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Limavady A, Marlais M. The extent of kidney involvement in paediatric tuberous sclerosis complex. Pediatr Nephrol 2024; 39:2927-2937. [PMID: 38832977 PMCID: PMC11349837 DOI: 10.1007/s00467-024-06417-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/16/2024] [Accepted: 05/16/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Tuberous sclerosis (TSC)-associated kidney disease is a leading cause of mortality in adults with TSC. This study aimed to understand TSC features in children, particularly kidney involvement, to inform clinical care for this specific group. METHODS This retrospective cohort study included all paediatric (< 19 years) TSC cases at a large tertiary paediatric nephrology centre. Relevant data were collected from patients' records, statistical analyses were performed to identify associations between variables, survival probabilities were estimated with Kaplan‒Meier curves, and log-rank tests were conducted to assess survival differences among genetic mutations. RESULTS A total of 182 children with TSC were included. Among the 145 children with available kidney imaging data, 78.6% (114/145) exhibited kidney lesions. Angiomyolipomas (AMLs) were significantly more prevalent in the TSC2 mutation group (p = 0.018). Children with TSC2 mutations generally had poorer lesion-free survival than those with TSC1 mutations, but this difference was only significant for AMLs (p = 0.030). The change in size of largest AMLs increased with age and doubled in children above 9 years; a similar pattern was observed when stratified by genetic mutation. In contrast, kidney cysts exhibited two peaks: one in children under 5 years (2.31 mm/year) and the second in children between 15-19 years (2.82 mm/year). Chronic kidney disease was observed in 12.3% (10/81) of children, and high-risk AMLs above 3 cm were observed in 9% (13/145). CONCLUSIONS While TSC kidney disease emerges later in the disease course than neurological features, our findings emphasise the importance of kidney surveillance during childhood, including routine kidney imaging, kidney function, and blood pressure monitoring.
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Affiliation(s)
- Andrew Limavady
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Matko Marlais
- Great Ormond Street Institute of Child Health, University College London, London, UK.
- Department of Paediatric Nephrology, Great Ormond Street Hospital, London, UK.
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2
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Mekahli D, Müller RU, Marlais M, Wlodkowski T, Haeberle S, de Argumedo ML, Bergmann C, Breysem L, Fladrowski C, Henske EP, Janssens P, Jouret F, Kingswood JC, Lattouf JB, Lilien M, Maleux G, Rozenberg M, Siemer S, Devuyst O, Schaefer F, Kwiatkowski DJ, Rouvière O, Bissler J. Clinical practice recommendations for kidney involvement in tuberous sclerosis complex: a consensus statement by the ERKNet Working Group for Autosomal Dominant Structural Kidney Disorders and the ERA Genes & Kidney Working Group. Nat Rev Nephrol 2024; 20:402-420. [PMID: 38443710 DOI: 10.1038/s41581-024-00818-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 03/07/2024]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by the presence of proliferative lesions throughout the body. Management of TSC is challenging because patients have a multifaceted systemic illness with prominent neurological and developmental impact as well as potentially severe kidney, heart and lung phenotypes; however, every organ system can be involved. Adequate care for patients with TSC requires a coordinated effort involving a multidisciplinary team of clinicians and support staff. This clinical practice recommendation was developed by nephrologists, urologists, paediatric radiologists, interventional radiologists, geneticists, pathologists, and patient and family group representatives, with a focus on TSC-associated kidney manifestations. Careful monitoring of kidney function and assessment of kidney structural lesions by imaging enable early interventions that can preserve kidney function through targeted approaches. Here, we summarize the current evidence and present recommendations for the multidisciplinary management of kidney involvement in TSC.
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Affiliation(s)
- Djalila Mekahli
- PKD Research Group, Laboratory of Ion Channel Research, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.
- Department of Paediatric Nephrology, University Hospitals Leuven, Leuven, Belgium.
| | - Roman-Ulrich Müller
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- CECAD, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Center for Rare Diseases Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Matko Marlais
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Tanja Wlodkowski
- Division of Paediatric Nephrology, Center for Paediatrics and Adolescent Medicine, University Hospital, Heidelberg, Germany
| | - Stefanie Haeberle
- Division of Paediatric Nephrology, Center for Paediatrics and Adolescent Medicine, University Hospital, Heidelberg, Germany
| | - Marta López de Argumedo
- Basque Office for Health Technology Assessment, (OSTEBA), Basque Government, Vitoria-Gasteiz, Spain
| | - Carsten Bergmann
- Department of Medicine IV, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Medizinische Genetik Mainz, Limbach Genetics, Mainz, Germany
| | - Luc Breysem
- Department of Radiology, University Hospital of Leuven, Leuven, Belgium
| | - Carla Fladrowski
- Associazione Sclerosi Tuberosa ASP, Rome, Italy
- European Tuberous Sclerosis Complex Association (ETSC), Oestrich-Winkel, Germany
| | - Elizabeth P Henske
- Center for LAM Research and Clinical Care, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Janssens
- Department of Nephrology and Arterial Hypertension, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel, Brussels, Belgium
| | - François Jouret
- Division of Nephrology, Department of Internal Medicine, University of Liège Hospital, Liège, Belgium
- Interdisciplinary Group of Applied Genoproteomics, Cardiovascular Sciences, University of Liège, Liège, Belgium
| | - John Christopher Kingswood
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Centre, St Georges University of London, London, UK
| | - Jean-Baptiste Lattouf
- Department of Surgery-Urology, CHUM-Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Marc Lilien
- Department of Paediatric Nephrology, Wilhelmina Children´s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Geert Maleux
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Micaela Rozenberg
- European Tuberous Sclerosis Complex Association (ETSC), Oestrich-Winkel, Germany
- Associação de Esclerose Tuberosa em Portugal, Lisbon, Portugal
| | - Stefan Siemer
- Department of Urology and Paediatric Urology, Saarland University, Homburg, Germany
| | - Olivier Devuyst
- Department of Physiology, Mechanisms of Inherited Kidney Disorders, University of Zurich, Zurich, Switzerland
- Institute for Rare Diseases, Saint-Luc Academic Hospital, UC Louvain, Brussels, Belgium
| | - Franz Schaefer
- Division of Paediatric Nephrology, Center for Paediatrics and Adolescent Medicine, University Hospital, Heidelberg, Germany
| | - David J Kwiatkowski
- Cancer Genetics Laboratory, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Olivier Rouvière
- Department of Radiology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Lyon, France, Faculté de médecine Lyon Est, Lyon, France
| | - John Bissler
- Department of Paediatrics, University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, TN, USA.
- Children's Foundation Research Institute (CFRI), Le Bonheur Children's Hospital, Memphis, TN, USA.
- Paediatric Medicine Department, St. Jude Children's Research Hospital, Memphis, TN, USA.
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Limavady A, Marlais M. Nutritional status as a predictive factor for paediatric tuberous sclerosis complex-associated kidney angiomyolipomas: a retrospective analysis. Eur J Pediatr 2024; 183:2563-2570. [PMID: 38483608 PMCID: PMC11098920 DOI: 10.1007/s00431-024-05520-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/09/2024] [Accepted: 03/09/2024] [Indexed: 05/19/2024]
Abstract
The purpose of this study is to determine the predictive factors of tuberous sclerosis complex (TSC)-associated kidney disease and its progression in children. Retrospective review of children with TSC in a tertiary children's hospital was performed. Relevant data were extracted, and Cox proportional hazards regression was used to establish predictors of kidney lesions. Logistic regression was conducted to identify factors predicting chronic kidney disease (CKD) and high-risk angiomyolipomas (above 3 cm). Kidney imaging data were available in 145 children with TSC; of these, 79% (114/145) had abnormal findings. The only significant predictive factor for cyst development was being female (HR = 0.503, 95% CI 0.264-0.956). Being female (HR = 0.505, 95% CI 0.272-0.937) and underweight (HR = 0.092, 95% CI 0.011-0.800) both lowers the risk of having angiomyolipomas, but TSC2 mutations (HR = 2.568, 95% CI 1.101-5.989) and being obese (HR = 2.555, 95%CI 1.243-5.255) increases risks. Ten (12%) of 81 children with kidney function tested demonstrate CKD stages II-V, and only angiomyolipomas above 3 cm predict CKD. Additionally, 13/145 (9%) children had high-risk angiomyolipomas, whereby current age (adjusted odds ratio (aOR) 1.015, 95% CI 1.004-1.026) and being overweight/obese (aOR 7.129, 95% CI 1.940-26.202) were significantly associated with angiomyolipomas above 3 cm. CONCLUSIONS While gender and genotype are known predictors, this study includes the novel finding of nutritional status as a predictor of TSC-associated kidney disease. This study sheds light on a possible complex interplay of hormonal influences, obesity, and kidney angiomyolipomas growth, and further investigations focusing on the impact of nutritional status on TSC-associated kidney disease are warranted. WHAT IS KNOWN • Gender and genotype are well-studied predictive factors in TSC kidney disease. WHAT IS NEW • Nutritional status may influence the development and the progression of kidney lesions in children with TSC and should not be overlooked. • Management guidelines of TSC-associated kidney disease can address nutritional aspects.
