Journal of Bone and Mineral Metabolism

, Volume 36, Issue 6, pp 723–733 | Cite as

Genetic analysis of adults heterozygous for ALPL mutations

  • Agnès Taillandier
  • Christelle Domingues
  • Annika Dufour
  • Françoise Debiais
  • Pascal Guggenbuhl
  • Christian Roux
  • Catherine Cormier
  • Bernard Cortet
  • Valérie Porquet-Bordes
  • Fabienne Coury
  • David Geneviève
  • Jean Chiesa
  • Thierry Colin
  • Elaine Fletcher
  • Agnès Guichet
  • Rose-Marie Javier
  • Michel Laroche
  • Michael Laurent
  • Ekkehart Lausch
  • Bruno LeHeup
  • Cédric Lukas
  • Georg Schwabe
  • Ineke van der Burgt
  • Christine Muti
  • Brigitte Simon-Bouy
  • Etienne MornetEmail author
Original Article


Hypophosphatasia (HPP) is a rare inherited metabolic bone disease due to a deficiency of the tissue nonspecific alkaline phosphatase isoenzyme (TNSALP) encoded by the ALPL gene. Patients have consistently low serum alkaline phosphatase (AP), so that this parameter is a good hallmark of the disease. Adult HPP is heterogeneous, and some patients present only mild nonpathognomonic symptoms which are also common in the general population such as joint pain, osteomalacia and osteopenia, chondrocalcinosis, arthropathy and musculoskeletal pain. Adult HPP may be recessively or dominantly inherited; the latter case is assumed to be due to the dominant negative effect (DNE) of missense mutations derived from the functional homodimeric structure of TNSALP. However, there is no biological argument excluding the possibility of other causes of dominant HPP. Rheumatologists and endocrinologists are increasingly solicited for patients with low AP and nonpathognomonic symptoms of HPP. Many of these patients are heterozygous for an ALPL mutation and a challenging question is to determine if these symptoms, which are also common in the general population, are attributable to their heterozygous ALPL mutation or not. In an attempt to address this question, we reviewed a cohort of 61 adult patients heterozygous for an ALPL mutation. Mutations were distinguished according to their statistical likelihood to show a DNE. One-half of the patients carried mutations predicted with no DNE and were slightly less severely affected by the age of onset, serum AP activity and history of fractures. We hypothesized that these mutations result in another mechanism of dominance or are recessive alleles. To identify other genetic factors that could trigger the disease phenotype in heterozygotes for potential recessive mutations, we examined the next-generation sequencing results of 32 of these patients for a panel of 12 genes involved in the differential diagnosis of HPP or candidate modifier genes of HPP. The heterozygous genotype G/C of the COL1A2 coding SNP rs42524 c.1645C > G (p.Pro549Ala) was associated with the severity of the phenotype in patients carrying mutations with a DNE whereas the homozygous genotype G/G was over-represented in patients carrying mutations without a DNE, suggesting a possible role of this variant in the disease phenotype. These preliminary results support COL1A2 as a modifier gene of HPP and suggest that a significant proportion of adult heterozygotes for ALPL mutations may have unspecific symptoms not attributable to their heterozygosity.


Adult hypophosphatasia Dominant inheritance Dominant negative effect Modifier gene 



Alkaline phosphatase liver-type


Alkaline phosphatase


Dominant negative effect




Next-generation sequencing


Prenatal benign


Tissue nonspecific alkaline phosphatase



We thank Carole Charle, Nicole Lavaud and Fabienne Vallon for technical assistance, and the Centre Hospitalier de Versailles for contributing to a version of the manuscript.

