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AlSayed M, Arafa D, Al-Khawajha H, Afqi M, Al-Sanna'a N, Sunbul R, Faden M. Consensus-based expert recommendations on the management of MPS IVa and VI in Saudi Arabia. Orphanet J Rare Dis 2024; 19:269. [PMID: 39020431 PMCID: PMC11253461 DOI: 10.1186/s13023-024-03237-3] [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: 02/15/2024] [Accepted: 05/28/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND Mucopolysaccharidosis type IVa (Morquio A syndrome) and mucopolysaccharidosis type VI (Maroteaux-Lamy syndrome) are rare inherited lysosomal storage diseases associated with significant functional impairment and a wide spectrum of debilitating clinical manifestations. These conditions are thought to have higher-than-average prevalence rates in Saudi Arabia due to high rates of consanguineous marriage in the country. There are several unmet needs associated with the management of these diseases in Saudi Arabia. MAIN BODY The aim of this manuscript is to contextualize unmet management needs and provide recommendations to optimize diagnosis, multidisciplinary care delivery, and local data generation in this disease area. An expert panel was assembled comprising seven consultant geneticists from across Saudi Arabia. The Delphi methodology was used to obtain a consensus on statements relating to several aspects of mucopolysaccharidosis types IVa and VI. A consensus was reached for all statements by means of an online, anonymized voting system. The consensus statements pertain to screening and diagnosis, management approaches, including recommendations pertaining to enzyme replacement therapy, and local data generation. CONCLUSION The consensus statements presented provide specific recommendations to improve diagnostic and treatment approaches, promote multidisciplinary care and data sharing, and optimize the overall management of these rare inherited diseases in Saudi Arabia.
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Affiliation(s)
- Moeenaldeen AlSayed
- Department of Medical Genomics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.
| | - Dia Arafa
- Consultant Pediatrician and Medical Genetics, Maternity and Children Hospital, Makkah, Saudi Arabia
| | - Huda Al-Khawajha
- Consultant Pediatrician & Medical Genetics, Maternity and Children Hospital, Al-Ahsa, Saudi Arabia
| | - Manal Afqi
- Clinical Genetics and Metabolic Disorders, Consultant Pediatrician, Maternity and Children Hospital, Madinah, Saudi Arabia
| | - Nouriya Al-Sanna'a
- Clinical Geneticist, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Rawda Sunbul
- Consultant Pediatrician and Medical Genetics, Qatif Central Hospital, Qatif, Saudi Arabia
| | - Maha Faden
- Genetic Unit, Maternity and Children Hospital, Consultant Pediatrician, Clinical Genetics - Metabolic and Skeletal Dysplasia, King Saud Medical City, Riyadh, Saudi Arabia
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Sohn YB, Wang R, Ashworth J, Broqua P, Tallandier M, Abitbol JL, Jozwiak E, Pollard L, Wood TC, Aslam T, Harmatz PR. Biomarkers of Glycosaminoglycans (GAG) accumulation in patients with mucopolysaccharidosis type VI-LeukoGAG, Corneal Opacification (COM) and Carotid Intima Media Thickening (CIMT). Mol Genet Metab Rep 2024; 38:101041. [PMID: 38234862 PMCID: PMC10792263 DOI: 10.1016/j.ymgmr.2023.101041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 12/18/2023] [Indexed: 01/19/2024] Open
Abstract
Mucopolysaccharidosis type VI (MPS VI) is an autosomal recessive lysosomal storage disorder characterized by deficient activity of arylsulfatase B enzyme (ASB) resulting in cellular accumulation of dermatan sulfate (DS) and chondroitin sulfate (CS) that leads to cell injury. Urinary glycosaminoglycans (GAG) are often used as a biomarker in MPS diseases for diagnosis and to monitor treatment efficacy. This study evaluated leukocyte GAGs (leukoGAG) and skin GAGs as alternate biomarkers representing intracellular GAG changes in patients with MPS VI and treated with enzyme replacement therapy (ERT). In addition, we evaluated corneal opacification measurements (COM) and carotid intima media thickness (CIMT) as indicators of GAG accumulation and tissue injury. The study was performed in a serial two-step design in a single center. A quantitative method to measure leukoGAG levels in leukocytes was developed in Study 1 to compare the GAG levels between MPS VI patients and a control group and to assess correlations between leukoGAG and urineGAG. Study 2 validated the leukoGAG measurement, assessed the effect of ERT infusion on leukoGAG and ASB activity in leukocytes, identified correlations between leukoGAG and other biomarkers, and assessed differences in GAG accumulation between MPS VI patients and control subjects. In Study 1, leukoCS and leukoDS levels were significantly higher in the MPS VI group than the control group (leukoCS: 37.9 ± 10.2 and 2.9 ± 1.5 μg/μg protein, respectively, p = 0.005; leukoDS: 0.26 ± 0.2 and 0.0 ± 0.0 μg/μg protein, respectively, p = 0.028) with positive correlations between leukoCS and urine CS and leukoDS and urineDS. In Study 2, leukoCS (32.0 ± 11.8 vs 6.9 ± 3.1 μg/mg protein, p = 0.005) and leukoDS (0.4 ± 0.1 and 0.2 ± 0.1 μg/mg protein, p = 0.020) were significantly higher compared with control subjects. Thus, these results highlight the potential of leukoGAG as a new biomarker representing intracellular GAG accumulation in MPS VI patients and may be valuable for patient management.
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Affiliation(s)
- Young Bae Sohn
- Department of Medical Genetics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Raymond Wang
- Children's Hospital of Orange County, Orange, CA, USA
| | | | | | | | | | - Erin Jozwiak
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | | | - Timothy C. Wood
- Section of Genetics and Metabolism, University of Colorado/Children's Hospital of Colorado, Aurora, CO, USA
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Conte F, Sam JE, Lefeber DJ, Passier R. Metabolic Cardiomyopathies and Cardiac Defects in Inherited Disorders of Carbohydrate Metabolism: A Systematic Review. Int J Mol Sci 2023; 24:ijms24108632. [PMID: 37239976 DOI: 10.3390/ijms24108632] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/25/2023] [Accepted: 05/02/2023] [Indexed: 05/28/2023] Open
Abstract
Heart failure (HF) is a progressive chronic disease that remains a primary cause of death worldwide, affecting over 64 million patients. HF can be caused by cardiomyopathies and congenital cardiac defects with monogenic etiology. The number of genes and monogenic disorders linked to development of cardiac defects is constantly growing and includes inherited metabolic disorders (IMDs). Several IMDs affecting various metabolic pathways have been reported presenting cardiomyopathies and cardiac defects. Considering the pivotal role of sugar metabolism in cardiac tissue, including energy production, nucleic acid synthesis and glycosylation, it is not surprising that an increasing number of IMDs linked to carbohydrate metabolism are described with cardiac manifestations. In this systematic review, we offer a comprehensive overview of IMDs linked to carbohydrate metabolism presenting that present with cardiomyopathies, arrhythmogenic disorders and/or structural cardiac defects. We identified 58 IMDs presenting with cardiac complications: 3 defects of sugar/sugar-linked transporters (GLUT3, GLUT10, THTR1); 2 disorders of the pentose phosphate pathway (G6PDH, TALDO); 9 diseases of glycogen metabolism (GAA, GBE1, GDE, GYG1, GYS1, LAMP2, RBCK1, PRKAG2, G6PT1); 29 congenital disorders of glycosylation (ALG3, ALG6, ALG9, ALG12, ATP6V1A, ATP6V1E1, B3GALTL, B3GAT3, COG1, COG7, DOLK, DPM3, FKRP, FKTN, GMPPB, MPDU1, NPL, PGM1, PIGA, PIGL, PIGN, PIGO, PIGT, PIGV, PMM2, POMT1, POMT2, SRD5A3, XYLT2); 15 carbohydrate-linked lysosomal storage diseases (CTSA, GBA1, GLA, GLB1, HEXB, IDUA, IDS, SGSH, NAGLU, HGSNAT, GNS, GALNS, ARSB, GUSB, ARSK). With this systematic review we aim to raise awareness about the cardiac presentations in carbohydrate-linked IMDs and draw attention to carbohydrate-linked pathogenic mechanisms that may underlie cardiac complications.
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Affiliation(s)
- Federica Conte
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
- Department of Applied Stem Cell Technologies, TechMed Centre, University of Twente, 7522 NH Enschede, The Netherlands
| | - Juda-El Sam
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Dirk J Lefeber
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
- Translational Metabolic Laboratory, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Robert Passier
- Department of Applied Stem Cell Technologies, TechMed Centre, University of Twente, 7522 NH Enschede, The Netherlands
- Department of Anatomy and Embryology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
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Brunetti-Pierri N, Ferla R, Ginocchio VM, Rossi A, Fecarotta S, Romano R, Parenti G, Yildiz Y, Zancan S, Pecorella V, Dell'Anno M, Graziano M, Alliegro M, Andria G, Santamaria F, Brunetti-Pierri R, Simonelli F, Nigro V, Vargas M, Servillo G, Borgia F, Soscia E, Gargaro M, Funghini S, Tedesco N, Le Brun PR, Rupar CA, Prasad C, O'Callaghan M, Mitchell JJ, Danos O, Marteau JB, Galimberti S, Valsecchi MG, Veron P, Mingozzi F, Fallarino F, la Marca G, Sivri HS, Auricchio A. Liver-Directed Adeno-Associated Virus-Mediated Gene Therapy for Mucopolysaccharidosis Type VI. NEJM EVIDENCE 2022; 1:EVIDoa2200052. [PMID: 38319253 DOI: 10.1056/evidoa2200052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND: Mucopolysaccharidosis type VI (MPS VI) is an inherited multisystem lysosomal disorder due to arylsulfatase B (ARSB) deficiency that leads to widespread accumulation of glycosaminoglycans (GAG), which are excreted in increased amounts in urine. MPS VI is characterized by progressive dysostosis multiplex, connective tissue and cardiac involvement, and hepatosplenomegaly. Enzyme replacement therapy (ERT) is available but requires life-long and costly intravenous infusions; moreover, it has limited efficacy on diseased skeleton and cardiac valves, compromised pulmonary function, and corneal opacities. METHODS: We enrolled nine patients with MPS VI 4 years of age or older in a phase 1/2 open-label gene therapy study. After ERT was interrupted, patients each received a single intravenous infusion of an adeno-associated viral vector serotype 8 expressing ARSB. Participants were sequentially enrolled in one of three dose cohorts: low (three patients), intermediate (two patients), or high (four patients). The primary outcome was safety; biochemical and clinical end points were secondary outcomes. RESULTS: The infusions occurred without severe adverse events attributable to the vector, meeting the prespecified end point. Participants in the low and intermediate dose cohorts displayed stable serum ARSB of approximately 20% of the mean healthy value but returned to ERT by 14 months after gene therapy because of increased urinary GAG. Participants in the high-dose cohort had sustained serum ARSB of 30% to 100% of the mean healthy value and a modest urinary GAG increase that did not reach a concentration at which ERT reintroduction was needed. In the high-dose group, there was no clinical deterioration for up to 2 years after gene therapy. CONCLUSIONS: Liver-directed gene therapy for participants with MPS VI did not have a dose-limiting side-effect and adverse event profile; high-dose treatment resulted in ARSB expression over at least 24 months with preliminary evidence of disease stabilization. (Funded by the Telethon Foundation ETS, the European Commission Seventh Framework Programme, and the Isaac Foundation; ClinicalTrials.gov number, NCT03173521; EudraCT number, 2016-002328-10.)
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Affiliation(s)
- Nicola Brunetti-Pierri
- Telethon Institute of Genetics and Medicine, Pozzuoli, Naples, Italy
- Department of Translational Medicine, "Federico II" University, Naples, Italy
| | - Rita Ferla
- Telethon Institute of Genetics and Medicine, Pozzuoli, Naples, Italy
- Department of Translational Medicine, "Federico II" University, Naples, Italy
| | - Virginia Maria Ginocchio
- Telethon Institute of Genetics and Medicine, Pozzuoli, Naples, Italy
- Department of Translational Medicine, "Federico II" University, Naples, Italy
| | - Alessandro Rossi
- Department of Translational Medicine, "Federico II" University, Naples, Italy
| | - Simona Fecarotta
- Dipartimento ad Attivitá Integrata Materno Infantile, "Federico II" University, Naples, Italy
| | - Roberta Romano
- Department of Translational Medicine, "Federico II" University, Naples, Italy
| | - Giancarlo Parenti
- Telethon Institute of Genetics and Medicine, Pozzuoli, Naples, Italy
- Department of Translational Medicine, "Federico II" University, Naples, Italy
| | - Yilmaz Yildiz
- Division of Pediatric Metabolism, Ihsan Dogramaci Children's Hospital, Hacettepe University, Ankara, Turkey
| | | | | | - Margherita Dell'Anno
- Telethon Institute of Genetics and Medicine, Pozzuoli, Naples, Italy
- Department of Translational Medicine, "Federico II" University, Naples, Italy
| | - Mafalda Graziano
- Telethon Institute of Genetics and Medicine, Pozzuoli, Naples, Italy
| | | | - Generoso Andria
- Department of Translational Medicine, "Federico II" University, Naples, Italy
| | | | - Raffaella Brunetti-Pierri
- Eye Clinic, Multidisciplinary Department of Medical, Surgical and Dental Sciences, Università degli Studi della Campania "Luigi Vanvitelli," Naples, Italy
| | - Francesca Simonelli
- Eye Clinic, Multidisciplinary Department of Medical, Surgical and Dental Sciences, Università degli Studi della Campania "Luigi Vanvitelli," Naples, Italy
| | - Vincenzo Nigro
- Telethon Institute of Genetics and Medicine, Pozzuoli, Naples, Italy
- Department of Precision Medicine, Università degli Studi della Campania "Luigi Vanvitelli," Naples, Italy
| | - Maria Vargas
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, "Federico II" University, Naples, Italy
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, "Federico II" University, Naples, Italy
| | - Francesco Borgia
- Department of Advanced Biomedical Sciences, Divisions of Cardiology and Cardiothoracic Surgery, "Federico II" University, Naples, Italy
| | - Ernesto Soscia
- Institute of Biostructure and Bioimaging, National Research Council, Napoli, Italy
| | - Marco Gargaro
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Silvia Funghini
- Newborn Screening, Clinical Chemistry and Pharmacology Laboratory, Meyer Children's University Hospital, Florence, Italy
| | - Novella Tedesco
- Genethon, Evry, France
- Integrare Research Unit UMR_S951 of Université Paris-Saclay, University Evry, INSERM, Evry, France
| | - Pierre Romain Le Brun
- Genethon, Evry, France
- Integrare Research Unit UMR_S951 of Université Paris-Saclay, University Evry, INSERM, Evry, France
| | - Charles A Rupar
- London Health Science Centre, Western University, London, Ontario, Canada
| | - Chitra Prasad
- London Health Science Centre, Western University, London, Ontario, Canada
| | - Mar O'Callaghan
- Servicio de Neurología, Unidad de Enfermedades Metabólicas, Clínica Rett, Hospital Sant Joan de Déu, Barcelona, Spain
| | - John J Mitchell
- Division of Medical Genetics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Pediatric Endocrinology, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Stefania Galimberti
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Maria Grazia Valsecchi
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Philippe Veron
- Genethon, Evry, France
- Integrare Research Unit UMR_S951 of Université Paris-Saclay, University Evry, INSERM, Evry, France
| | | | | | - Giancarlo la Marca
- Newborn Screening, Clinical Chemistry and Pharmacology Laboratory, Meyer Children's University Hospital, Florence, Italy
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - H Serap Sivri
- Division of Pediatric Metabolism, Ihsan Dogramaci Children's Hospital, Hacettepe University, Ankara, Turkey
| | - Alberto Auricchio
- Telethon Institute of Genetics and Medicine, Pozzuoli, Naples, Italy
- Department of Advanced Biomedical Sciences, "Federico II" University, Naples, Italy
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Rosser BA, Chan C, Hoschtitzky A. Surgical Management of Valvular Heart Disease in Mucopolysaccharidoses: A Review of Literature. Biomedicines 2022; 10:biomedicines10020375. [PMID: 35203584 PMCID: PMC8962304 DOI: 10.3390/biomedicines10020375] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/04/2022] [Accepted: 01/04/2022] [Indexed: 02/04/2023] Open
Abstract
Mucopolysaccharidoses are extremely rare diseases that are frequently presenting with structural heart problems of the aortic and mitral valve in combination with myocardial dysfunction. In a substantial proportion, this leads to heart failure and is a leading cause of death in these patients. As this glycosaminoglycan degradation defect is associated with other conditions strongly influencing the perioperative risk and choice of surgical technique, multidisciplinary planning is crucial to improve short- and long-term outcomes. The extensive variance in clinical presentation between different impaired enzymes, and further within subgroups, calls for personalised treatment plans. Enzyme replacement therapies and bone marrow transplantation carry great potential as they may significantly abrogate the progress of the disease and as such reduce the clinical burden and improve life expectancy. Nevertheless, structural heart interventions may be required. We reviewed the existing literature of the less than 50 published cases regarding surgical management, technique, and choice of prostheses. Although improvement in therapy has shown promising results in protecting valvar tissue when initiated in infancy, concerns regarding stability of this effect and durability of biological prostheses remain.
