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Larid G, Vix J, Preuss P, Robin F, Tison A, Delaveau C, Krajewski F, Bouvard B, Chu Miow Lin D, Guggenbuhl P, Maugars Y, Saraux A, Debiais F. Detection of hypophosphatasia in hospitalised adults in rheumatology and internal medicine departments: a multicentre study over 10 years. RMD Open 2024; 10:e004316. [PMID: 38580346 PMCID: PMC11002352 DOI: 10.1136/rmdopen-2024-004316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 03/15/2024] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION Hypophosphatasia (HPP) is a rare genetic disease caused by loss-of-function mutations in the ALPL gene encoding the tissue non-specific alkaline phosphatase (ALP). Mild HPP is usually misdiagnosed in adult age. While an elevated serum ALP value draws more attention than a low value, low serum ALP should be better recognised and may lead to HPP detection. METHODS Patients were selected from the records of the biochemistry department of six University Hospitals in France. Patients were hospitalised in the departments of rheumatology and internal medicine between 2007 and 2017. RESULTS 56 321 hospitalised patients had at least 2 serum ALP dosages and 664 of these patients had at least 2 low serum ALP≤35 UI/L. Among these 664 patients, 482 (72.6%) had fluctuating low values (mean age 62.9 years; 60% of women) and 182 patients (27.4%) had persistent low values below 35 IU/L (mean age 53.4 years; 67% of women). Among patients with persistent hypophosphatasaemia treated with bisphosphonates, 70.8% never had ALP measurement before treatment and 20.8% were treated despite an abnormal decrease of ALP. Genetic testing was performed in 18 patients and was positive in 11. Genetic diagnosis of HPP was at least 6.0% in persistent hypophosphatasaemia and at least 15.9% in patients with at least three symptoms suggestive of HPP. CONCLUSION In this 10-year retrospective study, 0.32% of adult patients hospitalised in the rheumatology and internal medicine departments had persistently low serum ALP, and among them, 6% had genetically proven HPP. Reported hypophosphatasaemia represented only 3.6% of hospitalised patients.
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Affiliation(s)
- Guillaume Larid
- Department of Rheumatology, CHU Poitiers, Poitiers, France
- LITEC, Poitiers University, Poitiers, France
| | - Justine Vix
- Department of Rheumatology, CHU Poitiers, Poitiers, France
| | | | | | | | | | | | | | - Delphine Chu Miow Lin
- Department of Rheumatology, CHU de Tours, Tours, France
- Université de Tours, Tours, France
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Whyte MP, Zhang F, Mack KE, Wenkert D, Gottesman GS, Ericson KL, Cole JT, Coburn SP. Pyridoxine challenge reflects pediatric hypophosphatasia severity and thereby examines tissue-nonspecific alkaline phosphatase's role in vitamin B 6 metabolism. Bone 2024; 181:117033. [PMID: 38307176 DOI: 10.1016/j.bone.2024.117033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/28/2023] [Accepted: 01/30/2024] [Indexed: 02/04/2024]
Abstract
Alkaline phosphatase (ALP) is detected in most human tissues. However, ALP activity is routinely assayed using high concentrations of artificial colorimetric substrates in phosphate-free laboratory buffers at lethal pH. Hypophosphatasia (HPP) is the inborn-error-of-metabolism caused by loss-of-function mutation(s) of the ALPL gene that encodes the ALP isoenzyme expressed in bone, liver, kidney, and elsewhere and is therefore designated "tissue-nonspecific" ALP (TNSALP). Consequently, HPP harbors clues concerning the biological function of this phosphohydrolase that is anchored onto the surface of cells. The biochemical signature of HPP features low serum ALP activity (hypophosphatasemia) together with elevated plasma levels of three natural substrates of TNSALP: i) phosphoethanolamine (PEA), a component of the linkage apparatus that binds ALPs and other proteins to the plasma membrane surface; ii) inorganic pyrophosphate (PPi), an inhibitor of bone and tooth mineralization; and iii) pyridoxal 5'-phosphate (PLP), the principal circulating vitameric form of vitamin B6 (B6). Autosomal dominant and autosomal recessive inheritance involving several hundred ALPL mutations underlies the remarkably broad-ranging expressivity of HPP featuring tooth loss often with muscle weakness and rickets or osteomalacia. Thus, HPP associates the "bone" isoform of TNSALP with biomineralization, whereas the physiological role of the "liver", "kidney", and other isoforms of TNSALP remains uncertain. Herein, to examine HPP's broad-ranging severity and the function of TNSALP, we administered an oral challenge of pyridoxine (PN) hydrochloride to 116 children with HPP. We assayed both pre- and post-challenge serum ALP activity and plasma levels of PLP, the B6 degradation product pyridoxic acid (PA), and the B6 vitamer pyridoxal (PL) that can enter cells. Responses were validated by PN challenge of 14 healthy adults and 19 children with metabolic bone diseases other than HPP. HPP severity was assessed using our HPP clinical nosology and patient height Z-scores. PN challenge of all study groups did not alter serum ALP activity in our clinical laboratory. In HPP, both the post-challenge PLP level and the PLP increment correlated (Ps < 0.0001) with the clinical nosology and height Z-scores (Rs = +0.6009 and + 0.4886, and Rs = -0.4846 and - 0.5002, respectively). In contrast, the plasma levels and increments of PA and PL from the PN challenge became less pronounced with HPP severity. We discuss how our findings suggest extraskeletal TNSALP primarily conditioned the PN challenge responses, and explain why they caution against overzealous B6 supplementation of HPP.
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Affiliation(s)
- Michael P Whyte
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children-St Louis, St. Louis, MO 63110, USA; Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA.
| | - Fan Zhang
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children-St Louis, St. Louis, MO 63110, USA.
| | - Karen E Mack
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children-St Louis, St. Louis, MO 63110, USA
| | - Deborah Wenkert
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children-St Louis, St. Louis, MO 63110, USA.
| | - Gary S Gottesman
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children-St Louis, St. Louis, MO 63110, USA; Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA.
| | - Karen L Ericson
- Department of Chemistry and Biochemistry, Purdue University Fort Wayne, Fort Wayne, IN 46805, USA.
| | - Jeffrey T Cole
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children-St Louis, St. Louis, MO 63110, USA.
| | - Stephen P Coburn
- Department of Chemistry and Biochemistry, Purdue University Fort Wayne, Fort Wayne, IN 46805, USA.
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Oto Y, Suzuki D, Morita T, Inoue T, Nitta A, Murakami N, Abe Y, Hamada Y, Akiyama T, Matsubara T. A case report of odonto-hypophosphatasia with a novel variant in the ALPL gene. J Pediatr Endocrinol Metab 2024; 37:276-279. [PMID: 38310522 DOI: 10.1515/jpem-2023-0549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/16/2024] [Indexed: 02/06/2024]
Abstract
OBJECTIVES Hypophosphatasia (HPP) is a rare skeletal dysplasia caused by variants in the alkaline phosphatase (ALPL) gene. More than 400 pathogenic variants of the ALPL gene have been registered in the ALPL gene variant database. Here, we describe the case of a Japanese child with odonto-hypophsphatasia (odonto-HPP) and a novel ALPL variant. CASE PRESENTATION At the age of 2 years and 1 month, he prematurely lost one deciduous tooth, with the root intact, when he fell and hit his face lightly. Three months later, he lost another adjacent deciduous tooth without incentive. His serum alkaline phosphatase (ALP) level was 72 U/L. His urine phosphoethanolamine (PEA) level was extremely high at 938 μmol/mg·Cre. The serum pyridoxal 5'-phosphaye (PLP) level was 255.9 nmol/L. Based on the clinical symptoms and laboratory findings, the patient was clinically diagnosed with odonto-HPP. Genetic analysis of the ALPL gene revealed a heterozygous variant (NM_000478.6:c.1151C>A, p.Thr384Lys). CONCLUSIONS We report a case of odonto-HPP with a novel variant in the ALPL gene. HPP is a rare disease, and the heterozygous mutation in the ALPL gene highlights the novelty of this case.
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Affiliation(s)
- Yuji Oto
- Department of Pediatrics, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Daiki Suzuki
- Department of Pediatrics, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Tsubasa Morita
- Department of Pediatrics, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Takeshi Inoue
- Child Development and Psychosomatic Medicine Center, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Akihisa Nitta
- Department of Pediatrics, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Nobuyuki Murakami
- Department of Pediatrics, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Yuuka Abe
- Center for Genetic Medicine, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Yoshinobu Hamada
- Center for Genetic Medicine, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Tomoyuki Akiyama
- Department of Pediatrics (Child Neurology), Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Tomoyo Matsubara
- Department of Pediatrics, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
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Brandi ML, Khan AA, Rush ET, Ali DS, Al-Alwani H, Almonaei K, Alsarraf F, Bacrot S, Dahir KM, Dandurand K, Deal C, Ferrari SL, Giusti F, Guyatt G, Hatcher E, Ing SW, Javaid MK, Khan S, Kocijan R, Lewiecki EM, Linglart A, M'Hiri I, Marini F, Nunes ME, Rockman-Greenberg C, Seefried L, Simmons JH, Starling SR, Ward LM, Yao L, Brignardello-Petersen R, Roux C. The challenge of hypophosphatasia diagnosis in adults: results from the HPP International Working Group Literature Surveillance. Osteoporos Int 2024; 35:439-449. [PMID: 37982856 DOI: 10.1007/s00198-023-06859-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 11/21/2023]
Abstract
Hypophosphatasia (HPP) is an inborn error of metabolism caused by reduced or absent activity of the tissue non-specific alkaline phosphatase (TNSALP) enzyme, resulting from pathogenic variants in the ALPL gene. Clinical presentation of HPP is highly variable, including lethal and severe forms in neonates and infants, a benign perinatal form, mild forms manifesting in adulthood, and odonto-HPP. Diagnosis of HPP remains a challenge in adults, as signs and symptoms may be mild and non-specific. Disease presentation varies widely; there are no universal signs or symptoms, and the disease often remains underdiagnosed or misdiagnosed, particularly by clinicians who are not familiar with this rare disorder. The absence of diagnosis or a delayed diagnosis may prevent optimal management for patients with this condition. Formal guidelines for the diagnosis of adults with HPP do not exist, complicating efforts for consistent diagnosis. To address this issue, the HPP International Working Group selected 119 papers that explicitly address the diagnosis of HPP in adults through a Medline, Medline In-Process, and Embase search for the terms "hypophosphatasia" and "HPP," and evaluated the pooled prevalence of 17 diagnostic characteristics, initially selected by a group of HPP clinical experts, in eligible studies and in patients included in these studies. Six diagnostic findings showed a pooled prevalence value over 50% and were considered for inclusion as major diagnostic criteria. Based on these results and according to discussion and consideration among members of the Working Group, we finally defined four major diagnostic criteria and five minor diagnostic criteria for HPP in adults. Authors suggested the integrated use of the identified major and minor diagnostic criteria, which either includes two major criteria, or one major criterion and two minor criteria, for the diagnosis of HPP in adults.
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Affiliation(s)
- Maria Luisa Brandi
- F.I.R.M.O. Italian Foundation for the Research On Bone Diseases, Florence, Italy.
- Donatello Bone Clinic, Villa Donatello Hospital, Florence, Italy.
| | - Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Eric T Rush
- Division of Clinical Genetics, Children's Mercy Kansas City and Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
- Division of Endocrinology, Metabolism, Osteoporosis, and Genetics, Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Dalal S Ali
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Hatim Al-Alwani
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Khulod Almonaei
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Farah Alsarraf
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Severine Bacrot
- Department of Genetics, Centre Hospitalier de Versailles, Hôpital André Mignot, Versailles, France
| | - Kathryn M Dahir
- Division of Endocrinology and Metabolism, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karel Dandurand
- Department of Medicine, Endocrinology and Metabolism, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Chad Deal
- Center for Osteoporosis and Metabolic Bone Disease, Department of Rheumatology, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Serge Livio Ferrari
- Division of Bone Diseases, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Francesca Giusti
- Donatello Bone Clinic, Villa Donatello Hospital, Florence, Italy
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Erin Hatcher
- Neuromuscular Clinic, McMaster University Medical Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Steven W Ing
- Division of Endocrinology, Diabetes, & Metabolism, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah Khan
- Bone Research and Education Centre, Oakville, ON, Canada
| | - Roland Kocijan
- Trauma Centre Meidling, Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA, 1St Medical Department Hanusch Hospital, 1140, Vienna, Austria
| | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - Agnes Linglart
- APHP, Bicêtre Paris-Sud, University Paris Sud, Paris-Saclay, Le Kremlin Bicêtre, Paris, France
| | - Iman M'Hiri
- Bone Research and Education Centre, Oakville, ON, Canada
| | - Francesca Marini
- F.I.R.M.O. Italian Foundation for the Research On Bone Diseases, Florence, Italy
| | - Mark E Nunes
- Division of Medical Genetics and Metabolism, Valley Children's HealthCare, Madera, CA, USA
| | | | - Lothar Seefried
- Musculoskeletal Center Würzburg, University of Würzburg, Würzburg, Germany
| | - Jill H Simmons
- Division of Endocrinology and Metabolism, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan R Starling
- Division of Clinical Genetics, Children's Mercy Kansas City and Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Leanne M Ward
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Christian Roux
- INSERM CRESS UMR 1153, Paris, France
- Université Paris-Cité, Department of Rheumatology, APHP-Centre, Cochin Hospital, Paris, France
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Khan AA, Brandi ML, Rush ET, Ali DS, Al-Alwani H, Almonaei K, Alsarraf F, Bacrot S, Dahir KM, Dandurand K, Deal C, Ferrari SL, Giusti F, Guyatt G, Hatcher E, Ing SW, Javaid MK, Khan S, Kocijan R, Linglart A, M'Hiri I, Marini F, Nunes ME, Rockman-Greenberg C, Roux C, Seefried L, Simmons JH, Starling SR, Ward LM, Yao L, Brignardello-Petersen R, Lewiecki EM. Hypophosphatasia diagnosis: current state of the art and proposed diagnostic criteria for children and adults. Osteoporos Int 2024; 35:431-438. [PMID: 37982857 PMCID: PMC10866785 DOI: 10.1007/s00198-023-06844-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 06/23/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND This manuscript provides a summary of the current evidence to support the criteria for diagnosing a child or adult with hypophosphatasia (HPP). The diagnosis of HPP is made on the basis of integrating clinical features, laboratory profile, radiographic features of the condition, and DNA analysis identifying the presence of a pathogenic variant of the tissue nonspecific alkaline phosphatase gene (ALPL). Often, the diagnosis of HPP is significantly delayed in both adults and children, and updated diagnostic criteria are required to keep pace with our evolving understanding regarding the relationship between ALPL genotype and associated HPP clinical features. METHODS An International Working Group (IWG) on HPP was formed, comprised of a multidisciplinary team of experts from Europe and North America with expertise in the diagnosis and management of patients with HPP. Methodologists (Romina Brignardello-Petersen and Gordon Guyatt) and their team supported the IWG and conducted systematic reviews following the GRADE methodology, and this provided the basis for the recommendations. RESULTS The IWG completed systematic reviews of the literature, including case reports and expert opinion papers describing the phenotype of patients with HPP. The published data are largely retrospective and include a relatively small number of patients with this rare condition. It is anticipated that further knowledge will lead to improvement in the quality of genotype-phenotype reporting in this condition. CONCLUSION Following consensus meetings, agreement was reached regarding the major and minor criteria that can assist in establishing a clinical diagnosis of HPP in adults and children.
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Affiliation(s)
- Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada.
| | - Maria Luisa Brandi
- F.I.R.M.O. Italian Foundation for the Research On Bone Diseases, Florence, Italy
- Donatello Bone Clinic, Villa Donatello Hospital, Florence, Italy
| | - Eric T Rush
- Division of Clinical Genetics, Children's Mercy Kansas City, Kansas City, MO, USA
- Division of Endocrinology, Metabolism, Osteoporosis and Genetics, Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Dalal S Ali
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Hatim Al-Alwani
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Khulod Almonaei
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Farah Alsarraf
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Severine Bacrot
- Department of Genetics, Centre Hospitalier de Versailles, Hôpital André Mignot, Versailles, France
| | - Kathryn M Dahir
- Division of Endocrinology and Metabolism, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karel Dandurand
- Department of Medicine, Endocrinology and Metabolism, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Chad Deal
- Center for Osteoporosis and Metabolic Bone Disease, Department of Rheumatology, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Serge Livio Ferrari
- Division of Bone Diseases, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Francesca Giusti
- Donatello Bone Clinic, Villa Donatello Hospital, Florence, Italy
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact at McMaster University, Hamilton, Canada
| | - Erin Hatcher
- Neuromuscular Clinic, McMaster University Medical Centre, Hamilton Health Sciences, Hamilton, Canada
| | - Steven W Ing
- Division of Endocrinology, Diabetes & Metabolism, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah Khan
- Bone Research and Education Centre, Oakville, ON, Canada
| | - Roland Kocijan
- Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA, Trauma Centre Meidling, 1St Medical Department Hanusch Hospital, 1140, Vienna, Austria
| | - Agnes Linglart
- APHP, Bicêtre Paris-Sud, UniversityParis Sud, Paris-Saclay, Le Kremlin Bicêtre, Paris, France
| | - Iman M'Hiri
- Bone Research and Education Centre, Oakville, ON, Canada
| | - Francesca Marini
- F.I.R.M.O. Italian Foundation for the Research On Bone Diseases, Florence, Italy
| | - Mark E Nunes
- Division of Medical Genetics and Metabolism, Valley Children's HealthCare, Madera, CA, USA
| | | | - Christian Roux
- INSERM CRESS UMR 1153, Paris, France
- Université Paris-Cité, Department of Rheumatology, APHP-Centre, Cochin Hospital, Paris, France
| | - Lothar Seefried
- Musculoskeletal Center Wuerzburg, University of Würzburg, Würzburg, Germany
| | - Jill H Simmons
- Division of Endocrinology and Metabolism, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan R Starling
- Division of Clinical Genetics, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Leanne M Ward
- Children's Hospital of Eastern Ontario, Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Liang Yao
- Department of Health Research Methods, Evidence and Impact at McMaster University, Hamilton, Canada
| | | | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
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Baroncelli GI, Carlucci G, Freri E, Giuca MR, Guarnieri V, Navarra G, Toschi B, Mora S. The diagnosis of hypophosphatasia in children as a multidisciplinary effort: an expert opinion. J Endocrinol Invest 2024; 47:739-747. [PMID: 37752373 PMCID: PMC10904512 DOI: 10.1007/s40618-023-02199-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/12/2023] [Indexed: 09/28/2023]
Abstract
Hypophosphatasia (HPP) is a rare genetic disorder in which pathogenic variants of the ALPL gene lead to a marked decrease of tissue non-specific alkaline phosphatase (TNSALP) activity. Although HPP is a systemic disorder, its clinical manifestations are more evident on bones, teeth, muscle and central nervous system. The clinical spectrum ranges from severe forms with extreme skeletal deformities, respiratory impairment, seizures, to very mild forms with onset in late adulthood and few clinical signs. The diagnosis can be suspected by measurement of TNSALP activity, but the insufficient awareness among health professionals and the lack of official guidelines are responsible for delayed diagnosis in children with HPP. The purpose of the current document is to provide an expert opinion directed at optimizing the diagnostic pathway of pediatric HPP. From April to December 2022, a multidisciplinary working group of 6 experts including two pediatric endocrinologists, a pediatric neurologist, a pediatric odontologist, a clinical geneticist, and a molecular biologist gathered in a series of periodic meetings to discuss the main issues related to the diagnosis of HPP in children and formalize an Expert Opinion statement. The experts agreed on a diagnostic trail that begins with the recognition of specific clinical signs, leading to biochemical analyses of TNSALP activity and vitamin B6 serum concentration. Very important are the neurological and dental manifestation of the disease that should be thoroughly investigated. The evaluation of TNSALP activity must consider sex and age variability and low activity must be persistent. Repeated blood measurements are thus necessary. The molecular analysis is then mandatory to confirm the diagnosis and for genetic counseling.
