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Kimura S, Sunouchi T, Watanabe S, Hoshino Y, Hidaka N, Kato H, Takeda S, Nangaku M, Makita N, Azuma K, Kojima T, Matsubara T, Saito T, Ito N. Latent metabolic bone disease, skeletal dysplasia and other conditions related to low bone formation among 38 patients with subtrochanteric femoral fractures: a retrospective observational study. Osteoporos Int 2024; 35:1633-1643. [PMID: 38951164 PMCID: PMC11364693 DOI: 10.1007/s00198-024-07168-4] [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] [Accepted: 06/20/2024] [Indexed: 07/03/2024]
Abstract
Subtrochanteric femoral fracture is rare and intractable due to the possible association with low bone formation. Retrospective analysis of 38 patients with subtrochanteric femoral fractures revealed that four patients suffered from disorders related to low bone formation and there were specific treatments for two of them. PURPOSE The main aim of this study was to detect latent metabolic bone diseases and skeletal dysplasia associated with low bone formation among patients with morphologic atypical femoral fracture (AFF). A second aim was to evaluate the frequency of recognized risk factors, such as antiresorptive agents, glucocorticoids, and age. METHODS Clinical information was retrospectively analyzed among 38 Japanese patients who were admitted to the Department of Orthopedic Surgery and Spinal Surgery and the Division of Emergency and Critical Care Medicine at the University of Tokyo Hospital with diagnoses of subtrochanteric fractures between February 2012 and March 2022. RESULTS Among 38 patients (including 30 females), 21 patients were aged 75 and over. Ten patients had past oral glucocorticoid use, and 18 had past antiresorptive agent use. Two patients were diagnosed with hypophosphatemic osteomalacia after the development of fractures. One patient was suspected to be a carrier of a loss-of-function variant of alkaline phosphatase, biomineralization associated (ALPL), and one other patient had previously been genetically diagnosed with pycnodysostosis. Among four patients with a diagnosis or suspicion of these metabolic bone diseases and skeletal dysplasia, four had past clinical fractures, two had past subtrochanteric femoral fractures, and two had subtrochanteric femoral fractures on both sides. CONCLUSION If clinicians encounter patients with morphologic AFF, latent diseases related to low bone formation should be carefully differentiated because appropriate treatment may prevent delayed union and recurrent fractures. Additionally, it may be desirable to exclude these bone diseases in advance before initiating long-term use of antiresorptive agents in osteoporotic patients by screening with serum alkaline phosphatase levels to reduce the risk of morphologic AFF.
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Affiliation(s)
- Soichiro Kimura
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Takashi Sunouchi
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - So Watanabe
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
- Department of Geriatric Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshitomo Hoshino
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Naoko Hidaka
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Hajime Kato
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Shu Takeda
- Division of Endocrinology, Toranomon Hospital Endocrine Center, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Noriko Makita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Kotaro Azuma
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
- Department of Geriatric Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Taro Kojima
- Department of Geriatric Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Takehiro Matsubara
- Department of Orthopedic Surgery and Spinal Surgery, The University of Tokyo Hospital, Tokyo, Japan
- Division of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Taku Saito
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
- Department of Orthopedic Surgery and Spinal Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan.
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan.
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Charoenngam N, Thongpiya J, Yingchoncharoen P, Ponvilawan B, Marangoz MS, Chenbhanich J, Ungprasert P. Atypical Femoral Fracture in Hypophosphatasia: A Systematic Review. Int J Endocrinol 2023; 2023:5544148. [PMID: 37731773 PMCID: PMC10508997 DOI: 10.1155/2023/5544148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/03/2023] [Accepted: 08/31/2023] [Indexed: 09/22/2023] Open
Abstract
Objective To summarize the characteristics of all reported patients with hypophosphatasia (HPP) who sustained atypical femoral fracture (AFF) and identify all available evidence to quantify the rate of coexistence between HPP and AFF. Methods Potentially eligible articles were identified from the MEDLINE and EMBASE databases from its inception to September 2022, using a search strategy consisting of terms related to "Hypophosphatasia" and "Atypical femoral fracture." Eligible articles must report one of the following information: (1) individual data of patients diagnosed with HPP and AFF, (2) prevalence of HPP among patients with AFF, or (3) prevalence of AFF among patients of HPP. Characteristics of patients reported in each study were extracted. Results A total of 148 articles were identified. After the systematic review, 24 articles met the eligibility criteria. A total of 28 patients with AFF and HPP were identified. The mean ± SD age of the reported patients was 53.8 ± 12.5 years, and 22 patients (78.6%) were female. Nine patients (32.1%) received antiresorptive medication (bisphosphonate and/or denosumab), and two patients (7.1%) received teriparatide prior to the development of AFF. Seven (25.0%) and eighteen (64.3%) patients sustained unilateral and bilateral AFF, respectively (laterality not reported in three cases). Thirteen patients (46.4%) had a history of fractures at other sites. Four (14.3%) and seven (25.0%) patients received asfotase alfa and teriparatide after sustaining AFF. Two studies reported the prevalence of AFF among patients with HPP of approximately 10%. One study reported one HPP patient in a cohort of 72 patients with AFF. Conclusions Based on the limited evidence, AFF occurred in up to 10% of patients with HPP. Based on the 28 case reports, about two-thirds did not receive antiresorptive treatment, suggesting that the HPP itself could potentially be a risk factor for AFF.
