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van der Sluijs P, Hoelen H, Schmidt A, Braakman I. The Folding Pathway of ABC Transporter CFTR: Effective and Robust. J Mol Biol 2024; 436:168591. [PMID: 38677493 DOI: 10.1016/j.jmb.2024.168591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/16/2024] [Accepted: 04/23/2024] [Indexed: 04/29/2024]
Abstract
De novo protein folding into a native three-dimensional structure is indispensable for biological function, is instructed by its amino acid sequence, and occurs along a vectorial trajectory. The human proteome contains thousands of membrane-spanning proteins, whose biosynthesis begins on endoplasmic reticulum-associated ribosomes. Nearly half of all membrane proteins traverse the membrane more than once, including therapeutically important protein families such as solute carriers, G-protein-coupled receptors, and ABC transporters. These mediate a variety of functions like signal transduction and solute transport and are often of vital importance for cell function and tissue homeostasis. Missense mutations in multispan membrane proteins can lead to misfolding and cause disease; an example is the ABC transporter Cystic Fibrosis Transmembrane Conductance Regulator (CFTR). Even though our understanding of multispan membrane-protein folding still is rather rudimental, the cumulative knowledge of 20 years of basic research on CFTR folding has led to development of drugs that modulate the misfolded protein. This has provided the prospect of a life without CF to the vast majority of patients. In this review we describe our understanding of the folding pathway of CFTR in cells, which is modular and tolerates many defects, making it effective and robust. We address how modulator drugs affect folding and function of CFTR, and distinguish protein stability from its folding process. Since the domain architecture of (mammalian) ABC transporters are highly conserved, we anticipate that the insights we discuss here for folding of CFTR may lay the groundwork for understanding the general rules of ABC-transporter folding.
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Affiliation(s)
- Peter van der Sluijs
- Cellular Protein Chemistry, Bijvoet Centre for Biomolecular Research, Utrecht University, 3584 CH Utrecht, the Netherlands.
| | - Hanneke Hoelen
- Cellular Protein Chemistry, Bijvoet Centre for Biomolecular Research, Utrecht University, 3584 CH Utrecht, the Netherlands; Present address: GenDx, Yalelaan 48, 3584 CM Utrecht, The Netherlands
| | - Andre Schmidt
- Cellular Protein Chemistry, Bijvoet Centre for Biomolecular Research, Utrecht University, 3584 CH Utrecht, the Netherlands; 3D-Pharmxchange, Tilburg, the Netherlands
| | - Ineke Braakman
- Cellular Protein Chemistry, Bijvoet Centre for Biomolecular Research, Utrecht University, 3584 CH Utrecht, the Netherlands
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Adang LA, Bonkowsky JL, Boelens JJ, Mallack E, Ahrens-Nicklas R, Bernat JA, Bley A, Burton B, Darling A, Eichler F, Eklund E, Emrick L, Escolar M, Fatemi A, Fraser JL, Gaviglio A, Keller S, Patterson MC, Orchard P, Orthmann-Murphy J, Santoro JD, Schöls L, Sevin C, Srivastava IN, Rajan D, Rubin JP, Van Haren K, Wasserstein M, Zerem A, Fumagalli F, Laugwitz L, Vanderver A. Consensus guidelines for the monitoring and management of metachromatic leukodystrophy in the United States. Cytotherapy 2024; 26:739-748. [PMID: 38613540 DOI: 10.1016/j.jcyt.2024.03.487] [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: 12/22/2023] [Revised: 03/20/2024] [Accepted: 03/24/2024] [Indexed: 04/15/2024]
Abstract
Metachromatic leukodystrophy (MLD) is a fatal, progressive neurodegenerative disorder caused by biallelic pathogenic mutations in the ARSA (Arylsulfatase A) gene. With the advent of presymptomatic diagnosis and the availability of therapies with a narrow window for intervention, it is critical to define a standardized approach to diagnosis, presymptomatic monitoring, and clinical care. To meet the needs of the MLD community, a panel of MLD experts was established to develop disease-specific guidelines based on healthcare resources in the United States. This group developed a consensus opinion for best-practice recommendations, as follows: (i) Diagnosis should include both genetic and biochemical testing; (ii) Early diagnosis and treatment for MLD is associated with improved clinical outcomes; (iii) The panel supported the development of newborn screening to accelerate the time to diagnosis and treatment; (iv) Clinical management of MLD should include specialists familiar with the disease who are able to follow patients longitudinally; (v) In early onset MLD, including late infantile and early juvenile subtypes, ex vivo gene therapy should be considered for presymptomatic patients where available; (vi) In late-onset MLD, including late juvenile and adult subtypes, hematopoietic cell transplant (HCT) should be considered for patients with no or minimal disease involvement. This document summarizes current guidance on the presymptomatic monitoring of children affected by MLD as well as the clinical management of symptomatic patients. Future data-driven evidence and evolution of these recommendations will be important to stratify clinical treatment options and improve clinical care.
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Affiliation(s)
- Laura A Adang
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | | | - Jaap Jan Boelens
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Eric Mallack
- Kennedy Krieger Institute, Baltimore, Maryland, USA
| | | | - John A Bernat
- University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Annette Bley
- University Children's Hospital, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Barbara Burton
- Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | | | | | - Lisa Emrick
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Maria Escolar
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Forge Biologics, Grove City, Ohio, USA
| | - Ali Fatemi
- Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Jamie L Fraser
- Children's National Hospital, Washington, District of Columbia, USA
| | - Amy Gaviglio
- Division of Laboratory Services, Newborn Screening and Molecular Biology Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA; Association of Public Health Laboratories, Silver Spring, Maryland, USA
| | | | - Marc C Patterson
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Clinical Genomics, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul Orchard
- University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Jonathan D Santoro
- University of Southern California, Children's Hospital Los Angeles, Keck School of Medicine, Los Angeles, California, USA
| | - Ludger Schöls
- Department of Neurology and Hertie-Institute for Clinical Brain Research German Center of Neurodegenerative Diseases (DZNE), Tübingen, Germany
| | | | - Isha N Srivastava
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Deepa Rajan
- University of Pittsburgh, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Keith Van Haren
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Melissa Wasserstein
- Department of Pediatrics, Albert Einstein College of Medicine and the Children's Hospital at Montefiore, Bronx, New York, USA
| | - Ayelet Zerem
- Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Lucia Laugwitz
- Department of Pediatric Neurology and Developmental Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Adeline Vanderver
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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3
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Wu M, Davis JD, Zhao C, Daley T, Oliver KE. Racial inequities and rare CFTR variants: Impact on cystic fibrosis diagnosis and treatment. J Clin Transl Endocrinol 2024; 36:100344. [PMID: 38765466 PMCID: PMC11099334 DOI: 10.1016/j.jcte.2024.100344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/21/2024] [Accepted: 04/14/2024] [Indexed: 05/22/2024] Open
Abstract
Cystic fibrosis (CF) has been traditionally viewed as a disease that affects White individuals. However, CF occurs among all races, ethnicities, and geographic ancestries. The disorder results from mutations in the CF transmembrane conductance regulator (CFTR). Varying incidence of CF is reported among Black, Indigenous, and People of Color (BIPOC), who typically exhibit worse clinical outcomes. These populations are more likely to carry rare CFTR variants omitted from newborn screening panels, leading to disparities in care such as delayed diagnosis and treatment. In this study, we present a case-in-point describing an individual of Gambian descent identified with CF. Patient genotype includes a premature termination codon (PTC) (c.2353C>T) and previously undescribed single nucleotide deletion (c.1970delG), arguing against effectiveness of currently available CFTR modulator-based interventions. Strategies for overcoming these two variants will likely include combinations of PTC suppressors, nonsense mediated decay inhibitors, and/or alternative approaches (e.g. gene therapy). Investigations such as the present study establish a foundation from which therapeutic treatments may be developed. Importantly, c.2353C>T and c.1970delG were not detected in the patient by traditional CFTR screening panels, which include an implicit racial and ethnic diagnostic bias as these tests are comprised of mutations largely observed in people of European ancestry. We suggest that next-generation sequencing of CFTR should be utilized to confirm or exclude a CF diagnosis, in order to equitably serve BIPOC individuals. Additional epidemiologic data, basic science investigations, and translational work are imperative for improving understanding of disease prevalence and progression, CFTR variant frequency, genotype-phenotype correlation, pharmacologic responsiveness, and personalized medicine approaches for patients with African ancestry and other historically understudied geographic lineages.
