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Funck-Brentano T, Vanjak A, Ostertag A, Nethander M, Fernandez S, Collet C, Hans D, van Rietbergen B, Cohen-Solal M. Evaluation of bone density and microarchitecture in adult patients with X-linked hypophosphatemic rickets: A pilot longitudinal study. Bone 2024; 187:117179. [PMID: 38960298 DOI: 10.1016/j.bone.2024.117179] [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: 03/08/2024] [Revised: 06/24/2024] [Accepted: 06/26/2024] [Indexed: 07/05/2024]
Abstract
X-linked Hypophosphatemia (XLH) is the most common type of inherited rickets. Although the clinical features are well characterized, bone structure, mineralization, and biomechanical properties are poorly known. Our aim was to analyze bone properties in the appendicular and axial skeleton of adults with XLH. In this observational case-control study, each affected patient (N = 14; 9 females; age 50 ± 15 years) was matched by sex, age and body mass index to a minimum of two healthy controls (N = 34). Dual-energy X-ray Absorptiometry (DXA) analyses revealed that areal bone mineral density (aBMD) was higher in XLH patients at the lumbar spine (Z score mean difference = +2.47 SD, P value = 1.4 × 10-3). Trabecular Bone Score was also higher at the lumbar spine (P value = 1.0 × 10-4). High Resolution peripheral Quantitative Computed Tomography (HRpQCT) demonstrated that bone cross-sectional area was larger at the distal radius (P value = 6 × 10-3). Total and trabecular volumetric BMD were lower at both sites. Trabecular bone volume fraction was also lower with fewer trabecular numbers at both sites. However, bone strength evaluated by micro-finite element analyzes revealed unaffected bone stiffness and maximum failure load. Evaluation of bone mineralization with aBMD by DXA at the distal radius correlated with vBMD by HRpQCT measurements at both sites. PTH levels were inversely correlated with trabecular vBMD and BV/TV at the tibia. We then followed a subset of nine patients (median follow-up of 4 years) and reassessed HRpQCT. At the tibia, we observed a greater decrease than expected from an age and sex standardized normal population in total and cortical vBMD as well as a trabecularization of the cortical compartment. In conclusion, in adult patients with XLH, bone mineral density is high at the axial skeleton but low at the appendicular skeleton. With time, microarchitectural alterations worsen. We propose that noninvasive evaluation methods of bone mineralization such as DXA including the radius should be part of the management of XLH patients. Larger studies are needed to evaluate the clinical significance of BMD changes in XLH patients under conventional or targeted therapies.
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Affiliation(s)
- Thomas Funck-Brentano
- BIOSCAR UMRS 1132, INSERM, Université Paris Cité, F-75475 Paris, France; Assistance Publique des Hôpitaux de Paris, Lariboisière Hospital, DMU Locomotion, Department of Rheumatology, F-75475 Paris, France; National Reference Center For Rare Bone Diseases, Lariboisière Hospital, APHP.Nord, Filière OSCAR, F-75475 Paris, France.
| | - Arnaud Vanjak
- BIOSCAR UMRS 1132, INSERM, Université Paris Cité, F-75475 Paris, France; Assistance Publique des Hôpitaux de Paris, Lariboisière Hospital, DMU Locomotion, Department of Rheumatology, F-75475 Paris, France; National Reference Center For Rare Bone Diseases, Lariboisière Hospital, APHP.Nord, Filière OSCAR, F-75475 Paris, France.
| | - Agnes Ostertag
- BIOSCAR UMRS 1132, INSERM, Université Paris Cité, F-75475 Paris, France
| | - Maria Nethander
- Center for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
| | - Sylvie Fernandez
- Assistance Publique des Hôpitaux de Paris, Lariboisière Hospital, DMU Locomotion, Department of Rheumatology, F-75475 Paris, France
| | - Corinne Collet
- Imagine Institut, Necker Hospital, Université Paris Cité, F-75475 Paris, France
| | - Didier Hans
- Center of Bone Diseases, Bone & Joint Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Bert van Rietbergen
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Martine Cohen-Solal
- BIOSCAR UMRS 1132, INSERM, Université Paris Cité, F-75475 Paris, France; Assistance Publique des Hôpitaux de Paris, Lariboisière Hospital, DMU Locomotion, Department of Rheumatology, F-75475 Paris, France; National Reference Center For Rare Bone Diseases, Lariboisière Hospital, APHP.Nord, Filière OSCAR, F-75475 Paris, France
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Brinker EJ, Hardcastle MR, Dittmer KE, Graff EC. Endocrine fibroblast growth factors in domestic animals. Domest Anim Endocrinol 2024; 89:106872. [PMID: 39059301 DOI: 10.1016/j.domaniend.2024.106872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 06/28/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024]
Abstract
Fibroblast growth factors (FGFs) are a group of structurally homologous yet functionally pleiotropic proteins. Canonical and intracellular FGFs have primarily autocrine or paracrine effects. However, the FGF19 subfamily, composed of FGF15/19, FGF21, and FGF23, act as endocrine hormones that regulate bile acid, metabolic, and phosphorus homeostasis, respectively. Current research in human and rodent models demonstrates the potential of these endocrine FGFs to target various diseases, including disorders of inherited hypophosphatemia, chronic liver disease, obesity, and insulin resistance. Many diseases targeted for therapeutic use in humans have pathophysiological overlaps in domestic animals. Despite the potential clinical and economic impact, little is known about endocrine FGFs and their signaling pathways in major domestic animal species compared with humans and laboratory animals. This review aims to describe the physiology of these endocrine FGFs, discuss their current therapeutic use, and summarize the contemporary literature regarding endocrine FGFs in domestic animals, focusing on potential future directions.
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Affiliation(s)
- Emily J Brinker
- Department of Pathobiology, College of Veterinary Medicine, 166 Greene Hall, Auburn University, AL, USA 36849; Department of Comparative Pathobiology, Cummings School of Veterinary Medicine at Tufts University, 200 Westboro Road, North Grafton, MA, USA 01536
| | - Michael R Hardcastle
- IDEXX Laboratories Pty. Ltd., 20A Maui Street, Pukete, Hamilton 3200, New Zealand
| | - Keren E Dittmer
- School of Veterinary Sciences, Massey University, Private Bag 11-222, Palmerston North 4442, New Zealand
| | - Emily C Graff
- Department of Pathobiology, College of Veterinary Medicine, 166 Greene Hall, Auburn University, AL, USA 36849; Scott-Ritchey Research Center, College of Veterinary Medicine, Dr. Auburn University, 1265 HC Morgan, AL, USA 36849.
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Portale AA, Ward L, Dahir K, Florenzano P, Ing SW, Jan de Beur SM, Martin RM, Meza-Martinez AI, Paloian N, Ashraf A, Dixon BP, Khan A, Langman C, Chen A, Wang C, Roberts MS, Tandon PK, Bedrosian C, Imel EA. Nephrocalcinosis and kidney function in children and adults with X-linked hypophosphatemia: baseline results from a large longitudinal study. J Bone Miner Res 2024; 39:1493-1502. [PMID: 39151033 DOI: 10.1093/jbmr/zjae127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 07/09/2024] [Accepted: 07/17/2024] [Indexed: 08/18/2024]
Abstract
BACKGROUND In patients with X-linked hypophosphatemia (XLH), conventional therapy with oral phosphate salts and active vitamin D has been associated with nephrocalcinosis. However, the nature of the relationships among XLH, its treatment, nephrocalcinosis, and kidney function remain poorly understood. METHODS Renal ultrasounds were performed and glomerular filtration rates were estimated (eGFR) at baseline in burosumab-naïve patients with XLH who participated in burosumab clinical trials (NCT02181764, NCT02526160, NCT02537431, NCT02163577, NCT02750618, NCT02915705) or enrolled in the XLH Disease Monitoring Program (XLH-DMP; NCT03651505). In this cross-sectional analysis, patient, disease, and treatment characteristics were described among patients with and without nephrocalcinosis. RESULTS The analysis included 196 children (mean [SD] age 7.6 [4.0] yr) and 318 adults (40.3 [13.1] yr). Mean (SD) height z-score was -1.9 (1.2) for children and -2.3 (1.7) for adults. Nearly all children (97%) and adults (94%) had previously received conventional therapy. Nephrocalcinosis was detected in 22% of children and 38% of adults. In children, reduced eGFR <90 mL/min/1.73 m2 was more prevalent in those with nephrocalcinosis (25%) than in those without (11%), a finding that was not observed in adults. Children with nephrocalcinosis had lower mean values of TmP/GFR (p<.05), serum 1,25(OH)2D (p<.05), and eGFR (p<.001) and higher mean serum calcium concentrations (p<.05) than did those without nephrocalcinosis. Adults with nephrocalcinosis had lower mean serum phosphorus (p<.01) and 1,25(OH)2D (p<.05) concentrations than those without. Exploratory logistic regression analyses revealed no significant associations between the presence of nephrocalcinosis and other described patient or disease characteristics. CONCLUSIONS Nephrocalcinosis was observed in nearly one-quarter of children and more than one-third of adults with XLH. Further study is needed to better understand the predictors and long-term consequences of nephrocalcinosis, with surveillance for nephrocalcinosis remaining important in the management of XLH.
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Affiliation(s)
- Anthony A Portale
- Division of Pediatric Nephrology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA 94158, United States
| | - Leanne Ward
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, ON K1H 8L1, Canada
| | - Kathryn Dahir
- Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Pablo Florenzano
- Department of Endocrinology, Faculty of Medicine, Pontificia Universidad Católica de Chile and Centro UC Traslacional en Endocrinología, CETREN-UC, 8320165 Santiago, Chile
| | - Steven W Ing
- Division of Endocrinology, Diabetes, and Metabolism, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Suzanne M Jan de Beur
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia School of Medicine, Charlotteville, VA 22903, United States
| | - Regina M Martin
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
| | | | - Neil Paloian
- University of Wisconsin School of Medicine and Public Health, Madison, WI 53726, United States
| | - Ambika Ashraf
- University of Alabama at Birmingham, Birmingham, AL 35294, United States
| | - Bradley P Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, United States
| | - Aliya Khan
- McMaster University, Hamilton, Ontario L8S 4L8, Canada
| | - Craig Langman
- Emeritus Professor of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, IL 60611, United States
| | - Angel Chen
- Ultragenyx Pharmaceutical Inc., Novato, CA 94949, United States
| | - Christine Wang
- Ultragenyx Pharmaceutical Inc., Novato, CA 94949, United States
| | | | - P K Tandon
- Ultragenyx Pharmaceutical Inc., Novato, CA 94949, United States
| | | | - Erik A Imel
- Indiana University School of Medicine, Indianapolis, IN 46202, United States
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Kiafzezi D, Stamati A, Karagiannis T, Goulis DG, Christoforidis A. Burosumab Efficacy and Safety in Patients with X-Linked Hypophosphatemia: Systematic Review and Meta-analysis of Real-World Data. Calcif Tissue Int 2024; 115:229-241. [PMID: 39008126 DOI: 10.1007/s00223-024-01250-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: 02/15/2024] [Accepted: 06/18/2024] [Indexed: 07/16/2024]
Abstract
To assess the efficacy and safety of burosumab in children and adults with X-linked hypophosphatemia based on real-world evidence. MEDLINE (via PubMed) and Cochrane Library were searched until 18 October 2023 for single-arm (before-after) studies. Registries including Clinicaltrials.gov, EU Clinical Trials, WHO International Clinical Trials Registry Platform, and conference abstracts. The outcomes were a change in serum phosphorus concentrations and change in RSS, a change in serum ALP, bone-specific ALP, a change in the ratio of Tubular maximum reabsorption of Phosphate to Glomerular Filtrate rate, a change in serum 1,25(OH)2D and 25(OH)2D concentrations, change in height Z-score, McMaster Universities Osteoarthritis Index (WOMAC) and safety outcomes. An inverse variance random-effects meta-analysis was applied for data synthesis. Fifteen studies (289 participants) were included. Burosumab treatment improved serum phosphate concentrations [mean difference 0.88 mg/dl, 95% confidence interval 0.70 to 1.07, I2 = 92%), Rickets Severity score (mean difference - 1.86, 95% confidence interval - 2.5 to - 1.21, I2 = 71%), serum alkaline phosphate concentrations (mean difference - 1.86, 95% confidence interval - 2.5 to - 1.21, I2 = 71%), serum 1,25(OH)2D concentrations (mean difference 18.91 pg/ml, 95% confidence interval 6.39 to 31.43, I2 = 96%) and renal phosphate reabsorption (mean difference 1.22 mg/dl, 95% confidence interval 0.70 to 1.74, I2 93%). Burosumab treatment improved overall clinical and laboratory findings in patients with X-linked hypophosphatemia.
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Affiliation(s)
- Damiani Kiafzezi
- Postgraduate Program "Research Methodology in Medicine and Health Sciences", Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Athina Stamati
- School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Thomas Karagiannis
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, 541 24, Thessaloniki, Greece
| | - Athanasios Christoforidis
- 1st Paediatric Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Ippokratio General Hospital, Thessaloniki, Greece
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5
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Kamenický P, Briot K, Munns CF, Linglart A. X-linked hypophosphataemia. Lancet 2024; 404:887-901. [PMID: 39181153 DOI: 10.1016/s0140-6736(24)01305-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 08/27/2024]
Abstract
X-linked hypophosphataemia is a genetic disease caused by defects in the phosphate regulating endopeptidase homolog X-linked (PHEX) gene and is characterised by X-linked dominant inheritance. The main consequence of PHEX deficiency is increased production of the phosphaturic hormone fibroblast growth factor 23 (FGF23) in osteoblasts and osteocytes. Chronic exposure to circulating FGF23 is responsible for renal phosphate wasting and decreased synthesis of calcitriol, which decreases intestinal phosphate absorption. These mechanisms result in lifelong hypophosphataemia, impaired growth plate and bone matrix mineralisation, and diverse manifestations in affected children and adults, including some debilitating morbidities and possibly increased mortality. Important progress has been made in disease knowledge and management over the past decade; in particular, targeting FGF23 is a therapeutic approach that has substantially improved outcomes. However, patients affected by this complex disease need lifelong care and innovative treatment strategies, such as gene repair of PHEX, are necessary to further limit the disease burden.
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Affiliation(s)
- Peter Kamenický
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France; Centre de Référence des Maladies du Métabolisme du Calcium et du Phosphate, Service d'Endocrinologie et des Maladies de la Reproduction, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France.
| | - Karine Briot
- Centre de Référence des Maladies du Métabolisme du Calcium et du Phosphate, Service de Rhumatologie, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Craig F Munns
- Department of Endocrinology and Diabetes, Queensland Children's Hospital and Child Health Research Centre and Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Agnès Linglart
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France; Service d'Endocrinologie et du Diabète de l'Enfant, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France
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6
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Phan P, Ternier G, Edirisinghe O, Kumar TKS. Exploring endocrine FGFs - structures, functions and biomedical applications. INTERNATIONAL JOURNAL OF BIOCHEMISTRY AND MOLECULAR BIOLOGY 2024; 15:68-99. [PMID: 39309613 PMCID: PMC11411148 DOI: 10.62347/palk2137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 07/17/2024] [Indexed: 09/25/2024]
Abstract
The family of fibroblast growth factors (FGFs) consists of 22 members with diverse biological functions in cells, from cellular development to metabolism. The family can be further categorized into three subgroups based on their three modes of action. FGF19, FGF21, and FGF23 are endocrine FGFs that act in a hormone-like/endocrine manner to regulate various metabolic activities. However, all three members of the endocrine family require both FGF receptors (FGFRs) and klotho co-receptors to elicit their functions. α-klotho and β-klotho act as scaffolds to bring endocrine FGFs closer to their receptors (FGFRs) to form active complexes. Numerous novel studies about metabolic FGFs' structures, mechanisms, and physiological insights have been published to further understand the complex molecular interactions and physiological activities of endocrine FGFs. Herein, we aim to review the structures, physiological functions, binding mechanisms to cognate receptors, and novel biomedical applications of endocrine FGFs in recent years.
