1
|
Carry BJ, Young K, Fielden S, Kelly MA, Sturm AC, Avila JD, Martin CL, Kirchner HL, Fornwalt BK, Haggerty CM. Genomic Screening for Pathogenic Transthyretin Variants Finds Evidence of Underdiagnosed Amyloid Cardiomyopathy From Health Records. JACC CardioOncol 2021; 3:550-561. [PMID: 34746851 PMCID: PMC8543083 DOI: 10.1016/j.jaccao.2021.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND New treatments for transthyretin amyloidosis improve survival, but diagnosis remains challenging. Pathogenic or likely pathogenic (P/LP) variants in the transthyretin (TTR) gene are one cause of transthyretin amyloidosis, and genomic screening has been proposed to identify at-risk individuals. However, data on disease features and penetrance are lacking to inform the utility of such population-based genomic screening for TTR. OBJECTIVES This study characterized the prevalence of P/LP variants in TTR identified through exome sequencing and the burden of associated disease from electronic health records for individuals with these variants from a large (N = 134,753), primarily European-ancestry cohort. METHODS We compared frequencies of common disease features and cardiac imaging findings between individuals with and without P/LP TTR variants. RESULTS We identified 157 of 134,753 (0.12%) individuals with P/LP TTR variants (43% male, median age 52 [Q1-Q3: 37-61] years). Seven P/LP variants accounted for all observations, the majority being V122I (p.V142I; 113, 0.08%). Approximately 60% (n = 91) of individuals with P/LP TTR variants (all V122I) had African ancestry. Diagnoses of amyloidosis were limited (2 of 157 patients), although related heart disease diagnoses, including cardiomyopathy and heart failure, were significantly increased in individuals with P/LP TTR variants who were aged >60 years. Fourteen percent (7 of 49) of individuals aged ≥60 or older with a P/LP TTR variant had heart disease and ventricular septal thickness >1.2 cm, only one of whom was diagnosed with amyloidosis. CONCLUSIONS Individuals with P/LP TTR variants identified by genomic screening have increased odds of heart disease after age 60 years, although amyloidosis is likely underdiagnosed without knowledge of the genetic variant.
Collapse
Key Words
- ATTR, transthyretin amyloidosis
- CI, confidence interval
- EHR, electronic health record
- HCC, hierarchical condition categories
- LP, likely pathogenic
- LV, left ventricle/ventricular
- OR, odds ratio
- P, pathogenic
- TTR, transthyretin
- amyloidosis
- cardiomyopathy
- electronic health records
- genomics
- hATTR, hereditary transthyretin amyloidosis
Collapse
Affiliation(s)
- Brendan J. Carry
- Heart Institute, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Katelyn Young
- Department of Internal Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Samuel Fielden
- Department of Translational Data Science and Informatics, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Melissa A. Kelly
- Genomic Medicine Institute, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Amy C. Sturm
- Heart Institute, Geisinger Medical Center, Danville, Pennsylvania, USA
- Genomic Medicine Institute, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - J. David Avila
- Department of Neurology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Christa L. Martin
- Genomic Medicine Institute, Geisinger Medical Center, Danville, Pennsylvania, USA
- Autism & Developmental Medicine Institute, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - H. Lester Kirchner
- Department of Population Health Sciences, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Brandon K. Fornwalt
- Heart Institute, Geisinger Medical Center, Danville, Pennsylvania, USA
- Department of Translational Data Science and Informatics, Geisinger Medical Center, Danville, Pennsylvania, USA
- Department of Radiology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Christopher M. Haggerty
- Heart Institute, Geisinger Medical Center, Danville, Pennsylvania, USA
- Department of Translational Data Science and Informatics, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Regeneron Genetics Center, Tarrytown, New York, USA
- Heart Institute, Geisinger Medical Center, Danville, Pennsylvania, USA
- Department of Internal Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
- Department of Translational Data Science and Informatics, Geisinger Medical Center, Danville, Pennsylvania, USA
- Genomic Medicine Institute, Geisinger Medical Center, Danville, Pennsylvania, USA
- Department of Neurology, Geisinger Medical Center, Danville, Pennsylvania, USA
- Autism & Developmental Medicine Institute, Geisinger Medical Center, Danville, Pennsylvania, USA
- Department of Population Health Sciences, Geisinger Medical Center, Danville, Pennsylvania, USA
- Department of Radiology, Geisinger Medical Center, Danville, Pennsylvania, USA
| |
Collapse
|
2
|
Abstract
Heritable cardiac amyloidosis (CA) is an underrecognized cause of morbidity and mortality in the USA. It results from the accumulation of the misfolded protein transthyretin within the myocardium, resulting in amyloid transthyretin-associated cardiomyopathy (ATTR-CM). Over 150 different pathologic point mutations within the transthyretin gene have been identified, each carrying variable clinical phenotypes and penetrance. In the USA, the most common cause of hereditary ATTR is the Val122Ile point mutation, with a prevalence of 3.4-4.0% in North Americans of African and Caribbean descent. Among Caucasians with hereditary ATTR-CM, the V30M mutation is the most commonly identified variant. Overall, the incidence of ATTR disease in the USA has been increasing, likely due to an increase in practitioner awareness, utilization of new non-invasive imaging technologies for ATTR diagnosis, and the growth of multidisciplinary amyloid programs across the country. Yet significant numbers of patients with evidence of left ventricular thickening on cardiac imaging, senile aortic stenosis, and/or symptoms of heart failure with preserved ejection fraction likely have undiagnosed CA, especially within the African American population. With the emergence of new disease-modifying therapies for ATTR, recognition and the prompt diagnosis of CA is important for patients and their potentially affected progeny. Herein, we review the genetics of heritable CA as well as the importance of genetic counseling and testing for patients and their families.
