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Yabe H, Koike T, Yamamoto S, Otsuka K, Nakajima J, Shibata M, Fujita S, Kaneko R, Akiyama K, Toyama D, Kato S, Morimoto T, Uchiyama A, Yabe M. Allogeneic stem cell transplantation for inherited metabolic disorders: 35 years' experience at a single institution. Int J Hematol 2024; 120:365-374. [PMID: 38951435 DOI: 10.1007/s12185-024-03810-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 06/06/2024] [Accepted: 06/24/2024] [Indexed: 07/03/2024]
Abstract
Hematopoietic stem cell transplants for inherited metabolic disorders performed at Tokai University Hospital between June 5, 1986, and May 28, 2021, were analyzed and compared between the period before 2007 and the period from 2007 onward based on availability of medical resources. Transplants were performed for 38 patients with mucopolysaccharidosis, 33 with adrenoleukodystrophy, and 16 with another disorder. Before 2007, oral busulfan-based regimens were mainly used. From 2007 onward, intravenous busulfan-based regimens or 4 Gy of thoracoabdominal irradiation (TAI), fludarabine, and melphalan (Mel)/treosulfan were adopted. Between 2002 and 2010, adrenoleukodystrophy was treated with 12 Gy of TAI and Mel. HLA-identical sibling bone marrow was used in 43% of cases before 2007 and 15% from 2007 onward, while alternative donors were selected for other transplants. Overall survival and event-free survival (EFS) before 2007 and from 2007 onward were 76% and 62%, and 97% and 85%, respectively (P = 0.006 and 0.017). Transplant era predicted superior overall survival and EFS, while myeloablative conditioning also predicted EFS. The incidence of primary graft failure decreased from 2007 onward, especially in cord blood transplant when 4 Gy of TAI with 150 mg/m2 fludarabine and 180 mg/m2 Mel or 42 g/m2 treosulfan were used as conditioning.
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Affiliation(s)
- Hiromasa Yabe
- Department of Pediatrics, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259 1193, Japan.
| | - Takashi Koike
- Department of Pediatrics, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259 1193, Japan
| | - Shohei Yamamoto
- Department of Pediatrics, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259 1193, Japan
| | - Kohei Otsuka
- Department of Pediatrics, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259 1193, Japan
| | - Junko Nakajima
- Department of Pediatrics, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259 1193, Japan
| | - Mayuko Shibata
- Department of Pediatrics, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259 1193, Japan
| | - Sachio Fujita
- Department of Pediatrics, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259 1193, Japan
| | - Ryota Kaneko
- Department of Pediatrics, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259 1193, Japan
| | - Kosuke Akiyama
- Department of Pediatrics, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259 1193, Japan
| | - Daisuke Toyama
- Department of Pediatrics, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259 1193, Japan
| | - Shunichi Kato
- Department of Pediatrics, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259 1193, Japan
| | - Tsuyoshi Morimoto
- Department of Pediatrics, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259 1193, Japan
| | - Atsushi Uchiyama
- Department of Pediatrics, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259 1193, Japan
| | - Miharu Yabe
- Department of Pediatrics, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259 1193, Japan
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Laoharawee K, Kleinboehl EW, Jensen JD, Peterson JJ, Slipek NJ, Wick BJ, Johnson MJ, Webber BR, Moriarity BS. Engineering Memory T Cells as a platform for Long-Term Enzyme Replacement Therapy in Lysosomal Storage Disorders. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.04.23.590790. [PMID: 38712248 PMCID: PMC11071424 DOI: 10.1101/2024.04.23.590790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Enzymopathy disorders are the result of missing or defective enzymes. Amongst these enzymopathies, mucopolysaccharidosis type I, is a rare genetic lysosomal storage disorder caused by mutations in the gene encoding alpha-L-iduronidase (IDUA), ultimately causes toxic build-up of glycosaminoglycans (GAGs). There is currently no cure and standard treatments provide insufficient relief to the skeletal structure and central nervous system (CNS). Human memory T cells (Tm) migrate throughout the body's tissues and can persist for years, making them an attractive approach for cellular-based, systemic enzyme replacement therapy. Here, we tested genetically engineered, IDUA-expressing Tm as a cellular therapy in an immunodeficient mouse model of MPS I. Our results demonstrate that a single dose of engineered Tm leads to detectable IDUA enzyme levels in the blood for up to 22 weeks and reduced urinary GAG excretion. Furthermore, engineered Tm take up residence in nearly all tested tissues, producing IDUA and leading to metabolic correction of GAG levels in the heart, lung, liver, spleen, kidney, bone marrow, and the CNS. Our study indicates that genetically engineered Tm holds great promise as a platform for cellular-based enzyme replacement therapy for the treatment of mucopolysaccharidosis type I and potentially many other enzymopathies and protein deficiencies.
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Liao R, Geng R, Yang Y, Xue Y, Chen L, Chen L. The top 100 most cited articles on mucopolysaccharidoses: a bibliometric analysis. Front Genet 2024; 15:1377743. [PMID: 38680422 PMCID: PMC11045982 DOI: 10.3389/fgene.2024.1377743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/29/2024] [Indexed: 05/01/2024] Open
Abstract
Background: Bibliometrics can trace general research trends in a particular field. Mucopolysaccharidoses (MPS), as a group of rare genetic diseases, seriously affect the quality of life of patients and their families. Scholars have devoted themselves to studying MPS's pathogenesis and treatment modalities and have published many papers. Therefore, we conducted a bibliometric and visual study of the top 100 most highly cited articles to provide researchers with an indication of the current state of research and potential directions in the field. Methods: The Web of Science Core Collection was searched for articles on MPS from 1 January 1900, to 8 November 2023, and the top 100 most cited articles were screened. The title, year of publication, institution, country, and first author of the articles were extracted and statistically analyzed using Microsoft Excel 2007. Keyword co-occurrence and collaborative networks were analyzed using VOSviewer 1.6.16. Results: A total of 9,273 articles were retrieved, and the top 100 most cited articles were filtered out. The articles were cited 18,790 times, with an annual average of 188 citations (122-507). Forty-two journals published these articles, with Molecular Genetics and Metabolism and Proceedings of the National Academy of Sciences of the United States being the most published journal (N = 8), followed by Pediatrics (N = 7), Blood (N = 6). The United States (N = 68), the UK (N = 25), and Germany (N = 20) were the top contributing countries. The Royal Manchester Children's Hospital (N = 20) and the University of North Carolina (N = 18) were the most contributing institutions. Muenzer J was the most prolific author (N = 14). Conclusion: We conducted a bibliometric and visual analysis of the top 100 cited articles in MPS. This study identifies the most influential articles currently available in the field of MPS, which provides a good basis for a better understanding of the disease and informs future research directions.
