This study is being done to determine if cryptic alterations exist within or near to the ALPL gene in patients with a clinical diagnosis of hypophosphatasia, but without identifiable alteration on commercial testing. Additionally, the study aims to characterize functional effects of certain variants of uncertain significance in patients with clinical diagnosis of hypophosphatasia.

Primary Study Objectives:

Determine if cryptic alterations exist within or near to the ALPL gene in patients with clinical diagnosis of hypophosphatasia, but without identifiable pathogenic or likely pathogenic variant on commercial testing.

Secondary Study Objective(s):

Characterize functional effects of variants of uncertain significance in patients with clinical diagnosis of hypophosphatasia

Further characterize the differential diagnosis of hypophosphatasemia in patients with skeletal disease

Inclusion Criteria:

Aim 1-

1. Diagnosis of Hypophosphatasia based on clinical features that include

   • History consistent with diagnosis of hypophosphatasia AND
   • Physical examination findings consistent with a diagnosis of hypophosphatasia AND
   • Presence of low serum alkaline phosphatase level for age and sex AND
   • Elevation of at least one natural substrate of alkaline phosphatase

2. Lack of detection of a variant on molecular analysis of the ALPL gene. When possible, first degree relatives (parents, siblings, or child) will be included for the sole purpose of trio testing. No additional information will be collected on first degree relatives.

Aim 2-

1. Missense variant in ALPL which is interpreted as a variant of uncertain significance by the American College of Medical Genetics Guidelines for Variant Interpretation
2. Variant has been interpreted as pathogenic, likely pathogenic, likely benign, or benign using ex-US interpretation guidelines

Exclusion Criteria:

Aim 1-

1. History and physical examination incompatible with a diagnosis of hypophosphatasia OR
2. Absence of hypophosphatasemia as measured by age and sex-matched control OR
3. Absence of at least one elevated natural substrate of alkaline phosphatase OR
4. Alternate diagnosis which could overlap with signs and symptoms of hypophosphatasia

Aim 2-

1. Inability to express variant in plasmid for residual enzyme and co-transfection analyses

Clinical diagnosis of hypophosphatasia with negative molecular testing.