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Cherian KE, Paul TV. Inherited fibroblast growth factor 23 excess. Best Pract Res Clin Endocrinol Metab 2024; 38:101844. [PMID: 38044258 DOI: 10.1016/j.beem.2023.101844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Syndromes of inherited fibroblast growth factor 23 (FGF-23) excess encompass a wide spectrum that includes X-linked hypophosphataemia (XLH), autosomal dominant and recessive forms of rickets as well as various syndromic conditions namely fibrous dysplasia/McCune Albright syndrome, osteoglophonic dysplasia, Jansen's chondrodysplasia and cutaneous skeletal hypophosphataemia syndrome. A careful attention to patient symptomatology, family history and clinical features, supported by appropriate laboratory tests will help in making a diagnosis. A genetic screen may be done to confirm the diagnosis. While phosphate supplements and calcitriol continue to be the cornerstone of treatment, in recent times burosumab, the monoclonal antibody against FGF-23 has been approved for the treatment of children and adults with XLH. While health-related outcomes may be improved by ensuring adherence and compliance to prescribed treatment with a smooth transition to adult care, bony deformities may persist in some, and this would warrant surgical correction.
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Sawamura K, Hamajima T, Izawa M, Kaneko H, Kitamura A, Kitoh H. Changes of the lower limb deformity in children with FGF23-related hypophosphatemic rickets treated with Burosumab: a single-center prospective study. J Pediatr Orthop B 2024; 33:90-96. [PMID: 36728857 DOI: 10.1097/bpb.0000000000001054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Fibroblast growth factor 23 (FGF23)-related hypophosphatemic rickets (HPR) are characterized by excess circulating FGF23 and low concentrations of serum phosphorus, leading to skeletal manifestations of rickets, including lower limb deformities in children. The objective of this study was to prospectively evaluate whether treatment with burosumab, a monoclonal antibody neutralizing FGF23, changes lower limb deformities in HPR. Patients who were 15 years of age or younger with a documented clinical diagnosis of HPR, receiving burosumab treatment, and had a minimum follow-up period of one year were included in the study. Various radiological parameters were measured from anteroposterior and lateral radiographs of the bilateral lower limbs taken before administration of burosumab and at 3, 6, 9, and 12 months after treatment for evaluation of lower limb alignment. Outcome was classified as 'improvement', 'no change', or 'deterioration' after 12 months treatment. Five patients (10 limbs), with a mean age of 7.2 years were included in this study. The outcome was 'improvement' in six limbs and 'no change' in four limbs. There were no limbs of 'deterioration'. The improvement in deformities after treatment was more significant in younger patients who originally showed severe lower limb deformities. Older patients with milder deformities, on the other hand, showed less improvement. Burosumab therapy favorably changed lower-limb malalignment in children with FGF23-related HPR.
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Affiliation(s)
- Kenta Sawamura
- Department of Orthopaedic Surgery, Aichi Children's Health and Medical Center, Obu
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya
| | - Takashi Hamajima
- Department of Endocrinology and Metabolism, Aichi Children's Health and Medical Center, Obu
| | - Masako Izawa
- Department of Endocrinology and Metabolism, Aichi Children's Health and Medical Center, Obu
| | - Hiroshi Kaneko
- Department of Orthopaedic Surgery, Aichi Children's Health and Medical Center, Obu
| | - Akiko Kitamura
- Department of Orthopaedic Surgery, Aichi Children's Health and Medical Center, Obu
| | - Hiroshi Kitoh
- Department of Orthopaedic Surgery, Aichi Children's Health and Medical Center, Obu
- Department of Comprehensive Pediatric Medicine, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
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Kocijan R, Mindler GT, Hartmann MA, Kraus DA, Raimann A, Zwerina J. Dissociation of clinical, laboratory, and bone biopsy findings in adult X-linked hypophosphatemia: a case report. Wien Med Wochenschr 2023; 173:339-345. [PMID: 36695943 DOI: 10.1007/s10354-022-01000-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/15/2022] [Indexed: 01/26/2023]
Abstract
X‑linked hypophosphatemia (XLH) is a phosphate wasting disorder. Typical serum constellations include low serum phosphate as well as high alkaline phosphatase (ALP) and fibroblast growth factor 23 (FGF-23 ) levels. Adult XLH patients usually suffer from (pseudo)fractures, enthesopathies, impaired mobility, and osteoarthritis. We report the case of a middle-aged woman with clinically mild disease, relatively balanced laboratory values, but bone non-healing of the femur post-surgery. Transiliac bone biopsy revealed pronounced osteomalacia and severe deterioration of bone microstructure. Due to the lack of XLH-typical symptoms, the patient was not substituted with calcitriol and phosphate in adulthood. Thus, laboratory findings and radiological examinations do not necessarily reflect bone metabolism in XLH. Bone biopsies should be considered in unclear cases or prior to surgery in adults with XLH.