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Affiliation(s)
| | | | | | | | | | - Lan Chen
- Department of Orthopedics, The Third People’s Hospital of Chengdu, Chengdu, China
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Jubert C, De Berranger E, Castelle M, Dalle JH, Ouachee-Chardin M, Sevin C, Yakoub-Agha I, Brassier A. [Inborn error of metabolism and allogenic hematopoietic cell transplantation: Guidelines from the SFGM-TC]. Bull Cancer 2023; 110:S1-S12. [PMID: 36244825 DOI: 10.1016/j.bulcan.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/07/2022]
Abstract
Inherited Metabolic Diseases (IMD) are rare genetic diseases, including both lysosomal and peroxisomal diseases. Lysosomal diseases are related to the deficiency of one or more lysosomal enzymes or transporter. Lysosomal diseases are progressive and involve several tissues with most often neurological damage. Among peroxisomal diseases, X-linked adrenoleukodystrophy (ALD) is a neurodegenerative disease combining neurological and adrenal damage. For these diseases, enzyme replacement therapy (ERT), allogeneic hematopoietic cell transplantation (allo-HCT) and gene therapy represent various possible treatment options, used alone or in combination. The purpose of this workshop is to describe the indications, modalities, and follow-up of allo-HCT as well as the use of ERT peri-transplant. All indications for transplant in these rare diseases are associated with comorbidities and are subject to criteria that must be discussed in a dedicated national multidisciplinary consultation meeting. There are some consensual indications in type I-H mucopolysaccharidosis (MPS-IH) and in the cerebral form of ALD. For other IMDs, no clear benefit from the transplant has been demonstrated. The ideal donor is a non-heterozygous HLA-identical sibling. The recommended conditioning is myeloablative combining fludarabine and busulfan. In MPS-IH, ERT has to be started at diagnosis and continued until complete chimerism and normal enzyme assay are achieved. The pre-transplant assessment and post-transplant follow-up are made according to the published recommendations (PNDS). Standard follow-up is carried out jointly by the transplant and referral teams.
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Affiliation(s)
- Charlotte Jubert
- CHU de Bordeaux, groupe hospitalier Pellegrin, unité d'hématologie oncologie pédiatrique, place Améli-Raba-Léon, 33076 Bordeaux cedex, France.
| | - Eva De Berranger
- CHRU de Lille, service d'hématologie pédiatrique, avenue Eugène-Avinée, 59037 Lille, France
| | - Martin Castelle
- CHU de Necker-Enfants Malades, unité d'immuno-hématologie et rhumatologie pédiatrique, 149, rue de Sèvres, 75015 Paris, France
| | - Jean-Hugues Dalle
- Hôpital Robert-Debré, GHU Nord-Université de Paris, service d'immuno-hématologie pédiatrique, 48, boulevard Serurier, 75019 Paris, France
| | - Marie Ouachee-Chardin
- Institut d'hématologie et d'oncologie pédiatrique, 1, place Joseph-Renault, 69008 Lyon, France
| | - Caroline Sevin
- CHU de Kremlin-Bicêtre, neurologie pédiatrique, 78, rue du General-Leclerc, 94275 Le Kremlin-Bicêtre, France; ICM, 47, boulevard de l'Hôpital, 75013 Paris, France
| | - Ibrahim Yakoub-Agha
- Université de Lille, CHRU de Lille, Infinite, Inserm U1286, 59000 Lille, France
| | - Anais Brassier
- CHU de Necker, centre de référence des maladies héréditaires du métabolisme, 149, rue de Sèvres, 75015 Paris, France
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Penon-Portmann M, Blair DR, Harmatz P. Current and new therapies for mucopolysaccharidoses. Pediatr Neonatol 2023; 64 Suppl 1:S10-S17. [PMID: 36464587 DOI: 10.1016/j.pedneo.2022.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/03/2022] [Indexed: 12/05/2022] Open
Abstract
The mucopolysaccharidoses (MPSs) are a subset of lysosomal storage diseases caused by deficiencies in the enzymes required to metabolize glycosaminoglycans (GAGs), a group of extracellular heteropolysaccharides that play diverse roles in human physiology. As a result, GAGs accumulate in multiple tissues, and affected patients typically develop progressive, multi-systemic symptoms in early childhood. Over the last 30 years, the treatments available for the MPSs have evolved tremendously. There are now multiple therapies that delay the progression of these debilitating disorders, although their effectiveness varies according to MPS sub-type. In this review, we discuss the basic principle underlying MPS treatment (enzymatic "cross correction"), and we review the three general modalities currently available: hematopoietic stem cell transplantation, enzymatic replacement, and gene therapy. For each treatment type, we discuss its effectiveness across the MPS subtypes, its inherent risks, and future directions. Long term, we suspect that treatment for the MPSs will continue to evolve, and through a combination of early diagnosis and effective management, these patients will continue to live longer lives with improved outcomes for quality of life.
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Affiliation(s)
- Monica Penon-Portmann
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA; Seattle Children's Hospital, Seattle, WA, USA.
| | - David R Blair
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA; Division of Medical Genetics and Genomics, Department of Pediatrics, UCSF, San Francisco, CA, USA
| | - Paul Harmatz
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
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MPSI Manifestations and Treatment Outcome: Skeletal Focus. Int J Mol Sci 2022; 23:ijms231911168. [PMID: 36232472 PMCID: PMC9569890 DOI: 10.3390/ijms231911168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/16/2022] [Accepted: 09/17/2022] [Indexed: 11/23/2022] Open
Abstract
Mucopolysaccharidosis type I (MPSI) (OMIM #252800) is an autosomal recessive disorder caused by pathogenic variants in the IDUA gene encoding for the lysosomal alpha-L-iduronidase enzyme. The deficiency of this enzyme causes systemic accumulation of glycosaminoglycans (GAGs). Although disease manifestations are typically not apparent at birth, they can present early in life, are progressive, and include a wide spectrum of phenotypic findings. Among these, the storage of GAGs within the lysosomes disrupts cell function and metabolism in the cartilage, thus impairing normal bone development and ossification. Skeletal manifestations of MPSI are often refractory to treatment and severely affect patients’ quality of life. This review discusses the pathological and molecular processes leading to impaired endochondral ossification in MPSI patients and the limitations of current therapeutic approaches. Understanding the underlying mechanisms responsible for the skeletal phenotype in MPSI patients is crucial, as it could lead to the development of new therapeutic strategies targeting the skeletal abnormalities of MPSI in the early stages of the disease.
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Yabe H. Allogeneic hematopoietic stem cell transplantation for inherited metabolic disorders. Int J Hematol 2022; 116:28-40. [PMID: 35594014 DOI: 10.1007/s12185-022-03383-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/01/2022] [Accepted: 05/01/2022] [Indexed: 11/26/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) has been used to treat patients with inherited metabolic disorders (IMDs) for more than 40 years. In the first two decades, various IMDs were treated by HSCT with a wide variety of donor sources and conditioning regimens selected at the institutional level. However, HSCT was not always successful due to post-transplant complications such as graft failure. In the third decade, myeloablative conditioning with targeted busulfan-based pharmacokinetic monitoring was established as an optimal conditioning regimen, and unrelated cord blood was recognized as an excellent donor source. During the fourth decade, further improvements were made to transplant procedures, including modification of the conditioning regimen, and the survival rate after HSCT markedly improved. Simultaneously, several long-term observational studies for patients after HSCT clarified its therapeutic effects on growth and development of cognitive function, fine motor skills, and activities of daily living when compared with enzyme replacement therapy. Although immune-mediated cytopenia was newly highlighted as a problematic morbidity after HSCT for IMDs, especially in younger patients who received unrelated cord blood, a recent study with rituximab added to the conditioning raised expectations that this issue can be overcome.
