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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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Borger O, Segev-Becker A, Perl L, Ben Simon A, Yackobovitch-Gavan M, Sheppes T, Brener A, Oren A, Lebenthal Y. Body composition, metabolic syndrome, and lifestyle in treatment-naïve gender-diverse youth in Israel. Pediatr Obes 2024:e13159. [PMID: 39155469 DOI: 10.1111/ijpo.13159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 07/11/2024] [Accepted: 07/14/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND There is a scarcity of published studies evaluating transgender/gender-diverse youth before initiating gender-affirming hormones. AIM To study the body composition, metabolic syndrome (MetS) components and lifestyle habits in treatment-naïve transgender youth. METHODS Cross-sectional study evaluating 153 transgender youth [median age 15.7 years, 94 transgender males] who attended The Israeli Children and Adolescents Gender Clinic between 6/2021-12/2022. Clinical, metabolic data and lifestyle habits (diet, physical activity and sleep patterns) were retrieved from the medical files. Body composition was determined by bioelectrical impedance analysis. Body mass index and muscle-to-fat ratio z-scores were calculated by sex designated at birth. RESULTS Weight categories differed between genders, with a greater proportion of subjects classified as underweight among transgender females, and a greater proportion affected by overweight/obese/severe obese among transgender males (p = 0.035). The odds for MetS components were increased by 2.2 for every 1 standard deviation decrease in the muscle-to-fat ratio z-score (95%CI: 1.45 to 3.26, p < 0.001). About one-third of the cohort did not meet any of the three lifestyle recommendations. Transgender males had increased odds for MetS components by 3.49 (95%CI: 1.63 to 7.44, p = 0.001). CONCLUSIONS Treatment-naïve transgender-male adolescents have an imbalance between muscle and adipose tissue, which places them at increased susceptibility for MetS components even prior to hormonal treatment.
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Affiliation(s)
- Ophir Borger
- The Institute of Pediatric Endocrinology, Diabetes and Metabolism, Dana-Dwek Children's Hospital, Tel Aviv, Israel
- The Nutrition & Dietetics Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Anat Segev-Becker
- The Institute of Pediatric Endocrinology, Diabetes and Metabolism, Dana-Dwek Children's Hospital, Tel Aviv, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liat Perl
- The Institute of Pediatric Endocrinology, Diabetes and Metabolism, Dana-Dwek Children's Hospital, Tel Aviv, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaf Ben Simon
- School of Medicine, Tel Aviv University, 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
| | - Tamar Sheppes
- The Institute of Pediatric Endocrinology, Diabetes and Metabolism, Dana-Dwek Children's Hospital, Tel Aviv, Israel
- The Psychological Services, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Avivit Brener
- The Institute of Pediatric Endocrinology, Diabetes and Metabolism, Dana-Dwek Children's Hospital, Tel Aviv, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaf Oren
- The Institute of Pediatric Endocrinology, Diabetes and Metabolism, Dana-Dwek Children's Hospital, Tel Aviv, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Lebenthal
- The Institute of Pediatric Endocrinology, Diabetes and Metabolism, Dana-Dwek Children's Hospital, Tel Aviv, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Lecoq AL, Schilbach K, Rocher L, Trabado S, Briot K, Herrou J, Forbes A, Garnier A, Piketty M, Bidlingmaier M, Rothenbuhler A, Linglart A, Carette C, Chaumet-Riffaud P, Kamenický P. Metabolically healthy obesity in adults with X-linked hypophosphatemia. Eur J Endocrinol 2024; 191:156-165. [PMID: 39120742 DOI: 10.1093/ejendo/lvae089] [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: 04/02/2024] [Revised: 06/19/2024] [Accepted: 07/11/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVES X-linked hypophosphatemia (XLH) is characterized by increased concentrations of circulating fibroblast growth factor 23 (FGF-23) resulting in phosphate wasting, hypophosphatemia, atypical growth plate and bone matrix mineralization. Epidemiologic studies suggest a relationship between FGF-23, obesity, and metabolic dysfunction. The prevalence of overweight and obesity is high in children with XLH. We aimed to evaluate the prevalence of obesity and metabolic complications in adults with XLH. METHODS We conducted a prospective cohort study in adult XLH patients from a single tertiary referral center. The proportion of patients with a BMI >25 kg/m2 was the main outcome measure. Body fat mass percentage (FM%) and adipose tissue surfaces were secondary outcome measures. Glucose homeostasis (plasma glucose and insulin concentrations after fasting and 2 hours after an oral glucose tolerance test) was explored in a subgroup of patients and compared with age-, sex-, and BMI-matched healthy controls. RESULTS Among 113 evaluated patients, 85 (75%) were female and 110 (97%) carried a PHEX mutation. Sixty-three (56%) patients were overweight or obese, with a median BMI of 25.3 [IQR, 22.7; 29.2] kg/m2. BMI was correlated with FM%, abdominal and thigh subcutaneous and intra-abdominal adipose tissue surfaces. The prevalence of impaired fasting glucose, impaired glucose tolerance, and diabetes was not different between XLH patients and matched controls. CONCLUSION The prevalence of overweight and obesity is high among XLH patients and is associated with excess fat mass. However, the prevalence of glucose homeostasis abnormalities is not increased in patients compared to healthy controls, suggesting that metabolically healthy overweight or obesity predominates.
