LRP5 -related primary osteoporosis: phenotypic spectrum and treatment response to zoledronic acid

Objectives Lipoprotein receptor–related protein-5 ( LRP5 )-related disorders are characterized by variably reduced vision and juvenile osteoporosis due to loss-of-function mutations in the low-density LRP5 gene. Compelling evidence on effectiveness of bisphosphonate treatment in these disorders remains limited. We aimed to describe the phenotypic spectrum and clinical, densitometric, and fracture outcomes following zoledronate therapy in children with LRP 5-related disorders. Case presentation Five patients (P1–P5), referred at a median age of 9 years for recurrent low-impact fractures with confirmed LRP5 mutations, were included. P1–P3 were siblings with a homozygous c.1259 G>Cp.(Gly420Ala), variant of likely pathogenic. P4 carried compound heterozygous mutations for three sequence variants, including novel pathogenic variants c.2449 C>T p.(Arg817Cys), and c.362A>Gp.(Lys121Arg), and P5 had a heterozygous c.4502C>Tp.(Pro1501Leu) variant, also identified in the mother, a variant of uncertain significance (VUS). Four patients (P2–P5) received zoledronate for a median duration of 2 years (range 1.5–11 years). Post-treatment, P2, P3, and P5 showed improvements in lumbar spine (LS) Bone Mineral Apparent Density (BMAD) Z-scores (+1.0, +0.7, and +2.7 respectively), remaining fracture-free. P4 exhibited an increase in LS BMAD (+0.3) and vertebral remodeling. Conclusions LRP 5-related disorders should be considered in patients with recurrent fractures and visual involvement. Zoledronate appears effective in improving bone density, reducing fracture frequency, and promoting vertebral remodeling, although further studies are required to determine optimal treatment duration.