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Zhu Z, Bo-Ran Ho B, Chen A, Amrhein J, Apetrei A, Carpenter TO, Lazaretti-Castro M, Colazo JM, McCrystal Dahir K, Geßner M, Gurevich E, Heier CA, Simmons JH, Hunley TE, Hoppe B, Jacobsen C, Kouri A, Ma N, Majumdar S, Molin A, Nokoff N, Ott SM, Peña HG, Santos F, Tebben P, Topor LS, Deng Y, Bergwitz C. An update on clinical presentation and responses to therapy of patients with hereditary hypophosphatemic rickets with hypercalciuria (HHRH). Kidney Int 2024; 105:1058-1076. [PMID: 38364990 PMCID: PMC11106756 DOI: 10.1016/j.kint.2024.01.031] [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: 09/05/2023] [Revised: 12/23/2023] [Accepted: 01/08/2024] [Indexed: 02/18/2024]
Abstract
Pathogenic variants in solute carrier family 34, member 3 (SLC34A3), the gene encoding the sodium-dependent phosphate cotransporter 2c (NPT2c), cause hereditary hypophosphatemic rickets with hypercalciuria (HHRH). Here, we report a pooled analysis of clinical and laboratory records of 304 individuals from 145 kindreds, including 20 previously unreported HHRH kindreds, in which two novel SLC34A3 pathogenic variants were identified. Compound heterozygous/homozygous carriers show above 90% penetrance for kidney and bone phenotypes. The biochemical phenotype for heterozygous carriers is intermediate with decreased serum phosphate, tubular reabsorption of phosphate (TRP (%)), fibroblast growth factor 23, and intact parathyroid hormone, but increased serum 1,25-dihydroxy vitamin D, and urine calcium excretion causing idiopathic hypercalciuria in 38%, with bone phenotypes still observed in 23% of patients. Oral phosphate supplementation is the current standard of care, which typically normalizes serum phosphate. However, although in more than half of individuals this therapy achieves correction of hypophosphatemia it fails to resolve the other outcomes. The American College of Medical Genetics and Genomics score correlated with functional analysis of frequent SLC34A3 pathogenic variants in vitro and baseline disease severity. The number of mutant alleles and baseline TRP (%) were identified as predictors for kidney and bone phenotypes, baseline TRP (%) furthermore predicted response to therapy. Certain SLC34A3/NPT2c pathogenic variants can be identified with partial responses to therapy, whereas with some overlap, others present only with kidney phenotypes and a third group present only with bone phenotypes. Thus, our report highlights important novel clinical aspects of HHRH and heterozygous carriers, raises awareness to this rare group of disorders and can be a foundation for future studies urgently needed to guide therapy of HHRH.
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Affiliation(s)
- Zewu Zhu
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Bryan Bo-Ran Ho
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Alyssa Chen
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - James Amrhein
- Pediatric Endocrinology and Diabetes, School of Medicine Greenville Campus, University of South Carolina, Greenville, South Carolina, USA
| | - Andreea Apetrei
- Caen University Hospital, Department of Genetics, UR7450 Biotargen, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, OSCAR Network, Caen, France
| | - Thomas Oliver Carpenter
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Marise Lazaretti-Castro
- Division of Endocrinology, Escola Paulista de Medicina-Universidade Federal de Sao Paulo (EPM-UNIFESP), Sao Paulo, Brazil
| | - Juan Manuel Colazo
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Kathryn McCrystal Dahir
- Division of Endocrinology, Program for Metabolic Bone Disorders, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michaela Geßner
- Pediatric Nephrology, Children's and Adolescents' Hospital, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Evgenia Gurevich
- Schneider Children's Medical Center of Israel, Pediatric Nephrology Institute, Petach Tikva, Israel; Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | | | - Jill Hickman Simmons
- Department of Pediatrics, Division of Endocrinology and Diabetes, Vanderbilt University School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Tracy Earl Hunley
- Division of Pediatric Nephrology, Vanderbilt University Medical Center, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Bernd Hoppe
- Division of Pediatric Nephrology, Department of Pediatrics, University of Bonn, Bonn, Germany
| | - Christina Jacobsen
- Division of Endocrinology, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne Kouri
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nina Ma
- Section of Pediatric Endocrinology, Children's Hospital Colorado, Aurora, Colorado, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sachin Majumdar
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Arnaud Molin
- Caen University Hospital, Department of Genetics, UR7450 Biotargen, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, OSCAR Network, Caen, France
| | - Natalie Nokoff
- Department of Pediatrics, Section of Endocrinology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Susan M Ott
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Helena Gil Peña
- Department of Pediatrics, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Fernando Santos
- Department of Pediatrics, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Peter Tebben
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Endocrinology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lisa Swartz Topor
- Division of Pediatric Endocrinology, Hasbro Children's Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Yanhong Deng
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Clemens Bergwitz
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA.
