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Kuehn K, Hahn A, Seefried L. Impact of Restricted Phosphorus, Calcium-adjusted Diet on Musculoskeletal and Mental Health in Hypophosphatasia. J Endocr Soc 2023; 8:bvad150. [PMID: 38111621 PMCID: PMC10726311 DOI: 10.1210/jendso/bvad150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Indexed: 12/20/2023] Open
Abstract
Context Impairments in musculoskeletal and mental health are common in adults with Hypophosphatasia (HPP). Restricted phosphorus intake has been suggested to positively affect symptoms in HPP, but there is a lack of interventional evidence. Objective This work aimed to evaluate the effect of a phosphorus-restricted, calcium-adjusted diet on musculoskeletal and mental health in HPP. Methods A prospective, noncontrolled, single-center interventional study (NuSTEPS II) was conducted among outpatients at the Osteology Department, University of Wuerzburg, Germany. A total of 26 adults with an established HPP diagnosis received a standardized diet with a defined daily intake of phosphorus (1160-1240 mg/d) and calcium (870-930 mg/d) over 8 weeks. Main outcome measures were functional testing and patient-reported outcome measures. Results At 8 weeks, significant improvements were observed in usual gait speed (P = .028) and the chair-rise test (P = .019), while no significant changes were seen in the 6-minute walk test (P = .468) and the timed up-and-go test (P = .230). Pain was not significantly reduced according to the visual analog scale (VAS) (P = .061), pain subscale of the 36-Item Short-Form Health Survey (SF-36) (P = .346), and Pain Disability Index (P = .686). Further, there was a significant improvement in the SF-36 vitality subscale (P = .022) while all other subscales as well as the Lower Extremity Functional Scale (P = .670) and the Fatigue Assessment Scale (P = .392) did not change significantly. Adjustments of mineral intake were not associated with relevant alterations regarding the intake of energy and energy-supplying nutrients or body composition. Conclusion Adjusting phosphorus and calcium intake may positively affect individual symptoms in adults with HPP, but overall clinical effectiveness regarding major issues like pain and endurance appears limited.
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Affiliation(s)
- Katinka Kuehn
- Faculty of Natural Science, Institute of Food Science and Human Nutrition, Leibniz University Hannover, 30167 Hanover, Germany
| | - Andreas Hahn
- Faculty of Natural Science, Institute of Food Science and Human Nutrition, Leibniz University Hannover, 30167 Hanover, Germany
| | - Lothar Seefried
- Clinical Trial Unit, Orthopedic Institute, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany
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Wiedemann P, Schmidt FN, Amling M, Yorgan TA, Barvencik F. Zinc and vitamin D deficiency and supplementation in hypophosphatasia patients - A retrospective study. Bone 2023; 175:116849. [PMID: 37487860 DOI: 10.1016/j.bone.2023.116849] [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: 06/02/2023] [Revised: 07/07/2023] [Accepted: 07/14/2023] [Indexed: 07/26/2023]
Abstract
Hypophosphatasia (HPP) is characterized by severe skeletal symptoms including mineralization defects, insufficiency fractures, and delayed facture healing or non-unions. HPP is caused by mutations of the tissue non-specific alkaline phosphatase (TNSALP). Zinc is a cofactor of TNSALP and vitamin D an important regulator of bone matrix mineralization. Data from this retrospective study indicates that deficiencies in zinc or vitamin D occur in HPP patients with a similar frequency as in the general population. While guidelines for repletion of these micronutrients have been established for the general population, the transferability of the efficacy and safety of these regiments to HPP patients still needed to be determined. We filtered for variant classification (ACMG 3-5, non-benign) and data completeness from a total cohort of 263 HPP patients. 73.5 % of this sub-cohort were vitamin D deficient while 27.2 % were zinc deficient. We retrospectively evaluated the effect of supplementation according to general guidelines in 10 patients with zinc-deficiency and 38 patients with vitamin d-deficiency. The treatments significantly raised serum zinc or vitamin D levels respectively. All other assessed disease markers (alkaline phosphatase, pyrodoxal-5-phosphate) or bone turnover markers (phosphate, calcium, parathyroid hormone, bone specific alkaline phosphatase, creatinine, desoxypyridinoline) remained unchanged. These results highlight that general guidelines for zinc and vitamin D repletion can be successfully applied to HPP patients in order to prevent deficiency symptoms without exacerbating the disease burden or causing adverse effects due to changes in bone and calcium homeostasis.
