vascular murmurs. Labs showed elevated serum creatinine, hypokalemia, metabolic alkalosis, elevated renin and aldosterone and hypercalciuria. Echocardiography identified ventricular hypertrophy. Computed tomography (CT) of the abdomen and magnetic resonance angiography of the head showed multiple tortuous or interrupted arteries and multiple calcifications in the renal sinus area. B-mode ultrasonography suggested thickening of the carotid and femoral artery walls, with numerous spotted calcifications. Genetic testing revealed that ABCC6 had a complex heterozygous mutation (exon 24: c.3340C > T and intron 30: c.4404-1G > A). Our panel of experts reviewed the evaluation of this patient with hypertension, proteinuria, hypercalciuria, and vascular abnormalities as well as the diagnosis and appropriate management of a rare disease.
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Affiliation(s)
- Tao Liu
- Department of Nephrology, Tianjin Children's Hospital (Children's Hospital, Tianjin University), Tianjin Key Laboratory of Birth Defects for Prevention and Treatment, 238 Longyan Road, Beichen District, Tianjin, 300134, China
| | - Wenhong Wang
- Department of Nephrology, Tianjin Children's Hospital (Children's Hospital, Tianjin University), Tianjin Key Laboratory of Birth Defects for Prevention and Treatment, 238 Longyan Road, Beichen District, Tianjin, 300134, China.
| | - Zhufeng Liu
- Department of Nephrology, Tianjin Children's Hospital (Children's Hospital, Tianjin University), Tianjin Key Laboratory of Birth Defects for Prevention and Treatment, 238 Longyan Road, Beichen District, Tianjin, 300134, China
| | - Guanghua Pei
- Ultrasonography Lab, Tianjin Children's Hospital (Children's Hospital, Tianjin University), Tianjin Key Laboratory of Birth Defects for Prevention and Treatment, Tianjin, China
| | - Chunxiang Wang
- Department of Imaging, Tianjin Children's Hospital (Children's Hospital, Tianjin University), Tianjin Key Laboratory of Birth Defects for Prevention and Treatment, Tianjin, China
| | - Ying Jiang
- Department of Nephrology, Tianjin Children's Hospital (Children's Hospital, Tianjin University), Tianjin Key Laboratory of Birth Defects for Prevention and Treatment, 238 Longyan Road, Beichen District, Tianjin, 300134, China
| | - Chuyue Pang
- Department of Nephrology, Tianjin Children's Hospital (Children's Hospital, Tianjin University), Tianjin Key Laboratory of Birth Defects for Prevention and Treatment, 238 Longyan Road, Beichen District, Tianjin, 300134, China
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8
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Gefen AM, Zaritsky JJ. Review of childhood genetic nephrolithiasis and nephrocalcinosis. Front Genet 2024; 15:1381174. [PMID: 38606357 PMCID: PMC11007102 DOI: 10.3389/fgene.2024.1381174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 03/04/2024] [Indexed: 04/13/2024] Open
Abstract
Nephrolithiasis (NL) is a common condition worldwide. The incidence of NL and nephrocalcinosis (NC) has been increasing, along with their associated morbidity and economic burden. The etiology of NL and NC is multifactorial and includes both environmental components and genetic components, with multiple studies showing high heritability. Causative gene variants have been detected in up to 32% of children with NL and NC. Children with NL and NC are genotypically heterogenous, but often phenotypically relatively homogenous, and there are subsequently little data on the predictors of genetic childhood NL and NC. Most genetic diseases associated with NL and NC are secondary to hypercalciuria, including those secondary to hypercalcemia, renal phosphate wasting, renal magnesium wasting, distal renal tubular acidosis (RTA), proximal tubulopathies, mixed or variable tubulopathies, Bartter syndrome, hyperaldosteronism and pseudohyperaldosteronism, and hyperparathyroidism and hypoparathyroidism. The remaining minority of genetic diseases associated with NL and NC are secondary to hyperoxaluria, cystinuria, hyperuricosuria, xanthinuria, other metabolic disorders, and multifactorial etiologies. Genome-wide association studies (GWAS) in adults have identified multiple polygenic traits associated with NL and NC, often involving genes that are involved in calcium, phosphorus, magnesium, and vitamin D homeostasis. Compared to adults, there is a relative paucity of studies in children with NL and NC. This review aims to focus on the genetic component of NL and NC in children.
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Affiliation(s)
- Ashley M. Gefen
- Phoenix Children’s Hospital, Department of Pediatrics, Division of Nephrology, Phoenix, AZ, United States
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9
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Dursun F, Turan İ, Bitkin EÇ, Bayramoğlu E, Çayır A, Erdeve ŞS, Çakır EDP, Çamtosun E, Dilek SO, Kırmızıbekmez H, Eser M, Türkyılmaz A, Karagüzel G. Natural history of ENPP1 deficiency: Nationwide Turkish Cohort Study of autosomal-recessive hypophosphataemic rickets type 2. Clin Endocrinol (Oxf) 2024. [PMID: 38324408 DOI: 10.1111/cen.15028] [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: 09/12/2023] [Revised: 12/09/2023] [Accepted: 01/24/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE Autosomal-recessive hypophosphataemic rickets type 2 (ARHR2) is a rare disease that is reported in survivors of generalized arterial calcification of infancy (GACI). DESIGN, PATIENTS AND MEASUREMENT The objective of this study was to characterize a multicenter paediatric cohort with ARHR2 due to ectonucleotide pyrophosphatase/phosphodiesterase family member 1 (ENPP1) deficiency and with a diagnosis of GACI or GACI-related findings. The clinical, biochemical and genetic characteristics of the patients were retrospectively retrieved. RESULTS We identified 18 patients from 13 families diagnosed with ARHR2. Fifteen of the patients had an ENPP1 variation confirmed with genetic analyses, and three were siblings of one of these patients, who had clinically diagnosed hypophosphataemic rickets (HRs) with the same presentation. From nine centres, 18 patients, of whom 12 (66.7%) were females, were included in the study. The mean age at diagnosis was 4.2 ± 2.2 (1.6-9) years. The most frequently reported clinical findings on admission were limb deformities (66.6%) and short stature (44.4%). At diagnosis, the mean height SD was -2.2 ± 1.3. Five of the patients were diagnosed with GACI in the neonatal period and treated with bisphosphonates. Other patients were initially diagnosed with ARHR2, but after the detection of a biallelic variant in the ENPP1 gene, it was understood that they previously had clinical findings associated with GACI. Three patients had hearing loss, and two had cervical fusion. After the treatment of HRs, one patient developed calcification, and one developed intimal proliferation. CONCLUSION ARHR2 represents one manifestation of ENPP1 deficiency that usually manifests later in life than GACI. The history of calcifications or comorbidities that might be associated with GACI will facilitate the diagnosis in patients with ARHR2, and patients receiving calcitriol and phosphate medication should be carefully monitored for signs of calcification or intimal proliferation.
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Affiliation(s)
- Fatma Dursun
- Department of Pediatric Endocrinology, SBU Umraniye Training and Research Hospital, University of Health Science, Istanbul, Türkiye
| | - İhsan Turan
- Department of Pediatric Endocrinology, Faculty of Medicine, Cukurova University, Adana, Türkiye
| | - Eda Çelebi Bitkin
- Department of Pediatric Endocrinology, Bakırkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Türkiye
| | - Elvan Bayramoğlu
- Department of Pediatric Endocrinology, Cerrahpaşa Faculty of Medicine, Istanbul University, İstanbul, Türkiye
| | - Atilla Çayır
- Department of Pediatric Endocrinology and Diabetes, Erzurum Education and Research Hospital, University of Health Science, Erzurum, Türkiye
| | - Şenay Savaş Erdeve
- Department of Pediatric Endocrinology, Ankara Etlik City Hospital, University of Health Science, Ankara, Türkiye
| | - Esra Deniz Papatya Çakır
- Department of Pediatric Endocrinology, Bakırkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Türkiye
| | - Emine Çamtosun
- Department of Pediatric Endocrinology, Faculty of Medicine, Inönü University, Malatya, Türkiye
| | - Semine Ozdemir Dilek
- Department of Pediatric Endocrinology, Adana City Training and Research Hospital, University of Health Science, Adana, Türkiye
| | - Heves Kırmızıbekmez
- Department of Pediatric Endocrinology, SBU Umraniye Training and Research Hospital, University of Health Science, Istanbul, Türkiye
| | - Metin Eser
- Department of Medical Genetic, Umraniye Training and Research Hospital, Istanbul, Türkiye
| | - Ayberk Türkyılmaz
- Department of Medical Genetic, Faculty of Medicine, Karadeniz Technical University, Trabzon, Türkiye
| | - Gülay Karagüzel
- Department of Pediatric Endocrinology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Türkiye
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10
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Ferreira CR, Carpenter TO, Braddock DT. ENPP1 in Blood and Bone: Skeletal and Soft Tissue Diseases Induced by ENPP1 Deficiency. ANNUAL REVIEW OF PATHOLOGY 2024; 19:507-540. [PMID: 37871131 PMCID: PMC11062289 DOI: 10.1146/annurev-pathmechdis-051222-121126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
The enzyme ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) codes for a type 2 transmembrane glycoprotein that hydrolyzes extracellular ATP to generate pyrophosphate (PPi) and adenosine monophosphate, thereby contributing to downstream purinergic signaling pathways. The clinical phenotypes induced by ENPP1 deficiency are seemingly contradictory and include early-onset osteoporosis in middle-aged adults and life-threatening vascular calcifications in the large arteries of infants with generalized arterial calcification of infancy. The progressive overmineralization of soft tissue and concurrent undermineralization of skeleton also occur in the general medical population, where it is referred to as paradoxical mineralization to highlight the confusing pathophysiology. This review summarizes the clinical presentation and pathophysiology of paradoxical mineralization unveiled by ENPP1 deficiency and the bench-to-bedside development of a novel ENPP1 biologics designed to treat mineralization disorders in the rare disease and general medical population.