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Affiliation(s)
- Malinda Wu
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Pediatric Institute, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Jacob D. Davis
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Conan Zhao
- Interdisciplinary Graduate Program in Quantitative Biosciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Tanicia Daley
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Pediatric Institute, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Kathryn E. Oliver
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Pediatric Institute, Children’s Healthcare of Atlanta, Atlanta, GA, USA
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Anton-Păduraru DT, Azoicăi AN, Trofin F, Mîndru DE, Murgu AM, Bocec AS, Iliescu Halițchi CO, Ciongradi CI, Sȃrbu I, Iliescu ML. Diagnosing Cystic Fibrosis in the 21st Century-A Complex and Challenging Task. Diagnostics (Basel) 2024; 14:763. [PMID: 38611676 PMCID: PMC11012009 DOI: 10.3390/diagnostics14070763] [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: 03/04/2024] [Revised: 03/24/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
Cystic fibrosis (CF) is a chronic and potentially life-threatening condition, wherein timely diagnosis assumes paramount significance for the prompt initiation of therapeutic interventions, thereby ameliorating pulmonary function, addressing nutritional deficits, averting complications, mitigating morbidity, and ultimately enhancing the quality of life and extending longevity. This review aims to amalgamate existing knowledge to provide a comprehensive appraisal of contemporary diagnostic modalities pertinent to CF in the 21st century. Deliberations encompass discrete delineations of each diagnostic modality and the elucidation of potential diagnostic quandaries encountered in select instances, as well as the delineation of genotype-phenotype correlations germane to genetic counseling endeavors. The synthesis underscores that, notwithstanding the availability and strides in diagnostic methodologies, including genetic assays, the sweat test (ST) retains its position as the preeminent diagnostic standard for CF, serving as a robust surrogate for CFTR functionality. Prospective clinical investigations in the realm of CF should be orchestrated with the objective of discerning novel diagnostic modalities endowed with heightened specificity and sensitivity.
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Affiliation(s)
- Dana-Teodora Anton-Păduraru
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (A.N.A.); (D.E.M.); (A.M.M.); (A.S.B.); (C.O.I.H.)
- “Sf.Maria” Children Emergency Hospital, 700309 Iaṣi, Romania; (C.I.C.); (I.S.)
| | - Alice Nicoleta Azoicăi
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (A.N.A.); (D.E.M.); (A.M.M.); (A.S.B.); (C.O.I.H.)
- “Sf.Maria” Children Emergency Hospital, 700309 Iaṣi, Romania; (C.I.C.); (I.S.)
| | - Felicia Trofin
- Department of Preventive Medicine and Interdisciplinarity—Microbiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania
| | - Dana Elena Mîndru
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (A.N.A.); (D.E.M.); (A.M.M.); (A.S.B.); (C.O.I.H.)
- “Sf.Maria” Children Emergency Hospital, 700309 Iaṣi, Romania; (C.I.C.); (I.S.)
| | - Alina Mariela Murgu
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (A.N.A.); (D.E.M.); (A.M.M.); (A.S.B.); (C.O.I.H.)
- “Sf.Maria” Children Emergency Hospital, 700309 Iaṣi, Romania; (C.I.C.); (I.S.)
| | - Ana Simona Bocec
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (A.N.A.); (D.E.M.); (A.M.M.); (A.S.B.); (C.O.I.H.)
| | - Codruța Olimpiada Iliescu Halițchi
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (A.N.A.); (D.E.M.); (A.M.M.); (A.S.B.); (C.O.I.H.)
| | - Carmen Iulia Ciongradi
- “Sf.Maria” Children Emergency Hospital, 700309 Iaṣi, Romania; (C.I.C.); (I.S.)
- 2nd Department of Surgery, Pediatric Surgery and Orthopedics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania
| | - Ioan Sȃrbu
- “Sf.Maria” Children Emergency Hospital, 700309 Iaṣi, Romania; (C.I.C.); (I.S.)
- 2nd Department of Surgery, Pediatric Surgery and Orthopedics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania
| | - Maria Liliana Iliescu
- Department of Preventive Medicine and Interdisciplinarity—Public Health and Health Management, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania;
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Palla JB, Laguna TA. Health inequities in the modulator era. Curr Opin Pulm Med 2023; 29:626-633. [PMID: 37611037 DOI: 10.1097/mcp.0000000000001005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
PURPOSE OF REVIEW To discuss the existing health inequities in people with cystic fibrosis (CF) and how the recent development of cystic fibrosis transmembrane regulator (CFTR) modulators may impact these inequities. RECENT FINDINGS People with CF (pwCF) from low socioeconomic status (SES) have more pulmonary exacerbations, worse nutritional status, lower pulmonary function, and an increased mortality rate with less access to lung transplantation. pwCF who identify as racial and ethnic minorities have earlier mortality, lower lung function, are less likely to be detected on newborn screening resulting in a delayed diagnosis, are underrepresented in clinic trials, and less likely to be eligible for a CFTR modulator. Female sex is associated with more pulmonary exacerbations and earlier mortality. Sexual gender minorities are a vulnerable population with worse health outcomes, and more research is needed in CF. CFTR modulators are inaccessible to low to middle-income countries due to significant cost burden. SUMMARY People with CF from low SES, racial and ethnic minorities, female sex, and sexual gender minorities face health inequities. CFTR modulator use will further widen existing health inequities given the unequal access to modulators based on nonqualifying genetics and exorbitant cost restricting use both on an individual and global level.
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Affiliation(s)
- John B Palla
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Theresa A Laguna
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
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Kozawa Y, Yamamoto A, Nakakuki M, Fujiki K, Kondo S, Okada T, Fukuyasu T, Yamaguchi M, Taniguchi I, Nomura N, Liu L, Higuchi M, Niwa E, Sohma Y, Naruse S, Takeyama Y, Ishiguro H. Clinical and genetic features of cystic fibrosis in Japan. J Hum Genet 2023; 68:671-680. [PMID: 37217688 DOI: 10.1038/s10038-023-01160-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/28/2023] [Accepted: 05/07/2023] [Indexed: 05/24/2023]
Abstract
Cystic fibrosis (CF) is an autosomal recessive disease caused by pathogenic variants in CF transmembrane conductance regulator (CFTR). While CF is the most common hereditary disease in Caucasians, it is rare in East Asia. In the present study, we have examined clinical features and the spectrum of CFTR variants of CF patients in Japan. Clinical data of 132 CF patients were obtained from the national epidemiological survey since 1994 and CF registry. From 2007 to 2022, 46 patients with definite CF were analyzed for CFTR variants. All exons, their boundaries, and part of promoter region of CFTR were sequenced and the presence of large deletion and duplications were examined by multiplex ligation-dependent probe amplification. CF patients in Japan were found to have chronic sinopulmonary disease (85.6%), exocrine pancreatic insufficiency (66.7%), meconium ileus (35.6%), electrolyte imbalance (21.2%), CF-associated liver disease (14.4%), and CF-related diabetes (6.1%). The median survival age was 25.0 years. The mean BMI percentile was 30.3%ile in definite CF patients aged < 18 years whose CFTR genotypes were known. In 70 CF alleles of East Asia/Japan origin, CFTR-dele16-17a-17b was detected in 24 alleles, the other variants were novel or very rare, and no pathogenic variants were detected in 8 alleles. In 22 CF alleles of Europe origin, F508del was detected in 11 alleles. In summary, clinical phenotype of Japanese CF patients is similar to European patients, but the prognosis is worse. The spectrum of CFTR variants in Japanese CF alleles is entirely different from that in European CF alleles.