Collapse
Affiliation(s)
- Scott Arno
- Henry Ford Hospitals, 2799 W. Grand Blvd, K14 Cardiology, Detroit, MI, 48202, USA
| | - Jennifer Cowger
- Henry Ford Hospitals, 2799 W. Grand Blvd, K14 Cardiology, Detroit, MI, 48202, USA.
| |
Collapse
|
3
|
Zanazzi G, Arshad M, Maurer MS, Brannagan TH, Tanji K. Demyelinating Neuropathy in a Patient Treated With Revusiran for Transthyretin (Thr60Ala) Amyloidosis. J Clin Neuromuscul Dis 2019; 20:120-128. [PMID: 30801482 PMCID: PMC6392216 DOI: 10.1097/cnd.0000000000000242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Transthyretin amyloidosis patients develop length-dependent peripheral neuropathy, autonomic dysfunction, and restrictive cardiomyopathy associated with deposition of amyloid fibrils in these tissues. Despite advances in management over the past decade, this disorder causes profound debilitation and ultimately proves fatal. In this report, we describe a man with late-onset cardiac amyloidosis due to a transthyretin Thr60Ala mutation who was treated with an investigational RNAi therapeutic, revusiran, which targets hepatic transthyretin production. Sixteen months into treatment, he developed bilateral lower-extremity weakness and numbness, worsening balance, difficulty manipulating objects with his hands, and finger numbness. Nerve conduction studies were consistent with multifocal demyelinating neuropathy. Intravenous immunoglobulin therapy improved sensation in his hands and feet, and improved hand dexterity. A sural nerve biopsy demonstrated demyelination with substantial axonal loss in the absence of histologically detectable endoneurial amyloid deposition. This case expands the clinicopathologic spectrum of transthyretin amyloidosis and may represent complex disease and treatment effects.
Collapse
Affiliation(s)
- George Zanazzi
- Division of Neuropathology, Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY
| | - Muhammad Arshad
- Department of Neurology, Columbia Neuropathy Research Center, The Neurological Institute of New York, Columbia University Medical Center, New York, NY; and
| | - Mathew S. Maurer
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Thomas H. Brannagan
- Department of Neurology, Columbia Neuropathy Research Center, The Neurological Institute of New York, Columbia University Medical Center, New York, NY; and
| | - Kurenai Tanji
- Division of Neuropathology, Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY
| |
Collapse
|
4
|
Nunes RJ, de Oliveira P, Lages A, Becker JD, Marcelino P, Barroso E, Perdigoto R, Kelly JW, Quintas A, Santos SCR. Transthyretin proteins regulate angiogenesis by conferring different molecular identities to endothelial cells. J Biol Chem 2013; 288:31752-60. [PMID: 24030829 DOI: 10.1074/jbc.m113.469858] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Familial amyloidotic polyneuropathy (FAP) has a high prevalence in Portugal, and the most common form of hereditary amyloidosis is caused by an amyloidogenic variant of transthyretin (TTR) with a substitution of methionine for valine at position 30 (V30M). Until now, the available efficient therapy is liver transplantation, when performed in an early phase of the onset of the disease symptoms. However, transplanted FAP patients have a significantly higher incidence of early hepatic artery thrombosis compared with non-FAP transplanted patients. Because FAP was described as an independent risk factor for early hepatic artery thrombosis, more studies to understand the underlying mechanisms involved in this outcome are of the utmost importance. Knowing that the liver is the major site for TTR production, we investigated the biological effects of TTR proteins in the vasculature and on angiogenesis. In this study, we identified genes differentially expressed in endothelial cells exposed to the WT or V30M tetramer. We found that endothelial cells may acquire different molecular identities when exposed to these proteins, and consequently TTR could regulate angiogenesis. Moreover, we show that V30M decreases endothelial survival by inducing apoptosis, and it inhibits migration. These findings provide new knowledge that may have critical implications in the prevention of early hepatic artery thrombosis in FAP patients after liver transplantation.
Collapse
Affiliation(s)
- Raquel J Nunes
- From the Angiogenesis Unit, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, 1649-028 Lisbon, Portugal
| | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Abstract
Amyloidosis is a heterogeneous group of diseases characterized by the pathological deposition of autologous proteins in an antiparallel β-sheet confirmation forming non-branching linear fibrils of indefinite length and an approximate diameter of 10-12 nm. Cardiac amyloidosis is caused by deposits in the heart and may lead to cardiac arrhythmia and low output failure. Following the diagnosis, classification of the amyloid protein and evaluation of further organ involvement is mandatory. Treatment approaches are based on reduction of the production of amyloid precursor proteins. Standard heart failure treatment is usually not well tolerated and the underlying disease remains unaffected. Cardiac amyloidosis, especially of the light chain type, is associated with a poor outcome. The clinical picture is uncharacteristic, therefore correct diagnosis of cardiac amyloidosis is often delayed in many patients. Combination of clinical symptoms of different organ systems should alert the physician to the diagnosis of amyloidosis.
Collapse
Affiliation(s)
- A V Kristen
- Abteilung für Innere Medizin III (Kardiologie, Angiologie, Pneumologie), Medizinische Universitätsklinik Heidelberg, Heidelberg, Deutschland
| | | |
Collapse
|
6
|
Abstract
There has been much progress in our understanding of transthyretin (TTR)-related amyloidosis including familial amyloidotic polyneuropathy (FAP), senile systemic amyloidosis and its related disorders from many clinical and experimental aspects. FAP is an inherited severe systemic amyloidosis caused by mutated TTR, and characterized by amyloid deposition mainly in the peripheral nervous system and the heart. Liver transplantation is the only available treatment for the disease. FAP is now recognized not to be a rare disease, and to have many variations based on genetical and biochemical variations of TTR. This chapter covers the recent advances in the clinical and pathological aspects of, and therapeutic approaches to FAP, and the trend as to the molecular pathogenesis of TTR.