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Affiliation(s)
- Hiromasa Yabe
- Department of Innovative Medical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
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Braunlin E, Abrahante JE, McElmurry R, Evans M, Smith M, Seelig D, O'Sullivan MG, Tolar J, Whitley CB, McIvor RS. Contribution of the innate and adaptive immune systems to aortic dilation in murine mucopolysaccharidosis type I. Mol Genet Metab 2022; 135:193-205. [PMID: 35165009 PMCID: PMC9109621 DOI: 10.1016/j.ymgme.2022.01.104] [Citation(s) in RCA: 2] [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: 10/13/2021] [Revised: 12/23/2021] [Accepted: 01/31/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Adult immunocompetent male C57Bl/6 mucopolysaccharidosis, type I (MPSI) mice develop aortic insufficiency (AI), dilated ascending aortas and decreased cardiac function, findings not observed in immune incompetent adult male NSG MPSI mice. We sought to determine why. METHODS Cardiac ultrasound measurements of ascending aorta and left ventricular dimensions and Doppler interrogation for AI were performed in 6-month-old male B6 MPSI (N = 12), WT (N = 6), NSG MPSI (N = 8), NSG (N = 6) mice. Urinary glycosaminoglycans, RNA sequencing with quantitative PCR were performed and aortic pathology assessed by routine and immunohistochemical staining on subsets of murine aortas. RESULTS Ascending aortic diameters were significantly greater, left ventricular function significantly decreased, and AI significantly more frequent in B6 MPSI mice compared to NSG MPSI mice (p < 0.0001, p = 0.008 and p = 0.02, respectively); NSG and B6 WT mice showed no changes. Urinary glycosaminoglycans were significantly greater in B6 and NSG MPSI mice and both were significantly elevated compared to WT controls (p = 0.003 and p < 0.0001, respectively). By RNA sequencing, all 11 components of the inflammasome pathway were upregulated in B6 MUT, but only Aim2 and Ctsb in NSG MUT mice and none in WT controls. Both B6 and NSG MUT mice demonstrated variably-severe intramural inflammation, vacuolated cells, elastin fragmentation and disarray, and intense glycosaminoglycans on histological staining. B6 MPSI mice demonstrated numerous medial MAC2+ macrophages and adventitial CD3+ T-cells while MAC2+ macrophages were sparse and CD3+ T-cells absent in NSG MPSI mice. CONCLUSIONS Aortic dilation, AI and decreased cardiac function occur in immunocompetent B6 MPSI male mice but not in immune incompetent NSG MPSI mice, unrelated to GAG excretion, upregulation of Ctsb, or routine histologic appearance. Upregulation of all components of the inflammasome pathway in B6 MUT, but not NSG MUT mice, and abundant medial MAC2 and adventitial CD3 infiltrates in B6, but not NSG, MPSI aortas differentiated the two strains. These results suggest that the innate and adaptive immune systems play a role in these cardiac findings which may be relevant to human MPSI.
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Affiliation(s)
- Elizabeth Braunlin
- Department of Pediatrics University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Juan E Abrahante
- University of Minnesota Informatics Institute University of Minnesota, Minneapolis, MN, USA.
| | - Ron McElmurry
- Department of Pediatrics University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Michael Evans
- Biostatistical Design and Analysis Center Clinical and Translational Science Institute University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Miles Smith
- Department of Genetics, Cell Biology and Development University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Davis Seelig
- Comparative Pathology Shared Resource, Department of Veterinary Clinical Sciences, College of Veterinary Medicine, St. Paul, MN, USA.
| | - M Gerard O'Sullivan
- Comparative Pathology Shared Resource, Department of Veterinary Clinical Sciences, College of Veterinary Medicine, St. Paul, MN, USA.
| | - Jakub Tolar
- Department of Blood and Marrow Transplant University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Chester B Whitley
- Gene Therapy Center Department of Pediatrics University of Minnesota Medical School Minneapolis, MN, USA.
| | - R Scott McIvor
- Department of Genetics, Cell Biology and Development University of Minnesota Medical School, Minneapolis, MN, USA.
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Qu Y, Liu H, Wei L, Nie S, Ding W, Liu S, Liu H, Jiang H. The Outcome of Allogeneic Hematopoietic Stem Cell Transplantation From Different Donors in Recipients With Mucopolysaccharidosis. Front Pediatr 2022; 10:877735. [PMID: 35844734 PMCID: PMC9279935 DOI: 10.3389/fped.2022.877735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/31/2022] [Indexed: 11/26/2022] Open
Abstract
There is limited information regarding hematopoietic stem cell transplantation (HSCT) for mucopolysaccharidosis (MPS) IV and VI. This study examined the full donor chimerism, specific lysosomal enzyme levels, and the survival of different MPS children after HSCT from various donor sources and compared the prognosis. A total of 42 children with MPS underwent HSCT, 9 cases were type I, 14 were type II, 15 were type IV, and 4 were type VI. A total of 24 patients received peripheral blood stem cells (PBSC) and 18 patients received umbilical cord blood (UCB). Patients who received PBSC were conditioned with intravenous (IV) busulfan every 6 h for a total of 16 doses, IV cyclophosphamide (CY, 200 mg/kg), and antihuman thymocyte globulin (ATG, 10 mg/kg). While conditioning regimen of patients who received UCB was adjusted to ATG (preposed, pre-) + busulfan + fludarabine + Cy, which includes IV ATG (pre-, 6 mg/kg), IV busulfan every 6 h for a total of 16 doses, IV fludarabine (200 mg/m2) and CY (200 mg/kg). Also, 95.2% (40 of 42) of patients achieved full donor chimerism, and all patients' specific lysosomal enzyme levels reached normal. The estimated overall survival (OS) at 1 year was 92.9%. There was no significant difference in 1-year OS between patients who received PBSC transplantation and those who received UCB grafts (87.5% vs. 100%, p = 0.0247). The incidence of acute and chronic GVHD did not differ between them. The incidences of pneumonia in PBSC recipients and UCB recipients were 45.8 and 33.3%, respectively, but there few patients suffering from respiratory failure (4.2 and 5.6%, respectively) due to pneumonia. The incidence of cytomegaloviremia was also high in both groups, 58.3 and 44.4% respectively, However, no patient developed CMV disease. All deaths (3 of 42) occurred in patients receiving PBSC grafts, and there was no death in patients receiving UCB grafts. There was no death after transplantation in patients with MPS IV and VI. In addition, respiratory and nervous system functions were improved, whereas valvular heart disease was improved in some patients but progressed in more patients after transplantation. In summary, HSCT is a good therapeutic option for MPS, not only for patients with MPS I or II but also for those with MPS IV or VI. The specific lysosomal enzyme levels can be completely restored to normal, which is the basis for patients to resolve a broad range of clinical outcomes. Moreover, UCB with suitable HLA (HLA-match above 7/10 and 4/6) is a suitable donor source for MPS. Patients who underwent UCB transplantation using the conditioning regimen ATG (pre-) + busulfan + fludarabine + Cy can achieve a higher proportion of full donor chimerism and survival with less severe complications. HSCT can improve organs function in patients with MPS, but it is still worth exploring.
