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Nicoletti T, Bink A, Helmchen B, Briel N, Frontzek K, Vlad B, Gaspert A, Boudriot E, Jung HH, Reuss AM, Weller M, Hortobágyi T. Neurologic involvement in cystinosis: Focus on brain lesions and new evidence of four-repeat (4R-) Tau immunoreactivity. J Neurol Sci 2024; 456:122841. [PMID: 38101161 DOI: 10.1016/j.jns.2023.122841] [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: 08/31/2023] [Revised: 11/10/2023] [Accepted: 12/08/2023] [Indexed: 12/17/2023]
Abstract
Nephropathic cystinosis is a rare autosomal recessive storage disorder caused by CTNS gene mutations, leading to autophagy-lysosomal pathway impairment and cystine crystals accumulation. Neurologic involvement is highly variable and includes both neurodevelopmental and neurodegenerative disturbances, as well as focal neurologic deficits. By presenting longitudinal data of a 28-year-old patient with a large infratentorial lesion, we summarized the pathology, clinical and imaging features of neurological involvement in cystinosis patients. Brain damage in form of cystinosis-related cerebral lesions occurs in advanced disease phases and is characterized by the accumulation of cystine crystals, subsequent inflammation with vasculitis-like features, necrosis, and calcification. Epilepsy is a frequent comorbidity in affected individuals. Steroids might play a role in the symptomatic treatment of "stroke-like" episodes due to edematous-inflammatory lesions, but probably do not change the overall prognosis. Lifelong compliance to depleting therapy with cysteamine still represents the main therapeutic option. However, consequences of CTNS gene defects are not restricted to cystine accumulation. New evidence of four-repeat (4R-) Tau immunoreactivity suggests concurrent progressive neurodegeneration in cystinosis patients, highlighting the need of innovative therapeutic strategies, and shedding light on the crosstalk between proteinopathies and autophagy-lysosomal system defects. Eventually, emerging easily accessible biomarkers such as serum neurofilament light chains (NfL) might detect subclinical neurologic involvement in cystinosis patients.
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Affiliation(s)
- Tommaso Nicoletti
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland.
| | - Andrea Bink
- Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland; Department of Neuroradiology, University Hospital Zurich, Switzerland
| | - Birgit Helmchen
- Department of Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Nils Briel
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland; Center for Neuropathology and Prion Research, Ludwig-Maximilians-University, Munich, Germany
| | - Karl Frontzek
- Institute of Neuropathology, University Hospital Zurich, Zurich, Switzerland; Queen Square Brain Bank for Neurological Disorders, UCL Queen Square Institute of Neurology, London, UK
| | - Benjamin Vlad
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Ariana Gaspert
- Department of Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Elisabeth Boudriot
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Hans Heinrich Jung
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Anna Maria Reuss
- Institute of Neuropathology, University Hospital Zurich, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Tibor Hortobágyi
- Institute of Neuropathology, University Hospital Zurich, Zurich, Switzerland
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Müller S, Kluck R, Jagodzinski C, Brügelmann M, Hohenfellner K, Büscher A, Kemper MJ, Fröde K, Oh J, Billing H, Thumfart J, Weber LT, Acham-Roschitz B, Arbeiter K, Tönshoff B, Hagenberg M, Pavičić L, Haffner D, Zivicnjak M. Chest configuration in children and adolescents with infantile nephropathic cystinosis compared with other chronic kidney disease entities and its clinical determinants. Pediatr Nephrol 2023; 38:3989-3999. [PMID: 37415042 PMCID: PMC10584709 DOI: 10.1007/s00467-023-06058-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Infantile nephropathic cystinosis (INC) is a systemic lysosomal storage disease causing intracellular cystine accumulation, resulting in renal Fanconi syndrome, progressive kidney disease (CKD), rickets, malnutrition, and myopathy. An INC-specific disproportionately diminished trunk length compared to leg length poses questions regarding the functionality of the trunk. METHODS Thus, we prospectively investigated thoracic dimensions and proportions, as well as their clinical determinants in 44 pediatric patients with INC with CKD stages 1-5 and 97 age-matched patients with CKD of other etiology between the ages of 2-17 years. A total of 92 and 221 annual measurements of patients with INC and CKD, respectively, were performed, and associations between anthropometric and clinical parameters were assessed using linear mixed-effects