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Cappello M, Barbara G, Bellini M, Consalvo D, Di Sabatino A, Marasco G, Principi M, Savarino EV, Tortora A, Obici L. Identification and management of gastrointestinal manifestations of hereditary transthyretin amyloidosis: Recommendations from an Italian group of experts. Dig Liver Dis 2024; 56:1014-1020. [PMID: 38105149 DOI: 10.1016/j.dld.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 11/23/2023] [Indexed: 12/19/2023]
Abstract
Gastrointestinal manifestations are common across all hereditary transthyretin amyloidosis (ATTRv) genotypes. However, they are poorly specific, and their recognition as part of ATTRv is difficult, resulting in misdiagnosis with more common conditions. Moreover, delays in diagnosis occur because of fragmented knowledge, a shortage of centers of excellence and specialists dedicated to ATTRv management, and the scarce involvement of gastroenterologists in multidisciplinary teams. A group of Italian gastroenterologists with experience in the management of ATTRv took part in a project aimed at assessing the awareness of ATTRv among the community of Italian gastroenterologists through an online survey and providing education about practical aspects of ATTRv management. Survey results reported low participation, and very few patients with ATTRv were cared for by gastroenterologists. This highlights the need for greater attention to rare diseases in gastroenterology and emphasizes increasing awareness of ATTRv and diagnostic suspicion. Based on the experts' recommendations, a diagnosis of ATTRv should be suspected when at least one of the 'red flags' is detected. Subsequently, it is suggested to promptly ask for genetic testing and exclude a serum and urinary monoclonal protein, even before the detection of amyloid in biopsy samples, particularly in non-endemic areas.
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Affiliation(s)
- Maria Cappello
- Gastroenterology and Hepatology Section, ProMiSe Department, University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy.
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, via Massarenti 9, 40138, Bologna, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138, Bologna, Italy
| | - Massimo Bellini
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Danilo Consalvo
- Department of Gastroenterology and Digestive Endoscopy, AORN ``Antonio Cardarelli'', Via Antonio Cardarelli 9, 80131, Napoli, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Therapeutics, University of Pavia, Piazzale Golgi 19, 27100 Pavia, Italy; First Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Piazzale Golgi 19, 27100 Pavia, Italy
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, University of Bologna, via Massarenti 9, 40138, Bologna, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138, Bologna, Italy
| | - Mariabeatrice Principi
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari, Piazza Umberto I, 70121, Bari, Italy
| | - Edoardo Vincenzo Savarino
- Gastroenterology Unit, Azienda Ospedale Università di Padova, via Nicolò Giustiniani 2, 35100, Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padua, via Nicolò Giustiniani 2, 35100, Italy
| | - Annalisa Tortora
- UOC Gastroenterologia, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale L.A. Scuro, 10, 37134 Verona VR, Italy
| | - Laura Obici
- Rare Diseases Unit and Amyloidosis Research and Treatment Centre, IRCCS San Matteo Hospital Foundation, viale Camillo Golgi 19, 27100, Pavia, Italy
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2
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Rauf SA, Shah HH, Khatri R, Ul Haq M, Dave T, Ali JP, Ali SK. Gastrointestinal amyloidosis in a 50-year-old patient with miliary tuberculosis: A case report. Clin Case Rep 2024; 12:e8978. [PMID: 38799515 PMCID: PMC11126638 DOI: 10.1002/ccr3.8978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 04/23/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024] Open
Abstract
This case highlights the importance of considering tuberculosis as an underlying cause of gastrointestinal amyloidosis, even in patients previously treated for the infection. Clinicians should maintain a high index of suspicion for atypical presentations of amyloidosis, especially in individuals with chronic inflammation, enabling early diagnosis and tailored management for improved patient outcomes. Abstract Gastrointestinal amyloidosis is a rare condition often associated with chronic inflammation. We present a unique case of a 50-year-old female with a history of miliary tuberculosis who developed gastrointestinal amyloidosis. The patient exhibited chronic loose stools, weight loss, abdominal pain, and urinary incontinence symptoms. Diagnostic workup revealed characteristic findings of amyloidosis on biopsy. Despite treatment for tuberculosis, her symptoms persisted, highlighting the challenging nature of managing this condition. This case underscores the importance of considering tuberculosis as a potential cause of secondary amyloidosis in patients with ongoing symptoms of inflammation and infection. Early recognition and tailored management are crucial in optimizing patient outcomes.
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Affiliation(s)
- Sameer Abdul Rauf
- Department of Internal MedicineLiaquat National Hospital and Medical CollegeKarachiPakistan
| | - Hussain Haider Shah
- Department of Internal MedicineDow University of Health SciencesKarachiPakistan
| | - Rahul Khatri
- Department of Internal MedicineLiaquat National Hospital and Medical CollegeKarachiPakistan
| | - Mansoor Ul Haq
- Department of GastroenterologyLiaquat National Hospital and Medical CollegeKarachiPakistan
| | - Tirth Dave
- Bukovinian State Medical UniversityChernivtsiUkraine
| | - Javaria Parwez Ali
- Department of HistopathologyLiaquat National Hospital and Medical CollegeKarachiPakistan
| | - Syed Khizar Ali
- Department of Internal MedicineLiaquat National Hospital and Medical CollegeKarachiPakistan
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3
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Nakane S, Koike H, Hayashi T, Nakatsuji Y. Autoimmune Autonomic Neuropathy: From Pathogenesis to Diagnosis. Int J Mol Sci 2024; 25:2296. [PMID: 38396973 PMCID: PMC10889307 DOI: 10.3390/ijms25042296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
Autoimmune autonomic ganglionopathy (AAG) is a disease of autonomic failure caused by ganglionic acetylcholine receptor (gAChR) autoantibodies. Although the detection of autoantibodies is important for distinguishing the disease from other neuropathies that present with autonomic dysfunction, other factors are important for accurate diagnosis. Here, we provide a comprehensive review of the clinical features of AAG, highlighting differences in clinical course, clinical presentation, and laboratory findings from other neuropathies presenting with autonomic symptoms. The first step in diagnosing AAG is careful history taking, which should reveal whether the mode of onset is acute or chronic, followed by an examination of the time course of disease progression, including the presentation of autonomic and extra-autonomic symptoms. AAG is a neuropathy that should be differentiated from other neuropathies when the patient presents with autonomic dysfunction. Immune-mediated neuropathies, such as acute autonomic sensory neuropathy, are sometimes difficult to differentiate, and therefore, differences in clinical and laboratory findings should be well understood. Other non-neuropathic conditions, such as postural orthostatic tachycardia syndrome, chronic fatigue syndrome, and long COVID, also present with symptoms similar to those of AAG. Although often challenging, efforts should be made to differentiate among the disease candidates.
