Kayser-Fleischer ring in Wilson's disease: a cohort study

Copper and its isotopes: a brief overview of its implications in geology, environmental system, and human health

Copper, a malleable and ductile transition metal, possesses two stable isotopes. These copper isotopic composition data have recently found diverse applications in various fields and disciplines. In geology, copper isotopes serve as tracers that aid in investigating ore formation processes and the mechanisms of copper deposits Likewise, it has emerged as a valuable tracer in polluted environments. In plant biology, copper acts as an essential micronutrient crucial for photosynthesis, respiration, and growth. Copper isotopes contribute to understanding how plants uptake and dispense copper from the soil within their tissues. Similarly, in animals, copper serves as an essential trace element, playing a vital role in growth, white blood cell function, and enzyme activity. In humans, copper acts as an antioxidant, neutralising harmful free radicals within the body. It also helps in maintaining the nervous and immune system. Furthermore, copper isotopes find medical applications, particularly in cancer diagnostics, neurodegenerative diseases, and targeted radiotherapy. However, excessive copper can have detrimental effects in humans such as it can cause liver damage, nausea, and abdominal pain, whilst in plants it can affect the growth of plants, photosynthesis, and membrane permeability. This review emphasises the significance of copper and its isotopes in geology, the environment, and human health.

Eye Involvement in Wilson’s Disease: A Review of the Literature

Wilson’s disease (WD) is an autosomal recessive genetic disorder due to a mutation of the ATP7B gene, resulting in impaired hepatic copper excretion and accumulation in various tissues. Ocular findings are one of the hallmarks of the disease. Many ophthalmological manifestations have been described and new techniques are currently available to improve their diagnosis and to follow their evolution. We have performed a systematic PubMed search to summarize available data of the recent literature on the most frequent ophthalmological disorders associated with WD, and to discuss the newest techniques used for their detection and follow-up during treatment. In total, 49 articles were retained for this review. The most common ocular findings seen in WD patients are Kayser–Fleischer ring (KFR) and sunflower cataracts. Other ocular manifestations may involve retinal tissue, visual systems and eye mobility. Diagnosis and follow-up under decoppering treatment of these ocular findings are generally easily performed with slit-lamp examination (SLE). However, new techniques are available for the precocious detection of ocular findings due to WD and may be of great value for non-experimented ophthalmologists and non-ophthalmologists practitioners. Among those techniques, anterior segment optical coherence tomography (AS-OCT) and Scheimpflug imaging are discussed.

Chelation therapy in liver diseases of childhood: Current status and response

Chelation is the mainstay of therapy in certain pediatric liver diseases. Copper and iron related disorders require chelation. Wilson’s disease (WD), one of the common causes of cirrhosis in children is treated primarily with copper chelating agents like D-penicillamine and trientine. D-Penicillamine though widely used due its high efficacy in hepatic WD is fraught with frequent adverse effects resulting discontinuation. Trientine, an alternative drug has comparable efficacy in hepatic WD but has lower frequency of adverse effects. The role of ammonium tetra-thiomolybdate is presently experimental in hepatic WD. Indian childhood cirrhosis is related to excessive copper ingestion, rarely seen in present era. D-Penicillamine is effective in the early part of this disease with reversal of clinical status. Iron chelators are commonly used in secondary hemochromatosis of liver in hemolytic anemias. There are strict chelation protocols during bone marrow transplant. The role of iron chelation in neonatal hemochromatosis is presently not in vogue due to its poor efficacy and availability of other modalities of therapy. Hereditary hemochromatosis is rare in children and the use of iron chelators in this condition is limited.

Role for Biochemical Assays and Kayser-Fleischer Rings in Diagnosis of Wilson's Disease

BACKGROUND & AIMS

Wilson disease is an autosomal recessive disorder that impairs copper homeostasis and is caused by homozygous or compound heterozygous mutations in ATP7B, which encodes a copper-transporting P-type ATPase. Patients have variable clinical manifestations and laboratory test results, resulting in diagnostic dilemmas. We aimed to identify factors associated with symptoms and features of Wilson disease from a large cohort, over 15 years.