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Affiliation(s)
- Phuc Phan
- Department of Chemistry and Biochemistry, Fulbright College of Art and Sciences, University of ArkansasFayetteville, AR 72701, USA
| | - Gaёtane Ternier
- Department of Chemistry and Biochemistry, Fulbright College of Art and Sciences, University of ArkansasFayetteville, AR 72701, USA
| | - Oshadi Edirisinghe
- Cell and Molecular Biology Program, University of ArkansasFayetteville, AR 72701, USA
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Wu H, Ying H, Zhao W, Sun Y, Wang Y, Chen X, Li G, Yao Y, Xu S, Li T, Fang L, Sun X, Wang N, Xu J, Guan Q, Xia W, Wang L, Gao L, Zhao J, Xu C. Characterization of Novel PHEX Variants in X-linked Hypophosphatemic Rickets and Genotype-PHEX Activity Correlation. J Clin Endocrinol Metab 2024; 109:2242-2255. [PMID: 38442738 PMCID: PMC11318995 DOI: 10.1210/clinem/dgae120] [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: 09/12/2023] [Revised: 12/12/2023] [Accepted: 03/05/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND X-linked hypophosphatemia (XLHR) is the most common genetic form of hypophosphatemic rickets (HR), which is caused by phosphate regulating endopeptidase homolog X-linked (PHEX) gene mutation. At present, the genotype-phenotype relationship of XLHR and the pathogenic role of PHEX are not fully understood. METHODS In this study, we summarized clinical features in a new cohort of 49 HR patients and detected 16 novel PHEX and 5 novel non-PHEX variants. Subsequently, we studied the pathogenesis of new variants by protein expression, glycosylation analysis, subcellular localization, and endopeptidase activity. RESULTS The results showed that missense variants (Q189H and X750R) slightly reduced protein expression without obviously altering protein length and localization, whereas truncating variants significantly impaired the synthesis of PHEX and produced a shorter immature protein in cells. Interestingly, no evident correlation was observed between mutation types and clinical phenotypes. However, when we analyzed the relationship between PHEX activity and serum phosphorus level, we found that patients with low PHEX activity tended to have severe hypophosphatemia and high rickets severity score. Following this observation, we established 2 new knock-in XLHR mouse models with 2 novel Phex variants (c.T1349C and c.C426G, respectively) using CRISPR/Cas9 technology. Both mouse models demonstrated clinical manifestations of XLHR seen in patients, and PhexC426G mice showed more severe phenotype than PhexT1349C mice, which further confirmed the rationality of genotype-PHEX enzymatic activity correlation analysis. CONCLUSION Therefore, our findings demonstrated that novel PHEX variants could disrupt protein function via affecting protein synthesis, post-translational modification, cellular trafficking, and catalytic activity. Our study facilitates a better understanding of XLHR pathogenic mechanism and PHEX activity-phenotype correlation, which is of crucial importance for future diagnosis and treatment of XLHR.
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Affiliation(s)
- Huixiao Wu
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan 250021, Shandong, China
| | - Hui Ying
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan 250021, Shandong, China
| | - Wanyi Zhao
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan 250021, Shandong, China
| | - Yan Sun
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
| | - Yanzhou Wang
- Department of Pediatric Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
| | - Xinyu Chen
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan 250021, Shandong, China
| | - Guimei Li
- Department of Pediatric, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
| | - Yangyang Yao
- Department of Pediatric Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
| | - Shuo Xu
- Department of Medical Imaging, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
| | - Tianyou Li
- Department of Pediatric Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
| | - Li Fang
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan 250021, Shandong, China
| | - Xiaoqing Sun
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan 250021, Shandong, China
| | - Ning Wang
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan 250021, Shandong, China
| | - Jin Xu
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan 250021, Shandong, China
| | - Qingbo Guan
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan 250021, Shandong, China
| | - Weibo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Li Wang
- Independent Researcher, Tucson, AZ 85705, USA
| | - Ling Gao
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan 250021, Shandong, China
| | - Jiajun Zhao
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan 250021, Shandong, China
| | - Chao Xu
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, China
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan 250021, Shandong, China
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Baroncelli GI, Grandone A, Aversa A, Sessa MR, Pelosini C, Michelucci A, Toschi B, Manca M, Isola A, Comberiati P. Safety and efficacy of burosumab in improving phosphate metabolism, bone health, and quality of life in adolescents with X-linked hypophosphatemic rickets. Eur J Med Genet 2024; 70:104958. [PMID: 38950880 DOI: 10.1016/j.ejmg.2024.104958] [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: 09/25/2023] [Revised: 05/21/2024] [Accepted: 06/28/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND AND OBJECTIVE X-linked hypophosphatemic rickets (XLH) is due to loss-of-function mutations in the phosphate-regulating endopeptidase homologue on the X chromosome (PHEX) that lead to increased fibroblast growth factor 23 (FGF23) production. FGF23 excess causes renal phosphate wasting and insufficient 1,25-dihydroxyvitamin D (1,25(OH)2D) synthesis with reduced intestinal phosphate absorption, ultimately resulting in chronic hypophosphatemia. Children with XLH show typical skeletal lesions of rickets, deformities of the lower limbs, stunted growth with disproportionate short stature, bone pain, and physical dysfunctions. Burosumab, a fully human IgG1 monoclonal antibody that binds to FGF23 to inhibit its activity, is more effective to improve the biochemical and clinical signs of XLH than conventional treatment with phosphate supplements and vitamin D active metabolites. Data on adolescents with XLH during the transition period to young adulthood are few. In this prospective case series, we aimed to assess safety and efficacy of burosumab in adolescents with XLH who discontinued long-term conventional therapy. METHODS Five Caucasian adolescents (4 males, 1 female; mean age 15.4 ± 1.5 years) with XLH were recruited and switched from conventional treatment to burosumab (0.8-1.2 mg/kg, s. c. QW2). Burosumab was continued for 12-48 months and, once discontinued, patients were followed-up for 6-12 months. In all patients, serum calcium, phosphate, alkaline phosphatase (ALP), parathyroid hormone (PTH), and 1,25(OH)2D levels, and renal tubular reabsorption of phosphate (TmP/GFR) values were assessed at entry and during burosumab. Intact FGF23 plasma levels were measured at entry. Patient-reported outcomes (PROs) were assessed at entry and every 3-6 months to evaluate the impact of low extremity pain, stiffness, and difficulties performing daily activities. RESULTS At entry, all patients showed hypophosphatemia, increased intact FGF23 levels, reduced TmP/GFR, insufficient 1,25(OH)2D levels, and in four out of five increased ALP levels. Two patients had radiological signs of rickets. During burosumab, all patients showed a significant increase in serum phosphate and 1,25(OH)2D levels, and in TmP/GFR values (P < 0.05 - P < 0.0001). Serum ALP levels significantly declined (P < 0.05) to normal values. No changes of serum calcium and PTH levels (PNS) were found during burosumab. PROs significantly improved (P < 0.02 - P < 0.0001) in all patients. Four patients discontinued burosumab when they turned 18 or 19, whereas one continued the treatment since he was still younger than 18 during the study period. Four patients who suspended burosumab showed a rapid decline in serum phosphate and 1,25(OH)2D levels and in TmP/GFR values; serum ALP levels increased, and PROs progressively worsened with a significant reduction in quality of life. These consequences were not observed in the patient who continued burosumab treatment. DISCUSSION Our data showed that conventional treatment improved only in part the signs and symptoms of XLH. Burosumab was well tolerated and was effective in improving phosphate metabolism, bone health, and PROs. All the benefits of burosumab were lost after its discontinuation. These results suggested that continuing burosumab is required to achieve and maintain the clinical benefits of the treatment during the transition to young adulthood in patients with XLH.
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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.
| | - Anna Grandone
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio Aversa
- Department of Experimental and Clinical Medicine, University Magna Graecia, Catanzaro, Italy
| | - Maria Rita Sessa
- Chemistry and Endocrinology Laboratory, Department of Laboratory Medicine, University Hospital, Pisa, Italy
| | - Caterina Pelosini
- Chemistry and Endocrinology Laboratory, Department of Laboratory Medicine, University Hospital, Pisa, Italy
| | - Angela Michelucci
- Unit of Molecular Genetics, Department of Laboratory Medicine, University Hospital, Pisa, Italy
| | - Benedetta Toschi
- Section of Medical Genetics, Department of Medical and Oncological Area, University Hospital, Pisa, Italy
| | - Mario Manca
- Unit of Orthopedics, Usl Northwest-Tuscany, Versilia Hospital, Camaiore, Italy
| | - Alessandro Isola
- Unit of Orthopedics, Usl Northwest-Tuscany, Versilia Hospital, Camaiore, Italy
| | - Pasquale Comberiati
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy
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Cotti S, Di Biagio C, Huysseune A, Koppe W, Forlino A, Witten PE. Matrix first, minerals later: fine-tuned dietary phosphate increases bone formation in zebrafish. JBMR Plus 2024; 8:ziae081. [PMID: 39045128 PMCID: PMC11264301 DOI: 10.1093/jbmrpl/ziae081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 06/13/2024] [Indexed: 07/25/2024] Open
Abstract
Bone matrix formation and mineralization are two closely related, yet separated processes. Matrix formation occurs first, mineralization is a second step strictly dependent on the dietary intake of calcium and phosphorus (P). However, mineralization is commonly used as diagnostic parameter for bone-related diseases. In this context, bone loss, often characterized as a condition with reduced bone mineral density, represents a major burden for human health, for which increased dietary mineral intake is generally recommended. Using a counterintuitive approach, we use a low-P diet followed by a sufficient-P intake to increase bone volume. We show in zebrafish by histology, qPCR, micro-CT, and enzyme histochemistry that a two-months period of reduced dietary P intake stimulates extensive formation of new bone matrix, associated with the upregulation of key genes required for both bone matrix formation and mineralization. The return to a P-sufficient diet initiates the mineralization of the abundant matrix previously deposited, thus resulting in a striking increase of the mineralized bone volume as proven at the level of the vertebral column, including vertebral bodies and arches. In summary, bone matrix formation is first stimulated with a low-P diet, and its mineralization is later triggered by a sufficient-P dietary intake. In zebrafish, the uncoupling of bone formation and mineralization by alternating low and sufficient dietary P intake significantly increases the bone volume without causing skeletal malformations or ectopic mineralization. A modification of this approach to stimulate bone formation, optimized for mammalian models, can possibly open opportunities to support treatments in patients that suffer from low bone mass.
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Affiliation(s)
- Silvia Cotti
- Biology Department, Evolutionary Developmental Biology, Ghent University, 9000 Gent, Belgium
- Department of Molecular Medicine, Biochemistry Unit, University of Pavia, 27100 Pavia, Italy
| | - Claudia Di Biagio
- Biology Department, Evolutionary Developmental Biology, Ghent University, 9000 Gent, Belgium
- Department of Biology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Ann Huysseune
- Biology Department, Evolutionary Developmental Biology, Ghent University, 9000 Gent, Belgium
- Department of Zoology, Charles University, 12800 Prague, Czech Republic
| | | | - Antonella Forlino
- Department of Molecular Medicine, Biochemistry Unit, University of Pavia, 27100 Pavia, Italy
| | - P Eckhard Witten
- Biology Department, Evolutionary Developmental Biology, Ghent University, 9000 Gent, Belgium
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Radler C, Calder P, Eidelman M, Horn J, Kold S, Langendörfer M, Manner HM, Sedki I, Vogt B. What's new in pediatric lower limb reconstruction? J Child Orthop 2024; 18:349-359. [PMID: 39100980 PMCID: PMC11295377 DOI: 10.1177/18632521241258351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 04/15/2024] [Indexed: 08/06/2024] Open
Abstract
The last years brought many advances relevant to lower limb reconstruction. It feels like guided growth has been looked at from every angle, and still there are new emerging concepts like rotational guided growth waiting to be validated. New hexapod external devices are more accurate and easier to use, and new unilateral fixators allow for more versatile and stable fixation and lengthening. Intramedullary nail lengthening has found its place as a standard procedure for various diagnoses in children and young adults. First results of new and exciting approaches like extramedullary implantable nail lengthening and lengthening plates have been reported. Pharmaceutical treatment has changed the course of certain diseases and must be integrated and considered when making a reconstructive treatment plan. As reconstructive surgery is rapidly advancing so are the technical options for prosthetic fitting, which makes it difficult for caregivers as well as for parents to make the decision between reconstruction and amputation surgery for the most severe cases of congenital deficiencies. This review is highlighting new developments of lower limb reconstruction and is reviewing the current literature.
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Affiliation(s)
- Christof Radler
- Department of Pediatric Orthopaedics and Adult Foot and Ankle Surgery, Orthopaedic Hospital Speising, Vienna, Austria
| | | | - Mark Eidelman
- Ruth Children’s Hospital, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel
| | - Joachim Horn
- Section of Children’s Orthopaedics and Reconstructive Surgery, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Søren Kold
- Department of Orthopaedics, Aalborg University Hospital, Aalborg, Denmark
| | - Micha Langendörfer
- Department of Paediatric Orthopaedics, Asklepios Klinik Sankt Augustin, Sankt Augustin, Germany
| | - Hans Michael Manner
- Department of Paediatric Orthopaedics, Schulthess Clinic, Zurich, Switzerland
| | - Imad Sedki
- Royal National Orthopaedic Hospital, London, UK
| | - Bjoern Vogt
- Paediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital, Muenster, Germany
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11
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Michigami T, Kang HG, Namba N, Ito N, Kubota T, Shintani A, Kabata D, Kanematsu M, Nishida Y, Fukumoto S, Ozono K. Burosumab treatment of X-linked hypophosphatemia patients: interim analysis of the SUNFLOWER longitudinal, observational cohort study. JBMR Plus 2024; 8:ziae079. [PMID: 39015507 PMCID: PMC11250265 DOI: 10.1093/jbmrpl/ziae079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 05/31/2024] [Accepted: 06/07/2024] [Indexed: 07/18/2024] Open
Abstract
X-linked hypophosphatemia (XLH) is a genetic disease that results in excessive FGF23, chronic hypophosphatemia, and musculoskeletal abnormalities, with affected patients experiencing symptoms such as bone pain, bone deformity, fracture, and pseudofracture. Burosumab is a fully human monoclonal antibody that binds to FGF23, improving lowered serum 1,25(OH)2D and phosphate levels in patients with XLH. There are insufficient data on the use of burosumab, its safety, and the outcomes of treated patients in a real-world setting. The SUNFLOWER (Study of longitUdinal observatioN For patients with X-Linked hypOphosphatemic rickets/osteomalacia in collaboration With Asian partnERs) study is an ongoing longitudinal, observational cohort study of patients with XLH in Japan and South Korea. Enrollment occurred between April 2018 and December 2020. This interim analysis compared the background characteristics of patients who received burosumab with those who did not, and assessed improvements in biomarkers, physical and motor function, health-related quality-of-life (HRQOL) and other patient-reported outcome (PRO) measures, as well as the safety of burosumab treatment in 143 Japanese patients from 15 institutions over 6 mo. The patients had a median [interquartile range] age of 17.5 [11.0, 38.8] yr and 98 (68.5%) were female. Among patients aged <18 and ≥18 yr, 40/73 (54.8%) and 25/70 (35.7%) received burosumab, respectively. More patients aged ≥18 who received burosumab had bone pain at baseline vs those not treated with burosumab (6/25, 24.0% vs 2/45, 4.4%, p=.021). Patients treated with burosumab had improved serum phosphate and 1,25(OH)2D levels; moreover, rickets severity and HRQOL/PRO measures, such as pain, appeared to improve over 6 mo of burosumab treatment, and no new safety concerns were identified. This study identified trends in the background characteristics of patients with XLH who receive burosumab in real-world clinical practice. Furthermore, the results support the use of burosumab therapy in real-world settings.