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Affiliation(s)
- Shunya Nakane
- Department of Neurology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Haruki Koike
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga 849-8501, Japan
| | - Tomohiro Hayashi
- Department of Neurology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Yuji Nakatsuji
- Department of Neurology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
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4
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Luhn C, Agis H, Hütterer E, Simonitsch‐Klupp I, Dawoud C, Stift A, Harpain F. Teduglutide in amyloidosis-associated intestinal failure. Clin Case Rep 2023; 11:e7653. [PMID: 37601424 PMCID: PMC10433832 DOI: 10.1002/ccr3.7653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/19/2023] [Indexed: 08/22/2023] Open
Abstract
Amyloidosis is a heterogeneous disease characterized by tissue deposition of abnormally folded fibrillary proteins that can manifest itself by a wide variety of symptoms depending on the affected organs. GI involvement among amyloidosis patients is common. Its clinical manifestation often presents with nonspecific symptoms such as weight loss, diarrhea, and malabsorption. With no specific treatment existing for GI amyloidosis, therapy focuses on impeding amyloid deposition and managing the patients' symptoms with supportive measures. Here, we present an AL-amyloidosis patient with GI involvement and intestinal failure (IF) who was successfully treated with the glucagon-like peptide-2 (GLP-2) analogue teduglutide. Over the course of treatment with teduglutide, the patient was able to achieve independence from parenteral nutrition and experienced a significant improvement in quality of life (QoL) as stool frequency and consistency improved, urinary output was stabilized and body weight as well as body composition improved over the course of teduglutide therapy. With no longer being exposed to the burden and associated risks of parenteral nutrition, we were able to reduce the potential morbidity and mortality rate as well as to improve the patient's overall QoL. Intestinal tissue biopsy workup revealed a histopathological correlate for the clinical response; Congo-Red-positive intestinal depositions almost completely disappeared within 6 months of teduglutide therapy. Implementing intestinotrophic GLP-2 analogue teduglutide may enrich the spectrum of treatment options for amyloidosis patients with IF who are dependent on parenteral support.
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Affiliation(s)
- Clara Luhn
- Division of Visceral Surgery, Department of General SurgeryMedical University ViennaViennaAustria
| | - Hermine Agis
- Division of Hematology and Hemostaseology, Department of Internal Medicine IMedical University of ViennaViennaAustria
| | - Elisabeth Hütterer
- Division of Oncology, Department of Internal Medicine IMedical University of ViennaViennaAustria
| | | | - Christopher Dawoud
- Division of Visceral Surgery, Department of General SurgeryMedical University ViennaViennaAustria
| | - Anton Stift
- Division of Visceral Surgery, Department of General SurgeryMedical University ViennaViennaAustria
| | - Felix Harpain
- Division of Visceral Surgery, Department of General SurgeryMedical University ViennaViennaAustria
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Pinto MV, França MC, Gonçalves MVM, Machado-Costa MC, Freitas MRGD, Gondim FDAA, Marrone CD, Martinez ARM, Moreira CL, Nascimento OJM, Covaleski APP, Oliveira ASBD, Pupe CCB, Rodrigues MMJ, Rotta FT, Scola RH, Marques W, Waddington-Cruz M. Brazilian consensus for diagnosis, management and treatment of hereditary transthyretin amyloidosis with peripheral neuropathy: second edition. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:308-321. [PMID: 37059440 PMCID: PMC10104762 DOI: 10.1055/s-0043-1764412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Hereditary transthyretin amyloidosis with peripheral neuropathy (ATTRv-PN) is an autosomal dominant inherited sensorimotor and autonomic polyneuropathy with over 130 pathogenic variants identified in the TTR gene. Hereditary transthyretin amyloidosis with peripheral neuropathy is a disabling, progressive and life-threatening genetic condition that leads to death in ∼ 10 years if untreated. The prospects for ATTRv-PN have changed in the last decades, as it has become a treatable neuropathy. In addition to liver transplantation, initiated in 1990, there are now at least 3 drugs approved in many countries, including Brazil, and many more are being developed. The first Brazilian consensus on ATTRv-PN was held in the city of Fortaleza, Brazil, in June 2017. Given the new advances in the area over the last 5 years, the Peripheral Neuropathy Scientific Department of the Brazilian Academy of Neurology organized a second edition of the consensus. Each panelist was responsible for reviewing the literature and updating a section of the previous paper. Thereafter, the 18 panelists got together virtually after careful review of the draft, discussed each section of the text, and reached a consensus for the final version of the manuscript.