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Affiliation(s)
- Anne-Lise Lecoq
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, AP-HP, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, 94 276 Le Kremlin Bicêtre Cedex, France
| | - Katharina Schilbach
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, 80336 Munich, Germany
| | - Laurence Rocher
- Université Paris-Saclay, BIOMAPS, UMR1281, AP-HP, Hôpital Antoine Béclère, Service de Radiologie, 92140 Clamart, France
| | - Séverine Trabado
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, AP-HP, Hôpital Bicêtre, Laboratoire de Génétique Moléculaire, Pharmacogénétique et Hormonologie, 94275 Le Kremlin Bicêtre Cedex, France
| | - Karine Briot
- Université Paris Cité, AP-HP, Hôpital Cochin, Service de Rhumatologie, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate Filière OSCAR, 75014 Paris, France
| | - Julia Herrou
- Université Paris Cité, AP-HP, Hôpital Cochin, Service de Rhumatologie, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate Filière OSCAR, 75014 Paris, France
| | - Aurélie Forbes
- AP-HP, Hôpital Bicêtre, Service de Biophysique et Médecine Nucléaire, 94275 Le Kremlin Bicêtre Cedex, France
| | - Anthony Garnier
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, AP-HP, Hôpital Bicêtre, Laboratoire de Génétique Moléculaire, Pharmacogénétique et Hormonologie, 94275 Le Kremlin Bicêtre Cedex, France
| | - Marie Piketty
- AP-HP, Hôpital Necker, Service d'Explorations fonctionnelles Physiologie et Neurophysiologie, 75015 Paris, France
| | - Martin Bidlingmaier
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, 80336 Munich, Germany
| | - Anya Rothenbuhler
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, AP-HP, Hôpital Bicêtre, Service d'Endocrinologie et Diabétologie de l'Enfant, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, Plateforme d'Expertise Paris Saclay Maladies Rares et Filière OSCAR, 94275 Le Kremlin Bicêtre Cedex, France
| | - Agnès Linglart
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, AP-HP, Hôpital Bicêtre, Service d'Endocrinologie et Diabétologie de l'Enfant, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, Plateforme d'Expertise Paris Saclay Maladies Rares et Filière OSCAR, 94275 Le Kremlin Bicêtre Cedex, France
| | - Claire Carette
- Université Paris-Cité, AP-HP, Hôpital Européen Georges Pompidou, Service de Nutrition, Centre Spécialisé Obésité, 75015 Paris, France
| | - Philippe Chaumet-Riffaud
- IHU FOReSIGHT, INSERM-DHOS CIC 1423, Hôpital National de la Vision des Quinze-Vingts, 75012 Paris, France
| | - Peter Kamenický
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, AP-HP, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, 94 276 Le Kremlin Bicêtre Cedex, France
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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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5
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Bosman A, Appelman-Dijkstra NM, Boot AM, de Borst MH, van de Ven AC, de Jongh RT, Bökenkamp A, van den Bergh JP, van der Eerden BCJ, Zillikens MC. Disease Manifestations and Complications in Dutch X-Linked Hypophosphatemia Patients. Calcif Tissue Int 2024; 114:255-266. [PMID: 38226986 PMCID: PMC10901935 DOI: 10.1007/s00223-023-01172-2] [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] [Accepted: 11/27/2023] [Indexed: 01/17/2024]
Abstract
X-linked hypophosphatemia (XLH) is the most common monogenetic cause of chronic hypophosphatemia, characterized by rickets and osteomalacia. Disease manifestations and treatment of XLH patients in the Netherlands are currently unknown. Characteristics of XLH patients participating in the Dutch observational registry for genetic hypophosphatemia and acquired renal phosphate wasting were analyzed. Eighty XLH patients, including 29 children, were included. Genetic testing, performed in 78.8% of patients, showed a PHEX mutation in 96.8%. Median (range) Z-score for height was - 2.5 (- 5.5; 1.0) in adults and - 1.4 (- 3.7; 1.0) in children. Many patients were overweight or obese: 64.3% of adults and 37.0% of children. All children received XLH-related medication e.g., active vitamin D, phosphate supplementation or burosumab, while 8 adults used no medication. Lower age at start of XLH-related treatment was associated with higher height at inclusion. Hearing loss was reported in 6.9% of children and 31.4% of adults. Knee deformities were observed in 75.0% of all patients and osteoarthritis in 51.0% of adult patients. Nephrocalcinosis was observed in 62.1% of children and 33.3% of adults. Earlier start of XLH-related treatment was associated with higher risk of nephrocalcinosis and detection at younger age. Hyperparathyroidism longer than six months was reported in 37.9% of children and 35.3% of adults. This nationwide study confirms the high prevalence of adiposity, hearing loss, bone deformities, osteoarthritis, nephrocalcinosis and hyperparathyroidism in Dutch XLH patients. Early start of XLH-related treatment appears to be beneficial for longitudinal growth but may increase development of nephrocalcinosis.
