Autosomal dominant hypophosphatemic rickets (ADHR) is unique among the disorders involving Fibroblast growth factor 23 (FGF23) because individuals with R176Q/W and R179Q/W mutations in the FGF23 176 RXXR 179 /S 180 proteolytic cleavage motif can cycle from unaffected status to delayed onset of disease. This onset may occur in physiological states associated with iron deficiency, including puberty and pregnancy. To test the role of iron status in development of the ADHR phenotype, WT and R176Q-Fgf23 knock-in (ADHR) mice were placed on control or low-iron diets. Both the WT and ADHR mice receiving low-iron diet had significantly elevated bone Fgf23 mRNA. WT mice on a low-iron diet maintained normal serum intact Fgf23 and phosphate metabolism, with elevated serum C-terminal Fgf23 fragments. In contrast, the ADHR mice on the low-iron diet had elevated intact and C-terminal Fgf23 with hypophosphatemic osteomalacia. We used in vitro iron chelation to isolate the effects of iron deficiency on Fgf23 expression. We found that iron chelation in vitro resulted in a significant increase in Fgf23 mRNA that was dependent upon Mapk. Thus, unlike other syndromes of elevated FGF23, our findings support the concept that late-onset ADHR is the product of gene-environment interactions whereby the combined presence of an Fgf23-stabilizing mutation and iron deficiency can lead to ADHR.Online Mendelian Inheritance in Man no. 193100) is characterized by low serum phosphate concentrations due to isolated renal phosphate wasting, inappropriately normal or low serum 1,25(OH) 2 vitamin D (1,25D) concentrations, and rickets/osteomalacia and fracture (1). Heterozygous missense mutations in the fibroblast growth factor-23 (FGF23) gene cause ADHR (2). These mutations replace the arginine (R) residues at positions 176 or 179 with glutamine (Q) or tryptophan (W) within a 176 RXXR 179 / S 180 subtilisin-like proprotein convertase (SPC) site that separates the conserved FGF-like N-terminal domain from the variable Cterminal tail (2-4). Acting through the coreceptor α-Klotho (5) and a fibroblast growth factor receptor (FGFR) (5, 6), FGF23 reduces renal phosphate reabsorption through down-regulation of the sodium phosphate cotransporters NPT2a and NPT2c and suppresses kidney 1,25(OH) 2 vitamin D production by inhibiting and increasing vitamin D 1α-hydroxylase (Cyp27b1) and 24-hydroxylase expression (Cyp24), respectively (7). Compared with WT Fgf23 protein, ADHR-mutant FGF23 shows increased but not complete resistance to SPC proteolytic cleavage (3, 4). When expressed in mammalian cells, the R176Q-, R179Q-, and R179W-FGF23 proteins are secreted primarily as the full-length (32-kDa) polypeptide, in contrast to the full-length and cleavage products (20 and 12 kDa) typically observed for WT FGF23 (3). This proteolytic event inactivates the mature FGF23 polypeptide, as full-length FGF23, but not N-terminal fragments (residues 25-179) or C-terminal fragments (residues 180-251), reduces serum phosphate concentrations when injected into rodents (4).The ADHR...

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The hormone fibroblast growth factor-23 (FGF23) plays a central role in phosphate metabolism, as demonstrated by several genetic disorders characterized by increased FGF23 serum levels, including autosomal dominant hypophosphatemic rickets, 1 X-linked hypophosphatemic rickets, 2 and autosomal recessive hypophosphatemic rickets. 3 Studies in animal models have shown that increased serum concentrations of FGF23 lead to renal phosphate wasting through downregulation of the proximal tubule (PT) apical membrane Type II (Npt2a and Npt2c) sodium-phosphate cotransporters. 4,5 The reciprocal disorder, familial hyperphosphatemic tumoral calcinosis (TC), caused by mutations in FGF23 and the glycosylating enzyme GALNT3, is characterized by decreased serum levels of active FGF23, normal parathyroid hormone levels, increased or normal 1,25(OH) 2 vitamin D levels, and often severe hyperphosphatemia due to excessive renal phosphate reabsorption. 6 The coreceptor ␣-Klotho (KL) was recently identified as necessary for FGF23 bioactivity. 7,8 KL is produced as two isoforms due to alternative splicing of the same five-exon gene. Membranebound KL (mKL) is a 130-kD singlepass transmembrane protein comprised of all five exons and is characterized by a large extracellular domain with a short cytoplasmic region of 11 residues that does not contain signaling capabilities. 9 The secreted form of KL (sKL) is 80 kD and is alternatively spliced within exon 3, producing a KL protein species that possesses the extracellular region, but not the transmembrane domain, and is secreted into the circulation. 9 A third isoform is produced by cleavage of mKL in proximity to the extracellular face of the plasma membrane, referred to as "cut mKL" (cKL), resulting in a protein that is also found in the circulation. 10 The circulating forms of KL have led to interpretations that KL itself may act as a hormone. 10 In vitro evidence supports associations between fibroblast growth factor receptor 1c and KL as part of a receptor complex to elicit FGF23 signaling through the mitogen activated protein kinase (MAPK) cascade and phospho-ERK1/2 (p-ERK1/2). 7,8 Underlying the importance of the formation of a KLfibroblast growth factor receptor complex, high levels of FGF23 signaling in vitro occur when KL and fibroblast growth factor receptor 1c are both present. 7 In support of FGF23-KL interactions, the Fgf23-and KL-null animals have identical hyperphosphatemic phenotypes. [11][12][13][14] Additionally, a novel recessive, inactivating mutation in the human KL gene resulted in impaired KL expression and a severe tumoral calcinosis phenotype, most likely due to end-organ resistance to FGF23. 15 Al- ABSTRACTFibroblast growth factor-23 (FGF23), a hormone central to phosphate and vitamin D metabolism, reduces renal absorption of phosphate by downregulating the sodium-phosphate cotransporter Npt2a. However, the mechanisms of FGF23 action in the kidney are unclear, as Npt2a localizes to the proximal tubule (PT) and the FGF23 coreceptor ␣-Klotho (KL) localizes to the dis...