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Affiliation(s)
- Toshimi Michigami
- Department of Bone and Mineral Research, Osaka Women’s and Children’s Hospital, Osaka Prefectural Hospital Organization, Osaka 594-1101, Japan
| | - Hee Gyung Kang
- Department of Pediatric Nephrology, Seoul National University Children’s Hospital, Seoul 03080, Republic of Korea
| | - Noriyuki Namba
- Division of Pediatrics and Perinatology, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan
| | - Nobuaki Ito
- Division of Therapeutic Development for Intractable Bone Diseases, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
| | - Takuo Kubota
- Department of Pediatrics, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Ayumi Shintani
- Department of Medical Statistics, Graduate School of Medicine, Osaka Metropolitan University, Osaka 545-8585, Japan
| | - Daijiro Kabata
- Department of Medical Statistics, Graduate School of Medicine, Osaka Metropolitan University, Osaka 545-8585, Japan
| | - Masanori Kanematsu
- Medical Affairs Department, Kyowa Kirin Co., Ltd., Tokyo 100-0004, Japan
| | - Yayoi Nishida
- Medical Affairs Department, Kyowa Kirin Co., Ltd., Tokyo 100-0004, Japan
| | - Seiji Fukumoto
- Department of Diabetes and Endocrinology, Tamaki-Aozora Hospital, Tokushima 779-3125, Japan
| | - Keiichi Ozono
- Center for Promoting Treatment of Intractable Diseases, ISEIKAI International General Hospital, Osaka 530-0052, Japan
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12
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Boardman-Pretty F, Clift AK, Mahon H, Sawoky N, Mughal MZ. The Diagnostic Odyssey in Children and Adolescents With X-linked Hypophosphatemia: Population-Based, Case-Control Study. J Clin Endocrinol Metab 2024; 109:2012-2018. [PMID: 38335127 PMCID: PMC11244174 DOI: 10.1210/clinem/dgae069] [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: 09/19/2023] [Revised: 01/09/2024] [Accepted: 02/08/2024] [Indexed: 02/12/2024]
Abstract
CONTEXT X-linked hypophosphatemia (XLH) is a rare genetic disorder causing renal phosphate wasting, which predicates musculoskeletal manifestations such as rickets. Diagnosis is often delayed. OBJECTIVE To explore the recording of clinical features, and the diagnostic odyssey of children and adolescents with XLH in primary care electronic healthcare records (EHRs) in the United Kingdom. METHODS Using the Optimum Patient Care Research Database, individuals aged 20 years or younger after January 1, 2000, at date of recorded XLH diagnosis were identified using Systematized Nomenclature of Medicine Clinical Terms (SNOMED)/Read codes and age-matched to 100 controls. Recording of XLH-related clinical features was summarized then compared between cases and controls using chi-squared or Fisher's exact test. RESULTS In total, 261 XLH cases were identified; 99 met the inclusion criteria. Of these, 84/99 had at least 1 XLH-related clinical feature recorded in their primary care EHR. Clinical codes for rickets, genu varum, and low phosphate were recorded prior to XLH diagnosis in under 20% of cases (median of 1, 1, and 3 years prior, respectively). Rickets, genu varum, low phosphate, nephrocalcinosis, and growth delay were significantly more likely to be recorded in cases. CONCLUSION This characterization of the EHR phenotypes of children and adolescents with XLH may inform future case-finding approaches to expedite diagnosis in primary care.
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Affiliation(s)
| | | | | | - Nadine Sawoky
- International Medical Affairs, Kyowa Kirin, Galashiels, TD1 1QH, UK
| | - M Zulf Mughal
- Department of Paediatric Endocrinology & Metabolic Bone Diseases, Royal Manchester Children’s Hospital, Manchester, M13 9WL, UK
- The Faculty of Biology, Medicine & Health, University of Manchester, Manchester, M13 9PL, UK
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13
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Alconcher L, Lucarelli L, Bronfen S. X-linked hypophosphatemia: long-term outcomes of different treatment strategies. Nefrologia 2024; 44:605-608. [PMID: 39097515 DOI: 10.1016/j.nefroe.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/30/2023] [Accepted: 05/07/2023] [Indexed: 08/05/2024] Open
Affiliation(s)
- Laura Alconcher
- Unidad Pediátrica de Nefrología, Hospital Interzonal General Dr. José Penna, Bahía Blanca, Buenos Aires, Argentina.
| | - Lucas Lucarelli
- Unidad Pediátrica de Nefrología, Hospital Interzonal General Dr. José Penna, Bahía Blanca, Buenos Aires, Argentina
| | - Sabrina Bronfen
- Unidad Pediátrica de Nefrología, Hospital Interzonal General Dr. José Penna, Bahía Blanca, Buenos Aires, Argentina
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14
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Wilson R, Mukherjee-Roy N, Gattineni J. The role of fibroblast growth factor 23 in regulation of phosphate balance. Pediatr Nephrol 2024:10.1007/s00467-024-06395-5. [PMID: 38874635 DOI: 10.1007/s00467-024-06395-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 04/22/2024] [Accepted: 04/22/2024] [Indexed: 06/15/2024]
Abstract
Phosphate is essential for numerous biological processes, and serum levels are tightly regulated to accomplish these functions. The regulation of serum phosphate in a narrow physiological range is a well-orchestrated process and involves the gastrointestinal (GI) tract, bone, kidneys, and several hormones, namely, parathyroid hormone, fibroblast growth factor 23 (FGF23), and 1,25-dihydroxyvitamin D (1,25 Vitamin D). Although primarily synthesized in the bone, FGF23, an endocrine FGF, acts on the kidney to regulate phosphate and Vitamin D homeostasis by causing phosphaturia and reduced levels of 1,25 Vitamin D. Recent studies have highlighted the complex regulation of FGF23 including transcriptional and post-translational modification and kidney-bone cross talk. Understanding FGF23 biology has led to the identification of novel therapeutic agents to treat diseases that disrupt phosphate metabolism secondary to FGF23. The focus of this review is to provide an overview of phosphate homeostasis, FGF23 biology, and the role of FGF23 in phosphate balance.
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Affiliation(s)
| | - Neije Mukherjee-Roy
- Division of Pediatric Nephrology, Department of Pediatrics, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, USA
| | - Jyothsna Gattineni
- Division of Pediatric Nephrology, Department of Pediatrics, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, USA.
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15
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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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16
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Chaturvedi D, Mehasi TE, Benbrahim A, ElDeeb L, Deeb A. Lessons learned from the real-world diagnosis and management of hereditary hypophosphatemic rickets. Bone Rep 2024; 21:101753. [PMID: 39011543 PMCID: PMC11247149 DOI: 10.1016/j.bonr.2024.101753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 03/20/2024] [Indexed: 07/17/2024] Open
Abstract
Hypophosphatemic rickets, which is often hereditary, is still under- or misdiagnosed in both children and adults, denying these individuals access to optimal management and genetic counseling. There have been recent calls to compile real-world data and share best practice on these rare conditions to guide clinical decision-making. Here we present eight clinical vignettes of patients with hypophosphatemic rickets encountered in our tertiary pediatric endocrinology practice. We describe the clinical features, genetics, and management of four cases of X-linked hypophosphatemia (PHEX mutations), one each of autosomal recessive hypophosphatemic rickets (DMP1 mutation) and autosomal recessive vitamin D-dependent rickets type 1A (CYP27B1 mutation), and two cases of distal renal tubular acidosis with FOXI1 mutation-associated hypophosphatemic rickets. Our cases prompt consideration of the (i) frequent misdiagnosis of hypophosphatemic rickets in clinical practice and the importance of comprehensive genetic testing; (ii) variable expressivity of the causative mutations; and (iii) a lack of responsiveness and/or compliance to conventional therapy and the value of burosumab in modern management, provided access is equitable. These cases highlight common real-world themes and challenges to managing patients presenting with these diverse conditions, especially the burden of disease hidden by misdiagnosis. In sharing these cases, we hope to raise awareness of these conditions, promote best practice in genetic diagnosis and management, and further advocate for reimbursement equity for the best available therapies.
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Affiliation(s)
- Deepti Chaturvedi
- Paediatric Endocrine Division, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Taif EmadEldin Mehasi
- Paediatric Endocrine Division, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Assia Benbrahim
- Paediatric Endocrine Division, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Lubna ElDeeb
- Clinical Trial Unit, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Asma Deeb
- Paediatric Endocrine Division, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
- Faculty of Health and Science, Khalifa University, Abu Dhabi, UAE
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Arhar A, Pavlič A, Hočevar L. Characteristics of oral health of patients with X-linked hypophosphatemia: case reports and literature review. BDJ Open 2024; 10:42. [PMID: 38821917 PMCID: PMC11143263 DOI: 10.1038/s41405-024-00223-6] [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: 02/05/2024] [Revised: 04/22/2024] [Accepted: 04/25/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND Oral health is impaired in X-linked hypophosphatemia (XLH), resulting in delayed dental development, malocclusion, and radiographic abnormalities. This study investigates the oral manifestations in Slovenian XLH patients, focusing on enamel and dentin abnormalities and a literature review of spontaneous periapical abscesses in XLH cases. OBJECTIVES To report XLH patients with specific oral signs and symptoms, histological analysis of affected teeth, and review of reported cases of XLH patients with spontaneous periapical abscesses. METHODS Case reports: Seven XLH patients from the National Registry of Patients with Rare Diseases underwent a detailed oral examination, including X-ray reviews. The patients who were expected to have tooth exfoliation or extraction were asked to donate their teeth for histological analysis by scanning electron microscopy. LITERATURE SEARCH A literature search of four electronic databases and a manual bibliography search aimed to identify documented cases of XLH with periapical abscesses up to January 21, 2024. Inclusion criteria were confirmed XLH patients with periapical abscesses in English peer-reviewed publications. RESULTS Tooth samples from three XLH patients showed reduced dentin mineralisation, affecting one-third to one-half of the outer dentin. Inadequate mineralisation, uneven dentin tubules, and cracks and chipping in the enamel were observed, indicating mineralisation deviations. Similar cracks extended into the dentin and were also present in the root of the examined tooth. Based on the content of the 75 items identified in the search, spontaneous abscesses are not uncommon in patients with XLH. CONCLUSIONS XLH significantly affects patients' lives and requires lifelong treatment. Dental examinations consistently revealed oral problems, including malocclusion. Histological analysis confirmed structural changes, especially in the dentin. Despite continued treatment, XLH patients may have an increased risk of oral pathologies. Further research is needed to understand the impact of XLH and its treatment on dental health.
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Affiliation(s)
- Ana Arhar
- Department of Paediatric and Preventive Dentistry, Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana, Slovenia
| | - Alenka Pavlič
- Department of Paediatric and Preventive Dentistry, Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana, Slovenia
- Department of Paediatric and Preventive Dentistry, University Medical Centre Ljubljana, Zaloška 2, Ljubljana, Slovenia
| | - Luka Hočevar
- Department of Paediatric and Preventive Dentistry, Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana, Slovenia.
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M. Boot A, Ariceta G, Beck-Nielsen SS, Brandi ML, Briot K, Collantes CDL, Giannini S, Haffner D, Keen R, Levtchenko E, Mughal MZ, Makitie O, Nilsson O, Schnabel D, Tripto-Shkolnik L, Zillikens MC, Liu J, Tudor A, Emma F. Real-world non-interventional post-authorization safety study of long-term use of burosumab in children and adolescents with X-linked hypophosphatemia: first interim analysis. Ther Adv Chronic Dis 2024; 15:20406223241247643. [PMID: 38764445 PMCID: PMC11102685 DOI: 10.1177/20406223241247643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 04/01/2024] [Indexed: 05/21/2024] Open
Abstract
Background X-linked hypophosphatemia (XLH) is a rare, progressive disorder characterized by excess fibroblast growth factor 23 (FGF23), causing renal phosphate-wasting and impaired active vitamin D synthesis. Burosumab is a recombinant human monoclonal antibody that inhibits FGF23, restoring patient serum phosphate levels. Safety data on long-term burosumab treatment are currently limited. Objectives This post-authorization safety study (PASS) aims to monitor long-term safety outcomes in children and adolescents (1-17 years) treated with burosumab for XLH. This first interim analysis reports the initial PASS safety outcomes. Design A 10-year retrospective and prospective cohort study. Methods This PASS utilizes International XLH Registry (NCT03193476) data, which includes standard diagnostic and monitoring practice data at participating European centers. Results At data cut-off (13 May 2021), 647 participants were included in the International XLH Registry; 367 were receiving burosumab, of which 67 provided consent to be included in the PASS. Mean (SD) follow-up time was 2.2 (1.0) years. Mean (SD) age was 7.3 (4.3) years (range 1.0-17.5 years). Mean duration of burosumab exposure was 29.7 (25.0) months. Overall, 25/67 participants (37.3%) experienced ⩾1 adverse event (AE) during follow-up; 83 AEs were reported. There were no deaths, no AEs leading to treatment withdrawal, nor serious AEs related to treatment. The most frequently reported AEs were classified as 'musculoskeletal and connective tissue disorders', with 'pain in extremity' most frequently reported, followed by 'infections and infestations', with 'tooth abscess' the most frequently reported. Conclusion In this first interim analysis of the PASS, covering the initial 2 years of data collection, the safety profile of burosumab is consistent with previously reported safety data. The PASS will provide long-term safety data over its 10-year duration for healthcare providers and participants with XLH that contribute to improvements in the knowledge of burosumab safety. Trial registration European Union electronic Register of Post-Authorisation Studies: EUPAS32190.
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Affiliation(s)
- Annemieke M. Boot
- Department of Pediatric Endocrinology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9713 GZ, The Netherlands
| | - Gema Ariceta
- Department of Pediatric Nephrology, University Hospital Vall d’Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Signe Sparre Beck-Nielsen
- Centre for Rare Diseases, Pediatric Department, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Karine Briot
- AP-HP, Department of Rheumatology, Cochin Hospital, Paris, France
| | - Carmen de Lucas Collantes
- Pediatric Nephrology, Hospital Infantil Universitario Niño Jesús, Universidad Autónoma de Madrid, Madrid, Spain
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Richard Keen
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - Elena Levtchenko
- Department of Pediatric Nephrology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - M. Zulf Mughal
- Department of Pediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Outi Makitie
- Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ola Nilsson
- Division of Pediatric Endocrinology, Center for Molecular Medicine, Department of Women’s and Children’s Health, Karolinska Institutet and University Hospital, Stockholm, Sweden
- Department of Pediatrics and School of Medical Sciences, Örebro University and University Hospital, Örebro, Sweden
| | - Dirk Schnabel
- Center for Chronically Sick Children, Pediatric Endocrinology, Charitè, University Medicine, Berlin, Germany
| | - Liana Tripto-Shkolnik
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel HaShomer, Israel
| | | | | | | | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
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Dodamani MH, Kumar SC, Bhattacharjee S, Barnabas R, Kumar S, Ranjan Lila A, Samad Memon S, Karlekar M, A Patil V, R Bandgar T. Efficacy and safety of burosumab compared with conventional therapy in patients with X-linked hypophosphatemia: A systematic review. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2024; 68:e230242. [PMID: 38788147 PMCID: PMC11156178 DOI: 10.20945/2359-4292-2023-0242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 11/29/2023] [Indexed: 05/26/2024]
Abstract
Burosumab, a monoclonal antibody directed against the fibroblast growth factor 23 (FGF23), has been approved for the treatment of X-linked hypophosphatemia (XLH). We conducted a systematic review to compare the efficacy and safety of burosumab versus conventional therapy (phosphorus and calcitriol) on XLH treatment. After a comprehensive literature search on MEDLINE/PubMed and Embase, we found nine studies for inclusion in the analysis. Risk of bias was assessed, and a random-effects model was used to determine the effect size. Clinical, biochemical, and radiological parameters of disease severity before and after treatment were analyzed and expressed in standardized mean difference (SMD). Burosumab resulted in normalization of phosphate homeostasis with an increase in renal tubular phosphate reabsorption and significant resolution of skeletal lesions (change in Thacher's total rickets severity score SMD: -1.46, 95% confidence interval [CI]: -1.76 to -1.17, p < 0.001, improvement in deformities, and decline in serum alkaline phosphatase levels [SMD: 130.68, 95% CI: 125.26-136.1, p < 0.001)]. Conventional therapy led to similar improvements in all these parameters but to a lower degree. In adults, burosumab normalized phosphorus levels (SMD: 1.23, 95% CI: 0.98-1.47, p < 0.001) with resultant clinical improvement. Burosumab treatment was well tolerated, with only mild treatment-related adverse effects. The present review indicates a potential role for burosumab in improving rickets, deformities, and growth in children with XLH. Given its superior efficacy and safety profile, burosumab could be an effective therapeutic option in children. We suggest further studies comparing burosumab versus conventional therapy in children and adults with XLH.