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Affiliation(s)
- Yuka Kozawa
- Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akiko Yamamoto
- Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Miyuki Nakakuki
- Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kotoyo Fujiki
- Department of Nutrition, Nagoya University of Arts and Sciences, Nisshin, Japan
| | - Shiho Kondo
- Department of Health and Nutrition, Nagoya Women's University, Nagoya, Japan
| | - Takuto Okada
- Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoya Fukuyasu
- Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Food and Nutrition, Tsu City College, Tsu, Japan
| | - Makoto Yamaguchi
- Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Itsuka Taniguchi
- Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nao Nomura
- Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Libin Liu
- Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mayuko Higuchi
- Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Erina Niwa
- Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiro Sohma
- Division of Molecular Therapy, Department of Pharmaceutical Sciences, School of Pharmacy and Center for Basic Medical Research, International University of Health and Welfare, Otawara, Japan
| | | | - Yoshifumi Takeyama
- Department of Surgery, Kindai University School of Medicine, Osakasayama, Japan
| | - Hiroshi Ishiguro
- Department of Human Nutrition, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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Halley MC, Halverson CME, Tabor HK, Goldenberg AJ. Rare Disease, Advocacy and Justice: Intersecting Disparities in Research and Clinical Care. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:17-26. [PMID: 37204146 PMCID: PMC10321139 DOI: 10.1080/15265161.2023.2207500] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Rare genetic diseases collectively impact millions of individuals in the United States. These patients and their families share many challenges including delayed diagnosis, lack of knowledgeable providers, and limited economic incentives to develop new therapies for small patient groups. As such, rare disease patients and families often must rely on advocacy, including both self-advocacy to access clinical care and public advocacy to advance research. However, these demands raise serious concerns for equity, as both care and research for a given disease can depend on the education, financial resources, and social capital available to the patients in a given community. In this article, we utilize three case examples to illustrate ethical challenges at the intersection of rare diseases, advocacy and justice, including how reliance on advocacy in rare disease may drive unintended consequences for equity. We conclude with a discussion of opportunities for diverse stakeholders to begin to address these challenges.
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Affiliation(s)
- Meghan C. Halley
- Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA, USA
| | - Colin M. E. Halverson
- Center for Bioethics, Indiana University School of Medicine, Indianapolis, IN, USA
- Charles Warren Fairbanks Center for Medical Ethics, Indianapolis, Indiana, USA
| | - Holly K. Tabor
- Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Aaron J. Goldenberg
- Department of Bioethics, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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8
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Palla JB. Disparities and therapeutic advances in cystic fibrosis. Pediatr Pulmonol 2023. [PMID: 37133222 DOI: 10.1002/ppul.26445] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/20/2023] [Indexed: 05/04/2023]
Abstract
Cystic fibrosis (CF) has seen a multitude of therapeutic advances targeting its downstream effects. This has led to a steady increase in survival over the past few decades. The recent development of disease-modifying drugs targeting the underlying CFTR mutation has revolutionized treatment for CF. Despite these advances, individuals with CF who are racial and ethnic minorities, from low socioeconomic status, or female sex have worse clinical outcomes. The inequitable access to CFTR modulators from cost and/or genetic eligibility has the potential to further worsen the existing health disparities seen within the CF community.
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Affiliation(s)
- John B Palla
- Division of Pulmonary and Sleep Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Yuzyuk TN, Nelson HA, Johnson LM. Inherited causes of exocrine pancreatic insufficiency in pediatric patients: clinical presentation and laboratory testing. Crit Rev Clin Lab Sci 2023:1-16. [PMID: 36876586 DOI: 10.1080/10408363.2023.2179968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Pediatric patients with exocrine pancreatic insufficiency (EPI) have symptoms that include abdominal pain, weight loss or poor weight gain, malnutrition, and steatorrhea. This condition can be present at birth or develop during childhood for certain genetic disorders. Cystic fibrosis (CF) is the most prevalent disorder in which patients are screened for EPI; other disorders also are associated with pancreatic dysfunction, such as hereditary pancreatitis, Pearson syndrome, and Shwachman-Diamond syndrome. Understanding the clinical presentation and proposed pathophysiology of the pancreatic dysfunction of these disorders aids in diagnosis and treatment. Testing pancreatic function is challenging. Directly testing aspirates produced from the pancreas after stimulation is considered the gold standard, but the procedures are not standardized or widely available. Instead, indirect tests are often used in diagnosis and monitoring. Although indirect tests are more widely available and easier to perform, they have inherent limitations due to a lack of sensitivity and/or specificity for EPI.
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Affiliation(s)
- Tatiana N Yuzyuk
- Department of Pathology, University of Utah/ARUP Laboratories, Salt Lake City, UT, USA
| | - Heather A Nelson
- Department of Pathology, University of Utah/ARUP Laboratories, Salt Lake City, UT, USA
| | - Lisa M Johnson
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA, USA
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10
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Rehani MR, Marcus MS, Harris AB, Farrell PM, Ren CL. Variation in cystic fibrosis newborn screening algorithms in the United States. Pediatr Pulmonol 2023; 58:927-933. [PMID: 36507555 DOI: 10.1002/ppul.26279] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/06/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
RATIONALE Cystic fibrosis (CF) newborn screening (NBS) algorithms in the United States vary by state. Differences in CF NBS algorithms could potentially affect the detection rate of CF newborns and lead to disparities in CF diagnosis amongst different racial and ethnic groups. OBJECTIVES Generate a database of CF NBS algorithms in the United States and identify processes that may potentially lead to missed diagnoses or lead to healthcare disparities. METHODS We sent an online survey to state and regional CF and NBS leaders about the type and threshold of immunoreactive trypsinogen (IRT) cutoff used and methods used for CFTR gene variant analysis. Follow-up by email and phone was done to ensure a response from every state, clarify responses, and resolve discordances. RESULTS There is wide variation in the NBS algorithms employed by different states. Approximately half the states use a floating IRT cutoff, and half use a fixed IRT cutoff. CFTR variant analysis also varies widely, with two states analyzing only for the F508del variant and four states incorporating CFTR gene sequencing. The other states use CFTR variant panels ranging from 23 to 365 CFTR variants. CONCLUSIONS CF NBS algorithms vary widely amongst the different states in the United States, which affects the ability of CF NBS to diagnose newborn infants with CF consistently and uniformly across the country and potentially may miss more infants with CF from minority populations. Our results identify an important area for quality improvement in CF NBS.
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Affiliation(s)
- Maryann R Rehani
- Milken Institute of Public Health, George Washington University, Washington, District of Columbia, USA.,Madison Waisman Center, University of Wisconsin, Madison, Wisconsin, USA
| | - Mary S Marcus
- Madison Waisman Center, University of Wisconsin, Madison, Wisconsin, USA
| | - Anne B Harris
- Madison Waisman Center, University of Wisconsin, Madison, Wisconsin, USA
| | - Philip M Farrell
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Clement L Ren
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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11
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Vockley J, Defay T, Goldenberg AJ, Gaviglio AM. Scaling genetic resources: New paradigms for diagnosis and treatment of rare genetic disease. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2023; 193:77-86. [PMID: 36448938 PMCID: PMC10038858 DOI: 10.1002/ajmg.c.32016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/25/2022] [Accepted: 11/15/2022] [Indexed: 12/05/2022]
Abstract
Development of genetic tests for rare genetic diseases has traditionally focused on individual diseases. Similarly, development of new therapies occurred one disease at a time. With >10,000 rare genetic diseases, this approach is not feasible. Diagnosis of genetic disorders has already transcended old paradigms as whole exome and genome sequencing have allowed expedient interrogation of all relevant genes in a single test. The growth of newborn screening has allowed identification of diseases in presymptomatic babies. Similarly, the ability to develop therapies is rapidly expanding due to technologies that leverage platform technology that address multiple diseases. However, movement from the basic science laboratory to clinical trials is still hampered by a regulatory system rooted in traditional trial design, requiring a fresh assessment of safe ways to obtain approval for new drugs. Ultimately, the number of nucleic acid-based therapies will challenge the ability of clinics focused on rare diseases to deliver them safely with appropriate evaluation and long-term follow-up. This manuscript summarizes discussions arising from a recent National Institutes of Health conference on nucleic acid therapy, with a focus on scaling technologies for diagnosis of rare disorders and provision of therapies across the age and disease spectrum.