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Affiliation(s)
- Barbara A. Rosser
- Department of Congenital Heart Surgery, Royal Brompton Hospital, London SW3 6NP, UK; (C.C.); (A.H.)
- Correspondence:
| | - Calvin Chan
- Department of Congenital Heart Surgery, Royal Brompton Hospital, London SW3 6NP, UK; (C.C.); (A.H.)
- Department of Surgery and Cancer, Imperial College London, St. Mary’s Hospital, London W2 1NY, UK
| | - Andreas Hoschtitzky
- Department of Congenital Heart Surgery, Royal Brompton Hospital, London SW3 6NP, UK; (C.C.); (A.H.)
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Poswar FDO, Santos HS, Santos ABS, Berger SV, de Souza CFM, Giugliani R, Baldo G. Progression of Cardiovascular Manifestations in Adults and Children With Mucopolysaccharidoses With and Without Enzyme Replacement Therapy. Front Cardiovasc Med 2022; 8:801147. [PMID: 35097020 PMCID: PMC8790121 DOI: 10.3389/fcvm.2021.801147] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 12/17/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Cardiovascular involvement is among the main features of MPS disorders and it is also a significant cause of morbidity and mortality. The range of manifestations includes cardiac valve disease, conduction abnormalities, left ventricular hypertrophy, and coronary artery disease. Here, we assessed the cardiovascular manifestations in a cohort of children and adults with MPS I, II, IV, and VI, as well as the impact of enzyme replacement therapy (ERT) on those manifestations. Methods: We performed a chart review of 53 children and 23 adults with different types of MPS that had performed echocardiograms from January 2000 until October 2018. Standardized Z scores were obtained for heart chamber sizes according to the body surface area. When available, echocardiographic measurements that were performed before ERT and at least 18 months after that date were used for the assessment of pre- and post-treatment parameters. Results: Left side valvular disease was a frequent finding, with mitral and aortic thickening being reported in most patients in all four MPS types. Left atrium dilatation was present in 26% of the patients; 25% had increased relative wall thickness; 28% had pulmonary hypertension. The cardiovascular involvement was, in general, more prevalent and more severe in adults than in children, including conduction disorders (40 vs. 16%), mitral stenosis (26 vs. 6%), aortic stenosis (13 vs. 4%), and systolic dysfunction (observed in only one adult patient). ERT promoted a significant reduction of the left ventricular hypertrophy parameters, but failed to improve valve abnormalities, pulmonary hypertension, and left atrial dilatation. Conclusions: Adult patients with MPS may develop severe cardiovascular involvement, not commonly observed in children, and clinicians should be aware of the need for careful monitoring and timely management of those potentially life-threatening complications. Our results also confirm the impact of long-term ERT on left ventricular hypertrophy and its limitations in reversing other prevalent cardiovascular manifestations.
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Affiliation(s)
- Fabiano de Oliveira Poswar
- Postgraduate Program in Genetics and Molecular Biology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.,Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Hallana Souza Santos
- Postgraduate Program in Genetics and Molecular Biology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Angela Barreto Santiago Santos
- Cardiology Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,Postgraduate Program in Cardiology and Cardiovascular Sciences, Medical School, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | - Roberto Giugliani
- Postgraduate Program in Genetics and Molecular Biology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.,Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,Department of Genetics, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Guilherme Baldo
- Postgraduate Program in Genetics and Molecular Biology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.,Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,Postgraduate Program in Physiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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7
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Brunelli MJ, Atallah ÁN, da Silva EM. Enzyme replacement therapy with galsulfase for mucopolysaccharidosis type VI. Cochrane Database Syst Rev 2021; 9:CD009806. [PMID: 34533215 PMCID: PMC8447860 DOI: 10.1002/14651858.cd009806.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Mucopolysaccharidosis type VI (MPS VI) or Maroteaux-Lamy syndrome is a rare genetic disorder caused by the deficiency of arylsulphatase B. The resultant accumulation of dermatan sulphate causes lysosomal damage. The clinical symptoms are related to skeletal dysplasia (i.e. short stature and degenerative joint disease). Other manifestations include cardiac disease, impaired pulmonary function, ophthalmological complications, hepatosplenomegaly, sinusitis, otitis, hearing loss and sleep apnea. Intellectual impairment is generally absent. Clinical manifestation is typically by two or three years of age; however, slowly progressive cases may not present until adulthood. Enzyme replacement therapy (ERT) with galsulfase is considered a new approach for treating MPS VI. OBJECTIVES To evaluate the effectiveness and safety of treating MPS VI by ERT with galsulfase compared to other interventions, placebo or no intervention. SEARCH METHODS Eletronic searches were performed on the Cystic Fibrosis and Genetic Disorders Group's Inborn Errors of Metabolism Trials Register. Date of the latest search: 09 June 2021. Further searches of the following databases were also performed: CENTRAL, MEDLINE, LILACS, the Journal of Inherited Metabolic Disease, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov. Date of the latest search: 20 August 2021. SELECTION CRITERIA Randomized and quasi-randomized controlled clinical studies of ERT with galsulfase compared to other interventions or placebo. DATA COLLECTION AND ANALYSIS Two authors independently screened the studies, assessed the risk of bias, extracted data and assessed the certainty of the the evidence using the GRADE criteria. MAIN RESULTS One study was included involving 39 participants who received either ERT with galsulfase (recombinant human arylsulphatase B) or placebo. This small study was considered overall to have an unclear risk of bias in relation to the design and implementation of the study, since the authors did not report how both the allocation generation and concealment were performed. Given the very low certainty of the evidence, we are uncertain whether at 24 weeks there was a difference between groups in relation to the 12-minute walk test, mean difference (MD) of 92.00 meters (95% confidence interval (CI) 11.00 to 172.00), or the three-minute stair climb, MD 5.70 (95% CI -0.10 to 11.50). In relation to respiratory tests, we are uncertain whether galsulfase makes any difference as compared to placebo in forced vital capacity in litres (FVC (L) (absolute change in baseline), given the very low certainty of the evidence. Cardiac function was not reported in the included study. We found that galsulfase, as compared to placebo, may decrease urinary glycosaminoglycan levels at 24 weeks, MD -227.00 (95% CI -264.00 to -190.00) (low-certainty evidence). We are uncertain whether there are differences between the galsulfase and placebo groups in relation to adverse events (very low-certainty evidence). In general, the dose of galsulfase was well tolerated and there were no differences between groups. These events include drug-related adverse events, serious and severe adverse events, those during infusion, drug-related adverse events during infusion, and deaths. More infusion-related reactions were observed in the galsulfase group and were managed with interruption or slowing of infusion rate or administration of antihistamines or corticosteroids drugs. No deaths occurred during the study. AUTHORS' CONCLUSIONS: The results of this review are based only on one small study (a 24-week randomised phase of the study and prior to the open-label extension). We are uncertain whether galsulfase is more effective than placebo, for treating people with MPS VI, in relation to the 12-minute walk test or the three-minute stair climb, as the certainty of the evidence has been assessed as very low. We found that galsulfase may reduce urinary glycosaminoglycans levels. We are also uncertain whether there are any differences between treatment groups in relation to cardiac or pulmonary functions, liver or spleen volume, overnight apnea-hypopnea, height and weight, quality of life and adverse effects. Further studies are needed to obtain more information on the long-term effectiveness and safety of ERT with galsulfase.
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Affiliation(s)
| | - Álvaro N Atallah
- Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
| | - Edina Mk da Silva
- Emergency Medicine and Evidence Based Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
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8
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Garcia P, Phillips D, Johnson J, Martin K, Randolph LM, Rosenfeld H, Harmatz P. Long-term outcomes of patients with mucopolysaccharidosis VI treated with galsulfase enzyme replacement therapy since infancy. Mol Genet Metab 2021; 133:100-108. [PMID: 33775523 DOI: 10.1016/j.ymgme.2021.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/05/2021] [Accepted: 03/06/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Long-term outcomes of patients with mucopolysaccharidosis (MPS) VI treated with galsulfase enzyme replacement therapy (ERT) since infancy were evaluated. METHODS The study was a multicenter, prospective evaluation using data from infants with MPS VI generated during a phase 4 study (ASB-008; Clinicaltrials.govNCT00299000) and clinical data collected ≥5 years after completion of the study. RESULTS Parents of three subjects from ASB-008 (subjects 1, 2, and 4) provided written informed consent to participate in the follow-up study. One subject was excluded as consent was not provided. Subjects 1, 2, and 4 were aged 0.7, 0.3, and 1.1 years, respectively, at initiation of galsulfase and 10.5, 7.9, and 10.5 years, respectively, at follow-up. All subjects had classical MPS VI based on pre-treatment urinary glycosaminoglycans and the early onset of clinical manifestations. At follow-up, subject 4 had normal stature for age; subjects 1 and 2 had short stature, but height remained around the 90th percentile of growth curves for untreated classical MPS VI. Six-minute walk distance was normal for age/height in subjects 1 (550 m) and 4 (506 m), and reduced for subject 2 (340 m). Subject 2 preserved normal respiratory function, while percent predicted forced vital capacity and forced expiratory volume in 1 s decreased over time in the other subjects. Skeletal dysplasia was already apparent in all subjects at baseline and continued to progress. Cardiac valve disease showed mild progression in subject 1, mild improvement in subject 4, and remained trivial in subject 2. All subjects had considerably reduced pinch and grip strength at follow-up, but functional dexterity was relatively normal for age and there was limited impact on activities of daily living. Bruininks-Oseretsky Test of Motor Proficiency (BOT-2) results showed that subjects 2 and 4 had numerous fine and gross motor competencies. Corneal clouding progressed in all subjects, while progression of hearing impairment was variable. Liver size normalized from baseline in subjects 1 and 4, and remained normal in subject 2. CONCLUSION Very early and continuous ERT appears to slow down the clinical course of MPS VI, as shown by preservation of endurance, functional dexterity, and several fine and gross motor competencies after 7.7-9.8 years of treatment, and less growth impairment or progression of cardiac disease than could be expected based on the patients' classical phenotype. ERT does not seem to prevent progression of skeletal or eye disease in the long term.
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Affiliation(s)
- Paula Garcia
- Hospital Pediátrico de Coimbra, Coimbra, Portugal
| | - Dawn Phillips
- UNC Chapel Hill Division of Physical Therapy, School of Medicine, Chapel Hill, NC, USA
| | - JoAnn Johnson
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Kenneth Martin
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | | | | | - Paul Harmatz
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA.
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9
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Safary A, Moghaddas-Sani H, Akbarzadeh-Khiavi M, Khabbazzi A, Rafi MA, Omidi Y. Enzyme replacement combinational therapy: effective treatments for mucopolysaccharidoses. Expert Opin Biol Ther 2021; 21:1181-1197. [PMID: 33653197 DOI: 10.1080/14712598.2021.1895746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Mucopolysaccharidoses (MPS), as a group of inherited lysosomal storage disorders (LSDs), are clinically heterogeneous and characterized by multi-systemic manifestations, such as skeletal abnormalities and neurological dysfunctions. The currently used enzyme replacement therapy (ERT) might be associated with several limitations including the low biodistribution of the enzymes into the main targets, immunological responses against foreign enzymes, and the high cost of the treatment procedure. Therefore, a suitable combination approach can be considered for the successful treatment of each type of MPS. AREAS COVERED In this review, we provide comprehensive insights into the ERT-based combination therapies of MPS by reviewing the published literature on PubMed and Scopus. We also discuss the recent advancements in the treatment of MPS and bring up the hopes and hurdles in the futuristic treatment strategies. EXPERT OPINION Given the complex pathophysiology of MPS and its involvement in different tissues, the ERT of MPS in combination with stem cell therapy or gene therapy is deemed to provide a personalized precision treatment modality with the highest therapeutic responses and minimal side effects. By the same token, new combinational approaches need to be evaluated by using drugs that target alternative and secondary pathological pathways.
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Affiliation(s)
- Azam Safary
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Research Center for Pharmaceutical Nanotechnology, Biomedicine Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Mostafa Akbarzadeh-Khiavi
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Alireza Khabbazzi
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad A Rafi
- Department of Neurology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvanian USA
| | - Yadollah Omidi
- Department of Pharmaceutical Sciences, College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida USA
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10
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Lin HY, Chen MR, Lee CL, Lin SM, Hung CL, Niu DM, Chang TM, Chuang CK, Lin SP. Natural progression of cardiac features and long-term effects of enzyme replacement therapy in Taiwanese patients with mucopolysaccharidosis II. Orphanet J Rare Dis 2021; 16:99. [PMID: 33622387 PMCID: PMC7903682 DOI: 10.1186/s13023-021-01743-2] [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: 07/02/2020] [Accepted: 02/11/2021] [Indexed: 11/29/2022] Open
Abstract
Background Cardiac abnormalities have been observed in patients with mucopolysaccharidosis type II (MPS II). The aim of this study was to investigate the cardiac features and natural progression of Taiwanese patients with MPS II, and evaluate the impact of enzyme replacement therapy (ERT) on cardiac structure and function. Methods The medical records and echocardiograms of 48 Taiwanese patients with MPS II (median age, 6.9 years; age range, 0.1–27.9 years) were reviewed. The relationships between age and each echocardiographic parameter were analyzed. Results The mean z-scores of left ventricular mass index (LVMI), interventricular septum diameter in diastole (IVSd), left ventricular posterior wall diameter in diastole (LVPWd), and aortic diameter were 1.10, 2.70, 0.95 and 1.91, respectively. Z scores > 2 were identified in 33%, 54%, 13%, and 46% for LVMI, IVSd, LVPWd, and aortic diameter, respectively. The most prevalent cardiac valve abnormality was mitral regurgitation (MR) (56%), followed by aortic regurgitation (AR) (33%). The severity of mitral stenosis (MS), MR, aortic stenosis (AS), AR, and the existence of valvular heart disease were all positively correlated with increasing age (p < 0.01). We also compared the echocardiographic parameters between two groups: (1) 12 patients who had up to 17 years of follow-up echocardiographic data without ERT, and (2) nine patients who had up to 12 years of follow-up data with ERT. The results showed that z-score changes of LVMI significantly improved in the patients who received ERT compared to those who did not receive ERT (0.05 versus 1.52, p < 0.05). However, the severity score changes of MS, MR, AS, and AR all showed gradual progression in both groups (p > 0.05). Conclusions High prevalence rates of valvular heart disease and cardiac hypertrophy were observed in the MPS II patients in this study. The existence and severity of cardiac hypertrophy and valvular heart disease in these patients worsened with increasing age, reinforcing the concept of the progressive nature of this disease. ERT for MPS II appeared to be effective in stabilizing or reducing the progression of cardiac hypertrophy, but it only had a limited effect on valvulopathy.