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Affiliation(s)
- Carlos R Ferreira
- Metabolic Medicine Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Thomas O Carpenter
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Demetrios T Braddock
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA;
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11
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Novais EJ, Narayanan R, Canseco JA, van de Wetering K, Kepler CK, Hilibrand AS, Vaccaro AR, Risbud MV. A new perspective on intervertebral disc calcification-from bench to bedside. Bone Res 2024; 12:3. [PMID: 38253615 PMCID: PMC10803356 DOI: 10.1038/s41413-023-00307-3] [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: 10/15/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 01/24/2024] Open
Abstract
Disc degeneration primarily contributes to chronic low back and neck pain. Consequently, there is an urgent need to understand the spectrum of disc degeneration phenotypes such as fibrosis, ectopic calcification, herniation, or mixed phenotypes. Amongst these phenotypes, disc calcification is the least studied. Ectopic calcification, by definition, is the pathological mineralization of soft tissues, widely studied in the context of conditions that afflict vasculature, skin, and cartilage. Clinically, disc calcification is associated with poor surgical outcomes and back pain refractory to conservative treatment. It is frequently seen as a consequence of disc aging and progressive degeneration but exhibits unique molecular and morphological characteristics: hypertrophic chondrocyte-like cell differentiation; TNAP, ENPP1, and ANK upregulation; cell death; altered Pi and PPi homeostasis; and local inflammation. Recent studies in mouse models have provided a better understanding of the mechanisms underlying this phenotype. It is essential to recognize that the presentation and nature of mineralization differ between AF, NP, and EP compartments. Moreover, the combination of anatomic location, genetics, and environmental stressors, such as aging or trauma, govern the predisposition to calcification. Lastly, the systemic regulation of calcium and Pi metabolism is less important than the local activity of PPi modulated by the ANK-ENPP1 axis, along with disc cell death and differentiation status. While there is limited understanding of this phenotype, understanding the molecular pathways governing local intervertebral disc calcification may lead to developing disease-modifying drugs and better clinical management of degeneration-related pathologies.
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Affiliation(s)
- Emanuel J Novais
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Unidade Local de Saúde do Litoral Alentejano, Orthopedic Department, Santiago do Cacém, Portugal
| | - Rajkishen Narayanan
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Koen van de Wetering
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alan S Hilibrand
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Makarand V Risbud
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
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12
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Yao R, Yang F, Zhang Q, Yu T, Yu Y, Chang G, Wang X. Clinical and Molecular Characterization of a Patient with Generalized Arterial Calcification of Infancy Caused by Rare ABCC6 Mutation. J Pers Med 2023; 14:54. [PMID: 38248755 PMCID: PMC10817667 DOI: 10.3390/jpm14010054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/19/2023] [Accepted: 12/25/2023] [Indexed: 01/23/2024] Open
Abstract
Generalized arterial calcification of infancy (GACI) is a rare autosomal-recessive disease characterized by extensive arterial calcification in infancy, with clinical manifestations such as arterial stenoses and heart failure. The ENPP1 inactivation mutation has been identified as a potential defect in most of the cases of GACI, while mutations in ABCC6 are demonstrated in patients who are genotyped as pseudoxanthoma elasticum and only limited cases of GACI are reported. Whole-exome sequencing was applied for the detection of pathogenic variants. Copy-number variants of pathogenic genes were also evaluated through a bioinformatic process and were further validated by real-time quantitative PCR. In this report, we described the clinical information and treatment of a patient with extensive arterial calcification. We have identified the underlying cause as biallelic mutations in ABCC6 (NM_00117: exon30, c.4223_4227dupAGCTC p.(Leu1410Serfs*56)) and a unique exonic deletion that spans from the first to the fourth exons of ABCC6 (chr16:16313388-16330869)). This discovery was made by utilizing a combined genetic testing approach. With the review of previously reported GACI patients with ABCC6 mutation, our work contributed to enriching the mutation spectrum of GACI and providing further information on this rare form of inherited disorder.
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Affiliation(s)
- Ruen Yao
- Department of Medical Genetics and Antenatal Diagnostic Center, Hainan Branch, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Sanya 572022, China; (R.Y.)
- Department of Medical Genetics and Molecular Diagnostic Laboratory, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Fan Yang
- Clinical Research Ward, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China; (F.Y.)
| | - Qianwen Zhang
- Department of Endocrinology and Metabolism, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Tingting Yu
- Department of Medical Genetics and Molecular Diagnostic Laboratory, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Ying Yu
- Department of Medical Genetics and Antenatal Diagnostic Center, Hainan Branch, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Sanya 572022, China; (R.Y.)
| | - Guoying Chang
- Clinical Research Ward, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China; (F.Y.)
- Department of Endocrinology and Metabolism, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Xiumin Wang
- Clinical Research Ward, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China; (F.Y.)
- Department of Endocrinology and Metabolism, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
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13
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Armstrong V, Backes CH, Rivera BK, Reo RM, Chaudhari BP, Wethall A, Truxal KV. An Infant with Thickened and Hyperechoic Main Pulmonary Artery. Neoreviews 2023; 24:e814-e818. [PMID: 38036445 DOI: 10.1542/neo.24-12-e814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Affiliation(s)
- Veronica Armstrong
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
- Ohio Perinatal Research Network (OPRN), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Carl H Backes
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
- Ohio Perinatal Research Network (OPRN), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
- The Heart Center, Nationwide Children's Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
| | - Brian K Rivera
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
- Ohio Perinatal Research Network (OPRN), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | | | - Bimal P Chaudhari
- Ohio Perinatal Research Network (OPRN), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
- Division of Genetic and Genomic Medicine, Nationwide Children's Hospital, Columbus, OH
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Ashley Wethall
- Ohio Perinatal Research Network (OPRN), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
| | - Kristen V Truxal
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Division of Genetic and Genomic Medicine, Nationwide Children's Hospital, Columbus, OH
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH
- Center for Gene Therapy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
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14
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Zhu Z, He Z, Tang T, Wang F, Chen H, Zhou J, Lin C, Chen G, Wang J, Li J, Liu X, Zhou Z, Liu S. Effect of mechanical stimulation on tissue heterotopic ossification: an in vivo experimental study. Front Physiol 2023; 14:1225898. [PMID: 37900947 PMCID: PMC10600381 DOI: 10.3389/fphys.2023.1225898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/22/2023] [Indexed: 10/31/2023] Open
Abstract
Background: Heterotopic ossification of tendons and ligaments (HOTL) is a common clinical condition characterized by the absence of discernible features and a lack of effective treatment. In vitro experiments have demonstrated that mechanical stimulation can induce cell differentiation toward osteogenesis, thereby promoting heterotopic ossification. Currently, there are few experimental designs aimed at inducing ligament stretching in mice, and the mechanism of heterotopic ossification may not entirely mirror that observed in clinical cases. Therefore, there is an urgent imperative to develop a novel and feasible animal model. Methods: In this study, all the Enpp1 gene deficiency mice (a mouse model with heterotopic ossification of multiple ligaments) were divided into three groups: the control group, the spinal brake group, and the hyperactive group (treadmill training group). An external spinal fixation device was designed to restrict mice's spinal flexion and extension at 6 weeks of age. The brace was adjusted weekly according to the changes in the size of the mice. Additionally, treadmill training was used to increase activity in the spinal ligaments and Achilles tendons of the mice. Micro-CT scanning and HE staining were performed at 12, 20, and 28 W to evaluate the degree of ossification in the spinal ligament and Achilles tendon. What's more, As one of the mechanical stimulation transduction signals, YAP plays a crucial role in promoting osteogenic differentiation of cells. Immunofluorescence was utilized to assess YAP expression levels for the purpose of determining the extent of mechanical stimulation in tissues. Results: Our findings showed that a few ossification lesions were detected behind the vertebral space of mice at 8 weeks of age. Spinal immobilization effectively restricts the flexion and extension of cervical and thoracic vertebrae in mice, delaying spinal ligament ossification and reducing chronic secondary spinal cord injury. Running exercises not only enhance the ossification area of the posterior longitudinal ligament (PLL) and Achilles tendons but also exacerbate secondary spinal cord injury. Further immunofluorescence results revealed a notable increase in YAP expression levels in tissues with severe ossification, suggesting that these tissues may be subjected to higher mechanical stimulation. Conclusion: Mechanical stimulation plays a pivotal role in the process of heterotopic ossification in tissues. Our study provided valid animal models to further explore the pathological mechanism of mechanical stimulation in HOTL development.
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Affiliation(s)
- Zhengya Zhu
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopaedic Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
- Department of Orthopaedic Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhongyuan He
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopaedic Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
- Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, Department of Spinal Surgery, Orthopaedic Research Institute, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Tao Tang
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopaedic Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
- Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, Department of Spinal Surgery, Orthopaedic Research Institute, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Fuan Wang
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopaedic Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
- Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, Department of Spinal Surgery, Orthopaedic Research Institute, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hongkun Chen
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopaedic Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Jiaxiang Zhou
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chengkai Lin
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopaedic Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Guoliang Chen
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Jianmin Wang
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopaedic Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Jianfeng Li
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopaedic Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Xizhe Liu
- Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, Department of Spinal Surgery, Orthopaedic Research Institute, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhiyu Zhou
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopaedic Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
- Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, Department of Spinal Surgery, Orthopaedic Research Institute, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shaoyu Liu
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopaedic Surgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
- Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, Department of Spinal Surgery, Orthopaedic Research Institute, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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15
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Kato H, Braddock DT, Ito N. Genetics of Diffuse Idiopathic Skeletal Hyperostosis and Ossification of the Spinal Ligaments. Curr Osteoporos Rep 2023; 21:552-566. [PMID: 37530996 PMCID: PMC10543536 DOI: 10.1007/s11914-023-00814-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 08/03/2023]
Abstract
PURPOSE OF REVIEW The study aims to provide updated information on the genetic factors associated with the diagnoses 'Diffuse Idiopathic Skeletal Hyperostosis' (DISH), 'Ossification of the Posterior Longitudinal Ligament' (OPLL), and in patients with spinal ligament ossification. RECENT FINDINGS Recent studies have advanced our knowledge of genetic factors associated with DISH, OPLL, and other spinal ossification (ossification of the anterior longitudinal ligament [OALL] and the yellow ligament [OYL]). Several case studies of individuals afflicted with monogenic disorders, such as X-linked hypophosphatemia (XLH), demonstrate the strong association of fibroblast growth factor 23-related hypophosphatemia with OPLL, suggesting that pathogenic variants in PHEX, ENPP1, and DMP1 are associated with FGF23-phosphate wasting phenotype and strong genetic factors placing patients at risk for OPLL. Moreover, emerging evidence demonstrates that heterozygous and compound heterozygous ENPP1 pathogenic variants inducing 'Autosomal Recessive Hypophosphatemic Rickets Type 2' (ARHR2) also place patients at risk for DISH and OPLL, possibly due to the loss of inhibitory plasma pyrophosphate (PPi) which suppresses ectopic calcification and enthesis mineralization. Our findings emphasize the importance of genetic and plasma biomarker screening in the clinical evaluation of DISH and OPLL patients, with plasma PPi constituting an important new biomarker for the identification of DISH and OPLL patients whose disease course may be responsive to ENPP1 enzyme therapy, now in clinical trials for rare calcification disorders.
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Affiliation(s)
- Hajime Kato
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan.
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan.