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Affiliation(s)
- G I Baroncelli
- Pediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
| | - G Carlucci
- OPT S.P.A., Soluzioni Per Il Mondo Healthcare, Milan, Italy
| | - E Freri
- Department of Pediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - M R Giuca
- Unit of Pediatric Dentistry, Department of Surgical Medical Molecular Pathology and Critical Area, Dental and Oral Surgery Clinic, University of Pisa, Pisa, Italy
| | - V Guarnieri
- Division of Medical Genetics, Fondazione IRCCS Casa Sollievo della Sofferenza, Foggia, Italy
| | - G Navarra
- OPT S.P.A., Soluzioni Per Il Mondo Healthcare, Milan, Italy
| | - B Toschi
- Section of Medical Genetics, Department of Medical and Oncological Area, University Hospital, Pisa, Italy
| | - S Mora
- Laboratory of Pediatric Endocrinology, Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy.
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Martínez-Heredia L, Muñoz-Torres M, Sanabria-de la Torre R, Jiménez-Ortas Á, Andújar-Vera F, González-Cejudo T, Contreras-Bolívar V, González-Salvatierra S, Gómez-Vida JM, García-Fontana C, García-Fontana B. Systemic effects of hypophosphatasia characterization of two novel variants in the ALPL gene. Front Endocrinol (Lausanne) 2024; 14:1320516. [PMID: 38234425 PMCID: PMC10792043 DOI: 10.3389/fendo.2023.1320516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/04/2023] [Indexed: 01/19/2024] Open
Abstract
Introduction Hypophosphatasia (HPP) is an inborn metabolic error caused by mutations in the ALPL gene encoding tissue non-specific alkaline phosphatase (TNSALP) and leading to decreased alkaline phosphatase (ALP) activity. Although the main characteristic of this disease is bone involvement, it presents a great genetic and clinical variability, which makes it a systemic disease. Methods Patients were recruited based on biochemical assessments. Diagnosis was made by measuring serum ALP and pyridoxal 5-phosphate levels and finally by Sanger sequencing of the ALPL gene from peripheral blood mononuclear cells. Characterization of the new variants was performed by transfection of the variants into HEK293T cells, where ALP activity and cellular localization were measured by flow cytometry. The dominant negative effect was analyzed by co-transfection of each variant with the wild-type gene, measuring ALP activity and analyzing cellular localization by flow cytometry. Results Two previously undescribed variants were found in the ALPL gene: leucine 6 to serine missense mutation (c.17T>C, L6S) affecting the signal peptide and threonine 167 deletion (c.498_500delCAC, T167del) affecting the vicinity of the active site. These mutations lead mainly to non-pathognomonic symptoms of HPP. Structural prediction and modeling tools indicated the affected residues as critical residues with important roles in protein structure and function. In vitro results demonstrated low TNSALP activity and a dominant negative effect in both mutations. The results of the characterization of these variants suggest that the pleiotropic role of TNSALP could be involved in the systemic effects observed in these patients highlighting digestive and autoimmune disorders associated with TNSALP dysfunction. Conclusions The two new mutations have been classified as pathogenic. At the clinical level, this study suggests that both mutations not only lead to pathognomonic symptoms of the disease, but may also play a role at the systemic level.
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Affiliation(s)
| | - Manuel Muñoz-Torres
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, Granada, Spain
- Department of Medicine, University of Granada, Granada, Spain
- Biomedical Research Network in Fragility and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
| | - Raquel Sanabria-de la Torre
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Department of Biochemistry, Molecular Biology III and Immunology, University of Granada, Granada, Spain
| | - Ángela Jiménez-Ortas
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Department of Biochemistry and Molecular Biology II, University of Granada, Granada, Spain
| | - Francisco Andújar-Vera
- Department of Computer Science and Artificial Intelligence, University of Granada, Granada, Spain
- Andalusian Research Institute in Data Science and Computational Intelligence (DaSCI Institute), Granada, Spain
- Bioinformatic Service, Instituto de Investigación Biosanitaria de Granada, Granada, Spain
| | - Trinidad González-Cejudo
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Clinical Analysis Unit, University Hospital Clínico San Cecilio, Granada, Spain
| | | | - Sheila González-Salvatierra
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, Granada, Spain
- Department of Medicine, University of Granada, Granada, Spain
| | | | - Cristina García-Fontana
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, Granada, Spain
- Biomedical Research Network in Fragility and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
| | - Beatriz García-Fontana
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, Granada, Spain
- Biomedical Research Network in Fragility and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
- Department of Cell Biology, University of Granada, Granada, Spain
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Rush E, Brandi ML, Khan A, Ali DS, Al-Alwani H, Almonaei K, Alsarraf F, Bacrot S, Dahir KM, Dandurand K, Deal C, Ferrari SL, Giusti F, Guyatt G, Hatcher E, Ing SW, Javaid MK, Khan S, Kocijan R, Lewiecki EM, Linglart A, M'Hiri I, Marini F, Nunes ME, Rockman-Greenberg C, Roux C, Seefried L, Starling SR, Ward L, Yao L, Brignardello-Petersen R, Simmons JH. Proposed diagnostic criteria for the diagnosis of hypophosphatasia in children and adolescents: results from the HPP International Working Group. Osteoporos Int 2024; 35:1-10. [PMID: 37982855 PMCID: PMC10786745 DOI: 10.1007/s00198-023-06843-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 06/23/2023] [Indexed: 11/21/2023]
Abstract
Hypophosphatasia (HPP) is a rare inborn error of metabolism that presents variably in both age of onset and severity. HPP is caused by pathogenic variants in the ALPL gene, resulting in low activity of tissue nonspecific alkaline phosphatase (TNSALP). Patients with HPP tend have a similar pattern of elevation of natural substrates that can be used to aid in diagnosis. No formal diagnostic guidelines currently exist for the diagnosis of this condition in children, adolescents, or adults. The International HPP Working Group is a comprised of a multidisciplinary team of experts from Europe and North America who have expertise in the diagnosis and management of patients with HPP. This group reviewed 93 papers through a Medline, Medline In-Process, and Embase search for the terms "HPP" and "hypophosphatasia" between 2005 and 2020 and that explicitly address either the diagnosis of HPP in children, clinical manifestations of HPP in children, or both. Two reviewers independently evaluated each full-text publication for eligibility and studies were included if they were narrative reviews or case series/reports that concerned diagnosis of pediatric HPP or included clinical aspects of patients diagnosed with HPP. This review focused on 15 initial clinical manifestations that were selected by a group of clinical experts.The highest agreement in included literature was for pathogenic or likely pathogenic ALPL variant, elevation of natural substrates, and early loss of primary teeth. The highest prevalence was similar, including these same three parameters and including decreased bone mineral density. Additional parameters had less agreement and were less prevalent. These were organized into three major and six minor criteria, with diagnosis of HPP being made when two major or one major and two minor criteria are present.
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Affiliation(s)
- Eric Rush
- Division of Clinical Genetics, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, USA.
- Department of Pediatrics, University of Missouri - Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, USA.
- Division of Endocrinology, Metabolism, Osteoporosis, and Genetics, Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, KS, USA.
| | - Maria Luisa Brandi
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy
- Donatello Bone Clinic, Villa Donatello Hospital, Florence, Italy
| | - Aliya Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Dalal S Ali
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Hatim Al-Alwani
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Khulod Almonaei
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Farah Alsarraf
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Severine Bacrot
- Department of Genetics, Centre Hospitalier de Versailles, Hôpital André Mignot, Versailles, France
| | - Kathryn M Dahir
- Division of Endocrinology and Metabolism, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karel Dandurand
- Department of Medicine, Endocrinology and Metabolism, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Chad Deal
- Center for Osteoporosis and Metabolic Bone Disease, Department of Rheumatology, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Serge Livio Ferrari
- Division of Bone Diseases, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Francesca Giusti
- Donatello Bone Clinic, Villa Donatello Hospital, Florence, Italy
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Erin Hatcher
- Neuromuscular Clinic, McMaster University Medical Centre, Hamilton Health Sciences, Hamilton, Canada
| | - Steven W Ing
- Division of Endocrinology, Diabetes, & Metabolism, Ohio State University Wexner Medical Center, Columbus, USA
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah Khan
- Bone Research and Education Centre, Oakville, ON, Canada
| | - Roland Kocijan
- 1st Medical Department, Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA, Trauma Centre Meidling, Hanusch Hospital, 1140, Vienna, Austria
| | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - Agnes Linglart
- APHP, Bicêtre Paris-Sud, University Paris Sud, Paris-Saclay, Le Kremlin Bicêtre, Paris, France
| | - Iman M'Hiri
- Bone Research and Education Centre, Oakville, ON, Canada
| | - Francesca Marini
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy
| | - Mark E Nunes
- Division of Medical Genetics and Metabolism, Valley Children's HealthCare, Madera, CA, USA
| | | | - Christian Roux
- Rheumatology Department, Hospital Pasteur 2 CHU, 06000, Nice, France
- Inserm, CNRS, iBV, Université Côte d'Azur, 06000, Nice, France
| | - Lothar Seefried
- Musculoskeletal Center Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - Susan R Starling
- Division of Clinical Genetics, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, USA
| | - Leanne Ward
- Children's Hospital of Eastern Ontario, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | | | - Jill H Simmons
- Division of Endocrinology and Metabolism, Vanderbilt University Medical Center, Nashville, TN, USA
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Farman MR, Rehder C, Malli T, Rockman-Greenberg C, Dahir K, Martos-Moreno GÁ, Linglart A, Ozono K, Seefried L, Del Angel G, Webersinke G, Barbazza F, John LK, Delana Mudiyanselage SMA, Högler F, Nading EB, Huggins E, Rush ET, El-Gazzar A, Kishnani PS, Högler W. The Global ALPL gene variant classification project: Dedicated to deciphering variants. Bone 2024; 178:116947. [PMID: 37898381 DOI: 10.1016/j.bone.2023.116947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 10/15/2023] [Accepted: 10/17/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND Hypophosphatasia (HPP) is an inherited multisystem disorder predominantly affecting the mineralization of bones and teeth. HPP is caused by pathogenic variants in ALPL, which encodes tissue non-specific alkaline phosphatase (TNSALP). Variants of uncertain significance (VUS) cause diagnostic delay and uncertainty amongst patients and health care providers. RESULTS The ALPL gene variant database (https://alplmutationdatabase.jku.at/) is an open-access archive for interpretation of the clinical significance of variants reported in ALPL. The database contains coding and non-coding variants, including single nucleotide variants, insertions/deletions and structural variants affecting coding or non-coding sequences of ALPL. Each variant in the database is displayed with details explaining the corresponding pathogenicity, and all reported genotypes and phenotypes, including references. In 2021, the ALPL gene variant classification project was established to reclassify VUS and continuously assess and update genetic, phenotypic, and functional variant information in the database. For this purpose, the database provides a unique submission system for clinicians, geneticists, genetic counselors, and researchers to submit VUS within ALPL for classification. An international, multidisciplinary consortium of HPP experts has been established to reclassify the submitted VUS using a multi-step process adhering to the stringent ACMG/AMP variant classification guidelines. These steps include a clinical phenotype assessment, deep literature research including artificial intelligence technology, molecular genetic assessment, and in-vitro functional testing of variants in a co-transfection model to measure ALP residual activity. CONCLUSION This classification project and the ALPL gene variant database will serve the global medical community, widen the genotypic and phenotypic HPP spectrum by reporting and characterizing new ALPL variants based on ACMG/AMP criteria and thus facilitate improved genetic counseling and medical decision-making for affected patients and families. The project may also serve as a gold standard framework for multidisciplinary collaboration for variant interpretation in other rare diseases.
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Affiliation(s)
- Mariam R Farman
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Catherine Rehder
- Duke University Medical Center, Department of Pathology, Durham, USA
| | - Theodora Malli
- Laboratory for Molecular Genetic Diagnostics, Ordensklinikum Linz, Linz, Austria
| | - Cheryl Rockman-Greenberg
- Department of Pediatrics and Child Health Max Rady College of Medicine, Rady Faculty of Health Sciences, Winnipeg, Canada
| | - Kathryn Dahir
- Vanderbilt University Medical Center, Program for Metabolic Bone Disorders, Nashville, TN, USA
| | - Gabriel Ángel Martos-Moreno
- Departments of Pediatrics & Pediatric Endocrinology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
- Department of Pediatrics, Universidad Autónoma de Madrid, Madrid, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición, ISCIII, Madrid, Spain
| | - Agnès Linglart
- AP-HP, Paris Saclay University, INSERM, Bicêtre Paris Saclay hospital, Le Kremlin-Bicêtre, France
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | | | - Gerald Webersinke
- Laboratory for Molecular Genetic Diagnostics, Ordensklinikum Linz, Linz, Austria
| | - Francesca Barbazza
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Lisa K John
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
| | | | - Florian Högler
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Erica Burner Nading
- Duke University Medical Center, Division of Medical Genetics, Department of Pediatrics, Durham, USA
| | - Erin Huggins
- Duke University Medical Center, Division of Medical Genetics, Department of Pediatrics, Durham, USA
| | - Eric T Rush
- Division of Clinical Genetics, Children's Mercy Hospital Kansas City, Kansas City, MO, USA
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
- Department of Pediatrics, University of Missouri – Kansas City School of Medicine, Kansas City, MO, USA
| | - Ahmed El-Gazzar
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Priya S Kishnani
- Duke University Medical Center, Division of Medical Genetics, Department of Pediatrics, Durham, USA
| | - Wolfgang Högler
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
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Pendleton EG, Nichenko AS, Mcfaline-Figueroa J, Raymond-Pope CJ, Schifino AG, Pigg TM, Barrow RP, Greising SM, Call JA, Mortensen LJ. Compromised Muscle Properties in a Severe Hypophosphatasia Murine Model. Int J Mol Sci 2023; 24:15905. [PMID: 37958888 PMCID: PMC10649932 DOI: 10.3390/ijms242115905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
Hypophosphatasia (HPP) is a rare metabolic bone disorder characterized by low levels of tissue non-specific alkaline phosphatase (TNAP) that causes under-mineralization of the bone, leading to bone deformity and fractures. In addition, patients often present with chronic muscle pain, reduced muscle strength, and an altered gait. In this work, we explored dynamic muscle function in a homozygous TNAP knockout mouse model of severe juvenile onset HPP. We found a reduction in skeletal muscle size and impairment in a range of isolated muscle contractile properties. Using histological methods, we found that the structure of HPP muscles was similar to healthy muscles in fiber size, actin and myosin structures, as well as the α-tubulin and mitochondria networks. However, HPP mice had significantly fewer embryonic and type I fibers than wild type mice, and fewer metabolically active NADH+ muscle fibers. We then used oxygen respirometry to evaluate mitochondrial function and found that complex I and complex II leak respiration were reduced in HPP mice, but that there was no disruption in efficiency of electron transport in complex I or complex II. In summary, the severe HPP mouse model recapitulates the muscle strength impairment phenotypes observed in human patients. Further exploration of the role of alkaline phosphatase in skeletal muscle could provide insight into mechanisms of muscle weakness in HPP.
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Affiliation(s)
- Emily G. Pendleton
- Regenerative Bioscience Center, Rhodes Center for ADS, University of Georgia, Athens, GA 30602, USA
| | - Anna S. Nichenko
- Regenerative Bioscience Center, Rhodes Center for ADS, University of Georgia, Athens, GA 30602, USA
- Department of Physiology & Pharmacology, University of Georgia, Athens, GA 30602, USA
| | - Jennifer Mcfaline-Figueroa
- Regenerative Bioscience Center, Rhodes Center for ADS, University of Georgia, Athens, GA 30602, USA
- Department of Physiology & Pharmacology, University of Georgia, Athens, GA 30602, USA
| | | | - Albino G. Schifino
- Regenerative Bioscience Center, Rhodes Center for ADS, University of Georgia, Athens, GA 30602, USA
- Department of Physiology & Pharmacology, University of Georgia, Athens, GA 30602, USA
| | - Taylor M. Pigg
- Regenerative Bioscience Center, Rhodes Center for ADS, University of Georgia, Athens, GA 30602, USA
| | - Ruth P. Barrow
- Regenerative Bioscience Center, Rhodes Center for ADS, University of Georgia, Athens, GA 30602, USA
| | - Sarah M. Greising
- School of Kinesiology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Jarrod A. Call
- Regenerative Bioscience Center, Rhodes Center for ADS, University of Georgia, Athens, GA 30602, USA
- Department of Physiology & Pharmacology, University of Georgia, Athens, GA 30602, USA
| | - Luke J. Mortensen
- Regenerative Bioscience Center, Rhodes Center for ADS, University of Georgia, Athens, GA 30602, USA
- Department of Physiology & Pharmacology, University of Georgia, Athens, GA 30602, USA
- School of Chemical, Materials and Biomedical Engineering, University of Georgia, Athens, GA 30602, USA
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11
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Fratzl-Zelman N, Linglart A, Bin K, Rauch F, Blouin S, Coutant R, Donzeau A. Combination of osteogenesis imperfecta and hypophosphatasia in three children with multiple fractures, low bone mass and severe osteomalacia, a challenge for therapeutic management. Eur J Med Genet 2023; 66:104856. [PMID: 37758163 DOI: 10.1016/j.ejmg.2023.104856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/05/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023]
Abstract
Osteogenesis imperfecta (OI) and hypophosphatasia (HPP) are rare skeletal disorders caused by mutations in the genes encoding collagen type I (COL1A, COL1A2) and tissue-non-specific isoenzyme of alkaline phosphatase (ALPL), respectively. Both conditions result in skeletal deformities and bone fragility although bone tissue abnormalities differ considerably. Children with OI have low bone mass and hypermineralized matrix, whereas HPP children develop rickets and osteomalacia. We report a family, father and three children, affected with growth retardation, low bone mass and recurrent fractures. None of them had rickets, blue sclera or dentinogenesis imperfecta. ALP serum levels were low and genetics revealed in the four probands heterozygous pathogenic mutations in COL1A2 c.838G > A (p.Gly280Ser) and in ALPL c.1333T > C (p.Ser445Pro). After multidisciplinary meeting, a diagnostic transiliac bone biopsy was indicated for each sibling for therapeutic decision. Bone histology and histomorphometry, as compared to reference values of children with OI type I as well as, to a control pediatric patient harboring the same COL1A2 mutation, revealed similarly decreased trabecular bone volume, increased osteocyte lacunae, but additionally severe osteomalacia. Quantitative backscattered electron imaging demonstrated that bone matrix mineralization was not as decreased as expected for osteomalacia. In summary, we observed within each biopsy samples classical features of OI and classical features of HPP. The apparent nearly normal bone mineralization density distribution results presumably from divergent effects of OI and HPP on matrix mineralization. A combination therapy was initiated with ALP enzyme-replacement and one month later with bisphosphonates. The ongoing treatment led to improved skeletal growth, increased BMD and markedly reduced fracture incidence.