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Affiliation(s)
- Hsiang-Yu Lin
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.,Department of Pediatrics, MacKay Memorial Hospital, No.92, Sec. 2, Chung-Shan North Road, Taipei, 10449, Taiwan.,Department of Medical Research, MacKay Memorial Hospital, 92 Chung-Shan N. Rd., Sec. 2, Taipei, 10449, Taiwan.,Department of Childhood Care and Education, MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan.,Department of Rare Disease Center, MacKay Memorial Hospital, Taipei, Taiwan
| | - Ming-Ren Chen
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.,Department of Pediatrics, MacKay Memorial Hospital, No.92, Sec. 2, Chung-Shan North Road, Taipei, 10449, Taiwan.,Department of Childhood Care and Education, MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Chung-Lin Lee
- Department of Childhood Care and Education, MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan.,Department of Pediatrics, MacKay Memorial Hospital, Hsinchu, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shan-Miao Lin
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.,Department of Pediatrics, MacKay Memorial Hospital, No.92, Sec. 2, Chung-Shan North Road, Taipei, 10449, Taiwan.,Department of Childhood Care and Education, MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Chung-Lieh Hung
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.,Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Dau-Ming Niu
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tung-Ming Chang
- Department of Pediatric Neurology, Changhua Christian Children's Hospital, Changhua, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Kuang Chuang
- Department of Medical Research, MacKay Memorial Hospital, 92 Chung-Shan N. Rd., Sec. 2, Taipei, 10449, Taiwan. .,College of Medicine, Fu-Jen Catholic University, Taipei, Taiwan.
| | - Shuan-Pei Lin
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan. .,Department of Pediatrics, MacKay Memorial Hospital, No.92, Sec. 2, Chung-Shan North Road, Taipei, 10449, Taiwan. .,Department of Medical Research, MacKay Memorial Hospital, 92 Chung-Shan N. Rd., Sec. 2, Taipei, 10449, Taiwan. .,Department of Rare Disease Center, MacKay Memorial Hospital, Taipei, Taiwan. .,Department of Infant and Child Care, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan.
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11
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Parini R, Deodato F. Intravenous Enzyme Replacement Therapy in Mucopolysaccharidoses: Clinical Effectiveness and Limitations. Int J Mol Sci 2020; 21:E2975. [PMID: 32340185 PMCID: PMC7215308 DOI: 10.3390/ijms21082975] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/13/2020] [Accepted: 04/21/2020] [Indexed: 12/21/2022] Open
Abstract
The aim of this review is to summarize the evidence on efficacy, effectiveness and safety of intravenous enzyme replacement therapy (ERT) available for mucopolysaccharidoses (MPSs) I, II, IVA, VI and VII, gained in phase III clinical trials and in observational post-approval studies. Post-marketing data are sometimes conflicting or controversial, possibly depending on disease severity, differently involved organs, age at starting treatment, and development of anti-drug antibodies (ADAs). There is general agreement that ERT is effective in reducing urinary glycosaminoglycans and liver and spleen volume, while heart and joints outcomes are variable in different studies. Effectiveness on cardiac valves, trachea and bronchi, hearing and eyes is definitely poor, probably due to limited penetration in the specific tissues. ERT does not cross the blood-brain barrier, with the consequence that the central nervous system is not cured by intravenously injected ERT. All patients develop ADAs but their role in ERT tolerance and effectiveness has not been well defined yet. Lack of reliable biomarkers contributes to the uncertainties about effectiveness. The data obtained from affected siblings strongly indicates the need of neonatal screening for treatable MPSs. Currently, other treatments are under evaluation and will surely help improve the prognosis of MPS patients.
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Affiliation(s)
- Rossella Parini
- UOS Malattie Metaboliche Rare, Clinica Pediatrica dell’Università Milano Bicocca, Fondazione MBBM, ATS Monza e Brianza, 20900 Monza, Italy
| | - Federica Deodato
- Division of Metabolic Disease, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
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12
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Lampe C, Harmatz PR, Parini R, Sharma R, Teles EL, Johnson J, Sivam D, Sisic Z. Enzyme replacement therapy initiated in adulthood: Findings from the mucopolysaccharidosis VI Clinical Surveillance Program. Mol Genet Metab 2019; 127:355-360. [PMID: 31324526 DOI: 10.1016/j.ymgme.2019.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/11/2019] [Accepted: 06/28/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the impact of galsulfase enzyme replacement therapy (ERT) when initiated in adulthood for patients with mucopolysaccharidosis (MPS) VI. METHODS In 2005, the multi-national, MPS VI Clinical Surveillance Program (CSP) was established to collect long-term observational data from routine clinical and laboratory assessments. A sub-analysis was performed in patients who started ERT at ≥16 years of age and had received galsulfase for ≥6 months. Urinary glycosaminoglycans (uGAG), 6-min walk test (6MWT), 3-min stair climb test (3MSCT), pulmonary function measures, cardiac function, ophthalmology measures, liver and spleen sizes, and safety were evaluated. RESULTS Of 223 patients enrolled in the CSP, 51 were included in the sub-analysis. Patients were between 16 and 63 years of age at first infusion. From pre-treatment baseline, uGAG level decreased by a mean (±standard deviation [SD]) of 66 (±45)% (N = 29) after a median follow-up of 7.2 years. 6MWT distance decreased slightly by a mean of 17 (±107) meters (N = 23) after 6.6 years. Stairs/min in the 3MSCT increased by a mean of 26 (±33) (N = 14) after 2.8 years. Pulmonary function measures, forced expiratory volume in 1 second and forced vital capacity, increased by a mean of 0.06 (±0.21) L after 7.3 years and 0.05 (±0.28) L after 7.2 years, respectively (N = 19 for both measures). Overall, galsulfase was well tolerated, with most adverse events reported being MPS-related clinical manifestations and not related to galsulfase. CONCLUSIONS Results of this sub-analysis of the CSP suggest that initiation of galsulfase in adulthood is well tolerated and can possibly stabilize MPS VI in the long term.
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Affiliation(s)
- Christina Lampe
- Department of Child Neurology, Justus-Liebig University, Gießen, Germany.
| | - Paul R Harmatz
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA.
| | - Rossella Parini
- Fondazione MBBM San Gerardo Hospital, Monza, Italy; San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Reena Sharma
- Salford Royal Hospital NHS Foundation Trust, Salford, UK.
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13
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Akyol MU, Alden TD, Amartino H, Ashworth J, Belani K, Berger KI, Borgo A, Braunlin E, Eto Y, Gold JI, Jester A, Jones SA, Karsli C, Mackenzie W, Marinho DR, McFadyen A, McGill J, Mitchell JJ, Muenzer J, Okuyama T, Orchard PJ, Stevens B, Thomas S, Walker R, Wynn R, Giugliani R, Harmatz P, Hendriksz C, Scarpa M. Recommendations for the management of MPS VI: systematic evidence- and consensus-based guidance. Orphanet J Rare Dis 2019; 14:118. [PMID: 31142378 PMCID: PMC6541999 DOI: 10.1186/s13023-019-1080-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/25/2019] [Indexed: 12/14/2022] Open
Abstract
Introduction Mucopolysaccharidosis (MPS) VI or Maroteaux-Lamy syndrome (253200) is an autosomal recessive lysosomal storage disorder caused by deficiency in N-acetylgalactosamine-4-sulfatase (arylsulfatase B). The heterogeneity and progressive nature of MPS VI necessitates a multidisciplinary team approach and there is a need for robust guidance to achieve optimal management. This programme was convened to develop evidence-based, expert-agreed recommendations for the general principles of management, routine monitoring requirements and the use of medical and surgical interventions in patients with MPS VI. Methods 26 international healthcare professionals from various disciplines, all with expertise in managing MPS VI, and three patient advocates formed the Steering Committee group (SC) and contributed to the development of this guidance. Members from six Patient Advocacy Groups (PAGs) acted as advisors and attended interviews to ensure representation of the patient perspective. A modified-Delphi methodology was used to demonstrate consensus among a wider group of healthcare professionals with expertise and experience managing patients with MPS VI and the manuscript has been evaluated against the validated Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument by three independent reviewers. Results A total of 93 guidance statements were developed covering five domains: (1) general management principles; (2) recommended routine monitoring and assessments; (3) enzyme replacement therapy (ERT) and hematopoietic stem cell transplantation (HSCT); (4) interventions to support respiratory and sleep disorders; (5) anaesthetics and surgical interventions. Consensus was reached on all statements after two rounds of voting. The greatest challenges faced by patients as relayed by consultation with PAGs were deficits in endurance, dexterity, hearing, vision and respiratory function. The overall guideline AGREE II assessment score obtained for the development of the guidance was 5.3/7 (where 1 represents the lowest quality and 7 represents the highest quality of guidance). Conclusion This manuscript provides evidence- and consensus-based recommendations for the management of patients with MPS VI and is for use by healthcare professionals that manage the holistic care of patients with the intention to improve clinical- and patient-reported outcomes and enhance patient quality of life. It is recognised that the guidance provided represents a point in time and further research is required to address current knowledge and evidence gaps. Electronic supplementary material The online version of this article (10.1186/s13023-019-1080-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Tord D Alden
- Department of Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hernan Amartino
- Child Neurology Department, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Jane Ashworth
- Department of Paediatric Ophthalmology, Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Kumar Belani
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
| | - Kenneth I Berger
- Departments of Medicine and Neuroscience and Physiology, New York University School of Medicine, André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY, USA
| | - Andrea Borgo
- Orthopaedics Clinic, Padova University Hospital, Padova, Italy
| | - Elizabeth Braunlin
- Division of Pediatric Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Yoshikatsu Eto
- Advanced Clinical Research Centre, Institute of Neurological Disorders, Kanagawa, Japan and Department of Paediatrics/Gene Therapy, Tokyo Jikei University School of Medicine, Tokyo, Japan
| | - Jeffrey I Gold
- Keck School of Medicine, Departments of Anesthesiology, Pediatrics, and Psychiatry & Behavioural Sciences, Children's Hospital Los Angeles, Department of Anesthesiology Critical Care Medicine, 4650 Sunset Boulevard, Los Angeles, CA, USA
| | - Andrea Jester
- Hand and Upper Limb Service, Department of Plastic Surgery, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Simon A Jones
- Willink Biochemical Genetic Unit, Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Cengiz Karsli
- Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, Toronto, Canada
| | - William Mackenzie
- Department of Orthopedics, Nemours/Alfred I. Dupont Hospital for Children, Wilmington, DE, USA
| | - Diane Ruschel Marinho
- Department of Ophthalmology, UFRGS, and Ophthalmology Service, HCPA, Porto Alegre, Brazil
| | | | - Jim McGill
- Department of Metabolic Medicine, Queensland Children's Hospital, Brisbane, Australia
| | - John J Mitchell
- Division of Pediatric Endocrinology, Montreal Children's Hospital, Montreal, QC, Canada
| | - Joseph Muenzer
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Torayuki Okuyama
- Department of Clinical Laboratory Medicine, National Centre for Child Health and Development, Tokyo, Japan
| | - Paul J Orchard
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | | | | | - Robert Walker
- Department of Paediatric Anaesthesia, Royal Manchester Children's Hospital, Manchester, UK
| | - Robert Wynn
- Department of Paediatric Haematology, Royal Manchester Children's Hospital, Manchester, UK
| | - Roberto Giugliani
- Department of Genetics, UFRGS, and Medical Genetics Service, HCPA, Porto Alegre, Brazil.
| | - Paul Harmatz
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Christian Hendriksz
- Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Maurizio Scarpa
- Center for Rare Diseases at Host Schmidt Kliniken, Wiesbaden, Germany and Department of Paediatrics, University of Padova, Padova, Italy
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14
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Harmatz PR, Lampe C, Parini R, Sharma R, Teles EL, Johnson J, Sivam D, Sisic Z. Enzyme replacement therapy outcomes across the disease spectrum: Findings from the mucopolysaccharidosis VI Clinical Surveillance Program. J Inherit Metab Dis 2019; 42:519-526. [PMID: 30834539 DOI: 10.1002/jimd.12079] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/27/2019] [Indexed: 11/08/2022]
Abstract
The impact of galsulfase enzyme replacement therapy in patients with mucopolysaccharidosis (MPS) VI with phenotypes at either end of the disease spectrum was evaluated. The MPS VI Clinical Surveillance Program (CSP) was established to collect long-term observational data from routine clinical and laboratory assessments. A subanalysis of the CSP was performed in patients with pretreatment urinary glycosaminoglycan (uGAG) levels <100 μg/mg and ≥200 μg/mg creatinine (low- and high-uGAG) who had received galsulfase for ≥6 months. uGAG, 6-minute walk test (6MWT), 3-minute stair climb test (3MSCT), pulmonary function measures, height/growth, cardiac function, and safety were evaluated. Patients with a high-uGAG level at pre-treatment baseline (N = 68) showed greater impairments in endurance and pulmonary function than those with low-baseline uGAG levels (N = 39). From pre-treatment baseline, the distance walked on the 6MWT in the low- and high-uGAG groups increased by a mean (±SD) of 49 (±151) meters and 42 (±165) meters (median follow-up 5.5 and 7.7 years), respectively. The number of stairs/min climbed in the 3MSCT in the low- and high-uGAG groups increased by a mean of 18 (±33) and 30 (±45) (median follow-up 2.8 and 3.5 years), respectively. Overall, pulmonary function remained unchanged for both groups. No impact was seen on cardiac function. Galsulfase was generally well tolerated in both groups, with most adverse events being MPS-related complications unrelated to galsulfase. Results of this CSP sub-analysis suggest that galsulfase stabilizes MPS VI in the long-term and has an acceptable safety profile, regardless of baseline disease severity.
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Affiliation(s)
- Paul R Harmatz
- Department of Gastroenterology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Christina Lampe
- Department of Child Neurology, Justus-Liebig University, Gieβen, Germany
| | - Rossella Parini
- Department of Paediatrics, Fondazione MBBM San Gerardo Hospital, Monza, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Reena Sharma
- Department of Endocrinology and Metabolic Medicine, Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - Elisa L Teles
- Department of Metabolic Diseases, São João Hospital, Porto, Portugal
| | - Julie Johnson
- BioMarin Pharmaceutical Inc., Novato, California, USA
| | - Debbie Sivam
- BioMarin Pharmaceutical Inc., Novato, California, USA
| | - Zlatko Sisic
- BioMarin Pharmaceutical Inc., Novato, California, USA
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Abstract
The lysosomal storage diseases (LSDs) are a group of inherited metabolic disorders that are caused for the most part by enzyme deficiencies within the lysosome resulting in accumulation of undegraded substrate. This storage process leads to a broad spectrum of clinical manifestations depending on the specific substrate and site of accumulation. Examples of LSDs include the mucopolysaccharidoses, mucolipidoses, oligosaccharidoses, Pompe disease, Gaucher disease, Fabry disease, the Niemann-Pick disorders, and neuronal ceroid lipofuscinoses. This review summarizes the main clinical features, diagnosis, and management of LSDs with an emphasis on those for which treatment is available.