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Affiliation(s)
- Andrew Limavady
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Matko Marlais
- Great Ormond Street Institute of Child Health, University College London, London, UK.
- Department of Paediatric Nephrology, Great Ormond Street Hospital, London, UK.
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Cockerell I, Christensen J, Hoei-Hansen CE, Holst L, Grenaa Frederiksen M, Issa-Epe AI, Nedregaard B, Solhoff R, Heimdal K, Johannessen Landmark C, Lund C, Nærland T. Effectiveness and safety of everolimus treatment in patients with tuberous sclerosis complex in real-world clinical practice. Orphanet J Rare Dis 2023; 18:377. [PMID: 38042867 PMCID: PMC10693167 DOI: 10.1186/s13023-023-02982-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 11/18/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND The randomised double-blinded placebo-controlled EXIST-1-3 studies have showed everolimus effective with adverse effects reported as acceptable in treatment of symptoms in patients with tuberous sclerosis complex (TSC), although evidence of outcomes in clinical practice remains limited. This study aimed to investigate, in clinical practice, the effectiveness and safety of everolimus for epilepsy, renal angiomyolipoma (rAML), and subependymal giant cell astrocytoma (SEGA) in patients with TSC. RESULTS The study included 64 patients with TSC (median age: 19, range 0.9-54 years) receiving everolimus treatment (Norway: n = 35; Denmark: n = 29). Among 45 patients with epilepsy, 14 (31%) were responders experiencing ≥ 50% reduction in seizure frequency in the last 3 months of treatment compared with the last 3 months before treatment. Nineteen (42%) patients changed their anti-seizure medications (ASMs). Responders were more common among patients < 18 years (46%) than among patients ≥ 18 years (14%, p = 0.03). In 29 patients with rAML, everolimus reduced (≥ 30% decrease) and stabilized (< 20% increase, ≤ 30% decrease) longest diameter of rAML in 38% and 59%, respectively, after a mean treatment duration of 37 months. SEGA volume was reduced in three patients by 71%, 43%, and 48% after 39, 34, and 82 months. Adverse effects were reported in 61 of 64 patients (95%) after a median treatment duration of 31 months (range 0-106), with oral ulceration/stomatitis (63%) and upper respiratory tract infections (38%) being the most common. The most common laboratory abnormalities were increased cholesterol (41%), anaemia (30%), and leucopoenia (25%). Grade 3-4 adverse effects were reported in 36% of cases, and life-threatening conditions were reported in two patients. Nine patients discontinued everolimus treatment. CONCLUSIONS Seizure reduction in this study sample was consistent with results from EXIST, but might be lower than expected, given that changes in concomitant ASMs are part of clinical practice. Seizure reduction was associated with younger age. As with EXIST, everolimus reduced or stabilised rAML size in most patients. SEGA volume was reduced in all three patients. Close follow-up is needed for this group, especially for children and patients who may not be able to report adverse effects.
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Affiliation(s)
- Ine Cockerell
- Department of Rare Disorders and Disabilities, National Centre for Rare Epilepsy-Related Disorders, Oslo University Hospital, Pb 4950, 0424, Nydalen, Oslo, Norway.
| | - Jakob Christensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Affiliated Member of the European Reference Network EpiCARE, Aarhus, Denmark
| | - Christina E Hoei-Hansen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Paediatrics, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lotte Holst
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Aart Imran Issa-Epe
- Section of Abdominal Radiology, Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Bård Nedregaard
- Section of Neuroradiology, Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Ragnar Solhoff
- Department of Neurology, Sørlandet Hospital, Arendal, Norway
| | - Ketil Heimdal
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Cecilie Johannessen Landmark
- Department of Pharmacy, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- The National Center for Epilepsy (SSE), Member of the ERN EpiCare, Oslo University Hospital, Oslo, Norway
- Section for Clinical Pharmacology, SSE, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Caroline Lund
- Department of Rare Disorders and Disabilities, National Centre for Rare Epilepsy-Related Disorders, Oslo University Hospital, Pb 4950, 0424, Nydalen, Oslo, Norway
| | - Terje Nærland
- K.G. Jebsen Center for Neurodevelopmental Disorders, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- NevSom, Department of Rare Disorders and Disabilities, Oslo University Hospital, Oslo, Norway
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The characteristics and optimal treatment of urolithiasis associated with tuberous sclerosis complex. Int Urol Nephrol 2021; 53:1785-1790. [PMID: 33899133 PMCID: PMC8380235 DOI: 10.1007/s11255-021-02871-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/20/2021] [Indexed: 11/12/2022]
Abstract
Purpose The most common renal symptoms of tuberous sclerosis complex (TSC) are angiomyolipomas (AMLs) and renal cysts; however, some patients with TSC also develop urolithiasis. We retrospectively investigated the characteristics and treatment of urolithiasis associated with TSC. Methods We analyzed 142 patients who met the diagnostic criteria for TSC, of whom 20 (14.1%) had urolithiasis. We compared the patients’ characteristics, urinary specific gravity, urine pH, serum calcium and intact parathyroid hormone in the urolithiasis and non-urolithiasis groups. In the urolithiasis group, the stone characteristics and various treatments were analyzed. Results The antiepileptic drugs topiramate and zonisamide were more frequently administered to the urolithiasis group than the non-urolithiasis group (P = 0.013, P = 0.048, respectively). The urine specific gravity and urine pH levels were higher in the urolithiasis group than in the non-urolithiasis group (P = 0.005, P = 0.042, respectively). A multivariate logistic regression analysis demonstrated that urine-specific gravity (P = 0.018; odds ratio 1.471; 95% confidence interval 1.098–1.872) was a significant predictor of TSC-associated urolithiasis. Four patients could not receive extracorporeal shock wave lithotripsy due to the risk of bleeding from the AML. Conclusion Patients with TSC who have an increased urine specific gravity, alkaline urine, and a longer administration of topiramate and zonisamide tend to demonstrate an increased risk of developing urolithiasis and therefore such cases require adequate care. If urolithiasis is comorbid with TSC-associated AML, the treatment options are more limited in cases with multiple AMLs around the stone due to an increased risk of hemorrhage.
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Goedken AM, Samuels JA, Sato TS, Harshman LA. Kidney Imaging Surveillance in Commercially Insured Patients With Tuberous Sclerosis Complex. Pediatr Neurol 2021; 117:21-26. [PMID: 33647778 DOI: 10.1016/j.pediatrneurol.2020.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/15/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Kidney disease has historically been the primary source of early mortality in adults with tuberous sclerosis complex (TSC). Kidney imaging surveillance promotes early detection of lesions requiring intervention. We describe kidney imaging frequency in relationship to patient-level characteristics for commercially insured patients with TSC in the United States. METHODS This retrospective observational study used 2003 to 2016 enrollment and claims data from a de-identified fully insured commercial health insurer. Patients with TSC less than 65 years were included. The patient-level kidney imaging rate was calculated as the number of kidney imaging procedures divided by length of continuous enrollment. A multiple linear regression model was used to determine the relationship between imaging rate and progression of TSC-associated kidney disease, number of specialists seen, and nephrologist care. RESULTS At least half of the 70 patients with TSC included in the study were aged 16 years or younger. Over a follow-up period of up to 14 years, the median kidney imaging rate was 0.13 procedures per year with 43% (N = 30) of patients lacking evidence of kidney imaging during the observation period. Imaging frequency increased with progression of TSC-associated kidney disease, more specialists, and nephrologist care (P < 0.05 for all three in regression model). CONCLUSIONS A substantial percentage of patients with TSC in the United States are at risk for delayed detection of kidney manifestations due to infrequent kidney imaging surveillance. Multispecialty care, including neurologists, may positively affect kidney surveillance rates.