models. RESULTS Patients with INC exhibited altered chest dimensions that were distinct from CKD controls, characterized by markedly increased chest depth to height and chest depth to chest width ratio z-scores (> 1.0), while those of patients with CKD were only mildly affected (z-score within ± 1.0). Ratio z-scores differed significantly between both patient groups from 2-6 years of age onward. The degree of chest disproportion in INC patients was significantly associated with both the degree of CKD and tubular dysfunction (e.g., low serum phosphate and bicarbonate) across three different age groups (2-6, 7-12, and 13-17 years). CONCLUSION Our data show an INC-specific alteration in thoracic shape from early childhood onward, which is distinct from CKD of other etiologies, suggesting early childhood subclinical changes of the musculoskeletal unit of the thoracic cage, which are associated with kidney function. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Sophia Müller
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Children's Hospital, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Rika Kluck
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Children's Hospital, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Celina Jagodzinski
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Children's Hospital, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Malina Brügelmann
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Children's Hospital, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | | | - Anja Büscher
- Department of Pediatrics II, University Hospital Essen, Essen, Germany
| | | | - Kerstin Fröde
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Children's Hospital, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Jun Oh
- Division of Pediatric Nephrology, University Children's Hospital Hamburg, Hamburg, Germany
| | - Heiko Billing
- Clinic for Pediatric and Adolescent Medicine, RHK Clinic Ludwigsburg, Ludwigsburg, Germany
| | - Julia Thumfart
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Lutz T Weber
- Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | | | - Klaus Arbeiter
- Division of Pediatric Nephrology and Gastroenterology, Medical University Vienna, Vienna, Austria
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Martina Hagenberg
- Children's Hospital St. Elisabeth and St. Barbara, Halle (Saale), Germany
| | | | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Children's Hospital, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Miroslav Zivicnjak
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Children's Hospital, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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Yang G, Mack H, Harraka P, Colville D, Savige J. Ocular manifestations of the genetic renal tubulopathies. Ophthalmic Genet 2023; 44:515-529. [PMID: 37702059 DOI: 10.1080/13816810.2023.2253901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 08/26/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND The genetic tubulopathies are rare and heterogenous disorders that are often difficult to identify. This study examined the tubulopathy-causing genes for ocular associations that suggested their genetic basis and, in some cases, the affected gene. METHODS Sixty-seven genes from the Genomics England renal tubulopathy panel were reviewed for ocular features, and for retinal expression in the Human Protein Atlas and an ocular phenotype in mouse models in the Mouse Genome Informatics database. The genes resulted in disease affecting the proximal tubules (n = 24); the thick ascending limb of the loop of Henle (n = 10); the distal convoluted tubule (n = 15); or the collecting duct (n = 18). RESULTS Twenty-five of the tubulopathy-associated genes (37%) had ocular features reported in human disease, 49 (73%) were expressed in the retina, although often at low levels, and 16 (24%) of the corresponding mouse models had an ocular phenotype. Ocular abnormalities were more common in genes affected in the proximal tubulopathies (17/24, 71%) than elsewhere (7/43, 16%). They included structural features (coloboma, microphthalmia); refractive errors (myopia, astigmatism); crystal deposition (in oxalosis, cystinosis) and sclerochoroidal calcification (in Bartter, Gitelman syndromes). Retinal atrophy was common in the mitochondrial-associated tubulopathies. Structural abnormalities and crystal deposition were present from childhood, but sclerochoroidal calcification typically occurred after middle age. CONCLUSIONS Ocular abnormalities are uncommon in the genetic tubulopathies but may be helpful in recognizing the underlying genetic disease. The retinal expression and mouse phenotype data suggest that further ocular associations may become apparent with additional reports. Early identification may be necessary to monitor and treat visual complications.