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Affiliation(s)
- Roland Kocijan
- 1st Medical Department Hanusch Hospital, Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA; Trauma Centre Meidling, Heinrich-Collin-Straße 30, 1140, Vienna, Austria.
- Vienna Bone and Growth Center, Vienna, Austria.
- School of medicine, Metabolic bone diseases unit, Sigmund Freud University Vienna, Vienna, Austria.
| | - Gabriel Tilmann Mindler
- Vienna Bone and Growth Center, Vienna, Austria
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
| | - Markus Alexander Hartmann
- 1st Medical Department Hanusch Hospital, Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA; Trauma Centre Meidling, Heinrich-Collin-Straße 30, 1140, Vienna, Austria
| | - Danial Arian Kraus
- 1st Medical Department Hanusch Hospital, Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA; Trauma Centre Meidling, Heinrich-Collin-Straße 30, 1140, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Adalbert Raimann
- Vienna Bone and Growth Center, Vienna, Austria
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Pulmonology, Allergology and Endocrinology, Medical University Vienna, Vienna, Austria
| | - Jochen Zwerina
- 1st Medical Department Hanusch Hospital, Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA; Trauma Centre Meidling, Heinrich-Collin-Straße 30, 1140, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
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Pecoraro C, Fioretti T, Perruno A, Klain A, Cioffi D, Ambrosio A, Passaro D, Annicchiarico Petruzzelli L, Di Domenico C, de Girolamo D, Vallone S, Cattaneo F, Ammendola R, Esposito G. De Novo Large Deletions in the PHEX Gene Caused X-Linked Hypophosphataemic Rickets in Two Italian Female Infants Successfully Treated with Burosumab. Diagnostics (Basel) 2023; 13:2552. [PMID: 37568915 PMCID: PMC10417872 DOI: 10.3390/diagnostics13152552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
Pathogenic variants in the PHEX gene cause rare and severe X-linked dominant hypophosphataemia (XLH), a form of heritable hypophosphatemic rickets (HR) characterized by renal phosphate wasting and elevated fibroblast growth factor 23 (FGF23) levels. Burosumab, the approved human monoclonal anti-FGF23 antibody, is the treatment of choice for XLH. The genetic and phenotypic heterogeneity of HR often delays XLH diagnoses, with critical effects on disease course and therapy. We herein report the clinical and genetic features of two Italian female infants with sporadic HR who successfully responded to burosumab. Their diagnoses were based on clinical and laboratory findings and physical examinations. Next-generation sequencing (NGS) of the genes associated with inherited HR and multiple ligation probe amplification (MLPA) analysis of the PHEX and FGF23 genes were performed. While a conventional analysis of the NGS data did not reveal pathogenic or likely pathogenic small nucleotide variants (SNVs) in the known HR-related genes, a quantitative analysis identified two different heterozygous de novo large intragenic deletions in PHEX, and this was confirmed by MLPA. Our molecular data indicated that deletions in the PHEX gene can be the cause of a significant fraction of XLH; hence, their presence should be evaluated in SNV-negative female patients. Our patients successfully responded to burosumab, demonstrating the efficacy of this drug in the treatment of XLH. In conclusion, the execution of a phenotype-oriented genetic test, guided by known types of variants, including the rarest ones, was crucial to reach the definitive diagnoses and ensure our patients of long-term therapy administration.
