Earlier Onset in Autosomal Dominant Hypophosphatemic Rickets of R179 than R176 Mutations in Fibroblast Growth Factor 23: Report of 20 Chinese Cases and Review of the Literature

Autosomal dominant hypophosphatemic rickets (ADHR) is a rare hereditary disorder characterized by variant onset ages and diverse phenotypes. Our aim is to explore the genotype-phenotype correlations between ADHR patients with R176 and R179 mutations in FGF23 gene. Clinical manifestations, laboratory examinations, and genetic analyses were collected from 20 patients in six Chinese ADHR kindreds in our hospital. Previously published ADHR literatures were reviewed. Among 20 Chinese ADHR mutation carriers, 11 patients revealed overt symptoms. 10/11 (90.9%) of which were females. Patients with R179 mutations presented with earlier onset than those with R176 mutation [1.3 (1.0, 37.0) years vs. 28.5 (19.0, 44.0) years]. More patients with R179 mutations had a history of rickets with lower extremity deformity [3/4 (75%) vs. 1/7 (14.3%), p<0.05]. The serum phosphate, i-FGF23 and c-FGF23 levels of patients with R179 and R176 mutations were 0.47 +/- 0.14 mmol/L versus 0.57 +/- 0.17 mmol/L, 79.6 +/- 87.0 pg/mL versus 79.9 +/- 107.4 pg/mL, and 33.4 +/- 3.0 RU/mL versus 121.3 +/- 177.6 RU/mL, respectively. 7/11 of patients had iron deficiency at onset of disease. When combined with previously reported seven ADHR families, difference was observed in the age of onset among symptomatic patients with R179 and R176 mutations [1.0 (0.9, 37.0) years vs. 24.5 (1.2, 57.0) years, p<0.05]. Patients with R179 mutation were more likely to have rickets than R176 mutation (11/13, 84.6% vs. 5/20, 25.0%, p<0.01) and lower extremity deformity (10/13, 76.9% vs. 6/19, 31.6%, p<0.01). ADHR patients with R179 mutations had earlier onset age and more rickets compared to those with mutations in R176, which partially explained the clinical heterogeneity of ADHR.