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Affiliation(s)
- Angela Sun
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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16
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Rodríguez MC, Ceaglio N, Antuña S, Tardivo MB, Etcheverrigaray M, Prieto C. Production of Therapeutic Enzymes by Lentivirus Transgenesis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1148:25-54. [PMID: 31482493 DOI: 10.1007/978-981-13-7709-9_2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Since ERT for several LSDs treatment has emerged at the beginning of the 1980s with Orphan Drug approval, patients' expectancy and life quality have been improved. Most LSDs treatment are based on the replaced of mutated or deficient protein with the natural or recombinant protein.One of the main ERT drawback is the high drug prices. Therefore, different strategies trying to optimize the global ERT biotherapeutic production have been proposed. LVs, a gene delivery tool, can be proposed as an alternative method to generate stable cell lines in manufacturing of recombinant proteins. Since LVs have been used in human gene therapy, clinical trials, safety testing assays and procedures have been developed. Moreover, one of the main advantages of LVs strategy to obtain manufacturing cell line is the short period required as well as the high protein levels achieved.In this chapter, we will focus on LVs as a recombinant protein production platform and we will present a case study that employs LVs to express in a manufacturing cell line, alpha-Galactosidase A (rhαGAL), which is used as ERT for Fabry disease treatment.
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Affiliation(s)
| | - Natalia Ceaglio
- Cell Culture Laboratory, UNL, CONICET, FBCB, Santa Fe, Argentina
| | | | | | | | - Claudio Prieto
- Cell Culture Laboratory, UNL, FBCB, Santa Fe, Argentina.
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17
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Abstract
The lysosomal storage diseases (LSDs) are a group of inherited metabolic disorders that are caused for the most part by enzyme deficiencies within the lysosome resulting in accumulation of undegraded substrate. This storage process leads to a broad spectrum of clinical manifestations depending on the specific substrate and site of accumulation. Examples of LSDs include the mucopolysaccharidoses, mucolipidoses, oligosaccharidoses, Pompe disease, Gaucher disease, Fabry disease, the Niemann-Pick disorders, and neuronal ceroid lipofuscinoses. This review summarizes the main clinical features, diagnosis, and management of LSDs with an emphasis on those for which treatment is available.
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Affiliation(s)
- Angela Sun
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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18
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Ley-Martos M, Guerrero JM, Lucas-Javato M, Remón-García C, García-Lozano JR, Colón C, Crujeiras P, Rodrigues D, Paúl-Sánchez P, Macher HC. Family study of a novel mutation of mucopolysaccharidosis type VI with a severe phenotype and good response to enzymatic replacement therapy: Case report. Medicine (Baltimore) 2018; 97:e12872. [PMID: 30335002 PMCID: PMC6211882 DOI: 10.1097/md.0000000000012872] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Mucopolysaccharidosis type VI (MPS VI) or Maroteaux-Lamy syndrome is produced by the deficiency of the enzyme arylsulfatase B, responsible for the hydrolysis of N-acetyl-D-galactosamine, chondroitin sulfate, and dermatan sulfate. PATIENT CONCERNS A 3-year-old male with Moroccan origins is the index case. He had healthy consanguineous parents and 4 healthy brothers and sisters. The patient showed a wide spectrum of symptoms including skeletal dysplasia and short stature with elevated glycosaminoglycans (GAGs) in urine. DIAGNOSES, INTERVENTIONS, AND OUTCOMES GAGs were quantified by spectrometry method with 1,9-dimethylen blue in 24-hour urine samples. The qualitative analysis of urine GAGs was obtained by thin-layer chromatography to determine the predominant presence of dermatan sulfate. The activities of both arylsulfatase B and beta-galactosidase as well as genetic studies were performed in dried blood spots. The genetic study was performed with deoxyribonucleic acid by massive sequencing a of lisosomal storage diseases. Results showed a new mutation c.263A > C with the severe phenotype in homozygous in the patient. The familiar study of ARSB and GLB1 genes presented some asymptomatic SNPs but with a discrete decrease in the activity of arylsulfatase B and beta-galactosidase. After an early detection by pediatricians, and both enzymatic and genetic confirmation, the patient had a good response to substitutive enzymatic treatment with galsulfase. LESSONS Mucoplysaccharidosis type VI is an autosomal recessive rare disease characterized by a lysosomal storage disorder. Although a number of mutations have been already associated to the disease, we have found a new mutation located in the arylsulfatase B enzyme gene. We have described that this mutation is the ultimate cause of a severe presentation of the disease.
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Affiliation(s)
- Myriam Ley-Martos
- Pediatric Neurology and Rare Diseases Unit, Department of Pediatry, Hospital Universitario Puerta del Mar, Cádiz
| | - Juan M. Guerrero
- Molecular Diagnosis and Rare Diseases Laboratory, Department of Clinical Chemistry, Hospital Universitario Virgen del Rocío and Instituto de Biomedicina de Sevilla (IBiS), Sevilla
| | - Marta Lucas-Javato
- Molecular Diagnosis and Rare Diseases Laboratory, Department of Clinical Chemistry, Hospital Universitario Virgen del Rocío and Instituto de Biomedicina de Sevilla (IBiS), Sevilla
| | - Cristina Remón-García
- Pneumology Unit, Department of Pediatry, Hospital Universitario Puerta del Mar, Cádiz
| | - J. Raúl García-Lozano
- Molecular Diagnosis Unit, Department of Clinical Immunology, Hospital Universitario Virgen del Rocío and Instituto de Biomedicina de Sevilla (IBiS), Sevilla
| | - Cristóbal Colón
- Diagnosis and Treatment of Congenital Metabolic Diseases Unit, Department of Pediatry, Hospital Clínico Universitario and Instituto de Investigacion en Salud (IDIS), Santiago de Compostela
| | - Pablo Crujeiras
- Diagnosis and Treatment of Congenital Metabolic Diseases Unit, Department of Pediatry, Hospital Clínico Universitario and Instituto de Investigacion en Salud (IDIS), Santiago de Compostela
| | - Daniel Rodrigues
- Diagnosis and Treatment of Congenital Metabolic Diseases Unit, Department of Pediatry, Hospital Clínico Universitario and Instituto de Investigacion en Salud (IDIS), Santiago de Compostela
| | | | - Hada C. Macher
- Molecular Diagnosis and Rare Diseases Laboratory, Department of Clinical Chemistry, Hospital Universitario Virgen del Rocío and Instituto de Biomedicina de Sevilla (IBiS), Sevilla
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Lin HY, Chen MR, Lin SM, Hung CL, Niu DM, Chuang CK, Lin SP. Cardiac features and effects of enzyme replacement therapy in Taiwanese patients with Mucopolysaccharidosis IVA. Orphanet J Rare Dis 2018; 13:148. [PMID: 30157891 PMCID: PMC6114849 DOI: 10.1186/s13023-018-0883-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 07/29/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Cardiac abnormalities have been observed in patients with mucopolysaccharidosis (MPS) of any type, with the most documented abnormalities being valvular heart disease and cardiac hypertrophy. However, few studies have focused on the cardiac features of MPS IVA. METHODS We reviewed the medical records, echocardiograms, and electrocardiograms of 32 Taiwanese patients with MPS IVA (16 males and 16 females; median age, 10.8 years; age range, 1.1 to 29.1 years) as well as the echocardiographic data of six patients who received enzyme replacement therapy (ERT) for 3-6 years. RESULTS Echocardiographic examinations (n = 32) revealed mean z scores of left ventricular mass index (LVMI), interventricular septum diameter in diastole (IVSd), left ventricular posterior wall diameter in diastole (LVPWd), and aortic diameter of 0.94, 2.70, 0.39, and 3.26, respectively. Z scores > 2 were identified in 25%, 50%, 29%, and 69% of the LVMI, IVSd, LVPWd, and aortic diameter values, respectively. Diastolic dysfunction [reversed ratio between early and late (atrial) ventricular filling velocity (E/A ratio < 1)] was identified in four patients (13%), however, the ejection fraction was normal (50-75%) in all of the patients. Sixteen patients (50%) had valvular heart disease and most were of mild degree. Fourteen (44%) had valvular stenosis, and 10 (31%) had regurgitation. The z scores of LVMI, IVSd, LVPWd, and aortic diameter, the severity scores of aortic stenosis and regurgitation, and the existence of a thickened interventricular septum were all positively correlated with increasing age (p < 0.05). For the 14 patients with valve thickening, the z scores of LVMI, IVSd and aortic diameter were all larger than those of the 18 patients without valve thickening (p < 0.05). For two patients who started ERT at a younger age (1.4 and 2.8 years, respectively), the z scores for LVMI, IVSd, and LVPWd all decreased after ERT. CONCLUSIONS A large proportion of the patients with MPS IVA had valvular heart disease and cardiac hypertrophy. Cardiac abnormalities worsened with increasing age in accordance with the progressive nature of this disease. ERT appeared to be effective in stabilizing or reducing cardiac hypertrophy, and better results may have been associated with starting ERT at a younger age.
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Affiliation(s)
- Hsiang-Yu Lin
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- Department of Pediatrics, Mackay Memorial Hospital, No.92, Sec. 2, Chung-Shan North Road, Taipei, 10449, Taiwan
- Department of Medical Research, Mackay Memorial Hospital, 92 Chung-Shan N. Rd., Sec. 2, Taipei, 10449, Taiwan
- Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Ming-Ren Chen
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- Department of Pediatrics, Mackay Memorial Hospital, No.92, Sec. 2, Chung-Shan North Road, Taipei, 10449, Taiwan
- Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Shan-Miao Lin
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- Department of Pediatrics, Mackay Memorial Hospital, No.92, Sec. 2, Chung-Shan North Road, Taipei, 10449, Taiwan
- Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Chung-Lieh Hung
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Dau-Ming Niu
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chih-Kuang Chuang
- Department of Medical Research, Mackay Memorial Hospital, 92 Chung-Shan N. Rd., Sec. 2, Taipei, 10449, Taiwan.
- College of Medicine, Fu-Jen Catholic University, Taipei, Taiwan.
| | - Shuan-Pei Lin
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan.
- Department of Pediatrics, Mackay Memorial Hospital, No.92, Sec. 2, Chung-Shan North Road, Taipei, 10449, Taiwan.
- Department of Medical Research, Mackay Memorial Hospital, 92 Chung-Shan N. Rd., Sec. 2, Taipei, 10449, Taiwan.
- Department of Infant and Child Care, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan.
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20
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Zhao RR, Ackers-Johnson M, Stenzig J, Chen C, Ding T, Zhou Y, Wang P, Ng SL, Li PY, Teo G, Rudd PM, Fawcett JW, Foo RS. Targeting Chondroitin Sulfate Glycosaminoglycans to Treat Cardiac Fibrosis in Pathological Remodeling. Circulation 2018; 137:2497-2513. [DOI: 10.1161/circulationaha.117.030353] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 12/21/2017] [Indexed: 12/21/2022]
Abstract
Background:
Heart failure is a leading cause of mortality and morbidity, and the search for novel therapeutic approaches continues. In the monogenic disease mucopolysaccharidosis VI, loss-of-function mutations in arylsulfatase B lead to myocardial accumulation of chondroitin sulfate (CS) glycosaminoglycans, manifesting as myriad cardiac symptoms. Here, we studied changes in myocardial CS in nonmucopolysaccharidosis failing hearts and assessed its generic role in pathological cardiac remodeling.
Methods:
Healthy and diseased human and rat left ventricles were subjected to histological and immunostaining methods to analyze glycosaminoglycan distribution. Glycosaminoglycans were extracted and analyzed for quantitative and compositional changes with Alcian blue assay and liquid chromatography–mass spectrometry. Expression changes in 20 CS-related genes were studied in 3 primary human cardiac cell types and THP-1–derived macrophages under each of 9 in vitro stimulatory conditions. In 2 rat models of pathological remodeling induced by transverse aortic constriction or isoprenaline infusion, recombinant human arylsulfatase B (rhASB), clinically used as enzyme replacement therapy in mucopolysaccharidosis VI, was administered intravenously for 7 or 5 weeks, respectively. Cardiac function, myocardial fibrosis, and inflammation were assessed by echocardiography and histology. CS-interacting molecules were assessed with surface plasmon resonance, and a mechanism of action was verified in vitro.
Results:
Failing human hearts displayed significant perivascular and interstitial CS accumulation, particularly in regions of intense fibrosis. Relative composition of CS disaccharides remained unchanged. Transforming growth factor–β induced CS upregulation in cardiac fibroblasts. CS accumulation was also observed in both the pressure-overload and the isoprenaline models of pathological remodeling in rats. Early treatment with rhASB in the transverse aortic constriction model and delayed treatment in the isoprenaline model proved rhASB to be effective at preventing cardiac deterioration and augmenting functional recovery. Functional improvement was accompanied by reduced myocardial inflammation and overall fibrosis. Tumor necrosis factor–α was identified as a direct binding partner of CS glycosaminoglycan chains, and rhASB reduced tumor necrosis factor–α—induced inflammatory gene activation in vitro in endothelial cells and macrophages.
Conclusions:
CS glycosaminoglycans accumulate during cardiac pathological remodeling and mediate myocardial inflammation and fibrosis. rhASB targets CS effectively as a novel therapeutic approach for the treatment of heart failure.
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Affiliation(s)
- Rong-Rong Zhao
- Cardiovascular Research Institute, National University of Singapore (R.R.Z., M.A.-J., T.D., Y.Z., P.W., P.Y.L., R.S.Y.F.)
| | - Matthew Ackers-Johnson
- Cardiovascular Research Institute, National University of Singapore (R.R.Z., M.A.-J., T.D., Y.Z., P.W., P.Y.L., R.S.Y.F.)
| | - Justus Stenzig
- Genome Institute of Singapore (J.S., S.L.N., R.S.Y.F.)
- Department of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (J.S.)
| | - Chen Chen
- Bioprocessing Technology Institute (C.C., G.T., P.M.R.), Agency for Science, Technology and Research
| | - Tao Ding
- Cardiovascular Research Institute, National University of Singapore (R.R.Z., M.A.-J., T.D., Y.Z., P.W., P.Y.L., R.S.Y.F.)
| | - Yue Zhou
- Cardiovascular Research Institute, National University of Singapore (R.R.Z., M.A.-J., T.D., Y.Z., P.W., P.Y.L., R.S.Y.F.)
| | - Peipei Wang
- Cardiovascular Research Institute, National University of Singapore (R.R.Z., M.A.-J., T.D., Y.Z., P.W., P.Y.L., R.S.Y.F.)
| | - Shi Ling Ng
- Genome Institute of Singapore (J.S., S.L.N., R.S.Y.F.)
| | - Peter Y. Li
- Cardiovascular Research Institute, National University of Singapore (R.R.Z., M.A.-J., T.D., Y.Z., P.W., P.Y.L., R.S.Y.F.)
| | - Gavin Teo
- Bioprocessing Technology Institute (C.C., G.T., P.M.R.), Agency for Science, Technology and Research
| | - Pauline M. Rudd
- Bioprocessing Technology Institute (C.C., G.T., P.M.R.), Agency for Science, Technology and Research
- Glycoscience Group, National Institute for Bioprocessing, Research and Training, Dublin, Ireland (P.M.R.)
| | - James W. Fawcett
- John van Geest Centre for Brain Repair, University of Cambridge, United Kingdom (J.W.F.)
| | - Roger S.Y. Foo
- Cardiovascular Research Institute, National University of Singapore (R.R.Z., M.A.-J., T.D., Y.Z., P.W., P.Y.L., R.S.Y.F.)