Collapse
Affiliation(s)
- Takamura Nagasaka
- Department of Neurology, University of Yamanashi, 1110 Shimokato, 409-3898, Chuou-city, Yamanashi, Japan,
| |
Collapse
|
7
|
Sattianayagam PT, Hahn AF, Whelan CJ, Gibbs SDJ, Pinney JH, Stangou AJ, Rowczenio D, Pflugfelder PW, Fox Z, Lachmann HJ, Wechalekar AD, Hawkins PN, Gillmore JD. Cardiac phenotype and clinical outcome of familial amyloid polyneuropathy associated with transthyretin alanine 60 variant. Eur Heart J 2011; 33:1120-7. [PMID: 21992998 DOI: 10.1093/eurheartj/ehr383] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
AIMS Familial amyloid polyneuropathy (FAP) is a dominantly inherited multi-system disease associated with transthyretin (TTR) mutations. Previous series have predominantly described patients with the TTR variant Val30Met (V30M), which is the most prevalent cause of FAP worldwide. Here, we report the dominant cardiac phenotype and outcome of FAP associated with TTR Thr60Ala (T60A), the most common UK variant. METHODS AND RESULTS Sixty consecutive patients with FAP associated with TTR T60A (FAP T60A) were prospectively evaluated in two centres between 1992 and 2009. Median (range) age of symptom development was 63 (45-78) years. A family history of amyloidosis was present in only 37%. Autonomic and peripheral neuropathy were present in 44 and 32 patients, respectively, at diagnosis. Cardiac involvement was evident on echocardiography at diagnosis in 56 patients, but was associated with reduced QRS voltages on electrocardiography in only 16% evaluable cases. Seventeen patients received implantable anti-arrhythmic devices. Median survival was 6.6 years following onset of symptoms and 3.4 years from diagnosis, and correlated with serum N-terminal prohormone brain natriuretic peptide (NT-proBNP) concentration and certain echocardiographic parameters at the latter. Orthotopic liver transplantation (OLT), performed to eliminate the predominant hepatic source of variant TTR T60A protein, was performed in eight patients including one who received a concomitant cardiac transplant. Cardiac amyloidosis progressed in all lone OLT recipients, of whom four died within 5 years. CONCLUSION Cardiac amyloidosis is almost always present at diagnosis in FAP T60A, and is a major determinant of its poor prognosis. Outcome of liver transplantation in FAP T60A has been discouraging.
Collapse
Affiliation(s)
- Prayman T Sattianayagam
- National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Hörnsten R, Pennlert J, Wiklund U, Lindqvist P, Jensen SM, Suhr OB. Heart complications in familial transthyretin amyloidosis: impact of age and gender. Amyloid 2010; 17:63-8. [PMID: 20462364 DOI: 10.3109/13506129.2010.483114] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Heart arrhythmia is common in Swedish patients with familial amyloidotic polyneuropathy (FAP), as well as cardiomyopathy. We investigated the relationship between Holter ECG and echocardiographic findings in 108 FAP patients, with particular focus on age and gender differences. Female patients were younger than male patients at symptom onset (p < 0.01). Only 4 of 39 patients with septal hypertrophy were females. Regression analysis showed that age of onset, gender and duration of disease were significantly related with intraventricular septum (IVS) thickness. Sixty-five patients (25 females) presented with abnormal 24-h ECG recordings. IVS thickness was not significantly related to conduction disturbances or the presence of ventricular arrhythmia (VA). However, IVS thickness and atrial dimension were both related to increased rate of supraventricular arrhythmia (SVA). Male gender was clearly associated with more pronounced septal thickness of the heart. Conduction disturbances were not related to IVS thickness, indicating that the distribution and extent of infiltration of the heart by amyloid are heterogeneous and related to gender and age of onset. These findings highlight the necessity of 24-h ECGs to detect conduction disturbances, due to their occurrence in the absence of echocardiographic evidence of amyloid deposition in the myocardium.
Collapse
Affiliation(s)
- Rolf Hörnsten
- Department of Surgical and Perioperative Science, Umeå University, Clinical Physiology, Heart Centre, Umeå, Sweden
| | | | | | | | | | | |
Collapse
|
9
|
Ihse E, Stangou AJ, Heaton ND, O’Grady J, Ybo A, Hellman U, Edvinsson Å, Westermark P. Proportion between wild-type and mutant protein in truncated compared to full-length ATTR: An analysis on transplanted transthyretin T60A amyloidosis patients. Biochem Biophys Res Commun 2009; 379:846-50. [PMID: 19118530 DOI: 10.1016/j.bbrc.2008.12.095] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Accepted: 12/16/2008] [Indexed: 10/21/2022]
|
10
|
Buxbaum J, Koziol J, Connors LH. Serum transthyretin levels in senile systemic amyloidosis: effects of age, gender and ethnicity. Amyloid 2008; 15:255-61. [PMID: 19065297 PMCID: PMC5612502 DOI: 10.1080/13506120802525285] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Serum transthyretin (TTR) levels are reduced in familial amyloidotic polyneuropathy (FAP). A single study of patients with senile systemic amyloidosis (SSA) in Sweden found that those individuals also had a significantly lower mean serum TTR concentration than age- and gender-matched controls. To determine if the same phenomenon prevailed in an ethnically more heterogeneous population, we compared the serum TTR levels, as determined by ELISA, in 45 documented SSA patients with congestive heart failure, 20 AL patients with congestive heart failure and population controls. Serum TTR concentrations in the controls were influenced in a statistically significant manner by age, gender and ethnicity. Although it is unlikely that such differences are clinically relevant, they must be considered when assessing the meaning of serum TTR concentrations in any clinically defined population. The serum concentrations in patients with SSA did not differ from age, gender and ethnically matched controls or from a group of AL patients with significant clinical cardiac involvement. We also compared TTR concentrations in 12 African-Americans carrying the TTR V122I allele with those in 826 African-Americans who were homozygous wild type at the TTR locus. The TTR V122I carriers had significantly lower serum TTR concentrations than appropriate controls even though the majority of such individuals had not reached the age of clinical or anatomic risk, i.e. over 60. Thus, as in carriers of other TTR mutations the serum TTR level is lower than normal, despite having a much later appearance of clinical disease.
