1
|
Arcidiacono GP, Camozzi V, Zaninotto M, Tripepi G, Fusaro M, Torres MO, Zanchetta F, Cannito M, Cecchinato A, Diogo M, Peleg Falb M, Plebani M, Simioni P, Sella S, Giannini S. Tubular phosphate transport: a comparison between different methods of urine sample collection in FGF23-dependent hypophosphatemic syndromes. Clin Chem Lab Med 2024; 62:1126-1132. [PMID: 38295343 DOI: 10.1515/cclm-2023-1292] [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: 11/14/2023] [Accepted: 01/23/2024] [Indexed: 02/02/2024]
Abstract
OBJECTIVES Tubular maximum phosphate reabsorption per glomerular filtration rate (TmP/GFR) is used to evaluate renal phosphate reabsorption and it is a useful tool for the differential diagnosis of hypophosphatemic syndromes. TmP/GFR is typically calculated from fasting plasma and second morning void urine samples, obtained 2 h after the first void (TmP/GFR 2 h). The purpose of this study was to evaluate if TmP/GFR calculated from 24 h urine collection (TmP/GFR 24 h) can be used as an alternative for TmP/GFR 2 h in patients with urine phosphate wasting. METHODS We enrolled adult patients with X-linked hypophosphatemia (XLH) or tumor-induced osteomalacia (TIO). All patients underwent blood and urine sample collections, to calculate TmP/GFR 24 h and TmP/GFR 2 h. RESULTS Twenty patients (17 XLH and 3 TIO), aged 24-78 years, were included. All patients had low TmP/GFR 2 h (0.35 mmol/L, IQR 0.24-0.47 mmol/L) and TmP/GFR 24 h (0.31 mmol/L, IQR 0.22-0.43 mmol/L). The concordance correlation coefficient between TmP/GFR 2 h and TmP/GFR 24 h was 0.86 (95 % CI: 0.69-0.93), with a systematic bias of 0.05 mmol/L (95 % limits of agreement: -0.10 to 0.20). Furthermore, in 70 % (i.e., 14 patients out of 20) and 80 % (i.e., 16 patients out of 20) of cases the difference between TmP/GFR 2 h and TmP/GFR 24 h was within ±30 % and ±35 %, respectively. CONCLUSIONS Despite TmP/GFR 2 and 24 h show a relatively suboptimal agreement, the difference between the two parameters appears to be small and not clinically significant in the setting of adult patients with FGF23-dependent urine phosphate wasting and secondary hypophosphatemia.
Collapse
Affiliation(s)
| | - Valentina Camozzi
- Department of Medicine, Endocrinology Unit, University of Padova, Padova, Italy
| | - Martina Zaninotto
- Department of Medicine, Laboratory Medicine Unit, University of Padova, Padova, Italy
| | - Giovanni Tripepi
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Clinical Epidemiology of Renal Diseases and Hypertension, Ospedali Riuniti, Reggio Calabria, Italy
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy
| | | | - Francesca Zanchetta
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Michele Cannito
- Department of Medicine, Endocrinology Unit, University of Padova, Padova, Italy
| | - Alberta Cecchinato
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Martin Diogo
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Mor Peleg Falb
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Mario Plebani
- Department of Medicine, Laboratory Medicine Unit, University of Padova, Padova, Italy
| | - Paolo Simioni
- Department of Medicine, General Medicine and Thrombotic and Hemorrhagic Diseases Unit, University of Padova, Padova, Italy
| | - Stefania Sella
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| |
Collapse
|
2
|