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Affiliation(s)
- Marcus Vinicius Pinto
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Rio de Janeiro RJ, Brazil
- Mayo Clinic, Department of Neurology, Rochester, Minnesota, United States
| | | | | | | | - Marcos Raimundo Gomes de Freitas
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Rio de Janeiro RJ, Brazil
| | | | - Carlo Domenico Marrone
- Pontifícia Universidade Católica do Rio Grande do Sul, Hospital São Lucas, Clínica Marrone e Ambulatório de Doenças Neuromusculare, Porto Alegre RS, Brazil
| | | | | | | | | | | | | | | | - Francisco Tellechea Rotta
- Hospital Moinhos de Vento, Porto Alegre RS, Brazil
- Santa Casa de Misericórdia de Porto Alegre, Porto Alegre RS, Brazil
| | | | - Wilson Marques
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil
| | - Márcia Waddington-Cruz
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Rio de Janeiro RJ, Brazil
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6
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Punnoose LR, Siddiqi H, Rosenthal J, Kittleson M, Witteles R, Alexander K. Implications of Extra-cardiac Disease in Patient Selection for Heart Transplantation: Considerations in Cardiac Amyloidosis. Card Fail Rev 2023; 9:e01. [PMID: 36891177 PMCID: PMC9987512 DOI: 10.15420/cfr.2022.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/26/2022] [Indexed: 02/01/2023] Open
Abstract
Disease-modifying therapies in both light chain and transthyretin amyloidosis have improved patient functional status and survival. Conceivably, as heart failure may progress despite amyloid therapies, more patients may be considered for heart transplantation. In earlier eras, extra-cardiac amyloid deposits significantly reduced post-heart transplant patient survival and functional status compared to the non-amyloid population. In the modern era, transplant centres have reported improved outcomes in amyloidosis as patient selection has grown more stringent. Importantly, systematic candidate evaluation should assess the degree of extra-cardiac involvement, the effectiveness of disease-modifying therapies and downstream effects on patients' nutrition and frailty. This review outlines such an overall approach while also considering that organ-specific selection criteria may vary between individual transplant centres. A methodical approach to patient evaluation will promote better understanding of the prevalence and severity of extra-cardiac disease in amyloidosis patients referred for heart transplantation and of any disparities in decision outcomes in this population.
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Affiliation(s)
- Lynn Raju Punnoose
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine Nashville, TN, US
| | - Hasan Siddiqi
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine Nashville, TN, US
| | - Julie Rosenthal
- Department of Cardiovascular Medicine, Mayo Clinic Phoenix, AZ, US
| | - Michelle Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center Los Angeles, CA, US
| | - Ronald Witteles
- Division of Cardiovascular Medicine, Stanford University School of Medicine Palo Alto, CA, US
| | - Kevin Alexander
- Division of Cardiovascular Medicine, Stanford University School of Medicine Palo Alto, CA, US
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7
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Dasgupta NR. Care of Patients With Transthyretin Amyloidosis: the Roles of Nutrition, Supplements, Exercise, and Mental Health. Am J Cardiol 2022; 185 Suppl 1:S35-S42. [PMID: 36549789 DOI: 10.1016/j.amjcard.2022.10.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 12/24/2022]
Abstract
Transthyretin (ATTR) amyloidosis is a debilitating disease that results in organ failure and eventual death. As the disease progresses, patients experience neurologic, gastrointestinal, and cardiovascular symptoms that increasingly compromise their nutritional status and exercise capacity. These symptoms cause considerable emotional stress and mental health challenges for patients and caregivers. This review summarizes common symptoms and mechanisms associated with malnutrition and exercise intolerance, and sources of emotional stress, and offers therapeutic strategies to address these issues. Although earlier diagnosis and disease-specific treatment are central to caring for patients with ATTR amyloidosis, additional attention to symptom-focused treatments to improve nutritional status, maintain exercise tolerance and capacity, and improve and maintain mental health are also important. In conclusion, a team-based approach involving multiple clinicians and providers can offer more comprehensive and coordinated care, support, and education for patients and caregivers.
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Affiliation(s)
- Noel R Dasgupta
- Department of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana.
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Mangiaterra S, Vincenzetti S, Rossi G, Marchegiani A, Gavazza A, Petit T, Sagratini G, Ricciutelli M, Cerquetella M. Evaluation of the Fecal Proteome in Healthy and Diseased Cheetahs (Acinonyx jubatus) Suffering from Gastrointestinal Disorders. Animals (Basel) 2022; 12:ani12182392. [PMID: 36139251 PMCID: PMC9494964 DOI: 10.3390/ani12182392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/11/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
Fecal proteomics allows for the identification of proteins and peptides present in stools and is useful in finding possible new biomarkers for diagnosing and/or monitoring gastrointestinal (GI) disorders. In the present study, we investigated the fecal proteome in healthy and diseased cheetahs (Acinonyx jubatus). Captive individuals of this species frequently show gastrointestinal disorders characterized by recurrent episodes of diarrhea, rare episodes of vomiting and weight loss, associated with Helicobacter spp. infection. Fecal proteomic evaluation has been performed by two-dimensional electrophoresis followed by liquid chromatography-tandem mass spectrometry. In healthy cheetahs, the results showed the presence of the following proteins: collagen alpha-1 (II) chain, transthyretin, IgG Fc-binding protein, titin, dystonin, isopentenyl-diphosphate Delta-isomerase 1, sodium/potassium-transporting ATPase subunit alpha-1 and protein disulfide-isomerase A6. The presence of albumin isoforms was found only in diseased cheetahs. The present paper reports the study of the fecal proteome in the cheetah, evidences some differences between healthy and diseased patients and confirms, once again, the potential of fecal proteomics for the study of the GI environment, with promising developments regarding the identification of new diagnostic/monitoring markers.