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16
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Ralph D, Levine M, Millán JL, Uitto J, Li Q. Weighing the Evidence for the Roles of Plasma Versus Local Pyrophosphate in Ectopic Calcification Disorders. J Bone Miner Res 2023; 38:457-463. [PMID: 36807615 PMCID: PMC10365072 DOI: 10.1002/jbmr.4791] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/02/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023]
Abstract
Ectopic calcification is characterized by inappropriate deposition of calcium mineral in nonskeletal connective tissues and can cause significant morbidity and mortality, particularly when it affects the cardiovascular system. Identification of the metabolic and genetic determinants of ectopic calcification could help distinguish individuals at the greatest risk of developing these pathological calcifications and could guide development of medical interventions. Inorganic pyrophosphate (PPi ) has long been recognized as the most potent endogenous inhibitor of biomineralization. It has been intensively studied as both a marker and a potential therapeutic for ectopic calcification. Decreased extracellular concentrations of PPi have been proposed to be a unifying pathophysiological mechanism for disorders of ectopic calcification, both genetic and acquired. However, are reduced plasma concentrations of PPi a reliable predictor of ectopic calcification? This perspective article evaluates the literature in favor and against a pathophysiological role of plasma versus tissue PPi dysregulation as a determinant of, and as a biomarker for, ectopic calcification. © 2023 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Douglas Ralph
- Genetics, Genomics and Cancer Biology Ph.D. Program, Jefferson College of Life Sciences, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, PA, USA.,PXE International Center of Excellence in Research and Clinical Care, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael Levine
- Division of Endocrinology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - José Luis Millán
- Sanford Children's Health Research Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Jouni Uitto
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, PA, USA.,PXE International Center of Excellence in Research and Clinical Care, Thomas Jefferson University, Philadelphia, PA, USA
| | - Qiaoli Li
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, PA, USA.,PXE International Center of Excellence in Research and Clinical Care, Thomas Jefferson University, Philadelphia, PA, USA
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17
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Liu J, Song X, Zhang D, Jiang Y, Ma M, Qiu Z, Xia W, Chen Y. Case report: Multiple arterial stenoses induced by autosomal-recessive hypophosphatemic rickets type 2 associated with mutation of ENPP1: a case study. Front Cardiovasc Med 2023; 10:1126445. [PMID: 37153460 PMCID: PMC10155832 DOI: 10.3389/fcvm.2023.1126445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/28/2023] [Indexed: 05/09/2023] Open
Abstract
Ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1)-related multiple arterial stenoses is a rare clinical syndrome in which global arterial calcification begins in infancy, with a high probability of early mortality, and hypophosphatemic rickets develops later in childhood. The vascular status of an ENPP1-mutated patient when they enter the rickets phase has not been thoroughly explored. In this study, we presented a case of an adolescent with an ENPP1 mutation who complained of uncontrolled hypertension. Systematic radiography showed renal, carotid, cranial, and aortic stenoses as well as random calcification foci on arterial walls. The patient was incorrectly diagnosed with Takayasu's arteritis, and cortisol therapy had little effect on reducing the vascular stenosis. As a result, phosphate replacement, calcitriol substitution, and antihypertensive medication were prescribed, and the patient was discharged for further examination. This research presented the vascular alterations of an ENPP1-mutanted patient, and while there is less calcification, intimal thickening may be the primary cause of arterial stenosis.
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Affiliation(s)
- Jie Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xitao Song
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Daming Zhang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yan Jiang
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Mingsheng Ma
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhengqing Qiu
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Weibo Xia
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yuexin Chen
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Correspondence: Yuexin Chen
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Lu P, Chen J, Chen M, Wang L, Xiang D, Yin J, Yang S. Case report: A rare homozygous variation in the ENPP1 gene, presenting with generalized arterial calcification of infancy in a Chinese infant. Front Cardiovasc Med 2023; 10:1105381. [PMID: 36937905 PMCID: PMC10020691 DOI: 10.3389/fcvm.2023.1105381] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/17/2023] [Indexed: 03/06/2023] Open
Abstract
Generalized arterial calcification of infancy (GACI) is a rare genetic disease characterized by arterial calcifications or stenoses and hypertension. GACI is caused by mutations in the ENPP1 or ABCC6 genes, and it often causes intrauterine or early infancy death. Here, we report a case of rare GACI caused by a homozygous variation in ENPP1, in a Chinese infant initially presenting with hypertension. The proband was an 8-month-old boy with in utero tricuspid valve calcification, presenting with hypertension at birth. Enhanced computed tomography revealed extensive arterial calcification. Genetic testing identified a homozygous variation in ENPP1 (c.783C > G p.Y261X), which led to the diagnosis of GACI. This mutation has been reported in only three Chinese patients, which all initially presented with hypophosphatemic rickets rather than GACI. This case enriches the clinical and genetic spectrum of ENPP1 mutations and reminds us that GACI should be considered in an infant presenting with hypertension and extensive arterial calcification, and that genetic testing should be performed.
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Fãgãrãşan A, Gozar L, Ghiragosian SER, Murariu M, Pop M, Crauciuc A, Miclea D, Şuteu CC. Severe early-onset manifestations of generalized arterial calcification of infancy (mimicking severe coarctation of the aorta) with ABCC6 gene variant - Case report and literature review. Front Cardiovasc Med 2022; 9:1032519. [PMID: 36606277 PMCID: PMC9807665 DOI: 10.3389/fcvm.2022.1032519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/24/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Generalized arterial calcification of infancy (GACI) is a rare cause of infantile heart failure and systemic hypertension with a poor prognosis, characterized by extensive calcification and proliferation of the intimal layer of large and medium sized arteries. Case report We present the first case report of successful surgical treatment of severe aortic arch obstruction by calcified plaques mimicking severe coarctation of the aorta and the outcome (of bisphosphonate therapy) in a newborn with GACI. Furthermore, we report the identification of a variant in ATP Binding Cassette Subfamily C, Member 6 (ABCC6) gene, possibly associated with severe early-onset manifestations of GACI. Conclusion This case report highlights the importance of considering GACI in an infant with heart failure, systemic hypertension, and evidence of increased echogenicity of the arterial vessels. We noted the favorable outcome in improving the aortic calcification in our patient after surgical treatment and bisphosphonates therapy. Early diagnosis and treatment improve the long-term prognosis. A better understanding of this rare genetic disease could lead to new therapeutic strategies.
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Affiliation(s)
- Amalia Fãgãrãşan
- Clinic of Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, Târgu Mureş, Romania,Department of Pediatrics III, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania
| | - Liliana Gozar
- Clinic of Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, Târgu Mureş, Romania,Department of Pediatrics III, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania,*Correspondence: Liliana Gozar,
| | - Simina-Elena Rusu Ghiragosian
- Department of Pediatrics III, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania,Simina-Elena Rusu Ghiragosian,
| | - Mircea Murariu
- Clinic of Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, Târgu Mureş, Romania
| | - Marian Pop
- ME1 Department, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania,Department of Radiology, Emergency Institute for Cardiovascular Diseases and Heart Transplant, Târgu Mureş, Romania
| | - Andrei Crauciuc
- Clinic of Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, Târgu Mureş, Romania
| | - Diana Miclea
- Department of Medical Genetics, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Carmen Corina Şuteu
- Clinic of Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, Târgu Mureş, Romania
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Abstract
Hypophosphatemic rickets typically presents in infancy or early childhood with skeletal deformities and growth plate abnormalities. The most common causes are genetic (such as X-linked hypophosphatemia), and these typically will result in lifelong hypophosphatemia and osteomalacia. Knowledge of phosphate metabolism, including the effects of fibroblast growth factor 23 (FGF23) (an osteocyte produced hormone that downregulates renal phosphate reabsorption and 1,25-dihydroxyvitamin-D (1,25(OH)2D) production), is critical to determining the underlying genetic or acquired causes of hypophosphatemia and to facilitate appropriate treatment. Serum phosphorus should be measured in any child or adult with musculoskeletal complaints suggesting rickets or osteomalacia. Clinical evaluation incudes thorough history, physical examination, laboratory investigations, genetic analysis (especially in the absence of a guiding family history), and imaging to establish etiology and to monitor severity and treatment course. The treatment depends on the underlying cause, but often includes active forms of vitamin D combined with phosphate salts, or anti-FGF23 antibody treatment (burosumab) for X-linked hypophosphatemia. The purpose of this article is to explore the approach to evaluating hypophosphatemic rickets and its treatment options.
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Affiliation(s)
- Sarah A Ackah
- Department of Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Erik A Imel
- Department of Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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21
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Chunn LM, Bissonnette J, Heinrich SV, Mercurio SA, Kiel MJ, Rutsch F, Ferreira CR. Estimation of ENPP1 deficiency genetic prevalence using a comprehensive literature review and population databases. Orphanet J Rare Dis 2022; 17:421. [PMID: 36461014 PMCID: PMC9717445 DOI: 10.1186/s13023-022-02577-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/20/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND ENPP1 Deficiency-caused by biallelic variants in ENPP1-leads to widespread arterial calcification in early life (Generalized Arterial Calcification of Infancy, GACI) or hypophosphatemic rickets in later life (Autosomal Recessive Hypophosphatemic Rickets type 2, ARHR2). A prior study using the Exome Aggregation Consortium (ExAC)-a database of exomes obtained from approximately 60,000 individuals-estimated the genetic prevalence at approximately 1 in 200,000 pregnancies. METHODS We estimated the genetic prevalence of ENPP1 Deficiency by evaluating allele frequencies from a population database, assuming Hardy-Weinberg equilibrium. This estimate benefitted from a comprehensive literature review using Mastermind ( https://mastermind.genomenon.com/ ), which uncovered additional variants and supporting evidence, a larger population database with approximately 140,000 individuals, and improved interpretation of variants as per current clinical guidelines. RESULTS We estimate a genetic prevalence of approximately 1 in 64,000 pregnancies, thus more than tripling the prior estimate. In addition, the carrier frequency of ENPP1 variants was found to be highest in East Asian populations, albeit based on a small sample. CONCLUSION These results indicate that a significant number of patients with ENPP1 Deficiency remain undiagnosed. Efforts to increase disease awareness as well as expand genetic testing, particularly in non-European populations are warranted, especially now that clinical trials for enzyme replacement therapy, which proved successful in animal models, are underway.