METHODS

We collected data from 715 patients (529 with symptoms, 146 without symptoms, and 40 uncategorized) and a genetic confirmation of Wilson's disease (mean age of diagnosis, 18.84 years), recruited from 3 hospitals in China from 2004 through 2019. We analyzed clinical data along with serum levels of ceruloplasmin (available from 636 patients), 24-hr urinary copper excretion (collected from 131 patients), Kayser-Fleisher rings (copper accumulation in eyes, with neurologic data from 355 patients), and magnetic resonance imaging (MRI) abnormalities. Differences among the groups were analyzed using 1-way analysis of variance followed by Tukey multiple comparison test.

RESULTS

Of the 529 patients with symptoms, 121 had hepatic features, 355 had neurologic features, 28 had osteomuscular features (premature osteoarthritis, skeletal deformities, and pathological bone fractures), and 25 had psychiatric symptoms. Age of onset was significantly younger in patients with hepatic (16.94 ± 1.03 years; P = .0105) or osteomuscular features (13 ± 1.33 years; P = .0001) than patients with neurological features (19.48 ± 0.46 years). Serum levels of ceruloplasmin differed among asymptomatic patients and patients with osteomuscular or neurologic symptoms of Wilson disease. Serum levels of ceruloplasmin ranged from 18.93 mg/L to approximately 120.00 mg/L (quantiles of 0.025 to approximately 0.975). Fifty-one of 131 patients (39%) had urinary copper excretion levels below 100 μg/24 hr; there was significant variation in levels of urinary copper excretion between patients older than 14 years vs 14 years or younger. Of the 355 patients with neurologic features, 244 patients (69%) had abnormal findings from MRI and Kayser-Fleisher rings; only 1 patient with abnormal findings from brain MRI was negative for Kayser-Fleisher rings.

CONCLUSIONS

Serum level of ceruloplasmin, 24-hour urinary copper excretion, and Kayser-Fleisher rings can be used to identify patients who might have Wilson disease. Patients with serum levels of ceruloplasmin below 120 mg/L and children with urinary copper excretion above 40 μg should undergo genetic testing for Wilson's disease. Patients with movement disorders and brain MRI abnormalities without Kayser-Fleisher rings are not likely to have Wilson disease.

Kayser-Fleischer-Ring – kann eine frühe Diagnosestellung den Krankheitsverlauf von Morbus Wilson verbessern?

Morbus Wilson ist eine seltene genetische Erkrankung des Kupferstoffwechsels, die zu einer erhöhten Kupferansammlung im Körper führt. Ablagerungen finden sich vor allem in Leber, zentralem Nervensystem, Niere und Auge. Unbehandelt kann die Erkrankung zu Bewegungsstörungen, Persönlichkeitsveränderungen, Leberversagen bis hin zum Tod führen. Differenzialdiagnostisch kommen viele Erkrankungen infrage. Eine Diagnosefindung ist nur durch spezifische Testverfahren möglich. Der Augenarzt hat somit eine besondere Rolle in der Früherkennung eines Morbus Wilson. In unserer Klinik stellte sich eine 19-jährige Patientin mit einem schwachen, im Verlauf entstehenden Kayser-Fleischer-Kornealring mit sonst unauffälligem ophthalmologischen Befund vor. Die Patientin hatte ein progredientes Leberversagen und erhielt 2 Monate nach Erstvorstellung in der Augenklinik eine Lebertransplantation. Eine frühzeitige augenärztliche Mitbeurteilung mit gründlicher Untersuchung ist von entscheidender Bedeutung für eine schnelle Diagnosestellung. Die Kupferablagerungen finden sich in der Descemet-Membran und beginnen in der Schwalbe-Linie. Der sog. Kayser-Fleischer-Ring zeigt sich an der Descemet-Membran bis zu 5 mm vom Limbus entfernt. Andere mögliche ophthalmologische Manifestationen stellen eine Chalkose der gesamten Descemet, ein Ikterus der Skleren oder eine Sonnenblumenkatarakt dar. Bei fehlenden Kupferablagerungen im Spaltlampenbefund sollte bei einem Verdacht auf einen Morbus Wilson immer auch eine Gonioskopie des Kammerwinkels erfolgen. Eine frühe Diagnosestellung kann Patienten vor unnötigen Komplikationen und Operationen schützen. Behandelt hat der Morbus Wilson eine gute Prognose.

