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Avan A, Członkowska A, Gaskin S, Granzotto A, Sensi SL, Hoogenraad TU. The Role of Zinc in the Treatment of Wilson’s Disease. Int J Mol Sci 2022; 23:ijms23169316. [PMID: 36012580 PMCID: PMC9409413 DOI: 10.3390/ijms23169316] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/09/2022] [Accepted: 08/15/2022] [Indexed: 02/06/2023] Open
Abstract
Wilson’s disease (WD) is a hereditary disorder of copper metabolism, producing abnormally high levels of non-ceruloplasmin-bound copper, the determinant of the pathogenic process causing brain and hepatic damage and dysfunction. Although the disease is invariably fatal without medication, it is treatable and many of its adverse effects are reversible. Diagnosis is difficult due to the large range and severity of symptoms. A high index of suspicion is required as patients may have only a few of the many possible biomarkers. The genetic prevalence of ATP7B variants indicates higher rates in the population than are currently diagnosed. Treatments have evolved from chelators that reduce stored copper to zinc, which reduces the toxic levels of circulating non-ceruloplasmin-bound copper. Zinc induces intestinal metallothionein, which blocks copper absorption and increases excretion in the stools, resulting in an improvement in symptoms. Two meta-analyses and several large retrospective studies indicate that zinc is equally effective as chelators for the treatment of WD, with the advantages of a very low level of toxicity and only the minor side effect of gastric disturbance. Zinc is recommended as a first-line treatment for neurological presentations and is gaining acceptance for hepatic presentations. It is universally recommended for lifelong maintenance therapy and for presymptomatic WD.
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Affiliation(s)
- Abolfazl Avan
- Department of Public Health, School of Medicine, Mashhad University of Medical Sciences, Mashhad 93518-88415, Iran
- Correspondence:
| | - Anna Członkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland
| | - Susan Gaskin
- Department of Civil Engineering, McGill University, Montreal, QC H3A 0C3, Canada
| | - Alberto Granzotto
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Department of Neuroscience, Imaging, and Clinical Sciences (DNISC), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Sue and Bill Gross Stem Cell Research Center, University of California-Irvine, Irvine, CA 92697, USA
| | - Stefano L. Sensi
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Department of Neuroscience, Imaging, and Clinical Sciences (DNISC), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Institute for Advanced Biomedical Technologies (ITAB), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Tjaard U. Hoogenraad
- Department of Neurology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
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Poujois A, Trocello JM, Djebrani-Oussedik N, Poupon J, Collet C, Girardot-Tinant N, Sobesky R, Habès D, Debray D, Vanlemmens C, Fluchère F, Ory-Magne F, Labreuche J, Preda C, Woimant F. Exchangeable copper: a reflection of the neurological severity in Wilson's disease. Eur J Neurol 2016; 24:154-160. [PMID: 27739240 DOI: 10.1111/ene.13171] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/29/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE The severity of Wilson's disease (WD) is linked to free copper accumulating in the liver and brain. Exchangeable copper (CuEXC) is a new technique to determine plasmatic copper and is useful in the diagnosis of WD. It is hypothesized that it may also enable a good evaluation of extra-hepatic involvement and its severity. METHODS Forty-eight newly diagnosed WD patients were prospectively evaluated using hepatic, neurological, ophthalmological and brain magnetic resonance imaging (MRI) scores. Three phenotypic presentations were distinguished: pre-symptomatic, hepatic and extra-hepatic. CuEXC was determined in addition to standard copper assays before decoppering therapy. Correlations between biological parameters and the different scores were determined and compared in the hepatic and extra-hepatic groups. RESULTS Extra-hepatic patients had significantly higher CuEXC values than those with the hepatic form (P < 0.0001). The overall ability of CuEXC to separate the two forms was satisfactory, with an area under the curve of 0.883 (95% confidence interval 0.771-0.996) and an optimal threshold for extra-hepatic diagnosis of 2.08 μmol/l (sensitivity 85.7%; specificity 94.1%). In extra-hepatic patients, CuEXC was the only biological marker to be positively correlated with the Unified Wilson Disease Rating Score (r = 0.45, P = 0.016), the Kayser-Fleischer ring score (r = 0.46, P = 0.014) and the brain MRI score (r = 0.38, P = 0.048), but it was not correlated with the hepatic score. CONCLUSIONS Exchangeable copper determination is useful when diagnosing WD as a value >2.08 μmol/l is indicative of the severity of the extra-hepatic involvement. In the case of purely hepatic presentation, atypical or mild neurological signs, it should encourage physicians to search for lesions in the brain and eyes.