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Affiliation(s)
| | | | - Samiksha Bhattacharjee
- Department of Clinical Pharmacology, Post-graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rohit Barnabas
- Department of Endocrinology, Seth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Sandeep Kumar
- Department of Endocrinology, Seth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Anurag Ranjan Lila
- Department of Endocrinology, Seth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Saba Samad Memon
- Department of Endocrinology, Seth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Manjiri Karlekar
- Department of Endocrinology, Seth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Virendra A Patil
- Department of Endocrinology, Seth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Tushar R Bandgar
- Department of Endocrinology, Seth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India,
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20
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Brener A, Cleper R, Baruch G, Rothschild E, Yackobovitch-Gavan M, Beer G, Zeitlin L, Kapusta L. Cardiovascular health in pediatric patients with X-linked hypophosphatemia under two years of burosumab therapy. Front Endocrinol (Lausanne) 2024; 15:1400273. [PMID: 38818505 PMCID: PMC11137213 DOI: 10.3389/fendo.2024.1400273] [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: 03/13/2024] [Accepted: 04/22/2024] [Indexed: 06/01/2024] Open
Abstract
Introduction X-linked hypophosphatemia (XLH) is caused by an inactivating mutation in the phosphate-regulating endopeptidase X-linked (PHEX) gene whose defective product fails to control phosphatonin fibroblast growth factor 23 (FGF23) serum levels. Although elevated FGF23 levels have been linked with detrimental cardiac effects, the cardiologic outcomes in XLH patients have been subject to debate. Our study aimed to evaluate the prevalence and severity of cardiovascular morbidity in pediatric XLH patients before, during, and after a 2-year treatment period with burosumab, a recombinant anti-FGF23 antibody. Methods This prospective observational study was conducted in a tertiary medical center, and included 13 individuals with XLH (age range 0.6-16.2 years) who received burosumab every 2 weeks. Clinical assessment at treatment initiation and after .5, 1, and 2 years of uninterrupted treatment included anthropometric measurements and cardiologic evaluations (blood pressure [BP], electrocardiogram, conventional echocardiography, and myocardial strain imaging). Results The linear growth of all patients improved significantly (mean height z-score: from -1.70 ± 0.80 to -0.96 ± 1.08, P=0.03). Other favorable effects were decline in overweight/obesity rates (from 46.2% to 23.1%) and decreased rates of elevated BP (systolic BP from 38.5% to 15.4%; diastolic BP from 38.5% to 23.1%). Electrocardiograms revealed no significant abnormality throughout the study period. Cardiac dimensions and myocardial strain parameters were within the normative range for age at baseline and remained unchanged during the study period. Conclusion Cardiologic evaluations provided reassurance that 2 years of burosumab therapy did not cause cardiac morbidity. The beneficial effect of this treatment was a reduction in cardiovascular risk factors, as evidenced by the lower prevalence of both overweight/obesity and elevated BP.
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Affiliation(s)
- Avivit Brener
- Institute of Pediatric Endocrinology and Diabetes, Dana-Dwek Children’s Hospital, Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roxana Cleper
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Pediatric Nephrology Unit, Dana-Dwek Children’s Hospital, Sourasky Medical Center, Tel Aviv, Israel
| | - Guy Baruch
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Internal Medicine, Sourasky Medical Center, Tel Aviv, Israel
| | - Ehud Rothschild
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Internal Medicine, Sourasky Medical Center, Tel Aviv, Israel
| | - Michal Yackobovitch-Gavan
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gil Beer
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Pediatric Cardiology Unit, Dana-Dwek Children’s Hospital, Sourasky Medical Center, Tel Aviv, Israel
| | - Leonid Zeitlin
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Metabolic Bone Disease Unit, Pediatric Orthopedic Department, Dana-Dwek Children’s Hospital, Sourasky Medical Center, Tel Aviv, Israel
| | - Livia Kapusta
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Pediatric Cardiology Unit, Dana-Dwek Children’s Hospital, Sourasky Medical Center, Tel Aviv, Israel
- Department of Pediatrics, Amalia Children’s Hospital, Radboud University Medical Centre, Nijmegen, Netherlands
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Chowdry F, Miller KM, Altun E, Wobker SE, Gottesman GS, Al-Ahmadie H, Rose TL, Wallen EM, Milowsky MI. Inflammatory myofibroblastic tumor in a patient with X-Linked hypophosphatemia: A case of Occam's razor or Hickam's dictum? Urol Case Rep 2024; 54:102710. [PMID: 38827529 PMCID: PMC11143430 DOI: 10.1016/j.eucr.2024.102710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/13/2024] [Indexed: 06/04/2024] Open
Abstract
We present the case of a patient with X-Linked Hypophosphatemia (XLH) and an inflammatory myofibroblastic tumor (IMT) of the bladder which prompted further investigation into the possible relationship between XLH and IMT i.e. a case of Occam's Razor or Hickam's Dictum?
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Affiliation(s)
- Farhan Chowdry
- University of North Carolina (UNC) School of Medicine, Chapel Hill, NC, USA
| | - Kelsey M. Miller
- Department of Pathology and Lab Medicine, UNC, Chapel Hill, NC, USA
| | - Ersan Altun
- University of North Carolina (UNC) School of Medicine, Chapel Hill, NC, USA
- Department of Radiology, UNC, Chapel Hill, NC, USA
- Department of Urology, UNC, Chapel Hill, NC, USA
| | - Sara E. Wobker
- University of North Carolina (UNC) School of Medicine, Chapel Hill, NC, USA
- Department of Pathology and Lab Medicine, UNC, Chapel Hill, NC, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
- Department of Urology, UNC, Chapel Hill, NC, USA
| | - Gary S. Gottesman
- Division of Bone and Mineral Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Hikmat Al-Ahmadie
- Department of Pathology and Laboratory Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Tracy L. Rose
- University of North Carolina (UNC) School of Medicine, Chapel Hill, NC, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
- Division of Oncology, Department of Medicine, UNC, Chapel Hill, NC, USA
- Department of Urology, UNC, Chapel Hill, NC, USA
| | | | - Matthew I. Milowsky
- University of North Carolina (UNC) School of Medicine, Chapel Hill, NC, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
- Division of Oncology, Department of Medicine, UNC, Chapel Hill, NC, USA
- Department of Urology, UNC, Chapel Hill, NC, USA
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22
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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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23
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Gun ZH, Osamor C, Taylor J, Li X, Szymczuk V, Boyce AM. Serum Phosphorus as a Driver of Skeletal Morbidity in Fibrous Dysplasia. J Clin Endocrinol Metab 2024; 109:1334-1340. [PMID: 37975816 PMCID: PMC11031212 DOI: 10.1210/clinem/dgad671] [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: 06/30/2023] [Revised: 09/19/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023]
Abstract
CONTEXT Fibrous dysplasia (FD) results in fractures, pain, and deformities. Abnormal osteoprogenitor cells overproduce FGF23, leading to hyperphosphaturia in most patients and frank hypophosphatemia in a subset. Studies suggest hypophosphatemia is associated with increased FD-related morbidity. However, the relationship between phosphorus and skeletal complications has not been investigated, and the optimal therapeutic target has not been determined. OBJECTIVE Characterize the impact of serum phosphorus on FD-related morbidity and identify levels associated with increased skeletal complications. METHODS Natural history study with 240 subjects at a clinical research center who had ≥1 fasting phosphorus level, determined as age- and sex-adjusted Z-scores. Subjects were categorized based on frank hypophosphatemia (Z-score ≤ -2; n = 48); low-normophosphatemia (> -2 to ≤ -1; n = 66); and high-normophosphatemia (> -1 to ≤ 2; n = 125). Main outcomes were fractures, orthopedic surgeries, and scoliosis. RESULTS Subjects with frank and low-normophosphatemia had increased fracture and surgery rates vs high-normophosphatemia. The prevalence of moderate to severe scoliosis was similarly higher in the frank and low-normophosphatemia groups. In a subanalysis of patients matched for Skeletal Burden Score ≥35, fracture and surgery rates remained higher in the frank hypophosphatemia group, suggesting association between phosphorus and skeletal complications is not explained by differences in FD burden alone. CONCLUSION Both frank hypophosphatemia and low-normophosphatemia are associated with increased FD-related complications. This supports FGF23-mediated hypophosphatemia as a driver of skeletal morbidity, which may impact a larger proportion of the FD/McCune-Albright syndrome population than previously recognized. These findings enable clinicians to identify at-risk patients and will inform development of prospective studies to determine optimal therapeutic targets.
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Affiliation(s)
- Zubeyir Hasan Gun
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
- Pediatric Endocrinology Inter-Institute Training Program, National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Charles Osamor
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
| | - Jocelyn Taylor
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
| | - Xiaobai Li
- Biostatistics and Clinical Epidemiology Service, NIH Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Vivian Szymczuk
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
- Pediatric Endocrinology Inter-Institute Training Program, National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Alison M Boyce
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
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Rivoira MA, Peralta López ME, Areco V, Díaz de Barboza G, Dionisi MP, Tolosa de Talamoni N. Emerging concepts on the FGF23 regulation and activity. Mol Cell Biochem 2024:10.1007/s11010-024-04982-6. [PMID: 38581553 DOI: 10.1007/s11010-024-04982-6] [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: 12/20/2023] [Accepted: 02/28/2024] [Indexed: 04/08/2024]
Abstract
Fibroblast growth factor 23 (FGF23) discovery has provided new insights into the regulation of Pi and Ca homeostasis. It is secreted by osteoblasts and osteocytes, and acts mainly in the kidney, parathyroid, heart, and bone. The aim of this review is to highlight the current knowledge on the factors modulating the synthesis of FGF23, the canonical and non-canonical signaling pathways of the hormone, the role of FGF23 in different pathophysiological conditions, and the anti-FGF23 therapy. This is a narrative review based on the search of PubMed database in the range of years 2000-2023 using the keywords local and systemic regulators of FGF23 synthesis, FGF23 receptors, canonical and non-canonical pathways, pathophysiological conditions and FGF23, and anti-FGF23 therapy, focusing the data on the molecular mechanisms. The regulation of FGF23 synthesis is complex and multifactorial. It is regulated by local factors and systemic regulators mainly involved in bone mineralization. The excessive FGF23 production is associated with different congenital diseases and with diseases occurring with a secondary high FGF23 production such as in chronic disease kidney and tumor-induced osteomalacia (TIO). The anti-FGF23 therapy appears to be useful to treat chromosome X-linked hypophosphatemia and TIO, but there are doubts about the handle of excessive FGF23 production in CKD. FGF23 biochemistry and pathophysiology are generating a plethora of knowledge to reduce FGF23 bioactivity at many levels that might be useful for future therapeutics of diseases associated with high-serum FGF23 levels.
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Affiliation(s)
- María Angélica Rivoira
- Laboratorio "Dr. Fernando Cañas", Cátedra de Bioquímica y Biología Molecular, Facultad de Ciencias Médicas, INICSA (CONICET-Universidad Nacional de Córdoba), Pabellón Argentina, 2do, Piso, Ciudad Universitaria, 5000, Córdoba, Argentina
| | - María Elena Peralta López
- Laboratorio "Dr. Fernando Cañas", Cátedra de Bioquímica y Biología Molecular, Facultad de Ciencias Médicas, INICSA (CONICET-Universidad Nacional de Córdoba), Pabellón Argentina, 2do, Piso, Ciudad Universitaria, 5000, Córdoba, Argentina
| | - Vanessa Areco
- Laboratorio "Dr. Fernando Cañas", Cátedra de Bioquímica y Biología Molecular, Facultad de Ciencias Médicas, INICSA (CONICET-Universidad Nacional de Córdoba), Pabellón Argentina, 2do, Piso, Ciudad Universitaria, 5000, Córdoba, Argentina
- Instituto Multidisciplinario de Investigación y Transferencia Agroalimentaria y Biotecnológica (IMITAB, CONICET-UNVM), Córdoba, Argentina
| | - Gabriela Díaz de Barboza
- Laboratorio "Dr. Fernando Cañas", Cátedra de Bioquímica y Biología Molecular, Facultad de Ciencias Médicas, INICSA (CONICET-Universidad Nacional de Córdoba), Pabellón Argentina, 2do, Piso, Ciudad Universitaria, 5000, Córdoba, Argentina
| | - María Paula Dionisi
- Cátedra de Clínica Médica II - UHMI Nº 2, Hospital San Roque, Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Córdoba, Argentina
| | - Nori Tolosa de Talamoni
- Laboratorio "Dr. Fernando Cañas", Cátedra de Bioquímica y Biología Molecular, Facultad de Ciencias Médicas, INICSA (CONICET-Universidad Nacional de Córdoba), Pabellón Argentina, 2do, Piso, Ciudad Universitaria, 5000, Córdoba, Argentina.
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Nakanishi T, Yamazaki M, Tachikawa K, Ueta A, Kawai M, Ozono K, Michigami T. Complex intrinsic abnormalities in osteoblast lineage cells of X-linked hypophosphatemia: Analysis of human iPS cell models generated by CRISPR/Cas9-mediated gene ablation. Bone 2024; 181:117044. [PMID: 38331306 DOI: 10.1016/j.bone.2024.117044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/04/2024] [Accepted: 02/05/2024] [Indexed: 02/10/2024]
Abstract
X-linked hypophosphatemia (XLH) is caused by inactivating variants of the phosphate regulating endopeptidase homolog X-linked (PHEX) gene. Although the overproduction of fibroblast growth factor 23 (FGF23) is responsible for hypophosphatemia and impaired vitamin D metabolism, the pathogenesis of XLH remains unclear. We herein generated PHEX-knockout (KO) human induced pluripotent stem (iPS) cells by applying CRISPR/Cas9-mediated gene ablation to an iPS clone derived from a healthy male, and analyzed PHEX-KO iPS cells with deletions extending from exons 1 to 3 and frameshifts by inducing them to differentiate into the osteoblast lineage. We confirmed the increased production of FGF23 in osteoblast lineage cells differentiated from PHEX-KO iPS cells. In vitro mineralization was enhanced in osteoblast lineage cells from PHEX-KO iPS cells than in those from isogenic control iPS cells, which reminded us of high bone mineral density and enthesopathy in patients with XLH. The extracellular level of pyrophosphate (PPi), an inhibitor of mineralization, was elevated, and this increase appeared to be partly due to the reduced activity of tissue non-specific alkaline phosphatase (TNSALP). Osteoblast lineage cells derived from PHEX-KO iPS cells also showed the increased expression of multiple molecules such as dentine matrix protein 1, osteopontin, RUNX2, FGF receptor 1 and early growth response 1. This gene dysregulation was similar to that in the osteoblasts/osteocytes of Phex-deficient Hyp mice, suggesting that common pathogenic mechanisms are shared between human XLH and Hyp mice. Moreover, we found that the phosphorylation of CREB was markedly enhanced in osteoblast lineage cells derived from PHEX-KO iPS cells, which appeared to be associated with the up-regulation of the parathyroid hormone related protein gene. PHEX deficiency also affected the response of the ALPL gene encoding TNSALP to extracellular Pi. Collectively, these results indicate that complex intrinsic abnormalities in osteoblasts/osteocytes underlie the pathogenesis of human XLH.
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Affiliation(s)
- Tatsuro Nakanishi
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka Prefectural Hospital Organization, Izumi, Osaka 594-1101, Japan; Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Miwa Yamazaki
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka Prefectural Hospital Organization, Izumi, Osaka 594-1101, Japan
| | - Kanako Tachikawa
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka Prefectural Hospital Organization, Izumi, Osaka 594-1101, Japan
| | - Ayu Ueta
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka Prefectural Hospital Organization, Izumi, Osaka 594-1101, Japan; 1st Department of Oral and Maxillofacial Surgery, Osaka University Graduate School of Dentistry, Suita, Osaka 565-0871, Japan
| | - Masanobu Kawai
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka Prefectural Hospital Organization, Izumi, Osaka 594-1101, Japan
| | | | - Toshimi Michigami
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka Prefectural Hospital Organization, Izumi, Osaka 594-1101, Japan.
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26
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Ito N, Hidaka N, Kato H. The pathophysiology of hypophosphatemia. Best Pract Res Clin Endocrinol Metab 2024; 38:101851. [PMID: 38087658 DOI: 10.1016/j.beem.2023.101851] [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] [Indexed: 02/27/2024]
Abstract
After identification of fibroblast growth factor (FGF) 23 as the pivotal regulator of chronic serum inorganic phosphate (Pi) levels, the etiology of disorders causing hypophosphatemic rickets/osteomalacia has been clarified, and measurement of intact FGF23 serves as a potent tool for differential diagnosis of chronic hypophosphatemia. Additionally, measurement of bone-specific alkaline phosphatase (BAP) is recommended to differentiate acute and subacute hypophosphatemia from chronic hypophosphatemia. This article divides the etiology of chronic hypophosphatemia into 4 groups: A. FGF23 related, B. primary tubular dysfunction, C. disturbance of vitamin D metabolism, and D. parathyroid hormone 1 receptor (PTH1R) mediated. Each group is further divided into its inherited form and acquired form. Topics for each group are described, including "ectopic FGF23 syndrome," "alcohol consumption-induced FGF23-related hypophosphatemia," "anti-mitochondrial antibody associated hypophosphatemia," and "vitamin D-dependent rickets type 3." Finally, a flowchart for differential diagnosis of chronic hypophosphatemia is introduced.