- Genome Institute of Singapore (J.S., S.L.N., R.S.Y.F.)
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Abstract
Infiltrative cardiomyopathies are characterized by abnormal accumulation or deposition of substances in cardiac tissue leading to cardiac dysfunction. These can be inherited, resulting from mutations in specific genes, which engender a diverse array of extracardiac features but overlapping cardiac phenotypes. This article provides an overview of each inherited infiltrative cardiomyopathy, describing the causative genes, the pathologic mechanisms involved, the resulting cardiac manifestations, and the therapies currently offered or being developed.
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22
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Enzyme replacement therapy attenuates disease progression in two Japanese siblings with mucopolysaccharidosis type VI: 10-Year follow up. Mol Genet Metab Rep 2017; 13:69-75. [PMID: 28983456 PMCID: PMC5622997 DOI: 10.1016/j.ymgmr.2017.08.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 08/30/2017] [Accepted: 08/30/2017] [Indexed: 11/20/2022] Open
Abstract
Early initiation of enzyme replacement therapy (ERT) has demonstrated clinical benefit in patients with mucopolysaccharidosis type VI (MPS VI), a progressive, multisystem autosomal recessive lysosomal disorder caused by N-acetylgalactosamine-4-sulphatase (ASB) deficiency and the consequent accumulation of glycosaminoglycan. A previous case report highlighted that 3 years of ERT with recombinant human ASB (galsulfase) was well tolerated and effective in two Japanese siblings with MPS VI who initiated ERT at 5.6 years and 6 weeks of age, respectively. This report describes 10-year follow-up data from these two siblings who continued ERT with weekly infusions of galsulfase 1 mg/kg. Ten years of ERT was well tolerated, and the older sibling reached puberty. He had typical MPS VI phenotypic features, but exhibited significant improvement in shoulder range of motion and had largely unchanged hearing and cardiac function. His skeletal deformity remained unchanged. In contrast, in the younger sibling, typical symptoms of MPS VI, including progressive dysmorphic facial features, hepatosplenomegaly, and hearing impairment were largely absent. Her joint mobility was preserved, although skeletal deformity, including claw-hand deformity, was observed. Both siblings had progressive corneal clouding. The observations in these two patients suggest that early ERT initiated in newborns can be well tolerated and effective in preventing or slowing MPS VI disease progression, but is limited in terms of its effects on bone symptoms. For this, new approaches or bone-targeting treatments would be necessary.
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Key Words
- 6MWT, 6-minute walk test
- ASB, N-acetylgalactosamine 4-sulfatase
- Case report
- Deficient N-acetylgalactosamine 4-sulfatase
- ECHO, echocardiography
- ERT, enzyme replacement therapy
- Enzyme replacement therapy
- GAG, glycosaminoglycan
- GH, growth hormone
- Galsulfase
- Glycosaminoglycan
- IGF-1, insulin-like growth factor 1
- MPS, mucopolysaccharidosis
- Mucopolysaccharidosis type VI
- NR, normal range
- ROM, range of motion
- TSH, thyroid stimulating hormone
- fT4, free thyroid hormone
- rh, recombinant human
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23
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Kılıç M, Dursun A, Coşkun T, Tokatlı A, Özgül RK, Yücel-Yılmaz D, Karaca M, Doğru D, Alehan D, Kadayıfçılar S, Genç A, Turan-Dizdar H, Gönüldaş B, Savcı S, Sağlam M, Aksoy C, Arslan U, Sivri HS. Genotypic-phenotypic features and enzyme replacement therapy outcome in patients with mucopolysaccharidosis VI from Turkey. Am J Med Genet A 2017; 173:2954-2967. [PMID: 28884960 DOI: 10.1002/ajmg.a.38459] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 06/07/2017] [Accepted: 08/02/2017] [Indexed: 01/14/2023]
Abstract
Mucopolysaccharidosis type VI (MPS VI) is a lysosomal storage disorder (LSD) characterized by a chronic, progressive course with multiorgan involvement. In our study, clinical, biochemical, molecular findings, and response to enzyme replacement therapy (ERT) for at least 6 months were evaluated in 20 patients with MPS VI. Treatment effects on clinical findings such as liver and spleen sizes, cardiac and respiratory parameters, visual and auditory changes, joints' range of motions, endurance tests and changes in urinary glycosaminoglycan excretions, before and after ERT were analyzed. ERT caused increased physical endurance and decreased urinary dermatan sulfate/chondroitin sulfate ratios. Changes in growth parameters, cardiac, respiratory, visual, auditory findings, and joint mobility were not significant. All patients and parents reported out an increased quality of life, which were not correlated with clinical results. The most prevalent mutation was p.L321P, accounting for 58.8% of the mutant alleles and two novel mutations (p.G79E and p.E390 K) were found. ERT was a safe but expensive treatment for MPS VI, with mild benefits in severely affected patients. Early treatment with ERT is mandatory before many organs and systems are involved.
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Affiliation(s)
- Mustafa Kılıç
- Sami Ulus Children Hospital, Division of Metabolism, Ankara, Turkey
| | - Ali Dursun
- Hacettepe University Children Hospital, Division of Metabolism, Ankara, Turkey
| | - Turgay Coşkun
- Hacettepe University Children Hospital, Division of Metabolism, Ankara, Turkey
| | - Ayşegül Tokatlı
- Hacettepe University Children Hospital, Division of Metabolism, Ankara, Turkey
| | - Rıza K Özgül
- Hacettepe University Children Hospital, Division of Metabolism, Ankara, Turkey
| | - Didem Yücel-Yılmaz
- Hacettepe University Children Hospital, Division of Metabolism, Ankara, Turkey
| | - Mehmet Karaca
- Faculty of Science and Arts, Department of Biology, Aksaray University, Aksaray, Turkey
| | - Deniz Doğru
- Hacettepe University Children Hospital, Division of Pediatric Pulmonology, Ankara, Turkey
| | - Dursun Alehan
- Hacettepe University Children Hospital, Division of Pediatric Cardiology, Ankara, Turkey
| | - Sibel Kadayıfçılar
- Faculty of Medicine, Department of Ophthalmology, Hacettepe University, Ankara, Turkey
| | - Aydan Genç
- Faculty of Medicine, Department of Ear Nose Throat, Division of Audiology, Hacettepe University, Ankara, Turkey
| | - Handan Turan-Dizdar
- Faculty of Medicine, Department of Ear Nose Throat, Division of Audiology, Hacettepe University, Ankara, Turkey
| | - Burhanettin Gönüldaş
- Faculty of Medicine, Department of Ear Nose Throat, Hacettepe University, Ankara, Turkey
| | - Sema Savcı
- Faculty of Health Sciences, Department of Physiotheraphy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Melda Sağlam
- Faculty of Health Sciences, Department of Physiotheraphy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Cemalettin Aksoy
- Faculty of Medicine, Department of Orthopaedics and Traumatology, Hacettepe University, Ankara, Turkey
| | - Umut Arslan
- Faculty of Medicine, Department of Biostatistics, Hacettepe University, Ankara, Turkey
| | - Hatice-Serap Sivri
- Hacettepe University Children Hospital, Division of Metabolism, Ankara, Turkey
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24
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Harmatz P, Hendriksz CJ, Lampe C, McGill JJ, Parini R, Leão-Teles E, Valayannopoulos V, Cole TJ, Matousek R, Graham S, Guffon N, Quartel A. The effect of galsulfase enzyme replacement therapy on the growth of patients with mucopolysaccharidosis VI (Maroteaux-Lamy syndrome). Mol Genet Metab 2017; 122:107-112. [PMID: 28457718 DOI: 10.1016/j.ymgme.2017.03.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/30/2017] [Accepted: 03/31/2017] [Indexed: 11/26/2022]
Abstract
Mucopolysaccharidosis (MPS) VI is an autosomal recessive lysosomal storage disorder arising from deficient activity of N-acetylgalactosamine-4-sulfatase (arylsulfatase B) and subsequent intracellular accumulation of the glycosaminoglycans (GAGs) dermatan sulfate and chondroitin-4-sulfate. Manifestations are multi-systemic and include skeletal abnormalities such as dysostosis multiplex and short stature. Reference height-for-age growth charts for treatment-naïve MPS VI patients have been published for both the slowly and rapidly progressing populations. Categorization of disease progression for these charts was based on urinary GAG (uGAG) level; high (>200μg/mg creatinine) levels identified subjects as rapidly progressing. Height data for 141 patients who began galsulfase treatment by the age of 18years were collected and stratified by baseline uGAG level and age at ERT initiation in 3-year increments. The reference MPS VI growth charts were used to calculate change in Z-score from pre-treatment baseline to last follow-up. Among patients with high baseline uGAG levels, galsulfase ERT was associated with an increase in Z-score for those beginning treatment at 0-3, >3-6, >6-9, >9-12, and >12-15years of age (p<0.05). Increases in Z-score were not detected for patients who began treatment between 15 and 18years of age, nor for patients with low (≤200μg/mg creatinine) baseline uGAG levels, regardless of age at treatment initiation. The largest positive deviation from untreated reference populations was seen in the high uGAG excretion groups who began treatment by 6years of age, suggesting an age- and severity-dependent impact of galsulfase ERT on growth.
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Affiliation(s)
- P Harmatz
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA.
| | - C J Hendriksz
- University of Pretoria, The Mark Holland Metabolic Unit, Salford Royal Foundation NHS Trust, Salford, UK
| | - C Lampe
- Department of Pediatric and Adolescent Medicine, Villa Metabolica, University Medical Center of the University of Mainz, Germany
| | - J J McGill
- Department of Metabolic Medicine, Lady Cilento Children's Hospital, South Brisbane, QLD, Australia
| | - R Parini
- UOS Malattie Metaboliche Rare, Clinica Pediatrica Ospedale San Gerardo, Monza, Italy
| | - E Leão-Teles
- Unidade Doenças Metabólicas, Hospital Pediátrico Integrado, Centro Hospitalar de S. João, Porto, Portugal
| | - V Valayannopoulos
- Reference Center for Inherited Metabolic Diseases and IMAGINE Institute, Necker-Enfants Malades Hospital, Paris, France
| | - T J Cole
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - R Matousek
- BioMarin Pharmaceutical Inc., Novato, CA, USA
| | - S Graham
- BioMarin Pharmaceutical Inc., Novato, CA, USA
| | - N Guffon
- Reference Center for Inherited Metabolic Diseases, Hôpital Femme Mère Enfant, Lyon, France
| | - A Quartel
- BioMarin Pharmaceutical Inc., Novato, CA, USA
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25
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The factors affecting lipid profile in adult patients with Mucopolysaccharidosis. Mol Genet Metab Rep 2017; 12:35-40. [PMID: 28560179 PMCID: PMC5440760 DOI: 10.1016/j.ymgmr.2017.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/12/2017] [Accepted: 05/12/2017] [Indexed: 11/29/2022] Open
Abstract
Background Mucopolysaccharidoses (MPS) are a group of rare inherited disorders characterized by abnormal accumulation of glycosaminoglycans (GAGs) within the myocytes and coronary arteries. Little is known about hyperlipidaemia as a potential cardiovascular risk factor in these patients. Baseline cholesterol data in adults are scarce. Therefore, the aim of this study was to analyse factors affecting lipid profile in different types of MPSs to determine if abnormalities in lipid profile contribute to the overall risk of cardiovascular disease. Methods Adult patients (above the age of 16) with MPS type I, II, III, IV and VI attending clinics in two Inherited Metabolic Disorders centres were included. Their lipid profile, lipoprotein (a), HbA1c, Glucose Tolerance Test (GTT), BMI and treatment type were extracted. Analysis included descriptive statistics and Student t-test. Results Eighty two patients with five MPS types (I, II, III, IV and VI) were included in the study; 29 were females (35%) and 53 were males (65%). BMI above 25 kg/m2 in all MPS types indicated that some patients were overweight for their height. Only one patient post-HSCT had diabetes. In 3 cases insulin was analysed during GTT and showed no insulin resistance despite raised BMI. Mean total cholesterol and LDL-cholesterol were below 5 mmol/L and 3 mmol/L, respectively, in five individual MPS types. Lipoprotein (a) was available for 6 MPS IV patients and was not significantly raised. Conclusions MPS disorders are not associated with significant hypercholesterolaemia or diabetes mellitus despite increased BMI. Total cholesterol and LDL-cholesterol were within the targets for primary prevention for non-MPS population. Lipoprotein (a) is not a useful marker of cardiovascular disease in a small group of adult MPS IV patients irrespectively of treatment option. Whether long-term cardiovascular risk is dependent on lipid profile, diabetes, obesity or GAGs deposition within the organ system remains unanswered.
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Christensen CL, Choy FYM. A Prospective Treatment Option for Lysosomal Storage Diseases: CRISPR/Cas9 Gene Editing Technology for Mutation Correction in Induced Pluripotent Stem Cells. Diseases 2017; 5:E6. [PMID: 28933359 PMCID: PMC5456334 DOI: 10.3390/diseases5010006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/15/2017] [Accepted: 02/20/2017] [Indexed: 02/06/2023] Open
Abstract
Ease of design, relatively low cost and a multitude of gene-altering capabilities have all led to the adoption of the sophisticated and yet simple gene editing system: clustered regularly interspaced short palindromic repeats/CRISPR-associated protein 9 (CRISPR/Cas9). The CRISPR/Cas9 system holds promise for the correction of deleterious mutations by taking advantage of the homology directed repair pathway and by supplying a correction template to the affected patient's cells. Currently, this technique is being applied in vitro in human-induced pluripotent stem cells (iPSCs) to correct a variety of severe genetic diseases, but has not as of yet been used in iPSCs derived from patients affected with a lysosomal storage disease (LSD). If adopted into clinical practice, corrected iPSCs derived from cells that originate from the patient themselves could be used for therapeutic amelioration of LSD symptoms without the risks associated with allogeneic stem cell transplantation. CRISPR/Cas9 editing in a patient's cells would overcome the costly, lifelong process associated with currently available treatment methods, including enzyme replacement and substrate reduction therapies. In this review, the overall utility of the CRISPR/Cas9 gene editing technique for treatment of genetic diseases, the potential for the treatment of LSDs and methods currently employed to increase the efficiency of this re-engineered biological system will be discussed.
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Affiliation(s)
- Chloe L Christensen
- Department of Biology, Centre for Biomedical Research, University of Victoria, 3800 Finnerty Rd., Victoria, BC V8P 5C2, Canada.
| | - Francis Y M Choy
- Department of Biology, Centre for Biomedical Research, University of Victoria, 3800 Finnerty Rd., Victoria, BC V8P 5C2, Canada.