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Affiliation(s)
- A Poujois
- National Reference Centre for Wilson's Disease, AP-HP, Lariboisière Hospital, Paris, France.,Neurology Department, AP-HP, Lariboisière Hospital, Paris, France
| | - J-M Trocello
- National Reference Centre for Wilson's Disease, AP-HP, Lariboisière Hospital, Paris, France.,Neurology Department, AP-HP, Lariboisière Hospital, Paris, France
| | - N Djebrani-Oussedik
- National Reference Centre for Wilson's Disease, AP-HP, Lariboisière Hospital, Paris, France.,Toxicology Laboratory, AP-HP, Lariboisière Hospital, Paris, France
| | - J Poupon
- National Reference Centre for Wilson's Disease, AP-HP, Lariboisière Hospital, Paris, France.,Toxicology Laboratory, AP-HP, Lariboisière Hospital, Paris, France
| | - C Collet
- National Reference Centre for Wilson's Disease, AP-HP, Lariboisière Hospital, Paris, France.,Molecular Biology and Biochemistry Department, AP-HP, Lariboisière Hospital, Paris, France
| | - N Girardot-Tinant
- National Reference Centre for Wilson's Disease, AP-HP, Lariboisière Hospital, Paris, France.,Neurology Department, AP-HP, Lariboisière Hospital, Paris, France
| | - R Sobesky
- National Reference Centre for Wilson's Disease, AP-HP, Lariboisière Hospital, Paris, France.,Hepatobiliary Centre, DHU Hepatinov, AP-HP, Paul Brousse Hospital, Villejuif, France
| | - D Habès
- National Reference Centre for Wilson's Disease, AP-HP, Lariboisière Hospital, Paris, France.,Hepatology and Pediatrics Department, AP-HP, Kremlin-Bicètre Hospital, Kremlin-Bicètre, France
| | - D Debray
- Hepatology and Pediatrics Department, AP-HP, Necker Hospital, Paris, France
| | - C Vanlemmens
- Hepatology and Gastroenterology Department, CHU Besancon, Besancon, France
| | - F Fluchère
- Neurology Department, CHU Marseille, Marseille, France
| | - F Ory-Magne
- Neurology Department, CHU Toulouse, Toulouse, France
| | - J Labreuche
- Biostatistics Unit, EA2694, CHRU Lille, Lille, France
| | - C Preda
- Mathematics Laboratory, UMR CNRS 8524, Lille, France
| | - F Woimant
- National Reference Centre for Wilson's Disease, AP-HP, Lariboisière Hospital, Paris, France.,Neurology Department, AP-HP, Lariboisière Hospital, Paris, France
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Abstract
Zinc is an essential trace element playing fundamental roles in cellular metabolism. It acts mostly by binding a wide range of proteins, thus affecting a broad spectrum of biological processes, which include cell division, growth and differentiation. Zinc is critical to a large number of structural proteins, enzymatic processes, and transcription factors. Zinc deficiency can result in a spectrum of clinical manifestations, such as poor of appetite, loss of body hair, altered taste and smell, testicular atrophy, cerebral and immune dysfunction, and diminished drug elimination capacity. These are common symptoms in patients with chronic liver diseases, especially liver cirrhosis. The liver is the main organ responsible for the zinc metabolism which can be affected by liver diseases. On the other hand, zinc deficiency may alter hepatocyte functions and also immune responses in inflammatory liver diseases. Liver cirrhosis represents the most advanced stage of chronic liver diseases and is the common outcome of chronic liver injury. It is associated with energy malnutrition, with numerous metabolic disorders, such as hypoalbuminemia, with imbalance between branched-chain amino acids and aromatic amino acids, and with reduced zinc serum concentrations. All these processes can influence the clinical outcome of patients, such ascites, hepatic encephalopathy and hepatocellular carcinoma. In the present review, we summarize the emerging evidence on the pitoval role of zinc in the pathogenesis of liver cirrhosis.