The FGF23 coreceptor αKlotho (αKL) is expressed as a membrane-bound protein (mKL) that forms heteromeric complexes with FGF receptors (FGFRs) to initiate intracellular signaling. It also circulates as an endoproteolytic cleavage product of mKL (cKL). Previously, a patient with increased plasma cKL as the result of a translocation [t(9;13)] in the αKLOTHO (KL) gene presented with rickets and a complex endocrine profile, including paradoxically elevated plasma FGF23, despite hypophosphatemia. The goal of this study was to test whether cKL regulates phosphate handling through control of FGF23 expression. To increase cKL levels, mice were treated with an adeno-associated virus producing cKL. The treated groups exhibited dose-dependent hypophosphatemia and hypocalcemia, with markedly elevated FGF23 (38 to 456 fold). The animals also manifested fractures, reduced bone mineral content, expanded growth plates, and severe osteomalacia, with highly increased bone Fgf23 mRNA (>150 fold). cKL activity in vitro was specific for interactions with FGF23 and was FGFR dependent. These results demonstrate that cKL potently stimulates FGF23 production in vivo, which phenocopies the KL translocation patient and metabolic bone syndromes associated with elevated FGF23. These findings have important implications for the regulation of αKL and FGF23 in disorders of phosphate handling and biomineralization. IntroductionThe bone-derived hormone FGF23 and its coreceptor αKlotho (αKL) are critical regulators of systemic phosphate metabolism. The αKL gene product is expressed as multiple species; the membrane-bound form (mKL) associates with FGF23 and FGF receptors (FGFRs) to signal through the MAPK cascade (1, 2). Two soluble species have also been reported, an alternatively spliced secreted form (sKL) (exons 1-3 of the 5-exon KL gene) and an endoproteolytic cleavage product of mKL (cKL) (3). Although sKL was identified as a potential αKL variant, only cKL protein was detectable in human and rodent plasma and cerebrospinal fluids (4). The cKL form has been implicated in directly mediating renal phosphate handling through paracrine activity (5); however, whether endocrine effects of cKL occur remains unclear. This possibility is highlighted by findings in a patient with a translocation in the αKLOTHO (KL) gene (t9;13), who presented with elevated plasma cKL and a ricketic phenotype (6). The biochemical and endocrine abnormalities were complex and included hypophosphatemia, hypocalcemia, inappropriately normal 1,25(OH) 2 vitamin D (1,25D), and severe hyperparathyroidism requiring surgical intervention. Of note, this patient also had sustained, highly elevated plasma FGF23 (>12 times the upper limit of normal), despite marked hypophosphatemia on or off calcitriol treatment (6). The paradoxically elevated FGF23 in this patient, together with a clinical phenotype resembling that of patients with severe autosomal dominant hypophosphatemic rickets, X-linked

Fibroblast growth factor 23 (FGF23) gain of function mutations can lead to autosomal dominant hypophosphatemic rickets (ADHR) disease onset at birth, or delayed onset following puberty or pregnancy. We previously demonstrated that the combination of iron deficiency and a knock-in R176Q FGF23 mutation in mature mice induced FGF23 expression and hypophosphatemia that paralleled the late-onset ADHR phenotype. Because anemia in pregnancy and in premature infants is common, the goal of this study was to test whether iron deficiency alters phosphate handling in neonatal life. Wild-type (WT) and ADHR female breeder mice were provided control or iron-deficient diets during pregnancy and nursing. Iron-deficient breeders were also made iron replete. Iron-deficient WT and ADHR pups were hypophosphatemic, with ADHR pups having significantly lower serum phosphate (p < 0.01) and widened growth plates. Both genotypes increased bone FGF23 mRNA (>50 fold; p < 0.01). WT and ADHR pups receiving low iron had elevated intact serum FGF23; ADHR mice were affected to a greater degree (p < 0.01). Iron-deficient mice also showed increased Cyp24a1 and reduced Cyp27b1, and low serum 1,25-dihydroxyvitamin D (1,25D). Iron repletion normalized most abnormalities. Because iron deficiency can induce tissue hypoxia, oxygen deprivation was tested as a regulator of FGF23, and was shown to stimulate FGF23 mRNA in vitro and serum C-terminal FGF23 in normal rats in vivo. These studies demonstrate that FGF23 is modulated by iron status in young WT and ADHR mice and that hypoxia independently controls FGF23 expression in situations of normal iron. Therefore, disturbed iron and oxygen metabolism in neonatal life may have important effects on skeletal function and structure through FGF23 activity on phosphate regulation.