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Affiliation(s)
- GeFei Yang
- Department of Medicine (Melbourne Health and Northern Health), The University of Melbourne, Royal Melbourne Hospital, Parkville, Australia
| | - Heather Mack
- Department of Surgery (Ophthalmology), The University of Melbourne, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Philip Harraka
- Department of Medicine (Melbourne Health and Northern Health), The University of Melbourne, Royal Melbourne Hospital, Parkville, Australia
| | - Deb Colville
- Department of Surgery (Ophthalmology), The University of Melbourne, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Judy Savige
- Department of Medicine (Melbourne Health and Northern Health), The University of Melbourne, Royal Melbourne Hospital, Parkville, Australia
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George RP, Winterberg PD, Garro R. Multidisciplinary and multidimensional approaches to transplantation in children with rare genetic kidney diseases. Pediatr Transplant 2023; 27:e14567. [PMID: 37522570 DOI: 10.1111/petr.14567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/31/2020] [Accepted: 11/16/2020] [Indexed: 08/01/2023]
Abstract
In this review, we describe the multidisciplinary, multidimensional care required to optimize outcomes for pediatric transplant recipients with rare genetic kidney diseases. Transplant success, recipient survival, and improvement in quality of life depend on collaboration between patients, families, and a team of specialists with medical, as well as nonmedical expertise. A multidisciplinary transplant team composed of experts from medicine, surgery, nursing, nutrition, social services, transplant coordination, psychology, and pharmacology, is now standard in most transplant centers and is critical to the success of a transplant. In addition to these professionals, other specialists, such as cardiologists, urologists, geneticists, metabolic disease specialists, occupational therapists, case management, child life, chaplain, and palliative care services, have a crucial role to play in the preparation, surgery, and follow-up care, especially when a pediatric patient has a rare genetic disorder leading to renal involvement, and the need for transplantation. In order to describe this multidisciplinary care, we divide the genetic renal diseases into five subgroups-metabolic and tubular disorders, glomerular diseases, congenital anomalies of the kidney and urinary tract, ciliopathies including cystic diseases, and miscellaneous renal conditions; and describe for each, the need for care beyond that provided by the standard transplant team members.
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Affiliation(s)
- Roshan P George
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine, and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Pamela D Winterberg
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine, and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Rouba Garro
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine, and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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Hohenfellner K, Zerell K, Haffner D. Cystinosis. Klin Monbl Augenheilkd 2023; 240:251-259. [PMID: 36977426 DOI: 10.1055/a-2022-8522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
Cystinosis is a very rare autosomal recessive lysosomal storage disorder with an incidence of 1 : 150,000 - 1 : 200,000, and is caused by mutations in the CTNS gene encoding the lysosomal membrane protein cystinosin, which transports cystine out of the lysosome into the cytoplasm. As a result, accumulation of cystine occurs in almost all cells and tissues, especially in the kidneys, leading to multiple organ involvement. Introduction of drug therapy with cysteamine in the mid 1980s, along with the availability of renal replacement therapy in childhood, have dramatically improved patient outcome. Whereas patients used to die without therapy with end-stage renal failure during the first decade of life, nowadays most patients live well into adulthood without renal replacement therapy, and several reach 40 years. There is robust evidence that early initiation and sustained lifelong therapy with cysteamine are both essential for morbidity and mortality. The rarity of the disease and the multi-organ involvement present an enormous challenge for those affected and the providers of care for this patient group.
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Affiliation(s)
- Katharina Hohenfellner
- Klinik für Kinder- und Jugendmedizin/Kindernephrologie, RoMed Kliniken, Rosenheim, Deutschland
| | - Kirstin Zerell
- Rosenheim, kbo-Heckscher-Klinikum gGmbH, München, Deutschland
| | - Dieter Haffner
- Klinik für Pädiatrische Nieren-, Leber- & Stoffwechselerkrankungen, MHH, Hannover, Deutschland
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Nießl C, Boulesteix AL, Oh J, Palm K, Schlingmann P, Wygoda S, Haffner D, Wühl E, Tönshoff B, Buescher A, Billing H, Hoppe B, Zirngibl M, Kettwig M, Moeller K, Acham-Roschitz B, Arbeiter K, Bald M, Benz M, Galiano M, John-Kroegel U, Klaus G, Marx-Berger D, Moser K, Mueller D, Patzer L, Pohl M, Seitz B, Treikauskas U, von Vigier RO, Gahl WA, Hohenfellner K. Relationship between age at initiation of cysteamine treatment, adherence with therapy, and glomerular kidney function in infantile nephropathic cystinosis. Mol Genet Metab 2022; 136:268-273. [PMID: 35835062 PMCID: PMC9395137 DOI: 10.1016/j.ymgme.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 10/17/2022]
Abstract
Infantile nephropathic cystinosis, due to impaired transport of cystine out of lysosomes, occurs with an incidence of 1 in 100-200,000 live births. It is characterized by renal Fanconi syndrome in the first year of life and glomerular dysfunction progression to end-stage kidney disease by approximately 10 years of age. Treatment with oral cysteamine therapy helps preserve glomerular function, but affected individuals eventually require kidney replacement therapy. This is because glomerular damage had already occurred by the time a child is diagnosed with cystinosis, typically in the second year of life. We performed a retrospective multicenter study to investigate the impact of initiating cysteamine treatment within the first 2 months of life in some infants and comparing two different levels of adherence in patients diagnosed at the typical age. We collected 3983 data points from 55 patients born between 1997 and 2020; 52 patients with 1592 data points could be further evaluated. These data were first analyzed by dividing the patient cohort into three groups: (i) standard treatment start with good adherence, (ii) standard treatment start with less good adherence, and (iii) early treatment start. At every age, mean estimated glomerular filtration rate (eGFR) was higher in early-treated patients than in later-treated patients. Second, a generalized additive mixed model (GAMM) was applied showing that patients with initiation of treatment before 2 months of age are expected to have a 34 ml/min/1.73 m2 higher eGFR than patients with later treatment start while controlling for adherence and patients' age. These data strongly suggest that oral cysteamine treatment initiated within 2 months of birth preserves kidney function in infantile nephropathic cystinosis and provide evidence of the utility of newborn screening for this disease.