Gonzalez Ballesteros LF, Ma NS, Gordon RJ, Ward L, Backeljauw P, Wasserman H, Weber DR, DiMeglio LA, Gagne J, Stein R, Cody D, Simmons K, Zimakas P, Topor LS, Agrawal S, Calabria A, Tebben P, Faircloth R, Imel EA, Casey L, Carpenter TO. Unexpected widespread hypophosphatemia and bone disease associated with elemental formula use in infants and children. Bone 2017; 97:287-292. [PMID: 28167344 PMCID: PMC5884631 DOI: 10.1016/j.bone.2017.02.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 01/30/2017] [Accepted: 02/02/2017] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Hypophosphatemia occurs with inadequate dietary intake, malabsorption, increased renal excretion, or shifts between intracellular and extracellular compartments. We noticed the common finding of amino-acid based elemental formula [EF] use in an unexpected number of cases of idiopathic hypophosphatemia occurring in infants and children evaluated for skeletal disease. We aimed to fully characterize the clinical profiles in these cases. METHODS A retrospective chart review of children with unexplained hypophosphatemia was performed as cases accumulated from various centres in North America and Ireland. Data were analyzed to explore any relationships between feeding and biochemical or clinical features, effects of treatment, and to identify a potential mechanism. RESULTS Fifty-one children were identified at 17 institutions with EF-associated hypophosphatemia. Most children had complex illnesses and had been solely fed Neocate® formula products for variable periods of time prior to presentation. Feeding methods varied. Hypophosphatemia was detected during evaluation of fractures or rickets. Increased alkaline phosphatase activity and appropriate renal conservation of phosphate were documented in nearly all cases. Skeletal radiographs demonstrated fractures, undermineralization, or rickets in 94% of the cases. Although the skeletal disease had often been attributed to underlying disease, most all improved with addition of supplemental phosphate or change to a different formula product. CONCLUSION The observed biochemical profiles indicated a deficient dietary supply or severe malabsorption of phosphate, despite adequate formula composition. When transition to an alternate formula was possible, biochemical status improved shortly after introduction to the alternate formula, with eventual improvement of skeletal abnormalities. These observations strongly implicate that bioavailability of formula phosphorus may be impaired in certain clinical settings. The widespread nature of the findings lead us to strongly recommend careful monitoring of mineral metabolism in children fed EF. Transition to alternative formula use or implementation of phosphate supplementation should be performed cautiously with as severe hypocalcemia may develop.
Collapse
Affiliation(s)
| | - Nina S Ma
- Boston Children's Hospital, Boston, MA, United States
| | | | - Leanne Ward
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | | | | | - David R Weber
- University of Rochester, Rochester, NY, United States
| | - Linda A DiMeglio
- Riley Hospital for Children, Indiana University, Indianapolis, IN, United States
| | - Julie Gagne
- Centre Hospitalier de l'Université Laval, Quebec City, QC, Canada
| | - Robert Stein
- Children's Hospital of Western Ontario, London, ON, Canada
| | - Declan Cody
- Our Lady's Children's Hospital, Crumlin, Ireland
| | | | - Paul Zimakas
- University of Vermont Medical Center, Burlington, VT, United States
| | - Lisa Swartz Topor
- Alpert Medical School of Brown University, Providence, RI, United States; Hasbro Children's Hospital, Providence, RI, United States
| | - Sungeeta Agrawal
- Alpert Medical School of Brown University, Providence, RI, United States; Hasbro Children's Hospital, Providence, RI, United States
| | - Andrew Calabria
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | | | - Ruth Faircloth
- Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Erik A Imel
- Riley Hospital for Children, Indiana University, Indianapolis, IN, United States
| | - Linda Casey
- British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Thomas O Carpenter
- Yale University School of Medicine, Department of Pediatrics, New Haven, CT, United States.