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Mitrovic S, Gouze H, Gossec L, Schaeverbeke T, Fautrel B. Mucopolysaccharidoses seen in adults in rheumatology. Joint Bone Spine 2017; 84:663-670. [PMID: 28196778 DOI: 10.1016/j.jbspin.2017.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 01/13/2017] [Indexed: 10/20/2022]
Abstract
Mucopolysaccharidoses are a group of rare lysosomal storage diseases including a great number of polymorph syndromes, each being related to a particular mutation responsible for a deficiency of glycosaminoglycan degrading enzymes, leading to an accumulation of glycosaminoglycans in tissues. Many of them are diagnosed in children or teenagers and have a severe prognosis because of organ failure, and are consequently usually not seen by the adult rheumatologist. However, some of them have a more progressive presentation, with musculoskeletal symptoms at the forefront and a lifespan that nearly reaches that of the general population. These milder forms are more likely to be diagnosed in adults, in patients who have suffered for years and sometimes even decades with unrecognized mucopolysaccharidosis. Indeed, they can sometimes mimic inflammatory rheumatic disorders, and therefore be misdiagnosed for a long time. Recognition and diagnosis of these attenuated forms can be a real challenge as they lead to moderate and/or nonspecific symptoms such as joint pain or stiffness. Hence, rheumatologists should know about them. Early diagnostic is essential since specific treatment, like enzyme replacement therapy, is now available for some subtypes and might, if given early, slow down the development of tissue damage, which is unfortunately irreversible. This article provides the opportunity to review the main clinical and radiographic features, the diagnostic strategy and the update of management, which should be multidisciplinary and led by an experienced physician in a reference centre. The contribution of the rheumatologist is important to ensure symptom control and prevent complications.
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Affiliation(s)
- Stéphane Mitrovic
- UPMC university Paris 06, institut Pierre-Louis d'épidémiologie et de santé publique, GRC-UPMC 08 (EEMOIS), Sorbonne universités, 75005 Paris, France; Department of rheumatology, Pitié-Salpêtrière hospital, AP-HP, 75013 Paris, France.
| | - Hélène Gouze
- UPMC university Paris 06, institut Pierre-Louis d'épidémiologie et de santé publique, GRC-UPMC 08 (EEMOIS), Sorbonne universités, 75005 Paris, France; Department of rheumatology, Pitié-Salpêtrière hospital, AP-HP, 75013 Paris, France
| | - Laure Gossec
- UPMC university Paris 06, institut Pierre-Louis d'épidémiologie et de santé publique, GRC-UPMC 08 (EEMOIS), Sorbonne universités, 75005 Paris, France; Department of rheumatology, Pitié-Salpêtrière hospital, AP-HP, 75013 Paris, France
| | - Thierry Schaeverbeke
- Department of rheumatology, Pellegrin hospital, Bordeaux university hospital, 33076 Bordeaux, France
| | - Bruno Fautrel
- UPMC university Paris 06, institut Pierre-Louis d'épidémiologie et de santé publique, GRC-UPMC 08 (EEMOIS), Sorbonne universités, 75005 Paris, France; Department of rheumatology, Pitié-Salpêtrière hospital, AP-HP, 75013 Paris, France
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Bell DJ, He C, Pauli JL, Naidoo R. Maroteaux-Lamy syndrome: a rare and challenging case of mitral valve replacement. Asian Cardiovasc Thorac Ann 2016; 26:560-562. [PMID: 30253663 DOI: 10.1177/0218492316675533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Maroteaux-Lamy syndrome is a very rare multisystem disorder. Cardiac valve surgery is common in these patients who present a unique set of perioperative and intraoperative challenges to the surgeon and treating team. We describe successful mitral valve replacement using an inverted aortic prosthesis in a 29-year-old lady with Maroteaux-Lamy syndrome, with a good result at 10 months.
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Affiliation(s)
- Douglas Jw Bell
- 1 Department of Cardiothoracic Surgery, The Prince Charles Hospital, Chermside, Australia
| | - Cheng He
- 1 Department of Cardiothoracic Surgery, The Prince Charles Hospital, Chermside, Australia
| | - John L Pauli
- 2 Department of Anatomical Pathology, The Prince Charles Hospital, Chermside, Australia
| | - Rishendran Naidoo
- 1 Department of Cardiothoracic Surgery, The Prince Charles Hospital, Chermside, Australia
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Mitchell J, Berger KI, Borgo A, Braunlin EA, Burton BK, Ghotme KA, Kircher SG, Molter D, Orchard PJ, Palmer J, Pastores GM, Rapoport DM, Wang RY, White K. Unique medical issues in adult patients with mucopolysaccharidoses. Eur J Intern Med 2016; 34:2-10. [PMID: 27296591 DOI: 10.1016/j.ejim.2016.05.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 05/13/2016] [Accepted: 05/15/2016] [Indexed: 10/21/2022]
Abstract
The mucopolysaccharidoses are a group of inherited metabolic diseases caused by deficiencies in enzymes involved in the sequential degradation of glycosaminoglycans (GAGs) leading to substrate accumulation in various tissues and organs. GAG accumulation can cause growth retardation and progressive damage to respiratory, cardiovascular, musculoskeletal, nervous, gastrointestinal, auditory, and visual systems. In the past, few people with severe phenotypic mucopolysaccharidosis (MPS) reached adulthood. However, better methods for diagnosis, multi-disciplinary care, and new therapies have extended lifespan, leading to an increasing number of patients surviving beyond childhood. The growing number of adult MPS patients poses significant challenges for clinicians who may not be familiar with the clinical manifestations of MPS. In addition, as new interventions have changed the natural history of these disorders, it is difficult to anticipate both the impact on life expectancy and other complications that may occur as these patients age. Because the MPS disorders are multi-organ diseases, their management requires a coordinated multi-disciplinary approach. Here we discuss the unique pattern of medical issues and multi-organ involvement in adult patients with MPS and identify the challenges that are associated with management of MPS. This review is based on information from an expert investigator meeting with MPS specialists held October 2-4, 2014 in Dublin, Ireland, as well as on current literature searches focusing on MPS and adults.
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Affiliation(s)
- John Mitchell
- Montreal Children's Hospital, Montreal, Quebec, Canada.
| | - Kenneth I Berger
- New York University School of Medicine, New York, NY, United States.
| | - Andrea Borgo
- Orthopaedics and Traumatology Hospital, Padova, Italia.
| | | | | | - Kemel A Ghotme
- Faculty of Medicine, Universidad de La Sabana, Santa Clara, Chía, Cundinamarca, Colombia, and Neurosurgery Unit, Fundación Santafé de Bogotá, Bogotá, Bogota D.C., Colombia.
| | | | - David Molter
- St. Louis Children's Hospital, St. Louis, MO, United States.
| | - Paul J Orchard
- University of Minnesota, Minneapolis, MN, United States.
| | - James Palmer
- Salford Royal Hospital, Salford, United Kingdom.
| | | | - David M Rapoport
- New York University School of Medicine, New York, NY, United States.
| | - Raymond Y Wang
- CHOC Children's Specialists, Orange, CA, United States and School of Medicine, University of California-Irvine, Orange, CA, United States.
| | - Klane White
- Children's Hospital Seattle, Seattle, WA, United States.
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Hendriksz CJ, Berger KI, Lampe C, Kircher SG, Orchard PJ, Southall R, Long S, Sande S, Gold JI. Health-related quality of life in mucopolysaccharidosis: looking beyond biomedical issues. Orphanet J Rare Dis 2016; 11:119. [PMID: 27561270 PMCID: PMC5000418 DOI: 10.1186/s13023-016-0503-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 08/17/2016] [Indexed: 11/28/2022] Open
Abstract
The mucopolysaccharidoses (MPS) comprise a heterogeneous family of rare, genetic lysosomal storage disorders that result in severe morbidity and reduced life expectancy. Emerging treatments for several of these disorders have triggered the search for clinically relevant biomarkers and clinical markers associated with treatment efficacy in populations and individuals. However, biomedical measures do not tell the whole story when characterizing a complex chronic disorder such as MPS. Health-related quality of life (HRQoL) tools that utilize patient reported outcomes to address patient parameters such as symptoms (pain, fatigue, psychological health), functioning (activity and limitations), or quality of life, have been used to supplement traditional biomedical endpoints. Many of these HRQoL tools have demonstrated that quality of life is negatively impacted in patients with MPS. There is both the opportunity and need to formally standardize and validate HRQoL tools for the different MPS disorders.
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Affiliation(s)
- Christian J Hendriksz
- Adult Inherited Metabolic Disorders, Consultant Transitional Metabolic Medicine, The Mark Holland Metabolic Unit, Salford Royal NHS Foundation Trust, Ladywell NW2- 2nd Floor Room 112, Salford, Manchester, M6 8HD, UK. .,Paediatrics and Child Health, University of Pretoria, Steve Biko Academic Unit, Pretoria, South Africa.
| | - Kenneth I Berger
- Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine and André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, USA
| | - Christina Lampe
- Centre for Rare Diseases, Clinic for children and adolescents, Helios Dr. Horst Schmidt Kliniken, Wiesbaden, Germany
| | - Susanne G Kircher
- Institute of Medical Chemistry and Medical Genetics, Medical University of Vienna, Vienna, Austria
| | - Paul J Orchard
- Department of Pediatrics, Division of Blood & Marrow Transplantation, University of Minnesota, Minneapolis, MN, USA
| | | | - Sarah Long
- School of Sociology and Social Policy, University of Bath, Bath, UK
| | | | - Jeffrey I Gold
- Keck School of Medicine, Departments of Anesthesiology, Pediatrics, and Psychiatry & Behavioral Sciences, Children's Hospital Los Angeles, Anesthesiology Critical Care Medicine, Pediatric Pain Management Clinic, University of Southern California, California, USA
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Lin HY, Chuang CK, Wang CH, Chien YH, Wang YM, Tsai FJ, Chou YY, Lin SJ, Pan HP, Niu DM, Hwu WL, Ke YY, Lin SP. Long-term galsulfase enzyme replacement therapy in Taiwanese mucopolysaccharidosis VI patients: A case series. Mol Genet Metab Rep 2016; 7:63-9. [PMID: 27134829 PMCID: PMC4834679 DOI: 10.1016/j.ymgmr.2016.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 04/06/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Information regarding the long-term outcome of enzyme replacement therapy (ERT) with recombinant human N-acetylgalactosamine 4-sulfatase (rhASB, galsulfase, Naglazyme®, BioMarin Pharmaceutical Inc.) for Taiwanese patients with mucopolysaccharidosis (MPS) VI is limited. METHODS Nine Taiwanese patients with MPS VI (4 males and 5 females; age range, 1.4 to 21.1 years) treated with weekly intravenous infusions of galsulfase (1.0 mg/kg) in 5 medical centers in Taiwan were reviewed. A set of biochemical and clinical assessments were evaluated annually. RESULTS After 6.2 to 11.2 years of galsulfase treatment, 6 patients experienced improvement over baseline in the 6-minute walk test by a mean of 150 m (59% change over time), and 3 patients also increased the 3-minute stair climb test by a mean of 60 steps (46%). In a manual dexterity test, 3 patients decreased the time required to pick up 10 coins and put the coins into a cup by 15 s (33%). Shoulder range of motion in all 9 patients improved, and Joint Pain and Stiffness Questionnaire scores improved by 0.42 points (21%). Four patients showed improved pulmonary function. Five patients had positive effects on cardiac-wall diameters. Four patients had improved cardiac diastolic function. Liver and spleen sizes as measured by abdominal ultrasonography remained the same or decreased in all 9 patients. However, the severity degree of valvular stenosis or regurgitation did not show improvement despite ERT. A mean overall 69% decrease in urinary glycosaminoglycan (GAG) excretion indicated a satisfactory biomarker response. CONCLUSIONS Long-term ERT was beneficial and safe for Taiwanese patients with MPS VI. This treatment reduced urinary GAG and had positive effects on a wide range of clinical functional assessments including endurance, mobility, joint function, pulmonary function, liver and spleen size, cardiac hypertrophy and diastolic dysfunction.
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Key Words
- 3MSCT, 3-minute stair climb test
- 6MWT, 6-minute walk test
- AC, air conduction
- ASB, N-acetylgalactosamine 4-sulfatase
- BC, bone conduction
- BMD, bone mineral density
- CHAQ, Childhood Health Assessment Questionnaire
- Cardiac hypertrophy
- DXA, dual energy x-ray absorptiometry
- Diastolic dysfunction
- E/A, ratio between early and late (atrial) ventricular filling velocity
- ERT, enzyme replacement therapy
- Enzyme replacement therapy
- FEV1, forced expiratory volume in 1 s
- FVC, Forced vital capacity
- GAG, glycosaminoglycan
- Galsulfase, recombinant human N-acetylgalactosamine 4-sulfatase
- Glycosaminoglycans
- HAQ, Health Assessment Questionnaire
- HAZ, height-for-age
- IVSd, interventricular septum thickness in diastole
- LVM, left ventricular mass
- LVMI, left ventricular mass index
- LVPWd, left ventricular posterior wall thickness in diastole
- MPS, mucopolysaccharidosis
- Mucopolysaccharidosis VI
- PTA, pure-tone audiometry
- Pulmonary function
- Z score, standard deviation score
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Affiliation(s)
- Hsiang-Yu Lin
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan
- Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
- Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Kuang Chuang
- Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
- Medical College, Fu-Jen Catholic University, Taipei, Taiwan
- Institute of Biotechnology, National Taipei University of Technology, Taipei, Taiwan
| | - Chung-Hsing Wang
- Department of Pediatrics, China Medical University Hospital, Taichung, Taiwan
| | - Yin-Hsiu Chien
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Mei Wang
- Department of Pediatrics, Changhua Christian Hospital, Changhua, Taiwan
| | - Fuu-Jen Tsai
- Department of Pediatrics, China Medical University Hospital, Taichung, Taiwan
| | - Yen-Yin Chou
- Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Shio Jean Lin
- Department of Pediatrics, Chi Mei Medical Center, Tainan, Taiwan
| | - Hui-Ping Pan
- Genetic Center, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Dau-Ming Niu
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wuh-Liang Hwu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Yuan Ke
- Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shuan-Pei Lin
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan
- Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
- Department of Infant and Child Care, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
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Lin HY, Chuang CK, Chen MR, Lin SM, Hung CL, Chang CY, Chiu PC, Tsai WH, Niu DM, Tsai FJ, Lin SJ, Hwu WL, Lin JL, Lin SP. Cardiac structure and function and effects of enzyme replacement therapy in patients with mucopolysaccharidoses I, II, IVA and VI. Mol Genet Metab 2016; 117:431-7. [PMID: 26899310 DOI: 10.1016/j.ymgme.2016.02.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 02/15/2016] [Accepted: 02/15/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND While enzyme replacement therapy (ERT) has been shown to improve endurance and joint mobility for patients with mucopolysaccharidoses (MPS) I, II, IVA and VI, the impact of ERT on cardiac abnormalities remains uncertain. METHODS Medical records and echocardiograms of 28 Taiwanese MPS patients (9 with MPS I, 7 with MPS II, 7 with MPS IVA, and 5 with MPS VI) treated with ERT for 1-10.8years were retrospectively reviewed. RESULTS At start of ERT, z scores>2 were identified in 46% and 75% for left ventricular mass index (LVMI) and interventricular septum thickness in diastole (IVSd) in these patients, respectively. Twenty-four patients (86%) had valvular heart disease. After ERT, the mean IVSd z score of all patients decreased significantly from 3.87 to 2.57 (p=0.016). For 11 patients starting ERT before 12years of age, z scores for both LVMI and IVSd decreased significantly (p<0.01) after ERT. However, the condition of valve regurgitation or stenosis did not show improvement despite ERT. CONCLUSIONS ERT was shown to be an effective therapy for reducing cardiac hypertrophy, with best results seen when ERT was started at an early age. ERT, however, had little impact on valvular heart disease.