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Affiliation(s)
- Jerry Vockley
- University of Pittsburgh Schools of Medicine and Public Health, Pittsburgh, Pennsylvania, USA
| | - Thomas Defay
- Alexion AstraZeneca Rare Diseases, Boston, Massachusetts, USA
| | - Aaron J Goldenberg
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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12
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Rock MJ, Baker M, Antos N, Farrell PM. Refinement of newborn screening for cystic fibrosis with next generation sequencing. Pediatr Pulmonol 2023; 58:778-787. [PMID: 36416003 DOI: 10.1002/ppul.26253] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 11/12/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Newborn screening for cystic fibrosis (CF) has been underway universally in the United States for more than a decade, as well in most European countries, and algorithms have been evolving throughout this period with quality improvement projects as immunoreactive trypsinogen (IRT) determinations alone have been transformed to a 2-tier strategy with DNA analyses. OBJECTIVE To apply next generation sequencing (NGS) as a screening method to expand the DNA tier and identify substantially more variants in the CF transmembrane conductance regulator (CFTR) gene to enhance sensitivity and equity while minimizing incidental findings. DESIGN Sequential evaluation and improvement plan in three phases using algorithm modifications coupled to statewide follow up and analysis of screening outcomes. RESULTS After demonstrating feasibility in the first phase, we studied an IRT/NGS algorithm that included CFTR Variants with Varying Clinical Consequences (VVCCs). This revealed a high identification of CF patients with 2-variants detected through screening, but for every CF case there were 1.4 with CF metabolic syndrome/CF screen positive, inconclusive diagnosis (CRMS/CFSPID). This led us to a third phase of improvement in which the VVCCs were eliminated except for R117H, resulting in 94% 2-variant detection of patients and 0.44:1 ratio of CRMS/CFSPID to CF. CONCLUSION NGS can be used with IRT as an effective method of identifying infants at risk for CF without an appreciable increase in detection of carriers. Its potential added value includes facilitating equity, enhancing sensitivity and detecting more CF patients with 2-variants during the screening process.
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Affiliation(s)
- Michael J Rock
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Mei Baker
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,Newborn Screening Laboratory, Wisconsin State Laboratory of Hygiene, University of Wisconsin school of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nicholas Antos
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Philip M Farrell
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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13
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Toward a Broader Understanding of Cystic Fibrosis Epidemiology and Its Impact on Clinical Manifestations. Clin Chest Med 2022; 43:579-590. [PMID: 36344067 DOI: 10.1016/j.ccm.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The incidence of cystic fibrosis remains constant in North America and Western Europe is 1 in 3500 live births, but survival and quality of life have improved. The cystic fibrosis population has shifted toward the adult age range with a concomitant shift in the spectrum of complications. Survival increased because of aggressive symptomatic therapy, earlier diagnosis by newborn screening, and the introduction of modulators of the cystic fibrosis transmembrane conductance regulator, so that predicted median survival age is now about 50 years. In the United States, members of low socioeconomic status populations or members of racial or ethnic minorities have benefitted less from these advances.
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14
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Montemayor K, Jain R. Cystic Fibrosis: Highly Effective Targeted Therapeutics and the Impact on Sex and Racial Disparities. Med Clin North Am 2022; 106:1001-1012. [PMID: 36280328 DOI: 10.1016/j.mcna.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
People with Cystic Fibrosis (CF) are living longer and healthier lives due in part to new therapies, called Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) modulators. However, disparities in outcomes still exist, with females demonstrating a shorter life expectancy than males; this is opposed to the typical female versus male life expectancy in the general United States population. In addition, minority populations such as those of Hispanic ethnicity and African Americans are less frequently eligible for these new CFTR modulators. The mechanisms driving this difference and the relative contribution of CFTR to the etiology are not yet elucidated.
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Affiliation(s)
- Kristina Montemayor
- Department of Medicine, Johns Hopkins University, 1830 E. Monument Street 5th Floor, Baltimore, MD 21205, USA
| | - Raksha Jain
- Department of Medicine, University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390-8558, USA.
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15
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Vaidyanathan S, Trumbull AM, Bar L, Rao M, Yu Y, Sellers ZM. CFTR genotype analysis of Asians in international registries highlights disparities in the diagnosis and treatment of Asian patients with cystic fibrosis. Genet Med 2022; 24:2180-2186. [PMID: 35857025 DOI: 10.1016/j.gim.2022.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 10/17/2022] Open
Abstract
PURPOSE Cystic fibrosis (CF) is not well-characterized in Asians, potentially resulting in delayed diagnosis and poor prognosis. We characterized CF in Asian subgroups to address these disparities. METHODS De-identified ethnicity and CFTR variant data were obtained from the United States, United Kingdom, and Canadian CF registries. We measured the prevalence of CF, CFTR variant allele frequencies, effectiveness of screening panels, and eligibility for modulator therapies. RESULTS The prevalence of CF was 1 in 74,982 people (Canada) to 1 in 13,340 people (United Kingdom) for South Asians and 1 in 256,541 (Canada) to 1 in 52,563 (United Kingdom) for other Asians, suggesting 26,000 to 146,000 patients with CF in South Asia. p.(F508del) variant was markedly less frequent in Asians than in non-Hispanic Whites. Splicing and nonsense variants occurred at high allelic frequencies in Asians, resulting in 41% to 49% of South Asians and 21% to 39% of other Asians being ineligible for CFTR modulator therapies. Hologic/EU2v1 panels failed to identify 37% to 47% of South Asian and 23% to 46% of other Asian patients with CF. CONCLUSIONS Among Asians, CF appears to be more common in South Asians. A significant CF population may exist in South Asia. CFTR variants in South and other Asians markedly differ from non-Hispanic Whites causing inequities in newborn screening, diagnosis, and treatment. New strategies are necessary to mitigate these health care disparities.
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Affiliation(s)
| | | | - Lilly Bar
- Center for Asian Health Research and Education, Stanford University, Stanford, CA
| | - Manaeha Rao
- Center for Asian Health Research and Education, Stanford University, Stanford, CA
| | - Yunnan Yu
- Center for Asian Health Research and Education, Stanford University, Stanford, CA
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16
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Sontag MK, Miller JI, McKasson S, Gaviglio A, Martiniano SL, West R, Vazquez M, Ren CL, Farrell PM, McColley SA, Kellar-Guenther Y. Newborn Screening for Cystic Fibrosis: A Qualitative Study of Successes and Challenges from Universal Screening in the United States. Int J Neonatal Screen 2022; 8:ijns8030038. [PMID: 35892468 PMCID: PMC9326751 DOI: 10.3390/ijns8030038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
Cystic fibrosis (CF) newborn screening (NBS) was universally adopted in 2009 in the United States. Variations in NBS practices between states may impact the timing of diagnosis and intervention. Quantitative metrics can provide insight into NBS programs (NBSP), but the nuances cannot be elucidated without additional feedback from programs. This study was designed to determine facilitators and barriers to timely diagnosis and intervention following NBS for CF. The median age at the first CF event for infants with CF within each state was used to define early and late states (n = 15 per group); multiple CF centers were invited in states with more than two CF centers. Thirty states were eligible, and 61 NBSP and CF centers were invited to participate in structured interviews to determine facilitators and barriers. Once saturation of themes was reached, no other interviews were conducted. Forty-five interviews were conducted (n = 16 early CF center, n = 12 late CF center, n = 11 early NBSP, and n = 6 late NBSP). Most interviewees reported good communication between CF centers and NBSP. Communication between primary care providers (PCPs) and families was identified as a challenge, leading to delays in referral and subsequent diagnosis. The misperception of low clinical risk in infants from racial and ethnic minority groups was a barrier to early diagnostic evaluation for all groups. NBSP and CF centers have strong relationships. Early diagnosis may be facilitated through more engagement with PCPs. Quality improvement initiatives should focus on continuing strong partnerships between CF centers and NBS programs, improving education, communication strategies, and partnerships with PCPs, and improving CF NBS timeliness and accuracy.
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Affiliation(s)
- Marci K. Sontag
- Center for Public Health Innovation at CI International, Littleton, CO 80120, USA; (J.I.M.); (S.M.); (R.W.); (Y.K.-G.)