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Affiliation(s)
- Amber M Goedken
- Division of Health Services Research, College of Pharmacy, University of Iowa, Iowa City, Iowa.
| | - Joshua A Samuels
- Division of Pediatric Nephrology and Hypertension, McGovern Medical School, University of Texas Health Science Center, Houston, Texas
| | - Takashi S Sato
- Division of Pediatric Radiology, Stead Family Children's Hospital, University of Iowa, Iowa City, Iowa
| | - Lyndsay A Harshman
- Division of Pediatric Nephrology, University of Iowa Stead Family Department of Pediatrics, University of Iowa, Iowa City, Iowa
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Performance of simultaneous multi-slice accelerated diffusion-weighted imaging for assessing focal renal lesions in pediatric patients with tuberous sclerosis complex. Pediatr Radiol 2021; 51:77-85. [PMID: 32845348 DOI: 10.1007/s00247-020-04798-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/07/2020] [Accepted: 08/04/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Diffusion-weighted imaging (DWI) is a useful MRI technique to characterize abdominal lesions in children, but long acquisition times can lead to image degradation. Simultaneous multi-slice accelerated DWI is a promising technique to shorten DWI scan times. OBJECTIVE To test the feasibility of simultaneous multi-slice DWI of the kidneys in pediatric patients with tuberous sclerosis complex (TSC) and to evaluate the accelerated protocol regarding image quality and quantitative apparent diffusion coefficient (ADC) values compared to standard echoplanar DWI sequence. MATERIALS AND METHODS We included 33 children and adolescents (12 female, 21 male; mean age 10±5 years) with TSC and renal cyst or angiomyolipoma on 3-tesla (T) MRI from 2017 to 2019. All studies included both free-breathing standard echoplanar DWI and simultaneous multi-slice DWI sequences. Subjective and quantitative image quality was evaluated using a predefined 5-point scale. ADC values were obtained for all renal cysts and angiomyolipomas ≥5 mm. All statistical analysis was performed using Stata/SE v15.1. RESULTS Simultaneous multi-slice DWI ADC values were slightly lower compared to standard echoplanar DWI for both renal cysts and angiomyolipomas (mean difference 0.05×10-3 mm2/s, 95% confidence interval [CI] 0.40-0.50 and 0.024×10-3 mm2/s, 95% CI 0.17-0.21, respectively, with P>0.1). Our results showed that renal lesions with ADC values >1.69×10-3 mm2/s were all cysts, whereas lesions with values <1.16×10-3 mm2/s were all angiomyolipomas. However, ADC values could not discriminate between lipid-rich and lipid-poor angiomyolipomas (P>0.1, for both sequences). CONCLUSION A 55% reduction in scan time was achieved using simultaneous multi-slice DWI for abdominal imaging in children with TSC, with near identical image quality as standard DWI. These results suggest that multi-slice techniques should be considered more broadly as an MRI acceleration technique in children.
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Efficacy, Retention and Tolerability of Everolimus in Patients with Tuberous Sclerosis Complex: A Survey-Based Study on Patients' Perspectives. CNS Drugs 2021; 35:1107-1122. [PMID: 34275102 PMCID: PMC8478774 DOI: 10.1007/s40263-021-00839-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The approval of everolimus (EVE) for the treatment of angiomyolipoma (2013), subependymal giant cell astrocytoma (2013) and drug-refractory epilepsy (2017) in patients with tuberous sclerosis complex (TSC) represents the first disease-modifying treatment option available for this rare and complex genetic disorder. OBJECTIVE The objective of this study was to analyse the use, efficacy, tolerability and treatment retention of EVE in patients with TSC in Germany from the patient's perspective. METHODS A structured cross-age survey was conducted at 26 specialised TSC centres in Germany and by the German TSC patient advocacy group between February and July 2019, enrolling children, adolescents and adult patients with TSC. RESULTS Of 365 participants, 36.7% (n = 134) reported the current or past intake of EVE, including 31.5% (n = 115) who were taking EVE at study entry. The mean EVE dosage was 6.1 ± 2.9 mg/m2 (median: 5.6 mg/m2, range 2.0-15.1 mg/m2) in children and adolescents and 4 ± 2.1 mg/m2 (median: 3.7 mg/m2, range 0.8-10.1 mg/m2) in adult patients. An early diagnosis of TSC, the presence of angiomyolipoma, drug-refractory epilepsy, neuropsychiatric manifestations, subependymal giant cell astrocytoma, cardiac rhabdomyoma and overall multi-organ involvement were associated with the use of EVE as a disease-modifying treatment. The reported efficacy was 64.0% for angiomyolipoma (75% in adult patients), 66.2% for drug-refractory epilepsy, and 54.4% for subependymal giant cell astrocytoma. The overall retention rate for EVE was 85.8%. The retention rates after 12 months of EVE therapy were higher among adults (93.7%) than among children and adolescents (88.7%; 90.5% vs 77.4% after 24 months; 87.3% vs 77.4% after 36 months). Tolerability was acceptable, with 70.9% of patients overall reporting adverse events, including stomatitis (47.0%), acne-like rash (7.7%), increased susceptibility to common infections and lymphoedema (each 6.0%), which were the most frequently reported symptoms. With a total score of 41.7 compared with 36.8 among patients not taking EVE, patients currently being treated with EVE showed an increased Liverpool Adverse Event Profile. Noticeable deviations in the sub-items 'tiredness', 'skin problems' and 'mouth/gum problems', which are likely related to EVE-typical adverse effects, were more frequently reported among patients taking EVE. CONCLUSIONS From the patients' perspective, EVE is an effective and relatively well-tolerated disease-modifying treatment option for children, adolescents and adults with TSC, associated with a high long-term retention rate that can be individually considered for each patient. Everolimus therapy should ideally be supervised by a centre experienced in the use of mechanistic target of rapamycin inhibitors, and adverse effects should be monitored on a regular basis.
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Xu Z, Wu J, Xu G, Luo H. Abdominal ultrasonographic manifestations in pediatric patients with tuberous sclerosis complex. Transl Pediatr 2020; 9:757-767. [PMID: 33457297 PMCID: PMC7804489 DOI: 10.21037/tp-20-150] [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] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a rare genetic disease which leads to formation of benign tumors in the brain and other organs of the body. Ultrasound (US) can detect the location, quantity, size and internal echo of TSC-associated renal diseases, liver angiomyolipoma (AML), and co-existing lesions, providing important diagnostic basis for clinical diagnosis. The aim of the present study was to investigate the abdominal ultrasonographic features of pediatric TSC and explore the advantages of abdominal ultrasonography in clinical practice. METHODS Data of children with TSC, who presented to the Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, between January 2016 and November 2018, were analyzed by a retrospective chart review. The cases were identified from electronic medical records (EMR) system and underwent ultrasonography, we yielded a total of 12 patients. RESULTS The 12 pediatric patients, including 5 boys and 7 girls, ranged in age from 9 months to 13 years old. And they all had a history of epilepsy. All the patients underwent brain magnetic resonance imaging (MRI) or computed tomography (CT) examination, which revealed a scattered distribution of multiple hyperintense nodules. Of the 12 patients, 10 had TSC-associated bilateral renal AMLs, 5 had hepatic AML, and 4 had renal cysts. CONCLUSIONS US is a useful and non-invasive tool for the detection of TSC-associated renal and liver lesions and for clinical follow-up among pediatric patients.