Compliance with ethical standards

Conflicts of interest statement

EM received honoraria from Alexion. CR received honoraria from Alexion and research grants from Ultragenix


  1. 1.
    Whyte MP (2017) Hypophosphatasia: an overview For 2017. Bone. CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Wenkert D, McAlister WH, Coburn SP, Zerega JA, Ryan LM, Ericson KL, Hersh JH, Mumm S, Whyte MP (2011) Hypophosphatasia: nonlethal disease despite skeletal presentation in utero (17 new cases and literature review). J Bone Miner Res 26:2389–2398CrossRefGoogle Scholar
  3. 3.
    Bloch-Zupan A (2016) Hypophosphatasia: diagnosis and clinical signs − a dental surgeon perspective. Int J Paediatr Dent 26:426–438CrossRefGoogle Scholar
  4. 4.
    Berkseth KE, Tebben PJ, Drake MT, Hefferan TE, Jewison DE, Wermers RA (2013) Clinical spectrum of hypophosphatasia diagnosed in adults. Bone 54:21–27CrossRefGoogle Scholar
  5. 5.
    Briot K, Roux C (2016) Adult hypophosphatasia. Curr Opin Rheumatol 28:448–451CrossRefGoogle Scholar
  6. 6.
    Shapiro JR, Lewiecki EM (2017) Hypophosphatasia in adults: clinical assessment and treatment considerations. J Bone Miner Res. CrossRefPubMedGoogle Scholar
  7. 7.
    Whyte MP (2010) Physiological role of alkaline phosphatase explored in hypophosphatasia. Ann N Y Acad Sci 1192:190–200CrossRefGoogle Scholar
  8. 8.
    Whyte MP, Greenberg CR, Salman NJ, Bober MB, McAlister WH et al (2012) Enzyme-replacement therapy in life-threatening hypophosphatasia. N Engl J Med 366:904–913CrossRefGoogle Scholar
  9. 9.
    Millan J (2006) Mammalian alkaline phosphatases: from biology to applications in medicine and biotechnology. Wiley-VCH Verlag GmbH, WeinheimCrossRefGoogle Scholar
  10. 10.
    Le Du MH, Stigbrand T, Taussig MJ, Menez A, Stura EA (2001) Crystal structure of alkaline phosphatase from human placenta at 1.8 A resolution. Implication for a substrate specificity. J Biol Chem 276:9158–9165CrossRefGoogle Scholar
  11. 11.
    Mornet E, Stura E, Lia-Baldini AS, Stigbrand T, Menez A, Le Du MH (2001) Structural evidence for a functional role of human tissue nonspecific alkaline phosphatase in bone mineralization. J Biol Chem 276:31171–31178CrossRefGoogle Scholar
  12. 12.
    Mornet E (2008) Hypophosphatasia. Best Pract Res Clin Rheumatol 22:113–127CrossRefGoogle Scholar
  13. 13.
    Vittur F, Stagani L, Moro L, de Bernard B (1984) Alkaline phosphatase binds to collagen: a hypothesis on the mechanism of extravesicular mineralization in epiphyseal cartilage. Experientia 40:836–837CrossRefGoogle Scholar
  14. 14.
    Wu LN, Genge BR, Llyod GC, Wuthier RE (1991) Collagen-binding proteins in collagenase-released matrix vesicles from cartilage. Interaction between matrix vesicle proteins and different types of collagen. J Biol Chem 266:1195–1203PubMedGoogle Scholar
  15. 15.
    Fauvert D, Brun-Heath I, Lia-Baldini AS, Bellazi L, Taillandier A, Serre JL, de Mazancourt P, Mornet E (2009) Mild forms of hypophosphatasia mostly result from dominant negative effect of severe alleles or from compound heterozygosity for severe and moderate alleles. BMC Med Genet 10:51CrossRefGoogle Scholar
  16. 16.
    Eberic FHS, Pralle H, Kabish A (1984) Adult hypophosphatasia without apparent skeletal disease: “ondotohypophosphatasia” in four heterozygote members of a family. Klin Wochenschr 62:371CrossRefGoogle Scholar
  17. 17.
    Eastman JR, Bixler D (1983) Clinical, laboratory, and genetic investigations of hypophosphatasia: support for autosomal dominant inheritance with homozygous lethality. J Craniofac Genet Dev Biol 3:213–234PubMedGoogle Scholar