- Colorado School of Public Health, University of Colorado Anschutz Medical Center, Aurora, CO 80045, USA
- Correspondence: ; Tel.: +1-303-867-1315
| | - Joshua I. Miller
- Center for Public Health Innovation at CI International, Littleton, CO 80120, USA; (J.I.M.); (S.M.); (R.W.); (Y.K.-G.)
| | - Sarah McKasson
- Center for Public Health Innovation at CI International, Littleton, CO 80120, USA; (J.I.M.); (S.M.); (R.W.); (Y.K.-G.)
| | - Amy Gaviglio
- Connetics Consulting, Minneapolis, MN 55417, USA;
| | - Stacey L. Martiniano
- Children’s Hospital Colorado, Aurora, CO 80045, USA;
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Rhonda West
- Center for Public Health Innovation at CI International, Littleton, CO 80120, USA; (J.I.M.); (S.M.); (R.W.); (Y.K.-G.)
| | - Marisol Vazquez
- Ann & Robert H. Lurie Children’s Hospital, Chicago, IL 60611, USA; (M.V.); (S.A.M.)
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Clement L. Ren
- Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
- Division of Pulmonary and Sleep Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Philip M. Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI 53705, USA;
| | - Susanna A. McColley
- Ann & Robert H. Lurie Children’s Hospital, Chicago, IL 60611, USA; (M.V.); (S.A.M.)
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Yvonne Kellar-Guenther
- Center for Public Health Innovation at CI International, Littleton, CO 80120, USA; (J.I.M.); (S.M.); (R.W.); (Y.K.-G.)
- Colorado School of Public Health, University of Colorado Anschutz Medical Center, Aurora, CO 80045, USA
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17
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McGarry ME, Gibb ER, Oates GR, Schechter MS. Left behind: The potential impact of CFTR modulators on racial and ethnic disparities in cystic fibrosis. Paediatr Respir Rev 2022; 42:35-42. [PMID: 35277357 PMCID: PMC9356388 DOI: 10.1016/j.prrv.2021.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/16/2021] [Indexed: 12/16/2022]
Abstract
The advent of CFTR modulators, a genomic specific medication, revolutionized the treatment of CF for many patients. However, given that these therapeutics were only developed for specific CFTR mutations, not all people with CF have access to such disease-modifying drugs. Racial and ethnic minority groups are less likely to have CFTR mutations that are approved for CFTR modulators. This exclusion has the potential to widen existing health disparities.
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Affiliation(s)
- Meghan E. McGarry
- Division of Pulmonary Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Elizabeth R. Gibb
- Division of Pulmonary Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Gabriela R. Oates
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Michael S. Schechter
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Virginia Commonwealth University and Children’s Hospital of Richmond at VCU, Richmond, VA
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18
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McBennett KA, Davis PB, Konstan MW. Increasing life expectancy in cystic fibrosis: Advances and challenges. Pediatr Pulmonol 2022; 57 Suppl 1:S5-S12. [PMID: 34672432 PMCID: PMC9004282 DOI: 10.1002/ppul.25733] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/30/2021] [Accepted: 10/03/2021] [Indexed: 01/14/2023]
Abstract
Since the first description of cystic fibrosis in 1938, there have been significant advances in both quality of life and longevity for people living with this disease. In this article we describe the milestones of the last 80 years and what we perceive to be the remaining barriers to normalcy for this population.
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Affiliation(s)
- Kimberly A McBennett
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Pamela B Davis
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael W Konstan
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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19
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Hutchins K, Barr E, Bellcross C, Ali N, Hunt WR. Evaluating Differences in the Disease Experiences of Minority Adults With Cystic Fibrosis. J Patient Exp 2022; 9:23743735221112629. [PMID: 35860790 PMCID: PMC9289912 DOI: 10.1177/23743735221112629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Extensive research has demonstrated disparities in health outcomes and survival
between non-Hispanic Caucasian (NHC) and non-Caucasian or Hispanic (minority)
persons with cystic fibrosis (CF) in the United States (US). However, very
little research has been done to explore the disease experiences of racial and
ethnic minority persons with CF. Adult subjects with CF were approached for
study participation and to characterize their experiential disease perceptions.
Survey data were analyzed using Chi-Square tests and Mann-Whitney
U-test for basic categorical and continuous variables, and
Kruskal-Wallis one-way ANOVA using ranks for Likert scales. Minority persons
reported significantly lower scores (more negative experience) when comparing
themselves to others with CF (15.18 ± 2.89 vs 18.40 ± 3.18,
P < .01), particularly in the areas of representation in
research, experience, and support. We were able to identify the unique
experiences of minority persons with CF, including perceived lower disease
understanding and poorer representation compared to most others with CF. Further
large studies are needed to develop and assess interventions that may be useful
for serving these diverse populations.
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Affiliation(s)
- Kia Hutchins
- Department of Human Genetics, Emory University, Atlanta, GA, USA
| | - Eileen Barr
- Department of Human Genetics, Emory University, Atlanta, GA, USA
| | | | - Nadia Ali
- Department of Human Genetics, Emory University, Atlanta, GA, USA
| | - William R. Hunt
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA, USA
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20
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Thakur N, Lovinsky-Desir S, Appell D, Bime C, Castro L, Celedón JC, Ferreira J, George M, Mageto Y, Mainous III AG, Pakhale S, Riekert KA, Roman J, Ruvalcaba E, Sharma S, Shete P, Wisnivesky JP, Holguin F. Enhancing Recruitment and Retention of Minority Populations for Clinical Research in Pulmonary, Critical Care, and Sleep Medicine: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 204:e26-e50. [PMID: 34347574 PMCID: PMC8513588 DOI: 10.1164/rccm.202105-1210st] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Well-designed clinical research needs to obtain information that is applicable to the general population. However, most current studies fail to include substantial cohorts of racial/ethnic minority populations. Such underrepresentation may lead to delayed diagnosis or misdiagnosis of disease, wide application of approved interventions without appropriate knowledge of their usefulness in certain populations, and development of recommendations that are not broadly applicable.Goals: To develop best practices for recruitment and retention of racial/ethnic minorities for clinical research in pulmonary, critical care, and sleep medicine.Methods: The American Thoracic Society convened a workshop in May of 2019. This included an international interprofessional group from academia, industry, the NIH, and the U.S. Food and Drug Administration, with expertise ranging from clinical and biomedical research to community-based participatory research methods and patient advocacy. Workshop participants addressed historical and current mistrust of scientific research, systemic bias, and social and structural barriers to minority participation in clinical research. A literature search of PubMed and Google Scholar was performed to support conclusions. The search was not a systematic review of the literature.Results: Barriers at the individual, interpersonal, institutional, and federal/policy levels were identified as limiting to minority participation in clinical research. Through the use of a multilevel framework, workshop participants proposed evidence-based solutions to the identified barriers.Conclusions: To date, minority participation in clinical research is not representative of the U.S. and global populations. This American Thoracic Society research statement identifies potential evidence-based solutions by applying a multilevel framework that is anchored in community engagement methods and patient advocacy.
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21
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Shum BOV, Bennett G, Navilebasappa A, Kumar RK. Racially equitable diagnosis of cystic fibrosis using next-generation DNA sequencing: a case report. BMC Pediatr 2021; 21:154. [PMID: 33789612 PMCID: PMC8011156 DOI: 10.1186/s12887-021-02609-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 03/11/2021] [Indexed: 12/03/2022] Open
Abstract
Background Cystic Fibrosis (CF) is one of the most prevalent autosomal recessive inherited disease in Caucasians. Rates of CF were thought to be negligible in non-Caucasians but growing epidemiological evidence shows CF is more common in Indian, African, Hispanic, Asian, and other ethnic groups than previously thought. Almost all second-tier molecular diagnostic tools currently used to confirm the diagnosis of CF consist of panels of the most common CF-causing DNA variants in Caucasians. However non-Caucasian individuals with CF often have a different spectrum of pathogenic variants than Caucasians, limiting the clinical utility of existing molecular diagnostic panels in this group. As a consequence of racially inequitable CF testing frameworks, non-Caucasians with CF encounter greater delays in diagnosis and associated harms than Caucasians. An unbiased approach of detecting CF-causing DNA variants using full gene sequencing could potentially address racial inequality in current CF testing. Case presentation We present the case of a female baby from rural India who had a borderline first-tier newborn screening result for CF. Instead of choosing a targeted CF panel for second-tier testing, we used next-generation DNA sequencing to comprehensively analyze the cystic fibrosis transmembrane conductance regulator gene as an unbiased approach for molecular confirmation of CF. Sequencing identified two pathogenic variants that cause CF. One variant (c.1521_1523delCTT) is the most common cause of CF, while the other variant (c.870-1G > C) is absent from all population allele databases and has not been found in the Indian population previously. The rare variant would not have been detected by all currently available targeted CF panels used for second- or third-tier molecular CF testing. Conclusions Our use of full gene sequencing as a second-tier CF test in a non-Caucasian patient avoided the problems of missed diagnosis from using Caucasian-biased targeted CF panels currently recommended for second-tier testing. Full gene sequencing should be considered as the standard methodology of second-tier CF testing to enable equal opportunity for CF diagnosis in non-Caucasians.