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Affiliation(s)
- Sara Mangiaterra
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, MC, Italy
- Correspondence:
| | - Silvia Vincenzetti
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, MC, Italy
| | - Giacomo Rossi
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, MC, Italy
| | - Andrea Marchegiani
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, MC, Italy
| | - Alessandra Gavazza
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, MC, Italy
| | | | - Gianni Sagratini
- School of Pharmacy, University of Camerino, Via Sant’Agostino, 1, 32032 Camerino, MC, Italy
| | - Massimo Ricciutelli
- School of Pharmacy, University of Camerino, Via Sant’Agostino, 1, 32032 Camerino, MC, Italy
| | - Matteo Cerquetella
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, MC, Italy
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9
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Ando Y, Adams D, Benson MD, Berk JL, Planté-Bordeneuve V, Coelho T, Conceição I, Ericzon BG, Obici L, Rapezzi C, Sekijima Y, Ueda M, Palladini G, Merlini G. Guidelines and new directions in the therapy and monitoring of ATTRv amyloidosis. Amyloid 2022; 29:143-155. [PMID: 35652823 DOI: 10.1080/13506129.2022.2052838] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The recent approval of three drugs for the treatment of amyloid transthyretin (ATTR) amyloidosis, both hereditary and wild-type, has opened a new era in the care of these diseases. ATTR amyloidosis is embedded in its pathophysiology, and the drugs target critical steps of the amyloid cascade. In addition to liver transplant, which removes the pathogenic variants, the introduction of gene silencers has allowed the suppression of both wild type and mutant transthyretin (TTR), thus extending the potential therapeutic range to wild-type cardiac amyloidosis. The kinetic stabilisation of TTR using small molecules has proved to be clinically effective both for amyloid neuropathy and cardiomyopathy. Gene silencers and kinetic stabilizers were recently approved on the basis of the outcome of phase III trials; however, comparative trials have not been performed, making it difficult to draw recommendations. Indications for liver transplantation have narrowed considerably. Here, guidelines for therapy are proposed based on expert consensus, acknowledging that the several drugs currently undergoing clinical trials will probably change in the near future the therapeutic armamentarium and, consequently, the therapeutic strategy. Indications for monitoring disease progression and drug efficacy are also provided for the management of these complexes, but now very treatable, diseases.
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Affiliation(s)
- Yukio Ando
- Department of Amyloidosis Research, Nagasaki International University, Sasebo, Japan
| | - David Adams
- Department of Neurology, French National Reference Centre for Familial Amyloidotic Polyneuropathy, CHU Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Merrill D Benson
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,RLR Veterans Affairs Medical Center, Indianapolis, IN, USA
| | - John L Berk
- Amyloidosis Center, Boston Medical Center, Boston University, Boston, MA, USA
| | - Violaine Planté-Bordeneuve
- Department of Neurology and Amyloid Network, Hospital Henri Mondor, APHP, East-Paris University, Créteil, France
| | - Teresa Coelho
- Andrade's Center, Centro Hospitalar Univerisitário do Porto - Hospital de Santo António, Porto, Portugal
| | - Isabel Conceição
- Department of Neurosciences and Mental Health, CHULN - Hospital de Santa Maria and Faculdade de Medicina, Instituto de Fisiologia, Universidade de Lisboa, Lisbon, Portugal
| | - Bo-Göran Ericzon
- Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Laura Obici
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Claudio Rapezzi
- Cardiologic Center, University of Ferrara, and Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
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10
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Carroll A, Dyck PJ, de Carvalho M, Kennerson M, Reilly MM, Kiernan MC, Vucic S. Novel approaches to diagnosis and management of hereditary transthyretin amyloidosis. J Neurol Neurosurg Psychiatry 2022; 93:668-678. [PMID: 35256455 PMCID: PMC9148983 DOI: 10.1136/jnnp-2021-327909] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/12/2022] [Indexed: 12/27/2022]
Abstract
Hereditary transthyretin amyloidosis (ATTRv) is a severe, adult-onset autosomal dominant inherited systemic disease predominantly affecting the peripheral and autonomic nervous system, heart, kidney and the eyes. ATTRv is caused by mutations of the transthyretin (TTR) gene, leading to extracellular deposition of amyloid fibrils in multiple organs including the peripheral nervous system. Typically, the neuropathy associated with ATTRv is characterised by a rapidly progressive and disabling sensorimotor axonal neuropathy with early small-fibre involvement. Carpal tunnel syndrome and cardiac dysfunction frequently coexist as part of the ATTRv phenotype. Although awareness of ATTRv polyneuropathy among neurologists has increased, the rate of misdiagnosis remains high, resulting in significant diagnostic delays and accrued disability. A timely and definitive diagnosis is important, given the emergence of effective therapies which have revolutionised the management of transthyretin amyloidosis. TTR protein stabilisers diflunisal and tafamidis can delay the progression of the disease, if treated early in the course. Additionally, TTR gene silencing medications, patisiran and inotersen, have resulted in up to 80% reduction in TTR production, leading to stabilisation or slight improvement of peripheral neuropathy and cardiac dysfunction, as well as improvement in quality of life and functional outcomes. The considerable therapeutic advances have raised additional challenges, including optimisation of diagnostic techniques and management approaches in ATTRv neuropathy. This review highlights the key advances in the diagnostic techniques, current and emerging management strategies, and biomarker development for disease progression in ATTRv.