Collapse
Affiliation(s)
- Joel Buxbaum
- Division of Rheumatology Research, WM Keck Autoimmune Disease Center, Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA, USA.
| | | | | |
Collapse
|
11
|
Abstract
Neuropathy is often a major manifestation of systemic amyloidosis. It is most frequently seen in patients with hereditary transthyretin (TTR) amyloidosis, but is also present in 20% of patients with systemic immunoglobulin light chain (primary) amyloidosis. Familial amyloid polyneuropathy (FAP) is the most common form of inherited amyloidotic polyneuropathy, with clinical and electrophysiologic findings similar to neuropathies with differing etiologies (e.g., diabetes mellitus). Hereditary amyloidosis is an adult-onset autosomal-dominant disease with varying degrees of penetrance. It is caused by specific gene mutations, but demonstration that a patient has one such mutation does not confirm the diagnosis of amyloidosis. Diagnosis requires tissue biopsy with demonstration of amyloid deposits either by special histochemical stains or electron microscopy. Transthyretin amyloidosis is treated by liver transplantation, which eliminates the mutated transthyretin from the blood, but for some patients continued amyloid deposition can occur from wild-type (normal) transthyretin. Presently, a study is ongoing to determine whether amyloid deposition can be inhibited by small organic molecules that are hypothesized to affect the fibril-forming ability of transthyretin. Proposed gene therapy with antisense oligonucleotides (ASOs) to suppress hepatic transthyretin synthesis is effective in a transgenic mouse model but has not yet been tested in humans.
Collapse
Affiliation(s)
- Merrill D Benson
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, MS-128, Indianapolis, IN 46202-5126, USA.
| | | |
Collapse
|
12
|
Abstract
Familial amyloidotic polyneuropathy (FAP) is an inherited autosomal dominant disease that is commonly caused by accumulation of deposits of transthyretin (TTR) amyloid around peripheral nerves. The only effective treatment for FAP is liver transplantation. However, recent studies on TTR aggregation provide clues to the mechanism of the molecular pathogenesis of FAP and suggest new avenues for therapeutic intervention. It is increasingly recognized that there are common features of a number of protein-misfolding diseases that can lead to neurodegeneration. As for other amyloidogenic proteins, the most toxic forms of aggregated TTR are likely to be the low-molecular-mass diffusible species, and there is increasing evidence that this toxicity is mediated by disturbances in calcium homeostasis. This article reviews what is already known about the mechanism of TTR aggregation in FAP and describes how recent discoveries in other areas of amyloid research, particularly Alzheimer's disease, provide clues to the molecular pathogenesis of FAP.
Collapse
Affiliation(s)
- Xu Hou
- Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria, Australia
| | | | | |
Collapse
|
13
|
Abstract
The cardiovascular system is a common target of amyloidosis. This review presents the current clinical and diagnostic approach to amyloidosis, with the emphasis on cardiovascular involvement. It summarises recent nomenclature, classification, and pathogenesis of amyloidosis. In addition, non-invasive possibilities are discussed, together with endomyocardial biopsies in the diagnosis of cardiac amyloidosis. Finally, recent advances in treatment and prognostic implications are presented.
Collapse
Affiliation(s)
- I Kholová
- Department of Pathology, Vrije Universiteit Medical Centre, De Boelelaan 1117, 1007 MB Amsterdam, The Netherlands
| | | |
Collapse
|
14
|
Hattori T, Takei YI, Koyama J, Nakazato M, Ikeda SI. Clinical and pathological studies of cardiac amyloidosis in transthyretin type familial amyloid polyneuropathy. Amyloid 2003; 10:229-39. [PMID: 14986482 DOI: 10.3109/13506120309041740] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
To clarify the clinicopathological features of cardiac amyloidosis in transthyretin (TTR) familial amyloid polyneuropathy (FAP), 169 patients were divided into three groups. Group I consisted of 113 patients with ATTR Val30Met who originated from an endemic focus, II consisted of 36 patients with ATTR Val30Met in nonendemic areas, and III consisted of 20 patients who had non-Val30Met ATTRs with 15 different gene mutations. The median age of onset in Group I was 34 years. On our initial examination, only one 65-year-old female patient was found to be suffering from congestive heart failure. During the follow-up of 65 patients, 7 developed congestive heart failure, the average duration of their illness being 8.7 years. In Group II, the median age of onset was 53 years and 6 of the 36 patients were diagnosed as having cardiac amyloidosis in the course of this disease. In 20 autopsied patients with ATTR Val30Met, congestive heart failure was clinically seen in 6 of the 20 and all 6 showed considerably increased cardiac weight (500g or more). In Group III patients with non-Val30Met ATTRs, the median age of onset was 51.5 years and 14 of the 20 patients had cardiac amyloidosis with congestive heart failure on admission or soon after a definite diagnosis. Cardiac amyloidosis occurs in the classical form of FAP with ATTR Val30Met, especially in older patients, and is also a common clinical manifestation in FAP patients with non-Val30Met ATTRs. In the pathogenesis of cardiac amyloidosis in ATTR FAP, aging seems to play an important role.