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Affiliation(s)
- Philip Wiedemann
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Felix N Schmidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Timur A Yorgan
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Florian Barvencik
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Feurstein J, Behanova M, Haschka J, Roetzer K, Uyanik G, Hadzimuratovic B, Witsch-Baumgartner M, Schett G, Zwerina J, Kocijan R. Identifying adult hypophosphatasia in the rheumatology unit. Orphanet J Rare Dis 2022; 17:435. [PMID: 36514157 PMCID: PMC9749273 DOI: 10.1186/s13023-022-02572-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 11/20/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The most frequent manifestation in adult hypophosphatasia (HPP) is musculoskeletal pain. The unspecific nature of its clinical presentation may prevent correct diagnosis. The aim of the study was to assess the prevalence of ALPL mutations in adult patients treated in rheumatological outpatient facilities with evident musculoskeletal symptoms typical for HPP. METHODS Over a period of 10 years 9,522 patients were screened in the rheumatology outpatient clinic of the Hanusch hospital Vienna. Serum ALP levels ≤ 40 U/L were found in 524 patients. After screening for secondary causes, 73 patients were invited for clinical evaluation. Genetic testing was performed in 23 patients with suspected HPP. Logistic regression models with Firth penalisation were used to estimate the unadjusted and BMI-adjusted association of each clinical factor with HPP. RESULTS Mutations in the ALPL gene were observed in 57% of genetically screened patients. Arthralgia, fractures, and pain were the leading symptoms in individuals with ALPL mutation. Chondrocalcinosis (OR 29.12; 95% CI 2.02-1593.52) and dental disease (OR 8.33; 95% CI 0.93-143.40) were associated with ALPL mutation, independent of BMI. Onset of symptoms in patients with ALPL mutation was at 35.1 (14.3) years, with a mean duration from symptoms to diagnosis of 14.4 (8.1) years. Bone mineral density (BMD) and trabecular bone score (TBS) as well as bone turnover markers were not indicative for HPP or ALPL mutation. CONCLUSION HPP can mimic rheumatologic diseases. Thus, HPP should be considered as a possible diagnosis in adult patients presenting with musculoskeletal pain of unknown origin in rheumatology outpatient clinics. In patients with persistently low ALP serum levels and unclear musculoskeletal pain, HPP as the underlying cause has to be considered.
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Affiliation(s)
- Julia Feurstein
- grid.413662.40000 0000 8987 0344Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1St Medical Department, Hanusch Hospital, Heinrich-Collin-Strasse 30, 1140 Vienna, Austria ,grid.413662.40000 0000 8987 03441St Medical Department, Hanusch Hospital Vienna, Vienna, Austria
| | - Martina Behanova
- grid.413662.40000 0000 8987 0344Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1St Medical Department, Hanusch Hospital, Heinrich-Collin-Strasse 30, 1140 Vienna, Austria
| | - Judith Haschka
- grid.413662.40000 0000 8987 0344Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1St Medical Department, Hanusch Hospital, Heinrich-Collin-Strasse 30, 1140 Vienna, Austria ,grid.413662.40000 0000 8987 03441St Medical Department, Hanusch Hospital Vienna, Vienna, Austria ,Vienna Bone and Growth Centre, Vienna, Austria
| | - Katharina Roetzer
- grid.413662.40000 0000 8987 0344Centre for Medical Genetics, Hanusch Hospital Vienna, Vienna, Austria ,grid.263618.80000 0004 0367 8888Medical Faculty of Genetics, Sigmund Freud University, Vienna, Austria
| | - Gökhan Uyanik
- grid.413662.40000 0000 8987 0344Centre for Medical Genetics, Hanusch Hospital Vienna, Vienna, Austria ,grid.263618.80000 0004 0367 8888Medical Faculty of Genetics, Sigmund Freud University, Vienna, Austria
| | - Benjamin Hadzimuratovic
- grid.413662.40000 0000 8987 03441St Medical Department, Hanusch Hospital Vienna, Vienna, Austria
| | - Martina Witsch-Baumgartner
- grid.5361.10000 0000 8853 2677Division Human Genetics, Department of Medical Genetics, Molecular and Clinical Pharmacology, Medical University Innsbruck, Innsbruck, Austria
| | - Georg Schett
- grid.5330.50000 0001 2107 3311Department of Internal Medicine 3, The University Clinic of Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Jochen Zwerina
- grid.413662.40000 0000 8987 0344Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1St Medical Department, Hanusch Hospital, Heinrich-Collin-Strasse 30, 1140 Vienna, Austria ,grid.413662.40000 0000 8987 03441St Medical Department, Hanusch Hospital Vienna, Vienna, Austria ,Vienna Bone and Growth Centre, Vienna, Austria
| | - Roland Kocijan
- grid.413662.40000 0000 8987 0344Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1St Medical Department, Hanusch Hospital, Heinrich-Collin-Strasse 30, 1140 Vienna, Austria ,grid.413662.40000 0000 8987 03441St Medical Department, Hanusch Hospital Vienna, Vienna, Austria ,Vienna Bone and Growth Centre, Vienna, Austria ,grid.263618.80000 0004 0367 8888Medical Faculty of Bone Diseases, Sigmund Freud University, Vienna, Austria