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Affiliation(s)
- Yuhua Qu
- Department of Hematology and Oncology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Hao Liu
- Department of Orthopedics, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Likun Wei
- Department of Stomatology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shushan Nie
- Department of Hematology and Oncology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wenjiao Ding
- Department of Hematology and Oncology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Sha Liu
- Department of Hematology and Oncology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Haiyan Liu
- Department of Hematology and Oncology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Hua Jiang
- Department of Hematology and Oncology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
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Carbajal-Rodríguez LM, Pérez-García M, Rodríguez-Herrera R, Rosales HS, Olaya-Vargas A. Long-term evolution of mucopolysaccharidosis type I in twins treated with enzyme replacement therapy plus hematopoietic stem cells transplantation. Heliyon 2021; 7:e07740. [PMID: 34458603 PMCID: PMC8379671 DOI: 10.1016/j.heliyon.2021.e07740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 10/17/2019] [Accepted: 08/05/2021] [Indexed: 11/20/2022] Open
Abstract
Mucopolysaccharidoses (MPSs) are a heterogeneous group of diseases that have in common the accumulation of glycosaminoglycans (mucopolysaccharides) within the lysosome. The diseases are caused by a deficiency of the enzyme α-L-iduronidase which is responsible for the degradation of glycosaminoglycans (GAGs or mucopolysaccharides). More than 100 mutations in the gene have been reported, resulting in marked clinical/response variability. MPSs usually present as multisystem and progressive clinical disorders which affect psychomotor and cardiovascular development, the cornea and the musculoskeletal system. Seven phenotypically distinct diseases have been described, and MPS type I (MPS-I) is divided into three clinical forms: severe (Hurler syndrome), intermediate (Hurler-Scheie syndrome) or mild (Scheie syndrome). For the treatment of MPS-I, Enzyme Replacement Therapy (ERT) with α-L-iduronidase and Hematopoietic Stem Cells Transplantation (HSCT), separately or in combination, have produced clinical improvement, especially with regards cardiovascular symptoms and psychomotor development. This article presents the long-term (more than seven years) follow-up of monochorionic, diamniotic twins who were diagnosed with MPS-I at an early stage, and treated with ERT (from age 10 months) plus HSCT (from age 18 months). Overall, the treatment has facilitated stable development with an overall good response and better control of symptoms associated with MPS-I.
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Affiliation(s)
- Luis M. Carbajal-Rodríguez
- Lysosomal Storage, Rare and Degenerative Diseases Clinic, Instituto Nacional de Pediatría, Insurgentes Sur 3700 – C, Insurgentes Cuicuilco, Mexico City, 04530, Mexico
| | - Martín Pérez-García
- Bone Marrow Transplantation Unit, Instituto Nacional de Pediatría, Av Insurgentes Sur 3700 c Insurgentes Cuicuilco, Mexico City, 04530, Mexico
| | - Raymundo Rodríguez-Herrera
- Lysosomal Storage, Rare and Degenerative Diseases Clinic, Instituto Nacional de Pediatría, Insurgentes Sur 3700 – C, Insurgentes Cuicuilco, Mexico City, 04530, Mexico
| | - Haydeé Salazar Rosales
- Bone Marrow Transplantation Unit, Instituto Nacional de Pediatría, Av Insurgentes Sur 3700 c Insurgentes Cuicuilco, Mexico City, 04530, Mexico
| | - Alberto Olaya-Vargas
- Bone Marrow Transplantation Unit, Instituto Nacional de Pediatría, Av Insurgentes Sur 3700 c Insurgentes Cuicuilco, Mexico City, 04530, Mexico
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Shapiro EG, Eisengart JB. The natural history of neurocognition in MPS disorders: A review. Mol Genet Metab 2021; 133:8-34. [PMID: 33741271 DOI: 10.1016/j.ymgme.2021.03.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/02/2021] [Accepted: 03/04/2021] [Indexed: 01/22/2023]
Abstract
MPS disorders are associated with a wide spectrum of neurocognitive effects, from mild problems with attention and executive functions to progressive and degenerative neuronopathic disease. Studies of the natural history of neurocognition are necessary to determine the profile of abnormality and the rates of change, which are crucial to select endpoints for clinical trials of brain treatments and to make clinical recommendations for interventions to improve patients' quality of life. The goal of this paper is to review neurocognitive natural history studies to determine the current state of knowledge and assist in directing future research in all MPS disorders. There are seven different types of MPS diseases, each resulting from a specific enzyme deficiency and each having a separate natural history. MPS IX, will not be discussed as there are only 4 cases reported in the literature without cognitive abnormality. For MPS IH, hematopoietic cell transplant (HCT) is standard of care and many studies have documented the relationship between age at treatment and neurocognitive outcome, and to a lesser extent, neurocognitive status at baseline. However, the mortality and morbidity associated with the transplant process and residual long-term problems after transplant, have led to renewed efforts to find better treatments. Rather than natural history, new trials will likely need to use the developmental trajectories of the patients with HCT as a comparators. The literature has extensive data regarding developmental trajectories post-HCT. For attenuated MPS I, significant neurocognitive deficits have been documented, but more longitudinal data are needed in order to support a treatment directed at their attention and executive function abnormalities. The neuronopathic form of MPS II has been a challenge due to the variability of the trajectory of the disease with differences in timing of slowing of development and decline. Finding predictors of the course of the disease has only been partially successful, using mutation type and family history. Because of lack of systematic data and clinical trials that precede a thorough understanding of the disease, there is need for a major effort to gather natural history data on the entire spectrum of MPS II. Even in the attenuated disease, attention and executive function abnormalities need documentation. Lengthy detailed longitudinal studies are needed to encompass the wide variability in MPS II. In MPS IIIA, the existence of three good natural history studies allowed a quasi-meta-analysis. In patients with a rapid form of the disease, neurocognitive development slowed up until 42 to 47 months, halted up to about 54 months, then declined rapidly thereafter, with a leveling off at an extremely low age equivalent score below 22 months starting at about chronological age of 6. Those with slower or attenuated forms have been more variable and difficult to characterize. Because of the plethora of studies in IIIA, it has been recommended that data be combined from natural history studies to minimize the burden on parents and patients. Sufficient data exists to understand the natural history of cognition in MPS IIIA. MPS IIIB is quite similar to IIIA, but more attenuated patients in that phenotype have been reported. MPS IIIC and D, because they are so rare, have little documentation of natural history despite the prospects of treatments. MPS IV and VI are the least well documented of the MPS disorders with respect to their neurocognitive natural history. Because, like attenuated MPS I and II, they do not show progression of neurocognitive abnormality and most patients function in the range of normality, their behavioral, attentional, and executive function abnormalities have been ignored to the detriment of their quality of life. A peripheral treatment for MPS VII, extremely rare even among MPS types, has recently been approved with a post-approval monitoring system to provide neurocognitive natural history data in the future. More natural history studies in the MPS forms with milder cognitive deficits (MPS I, II, IV, and VI) are recommended with the goal of improving these patients' quality of life with and without new brain treatments, beyond the benefits of available peripheral enzyme replacement therapy. Recommendations are offered at-a-glance with respect to what areas most urgently need attention to clarify neurocognitive function in all MPS types.
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Affiliation(s)
- Elsa G Shapiro
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA; Shapiro Neuropsychology Consulting LLC, Portland, OR, USA.
| | - Julie B Eisengart
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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Hampe CS, Wesley J, Lund TC, Orchard PJ, Polgreen LE, Eisengart JB, McLoon LK, Cureoglu S, Schachern P, McIvor RS. Mucopolysaccharidosis Type I: Current Treatments, Limitations, and Prospects for Improvement. Biomolecules 2021; 11:189. [PMID: 33572941 PMCID: PMC7911293 DOI: 10.3390/biom11020189] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 12/16/2022] Open
Abstract
Mucopolysaccharidosis type I (MPS I) is a lysosomal disease, caused by a deficiency of the enzyme alpha-L-iduronidase (IDUA). IDUA catalyzes the degradation of the glycosaminoglycans dermatan and heparan sulfate (DS and HS, respectively). Lack of the enzyme leads to pathologic accumulation of undegraded HS and DS with subsequent disease manifestations in multiple organs. The disease can be divided into severe (Hurler syndrome) and attenuated (Hurler-Scheie, Scheie) forms. Currently approved treatments consist of enzyme replacement therapy (ERT) and/or hematopoietic stem cell transplantation (HSCT). Patients with attenuated disease are often treated with ERT alone, while the recommended therapy for patients with Hurler syndrome consists of HSCT. While these treatments significantly improve disease manifestations and prolong life, a considerable burden of disease remains. Notably, treatment can partially prevent, but not significantly improve, clinical manifestations, necessitating early diagnosis of disease and commencement of treatment. This review discusses these standard therapies and their impact on common disease manifestations in patients with MPS I. Where relevant, results of animal models of MPS I will be included. Finally, we highlight alternative and emerging treatments for the most common disease manifestations.
