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  • Review Article
  • Published:

The FGF23–Klotho axis: endocrine regulation of phosphate homeostasis

Nature Reviews Endocrinology volume 5, pages 611–619 (2009)Cite this article

Abstract

Appropriate levels of phosphate in the body are maintained by the coordinated regulation of the bone-derived growth factor FGF23 and the membrane-bound protein Klotho. The endocrine actions of FGF23, in association with parathyroid hormone and vitamin D, mobilize sodium–phosphate cotransporters that control renal phosphate transport in proximal tubular epithelial cells. The availability of an adequate amount of Klotho is essential for FGF23 to exert its phosphaturic effects in the kidney. In the presence of Klotho, FGF23 activates downstream signaling components that influence the homeostasis of phosphate, whereas in the absence of this membrane protein, it is unable to exert such regulatory effects, as demonstrated convincingly in animal models. Several factors, including phosphate and vitamin D, can regulate the production of both FGF23 and Klotho and influence their functions. In various acquired and genetic human diseases, dysregulation of FGF23 and Klotho is associated with vascular and skeletal anomalies owing to altered phosphate turnover. In this Review, I summarize how the endocrine effects of bone-derived FGF23, in coordination with Klotho, can regulate systemic phosphate homeostasis, and how an inadequate balance of these molecules can lead to complications that are caused by abnormal mineral ion metabolism.

Key Points

  • FGF23 is a bone-derived growth factor that can influence the homeostasis of phosphate and vitamin D

  • Systemic regulation of phosphate homeostasis by FGF23 is dependent on the activity of the membrane protein Klotho

  • Determination of serum FGF23 levels might improve the diagnosis and prognosis of various diseases associated with abnormal mineral ion metabolism, including tumor-induced osteomalacia and chronic kidney diseases

  • Restoration of normal FGF23 activity, by targeting FGF23 or Klotho, might have therapeutic benefits in diseases associated with abnormal mineral ion metabolism

  • Hyperphosphatemia might have more serious consequences in both skeletal and nonskeletal tissues than usually appreciated

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Figure 1: Serum phosphate lowering effects of FGF23.
Figure 2: Gross features, survival and serum FGF23 levels in Kl-knockout mice.
Figure 3: Renal expression of NaPi-2a and serum levels of phosphate in Kl-knockout mice.
Figure 4: The endocrine effects of vitamin D on phosphate metabolism.

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Acknowledgements

The author thanks T. Nakatani and M. Ohnishi (Harvard School of Dental Medicine, Boston) for technical assistance and T. Taguchi (Nagasaki University, Japan) for continued help and encouragement. Some of the original research that formed the basis of this Review is supported by a grant (R01-DK077276 to M.S.R.) from the National Institute of Diabetes and Digestive and Kidney Diseases, and institutional support from Nagasaki University School of Biomedical Science and Harvard School of Dental Medicine.

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Razzaque, M. The FGF23–Klotho axis: endocrine regulation of phosphate homeostasis. Nat Rev Endocrinol 5, 611–619 (2009). https://doi.org/10.1038/nrendo.2009.196

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