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Affiliation(s)
- Nadja Fratzl-Zelman
- Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1st Med. Department Hanusch Hospital, Vienna, Austria; Vienna Bone and Growth Center, Vienna, Austria.
| | - Agnès Linglart
- AP-HP, Paris Saclay University, INSERM, Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, Platform of Expertise for Rare Diseases, OSCAR Filière, EndoERN and BOND ERN Center, Endocrinology and Diabetes for Children, Bicêtre Paris Saclay Hospital, France
| | - Kim Bin
- Pediatric Orthopedic Surgery Angers University Hospital, Angers, France
| | - Frank Rauch
- Shriners Hospital for Children, Canada, Montreal, QC, Canada
| | - Stéphane Blouin
- Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1st Med. Department Hanusch Hospital, Vienna, Austria; Vienna Bone and Growth Center, Vienna, Austria
| | - Régis Coutant
- AP-HP, Paris Saclay University, INSERM, Reference Center for Rare Diseases of the Calcium and Phosphate Metabolism, Platform of Expertise for Rare Diseases, OSCAR Filière, EndoERN and BOND ERN Center, Endocrinology and Diabetes for Children, Bicêtre Paris Saclay Hospital, France; Department of Pediatric Endocrinology and Diabetology, Competence Center for Rare Diseases of the Calcium and Phosphate Metabolism, Angers University Hospital, Angers, France
| | - Aurélie Donzeau
- Department of Pediatric Endocrinology and Diabetology, Competence Center for Rare Diseases of the Calcium and Phosphate Metabolism, Angers University Hospital, Angers, France
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Calmarza P, Lapresta C, Martínez García M, Ochoa J, Sienes Bailo P, Acha Pérez J, Beltrán Audera J, González-Roca E. Musculoskeletal pain and muscular weakness as the main symptoms of adult hypophosphatasia in a Spanish cohort: clinical characterization and identification of a new ALPL gene variant. J Bone Miner Metab 2023; 41:654-665. [PMID: 37351650 DOI: 10.1007/s00774-023-01440-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/15/2023] [Indexed: 06/24/2023]
Abstract
INTRODUCTION Hypophosphatasia (HPP) is a rare inherited disorder, caused by mutations in the alkaline phosphatase (ALPL) gene, which encodes for the tissue non-specific alkaline phosphatase (TNSALP) isoform of alkaline phosphatase (ALP). Adult HPP is one of the mild forms that presents with unspecific signs such as osteopenia, osteomalacia and muscle involvement. Our purpose was to identify and characterize possibly misdiagnosed adult HPP patients at a clinical and biochemical level. MATERIAL AND METHODS At the laboratory of Miguel Servet University Hospital we retrospectively reviewed serum ALP levels in adults over a 48-month period. The clinical records of individuals with consistently low ALP levels were reviewed to exclude secondary causes. Those with persistent hypophosphatasemia were screened for symptoms of HPP. The study participants were evaluated at biochemical and genetic levels. RESULTS We identified 705 ALP determinations (out of 384,000 processed) in 589 patients below the reference range (30 U/l). Only 21 patients with clinical signs and symptoms of HPP were selected for genetic testing. Finally, only 12 patients participated in the study, 83.3% of whom (10/12) harbored a pathogenic or likely pathogenic variant in a heterozygous state. The major symptoms of our cohort were the presence of musculoskeletal pain (100% of patients) and muscular weakness (83.3% patients). CONCLUSION Mild HPP patients presenting with diffuse symptoms such as musculoskeletal pain may be undiagnosed or misdiagnosed as osteoporosis patients by routine diagnosis. It is important to identify these individuals, to avoid inappropriate treatment with antiresorptive drugs.
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Affiliation(s)
- Pilar Calmarza
- Clinical Biochemistry Department, IIS Aragón, Miguel Servet University Hospital, Network Research Center in Cardiovascular Diseases (CIBERCV), University of Zaragoza, 50009, Zaragoza, Spain.
| | - Carlos Lapresta
- Preventive Medicine Department, Miguel Servet University Hospital, 50009, Zaragoza, Spain
| | | | - José Ochoa
- Occupational Risk Prevention Service, MAS Prevention, Zaragoza, Spain
| | - Paula Sienes Bailo
- Clinical Biochemistry Department, Miguel Servet University Hospital, 50009, Zaragoza, Spain
| | - Javier Acha Pérez
- Endocrinology Department, Miguel Servet University Hospital, 50009, Zaragoza, Spain
| | - Jesús Beltrán Audera
- Rheumatology department, Miguel Servet University Hospital, 50009, Zaragoza, Spain
| | - Eva González-Roca
- Molecular Biology Core Lab/Immunology Department, CDB. Hospital Clínic, Barcelona, Spain
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13
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Cinque L, Pugliese F, Salcuni AS, Trombetta D, Battista C, Biagini T, Augello B, Nardella G, Conti F, Corbetta S, Fischetto R, Foiadelli T, Gaudio A, Giannini C, Grosso E, Guabello G, Massuras S, Palermo A, Politano L, Pigliaru F, Ruggeri RM, Scarano E, Vicchio P, Cannavò S, Celli M, Petrizzelli F, Mastroianno M, Castori M, Scillitani A, Guarnieri V. Clinical and molecular description of the first Italian cohort of 33 subjects with hypophosphatasia. Front Endocrinol (Lausanne) 2023; 14:1205977. [PMID: 37600704 PMCID: PMC10433156 DOI: 10.3389/fendo.2023.1205977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/21/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction Hypophosphatasia (HPP) is a rare genetic disease caused by inactivating variants of the ALPL gene. Few data are available on the clinical presentation in Italy and/or on Italian HPP surveys. Methods There were 30 suspected HPP patients recruited from different Italian tertiary cares. Biological samples and related clinical, biochemical, and anamnestic data were collected and the ALPL gene sequenced. Search for large genomic deletions at the ALPL locus (1p36) was done. Phylogenetic conservation and modeling were applied to infer the effect of the variants on the protein structure. Results There were 21 ALPL variants and one large genomic deletion found in 20 out of 30 patients. Unexpectedly, NGS-driven differential diagnosis allowed uncovering three hidden additional HPP cases, for a total of 33 HPP subjects. Eight out of 24 coding variants were novel and classified as "pathogenic", "likely pathogenic", and "variants of uncertain significance". Bioinformatic analysis confirmed that all the variants strongly destabilize the homodimer structure. There were 10 cases with low ALP and high VitB6 that resulted negative to genetic testing, whereas two positive cases have an unexpected normal ALP value. No association was evident with other biochemical/clinical parameters. Discussion We present the survey of HPP Italian patients with the highest ALPL mutation rate so far reported and confirm the complexity of a prompt recognition of the syndrome, mostly for HPP in adults. Low ALP and high VitB6 values are mandatory for the genetic screening, this latter remaining the gold standard not only to confirm the clinical diagnosis but also to make differential diagnosis, to identify carriers, to avoid likely dangerous therapy in unrecognized cases.
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Affiliation(s)
- Luigia Cinque
- Department of Pediatrics, “G D’Annunzioof Pediatrics, ” University of Chieti-Pescara, Foggia, Italy
| | - Flavia Pugliese
- Unit of Endocrinology, Fondazione Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Casa Sollievo della Sofferenza, Foggia, Italy
| | - Antonio Stefano Salcuni
- Endocrinology and Metabolism Unit, University-Hospital S. Maria della Misericordia, Udine, Italy
| | - Domenico Trombetta
- Laboratory of Oncology, Fondazione Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Casa Sollievo della Sofferenza, Foggia, Italy
| | - Claudia Battista
- Unit of Endocrinology, Fondazione Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Casa Sollievo della Sofferenza, Foggia, Italy
| | - Tommaso Biagini
- Laboratory of Bioinformatics, Fondazione Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Bartolomeo Augello
- Department of Pediatrics, “G D’Annunzioof Pediatrics, ” University of Chieti-Pescara, Foggia, Italy
| | - Grazia Nardella
- Department of Pediatrics, “G D’Annunzioof Pediatrics, ” University of Chieti-Pescara, Foggia, Italy
| | - Francesco Conti
- Department of Clinical and Molecular Medicine, La Sapienza University, Rome, Italy
| | - Sabrina Corbetta
- Endocrinology and Diabetology Service, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Istituto Ortopedico Galeazzi, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Rita Fischetto
- Clinical Genetics Unit, Department of Pediatric Medicine, Giovanni XXIII Children’s Hospital, Bari, Italy
| | - Thomas Foiadelli
- Pediatric Clinic, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo Foundation-University of Pavia, Pavia, Italy
| | - Agostino Gaudio
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Cosimo Giannini
- Department of Pediatrics, “G D’Annunzio” University of Chieti-Pescara, Chieti, Italy
| | - Enrico Grosso
- Medical Genetics, Città della Salute e della Scienza University Hospital, Torino, Italy
| | - Gregorio Guabello
- Reumatology Unit, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Istituto Ortopedico Galeazzi, Milan, Italy
| | - Stefania Massuras
- Medical Genetics, Città della Salute e della Scienza University Hospital, Torino, Italy
| | - Andrea Palermo
- Unit of Endocrinology and Diabetes, Departmental Faculty of Medicine and Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Luisa Politano
- Cardiomiology and Medical Genetics, University Hospital of Campania Luigi Vanvitelli, Naples, Italy
| | - Francesca Pigliaru
- Endocrine Unit, Azienda Ospedaliera-Universitaria of Cagliari, Cagliari, Italy
| | - Rosaria Maddalena Ruggeri
- Unit of Endocrinology, Department of Human Pathology DETEV “G. Barresi”, University of Messina, Messina, Italy
| | - Emanuela Scarano
- Rare Diseases Unit, Department of Pediatrics, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria S. Orsola, Bologna, Bologna, Italy
| | - Piera Vicchio
- Department of Pediatrics, Jazzolino Hospital, Vibo Valentia, Italy
| | - Salvatore Cannavò
- Unit of Endocrinology, Department of Human Pathology DETEV “G. Barresi”, University of Messina, Messina, Italy
| | - Mauro Celli
- Rare Bone Metabolism Center, Azienda Ospedaliera Universitaria (AOU) Policlinico Umberto I, Roma, Italy
| | - Francesco Petrizzelli
- Laboratory of Bioinformatics, Fondazione Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Mario Mastroianno
- Scientific Direction, Fondazione Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Casa Sollievo della Sofferenza, Foggia, Italy
| | - Marco Castori
- Department of Pediatrics, “G D’Annunzioof Pediatrics, ” University of Chieti-Pescara, Foggia, Italy
| | - Alfredo Scillitani
- Unit of Endocrinology, Fondazione Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Casa Sollievo della Sofferenza, Foggia, Italy
| | - Vito Guarnieri
- Department of Pediatrics, “G D’Annunzioof Pediatrics, ” University of Chieti-Pescara, Foggia, Italy
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Yu Y, Rong K, Yao D, Zhang Q, Cao X, Rao B, Xia Y, Lu Y, Shen Y, Yao Y, Xu H, Ma P, Cao Y, Qin A. The structural pathology for hypophosphatasia caused by malfunctional tissue non-specific alkaline phosphatase. Nat Commun 2023; 14:4048. [PMID: 37422472 PMCID: PMC10329691 DOI: 10.1038/s41467-023-39833-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 06/30/2023] [Indexed: 07/10/2023] Open
Abstract
Hypophosphatasia (HPP) is a metabolic bone disease that manifests as developmental abnormalities in bone and dental tissues. HPP patients exhibit hypo-mineralization and osteopenia due to the deficiency or malfunction of tissue non-specific alkaline phosphatase (TNAP), which catalyzes the hydrolysis of phosphate-containing molecules outside the cells, promoting the deposition of hydroxyapatite in the extracellular matrix. Despite the identification of hundreds of pathogenic TNAP mutations, the detailed molecular pathology of HPP remains unclear. Here, to address this issue, we determine the crystal structures of human TNAP at near-atomic resolution and map the major pathogenic mutations onto the structure. Our study reveals an unexpected octameric architecture for TNAP, which is generated by the tetramerization of dimeric TNAPs, potentially stabilizing the TNAPs in the extracellular environments. Moreover, we use cryo-electron microscopy to demonstrate that the TNAP agonist antibody (JTALP001) forms a stable complex with TNAP by binding to the octameric interface. The administration of JTALP001 enhances osteoblast mineralization and promoted recombinant TNAP-rescued mineralization in TNAP knockout osteoblasts. Our findings elucidate the structural pathology of HPP and highlight the therapeutic potential of the TNAP agonist antibody for osteoblast-associated bone disorders.
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Affiliation(s)
- Yating Yu
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedics Implant, the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
- Institute of Precision Medicine, the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Shanghai, 200125, China
| | - Kewei Rong
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedics Implant, the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Deqiang Yao
- State Key Laboratory of Oncogenes and Related Genes, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Qing Zhang
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedics Implant, the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
- Institute of Precision Medicine, the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Shanghai, 200125, China
| | - Xiankun Cao
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedics Implant, the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Bing Rao
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedics Implant, the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
- Institute of Precision Medicine, the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Shanghai, 200125, China
| | - Ying Xia
- Institute of Precision Medicine, the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Shanghai, 200125, China
| | - Yi Lu
- Institute of Precision Medicine, the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Shanghai, 200125, China
| | - Yafeng Shen
- Institute of Precision Medicine, the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Shanghai, 200125, China
| | - Ying Yao
- Shanghai Institute for Advanced Immunochemical Studies, ShanghaiTech University, Shanghai, 201210, China
| | - Hongtao Xu
- Shanghai Institute for Advanced Immunochemical Studies, ShanghaiTech University, Shanghai, 201210, China
| | - Peixiang Ma
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedics Implant, the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China.
| | - Yu Cao
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedics Implant, the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China.
- Institute of Precision Medicine, the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Shanghai, 200125, China.
| | - An Qin
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedics Implant, the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China.
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15
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Riancho JA. Diagnostic Approach to Patients with Low Serum Alkaline Phosphatase. Calcif Tissue Int 2023; 112:289-296. [PMID: 36348061 DOI: 10.1007/s00223-022-01039-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Increased serum levels of alkaline phosphatase (ALP) are widely recognized as a biochemical marker of many disorders affecting the liver or bone. However, the approach for patients with low ALP phosphatase is not well-established. Low serum ALP is an epiphenomenon of many severe acute injuries and diseases. Persistently low serum ALP may be secondary to drug therapy (including antiresorptives) or a variety of acquired disorders, such as malnutrition, vitamin and mineral deficiencies, endocrine disorders, etc. Hypophosphatasia, due to pathogenic variants of the ALPL gene, which encodes tissue non-specific ALP, is the most common genetic cause of low serum ALP. Marked bone hypomineralization is frequent in severe pediatric-onset cases. However, adult forms of hypophosphatasia usually present with milder manifestations, such as skeletal pain, chondrocalcinosis, calcific periarthritis, dental problems, and stress fractures. The diagnostic approach to these patients is discussed. Measuring several ALP substrates, such as pyrophosphate, pyridoxal phosphate, or phosphoethanolamine, may help to establish enzyme deficiency. Gene analysis showing a pathogenic variant in ALPL may confirm the diagnosis. However, a substantial proportion of patients show normal results after sequencing ALPL exons. It is still unknown if those patients carry unidentified mutations in regulatory regions of ALPL, epigenetic changes, or abnormalities in other genes.
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Affiliation(s)
- Jose A Riancho
- Departamento de Medicina y Psiquiatría, Universidad de Cantabria, Servicio de Medicina Interna, Hospital UM Valdecilla-IDIVAL, Av Valdecilla sn, 39008, Santander, Spain.
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Kim I, Noh ES, Kim MS, Jang JH, Jeon TY, Choi HW, Cho SY. Six-year clinical outcomes of enzyme replacement therapy for perinatal lethal and infantile hypophosphatasia in Korea: Two case reports. Medicine (Baltimore) 2023; 102:e32800. [PMID: 36820543 PMCID: PMC9907957 DOI: 10.1097/md.0000000000032800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
INTRODUCTION Hypophosphatasia (HPP) is a genetic disease caused by loss-of-function mutations in ALPL, which encodes tissue-nonspecific alkaline phosphatase (ALP). Early diagnosis and treatment of perinatal and infantile HPP are important because of their high mortality rates. Enzyme replacement therapy (ERT) using human recombinant tissue-nonspecific ALP asfotase alfa was introduced in Korea in 2016. We report the first experience of ERT over 6 years for perinatal lethal and infantile HPP in Korea. PATIENT CONCERNS The first patient was a 6-week-old Korean boy with a failure to thrive. The second patient was an 8-day-old Korean-Uzbek body with generalized tonic-clonic seizure with cyanosis. DIAGNOSES HPP was suspected in both patients because of the very low level of ALP activity and rachitic findings on radiographs, and the disease was confirmed by Sanger sequencing of the ALPL gene. INTERVENTION The first patient with infantile HPP started ERT at 21 months of age and the second patient with perinatal HPP started ERT at 30 days of age. Both patients received asfotase alfa (2 mg/kg 3 times per week subcutaneously, adjusted to 3 mg/kg 3 times per week if required) for 6 years. OUTCOMES After 6 years of ERT, radiographic findings and growth standard deviation scores improved in both patients. The second patient showed no evidence of rickets after 3 years of ERT. Mechanical respiratory support and supplemental oxygen were not required after 4.5 years of treatment in the first patient and at 2 months after treatment in the second patient. CONCLUSION Among the 2 patients, the patient who started ERT early had a much better prognosis despite a more severe initial clinical presentation. Our results suggest that early diagnosis and prompt treatment play an important role in improving long-term prognosis and avoiding morbidity and premature mortality in patients with perinatal and infantile HPP.