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Affiliation(s)
| | | | - Troy C. Lund
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA; (T.C.L.); (P.J.O.); (J.B.E.)
| | - Paul J. Orchard
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA; (T.C.L.); (P.J.O.); (J.B.E.)
| | - Lynda E. Polgreen
- The Lundquist Institute at Harbor, UCLA Medical Center, Torrance, CA 90502, USA;
| | - Julie B. Eisengart
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA; (T.C.L.); (P.J.O.); (J.B.E.)
| | - Linda K. McLoon
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Sebahattin Cureoglu
- Department of Otolaryngology, Head and Neck Surgery, University of Minnesota, Minneapolis, MN 55455, USA; (S.C.); (P.S.)
| | - Patricia Schachern
- Department of Otolaryngology, Head and Neck Surgery, University of Minnesota, Minneapolis, MN 55455, USA; (S.C.); (P.S.)
| | - R. Scott McIvor
- Immusoft Corp, Minneapolis, MN 55413, USA;
- Department of Genetics, Cell Biology and Development and Center for Genome Engineering, University of Minnesota, Minneapolis, MN 55455, USA
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Mucopolysaccharidoses I and II: Brief Review of Therapeutic Options and Supportive/Palliative Therapies. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2408402. [PMID: 33344633 PMCID: PMC7732385 DOI: 10.1155/2020/2408402] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/08/2020] [Accepted: 11/21/2020] [Indexed: 12/30/2022]
Abstract
Purpose. Mucopolysaccharidoses (MPS) are group of inherited lysosomal storage diseases caused by mutations of enzymes involved in catalyzing different glycosaminoglycans (GAGs). MPS I and MPS II exhibit both somatic and neurological symptoms with a relatively high disease incidence. Hematopoietic stem cell therapy (HSCT) and intravenous enzyme replacement therapy (ERT) have had a significant impact on the treatment and comprehension of disease. This review is aimed at providing a comprehensive evaluation of the pros and cons of HSCT and ERT, as well as an up-to-date knowledge of new drugs under development. In addition, multiple disease management strategies for the uncontrollable manifestations of MPS I and MPS II to improve patients' quality of life are presented. Findings. Natural history of MPS I and MPS II shows that somatic and neurological symptoms occur earlier in severe forms of MPS I than in MPS II. ERT increases life expectancy and alleviates some of the somatic symptoms, but musculoskeletal, ophthalmological, and central nervous system (CNS) manifestations are not controlled. Additionally, life-long treatment burdens and immunogenicity restriction are unintended consequences of ERT application. HSCT, another treatment method, is effective in controlling the CNS symptoms and hence has been adopted as the standard treatment for severe types of MPS I. However, it is ineffective in MPS II, which can be explained by the relatively late diagnosis. In addition, several factors such as transplant age limits or graft-versus-host disease in HSCT have limited its application for patients. Novel therapies, including BBB-penetrable-ERT, gene therapy, and substrate reduction therapy, are under development to control currently unmanageable manifestations. BBB-penetrable-ERT is being studied comprehensively in the hopes of being used in the near future as a method to effectively control CNS symptoms. Gene therapy has the potential to “cure” the disease with a one-time treatment rather than just alleviate symptoms, which makes it an attractive treatment strategy. Several clinical studies on gene therapy reveal that delivering genes directly into the brain achieves better results than intravenous administration in patients with neurological symptoms. Considering new drugs are still in clinical stage, disease management with close monitoring and supportive/palliative therapy is of great importance for the time being. Proper rehabilitation therapy, including physical and occupational therapy, surgical intervention, or medications, can benefit patients with uncontrolled musculoskeletal, respiratory, ophthalmological, and neurological manifestations.
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Pomegranate peel extract ameliorates liver fibrosis induced by carbon tetrachloride in rats through suppressing p38MAPK/Nrf2 pathway. J Funct Foods 2020. [DOI: 10.1016/j.jff.2019.103712] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Polgreen LE, Lund TC, Braunlin E, Tolar J, Miller BS, Fung E, Whitley CB, Eisengart JB, Northrop E, Rudser K, Miller WP, Orchard PJ. Clinical trial of laronidase in Hurler syndrome after hematopoietic cell transplantation. Pediatr Res 2020; 87:104-111. [PMID: 31434105 PMCID: PMC6960090 DOI: 10.1038/s41390-019-0541-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/17/2019] [Accepted: 06/30/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Mucopolysaccharidosis I (MPS IH) is a lysosomal storage disease treated with hematopoietic cell transplantation (HCT) because it stabilizes cognitive deterioration, but is insufficient to alleviate all somatic manifestations. Intravenous laronidase improves somatic burden in attenuated MPS I. It is unknown whether laronidase can improve somatic disease following HCT in MPS IH. The objective of this study was to evaluate the effects of laronidase on somatic outcomes of patients with MPS IH previously treated with HCT. METHODS This 2-year open-label pilot study of laronidase included ten patients (age 5-13 years) who were at least 2 years post-HCT and donor engrafted. Outcomes were assessed semi-annually and compared to historic controls. RESULTS The two youngest participants had a statistically significant improvement in growth compared to controls. Development of persistent high-titer anti-drug antibodies (ADA) was associated with poorer 6-min walk test (6MWT) performance; when patients with high ADA titers were excluded, there was a significant improvement in the 6MWT in the remaining seven patients. CONCLUSIONS Laronidase seemed to improve growth in participants <8 years old, and 6MWT performance in participants without ADA. Given the small number of patients treated in this pilot study, additional study is needed before definitive conclusions can be made.
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Affiliation(s)
- Lynda E. Polgreen
- 0000000419368657grid.17635.36University of Minnesota Masonic Children’s Hospital, Minneapolis, MN USA ,Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA USA
| | - Troy C. Lund
- 0000000419368657grid.17635.36University of Minnesota Masonic Children’s Hospital, Minneapolis, MN USA
| | - Elizabeth Braunlin
- 0000000419368657grid.17635.36University of Minnesota Masonic Children’s Hospital, Minneapolis, MN USA
| | - Jakub Tolar
- 0000000419368657grid.17635.36University of Minnesota Masonic Children’s Hospital, Minneapolis, MN USA
| | - Bradley S. Miller
- 0000000419368657grid.17635.36University of Minnesota Masonic Children’s Hospital, Minneapolis, MN USA
| | - Ellen Fung
- 0000 0004 0433 7727grid.414016.6Children’s Hospital Oakland Research Institute, Oakland, CA USA
| | - Chester B. Whitley
- 0000000419368657grid.17635.36University of Minnesota Masonic Children’s Hospital, Minneapolis, MN USA
| | - Julie B. Eisengart
- 0000000419368657grid.17635.36University of Minnesota Masonic Children’s Hospital, Minneapolis, MN USA
| | - Elise Northrop
- 0000000419368657grid.17635.36Division of Biostatistics, University of Minnesota, Minneapolis, MN USA
| | - Kyle Rudser
- 0000000419368657grid.17635.36Division of Biostatistics, University of Minnesota, Minneapolis, MN USA
| | - Weston P. Miller
- 0000000419368657grid.17635.36University of Minnesota Masonic Children’s Hospital, Minneapolis, MN USA ,0000 0004 0410 9476grid.421831.dSangamo Therapeutics, Richmond, CA USA
| | - Paul J. Orchard
- 0000000419368657grid.17635.36University of Minnesota Masonic Children’s Hospital, Minneapolis, MN USA
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Abstract
Mucopolysaccharidoses (MPS) are inborn errors of metabolism produced by a deficiency of one of the enzymes involved in the degradation of glycosaminoglycans (GAGs). Although taken separately, each type is rare. As a group, MPS are relatively frequent, with an overall estimated incidence of around 1 in 20,000-25,000 births. Development of therapeutic options for MPS, including hematopoietic stem cell transplantation (HSCT) and enzyme replacement therapy (ERT), has modified the natural history of many MPS types. In spite of the improvement in some tissues and organs, significant challenges remain unsolved, including blood-brain barrier (BBB) penetration and treatment of lesions in avascular cartilage, heart valves, and corneas. Newer approaches, such as intrathecal ERT, ERT with fusion proteins to cross the BBB, gene therapy, substrate reduction therapy (SRT), chaperone therapy, and some combination of these strategies may provide better outcomes for MPS patients in the near future. As early diagnosis and early treatment are imperative to improve therapeutic efficacy, the inclusion of MPS in newborn screening programs should enhance the potential impact of treatment in reducing the morbidity associated with MPS diseases. In this review, we evaluate available treatments, including ERT and HSCT, and future treatments, such as gene therapy, SRT, and chaperone therapy, and describe the advantages and disadvantages. We also assess the current clinical endpoints and biomarkers used in clinical trials.