Evaluation and grading of Kayser-Fleischer ring in Wilson disease by Scheimpflug camera

PURPOSE

Evaluation the anterior segment parameters of Wilson disease patients with Kayser-Fleischer ring, the diagnostic power of Scheimpflug imaging for Kayser-Fleischer ring and suggest a scoring system.

MATERIALS AND METHODS

A total of 44 eyes of 22 Wilson disease patients with Kayser-Fleischer ring and 40 right eyes of 40 healthy age matched subjects were enrolled to the study. Serum ceruloplasmin and urine copper/24 hours levels were recorded. Anterior segment parameters including steep and flat keratometry, corneal thickness at central, 2, 4, 6, 8 and 10 mm, anterior chamber angle width, volume and depth, corneal volume, pupillary diameter were evaluated by Scheimpflug imaging. Images of cornea were scored according to Kayser-Fleischer ring size.

RESULTS

Serum ceruloplasmin level was below 10 mg/dL in 17 patients and was 12, 18.5, 20, 22, 37 mg/dl in the remaining five patients. Urinary copper/24 hours was 249.55 ± 304.14 (23-1050) µg/day. Central corneal thickness and corneal thickness at 2 mm were statistically different (p values 0.02, 0.04, respectively). Scheimpflug images apparently showed Kayser-Fleischer ring as a hyper-reflective band at the corneal endothelial surface. Kayser-Fleischer ring in 24 eyes was grade 1, 16 eyes were grade 2 and 4 eyes were grade 3.

CONCLUSION

Scheimpflug imaging seems to be a helpful diagnostic tool for detecting and grading the Kayser-Fleischer ring. Corneal thickness in Wilson disease patients with Kayser-Fleischer ring tends to be higher, so that the possible affection in corneal thickness should be kept in mind for clinical evaluation of these patients.

Importance of a Liver Biopsy in the Management of Wilson Disease

A 37-year-old Wilson disease patient treated with D-penicillamine visited our hospital for the evaluation of his liver function. Laboratory data showed a low serum copper level and ceruloplasmin. The ratio of urinary copper to urinary creatinine in a spot urinary analysis after 4 days' cessation of D-penicillamine was under 0.1. We concluded that the copper chelation was excessive and changed D-penicillamine to zinc acetate. However, his liver function test results did not normalize. We performed a liver biopsy and discovered a high copper content. The liver dysfunction was improved after resuming chelating therapy. Accurate measurement of the hepatic copper content via a biopsy is important for the adequate management of this disease.

Challenges in the diagnosis of Wilson disease

The understanding and management of Wilson disease (WD) have dramatically improved since the first description of the disease by K. Wilson more than a century ago. However, the persistent long delay between the first symptoms and diagnosis emphasizes challenges in diagnosing earlier this copper overload disorder. As a treatable disease, WD should be detected early in the course of the disease by any health professionals at any care level, but the rare prevalence of the disease explains the lack of awareness of referring physicians. The most important challenge is to train physicians to recognize atypical or rare symptoms of WD that will lead to discuss the diagnosis more systematically. Atypia can come from the age of onset, the liver [non-alcoholic steatohepatitis (NASH) presentation], the central or peripheral nervous system (neuropathy, epilepsy, sleep disorders…) or may be due to lesions of other organs (renal manifestations, osteo-articular disorders or endocrine disturbances). Isolated biological anomalies, rare radiological findings or inadequate interpretation of copper test may also lead to misdiagnosis. The second challenge is to confirm the diagnosis faster and more effectively so as not to delay the initiation of treatment, and expand family screening as the genetic prevalence is higher than previously expected. Generalization of the exchangeable copper assay and the next generation sequencing (NGS) are two promising ways to overcome this ultimate challenge. By drawing attention to the earliest and rare symptoms and to new biomarkers and diagnostic tools, we hope that this article will increase diagnostic awareness and reduce delays so that patients can start their treatment earlier in the course of the illness and thus have a better disease prognosis.