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Affiliation(s)
| | | | | | | | | | - Frank Rutsch
- grid.16149.3b0000 0004 0551 4246Department of General Paediatrics, Muenster University Children’s Hospital, Münster, Germany
| | - Carlos R. Ferreira
- grid.280128.10000 0001 2233 9230Metabolic Medicine Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD USA
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22
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Mercurio SA, Chunn LM, Khursigara G, Nester C, Wray K, Botschen U, Kiel MJ, Rutsch F, Ferreira CR. ENPP1 deficiency: A clinical update on the relevance of individual variants using a locus-specific patient database. Hum Mutat 2022; 43:1673-1705. [PMID: 36150100 DOI: 10.1002/humu.24477] [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: 03/16/2022] [Revised: 09/16/2022] [Accepted: 09/21/2022] [Indexed: 01/24/2023]
Abstract
Loss-of-function variants in the ectonucleotide pyrophosphatase/phosphodiesterase family member 1 (ENPP1) cause ENPP1 Deficiency, a rare disorder characterized by pathological calcification, neointimal proliferation, and impaired bone mineralization. The consequence of ENPP1 Deficiency is a broad range of age dependent symptoms and morbidities including cardiovascular complications and 50% mortality in infants, autosomal recessive hypophosphatemic rickets type 2 (ARHR2) in children, and joint pain, osteomalacia and enthesopathies in adults. Recent research continues to add to the growing clinical presentation profile as well as expanding the role of ENPP1 itself. Here we review the current knowledge on the spectrum of clinical and genetic findings of ENPP1 Deficiency reported in patients diagnosed with GACI or ARHR2 phenotypes using a comprehensive database of known ENPP1 variants with associated clinical data. A total of 108 genotypes were identified from 154 patients. Of the 109 ENPP1 variants reviewed, 72.5% were demonstrably disease-causing, a threefold increase in pathogenic/likely pathogenic variants over other databases. There is substantial heterogeneity in disease severity, even among patients with the same variant. The approach to creating a continuously curated database of ENPP1 variants accessible to clinicians is necessary to increase the diagnostic yield of clinical genetic testing and accelerate diagnosis of ENPP1 Deficiency.
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Affiliation(s)
- Stephanie A Mercurio
- Department of Data Science, Curation Division, Genomenon Inc., Ann Arbor, Michigan, USA
| | - Lauren M Chunn
- Department of Scientific Communication and Strategy, Genomenon Inc., Ann Arbor, Michigan, USA
| | - Gus Khursigara
- Department of Medical Affairs, Inozyme Pharma, Boston, Massachusetts, USA
| | - Catherine Nester
- Department of Physician and Patient Strategies, Inozyme Pharma, Boston, Massachusetts, USA
| | - Kathleen Wray
- Department of Medical Affairs, Inozyme Pharma, Boston, Massachusetts, USA
| | - Ulrike Botschen
- Department of General Paediatrics, Muenster University Children's Hospital, Münster, Germany
| | - Mark J Kiel
- Department of Scientific Communication and Strategy, Genomenon Inc., Ann Arbor, Michigan, USA
| | - Frank Rutsch
- Department of General Paediatrics, Muenster University Children's Hospital, Münster, Germany
| | - Carlos R Ferreira
- Metabolic Medicine Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
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23
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Shore RM. Disorders of phosphate homeostasis in children, part 2: hypophosphatemic and hyperphosphatemic disorders. Pediatr Radiol 2022; 52:2290-2305. [PMID: 35536416 DOI: 10.1007/s00247-022-05373-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: 09/19/2021] [Revised: 02/07/2022] [Accepted: 04/01/2022] [Indexed: 11/25/2022]
Abstract
Phosphorus, predominantly in the form of inorganic phosphate PO4-3, has many essential physiological functions. In the skeleton, phosphate and calcium form the mineral component and phosphate is also essential in regulating function of skeletal cells. Considerable advances have been made in our understanding of phosphate homeostasis since the recognition of fibroblast growth factor-23 (FGF23) as a bone-derived phosphaturic hormone. This second part of a two-part review of disorders of phosphate homeostasis in children covers hypophosphatemic and hyperphosphatemic disorders that are of interest to the pediatric radiologist, emphasizing, but not limited to, those related to abnormalities of FGF23 signaling.
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Affiliation(s)
- Richard M Shore
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL, 60611, USA.
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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24
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Ramirez-Suarez KI, Cohen SA, Barrera CA, Levine MA, Goldberg DJ, Otero HJ. Longitudinal assessment of vascular calcification in generalized arterial calcification of infancy. Pediatr Radiol 2022; 52:2329-2341. [PMID: 35438330 PMCID: PMC10406615 DOI: 10.1007/s00247-022-05364-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 02/18/2022] [Accepted: 03/18/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Generalized arterial calcification of infancy (GACI), also known as idiopathic infantile arterial calcification, is a very uncommon genetic disorder characterized by calcifications and stenoses of large- and medium-size arteries that can lead to end-organ damage. OBJECTIVE To describe changes in imaging findings in 10 children with GACI at a single institution from 2010 to 2021. MATERIALS AND METHODS In this retrospective study we reviewed initial and follow-up body imaging in children with genetic confirmation of GACI at our hospital. All initial images were analyzed for the presence and distribution of arterial calcifications, stenoses and wall thickening/irregularity within the chest, abdomen and pelvis. We compared available follow-up studies to the initial imaging findings. We extracted clinical information including prenatal and postnatal treatment from the children's medical records. RESULTS We evaluated 10 children (five boys) with a diagnosis of GACI. Median age at first body imaging was 8 days (range: 1 day to 5 years). Six children were identified prenatally and four postnatally. Postnatal presentation included cardiac failure, seizures and hypertension. Images in newborns (n = 8) most commonly showed diffuse arterial calcifications (6/8; 75%), while stenoses were less common (2/8; 25%) during this period. Two children were diagnosed after the neonatal period - one in infancy and one during childhood. In total, half the children (5/10; 50%) had arterial stenoses - three cases visualized at first imaging and two identified on follow-up images during infancy. Stenoses had completely resolved in one child (1/5; 20%) at last follow-up. Eight children received prenatal or postnatal treatment or both. All children who received both prenatal and postnatal treatment (n = 4) had completely resolved calcifications at last follow-up. CONCLUSION Children with GACI might have characteristic vascular calcifications at birth that raise the suspicion of this disease. Arterial calcifications decrease or disappear spontaneously or after treatment, but arterial stenoses usually persist. Calcifications and arterial stenoses can be easily identified and followed with non-contrast CT and CT angiography.
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Affiliation(s)
- Karen I Ramirez-Suarez
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Sara A Cohen
- Department of Radiology at Weill Cornell Medicine, New York, NY, USA
| | - Christian A Barrera
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Michael A Levine
- Division of Endocrinology and Diabetes, Center for Bone Health, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David J Goldberg
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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25
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Disorders of phosphate homeostasis in children, part 1: primer on mineral ion homeostasis and the roles of phosphate in skeletal biology. Pediatr Radiol 2022; 52:2278-2289. [PMID: 35536415 DOI: 10.1007/s00247-022-05374-y] [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: 09/19/2021] [Revised: 01/22/2022] [Accepted: 04/01/2022] [Indexed: 10/18/2022]
Abstract
Phosphate has extensive physiological roles including energy metabolism, genetic function, signal transduction and membrane integrity. Regarding the skeleton, not only do phosphate and calcium form the mineral component of the skeleton, but phosphate is also essential in regulating function of skeletal cells. Although our understanding of phosphate homeostasis has lagged behind and remains less than that for calcium, considerable advances have been made since the recognition of fibroblast growth factor-23 (FGF23) as a bone-derived phosphaturic hormone that is a major regulator of phosphate homeostasis. In this two-part review of disorders of phosphate homeostasis in children, part 1 covers the basics of mineral ion homeostasis and the roles of phosphate in skeletal biology. Part 1 includes phosphate-related disorders of mineralization for which overall circulating mineral ion homeostasis remains normal. Part 2 covers hypophosphatemic and hyperphosphatemic disorders, emphasizing, but not limited to, those related to increased and decreased FGF23 signaling, respectively.
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26
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Zimmerman K, Li X, von Kroge S, Stabach P, Lester ER, Chu EY, Srivastava S, Somerman MJ, Tommasini SM, Busse B, Schinke T, Carpenter TO, Oheim R, Braddock DT. Catalysis-Independent ENPP1 Protein Signaling Regulates Mammalian Bone Mass. J Bone Miner Res 2022; 37:1733-1749. [PMID: 35773783 PMCID: PMC9709593 DOI: 10.1002/jbmr.4640] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 06/09/2022] [Accepted: 06/17/2022] [Indexed: 11/06/2022]
Abstract
Biallelic ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) deficiency induces vascular/soft tissue calcifications in generalized arterial calcification of infancy (GACI), and low bone mass with phosphate-wasting rickets in GACI survivors (autosomal hypophosphatemic rickets type-2). ENPP1 haploinsufficiency induces early-onset osteoporosis and mild phosphate wasting in adults. Both conditions demonstrate the unusual combination of reduced accrual of skeletal mineral, yet excess and progressive heterotopic mineralization. ENPP1 is the only enzyme that generates extracellular pyrophosphate (PPi), a potent inhibitor of both bone and heterotopic mineralization. Life-threatening vascular calcification in ENPP1 deficiency is due to decreased plasma PPi; however, the mechanism by which osteopenia results is not apparent from an understanding of the enzyme's catalytic activity. To probe for catalysis-independent ENPP1 pathways regulating bone, we developed a murine model uncoupling ENPP1 protein signaling from ENPP1 catalysis, Enpp1T238A mice. In contrast to Enpp1asj mice, which lack ENPP1, Enpp1T238A mice have normal trabecular bone microarchitecture and favorable biomechanical properties. However, both models demonstrate low plasma Pi and PPi, increased fibroblast growth factor 23 (FGF23), and by 23 weeks, osteomalacia demonstrating equivalent phosphate wasting in both models. Reflecting findings in whole bone, calvarial cell cultures from Enpp1asj mice demonstrated markedly decreased calcification, elevated transcription of Sfrp1, and decreased nuclear β-catenin signaling compared to wild-type (WT) and Enpp1T238A cultures. Finally, the decreased calcification and nuclear β-catenin signaling observed in Enpp1asj cultures was restored to WT levels by knockout of Sfrp1. Collectively, our findings demonstrate that catalysis-independent ENPP1 signaling pathways regulate bone mass via the expression of soluble Wnt inhibitors such as secreted frizzled-related protein 1 (SFRP1), whereas catalysis dependent pathways regulate phosphate homeostasis through the regulation of plasma FGF23. © 2022 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Kristin Zimmerman
- Department of Pathology, Yale University School of Medicine, New Haven Connecticut, 06510
| | - Xiaochen Li
- Department of Pathology, Yale University School of Medicine, New Haven Connecticut, 06510
| | - Simon von Kroge
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, 22529 Hamburg, Germany
| | - Paul Stabach
- Department of Pathology, Yale University School of Medicine, New Haven Connecticut, 06510
| | - Ethan R. Lester
- Department of Pathology, Yale University School of Medicine, New Haven Connecticut, 06510
| | - Emily Y. Chu
- National Institute of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, MD, USA
- Department of General Dentistry, Operative Division, University of Maryland School of Dentistry, Baltimore, Maryland, 21202
| | - Shivani Srivastava
- Department of Pathology, Yale University School of Medicine, New Haven Connecticut, 06510
| | - Martha J. Somerman
- National Institute of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Steven M. Tommasini
- Department of Orthopædics and Rehabilitation, Yale University School of Medicine, New Haven Connecticut, 06510
| | - Björn Busse
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, 22529 Hamburg, Germany
| | - Thorsten Schinke
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, 22529 Hamburg, Germany
| | - Thomas O. Carpenter
- Department of Pediatrics at Yale University School of Medicine, New Haven Connecticut, 06510
| | - Ralf Oheim
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, 22529 Hamburg, Germany
| | - Demetrios T. Braddock
- Department of Pathology, Yale University School of Medicine, New Haven Connecticut, 06510
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Ralph D, Levine MA, Richard G, Morrow M, Flynn E, Uitto J, Li Q. Mutation update: Variants of the ENPP1 gene in pathologic calcification, hypophosphatemic rickets, and cutaneous hypopigmentation with punctate keratoderma. Hum Mutat 2022; 43:1183-1200. [PMID: 35475527 PMCID: PMC9357117 DOI: 10.1002/humu.24391] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/07/2022] [Accepted: 04/22/2022] [Indexed: 11/11/2022]
Abstract
ENPP1 encodes ENPP1, an ectonucleotidase catalyzing hydrolysis of ATP to AMP and inorganic pyrophosphate (PPi), and an endogenous plasma protein physiologically preventing ectopic calcification of connective tissues. Mutations in ENPP1 have been reported in association with a range of human genetic diseases. In this mutation update, we provide a comprehensive review of all the pathogenic variants, likely pathogenic variants, and variants of unknown significance in ENPP1 associated with three autosomal recessive disorders-generalized arterial calcification of infancy (GACI), autosomal recessive hypophosphatemic rickets type 2 (ARHR2), and pseudoxanthoma elasticum (PXE), as well as with a predominantly autosomal dominant disorder-Cole disease. The classification of all variants is determined using the latest ACMG guidelines. A total of 140 ENPP1 variants were curated consisting of 133 previously reported variants and seven novel variants, with missense variants being the most prevalent (70.0%, 98/140). While the pathogenic variants are widely distributed in the ENPP1 gene of patientsgen without apparent genotype-phenotype correlation, eight out of nine variants associated with Cole disease are confined to the somatomedin-B-like (SMB) domains critical for homo-dimerization of the ENPP1 protein.