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Shafaat M, Hashemi M, Majd A, Abiri M, Zeinali S. Genetic testing of Mucopolysaccharidoses disease using multiplex PCR- based panels of STR markers: in silico analysis of novel mutations. Metab Brain Dis 2019; 34:1447-1455. [PMID: 31236806 DOI: 10.1007/s11011-019-00434-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/13/2019] [Indexed: 12/22/2022]
Abstract
The Mucopolysaccharidoses (MPS) are group of inherited metabolic diseases caused by the deficiency of enzymes required to degrade glycosaminoglycans (GAGs) in the lysosomes. GAGs are sulfated polysaccharides involving repeating disaccharides, uronic acid and hexosamines including chondroitin sulfate (CS), dermatan sulfate (DS), heparan sulfate (HS) and keratan sulfate (KS). Hyaluronan is excluded in terms of being non-sulfated in the GAG family. Different types of mutations have been identified as the causative agent in all types of MPS. Herein, we planned to investigate the pathogenic mutations in different types of MPS including type I (IDUA gene), IIIA (SGSH) and IIIB (NAGLU) in the eight Iranian patients. Autozygosity mapping was performed to identify the potential pathogenic variants in these 8 patients indirectly with the clinical diagnosis of MPSs. so three panels of STR (Short Tandem Repeat) markres flanking IDUA, SGSH and NAGLU genes were selected for multiplex PCR amplification. Then in each family candidate gene was sequenced to identify the pathogenic mutation. Our study showed two novel mutations c.469 T > C and c.903C > G in the IDUA gene, four recurrent mutations: c.1A > C in IDUA, c.220C > T, c.1298G > A in SGSH gene and c.457G > A in the NAGLU gene. The c.1A > C in IDUA was the most common mutation in our study. In silico analysis were performed as well to predict the pathogenicity of the novel variants.
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Affiliation(s)
- Mehdi Shafaat
- Department of Biology, Faculty of Science, North Tehran Branch of Islamic Azad University, Tehran, Iran
| | - Mehrdad Hashemi
- Department of Genetics, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Ahmad Majd
- Department of Biology, Faculty of Science, North Tehran Branch of Islamic Azad University, Tehran, Iran
| | - Maryam Abiri
- Department of Medical Genetics and Molecular biology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Sirous Zeinali
- Department of Molecular Medicine, Biotechnology Research Center, Pasteur Institute of Iran, Pasteur St, Tehran, Iran.
- Dr. Zeinali's Medical Genetics Lab, Kawsar Human Genetics Center, No. 41 Majlesi St., Vali Asr St., Postal Code, Tehran, 1595645513, Iran.
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Intrathecal enzyme replacement for Hurler syndrome: biomarker association with neurocognitive outcomes. Genet Med 2019; 21:2552-2560. [PMID: 31019279 PMCID: PMC6831510 DOI: 10.1038/s41436-019-0522-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/15/2019] [Indexed: 11/08/2022] Open
Abstract
PURPOSE Abnormalities in cerebrospinal fluid (CSF) have been reported in Hurler syndrome, a fatal neurodegenerative lysosomal disorder. While no biomarker has predicted neurocognitive response to treatment, one of these abnormalities, glycosaminoglycan nonreducing ends (NREs), holds promise to monitor therapeutic efficacy. A trial of intrathecal enzyme replacement therapy (ERT) added to standard treatment enabled tracking of CSF abnormalities, including NREs. We evaluated safety, biomarker response, and neurocognitive correlates of change. METHODS In addition to intravenous ERT and hematopoietic cell transplantation, patients (N = 24) received intrathecal ERT at four peritransplant time points; CSF was evaluated at each point. Neurocognitive functioning was quantified at baseline, 1 year, and 2 years posttransplant. Changes in CSF biomarkers and neurocognitive function were evaluated for an association. RESULTS Over treatment, there were significant decreases in CSF opening pressure, biomarkers of disease activity, and markers of inflammation. Percent decrease in NRE from pretreatment to final intrathecal dose posttransplant was positively associated with percent change in neurocognitive score from pretreatment to 2 years posttransplant. CONCLUSION Intrathecal ERT was safe and, in combination with standard treatment, was associated with reductions in CSF abnormalities. Critically, we report evidence of a link between a biomarker treatment response and neurocognitive outcome in Hurler syndrome.
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Jimenez J, Sakthivel M, Nischal KK, Fedorchak MV. Drug delivery systems and novel formulations to improve treatment of rare corneal disease. Drug Discov Today 2019; 24:1564-1574. [PMID: 30872110 DOI: 10.1016/j.drudis.2019.03.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/17/2019] [Accepted: 03/05/2019] [Indexed: 02/07/2023]
Abstract
As the field of ocular drug delivery grows so does the potential for novel drug discovery or reformulation in lesser-known diseases of the eye. In particular, rare corneal diseases are an interesting area of research because drug delivery is limited to the outermost tissue of the eye. This review will highlight the opportunities and challenges of drug reformulation and alternative treatment approaches for rare corneal diseases. The barriers to effective drug delivery and proposed solutions in development will be discussed along with an overview of corneal rare disease resources, their current treatments and ophthalmic drug delivery systems that could benefit such cases. The regulatory considerations for effective translation of orphan-designated products will also be discussed.
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Affiliation(s)
- Jorge Jimenez
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Meera Sakthivel
- Department of Biological Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kanwal K Nischal
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Morgan V Fedorchak
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA; Department of Chemical Engineering, University of Pittsburgh, Pittsburgh, PA, USA; Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA.