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Affiliation(s)
- Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan; Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan.
| | - Naoko Hidaka
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan; Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan.
| | - Hajime Kato
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan; Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan.
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27
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Goyal A, Tandon N. Burosumab: Current status and future prospects. Best Pract Res Clin Endocrinol Metab 2024; 38:101826. [PMID: 37858479 DOI: 10.1016/j.beem.2023.101826] [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] [Indexed: 10/21/2023]
Abstract
Hypophosphatemic rickets/osteomalacia caused by FGF23 excess is conventionally treated with multiple doses of inorganic phosphate salts and active vitamin D analogs. However, conventional therapy targets the consequences of elevated FGF23 and not the elevated FGF23 itself and is associated with poor adherence and long-term complications such as nephrocalcinosis and secondary/tertiary hyperparathyroidism. Burosumab is a fully human IgG1 monoclonal antibody that binds to and neutralises FGF-23, thereby leading to improvement in phosphate homeostasis and healing of rickets and osteomalacia. Data from phase 2 and 3 trials report overall safety and efficacy and Burosumab is now FDA approved for treatment of XLH and TIO in children and adults. Cost and absence of long-term data are major issues with Burosumab which should be addressed in near future. At present, experts recommend Burosumab use in patients with severe disease or those with mild-moderate disease and a failed response to a trial of conventional therapy.
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Affiliation(s)
- Alpesh Goyal
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, Convergence Block, Room no 7002, Seventh Floor, New Delhi 110029, India.
| | - Nikhil Tandon
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, Convergence Block, Room no 7002, Seventh Floor, New Delhi 110029, India.
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28
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Cherian KE, Paul TV. Inherited fibroblast growth factor 23 excess. Best Pract Res Clin Endocrinol Metab 2024; 38:101844. [PMID: 38044258 DOI: 10.1016/j.beem.2023.101844] [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] [Indexed: 12/05/2023]
Abstract
Syndromes of inherited fibroblast growth factor 23 (FGF-23) excess encompass a wide spectrum that includes X-linked hypophosphataemia (XLH), autosomal dominant and recessive forms of rickets as well as various syndromic conditions namely fibrous dysplasia/McCune Albright syndrome, osteoglophonic dysplasia, Jansen's chondrodysplasia and cutaneous skeletal hypophosphataemia syndrome. A careful attention to patient symptomatology, family history and clinical features, supported by appropriate laboratory tests will help in making a diagnosis. A genetic screen may be done to confirm the diagnosis. While phosphate supplements and calcitriol continue to be the cornerstone of treatment, in recent times burosumab, the monoclonal antibody against FGF-23 has been approved for the treatment of children and adults with XLH. While health-related outcomes may be improved by ensuring adherence and compliance to prescribed treatment with a smooth transition to adult care, bony deformities may persist in some, and this would warrant surgical correction.
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29
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Gun ZH, Arif A, Boyce AM. Fibrous dysplasia in children and its management. Curr Opin Endocrinol Diabetes Obes 2024; 31:60-66. [PMID: 38010041 DOI: 10.1097/med.0000000000000847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide a comprehensive overview into the diagnosis and management of fibrous dysplasia (FD) in children. RECENT FINDINGS FD is a mosaic disorder arising from somatic Gα s variants, leading to impaired osteogenic cell differentiation. Fibro-osseous lesions expand during childhood and reach final disease burden in early adulthood. The mainstay of treatment focuses on surgical correction of skeletal deformities, physiatric care, and medical management of associated hyperfunctioning endocrinopathies. Bisphosphonates may be helpful to treat bone pain, but do not alter lesion quality or progression. Emerging evidence suggests that the RANKL inhibitor denosumab may be effective in improving lesion activity and mineralization, however further studies are needed to determine the potential utility of this and other novel therapies, particularly in children with FD. SUMMARY Management of children with FD has unique challenges related to skeletal growth and age-related lesion progression. Inclusion of children in clinical research is critical to develop effective treatment strategies to treat FD lesions and prevent their development.
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Affiliation(s)
- Zubeyir Hasan Gun
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health
- Pediatric Endocrinology Inter-Institute Training Program, National Institute of Child Health and Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Aleena Arif
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health
| | - Alison M Boyce
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health
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30
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Formosa MM, Christou MA, Mäkitie O. Bone fragility and osteoporosis in children and young adults. J Endocrinol Invest 2024; 47:285-298. [PMID: 37668887 PMCID: PMC10859323 DOI: 10.1007/s40618-023-02179-0] [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: 07/05/2023] [Accepted: 08/16/2023] [Indexed: 09/06/2023]
Abstract
Osteoporosis is a metabolic bone disorder which increases fragility fracture risk. Elderly individuals, especially postmenopausal women, are particularly susceptible to osteoporosis. Although rare, osteoporosis in children and young adults is becoming increasingly evident, highlighting the need for timely diagnosis, management and follow-up. Early-onset osteoporosis is defined as the presence of a low BMD (Z-score of ≤ -2.0 in individuals aged < 20 years; T-score of ≤ -2.5 in those aged between 20 to 50 years) accompanied by a clinically significant fracture history, or the presence of low-energy vertebral compression fractures even in the absence of osteoporosis. Affected children and young adults should undergo a thorough diagnostic workup, including collection of clinical history, radiography, biochemical investigation and possibly bone biopsy. Once secondary factors and comorbidities are excluded, genetic testing should be considered to determine the possibility of an underlying monogenic cause. Defects in genes related to type I collagen biosynthesis are the commonest contributors of primary osteoporosis, followed by loss-of-function variants in genes encoding key regulatory proteins of canonical WNT signalling (specifically LRP5 and WNT1), the actin-binding plastin-3 protein (encoded by PLS3) resulting in X-linked osteoporosis, and the more recent sphingomyelin synthase 2 (encoded by SGMS2) which is critical for signal transduction affecting sphingomyelin metabolism. Despite these discoveries, genetic causes and underlying mechanisms in early-onset osteoporosis remain largely unknown, and if no causal gene is identified, early-onset osteoporosis is deemed idiopathic. This calls for further research to unravel the molecular mechanisms driving early-onset osteoporosis that consequently will aid in patient management and individualised targeted therapy.
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Affiliation(s)
- M M Formosa
- Department of Applied Biomedical Science, Faculty of Health Sciences, University of Malta, Msida, Malta
- Center for Molecular Medicine and Biobanking, University of Malta, Msida, Malta
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M A Christou
- Department of Endocrinology, School of Medicine, University of Ioannina, Ioannina, Greece
- Department of Hygiene and Epidemiology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - O Mäkitie
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland.
- Folkhälsan Research Centre, Folkhälsan Institute of Genetics, Helsinki, Finland.
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden.
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31
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Qian C, Ito N, Tsuji K, Sato S, Kikuchi K, Yoshii T, Miyata T, Asou Y. A PAI-1 antagonist ameliorates hypophosphatemia in the Hyp vitamin D-resistant rickets model mouse. FEBS Open Bio 2024; 14:290-299. [PMID: 38050660 PMCID: PMC10839342 DOI: 10.1002/2211-5463.13745] [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: 08/01/2023] [Revised: 11/20/2023] [Accepted: 12/04/2023] [Indexed: 12/06/2023] Open
Abstract
Congenital fibroblast growth factor 23 (FGF23)-related hypophosphatemic rickets/osteomalacia is a rare bone metabolism disorder characterized by hypophosphatemia and caused by genetic abnormalities that result in excessive secretion of FGF23. Hyp mice are a model of X-linked hypophosphatemia (XLH) caused by deletion of the PHEX gene and excessive production of FGF23. The purpose of this study was to investigate the potential of TM5614 as a therapeutic agent for the treatment of congenital FGF23-related hypophosphatemic rickets and osteomalacia in humans by administering TM5614 to Hyp mice and examining its curative effect on hypophosphatemia. After a single oral administration of TM5614 10 mg·kg-1 to female Hyp mice starting at 17 weeks of age, the serum phosphate concentration increased with a peak at 6 h after administration. ELISA confirmed that TM5614 administration decreased the intact FGF23 concentration in the blood. Expression of 25-hydroxyvitamin D-1α-hydroxylase protein encoded by Cyp27b1 mRNA in the kidney was suppressed in Hyp mice, and treatment with 10 mg·kg-1 of TM5614 normalized the expression of 25-hydroxyvitamin D-1α-hydroxylase protein and Cyp27b1 mRNA in the kidneys of these mice. Our data indicate that oral administration of TM5614 ameliorates hypophosphatemia in Hyp mice, suggesting that TM5614 may be an effective treatment for congenital FGF23-related hypophosphatemic rickets and osteomalacia.
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Affiliation(s)
- Cheng Qian
- Department of Orthopedics SurgeryTokyo Medical and Dental UniversityJapan
| | - Nobuaki Ito
- Division of Nephrology and EndocrinologyThe University of Tokyo HospitalJapan
| | - Kunikazu Tsuji
- Department of Orthopedics SurgeryTokyo Medical and Dental UniversityJapan
| | - Shingo Sato
- Department of Orthopedics SurgeryTokyo Medical and Dental UniversityJapan
| | - Katsushi Kikuchi
- Department of Orthopedics SurgeryTokyo Medical and Dental UniversityJapan
| | - Toshitaka Yoshii
- Department of Orthopedics SurgeryTokyo Medical and Dental UniversityJapan
| | - Toshio Miyata
- United Centers for Advanced Research and Translational MedicineTohoku UniversitySendaiJapan
| | - Yoshinori Asou
- Department of Orthopedics SurgeryTokyo Medical and Dental UniversityJapan
- China‐Japan Friendship Institution of MedicineShanghai UniversityChina
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32
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Celebi Torabfam G, Porsuk MH. The Role of the Receptor Activator of Nuclear Factor Kappa-B Ligand/Osteoprotegerin Ratio in Vascular Diseases: A Therapeutic Approach. Angiology 2024:33197231226275. [PMID: 38171493 DOI: 10.1177/00033197231226275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Cardiovascular and bone diseases contribute independently to mortality and global health. The exact mechanisms involved in the pathophysiology shared between bone and vascular diseases are not well defined. Endothelial cells and osteoblasts communicate during osteogenesis, thus establishing a connection between angiogenesis and osteogenesis. One shared mechanism may involve osteoprotegerin (OPG) and its ligand Receptor Activator of NF-κB Ligand (RANKL). The RANKL/OPG ratio is an important modulator for the skeletal, immunological, and vascular systems. OPG levels are elevated due to either osteogenic causes or inflammatory responses in the vasculature. The data obtained from clinical and in vitro studies support the role of the RANKL/OPG ratio as a potential marker for the progression of endothelial damage. Therefore, determining the therapeutic approaches for the targeting RANKL/OPG ratio and evaluating its usage as a biomarker in cardiovascular and bone pathophysiology are needed. By integrating the protective and disease-causing role of OPG with its ligand, this review outlines the role of the RANKL/OPG ratio at the molecular level. We also consider targeted therapeutic approaches.
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Affiliation(s)
- Gizem Celebi Torabfam
- Faculty of Engineering and Natural Sciences, Molecular Biology, Genetics, and Bioengineering Program, Sabanci University, Istanbul, Turkey
| | - Melis Hazal Porsuk
- Faculty of Engineering and Natural Sciences, Molecular Biology, Genetics, and Bioengineering Program, Sabanci University, Istanbul, Turkey
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33
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Phan P, Sonnaila S, Ternier G, Edirisinghe O, Okoto PS, Kumar TKS. Overexpression and Purification of Mitogenic and Metabolic Fibroblast Growth Factors. Methods Mol Biol 2024; 2762:151-181. [PMID: 38315365 DOI: 10.1007/978-1-0716-3666-4_10] [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] [Indexed: 02/07/2024]
Abstract
Fibroblast growth factors (FGFs) are proteins with a vast array of biological activity, such as cell development and repair, glucose and bile acid metabolisms, and wound healing. Due to their critical and diverse physiological functions, FGFs are believed to possess potential as therapeutic agents for many diseases and conditions that warrant further investigations. Thus, a simple, cost-efficient method to purify these biologically active signaling proteins is desirable. Herein, we introduce such techniques to purify FGFs that possess either high heparin-binding affinity or low to no heparin-binding affinity. This method takes advantage of the high affinity toward heparin sulfate from paracrine FGF1 to isolate the targeted protein. It also accounts for FGF members that have low heparin affinity, such as the metabolic FGFs, by introducing poly-histidine tags in the recombinant protein in combination with the immobilized metal affinity chromatography. Subsequently, the purified FGF products are separated from the other small protein by high-speed centrifugation. Products are then subjected to other biophysical experiments like SDS-PAGE, mass spectrometry, circular dichroism, intrinsic fluorescence, isothermal titration calorimetry, differential scanning calorimetry, and biological cell activity assay to confirm that the target proteins are purified with intact native conformation and no significant change in the intrinsic characteristics and biological activities.
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Affiliation(s)
- Phuc Phan
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, AR, USA
| | - Shivakumar Sonnaila
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, AR, USA
| | - Gaetane Ternier
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, AR, USA
| | - Oshadi Edirisinghe
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, AR, USA
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34
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Ward LM, Högler W, Glorieux FH, Portale AA, Whyte MP, Munns CF, Nilsson O, Simmons JH, Padidela R, Namba N, Cheong HI, Sochett E, Muroya K, Tanaka H, Pitukcheewanont P, Gottesman GS, Biggin A, Perwad F, Chen A, Lawrence Merritt II J, Imel EA. Burosumab vs conventional therapy in children with X-linked hypophosphatemia: results of the open-label, phase 3 extension period. JBMR Plus 2024; 8:ziad001. [PMID: 38690124 PMCID: PMC11059996 DOI: 10.1093/jbmrpl/ziad001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/06/2023] [Indexed: 05/02/2024] Open
Abstract
In a randomized, open-label phase 3 study of 61 children aged 1-12 years old with X-linked hypophosphatemia (XLH) previously treated with conventional therapy, changing to burosumab every 2 weeks (Q2W) for 64 weeks improved the phosphate metabolism, radiographic rickets, and growth compared with conventional therapy. In this open-label extension period (weeks 64-88), 21 children continued burosumab Q2W at the previous dose or crossed over from conventional therapy to burosumab starting at 0.8 mg/kg Q2W with continued clinical radiographic assessments through week 88. Efficacy endpoints and safety observations were summarized descriptively for both groups (burosumab continuation, n = 6; crossover, n = 15). At week 88 compared with baseline, improvements in the following outcomes were observed in the burosumab continuation and crossover groups, respectively: mean (SD) RGI-C rickets total score (primary outcome), +2.11 (0.27) and +1.89 (0.35); mean (SD) RGI-C lower limb deformity score, +1.61 (0.91) and +0.73 (0.82); and mean (SD) height Z-score + 0.41 (0.50) and +0.08 (0.34). Phosphate metabolism normalized rapidly in the crossover group and persisted in the continuation group. Mean (SD) serum alkaline phosphatase decreased from 169% (43%) of the upper limit of normal (ULN) at baseline to 126% (51%) at week 88 in the continuation group and from 157% (33%) of the ULN at baseline to 111% (23%) at week 88 in the crossover group. During the extension period, treatment-emergent adverse events (AEs) were reported in all 6 children in the burosumab continuation group and 14/15 children in the crossover group. The AE profiles in the randomized and extension periods were similar, with no new safety signals identified. Improvements from baseline in radiographic rickets continued in the extension period among children with XLH who remained on burosumab. Children who crossed over from conventional therapy to burosumab demonstrated a rapid improvement in phosphate metabolism and improved rickets healing over the ensuing 22 weeks.