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Affiliation(s)
- Nipith Charoenngam
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, USA
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jerapas Thongpiya
- Department of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | | | - Ben Ponvilawan
- Department of Medicine, University of Kansas Missouri Medical Center, Jefferson, MO, USA
| | - Mehmet S. Marangoz
- Department of Endocrinology and Metabolism, Mount Auburn Hospital, Cambridge, MA, USA
| | - Jirat Chenbhanich
- Department of Genetics and Genomic Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Patompong Ungprasert
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio, USA
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Ng E, Ashkar C, Seeman E, Schneider HG, Nguyen H, Ebeling PR, Sztal-Mazer S. A low serum alkaline phosphatase may signal hypophosphatasia in osteoporosis clinic patients. Osteoporos Int 2023; 34:327-337. [PMID: 36434431 DOI: 10.1007/s00198-022-06597-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022]
Abstract
UNLABELLED Low serum alkaline phosphatase (ALP) was found in 9% of patients attending an osteoporosis clinic, 0.6% of hospital patients, and 2/22 with an atypical femoral fracture. Hypophosphatasia was diagnosed in 3% of osteoporosis clinic patients with low ALP. Low ALP is a screening tool for hypophosphatasia, a condition potentially aggravated by antiresorptive therapy. INTRODUCTION Hypophosphatasia (HPP) is an inherited disorder associated with impaired primary mineralisation of osteoid (osteomalacia). HPP may be misdiagnosed as osteoporosis, a reduction in the volume of normally mineralized bone. Both illnesses may result in fragility fractures, although stress and atypical fractures are more common in HPP. Antiresorptive therapy, first-line treatment for osteoporosis, is relatively contraindicated in HPP. Misdiagnosis and mistreatment can be avoided by recognising a low serum alkaline phosphatase (ALP). Our aim was to determine the prevalence of a low ALP (< 30 IU/L) in patients attending an osteoporosis clinic, in a hospital-wide setting, and in a group of patients with atypical femoral fractures (AFF). METHODS This was a retrospective study of patients attending an osteoporosis clinic at a tertiary hospital during 8 years (2012-2020). Patients were categorised into those with a transiently low ALP, those with low ALP on ≥ 2 occasions but not the majority of measurements, and those with a persistently low ALP. ALP levels were also assessed in hospital-wide records and a group of patients with AFF. RESULTS Of 1839 patients attending an osteoporosis clinic, 168 (9%) had ≥ 1 low ALP, 50 (2.7%) had low ALP for ≥ 2 months, and seven (0.4%) had persistently low ALP levels. HPP was diagnosed in five patients, four of whom had persistently low ALP levels. The prevalence of HPP was 0.3% in the osteoporosis clinic and 3% in patients with ≥ 1 low ALP. Low ALP occurred in 0.6% of all hospital patients and 2/22 with AFF. CONCLUSION Persistently low ALP in osteoporosis clinic attendees is easy to identify and signals the possibility of hypophosphatasia, a condition that may be mistaken for osteoporosis and incorrectly treated with antiresorptive therapy.
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Affiliation(s)
- Elisabeth Ng
- Department of Endocrinology & Diabetes, Alfred Health, Melbourne, Australia.