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Affiliation(s)
- A Bosman
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - N M Appelman-Dijkstra
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - A M Boot
- Department of Pediatrics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - M H de Borst
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - A C van de Ven
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R T de Jongh
- Department of Internal Medicine, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - A Bökenkamp
- Department of Pediatric Nephrology, Amsterdam University Medical Center, Emma Children's Hospital, Amsterdam, The Netherlands
| | - J P van den Bergh
- Department of Internal Medicine, VieCuri Medical Center, Venlo, The Netherlands
| | - B C J van der Eerden
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - M C Zillikens
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000, CA, Rotterdam, The Netherlands.
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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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7
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Ariceta G, Beck-Nielsen SS, Boot AM, Brandi ML, Briot K, de Lucas Collantes C, Emma F, Giannini S, Haffner D, Keen R, Levtchenko E, Mӓkitie O, Mughal MZ, Nilsson O, Schnabel D, Tripto-Shkolnik L, Liu J, Williams A, Wood S, Zillikens MC. The International X-Linked Hypophosphatemia (XLH) Registry: first interim analysis of baseline demographic, genetic and clinical data. Orphanet J Rare Dis 2023; 18:304. [PMID: 37752558 PMCID: PMC10523658 DOI: 10.1186/s13023-023-02882-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 08/24/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND X-linked hypophosphatemia (XLH) is a rare, hereditary, progressive, renal phosphate-wasting disorder characterized by a pathological increase in FGF23 concentration and activity. Due to its rarity, diagnosis may be delayed, which can adversely affect outcomes. As a chronic disease resulting in progressive accumulation of musculoskeletal manifestations, it is important to understand the natural history of XLH over the patient's lifetime and the impact of drug treatments and other interventions. This multicentre, international patient registry (International XLH Registry) was established to address the paucity of these data. Here we present the findings of the first interim analysis of the registry. RESULTS The International XLH Registry was initiated in August 2017 and includes participants of all ages diagnosed with XLH, regardless of their treatment and management. At the database lock for this first interim analysis (29 March 2021), 579 participants had entered the registry before 30 November 2020 and are included in the analysis (360 children [62.2%], 217 adults [37.5%] and 2 whose ages were not recorded [0.3%]; 64.2% were female). Family history data were available for 319/345 (92.5%) children and 145/187 (77.5%) adults; 62.1% had biological parents affected by XLH. Genetic testing data were available for 341 (94.7%) children and 203 (93.5%) adults; 370/546 (67.8%) had genetic test results; 331/370 (89.5%) had a confirmed PHEX mutation. A notably longer time to diagnosis was observed in adults ≥ 50 years of age (mean [median] duration 9.4 [2.0] years) versus all adults (3.7 [0.1] years) and children (1.0 [0.2] years). Participants presented with normal weight, shorter length or height and elevated body mass index (approximately - 2 and + 2 Z-scores, respectively) versus the general population. Clinical histories were collected for 349 participants (239 children and 110 adults). General data trends for prevalence of bone, dental, renal and joint conditions in all participants were aligned with expectations for a typical population of people with XLH. CONCLUSION The data collected within the International XLH Registry, the largest XLH registry to date, provide substantial information to address the paucity of natural history data, starting with demographic, family history, genetic testing, diagnosis, auxology and baseline data on clinical presentation.