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Affiliation(s)
- Zhihua Xu
- Department of Ultrasonic Diagnosis, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Junbo Wu
- Department of Ultrasound Imaging, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guimin Xu
- Department of Anesthesia, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Hongxia Luo
- Department of Ultrasonic Diagnosis, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
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Kingswood JC, Belousova E, Benedik MP, Carter T, Cottin V, Curatolo P, Dahlin M, D'Amato L, Beaure d'Augères G, de Vries PJ, Ferreira JC, Feucht M, Fladrowski C, Hertzberg C, Jozwiak S, Lawson JA, Macaya A, Marques R, Nabbout R, O'Callaghan F, Qin J, Sander V, Shah S, Takahashi Y, Touraine R, Youroukos S, Zonnenberg B, Jansen AC, Sauter M. Renal Manifestations of Tuberous Sclerosis Complex: Key Findings From the Final Analysis of the TOSCA Study Focussing Mainly on Renal Angiomyolipomas. Front Neurol 2020; 11:972. [PMID: 33041968 PMCID: PMC7526256 DOI: 10.3389/fneur.2020.00972] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/24/2020] [Indexed: 12/18/2022] Open
Abstract
Renal angiomyolipomas are one of the most common renal manifestations in patients with tuberous sclerosis complex (TSC), with potentially life-threatening complications and a poor prognosis. Despite the considerable progress in understanding TSC-associated renal angiomyolipomas, there are no large scale real-world data. The aim of our present study was to describe in detail the prevalence and outcome of renal angiomyolipomas in patients with TSC, enrolled into the TuberOus SClerosis registry to increase disease Awareness (TOSCA) from 170 sites across 31 countries worldwide. We also sought to evaluate the relationship of TSC-associated renal angiomyolipomas with age, gender and genotype. The potential risk factors for renal angiomyolipoma-related bleeding and chronic kidney disease (CKD) were studied in patients who participated in the TOSCA renal angiomyolipoma substudy. Of the 2,211 eligible patients, 1,062 (48%) reported a history of renal angiomyolipomas. The median age of TSC diagnosis for the all subjects (n = 2,211) was 1 year. The median age of diagnosis of renal angiomyolipoma in the 1,062 patients was 13 years. Renal angiomyolipomas were significantly more prevalent in female patients (p < 0.0001). Rates of angiomyolipomas >3 cm (p = 0.0119), growing lesions (p = 0.0439), and interventions for angiomyolipomas (p = 0.0058) were also higher in females than males. Pre-emptive intervention for renal angiomyolipomas with embolisation, surgery, or mammalian target of rapamycin (mTOR) inhibitor may have abolished the gender difference in impaired renal function, hypertension, and other complications. The rate of interventions for angiomyolipomas was less common in children than in adults, but interventions were reported in all age groups. In the substudy of 76 patients the complication rate was too low to be useful in predicting risk for more severe CKD. In addition, in this substudy no patient had a renal hemorrhage after commencing on an mTOR inhibitor. Our findings confirmed that renal angiomyolipomas in subjects with TSC1 mutations develop on average at the later age, are relatively smaller in size and less likely to be growing; however, by age 40 years, no difference was observed in the percentage of patients with TSC1 and TSC2 mutations needing intervention. The peak of appearance of new renal angiomyolipomas was observed in patients aged between 18 and 40 years, but, given that angiomyolipomas can occur later, lifelong surveillance is necessary. We found that pre-emptive intervention was dramatically successful in altering the outcome compared to historical controls; with high pre-emptive intervention rates but low rates of bleeding and other complications. This validates the policy of surveillance and pre-emptive intervention recommended by clinical guidelines.
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Affiliation(s)
- J Chris Kingswood
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Centre, St Georges University of London, London, United Kingdom
| | - Elena Belousova
- Research and Clinical Institute of Pediatrics, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Mirjana P Benedik
- Child Neurology Department, SPS Pediatrična Klinika, Ljubljana, Slovenia
| | - Tom Carter
- TSA Tuberous Sclerosis Association, Nottingham, United Kingdom
| | - Vincent Cottin
- Hôpital Louis Pradel, Claude Bernard University Lyon 1, Lyon, France
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University Hospital, Rome, Italy
| | - Maria Dahlin
- Neuropediatric Department, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | | | | | - Petrus J de Vries
- Division of Child and Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | - José C Ferreira
- Neurology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Martha Feucht
- Medical University of Vienna, Universitätsklinik für Kinder-und Jugendheilkunde, Affiliated Partner of the ERN EpiCARE, Vienna, Austria
| | - Carla Fladrowski
- Associazione Sclerosi Tuberosa ONLUS, Milan, Italy.,European Tuberous Sclerosis Complex Association, Dattein, Germany
| | - Christoph Hertzberg
- Zentrum für Neuropädiatrie und Sozialpädiatrie, Vivantes-Klinikum Neukölln, Berlin, Germany
| | - Sergiusz Jozwiak
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland.,Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - John A Lawson
- The Tuberous Sclerosis Multidisciplinary Management Clinic, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Alfons Macaya
- Pediatric Neurology Section, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ruben Marques
- Novartis Farma S.p.A., Origgio, Italy.,Institute of Biomedicine (IBIOMED), University of Leon, León, Spain
| | - Rima Nabbout
- Department of Pediatric Neurology, Necker Enfants Malades Hospital, Paris Descartes University, Paris, France
| | - Finbar O'Callaghan
- Institute of Child Health, University College London, London, United Kingdom
| | - Jiong Qin
- Department of Pediatrics, Peking University People's Hospital (PKUPH), Beijing, China
| | - Valentin Sander
- Department of Neurology and Rehabilitation, Tallinn Children Hospital, Tallinn, Estonia
| | - Seema Shah
- Novartis Healthcare Pvt. Ltd., Hyderabad, India
| | - Yukitoshi Takahashi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Renaud Touraine
- Department of Genetics, CHU-Hôpital Nord, Saint-Étienne, France
| | - Sotiris Youroukos
- First Department of Paediatrics, Athens University, St. Sophia Children's Hospital, Athens, Greece
| | - Bernard Zonnenberg
- Department of Internal Medicine, University Medical Center, Utrecht, Netherlands
| | - Anna C Jansen
- Pediatric Neurology Unit, Department of Pediatrics, UZ Brussel VUB, Brussels, Belgium
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11
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Tarasewicz A, Dębska-Ślizień A, Rutkowska B, Szurowska E. Living Donor Preemptive Kidney Transplantation in Tuberous Sclerosis Complex Patient and the Role of Mammalian Target of Rapamycin Inhibitor: A Case Report. Transplant Proc 2020; 52:2520-2523. [PMID: 32448667 DOI: 10.1016/j.transproceed.2020.01.128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/26/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Kidney transplantation (KT) is the preferred treatment for end-stage kidney disease (ESKD), while preemptive (PE) living donor (LD) KT is associated with better survival, quality of life, and lower costs. Tuberous sclerosis complex (TSC) is a genetic multisystem disorder. Renal involvement (multiple bilateral angiomyolipoma [AMLs], cysts, renal cell carcinoma [RCC]) is related to significant morbidity, including ESKD and KT. Nephrectomy in TSC patients before KT is controversial. Affected kidneys carry a risk of hemorrhage or malignancy, while AMLs may be fat-poor and are often hardly distinguishable from RCC in magnetic resonance (MR)/computed tomography. On the other hand nephrectomy impedes PE KT. Mammalian target of rapamycin inhibitors (mTORi) have proved efficacy in many TSC complications, including AMLs, fat-poor AMLs, TSC-related RCC, and immunosuppressive (IS) treatment. CASE REPORT A 29-year-old female TSC patient was referred for evaluation to the TSC reference center. Her family history was negative for TSC. A clinical evaluation revealed multisystem TSC manifestation (skin, brain, lungs, kidneys). MR disclosed indeterminate fat-poor renal lesions, possibly AMLs, but RCC could not be excluded. A comparison with previous MR did not show any significant progression. Due to ESKD, the patient was qualified for PE LD (mother) KT. mTORi, sirolimus, was used in IS. Creatinine at discharge was 2.1 mg/dL. Sixteen months later, MR showed significant reduction in tumor size. Two years after KT, graft function remained stable (creatinine 1.98 mg/dL). No complications related to renal lesions occurred. CONCLUSIONS mTORi are the therapy of choice in TSC patients after KT, achieving IS effect and improvement in TSC manifestations while avoiding nephrectomy and management of patients with indeterminate renal lesions, especially in the case of PE KT.
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Affiliation(s)
- Agnieszka Tarasewicz
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland.