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Affiliation(s)
- Antonia Carroll
- Brain and Mind Centre, Faculty of Medicine and Health, Translational Research Collective, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - P James Dyck
- Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mamede de Carvalho
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Department of Neurosciences and Mental Health, Hospital de Santa Maria, Lisboa, Portugal
| | - Marina Kennerson
- Northcott Neuroscience Laboratory, ANZAC Research Institute, Molecular Medicine Laboratory Concord Repatriation General Hospital, and Concord Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Mary M Reilly
- MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK
| | - Matthew C Kiernan
- Bushell Chair of Neurology, Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia.,Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Steve Vucic
- Brain and Nerve Research Center, Concord Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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11
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Jobbé‐Duval A, Bézard M, Moutereau S, Kharoubi M, Oghina S, Zaroui A, Galat A, Chalard C, Hugon‐Vallet E, Lemonnier F, Eyharts D, Poulot E, Fanen P, Funalot B, Molinier‐Frenkel V, Audard V, Hittinger L, Delbarre MA, Teiger E, Damy T. Prevalence and determinants of iron deficiency in cardiac amyloidosis. ESC Heart Fail 2022; 9:1314-1327. [PMID: 35128833 PMCID: PMC8934992 DOI: 10.1002/ehf2.13818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 12/23/2021] [Accepted: 01/17/2022] [Indexed: 12/16/2022] Open
Abstract
Aims Iron deficiency (ID) is common in patient with chronic heart failure (HF) and has been widely studied. In contrast, data concerning ID in cardiac amyloidosis (CA) are limited. Amyloidosis is a severe and fatal systemic disease, characterized by an accumulation of amyloid fibrils in various tissues/organs, including nerves, kidneys, gastrointestinal tract, and heart. Amyloid deposits in the heart eventually cause HF. The main subtypes of CA are light chain (AL), hereditary transthyretin (ATTRv), and wild‐type transthyretin (ATTRwt). We performed this study to determine the prevalence, clinical outcome (all‐cause mortality), and determinants of ID among the three main subtypes of CA. Methods and results Iron deficiency status were analysed in 816 CA patients enrolled at the French Referral Centre for Cardiac Amyloidosis: 271 (33%) had AL, 164 (20%) ATTRv, and 381 (47%) ATTRwt. ID affected 49% of CA patients, 45% with AL, 58% with ATTRv, and 48% with ATTRwt. We identified ATTR status (ATTRv P = 0.003, ATTRwt P = 0.037), diabetes (P = 0.003), aspirin treatment (P = 0.009), haemoglobin levels (P = 0.006), and altered global longitudinal strain (P = 0.02) as independent ID determinants. There is no difference in all‐cause mortality considering ID status. Conclusions Iron deficiency is common in patients with CA, irrespective of the subtype. Patients seem more likely to have ID if diagnosed with ATTR, if diabetic, and/or treated with aspirin. In CA, the benefit of intravenous iron therapy, for ID, on morbidity and mortality needs further study.
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Affiliation(s)
- Antoine Jobbé‐Duval
- Heart Failure and Transplant Department ‘Louis Pradel’ Cardiologic Hospital, Hospices Civils de Lyon Lyon France
| | - Mélanie Bézard
- Department of Cardiology, French Referral Centre for Cardiac Amyloidosis, Cardiogen Network GRC Amyloid Research Institute, DHU A‐TVB, InsermU955, Henri Mondor Teaching Hospital, APHP 51 Avenue Marechal de Lattre de Tassigny Creteil 94000 France
| | - Stéphane Moutereau
- Department of Biochemistry Henri Mondor Teaching Hospital, APHP Creteil France
| | - Mounira Kharoubi
- Department of Cardiology, French Referral Centre for Cardiac Amyloidosis, Cardiogen Network GRC Amyloid Research Institute, DHU A‐TVB, InsermU955, Henri Mondor Teaching Hospital, APHP 51 Avenue Marechal de Lattre de Tassigny Creteil 94000 France
| | - Silvia Oghina
- Department of Cardiology, French Referral Centre for Cardiac Amyloidosis, Cardiogen Network GRC Amyloid Research Institute, DHU A‐TVB, InsermU955, Henri Mondor Teaching Hospital, APHP 51 Avenue Marechal de Lattre de Tassigny Creteil 94000 France
| | - Amira Zaroui
- Department of Cardiology, French Referral Centre for Cardiac Amyloidosis, Cardiogen Network GRC Amyloid Research Institute, DHU A‐TVB, InsermU955, Henri Mondor Teaching Hospital, APHP 51 Avenue Marechal de Lattre de Tassigny Creteil 94000 France
| | - Arnault Galat
- Department of Cardiology, French Referral Centre for Cardiac Amyloidosis, Cardiogen Network GRC Amyloid Research Institute, DHU A‐TVB, InsermU955, Henri Mondor Teaching Hospital, APHP 51 Avenue Marechal de Lattre de Tassigny Creteil 94000 France
| | - Coraline Chalard
- Department of Cardiology, French Referral Centre for Cardiac Amyloidosis, Cardiogen Network GRC Amyloid Research Institute, DHU A‐TVB, InsermU955, Henri Mondor Teaching Hospital, APHP 51 Avenue Marechal de Lattre de Tassigny Creteil 94000 France
| | - Elisabeth Hugon‐Vallet
- Heart Failure and Transplant Department ‘Louis Pradel’ Cardiologic Hospital, Hospices Civils de Lyon Lyon France
| | - Francois Lemonnier
- Department of Haematology Henri Mondor Teaching Hospital, APHP Creteil France
| | - Damien Eyharts
- Department of Cardiology, French Referral Centre for Cardiac Amyloidosis, Cardiogen Network GRC Amyloid Research Institute, DHU A‐TVB, InsermU955, Henri Mondor Teaching Hospital, APHP 51 Avenue Marechal de Lattre de Tassigny Creteil 94000 France
| | - Elsa Poulot
- Department of Pathology Henri Mondor Teaching Hospital, APHP Creteil France
| | - Pascale Fanen
- Department of Genetics Henri Mondor Teaching Hospital, APHP Creteil France
| | - Benoit Funalot
- Department of Genetics Henri Mondor Teaching Hospital, APHP Creteil France
| | | | - Vincent Audard
- Department of Nephrology Henri Mondor Teaching Hospital, APHP Creteil France
| | - Luc Hittinger
- Department of Cardiology, French Referral Centre for Cardiac Amyloidosis, Cardiogen Network GRC Amyloid Research Institute, DHU A‐TVB, InsermU955, Henri Mondor Teaching Hospital, APHP 51 Avenue Marechal de Lattre de Tassigny Creteil 94000 France
| | - Marc Antoine Delbarre