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Affiliation(s)
- Douglas Ralph
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, PA
- Genetics, Genomics and Cancer Biology Ph.D. Program, Jefferson College of Life Sciences, Thomas Jefferson University, Philadelphia, PA
- PXE International Center of Excellence in Research and Clinical Care, Thomas Jefferson University, Philadelphia, PA
| | - Michael A. Levine
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | | | | | - Jouni Uitto
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, PA
- PXE International Center of Excellence in Research and Clinical Care, Thomas Jefferson University, Philadelphia, PA
| | - Qiaoli Li
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, PA
- PXE International Center of Excellence in Research and Clinical Care, Thomas Jefferson University, Philadelphia, PA
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28
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Collins MT, Marcucci G, Anders HJ, Beltrami G, Cauley JA, Ebeling PR, Kumar R, Linglart A, Sangiorgi L, Towler DA, Weston R, Whyte MP, Brandi ML, Clarke B, Thakker RV. Skeletal and extraskeletal disorders of biomineralization. Nat Rev Endocrinol 2022; 18:473-489. [PMID: 35578027 DOI: 10.1038/s41574-022-00682-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2022] [Indexed: 12/15/2022]
Abstract
The physiological process of biomineralization is complex and deviation from it leads to a variety of diseases. Progress in the past 10 years has enhanced understanding of the genetic, molecular and cellular pathophysiology underlying these disorders; sometimes, this knowledge has both facilitated restoration of health and clarified the very nature of biomineralization as it occurs in humans. In this Review, we consider the principal regulators of mineralization and crystallization, and how dysregulation of these processes can lead to human disease. The knowledge acquired to date and gaps still to be filled are highlighted. The disorders of mineralization discussed comprise a broad spectrum of conditions that encompass bone disorders associated with alterations of mineral quantity and quality, as well as disorders of extraskeletal mineralization (hyperphosphataemic familial tumoural calcinosis). Included are disorders of alkaline phosphatase (hypophosphatasia) and phosphate homeostasis (X-linked hypophosphataemic rickets, fluorosis, rickets and osteomalacia). Furthermore, crystallopathies are covered as well as arterial and renal calcification. This Review discusses the current knowledge of biomineralization derived from basic and clinical research and points to future studies that will lead to new therapeutic approaches for biomineralization disorders.
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Affiliation(s)
- Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD, USA.
| | - Gemma Marcucci
- Bone Metabolic Diseases Unit, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Hans-Joachim Anders
- Department of Medicine IV, Hospital of the University of Munich, Ludwig-Maximilians University, Munich, Germany
| | - Giovanni Beltrami
- Department Paediatric Orthopedic Oncology, Careggi and Meyer Children Hospital, Florence, Italy
| | - Jane A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Rajiv Kumar
- Departments of Medicine, Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Agnès Linglart
- APHP, Endocrinologie et diabète de l'enfant, Paris, France
| | - Luca Sangiorgi
- Medical Genetics and Skeletal Rare Diseases, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Dwight A Towler
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ria Weston
- Cardiovascular Research Group, Manchester Metropolitan University, Manchester, UK
| | - Michael P Whyte
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children-St Louis, St Louis, MO, USA
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St Louis, MO, USA
| | | | - Bart Clarke
- Mayo Clinic Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Rochester, MN, USA
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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29
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O’Brien C, Khursigara G, Huertas P, Leiro B, Molloy L, Nester C. Lifelong impact of ENPP1 Deficiency and the early onset form of ABCC6 Deficiency from patient or caregiver perspective. PLoS One 2022; 17:e0270632. [PMID: 35895733 PMCID: PMC9328542 DOI: 10.1371/journal.pone.0270632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 06/15/2022] [Indexed: 12/02/2022] Open
Abstract
The ectonucleotide pyrophosphatase/phosphodiesterase family member 1 (ENPP1) and ATP-binding cassette subfamily C member 6 (ABCC6) proteins play a prominent role in inhibiting ectopic calcification and arterial stenosis. Patients with ENPP1 Deficiency or infant onset ABCC6 Deficiency often present with pathological calcification, narrowed blood vessels, multiorgan dysfunction and high infant mortality. The heterogenous presentation and progression is well documented. Our objective was to characterize how these morbidities lead to burden of illness and poor quality of life across ages from the patient/caregiver perspective. Patients/caregivers were interviewed via phone using Institutional Review Board–approved questionnaires. Patient-reported outcomes were collected via validated instruments. Thirty-one caregivers and 7 patients participated: infant onset ABCC6 Deficiency, n = 6 (infants/children); ENPP1 Deficiency, n = 32 (13 infants, 12 children, 7 adults). ENPP1 and ABCC6-deficient children aged <8 years and aged 8–18 years reported poor school functioning (0.69 vs 0.72 effect size, respectively) and poor physical health (0.88 vs 1, respectively). In the total ENPP1 cohort, 72% (23/32) reported bone/joint pain and/or mobility/fatigue issues. Three of seven ENPP1-deficient adults reported moderate to severe pain (>4), as measured by the Brief Pain Inventory (BPI), that interfered with daily activities despite pain medication. Top reported burdens for caregivers of infants with ABCC6/ENPP1 Deficiencies included heart-related issues and hospitalizations. Treatment/medications, and hearing loss were the highest burdens reported by caregivers/families of the pediatric ENPP1 Deficiency cohort, whereas adults reported bone/joint pain and mobility impairment as the greatest burdens. Individuals with ENPP1 Deficiency or infant onset ABCC6 Deficiency experience lifelong morbidity causing substantial physical and emotional burden to patients/caregivers.
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Affiliation(s)
| | - Gus Khursigara
- Inozyme Pharma Inc, Boston, Massachusetts, United States of America
| | - Pedro Huertas
- Mirror Neuron Partners LLC and Harvard–MIT Program in Health Sciences and Technology, Boston, Massachusetts, United States of America
| | - Beth Leiro
- Inozyme Pharma Inc, Boston, Massachusetts, United States of America
| | - Liz Molloy
- GACI Global, Argyle, Texas, United States of America
| | - Catherine Nester
- Inozyme Pharma Inc, Boston, Massachusetts, United States of America
- * E-mail:
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Theng EH, Brewer CC, Oheim R, Zalewski CK, King KA, Delsmann MM, Rolvien T, Gafni RI, Braddock DT, Jeffrey Kim H, Ferreira CR. Characterization of hearing-impairment in Generalized Arterial Calcification of Infancy (GACI). Orphanet J Rare Dis 2022; 17:273. [PMID: 35854274 PMCID: PMC9295326 DOI: 10.1186/s13023-022-02410-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 06/26/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Hearing loss (HL) has been sporadically described, but not well characterized, in Generalized Arterial Calcification of Infancy (GACI), a rare disease in which pathological calcification typically presents in infancy. OBJECTIVES This study aims to describe the clinical audiologic and otologic features and potential etiology of hearing impairment in GACI and gain pathophysiological insight from a murine model of GACI. DESIGN Cross-sectional cohort study of individuals with GACI. Murine ossicle micromorphology of the ENPP1asj/asj mutant compared to wild-type. SETTING Clinical research hospital; basic science laboratory. PARTICIPANTS Nineteen individuals with GACI who met clinical, biochemical, and genetic criteria for diagnosis. MAIN OUTCOMES AND MEASURES Clinical, biochemical, and radiologic features associated with hearing status. RESULTS Pure-tone thresholds could be established in 15 (n = 30 ears) of the 19 patients who underwent audiological assessments. The prevalence of HL was 50% (15/30) of ears, with conductive HL in 80% and sensorineural HL in 20%. In terms of patients with HL (n = 8), seven patients had bilateral HL and one patient had unilateral HL. Degree of HL was mild to moderate for 87% of the 15 ears with hearing loss. Of those patients with sufficient pure-tone and middle ear function data, 80% (8/10) had audiometric configurations suggestive of ossicular chain dysfunction (OCD). Recurrent episodes of otitis media (ROM) requiring pressure-equalizing tube placement were common. In patients who underwent cranial CT, 54.5% (6/11) had auricular calcification. Quantitative backscattered electron imaging (qBEI) of murine ossicles supports an OCD component of auditory dysfunction in GACI, suggesting loss of ossicular osteocytes without initiation of bone remodeling. CONCLUSIONS AND RELEVANCE Hearing loss is common in GACI; it is most often conductive, and mild to moderate in severity. The etiology of HL is likely multifactorial, involving dysfunction of the ossicular chain and/or recurrent otitis media. Clinically, this study highlights the importance of early audiologic and otologic evaluation in persons with GACI. Novel findings of high rates of OCD and ROM may inform management, and in cases of unclear HL etiology, dedicated temporal bone imaging should be considered.