Clinical presentations of Wilson disease

The main presenting features of Wilson disease, many of which mimic common hepatic and neurologic disorders, are discussed. There is a need for specialists in these and related fields to be aware of hints from within and, more importantly, outside their area of expertise that should alert them to consider the diagnosis. Delayed diagnosis and treatment are potentially damaging for the patient. The importance of recognising and promptly investigating Wilson disease at the initial presentation should be understood by all those who assess patients with hepatic or neurologic disorders and/or train others in their specialty.

Wilson's Disease: Clinical Practice Guidelines of the Indian National Association for Study of the Liver, the Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition, and the Movement Disorders Society of India

Clinical practice guidelines for Wilson's disease (WD) have been published by the American Association for the Study of Liver Diseases and European Association for the Study of the Liver in 2008 and 2012, respectively. Their focus was on the hepatic aspects of the disease. Recently, a position paper on pediatric WD was published by the European Society of Pediatric Gastroenterology Hepatology and Nutrition. A need was felt to harmonize guidelines for the hepatic, pediatric, and neurological aspects of the disease and contextualize them to the resource-constrained settings. Therefore, experts from national societies from India representing 3 disciplines, hepatology (Indian National Association for Study of the Liver), pediatric hepatology (Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition), and neurology (Movement Disorders Society of India) got together to evolve fresh guidelines. A literature search on retrospective and prospective studies of WD using MEDLINE (PubMed) was performed. Members voted on each recommendation, using the nominal voting technique. The Grades of Recommendation, Assessment, Development and Evaluation system was used to determine the quality of evidence. Questions related to diagnostic tests, scoring system, and its modification to a version suitable for resource-constrained settings were posed. While ceruloplasmin and 24-h urine copper continue to be important, there is little role of serum copper and penicillamine challenge test in the diagnostic algorithm. A new scoring system - Modified Leipzig score has been suggested with extra points being added for family history and serum ceruloplasmin lower than 5 mg/dl. Liver dry copper estimation and penicillamine challenge test have been removed from the scoring system. Differences in pharmacological approach to neurological and hepatic disease and global monitoring scales have been included. Rising bilirubin and worsening encephalopathy are suggested as indicators predicting need for liver transplant but need to be validated. The clinical practice guidelines provide recommendations for a comprehensive management of WD which will be of value to all specialties.

Corneal manifestations of selected systemic diseases: A review

The corneal manifestations of several selected systemic diseases are reviewed. Metabolic, immunologic and inflammatory and infectious diseases are included. A brief overview of each disease and how it manifests in the cornea is discussed. The importance of conducting a slit-lamp examination on every patient is emphasised.

Therapeutic hepatocyte transplant for inherited metabolic disorders: functional considerations, recent outcomes and future prospects

The applications, outcomes and future strategies of hepatocyte transplantation (HTx) as a corrective intervention for inherited metabolic disease (IMD) are described. An overview of HTx in IMDs, as well as preclinical evaluations in rodent and other mammalian models, is summarized. Current treatments for IMDs are highlighted, along with short- and long-term outcomes and the potential for HTx to supplement or supplant these treatments. Finally, the advantages and disadvantages of HTx are presented, highlighted by long-term challenges with interorgan engraftment and expansion of transplanted cells, in addition to the future prospects of stem cell transplants. At present, the utility of HTx is represented by the potential to bridge patients with life-threatening liver disease to organ transplantation, especially as an adjuvant intervention where severe organ shortages continue to pose challenges.