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Affiliation(s)
- Bennett O V Shum
- Preventive Health Division, Genepath, 302B 7 Help St, Chatswood, NSW, Australia. .,EMBL Australia Node in Single Molecule Science, School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia.
| | - Glenn Bennett
- Preventive Health Division, Genepath, 302B 7 Help St, Chatswood, NSW, Australia
| | | | - R Kishore Kumar
- Cloudnine Hospitals, 1533, 3rd Block, Jayanagar, Bengaluru, Karnataka, India
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22
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Phenotypic Presentations of Cystic Fibrosis in Children of African Descent. Genes (Basel) 2021; 12:genes12030458. [PMID: 33807078 PMCID: PMC8004676 DOI: 10.3390/genes12030458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/11/2021] [Accepted: 03/16/2021] [Indexed: 11/17/2022] Open
Abstract
The Robert Debre Pediatric Cystic Fibrosis (CF) centre, located in the North East of Paris, a multicultural area, is in charge of a cohort of around a hundred and sixty children diagnosed with CF. Between 2000 and 2019, the proportion of children of African descent in this centre increased from 2% to 10%. We report the clinical features of 17 children of African descent diagnosed with CF: 4 (23%) were diagnosed after a meconium ileus, 14 (83%) had exocrine pancreatic insufficiency, and 7 (41%) had early Pseudomonas aeruginosa infection before the age of two. Even though the majority of patients were diagnosed through NBS, the twenty-nine-mutation testing kit proved less effective in non-Caucasian populations, with a false negative rate of 25% in this series. CF is definitely not solely a Caucasian disease and the literature reveals similar phenotypes in Caucasian and African people provided that they present the same CFTR mutations. Clinicians have to keep in mind that the diagnosis of CF in patients of African descent must be evoked in the case of symptoms and a sweat test must be performed, despite a negative result for NBS.
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23
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Fraiman YS, Wojcik MH. The influence of social determinants of health on the genetic diagnostic odyssey: who remains undiagnosed, why, and to what effect? Pediatr Res 2021; 89:295-300. [PMID: 32932427 PMCID: PMC7897209 DOI: 10.1038/s41390-020-01151-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/11/2020] [Accepted: 08/26/2020] [Indexed: 01/30/2023]
Abstract
Although Mendelian genetic disorders are individually rare, they are collectively more common and contribute disproportionately to pediatric morbidity and mortality. Remarkable advances in the past decade have led to identification of the precise genetic variants responsible for many of these conditions. Confirming the molecular diagnosis through genetic testing allows for individualized treatment plans in addition to ending the diagnostic odyssey, which not only halts further unnecessary testing but may also result in immense psychological benefit, leading to improved quality of life. However, ensuring equitable application of these advances in genomic technology has been challenging. Though prior studies have revealed disparities in testing for genetic predisposition to cancer in adults, little is known about the prevalence and nature of disparities in diagnostic testing in the pediatric rare disease population. While it seems logical that those with impaired access to healthcare would be less likely to receive the genetic testing needed to end their odyssey, few studies have addressed this question directly and the potential impact on health outcomes. This review synthesizes the available evidence regarding disparities in pediatric genetic diagnosis, defining the need for further, prospective studies with the ultimate goal of delivering precision medicine to all who stand to benefit. IMPACT: Social determinants of health are known to contribute to inequality in outcomes, though the impact on pediatric rare disease patients is not fully understood. Diagnostic genetic testing is a powerful tool, though it may not be available to all in need. This article represents the first effort, to our knowledge, to evaluate the existing literature regarding disparities in genetic testing for pediatric rare disease diagnosis and identify gaps in care.
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Affiliation(s)
- Yarden S. Fraiman
- Division of Newborn Medicine, Boston Children’s Hospital/Harvard Medical School, Boston, MA
| | - Monica H. Wojcik
- Division of Newborn Medicine, Boston Children’s Hospital/Harvard Medical School, Boston, MA,Division of Genetics and Genomics, Boston Children’s Hospital/Harvard Medical School, Boston, MA
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24
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Januska MN, Marx L, Walker PA, Berdella MN, Langfelder-Schwind E. The CFTR variant profile of Hispanic patients with cystic fibrosis: Impact on access to effective screening, diagnosis, and personalized medicine. J Genet Couns 2020; 29:607-615. [PMID: 32227567 DOI: 10.1002/jgc4.1271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 11/11/2022]
Abstract
Hispanic patients comprise an appreciable and increasing proportion of patients with cystic fibrosis (CF) in the United States (US). Hispanic patients with CF are known to have increased morbidity and mortality compared to non-Hispanic white patients with CF, and ongoing investigations are underway to identify contributing factors amenable to intervention in order to address the disparate health outcomes. One contributing factor is the different CF transmembrane conductance regulator (CFTR) variant profile observed in Hispanic patients with CF. The most common CFTR variant, p.Phe508del (legacy name F508del), is proportionally underrepresented in Hispanic patients with CF. This difference has implications for prenatal screening, newborn screening (NBS), and CFTR variant-specific therapeutic options. In particular, the recent approval of a highly effective CFTR modulator for patients carrying at least one copy of F508del, elexacaftor/tezacaftor/ivacaftor triple combination therapy, underscores the potential for unequal access to personalized treatment for Hispanic patients with CF. We report the CFTR variant profiles of Hispanic patients with CF and non-CF Hispanic infants with a false-positive New York State CF NBS at a single center in New York City over a 5-year study period, as an opportunity to address the racial and ethnic disparities that currently exist in CF screening, diagnosis, and treatment. In addition to the previously documented disparate prevalence of the CFTR variant F508del in Hispanic patients, we observed two CFTR variants, p.His609Arg (legacy name H609R) and p.Thr1036Asn (legacy name T1036N), frequently identified in our Hispanic patients of Ecuadorian and Mexican ancestry, respectively, that are not well-described in the US population. The presence of population-specific and individually rare CFTR variants in Hispanic patients with CF further accentuates the disparity in health outcomes, as these CFTR variants are often absent from prenatal and NBS CFTR variant panels, potentially delaying diagnosis, and without an approved CFTR variant-specific therapy.
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Affiliation(s)
- Megan N Januska
- Department of Pulmonary, Critical Care, and Sleep Medicine, The Cystic Fibrosis Center at Mount Sinai Beth Israel, New York City, New York.,Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Laura Marx
- Department of Pulmonary, Critical Care, and Sleep Medicine, The Cystic Fibrosis Center at Mount Sinai Beth Israel, New York City, New York.,Department of Pediatrics, Genetics and Metabolic Clinic, St. Luke's Children's Hospital, Boise, Idaho
| | - Patricia A Walker
- Department of Pulmonary, Critical Care, and Sleep Medicine, The Cystic Fibrosis Center at Mount Sinai Beth Israel, New York City, New York
| | - Maria N Berdella
- Department of Pulmonary, Critical Care, and Sleep Medicine, The Cystic Fibrosis Center at Mount Sinai Beth Israel, New York City, New York.,Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Elinor Langfelder-Schwind
- Department of Pulmonary, Critical Care, and Sleep Medicine, The Cystic Fibrosis Center at Mount Sinai Beth Israel, New York City, New York
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25
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Bergougnoux A, Lopez M, Girodon E. The Role of Extended CFTR Gene Sequencing in Newborn Screening for Cystic Fibrosis. Int J Neonatal Screen 2020; 6:23. [PMID: 33073020 PMCID: PMC7422980 DOI: 10.3390/ijns6010023] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/19/2020] [Indexed: 01/25/2023] Open
Abstract
There has been considerable progress in the implementation of newborn screening (NBS) programs for cystic fibrosis (CF), with DNA analysis being part of an increasing number of strategies. Thanks to advances in genomic sequencing technologies, CFTR-extended genetic analysis (EGA) by sequencing its coding regions has become affordable and has already been included as part of a limited number of core NBS programs, to the benefit of admixed populations. Based on results analysis of existing programs, the values and challenges of EGA are reviewed in the perspective of its implementation on a larger scale. Sensitivity would be increased at best by using EGA as a second tier, but this could be at the expense of positive predictive value, which improves, however, if EGA is applied after testing a variant panel. The increased detection of babies with an inconclusive diagnosis has proved to be a major drawback in programs using EGA. The lack of knowledge on pathogenicity and penetrance associated with numerous variants hinders the introduction of EGA as a second tier, but EGA with filtering for all known CF variants with full penetrance could be a solution. The issue of incomplete knowledge is a real challenge in terms of the implemention of NBS extended to many genetic diseases.