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Affiliation(s)
- Leanne M Ward
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, K1H 8L1, Canada
| | - Wolfgang Högler
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, 4040 Linz, Austria
- Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - Francis H Glorieux
- Department of Surgery, Pediatrics, and Human Genetics, Shriners Hospitals for Children and McGill University, Montreal, Quebec, H4A 0A9, Canada
| | - Anthony A Portale
- Department of Pediatrics, University of California, San Francisco, CA, 94158, United States
| | - Michael P Whyte
- Shriners Hospitals for Children St Louis, St Louis, MO, 63110, United States
| | - Craig F Munns
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, 4072, Australia
- Faculty of Medicine, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, 4072, Australia
- Department of Endocrinology and Diabetes, Queensland Children’s Hospital, Brisbane, Queensland, 4072, Australia
| | - Ola Nilsson
- Division of Pediatric Endocrinology, Department of Women’s and Children’s Health, Center for Molecular Medicine, Karolinska Institutet and University Hospital, SE-17176 Stockholm, Sweden
- Department of Pediatrics, School of Medical Sciences, Örebro University and University Hospital, S-701 82 Örebro, Sweden
| | - Jill H Simmons
- Division of Endocrinology and Diabetes, Department of Pediatrics, Vanderbilt University School of Medicine, Vanderbilt University, Nashville, TN, 37232, United States
| | - Raja Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, M13 9WL, United Kingdom
| | - Noriyuki Namba
- Department of Pediatrics, Osaka Hospital, Japan Community Healthcare Organization, Osaka, 553-0003, Japan
- Osaka University Graduate School of Medicine, Osaka, 565-0871, Japan
| | - Hae Il Cheong
- Department of Pediatrics, Hallym University Sacred Heart Hospital, Dongan-gu, Anyang, 14068, South Korea
| | - Etienne Sochett
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, M5G 1E8, Canada
| | - Koji Muroya
- Department of Endocrinology, Kanagawa Children’s Medical Center, Yokohama, Kanagawa 232-0066, Japan
| | - Hiroyuki Tanaka
- Division of Pediatrics, Okayama Saiseikai General Hospital Outpatient Center, Kita-ku, Okayama, 700-8511, Japan
| | - Pisit Pitukcheewanont
- Center of Endocrinology, Diabetes and Metabolism, Children’s Hospital of Los Angeles, Los Angeles, CA, 90027, United States
| | - Gary S Gottesman
- Shriners Hospitals for Children St Louis, St Louis, MO, 63110, United States
| | - Andrew Biggin
- Department of Endocrinology, The University of Sydney Children’s Hospital Westmead Clinical School, The Children’s Hospital at Westmead, Westmead, New South Wales, 2145, Australia
| | - Farzana Perwad
- Department of Pediatrics, University of California, San Francisco, CA, 94158, United States
| | - Angel Chen
- Ultragenyx Pharmaceutical Inc., Novato, CA, 94949, United States
| | | | - Erik A Imel
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, United States
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35
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Park E, Kang HG. X-linked hypophosphatemic rickets: from diagnosis to management. Clin Exp Pediatr 2024; 67:17-25. [PMID: 37321578 PMCID: PMC10764665 DOI: 10.3345/cep.2022.01459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 02/02/2023] [Accepted: 03/28/2023] [Indexed: 06/17/2023] Open
Abstract
X-linked hypophosphatemia (XLH), the most common cause of hypophosphatemic rickets, affects one in every 20,000 people. Although conventional therapy for XLH was introduced approximately 4 decades ago, the temporary replacement of oral phosphate salts and activated vitamin D cannot completely control chronic hypophosphatemia, leaving patients with incomplete healing and residual skeletal deformity as well as at risk of endocrine abnormalities and adverse drug reactions. However, understanding the pathophysiology has led to the development of a targeted therapy, burosumab, a fibroblast growth factor-23 inhibitor that was recently approved in Korea for the treatment of XLH. This review provides insight into the diagnosis, evaluation, treatment, and recommended follow-up for a typical case of XLH and reviews its pathophysiology.
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Affiliation(s)
- Eujin Park
- Department of Pediatrics, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Departments of Pediatrics, Seoul National University Children’s Hospital, Seoul, Korea
- Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
- Wide River Institute of Immunology, Seoul National University, Hongcheon, Korea
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36
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Edmonston D, Grabner A, Wolf M. FGF23 and klotho at the intersection of kidney and cardiovascular disease. Nat Rev Cardiol 2024; 21:11-24. [PMID: 37443358 DOI: 10.1038/s41569-023-00903-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/15/2023]
Abstract
Cardiovascular disease is the leading cause of death in patients with chronic kidney disease (CKD). As CKD progresses, CKD-specific risk factors, such as disordered mineral homeostasis, amplify traditional cardiovascular risk factors. Fibroblast growth factor 23 (FGF23) regulates mineral homeostasis by activating complexes of FGF receptors and transmembrane klotho co-receptors. A soluble form of klotho also acts as a 'portable' FGF23 co-receptor in tissues that do not express klotho. In progressive CKD, rising circulating FGF23 levels in combination with decreasing kidney expression of klotho results in klotho-independent effects of FGF23 on the heart that promote left ventricular hypertrophy, heart failure, atrial fibrillation and death. Emerging data suggest that soluble klotho might mitigate some of these effects via several candidate mechanisms. More research is needed to investigate FGF23 excess and klotho deficiency in specific cardiovascular complications of CKD, but the pathophysiological primacy of FGF23 excess versus klotho deficiency might never be precisely resolved, given the entangled feedback loops that they share. Therefore, randomized trials should prioritize clinical practicality over scientific certainty by targeting disordered mineral homeostasis holistically in an effort to improve cardiovascular outcomes in patients with CKD.
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Affiliation(s)
- Daniel Edmonston
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Alexander Grabner
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
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Aljuraibah F, Alalwan I, Habeb A. Diagnostic and New Therapeutic Approaches to Two Challenging Pediatric Metabolic Bone Disorders: Hypophosphatasia and X-linked Hypophosphatemic Rickets. Curr Pediatr Rev 2024; 20:395-404. [PMID: 37927073 DOI: 10.2174/0115733963206838231031102750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/09/2023] [Accepted: 10/03/2023] [Indexed: 11/07/2023]
Abstract
The diagnosis and management of metabolic bone disease among children can be challenging. This difficulty could be due to many factors, including limited awareness of these rare conditions, the complex pathophysiology of calcium and phosphate homeostasis, the overlapping phenotype with more common disorders (such as rickets), and the lack of specific treatments for these rare disorders. As a result, affected individuals could experience delayed diagnosis or misdiagnosis, leading to improper management. In this review, we describe the challenges facing diagnostic and therapeutic approaches to two metabolic bone disorders (MBD) among children: hypophosphatasia (HPP) and X-linked hypophosphatemia (XLH). We focus on explaining the pathophysiological processes that conceptually underpin novel therapeutic approaches, as well as these conditions' clinical or radiological similarity to nutritional rickets. Particularly in areas with limited sun exposure and among patients not supplementing vitamin D, nutritional rickets are still more common than HPP and XLH, and pediatricians and primary physicians frequently encounter this disorder in their practices. More recently, our understanding of these disorders has significantly improved, leading to the development of novel therapies. Asfotas alfa, a recombinant, human- tissue, nonspecific alkaline phosphatase, improved the survival of patients with HPP. Burosumab, a human monoclonal anti-FGF23 antibody, was recently approved as a specific therapy for XLH. We also highlight the current evidence on these two specific therapies' safety and effectiveness, though long-term data are still needed. Both HPP and XLH are multisystemic disorders that should be managed by multidisciplinary teams. Finally, recognizing these conditions in early stages will enable affected children and young adults to benefit from newly introduced, specific therapies.
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Affiliation(s)
- Fahad Aljuraibah
- Department of Pediatrics, King Abdullah Specialist Children's Hospital, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud bin Abdul-Aziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs Riyadh, Saudi Arabia
| | - Ibrahim Alalwan
- Department of Pediatrics, King Abdullah Specialist Children's Hospital, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud bin Abdul-Aziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs Riyadh, Saudi Arabia
| | - Abdelhadi Habeb
- Department of Pediatrics, Prince Mohammed bin Abdulaziz Hospital for National Guard, Al-Madinah, Saudi Arabia
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AlSubaihin A, Harrington J. Hereditary Rickets: A Quick Guide for the Pediatrician. Curr Pediatr Rev 2024; 20:380-394. [PMID: 36475338 DOI: 10.2174/1573396319666221205123402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 09/10/2022] [Accepted: 11/01/2022] [Indexed: 12/12/2022]
Abstract
With the increased discovery of genes implicated in vitamin D metabolism and the regulation of calcium and phosphate homeostasis, a growing number of genetic forms of rickets are now recognized. These are categorized into calciopenic and phosphopenic rickets. Calciopenic forms of hereditary rickets are caused by genetic mutations that alter the enzymatic activity in the vitamin D activation pathway or impair the vitamin D receptor action. Hereditary forms of phosphopenic rickets, on the other hand, are caused by genetic mutations that lead to increased expression of FGF23 hormone or that impair the absorptive capacity of phosphate at the proximal renal tubule. Due to the clinical overlap between acquired and genetic forms of rickets, identifying children with hereditary rickets can be challenging. A clear understanding of the molecular basis of hereditary forms of rickets and their associated biochemical patterns allow the health care provider to assign the correct diagnosis, avoid non-effective interventions and shorten the duration of the diagnostic journey in these children. In this mini-review, known forms of hereditary rickets listed on the Online Mendelian Inheritance in Man database are discussed. Further, a clinical approach to identify and diagnose children with hereditary forms of rickets is suggested.
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Affiliation(s)
- Abdulmajeed AlSubaihin
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- King Saud University Medical City, Riyadh, Saudi Arabia
| | - Jennifer Harrington
- Division of Endocrinology, Women's and Children's Health Network, North Adelaide, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
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Courbon G, Kentrup D, Thomas JJ, Wang X, Tsai HH, Spindler J, Von Drasek J, Ndjonko LM, Martinez-Calle M, Lynch S, Hivert L, Wang X, Chang W, Feng JQ, David V, Martin A. FGF23 directly inhibits osteoprogenitor differentiation in Dmp1-knockout mice. JCI Insight 2023; 8:e156850. [PMID: 37943605 PMCID: PMC10807721 DOI: 10.1172/jci.insight.156850] [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: 11/18/2021] [Accepted: 11/01/2023] [Indexed: 11/12/2023] Open
Abstract
Fibroblast growth factor 23 (FGF23) is a phosphate-regulating (Pi-regulating) hormone produced by bone. Hereditary hypophosphatemic disorders are associated with FGF23 excess, impaired skeletal growth, and osteomalacia. Blocking FGF23 became an effective therapeutic strategy in X-linked hypophosphatemia, but testing remains limited in autosomal recessive hypophosphatemic rickets (ARHR). This study investigates the effects of Pi repletion and bone-specific deletion of Fgf23 on bone and mineral metabolism in the dentin matrix protein 1-knockout (Dmp1KO) mouse model of ARHR. At 12 weeks, Dmp1KO mice showed increased serum FGF23 and parathyroid hormone levels, hypophosphatemia, impaired growth, rickets, and osteomalacia. Six weeks of dietary Pi supplementation exacerbated FGF23 production, hyperparathyroidism, renal Pi excretion, and osteomalacia. In contrast, osteocyte-specific deletion of Fgf23 resulted in a partial correction of FGF23 excess, which was sufficient to fully restore serum Pi levels but only partially corrected the bone phenotype. In vitro, we show that FGF23 directly impaired osteoprogenitors' differentiation and that DMP1 deficiency contributed to impaired mineralization independent of FGF23 or Pi levels. In conclusion, FGF23-induced hypophosphatemia is only partially responsible for the bone defects observed in Dmp1KO mice. Our data suggest that combined DMP1 repletion and FGF23 blockade could effectively correct ARHR-associated mineral and bone disorders.
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Affiliation(s)
- Guillaume Courbon
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dominik Kentrup
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jane Joy Thomas
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Xueyan Wang
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Hao-Hsuan Tsai
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jadeah Spindler
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John Von Drasek
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Laura Mazudie Ndjonko
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Marta Martinez-Calle
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sana Lynch
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Lauriane Hivert
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Xiaofang Wang
- Texas A&M School of Dentistry, Texas A&M University, Dallas, Texas, USA
| | - Wenhan Chang
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jian Q. Feng
- Shanxi Medical University School and Hospital of Stomatology, Clinical Medical Research Center of Oral Diseases of Shanxi Province, Taiyuan, China
| | - Valentin David
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Aline Martin
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Wang S, Wang X, He M, Li Y, Xiao M, Ma H. Efficacy and Safety of Burosumab in X-linked Hypophosphatemia. J Clin Endocrinol Metab 2023; 109:293-302. [PMID: 37497620 DOI: 10.1210/clinem/dgad440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/06/2022] [Accepted: 07/25/2023] [Indexed: 07/28/2023]
Abstract
CONTEXT Burosumab is approved for the treatment of X-linked hypophosphatemia (XLH). OBJECTIVE To assess the efficacy and safety of burosumab in XLH patients, we conducted a systematic review and meta-analysis. METHODS We searched PubMed, the Cochrane Library, Embase, ClinicalTrials.gov, and Web of Science for studies on the use of burosumab in patients with XLH. Meta-analysis of randomized controlled trials (RCTs) and single-arm trials (SATs) was done to explore burosumab treatment on the efficacy and safety of XLH. RESULTS Of the 8 eligible articles, 5 were from RCTs and 3 were from SATs. Compared with the control group in RCTs, serum phosphorus level was significantly increased in the burosumab group (0.52 mg/dL, 95% CI 0.24-0.80 mg/dL). A meta-analysis of the burosumab arms in all trials revealed significant increase in serum phosphorus levels (0.78 mg/dL, 95% CI 0.61-0.96 mg/dL), TmP/GFR (0.86 mg/dL, 95% CI 0.60-1.12 mg/dL), and 1,25-dihydroxyvitamin D level (13.23 pg/mL, 95% CI 4.82-21.64 pg/mL) as well. Changes in secondary events also validated the effects of burosumab treatment. Compared with the control group, in RCTs, the safety profile of burosumab is not much different from the control group. Data of the single-arm combined group demonstrated the incidence of any treatment emergency adverse event (TEAE) and the related TEAE rate were high, but the severity of most adverse events is mild to moderate, and the rate of serious TEAE is low. CONCLUSION This study suggests that burosumab can be an option for patients with XLH and did not significantly increase the incidence of adverse events.
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Affiliation(s)
- Sen Wang
- Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xiaoqin Wang
- Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Miao He
- Department of Neurology, The Ninth Clinical Medical College Affiliated to Shanxi Medical University, Taiyuan 030000, China
| | - Yuanfen Li
- Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Minghui Xiao
- Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Houxun Ma
- Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Lira Dos Santos EJ, Nakajima K, Po J, Hanai A, Zhukouskaya V, Biosse Duplan M, Linglart A, Shimada T, Chaussain C, Bardet C. Dental impact of anti-fibroblast growth factor 23 therapy in X-linked hypophosphatemia. Int J Oral Sci 2023; 15:53. [PMID: 38052774 DOI: 10.1038/s41368-023-00259-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 11/03/2023] [Accepted: 11/05/2023] [Indexed: 12/07/2023] Open
Abstract
Elevated fibroblast growth factor 23 (FGF23) in X-linked hypophosphatemia (XLH) results in rickets and phosphate wasting, manifesting by severe bone and dental abnormalities. Burosumab, a FGF23-neutralizing antibody, an alternative to conventional treatment (phosphorus and active vitamin D analogs), showed significant improvement in the long bone phenotype. Here, we examined whether FGF23 antibody (FGF23-mAb) also improved the dentoalveolar features associated with XLH. Four-week-old male Hyp mice were injected weekly with 4 or 16 mg·kg-1 of FGF23-mAb for 2 months and compared to wild-type (WT) and vehicle (PBS) treated Hyp mice (n = 3-7 mice). Micro-CT analyses showed that both doses of FGF23-mAb restored dentin/cementum volume and corrected the enlarged pulp volume in Hyp mice, the higher concentration resulting in a rescue similar to WT levels. FGF23-mAb treatment also improved alveolar bone volume fraction and mineral density compared to vehicle-treated ones. Histology revealed improved mineralization of the dentoalveolar tissues, with a decreased amount of osteoid, predentin and cementoid. Better periodontal ligament attachment was also observed, evidenced by restoration of the acellular cementum. These preclinical data were consistent with the retrospective analysis of two patients with XLH showing that burosumab treatment improved oral features. Taken together, our data show that the dentoalveolar tissues are greatly improved by FGF23-mAb treatment, heralding its benefit in clinics for dental abnormalities.