- Department of Endocrinology, Monash Health, Clayton, Australia.
| | - Claudia Ashkar
- Department of Endocrinology & Diabetes, Alfred Health, Melbourne, Australia
| | - Ego Seeman
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology, Austin Health, Melbourne, Australia
| | - Hans G Schneider
- Department of Endocrinology & Diabetes, Alfred Health, Melbourne, Australia
- Clinical Biochemistry Unit, Alfred Pathology Service, Alfred Health, Melbourne, Australia
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
| | - Hanh Nguyen
- Department of Endocrinology, Monash Health, Clayton, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Australia
| | - Peter R Ebeling
- Department of Endocrinology, Monash Health, Clayton, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Australia
| | - Shoshana Sztal-Mazer
- Department of Endocrinology & Diabetes, Alfred Health, Melbourne, Australia
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
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Dahir KM, Seefried L, Kishnani PS, Petryk A, Högler W, Linglart A, Martos-Moreno GÁ, Ozono K, Fang S, Rockman-Greenberg C. Clinical profiles of treated and untreated adults with hypophosphatasia in the Global HPP Registry. Orphanet J Rare Dis 2022; 17:277. [PMID: 35854311 PMCID: PMC9295501 DOI: 10.1186/s13023-022-02393-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 06/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background The clinical signs and symptoms of hypophosphatasia (HPP) can manifest during any stage of life. The age at which a patient’s symptoms are reported can impact access to targeted treatment with enzyme replacement therapy (asfotase alfa), as this treatment is indicated for patients with pediatric-onset HPP in most countries. As such, many patients reported to have adult-onset HPP typically do not receive treatment. Comparison of the disease in treated and untreated adult patients is confounded by the approved indication. To avoid this confounding factor, a comparison between baseline disease manifestations prominent among treated versus untreated adult patients was limited to those with pediatric-onset HPP using data collected from the Global HPP Registry. The hypothesis was that treated adults will have a greater disease burden at baseline than untreated adults. The analysis of disease manifestations in adults with adult-onset HPP was conducted separately. Results A total of 398 adults with HPP were included; 213 with pediatric-onset (114 treated, 99 untreated) and 141 with adult-onset HPP (2 treated and 139 untreated). The treated, pediatric-onset patients were more likely to have a history of pain (prevalence ratio [PR]: 1.3, 95% confidence interval [CI] 1.1, 1.4), skeletal (PR: 1.3, 95% CI 1.1, 1.6), constitutional/metabolic (PR: 1.7, 95% CI 1.3, 2.0), muscular (PR: 1.8, 95% CI 1.4, 2.1) and neurological (PR: 1.7, 95% CI 1.1, 2.3) manifestations of HPP, and also had poorer measures for health-related quality of life, pain, and disability compared with untreated pediatric-onset patients. In patients with adult-onset HPP, the most frequent signs and symptoms were chronic bone pain (52.5%), dental manifestations (42.6%), fatigue (23.4%), recurrent fractures or pseudofractures (22.0%), and generalized body pain (22.0%). Conclusions Along with the more classical skeletal signs and symptoms, pain, muscular, and constitutional/metabolic manifestations are common in adults with HPP, regardless of age of disease onset, highlighting a full spectrum of HPP manifestations.
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Affiliation(s)
- Kathryn M Dahir
- Program for Metabolic Bone Disorders at Vanderbilt, Endocrinology and Diabetes, Vanderbilt University Medical Center, 8210 Medical Center East, 1215 21st Avenue South, Nashville, TN, 37232-8148, USA.
| | | | | | - Anna Petryk
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | - Wolfgang Högler
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Agnès Linglart
- DMU 3 SEA, Service d'endocrinologie et Diabète de L'enfant, filière OSCAR, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, Paris-Saclay University, AP-HP, INSERM, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Gabriel Ángel Martos-Moreno
- Departments of Pediatrics and Pediatric Endocrinology Hospital Infantil, CIBERobn, ISCIII, Universitario Niño Jesús, IIS La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Shona Fang
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
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Zhou W, van Rooij JGJ, Ebeling PR, Verkerk AJMH, Zillikens MC. The Genetics of Atypical Femur Fractures-a Systematic Review. Curr Osteoporos Rep 2021; 19:123-130. [PMID: 33587247 PMCID: PMC8016774 DOI: 10.1007/s11914-021-00658-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Atypical femur fractures (AFFs) are rare subtrochanteric or diaphyseal fractures regarded as side effects of bisphosphonates (BPs), possibly with a genetic background. Here, we summarize the most recent knowledge about genetics of AFFs. RECENT FINDINGS AFF has been reported in 57 patients with seven different monogenic bone disorders including hypophosphatasia and osteogenesis imperfecta; 56.1% had never used BPs, while 17.5% were diagnosed with the disorder only after the AFF. Gene mutation finding in familial and sporadic cases identified possible AFF-related variants in the GGPS1 and ATRAID genes respectively. Functional follow-up studies of mutant proteins showed possible roles in AFF. A recent small genome-wide association study on 51 AFF cases did not identify significant hits associated with AFF. Recent findings have strengthened the hypothesis that AFFs have underlying genetic components but more studies are needed in AFF families and larger cohorts of sporadic cases to confirm previous results and/or find novel gene variants involved in the pathogenesis of AFFs.
