Hyperphosphatemia with low FGF7 and normal FGF23 and sFRP4 levels in the circulation characterizes pediatric hypophosphatasia

• Published in: Bone (New York, N.Y.) Vol. 134; p. 115300
• Main Authors: Whyte, Michael P., Zhang, Fan, Wenkert, Deborah, Mumm, Steven, Berndt, Theresa J., Kumar, Rajiv
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.05.2020
• Subjects: Adult; Alkaline Phosphatase; ALPL; Animals; Asfotase alfa; Bisphosphonate; Child; Etidronate; Fibroblast Growth Factor 7; Fibroblast Growth Factor-23; Fibroblast Growth Factors; GACI; Generalized arterial calcification of infancy; Humans; Hydroxyapatite; Hyperphosphatemia; Hypophosphatasia - complications; Hypophosphatemia; Inborn-error-of-metabolism; Inorganic pyrophosphate; PHEX; Phosphatonin; Prospective Studies; Proto-Oncogene Proteins; Pseudoxanthoma elasticum; Rats; Rickets; TmP/GFR; X-linked hypophosphatemia; Alkaline phosphatase; GACI; Phosphatonin; Bisphosphonate; Hydroxyapatite; Inborn-error-of-metabolism; PHEX; Generalized arterial calcification of infancy; TmP/GFR; Rickets; X-linked hypophosphatemia; Asfotase alfa; ALPL; Hypophosphatemia; Inorganic pyrophosphate; Pseudoxanthoma elasticum; Etidronate
• ISSN: 8756-3282; 1873-2763; 1873-2763
• DOI: 10.1016/j.bone.2020.115300

Hypophosphatasia (HPP) is the inborn-error-of-metabolism caused by loss-of-function mutation(s) of the ALPL gene that encodes the tissue-nonspecific isoenzyme of alkaline phosphatase (TNSALP). TNSALP in healthy individuals is on cell surfaces richly in bone, liver, and kidney. Thus, TNSALP natural substrates accumulate extracellularly in HPP, including inorganic pyrophosphate (PPi), a potent inhibitor of hydroxyapatite crystal formation and growth. Superabundance of extracellular PPi (ePPi) in HPP impairs mineralization of bones and teeth, often leading to rickets during childhood and osteomalacia in adult life and to tooth loss at any age. HPP's remarkably broad-ranging severity is largely explained by nearly four hundred typically missense mutations throughout the ALPL gene that are transmitted as an autosomal dominant or autosomal recessive trait. In the clinical laboratory, the biochemical hallmark of HPP is low serum ALP activity (hypophosphatasemia). However, our experience indicates that hyperphosphatemia from increased renal reclamation of filtered inorganic phosphate (Pi) is also common. Herein, from our prospective single-center study, we document throughout the clinical spectrum of non-lethal pediatric HPP that hyperphosphatemia reflects increased renal tubular threshold maximum for phosphorus adjusted for the glomerular filtration rate (TmP/GFR). To explore its pathogenesis, we studied mineral metabolism and quantitated circulating levels of three phosphatonins [fibroblast growth factor 23 (FGF23), secreted frizzled-related protein 4 (sFRP4), and fibroblast growth factor 7 (FGF7)] in 41 pediatric patients with HPP, 73 with X-linked hypophosphatemia (XLH), and 15 healthy pediatric control (CTR) subjects. The HPP and XLH cohorts had normal serum total and ionized calcium and parathyroid hormone levels (Ps > 0.10) and uncompromised glomerular filtration. In XLH, serum FGF23 was characteristically elevated (P < 0.0001) and despite hypophosphatemia sFRP4 was normal (P > 0.4) while FGF7 was low (P < 0.0001). In HPP, despite hyperphosphatemia serum FGF23 and sFRP4 were normal (Ps > 0.8) while FGF7 was low (P < 0.0001). Subsequently, in rats, we confirmed that FGF7 is phosphaturic. Thus, hyperphosphatemia in non-lethal pediatric HPP is associated with phosphatonin insufficiency together with, as we discuss, ePPi excess and diminished renal TNSALP activity. •Hypophosphatasia (HPP) is characterized by alkaline phosphatase (ALP) deficiency.•Inorganic pyrophosphate, a mineralization inhibitor, accumulates endogenously.•Hyperphosphatemia from increased TmP/GFR spans the severity of pediatric HPP.•In pediatric HPP, serum FGF7 levels are low and FGF23 and sFRP4 levels are normal.•Hyperphosphatemia in pediatric HPP is associated with phosphatonin insufficiency.