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Affiliation(s)
- Hsiang-Yu Lin
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan; Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Kuang Chuang
- Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan; Medical College, Fu-Jen Catholic University, Taipei, Taiwan; Institute of Biotechnology, National Taipei University of Technology, Taipei, Taiwan
| | - Ming-Ren Chen
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Shan-Miao Lin
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Chung-Lieh Hung
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chia-Ying Chang
- Department of Pediatrics, Mackay Memorial Hospital, Hsinchu, Taiwan
| | - Pao Chin Chiu
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wen-Hui Tsai
- Department of Pediatrics, Chi Mei Medical Center, Tainan, Taiwan
| | - Dau-Ming Niu
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fuu-Jen Tsai
- Department of Pediatrics, China Medical University Hospital, Taichung, Taiwan
| | - Shio Jean Lin
- Department of Pediatrics, Chi Mei Medical Center, Tainan, Taiwan
| | - Wuh-Liang Hwu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ju-Li Lin
- Division of Genetics and Endocrinology, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Shuan-Pei Lin
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan; Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan; Department of Infant and Child Care, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan.
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Brunelli MJ, Atallah ÁN, da Silva EMK. Enzyme replacement therapy with galsulfase for mucopolysaccharidosis type VI. Cochrane Database Syst Rev 2016; 3:CD009806. [PMID: 26943923 DOI: 10.1002/14651858.cd009806.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Mucopolysaccharidosis type VI or Maroteaux-Lamy syndrome is a rare genetic disorder caused by the deficiency of arylsulphatase B. The resultant accumulation of dermatan sulphate causes lysosomal damage.The clinical symptoms are related to skeletal dysplasia (i.e. short stature and degenerative joint disease). Other manifestations include cardiac disease, impaired pulmonary function, ophthalmological complications, hepatosplenomegaly, sinusitis, otitis, hearing loss and sleep apnea. Intellectual impairment is generally absent. Clinical manifestation is typically by two or three years of age; however, slowly progressive cases may not present until adulthood.Enzyme replacement therapy with galsulfase is considered a new approach for treating mucopolysaccharidosis type VI. OBJECTIVES To evaluate the effectiveness and safety of treating mucopolysaccharidosis VI by enzyme replacement therapy with galsulfase compared to other interventions, placebo or no intervention. SEARCH METHODS Eletronic searches were performed on the Cystic Fibrosis and Genetic Disorders Group's Inborn Errors of Metabolism Trials Register, in CENTRAL, MEDLINE, LILACS, the Journal of Inherited Metabolic Disease and ClinicalTrials.gov. Date of the last search of the Cystic Fibrosis and Genetic Disorders Group's Inborn Errors of Metabolism Trials Register: 05 February 2016. SELECTION CRITERIA Randomized and quasi-randomized controlled clinical studies of enzyme replacement therapy with galsulfase compared to other interventions or placebo. DATA COLLECTION AND ANALYSIS Two authors independently screened the studies, assessed the risk of bias and extracted data. MAIN RESULTS One study was included involving 39 participants who received either enzyme replacement therapy with galsulfase (recombinant human arylsulphatase B) or placebo. This small study was considered to be of overall unclear quality, since the authors did not report how both the allocation generation and concealment were performed.The key finding at 24 weeks in the 12-minute walk test was a statistically significant mean difference of 92.00 meters between the two groups in favour of the galsulfase group (95% confidence interval 11.00 to 172.00). While week 24 results for the three-minute stair climb demonstrated some improvement in the treatment group as compared to the placebo group, this was not significant, mean difference 5.70 (95% confidence interval -0.10 to 11.50).A significant decrease in the urinary glycosaminoglycan levels was observed in favour of the galsulfase group at 24 weeks, mean difference -227.00 (95% confidence interval -264.00 to -190.00).In general, the dose of galsulfase was well tolerated and there were no significant differences in relation to adverse events. These events include drug-related adverse events, serious and severe adverse events, those during infusion, drug-related adverse events during infusion, and deaths. More infusion-related reactions were observed in the galsulfase group and were managed with interruption or slowing of infusion rate or administration of antihistamines or corticosteroids drugs. No deaths occurred during the study. AUTHORS' CONCLUSIONS The results of one small study (based on 24-week randomised phase of the study and prior to the open-label extension) demonstrated that galsulfase is more effective than placebo in people with MPS VI, with significant improvements in the 12-minute walk test and a reduction in urinary glycosaminoglycans.There were no significant changes in cardiac or pulmonary functions, liver or spleen volume, overnight apnea-hypopnea, height and weight, quality of life and adverse effects.Further studies are needed to obtain more information on the long-term effectiveness and safety of enzyme replacement therapy with galsulfase.
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Affiliation(s)
- Marcela Junqueira Brunelli
- Universidade Federal de São Paulo, Dr Wladimir dos Santos Mello 122, São Paulo, São Paulo, Brazil, 04112-030
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Abstract
Mucopolysaccharidosis type VI (MPS VI) is a progressive, autosomal, recessive lysosomal disorder. This disorder, due to a deficiency in N-acetylgalactosamine-4-sulfatase (ASB), results in an accumulation of glycosaminoglycan (GAG), causing multiple organ failures. In this study, monochorionic biamniotic twins with the severe form of MPS VI underwent enzyme replacement therapy (ERT) with weekly infusions of recombinant human ASB (galsulfase) at 1 mg/kg. After 9 years of ERT, a comprehensive clinical examination was performed. Several types of biochemical, immunological, and genetic investigations were also conducted. Both twins showed the typical symptoms and signs of MPS VI at baseline, including short stature, progressive dysmorphic facial features, and dysostosis multiplex. Twin 2 presented stronger multisystemic involvement, with marked musculoskeletal, neurological, and odontological components. She also developed an ischemic spinal cord lesion after surgery, which is the first case described in the literature in Maroteaux-Lamy syndrome. However, the extent of disease was found to be equally stabilized in the two sisters, concretely the cardiac and respiratory functions and body length. The early diagnosis and treatment of MPS VI are critical for an optimal clinical outcome, and further evidence for the new treatment strategies is needed.
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Personalized Pharmacoperones for Lysosomal Storage Disorder: Approach for Next-Generation Treatment. ADVANCES IN PROTEIN CHEMISTRY AND STRUCTURAL BIOLOGY 2015; 102:225-65. [PMID: 26827607 DOI: 10.1016/bs.apcsb.2015.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Lysosomal storage disorders (LSDs) are a collection of inborn errors of metabolic disorders affected by mutations in lysosome functional genes, commonly acid hydrolases. From the past decades, many approaches like enzyme replacement therapy, substrate reduction therapy are followed to treat these conditions. However, all these approaches have their own limitations. Proof-of-concept studies on pharmacological chaperone therapy (PCT) is now transformed into clinical practice to treat LSDs. Furthermore, it is narrowed with individuals to chaperone sensitive, specific mutations. Hence, personalizing the PCT will be a new direction to combat LSDs. In this review, we have discussed the available clinical strategies and pointed the light on how pharmacological chaperones can be personalized and hopeful to be a next-generation approach to address LSDs.
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Suarez-Guerrero JL, Gómez Higuera PJI, Arias Flórez JS, Contreras-García GA. [Mucopolysaccharidosis: clinical features, diagnosis and management]. ACTA ACUST UNITED AC 2015; 87:295-304. [PMID: 26613630 DOI: 10.1016/j.rchipe.2015.10.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 07/24/2015] [Indexed: 10/22/2022]
Abstract
The mucopolysaccharidoses (MPS) are a group of rare (orphan) diseases, characterised by a deficiency of enzymes involved in the metabolism of glycosaminoglycans (GAGs) at lysosomal level. When there is a deficiency of a particular enzyme there is an accumulation of GAGs in the cells resulting in progressive cellular damage, which can affect multiple organ systems and lead to organ failure. Diagnosis is based on knowledge of the clinical manifestations, performing biochemical analyses to identify the type of GAG that is accumulating, and confirm the type of disorder with the corresponding enzymatic determination. Their identification is essential to initiate early treatment, taking into account that multidisciplinary management and enzyme replacement therapy is available for MPS I (Hurler syndrome), MPS II (Hunter syndrome), MPS IV (Morquio syndrome), and MPS VI (Maroteaux-Lamy syndrome. In this review, an analysis is made of each of these syndromes, as well as their diagnosis and treatment.
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Affiliation(s)
- Jorge Luis Suarez-Guerrero
- UIS-HUS, Grupo de investigación en Genética Humana, Facultad de Salud, Universidad Industrial de Santander, Bucaramanga, Colombia.
| | | | | | - Gustavo Adolfo Contreras-García
- Grupo de investigación en Genética Humana, Universidad Industrial de Santander, Departamento de Pediatría-Hospital Universitario de Santander, Bucaramanga, Colombia
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Horovitz DDG, Acosta AX, de Rosso Giuliani L, Ribeiro EM. Mucopolysaccharidosis type VI on enzyme replacement therapy since infancy: Six years follow-up of four children. Mol Genet Metab Rep 2015. [PMID: 28649537 PMCID: PMC5471404 DOI: 10.1016/j.ymgmr.2015.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Dafne D G Horovitz
- Centro de Genetica Medica, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira/FIOCRUZ, Rio de Janeiro, RJ, Brazil
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Godman B, Malmström RE, Diogene E, Gray A, Jayathissa S, Timoney A, Acurcio F, Alkan A, Brzezinska A, Bucsics A, Campbell SM, Czeczot J, de Bruyn W, Eriksson I, Yusof FAM, Finlayson AE, Fürst J, Garuoliene K, Guerra Júnior A, Gulbinovič J, Jan S, Joppi R, Kalaba M, Magnisson E, McCullagh L, Miikkulainen K, Ofierska-Sujkowska G, Pedersen HB, Selke G, Sermet C, Spillane S, Supian A, Truter I, Vlahović-Palčevski V, Vien LE, Vural EH, Wale J, Władysiuk M, Zeng W, Gustafsson LL. Are new models needed to optimize the utilization of new medicines to sustain healthcare systems? Expert Rev Clin Pharmacol 2015; 8:77-94. [PMID: 25487078 DOI: 10.1586/17512433.2015.990380] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Medicines have made an appreciable contribution to improving health. However, even high-income countries are struggling to fund new premium-priced medicines. This will grow necessitating the development of new models to optimize their use. The objective is to review case histories among health authorities to improve the utilization and expenditure on new medicines. Subsequently, use these to develop exemplar models and outline their implications. A number of issues and challenges were identified from the case histories. These included the low number of new medicines seen as innovative alongside increasing requested prices for their reimbursement, especially for oncology, orphan diseases, diabetes and HCV. Proposed models center on the three pillars of pre-, peri- and post-launch including critical drug evaluation, as well as multi-criteria models for valuing medicines for orphan diseases alongside potentially capping pharmaceutical expenditure. In conclusion, the proposed models involving all key stakeholder groups are critical for the sustainability of healthcare systems or enhancing universal access. The models should help stimulate debate as well as restore trust between key stakeholder groups.
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Affiliation(s)
- Brian Godman
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
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Politei J, Schenone AB, Gustavo C, Alejandra A, Marina S. Mucopolysaccharidosis VI. JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2015. [DOI: 10.1177/2326409814567130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Juan Politei
- Fundación para el Estudio de las Enfermedades Neurometabólicas (Foundation for the Study of Neurometabolic Diseases [FESEN]), Buenos Aires, Argentina
| | - Andrea Beatriz Schenone
- Fundación para el Estudio de las Enfermedades Neurometabólicas (Foundation for the Study of Neurometabolic Diseases [FESEN]), Buenos Aires, Argentina
| | - Cabrera Gustavo
- Cardiology Service, Del Viso Medical Center, Buenos Aires, Argentina
| | - Antacle Alejandra
- Ophthalmology Service, Sanatorio Mater Dei (private clinic), Buenos Aires, Argentina
| | - Szlago Marina
- Fundación para el Estudio de las Enfermedades Neurometabólicas (Foundation for the Study of Neurometabolic Diseases [FESEN]), Buenos Aires, Argentina
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Giugliani R, Lampe C, Guffon N, Ketteridge D, Leão-Teles E, Wraith JE, Jones SA, Piscia-Nichols C, Lin P, Quartel A, Harmatz P. Natural history and galsulfase treatment in mucopolysaccharidosis VI (MPS VI, Maroteaux-Lamy syndrome)--10-year follow-up of patients who previously participated in an MPS VI Survey Study. Am J Med Genet A 2014; 164A:1953-64. [PMID: 24764221 DOI: 10.1002/ajmg.a.36584] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 03/16/2014] [Indexed: 12/25/2022]
Abstract
Mucopolysaccharidosis VI (MPS VI) is a clinically heterogeneous and progressive disorder with multiorgan manifestations caused by deficient N-acetylgalactosamine-4-sulfatase activity. A cross-sectional Survey Study in individuals (n = 121) affected with MPS VI was conducted between 2001 and 2002 to establish demographics, urinary glycosaminoglycan (GAG) levels, and clinical progression of disease. We conducted a Resurvey Study (ClinicalTrials.gov: NCT01387854) to obtain 10-year follow-up data, including medical histories and clinical assessments (n = 59), and survival status over 12 years (n = 117). Patients received a mean (SD) of 6.8 (2.2) years of galsulfase ERT between baseline (Survey Study) and follow-up. ERT patients increased in height by 20.4 cm in the 4-7-year-old baseline age group and by 16.8 cm in the 8-12-year-old baseline age group. ERT patients <13 years-old demonstrated improvement in forced vital capacity (FVC) by 68% and forced expiratory volume in 1 sec (FEV1) by 55%, and those ≥13 years-old increased FVC by 12.8% and maintained FEV1. Patients with >200 µg/mg baseline uGAG levels increased FVC by 48% in the <13-year-old baseline age group and by 15% in the ≥13-year-old baseline age group. ERT patients who completed the 6-min walk test demonstrated a mean (SD) increase of 65.7 (100.6) m. Cardiac outcomes did not significantly improve or worsen. Observed mortality rate among naïve patients was 50% (7/14) and 16.5% (17/103) in the ERT group (unadjusted hazard ratio, 0.24; 95% CI, 0.10-0.59). Long-term galsulfase ERT was associated with improvements in pulmonary function and endurance, stabilized cardiac function and increased survival.