| |
Collapse
|
3
|
Giovannini I, Chiarla C, Giuliante F, Ardito F, Vellone M, Nuzzo G. Hepatic resection-related hypophosphatemia is of renal origin as manifested by isolated hyperphosphaturia. Ann Surg 2006; 243:429; author reply 429. [PMID: 16495716 PMCID: PMC1448946 DOI: 10.1097/01.sla.0000202002.17260.c4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
4
|
Rendina D, Mossetti G, De Filippo G, Cioffi M, Strazzullo P. Fibroblast growth factor 23 is increased in calcium nephrolithiasis with hypophosphatemia and renal phosphate leak. J Clin Endocrinol Metab 2006; 91:959-63. [PMID: 16352682 DOI: 10.1210/jc.2005-1606] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [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] [Indexed: 02/12/2023]
Abstract
CONTEXT Nephrolithiasis affects about 10% of the population in industrialized countries, with calcium salts composing more than 80% of renal stones. A significant percentage of patients with calcium nephrolithiasis and normal parathyroid function show hypophosphatemia and reduced renal phosphate reabsorption (i.e. a renal phosphate leak). OBJECTIVES The objective of the study was to compare serum levels of fibroblast growth factor 23 (FGF23), a regulator of phosphate homeostasis, in 110 recurrent stone formers with or without renal phosphate leak, six patients affected by X-linked hypophosphatemic rickets, five patients affected by oncogenic osteomalacia, and 60 unrelated healthy controls. DESIGN This was a prospective interventional study. METHODS Renal phosphate leak was identified based on the occurrence of idiopathic hypophosphatemia [serum phosphate concentration < 2.50 mg/dl (<0.80 mmol/liter)] and reduced renal threshold phosphate concentration [<2.2 mg/liter (<0.70 mmol/liter)]. RESULTS In 22 stone formers with renal phosphate leak, serum FGF23 concentration was significantly higher as compared with 88 stone formers without renal phosphate leak and with controls [83.3 (65.6-101.1) vs. 32.1 (26.8-37.4) and 24.5 (19.8-29.1) reference units (RU)/ml, respectively]. Stone formers with renal phosphate leak showed lower FGF23, compared with patients with oncogenic osteomalacia and X-linked hypophosphatemic rickets [572.3 (235.9-908.7) RU/ml]. Among stone formers and controls, serum FGF23 concentration displayed a strong inverse association with serum phosphate (r = -0.784, P = 0.009) and the rate of tubular phosphate reabsorption (r = -0.791, P = 0.008). CONCLUSIONS In our study population, renal phosphate leak affected 20% of stone formers and was strongly associated with increased serum FGF23 concentration.
Collapse
Affiliation(s)
- Domenico Rendina
- Department of Clinical and Experimental Medicine, Università Federico II, Via S. Pansini, 5-80131 Naples, Italy
| | | | | | | | | |
Collapse
|
5
|
Fine DM. Editorial comment: tenofovir nephrotoxicity--vigilance required. AIDS Read 2005; 15:362-3. [PMID: 16044578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
|
6
|
Ungari C, Rocchi G, Rinna C, Agrillo A, Lattanzi A, Pagnoni M. Hypophosphaturic mesenchymal tumor of the ethmoid associated with oncogenic osteomalacia. J Craniofac Surg 2004; 15:523-7. [PMID: 15111823 DOI: 10.1097/00001665-200405000-00036] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Oncogenic osteomalacia is an uncommon syndrome characterized by bone pain, proximal muscle weakness, hypophosphatemia, hyperphosphaturia, and a low plasma concentration of 1,25-dihydroxy-vitamin D. The disease affects both sexes at around 40 years of age, although it can sometimes affect children and adolescents. Generally, the syndrome is associated with a tumor, usually benign, of mesenchymal origin and is resolved after removal of the tumor; this syndrome can sometimes be associated with malignant tumors. These tumors seem to be histologically heterogeneous and are generally localized in soft tissues and bone. In this article, a case of oncogenic osteomalacia associated with a hypophosphaturic mesenchymal tumor of the ethmoid is reported in a 24-year-old man. After surgical and radical removal of the tumor, the patient noted a decrease in the clinical symptoms and signs.