- Department of Cardiology, French Referral Centre for Cardiac Amyloidosis, Cardiogen Network GRC Amyloid Research Institute, DHU A‐TVB, InsermU955, Henri Mondor Teaching Hospital, APHP 51 Avenue Marechal de Lattre de Tassigny Creteil 94000 France
| | - Emmanuel Teiger
- Department of Cardiology, French Referral Centre for Cardiac Amyloidosis, Cardiogen Network GRC Amyloid Research Institute, DHU A‐TVB, InsermU955, Henri Mondor Teaching Hospital, APHP 51 Avenue Marechal de Lattre de Tassigny Creteil 94000 France
| | - Thibaud Damy
- Department of Cardiology, French Referral Centre for Cardiac Amyloidosis, Cardiogen Network GRC Amyloid Research Institute, DHU A‐TVB, InsermU955, Henri Mondor Teaching Hospital, APHP 51 Avenue Marechal de Lattre de Tassigny Creteil 94000 France
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12
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Hsueh HW, Chao CC, Chang K, Jeng YM, Katsuno M, Koike H, Hsieh ST. Unique Phenotypes With Corresponding Pathology in Late-Onset Hereditary Transthyretin Amyloidosis of A97S vs. V30M. Front Aging Neurosci 2022; 13:786322. [PMID: 35153720 PMCID: PMC8826435 DOI: 10.3389/fnagi.2021.786322] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/29/2021] [Indexed: 12/22/2022] Open
Abstract
ObjectiveHereditary transthyretin amyloidosis (ATTRv) encompasses different phenotypes among various genotypes. The analysis of the natural history and risk factors of faster progression in different genotypes would refine the treatment strategy.MethodsThe clinical manifestations of ATTRv from A97S (p.A117S) of Taiwanese and late-onset V30M (p.V50M) of Japanese were compared. An autopsy study of A97S was performed.ResultsThere existed three unique features in the A97S cohort compared to the V30M cohort: (1) dysphagia, (2) carpal tunnel syndrome (CTS), and (3) onset age. First, dysphagia was common in A97S (53.4%) but not in V30M and served as a contributor to fast disease progression. All phases of swallowing were affected. In the autopsy pathology, there were extensive amyloid deposits in the viscera and nerves of the tongue, larynx, and esophagus. In A97S, 45 patients (43.3%) had a history of CTS before the onset of length-dependent symptoms by 3 years. The amyloid deposition was more prominent in the median nerve than that in the transverse carpal ligament. The onset age at different stages was younger in the A97S cohort than the V30M cohort by 4–5 years.ConclusionThese phenotypic characteristics together with autopsy pathology in A97S are distinct from V30M. Early dysphagia in A97S correlated with fast progression. In A97S, median neuropathy leading to CTS might be in a continuous spectrum of ATTRv course rather than an independent disease entity. Such observations may serve as a foundation to explore and analyze unique phenotypes among various genotypes.
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Affiliation(s)
- Hsueh-Wen Hsueh
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Anatomy and Cell Biology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chi-Chao Chao
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Koping Chang
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yung-Ming Jeng
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
- *Correspondence: Haruki Koike,
| | - Sung-Tsang Hsieh
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Anatomy and Cell Biology, National Taiwan University College of Medicine, Taipei, Taiwan
- Graduate Institute of Brain and Mind Sciences, National Taiwan University College of Medicine, Taipei, Taiwan
- Center of Precision Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Sung-Tsang Hsieh,
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13
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Abstract
Amyloidosis is a very rare condition, which, due to its rarity, is often missed or diagnosed in an advanced stage of the disease, causing significant morbidity and mortality. In this review we describe the existing types of amyloidosis focusing on the gastro-intestinal tract. Amyloidosis occurs when abnormal protein fibrils (amyloid) deposit in the muscularis mucosae. This can cause an array of symptoms ranging from (in order of occurrence): gastro-intestinal bleeding, heartburn, unintentional weight loss, early satiety, constipation, diarrhea, nausea, vomiting and fecal incontinence (1). Treatment is focused on the underlying condition (if any) causing the production and deposition of the abnormal fibrils, in combination of symptomatic treatment.
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14
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Rossi G, Gavazza A, Vincenzetti S, Mangiaterra S, Galosi L, Marchegiani A, Pengo G, Sagratini G, Ricciutelli M, Cerquetella M. Clinicopathological and Fecal Proteome Evaluations in 16 Dogs Presenting Chronic Diarrhea Associated with Lymphangiectasia. Vet Sci 2021; 8:242. [PMID: 34679072 PMCID: PMC8537460 DOI: 10.3390/vetsci8100242] [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: 06/16/2021] [Revised: 09/10/2021] [Accepted: 10/14/2021] [Indexed: 12/21/2022] Open
Abstract
Canine intestinal lymphangiectasia (IL) is a condition characterized by variably severe gastrointestinal signs, frequently associated with laboratory abnormalities; the research for markers allowing a better understanding of the severity degree and/or obtaining an early diagnosis and/or monitoring is continuously progressing. In the present study, we investigated possible new diagnostic/follow-up markers in IL dogs, namely, serum C-reactive protein, serum bacterial lipopolysaccharide, serum cleaved cytokeratin 18, serum citrulline, and zonulin (in both serum and feces). A fecal proteomic study looking for possible confirmation and/or new marker candidates was also performed. All markers in both substrates, with the exception of serum citrulline, significantly differed between diseased and control dogs. Fecal proteomics allowed the retrieval of three proteins in IL dogs (Fc fragment of IgG-binding protein; transthyretin; proproteinase E) that were not previously found in clinically healthy subjects. Although further studies are needed, C-reactive protein, bacterial lipopolysaccharide, cleaved cytokeratin 18, and zonulin (in both serum and feces) resulted as promising markers for canine IL; similarly, fecal proteomics represents a road worthy of being pursued in the search for candidate biomarkers.