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Affiliation(s)
- Christina Nießl
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Working group "Biometry in Molecular Medicine", Ludwig-Maximilians-University of Munich, Marchoninistr. 15, 81377 Munich, Germany.
| | - Anne-Laure Boulesteix
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Working group "Biometry in Molecular Medicine", Ludwig-Maximilians-University of Munich, Marchoninistr. 15, 81377 Munich, Germany.
| | - Jun Oh
- Department of Pediatrics, Pediatric Nephrology, University Center Hamburg/Eppendorf, Martinistr. 52, 20251 Hamburg, Germany.
| | - Katja Palm
- Department of Pediatrics, University Hospital Magdeburg, Leipzigerstr. 44, 39120 Magdeburg, Germany.
| | - Peter Schlingmann
- Department of General Pediatrics, Pediatric Nephrology, University Children's Hospital Münster, Waldeyerstr. 22, 48149 Münster, Germany.
| | - Simone Wygoda
- KFH Pediatric Kidney Center Leipzig, Delitzscherstr. 14, 04129 Leipzig, Germany.
| | - Dieter Haffner
- Department of Pediatrics, Department of Pediatric Kidney, Liver and Metabolic Diseases, Medical School, Carl-Neuberg-str. 1, 30625 Hannover, Germany.
| | - Elke Wühl
- Department of Pediatrics I, Division of Pediatric Nephrology, University Children 's Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
| | - Burkhard Tönshoff
- Department of Pediatrics I, Division of Pediatric Nephrology, University Children 's Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Anja Buescher
- Department of Pediatrics II, University Hospital of Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany.
| | - Heiko Billing
- Department of Pediatrics, Riedstraße 12, 74321 Bietigheim-Bissingen, Germany.
| | - Bernd Hoppe
- KNZ - Kindernierenzentrum Bonn, Im Mühlenbach 2B, 53127 Bonn, Germany.
| | - Matthias Zirngibl
- Department of General Pediatrics/Hematology/Oncology, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany.
| | - Matthias Kettwig
- Department of Pediatrics, University Hospital Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany.
| | - Kristina Moeller
- Department of Pediatrics, Gesundheit Nord, Klinikverbund Bremen, Kürfürstenallee 130, 28211 Bremen, Germany.
| | - Birgit Acham-Roschitz
- Department of Pediatrics, Medical University of Graz, Auenbruggerplatz 34, 8036 Graz, Austria.
| | - Klaus Arbeiter
- Pediatric Dialysis Unit, Clinic of Pediatric and Adolescent Medicine, Department of Pediatric Nephrology and Gastroenterology, Medical University Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Martin Bald
- Department of Pediatric Nephrology Olgahospital, Clinics of Stuttgart, Kriegsbergstr. 62, 70174 Stuttgart, Germany.
| | - Marcus Benz
- Pediatric Nephrology Dachau, Schleißheimerstr. 12, 85221 Dachau, Germany.
| | - Matthias Galiano
- Pediatric Nephrology, Department of Pediatrics and Adolescent Medicine, University Hospital of Erlangen, Loschgestr. 15, 91052 Erlangen, Germany.
| | - Ulrike John-Kroegel
- Department of Pediatric Nephrology, University Children's hospital Jena, Kastanienstr. 1, 07747 Jena, Germany.
| | - Guenter Klaus
- Pediatric Rheumatology, University Children's hospital, Philipps University of Marburg, Baldingerstr, 35043 Marburg, Germany.
| | - Daniela Marx-Berger
- Children's Hospital of Eastern Switzerland, Claudiusstr. 6, 9006 St. Gallen, Switzerland.