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Affiliation(s)
- Insung Kim
- Department of Public Health Administration, Asan City Health Center, Asan, Korea
| | - Eu-Seon Noh
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min-Sun Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ja-Hyun Jang
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Yeon Jeon
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hae Won Choi
- Department of Orthodontics, The Institute of Oral Health Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Yoon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- * Correspondence: Sung Yoon Cho, Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea (e-mail: )
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Sadhukhan S, Mehta P, Rajender S, Gupta SK, Chattopadhyay N. Proposing a clinical algorithm for better diagnosis of hypophosphatasia in resource-limiting situations. Osteoporos Int 2022; 33:2479-2493. [PMID: 35776147 DOI: 10.1007/s00198-022-06480-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 06/16/2022] [Indexed: 10/17/2022]
Abstract
Early diagnosis of hypophosphatasia (HPP) is challenging. Here, we propose to broaden the diagnostic criteria of HPP by reviewing published data on BMD and fractures in HPP patients. Non-osteoporotic fractures and higher than normal lumbar BMD were recurrent in HPP patients and could be included as diagnostic criteria. HPP is a genetic disorder caused by autosomal recessive or dominant loss-of-function mutations in the ALPL gene that encodes for tissue-nonspecific alkaline phosphatase (TNSALP). Expressive genetic heterogeneity and varying severity of TNSALP deficiency lead to a wide-ranging presentation of skeletal diseases at different ages that coupled with HPP's rarity and limitation of biochemical and mutational studies present serious hurdles to early diagnosis and management of HPP. To widen the scope of HPP diagnosis, we assessed the possibility of areal bone mineral density (BMD) as an additional clinical feature of this disease. PubMed, Web of Science, and ScienceDirect were searched with the following keywords: ("Hypophosphatasia OR HPP") AND ("Bone Mineral Density OR BMD") AND "Human". Studies and case reports of subjects with age ≥ 18 years and having BMD data were included. We pooled data from 25 publications comprising 356 subjects (90 males, 266 females). Only four studies had a control group. Biochemical hallmarks, pyridoxal 5'-phosphate (PLP) and phosphoethanolamine (PEA), were reported in fifteen and six studies, respectively. Twenty studies reported genetic data, nineteen studies reported non-vertebral fractures, all studies reported lumbar spine (LS) BMD, and nineteen reported non-vertebral BMD. Higher than normal and normal BMD at LS were reported in three and two studies, respectively. There was marked heterogeneity in BMD at the non-vertebral sites. Higher than normal or normal LS BMD in an adult with minimal or insufficient fractures, pseudofractures, non-healing fractures, fragility fractures, and stress fractures may be included in the diagnostic protocol of HPP. However, genetic testing is recommended for a definitive diagnosis.
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Affiliation(s)
- Sreyanko Sadhukhan
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Lucknow, India
- Academy of Scientific and Innovative Research, Ghaziabad, 201002, India
| | - Poonam Mehta
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Lucknow, India
- Academy of Scientific and Innovative Research, Ghaziabad, 201002, India
| | - Singh Rajender
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Lucknow, India
- Academy of Scientific and Innovative Research, Ghaziabad, 201002, India
| | - Sushil Kumar Gupta
- Department of Endocrinology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, India
| | - Naibedya Chattopadhyay
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Lucknow, India.
- Academy of Scientific and Innovative Research, Ghaziabad, 201002, India.
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Hepp N, Frederiksen AL, Duno M, Jørgensen NR, Jensen JEB. Biochemical and clinical manifestations in adults with hypophosphatasia: a national cross-sectional study. Osteoporos Int 2022; 33:2595-2605. [PMID: 35986118 DOI: 10.1007/s00198-022-06536-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 08/15/2022] [Indexed: 11/24/2022]
Abstract
UNLABELLED Hypophosphatasia (HPP) is a rare disease affecting bone mineralization. Adults with HPP have an increased occurrence of low-energy fractures, which cannot be explained by reduced bone mass assessed by dual energy X-ray absorptiometry. The bone phenotype in adults with HPP requires further studies investigating bone strength and bone structural parameters. INTRODUCTION Hypophosphatasia (HPP) is a rare inherited disorder of bone and mineral metabolism, characterized by broad-ranging clinical manifestations and severity. However, studies investigating the clinical spectrum in adults with HPP compared to a control group are scarce. The aim of this study was to evaluate biochemical and clinical characteristics as well as bone health in a Danish cohort of adults with HPP. METHODS We conducted a cross-sectional study assessing biochemical parameters, fracture prevalence, bone mineral density (BMD), bone turnover markers, physical performance and pain characteristics in 40 adults with HPP and 40 sex-, age-, BMI- and menopausal status-matched healthy controls. RESULTS Patients with HPP had a significantly higher prevalence of non-vertebral, low-energy fractures (p = < 0.001). BMD at the lumbar spine, total hip, femoral neck, forearm and whole body did not differ between the groups. Low levels of the bone-specific alkaline phosphatase correlated significantly with higher BMD at the lumbar spine and femoral neck in both groups. The bone formation marker N-terminal propeptide of type 1 procollagen was significantly lower in patients with HPP than healthy controls (p = 0.006). Adults with HPP had significantly reduced walking capability (p = < 0.001) and lower body strength (p = < 0.001). Chronic pain was significantly more prevalent in adults with HPP than the control group (p = 0.029). CONCLUSIONS The increased occurrence of low-energy fractures in adults with HPP is not explained by low BMD. Adults with HPP have reduced physical performance when compared with healthy controls.
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Affiliation(s)
- Nicola Hepp
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark.
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200, Copenhagen, Denmark.
| | - Anja Lisbeth Frederiksen
- Department of Clinical Genetics, Aalborg University Hospital, Ladegaardsgade 5, 9000, Aalborg C, Denmark
- Department of Clinical Research, Aalborg University, Fredrik Bajers Vej 7K, 9220, Aalborg Ø, Denmark
| | - Morten Duno
- Department of Clinical Genetics, University Hospital Copenhagen Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Niklas Rye Jørgensen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200, Copenhagen, Denmark
- Department of Clinical Biochemistry, Rigshospitalet, Valdemar Hansens Vej 13, 2600, Glostrup, Denmark
| | - Jens-Erik Beck Jensen
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200, Copenhagen, Denmark
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Koh AJ, Nam HK, Michalski MN, Do J, McCauley LK, Hatch NE. Anabolic actions of parathyroid hormone in a hypophosphatasia mouse model. Osteoporos Int 2022; 33:2423-2433. [PMID: 35871207 PMCID: PMC9568459 DOI: 10.1007/s00198-022-06496-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 07/07/2022] [Indexed: 11/17/2022]
Abstract
UNLABELLED Hypophosphatasia, the rare heritable disorder caused by TNAP enzyme mutations, presents wide-ranging severity of bone hypomineralization and skeletal abnormalities. Intermittent PTH (1-34) increased long bone volume in Alpl-/- mice but did not alter the skull phenotype. PTH may have therapeutic value for adults with TNAP deficiency-associated osteoporosis. INTRODUCTION Hypophosphatasia is the rare heritable disorder caused by mutations in the tissue non-specific alkaline phosphatase (TNAP) enzyme leading to TNAP deficiency. Individuals with hypophosphatasia commonly present with bone hypomineralization and skeletal abnormalities. The purpose of this study was to determine the impact of intermittent PTH on the skeletal phenotype of TNAP-deficient Alpl-/- mice. METHODS Alpl-/- and Alpl+/+ (wild-type; WT) littermate mice were administered PTH (1-34) (50 µg/kg) or vehicle control from days 4 to 12 and skeletal analyses were performed including gross measurements, micro-CT, histomorphometry, and serum biochemistry. RESULTS Alpl-/- mice were smaller with shorter tibial length and skull length compared to WT mice. Tibial BV/TV was reduced in Alpl-/- mice and daily PTH (1-34) injections significantly increased BV/TV and BMD but not TMD in both WT and Alpl-/- tibiae. Trabecular spacing was not different between genotypes and was decreased by PTH in both genotypes. Serum P1NP was unchanged while TRAcP5b was significantly lower in Alpl-/- vs. WT mice, with no PTH effect, and no differences in osteoclast numbers. Skull height and width were increased in Alpl-/- vs. WT mice, and PTH increased skull width in WT but not Alpl-/- mice. Frontal skull bones in Alpl-/- mice had decreased BV/TV, BMD, and calvarial thickness vs. WT with no significant PTH effects. Lengths of cranial base bones (basioccipital, basisphenoid, presphenoid) and lengths of synchondroses (growth plates) between the cranial base bones, plus bone of the basioccipitus, were assessed. All parameters were reduced (except lengths of synchondroses, which were increased) in Alpl-/- vs. WT mice with no PTH effect. CONCLUSION PTH increased long bone volume in the Alpl-/- mice but did not alter the skull phenotype. These data suggest that PTH can have long bone anabolic activity in the absence of TNAP, and that PTH may have therapeutic value for individuals with hypophosphatasia-associated osteoporosis.
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Affiliation(s)
- Amy J Koh
- Department of Periodontology and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, MI, USA
| | - Hwa Kyung Nam
- Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor, MI, USA
| | - Megan N Michalski
- Department of Cell Biology, Van Andel Institute, Grand Rapids, MI, USA
| | - Justin Do
- Department of Periodontology and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, MI, USA
| | - Laurie K McCauley
- Department of Periodontology and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, MI, USA.
- Department of Pathology, School of Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Nan E Hatch
- Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor, MI, USA.
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20
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Glotov OS, Savostyanov KV, Nagornova TS, Chernov AN, Fedyakov MA, Raspopova AN, Krasnoukhov KN, Danilov LG, Moiseeva NV, Kalinin RS, Tsai VV, Eismont YA, Voinova VY, Vitebskaya AV, Gurkina EY, Kuzenkova LM, Sosnina IB, Pushkov AA, Zhanin IS, Zakharova EY. Clinical and Genetic Characteristics of Pediatric Patients with Hypophosphatasia in the Russian Population. Int J Mol Sci 2022; 23:ijms232112976. [PMID: 36361766 PMCID: PMC9654387 DOI: 10.3390/ijms232112976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Hypophosphatasia (HPP) is a rare inherited disease caused by mutations (pathogenic variants) in the ALPL gene which encodes tissue-nonspecific alkaline phosphatase (TNSALP). HPP is characterized by impaired bone mineral metabolism due to the low enzymatic activity of TNSALP. Knowledge about the structure of the gene and the features and functions of various ALPL gene variants, taking into account population specificity, gives an understanding of the hereditary nature of the disease, and contributes to the diagnosis, prevention, and treatment of the disease. The purpose of the study was to describe the spectrum and analyze the functional features of the ALPL gene variants, considering various HPP subtypes and clinical symptoms in Russian children. (2) From 2014−2021, the study included the blood samples obtained from 1612 patients with reduced alkaline phosphatase activity. The patients underwent an examination with an assessment of their clinical symptoms and biochemical levels of TNSALP. DNA was isolated from dried blood spots (DBSs) or blood from the patients to search for mutations in the exons of the ALPL gene using Sanger sequencing. The PCR products were sequenced using a reagent BigDye Terminator 3.1 kit (Applied Biosystems). Statistical analysis was performed using the GraphPad Prism 8.01 software. (3) The most common clinical symptoms in Russian patients with HPP and two of its variants (n = 22) were bone disorders (75%), hypomyotonia (50%), and respiratory failure (50%). The heterozygous carriage of the causal variants of the ALPL gene was detected in 225 patients. A total of 2 variants were found in 27 patients. In this group (n = 27), we identified 28 unique variants of the ALPL gene, of which 75.0% were missense, 17.9% were frameshift, 3.6% were splicing variants, and 3.6% were duplications. A total of 39.3% (11/28) of the variants were pathogenic, with two variants being probably pathogenic, and 15 variants had unknown clinical significance (VUS). Among the VUS group, 28.6% of the variants (7/28) were discovered by us for the first time. The most common variants were c.571G > A (p.Glu191Lys) and c.1171del (Arg391Valfs*12), with frequencies of 48.2% (13/28) and 11% (3/28), respectively. It was found that the frequency of nonsense variants of the ALPL gene was higher (p < 0.0001) in patients with the perinatal form compared to the infantile and childhood forms of HPP. Additionally, the number of homozygotes in patients with the perinatal form exceeded (p < 0.01) the frequencies of these genotypes in children with infantile and childhood forms of HPP. On the contrary, the frequencies of the compound-heterozygous and heterozygous genotypes were higher (p < 0.01) in patients with infantile childhood HPP than in perinatal HPP. In the perinatal form, residual TNSALP activity was lower (p < 0.0005) in comparison to the infantile and childhood (p < 0.05) forms of HPP. At the same time, patients with the heterozygous and compound-heterozygous genotypes (mainly missense variants) of the ALPL gene had greater residual activity (of the TNSALP protein) regarding those homozygous patients who were carriers of the nonsense variants (deletions and duplications) of the ALPL gene. Residual TNSALP activity was lower (p < 0.0001) in patients with pathogenic variants encoding the amino acids from the active site and the calcium and crown domains in comparison with the nonspecific region of the protein.
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Affiliation(s)
- Oleg S. Glotov
- Department of Genomic Medicine, D. O. Ott Research Institute of Obstetrics, Gynaecology and Reproductology, 199034 Saint-Petersburg, Russia
- Department of Experimental Medical Virology, Molecular Genetics and Biobanking of Pediatric Research and Clinical Center for Infectious Diseases, 197022 Saint-Petersburg, Russia
- Correspondence: (O.S.G.); (A.N.C.)
| | | | | | - Alexandr N. Chernov
- Department of Genomic Medicine, D. O. Ott Research Institute of Obstetrics, Gynaecology and Reproductology, 199034 Saint-Petersburg, Russia
- Bioenergetics Department of Life Sciences, The National Institute for Biotechnology in the Negev, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel
- Department of General Pathology and Pathological Physiology, Institute of Experimental Medicine, 197376 Saint-Petersburg, Russia
- Correspondence: (O.S.G.); (A.N.C.)
| | - Mikhail A. Fedyakov
- CerbaLab Ltd., 199106 Saint-Petersburg, Russia
- City Hospital No. 40, St.-Petersburg, 9 Borisova Str., Sestrorezk, 197706 Saint-Petersburg, Russia
| | | | | | - Lavrentii G. Danilov
- CerbaLab Ltd., 199106 Saint-Petersburg, Russia
- Department of Genetics and Biotechnology, Saint-Petersburg State University, 199034 Saint-Petersburg, Russia
| | | | - Roman S. Kalinin
- Department of Genomic Medicine, D. O. Ott Research Institute of Obstetrics, Gynaecology and Reproductology, 199034 Saint-Petersburg, Russia
- Department of Experimental Medical Virology, Molecular Genetics and Biobanking of Pediatric Research and Clinical Center for Infectious Diseases, 197022 Saint-Petersburg, Russia
| | - Victoria V. Tsai
- Department of Genomic Medicine, D. O. Ott Research Institute of Obstetrics, Gynaecology and Reproductology, 199034 Saint-Petersburg, Russia
- Department of Experimental Medical Virology, Molecular Genetics and Biobanking of Pediatric Research and Clinical Center for Infectious Diseases, 197022 Saint-Petersburg, Russia
- CerbaLab Ltd., 199106 Saint-Petersburg, Russia
| | - Yuri A. Eismont
- Department of Experimental Medical Virology, Molecular Genetics and Biobanking of Pediatric Research and Clinical Center for Infectious Diseases, 197022 Saint-Petersburg, Russia
- CerbaLab Ltd., 199106 Saint-Petersburg, Russia
| | - Victoria Y. Voinova
- Veltischev Research and Clinical Institute for Pediatrics, Pirogov Russian National Research Medical University, 117997 Moscow, Russia
| | - Alisa V. Vitebskaya
- Department of Children’s Diseases of N.F. Filatov Clinical Institute for Children’s Health, I.M. Sechenov First Moscow State Medical University, 119991 Moscow, Russia
| | - Elena Y. Gurkina
- Children’s Rehabilitation Clinic Almazov National Medical Research Centre, 197341 Saint-Petersburg, Russia
| | - Ludmila M. Kuzenkova
- National Medical Research Center of Children Health, 119991 Moscow, Russia
- Department of Children’s Diseases of N.F. Filatov Clinical Institute for Children’s Health, I.M. Sechenov First Moscow State Medical University, 119991 Moscow, Russia
| | - Irina B. Sosnina
- Saint-Petersburg State Budgetary Healthcare Institution “Consulting and Diagnostic Center for Children”, 192289 Saint-Petersburg, Russia
| | | | - Ilya S. Zhanin
- National Medical Research Center of Children Health, 119991 Moscow, Russia
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Hepp N, Folkestad L, Møllebæk S, Frederiksen AL, Duno M, Jørgensen NR, Hermann AP, Jensen JEB. Bone-microarchitecture and bone-strength in a sample of adults with hypophosphatasia and a matched reference population assessed by HR-pQCT and impact microindentation. Bone 2022; 160:116420. [PMID: 35421614 DOI: 10.1016/j.bone.2022.116420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/03/2022] [Accepted: 04/07/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Hypophosphatasia (HPP) is an autosomal recessive or dominate disease affecting bone mineralization, and adults with HPP are in risk to develop metatarsal stress fractures and femoral pseudofractures. Given to the scarce data on the bone quality and its association to the fracture risk in adults with HPP, this study aimed to evaluate bone turnover, bone strength and structure in adults with HPP. METHODS In this cross-sectional study, we included 14 adults with genetically verified HPP and 14 sex-, age-, BMI-, and menopausal status-matched reference individuals. We analyzed bone turnover markers, and measured bone material strength index (BMSi) by impact microindentation. Bone geometry, volumetric density and bone microarchitecture as well as failure load at the distal radius and tibia were evaluated using a second-generation high-resolution peripheral quantitative computed tomography system. RESULTS Bone turnover markers did not differ between patients with HPP and reference individuals. BMSi did not differ between the groups (67.90 [63.75-76.00] vs 65.45 [58.43-69.55], p = 0.149). Parameters of bone geometry and volumetric density did not differ between adults with HPP and the reference group. Patients with HPP had a tendency toward higher trabecular separation (0.664 [0.613-0.724] mm vs 0.620 [0.578-0.659] mm, p = 0.054) and inhomogeneity of trabecular network (0.253 [0.235-0.283] mm vs 0.229 [0.208-0.252] mm, p = 0.056) as well as lower trabecular bone volume fraction (18.8 [16.4-22.7] % vs 22.8 [20.6-24.7] %, p = 0.054) at the distal radius. In addition, compound heterozygous adults with HPP had a significantly higher cortical porosity at the distal radius than reference individuals (1.5 [0.9-2.2] % vs 0.7 [0.6-0.7] %, p = 0.041). CONCLUSIONS BMSi is not reduced in adults with HPP. Increased cortical porosity may contribute to the occurrence of femoral pseudofractures in compound heterozygous adults with HPP. However, further studies investigating larger cohorts of adults with HPP using methods of bone histomorphometry are recommended to adequately assess the bone quality in adults with HPP.