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Affiliation(s)
- Giacomo Rossi
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, Italy; (G.R.); (A.G.); (S.V.); (L.G.); (A.M.); (M.C.)
| | - Alessandra Gavazza
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, Italy; (G.R.); (A.G.); (S.V.); (L.G.); (A.M.); (M.C.)
| | - Silvia Vincenzetti
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, Italy; (G.R.); (A.G.); (S.V.); (L.G.); (A.M.); (M.C.)
| | - Sara Mangiaterra
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, Italy; (G.R.); (A.G.); (S.V.); (L.G.); (A.M.); (M.C.)
| | - Livio Galosi
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, Italy; (G.R.); (A.G.); (S.V.); (L.G.); (A.M.); (M.C.)
| | - Andrea Marchegiani
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, Italy; (G.R.); (A.G.); (S.V.); (L.G.); (A.M.); (M.C.)
| | - Graziano Pengo
- St. Antonio Veterinary Clinic, S.S. 415 Paullese 6, 26020 Madignano, Italy;
| | - Gianni Sagratini
- School of Pharmacy, University of Camerino, Via Sant’Agostino 1, 62032 Camerino, Italy; (G.S.); (M.R.)
| | - Massimo Ricciutelli
- School of Pharmacy, University of Camerino, Via Sant’Agostino 1, 62032 Camerino, Italy; (G.S.); (M.R.)
| | - Matteo Cerquetella
- School of Biosciences and Veterinary Medicine, University of Camerino, Via Circonvallazione 93/95, 62024 Matelica, Italy; (G.R.); (A.G.); (S.V.); (L.G.); (A.M.); (M.C.)
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15
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Obici L, Mussinelli R. Current and Emerging Therapies for Hereditary Transthyretin Amyloidosis: Strides Towards a Brighter Future. Neurotherapeutics 2021; 18:2286-2302. [PMID: 34850359 PMCID: PMC8804119 DOI: 10.1007/s13311-021-01154-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 12/19/2022] Open
Abstract
The past few years have witnessed an unprecedented acceleration in the clinical development of novel therapeutic options for hereditary transthyretin amyloidosis. Recently approved agents and drugs currently under investigation not only represent a major breakthrough in this field but also provide validation of the therapeutic potential of innovative approaches, like RNA interference and CRISPR-Cas9-mediated gene editing, in rare inherited disorders. In this review, we describe the evolving therapeutic landscape for hereditary transthyretin amyloidosis and discuss how this highly disabling and fatal condition is turning into a treatable disease. We also provide an overview of the molecular mechanisms involved in transthyretin (TTR) amyloid formation and regression, to highlight how a deeper understanding of these processes has contributed to the identification of novel treatment targets. Finally, we focus on major areas of uncertainty and unmet needs that deserve further efforts to improve long-term patients' outcomes and allow for a brighter future.
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Affiliation(s)
- Laura Obici
- Amyloidosis Research and Treatment Centre, IRCCS Fondazione Policlinico San Matteo, Viale Golgi, 19, 27100, Pavia, Italy.
| | - Roberta Mussinelli
- Amyloidosis Research and Treatment Centre, IRCCS Fondazione Policlinico San Matteo, Viale Golgi, 19, 27100, Pavia, Italy
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16
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Nakov R, Suhr OB, Ianiro G, Kupcinskas J, Segal JP, Dumitrascu DL, Heinrich H, Mikolasevic I, Stojkovic-Lalosevic M, Barbov I, Sarafov S, Tournev I, Nakov V, Wixner J. Recommendations for the diagnosis and management of transthyretin amyloidosis with gastrointestinal manifestations. Eur J Gastroenterol Hepatol 2021; 33:613-622. [PMID: 33394808 DOI: 10.1097/meg.0000000000002030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Transthyretin amyloid (ATTR) amyloidosis is an adult-onset, rare systemic disorder characterized by the accumulation of misfolded fibrils in the body, including the peripheral nerves, the heart and the gastrointestinal tract. Gastrointestinal manifestations are common in hereditary (ATTRv) amyloidosis and are present even before the onset of the polyneuropathy in some cases. Delays in diagnosis of ATTRv amyloidosis with gastrointestinal manifestations commonly occur because of fragmented knowledge among gastroenterologists and general practitioners, as well as a shortage of centers of excellence and specialists dedicated to disease management. Although the disease is becoming well-recognized in the societies of Neurology and Cardiology, it is still unknown for most gastroenterologists. This review presents the recommendations for ATTRv amyloidosis with gastrointestinal manifestations elaborated by a working group of European gastroenterologists and neurologists, and aims to provide digestive health specialists with an overview of crucial aspects of ATTRv amyloidosis diagnosis to help facilitate rapid and accurate identification of the disease by focusing on disease presentation, misdiagnosis and management of gastrointestinal symptoms.