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Beata Rutkowska
- Department of Radiology, University Clinic Center, Gdańsk, Poland
| | - Edyta Szurowska
- 2nd Department of Radiology, Medical University of Gdańsk, Gdańsk, Poland
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12
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Kingswood JC, Belousova E, Benedik MP, Carter T, Cottin V, Curatolo P, Dahlin M, D' Amato L, d'Augères GB, de Vries PJ, Ferreira JC, Feucht M, Fladrowski C, Hertzberg C, Jozwiak S, Lawson JA, Macaya A, Marques R, Nabbout R, O'Callaghan F, Qin J, Sander V, Sauter M, Shah S, Takahashi Y, Touraine R, Youroukos S, Zonnenberg B, Jansen AC. Renal angiomyolipoma in patients with tuberous sclerosis complex: findings from the TuberOus SClerosis registry to increase disease Awareness. Nephrol Dial Transplant 2019; 34:502-508. [PMID: 29697822 PMCID: PMC6399480 DOI: 10.1093/ndt/gfy063] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 02/06/2018] [Indexed: 12/31/2022] Open
Abstract
Background Renal angiomyolipoma occurs at a high frequency in patients with tuberous sclerosis complex (TSC) and is associated with potentially life-threatening complications. Despite this frequency and severity, there are no large population-based cohort studies. Here we present baseline and follow-up data of the international TuberOus SClerosis registry to increase disease Awareness (TOSCA) with an aim to provide detailed clinical characteristics of renal angiomyolipoma among patients with TSC. Methods Patients of any age with a documented clinic visit for TSC within 12 months or who were newly diagnosed with TSC before participation in the registry were eligible. Data specific to renal angiomyolipoma included physical tumour characteristics (multiple, bilateral, lesion size and growing lesions), clinical signs and symptoms, and management. The effects of age, gender and genotype on the prevalence of renal angiomyolipoma were also evaluated. Results Renal angiomyolipoma was reported in 51.8% of patients at baseline, with higher frequency in female patients (57.8% versus 42.2%). The median age at diagnosis was 12 years. Prevalence of angiomyolipoma was higher in patients with TSC2 compared with TSC1 mutations (59.2% versus 33.3%, P < 0.01). Of the 1031 patients with angiomyolipoma at baseline, multiple lesions were reported in 88.4% and bilateral in 83.9% of patients, while the size of angiomyolipoma was >3 cm in 34.3% of patients. Most patients were asymptomatic (82%). Frequently reported angiomyolipoma-related symptoms included bleeding, pain, elevated blood pressure and impaired renal function. Embolization and mammalian target of rapamycin inhibitors were the two most common treatment modalities. Conclusions The TOSCA registry highlights the burden of renal angiomyolipoma in patients with TSC and shows that renal manifestations are initially asymptomatic and are influenced by gender and genotype. Furthermore, the occurrence of significant problems from angiomyolipoma in a minority of younger patients suggests that surveillance should begin in infancy or at initial diagnosis.
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Affiliation(s)
| | - Elena Belousova
- Research and Clinical Institute of Pediatrics, Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | | | - Tom Carter
- TSA Tuberous Sclerosis Association, Nottingham, UK
| | - Vincent Cottin
- Hôpital Louis Pradel, Claude Bernard University Lyon 1, Lyon, France
| | - Paolo Curatolo
- Department of Neurosciences, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital, Rome, Italy
| | - Maria Dahlin
- Department of Pediatric Neurology, Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Petrus J de Vries
- Division of Child and Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | - José C Ferreira
- Department of Neurology, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Martha Feucht
- Department of Paediatrics, Universitätsklinik für Kinder-und Jugendheilkunde, Vienna, Austria
| | - Carla Fladrowski
- Associazione Sclerosi Tuberosa ONLUS, Milan, Italy.,European Tuberous Sclerosis Complex Association, In den Birken, Dattein, Germany
| | - Christoph Hertzberg
- Chefarzt des Zentrums für Sozial- und Neuropädiatrie, Vivantes-Klinikum Neukölln, Berlin, Germany
| | - Sergiusz Jozwiak
- Department of Child Neurology, Warsaw Medical University, Warsaw, Poland.,Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - John A Lawson
- The Tuberous Sclerosis Multidisciplinary Management Clinic, Sydney Children's Hospital, Randwick, Australia
| | - Alfons Macaya
- Sección de Neurología Pediátrica, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ruben Marques
- Novartis Farma S.p.A., Origgio, Italy.,The Institute of Biomedicine University of Leon, Spain
| | - Rima Nabbout
- Department of Pediatric Neurology, Necker Enfants Malades Hospital, Paris Descartes University, Paris, France
| | | | - Jiong Qin
- Department of Pediatrics, Peking University People's Hospital (PKUPH), Beijing, China
| | - Valentin Sander
- Department of Neurology, Tallinn Children Hospital, Tallinn, Estonia
| | - Matthias Sauter
- Abteilung für Hygiene und Infektiologie, Klinikverbund Kempten-Oberallgäu gGmbH, Kempten, Germany
| | - Seema Shah
- Novartis Healthcare Pvt. Ltd, Hyderabad, Telangana, India
| | - Yukitoshi Takahashi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Urushiyama Aoi-ku Shizuoka, Japan
| | - Renaud Touraine
- Department of Genetics, CHU-Hôpital Nord, Saint Etienne, France
| | - Sotiris Youroukos
- First Department of Paediatrics, Athens University Medical School, St Sophia Children's Hospital, Athens, Greece
| | - Bernard Zonnenberg
- Department of Medical Oncology, University Medical Center, Utrecht, The Netherlands
| | - Anna C Jansen
- Department of Pediatrics, Pediatric Neurology Unit, UZ Brussel VUB, Brussels, Belgium
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13
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Ariceta G, Buj MJ, Furlano M, Martínez V, Matamala A, Morales M, Robles NR, Sans L, Villacampa F, Torra R. Recommendations for the management of renal involvement in the tuberous sclerosis complex. Nefrologia 2019; 40:142-151. [PMID: 31722796 DOI: 10.1016/j.nefro.2019.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/04/2019] [Accepted: 07/15/2019] [Indexed: 12/01/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare, hereditary, multisystemic disease with a broad phenotypic spectrum. Its management requires the collaboration of multiple specialists. Just as in the paediatric age, the paediatric neurologist takes on special importance; in adulthood, renal involvement is the cause of the greatest morbidity and mortality. There are several recommendations on the general management of patients with TSC but none that focuses on renal involvement. These recommendations respond to the need to provide guidelines to facilitate a better knowledge and diagnostic-therapeutic management of the renal involvement of TSC through a rational use of complementary tests and the correct use of available treatments. Their elaboration has been based on consensus within the hereditary renal diseases working group of the SEN/REDINREN (Spanish Society of Nephrology/Kidney Research Network). It has also counted on the participation of non-nephrologist specialists in TSC in order to expand the vision of the disease.
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Affiliation(s)
- Gema Ariceta
- Servicio de Nefrología Pediátrica, Hospital Valle Hebrón, REDINREN, Barcelona, España
| | - María José Buj
- Servicio de Radiología, Hospital 12 de Octubre, Madrid, España
| | - Mónica Furlano
- Enfermedades Renales Hereditarias, Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, Universitat Autónoma de Barcelona, REDINREN, Barcelona, España
| | - Víctor Martínez
- Servicio de Nefrología, Hospital Virgen de la Arrixaca, Murcia, España
| | - Anna Matamala
- Departamento de Enfermería, Fundació Puigvert, Barcelona, España
| | | | | | - Laia Sans
- Servicio de Nefrología, Hospital del Mar, REDINREN, Barcelona, España
| | - Felipe Villacampa
- Servicio de Urología, Clínica Universidad de Navarra, Madrid, España
| | - Roser Torra
- Enfermedades Renales Hereditarias, Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, Universitat Autónoma de Barcelona, REDINREN, Barcelona, España.
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14
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Champy CM, Campi R, Grande P, de la Taille A, Méjean A, Granger B, Bitker MO, Rouprêt M. How many surgically-treated angiomyolipomas are related to tuberous sclerosis complex? Insights from a retrospective multicenter study. MINERVA UROL NEFROL 2019; 72:200-206. [PMID: 31619031 DOI: 10.23736/s0393-2249.19.03522-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Patients with TSC - related renal angiomyolipoma (AML) are eligible for targeted therapy with mTOR inhibitors, avoiding the morbidity of interventional management. Despite clinical criteria for TSC diagnosis have been defined, their use in routine clinical practice is likely suboptimal, leading to potential misclassification of TSC-related AML. The study aims to assess the proportion and characteristics of surgically-treated patients with putative sporadic AML that would have been re-classified as TSC-related. METHODS We retrospectively reviewed a prospectively collected multi-institutional database to select patients with suspected TSC-related AML among those undergoing surgery at three referral Centers over 11-years (2005-2015). Possible diagnosis of TSC was defined according to the 2012 International Tuberous Sclerosis Complex Consensus (ITSCC) criteria. The proportion and characteristics of patients with possible TSC-related AML (as compared to those of patients with sporadic AML) were considered the main study endpoints. RESULTS Overall, 132 patients were included. Of these, 10 (7.6%) were considered TSC-related. Most patients (84%) were female. Patients with TSC-related AML were likely to be younger (median age 53 vs. 56 years, P=0.29), symptomatic at diagnosis (70% vs. 21%, P=0.002), with slightly worse preoperative physical status (median ASA score 2 vs. 1, P=0.001) and bilateral disease (30% vs. 7.4%, P=0.04) as compared to patients with sporadic AML. Anatomic complexity and tumor size were also higher among TSC-related AMLs. CONCLUSIONS A non-negligible proportion of surgically-treated, putative sporadic AMLs were reclassified as potentially hereditary (TSC-related). As TSC patients may be treated with targeted therapies, our findings may increase urologists' awareness of TSC-related AML and prompt the design of future studies evaluating targeted diagnostic pathways for these patients.