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Affiliation(s)
- Nicola Hepp
- Dept. of Endocrinology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark; Dept. of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200 Copenhagen, Denmark.
| | - Lars Folkestad
- Dept. of Endocrinology and Metabolism, Odense University Hospital, Kløvervænget 6, 5000 Odense C, Denmark; Dept. of Clinical Research, University of Southern Denmark, Winsløwparken 19, 5000 Odense C, Denmark
| | - Simone Møllebæk
- Dept. of Endocrinology and Metabolism, Odense University Hospital, Kløvervænget 6, 5000 Odense C, Denmark
| | - Anja Lisbeth Frederiksen
- Dept. of Clinical Genetics, Aalborg University Hospital, Ladegaardsgade 5, 9000 Aalborg C, Denmark; Dept. of Clinical Research, Aalborg University, Fredrik Bajers Vej 7K, 9220 Aalborg Ø, Denmark
| | - Morten Duno
- Dept. of Clinical Genetics, University Hospital Copenhagen Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Niklas Rye Jørgensen
- Dept. of Clinical Biochemistry, Rigshospitalet, Valdemar Hansens Vej 13, 2600 Glostrup, Denmark; Dept. of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200 Copenhagen, Denmark
| | - Anne Pernille Hermann
- Dept. of Endocrinology and Metabolism, Odense University Hospital, Kløvervænget 6, 5000 Odense C, Denmark
| | - Jens-Erik Beck Jensen
- Dept. of Endocrinology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark; Dept. of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3 B, 2200 Copenhagen, Denmark
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22
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Salles Rosa Neto N, Englert D, McAlister WH, Mumm S, Mills D, Veis DJ, Burshell A, Boyde A, Whyte MP. Periarticular calcifications containing giant pseudo-crystals of francolite in skeletal fluorosis from 1,1-difluoroethane "huffing". Bone 2022; 160:116421. [PMID: 35429657 DOI: 10.1016/j.bone.2022.116421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/03/2022] [Accepted: 04/08/2022] [Indexed: 01/28/2023]
Abstract
Inhalant use disorder is a psychiatric condition characterized by repeated deliberate inhalation from among a broad range of household and industrial chemical products with the intention of producing psychoactive effects. In addition to acute intoxication, prolonged inhalation of fluorinated compounds can cause skeletal fluorosis (SF). We report a young woman referred for hypophosphatasemia and carrying a heterozygous ALPL gene variant (c.457T>C, p.Trp153Arg) associated with hypophosphatasia, the heritable metabolic bone disease featuring impaired skeletal mineralization, who instead suffered from SF. Manifestations of her SF included recurrent articular pain, axial osteosclerosis, elevated bone mineral density, maxillary exostoses, and multifocal periarticular calcifications. SF was suspected when a long history was discovered of 'huffing' a computer cleaner containing 1,1-difluoroethane. Investigation revealed markedly elevated serum and urine levels of F-. Histopathology and imaging techniques including backscattered electron mode scanning electron microscopy, X-ray microtomography, energy dispersive and wavelength dispersive X-ray emission microanalysis, and polarized light microscopy revealed that her periarticular calcifications were dystrophic deposition of giant pseudo-crystals of francolite, a carbonate-rich fluorapatite. Identifying unusual circumstances of F- exposure is key for diagnosing non-endemic SF. Increased awareness of the disorder can be lifesaving.
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Affiliation(s)
- Nilton Salles Rosa Neto
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
| | - Daniel Englert
- Endocrinology Department, Ochsner Medical Center, New Orleans, LA 70121, USA.
| | - William H McAlister
- Pediatric Radiology Section, Mallinckrodt Institute of Radiology at St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Steven Mumm
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
| | - David Mills
- Dental Physical Sciences, Dental Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, E1 4NS, UK.
| | - Deborah J Veis
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
| | - Alan Burshell
- Endocrinology Department, Ochsner Medical Center, New Orleans, LA 70121, USA.
| | - Alan Boyde
- Dental Physical Sciences, Dental Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, E1 4NS, UK.
| | - Michael P Whyte
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA.
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23
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Marini F, Masi L, Giusti F, Cianferotti L, Cioppi F, Marcucci G, Ciuffi S, Biver E, Toro G, Iolascon G, Iantomasi T, Brandi ML. ALPL Genotypes in Patients With Atypical Femur Fractures or Other Biochemical and Clinical Signs of Hypophosphatasia. J Clin Endocrinol Metab 2022; 107:e2087-e2094. [PMID: 34935951 DOI: 10.1210/clinem/dgab914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Hypophosphatasia (HPP) is a rare metabolic disorder caused by deficiency of alkaline phosphatase (ALP) enzyme activity, leading to defective mineralization, due to pathogenic variants of the ALPL gene, encoding the tissue nonspecific alkaline phosphatase (TNSALP) enzyme. Inheritance can be autosomal recessive or autosomal dominant. An abnormal ALPL genetic test enables accurate diagnosis, avoiding the administration of contraindicated antiresorptive drugs that, in patients with HPP, substantially increase the risk of atypical femur fractures (AFFs) and worsen the fracture healing process that is usually already compromised in these patients. OBJECTIVE Performing ALPL genetic testing to identify rare variants in suspected adult patients with HPP. Comparing frequencies of ALPL common variants in individuals with biochemical and/or clinical signs suggestive of adult HPP and non-HPP controls, and among different clinical subgroups of patients with a clinical suspicion of adult HPP. METHODS Patients with suspected adult HPP were retrospectively selected for the genetic testing of the ALPL gene. Patients included were from 3 main European Bone Units (Florence, Naples, and Geneva); 106 patients with biochemical and/or clinical signs suggestive of a mild form of HPP were included. RESULTS Genetic testing led to the identification of a heterozygote rare variant in 2.8% of cases who were initially referred as suspected osteoporosis. The analysis of frequencies of ALPL common variants showed a high prevalence (30.8%) of homozygosity in subjects who developed an AFF, in association with normal serum total ALP activity. CONCLUSION The results suggest homozygosity of common ALPL variants as a possible genetic mark of risk for these fractures.
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Affiliation(s)
- Francesca Marini
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy
| | - Laura Masi
- University Hospital of Florence, Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - Francesca Giusti
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Luisella Cianferotti
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
- University Hospital of Florence, Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - Federica Cioppi
- University Hospital of Florence, Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - Gemma Marcucci
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
- University Hospital of Florence, Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - Simone Ciuffi
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Emmanuel Biver
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Teresa Iantomasi
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Maria Luisa Brandi
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy
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24
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Xiao F, Zhou Z, Song X, Gan M, Long J, Verkhivker G, Hu G. Dissecting mutational allosteric effects in alkaline phosphatases associated with different Hypophosphatasia phenotypes: An integrative computational investigation. PLoS Comput Biol 2022; 18:e1010009. [PMID: 35320273 PMCID: PMC8979438 DOI: 10.1371/journal.pcbi.1010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 04/04/2022] [Accepted: 03/10/2022] [Indexed: 11/18/2022] Open
Abstract
Hypophosphatasia (HPP) is a rare inherited disorder characterized by defective bone mineralization and is highly variable in its clinical phenotype. The disease occurs due to various loss-of-function mutations in ALPL, the gene encoding tissue-nonspecific alkaline phosphatase (TNSALP). In this work, a data-driven and biophysics-based approach is proposed for the large-scale analysis of ALPL mutations-from nonpathogenic to severe HPPs. By using a pipeline of synergistic approaches including sequence-structure analysis, network modeling, elastic network models and atomistic simulations, we characterized allosteric signatures and effects of the ALPL mutations on protein dynamics and function. Statistical analysis of molecular features computed for the ALPL mutations showed a significant difference between the control, mild and severe HPP phenotypes. Molecular dynamics simulations coupled with protein structure network analysis were employed to analyze the effect of single-residue variation on conformational dynamics of TNSALP dimers, and the developed machine learning model suggested that the topological network parameters could serve as a robust indicator of severe mutations. The results indicated that the severity of disease-associated mutations is often linked with mutation-induced modulation of allosteric communications in the protein. This study suggested that ALPL mutations associated with mild and more severe HPPs can exert markedly distinct effects on the protein stability and long-range network communications. By linking the disease phenotypes with dynamic and allosteric molecular signatures, the proposed integrative computational approach enabled to characterize and quantify the allosteric effects of ALPL mutations and role of allostery in the pathogenesis of HPPs.
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Affiliation(s)
- Fei Xiao
- Center for Systems Biology, Department of Bioinformatics, School of Biology and Basic Medical Sciences, Soochow University, Suzhou, China
| | - Ziyun Zhou
- Center for Systems Biology, Department of Bioinformatics, School of Biology and Basic Medical Sciences, Soochow University, Suzhou, China
| | - Xingyu Song
- Department of Chemistry, Multiscale Research Institute of Complex Systems and Institute of Biomedical Sciences, Fudan University, Shanghai, China
| | - Mi Gan
- Center for Systems Biology, Department of Bioinformatics, School of Biology and Basic Medical Sciences, Soochow University, Suzhou, China
| | - Jie Long
- Center for Systems Biology, Department of Bioinformatics, School of Biology and Basic Medical Sciences, Soochow University, Suzhou, China
| | - Gennady Verkhivker
- Department of Computational and Data Sciences, Chapman University, One University Drive, Orange, California, United States of America
- Department of Biomedical and Pharmaceutical Sciences, Chapman University Pharmacy School 9401 Jeronimo Rd, Irvine, California, United States of America
| | - Guang Hu
- Center for Systems Biology, Department of Bioinformatics, School of Biology and Basic Medical Sciences, Soochow University, Suzhou, China
- * E-mail:
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25
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Bernhard E, Nitschke Y, Khursigara G, Sabbagh Y, Wang Y, Rutsch F. A Reference Range for Plasma Levels of Inorganic Pyrophosphate in Children Using the ATP Sulfurylase Method. J Clin Endocrinol Metab 2022; 107:109-118. [PMID: 34498693 PMCID: PMC8684482 DOI: 10.1210/clinem/dgab615] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE Generalized arterial calcification of infancy, pseudoxanthoma elasticum, autosomal recessive hypophosphatemic rickets type 2, and hypophosphatasia are rare inherited disorders associated with altered plasma levels of inorganic pyrophosphate (PPi). In this study, we aimed to establish a reference range for plasma PPi in the pediatric population, which would be essential to support its use as a biomarker in children with mineralization disorders. METHODS Plasma samples were collected from 200 children aged 1 day to 18 years who underwent blood testing for medical conditions not affecting plasma PPi levels. PPi was measured in proband plasma utilizing a validated adenosine triphosphate (ATP) sulfurylase method. RESULTS The analytical sensitivity of the ATP sulfurylase assay consisted of 0.15 to 10 µM PPi. Inter- and intra-assay coefficients of variability on identical samples were below 10%. The standard range of PPi in the blood plasma of children and adolescents aged 0 to 18 years was calculated as 2.36 to 4.44 µM, with a median of 3.17 µM, with no difference between male and female probands. PPi plasma levels did not differ significantly in different pediatric age groups. MAIN CONCLUSIONS Our results yielded no noteworthy discrepancy to the reported standard range of plasma PPi in adults (2-5 µM). We propose the described ATP sulfurylase method as a diagnostic tool to measure PPi levels in plasma as a biomarker in the pediatric population.
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Affiliation(s)
- Eva Bernhard
- Department of General Pediatrics, Muenster University Children’s Hospital, Muenster, Germany
| | - Yvonne Nitschke
- Department of General Pediatrics, Muenster University Children’s Hospital, Muenster, Germany
| | | | | | - Yongbao Wang
- National Jewish Health Advanced Diagnostic Laboratories, Denver, CO, USA
| | - Frank Rutsch
- Department of General Pediatrics, Muenster University Children’s Hospital, Muenster, Germany
- Correspondence: Frank Rutsch, MD, Department of General Pediatrics, Muenster University Children’s Hospital, Albert-Schweitzer-Campus 1, Gebäude A1, D-48149 Muenster, Germany.
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26
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Sanabria-de la Torre R, Martínez-Heredia L, González-Salvatierra S, Andújar-Vera F, Iglesias-Baena I, Villa-Suárez JM, Contreras-Bolívar V, Corbacho-Soto M, Martínez-Navajas G, Real PJ, García-Fontana C, Muñoz-Torres M, García-Fontana B. Characterization of Genetic Variants of Uncertain Significance for the ALPL Gene in Patients With Adult Hypophosphatasia. Front Endocrinol (Lausanne) 2022; 13:863940. [PMID: 35498405 PMCID: PMC9047899 DOI: 10.3389/fendo.2022.863940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/14/2022] [Indexed: 11/29/2022] Open
Abstract
Hypophosphatasia (HPP) a rare disease caused by mutations in the ALPL gene encoding for the tissue-nonspecific alkaline phosphatase protein (TNSALP), has been identified as a potentially under-diagnosed condition worldwide which may have higher prevalence than currently established. This is largely due to the overlapping of its symptomatology with that of other more frequent pathologies. Although HPP is usually associated with deficient bone mineralization, the high genetic variability of ALPL results in high clinical heterogeneity, which makes it difficult to establish a specific HPP symptomatology. In the present study, three variants of ALPL gene with uncertain significance and no previously described (p.Del Glu23_Lys24, p.Pro292Leu and p.His379Asn) were identified in heterozygosis in patients diagnosed with HPP. These variants were characterized at phenotypic, functional and structural levels. All genetic variants showed significantly lower in vitro ALP activity than the wild-type (WT) genotype (p-value <0.001). Structurally, p.His379Asn variant resulted in the loss of two Zn2+ binding sites in the protein dimer which may greatly affect ALP activity. In summary, we identified three novel ALPL gene mutations associated with adult HPP. The correct identification and characterization of new variants and the subsequent study of their phenotype will allow the establishment of genotype-phenotype relationships that facilitate the management of the disease as well as making it possible to individualize treatment for each specific patient. This would allow the therapeutic approach to HPP to be personalized according to the unique genetic characteristics and clinical manifestations of each patient.
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Affiliation(s)
- Raquel Sanabria-de la Torre
- Department of Medicine, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
| | - Luis Martínez-Heredia
- Department of Medicine, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
| | - Sheila González-Salvatierra
- Department of Medicine, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
| | - Francisco Andújar-Vera
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Department of Computer Science and Artificial Intelligence, University of Granada, Granada, Spain
- Andalusian Research Institute in Data Science and Computational Intelligence (DaSCI Institute), Granada, Spain
| | | | - Juan Miguel Villa-Suárez
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Clinical Analysis Unit, University Hospital Clínico San Cecilio, Granada, Spain
| | - Victoria Contreras-Bolívar
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, Granada, Spain
| | | | - Gonzalo Martínez-Navajas
- Gene Regulation, Stem Cells and Development Lab, Pfizer-University of Granada-Junta de Andalucía Centre for Genomics and Oncological Research (GENYO), Granada, Spain
- Department of Biochemistry and Molecular Biology I, Faculty of Science, University of Granada, Granada, Spain
| | - Pedro J. Real
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Gene Regulation, Stem Cells and Development Lab, Pfizer-University of Granada-Junta de Andalucía Centre for Genomics and Oncological Research (GENYO), Granada, Spain
- Department of Biochemistry and Molecular Biology I, Faculty of Science, University of Granada, Granada, Spain
| | - Cristina García-Fontana
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, Granada, Spain
- Biomedical Research Network in Fragility and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
- *Correspondence: Cristina García-Fontana, ; Manuel Muñoz-Torres,
| | - Manuel Muñoz-Torres
- Department of Medicine, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, Granada, Spain
- Biomedical Research Network in Fragility and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
- *Correspondence: Cristina García-Fontana, ; Manuel Muñoz-Torres,
| | - Beatriz García-Fontana
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
- Endocrinology and Nutrition Unit, University Hospital Clínico San Cecilio, Granada, Spain
- Biomedical Research Network in Fragility and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
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27
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Santurtún M, Mediavilla-Martinez E, Vega AI, Gallego N, Heath KE, Tenorio JA, Lapunzina P, Riancho-Zarrabeitia L, Riancho JA. Pain and health-related quality of life in patients with hypophosphatasemia with and without ALPL gene mutations. Front Endocrinol (Lausanne) 2022; 13:965476. [PMID: 36072928 PMCID: PMC9442670 DOI: 10.3389/fendo.2022.965476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/26/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Low serum alkaline phosphatase levels are the hallmark of hypophosphatasia, a disorder due to pathogenic variants of the ALPL gene. However, some patients do not carry ALPL variants and the cause of low alkaline phosphatase remains unknown. We aimed to determine health-related quality of life in adults with low alkaline phosphatase and explore the differences between patients with and without ALPL mutations. METHODS We studied 35 adult patients with persistently low alkaline phosphatase unrelated to secondary acquired causes who had ALPL sequenced, and 35 controls of similar age. Three questionnaires about body pain (Brief Pain Inventory, BPI), physical disability (Health Assessment Questionnaire Disability Index, HAQ-DI), and health-related quality of life (36-item Short-Form Health Survey, SF-36) were delivered by telephone interviews. RESULTS The mean BPI intensity and interference scores were higher in the patient group (p=0.04 and 0.004, respectively). All domains of the HAQ instrument tended to score better in the control group, with significant differences in the "reach" score (p=0.037) and the overall mean score (0.23 vs 0.09; p=0.029). Patients scored worse than controls in several SF-36 dimensions (Role physical, p=0.039; Bodily pain p=0.046; Role emotional, p=0.025). Patients with and without pathogenic variants scored similarly across all tests, without between-group significant differences. CONCLUSIONS Patients with persistently low levels of alkaline phosphatase have significantly worse scores in body pain and other health-related quality of life dimensions, without differences between patients with and without pathogenic variants identified in ALPL gene. This is consistent with the latter ones carrying mutations in regulatory regions.