Collapse
Affiliation(s)
- Takeshi Hattori
- Third Department of Medicine, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | | | | | | | | |
Collapse
|
15
|
Guirl MJ, Högenauer C, Santa Ana CA, Porter JL, Little KH, Stone MJ, Fordtran JS. Rapid intestinal transit as a primary cause of severe chronic diarrhea in patients with amyloidosis. Am J Gastroenterol 2003; 98:2219-25. [PMID: 14572571 DOI: 10.1111/j.1572-0241.2003.07695.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The cause of severe diarrhea in patients with systemic amyloidosis is obscure. We therefore performed pathophysiological studies in three such patients in an effort to determine the mechanism of amyloid diarrhea. METHODS Epithelial cell absorption rate of electrolytes was measured during steady state GI perfusion of a saline-mannitol solution. GI transit time of PEG and absorption of radiolabeled bile acid were measured simultaneously while subjects ingested three meals per day. To obtain a diarrhea control group for transit time and bile acid absorption, normal subjects were studied when they had diarrhea caused by ingestion of Milk of Magnesia (MOM). RESULTS Diarrhea could not be explained by malabsorption of ingested nutrients, bacterial overgrowth, bile acid malabsorption, or epithelial cell malabsorption of electrolytes. However, 25% of polyethylene glycol (PEG) ingested with a standard meal was recovered in stool in 45 min, which is 10 times faster than in normal subjects with equally severe diarrhea caused by ingestion of MOM. All of the patients had autonomic neuropathy that remained unrecognized for 15-36 months after onset of chronic diarrhea; it seems likely that this was the cause of rapid transit. CONCLUSIONS Severe chronic diarrhea in three patients with systemic amyloidosis was mediated by extremely rapid transit of chyme and digestive secretions through the intestine.
Collapse
|
16
|
Ikeda SI. Clinical picture and outcome of transthyretin-related familial amyloid polyneuropathy (FAP) in Japanese patients. Clin Chem Lab Med 2002; 40:1257-61. [PMID: 12553427 DOI: 10.1515/cclm.2002.217] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Familial amyloid polyneuropathy (FAP) was once considered to be a disease peculiar to endemic areas, but it is now recognized that FAP kindreds exist in worldwide places. The amyloid precursor of FAP is a variant form of transthyretin (TTR) with one amino acid substitution, which is ascribed to a mutation of TTR gene. Corresponding to the variety of the clinical phenotypes of FAP, more than 80 mutations have been identified as causative gene abnormality in this disease. Since the vast majority of TTR in serum is produced in the liver, liver transplantation has become widely accepted as a valuable treatment for FAP.
Collapse
Affiliation(s)
- Shu-ichi Ikeda
- Third Department of Medicine, Shinshu University School of Medicine, Matsumoto, Japan.
| |
Collapse
|
17
|
Kotani N, Hattori T, Yamagata S, Tokuda T, Shirasawa A, Yamaguchi S, Kobayashi S, Ikeda SI. Transthyretin Thr60Ala Appalachian-type mutation in a Japanese family with familial amyloidotic polyneuropathy. Amyloid 2002; 9:31-4. [PMID: 12000195 DOI: 10.3109/13506120209072442] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A Japanese case with familial amyloidotic polyneuropathy (FAP) associated with the transthyretin mutation Thr60Ala (Appalachian-type mutation) is described This is the first reported case of a non-Caucasian harboring this type of TTR mutation. The patient developed severe late-onset restrictive cardiomyopathy as well as sensorimotor and autonomic polyneuropathy, which were essentially similar to the previously reported clinical pictures of Appalachian-type FAP.
Collapse
Affiliation(s)
- Nobuhiro Kotani
- Department of Internal Medicine IV, Shimane Medical University, Izumo, Japan
| | | | | | | | | | | | | | | |
Collapse
|
18
|
Affiliation(s)
- R A Kyle
- Department of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| |
Collapse
|
19
|
|
20
|
Abstract
Peripheral nerve amyloidosis is the cardinal feature of familial amyloid polyneuropathy (FAP) but can also be seen in primary light chain (AL) amyloidosis and dialysis (beta 2-microglobulin) related amyloidosis. The generalized neuropathy seen in all forms of peripheral nerve amyloidosis is similar, characterized by a severe progressive mixed neuropathy with autonomic dysfunction. Pathologically, amyloid is found in the peripheral nervous system as amorphous, eosinophilic, extracellular deposits. FAP is most commonly associated with variant plasma transthyretin (TTR), although it has also been described in association with mutant apolipoprotein A-1 and gelsolin. There are now at least 36 point mutations in the TTR gene associated with FAP and these continue to be described. Recent studies on the possible role individual point mutations in the TTR gene may play in amyloidosis have helped give us an insight into the mechanisms behind peripheral nerve amyloidosis. This article reviews the clinical and pathological features of the peripheral nerve amyloidosis and discusses theories of amyloidogenesis based on studies of FAP.
Collapse
Affiliation(s)
- M M Reilly
- National Hospital for Neurology and Neurosurgery, London, U.K
| | | |
Collapse
|
21
|
Reilly MM, Staunton H, Harding AE. Familial amyloid polyneuropathy (TTR ala 60) in north west Ireland: a clinical, genetic, and epidemiological study. J Neurol Neurosurg Psychiatry 1995; 59:45-9. [PMID: 7608709 PMCID: PMC1073600 DOI: 10.1136/jnnp.59.1.45] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A cluster of cases of familial amyloid polyneuropathy has been described in Donegal, north west Ireland. Two patients from this region have been shown to have the ala 60 mutation in the transthyretin gene. Three kindreds with this mutation have also been described in the United States. Genealogical and haplotype studies indicate that all known patients with this mutation are related and are descended from a founder in north west Ireland. There is evidence for reduced penetrance of this disorder. A population based study showed that 1.1% of the population in this area in north west Ireland carry the mutation. This has implications in terms of diagnosis, genetic counselling, and treatment in the future.