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Affiliation(s)
- Cécile M Champy
- Sorbonne Université, GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Riccardo Campi
- Sorbonne Université, GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France.,Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Pietro Grande
- Sorbonne Université, GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France.,Department of Obstetrical and Gynecological Sciences and Urologic Sciences, 'Sapienza' University, Rome, Italy
| | - Alexandre de la Taille
- Department of Urology, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) CHU Mondor, Faculté de Médecine, Créteil, France
| | - Arnaud Méjean
- Department of Urology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Benjamin Granger
- Department of Biostatistics, Groupe Hospitalo-Universitaire EST, Pitié-Salpétrière Hospital, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Marc-Olivier Bitker
- Sorbonne Université, GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Morgan Rouprêt
- Sorbonne Université, GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France -
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15
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Valianou M, Filippidou N, Johnson DL, Vogel P, Zhang EY, Liu X, Lu Y, Yu JJ, Bissler JJ, Astrinidis A. Rapalog resistance is associated with mesenchymal-type changes in Tsc2-null cells. Sci Rep 2019; 9:3015. [PMID: 30816188 PMCID: PMC6395747 DOI: 10.1038/s41598-019-39418-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 01/24/2019] [Indexed: 01/26/2023] Open
Abstract
Tuberous Sclerosis Complex (TSC) and Lymphangioleiomyomatosis (LAM) are caused by inactivating mutations in TSC1 or TSC2, leading to mTORC1 hyperactivation. The mTORC1 inhibitors rapamycin and analogs (rapalogs) are approved for treating of TSC and LAM. Due to their cytostatic and not cytocidal action, discontinuation of treatment leads to tumor regrowth and decline in pulmonary function. Therefore, life-long rapalog treatment is proposed for the control of TSC and LAM lesions, which increases the chances for the development of acquired drug resistance. Understanding the signaling perturbations leading to rapalog resistance is critical for the development of better therapeutic strategies. We developed the first Tsc2-null rapamycin-resistant cell line, ELT3-245, which is highly tumorigenic in mice, and refractory to rapamycin treatment. In vitro ELT3-245 cells exhibit enhanced anchorage-independent cell survival, resistance to anoikis, and loss of epithelial markers. A key alteration in ELT3-245 is increased β-catenin signaling. We propose that a subset of cells in TSC and LAM lesions have additional signaling aberrations, thus possess the potential to become resistant to rapalogs. Alternatively, when challenged with rapalogs TSC-null cells are reprogrammed to express mesenchymal-like markers. These signaling changes could be further exploited to induce clinically-relevant long-term remissions.
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Affiliation(s)
- Matthildi Valianou
- Division of Pediatric Nephrology, Department of Pediatrics, College of Medicine, University of Tennessee Health Sciences Center, Memphis, TN, 38103, USA.,Tuberous Sclerosis Complex Center of Excellence, Le Bonheur Children's Hospital, Memphis, TN, 38103, USA
| | - Natalia Filippidou
- Division of Pediatric Nephrology, Department of Pediatrics, College of Medicine, University of Tennessee Health Sciences Center, Memphis, TN, 38103, USA.,Tuberous Sclerosis Complex Center of Excellence, Le Bonheur Children's Hospital, Memphis, TN, 38103, USA
| | - Daniel L Johnson
- Office of Research Molecular Bioinformatics Core, University of Tennessee Health Sciences Center, Memphis, TN, 38103, USA
| | - Peter Vogel
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN, 38105, USA
| | - Erik Y Zhang
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Xiaolei Liu
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Yiyang Lu
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Jane J Yu
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - John J Bissler
- Division of Pediatric Nephrology, Department of Pediatrics, College of Medicine, University of Tennessee Health Sciences Center, Memphis, TN, 38103, USA.,Tuberous Sclerosis Complex Center of Excellence, Le Bonheur Children's Hospital, Memphis, TN, 38103, USA.,Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, 38105, USA
| | - Aristotelis Astrinidis
- Division of Pediatric Nephrology, Department of Pediatrics, College of Medicine, University of Tennessee Health Sciences Center, Memphis, TN, 38103, USA. .,Tuberous Sclerosis Complex Center of Excellence, Le Bonheur Children's Hospital, Memphis, TN, 38103, USA. .,Department of Immunotherapeutics and Biotechnology, School of Pharmacy, Texas Tech University Health Sciences Center, Abilene, TX, 79601, USA.
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16
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Dragoumi P, O'Callaghan F, Zafeiriou DI. Diagnosis of tuberous sclerosis complex in the fetus. Eur J Paediatr Neurol 2018; 22:1027-1034. [PMID: 30279084 DOI: 10.1016/j.ejpn.2018.08.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 12/18/2022]
Abstract
Tuberous sclerosis complex is a dominantly inherited genetic disorder of striking clinical variability. It is caused by mutations in either TSC1 or TSC2 gene, which regulate cell growth and proliferation by inhibition of mTORC1 signaling. TS is characterized by the development of benign tumors in many tissues and organs and its neurological manifestations include epilepsy, autism, cognitive and behavioral dysfunction, and giant cell tumors. With mechanism-based mTOR inhibitors therapy now available for many of its manifestations, early diagnosis of TSC is very important in order to offer appropriate care, long-term surveillance and parental counseling. Fetal ultrasound and MRI imaging techniques have evolved and may capture even earlier the following TSC-associated lesions: cardiac rhabdomyomas, subependymal nodules, cortical tubers and renal cysts. Often these represent an incidental finding during a routine ultrasound. Furthermore, in the past decades prenatal molecular diagnosis of TSC has emerged as an important option for families with a known affected member; however, the existing evidence with regards to the clinical characteristics and long-term outcome of babies diagnosed prenatally with TSC is yet limited and the path that follows early TSC detection merits further research.
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Affiliation(s)
- Pinelopi Dragoumi
- 1st Department of Pediatrics, Developmental Center "A. Fokas", Aristotle University of Thessaloniki, "Hippokratio" General Hospital, Thessaloniki, Greece
| | - Finbar O'Callaghan
- University College London, Institute of Child Health, Head of Clinical Neurosciences Section, Children's Department, London, UK
| | - Dimitrios I Zafeiriou
- 1st Department of Pediatrics, Developmental Center "A. Fokas", Aristotle University of Thessaloniki, "Hippokratio" General Hospital, Thessaloniki, Greece.
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17
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Razik A, Das CJ, Sharma S. Angiomyolipoma of the Kidneys: Current Perspectives and Challenges in Diagnostic Imaging and Image-Guided Therapy. Curr Probl Diagn Radiol 2018; 48:251-261. [PMID: 29685402 DOI: 10.1067/j.cpradiol.2018.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 03/14/2018] [Accepted: 03/16/2018] [Indexed: 12/22/2022]
Abstract
Angiomyolipomas (AML) are benign tumors of the kidneys frequently encountered in radiologic practice in large tertiary centers. In comparison to renal cell carcinomas (RCC), AML are seldom treated unless they are large, undergo malignant transformation or develop complications like acute hemorrhage. The common garden triphasic (classic) AML is an easy diagnosis, however, some variants lack macroscopic fat in which case the radiologic differentiation from RCC becomes challenging. Several imaging features, both qualitative and quantitative, have been described in differentiating the 2 entities. Although minimal fat AML is not entirely a radiologic diagnosis, the suspicion raised on imaging necessitates sampling and potentially avoids an unwanted surgery. Recently a new variant, epitheloid AML has been described which often has atypical imaging features and is at a higher risk for malignant transformation. Apart from the diagnosis, the radiologist also needs to convey information regarding nephrometric scores which help in surgical decision-making. Recently, more and more AMLs are managed with selective arterial embolization and percutaneous ablation, both of which are associated with less morbidity when compared to surgery. The purpose of this article is to review the imaging and pathologic features of classic AML as well as the differentiation of minimal fat AML from RCC. In addition, an overview of nephrometric scoring and image-guided interventions is also provided.