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Affiliation(s)
- Anne Bergougnoux
- Molecular Genetics Laboratory, CHU Montpellier, EA7402 University of Montpellier, 34093 Montpellier CEDEX 5, France;
| | - Maureen Lopez
- Molecular Genetics Laboratory, Cochin Hospital, APHP. Centre, University of Paris, 75014 Paris, France;
| | - Emmanuelle Girodon
- Molecular Genetics Laboratory, Cochin Hospital, APHP. Centre, University of Paris, 75014 Paris, France;
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26
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McGarry ME, Neuhaus JM, Nielson DW, Ly NP. Regional variations in longitudinal pulmonary function: A comparison of Hispanic and non-Hispanic subjects with cystic fibrosis in the United States. Pediatr Pulmonol 2019; 54:1382-1390. [PMID: 31144477 PMCID: PMC6702095 DOI: 10.1002/ppul.24377] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/23/2019] [Accepted: 05/08/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND Hispanic subjects with cystic fibrosis (CF) have increased morbidity and mortality than non-Hispanic white subjects. The ethnic disparity in mortality varies by region. Factors influencing pulmonary function vary by both ethnicity and region. OBJECTIVE To determine if the ethnic difference in pulmonary function varies by region. METHODS This retrospective cohort study compared differences in longitudinal pulmonary function (percent-predicted forced vital capacity [FVC], forced expiratory volume in 1 second [FEV1 ], forced expiratory flow at 25% to 75% [FEF25-75 ], FEV1 /FVC, and FEV1 decline) between Hispanic and non-Hispanic white subjects with CF by Census region of the United States (West, South, Midwest, and Northeast). Subjects were of ages 6 to 25 years and in the CF Foundation Patient Registry from 2008 to 2013. We used linear mixed effects models with subject-specific slopes and intercepts, adjusting for 14 demographic and clinical variables. RESULTS Of 14 932 subjects, 1433 (9.6%) were Hispanic and 13 499 (90.4%) were non-Hispanic white. Hispanic subjects' FEV1 was 9.0% (8.3%-9.8%) lower than non-Hispanic white subjects in the West, while Hispanic subjects' FEV1 was only 4.0% (3.0%-5.0%) lower in the Midwest, 4.4% (3.1%-5.7%) lower in the Northeast, and 4.4% (3.2%-5.5%) lower in the South. Similarly, FVC and FEF25-75 were lower among Hispanic subjects compared to non-Hispanic white subjects in all US regions, with the biggest differences in the West. Only in the West was FEV1 /FVC significantly lower in Hispanic subjects (-0.019; -0.022 to -0.015). FEV1 decline was not significantly different between ethnicities in any region. CONCLUSIONS In CF, Hispanic subjects have lower pulmonary function than non-Hispanic white subjects in all geographic regions with the largest difference in occurring in the West.
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Affiliation(s)
- Meghan E McGarry
- Department of Pediatrics, University of California, San Francisco, California
| | - John M Neuhaus
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Dennis W Nielson
- Department of Pediatrics, University of California, San Francisco, California
| | - Ngoc P Ly
- Department of Pediatrics, University of California, San Francisco, California
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27
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Abul-Husn NS, Kenny EE. Personalized Medicine and the Power of Electronic Health Records. Cell 2019; 177:58-69. [PMID: 30901549 PMCID: PMC6921466 DOI: 10.1016/j.cell.2019.02.039] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/13/2019] [Accepted: 02/22/2019] [Indexed: 02/06/2023]
Abstract
Personalized medicine has largely been enabled by the integration of genomic and other data with electronic health records (EHRs) in the United States and elsewhere. Increased EHR adoption across various clinical settings and the establishment of EHR-linked population-based biobanks provide unprecedented opportunities for the types of translational and implementation research that drive personalized medicine. We review advances in the digitization of health information and the proliferation of genomic research in health systems and provide insights into emerging paths for the widespread implementation of personalized medicine.
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Affiliation(s)
- Noura S Abul-Husn
- The Center for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA; The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eimear E Kenny
- The Center for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA; The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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28
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Foil KE, Powers A, Raraigh KS, Wallis K, Southern KW, Salinas D. The increasing challenge of genetic counseling for cystic fibrosis. J Cyst Fibros 2018; 18:167-174. [PMID: 30527892 DOI: 10.1016/j.jcf.2018.11.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/30/2018] [Accepted: 11/26/2018] [Indexed: 12/12/2022]
Abstract
Genetic counseling for cystic fibrosis (CF) is challenged by intricate molecular mechanisms, complex phenotypes, and psychosocial needs. CFTR variant interpretation has become critical; this manuscript examines variant nomenclature and classes, as well as opportunities and challenges posed by genetic technologies and genotype-directed therapies. With post-graduate training in medical genetics and counseling, genetic counselors educate patients and families, facilitate testing and interpretation, and help integrate genetic information into diagnosis and treatment. They support families, ranging from carrier couples or new parents, to children understanding their disease, to adults with CF contemplating reproduction. The changing face of CF increasingly highlights the critical importance of genetic information to patients and their families. Genetic counselors are uniquely poised to translate this information in diagnostics and personalized care. Genetic counselors straddle molecular and clinical realms, helping patients adapt, plan, and gain access to appropriate therapies.
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Affiliation(s)
- Kimberly E Foil
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC, 29425, United States.
| | - Amy Powers
- Division of Pediatric Pulmonary and Sleep Medicine, University of Minnesota Health, Minneapolis, MN, 55455, United States.
| | - Karen S Raraigh
- Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD 21287, United States.
| | - Kimberly Wallis
- Center for Human Genetics, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, Kimberly, United States.
| | - Kevin W Southern
- Department of Women's and Children's Health, Alder Hey Children's Hospital, University of Liverpool, Liverpool, England L12 2AP, United Kingdom.
| | - Danieli Salinas
- Children's Hospital Los Angeles, Pediatric Pulmonology Division, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, United States.