Collapse
Affiliation(s)
- Claudio Ungari
- Department of Maxillofacial Surgery, University of Rome La Sapienza, Rome, Italy
| | | | | | | | | | | |
Collapse
|
7
|
Abstract
AIM To analyse the role of serum and urinary calcium and phosphorus levels in early detection of mineral deficiency in very low birthweight (VLBW) infants born appropriate (AGA) and small for gestational age (SGA). METHODS 64 VLBW infants were included in a cohort study and divided into two groups: AGA (n = 30) and SGA infants (n = 34). Then, they were divided according to the presence of radiological signs of metabolic bone disease (MBD): with MBD (n = 21) and without MBD (n = 34). Blood samples and 6 h urine collections were obtained for calcium, phosphorus, alkaline phosphatase activity and creatinine determinations between 3 and 5 wk of life. RESULTS There were no biochemical differences between AGA and SGA. Higher values of urinary calcium (MBD = 31.9 +/- 20.2, without MBD = 19.8 +/- 15.4; p = 0.017), calciuria (MBD = 2.3 +/- 0.3, without MBD = 1.4 +/- 0.8; p = 0.037) and alkaline phosphatase activity (MBD = 369 +/- 114, without MBD = 310 +/- 93; p = 0.04) were found in infants who developed MBD. Both groups showed high tubular phosphorus reabsorption indicating mineral deficiency. CONCLUSION Serum calcium and phosphorus levels are not good markers in early detection of mineral deficiency. However, the monitoring of calcium urinary levels may be helpful in early detection of mineral deficiency.
Collapse
Affiliation(s)
- M Catache
- Department of Pediatrics, Nursery Annex to Maternity Ward, Children's Institute, Clinics Hospital, School of Medicine University of São Paulo, SP, Brazil.
| | | |
Collapse
|
8
|
Reis-Filho JS, Paiva ME, Lopes JM. Pathologic quiz case. A 36-year-old woman with muscle pain and weakness. Phosphaturic mesenchymal tumor (mixed connective tissue variant)/oncogenic osteomalacia. Arch Pathol Lab Med 2002; 126:1245-6. [PMID: 12385334 DOI: 10.5858/2002-126-1245-pqcayo] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
9
|
Abstract
BACKGROUND Patients undergoing successful kidney transplantation often manifest overt hypophosphatemia associated with exaggerated phosphaturia during the early post-transplant period (2 weeks to 3 months). The mechanism for this phenomenon has not been fully elucidated. We tested the hypothesis that a circulating serum factor [non-parathyroid hormone (non-PTH)], which operates during chronic renal failure (CRF) to maintain phosphate (Pi) homeostasis, can increase fractional excretion of Pi (FE(PO4)) in normal functioning kidney grafts during the early post-transplant period, thereby causing phosphaturia and hypophosphatemia. METHODS Five groups of patients were studied: control subjects (group 1, N = 16), "early" (2 weeks to 1 month) post-transplant patients (group 2, N = 22), "late" (9 to 12 months) post-transplant patients (group 3, N = 14), patients with advanced CRF (glomerular filtration rate = 30 to 40 mL/min; group 4, N = 8), and patients who suffered from end-stage renal failure and were treated by chronic hemodialysis (group 5, N = 14). Group 2 manifested significant hypophosphatemia and phosphaturia when compared with groups 1 and 3 (Pi = 0.9 +/- 0.003 mg/dL, FE(PO4) = 68+/- 5%, P < 0.0005 vs. groups 1 and 3). Sera were taken from each of the five subject groups and applied to the proximal tubular opossum kidney (OK) cells. The activity of Na/Pi-type 4 (that is, OK-specific type II transporter) was evaluated by measuring Na(+)-dependent (32)Pi flux. The expression of Na/Pi type II mRNA and the abundance of Na/Pi protein were determined by Northern and Western blot assays, respectively. RESULTS When compared with sera from groups 1 and 3, 10% sera taken from groups 2, 4, and 5 (incubated overnight with OK cells) inhibited (32)Pi flux by 25 to 30% (P < 0.0003). Both Na/Pi mRNA and the expression of Na/Pi protein were markedly augmented under the same conditions (P < 0.05 groups 2, 4, and 5 vs. groups 1 and 3). Time-course analysis revealed that the up-regulation of Na/Pi protein by sera from groups 2, 4, and 5 was observed as early as four hours of incubation, whereas augmented abundance of Na/Pi mRNA was only seen after eight hours of incubation. The addition of PTH (1-34) to sera from groups 2, 4, and 5 abolished the augmented expression of NaPi protein. We labeled OK cell surface membrane proteins with N-hydroxysuccinimide bound to biotin (NHS-SS-biotin). Biotinylated transporters incubated with the different sera were precipitated by strepavidin and identified by Western blot analysis. Cells incubated in sera from group 2 showed increased membrane bound transporter when compared with control sera, whereas the intracellular pool of the transporter was comparable between the two groups. CONCLUSION A non-PTH circulating serum factor (possibly phosphatonin) that increases FE(PO4) during CRF is also responsible for phosphaturia and hypophosphatemia in the early period following successful kidney transplantation. The putative factor inactivates Na/Pi activity along with inhibition of the transporter trafficking from the cell membrane into the cytosol.