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Affiliation(s)
- Abdul Razik
- Department of Radiology, All India Institute of Medical Sciences (A.I.I.M.S), New Delhi, India
| | - Chandan J Das
- Department of Radiology, All India Institute of Medical Sciences (A.I.I.M.S), New Delhi, India.
| | - Sanjay Sharma
- Department of Radiology, All India Institute of Medical Sciences (A.I.I.M.S), New Delhi, India
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Cockerell I, Guenin M, Heimdal K, Bjørnvold M, Selmer KK, Rouvière O. Renal manifestations of tuberous sclerosis complex: patients' and parents' knowledge and routines for renal follow-up - a questionnaire study. BMC Nephrol 2018; 19:39. [PMID: 29439672 PMCID: PMC5812037 DOI: 10.1186/s12882-018-0835-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 01/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Renal angiomyolipomas (AMLs) are a major clinical feature in patients with tuberous sclerosis complex (TSC). Spontaneous bleeding can be life threatening, and appropriate information and proper surveillance and management are important to limit morbidity and mortality. Because TSC is a rare disease, patients are at risk of suboptimal medical management. Our aim was to investigate patients' and parents' knowledge about renal angiomyolipomas (AMLs) in Tuberous Sclerosis Complex (TSC) and to identify current routines for renal follow-up. METHODS A questionnaire survey was initiated by the French Reference Centre on TSC. It was distributed in France through university hospitals and the patients' association (2009-2011), and to patients registered by the Norwegian National Centre for Rare Epilepsy-Related Disorders (2013-2014). Contingency tables with Chi-Square test for independence (with Yates Continuity Correction) and Pearson-Chi-Square value were used for correlation statistics. RESULTS We included 357 patients (France, n=257; Norway n=100). Most participants knew that TSC is associated with AMLs. However, 42 % did not know about the risk of AMLrelated bleeding, and 37 % had been informed about the risk of bleeding only after the age of 15 years. Furthermore, 14 % did not know whether they themselves or their child had AMLs. Patients had less knowledge than parents. Medical consultations and patient associations were the main sources of information. Among 30 % of patients, renal imaging was not received at all, or not conducted every 1-3 years, as recommended by current guidelines. Regular imaging was more frequent in patients with AMLs < 15 years, than in patients with AMLs ≥ 15 years. Ultrasound was the most frequently used imaging modality. CONCLUSIONS Knowledge of renal AML in TSC patients and their parents was lower than expected, and follow-up by renal imaging was suboptimal for a substantial proportion of patients. Patients and parents should be informed about the risk and symptoms of renal bleeding, at the latest when the patient is 15 years. Monitoring the growth of AMLs should be standardized to comply with guidelines. Transition between adolescence and adulthood is a high-risk period and ensuring appropriate follow-up at this time is particularly important.
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Affiliation(s)
- I Cockerell
- Department of Rare Disorders and Disabilities, Oslo University Hospital, National Centre for Rare Epilepsy-Related Disorders, Pb 4950, Nydalen, 0424, Oslo, Norway.
| | - M Guenin
- Department of Urinary and Vascular Imaging, Hôpital Edouard Herriot, Lyon, France
| | - K Heimdal
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - M Bjørnvold
- National Centre for Epilepsy, Division for Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - K K Selmer
- Department of Rare Disorders and Disabilities, Oslo University Hospital, National Centre for Rare Epilepsy-Related Disorders, Pb 4950, Nydalen, 0424, Oslo, Norway.,Department of Medical Genetics, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - O Rouvière
- Department of Urinary and Vascular Imaging, Hôpital Edouard Herriot, Lyon, France
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Brakemeier S, Vogt L, Adams LC, Zukunft B, Diederichs G, Hamm B, Budde K, Eckardt KU, Makowski MR. Sclerotic bone lesions as a potential imaging biomarker for the diagnosis of tuberous sclerosis complex. Sci Rep 2018; 8:953. [PMID: 29343816 PMCID: PMC5772483 DOI: 10.1038/s41598-018-19399-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/29/2017] [Indexed: 01/15/2023] Open
Abstract
Tuberous-sclerosis-complex (TSC) is associated with a high lifetime risk of severe complications. Clinical manifestations are largely variable and diagnosis is often missed. Sclerotic-bone-lesions (SBL) could represent a potential imaging biomarker for the diagnosis of TSC. In this study, computed tomography (CT) data sets of 49 TSC patients (31 females) were included and compared to an age/sex matched control group. Imaging features of SBLs included frequency, size and location pattern. Sensitivities, specificities and cutoff values for the diagnosis of TSC were established for the skull, thorax, and abdomen/pelvis. In TSC patients, 3439 SBLs were detected, including 665 skull SBLs, 1426 thoracal SBLs and 1348 abdominal/pelvic SBLs. In the matched control-collective, 157 SBLs could be found. The frequency of SBLs enabled a reliable differentiation between TSC patients and the control collective with the following sensitivities and specificities. Skull: ≥5 SBLs, 0.783, 1; thorax: ≥4 SBLs, 0.967, 0.967; abdomen/pelvis: ≥5 SBLs: 0.938, 0.906. SBL size was significantly larger compared to controls (p < 0.05). Based on the frequency, size and location pattern of SBLs TSC can be suspected. SBLs may serve as a potential imaging biomarker in the workup of TSC patients.
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Affiliation(s)
- Susanne Brakemeier
- Department of Nephrology and Medical Intensive Care, Charité, Charitéplatz 1, 10117, Berlin, Germany.
| | - Lars Vogt
- Department of Radiology, Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Lisa C Adams
- Department of Radiology, Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Bianca Zukunft
- Department of Nephrology and Medical Intensive Care, Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Gerd Diederichs
- Department of Radiology, Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Bernd Hamm
- Department of Radiology, Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité, Charitéplatz 1, 10117, Berlin, Germany
| | - Marcus R Makowski
- Department of Radiology, Charité, Charitéplatz 1, 10117, Berlin, Germany.,King's College London, Division of Imaging Sciences, Westminster Bridge Road, London, SE1 7EH, United Kingdom
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20
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Moura CS, Rosenberg ZB, Abrahamowicz M, Bernatsky S, Behlouli H, Pilote L. Treatment Discontinuation and Clinical Events in Type 2 Diabetes Patients Treated with Dipeptidyl Peptidase-4 Inhibitors or NPH Insulin as Third-Line Therapy. J Diabetes Res 2018; 2018:4817178. [PMID: 29713649 PMCID: PMC5866860 DOI: 10.1155/2018/4817178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/21/2018] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To compare dipeptidyl peptidase-4 (DPP-4) inhibitors with neutral protamine Hagedorn (NPH) insulin, in terms of effectiveness and safety for the management of patients with type 2 diabetes mellitus (DM2) not controlled on metformin and sulfonylureas. METHODS A retrospective cohort study of individuals with DM2 newly dispensed with either DPP-4 inhibitors or NPH as third-line therapy, after metformin and sulfonylurea. Treatment discontinuation, macrovascular outcomes, and hypoglycemia were compared using multivariable Cox regression models, adjusted for sex, age, year of cohort entry, place of residence, hypertension, past history of hypoglycemia, diabetic ketoacidosis, comorbidities, and number of visits to emergency departments, outpatient physician, and hospitalizations. RESULTS Treatment discontinuation and hypoglycemia occurred more frequently with NPH than with DPP-4 inhibitor users. In the adjusted Cox model, the use of NPH compared to that of DPP-4 inhibitors was associated with a higher risk of discontinuation (HR: 1.33; 95% CI 1.27-1.40) and hypoglycemia (HR: 2.98; 95% CI 2.72-3.28). Risk of cardiovascular events was similar across groups. CONCLUSIONS This real-world analysis suggests that DM2 patients initiating third-line therapy with NPH have poorer control of diabetes when compared to DPP-4 inhibitor initiators.