  18. 18.
    Whyte MP (2017) Hypophosphatasia: an overview For 2017. Bone 102:15–25. CrossRefPubMedGoogle Scholar
  19. 19.
    Fraser D (1957) Hypophosphatasia. Am J Med 22:730–746CrossRefGoogle Scholar
  20. 20.
    Mornet E, Yvard A, Taillandier A, Fauvert D, Simon-Bouy B (2011) A molecular-based estimation of the prevalence of hypophosphatasia in the European population. Ann Hum Genet 75:439–445CrossRefGoogle Scholar
  21. 21.
    McKiernan FE, Berg RL, Fuehrer J (2014) Clinical and radiographic findings in adults with persistent hypophosphatasemia. J Bone Miner Res 29:1651–1660CrossRefGoogle Scholar
  22. 22.
    Nielson CM, Zmuda JM, Carlos AS, Wagoner WJ, Larson EA, Orwoll ES, K RF (2012) Rare coding variants in ALPL are associated with low serum alkaline phosphatase and low bone mineral density. J Bone Miner Res 27:93–103CrossRefGoogle Scholar
  23. 23.
    Riancho-Zarrabeitia L, Garcia-Unzueta M, Tenorio JA, Gomez-Gerique JA, Ruiz Perez VL, Heath KE, Lapunzina P, Riancho JA (2016) Clinical, biochemical and genetic spectrum of low alkaline phosphatase levels in adults. Eur J Intern Med 29:40–45CrossRefGoogle Scholar
  24. 24.
    McKiernan FE, Dong J, Berg RL, Scotty E, Mundt P, Larson L, Rai I (2017) Mutational and biochemical findings in adults with persistent hypophosphatasemia. Osteoporos Int 28:2343–2348CrossRefGoogle Scholar
  25. 25.
    Tenorio J, Alvarez I, Riancho-Zarrabeitia L, Martos-Moreno GA, Mandrile G et al (2017) Molecular and clinical analysis of ALPL in a cohort of patients with suspicion of hypophosphatasia. Am J Med Genet A 173:601–610. CrossRefPubMedGoogle Scholar
  26. 26.
    Nielson CM, Zmuda JM, Carlos AS, Wagoner WJ, Larson EA, Orwoll ES, Klein RF (2012) Rare coding variants in ALPL are associated with low serum alkaline phosphatase and low bone mineral density. J Bone Miner Res 27:93–103CrossRefGoogle Scholar
  27. 27.
    Derouault P, Parfait B, Moulinas R, Barrot CC, Sturtz F, Merillou S, Lia AS (2017) ‘COV’COP’ allows to detect CNVs responsible for inherited diseases among amplicons sequencing data. Bioinformatics 33:1586–1588. CrossRefPubMedGoogle Scholar
  28. 28.
    Lia-Baldini AS, Muller F, Taillandier A, Gibrat JF, Mouchard M, Robin B, Simon-Bouy B, Serre JL, Aylsworth AS, Bieth E, Delanote S, Freisinger P, Hu JC, Krohn HP, Nunes ME, Mornet E (2001) A molecular approach to dominance in hypophosphatasia. Hum Genet 109:99–108CrossRefGoogle Scholar
  29. 29.
    Numa-Kinjoh N, Komaru K, Ishida Y, Sohda M, Oda K (2015) Molecular phenotype of tissue-nonspecific alkaline phosphatase with a proline (108) to leucine substitution associated with dominant odontohypophosphatasia. Mol Genet Metab 115:180–185CrossRefGoogle Scholar
  30. 30.
    Ishida Y, Komaru K, Ito M, Amaya Y, Kohno S, Oda K (2003) Tissue-nonspecific alkaline phosphatase with an Asp(289) → Val mutation fails to reach the cell surface and undergoes proteasome-mediated degradation. J Biochem (Tokyo) 134:63–70CrossRefGoogle Scholar
  31. 31.
    Ishida Y, Komaru K, Oda K (2011) Molecular characterization of tissue-nonspecific alkaline phosphatase with an Ala to Thr substitution at position 116 associated with dominantly inherited hypophosphatasia. Biochim Biophys Acta 1812:326–332CrossRefGoogle Scholar
  32. 32.
    Sultana S, Al-Shawafi HA, Makita S, Sohda M, Amizuka N, Takagi R, Oda K (2013) An asparagine at position 417 of tissue-nonspecific alkaline phosphatase is essential for its structure and function as revealed by analysis of the N417S mutation associated with severe hypophosphatasia. Mol Genet Metab 109:282–288CrossRefGoogle Scholar