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Affiliation(s)
- Gema Ariceta
- Department of Pediatric Nephrology, Hospital Vall d'Hebron, Universitat Autonoma Barcelona, Barcelona, Spain.
| | - Signe Sparre Beck-Nielsen
- Centre for Rare Diseases, Aarhus University Hospital, Åarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Åarhus, Denmark
| | - Annemieke M Boot
- Department of Pediatrics, Division of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Karine Briot
- Hôpital Cochin, Service de Rhumatologie, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate Filière OSCAR, AP-HP, Paris, France
| | | | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Rome, Italy
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padova, Padua, 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 and Development and Regeneration, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Outi Mӓkitie
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University Hospital's NHS Trust, Manchester, UK
| | - 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, Sweden
- School of Medical Sciences and Department of Pediatrics, Örebro University and University Hospital, Örebro, Sweden
| | - Dirk Schnabel
- Center for Chronically Sick Children, Pediatric Endocrinology, Charité, University Medicine Berlin, Berlin, Germany
| | - Liana Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Sue Wood
- Kyowa Kirin International, Marlow, UK
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Ewert A, Rehberg M, Schlingmann KP, Hiort O, John-Kroegel U, Metzing O, Wühl E, Schaefer F, Kemper MJ, Derichs U, Richter-Unruh A, Patzer L, Albers N, Dunstheimer D, Haberland H, Heger S, Schröder C, Jorch N, Schmid E, Staude H, Weitz M, Freiberg C, Leifheit-Nestler M, Zivicnjak M, Schnabel D, Haffner D. Effects of Burosumab Treatment on Mineral Metabolism in Children and Adolescents With X-linked Hypophosphatemia. J Clin Endocrinol Metab 2023; 108:e998-e1006. [PMID: 37097907 DOI: 10.1210/clinem/dgad223] [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: 11/25/2022] [Revised: 04/05/2023] [Accepted: 04/13/2023] [Indexed: 04/26/2023]
Abstract
CONTEXT Burosumab has been approved for the treatment of children and adults with X-linked hypophosphatemia (XLH). Real-world data and evidence for its efficacy in adolescents are lacking. OBJECTIVE To assess the effects of 12 months of burosumab treatment on mineral metabolism in children (aged <12 years) and adolescents (aged 12-18 years) with XLH. DESIGN Prospective national registry. SETTING Hospital clinics. PATIENTS A total of 93 patients with XLH (65 children, 28 adolescents). MAIN OUTCOME MEASURES Z scores for serum phosphate, alkaline phosphatase (ALP), and renal tubular reabsorption of phosphate per glomerular filtration rate (TmP/GFR) at 12 months. RESULTS At baseline, patients showed hypophosphatemia (-4.4 SD), reduced TmP/GFR (-6.5 SD), and elevated ALP (2.7 SD, each P < .001 vs healthy children) irrespective of age, suggesting active rickets despite prior therapy with oral phosphate and active vitamin D in 88% of patients. Burosumab treatment resulted in comparable increases in serum phosphate and TmP/GFR in children and adolescents with XLH and a steady decline in serum ALP (each P < .001 vs baseline). At 12 months, serum phosphate, TmP/GFR, and ALP levels were within the age-related normal range in approximately 42%, 27%, and 80% of patients in both groups, respectively, with a lower, weight-based final burosumab dose in adolescents compared with children (0.72 vs 1.06 mg/kg, P < .01). CONCLUSIONS In this real-world setting, 12 months of burosumab treatment was equally effective in normalizing serum ALP in adolescents and children, despite persistent mild hypophosphatemia in one-half of patients, suggesting that complete normalization of serum phosphate is not mandatory for substantial improvement of rickets in these patients. Adolescents appear to require lower weight-based burosumab dosage than children.