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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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Dodamani MH, Memon SS, Karlekar M, Lila AR, Khan M, Sarathi V, Arya S, Jamale T, Thakare S, Patil VA, Shah NS, Bergwitz C, Bandgar TR. Hereditary Hypophosphatemic Rickets with Hypercalciuria Presenting with Enthesopathy, Renal Cysts, and High Serum c-Terminal FGF23: Single-Center Experience and Systematic Review. Calcif Tissue Int 2024; 114:137-146. [PMID: 37981601 DOI: 10.1007/s00223-023-01156-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/10/2023] [Indexed: 11/21/2023]
Abstract
Hereditary hypophosphatemic rickets with hypercalciuria (HHRH) is a rare disorder of phosphate homeostasis. We describe a single-center experience of genetically proven HHRH families and perform systematic review phenotype-genotype correlation in reported biallelic probands and their monoallelic relatives. Detailed clinical, biochemical, radiological, and genetic data were retrieved from our center and a systematic review of Pub-Med and Embase databases for patients and relatives who were genetically proven. Total of nine subjects (probands:5) carrying biallelic SLC34A3 mutations (novel:2) from our center had a spectrum from rickets/osteomalacia to normal BMD, with hypophosphatemia and hypercalciuria in all. We describe the first case of genetically proven HHRH with enthesopathy. Elevated FGF23 in another patient with hypophosphatemia, iron deficiency anemia, and noncirrhotic periportal fibrosis led to initial misdiagnosis as tumoral osteomalacia. On systematic review of 58 probands (with biallelic SLC34A3 mutations; 35 males), early-onset HHRH and renal calcification were present in ~ 70% and late-onset HHRH in 10%. c.575C > T p.(Ser192Leu) variant occurred in 53% of probands without skeletal involvement. Among 110 relatives harboring monoallelic SLC34A3 mutation at median age 38 years, renal calcification, hypophosphatemia, high 1,25(OH)2D, and hypercalciuria were observed in ~30%, 22.3%, 40%, and 38.8%, respectively. Renal calcifications correlated with age but were similar across truncating and non-truncating variants. Although most relatives were asymptomatic for bone involvement, 6/12(50%) had low bone mineral density. We describe the first monocentric HHRH case series from India with varied phenotypes. In a systematic review, frequent renal calcifications and low BMD in relatives with monoallelic variants (HHRH trait) merit identification.
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Affiliation(s)
- Manjunath Havalappa Dodamani
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, OPD, Parel, Mumbai, Maharashtra, 400012, India
| | - Saba Samad Memon
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, OPD, Parel, Mumbai, Maharashtra, 400012, India.
| | - Manjiri Karlekar
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, OPD, Parel, Mumbai, Maharashtra, 400012, India
| | - Anurag Ranjan Lila
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, OPD, Parel, Mumbai, Maharashtra, 400012, India
| | - Mustafa Khan
- Department of Endocrinology, Brown University, 375 Wampanoag Trail, Providence, RI, 02913, USA
- Section Endocrinology and Metabolism, Yale University School of Medicine, Anlyan Center, Office S117, Lab S110, 1 Gilbert Street, New Haven, CT, 06519, USA
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
| | - Sneha Arya
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, OPD, Parel, Mumbai, Maharashtra, 400012, India
| | - Tukaram Jamale
- Department of Nephrology, Seth G.S Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Sayali Thakare
- Department of Nephrology, Seth G.S Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Virendra A Patil
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, OPD, Parel, Mumbai, Maharashtra, 400012, India
| | - Nalini S Shah
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, OPD, Parel, Mumbai, Maharashtra, 400012, India
| | - Clemens Bergwitz
- Section Endocrinology and Metabolism, Yale University School of Medicine, Anlyan Center, Office S117, Lab S110, 1 Gilbert Street, New Haven, CT, 06519, USA
| | - Tushar R Bandgar
- Department of Endocrinology, Seth G.S Medical College & KEM Hospital, OPD, Parel, Mumbai, Maharashtra, 400012, India
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Filler G, Schott C, Salerno FR, Ens A, McIntyre CW, Díaz González de Ferris ME, Stein R. Growth hormone therapy in HHRH. Bone Rep 2022; 16:101591. [PMID: 35663378 PMCID: PMC9156862 DOI: 10.1016/j.bonr.2022.101591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/08/2022] [Accepted: 05/16/2022] [Indexed: 01/20/2023] Open
Abstract