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29
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Chuang SYC, Sealy L, Selvadurai H, Dutt S, Ooi CY. An unusual case of haemolytic anaemia and failure to thrive in a Burmese refugee baby. J Paediatr Child Health 2017; 53:500-502. [PMID: 28370599 DOI: 10.1111/jpc.13520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 11/21/2016] [Accepted: 12/15/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Sandra Y-C Chuang
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Respiratory Department, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Louise Sealy
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Hiran Selvadurai
- Respiratory Department, Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Sydney Medical School, Discipline of Paediatric and Child Helath, University of Sydney, Sydney, New South Wales, Australia
| | - Shoma Dutt
- Sydney Medical School, Discipline of Paediatric and Child Helath, University of Sydney, Sydney, New South Wales, Australia.,Department of Gastroenterology, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Chee Y Ooi
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Department of Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia
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30
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Behar DM, Inbar O, Shteinberg M, Gur M, Mussaffi H, Shoseyov D, Ashkenazi M, Alkrinawi S, Bormans C, Hakim F, Mei-Zahav M, Cohen-Cymberknoh M, Dagan A, Prais D, Sarouk I, Stafler P, Bar Aluma BE, Akler G, Picard E, Aviram M, Efrati O, Livnat G, Rivlin J, Bentur L, Blau H, Kerem E, Singer A. Nationwide genetic analysis for molecularly unresolved cystic fibrosis patients in a multiethnic society: implications for preconception carrier screening. Mol Genet Genomic Med 2017; 5:223-236. [PMID: 28546993 PMCID: PMC5441412 DOI: 10.1002/mgg3.278] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 01/07/2017] [Accepted: 01/13/2017] [Indexed: 12/18/2022] Open
Abstract
Background Preconception carrier screening for cystic fibrosis (CF) is usually performed using ethnically targeted panels of selected mutations. This has been recently challenged by the use of expanded, ethnically indifferent, pan‐population panels. Israel is characterized by genetically heterogeneous populations carrying a wide range of CFTR mutations. To assess the potential of expanding the current Israeli preconception screening program, we sought the subset of molecularly unresolved CF patients listed in the Israeli CF data registry comprising ~650 patients. Methods An Israeli nationwide genotyping of 152 CF cases, representing 176 patients lacking molecular diagnosis, was conducted. Molecular analysis included Sanger sequencing for all exons and splice sites, multiplex ligation probe amplification (MLPA), and next‐generation sequencing of the poly‐T/TG tracts. Results We identified 54 different mutations, of which only 16 overlapped the 22 mutations included in the Israeli preconception screening program. A total of 29/54 (53.7%) mutations were already listed as CF causing by the CFTR2 database, and only 4/54 (7.4%) were novel. Molecular diagnosis was reached in 78/152 (51.3%) cases. Prenatal diagnosis of 24/78 (30.8%) cases could have been achieved by including all CFTR2‐causing mutations in the Israeli panel. Conclusions Our data reveal an overwhelming hidden abundance of CFTR gene mutations suggesting that expanded preconception carrier screening might achieve higher preconception detection rates.
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Affiliation(s)
- Doron M Behar
- Clalit National Personalized Medicine ProgramDepartment of Community Medicine and EpidemiologyCarmel Medical CenterHaifaIsrael.,Bruce Rappaport Faculty of MedicineTechnion-Israel Institute of TechnologyHaifaIsrael.,Gene by GeneGenomic Research CenterHoustonTexas
| | - Ori Inbar
- The Cystic Fibrosis Foundation of IsraelRamat GanIsrael
| | - Michal Shteinberg
- Bruce Rappaport Faculty of MedicineTechnion-Israel Institute of TechnologyHaifaIsrael.,Pulmonology Institute and CF CenterCarmel Medical CenterHaifaIsrael
| | - Michal Gur
- Bruce Rappaport Faculty of MedicineTechnion-Israel Institute of TechnologyHaifaIsrael.,Pediatric Pulmonary Institute and CF CenterRappaport Children's HospitalRambam Health Care CampusHaifaIsrael
| | - Huda Mussaffi
- Kathy and Lee Graub Cystic Fibrosis CenterSchneider Children's Medical Center of IsraelPetach TikvaIsrael.,Sackler Faculty of MedicineTel Aviv UniversityRamat AvivIsrael
| | - David Shoseyov
- Cystic Fibrosis CenterHadassah-Hebrew University Medical CenterJerusalemIsrael
| | | | | | | | - Fahed Hakim
- Bruce Rappaport Faculty of MedicineTechnion-Israel Institute of TechnologyHaifaIsrael.,Pediatric Pulmonary Institute and CF CenterRappaport Children's HospitalRambam Health Care CampusHaifaIsrael
| | - Meir Mei-Zahav
- Kathy and Lee Graub Cystic Fibrosis CenterSchneider Children's Medical Center of IsraelPetach TikvaIsrael.,Sackler Faculty of MedicineTel Aviv UniversityRamat AvivIsrael
| | | | - Adi Dagan
- Cystic Fibrosis CenterSheba Medical CenterRamat GanIsrael
| | - Dario Prais
- Kathy and Lee Graub Cystic Fibrosis CenterSchneider Children's Medical Center of IsraelPetach TikvaIsrael.,Sackler Faculty of MedicineTel Aviv UniversityRamat AvivIsrael
| | - Ifat Sarouk
- Cystic Fibrosis CenterSheba Medical CenterRamat GanIsrael
| | - Patrick Stafler
- Kathy and Lee Graub Cystic Fibrosis CenterSchneider Children's Medical Center of IsraelPetach TikvaIsrael.,Sackler Faculty of MedicineTel Aviv UniversityRamat AvivIsrael
| | | | - Gidon Akler
- Gene by GeneGenomic Research CenterHoustonTexas
| | - Elie Picard
- Cystic Fibrosis CenterShaare Zedek Medical CenterHebrew University Medical CenterJerusalemIsrael
| | - Micha Aviram
- Cystic Fibrosis CenterSoroka Medical CenterBeershevaIsrael
| | - Ori Efrati
- Cystic Fibrosis CenterSheba Medical CenterRamat GanIsrael
| | - Galit Livnat
- Bruce Rappaport Faculty of MedicineTechnion-Israel Institute of TechnologyHaifaIsrael.,Pulmonology Institute and CF CenterCarmel Medical CenterHaifaIsrael
| | - Joseph Rivlin
- Bruce Rappaport Faculty of MedicineTechnion-Israel Institute of TechnologyHaifaIsrael.,Pulmonology Institute and CF CenterCarmel Medical CenterHaifaIsrael
| | - Lea Bentur
- Bruce Rappaport Faculty of MedicineTechnion-Israel Institute of TechnologyHaifaIsrael.,Pediatric Pulmonary Institute and CF CenterRappaport Children's HospitalRambam Health Care CampusHaifaIsrael
| | - Hannah Blau
- Kathy and Lee Graub Cystic Fibrosis CenterSchneider Children's Medical Center of IsraelPetach TikvaIsrael.,Sackler Faculty of MedicineTel Aviv UniversityRamat AvivIsrael
| | - Eitan Kerem
- Cystic Fibrosis CenterHadassah-Hebrew University Medical CenterJerusalemIsrael
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31
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Caggana M. Newborn screening for cystic fibrosis: can one algorithm fit all? Expert Rev Mol Diagn 2017; 17:205-207. [DOI: 10.1080/14737159.2017.1288100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Michele Caggana
- Newborn Screening Program, New York State Department of Health, Division of Genetics, Wadsworth Center, Albany, NY, USA
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32
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Lopes-Pacheco M. CFTR Modulators: Shedding Light on Precision Medicine for Cystic Fibrosis. Front Pharmacol 2016; 7:275. [PMID: 27656143 PMCID: PMC5011145 DOI: 10.3389/fphar.2016.00275] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 08/11/2016] [Indexed: 12/15/2022] Open
Abstract
Cystic fibrosis (CF) is the most common life-threatening monogenic disease afflicting Caucasian people. It affects the respiratory, gastrointestinal, glandular and reproductive systems. The major cause of morbidity and mortality in CF is the respiratory disorder caused by a vicious cycle of obstruction of the airways, inflammation and infection that leads to epithelial damage, tissue remodeling and end-stage lung disease. Over the past decades, life expectancy of CF patients has increased due to early diagnosis and improved treatments; however, these patients still present limited quality of life. Many attempts have been made to rescue CF transmembrane conductance regulator (CFTR) expression, function and stability, thereby overcoming the molecular basis of CF. Gene and protein variances caused by CFTR mutants lead to different CF phenotypes, which then require different treatments to quell the patients' debilitating symptoms. In order to seek better approaches to treat CF patients and maximize therapeutic effects, CFTR mutants have been stratified into six groups (although several of these mutations present pleiotropic defects). The research with CFTR modulators (read-through agents, correctors, potentiators, stabilizers and amplifiers) has achieved remarkable progress, and these drugs are translating into pharmaceuticals and personalized treatments for CF patients. This review summarizes the main molecular and clinical features of CF, emphasizes the latest clinical trials using CFTR modulators, sheds light on the molecular mechanisms underlying these new and emerging treatments, and discusses the major breakthroughs and challenges to treating all CF patients.
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Affiliation(s)
- Miquéias Lopes-Pacheco
- Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro Rio de Janeiro, Brazil
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