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Affiliation(s)
- Maite Santurtún
- Departamento de Enfermería, Hospital Padre Meni, Universidad de Cantabria, Santander, Spain
| | | | - Ana I. Vega
- Servicio de Genética, Hospital UM Valdecila, Santander, Spain
| | - Natalia Gallego
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Instituto de Genética Médica y Molecular, Hospital U Lapaz, Instituto de Investigación Sanitaria La Paz (IDIPAZ), Madrid, Spain
- ERN-ITHACA, Brussels, Belgium
| | - Karen E. Heath
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Instituto de Genética Médica y Molecular, Hospital U Lapaz, Instituto de Investigación Sanitaria La Paz (IDIPAZ), Madrid, Spain
- ERN-ITHACA, Brussels, Belgium
| | - Jair A. Tenorio
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Instituto de Genética Médica y Molecular, Hospital U Lapaz, Instituto de Investigación Sanitaria La Paz (IDIPAZ), Madrid, Spain
- ERN-ITHACA, Brussels, Belgium
| | - Pablo Lapunzina
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Instituto de Genética Médica y Molecular, Hospital U Lapaz, Instituto de Investigación Sanitaria La Paz (IDIPAZ), Madrid, Spain
- ERN-ITHACA, Brussels, Belgium
| | - Leyre Riancho-Zarrabeitia
- Servicio de Reumatología, Hospital U Sierrallana Torrelavega, Instituto de Investigación Sanitaria Valdecilla (IDIVAL), Santander, Spain
| | - José A. Riancho
- Departamento de Medicina y Psiquiatría, Servicio de Medicina Interna, Hospital Valdecilla, Instituto de Investigación Sanitaria Valdecilla (IDIVAL), Universidad de Cantabria, Santander, Spain
- *Correspondence: José A. Riancho,
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Masi L, Marini F, Franceschelli F, Leoncini G, Cianferotti L, Cioppi F, Giusti F, Marcucci G, Gronchi G, Brandi ML. Polymorphic variants of alkaline phosphatase gene correlate with clinical signs of adult hypophosphatasia? Osteoporos Int 2021; 32:2461-2472. [PMID: 34097127 PMCID: PMC8608776 DOI: 10.1007/s00198-021-05893-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 02/15/2021] [Indexed: 11/28/2022]
Abstract
UNLABELLED We analyzed polymorphism of the ALPL gene in patients with low serum levels of tissue-nonspecific alkaline phosphatase (TNAP). The presence of three or more of the less frequent alleles of ALPL polymorphisms was associated with significantly lower TNAP serum level and higher frequencies of metatarsal fractures, which may help confirm a clinical suspicion of adult hypophosphatasia. INTRODUCTION Alkaline phosphatases (ALPs) are membrane-bound enzymes that hydrolyze monophosphate esters at a high pH (pH 8-10). Inorganic pyrophosphate, pyridoxal 5-phosphate, the activated form of vitamin B6 (PLP), and phosphoethanolamine (PEA), are natural substrates of ALPs. Hypophosphatasia (HPP, OMIM 146300, 241500, 241510) is a heterogeneous rare metabolic bone disease caused by loss-of-function mutations in the tissue-nonspecific alkaline phosphatase gene (ALPL; MIM 171760) with a deficiency of TNAP. Clinical presentation of HPP in adults demonstrated a wide range of manifestations, many of which are nonspecific. In the present study, we screened the polymorphic genetic variants of ALPL in 56 subjects presenting low serum levels of TNAP and/or other clinical signs of adult HPP in order to evaluate a possible role of polymorphic variants in the diagnosis and management of HPP in adults. METHODS Genomic DNA was extracted from peripheral blood and ALPL gene was sequenced by PCR-based Sanger technique. RESULTS Fourteen different polymorphic variants were found in the study population. A lower serum level of TNAP and higher frequencies of metatarsal fractures were observed in patients bearing three or more of the minor frequency alleles (MFAs) of the ALPL polymorphic variants. The presence of some MFAs, mostly as a contemporary presence of three or more of them, was found to be mainly represented in patients having both a significantly lower level of TNAP and a higher level of vitamin B6. CONCLUSION The genetic analysis and presence of some polymorphic variants may be an instrument to confirm clinical and biochemical data, consider adult HPP, and help clinicians be cautious in the administration of anti-reabsorption drugs.
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Affiliation(s)
- L Masi
- University Hospital of Florence, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy
| | - F Marini
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - F Franceschelli
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - G Leoncini
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - L Cianferotti
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - F Cioppi
- University Hospital of Florence, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy
| | - F Giusti
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - G Marcucci
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - G Gronchi
- Deparment of Neuroscience, Psychology Drug Research and Child's Health, University of Florence, Florence, Italy
| | - M L Brandi
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy.
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Whyte MP, May JD, McAlister WH, Burgener K, Cortez SR, Kreienkamp R, Castro O, Verzola R, Zavala AS, McPherson CC, Gottesman GS, Ericson KL, Coburn SP, Arbelaez AM. Vitamin B 6 deficiency with normal plasma levels of pyridoxal 5'-phosphate in perinatal hypophosphatasia. Bone 2021; 150:116007. [PMID: 34000433 DOI: 10.1016/j.bone.2021.116007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/29/2021] [Accepted: 05/10/2021] [Indexed: 01/29/2023]
Abstract
Pyridoxal 5'-phosphate (PLP), the principal circulating form of vitamin B6 (B6), is elevated in the plasma of individuals with hypophosphatasia (HPP). HPP is the inborn-error-of-metabolism caused by loss-of-function mutation(s) of ALPL, the gene that encodes the "tissue-nonspecific" isoenzyme of alkaline phosphatase (TNSALP). PLP accumulates extracellularly in HPP because it is a natural substrate of this cell-surface phosphomonoester phosphohydrolase. Even individuals mildly affected by HPP manifest this biochemical hallmark, which is used for diagnosis. Herein, an exclusively breast-fed newborn boy with life-threatening perinatal HPP had uniquely normal instead of markedly elevated plasma PLP levels before beginning asfotase alfa (AA) TNSALP-replacement therapy. These abnormal PLP levels were explained by B6 deficiency, confirmed by his low plasma level of 4-pyridoxic acid (PA), the B6 degradation product. His mother, a presumed carrier of one of his two ALPL missense mutations, had serum ALP activity of 50 U/L (Nl 40-130) while her plasma PLP level was 9 μg/L (Nl 5-50) and PA was 3 μg/L (Nl 3-30). Her dietary history and breast milk pyridoxal (PL) level indicated she too was B6 deficient. With B6 supplementation using a breast milk fortifier, the patient's plasma PA level corrected, while his PLP level remained in the normal range but now in keeping with AA treatment. Our experience reveals that elevated levels of PLP in the circulation in HPP require some degree of B6 sufficiency, and that anticipated increases in HPP can be negated by hypovitaminosis B6.
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Affiliation(s)
- Michael P Whyte
- Division of Pediatric Endocrinology, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA; Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St Louis, St. Louis, MO 63110, USA.
| | - Jennifer D May
- Division of Pediatric Endocrinology, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - William H McAlister
- Mallinckrodt Institute of Radiology, Washington University School of Medicine at St. Louis Children's Hospital, St. Louis, MO 63110, USA.
| | - Katherine Burgener
- Division of Pediatric Endocrinology, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Samuel R Cortez
- Division of Pediatric Endocrinology, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Raymond Kreienkamp
- Division of Pediatric Endocrinology, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Olivia Castro
- Nutritional Services, Department of Pediatrics, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Rachel Verzola
- Nutritional Services, Department of Pediatrics, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Ana Solis Zavala
- Division of Pediatric Endocrinology, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Christopher C McPherson
- Department of Pharmacy, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Gary S Gottesman
- Division of Pediatric Endocrinology, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St Louis, St. Louis, MO 63110, USA.
| | - Karen L Ericson
- Department of Chemistry, Purdue University Fort Wayne, Fort Wayne, IN 46805, USA.
| | - Stephen P Coburn
- Department of Chemistry, Purdue University Fort Wayne, Fort Wayne, IN 46805, USA.
| | - Ana Maria Arbelaez
- Division of Pediatric Endocrinology, St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO 63110, USA.
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Kato M, Michigami T, Tachikawa K, Kato M, Yabe I, Shimizu T, Asaka T, Kitagawa Y, Atsumi T. Novel mutation in the ALPL gene with a dominant negative effect in a Japanese family. J Bone Miner Metab 2021; 39:804-809. [PMID: 33821301 DOI: 10.1007/s00774-021-01219-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/25/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Hypophosphatasia (HPP) is caused by mutations in the ALPL gene encoding tissue nonspecific alkaline phosphatase (TNSALP) and inherited in either an autosomal recessive or autosomal dominant manner. It is characterized clinically by defective mineralization of bone, dental problems, and low serum ALP levels. In the current report, we demonstrate a novel mutation in the ALPL gene (c.244G > A p.Gly82Arg) in a Japanese family with low serum ALP levels. MATERIALS AND METHODS The ALPL gene analysis using hybridization capture-based next-generation sequencing was performed. The expression plasmids of the wild type and mutated TNSALP were introduced into COS-7 cells. The enzymatic activity of ALP in the cell lysates was measured using p-nitrophenylphosphate as a substrate. RESULTS TNSALP with the novel ALPL mutation (c.244G > A p.Gly82Arg) completely lost its enzymatic activity and suppressed that of wild-type TNSALP, corroborating its dominant negative effect. The diagnosis of autosomal dominant HPP was confirmed in three members of the family. CONCLUSION Our approach would help to avoid the inappropriate use of bone resorption inhibitors for currently mis- or under-diagnosed HPP, given that the presence of further, yet undetected mutations of the ALPL gene are plausible.
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Affiliation(s)
- Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N15W7, Kita-Ku, Sapporo, 060-8638, Japan.
| | - Toshimi Michigami
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka Prefectural Hospital Organization, Osaka, Japan
| | - Kanako Tachikawa
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka Prefectural Hospital Organization, Osaka, Japan
| | - Momoko Kato
- The Division of Clinical Genetics, Hokkaido University Hospital, Sapporo, Japan
| | - Ichiro Yabe
- The Division of Clinical Genetics, Hokkaido University Hospital, Sapporo, Japan
| | - Tomohiro Shimizu
- Department of Orthopedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takuya Asaka
- Oral Diagnosis and Medicine, Hokkaido University, Sapporo, Japan
| | | | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N15W7, Kita-Ku, Sapporo, 060-8638, Japan
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Garcia-Carretero R, Olid-Velilla M, Perez-Torrella D, Torres-Pacho N, Darnaude-Ortiz MT, Bustamate-Zuloeta AD, Tenorio JA. Predictive modeling of hypophosphatasia based on a case series of adult patients with persistent hypophosphatasemia. Osteoporos Int 2021; 32:1815-1824. [PMID: 33619648 DOI: 10.1007/s00198-021-05885-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 02/09/2021] [Indexed: 10/22/2022]
Abstract
UNLABELLED Approximately half of individuals with hypophosphatasemia (low levels of serum alkaline phosphatase) have hypophosphatasia, a rare genetic disease in which patients may have stress fractures, bone and joint pain, or premature tooth loss. We developed a predictive model based on specific biomarkers of this disease to better diagnose this condition. INTRODUCTION Hypophosphatasemia is a condition in which low levels of alkaline phosphatase (ALP) are detected in the serum. Some individuals presenting with this condition may have a rare genetic disease called hypophosphatasia (HPP), which involves mineralization of the bone and teeth. Lack of awareness of HPP and its nonspecific symptoms make this genetic disease difficult to diagnose. We developed a predictive model based on biomarkers of HPP such as ALP and pyridoxal 5'-phosphate (PLP), because clinical manifestations sometimes are not recognized as symptoms of HPP. METHODS We assessed 325,000 ALP results between 2010 and 2015 to identify individuals suspected of having HPP. We performed univariate and multivariate analyses to characterize the relationship between hypophosphatasemia and HPP. Using several machine learning algorithms, we developed several models based on biomarkers and compared their performance to determine the best model. RESULTS The final cohort included 45 patients who underwent a genetic test. Half (23 patients) showed a mutation of the ALPL gene that encodes the tissue-nonspecific ALP enzyme. ALP (odds ratio [OR] 0.61, 95% confidence interval [CI] 0.3-0.8, p = 0.01) and PLP (OR 1.06, 95% CI 1.01-1.15, p = 0.04) were the only variables significantly associated with the presence of HPP. Support vector machines and logistic regression were the machine learning algorithms that provided the best predictive models in terms of classification (area under the curve 0.936 and 0.844, respectively). CONCLUSIONS Given the high probability of a misdiagnosis, its nonspecific symptoms, and a lack of awareness of serum ALP levels, it is difficult to make a clinical diagnosis of HPP. Predictive models based on biomarkers are necessary to achieve a proper diagnosis. Our proposed machine learning approaches achieved reasonable performance compared to traditional statistical methods used in biomedicine, increasing the likelihood of properly diagnosing such a rare disease as HPP.
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Affiliation(s)
- R Garcia-Carretero
- Department of Internal Medicine, Mostoles University Hospital, Rey Juan Carlos University, Madrid, Spain.
| | - M Olid-Velilla
- Department of Internal Medicine, Mostoles University Hospital, Madrid, Spain
| | - D Perez-Torrella
- Department of Laboratory of Clinical Analysis, Mostoles University Hospital, Madrid, Spain
| | - N Torres-Pacho
- Department of Internal Medicine, Mostoles University Hospital, Madrid, Spain
| | - M-T Darnaude-Ortiz
- Department of Clinical Genetics, Mostoles University Hospital, Madrid, Spain
| | | | - J-A Tenorio
- Institute of Medical and Molecular Genetics (INGEMM), La Paz University Hospital, Madrid, Spain
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İnci A, Ergin FBC, Yüce BT, Çiftçi B, Demir E, Buyan N, Okur İ, Biberoğlu G, Öktem RM, Tümer L, Ezgü FS. Hypophosphatasia: is it an underdiagnosed disease even by expert physicians? J Bone Miner Metab 2021; 39:598-605. [PMID: 33404770 DOI: 10.1007/s00774-020-01193-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 12/06/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Hypophosphatasia (HPP) is caused by mutations in the ALPL that encodes the tissue-nonspecific isoenzyme of alkaline phosphatase (ALP). Clinical manifestations range from extreme life-threatening lethal forms to no signs or symptoms at all. MATERIALS AND METHODS Consecutive 30,000 outpatients and inpatients with ALP data were screened retrospectively, out of which 1000 patients were found to have low levels of ALP more than once. Then, patients were evaluated for the symptoms and signs of HPP with further biochemical and genetic analyses. RESULTS Thirty-seven patients who had severe musculoskeletal pain, recurrent fractures, and tooth anomalies were then screened with substrate and DNA sequencing analyses for HPP. It was determined that eight patients had variants in the ALPL gene. A total of eight different ALPL variants were identified in eight patients. The variants, namely c.244G > C (p.Gly82Arg), c.1444C > T (p.His482Tyr), c.1487A > G (p.Asn493Ser), and c.675_676insCA (p.Met226GlnfsTer52), had not been previously reported. DISCUSSION Considering the wide spectrum of clinical signs and symptoms, HPP should be among the differential lists of bone, muscle, and tooth abnormalities at any age.
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Affiliation(s)
- Aslı İnci
- Department of Pediatric Metabolism, Gazi University School of Medicine, 06500, Beşevler, Ankara, Turkey.
| | - Filiz Başak Cengiz Ergin
- Department of Pediatric Metabolism, Gazi University School of Medicine, 06500, Beşevler, Ankara, Turkey
| | - Burcu Topcu Yüce
- Department of Pediatric Metabolism, Gazi University School of Medicine, 06500, Beşevler, Ankara, Turkey
| | - Bahattin Çiftçi
- Department of Pediatric Metabolism, Gazi University School of Medicine, 06500, Beşevler, Ankara, Turkey
| | - Ercan Demir
- Department of Pediatric Neurology, Gazi University School of Medicine, 06500, Beşevler, Ankara, Turkey
| | - Necla Buyan
- Department of Pediatric Nephrology, Gazi University School of Medicine, 06500, Beşevler, Ankara, Turkey
| | - İlyas Okur
- Department of Pediatric Metabolism, Gazi University School of Medicine, 06500, Beşevler, Ankara, Turkey
| | - Gürsel Biberoğlu
- Department of Pediatric Metabolism, Gazi University School of Medicine, 06500, Beşevler, Ankara, Turkey
| | - Rıdvan Murat Öktem
- Department of Pediatric Metabolism, Gazi University School of Medicine, 06500, Beşevler, Ankara, Turkey
| | - Leyla Tümer
- Department of Pediatric Metabolism, Gazi University School of Medicine, 06500, Beşevler, Ankara, Turkey
| | - Fatih Süheyl Ezgü
- Department of Pediatric Metabolism, Gazi University School of Medicine, 06500, Beşevler, Ankara, Turkey
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Papadopoulou A, Bountouvi E, Sideri V, Moutsatsou P, Skarakis NS, Doulgeraki A, Karachaliou FE. Parietal aplasia and hypophosphatasia in a child harboring a novel mutation in RUNX2 and a likely pathogenic variant in TNSALP. Bone 2021; 146:115904. [PMID: 33647526 DOI: 10.1016/j.bone.2021.115904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/03/2021] [Accepted: 02/23/2021] [Indexed: 11/30/2022]
Abstract
Cleidocranial dysplasia is a dominantly inherited skeletal dysplasia resulting from inherited or spontaneous mutations of Runt-related transcription factor 2 gene (RUNX2). It represents a clinical continuum typically characterized by wide calvarial sutures, clavicular hypoplasia and dental abnormalities. CDD has been rarely associated with skeletal and biochemical features that mimic hypophosphatasia. We report clinical, biochemical and molecular profile of a 3-year-old female with CCD, presented in utero with large cranial defects. She displayed severe parietal dysplasia, wide cranial sutures, clavicular abnormalities and biochemical features of hypophospatasia (HHP). She was preliminary diagnosed with benign perinatal HHP, harboring a likely pathogenic heterozygous TNSALP variant (p.Ser181Leu) inherited by the mother, who also displayed low levels of ALP. Asfotase alfa was introduced for a six-month-period with rather positive impact on cranial ossification. Nevertheless, focal skeletal disease (cranium and clavicles) and absence of clinical symptoms in the mother, carrier of the same genetic variant, posed diagnosis into question and further genetic analysis detected the novel spontaneous frameshift mutation c.1191delC (p.Phe398Leufs*86) in RUNX2 gene, establishing the CCD diagnosis. Although genotype-phenotype correlations are difficult, p.Phe398Leufs*86 appears to be associated with a severe cranial phenotype and absence of parietal bones, similarly to other adjacent frameshift/splicing mutations. The TNSALP variant (p.Ser181Leu) may contributed to patient's final phenotype, as well as to maternal low ALP levels. However, since low ALP levels have been also reported in few CCD patients with no alterations in TNSALP gene, studies to elucidate RUNX2 and TNSALP interactions could shed more light on differential diagnosis between CCD and HHP, CCD appropriate therapy and genetic counselling. ACCESSION NUMBER: (SUB8185506).