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Affiliation(s)
- Roberto Giugliani
- Medical Genetics Service, HCPA, Department of Genetics, UFRGS, and INAGEMP, Porto Alegre, Brazil
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Lourenço CM, Giugliani R. Evaluation of galsulfase for the treatment of mucopolysaccharidosis VI (Maroteaux-Lamy syndrome). Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.885833] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Harmatz PR, Garcia P, Guffon N, Randolph LM, Shediac R, Braunlin E, Lachman RS, Decker C. Galsulfase (Naglazyme®) therapy in infants with mucopolysaccharidosis VI. J Inherit Metab Dis 2014; 37:277-87. [PMID: 24108527 PMCID: PMC3976509 DOI: 10.1007/s10545-013-9654-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 08/28/2013] [Accepted: 09/11/2013] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of two dose levels of galsulfase (Naglazyme®) in infants with MPS VI. STUDY DESIGN This was a phase 4, multicenter, multinational, open-label, two-dose level study. Subjects were randomized 1:1 to receive weekly infusions of 1.0 or 2.0 mg/kg of galsulfase for a minimum of 52 weeks. Progression of skeletal dysplasia was determined by monitoring physical appearance, radiographic changes, and growth. Urinary glycosaminoglycan (GAG) levels, gross and fine motor function, cardiac function, vision, hearing, and health resource utilization were evaluated. Safety assessments were performed. RESULTS Four infants (aged 3.3-12.7 months) participated in the study. Galsulfase was well tolerated at 1.0 and 2.0 mg/kg/week dose levels with no drug-related serious adverse events. Two subjects experienced a total of four possible treatment-related adverse events which were all considered mild. Length and weight remained within age-expected norms. Skeletal abnormalities continued to progress in all subjects. High baseline urinary GAG levels (mean: 870 μg/mg creatinine) decreased by approximately 70%; these reduced levels were maintained (mean: 220 μg/mg creatinine at week 52) despite the development of anti-galsulfase antibodies. Hearing, cardiac function, hepatosplenomegaly, and facial dysmorphism stabilized or improved, but corneal clouding progressed. There was no clear difference in safety or efficacy between the two doses. CONCLUSIONS Galsulfase at two dose levels was safe and well tolerated in infants. Normal growth was maintained but skeletal abnormalities continued to progress. Urinary GAG levels decreased with treatment. Early initiation of galsulfase may prevent or slow progression of some disease manifestations.
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Affiliation(s)
- Paul R Harmatz
- Children's Hospital & Research Center Oakland, 747 52nd Street, Oakland, CA, USA,
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Muenzer J. Early initiation of enzyme replacement therapy for the mucopolysaccharidoses. Mol Genet Metab 2014; 111:63-72. [PMID: 24388732 DOI: 10.1016/j.ymgme.2013.11.015] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 11/29/2013] [Accepted: 11/29/2013] [Indexed: 10/25/2022]
Abstract
The mucopolysaccharidoses (MPS), a group of rare genetic disorders caused by defects in glycosaminoglycan (GAG) catabolism, are progressive, multi-systemic diseases with a high burden of morbidity. Enzyme replacement therapy (ERT) is available for MPS I, II, and VI, and may improve walking ability, endurance, and pulmonary function as evidenced by data from pivotal trials and extension studies. Despite these demonstrable benefits, cardiac valve disease, joint disease, and skeletal disease, all of which cause significant morbidity, do not generally improve with ERT if pathological changes are already established. Airway disease improves, but usually does not normalize. These limitations can be well understood by considering the varied functions of GAG in the body. Disruption of GAG catabolism has far-reaching effects due to the triggering of secondary pathogenic cascades. It appears that many of the consequences of these secondary pathogenic events, while they may improve on treatment, cannot be fully corrected even with long-term exposure to enzyme, thereby supporting the treatment of patients with MPS before the onset of clinical disease. This review examines the data from clinical trials and other studies in human patients to explore the limits of ERT as currently used, then discusses the pathophysiology, fetal tissue studies, animal studies, and sibling reports to explore the question of how early to treat an MPS patient with a firm diagnosis. The review is followed by an expert opinion on the rationale for and the benefits of early treatment.
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Affiliation(s)
- Joseph Muenzer
- Division of Genetics and Metabolism, Department of Pediatrics, CB 7487, Medical School Wing E Room 117, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7487, USA.
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Braunlin E, Orchard PJ, Whitley CB, Schroeder L, Reed RC, Manivel JC. Unexpected coronary artery findings in mucopolysaccharidosis. Report of four cases and literature review. Cardiovasc Pathol 2014; 23:145-51. [PMID: 24508139 DOI: 10.1016/j.carpath.2014.01.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 12/30/2013] [Accepted: 01/03/2014] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION The mucopolysaccharidosis syndromes are a group of lethal inherited disorders affecting multiple organ systems by the progressive deposition of glycosaminoglycan. Advances in treatment such as enzyme replacement and hematopoietic stem cell transplantation have significantly improved the outcome of these disorders. An in-depth understanding of the pathophysiology of heart disease in these disorders is essential since death from cardiac causes continues to be common. Epicardial coronary artery luminal narrowing from myointimal proliferation and glycosaminoglycan deposition is well described in severe mucopolysaccharidosis type I [Hurler syndrome, mucopolysaccharide IH] but poorly understood in other "non-Hurler" phenotypes of these disorders. Given the rarity of these conditions, autopsy specimens are uncommon. METHODS Tissue from epicardial coronary arteries from autopsies of four patients with non-Hurler mucopolysaccharidosis (attenuated type I, type IIIA, type IIIC, and type VI) who had died after hematopoietic cell transplantation (within 1 month in three cases; after 5 years in the fourth) was examined by light microscopy. RESULTS Unexpectedly, near-normal coronary arteries were observed in the patient with attenuated mucopolysaccharidosis type I, while the coronaries from patients with type IIIA, IIIC, and VI demonstrated classic histologic features of glycosaminoglycan deposition. The most severe findings were found in the MPS IIIC patient who had 5 years of full donor engraftment after transplantation. CONCLUSIONS Our current understanding of the cardiac manifestations of the mucopolysaccharidoses fails to explain why near-normal coronary arteries may be observed when abnormalities would be most likely to be expected and, conversely, why significant histopathology is present when it would be least expected. Identification of downstream effects of glycosaminoglycan deposition may identify other metabolites or metabolic pathways that are important in the clinicopathologic manifestations of these diseases. SUMMARY The mucopolysaccharidosis diseases are a group of inherited disorders affecting multiple organ systems by the progressive deposition of glycosaminoglycan. Severe coronary artery disease is well recognized in severe type I mucopolysaccharidosis (Hurler syndrome), but unexpected coronary artery disease occurs in other, "non-Hurler" mucopolysaccharidoses. Factors responsible for the development of coronary pathology in the mucopolysaccharidoses remain elusive.
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Affiliation(s)
| | - Paul J Orchard
- Department of Pediatrics, University of Minnesota Medical School
| | - Chester B Whitley
- Department of Pediatrics, University of Minnesota Medical School; Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN
| | - Luke Schroeder
- Department of Pediatrics, University of Minnesota Medical School
| | - Robyn C Reed
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School
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Bigg PW, Sleeper MM, O’Donnell PA, Liu Y, Wu S, Casal ML, Haskins ME, Ponder KP. The effect of neonatal gene therapy with a gamma retroviral vector on cardiac valve disease in mucopolysaccharidosis VII dogs after a decade. Mol Genet Metab 2013; 110:311-8. [PMID: 23860311 PMCID: PMC3800273 DOI: 10.1016/j.ymgme.2013.06.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 06/18/2013] [Accepted: 06/18/2013] [Indexed: 10/26/2022]
Abstract
Mucopolysaccharidosis VII (MPS VII) is due to deficient activity of the lysosomal enzyme β-glucuronidase (GUSB) and results in the accumulation of glycosaminoglycans (GAGs). This study determined the long-term effect of neonatal intravenous injection of a gamma retroviral vector (RV) on cardiac valve disease in MPS VII dogs. Transduced hepatocytes secreted GUSB into the blood for up to 11 years at levels similar to or greater than those achieved with enzyme replacement therapy (ERT). Valve regurgitation and thickening were scored from 0 (normal) to +4 (severely abnormal). At 1 year, untreated MPS VII dogs had mitral regurgitation, mitral valve thickening, aortic regurgitation, and aortic valve thickening scores of 2.3 ± 0.7, 2.3 ± 0.6, 1.8 ± 0.5, and 1.6 ± 0.7, respectively, which were higher than the values of 0.6 ± 0.1, 0.1 ± 0.4, 0.3 ± 0.8, and 0.1 ± 0.4, respectively, in treated MPS VII dogs. Treated MPS VII dogs maintained low aortic regurgitation and aortic valve thickening scores in their lifetime. Although mitral regurgitation and mitral valve thickening scores increased to 2.0 at ≥ 8 years of age in the treated MPS VII dogs, older normal dogs from the colony had similar scores, making it difficult to assess mitral valve disease. Older treated dogs had calcification within the mitral and the aortic valve annulus, while GUSB staining demonstrated enzyme activity within the mitral valve. We conclude that neonatal RV-mediated gene therapy reduced cardiac valve disease in MPS VII dogs for up to 11 years, and propose that neonatal initiation of ERT should have a similar effect.
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Affiliation(s)
- Paul W. Bigg
- Department of Internal Medicine, Washington University School of Medicine, St. Louis MO
| | - Meg M. Sleeper
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patricia A. O’Donnell
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yuli Liu
- Department of Internal Medicine, Washington University School of Medicine, St. Louis MO
| | - Susan Wu
- Department of Internal Medicine, Washington University School of Medicine, St. Louis MO
| | - Margret L. Casal
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark E. Haskins
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Katherine P. Ponder
- Department of Internal Medicine, Washington University School of Medicine, St. Louis MO
- Department of Biochemistry and Molecular Biophysics, Washington University School of Medicine, St. Louis MO
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an update on ocular manifestations of mucopolysaccharidoses (MPS), to highlight diagnostic pitfalls in the evaluation of affected patients, and to briefly review etiopathogenesis, systemic manifestations, and therapeutic interventions in MPS. RECENT FINDINGS Advances in hematopoietic stem cell transplantation and enzyme replacement therapy for MPS have led to decreased morbidity and increased life-span of patients. Besides other causes, visual impairment because of corneal opacification, retinal degeneration, and optic atrophy remains a common cause of disability in MPS. The application of a standard ophthalmic evaluation protocol may serve as an important diagnostic and disease monitoring tool in patients. SUMMARY Diagnostic delays are not uncommon in patients with MPS. Given the early ocular involvement in MPS, ophthalmologists play a crucial role in early detection and follow-up of patients with MPS. Ophthalmic evaluation can be impeded by corneal opacification and patient cooperation. Altered corneal biomechanics confound intraocular pressure measurements. Recently developed therapies have made early detection increasingly important. Accurate diagnosis of specific MPS subtypes is of paramount importance for initiating appropriate therapy. Combined with advances in supportive care of ocular and systemic manifestations, the prognosis for patients with MPS has vastly improved.
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Brands M, Roelants J, de Krijger R, Bogers A, Reuser A, van der Ploeg A, Helbing W. Macrophage involvement in mitral valve pathology in mucopolysaccharidosis type VI (Maroteaux-Lamy syndrome). Am J Med Genet A 2013; 161A:2550-3. [PMID: 23949968 DOI: 10.1002/ajmg.a.36105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 05/26/2013] [Indexed: 11/12/2022]
Abstract
Maroteaux-Lamy syndrome (mucopolysaccharidosis type VI) is a rare lysosomal storage disorder in which the pathologic storage of glycosaminoglycans in various tissues can lead to severe symptoms, including cardiomyopathy. We report on a child with Maroteaux-Lamy syndrome whose cardiac condition deteriorated and eventually led to cardiac failure at the age of 7 years due to severe mitral regurgitation. She received a mitral valve replacement and tricuspid repair with successful outcome. Histologic examination of the mitral valve showed abundant "clear" cells in both the leaflets and chordae tendineae. In Hurler disease (MPS I), similar cells have been identified as activated valvular interstitial cells (VICs, a myofibroblast like cell type). Here we report that the "clear" cells are CD68 positive, a frequently used marker of macrophage lineage. The "clear" cells remained unstained with the more specific macrophage marker CD14 while persistent staining of other cells demonstrated macrophage infiltration. From these observations, we infer that macrophages are involved in mitral valve pathology in MPS VI.
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Affiliation(s)
- Marion Brands
- Center for Lysosomal and Metabolic Diseases, Departments of Pediatrics and Clinical Genetics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Dilger H, Leissner L, Bosanska L, Lampe C, Plöckinger U. Illness perception and clinical treatment experiences in patients with M. Maroteaux-Lamy (mucopolysaccharidosis type VI) and a Turkish migration background in Germany. PLoS One 2013; 8:e66804. [PMID: 23826140 PMCID: PMC3691296 DOI: 10.1371/journal.pone.0066804] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 05/15/2013] [Indexed: 11/19/2022] Open
Abstract
Introduction Mucopolysaccharidosis VI (MPS VI) is an inherited lysosomal storage disease caused by a mutation of the gene for arylsulfatase B (ASB). Of the thirty-one patients registered in Germany, almost fifty percent have a Turkish migration background. MPS VI is treated by enzyme replacement therapy (ERT), which is time-consuming and expensive. Methods This interdisciplinary study explored the illness perceptions and clinical treatment experiences among ten MPS VI patients with a Turkish migration background in two centers for metabolic diseases (Berlin and Mainz, Germany). The clinical treatment situation was observed and semi-structured interviews were conducted with patients and health care personnel, in addition to participatory observation in four patients' everyday environments in Berlin. The data from the interviews, patient records, and personal field notes were encoded, cross-related, and analyzed. Results Patients' acknowledgement of the disease and coping strategies are influenced predominantly by the perception of their individual health status and the handling of the disease within their family. Patients' willingness to cooperate with treatment strategies is further modified by their knowledge of the disease and the relationships with their health care providers. In this analysis, cultural factors turned out to be marginally relevant. Conclusion As with other chronic and debilitating diseases, effective treatment strategies have to reach beyond delivering medication. Health care providers need to strengthen the support for patients with a migration background. In this regard, they should respect the patients' cultural and social background and their personal perception of the disease and the therapy. Yet structural and social aspects (clinical setting, family and educational background) may be more crucial here than “cultural barriers.”
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Affiliation(s)
- Hansjörg Dilger
- Institute of Social and Cultural Antropology, Freie Universität Berlin, Berlin, Germany
| | - Linn Leissner
- Institute of Social and Cultural Antropology, Freie Universität Berlin, Berlin, Germany
- * E-mail:
| | - Lenka Bosanska
- Centre of Excellence for Rare Metabolic Diseases, Interdisciplinary Centre of Metabolism, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Pediatric and Adolecscent Medicine, Villa Metabolica, University Medical Center Mainz, Mainz, Germany
| | - Christina Lampe
- Department of Pediatric and Adolecscent Medicine, Villa Metabolica, University Medical Center Mainz, Mainz, Germany
| | - Ursula Plöckinger
- Centre of Excellence for Rare Metabolic Diseases, Interdisciplinary Centre of Metabolism, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Pediatric and Adolecscent Medicine, Villa Metabolica, University Medical Center Mainz, Mainz, Germany
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Piva E, Pelloso M, Ciubotaru D, Penello L, Burlina A, Plebani M. The role of automated analyzers in detecting abnormal granulation of leucocytes in lysosomal storage diseases: Maroteaux-Lamy disease. Am J Hematol 2013; 88:527. [PMID: 23339092 DOI: 10.1002/ajh.23377] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 11/28/2012] [Accepted: 12/06/2012] [Indexed: 11/08/2022]
Affiliation(s)
- Elisa Piva
- Department of Laboratory Medicine; Padua University School of Medicine; Padua; Italy
| | - Michela Pelloso
- Department of Laboratory Medicine; Padua University School of Medicine; Padua; Italy
| | - Daniela Ciubotaru
- Department of Laboratory Medicine; Padua University School of Medicine; Padua; Italy
| | - Laura Penello
- Department of Laboratory Medicine; Padua University School of Medicine; Padua; Italy
| | - Alberto Burlina
- Metabolic Disorders Unit of the Department of Pediatrics; University of Padua; Padua; Italy
| | - Mario Plebani
- Department of Laboratory Medicine; Padua University School of Medicine; Padua; Italy
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