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Affiliation(s)
- Cristiano S. Moura
- Centre for Outcome Research & Evaluation (CORE), McGill University, Montréal, QC, Canada H3A 0G4
| | - Zale B. Rosenberg
- Centre for Outcome Research & Evaluation (CORE), McGill University, Montréal, QC, Canada H3A 0G4
| | - Michal Abrahamowicz
- Centre for Outcome Research & Evaluation (CORE), McGill University, Montréal, QC, Canada H3A 0G4
- Department of Epidemiology, McGill University, Biostatistics and Occupational Health, Montréal, QC, Canada H3A 0G4
| | - Sasha Bernatsky
- Centre for Outcome Research & Evaluation (CORE), McGill University, Montréal, QC, Canada H3A 0G4
- Department of Epidemiology, McGill University, Biostatistics and Occupational Health, Montréal, QC, Canada H3A 0G4
| | - Hassan Behlouli
- Centre for Outcome Research & Evaluation (CORE), McGill University, Montréal, QC, Canada H3A 0G4
| | - Louise Pilote
- Centre for Outcome Research & Evaluation (CORE), McGill University, Montréal, QC, Canada H3A 0G4
- Division of General Internal Medicine, McGill University, McGill University Health Centre, Montréal, QC, Canada H3A 0G4
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21
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The Risks of Renal Angiomyolipoma: Reviewing the Evidence. J Kidney Cancer VHL 2017; 4:13-25. [PMID: 29090118 PMCID: PMC5644357 DOI: 10.15586/jkcvhl.2017.97] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 09/23/2017] [Indexed: 12/26/2022] Open
Abstract
Renal angiomyolipoma (RAML), though a rare benign tumor, may impose a significant morbidity or even mortality due to its unique characteristics and the complications subsequent to its treatment. The classic tumor variant is composed of smooth muscular, vascular, and fatty components. The most straightforward diagnosis is when the fat component is abundant and gives a characteristic appearance on different imaging studies. In fat-poor lesions, however, the diagnosis is difficult and presumed a renal cell carcinoma. Yet, some variants of RAML, though rare, express an aggressive behavior leading to metastasis and mortality. The challenge lies in the early detection of benign variants and identifying aggressive lesions for proper management. Another challenge is when the vascular tissue component predominates and poses a risk of hemorrhage that may extend to the retroperitoneum in a massive life-threatening condition. The predicament here is to identify the characteristics of tumors at risk of bleeding and provide a prophylactic treatment. According to the clinical presentation, different treatment modalities, prophylactic or therapeutic, are available that span the spectrum of observation, embolization, or surgery. Renal impairment may result from extensive tumor burden or as a complication of the management itself. Improvement of diagnostic techniques, super-selective embolization, nephron-sparing surgery, and late treatment with the mammalian target of rapamycin inhibitors have provided more effective and safe management strategies. In this review, we examine the evidence pertaining to the risks imposed by RAML to the patients and identify merits and hazards associated with different treatment modalities.
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Buj Pradilla MJ, Martí Ballesté T, Torra R, Villacampa Aubá F. Recommendations for imaging-based diagnosis and management of renal angiomyolipoma associated with tuberous sclerosis complex. Clin Kidney J 2017; 10:728-737. [PMID: 29225800 PMCID: PMC5716090 DOI: 10.1093/ckj/sfx094] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 07/16/2017] [Indexed: 01/12/2023] Open
Abstract
Renal angiomyolipomas are found in up to 80% of tuberous sclerosis complex (TSC) patients. Although these tumours are usually asymptomatic, lesions >3 cm in diameter are prone to bleeding and up to 10% of TSC patients may experience a massive and potentially fatal retroperitoneal haemorrhage. Diagnosis can be complicated because of the initial lack of symptoms and the fat-poor content of atypical renal angiomyolipomas. After diagnosis, tumour growth and the emergence of new tumours must be monitored. Treatment with mammalian target of rapamycin (mTOR) inhibitors can reduce tumour size and is indicated in patients with TSC-associated renal angiomyolipomas >3 cm in diameter. Imaging-based assessment of kidney disease is essential to the diagnosis and management of patients with TSC. The aims of imaging studies in this context are to detect and characterize tumours, assess and detect the risk of complications and evaluate the response to treatment, especially in patients treated with mTOR inhibitors. A multidisciplinary expert panel developed a series of recommendations based on current evidence and professional experience for imaging studies in adults and children with TSC-associated renal angiomyolipoma. The recommendations cover radiological diagnosis and follow-up of the classic and atypical or fat-poor TSC-associated renal angiomyolipomas, biopsy indications, minimal requirements for radiological requests and reports and recommended technical features and protocols for computed tomography and magnetic resonance imaging.
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Affiliation(s)
| | | | - Roser Torra
- Inherited Renal Diseases, Department of Nephrology, Fundació Puigvert, REDINREN, IIB Sant Pau, Universitat Autónoma de Barcelona, Spain
| | - Felipe Villacampa Aubá
- Department of Urology, University Hospital 12 de Octubre, Madrid, Spain.,Centro de investigación Biomédica en Red de Cáncer CIBERONC
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23
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Song X, Liu Z, Cappell K, Gregory C, Said Q, Prestifilippo J, Charles H, Hulbert J, Bissler J. Natural history of patients with tuberous sclerosis complex related renal angiomyolipoma. Curr Med Res Opin 2017; 33:1277-1282. [PMID: 28358266 DOI: 10.1080/03007995.2017.1313726] [Citation(s) in RCA: 4] [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] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To examine temporal relationships between tuberous sclerosis complex (TSC) and renal angiomyolipoma diagnosis and outcomes, treatment, and healthcare utilization. METHODS Administrative data from the MarketScan Commercial Database was used to select TSC-related renal angiomyolipoma patients during 1 January 2000-31 March 2013. Patients were followed until the earliest of inpatient death or end of enrollment or study. Occurrence of kidney-related outcomes, kidney-related procedures, and all-cause healthcare utilization and time to occurrence were reported. Kaplan-Meier curves were used to display the unadjusted distribution of time to outcome. RESULTS A total of 605 patients were selected (<18 years N = 225; ≥18 years N = 380). Mean time from TSC to renal angiomyolipoma diagnosis was 25.7 months in younger and 16.9 months in older patients. Patients ≥18 years had higher rates of chronic kidney disease (CKD), hematuria, kidney failure, embolization (EMB), and partial and complete nephrectomy compared to patients <18 years (all p < .05). Mean time from TSC-related renal angiomyolipoma diagnosis to CKD, hematuria, kidney failure, EMB, first emergency room and inpatient visits was shorter in older compared to younger patients (all p < .05). Probability of developing CKD was approximately 0.8 and 0.95 within 3 years in younger and older patients, respectively. CONCLUSIONS Patients with TSC-related renal angiomyolipoma had high rates of kidney-related outcomes and procedures. These events sometimes preceded the angiomyolipoma diagnosis. A key study limitation was that due to the small sample size, results may have been biased by outliers. Research is needed to determine whether earlier angiomyolipoma diagnosis can impact occurrence of events and reduce healthcare utilization.
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Affiliation(s)
- Xue Song
- a Truven Health Analytics Inc., an IBM Company , Cambridge , MA , USA
| | - Zhimei Liu
- b Novartis Pharmaceuticals Corporation , East Hanover , USA
| | - Katherine Cappell
- a Truven Health Analytics Inc., an IBM Company , Cambridge , MA , USA
| | | | - Qayyim Said
- b Novartis Pharmaceuticals Corporation , East Hanover , USA
| | | | - Hearns Charles
- c South Florida Vascular Associates , Coconut Creek , FL , USA
| | | | - John Bissler
- e LeBonheur Children's Hospital and St. Jude Children's Research Hospital , Memphis , TN , USA
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24
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Renal angiomyolipomas: At least two diseases. A series of patients treated at two European institutions. Eur J Surg Oncol 2017; 43:831-836. [DOI: 10.1016/j.ejso.2016.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 11/07/2016] [Accepted: 11/17/2016] [Indexed: 02/03/2023] Open
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Wang C, Yang M, Tong X, Wang J, Guan H, Niu G, Yan Z, Zhang B, Zou Y. Transarterial embolization for renal angiomyolipomas: A single centre experience in 79 patients. J Int Med Res 2017; 45:706-713. [PMID: 28415927 PMCID: PMC5536643 DOI: 10.1177/0300060516684251] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective To evaluate the long-term efficacy and safety of selective arterial embolization (SAE) in the treatment of renal angiomyolipomas (AMLs). Methods This was a retrospective review of medical records and imaging findings from patients with renal AMLs who attended our clinic and received SAE between January 2007 and January 2014. Only patents with complete medical records, preoperative computed tomography scans using typical imaging and follow-up data were included. Results A total of 79 patients were enrolled in the study. Technical and clinical success rates were 100% and 91% ( n = 72), respectively. Only two patients experienced major complications. Post-embolization syndrome (i.e. fever, abdominal pain, nausea or vomiting) was reported in 68 (86%) patients, but all symptoms were mild and resolved with conservative measures. Mean radiological and clinical follow-up periods were 16.8 and 35.9 months, respectively. In 75 (95%) patients, tumours decreased in size; mean ± SD tumour size significantly decreased from 8.4 ± 3.5 cm pre-embolization to 6.7 ± 3.0 cm post-embolization . Conclusions This study provides long-term evidence that SAE is a safe and effective method in the treatment of patients with renal AMLs.
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Affiliation(s)
- Chengen Wang
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
| | - Min Yang
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
| | - Xiaoqiang Tong
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
| | - Jian Wang
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
| | - Haitao Guan
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
| | - Guochen Niu
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
| | - Ziguang Yan
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
| | - Bihui Zhang
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
| | - Yinghua Zou
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
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