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Affiliation(s)
- Anna Papadopoulou
- Third Department of Pediatrics, National & Kapodistrian University of Athens, University General Hospital "Attikon", Medical School, Athens, Greece; Department of Clinical Biochemistry, National & Kapodistrian University of Athens, University General Hospital "Attikon", Medical School, Athens, Greece.
| | - Evangelia Bountouvi
- Third Department of Pediatrics, National & Kapodistrian University of Athens, University General Hospital "Attikon", Medical School, Athens, Greece
| | - Vassiliki Sideri
- Third Department of Pediatrics, National & Kapodistrian University of Athens, University General Hospital "Attikon", Medical School, Athens, Greece
| | - Paraskevi Moutsatsou
- Department of Clinical Biochemistry, National & Kapodistrian University of Athens, University General Hospital "Attikon", Medical School, Athens, Greece
| | - Nikitas Spyridon Skarakis
- Department of Clinical Biochemistry, National & Kapodistrian University of Athens, University General Hospital "Attikon", Medical School, Athens, Greece; Department of Endocrinology and Diabetes Center, "G. Gennimatas", General Hospital of Athens, Athens, Greece
| | - Artemis Doulgeraki
- Department of Bone and Mineral Metabolism, Institute of Child Health, Athens, Greece
| | - Fotini Eleni Karachaliou
- Third Department of Pediatrics, National & Kapodistrian University of Athens, University General Hospital "Attikon", Medical School, Athens, Greece
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Hur YJ, Lee BL, Chung WY, Yu S, Jun KR, Oh SH. Compound Heterozygous PIGT Mutations in Multiple Congenital Anomalies-Hypotonia-Seizures Syndrome: First Case in Korea and Characterization by Persistent Hypophosphatasia. Ann Clin Lab Sci 2021; 51:422-425. [PMID: 34162574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Mutations of phosphatidylinositol glycan biosynthesis class T (PIGT), which encodes a subunit of the glycosylphosphatidylinositol (GPI) transamidase complex, can lead to multiple anomalies, including seizures, intellectual disabilities, facial dysmorphism, and various congenital malformations. We performed whole-exome sequencing in a patient with seizures, intellectual disabilities, truncal ataxia, facial dysmorphism, and persistent hypophosphatasia without rickets or bone mineralization defects, and identified two heterozygous mutations in PIGT, c.250G>T (p.Glu84*) and c.1582G>A (p.Val528Met). GPI-linked protein analyses found no abnormalities. Although the patient's hypophosphatasia persists, no skeletal, urological, or dental abnormalities were found. The seizures disappeared after administering antiepileptic drugs. PIGT mutations should be considered in patients with multiple congenital symptoms and persistent hypophosphatasia.
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Affiliation(s)
- Yun Jung Hur
- Department of Pediatrics, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Bo Lyun Lee
- Department of Pediatrics, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Woo Yeong Chung
- Department of Pediatrics, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Shinae Yu
- Department of Laboratory Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Kyung Ran Jun
- Department of Laboratory Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Seung Hwan Oh
- Department of Laboratory Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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Kishnani PS, Del Angel G, Zhou S, Rush ET. Investigation of ALPL variant states and clinical outcomes: An analysis of adults and adolescents with hypophosphatasia treated with asfotase alfa. Mol Genet Metab 2021; 133:113-121. [PMID: 33814268 DOI: 10.1016/j.ymgme.2021.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/03/2021] [Accepted: 03/14/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hypophosphatasia (HPP), a rare metabolic disease, can be inherited in an autosomal recessive (biallelic) or an autosomal dominant (monoallelic) manner. Most of the severe, early-onset, frequently lethal HPP in infants is acquired through recessive inheritance; less severe, later-onset, typically nonlethal HPP phenotypes are acquired through either dominant or recessive inheritance. HPP's variable clinical presentation arises from >400 identified ALPL pathogenic variants with likely variable penetrance, especially with autosomal dominant inheritance. This post hoc analysis investigated the relationship between ALPL variant state (biallelic and monoallelic) and clinical outcomes with asfotase alfa in HPP. METHODS Data were pooled from two phase 2, randomized, open-label studies in adolescents and adults with HPP; one study evaluated the efficacy and safety of different doses of asfotase alfa (n = 25), and the other assessed the pharmacodynamics and safety of asfotase alfa (n = 19). Patients were grouped by ALPL variant state (biallelic or monoallelic). Available data from both studies included ALPL pathogenic variant state, Baseline characteristics, HPP-specific medical history, and Baseline TNSALP substrate levels (inorganic pyrophosphate [PPi] and pyridoxal 5'-phosphate [PLP]) concentrations). Clinical outcomes over 5 years of treatment were available from only the efficacy and safety study. RESULTS In total, 44 patients with known variant status were included in the pooled analysis (biallelic, n = 30; monoallelic, n = 14). The most common pathogenic variant was c.571G > A (p.Glu191Lys) in biallelic patients (allele frequency: 19/60) and c.1133A > T (p.Asp378Val) in monoallelic patients (allele frequency: 7/28). Median (min, max) Baseline PPi concentrations were significantly higher in patients with a biallelic vs monoallelic variant state (5.3 [2.2, 12.1] vs 4.3 [3.5, 7.4] μM; P = 0.0113), as were Baseline PLP concentrations (221.4 [62.4, 1590.0] vs 75.1 [28.8, 577.0] ng/mL; P= 0.0022). HPP-specific medical history was generally similar between biallelic and monoallelic patients in terms of incidence and type of manifestations; notable exceptions included fractures, which were more common among monoallelic patients, and delayed walking and bone deformities such as abnormally shaped chest and head and bowing of arms or legs, which were more common among biallelic patients. Data from the efficacy and safety study (n = 19) showed that median PPi and PLP concentrations were normalized over 5 years of treatment in patients with both variant states. Median % predicted distance walked on the 6-Minute Walk Test remained within the normal range for monoallelic patients over 4 years of treatment, and improved from below normal (<84%) to normal in biallelic patients. CONCLUSIONS Although patients with biallelic variants had significantly higher Baseline PPi and PLP levels than monoallelic variants, both groups generally showed similar pretreatment Baseline clinical characteristics. Treatment with asfotase alfa for up to 5 years normalized TNSALP substrate concentrations and improved functional outcomes, with no clear differences between biallelic and monoallelic variant states. This study suggests that patients with HPP have significant disease burden, regardless of ALPL variant state.
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Affiliation(s)
- Priya S Kishnani
- Department of Pediatrics, Duke University Medical Center, 2351 Erwin Road, Durham, NC, USA.
| | | | - Shanggen Zhou
- Covance, Inc., 206 Carnegie Center Dr, Princeton, NJ, USA.
| | - Eric T Rush
- Children's Mercy Hospital Kansas City, 2401 Gillham Rd, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA; University of Kansas School of Medicine, Kansas City, KS, USA.
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36
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Liu M, Liu M, Liang X, Wu D, Li W, Su C, Cao B, Chen J, Gong C. Clinical and genetic characteristics of hypophosphatasia in Chinese children. Orphanet J Rare Dis 2021; 16:159. [PMID: 33827627 PMCID: PMC8028151 DOI: 10.1186/s13023-021-01798-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/30/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Hypophosphatasia (HPP) is a rare inherited disorder, which is caused by loss-of-function mutations in the ALPL gene. HPP is a heterogeneous disease that has a wide spectrum of phenotypes. Few studies were carried out in the Chinese population with HPP, especially in children. METHODS The clinical and genetic characteristics of 10 Chinese children with HPP who were referred to the Beijing Children's Hospital were described. Previously reported HPP cases of children in China were also reviewed. RESULTS A total of 33 cases were identified, which included 2 perinatal lethal HPP, 10 infantile HPP, 10 childhood HPP, and 11 odonto HPP. The male-to-female ratio was 24:9. The average age at onset was 0.69 years (ranged from 2 h after birth to 14 years), while the average age at clinical diagnosis was 3.87 years (ranged from 2 h after birth to 19 years). Serum alkaline phosphatase (ALP) levels were significantly decreased in patients with perinatal lethal/infantile HPP when compared with those with the mild forms of HPP childhood/odonto HPP (P < 0.01). Although serum phosphate levels were not different (P > 0.05), serum calcium levels were elevated, and serum intact parathyroid hormone levels were decreased in patients with perinatal lethal/infantile HPP in comparison with those with the childhood/odonto HPP (P all < 0.01). Genetic analyses identified 40 mutations in 31 HPP cases, including 28 missense mutations, 9 frameshift mutations, 2 splice junction alterations, and 1 regulatory mutation. Of which, 5 novel mutations were identified in our present study: 2 frameshift mutations (p.Arg138GlyfsTer27, p.Leu511Profs*272); 2 missense mutations (p.Ala176Val, p.Phe268Leu), and 1 splice junction alteration (c.297+5G>A). Compound heterozygous mutations accounted for 80.6% of all variants. No mutational "hot-spot" was found. Most mutations of ALPL were located in exons 5, 7, 10, and 3. Notably, subjects that carrying single heterozygous mutations showed milder phenotypes of HPP, while subjects with nonsense mutations were associated with a severer phenotype. CONCLUSIONS HPP is a rare disease with often delayed diagnosis, and the incidence of HPP in China may be seriously underestimated. The present study expands the phenotypic and genotypic spectrum and the understanding of HPP in Chinese children. These findings will be useful for clinical assessment and shorten the diagnosis time for pediatric HPP in China.
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Affiliation(s)
- Meijuan Liu
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Min Liu
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Xuejun Liang
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Di Wu
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Wenjing Li
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Chang Su
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Bingyan Cao
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Jiajia Chen
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Chunxiu Gong
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.
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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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38
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Jandl NM, Schmidt T, Rolvien T, Stürznickel J, Chrysostomou K, von Vopelius E, Volk AE, Schinke T, Kubisch C, Amling M, Barvencik F. Genotype-Phenotype Associations in 72 Adults with Suspected ALPL-Associated Hypophosphatasia. Calcif Tissue Int 2021; 108:288-301. [PMID: 33191482 PMCID: PMC7881968 DOI: 10.1007/s00223-020-00771-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/12/2020] [Indexed: 12/11/2022]
Abstract
Hypophosphatasia (HPP) is a rare inborn error of metabolism due to a decreased activity of tissue nonspecific alkaline phosphatase (TNSALP). As the onset and severity of HPP are heterogenous, it can be challenging to determine the pathogenicity of detected rare ALPL variants in symptomatic patients. We aimed to characterize patients with rare ALPL variants to propose which patients can be diagnosed with adult HPP. We included 72 patients with (1) clinical symptoms of adult HPP or positive family history and (2) low TNSALP activity and/or high pyridoxal 5'-phosphate (PLP) levels, who underwent ALPL gene sequencing. The patients were analyzed and divided into three groups depending on ALPL variant pathogenicity according to the classification of the American College of Medical Genetics and Genomics (ACMG). Reported pathogenic (n = 34 patients), rare (n = 17) and common (n = 21) ALPL variants only were found. Muscular complaints were the most frequent symptoms (> 80%), followed by bone affection (> 50%). Tooth involvement was significantly more common in patients with pathogenic or rare ALPL variants. Seven rare variants could be classified as likely pathogenic (ACMG class 4) of which five have not yet been described. Inconclusive genetic findings and less specific symptoms make diagnosis difficult in cases where adult HPP is not obvious. As not every pathogenic or rare ALPL variant leads to a manifestation of HPP, only patients with bone complications and at least one additional complication concerning teeth, muscle, central nervous and mental system, repeated low TNSALP activity and high PLP levels should be diagnosed as adult HPP if rare ALPL gene variants of ACMG class 4 or higher support the diagnosis.
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Affiliation(s)
- Nico Maximilian Jandl
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Tobias Schmidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Tim Rolvien
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Julian Stürznickel
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Konstantin Chrysostomou
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Emil von Vopelius
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Alexander E Volk
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Thorsten Schinke
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Christian Kubisch
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany.
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39
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Sperelakis-Beedham B, Taillandier A, Domingues C, Guberto M, Colin E, Porquet-Bordes V, Rothenbuhler A, Salles JP, Wenkert D, Zankl A, Muti C, Bacrot S, Simon-Bouy B, Mornet E. Utility of genetic testing for prenatal presentations of hypophosphatasia. Mol Genet Metab 2021; 132:198-203. [PMID: 33549410 DOI: 10.1016/j.ymgme.2021.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 01/13/2023]
Abstract
Hypophosphatasia (HPP) is a rare inherited disease affecting bone and dental mineralization due to loss-of-function mutations in the ALPL gene encoding the tissue nonspecific alkaline phosphatase (TNSALP). Prenatal benign HPP (PB HPP) is a rare form of HPP characterized by in utero skeletal manifestations that progressively improve during pregnancy but often still leave symptoms after birth. Because the prenatal context limits the diagnostic tools, the main difficulty for clinicians is to distinguish PB HPP from perinatal lethal HPP, the most severe form of HPP. We previously attempted to improve genotype phenotype correlation with the help of a new classification of variants based on functional testing. Among 46 perinatal cases detected in utero or in the neonatal period for whose ALPL variants could be classified, imaging alone was thought to clearly diagnose severe lethal HPP in 35 cases, while in 11 cases, imaging abnormalities could not distinguish between perinatal lethal and BP HPP. We show here that our classification of ALPL variants may improve the ability to distinguish between perinatal lethal and PB HPP in utero.
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Affiliation(s)
| | - Agnès Taillandier
- Unité de Génétique constitutionnelle, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Christelle Domingues
- Unité de Génétique constitutionnelle, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Mihelaiti Guberto
- Unité de Génétique constitutionnelle, Centre Hospitalier de Versailles, Le Chesnay, France
| | | | - Valérie Porquet-Bordes
- Pédiatrie - Endocrinologie, génétique et gynécologie médicale, Hôpital des enfants (CHU Toulouse), Toulouse, France
| | - Anya Rothenbuhler
- Service d'endocrinologie et diabète de l'enfant, Hôpital Bicêtre (Hôpitaux Universitaires Paris Saclay - APHP), Paris, France
| | - Jean-Pierre Salles
- Pédiatrie - Endocrinologie, génétique et gynécologie médicale, Hôpital des enfants (CHU Toulouse), Toulouse, France
| | - Deborah Wenkert
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, USA; Wenkert & Young, LLC, Thousand Oaks, CA 91362, USA
| | - Andreas Zankl
- Department of Clinical Genetics, Sydney Children's Hospital Network (Westmead), Westmead, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Bone Biology Division and Kinghorn Centre for Clinical Genomics, Garvan Institute of Medical Research, Darlinghurst, Australia
| | - Christine Muti
- Unité de Génétique constitutionnelle, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Séverine Bacrot
- Unité de Génétique constitutionnelle, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Brigitte Simon-Bouy
- Unité de Génétique constitutionnelle, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Etienne Mornet
- Unité de Génétique constitutionnelle, Centre Hospitalier de Versailles, Le Chesnay, France.
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40
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Rossi M, Battafarano G, De Martino V, Scillitani A, Minisola S, Del Fattore A. Looking for new anabolic treatment from rare diseases of bone formation. J Endocrinol 2021; 248:R29-R40. [PMID: 33258798 DOI: 10.1530/joe-20-0285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/24/2020] [Indexed: 11/08/2022]
Abstract
Bone remodelling is a complex mechanism regulated by osteoclasts and osteoblasts and perturbation of this process leads to the onset of diseases, which may be characterised by altered bone erosion or formation. In this review, we will describe some bone formation-related disorders as sclerosteosis, van Buchem disease, hypophosphatasia and Camurati-Engelmann disease. In the past decades, the research focused on these rare disorders offered the opportunity to understand important pathways regulating bone formation. Thus, the identification of the molecular defects behind the etiopathology of these diseases will open the way for new therapeutic approaches applicable also to the management of more common bone diseases including osteoporosis.
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Affiliation(s)
- Michela Rossi
- Bone Physiopathology Unit, Genetics and Rare Diseases Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giulia Battafarano
- Bone Physiopathology Unit, Genetics and Rare Diseases Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Viviana De Martino
- Department of Clinical, Internal, Anaesthesiology and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Alfredo Scillitani
- Endocrinology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Casa Sollievo della Sofferenza, Foggia, Italy
| | - Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiology and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Andrea Del Fattore
- Bone Physiopathology Unit, Genetics and Rare Diseases Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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41
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Abstract
UNLABELLED In adult hypophosphatasia (HPP) patients, elevated lumbar spine dual X-ray absorptiometry (DXA) values are associated with markers of disease severity and disease-specific fracture risk while femoral bone mineral density (BMD), being largely unaffected by the disease severity, may still be useful to monitor other causes of increased fracture risk due to low BMD. INTRODUCTION Hypophosphatasia (HPP) is a rare inherited metabolic disorder due to deficient activity of the tissue-nonspecific alkaline phosphatase (TNAP). Clinical manifestation in adult HPP patients is manifold including an increased risk for fractures, but data regarding clinical significance of DXA measurement and associations with fracture risk and disease severity is scarce. METHODS Retrospective single-center analysis of DXA scans in patients with confirmed HPP (documented mutation, clinical symptoms, low alkaline phosphatase activity). Further data evaluation included disease-related fractures, laboratory results (alkaline phosphatase, pyridoxalphosphate, phosphoethanolamine), and medical history. RESULTS Analysis included 110 patients (84 female, mean age of 46.2 years) of whom 37.3% (n = 41) were harboring two mutations. Average T-Score level at the lumbar spine was - 0.1 (SD 1.9), and mean total hip T-Score was - 1.07 (SD 0.15). Both lower ALP activity and higher substrate levels (pyridoxalphosphate and phosphoethanolamine) were significantly correlated with increased lumbar spine T-Score levels (p < 0.001) while BMD at the hip was not affected by indicators of disease severity. Increased lumbar spine BMD was significantly associated with an increased risk for HPP-related fractures, prevalent in 22 (20%) patients (p < 0.001) with 21 of them having biallelic mutations. CONCLUSION BMD in adult HPP patients is not systematically reduced. Conversely, increased lumbar spine BMD appears to be associated with severely compromised mineralization and increased risk for HPP-related fractures while BMD at the hip appears unaffected by indicators of disease severity, suggesting suitability of this anatomic location for assessing and discerning disorders with increased fracture risk owing to reduced BMD like osteoporosis. TRIAL REGISTRATION NUMBER German register for clinical studies (DRKS00014022) DATE OF REGISTRATION: 02/10/2018 - retrospectively registered.
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Affiliation(s)
- F Genest
- Clinical Trial Unit, Orthopedic Department, University of Wuerzburg, Brettreichstrasse 11, 97074, Wuerzburg, Germany
| | - L Claußen
- Clinical Trial Unit, Orthopedic Department, University of Wuerzburg, Brettreichstrasse 11, 97074, Wuerzburg, Germany
| | - D Rak
- Clinical Trial Unit, Orthopedic Department, University of Wuerzburg, Brettreichstrasse 11, 97074, Wuerzburg, Germany
| | - L Seefried
- Clinical Trial Unit, Orthopedic Department, University of Wuerzburg, Brettreichstrasse 11, 97074, Wuerzburg, Germany.