Background Hereditary Hypophosphatemic Rickets with Hypercalciuria (HHRH) (SLC34A3 gene, OMIM 241530) is an autosomal recessive disorder that results in a loss of function of the sodium-phosphate NPT2c channel at the proximal tubule. Phosphate supplementation rarely improves serum phosphate, hypercalciuria, nephrocalcinosis, 1,25(OH)2 vitamin D (1,25(OH)2D) levels or short stature. Methods We describe 23Na MRI and the successful use of recombinant human growth hormone (rhGH) and Fluconazole to improve growth (possibly confounded by puberty) and hypercalciuria in a now 12-year-old male with HHRH (novel homozygous SLC34A3 mutation, c.835_846 + 10del.T). Results The patient had chronic bone pain, hypophosphatemia (0.65 mmol/L[reference interval 1.1-1.9]), pathological fractures and medullary nephrocalcinosis/hypercalciuria (urinary calcium/creatinine ratio 1.66 mol/mmol[<0.6]). TmP/GFR was 0.65 mmol/L[0.97-1.64]; 1,25(OH)2D was >480 pmol/L[60-208]. Rickets Severity Score was 4. Treatment with 65 mg/kg/day of sodium phosphate and potassium citrate 10 mmol TID failed to correct the abnormalities.Adding rhGH at 0.35 mg/kg/week to the phosphate therapy, improved bone pain, height z-score from -2.09 to -1.42 over 6 months, without a sustained effect on TmP/GFR. Fluconazole was titrated to 100 mg once daily, resulting for the first time in a reduction of the 1,25(OH)2D to 462 and 426 pmol/L; serum phosphate 0.87 mmol/L, and calcium/creatinine ratio of 0.73.23Na MRI showed normal skin (z-score + 0.68) and triceps surae muscle (z-score + 1.5) Na+ levels; despite a defect in a sodium transporter, hence providing a rationale for a low sodium diet to improve hypercalciuria. Conclusions The addition of rhGH, Fluconazole and salt restriction to phosphate/potassium supplementation improved the conventional therapy. Larger studies are needed to confirm our findings.
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Affiliation(s)
- Guido Filler
- Departments of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
- Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
- Pathology & Laboratory Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
- Lilibeth Caberto Kidney Clinical Research Unit, London, Ontario, Canada
| | - Clara Schott
- Medical Sciences, University of Western Ontario, Canada
| | - Fabio Rosario Salerno
- Biophysics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
- Lilibeth Caberto Kidney Clinical Research Unit, London, Ontario, Canada
| | - Andrea Ens
- Departments of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Christopher William McIntyre
- Departments of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
- Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
- Biophysics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
- Lilibeth Caberto Kidney Clinical Research Unit, London, Ontario, Canada
| | | | - Robert Stein
- Departments of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
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Christensen S, Tebben PJ, Sas D, Creo AL. Variable Clinical Presentation of Children with Hereditary Hypophosphatemic Rickets with Hypercalciuria: A Case Series and Review of the Literature. Horm Res Paediatr 2022; 94:374-389. [PMID: 34666334 DOI: 10.1159/000520299] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 10/19/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Hereditary hypophosphatemic rickets with hypercalciuria (HHRH) is a rare condition of renal phosphate wasting due to SLC34A3 mutations [Am J Hum Genet. 2006;78(2):193-201]. Patients exhibit low serum phosphorus, high 1,25-dihydroxyvitamin D, and inappropriately high urine phosphate and calcium. However, symptoms vary, and little is known about specific phenotype-genotype correlations. METHODS We report 3 HHRH cases in unrelated 12-year-old, 9-year-old, and 14-year-old patients and perform a systematic literature review. RESULTS All 3 patients exhibited labs typical of HHRH. Yet, their presentations differed, and 2 novel SLC34A3 variants were identified. As found in the literature review, bone symptoms are most common (50%), followed by renal symptoms (17%), combined bone and renal symptoms (18%), and asymptomatic (9%). CONCLUSION These 3 cases highlight the variability of presenting signs and symptoms among individuals with HHRH. An accurate diagnosis is critical as treatment differs from other disorders of phosphate wasting, urinary stones, and mineralization defects.
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Affiliation(s)
- Stephanie Christensen
- Division of General Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter J Tebben
- Division of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - David Sas
- Division of Pediatric Nephrology and Hypertension, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ana L Creo
- Division of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
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