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Affiliation(s)
- Carmine Pecoraro
- Paediatric Nephrology, Dialysis and Renal Transplantation Unit, Santobono Pausilipon Children’s Hospital, 80129 Naples, Italy;
| | - Tiziana Fioretti
- CEINGE—Advanced Biotechnologies Franco Salvatore, 80145 Naples, Italy; (T.F.); (A.A.); (D.P.); (C.D.D.); (D.d.G.)
| | - Assunta Perruno
- Primary Care Pediatrician, ASL NA2 North, 80027 Naples, Italy;
| | - Antonella Klain
- Pediatric Endocrinology Unit, Santobono Pausilipon Children’s Hospital, 80129 Naples, Italy; (A.K.); (D.C.)
| | - Daniela Cioffi
- Pediatric Endocrinology Unit, Santobono Pausilipon Children’s Hospital, 80129 Naples, Italy; (A.K.); (D.C.)
| | - Adelaide Ambrosio
- CEINGE—Advanced Biotechnologies Franco Salvatore, 80145 Naples, Italy; (T.F.); (A.A.); (D.P.); (C.D.D.); (D.d.G.)
| | - Diego Passaro
- CEINGE—Advanced Biotechnologies Franco Salvatore, 80145 Naples, Italy; (T.F.); (A.A.); (D.P.); (C.D.D.); (D.d.G.)
| | - Luigi Annicchiarico Petruzzelli
- Paediatric Nephrology, Dialysis and Renal Transplantation Unit, Santobono Pausilipon Children’s Hospital, 80129 Naples, Italy;
| | - Carmela Di Domenico
- CEINGE—Advanced Biotechnologies Franco Salvatore, 80145 Naples, Italy; (T.F.); (A.A.); (D.P.); (C.D.D.); (D.d.G.)
| | - Domenico de Girolamo
- CEINGE—Advanced Biotechnologies Franco Salvatore, 80145 Naples, Italy; (T.F.); (A.A.); (D.P.); (C.D.D.); (D.d.G.)
| | - Sabrina Vallone
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, 80131 Naples, Italy; (S.V.); (F.C.); (R.A.)
| | - Fabio Cattaneo
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, 80131 Naples, Italy; (S.V.); (F.C.); (R.A.)
| | - Rosario Ammendola
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, 80131 Naples, Italy; (S.V.); (F.C.); (R.A.)
| | - Gabriella Esposito
- CEINGE—Advanced Biotechnologies Franco Salvatore, 80145 Naples, Italy; (T.F.); (A.A.); (D.P.); (C.D.D.); (D.d.G.)
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, 80131 Naples, Italy; (S.V.); (F.C.); (R.A.)
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Presentation and Diagnosis of Pediatric X-Linked Hypophosphatemia. ENDOCRINES 2023. [DOI: 10.3390/endocrines4010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
X-linked hypophosphatemia (XLH) is a rare type of hereditary hypophosphatemic rickets. Patients with XLH have various symptoms that lower their QOL as defined by HAQ, RAPID3, SF36-PCS, and SF36-MCS in adult patients and SF-10 and PDCOI in pediatric patients. Early diagnosis and treatment are needed to reduce the burden, but the condition is often diagnosed late in childhood. The present review aims to summarize the symptoms, radiological and biological characteristics, and long-term prognosis of pediatric XLH. Typical symptoms of XLH are lower leg deformities (age six months or later), growth impairment (first year of life or later), and delayed gross motor development with progressive lower limb deformities (second year of life or later). Other symptoms include dental abscess, bone pain, hearing impairment, and Chiari type 1 malformation. Critical, radiological findings of rickets are metaphyseal widening, cupping, and fraying, which tend to occur in the load-bearing bones. The Rickets Severity Score, validated for XLH, is useful for assessing the severity of rickets. The biochemical features of XLH include elevated FGF23, hypophosphatemia, low 1,25(OH)2D, and elevated urine phosphate. Renal phosphate wasting can be assessed using the tubular maximum reabsorption of phosphate per glomerular filtration rate (TmP/GFR), which yields low values in patients with XLH. XLH should be diagnosed early because the multisystem symptoms often worsen over time. The present review aims to help physicians diagnose XLH at an early stage.