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Affiliation(s)
- Wei Zhou
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeroen G J van Rooij
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Neurology & Alzheimer Center, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Australia
| | - Annemieke J M H Verkerk
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Rassie K, Dray M, Michigami T, Cundy T. Bisphosphonate Use and Fractures in Adults with Hypophosphatasia. JBMR Plus 2019; 3:e10223. [PMID: 31687651 PMCID: PMC6820463 DOI: 10.1002/jbm4.10223] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 06/24/2019] [Accepted: 07/15/2019] [Indexed: 02/06/2023] Open
Abstract
Adults with hypophosphatasia (HPP) may suffer femoral fractures resembling the atypical femoral fractures that can occur with long‐term bisphosphonate treatment, and there is an emerging consensus that bisphosphonates should not be used in adults with HPP and low bone mass. However, the spectrum of HPP in adults is wide: ranging from the severely affected—who commonly have osteomalacia—through to the minimally affected. The former typically have biallelic and the latter, heterozygous ALPL mutations. We have reviewed reports of fractures in adults with genetically proven HPP which suggest that the risk of fracture is at least 200‐fold greater in those with biallelic mutations. We also discuss two cases of postmenopausal women with heterozygous ALPL mutations. One had fractures and severe osteoporosis, but histology revealed no evidence of osteomalacia. The second had taken alendronate for 8 years, but despite profound suppression of bone turnover, histology again revealed no evidence of osteomalacia. The management of adults with HPP who have coexisting osteoporosis is challenging. More data are clearly needed, but we suggest that the risks of bisphosphonate therapy may be relatively low in patients who have heterozygous mutations and no histological evidence of osteomalacia. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Kate Rassie
- Department of Endocrinology Greenlane Clinical Centre Auckland New Zealand
| | - Michael Dray
- Department of Pathology Waikato Hospital Hamilton New Zealand
| | - Toshimi Michigami
- Department of Bone & Mineral Research Osaka Women's & Children's Hospital Isumi Japan
| | - Tim Cundy
- Department of Endocrinology Greenlane Clinical Centre Auckland New Zealand.,Department of Medicine, Faculty of Medical & Health Sciences University of Auckland Auckland New Zealand
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Martins L, de Almeida AB, Dos Santos EJL, Foster BL, Machado RA, Kantovitz KR, Coletta RD, Nociti FH. A novel combination of biallelic ALPL mutations associated with adult hypophosphatasia: A phenotype-genotype association and computational analysis study. Bone 2019; 125:128-139. [PMID: 31077853 DOI: 10.1016/j.bone.2019.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/28/2019] [Accepted: 05/07/2019] [Indexed: 02/07/2023]
Abstract
Hypophosphatasia (HPP) is an inherited metabolic disorder that causes defective skeletal and dental mineralization. HPP exhibits a markedly heterogeneous range of clinical manifestations caused by dysfunction of the tissue-nonspecific isozyme of alkaline phosphatase (TNSALP), resulting from loss-of-function mutations in the ALPL gene. HPP has been associated with predominantly missense mutations in ALPL, and a number of compound heterozygous genotypes have been identified. Here, we describe a case of a subject with adult-onset HPP caused by a novel combination of missense mutations p.Gly473Ser and p.Ala487Val, resulting in chronic musculoskeletal pain, myopathy, persistent fatigue, vomiting, and an uncommon dental phenotype of short-rooted permanent teeth. Pedigree and biochemical analysis indicated that severity of symptoms was correlated with levels of residual ALP activity, and co-segregated with the p.Gly473Ser missense mutation. Bioinformatic analysis to predict the structural and functional impact of each of the point mutations in the TNSALP molecule, and its potential contribution to the clinical symptoms, revealed that the affected Gly473 residue is localized in the homodimer interface and predicted to have a dominant negative effect. The affected Ala487 residue was predicted to bind to Tyr479, which is closely located the N-terminal α-helix of TNSALP monomer 2, suggesting that both changes may impair dimer stability and catalytic functions. In conclusion, these findings assist in defining genotype-phenotype associations for HPP, and further define specific sites within the TNSALP molecule potentially related to neuromuscular manifestations in adult HPP, allowing for a better understanding of HPP pathophysiology.