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Affiliation(s)
- Elis J Lira Dos Santos
- Université Paris Cité, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France
| | - Kenta Nakajima
- R&D Division, Kyowa Kirin, Co., Ltd, 3-6-6 Asahi-machi, Machida-shi, Tokyo, Japan
| | - Julien Po
- Université Paris Cité, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France
| | - Ayako Hanai
- R&D Division, Kyowa Kirin, Co., Ltd, 3-6-6 Asahi-machi, Machida-shi, Tokyo, Japan
| | - Volha Zhukouskaya
- Université Paris Cité, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France
| | - Martin Biosse Duplan
- Université Paris Cité, Institut Imagine, INSERM UMR 1163, Paris, France
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Dental Medicine Department, Bretonneau Hospital, GHN-Université Paris Cité, Paris, France
| | - Agnès Linglart
- Paris-Saclay University, AP-HP, INSERM U1185, DMU SEA, Endocrinology and Diabetes for Children, Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR filière, EndoRare, and BOND ERNs, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Takashi Shimada
- Medical Affairs Department, Kyowa Kirin, Co., Ltd, 1-9-2 Otemachi, Chiyoda-ku, Tokyo, Japan
| | - Catherine Chaussain
- Université Paris Cité, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Dental Medicine Department, Bretonneau Hospital, GHN-Université Paris Cité, Paris, France
| | - Claire Bardet
- Université Paris Cité, Institut des maladies musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Montrouge, France.
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Poon KS, Tan KML, Zacharin M, Ho CWL. A De Novo Mosaic PHEX Variant Causing Sporadic X-Linked Hypophosphatemic Rickets in a 2-Year-Old Girl. J Pediatr Genet 2023; 12:308-311. [PMID: 38162152 PMCID: PMC10756725 DOI: 10.1055/s-0041-1728746] [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: 01/08/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
Pathogenic variants in the PHEX gene are causative of X-linked hypophosphatemic rickets (XLH). We present a case of a 2-year-old girl with hypophosphatemic rickets with genu varum and short stature without any family history of XLH. Next generation sequencing of the PHEX gene identified a splice donor variant, NM_000444.6:c.1173 + 5G > A in intron 10. This variant had a mosaic pattern with only 22% of the sequence reads showing the variant allele and was not present in the girl's parents, both of whom had a normal phenotype. This is a sporadic case of a de novo mosaic splice-site variant in the PHEX gene.
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Affiliation(s)
- Kok-Siong Poon
- Department of Laboratory Medicine, National University Hospital, Singapore
| | - Karen Mei-Ling Tan
- Department of Laboratory Medicine, National University Hospital, Singapore
| | - Margaret Zacharin
- Department of Hormone Research, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Victoria, Australia
- Department of Endocrinology & Diabetes, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Cindy Wei-Li Ho
- Department of Paediatrics, Khoo Teck Puat - National University Children's Medical Institute, National University Health System, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Yadav PS, Kobelski MM, Martins JS, Tao T, Liu ES, Demay MB. Impaired Growth Plate Maturation in XLH Is due to Both Excess FGF23 and Decreased 1,25-Dihydroxyvitamin D Signaling. Endocrinology 2023; 165:bqad186. [PMID: 38066669 PMCID: PMC10732678 DOI: 10.1210/endocr/bqad186] [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: 08/30/2023] [Indexed: 12/22/2023]
Abstract
X-linked hypophosphatemia (XLH) is the most common form of hereditary hypophosphatemic rickets. The genetic basis for XLH is loss of function mutations in the phosphate-regulating endopeptidase X-linked (PHEX), which leads to increased circulating fibroblast growth factor 23 (FGF23). This increase in FGF23 impairs activation of vitamin D and attenuates renal phosphate reabsorption, leading to rickets. Previous studies have demonstrated that ablating FGF23 in the Hyp mouse model of XLH leads to hyperphosphatemia, high levels of 1,25-dihydroxyvitamin D, and is not associated with the development of rickets. Studies were undertaken to define a role for the increase in 1,25-dihydroxyvitamin D levels in the prevention of rickets in Hyp mice lacking FGF23. These mice were mated to mice lacking Cyp27b1, the enzyme responsible for activating vitamin D metabolites, to generate Hyp mice lacking both FGF23 and 1,25-dihydroxyvitamin D (FCH mice). Mice were fed a special diet to maintain normal mineral ion homeostasis. Despite normal mineral ions, Hyp mice lacking both FGF23 and Cyp27b1 developed rickets, characterized by an interrupted, expanded hypertrophic chondrocyte layer and impaired hypertrophic chondrocyte apoptosis. This phenotype was prevented when mice were treated with 1,25-dihydroxyvitamin D from day 2 until sacrifice on day 30. Interestingly, mice lacking FGF23 and Cyp27b1 without the PHEX mutation did not exhibit rickets. These findings define an essential PHEX-dependent, FGF23-independent role for 1,25-dihydroxyvitamin D in XLH and have important therapeutic implications for the treatment of this genetic disorder.
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Affiliation(s)
- Prem Swaroop Yadav
- Endocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
| | | | - Janaina S Martins
- Endocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Tao Tao
- Endocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Eva S Liu
- Harvard Medical School, Boston, MA 02115, USA
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Marie B Demay
- Endocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
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Herrou J, Fechtenbaum J, Rothenbuhler A, Kamenický P, Roux C, Linglart A, Briot K. Development of Spinal Enthesopathies in Adults With X-linked Hypophosphatemia. J Clin Endocrinol Metab 2023; 108:e1524-e1531. [PMID: 37390471 DOI: 10.1210/clinem/dgad383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/09/2023] [Accepted: 06/26/2023] [Indexed: 07/02/2023]
Abstract
CONTEXT Musculoskeletal complications are the main manifestations in adults with X-linked hypophosphatemia (XLH). Enthesopathy significantly impairs quality of life. OBJECTIVE To identify the risk factors associated with the development and progression of spinal enthesopathies in adults with XLH. DESIGN AND SETTING We conducted a retrospective study in the French Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism. PATIENTS Adults XLH patients with 2 EOS® imaging performed at least 2 years apart at the same center between June 2011 and March 2022. The progression of enthesopathies was defined as a new enthesopathy at least 1 intervertebral level in patients with or without presence of enthesopathy at baseline. MAIN OUTCOME MEASURES Demographic, treatment, PHEX mutation with the progression of enthesopathies. RESULTS Fifty-one patients (66.7% of women, mean age 42.1 ± 13.4 years) underwent 2 EOS imaging with an average interval of 5.7 (± 2.31) years.Progression of spinal enthesopathies was observed in 27 (52.9%) patients. In univariate analysis, patients with a progression of spinal enthesopathies were significantly older (P < .0005), were significantly older at treatment initiation (P = .02), presented with dental complications (P = .03), received less frequently treatment during childhood with phosphate and/or vitamin D analogs (P = .06), and presented more frequently with hip osteoarthritis (P = .002) at baseline. In multivariate analysis, none of these factors was associated with a progression of spinal enthesopathies. CONCLUSION This study confirms the high proportion of patients with a progression of spinal enthesopathies. Age seems to be the main factor associated with progression.
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Affiliation(s)
- Julia Herrou
- Department of Rheumatology, INSERM UMR 1153, Université de Paris-Cité, APHP Centre, Cochin Hospital, 75014 Paris, France
- Department of Rheumatology, APHP Centre, Cochin Hospital, 75014 Paris, France
| | - Jacques Fechtenbaum
- Department of Rheumatology, APHP Centre, Cochin Hospital, 75014 Paris, France
| | - Anya Rothenbuhler
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
- Department of Endocrinology and Diabetes for Children, APHP, Bicêtre Paris Saclay Hospital, 94270 Le Kremlin Bicêtre, France
- APHP, Plateforme d'expertise Paris Saclay maladies rares, Bicêtre Paris Saclay Hospital, 94270 Le Kremlin Bicêtre, France
| | - Peter Kamenický
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
- Université Paris-Saclay, INSERM UMR-S 1185, Physiologie et Physiopathologie Endocriniennes, 94270 Le Kremlin-Bicêtre, France
| | - Christian Roux
- Department of Rheumatology, INSERM UMR 1153, Université de Paris-Cité, APHP Centre, Cochin Hospital, 75014 Paris, France
- Department of Rheumatology, APHP Centre, Cochin Hospital, 75014 Paris, France
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
| | - Agnès Linglart
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
- Department of Endocrinology and Diabetes for Children, APHP, Bicêtre Paris Saclay Hospital, 94270 Le Kremlin Bicêtre, France
- APHP, Plateforme d'expertise Paris Saclay maladies rares, Bicêtre Paris Saclay Hospital, 94270 Le Kremlin Bicêtre, France
| | - Karine Briot
- Department of Rheumatology, INSERM UMR 1153, Université de Paris-Cité, APHP Centre, Cochin Hospital, 75014 Paris, France
- Department of Rheumatology, APHP Centre, Cochin Hospital, 75014 Paris, France
- Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, OSCAR Network for Rare Bone and Calcium Phosphate Disorders, Paris, France
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Niazi SK. A Critical Analysis of the FDA's Omics-Driven Pharmacodynamic Biomarkers to Establish Biosimilarity. Pharmaceuticals (Basel) 2023; 16:1556. [PMID: 38004421 PMCID: PMC10675618 DOI: 10.3390/ph16111556] [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: 09/02/2023] [Revised: 09/25/2023] [Accepted: 09/29/2023] [Indexed: 11/26/2023] Open
Abstract
Demonstrating biosimilarity entails comprehensive analytical assessment, clinical pharmacology profiling, and efficacy testing in patients for at least one medical indication, as required by the U.S. Biologics Price Competition and Innovation Act (BPCIA). The efficacy testing can be waived if the drug has known pharmacodynamic (PD) markers, leaving most therapeutic proteins out of this concession. To overcome this, the FDA suggests that biosimilar developers discover PD biomarkers using omics technologies such as proteomics, glycomics, transcriptomics, genomics, epigenomics, and metabolomics. This approach is redundant since the mode-action-action biomarkers of approved therapeutic proteins are already available, as compiled in this paper for the first time. Other potential biomarkers are receptor binding and pharmacokinetic profiling, which can be made more relevant to ensure biosimilarity without requiring biosimilar developers to conduct extensive research, for which they are rarely qualified.
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Affiliation(s)
- Sarfaraz K Niazi
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Illinois, Chicago, IL 60612, USA
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Mohamed FF, Hoac B, Phanrungsuwan A, Tan MH, Giovani PA, Ghiba S, Murshed M, Foster BL, McKee MD. Contributions of increased osteopontin and hypophosphatemia to dentoalveolar defects in osteomalacic Hyp mice. Bone 2023; 176:116886. [PMID: 37634682 PMCID: PMC10529969 DOI: 10.1016/j.bone.2023.116886] [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: 04/01/2023] [Revised: 06/10/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023]
Abstract
X-linked hypophosphatemia (XLH) is an inherited disorder caused by inactivating mutations in the PHEX gene leading to renal phosphate wasting, rickets and osteomalacia. XLH is also associated with dentoalveolar mineralization defects in tooth enamel, dentin and cementum, and in alveolar bone, which lead to an increased prevalence of dental abscesses, periodontal disease and tooth loss. Genetic mouse experiments, and deficiencies in XLH patient therapies where treatments do not fully ameliorate mineralization defects, suggest that other pathogenic mechanisms may exist in XLH. The mineralization-inhibiting, secreted extracellular matrix phosphoprotein osteopontin (OPN, gene Spp1) is a substrate for the PHEX enzyme whereby extensive and inactivating degradation of inhibitory OPN by PHEX facilitates mineralization. Conversely, excess OPN accumulation in skeletal and dental tissues - for example in XLH where inactivating mutations in the PHEX gene limit degradation of inhibitory OPN, or as occurs in Fgf23-null mice - contributes to mineralization defects. We hypothesized that Spp1/OPN ablation in Hyp mice (a mouse model for XLH) would reduce dentoalveolar mineralization defects. Immunostaining revealed increased OPN in Hyp vs. wild-type (WT) alveolar bone, particularly in osteocyte lacunocanalicular networks where Hyp mice have characteristic hypomineralized peri-osteocytic lesions (POLs). Micro-computed tomography and histology showed that ablation of Spp1 in Hyp mice (Hyp;Spp1-/-) on a normal diet did not ameliorate bulk defects in enamel, dentin, or alveolar bone. On a high-phosphate diet, both Hyp and Hyp;Spp1-/- mice showed improved mineralization of enamel, dentin, and alveolar bone. Silver staining indicated Spp1 ablation did not improve alveolar or mandibular bone osteocyte POLs in Hyp mice; however, they were normalized by a high-phosphate diet in both Hyp and Hyp;Spp1-/- mice, although inducing increased OPN. Collectively, these data indicate that despite changes in OPN content in the dentoalveolar mineralized tissues, there exist other compensatory mineralization mechanisms that arise from knockout of Spp1/OPN in the Hyp background.
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Affiliation(s)
- Fatma F Mohamed
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - Betty Hoac
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC, Canada
| | | | - Michelle H Tan
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | | | - Sana Ghiba
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - Monzur Murshed
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC, Canada; Department of Medicine, Faculty of Medicine, McGill University, Montreal, QC, Canada; Shriners Hospital for Children, Montreal, QC, Canada
| | - Brian L Foster
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA.
| | - Marc D McKee
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC, Canada; Department of Anatomy and Cell Biology, School of Biomedical Sciences, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada.
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Levy-Shraga Y, Levi S, Regev R, Gal S, Brener A, Lebenthal Y, Gillis D, Strich D, Zung A, Cleper R, Borovitz Y, Bello R, Tenenbaum A, Zadik Z, Davidovits M, Zeitlin L, Tiosano D. Linear growth of children with X-linked hypophosphatemia treated with burosumab: a real-life observational study. Eur J Pediatr 2023; 182:5191-5202. [PMID: 37707589 DOI: 10.1007/s00431-023-05190-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/30/2023] [Accepted: 09/02/2023] [Indexed: 09/15/2023]
Abstract
To assess the long-term efficacy of burosumab for pediatric patients with X-linked hypophosphatemia, focusing on linear growth. This multi-center retrospective study included 35 pediatric patients who began treatment with burosumab between January 2018 and January 2021. We collected clinical data, anthropometric measurements, laboratory results, and Rickets Severity Score (RSS), from 2 years prior to treatment initiation and up to 4 years after. Burosumab was initiated at a mean age of 7.5 ± 4.4 years (range 0.6-15.9), with a mean initial dose of 0.8 ± 0.3 mg/kg, which was subsequently increased to 1.1 ± 0.4 mg/kg. The patients were followed for 2.9 ± 1.4 years (range 1-4) after initiating burosumab. Serum phosphorus levels increased from 2.7 ± 0.8 mg/dl at burosumab initiation to 3.4 ± 0.6 mg/dl after 3 months and remained stable (p < 0.001). Total reabsorption of phosphorus increased from 82.0 ± 6.8 to 90.1 ± 5.3% after 12 months of treatment (p = 0.041). The RSS improved from 1.7 ± 1.0 at burosumab initiation to 0.5 ± 0.6 and 0.3 ± 0.6 after 12 and 24 months, respectively (p < 0.001). Both height z-score and weight z-score improved from burosumab initiation to the end of the study: from - 2.07 ± 1.05 to - 1.72 ± 1.04 (p < 0.001) and from - 0.51 ± 1.12 to - 0.11 ± 1.29 (p < 0.001), respectively. Eight children received growth hormone combined with burosumab treatment. Height z-score improved among those who received growth hormone (from - 2.33 ± 1.12 to - 1.94 ± 1.24, p = 0.042) and among those who did not (from - 2.01 ± 1.01 to - 1.66 ± 1.01, p = 0.001). CONCLUSION Burosumab treatment in a real-life setting improved phosphate homeostasis and rickets severity and enhanced linear growth. WHAT IS KNOWN • Compared to conventional therapy, burosumab treatment has been shown to increase serum phosphate levels and reduce the severity of rickets. • The effect of burosumab on growth is still being study. WHAT IS NEW • Height z-score improved between the start of burosumab treatment and the end of the study (-2.07 ± 1.05 vs. -1.72 ± 1.04, p < 0.001). • Eight children received burosumab combined with growth hormone treatment without side effects during the concomitant treatments.
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Affiliation(s)
- Yael Levy-Shraga
- Pediatric Endocrinology Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, 52621, Israel.