Collapse
Affiliation(s)
- J Green
- Department of Nephrology, Rambam Medical Center, B. Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
| | | | | | | | | | | |
Collapse
|
10
|
Prié D, Blanchet FB, Essig M, Jourdain JP, Friedlander G. Dipyridamole decreases renal phosphate leak and augments serum phosphorus in patients with low renal phosphate threshold. J Am Soc Nephrol 1998; 9:1264-9. [PMID: 9644637 DOI: 10.1681/asn.v971264] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
It has been shown that an acute infusion of dipyridamole increased renal phosphate reabsorption in rats and humans. A prospective study was performed to determine whether chronic treatment by dipyridamole given orally could decrease renal phosphate leak and increase serum phosphorus in patients with idiopathic low renal phosphate threshold (TmPO4/GFR < 0.77 mM). Sixty-four patients with low TmPO4/GFR were included and treated with dipyridamole (75 mg, 4 times daily) for more than 12 mo. Serum phosphorus, TmPO4/GFR, parathyroid hormone, serum calcium, and 1,25-dihydroxyvitamin D were measured sequentially before treatment, and after 3, 6 to 9, and 12 mo of treatment. Under chronic treatment with dipyridamole, TmPO4/GFR and serum phosphorus significantly increased in 80% of patients within 3 mo, with maximal values reached within 9 mo. This improvement persisted after 12 mo of treatment. In 28 patients, 1,25-dihydroxyvitamin D concentrations were above the normal range (> 42 pg/ml) and normalized in parallel with the increase of serum phosphorus. The 24-h calcium excretion (which was initially increased in patients with high vitamin D concentrations) and urolithiasis decreased under treatment. Ionized serum calcium and parathyroid hormone remained unchanged. After 2 yr, treatment was discontinued in three patients; serum phosphorus and TmPO4/GFR decreased within 1 mo after discontinuation. Dipyridamole at a dose of 75 mg 4 times daily increases low TmPO4/GFR and improves hypophosphatemia in patients with renal phosphate losses and can be used to treat these patients.
Collapse
Affiliation(s)
- D Prié
- Service de Physiologie-Explorations Fonctionnelles, Hopital Bichat, Assistance Publique-Hôpitaux de Paris, France
| | | | | | | | | |
Collapse
|
11
|
Abstract
We describe the development of severe hypophosphatemia and urinary phosphate wasting in two patients with multiple myeloma. In both cases, the serum phosphorus was repeatedly less than 1.0 mg/dL despite vigorous replacement, and the calculated fractional excretion of urinary phosphorus was greater than 100%. Neither patient demonstrated other tubular defects typical of Fanconi's syndrome. With treatment of the myeloma, both patients achieved normalization of the serum phosphorus and no longer required phosphorus supplementation. We believe that multiple myeloma should be considered in the differential diagnosis in patients with profound hypophosphatemia, urinary phosphate wasting, and otherwise intact tubular function.
Collapse
Affiliation(s)
- T Dash
- Division of Nephrology, New England Medical Center Hospitals, Boston, MA 02111, USA
| | | | | |
Collapse
|