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Affiliation(s)
- Radislav Nakov
- Department of Gastroenterology, Clinic of Gastroenterology, Tsaritsa Joanna University Hospital, Medical University of Sofia, Sofia, Bulgaria
| | - Ole B Suhr
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Gianluca Ianiro
- Department of Gastroenterology, Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Juozas Kupcinskas
- Department of Gastroenterology and Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jonathon P Segal
- Department of Gastroenterology and Hepatology, St Mary's Hospital, London, UK
| | - Dan L Dumitrascu
- Second Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Henriette Heinrich
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | | | | | - Ivan Barbov
- Department of Neurology, University Clinic for Neurology, Skopje, Republic of North Macedonia
| | - Stayko Sarafov
- Department of Neurology, Expert Center for Hereditary Neurological and Metabolic Disorders, ATTR Amyloidosis Expert Center, Clinic of Nervous Diseases, Alexandrovska University Hospital, Medical University of Sofia
| | - Ivailo Tournev
- Department of Neurology, Expert Center for Hereditary Neurological and Metabolic Disorders, ATTR Amyloidosis Expert Center, Clinic of Nervous Diseases, Alexandrovska University Hospital, Medical University of Sofia
- Department of Cognitive Science and Psychology, New Bulgarian University, Sofia, Bulgaria
| | - Ventsislav Nakov
- Department of Gastroenterology, Clinic of Gastroenterology, Tsaritsa Joanna University Hospital, Medical University of Sofia, Sofia, Bulgaria
| | - Jonas Wixner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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17
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Huh Y, Riley S, Harnisch L, Nicholas T. Population pharmacokinetic modelling and simulation of tafamidis in healthy subjects and patients with transthyretin amyloidosis. Br J Clin Pharmacol 2021; 87:3574-3587. [PMID: 33586186 DOI: 10.1111/bcp.14773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/25/2021] [Accepted: 02/01/2021] [Indexed: 01/05/2023] Open
Abstract
AIMS Since the first approval for transthyretin amyloid polyneuropathy patients, new formulations and different strength of tafamidis have been developed and tested in a different population (transthyretin amyloid cardiomyopathy). The objective of this analysis was to develop a unified population pharmacokinetic (PK) model of tafamidis, which can describe the PK of various different formulations in healthy subjects as well as patients with TTR amyloidosis, and to understand effects of intrinsic and extrinsic factors on the PK variability. METHODS Pooled data from 23 clinical studies (17 Phase 1 and 6 Phase 2/3 studies) were used for the analysis. The plasma concentration-time data were analysed using a nonlinear mixed effects modelling methodology. Covariate analysis was performed using a stepwise covariate model building procedure. RESULTS The final model was a 2-compartment model with first-order absorption and elimination coupled with an absorption lag time for nonsolution formations. Body weight, food and tafamidis formulations were incorporated as structural covariates on PK parameters. Covariate analysis further identified age ≥65 years (14.5% decrease) and moderate hepatic impairment effects (57.6% increase) on apparent clearance and transthyretin amyloid polyneuropathy effect (17.3% decrease) on F. However, model-based clinical trial simulation results indicated that tafamidis steady-state exposure changes were not clinically meaningful under the tested conditions. CONCLUSIONS The unified population PK model of tafamidis was developed based on 23 studies. Subsequent clinical trial simulations indicated that no significant changes in tafamidis exposure necessitating a dose modification are expected due to either extrinsic or intrinsic factors. The model was used to support labelling statements for dose recommendations in special populations.
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Affiliation(s)
- Yeamin Huh
- Global Product Development, Pfizer Inc, Groton, CT, USA
| | - Steve Riley
- Global Product Development, Pfizer Inc, Groton, CT, USA
| | - Lutz Harnisch
- Global Product Development, Pfizer Inc, Sandwich, Kent, UK
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18
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Dahiya DS, Kichloo A, Singh J, Albosta M, Wani F. Gastrointestinal amyloidosis: A focused review. World J Gastrointest Endosc 2021; 13:1-12. [PMID: 33520102 PMCID: PMC7809597 DOI: 10.4253/wjge.v13.i1.1] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/16/2020] [Accepted: 12/28/2020] [Indexed: 02/06/2023] Open
Abstract
Amyloidosis, a heterogenous group of disorders, is characterized by the extracellular deposition of autologous, insoluble, fibrillar misfolded proteins. These extracellular proteins deposit in tissues aggregated in ß-pleated sheets arranged in an antiparallel fashion and cause distortion to the tissue architecture and function. In the current literature, about 60 heterogeneous amyloidogenic proteins have been identified, out of which 27 have been associated with human disease. Classified as a rare disease, amyloidosis is known to have a wide range of possible etiologies and clinical manifestations. The exact incidence and prevalence of the disease is currently unknown. In both systemic and localized amyloidosis, there is infiltration of the abnormal proteins in the layers of the gastrointestinal (GI) tract or the liver parenchyma. The gold standard test for establishing a diagnosis is tissue biopsy followed by Congo Red staining and apple-green birefringence of the Congo Red-stained deposits under polarized light. However, not all patients may have a positive tissue confirmation of the disease. In these cases additional workup and referral to a gastroenterologist may be warranted. Along with symptomatic management, the treatment for GI amyloidosis consists of observation or localized surgical excision in patients with localized disease, and treatment of the underlying pathology in cases of systemic amyloidosis. In this review of the literature, we describe the subtypes of amyloidosis, with a primary focus on the epidemiology, pathogenesis, clinical features, diagnosis and treatment strategies available for GI amyloidosis.
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Affiliation(s)
| | - Asim Kichloo
- Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
- Internal Medicine, Samaritan Medical Center, Watertown, NY 13601, United States
| | - Jagmeet Singh
- Internal Medicine, Guthrie Robert Packer Hospital, Sayre, PA 18840, United States
| | - Michael Albosta
- Internal Medicine, Central Michigan University, Saginaw, MI 48603, United States
| | - Farah Wani
- Family Medicine, Samaritan Medical Center, Watertown, NY 13601, United States
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