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Shelly Levi
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Pediatric Nephrology, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Ravit Regev
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shoshana Gal
- Division of Pediatric Endocrinology, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Avivit Brener
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yael Lebenthal
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - David Gillis
- Pediatric Endocrinology Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical School, Jerusalem, Israel
| | - David Strich
- Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical School, Jerusalem, Israel
- Department of Pediatrics, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Amnon Zung
- Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical School, Jerusalem, Israel
- Pediatrics Department, Kaplan Medical Center, Rehovot, Israel
| | - Roxana Cleper
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Nephrology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yael Borovitz
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Pediatric Nephrology, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Rachel Bello
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Shafer Institute for Endocrinology and Diabetes, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Ariel Tenenbaum
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Shafer Institute for Endocrinology and Diabetes, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Zvi Zadik
- Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical School, Jerusalem, Israel
- Pediatrics Department, Kaplan Medical Center, Rehovot, Israel
| | - Miriam Davidovits
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Pediatric Nephrology, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Leonid Zeitlin
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Orthopedic Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Dov Tiosano
- Division of Pediatric Endocrinology, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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Imel EA, Glorieux FH, Whyte MP, Portale AA, Munns CF, Nilsson O, Simmons JH, Padidela R, Namba N, Cheong HI, Pitukcheewanont P, Sochett E, Högler W, Muroya K, Tanaka H, Gottesman GS, Biggin A, Perwad F, Chen A, Roberts MS, Ward LM. Burosumab vs Phosphate/Active Vitamin D in Pediatric X-Linked Hypophosphatemia: A Subgroup Analysis by Dose Level. J Clin Endocrinol Metab 2023; 108:2990-2998. [PMID: 37084401 PMCID: PMC10583998 DOI: 10.1210/clinem/dgad230] [Citation(s) in RCA: 2] [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: 06/16/2022] [Revised: 03/16/2023] [Accepted: 04/17/2023] [Indexed: 04/23/2023]
Abstract
CONTEXT In an open-label, randomized, controlled, phase 3 trial in 61 children aged 1 to 12 years with X-linked hypophosphatemia (XLH), burosumab improved rickets vs continuing conventional therapy with active vitamin D and phosphate. OBJECTIVE We conducted an analysis to determine whether skeletal responses differed when switching to burosumab vs continuing higher or lower doses of conventional therapy. METHODS Conventional therapy dose groups were defined as higher-dose phosphate [greater than 40 mg/kg] (HPi), lower-dose phosphate [40 mg/kg or less] (LPi), higher-dose alfacalcidol [greater than 60 ng/kg] or calcitriol [greater than 30 ng/kg] (HD), and lower-dose alfacalcidol [60 ng/kg or less] or calcitriol [30 ng/kg or less] (LD). RESULTS At week 64, the Radiographic Global Impression of Change (RGI-C) for rickets was higher (better) in children randomly assigned to burosumab vs conventional therapy for all prebaseline dose groups: HPi (+1.72 vs +0.67), LPi (+2.14 vs +1.08), HD (+1.90 vs +0.94), LD (+2.11 vs +1.06). At week 64, the RGI-C for rickets was also higher in children randomly assigned to burosumab (+2.06) vs conventional therapy for all on-study dose groups: HPi (+1.03), LPi (+1.05), HD (+1.45), LD (+0.72). Serum alkaline phosphatase (ALP) also decreased in the burosumab-treated patients more than in the conventional therapy group, regardless of on-study phosphate and active vitamin D doses. CONCLUSION Prior phosphate or active vitamin D doses did not influence treatment response after switching to burosumab among children with XLH and active radiographic rickets. Switching from conventional therapy to burosumab improved rickets and serum ALP more than continuing either higher or lower doses of phosphate or active vitamin D.
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Affiliation(s)
- Erik A Imel
- Departments of Medicine and Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Francis H Glorieux
- Emeritus Director of Research, Shriners Hospitals for Children–Canada, Montreal, QC H4A 0A9, Canada
| | - Michael P Whyte
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children–St. Louis, St Louis, MO 63110, USA
| | - Anthony A Portale
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA 94115, USA
| | - Craig F Munns
- The University of Queensland, Queensland Children’s Hospital, South Brisbane, QLD 4101, Australia
| | - Ola Nilsson
- Division of Pediatric Endocrinology and Center for Molecular Medicine, Department of Women’s and Children’s Health, Karolinska Institutet and University Hospital, Stockholm 171 64, Sweden
- School of Medical Sciences and Department of Pediatrics, Örebro University and University Hospital, Örebro 701 85, Sweden
| | - Jill H Simmons
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Raja Padidela
- Paediatric Endocrinology, Royal Manchester Children’s Hospital and Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Noriyuki Namba
- Department of Pediatrics, Osaka Hospital, Japan Community Healthcare Organization, Osaka 553-0003, Japan
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita 565-0871, Japan
| | - Hae Il Cheong
- Department of Pediatrics, Hallym University Sacred Heart Hospital, Anyang-si, Gyeonggi-do, South Korea
| | - Pisit Pitukcheewanont
- Children's Hospital Los Angeles, Los Angeles, CA and Keck School of Medicine of USC, Los Angeles, CA 90027, USA
| | - Etienne Sochett
- Department of Endocrinology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Wolfgang Högler
- Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz 4040, Austria
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Koji Muroya
- Kanagawa Children’s Medical Center, Yokohama 232-0066, Japan
| | | | - Gary S Gottesman
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children–St. Louis, St Louis, MO 63110, USA
- Washington University School of Medicine, St Louis, MO 63110, USA
| | - Andrew Biggin
- Children’s Hospital Westmead, Westmead 2145, Australia
| | - Farzana Perwad
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA 94115, USA
| | - Angel Chen
- Ultragenyx Pharmaceutical Inc, Novato, CA 94949, USA
| | | | - Leanne M Ward
- Department of Pediatrics, University of Ottawa, Children’s Hospital of Eastern Ontario, Ottawa, Ontario K1H 8L1, Canada
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Boros E, Ertl DA, Berkenou J, Audrain C, Lecoq AL, Kamenicky P, Briot K, Amouroux C, Zhukouskaya V, Gueorguieva I, Mignot B, Girerd B, Porquet Bordes V, Salles JP, Edouard T, Coutant R, Bacchetta J, Linglart A, Rothenbuhler A. Adult height improved over decades in patients with X-linked hypophosphatemia: a cohort study. Eur J Endocrinol 2023; 189:469-475. [PMID: 37831782 DOI: 10.1093/ejendo/lvad144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/28/2023] [Accepted: 09/07/2023] [Indexed: 10/15/2023]
Abstract
OBJECTIVES The aim of this study is to analyze height after cessation of growth (final height [FH]) and its evolution over the last decades in X-linked hypophosphatemia (XLH) patients in France, as the data on natural history of FH in XLH are lacking. DESIGN We performed a retrospective observational study in a large cohort of French XLH patients with available data on FH measurements. MATERIALS AND METHODS We divided patients into 3 groups according to their birth year: group 1 born between 1950 and 1974, group 2 born between 1975 and 2000, and group 3 born between 2001 and 2006, respectively, and compared their FHs. RESULTS A total of 398 patients were included. Mean FHs were the following: for group 1, -2.31 ± 1.11 standard deviation score (SDS) (n = 127), 156.3 ± 9.7 cm in men and 148.6 ± 6.5 cm in women; for group 2, -1.63 ± 1.13 SDS (n = 193), 161.6 ± 8.5 cm in men and 153.1 ± 7.2 cm in women; and for group 3, -1.34 ± 0.87 SDS (n = 78), 165.1 ± 5.5 cm in men and 154.7 ± 6 cm in women. We report a significant increase in mean FH SDS over 3 generations of patients, for both men and women (P < .001). Final height SDS in male (-2.08 ± 1.18) was lower than in female (-1.70 ± 1.12) (P = .002). CONCLUSION The FH of XLH patients in France increased significantly over the last decades. Even though men's FHs improved more than women's, men with XLH remain shorter reflecting a more severe disease phenotype. While the results are promising, most patients with XLH remain short leaving room for improvement.
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Affiliation(s)
- Emese Boros
- Pediatric Endocrinology Unit, Hôpital Universitaire de Bruxelles (HUB), Hôpital Universitaire des Enfants Reine Fabiola (HUDERF), Université Libre de Bruxelles, Brussels 1020, Belgium
| | - Diana-Alexandra Ertl
- AP-HP, Department of Endocrinology and Diabetes for Children, Department of Adolescent Medicine, Bicetre Paris-Saclay University Hospital, 78 Rue du General Leclerc, Le Kremlin-Bicêtre 94270, France
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filiere OSCAR and Platform of Expertise for Rare Diseases Paris-Saclay, Bicetre Paris-Saclay Hospital, 78 Rue du General Leclerc, Le Kremlin-Bicêtre 94270, France
| | - Jugurtha Berkenou
- AP-HP, Department of Endocrinology and Diabetes for Children, Department of Adolescent Medicine, Bicetre Paris-Saclay University Hospital, 78 Rue du General Leclerc, Le Kremlin-Bicêtre 94270, France
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filiere OSCAR and Platform of Expertise for Rare Diseases Paris-Saclay, Bicetre Paris-Saclay Hospital, 78 Rue du General Leclerc, Le Kremlin-Bicêtre 94270, France
| | - Christelle Audrain
- AP-HP, Department of Endocrinology and Diabetes for Children, Department of Adolescent Medicine, Bicetre Paris-Saclay University Hospital, 78 Rue du General Leclerc, Le Kremlin-Bicêtre 94270, France
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filiere OSCAR and Platform of Expertise for Rare Diseases Paris-Saclay, Bicetre Paris-Saclay Hospital, 78 Rue du General Leclerc, Le Kremlin-Bicêtre 94270, France
| | - Anne Lise Lecoq
- AP-HP, Centre de Recherche Clinique Paris Saclay, Hôpital Bicêtre, Le Kremlin-Bicêtre 94270, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, Filière OSCAR, 78 rue du Général Leclerc, Le Kremlin-Bicêtre 94270, France
| | - Peter Kamenicky
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, Filière OSCAR, 78 rue du Général Leclerc, Le Kremlin-Bicêtre 94270, France
- Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, Inserm, Le Kremlin-Bicêtre 94276, France
| | - Karine Briot
- Rheumatology Department, Université Paris-Cité, Cochin Hospital, Paris 75014, France
| | - Cyril Amouroux
- Service de Néphrologie et Endocrinologie Pédiatriques, CHU de Montpellier, Montpellier 34090, France
- Faculté de Médecine, Université de Montpellier, Montpellier 34090, France
- Centres Maladies Rares Métabolisme du Calcium et du Phosphore et Maladies Osseuses Constitutionnelles, Filière de Santé Maladies Rares OSCAR, 34090 Montpellier, France
| | - Volha Zhukouskaya
- AP-HP, Department of Endocrinology, Hôpital Cochin, Paris 75014, France
- Institut des Maladies Musculo-squelettiques, Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496 and FHU-DDS-Net, Dental School, and Plateforme d'Imagerie du Vivant (PIV), Université Paris Cité, Montrouge 92129, France
- Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, Plateforme d'Expertise Maladies Rares Paris Saclay, Filière OSCAR, EndoRare and BOND ERN, Hôpital de Bicêtre, Le Kremlin-Bicêtre 94270, France
| | - Iva Gueorguieva
- Pediatric Endocrine Unit, CHU Lille, Université Lille, Lille 59800, France
| | - Brigitte Mignot
- Service de Médecine Pédiatrique, CHRU J Minjoz, 3 Boulevard Fleming, Besançon 25030, France
| | - Barbara Girerd
- AP-HP, Department of Endocrinology and Diabetes for Children, Department of Adolescent Medicine, Bicetre Paris-Saclay University Hospital, 78 Rue du General Leclerc, Le Kremlin-Bicêtre 94270, France
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filiere OSCAR and Platform of Expertise for Rare Diseases Paris-Saclay, Bicetre Paris-Saclay Hospital, 78 Rue du General Leclerc, Le Kremlin-Bicêtre 94270, France
| | - Valerie Porquet Bordes
- Endocrine, Bone Diseases and Genetics Unit, Reference Centre for Rare Diseases of Calcium and Phosphate Metabolism, Competence Centre for Bone Diseases, ERN BOND, OSCAR Network, Children's Hospital, Toulouse University Hospital, Toulouse 31059, France
| | - Jean Pierre Salles
- Unité d'Endocrinologie, Maladies Osseuses, Hôpital des Enfants, Centre de Référence des Maladies Rares du Calcium et du Phosphate, ENR BOND, Hôpital des Enfants, CHU de Toulouse, TSA 70034, Toulouse 31059, France
- INFINITY CENTER, INSERM CNRS UMR 1291, Université de Toulouse, Paul Sabatier Toulouse III, Hôpital Purpan, Toulouse 31024, France
| | - Thomas Edouard
- Endocrine, Bone Diseases and Genetics Unit, Toulouse University Hospital, Toulouse 31059, France
| | - Régis Coutant
- Unité d' Endocrinologie Diabetologie Pédiatrique and Centre des Maladies Rares de la Réceptivité Hormonale, CHU-Angers, Angers 49055, France
| | - Justine Bacchetta
- Centre de Référence des Maladies Rénales Rares, Centre de Référence des Maladies Rares du Calcium et du Phosphore, Filières Santé Maladies Rares OSCAR et ORKID, Filières Santé ERKNet et BOND, INSERM1033, Université de Lyon, Lyon 69372, France
| | - Agnès Linglart
- AP-HP, Department of Endocrinology and Diabetes for Children, Department of Adolescent Medicine, Bicetre Paris-Saclay University Hospital, 78 Rue du General Leclerc, Le Kremlin-Bicêtre 94270, France
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filiere OSCAR and Platform of Expertise for Rare Diseases Paris-Saclay, Bicetre Paris-Saclay Hospital, 78 Rue du General Leclerc, Le Kremlin-Bicêtre 94270, France
- Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, Inserm, Le Kremlin-Bicêtre 94276, France
| | - Anya Rothenbuhler
- AP-HP, Department of Endocrinology and Diabetes for Children, Department of Adolescent Medicine, Bicetre Paris-Saclay University Hospital, 78 Rue du General Leclerc, Le Kremlin-Bicêtre 94270, France
- AP-HP, Reference Center for Rare Disorders of the Calcium and Phosphate Metabolism, Filiere OSCAR and Platform of Expertise for Rare Diseases Paris-Saclay, Bicetre Paris-Saclay Hospital, 78 Rue du General Leclerc, Le Kremlin-Bicêtre 94270, France
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50
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Horinouchi Y, Shiota S, Kaimori R, Yoshimura K, Utsunomiya-Nishimizu R, Yamamoto K, Miyazaki E. A Case of Tumor-Induced Osteomalacia Detected by Venous Sampling. Int Med Case Rep J 2023; 16:659-665. [PMID: 37840970 PMCID: PMC10576504 DOI: 10.2147/imcrj.s425599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/21/2023] [Indexed: 10/17/2023] Open
Abstract
Tumor-induced osteomalacia (TIO) can cause osteomalacia due to excessive production of fibroblast growth factor 23 (FGF23) by the tumor. Since TIO is a very rare disease, it is often misdiagnosed as intervertebral disc herniation, spondyloarthritis, or osteoporosis. We report a 65-year-old man who developed generalized arthralgia and difficulty walking two years ago and was diagnosed with multiple fractures throughout his body. He was initially diagnosed with osteoporosis and was treated with calcitriol. However, he was referred to our hospital since his symptoms did not improve. We diagnosed tumor-induced osteomalacia based on low serum phosphorus, high bone-type alkaline phosphatase, high FGF23 levels, and the presence of two tumors. The responsible tumor was identified using FGF23 levels in venous sampling. As the location of the tumor made surgical resection difficult, we selected treatment with burosumab, a human monoclonal antibody against FGF23, leading to improvement in the hypophosphatemia and pain, such that he was able to walk with a cane. In cases of osteoporosis with hypophosphatemia, general physicians should keep TIO in mind, and attempt to identify the responsible tumor lesion.
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Affiliation(s)
- Yasuo Horinouchi
- Department of General Medicine, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Seiji Shiota
- Department of General Medicine, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Ryo Kaimori
- Department of General Medicine, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Katsuhiko Yoshimura
- Department of General Medicine, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Rie Utsunomiya-Nishimizu
- Department of General Medicine, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Kyoko Yamamoto
- Department of General Medicine, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Eishi Miyazaki
- Department of General Medicine, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
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