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Conner T, Cook F, Fernandez V, Rascati K, Rangel-Miller V. An online survey on burden of illness among families with post-stem cell transplant mucopolysaccharidosis type I children in the United States. Orphanet J Rare Dis 2019; 14:48. [PMID: 30777108 PMCID: PMC6378738 DOI: 10.1186/s13023-019-1027-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/07/2019] [Indexed: 11/24/2022] Open
Abstract
Background Severe mucopolysaccharidosis type I (also known as Hurler syndrome) is a rare devasting recessive genetic disease caused by the deficiency of an enzyme. Hematopoietic stem cell transplant is the standard of care in the United States, usually conducted before the child is 3 years of age, but little is known about the continued medical and educational needs of the child after transplant. A greater understanding of the burden of illness on the primary caregiver is also needed. Therefore, this online survey sought to gather information on the burden of severe MPS I in the United States at least 1 year after transplant. Results Thirty-two respondents reported that children with severe MPS I have significant medical and educational needs after transplant. Healthcare resource use was frequent, especially in the outpatient setting specifically for bone, cardiac, and vision complications that were not relieved by HSCT. Twenty-five percent of the children had been hospitalized at least once in the last year and two had been hospitalized twice. The most common reasons for overnight hospitalizations included orthopedic surgeries and respiratory infections. Among children ages 5 and older, only 3 of 28 (11%) were able to attend school with no special support. While caregivers were generally satisfied with the healthcare services their child receives, 69% of working caregivers reported negative impact on their ability to conduct work tasks, and 54% of caregivers did not work so that they could care for the child. Conclusions Results suggest that severe MPS I children continue to require medical care and special support for education. Future research on the burden of illness on families affected by severe MPS I is needed to better understand total cost of care, and to identify therapies and interventions that reduce burden of illness. Future studies that compare cost of and access to health care in different countries may provide a more global view of the burden of MPS I.
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Affiliation(s)
- Therese Conner
- REGENXBIO Inc., 9600 Blackwell Road, Suite 210, Rockville, MD, 20850, USA.
| | - Francesca Cook
- REGENXBIO Inc., 9600 Blackwell Road, Suite 210, Rockville, MD, 20850, USA
| | - Vivian Fernandez
- REGENXBIO Inc., 9600 Blackwell Road, Suite 210, Rockville, MD, 20850, USA
| | - Karen Rascati
- University of Texas at Austin, College of Pharmacy, Austin, TX, USA
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Taylor M, Khan S, Stapleton M, Wang J, Chen J, Wynn R, Yabe H, Chinen Y, Boelens JJ, Mason RW, Kubaski F, Horovitz DDG, Barth AL, Serafini M, Bernardo ME, Kobayashi H, Orii KE, Suzuki Y, Orii T, Tomatsu S. Hematopoietic Stem Cell Transplantation for Mucopolysaccharidoses: Past, Present, and Future. Biol Blood Marrow Transplant 2019; 25:e226-e246. [PMID: 30772512 DOI: 10.1016/j.bbmt.2019.02.012] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/11/2019] [Indexed: 12/16/2022]
Abstract
Allogenic hematopoietic stem cell transplantation (HSCT) has proven to be a viable treatment option for a selected group of patients with mucopolysaccharidoses (MPS), including those with MPS types I, II, IVA, VI, and VII. Early diagnosis and timely referral to an expert in MPS are critical, followed by a complete examination and evaluation by a multidisciplinary team, including a transplantation physician. Treatment recommendations for MPS are based on multiple biological, sociological, and financial factors, including type of MPS, clinical severity, prognosis, present clinical signs and symptoms (disease stage), age at onset, rate of progression, family factors and expectations, financial burden, feasibility, availability, risks and benefits of available therapies such as HSCT, enzyme replacement therapy (ERT), surgical interventions, and other supportive care. International collaboration and data review are critical to evaluating the therapeutic efficacy and adverse effects of HSCT for MPS. Collaborative efforts to assess HSCT for MPS have been ongoing since the first attempt at HSCT in a patient with MPS reported in 1981. The accumulation of data since then has made it possible to identify early outcomes (ie, transplantation outcomes) and long-term disease-specific outcomes resulting from HSCT. The recent identification of predictive factors and the development of innovative regimens have significantly improved the outcomes of both engraftment failure and transplantation-related mortality. Assessment of long-term outcomes has considered a variety of factors, including type of MPS, type of graft, age at transplantation, and stage of disease progression, among others. Studies on long-term outcomes are considered a key factor in the use of HSCT in patients with MPS. These studies have shown the effects and limitations of HSCT on improving disease manifestations and quality of life. In this review, we summarize the efficacy, side effects, risks, and cost of HSCT for each type of MPS.
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Affiliation(s)
- Madeleine Taylor
- Department of Biomedical, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; Deparment of Biological Science, University of Delaware, Newark, Delaware
| | - Shaukat Khan
- Department of Biomedical, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Molly Stapleton
- Department of Biomedical, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; Deparment of Biological Science, University of Delaware, Newark, Delaware
| | - Jianmin Wang
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Chen
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Robert Wynn
- Department of Paediatric Haematology and Cell Therapy, University of Manchester, Manchester, United Kingdom
| | - Hiromasa Yabe
- Department of Cell Transplantation and Regenerative Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Yasutsugu Chinen
- Department of Pediatrics, Faculty of Medicine, University of the Ryukyus, Nishihara, Japan
| | - Jaap Jan Boelens
- Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert W Mason
- Department of Biomedical, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; Deparment of Biological Science, University of Delaware, Newark, Delaware
| | - Francyne Kubaski
- Medical Genetics Service, Hospital de ClÃnicas de Porto Alegre (HCPA), Department of Genetics and Molecular Biology- Program Partnership Graduate in Genetics and Molecular Biology (PPGBM), Federal University of Rio Grande do Sul (UFRGS), and National Institute of Populational Medical Genetics (INAGEMP), Porto Alegre, Brazil
| | - Dafne D G Horovitz
- Medical Genetics Department, National Institute of Women, Children, and Adolescent Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Anneliese L Barth
- Medical Genetics Department, National Institute of Women, Children, and Adolescent Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Marta Serafini
- Department of Pediatrics, Dulbecco Telethon Institute, University of Milano-Bicocca, Monza, Italy
| | - Maria Ester Bernardo
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, San Raffaele-Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Hironori Kobayashi
- Department of Pediatrics, Shimane University Faculty of Medicine, Shimane, Japan
| | - Kenji E Orii
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Yasuyuki Suzuki
- Medical Education Development Center, Gifu University, Gifu, Japan
| | - Tadao Orii
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Shunji Tomatsu
- Department of Biomedical, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; Department of Pediatrics, Shimane University Faculty of Medicine, Shimane, Japan; Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan; Department of Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania.
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Wadhwa A, Chen Y, Holmqvist A, Wu J, Ness E, Parman M, Kung M, Hageman L, Francisco L, Braunlin E, Miller W, Lund T, Armenian S, Arora M, Orchard P, Bhatia S. Late Mortality after Allogeneic Blood or Marrow Transplantation for Inborn Errors of Metabolism: A Report from the Blood or Marrow Transplant Survivor Study-2 (BMTSS-2). Biol Blood Marrow Transplant 2019; 25:328-334. [PMID: 30292746 PMCID: PMC9940306 DOI: 10.1016/j.bbmt.2018.09.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 09/26/2018] [Indexed: 01/05/2023]
Abstract
Allogeneic blood or marrow transplantation (BMT) is currently considered the standard of care for patients with specific inborn errors of metabolism (IEM). However, there is a paucity of studies describing long-term survival and cause-specific late mortality after BMT in these patients with individual types of IEM. We studied 273 patients who had survived ≥2 years after allogeneic BMT for IEM performed between 1974 and 2014. The most prevalent IEM in our cohort were X-linked adrenoleukodystrophy (ALD; 37.3%), Hurler syndrome (35.1%), and metachromatic leukodystrophy (MLD; 10.2%). Conditional on surviving ≥2 years after BMT, the overall survival for the entire cohort was 85.5 ± 2.4% at 10 years and 73.5 ± 3.7% at 20 years. The cohort had a 29-fold increased risk of late death compared with an age- and sex-matched cohort from the general US population (95% CI, 22- to 38-fold). The increased relative mortality was highest in the 2- to 5-year period after BMT (standardized mortality ratio [SMR], 207; 95% confidence interval [CI], 130 to 308) and declined with increasing time from BMT, but remained elevated for ≥21 years after BMT (SMR, 9; 95% CI, 4 to 18). Sequelae from the progression of primary disease were the most common causes of late mortality in this cohort (76%). The use of T cell-depleted grafts in patients with ALD and Hurler syndrome was a risk factor for late mortality. Younger age at BMT and use of busulfan and cyclosporine were protective in patients with Hurler syndrome. Our findings demonstrate relatively favorable overall survival in ≥2-year survivors of allogeneic BMT for IEM, although primary disease progression continues to be responsible for the majority of late deaths.