  33. 33.
    Yang H, Wang L, Geng J, Yu T, Yao RE, Shen Y, Yin L, Ying D, Huang R, Zhou Y, Chen H, Liu L, Mo X, Shen Y, Fu Q, Yu Y (2013) Characterization of six missense mutations in the tissue-nonspecific alkaline phosphatase (TNSALP) gene in Chinese children with hypophosphatasia. Cell Physiol Biochem 32:635–644CrossRefGoogle Scholar
  34. 34.
    Muller HL, Yamazaki M, Michigami T, Kageyama T, Schonau E, Schneider P, Ozono K (2000) Asp361Val Mutant of alkaline phosphatase found in patients with dominantly inherited hypophosphatasia inhibits the activity of the wild-type enzyme. J Clin Endocrinol Metab 85:743–747CrossRefGoogle Scholar
  35. 35.
    Zhu T, Gan YH, Liu H (2012) Functional evaluation of mutations in the tissue-nonspecific alkaline phosphatase gene. Chin J Dent Res 15:99–104PubMedGoogle Scholar
  36. 36.
    Makita S, Al-Shawafi HA, Sultana S, Sohda M, Nomura S, Oda K (2012) A dimerization defect caused by a glycine substitution at position 420 by serine in tissue-nonspecific alkaline phosphatase associated with perinatal hypophosphatasia. FEBS J 279:4327–4337CrossRefGoogle Scholar
  37. 37.
    Mentrup B, Marschall C, Barvencik F, Amling M, Plendl H, Jakob F, Beck C (2011) Functional characterization of a novel mutation localized in the start codon of the tissue-nonspecific alkaline phosphatase gene (in eng). Bone 48:1401–1408. CrossRefPubMedGoogle Scholar
  38. 38.
    Taillandier A, Lia-Baldini AS, Mouchard M, Robin B, Muller F, Simon-Bouy B, Serre JL, Bera-Louville A, Bonduelle M, Eckhardt J, Gaillard D, Myhre AG, Kortge-Jung S, Larget-Piet L, Malou E, Sillence D, Temple IK, Viot G, Mornet E (2001) Twelve novel mutations in the tissue-nonspecific alkaline phosphatase gene (ALPL) in patients with various forms of hypophosphatasia. Hum Mutat 18:83–84CrossRefGoogle Scholar
  39. 39.
    Takinami H, Goseki-Sone M, Watanabe H, Orimo H, Hamatani R, Fukushi-Irie M, Ishikawa I (2004) The mutant (F310L and V365I) tissue-nonspecific alkaline phosphatase gene from hypophosphatasia. J Med Dent Sci 51:67–74PubMedGoogle Scholar
  40. 40.
    Komaru K, Satou Y, Al-Shawafi HA, Numa-Kinjoh N, Sohda M, Oda K (2016) Glycosylation-deficient mutations in tissue-nonspecific alkaline phosphatase impair its structure and function and are linked to infantile hypophosphatasia. FEBS J 283:1168–1179CrossRefGoogle Scholar
  41. 41.
    Hofmann C, Liese J, Schwarz T, Kunzmann S, Wirbelauer J, Nowak J, Hamann J, Girschick H, Graser S, Dietz K, Zeck S, Jakob F, Mentrup B (2013) Compound heterozygosity of two functional null mutations in the ALPL gene associated with deleterious neurological outcome in an infant with hypophosphatasia. Bone 55:150–157. CrossRefPubMedGoogle Scholar
  42. 42.
    Al-Shawafi HA, Komaru K, Oda K (2017) Molecular defect of tissue-nonspecific alkaline phosphatase bearing a substitution at position 426 associated with hypophosphatasia. Mol Cell Biochem 427:169–176. CrossRefPubMedGoogle Scholar
  43. 43.
    Lia-Baldini AS, Brun-Heath I, Carrion C, Simon-Bouy B, Serre JL, Nunes ME, Mornet E (2008) A new mechanism of dominance in hypophosphatasia: the mutated protein can disturb the cell localization of the wild-type protein. Hum Genet 123:429–432CrossRefGoogle Scholar
  44. 44.
    Brun-Heath I, Chabrol E, Fox M, Drexler K, Petit C, Taillandier A, De Mazancourt P, Serre JL, Mornet E (2008) A case of lethal hypophosphatasia providing new insights into the perinatal benign form of hypophosphatasia and expression of the ALPL gene. Clin Genet 73:245–250CrossRefGoogle Scholar
  45. 45.