Collapse
Affiliation(s)
- M M Reilly
- University Department of Clinical Neurology, Institute of Neurology, London, UK
| | | | | |
Collapse
|
22
|
Simeoni E, Bauman A, Stenmark J, O'Brien J. Evaluation of a community arthritis program in Australia: dissemination of a developed program. ARTHRITIS CARE AND RESEARCH : THE OFFICIAL JOURNAL OF THE ARTHRITIS HEALTH PROFESSIONS ASSOCIATION 1995; 8:102-7. [PMID: 7794983 DOI: 10.1002/art.1790080208] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of a community-based arthritis education program conducted in a number of locations throughout the Sydney, Australia, metropolitan area. METHODS The program, based on earlier work, comprised 6 weekly sessions of 2.5 hours' duration. The study sample included 175 men and women with different types of arthritis, divided into intervention (n = 104) and control (n = 71) groups. Five outcome measures were selected to evaluate effectiveness of the program: pain perception, knowledge level, self-efficacy, disability index, and self-management behavior. RESULTS The results indicated that the program was effective in increasing knowledge level (F[1,222] = 10.3, P = 0.001 at 6 weeks; F[1,108] = 7.8, P = 0.006 at 6 months), and a statistically significant difference was found in disability satisfaction 6 months after intervention (F[1,98] = 5.9, P = 0.01], but no statistically significant difference was found in pain perception, self-efficacy, and disability index. CONCLUSION This research supports some of the successful outcomes which follow an arthritis education program: increased knowledge level and increased disability satisfaction.
Collapse
|
23
|
|
24
|
Abstract
Familial amyloid polyneuropathy (FAP) is most commonly associated with variant plasma transthyretin, although it has also been described in association with mutant apolipoprotein A-1 and gelsolin. There are now approximately 26 point mutations in the transthyretin gene associated with FAP. Because of the overlapping clinical phenotypes described with these mutations, it is now more appropriate to classify the various forms of FAP according to the underlying genetic defect rather than on clinical grounds. Many questions concerning the amyloidogenic nature of transthyretin and the variability of organ involvement depending on the underlying mutation remain unanswered. The recent use of liver transplantation for treatment appears to be promising.
Collapse
Affiliation(s)
- M M Reilly
- University Department of Clinical Neurology, Institute of Neurology, London, U.K
| | | |
Collapse
|
25
|
Harrison HH, Gordon ED, Nichols WC, Benson MD. Biochemical and clinical characterization of prealbuminCHICAGO: an apparently benign variant of serum prealbumin (transthyretin) discovered with high-resolution two-dimensional electrophoresis. AMERICAN JOURNAL OF MEDICAL GENETICS 1991; 39:442-52. [PMID: 1877623 DOI: 10.1002/ajmg.1320390415] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We report identification, biochemical, clinical, and genetic studies of an apparently benign, electrophoretic variant of serum prealbumin (PALB, transthyretin, TTR) in a North American kindred of Swedish ancestry. The variant polypeptide stems from a C to T point mutation in exon 4 which results in methionine instead of threonine at position 119 of the mature molecule. It was discovered incidentally in a girl with classic alpha-1-anti-trypsin (A1AT) deficiency and her father during diagnostic A1AT phenotyping by ISO-DALT high-resolution two-dimensional electrophoresis (2DE). Twelve relatives in the four-generation paternal kindred, including five individuals who were heterozygous for the variant prealbumin, were studied. In each of these five heterozygotes, the variant allele product was equimolar and isoelectric with the normal protein, yet migrated with an apparently lower mass in the SDS-PAGE dimension. The inheritance pattern was consistent with autosomal dominant transmission. Histories and physical examinations showed no evidence of amyloidosis, as has been observed with other variants of prealbumin. Mean values of serum prealbumin and retinol binding protein levels were higher in the carriers as compared to the normal relatives in the family, but the difference was not statistically significant. Thyroid hormone levels and distribution of thyroxine and triiodothyronine among binding proteins in serum were within reference limits. Four members of the lineage had dominant, scalp-restricted keratinaceous cysts, yet only three of these four individuals had the variant. We counseled the family that this is likely a benign variant with regard to amyloidosis-related morbidity or shortened life span, although senile effects cannot be entirely ruled out. The provisional designation assigned to this allele is PALBCHICAGO. The substitution of methionine at position 119, as predicted by the DNA sequence, was confirmed by amino acid sequencing of CNBr and tryptic peptides. This substitution occurs at a CpG dinucleotide that may be a point mutational "hot spot," as has been postulated for the methionine-30 and isoleucine-122 PALB variants. The apparently lower mass of the variant probably results from a more compact conformation in SDS. With the exception of histidine-58, a charge substitution, all other amyloidosis-related prealbumin variant polypeptides had normal mobility in the ISO-DALT 2DE system.
Collapse
Affiliation(s)
- H H Harrison
- Dept. of Pathology, University of Chicago Pritzker School of Medicine, IL 60637
| | | | | | | |
Collapse
|
26
|
Affiliation(s)
- D R Jacobson
- Medical Service, New York Veterans Affairs Medical Center, New York
| | | |
Collapse
|
27
|
Maury CP, Baumann M. Isolation and characterization of cardiac amyloid in familial amyloid polyneuropathy type IV (Finnish): relation of the amyloid protein to variant gelsolin. BIOCHIMICA ET BIOPHYSICA ACTA 1990; 1096:84-6. [PMID: 2176550 DOI: 10.1016/0925-4439(90)90016-i] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Amyloid subunit protein was isolated from familial amyloid polyneuropathy type IV (Finnish type) cardiac tissue and purified to homogeneity. N-terminal amino acid sequence analysis shows that the amyloid protein is a fragment of the inner region of human gelsolin. When compared with the predicted sequence of human plasma gelsolin, the amyloid protein contains an asparagine-for-aspartic acid substitution at position 15 corresponding to residue 187 of the secreted protein. Antibodies raised against the amyloidogenic region of gelsolin specifically stained the amyloid deposited in tissues in familial amyloidosis type IV. The results show that the subunit amyloid protein in familial amyloid polyneuropathy type IV represents a unique type of amyloid derived from a variant (Asn-187) gelsolin molecule by limited proteolysis.