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Affiliation(s)
- Annika Ewert
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover 30625, Germany
| | - Mirko Rehberg
- Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne 50937, Germany
| | - Karl Peter Schlingmann
- Department of General Pediatrics, Pediatric Nephrology, University Children's Hospital, Münster 48149, Germany
| | - Olaf Hiort
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics and Adolescent Medicine, University of Lübeck, Lübeck 23562, Germany
| | | | | | - Elke Wühl
- Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg 69120, Germany
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg 69120, Germany
| | - Markus J Kemper
- Asklepios Children's Hospital Hamburg-Heidberg, Hamburg-Heidberg 22417, Germany
| | - Ute Derichs
- University Children's Hospital, Mainz 55131, Germany
| | | | - Ludwig Patzer
- St. Elisabeth and St. Barbara Children's Hospital, Halle/Saale 06110, Germany
| | - Norbert Albers
- Christliches Kinderhospital Osnabrück, Osnabrück 49074, Germany
| | | | - Holger Haberland
- Children's Hospital, Sana Klinikum Lichtenberg, Berlin Lichtenberg 10365, Germany
| | - Sabine Heger
- Kinderkrankenhaus auf der Bult, Hannover 30173, Germany
| | - Carmen Schröder
- University Children's Hospital Greifswald, Greifswald 17475, Germany
| | - Norbert Jorch
- University Children's Hospital, Evangelisches Klinikum Bethel, Bielefeld 33617, Germany
| | - Elmar Schmid
- Clinic for Pediatric Nephrology Hirschaid, Hirschaid 96114, Germany
| | - Hagen Staude
- University Children's Hospital Rostock, Rostock 18057, Germany
| | - Marcus Weitz
- Department of General Pediatrics and Hematology/Oncology, University Children's Hospital, University Hospital Tübingen, Tübingen 72076, Germany
| | - Clemens Freiberg
- Department of Pediatrics and Adolescent Medicine, University Medical Center Göttingen, Göttingen 37075, Germany
| | - Maren Leifheit-Nestler
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover 30625, Germany
| | - Miroslav Zivicnjak
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover 30625, Germany
| | - Dirk Schnabel
- Center for Chronically Sick Children, Pediatric Endocrinology, University Medicine, Charité, Berlin 13353, Germany
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover 30625, Germany
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Arcidiacono T, Foligno NE, Brioni E, Bologna A, Weber G, Mora S, Pitea M, Vitale C, Vezzoli G. Different Efficacy of Burosumab on Physical Performance and Serum Phosphate in Adult Patients with X-Linked Hyphophosphatemic Rickets during the First Six-Month of Treatment. J Clin Med 2023; 12:jcm12082906. [PMID: 37109242 PMCID: PMC10143203 DOI: 10.3390/jcm12082906] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
Burosumab is a monoclonal anti-FGF23 antibody used to treat patients with X-linked hypophosphatemic rickets (XLH). Its effect on serum phosphate and physical performance was compared in patients during a 6-month treatment with burosumab. Eight adult patients with XHL were treated with burosumab (1 mg/kg s.c. every 28 days). In the first 6 months of treatment, calcium-phosphate metabolism variables were measured, and muscle performance (tested with chair and walking test) and quality of life (tested with fatigue, BPI-pain and BPI-life questionnaires) were estimated. A significant increase in serum phosphate was observed during the treatment. From the 16th week, serum phosphate became significantly lower than its value in the 4th week. No patients had serum phosphate below the normal range at the 10th week, but seven patients were hypophosphatemic in the 20th and 24th week. All patients improved the execution time of the chair test and walking test, which reached a plateau after the 12th week. BPI-pain and BPI-life scores significantly decreased from baseline to the 24th week. In conclusion, a six-month burosumab treatment may significantly improve the general condition and physical performance of adult patients with XLH; this improvement was more stable and more indicative of treatment efficacy than that of serum phosphate.