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Akta C, Wenzel-Schwarz F, Stauffer A, Kranzl A, Raimann A, Kocijan R, Ganger R, Mindler GT. The ankle in XLH: Reduced motion, power and quality of life. Front Endocrinol (Lausanne) 2023; 14:1111104. [PMID: 37033213 PMCID: PMC10073673 DOI: 10.3389/fendo.2023.1111104] [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: 11/29/2022] [Accepted: 02/23/2023] [Indexed: 04/11/2023] Open
Abstract
BACKGROUND X-linked hypophosphatemia (OMIM 307800) is a rare bone disease caused by a phosphate-wasting condition with lifelong clinical consequences. Those affected suffer from bone pain, complex skeletal deformities, impaired mobility and a reduced quality of life. Early osteoarthritis and reduced range of motion of the lower limbs are known pathologies in XLH patients. However, XLH-specific data on the affected compartments such as the ankle joint through the evaluation of radiographic and gait analysis data is still lacking. PATIENTS AND METHODS In this cross-sectional study, patients with genetically verified XLH, age ≥ 16 - 50 years and a complete record of gait analysis and or radiographic analysis data were included. Clinical examination, radiological and gait analysis data were compared to norms using the dataset of our gait laboratory registry. Radiographic analysis included tibial deformity analysis and assessment of osteoarthritis and enthesopathies. Western Ontario and McMaster Universities Arthritis Index (WOMAC), SF36v2, American Orthopedic Foot and Ankle Society score (AOFAS) and the Foot and Ankle Outcome Score (FAOS) were used. Twentythree participants with 46 limbs were eligible for the study. RESULTS A total of 23 patients (n=46 feet) met the inclusion criteria. Patients with XLH had significantly reduced gait quality, ankle power and plantar flexion (p < 0.001) compared to a historic gait laboratory control group. Ankle valgus deformity was detected in 22 % and ankle varus deformity in 30 % of the patients. The subtalar joint (59.1%) as well as the anterior tibiotalar joint (31.1%) were the main localizations of moderate to severe joint space narrowing. Ankle power was decreased in moderate and severe subtalar joint space narrowing (p < 0.05) compared to normal subtalar joint space narrowing. No lateral or medial ligament instability of the ankle joint was found in clinical examination. Tibial procurvatum deformity led to lower ankle power (p < 0.05). CONCLUSIONS This study showed structural and functional changes of the ankle in patients with XLH. Subtalar ankle osteoarthritis, patient reported outcome scores and clinical ankle restriction resulted in lower gait quality and ankle power.
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Affiliation(s)
- Celine Akta
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
- Medical Faculty of Bone Diseases, Sigmund Freud University, Vienna, Austria
| | - Florian Wenzel-Schwarz
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Alexandra Stauffer
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Andreas Kranzl
- Vienna Bone and Growth Center, Vienna, Austria
- Laboratory for Gait and Movement Analysis, Orthopaedic Hospital Speising, Vienna, Austria
| | - Adalbert Raimann
- Vienna Bone and Growth Center, Vienna, Austria
- Comprehensive Center for Pediatrics, Department of Pediatrics and Adolescent Medicine, Division of Pediatric Pulmonology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria
| | - Roland Kocijan
- Vienna Bone and Growth Center, Vienna, Austria
- Medical Faculty of Bone Diseases, Sigmund Freud University, Vienna, Austria
- 1st Medical Department, Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, Hanusch Hospital, Vienna, Austria
| | - Rudolf Ganger
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Gabriel T. Mindler
- Department of Pediatric Orthopaedics, Orthopaedic Hospital Speising, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
- *Correspondence: Gabriel T. Mindler,
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Orthopedic Complications and Management in Children with X-Linked Hypophosphatemia. ENDOCRINES 2022. [DOI: 10.3390/endocrines3030039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
X-linked hypophosphatemia is an inheritable disease of renal phosphate wasting that results in clinically manifestations associated with rickets or osteomalacia. The various symptoms in the skeletal system are well recognized, such as short stature; lower limb deformities; and bone, joint, or muscle pain, and it is often difficult to control these symptoms, despite the use of medication therapy in growing children. In addition, lower limb deformities can lead to degenerative osteoarthritis and dysfunction of lower limbs at the skeletal maturity. To prevent from future manifestation of those symptoms, orthopedic surgeries are applicable to growing patients with severe skeletal deformities or without response to conventional medication. Bone deformities are treated by acute or gradual corrective osteotomies and temporally hemiepiphysiodesis using guided growth method. The clinicians should choose the right procedure based on age, symptoms and state of deformities of the patient.
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