Collapse
Affiliation(s)
- C P Maury
- Fourth Department of Medicine, University of Helsinki, Finland
| | | |
Collapse
|
28
|
Koeppen AH, Wallace MR, Benson MD, Altland K. Familial amyloid polyneuropathy: alanine-for-threonine substitution in the transthyretin (prealbumin) molecule. Muscle Nerve 1990; 13:1065-75. [PMID: 2122246 DOI: 10.1002/mus.880131109] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A previously reported family with amyloid polyneuropathy (FAP) was reinvestigated to determine the type of mutation in the transthyretin (prealbumin) molecule. Transthyretin was isolated from amyloid-laden myocardium and serum, and tryptic peptides were resolved by high-performance liquid chromatography. Amino acid sequencing of an anomalous peptide revealed an alanine-for-threonine substitution corresponding to position No. 60 of the transthyretin monomer. Detection of the FAP gene in asymptomatic carriers was accomplished by hybrid isoelectric focusing of transthyretin in the presence of dithiothreitol and high concentrations of urea, and by Southern blotting of Pvull-digested leukocyte deoxyribonucleic acid. This type of FAP was found to be identical to the previously described Appalachian amyloid. Patients with FAP and their asymptomatic gene-carrying offspring had significantly reduced levels of serum transthyretin and retinol-binding protein.
Collapse
Affiliation(s)
- A H Koeppen
- Neurology Service, Veterans Administration Medical Center, Albany, New York 12208
| | | | | | | |
Collapse
|
29
|
Mendell JR, Jiang XS, Warmolts JR, Nichols WC, Benson MD. Diagnosis of Maryland/German familial amyloidotic polyneuropathy using allele-specific, enzymatically amplified, genomic DNA. Ann Neurol 1990; 27:553-7. [PMID: 2360796 DOI: 10.1002/ana.410270516] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Diagnoses of familial amyloidotic polyneuropathies have been traditionally based on attempts to distinguish clinical features and ancestry or geographic origin of cases. Most are associated with extracellular deposition of a variant prealbumin (also known as transthyretin). Recent molecular studies demonstrated eight distinct amyloid-associated point mutations in the prealbumin gene on the long arm of chromosome 18 that are associated with hereditary amyloidosis. These findings provide for means of diagnosis using recombinant DNA methods. In a family with the Maryland/German type of familial amyloidotic polyneuropathy, the proband and 2 of 5 at-risk offspring were diagnosed using the polymerase chain reaction. Allele-specific enzymatic amplification of genomic DNA demonstrated the histidine-58 variant prealbumin gene. This study confirms the point mutation of the prealbumin gene as a cause for this type of familial amyloidotic polyneuropathy. Preclinical diagnosis illustrates the potential for development of treatment strategies prior to disease onset.
Collapse
Affiliation(s)
- J R Mendell
- Department of Neurology, Ohio State University, Columbus 43210
| | | | | | | | | |
Collapse
|
30
|
Affiliation(s)
- R A Kyle
- Mayo Medical School, Rochester, Minnesota
| | | |
Collapse
|
31
|
Nichols WC, Benson MD. Hereditary amyloidosis: detection of variant prealbumin genes by restriction enzyme analysis of amplified genomic DNA sequences. Clin Genet 1990; 37:44-53. [PMID: 2154345 DOI: 10.1111/j.1399-0004.1990.tb03389.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The autosomal dominant prealbumin amyloidoses are late-onset disorders characterized by varying degrees of peripheral neuropathy, nephropathy and cardiomyopathy. To date, seven different single amino acid mutations in the plasma protein prealbumin (transthyretin) have been found to be associated with amyloidosis and each is the result of a single nucleotide change in the prealbumin gene. By virtue of the restriction endonuclease sites created by the point mutations which give rise to the protein variants, direct DNA tests using Southern analysis have already been developed for detection of the Met-30, Ile-33, Ala-60, Tyr-77 and Ser-84 prealbumin genes. As an alternative to Southern analysis, we have amplified discrete regions of the prealbumin gene using polymerase chain reaction (PCR) and used restriction enzyme analysis of the PCR products to detect the Met-30, Ala-60, Tyr-77 and Ser-84 prealbumin genes after agarose gel electrophoresis and staining with ethidium bromide. In comparison to Southern analysis these alternative tests yield results much more quickly and avoid the use and handling of radioactively labeled probes.
Collapse
Affiliation(s)
- W C Nichols
- Department of Medical Genetics, Indiana University School of Medicine, Indianapolis
| | | |
Collapse
|
32
|
Nichols WC, Padilla LM, Benson MD. Prenatal detection of a gene for hereditary amyloidosis. AMERICAN JOURNAL OF MEDICAL GENETICS 1989; 34:520-4. [PMID: 2516414 DOI: 10.1002/ajmg.1320340413] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Autosomal dominant amyloidosis of the Indiana/Swiss type (familial amyloidotic polyneuropathy type II) is a late-onset disorder characterized by carpal tunnel syndrome, peripheral neuropathy, vitreous opacities, and cardiomyopathy. The genetic basis of the disease is a variant of plasma prealbumin (transthyretin) which has a serine for isoleucine substitution at amino acid 84 of the 127 residue prealbumin molecule. Using the polymerase chain reaction (PCR), we amplified exon 3 of the prealbumin gene in DNA extracted from amniocytes of a fetus at-risk of carrying the serine-84 prealbumin gene. By allele-specific oligonucleotide analysis as well as restriction enzyme analysis of the amplification products it was determined that the fetus was a carrier of the serine-84 variant gene. This finding was confirmed at birth by Southern blot analysis using DNA obtained from cord blood. This is the first report of the prenatal detection of a gene for hereditary amyloidosis.