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Seefried L, Rak D, Petryk A, Genest F. Bone turnover and mineral metabolism in adult patients with hypophosphatasia treated with asfotase alfa. Osteoporos Int 2021; 32:2505-2513. [PMID: 34215909 PMCID: PMC8608777 DOI: 10.1007/s00198-021-06025-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/31/2021] [Indexed: 11/04/2022]
Abstract
UNLABELLED There is limited understanding of how asfotase alfa affects mineral metabolism and bone turnover in adults with pediatric-onset hypophosphatasia. This study showed that adults with hypophosphatasia treated with asfotase alfa experienced significant changes in biochemical markers of bone and mineral metabolism, possibly reflecting enhanced bone remodeling of previously osteomalacic bone. INTRODUCTION Hypophosphatasia (HPP), due to a tissue nonspecific alkaline phosphatase (TNSALP) deficiency, can cause impaired bone mineralization and turnover. Although HPP may be treated with asfotase alfa, an enzyme replacement therapy, limited data are available on how treatment with asfotase alfa affects mineral metabolism and bone turnover in adults with HPP. METHODS ALP substrates, bone turnover and mineral metabolism markers, and bone mineral density (BMD) data from EmPATHY, a single-center, observational study of adults (≥ 18 years) with pediatric-onset HPP treated with asfotase alfa (NCT03418389), were collected during routine clinical care and analyzed from baseline through 24 months of treatment. RESULTS Data from 21 patients showed significantly increased ALP activity and reduced urine phosphoethanolamine (PEA)/creatinine (Cr) ratios after baseline through 24 months of asfotase alfa treatment. There were significant transient increases in parathyroid hormone 1-84 (PTH), osteocalcin, and procollagen type 1 N-propeptide (P1NP) levels at 3 and 6 months and in tartrate-resistant acid phosphatase 5b (TRAP5b) levels at 3 months, with a significant decrease in N-terminal telopeptide of type 1 collagen (NTX) levels at 24 months. Lumbar spine BMD T scores continuously increased during treatment. CONCLUSION Significant changes in bone turnover and mineral metabolism markers after asfotase alfa treatment suggest that treatment-mediated mineralization may enable remodeling and bone turnover on previously unmineralized surfaces. Urine PEA/Cr ratios may be a useful parameter in monitoring treatment during routine care.
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Affiliation(s)
- L Seefried
- Orthopedic Clinic König-Ludwig-Haus, Julius-Maximilians-Universität Würzburg, Brettreichstr. 11, 97070, Würzburg, Germany.
| | - D Rak
- Orthopedic Clinic König-Ludwig-Haus, Julius-Maximilians-Universität Würzburg, Brettreichstr. 11, 97070, Würzburg, Germany
| | - A Petryk
- Alexion Pharmaceuticals, Inc., Boston, MA, USA
| | - F Genest
- Orthopedic Clinic König-Ludwig-Haus, Julius-Maximilians-Universität Würzburg, Brettreichstr. 11, 97070, Würzburg, Germany
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Abstract
Delineating the genetic background and the underlying pathophysiology of rare skeletal dysplasias enables a broader understanding of these disorders as well as novel perspectives regarding differential diagnosis and targeted development of therapeutic approaches. Hypophosphatasia (HPP) due to genetically determined Alkaline Phosphatase deficiency exemplifies this development. While an enzyme replacement therapy could be established for severe HPP with the prevailing bone manifestation, the clinical impact of not immediately bone-related manifestations just being successively understood. Correspondingly, the elucidation of the pathophysiology underlying renal phosphate wasting expanded our knowledge regarding phosphate metabolism and bone health and facilitated the development of an anti-FGF-23 Antibody for targeted treatment of X‑linked Hypophosphatemia (XLH). Evolutions regarding the nosology of osteogenesis imperfecta (OI) along with the identification of further causative genes also detected in the context of genetically determined osteoporosis illustrate the pathophysiologic interrelation between monogenetic bone dysplasias and multifactorial osteoporosis. While current therapeutic strategies for OI follow osteoporosis treatment, the expanding knowledge about OI forms the fundament for establishing improved treatment strategies-for both OI and osteoporosis. Similar developments are emerging regarding rare skeletal disorders like Achondroplasia, Fibrodysplasia ossificans progressive and Morbus Morquio (Mukopolysaccharidosis Type IV).
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Affiliation(s)
- Lothar Seefried
- Orthopädisches Zentrum für Muskuloskeletale Forschung, Universität Würzburg, Brettreichstr. 11, 97074, Würzburg, Deutschland.
| | - Franz Jakob
- Orthopädisches Zentrum für Muskuloskeletale Forschung, Universität Würzburg, Brettreichstr. 11, 97074, Würzburg, Deutschland
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