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Affiliation(s)
- Elizabeth H Theng
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Carmen C Brewer
- Audiology Unit, Otolaryngology Branch, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, MD, USA
| | - Ralf Oheim
- Martin Seitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christopher K Zalewski
- Audiology Unit, Otolaryngology Branch, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, MD, USA
| | - Kelly A King
- Audiology Unit, Otolaryngology Branch, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, MD, USA
| | - Maximillian M Delsmann
- Martin Seitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Rolvien
- Martin Seitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rachel I Gafni
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | | | - H Jeffrey Kim
- Office of Clinical Director, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, MD, USA.
- Department of Otolaryngology-Head & Neck Surgery, District of Columbia, Georgetown University Hospital, Washington, USA.
| | - Carlos R Ferreira
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, 49 Convent Dr, Building 49, Room 4A38, Bethesda, MD, 20892, USA.
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Kawai K, Sato Y, Kawakami R, Sakamoto A, Cornelissen A, Mori M, Ghosh S, Kutys R, Virmani R, Finn AV. Generalized Arterial Calcification of Infancy (GACI): Optimizing Care with a Multidisciplinary Approach. J Multidiscip Healthc 2022; 15:1261-1276. [PMID: 35677616 PMCID: PMC9167688 DOI: 10.2147/jmdh.s251861] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 04/22/2022] [Indexed: 11/23/2022] Open
Abstract
It is very unusual to see evidence of arterial calcification in infants and children, and when detected, genetic disorders of calcium metabolism should be suspected. Generalized arterial calcification of infancy (GACI) is a hereditary disease, which is characterized by severe arterial calcification of medium sized arteries, mostly involving the media with marked intimal proliferation and ectopic mineralization of the extravascular tissues. It is caused by inactivating variants in genes encoding either ENPP1, in a majority of cases (70–75%), or ABCC6, in a minority (9–10%). Despite similar histologic appearances between ENPP1 and ABCC6 deficiencies, including arterial calcification, organ calcification, and cardiovascular calcification, mortality is higher in subjects carrying the ENPP1 versus ABCC6 variants (40% vs 10%, respectively). Overall mortality in individuals with GACI is high (55%) before the age of 6 months, with 24.4% dying in utero or being stillborn. Rare cases show spontaneous regression with age, while others who survive into adulthood often manifest musculoskeletal complications (osteoarthritis and interosseous membrane ossification), enthesis mineralization, and cervical spine fusion. Despite recent advances in the understanding of the genetic mechanisms underlying this disease, there is still no ideal therapy for the resolution of vascular calcification in GACI. Although bisphosphonates with anti-calcification properties have been commonly used for the treatment of CAGI, their benefit is controversial, with favorable results reported at one year and questionable benefit with delayed initiation of treatment. Enzyme replacement therapy with administration of recombinant form of ENPP1 prevents calcification and mortality, improves hypertension and cardiac function, and prevents intimal proliferation and osteomalacia in mouse models of ENPP1 deficiency. Therefore, newer treatments targeting genes are on the horizon. In this article, we review up to date knowledge of the understanding of GACI, its clinical, pathologic, and etiologic understanding and treatment in support of more comprehensive care of GACI patients.
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Affiliation(s)
| | - Yu Sato
- CVPath Institute, Gaithersburg, MD, USA
| | | | | | | | | | | | | | | | - Aloke V Finn
- CVPath Institute, Gaithersburg, MD, USA
- University of Maryland, School of Medicine, Baltimore, MD, USA
- Correspondence: Aloke V Finn, 19 Firstfield Road, Gaithersburg, MD, 20878, USA, Tel +301.208.3570, Fax +301.208.3745, Email
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Leftheriotis G, Navasiolava N, Clotaire L, Duranton C, Le Saux O, Bendahhou S, Laurain A, Rubera I, Martin L. Relationships between Plasma Pyrophosphate, Vascular Calcification and Clinical Severity in Patients Affected by Pseudoxanthoma Elasticum. J Clin Med 2022; 11:jcm11092588. [PMID: 35566717 PMCID: PMC9100273 DOI: 10.3390/jcm11092588] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/28/2022] [Accepted: 04/30/2022] [Indexed: 12/10/2022] Open
Abstract
Pseudoxanthoma elasticum (PXE; OMIM 264800) is an autosomal recessive metabolic disorder characterized by progressive calcification in the skin, the Bruch’s membrane, and the vasculature. Calcification in PXE results from a low level of circulating pyrophosphate (PPi) caused by ABCC6 deficiency. In this study, we used a cohort of 107 PXE patients to determine the pathophysiological relationship between plasma PPi, coronary calcification (CAC), lower limbs arterial calcification (LLAC), and disease severity. Overall, our data showed a deficit in plasma PPi in PXE patients compared to controls. Remarkably, affected females showed higher PPi levels than males, but a lower LLAC. There was a strong correlation between age and PPi in PXE patients (r = 0.423, p < 0.0001) but not in controls (r = 0.059, p = 0.828). A weak correlation was found between PPi and CAC (r = 0.266, p < 0.02); however, there was no statistically significant connection with LLAC (r = 0.068, p = 0.518) or a severity score (r = 0.077, p = 0.429). Surprisingly, we found no significant correlation between plasma alkaline phosphatase activity and PPi (r = 0.113, p = 0.252) or between a 10-year cardiovascular risk score and all other variables. Multivariate analysis confirmed that LLAC and CAC were strongly dependent on age, but not on PPi. Our data showed that arterial calcification is only weakly linked to circulating PPi levels and that time (i.e., age) appears to be the major determinant of disease severity and calcification in PXE. These data are important to better understand the natural history of this disease but also for the follow-up and management of patients, and the design of future clinical trials. Our results also show that PPi is not a good biomarker for the evaluation of disease severity and progression.
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Affiliation(s)
- Georges Leftheriotis
- University Hospital Nice, Vascular Physiology and Medicine Unit, 06000 Nice, France
- Université Côte d’Azur, LP2M, UMR CNRS 7370, LabEx ICST, 06107 Nice, France; (L.C.); (C.D.); (S.B.); (A.L.); (I.R.)
- Correspondence: or
| | - Nastassia Navasiolava
- PXE Reference Center, MAGEC Nord, University Hospital of Angers, 49000 Angers, France; (N.N.); (L.M.)
| | - Laetitia Clotaire
- Université Côte d’Azur, LP2M, UMR CNRS 7370, LabEx ICST, 06107 Nice, France; (L.C.); (C.D.); (S.B.); (A.L.); (I.R.)
| | - Christophe Duranton
- Université Côte d’Azur, LP2M, UMR CNRS 7370, LabEx ICST, 06107 Nice, France; (L.C.); (C.D.); (S.B.); (A.L.); (I.R.)
| | - Olivier Le Saux
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI 96817, USA;
| | - Saïd Bendahhou
- Université Côte d’Azur, LP2M, UMR CNRS 7370, LabEx ICST, 06107 Nice, France; (L.C.); (C.D.); (S.B.); (A.L.); (I.R.)
| | - Audrey Laurain
- Université Côte d’Azur, LP2M, UMR CNRS 7370, LabEx ICST, 06107 Nice, France; (L.C.); (C.D.); (S.B.); (A.L.); (I.R.)
| | - Isabelle Rubera
- Université Côte d’Azur, LP2M, UMR CNRS 7370, LabEx ICST, 06107 Nice, France; (L.C.); (C.D.); (S.B.); (A.L.); (I.R.)
| | - Ludovic Martin
- PXE Reference Center, MAGEC Nord, University Hospital of Angers, 49000 Angers, France; (N.N.); (L.M.)
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Ralph D, van de Wetering K, Uitto J, Li Q. Inorganic Pyrophosphate Deficiency Syndromes and Potential Treatments for Pathologic Tissue Calcification. THE AMERICAN JOURNAL OF PATHOLOGY 2022; 192:762-770. [PMID: 35182493 PMCID: PMC9088198 DOI: 10.1016/j.ajpath.2022.01.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/19/2022] [Accepted: 01/24/2022] [Indexed: 02/08/2023]
Abstract
Pathologic soft tissue calcification can occur in both genetic and acquired clinical conditions, causing significant morbidity and mortality. Although the pathomechanisms of pathologic calcification are poorly understood, major progress has been made in recent years in defining the underlying genetic defects in Mendelian disorders of ectopic calcification. This review presents an overview of the pathophysiology of five monogenic disorders of pathologic calcification: pseudoxanthoma elasticum, generalized arterial calcification of infancy, arterial calcification due to deficiency of CD73, ankylosis, and progeria. These hereditary disorders, caused by mutations in genes encoding ATP binding cassette subfamily C member 6, ectonucleotide pyrophosphatase/phosphodiesterase 1, CD73, progressive ankylosis protein, and lamin A/C proteins, respectively, are inorganic pyrophosphate (PPi) deficiency syndromes with reduced circulating levels of PPi, the principal physiologic inhibitor of calcium hydroxyapatite deposition in soft connective tissues. In addition to genetic diseases, PPi deficiency has been encountered in acquired clinical conditions accompanied by pathologic calcification. Because specific and effective treatments are lacking for pathologic calcification, the unifying finding of PPi deficiency suggests that PPi-targeted therapies may be beneficial to counteract pathologic soft tissue calcification in both genetic and acquired diseases.
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Affiliation(s)
- Douglas Ralph
- Genetics, Genomics, and Cancer Biology Ph.D. Program, Jefferson College of Life Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, Jefferson Institute of Molecular Medicine, and the PXE International Center of Excellence in Research and Clinical Care, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Koen van de Wetering
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, Jefferson Institute of Molecular Medicine, and the PXE International Center of Excellence in Research and Clinical Care, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jouni Uitto
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, Jefferson Institute of Molecular Medicine, and the PXE International Center of Excellence in Research and Clinical Care, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Qiaoli Li
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, Jefferson Institute of Molecular Medicine, and the PXE International Center of Excellence in Research and Clinical Care, Thomas Jefferson University, Philadelphia, Pennsylvania.
