The phosphatonin pathway: new insights in phosphate homeostasis

Serum phosphate concentrations are maintained within a defined range by processes that regulate the intestinal absorption and renal excretion of inorganic phosphate. The hormones currently believed to influence these processes are parathyroid hormone (PTH) and the active metabolite of vitamin D, 1alpha,25-dihydroxyvitamin D (1alpha,25(OH)2D). A new class of phosphate-regulating factors, collectively known as the phosphatonins, have been shown to be associated with the hypophosphatemic diseases, tumor-induced osteomalacia (TIO), X-linked hypophosphatemic rickets (XLH), and autosomal-dominant hypophosphatemic rickets (ADHR). These factors, which include fibroblast growth factor 23 (FGF23) and secreted frizzled-related protein 4 (FRP4), decrease extracellular fluid phosphate concentrations by directly reducing renal phosphate reabsorption and by suppressing 1alpha,25(OH)2D formation through the inhibition of 25-hydroxyvitamin D 1alpha-hydroxylase. The role of these substances under normal or pathologic conditions is not yet clear. For example, it is unknown whether any of the phosphatonins are directly responsible for the decreased concentrations of 1alpha,25(OH)2D observed in chronic and end-stage kidney disease or whether they are induced in an attempt to correct the hyperphosphatemia seen in late stages of chronic renal failure. Future experiments should clarify their physiologic and pathologic roles in phosphate metabolism.