    Taillandier A, Domingues C, De Cazanove C, Porquet-Bordes V, Monnot S et al (2015) Molecular diagnosis of hypophosphatasia and differential diagnosis by targeted next generation sequencing. Mol Genet Metab 116:215–220CrossRefGoogle Scholar
  46. 46.
    Mornet E (2017) The tissue nonspecific alkaline phosphatase gene mutations database. Université de Versailles Saint-Quentin en Yvelines. Accessed May 21, 2017Google Scholar
  47. 47.
    Whyte MP, Zhang F, Wenkert D, McAlister WH, Mack KE, Benigno MC, Coburn SP, Wagy S, Griffin DM, Ericson KL, Mumm S (2015) Hypophosphatasia: validation and expansion of the clinical nosology for children from 25 years experience with 173 pediatric patients. Bone 75:229–239CrossRefGoogle Scholar
  48. 48.
    Hofmann C, Girschick H, Mornet E, Schneider D, Jakob F, Mentrup B (2014) Unexpected high intrafamilial phenotypic variability observed in hypophosphatasia. Eur J Hum Genet 22:1160–1164. CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Taketani T, Onigata K, Kobayashi H, Mushimoto Y, Fukuda S, Yamaguchi S (2014) Clinical and genetic aspects of hypophosphatasia in Japanese patients. Arch Dis Child 99:211–215CrossRefGoogle Scholar
  50. 50.
    Moulin P, Vaysse F, Bieth E, Mornet E, Gennero I, Dalicieux-Laurencin S, Baunin C, Tauber MT, De Gauzy JS, Salles JP (2009) Hypophosphatasia may lead to bone fragility: don’t miss it. Eur J Pediatr 168:783–788CrossRefGoogle Scholar
  51. 51.
    Hu JC, Plaetke R, Mornet E, Zhang C, Sun X, Thomas HF, Simmer JP (2000) Characterization of a family with dominant hypophosphatasia. Eur J Oral Sci 108:189–194CrossRefGoogle Scholar
  52. 52.
    Bossi M, Hoylaerts MF, Millan JL (1993) Modifications in a flexible surface loop modulate the isozyme-specific properties of mammalian alkaline phosphatases. J Biol Chem 268:25409–25416PubMedGoogle Scholar
  53. 53.
    Cui L, Houston DA, Farquharson C, MacRae VE (2016) Characterisation of matrix vesicles in skeletal and soft tissue mineralisation. Bone 87:147–158. CrossRefPubMedGoogle Scholar
  54. 54.
    Mornet E, Beck C, Bloch-Zupan A, Girschick H, Le Merrer M (2011) Clinical utility gene card for: hypophosphatasia. Eur J Hum Genet 19(3).
  55. 55.
    Byers PH, Krakow D, Nunes ME, Pepin M (2006) Genetic evaluation of suspected osteogenesis imperfecta (OI). Genet Med 8:383–388CrossRefGoogle Scholar
  56. 56.
    Lindahl K, Rubin CJ, Brändström H, Karlsson MK, Holmberg A, Ohlsson C, Mellström D, Orwoll E, Mallmin H, Kindmark A, Ljunggren O (2009) Heterozygosity for a coding SNP in COL1A2 confers a lower BMD and an increased stroke risk. Biochem Biophys Res Commun 384:501–505CrossRefGoogle Scholar
  57. 57.
    Zuo C, Wen F, Li M, Zhang X, Chen H, Wu K, Zeng R (2012) COL1A2 polymorphic markers confer an increased risk of neovascular age-related macular degeneration in a Han Chinese population. Mol Vis 18:1787–1793PubMedPubMedCentralGoogle Scholar
  58. 58.
    Liu W, Pang B, Lu M, Song H, Sun B, Zhu Y, Pang Q (2012) The rs42524 COL1A2 polymorphism is associated with primary intracerebral hemorrhage in a Chinese population. J Clin Neurosci 19:1711–1714CrossRefGoogle Scholar
  59. 59.
    Hoylaerts MF, Millan JL (1991) Site-directed mutagenesis and epitope-mapped monoclonal antibodies define a catalytically important conformational difference between human placental and germ cell alkaline phosphatase. Eur J Biochem 202:605–616CrossRefGoogle Scholar
  60. 60.
    Maman E, Borderie D, Roux C, Briot K (2016) Absence of recognition of low alkaline phosphatase level in a tertiary care hospital. Osteoporos Int 27:1251–1254. CrossRefPubMedGoogle Scholar