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Affiliation(s)
| | - Dirk Reinhold
- Institute of Molecular and Clinical Immunology, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
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Ochoa Palominos A, Ibáñez Samaniego L, Catalina Rodríguez MV, Pajares Díaz J, Clemente Ricote G. [Wilson's disease: clinical spectrum of liver disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 36:86-91. [PMID: 23089210 DOI: 10.1016/j.gastrohep.2012.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 07/20/2012] [Accepted: 07/24/2012] [Indexed: 01/29/2023]
Abstract
Wilson's disease is a hereditary autosomal recessive disorder of copper metabolism,characterized by copper accumulation in the liver and brain. This rare entity, which has a broad clinical spectrum, is often difficult to diagnose and should therefore always be suspected in patients with liver disease of unclear cause. We describe two types of manifestation of liver disease in two patients; the first developed fulminant hepatic failure requiring urgent liver transplantation and the second showed advanced chronic liver disease and received standard medical treatment. The objective of this clinical observation is to analyze the diagnosis of Wilson's disease in two patients with distinct onset, illustrating the broad clinical spectrum of the disease, and its treatment.
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Affiliation(s)
- Alejandra Ochoa Palominos
- Sección de Hepatología, Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón, Madrid, España
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Abstract
Zinc is an essential trace element required for normal cell growth, development, and differentiation. It is involved in DNA synthesis, RNA transcription, and cell division and activation. It is a critical component in many zinc protein/enzymes, including critical zinc transcription factors. Zinc deficiency/altered metabolism is observed in many types of liver disease, including alcoholic liver disease (ALD) and viral liver disease. Some of the mechanisms for zinc deficiency/altered metabolism include decreased dietary intake, increased urinary excretion, activation of certain zinc transporters, and induction of hepatic metallothionein. Zinc deficiency may manifest itself in many ways in liver disease, including skin lesions, poor wound healing/liver regeneration, altered mental status, or altered immune function. Zinc supplementation has been documented to block/attenuate experimental ALD through multiple processes, including stabilization of gut-barrier function, decreasing endotoxemia, decreasing proinflammatory cytokine production, decreasing oxidative stress, and attenuating apoptotic hepatocyte death. Clinical trials in human liver disease are limited in size and quality, but it is clear that zinc supplementation reverses clinical signs of zinc deficiency in patients with liver disease. Some studies suggest improvement in liver function in both ALD and hepatitis C following zinc supplementation, and 1 study suggested improved fibrosis markers in hepatitis C patients. The dose of zinc used for treatment of liver disease is usually 50 mg of elemental zinc taken with a meal to decrease the potential side effect of nausea.
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Affiliation(s)
| | - Zhanxiang Zhou
- University of North Carolina Greensboro, Greensboro, North Carolina
| | - Matthew Cave
- University of Louisville Medical Center, Louisville, Kentucky
| | - Ashutosh Barve
- University of Louisville Medical Center, Louisville, Kentucky
| | - Craig J. McClain
- Correspondence Author: Craig J. McClain, University of Louisville Medical Center, 550 S Jackson St, ACB 3rd Floor, Louisville, KY 40292, USA,
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