Collapse
Affiliation(s)
- W C Nichols
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | | | | |
Collapse
|
33
|
Gorevic PD, Prelli FC, Wright J, Pras M, Frangione B. Systemic senile amyloidosis. Identification of a new prealbumin (transthyretin) variant in cardiac tissue: immunologic and biochemical similarity to one form of familial amyloidotic polyneuropathy. J Clin Invest 1989; 83:836-43. [PMID: 2646319 PMCID: PMC303756 DOI: 10.1172/jci113966] [Citation(s) in RCA: 111] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Isolated amyloid fibrils from three cases of systemic senile amyloidosis (SSA) contained subunit proteins with molecular masses of 14 (10-20%), 10-12 (60-80%), and 5-6 kD (5-10%) when fractionated under reducing and dissociating conditions. This grouping was identical to that seen in SKO, a case of familial amyloidotic polyneuropathy (FAP) studied earlier. Amino acid sequencing confirmed that SSA subunit proteins were in fact prealbumin (transthyretin). Complete sequence analysis of one SSA preparation revealed the presence of a new variant Pa (TTr) molecule with a single amino acid substitution of isoleucine for valine at position 122. Further studies used an antiserum specific for SKO IV, a subunit protein of SKO previously shown to correspond to carboxy-terminal 78 residues (positions 49-127) of (TTr). Anti-SKO IV reacted with SSA in tissue at equivalent dilutions to anti-Pa (TTr) and with the 10-12-kD fraction of SSA on Western blots; reactivity was blocked by SKO IV, but not by Pa (TTr). SSA is a form of systemic amyloidosis caused by tissue deposition of Pa (TTr) and its fragments, with shared conformational or subunit antigenicity to at least one form of FAP. Identification of a new variant Pa (TTr) molecule in one case suggests further that SSA may be a genetically determined disease expressed late in life.
Collapse
Affiliation(s)
- P D Gorevic
- Department of Medicine, State University of New York, Stony Brook 11794
| | | | | | | | | |
Collapse
|
34
|
Abstract
Amyloidosis has received considerable attention recently because of its association with Alzheimer's disease. Actually, the amyloid in the cortical plaques, which is characteristic of Alzheimer's disease, is a localized form of amyloid deposition. Although intracranial vascular amyloid deposits which contain the A4 or beta-protein are usually associated with Alzheimer's disease, deposition of this amyloid fibril substance in other organs of the body has not been described. Much less attention has been paid to amyloid involvement of the PNS which is a fascinating subject in itself and is the subject of this review.
Collapse
|
35
|
Abstract
Familial amyloidosis, once described as a puzzling and highly unusual form of polyneuropathy, is now recognized to be a collection of familial diseases with usually autosomal-dominant inheritance and widespread ethnic distribution. Familial amyloidosis occurs throughout the world and encompasses an extremely broad spectrum of clinical manifestations. In some families, progressive peripheral neuropathy dominates the illness, while in others, renal failure, ocular amyloid deposits, cardiac decompensation, or intracranial hemorrhage is the most significant clinical feature. The Portuguese (type I) and the Iowa (type III) neuropathies characteristically begin with lower limb involvement, while in the Indiana (type II) form, upper limb neuropathy is seen first; in the Japanese families with familial amyloid polyneuropathy, symptoms first become evident around age 40, whereas in the Texas family, onset is in the seventh decade. The prognosis for the different families is highly variable. Current classification of the familial amyloid polyneuropathy syndromes is based on their characteristic clinical presentations, but ongoing biochemical identification of the protein composition of amyloid substance in each form will make a more rational nosology feasible in the near future. To date, no therapy has been shown to arrest or reverse the progressive accumulation of amyloid deposits in most forms of familial amyloidosis. Familial Mediterranean fever is a major exception, and the incidence of amyloidosis associated with this disease has been dramatically reduced by the widespread prophylactic use of colchicine. Technology currently available permits the reliable identification of asymptomatic relatives at risk for developing amyloid neuropathy as well as the prenatal identification of carriers of the mutant transthyretin gene. These strategies can be used in genetic counseling aimed at reducing the continued propagation of the mutant gene.
Collapse
Affiliation(s)
- J Varga
- Division of Rheumatology, Thomas Jefferson University, Philadelphia, PA 19107
| | | |
Collapse
|
36
|
Benson MD. Hereditary amyloidosis--disease entity and clinical model. HOSPITAL PRACTICE (OFFICE ED.) 1988; 23:165-72, 177, 181. [PMID: 3126202 DOI: 10.1080/21548331.1988.11703443] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
|
37
|
Wallace MR, Dwulet FE, Williams EC, Conneally PM, Benson MD. Identification of a new hereditary amyloidosis prealbumin variant, Tyr-77, and detection of the gene by DNA analysis. J Clin Invest 1988; 81:189-93. [PMID: 2891727 PMCID: PMC442492 DOI: 10.1172/jci113293] [Citation(s) in RCA: 65] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
In the last several years, five human plasma prealbumin (transthyretin) variants have been discovered in association with hereditary amyloidosis, a late-onset fatal disorder. We recently studied a patient of German descent with peripheral neuropathy and bowel dysfunction. Biopsied rectal tissue contained amyloid that stained with anti-human prealbumin. Amino acid sequence analysis of the patient's plasma prealbumin revealed both normal and variant prealbumin molecules, with the variant containing a tyrosine at position 77 instead of serine. We predicted a single nucleotide change in codon 77 of the variant prealbumin gene, which we then detected in the patient's DNA using the restriction enzyme SspI and a specifically tailored genomic prealbumin probe. DNA tests of other family members identified several gene carriers. This is the sixth prealbumin variant implicated in amyloidosis, and adds to the accumulating evidence that the prealbumin amyloidoses are more varied and prevalent than previously thought.
Collapse
Affiliation(s)
- M R Wallace
- Department of Medical Genetics, Indiana University School of Medicine, Indianapolis 46223
| | | | | | | | | |
Collapse
|