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Reed AK, Chiu P, Carreon CK, Sanders SP, Del Nido PJ, Baird CW. Unrepairable Infant Mitral Valve: An Unexpected Case of Decompensated Heart Failure. Circulation 2022; 145:1175-1178. [PMID: 35404678 DOI: 10.1161/circulationaha.121.056881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Peter Chiu
- Department of Cardiac Surgery (P.C., P.J.d.N., C.W.B.), Boston Children's Hospital/Harvard Medical School, MA
| | - Chrystalle Katte Carreon
- Department of Pathology (C.K.C., S.P.S.), Boston Children's Hospital/Harvard Medical School, MA.,Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, MA (C.K.C., S.P.S.)
| | - Stephen P Sanders
- Department of Pathology (C.K.C., S.P.S.), Boston Children's Hospital/Harvard Medical School, MA.,Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, MA (C.K.C., S.P.S.)
| | - Pedro J Del Nido
- Department of Cardiac Surgery (P.C., P.J.d.N., C.W.B.), Boston Children's Hospital/Harvard Medical School, MA
| | - Christopher W Baird
- Department of Cardiac Surgery (P.C., P.J.d.N., C.W.B.), Boston Children's Hospital/Harvard Medical School, MA
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35
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Ralph D, Nitschke Y, Levine MA, Caffet M, Wurst T, Saeidian AH, Youssefian L, Vahidnezhad H, Terry SF, Rutsch F, Uitto J, Li Q. ENPP1 variants in patients with GACI and PXE expand the clinical and genetic heterogeneity of heritable disorders of ectopic calcification. PLoS Genet 2022; 18:e1010192. [PMID: 35482848 PMCID: PMC9089899 DOI: 10.1371/journal.pgen.1010192] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 05/10/2022] [Accepted: 04/05/2022] [Indexed: 12/17/2022] Open
Abstract
Pseudoxanthoma elasticum (PXE) and generalized arterial calcification of infancy (GACI) are clinically distinct genetic entities of ectopic calcification associated with differentially reduced circulating levels of inorganic pyrophosphate (PPi), a potent endogenous inhibitor of calcification. Variants in ENPP1, the gene mutated in GACI, have not been associated with classic PXE. Here we report the clinical, laboratory, and molecular evaluations of ten GACI and two PXE patients from five and two unrelated families registered in GACI Global and PXE International databases, respectively. All patients were found to carry biallelic variants in ENPP1. Among ten ENPP1 variants, one homozygous variant demonstrated uniparental disomy inheritance. Functional assessment of five previously unreported ENPP1 variants suggested pathogenicity. The two PXE patients, currently 57 and 27 years of age, had diagnostic features of PXE and had not manifested the GACI phenotype. The similarly reduced PPi plasma concentrations in the PXE and GACI patients in our study correlate poorly with their disease severity. This study demonstrates that in addition to GACI, ENPP1 variants can cause classic PXE, expanding the clinical and genetic heterogeneity of heritable ectopic calcification disorders. Furthermore, the results challenge the current prevailing concept that plasma PPi is the only factor governing the severity of ectopic calcification. Biallelic inactivating mutations in the ENPP1 gene cause generalized arterial calcification of infancy (GACI), a frequently fatal disease characterized by infantile onset of widespread arterial calcification and/or narrowing of large and medium-sized vessels often resulting in the early demise of affected individuals. Significantly reduced, almost zero plasma levels of a potent and endogenous calcification inhibitor, inorganic pyrophosphate (PPi), is thought to be the underlying cause of vascular calcification in GACI. Mutations in ENPP1 have not been found in patients with pseudoxanthoma elasticum (PXE), another genetic multisystem ectopic calcification disorder caused by mutations in the ABCC6 gene. This study reports that ENPP1 mutations can also cause PXE with more favorable clinical outcomes. In addition, it was previously thought that plasma PPi levels correlate with vascular calcification severity. However, we here show that vascular calcification severity does not correlate with plasma PPi levels. The results suggest that in addition to PPi, the long-believed determinant of ectopic calcification, additional mechanisms may be at play in regulating ectopic calcification.
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Affiliation(s)
- Douglas Ralph
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, and Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- Genetics, Genomics and Cancer Biology Ph.D. Program, Jefferson College of Life Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- PXE International Center of Excellence in Research and Clinical Care, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | | | - Michael A. Levine
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Matthew Caffet
- PXE International, Inc., Damascus, Maryland, United States of America
| | - Tamara Wurst
- PXE International, Inc., Damascus, Maryland, United States of America
| | - Amir Hossein Saeidian
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, and Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- Genetics, Genomics and Cancer Biology Ph.D. Program, Jefferson College of Life Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Leila Youssefian
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, and Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Hassan Vahidnezhad
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, and Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Sharon F. Terry
- PXE International, Inc., Damascus, Maryland, United States of America
| | - Frank Rutsch
- Münster University Children’s Hospital, Münster, Germany
| | - Jouni Uitto
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, and Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- PXE International Center of Excellence in Research and Clinical Care, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Qiaoli Li
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, and Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- PXE International Center of Excellence in Research and Clinical Care, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- * E-mail:
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Ferreira CR, Ansh AJ, Nester C, O’Brien C, Stabach PR, Murtada SI, Lester ER, Khursigara G, Molloy L, Carpenter TO, Braddock DT. Musculoskeletal Comorbidities and Quality of Life in ENPP1-Deficient Adults and the Response of Enthesopathy to Enzyme Replacement Therapy in Murine Models. J Bone Miner Res 2022; 37:494-504. [PMID: 34882836 PMCID: PMC9667476 DOI: 10.1002/jbmr.4487] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 11/04/2021] [Accepted: 12/05/2021] [Indexed: 12/20/2022]
Abstract
Ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) deficiency leads to cardiovascular calcification in infancy, fibroblast growth factor 23 (FGF23)-mediated hypophosphatemic rickets in childhood, and osteomalacia in adulthood. Excessive enthesis mineralization and cervical spine fusion have been previously reported in patients with biallelic ENPP1 deficiency, but their effect on quality of life is unknown. We describe additional musculoskeletal complications in patients with ENPP1 deficiency, namely osteoarthritis and interosseous membrane ossification, and for the first time evaluate health-related quality of life (HRQoL) in patients with this disease, both subjectively via narrative report, and objectively via the Brief Pain Inventory-Short Form, and a Patient Reported Outcome Measurement Information System Physical Function (PROMIS PF) short form. Residual pain, similar in magnitude to that identified in adult patients with X-linked hypophosphatemia, was experienced by the majority of patients despite use of analgesic medications. Impairment in physical function varied from mild to severe. To assess murine ENPP1 deficiency for the presence of enthesopathy, and for the potential response to enzyme replacement therapy, we maintained Enpp1asj/asj mice on regular chow for 23 weeks and treated cohorts with either vehicle or a long-acting form of recombinant ENPP1. Enpp1asj/asj mice treated with vehicle exhibited robust calcification throughout their Achilles tendons, whereas two-thirds of those treated with ENPP1 enzyme replacement exhibited complete or partial suppression of the Achilles tendon calcification. Our combined results document that musculoskeletal complications are a significant source of morbidity in biallelic ENPP1 deficiency, a phenotype which is closely recapitulated in Enpp1asj/asj mice. Finally, we show that a long-acting form of recombinant ENPP1 prevents the development of enthesis calcification at the relatively modest dose of 0.3 mg/kg per week, suggesting that suppression of enthesopathy may be attainable upon dose escalation. © 2021 American Society for Bone and Mineral Research (ASBMR). This article has been contributed to by US Government employees and their work is in the public domain in the USA.
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Affiliation(s)
- Carlos R. Ferreira
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Anenya Jai Ansh
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | | | | | - Paul R. Stabach
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Sae-Il Murtada
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Ethan R. Lester
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | | | | | - Thomas O. Carpenter
- Department of Pediatrics (Endocrinology), Yale University School of Medicine, New Haven, CT, USA
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Yunfeng L, Tongyan H, Jing W, Xiaomei T. Case Report: A Novel Genetic Mutation Causes Idiopathic Infantile Arterial Calcification in Preterm Infants. Front Genet 2022; 12:763916. [PMID: 35003211 PMCID: PMC8733597 DOI: 10.3389/fgene.2021.763916] [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: 08/24/2021] [Accepted: 12/07/2021] [Indexed: 01/01/2023] Open
Abstract
Idiopathic infantile arterial calcification (IIAC), also known as generalized arterial calcification of infancy (GACI), is a heritable ectopic mineralization disorder that results in diffuse arterial calcifications and or stenosis, which are attributed to mutations in the ENPP1 gene. In this case study, we report the development of IIAC in a 2-month-old male preterm infant. The patient presented with severe hypertension and seizures, which revealed diffused calcifications and c.130C > T and c.1112A > T mutations in the ENPP1 gene. With biphosphonate, antihypertensive, and control epilepsy therapy, his blood pressure was maintained at 110–120/50–60 mmHg. Intellectual motor development retardation was anticipated in this patient. To the best of our knowledge, this is the first case in which a novel c.130C > T mutation in the ENPP1 gene has been identified, and the administration of bisphosphonates to patients with IIAC has been assessed.
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Affiliation(s)
- Liu Yunfeng
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Han Tongyan
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Wang Jing
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Tong Xiaomei
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
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38
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Choe Y, Shin CH, Lee YA, Kim MJ, Lee YJ. Case Report and Review of Literature: Autosomal Recessive Hypophosphatemic Rickets Type 2 Caused by a Pathogenic Variant in ENPP1 Gene. Front Endocrinol (Lausanne) 2022; 13:911672. [PMID: 35966073 PMCID: PMC9374118 DOI: 10.3389/fendo.2022.911672] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 06/01/2022] [Indexed: 11/29/2022] Open
Abstract
Autosomal recessive hypophosphatemic rickets type 2 (ARHR2) is a rare form of hereditary rickets, which is characterized by defective bone mineralization and renal phosphate wasting due to a loss-of-function variant in the ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) gene. Although pathogenic variant of ENPP1 has been known to manifest other phenotypes including arterial calcification, hearing loss, ossification of posterior longitudinal ligament, or pseudoxanthoma elasticum, there have been few reports including systematic examination in individuals diagnosed with ARHR2 to date. Herein, we report a case of ARHR2 with a bi-allelic pathogenic variant of ENPP1, in which the patient presented with gait abnormalities with severe genu varum at 26 months of age. Targeted gene panel sequencing was performed to investigate the genetic cause of rickets, and a homozygous nonsense variant in ENPP1, c.783C>G (p.Tyr261*), was identified. The patient was treated with oral phosphate and active vitamin D supplements and underwent corrective osteotomy for varus deformity. His phenotype was limited to rickets. A periodic systematic evaluation is needed to identify any comorbidities in ARHR2 patients since ENPP1 variants may present phenotypes other than rickets and symptoms may evolve or change over time.
