X-linked dominant hypophosphatemic rickets (HYP) is the most common form of hereditary rickets. Recently we have cloned the PEX gene and shown it to be mutated and deleted in HYP individuals. We have now completely sequenced a 243-kb genomic region containing PEX and have identified all intron-exon boundary sequences. We show that PEX, homologous to members of a neutral endopeptidase family, has an exon organization that is very similar to neprilysin. We have performed an extensive mutation analysis examining all 22 PEX coding exons in 29 familial and 14 sporadic cases of hypophosphatemia. Sequence changes include missense, frameshift, nonsense, and splice site mutations and intragenic deletions. A mutation was found in 25 (86%) of the 29 familial cases and 8 (57%) of the 14 sporadic cases. Our data provide the first evidence that most of the familial and also a large number of the sporadic cases of hypophosphatemia are caused by loss-of-function mutations in PEX.[The sequence data described in this paper have been submitted to GenBank under accession nos. Y08111-Y08132 and Y10196.] X-linked dominant hypophosphatemic rickets [HYP; MIM 307800 (Mendelian inheritance in man number); McKusick 1994] has an incidence of 1 in 20,000 individuals and is the most common form of hypophosphatemia. The main physiological traits of the disease are a leak of phosphate from the kidney causing low phosphate levels in the blood and defective bone mineralization. Patients exhibit rickets and osteomalacia, lower extremity deformities, short stature, bone pain, dental abnormalities, and abnormal vitamin D metabolism. Several other less common disorders of inherited renal phosphate wasting also exist, including an autosomal dominant form (ADHR; McKusick 1994, MIM 193100;Econs and McEnery 1997) and hereditary hypophosphatemic rickets with hypercalciuria (HHRH; McKusick 1994, MIM 241530), which shows a complex inheritance pattern (Tieder et al. 1987). An additional tumor-induced form of hypophosphatemia exists, oncogenic hypophosphatemic osteomalacia, in which removal of the tumor leads to a return in normal phosphate levels (Fukomoto et al. 1979;Lobaugh et al. 1984;Weidner et al. 1985). These additional forms of the disease suggest that phosphate homeostasis is a complex process involving multiple gene products.Recently we cloned a candidate gene, PEX, for the X-linked dominant form of hypophosphatemic rickets, localized to the human Xp22 region (HYP
GENOME RESEARCH 573Cold Spring Harbor Laboratory Press on May 10, 2018 -Published by genome.cshlp.org Downloaded from Consortium 1995). PEX has homologies to a family of zinc metalloproteases that includes neprilysin (NEP; D' Adamio et al. 1989), the Kell antigen (KELL; Lee et al. 1991) and endothelin-converting enzymes 1 and 2 (ECE-1 and ECE-2; Schmidt et al. 1994;Xu et al. 1994;Emoto and Yanagisawa 1995). NEP is known to inactivate a wide variety of peptide hormones, whereas ECE-1 and ECE-2 process inactive big endothelin 1 to its active form. A substrate for PEX has not yet been ...