Copyright information

© The Japanese Society for Bone and Mineral Research and Springer Japan KK, part of Springer Nature 2017

Authors and Affiliations

  • Agnès Taillandier
    • 1
  • Christelle Domingues
    • 1
  • Annika Dufour
    • 1
  • Françoise Debiais
    • 2
  • Pascal Guggenbuhl
    • 3
  • Christian Roux
    • 4
  • Catherine Cormier
    • 4
  • Bernard Cortet
    • 5
  • Valérie Porquet-Bordes
    • 6
  • Fabienne Coury
    • 7
  • David Geneviève
    • 8
  • Jean Chiesa
    • 9
  • Thierry Colin
    • 10
  • Elaine Fletcher
    • 11
  • Agnès Guichet
    • 12
  • Rose-Marie Javier
    • 13
  • Michel Laroche
    • 14
  • Michael Laurent
    • 15
  • Ekkehart Lausch
    • 16
  • Bruno LeHeup
    • 17
  • Cédric Lukas
    • 18
  • Georg Schwabe
    • 19
  • Ineke van der Burgt
    • 20
  • Christine Muti
    • 1
  • Brigitte Simon-Bouy
    • 1
  • Etienne Mornet
    • 1
    Email author
  1. 1.Unité de Génétique Constitutionnelle, Service de BiologieCentre Hospitalier de VersaillesLe ChesnayFrance
  2. 2.Service de RhumatologieCHU de PoitiersPoitiers cedexFrance
  3. 3.Service de Rhumatologie, hôpital SudCHU de RennesRennes cedex 2France
  4. 4.Service de RhumatologieHôpital CochinParisFrance
  5. 5.Service de RhumatologieCHRU de LilleLilleFrance
  6. 6.Endocrinologie, Maladies Osseuses, Génétique et Gynécologie MédicaleHôpital des Enfants, CHU de ToulouseToulouse Cedex 9France
  7. 7.Service de RhumatologieCHU Lyon, Centre Hospitalier Lyon-SudPierre BéniteFrance
  8. 8.Service de Génétique Clinique, Département de Génétique Médicale, maladies rares et médecine personnalisée, CHU Montpellieruniversité Montpellier, unité Inserm U1183MontpellierFrance
  9. 9.Department of GeneticsUniversity HospitalNîmesFrance
  10. 10.Service de RhumatologieCH Public du CotentinCherbourgFrance
  11. 11.Clinical Genetics, Molecular Medicine CenterWestern General HospitalEdinburghUK
  12. 12.Département Biochimie et génétiqueCHU d’AngersAngersFrance
  13. 13.Service de RhumatologieCHU de StrasbourgStrasbourgFrance
  14. 14.Service de RhumatologieHôpital Pierre-Paul RiquetToulouseFrance
  15. 15.Center for Metabolic Bone DiseasesUniversity Hospitals LeuvenLeuvenBelgium
  16. 16.Universitätsklinikum Freiburg, Zentrum für Kinder- und JugendmedizinFreiburgGermany
  17. 17.Médecine infantile 3CHU NancyVandoeuvreFrance
  18. 18.Département de RhumatologieCHRU MontpellierMontpellierFrance
  19. 19.Otto-Heubner-Centrum für Kinder und Jugendmedizin Allgemeine Päediatrie CharitéBerlinGermany
  20. 20.Department of Human GeneticsRadboudumcNijmegenNetherlands

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