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Affiliation(s)
- Teresa Arcidiacono
- Nephrology and Dialysis Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Postgraduate School of Nephrology, Vita Salute San Raffaele University, 20132 Milan, Italy
| | - Nadia E Foligno
- Nephrology and Dialysis Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Postgraduate School of Nephrology, Vita Salute San Raffaele University, 20132 Milan, Italy
| | - Elena Brioni
- Nephrology and Dialysis Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Arianna Bologna
- Nephrology and Dialysis Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Postgraduate School of Nephrology, Vita Salute San Raffaele University, 20132 Milan, Italy
| | - Giovanna Weber
- Department of Pediatrics, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, 20132 Milan, Italy
| | - Stefano Mora
- Laboratory of Pediatric Endocrinology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Marco Pitea
- Department of Pediatrics, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, 20132 Milan, Italy
| | - Corrado Vitale
- Nephrology and Dialysis Unit, Mauriziano Hospital, 10128 Turin, Italy
| | - Giuseppe Vezzoli
- Nephrology and Dialysis Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Postgraduate School of Nephrology, Vita Salute San Raffaele University, 20132 Milan, Italy
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10
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Jazbinšek S, Koce M, Kotnik P. Novel Treatment Options in Childhood Bone Diseases. Horm Res Paediatr 2022; 96:590-598. [PMID: 35235937 DOI: 10.1159/000523868] [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: 11/29/2021] [Accepted: 02/17/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Several novel treatment options have recently become available in childhood bone diseases. The purpose of this article is to provide an update on some of the therapeutic agents used in the treatment of pediatric osteoporosis, X-linked hypophosphatemic rickets, and achondroplasia (ACH). SUMMARY Vitamin D3 and Ca supplementation remains the basis of childhood osteoporosis treatment. Bisphosphonate (BP) therapy is the main antiresorptive therapeutic option, while denosumab, a human monoclonal IgG2 antibody with high affinity and specificity for a primary regulator of bone resorption - RANKL, represents a possible alternative. Its potent inhibition of bone resorption and turnover process leads to continuous increase of bone mineral density throughout the treatment also in the pediatric population. With a half-life much shorter than BPs, its effects are rapidly reversible upon discontinuation. Safety and dosing concerns in children remain. Novel treatment options have recently become available in two rare bone diseases. Burosumab, a monoclonal antibody against FGF-23, has been approved for the treatment of children with X-linked hypophosphatemic rickets older than 1 year. It presents an effective, more etiology-based treatment for rickets compared to conventional therapy, without the need for multiple daily oral phosphate supplementation. Its long-term efficacy and safety are currently being investigated. After years of anticipation, a novel treatment option for ACH has become available. C-type natriuretic peptide analog vosoritide effectively increases proportional growth and has a reasonable safety profile in children >2 years. Its effect on other features of the disease and the final height is yet to be determined. Several other treatment options for ACH exploring different therapeutic approaches are currently being investigated. KEY MESSAGES Denosumab is effective in the treatment of childhood-onset osteoporosis; however, further studies are necessary to determine the optimal treatment protocol. Burosumab is more etiology-based and convenient in comparison to conventional treatment of X-linked hypophospha--temic rickets in children and adults. Vosoritide importantly changes the natural course of achondroplasia, at least in the short term.
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Affiliation(s)
- Sončka Jazbinšek
- Division of Pediatrics, Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Maša Koce
- Division of Pediatrics, Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Primož Kotnik
- Division of Pediatrics, Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Division of Pediatrics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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11
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Brener R, Zeitlin L, Lebenthal Y, Brener A. Dental health of pediatric patients with X-linked hypophosphatemia (XLH) after three years of burosumab therapy. Front Endocrinol (Lausanne) 2022; 13:947814. [PMID: 36051396 PMCID: PMC9425915 DOI: 10.3389/fendo.2022.947814] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
An inactivating PHEX gene mutation with the resultant accumulation of several mineralization-inhibiting proteins (e.g., FGF23) causes skeletal and dental morbidity in X-linked hypophosphatemia (XLH). This prospective case-control study explored the effect of burosumab, an anti-FGF23 antibody, on dental health of children with XLH. Ten children (age 4.3-15 years) with XLH underwent burosumab treatment per protocol. Assessment of their dental status at treatment initiation and after 1 and 3 years of treatment included clinical, laboratory and radiographic evaluation of rickets and dentition. Orthopantomographic examinations of ten healthy sex- and age-matched controls were selected for comparison. Coronal and pulp dimensions of a selected permanent mandibular molar were measured with Planmeca Romexis® software. One year of treatment led to improvement of height z-score (p=0.019) and healing of the rickets (p<0.001) in the XLH patients, and those achievements were maintained after three years of treatment. Dental morphology of XLH patients, distinguished by increased pulp-coronal ratios compared to controls (p=0.002), remained larger after the first year of treatment (p<0.001) and did not attain the decrease expected with age after three years of treatment. Five patients had a history of recurrent dental abscesses, with three having undergone at least one episode during the year before burosumab initiation. One patient sustained recurrent abscesses throughout three years of treatment. The persistence of the unique dental morphology of XLH patients undergoing burosumab therapy, as evidenced by excessively larger pulp dimensions, supports the role of other PHEX gene-related local mineralization inhibitors, such as osteopontin, in the pathogenesis of dental morbidity.
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Affiliation(s)
- Rafi Brener
- The Endodontic Unit, Galilee College of Dental Sciences, Galilee Medical Center, Nahariya, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Leonid Zeitlin
- The Metabolic Bone Disease Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Lebenthal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Avivit Brener
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- *Correspondence: Avivit Brener,
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