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Kramer K, Chavez MB, Tran AT, Farah F, Tan MH, Kolli TN, Dos Santos EJL, Wimer HF, Millán JL, Suva LJ, Gaddy D, Foster BL. Dental defects in the primary dentition associated with hypophosphatasia from biallelic ALPL mutations. Bone 2021; 143:115732. [PMID: 33160095 PMCID: PMC7769999 DOI: 10.1016/j.bone.2020.115732] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022]
Abstract
ALPL encodes tissue-nonspecific alkaline phosphatase (TNAP), an enzyme expressed in bone, teeth, liver, and kidney. ALPL loss-of-function mutations cause hypophosphatasia (HPP), an inborn error-of-metabolism that produces skeletal and dental mineralization defects. Case reports describe widely varying dental phenotypes, making it unclear how HPP comparatively affects the three unique dental mineralized tissues: enamel, dentin, and cementum. We hypothesized that HPP affected all dental mineralized tissues and aimed to establish quantitative measurements of dental tissues in a subject with HPP. The female proband was diagnosed with HPP during childhood based on reduced alkaline phosphatase activity (ALP), mild rachitic skeletal effects, and premature primary tooth loss. The diagnosis was subsequently confirmed genetically by the presence of compound heterozygous ALPL mutations (exon 5: c.346G>A, p.A116T; exon 10: c.1077C>G, p.I359M). Dental defects in 8 prematurely exfoliated primary teeth were analyzed by high resolution micro-computed tomography (micro-CT) and histology. Similarities to the Alpl-/- mouse model of HPP were identified by additional analyses of murine dentoalveolar tissues. Primary teeth from the proband exhibited substantial remaining root structure compared to healthy control teeth. Enamel and dentin densities were not adversely affected in HPP vs. control teeth. However, analysis of discrete dentin regions revealed an approximate 10% reduction in the density of outer mantle dentin of HPP vs. control teeth. All 4 incisors and the molar lacked acellular cementum by micro-CT and histology, but surprisingly, 2 of 3 prematurely exfoliated canines exhibited apparently normal acellular cementum. Based on dentin findings in the proband's teeth, we examined dentoalveolar tissues in a mouse model of HPP, revealing that the delayed initiation of mineralization in the incisor mantle dentin was associated with a broader lack of circumpulpal dentin mineralization. This study describes a quantitative approach to measure effects of HPP on dental tissues. This approach has uncovered a previously unrecognized novel mantle dentin defect in HPP, as well as a surprising and variable cementum phenotype within the teeth from the same HPP subject.
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Affiliation(s)
- K Kramer
- Division of Orthodontics, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - M B Chavez
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - A T Tran
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - F Farah
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - M H Tan
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - T N Kolli
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - E J Lira Dos Santos
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA; Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, University of Campinas-UNICAMP, Piracicaba, SP, Brazil
| | - H F Wimer
- Department of Vertebrate Zoology, National Museum of Natural History, Smithsonian Institution, Washington, DC, USA; National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - J L Millán
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - L J Suva
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
| | - D Gaddy
- Department of Veterinary Integrative Biosciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
| | - B L Foster
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA.
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Vislobokova EV, Kiselnikova LP, Lezhnev DA, Murtazaev SS, Sholokhova NA. [Periodontal status evaluation in adolescents with hereditary rickets-like diseases]. Stomatologiia (Mosk) 2021; 100:63-69. [PMID: 34953191 DOI: 10.17116/stomat202110006163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Hypophosphatemic rickets (HPPR) and hypophosphatasia (HPP) are hereditary pathologies accompanied by phosphorus metabolism problems and rickets deformities of the skeleton. Periodontal diseases, their diagnostic methods and factors affecting the progress of periodontal tissue damage are the least studied among the dental manifestations of HPPR and HPP. OBJECTIVE The aim of present cohort study was evaluation of periodontal tissue status in adolescents with HPPR and HPP. MATERIALS AND METHODS A dental examination of 20 adolescents aged 12 to 18 years with genetically and biochemically confirmed hereditary rickets-like diseases (E83.3 Disorders of phosphorus metabolism and phosphatases: hypophosphatemic rickets (HPPR) and hypophosphatasia (HPP)) was performed at the Pediatric Dentistry Department of Moscow State University of Medicine and Dentistry. In the present study clinical examination and cone-beam computed tomography (CBCT) data of patients were analyzed. RESULTS According to the clinical examination data, a strong direct correlation was found between patient's age and the periodontal diseases severity (correlation coefficient r=0.87) in the study group. CBCT revealed the significant alveolar bone hypomineralization in adolescents with HPPR and HPP in comparison to control group (p<0.05). According to the measurement results obtained a strong inverse correlation between alveolar bone mineral density and alveolar bone reduction (correlation coefficient r= -0.74) in adolescents with hereditary rickets-like diseases was revealed. CONCLUSION The diagnostic options of CBCT allow to begin comprehensive dental treatment of patients with HPPR and HPP at an early stage of periodontal disease preventing further development of pathology.
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Affiliation(s)
- E V Vislobokova
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov, Moscow, Russia
| | - L P Kiselnikova
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov, Moscow, Russia
| | - D A Lezhnev
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov, Moscow, Russia
| | - S S Murtazaev
- Tashkent State Dental Institute, Tashkent, Uzbekistan
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Matsuda N, Takasawa K, Ohata Y, Takishima S, Kubota T, Ishihara Y, Fujiwara M, Ogawa E, Morio T, Kashimada K, Ozono K. Potential pathological role of single nucleotide polymorphism (c.787T>C) in alkaline phosphatase (ALPL) for the phenotypes of hypophosphatasia. Endocr J 2020; 67:1227-1232. [PMID: 32779619 DOI: 10.1507/endocrj.ej20-0203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Hypophosphatasia (HPP; OMIM 241510, 241500, and 146300) is an inherited metabolic disease characterized by defects of bone and tooth mineralization, which is caused by loss-of-function mutations in the ALPL gene encoding tissue non-specific alkaline phosphatase (TNSALP). In the last three decades, several studies have focused on the genotype-phenotype correlation in hypophosphatasia (HPP). In particular, functional tests based on in vitro analysis for the residual enzymatic activities of mutations have revealed a clear but imperfect genotype-phenotype correlation, suggesting that multiple potential factors modulate the phenotype. One of the missense variants identified in the tissue non-specific alkaline phosphatase (ALPL) gene, c.787T>C, has been considered as a benign polymorphism in HPP; however, its pathogenicity and role in disease manifestation remain controversial. We here report our recent experience of three unrelated families harboring the c.787T>C variant, suggesting clinical implications regarding the controversial pathogenicity of c.787T>C. First, despite the lack of obvious clinical phenotypes, homozygous c.787T>C would decrease the serum level of ALP activity. Second, c.787T>C might deteriorate phenotypes of a patient harboring another ALPL variant, especially one that has thus far presumed to be benign, e.g., the c.1144G>A variant. These cases contribute to the recent advances in understanding HPP to facilitate clinical recognition of more subtle phenotypes, further providing insights into the pathogenesis of HPP.
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Affiliation(s)
- Nozomi Matsuda
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
- Department of Pediatrics, Soka Municipal Hospital, Saitama 340-8560, Japan
| | - Kei Takasawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
| | - Yasuhisa Ohata
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Shigeru Takishima
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
- Department of Pediatrics, Soka Municipal Hospital, Saitama 340-8560, Japan
| | - Takuo Kubota
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Yasuki Ishihara
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
- The first Department of Oral and Maxillofacial Surgery, Osaka University Graduate School of Dentistry, Osaka 565-0871, Japan
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Makoto Fujiwara
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
- The first Department of Oral and Maxillofacial Surgery, Osaka University Graduate School of Dentistry, Osaka 565-0871, Japan
| | - Erika Ogawa
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo 101-8309, Japan
| | - Tomohiro Morio
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
| | - Kenichi Kashimada
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
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45
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Kato M, Hattori T, Shimizu T, Ninagawa K, Izumihara R, Nomoto H, Tanimura K, Atsumi T. Intrafamilial phenotypic distinction of hypophosphatasia with identical tissue nonspecific alkaline phosphatase gene mutation: a family report. J Bone Miner Metab 2020; 38:903-907. [PMID: 32772198 DOI: 10.1007/s00774-020-01137-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 07/30/2020] [Indexed: 10/23/2022]
Abstract
Hypophosphatasia (HPP) is caused by mutations in the tissue nonspecific alkaline phosphatase (TNSALP) gene in an autosomal recessive or dominant manner and characterized by defective mineralization of bone and low serum ALP levels. In this report, we present a family with HPP mother (case 1) and HPP child (case 2) who have identical TNSALP gene mutation (c.1015G>A p.Gly339Arg heterozygous mutation) but distinct clinical phenotypes. Whereas case 1 appeared to be asymptomatic despite extremely low levels of serum ALP, case 2 had several HPP-related symptoms, such as tooth loss, fractures, short stature, with slightly decreased ALP levels. Upon the diagnosis of HPP, case 1 discontinued denosumab, which was used to treat her rheumatoid arthritis, concerning the risk of atypical femoral fractures. The clinical course of this family was suggestive in a genotype-phenotype imbalance in HPP, the underdiagnosis of HPP in adults, and the risk of atypical femoral fractures using bone resorption inhibitors.
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Affiliation(s)
- Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N15W7, Kita-Ku, Sapporo, 060-8638, Japan.
| | | | - Tomohiro Shimizu
- Department of Orthopedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Keita Ninagawa
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N15W7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Rimi Izumihara
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N15W7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Hiroshi Nomoto
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N15W7, Kita-Ku, Sapporo, 060-8638, Japan
| | | | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N15W7, Kita-Ku, Sapporo, 060-8638, Japan
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46
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Martins L, Dos Santos EL, de Almeida AB, Machado RA, Lyrio AM, Foster BL, Kantovitz KR, Coletta RD, Nociti FH. A novel de novo heterozygous ALPL nonsense mutation associated with adult hypophosphatasia. Osteoporos Int 2020; 31:2251-2257. [PMID: 32572521 PMCID: PMC8214176 DOI: 10.1007/s00198-020-05490-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 06/03/2020] [Indexed: 12/20/2022]
Abstract
UNLABELLED Using genetic, clinical, biochemical, and radiographic assessment and bioinformatic approaches, we present an unusual case of adult HPP caused by a novel de novo heterozygous nonsense mutation in the alkaline phosphatase (ALPL). INTRODUCTION Hypophosphatasia (HPP) is caused by genetic alterations of the ALPL gene, encoding the tissue-nonspecific isozyme of alkaline phosphatase (TNSALP). Here, the purpose was to perform clinical and molecular investigation in a 36-year-old Caucasian woman suspected to present adult HPP. METHODS Medical and dental histories were obtained for the proposita and family members, including biochemical, radiographic, and dental assessments. ALPL mutational analysis was performed by the Sanger sequencing method, and the functional impact prediction of the identified mutations was assessed by bioinformatic methods. RESULTS We identified a novel heterozygous nonsense mutation in the ALPL gene (NM_000478.6:c.768G>A; W[TGG]>*[TGA]) associated with spontaneous vertebral fracture, severe back pain, musculoskeletal pain, low bone density, and short-rooted permanent teeth loss. Functional prediction analysis revealed that the Trp256Ter mutation led to a complete loss of TNSALP crown domain and extensive loss of other functional domains (calcium-binding domain, active site vicinity, and zinc-binding site) and over 60% loss of homodimer interface residues, suggesting that the mutant TNSALP molecules are nonfunctional and form unstable homodimers. Genotyping of the ALPL in the proposita's parents, sister, and niece revealed that in this case, HPP occurred due to a de novo mutation. CONCLUSION The present study describes a novel genotype-phenotype and structure-function relationship for HPP, contributing to a better molecular comprehension of HPP etiology and pathophysiology.
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Affiliation(s)
- L Martins
- Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, State University of Campinas - UNICAMP, Av. Limeira, 901, Piracicaba, SP, 13414-903, Brazil
| | - E L Dos Santos
- Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, State University of Campinas - UNICAMP, Av. Limeira, 901, Piracicaba, SP, 13414-903, Brazil
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - A B de Almeida
- Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, State University of Campinas - UNICAMP, Av. Limeira, 901, Piracicaba, SP, 13414-903, Brazil
| | - R A Machado
- Department of Oral Diagnosis, Piracicaba Dental School, State University of Campinas - UNICAMP, Piracicaba, SP, Brazil
- Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo (HRAC/USP), Bauru, SP, Brazil
| | - A M Lyrio
- Pontifical Catholic University of Campinas, Campinas, SP, Brazil
| | - B L Foster
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - K R Kantovitz
- Department of Dental Materials, São Leopoldo Research Center, Campinas, SP, Brazil
| | - R D Coletta
- Department of Oral Diagnosis, Piracicaba Dental School, State University of Campinas - UNICAMP, Piracicaba, SP, Brazil
| | - F H Nociti
- Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, State University of Campinas - UNICAMP, Av. Limeira, 901, Piracicaba, SP, 13414-903, Brazil.
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47
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Li XY, Wan XH, Chen L, Guo WH, Wang L. A compound heterozygous ALPL variant in a patient with dystonia-parkinsonism and hypointensity in basal ganglia: A case report. Parkinsonism Relat Disord 2020; 78:184-185. [PMID: 32956941 DOI: 10.1016/j.parkreldis.2020.07.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/20/2020] [Accepted: 07/29/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Xin-Yao Li
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 100730, China
| | - Xin-Hua Wan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 100730, China
| | - Lin Chen
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 100730, China
| | - Wei-Hong Guo
- Department of Vasculocardiology, Fuwai Hospital, Chinese Academy of Medical Sciences, 100037, China
| | - Lin Wang
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 100730, China.
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48
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Okawa R, Kadota T, Matayoshi S, Nakano K. Dental Manifestations Leading to the Diagnosis of Hypophosphatasia in Two Children. J Dent Child (Chic) 2020; 87:179-183. [PMID: 33349304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Hypophosphatasia (HPP) is an inherited bone disease caused by mutation of the alkaline phosphatase, biomineralization associated (ALPL) gene and is characterized by bone hypomineralization and/or early exfoliation of primary teeth. Dental manifestations can lead to the diagnosis of milder types of HPP. The purpose of this paper is to report the case of two patients with growth and development problems who were referred to a dental clinic due to early exfoliation of primary teeth and were subsequently diagnosed with childhood HPP with bone symptoms. Early diagnosis of HPP and management of growth and development are important, as HPP is a progressive disease. When dentists detect early exfoliation of the mandibular incisors before four years of age, they should refer the patient for investigation of HPP. Growth and development should be closely monitored in patients with early primary tooth exfoliation.
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Affiliation(s)
- Rena Okawa
- Dr. Okawa is an associate professor, Department of Pediatric Dentistry, Graduate School of Dentistry Osaka University, Osaka, Japan;,
| | - Tamami Kadota
- Drs. Kadota, Department of Pediatric Dentistry, Graduate School of Dentistry Osaka University, Osaka, Japan
| | - Saaya Matayoshi
- Matayoshi are graduate students, Department of Pediatric Dentistry, Graduate School of Dentistry Osaka University, Osaka, Japan
| | - Kazuhiko Nakano
- Dr. Nakano is a professor, Department of Pediatric Dentistry, Graduate School of Dentistry Osaka University, Osaka, Japan
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49
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Whyte MP, Ma NS, Mumm S, Gottesman GS, McAlister WH, Nenninger AR, Bijanki VN, Ericson KL, Magnusson P. Persistent idiopathic hyperphosphatasemia from bone alkaline phosphatase in a healthy boy. Bone 2020; 138:115459. [PMID: 32474245 DOI: 10.1016/j.bone.2020.115459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/26/2020] [Accepted: 05/26/2020] [Indexed: 11/19/2022]
Abstract
Alkaline phosphatase (ALP) in humans comprises a family of four cell-surface phosphomonoester phosphohydrolase isozymes. Three genes separately encode the "tissue-specific" ALPs whereas the fourth gene encodes ubiquitous homodimeric "tissue-nonspecific" ALP (TNSALP) richly expressed in bone, liver, kidney, and developing teeth. TNSALP monomers have five putative N-linked glycosylation sites where different post-translational modifications account for this isozyme's distinctive physicochemical properties in different organs. Three bone-derived TNSALP (BALP) isoforms (B/I, B1, and B2) are present in healthy serum, whereas a fourth BALP isoform (B1x) can circulate in chronic kidney disease. Herein, we report a healthy boy with persistent hyperphosphatasemia due to BALP levels two- to threefold higher than age-appropriate reference values. High-performance liquid chromatography, electrophoresis, heat inactivation, catalysis inhibition, and polyethylene glycol precipitation revealed increased serum B/I, B1, and B2 differing from patterns found in skeletal diseases. B/I was ~23-fold elevated. Absence of mental retardation and physical stigmata excluded Mabry syndrome, the ALP-anchoring disorder causing hyperphosphatasemia. Routine biochemical studies indicated intact mineral homeostasis. Serum N-terminal propeptide of type I procollagen (P1NP) level was normal, but C-terminal cross-linking telopeptide of type I collagen (CTX) level was elevated. However, radiological studies showed no evidence for a generalized skeletal disturbance. Circulating pyridoxal 5'-phosphate, a TNSALP natural substrate, was not low despite the laboratory hyperphosphatasemia, thereby suggesting BALP phosphohydrolase activity was not elevated endogenously. Mutation analysis of the ALPL gene encoding TNSALP revealed no defect. His non-consanguineous healthy parents had serum total ALP activity and BALP protein levels that were normal. Our patient's sporadic idiopathic hyperphosphatasemia could reflect altered post-translational modification together with increased expression and/or impaired degradation of BALP.
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Affiliation(s)
- Michael P Whyte
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children, St. Louis, MO 63110, USA; Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA.
| | - Nina S Ma
- Division of Endocrinology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA.
| | - Steven Mumm
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children, St. Louis, MO 63110, USA; Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA.
| | - Gary S Gottesman
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children, St. Louis, MO 63110, USA.
| | - William H McAlister
- Mallinckrodt Institute of Radiology, Washington University School of Medicine at St. Louis Children's Hospital, St. Louis, MO 63110, USA.
| | - Angela R Nenninger
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children, St. Louis, MO 63110, USA.
| | - Vinieth N Bijanki
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children, St. Louis, MO 63110, USA.
| | - Karen L Ericson
- Department of Chemistry, Purdue University-Fort Wayne, Fort Wayne, IN 46805, USA.
| | - Per Magnusson
- Department of Clinical Chemistry and Department of Biomedical and Clinical Sciences, Linköping University, SE-58185 Linköping, Sweden.
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50
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Bloch-Zupan A, Baujat G, Ursprung S. [Living with hypophosphatasia]. Rev Prat 2020; 70:751-752. [PMID: 33739721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Agnès Bloch-Zupan
- Présidente du Conseil scientifique international de Hypophosphatasie Europe depuis 2008, chirurgien-dentiste, Professeur des universités, praticien hospitalier, enseignant chercheur au Centre de référence des maladies rares orales et dentaires des HUS de Strasbourg, France
| | - Geneviève Baujat
- Pédiatre, généticienne et clinicienne au Centre de référence maladies osseuses constitutionnelles, Paris, France
| | - Steve Ursprung
- Cofondateur de Hypophosphatasie Europe, vice-président du Conseil scientifique international en qualité de « malade expert », Huningue, France Association Hypophosphatasie Europe
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