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Affiliation(s)
- Yunsoo Choe
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, South Korea
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, South Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, South Korea
| | - Man Jin Kim
- Department of Genomic Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Yun Jeong Lee
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, South Korea
- *Correspondence: Yun Jeong Lee,
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Höppner J, Kornak U, Sinningen K, Rutsch F, Oheim R, Grasemann C. Autosomal recessive hypophosphatemic rickets type 2 (ARHR2) due to ENPP1-deficiency. Bone 2021; 153:116111. [PMID: 34252603 DOI: 10.1016/j.bone.2021.116111] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/01/2021] [Accepted: 07/06/2021] [Indexed: 12/25/2022]
Abstract
Awareness for hypophosphatemic rickets has increased in the last years, based on the availability of specific medical treatments. Autosomal recessive hypophosphatemic rickets type 2 (ARHR2) is a rare form of hypophosphatemic rickets, which is known to develop in survivors of generalized arterial calcification of infancy (GACI). Both disorders are based on a deficiency of ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) and present with a high clinical variability and a lack of a phenotype-genotype association. ARHR2 is characterized by phosphate wasting due to elevated fibroblast growth factor 23 (FGF23) levels and might represent a response of the organism to minimize ectopic calcification in individuals with ENPP1-deficiency. This report reviews the recent clinical and preclinical data on this ultra-rare disease in childhood.
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Affiliation(s)
- Jakob Höppner
- Center for Rare Diseases Ruhr CeSER, Ruhr-University Bochum and Witten/Herdecke University, Germany; Department of Pediatrics, St.-Josef Hospital Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Uwe Kornak
- Institute for Human Genetics, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Kathrin Sinningen
- Department of Pediatrics, St.-Josef Hospital Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Frank Rutsch
- Department of General Pediatrics, Münster University Children's Hospital, Münster, Germany
| | - Ralf Oheim
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Corinna Grasemann
- Center for Rare Diseases Ruhr CeSER, Ruhr-University Bochum and Witten/Herdecke University, Germany; Department of Pediatrics, St.-Josef Hospital Bochum, Ruhr-University Bochum, Bochum, Germany.
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40
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Ferreira CR, Kintzinger K, Hackbarth ME, Botschen U, Nitschke Y, Mughal MZ, Baujat G, Schnabel D, Yuen E, Gahl WA, Gafni RI, Liu Q, Huertas P, Khursigara G, Rutsch F. Ectopic Calcification and Hypophosphatemic Rickets: Natural History of ENPP1 and ABCC6 Deficiencies. J Bone Miner Res 2021; 36:2193-2202. [PMID: 34355424 PMCID: PMC8595532 DOI: 10.1002/jbmr.4418] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/29/2021] [Accepted: 08/01/2021] [Indexed: 02/06/2023]
Abstract
Generalized arterial calcification of infancy (GACI) is a rare disorder caused by ENPP1 or ABCC6 variants. GACI is characterized by low pyrophosphate, arterial calcification, and high mortality during the first year of life, but the natural course and possible differences between the causative genes remain unknown. In all, 247 individual records for patients with GACI (from birth to 58.3 years of age) across 19 countries were reviewed. Overall mortality was 54.7% (13.4% in utero or stillborn), with a 50.4% probability of death before the age of 6 months (critical period). Contrary to previous publications, we found that bisphosphonate treatment had no survival benefit based on a start-time matched analysis and inconclusive results when initiated within 2 weeks of birth. Despite a similar prevalence of GACI phenotypes between ENPP1 and ABCC6 deficiencies, including arterial calcification (77.2% and 89.5%, respectively), organ calcification (65.8% and 84.2%, respectively), and cardiovascular complications (58.4% and 78.9%, respectively), mortality was higher for ENPP1 versus ABCC6 variants (40.5% versus 10.5%, respectively; p = 0.0157). Higher prevalence of rickets was reported in 70.8% of surviving affected individuals with ENPP1 compared with that of ABCC6 (11.8%; p = 0.0001). Eleven affected individuals presenting with rickets and without a GACI diagnosis, termed autosomal recessive hypophosphatemic rickets type 2 (ARHR2), all had confirmed ENPP1 variants. Approximately 70% of these patients demonstrated evidence of ectopic calcification or complications similar to those seen in individuals with GACI, which shows that ARHR2 is not a distinct condition from GACI but represents part of the spectrum of ENPP1 deficiency. Overall, this study identified an early mortality risk in GACI patients despite attempts to treat with bisphosphonates, high prevalence of rickets almost exclusive to ENPP1 deficiency, and a spectrum of heterogenous calcification and multiple organ complications with both ENPP1 and ABCC6 variants, which suggests an overlapping pathology. © 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). This article has been contributed to by US Government employees and their work is in the public domain in the USA.
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Affiliation(s)
- Carlos R Ferreira
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kristina Kintzinger
- Department of General Pediatrics, Münster University Children's Hospital, Münster, Germany
| | - Mary E Hackbarth
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ulrike Botschen
- Department of General Pediatrics, Münster University Children's Hospital, Münster, Germany
| | - Yvonne Nitschke
- Department of General Pediatrics, Münster University Children's Hospital, Münster, Germany
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Genevieve Baujat
- Centre de Référence Maladies Osseuses Constitutionnelles (CR MOC) et Filière OSCAR, Département de Génétique, Hôpital Necker-Enfants Malades, Paris, France
| | - Dirk Schnabel
- Center for Chronically Sick Children, Pediatric Endocrinology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Eric Yuen
- Inozyme Pharma, Inc., Boston, MA, USA
| | - William A Gahl
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rachel I Gafni
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Qing Liu
- Quantitative & Regulatory Medical Science, LLC, Long Valley, NJ, USA
| | | | | | - Frank Rutsch
- Department of General Pediatrics, Münster University Children's Hospital, Münster, Germany
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Ferreira CR, Blau N. Clinical and biochemical footprints of inherited metabolic diseases. IV. Metabolic cardiovascular disease. Mol Genet Metab 2021; 132:112-118. [PMID: 33388235 PMCID: PMC7867625 DOI: 10.1016/j.ymgme.2020.12.290] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/16/2020] [Accepted: 12/16/2020] [Indexed: 12/12/2022]
Abstract
Inherited metabolic diseases account for 15-20% of all cases of pediatric cardiomyopathy, with a high mortality of 15-47%. Metabolic diseases can also commonly be associated with other types of cardiovascular involvement such as arrhythmias, valvulopathy or vasculopathy. We reviewed and updated the list of known metabolic etiologies associated with cardiovascular involvement, and found 246 relevant inborn errors of metabolism. This represents the fourth of a series of articles attempting to create and maintain a comprehensive list of clinical and metabolic differential diagnoses according to system involvement.
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Affiliation(s)
- Carlos R Ferreira
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Nenad Blau
- Division of Metabolism, University Children's Hospital, Zürich, Switzerland.
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Laurent MR, De Schepper J, Trouet D, Godefroid N, Boros E, Heinrichs C, Bravenboer B, Velkeniers B, Lammens J, Harvengt P, Cavalier E, Kaux JF, Lombet J, De Waele K, Verroken C, van Hoeck K, Mortier GR, Levtchenko E, Vande Walle J. Consensus Recommendations for the Diagnosis and Management of X-Linked Hypophosphatemia in Belgium. Front Endocrinol (Lausanne) 2021; 12:641543. [PMID: 33815294 PMCID: PMC8018577 DOI: 10.3389/fendo.2021.641543] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/19/2021] [Indexed: 12/11/2022] Open
Abstract
X-linked hypophosphatemia (XLH) is the most common genetic form of hypophosphatemic rickets and osteomalacia. In this disease, mutations in the PHEX gene lead to elevated levels of the hormone fibroblast growth factor 23 (FGF23), resulting in renal phosphate wasting and impaired skeletal and dental mineralization. Recently, international guidelines for the diagnosis and treatment of this condition have been published. However, more specific recommendations are needed to provide guidance at the national level, considering resource availability and health economic aspects. A national multidisciplinary group of Belgian experts convened to discuss translation of international best available evidence into locally feasible consensus recommendations. Patients with XLH may present to a wide array of primary, secondary and tertiary care physicians, among whom awareness of the disease should be raised. XLH has a very broad differential-diagnosis for which clinical features, biochemical and genetic testing in centers of expertise are recommended. Optimal care requires a multidisciplinary approach, guided by an expert in metabolic bone diseases and involving (according to the individual patient's needs) pediatric and adult medical specialties and paramedical caregivers, including but not limited to general practitioners, dentists, radiologists and orthopedic surgeons. In children with severe or refractory symptoms, FGF23 inhibition using burosumab may provide superior outcomes compared to conventional medical therapy with phosphate supplements and active vitamin D analogues. Burosumab has also demonstrated promising results in adults on certain clinical outcomes such as pseudofractures. In summary, this work outlines recommendations for clinicians and policymakers, with a vision for improving the diagnostic and therapeutic landscape for XLH patients in Belgium.
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Affiliation(s)
- Michaël R. Laurent
- Centre for Metabolic Bone Diseases, University Hospitals Leuven, Leuven, Belgium
- *Correspondence: Michaël R. Laurent,
| | - Jean De Schepper
- Division of Pediatric Endocrinology, KidZ Health Castle, University Hospital Brussels, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Department of Pediatric Endocrinology, University Hospital Ghent, Ghent, Belgium
| | - Dominique Trouet
- Department of Pediatric Nephrology, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
| | - Nathalie Godefroid
- Pediatric Nephrology, Cliniques Universitaires St. Luc (UCL), Brussels, Belgium
| | - Emese Boros
- Paediatric Endocrinology Unit, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Claudine Heinrichs
- Paediatric Endocrinology Unit, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Bert Bravenboer
- Department of Endocrinology, University Hospital Brussels, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Brigitte Velkeniers
- Department of Endocrinology, University Hospital Brussels, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Johan Lammens
- Department of Orthopaedic Surgery and Department of Development and Regeneration, Prometheus LRD Division of Skeletal Tissue Engineering, KU Leuven - University Hospitals Leuven, Leuven, Belgium
| | - Pol Harvengt
- XLH Belgium, Belgian X-Linked Hypophosphatemic Rickets (XLH) Patient Association, Waterloo, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, University Hospital Center of Liège, University of Liège, Liège, Belgium
| | - Jean-François Kaux
- Physical Medicine, Rehabilitation and Sports Traumatology, University and University Hospital of Liège, Liège, Belgium
| | - Jacques Lombet
- Division of Nephrology, Department of Pediatrics, University Hospital Center of Liège, Liège, Belgium
| | - Kathleen De Waele
- Department of Pediatric Endocrinology, University Hospital Ghent, Ghent, Belgium
| | - Charlotte Verroken
- Unit for Osteoporosis and Metabolic Bone Diseases, Department of Endocrinology and Metabolism, Ghent University Hospital, Ghent, Belgium
| | - Koenraad van Hoeck
- Department of Pediatric Nephrology, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
| | - Geert R. Mortier
- Department of Medical Genetics, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Elena Levtchenko
- Department of Pediatrics/Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Johan Vande Walle
- Department of Pediatric Nephrology, University Hospital Ghent, Ghent, Belgium
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