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Affiliation(s)
- Aman Wadhwa
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Yanjun Chen
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Anna Holmqvist
- Pediatric Oncology and Hematology, Ska ne University Hospital, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Jessica Wu
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Emily Ness
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mariel Parman
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michelle Kung
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lindsey Hageman
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Liton Francisco
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth Braunlin
- Division of Pediatric Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Weston Miller
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota,Sangamo Therapeutics, Richmond, California
| | - Troy Lund
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Saro Armenian
- Pediatric Hematology and Oncology, City of Hope, Duarte, California
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Paul Orchard
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Smita Bhatia
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama.
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Braunlin E, Miettunen K, Lund T, Luquette M, Orchard P. Hematopoietic cell transplantation for severe MPS I in the first six months of life: The heart of the matter. Mol Genet Metab 2019; 126:117-120. [PMID: 30503158 DOI: 10.1016/j.ymgme.2018.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 11/12/2018] [Accepted: 11/12/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hematopoietic cell transplantation (HCT) is accepted therapy for severe mucopolysaccharidosis type I (MPS IH). With implementation of newborn screening (NBS) for MPS I in the US, HCT may now occur earlier than 1-2 years of age and it might be assumed that cardiac issues will be fewer. To examine this hypothesis, we reviewed our records for any MPS IH infant who underwent HCT at ≤6 months of age. STUDY PATIENTS Pre- and (most recent) post-HCT cardiac echos and clinical courses were reviewed in all infants with MPS IH undergoing HCT at ≤6 months of age. RESULTS 7 MPS IH infants (4 M) who were diagnosed at median (range) (MEDRNG) of 14 (3, 22) days of life (DOL) by NBS [2] or because an older sib had MPS IH [5], began enzyme replacement therapy at MEDRNG of 48 (7, 62) DOL. First pre-HCT echo was performed at MEDRNG of 45 (0, 88) DOL. HCT (6 cord blood, 1 related) occurred at MEDRNG of 131 (105, 183) DOL with most recent echo at MEDRNG of 408 (10, 1897) days after HCT. Mitral regurgitation (≥mild) occurred before (2/7) and after (2/7) HCT; LVH (2/7) occurred after HCT; PFO was common before (5/7) and after (3/7) HCT. One infant had severely decreased function at initial echo and required ICU management. Another infant with a patent foramen ovale and indwelling central line required additional neuroimaging to determine the cause of a seizure. A final infant died unexpectedly 69 days post-HCT without evidence of occlusive coronary disease at autopsy. CONCLUSIONS In addition to the traditional phenotypic features of severe MPS I, newborns presenting for HCT have cardiac and non-cardiac problems unique to their young age. Recognition of these issues is essential for optimal outcomes.
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Affiliation(s)
- Elizabeth Braunlin
- Pediatric Cardiology, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, United States.
| | - Kelly Miettunen
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Troy Lund
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Mark Luquette
- Department of Pathology, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Paul Orchard
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, United States
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Orchard PJ. Cellular Therapy in Rare Childhood Neurologic Disease: Lessons, Outcomes, and Access. J Child Neurol 2018; 33:877-881. [PMID: 30203711 DOI: 10.1177/0883073818797875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Paul J Orchard
- 1 Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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25
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Fu HX, Huang XJ. [Advances in haploidentical hematopoietic stem cell transplantation for non-malignant hematological diseases]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 39:691-696. [PMID: 30180476 PMCID: PMC7342844 DOI: 10.3760/cma.j.issn.0253-2727.2018.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Indexed: 11/05/2022]
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26
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Braunlin E, Steinberger J, DeFor T, Orchard P, Kelly AS. Metabolic Syndrome and Cardiovascular Risk Factors after Hematopoietic Cell Transplantation in Severe Mucopolysaccharidosis Type I (Hurler Syndrome). Biol Blood Marrow Transplant 2018; 24:1289-1293. [DOI: 10.1016/j.bbmt.2018.01.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 01/20/2018] [Indexed: 01/08/2023]
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Pantel JT, Zhao M, Mensah MA, Hajjir N, Hsieh TC, Hanani Y, Fleischer N, Kamphans T, Mundlos S, Gurovich Y, Krawitz PM. Advances in computer-assisted syndrome recognition by the example of inborn errors of metabolism. J Inherit Metab Dis 2018; 41:533-539. [PMID: 29623569 PMCID: PMC5959962 DOI: 10.1007/s10545-018-0174-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 03/13/2018] [Accepted: 03/18/2018] [Indexed: 11/26/2022]
Abstract
Significant improvements in automated image analysis have been achieved in recent years and tools are now increasingly being used in computer-assisted syndromology. However, the ability to recognize a syndromic facial gestalt might depend on the syndrome and may also be confounded by severity of phenotype, size of available training sets, ethnicity, age, and sex. Therefore, benchmarking and comparing the performance of deep-learned classification processes is inherently difficult. For a systematic analysis of these influencing factors we chose the lysosomal storage diseases mucolipidosis as well as mucopolysaccharidosis type I and II that are known for their wide and overlapping phenotypic spectra. For a dysmorphic comparison we used Smith-Lemli-Opitz syndrome as another inborn error of metabolism and Nicolaides-Baraitser syndrome as another disorder that is also characterized by coarse facies. A classifier that was trained on these five cohorts, comprising 289 patients in total, achieved a mean accuracy of 62%. We also developed a simulation framework to analyze the effect of potential confounders, such as cohort size, age, sex, or ethnic background on the distinguishability of phenotypes. We found that the true positive rate increases for all analyzed disorders for growing cohorts (n = [10...40]) while ethnicity and sex have no significant influence. The dynamics of the accuracies strongly suggest that the maximum distinguishability is a phenotype-specific value, which has not been reached yet for any of the studied disorders. This should also be a motivation to further intensify data sharing efforts, as computer-assisted syndrome classification can still be improved by enlarging the available training sets.
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Affiliation(s)
- Jean T Pantel
- Institute of Human Genetics and Medical Genetics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Institute for Genomic Statistics and Bioinformatics, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch 2, 10178, Berlin, Germany
| | - Max Zhao
- Institute of Human Genetics and Medical Genetics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Institute for Genomic Statistics and Bioinformatics, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| | - Martin A Mensah
- Institute of Human Genetics and Medical Genetics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch 2, 10178, Berlin, Germany
| | - Nurulhuda Hajjir
- Institute of Human Genetics and Medical Genetics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Tzung-Chien Hsieh
- Institute of Human Genetics and Medical Genetics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Institute for Genomic Statistics and Bioinformatics, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| | | | | | | | - Stefan Mundlos
- Institute of Human Genetics and Medical Genetics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | | | - Peter M Krawitz
- Institute of Human Genetics and Medical Genetics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Institute for Genomic Statistics and Bioinformatics, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany.
- GeneTalk, Bonn, Germany.
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