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...