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Affiliation(s)
- Luciane Martins
- Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, University of Campinas - UNICAMP, Piracicaba, SP, Brazil
| | - Amanda Bandeira de Almeida
- Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, University of Campinas - UNICAMP, Piracicaba, SP, Brazil
| | - Elis Janaína Lira Dos Santos
- Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, University of Campinas - UNICAMP, Piracicaba, SP, Brazil
| | - Brian L Foster
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - Renato Assis Machado
- Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas - UNICAMP, Piracicaba, SP, Brazil
| | - Kamila Rosamilia Kantovitz
- Department of Pediatric Dentistry, Piracicaba Dental School, University of Campinas - UNICAMP, Piracicaba, SP, Brazil; Department of Dental Materials, São Leopoldo Mandic School of Dentistry and Research Center, Campinas, SP, Brazil
| | - Ricardo D Coletta
- Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas - UNICAMP, Piracicaba, SP, Brazil
| | - Francisco H Nociti
- Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, University of Campinas - UNICAMP, Piracicaba, SP, Brazil.
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Galeano-Valle F, Vengoechea J, Galindo RJ. A rare mutation in hypophosphatasia: a case report of adult form and review of the literature. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2019; 63:89-93. [PMID: 30864637 PMCID: PMC10118836 DOI: 10.20945/2359-3997000000108] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 12/11/2018] [Indexed: 11/23/2022]
Abstract
Hypophosphatasia is a rare inborn error of metabolism characterized by low serum alkaline phosphatase activity due to loss-of-function mutations in the gene encoding the tissue-nonspecific isoenzyme of alkaline phosphatase (TNSALP). Extracellular accumulation of TNSALP substrates leads to dento-osseous and arthritic complications featuring tooth loss, rickets or osteomalacia, and calcific arthopathies. Mild hypophosphatasia usually has autosomal dominant inheritance, severe cases are either autosomal recessive or due to a dominant negative effect. Clinical manifestations of hypophosphatasia are extremely variable, ranging from life threatening to asymptomatic clinical presentations. The clinical presentation of the adult-onset hypophosphatasia is highly variable. Fractures, joint complications of chondrocalcinosis, calcifying polyarthritis and multiple pains may reveal minor forms of the disease in adults. It is important to recognize the disease to provide the best supportive treatment and to prevent the use of anti-resorption drugs in these patients. Bone-targeted enzyme-replacement therapy (asfotase alfa) was approved in 2015 to treat pediatric-onset hypophosphatasia. We present a case of a 41-year-old male diagnosed with adult form of hypophosphatasia with a rare ALPL mutation that has been previously described only once and review the literature on the adult form of the disease and its genetic mechanism.
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Bowden SA, Foster BL. Alkaline Phosphatase Replacement Therapy for Hypophosphatasia in Development and Practice. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1148:279-322. [PMID: 31482504 DOI: 10.1007/978-981-13-7709-9_13] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Hypophosphatasia (HPP) is an inherited disorder that affects bone and tooth mineralization characterized by low serum alkaline phosphatase. HPP is caused by loss-of-function mutations in the ALPL gene encoding the protein, tissue-nonspecific alkaline phosphatase (TNSALP). TNSALP is expressed by mineralizing cells of the skeleton and dentition and is associated with the mineralization process. Generalized reduction of activity of the TNSALP leads to accumulation of its substrates, including inorganic pyrophosphate (PPi) that inhibits physiological mineralization. This leads to defective skeletal mineralization, with manifestations including rickets, osteomalacia, fractures, and bone pain, all of which can result in multi-systemic complications with significant morbidity, as well as mortality in severe cases. Dental manifestations are nearly universal among affected individuals and feature most prominently premature loss of deciduous teeth. Management of HPP has been limited to supportive care until the introduction of a TNSALP enzyme replacement therapy (ERT), asfotase alfa (AA). AA ERT has proven to be transformative, improving survival in severely affected infants and increasing overall quality of life in children and adults with HPP. This chapter provides an overview of TNSALP expression and functions, summarizes HPP clinical types and pathologies, discusses early attempts at therapies for HPP, summarizes development of HPP mouse models, reviews design and validation of AA ERT, and provides up-to-date accounts of AA ERT efficacy in clinical trials and case reports, including therapeutic response, adverse effects, limitations, and potential future directions in therapy.
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Affiliation(s)
- S A Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH, USA.
| | - B L Foster
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
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