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  1. Jonathan Samuel Fenn1,
  2. Nathan Lorde2,
  3. John Martin Ward3,
  4. Ingrid Borovickova4
  1. 1 Black Country Pathology Services, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
  2. 2 Department of Clinical Chemistry, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
  3. 3 Department of Radiology, McGill University Health Center, Montreal, Québec, Canada
  4. 4 Department of Biochemical Genetics, Children’s Health Ireland at Temple Street, Dublin, Ireland
  1. Correspondence to Dr Jonathan Samuel Fenn, Black Country Pathology Services, The Royal Wolverhampton NHS Trust, Wolverhampton, UK; j.fenn1{at}


Hypophosphatasia (HPP) is a group of inherited disorders characterised by the impaired mineralisation of bones and/or teeth and low serum alkaline phosphatase (ALP) activity. It is caused by a mutation in the ALPL gene encoding the tissue-non-specific isoenzyme of ALP (TNSALP) resulting in a loss of function. The disease is highly heterogenous in its clinical expression ranging from stillbirth without mineralised bone to the mild form of late adult onset with symptoms and signs such as musculoskeletal pain, arthropathy, lower-extremity fractures, premature loss of teeth or an incidental finding of reduced serum ALP activity. A classification based on the age at diagnosis and the presence or absence of bone symptoms was historically used: perinatal, prenatal benign, infantile, childhood, adult and odontohypophosphatasia. These subtypes are known to have overlapping signs and complications. Three forms of HPP distinguishable by their genetic characteristics have been described: severe, moderate and mild. Severe forms of HPP (perinatal and infantile severe) are recessively inherited, whereas moderate HPP may be dominantly or recessively inherited. The biochemical hallmark of HPP is persistently low serum ALP for age and increase in natural substrates of TNSALP, pyridoxal 5′-phosphate and phosphoethanolamine supported by radiological findings. The diagnosis is confirmed by ALPL sequencing. A multidisciplinary team of experts is essential for the effective management. Calcium restriction is recommended in infants/children to manage hypercalcaemia. A targeted enzyme replacement therapy for HPP has become available and correct diagnosis is crucial to allow early treatment.

  • chemistry
  • clinical
  • proteins
  • biochemistry

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  • Handling editor Patrick J Twomey.

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  • Contributors All authors contributed equally to this manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.