| | - Katja Moser
- Children's Hospital Aschaffenburg, Am Hasenkopf 1, 63739 Aschaffenburg, Germany.
| | - Dirk Mueller
- Department of Neonatology and Pediatrics, Gesundheit Nordhessen, Mönchebergstraße 41-43, 34125 Kassel, Germany.
| | - Ludwig Patzer
- Department of Pediatric Nephrology, Department of Pediatrics, Krankenhaus Halle Saale, Mauerstr. 5, 06110 Halle Saale, Germany.
| | - Martin Pohl
- Department of Pediatric Nephrology, Department of Pediatrics, University Children 's Hospital Freiburg, Mathildenstr. 1, 79106 Freiburg, Germany.
| | - Barbara Seitz
- KFH Pediatric Kidney Center Munich, Parzivalstr. 16, 80804 Munich, Germany.
| | - Ulrike Treikauskas
- Department of Pediatric Nephrology, Department of Pediatrics, RoMed Kliniken, Pettenkoferstr. 10, 83022 Rosenheim, Germany.
| | - Rodo O von Vigier
- Pediatric Clinic, Wildermeth Children's Hospital, Vogelsang 84, 2502 Biel-Bienne, Switzerland.
| | - William Allen Gahl
- National Genome Research Institute (NHGRI), National Institutes of Health, Medical Genetics Branch, 9000 Rockville Pike, Bethesda, MD 20892, USA.
| | - Katharina Hohenfellner
- Department of Pediatric Nephrology, Department of Pediatrics, RoMed Kliniken, Pettenkoferstr. 10, 83022 Rosenheim, Germany.
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Hohenfellner K, Nießl C, Haffner D, Oh J, Okorn C, Palm K, Schlingmann KP, Wygoda S, Gahl WA. Beneficial effects of starting oral cysteamine treatment in the first 2 months of life on glomerular and tubular kidney function in infantile nephropathic cystinosis. Mol Genet Metab 2022; 136:282-288. [PMID: 35843134 PMCID: PMC9413354 DOI: 10.1016/j.ymgme.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 10/17/2022]
Abstract
Nephropathic cystinosis is a rare lysosomal storage disease whose basic defect, impaired transport of cystine out of lysosomes, results in intracellular cystine storage. Affected individuals exhibit renal Fanconi Syndrome in infancy, end-stage kidney disease at approximately 10 years of age, and many other systemic complications. Oral cysteamine therapy mitigates the detrimental effects on glomerular function and prevents most of the late complications of the disease but has not shown benefit with respect to the early tubular damage of cystinosis. This is because cystinosis is generally diagnosed in the second year of life, after the damage to kidney tubular function has already occurred. We longitudinally evaluated 6 infants diagnosed and treated with cysteamine from before 2 months of age. The 4 infants with good compliance with cysteamine and consistently low leucocyte cystine levels maintained normal eGFR values, exhibited only minor degrees of renal Fanconi Syndrome, and maintained normal serum levels of potassium, bicarbonate, phosphate, and calcium without electrolyte or mineral supplementation through 2, 4, 10 and 16 years of age. Thus, renal Fanconi syndrome can be attenuated by early administration of cysteamine and renew the call for molecular-based newborn screening for cystinosis.
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Affiliation(s)
- Katharina Hohenfellner
- Department of Pediatrics, Pediatric Nephrology, RoMed Kliniken, Pettenkoferstr.10, 83022 Rosenheim, Germany.
| | - Christina Nießl
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Working group "Biometry in Molecular Medicine", Ludwig-Maximilians-University of Munich, Marchoninistr.15, 81377 Munich, Germany.
| | - Dieter Haffner
- Department of Pediatrics, Department of Pediatric Kidney, Liver and Metabolic Diseases, Medical School, Carl-Neuberg-str.1, 30625 Hannover, Germany.
| | - Jun Oh
- Department of Pediatrics, Pediatric Nephrology, University Center Hamburg/Eppendorf, Martinistr. 52, 20251 Hamburg, Germany.
| | - Christine Okorn
- Department of Pediatrics II, University Hospital of Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany.
| | - Katja Palm
- Department of Pediatrics, University Hospital Magdeburg, Leipzigerstr. 44, 39120 Magdeburg, Germany.
| | - Karl-Peter Schlingmann
- Department of General Pediatrics, Pediatric Nephrology, University Children's Hospital Münster, Waldeyerstr.22, 48149 Münster, Germany.
| | - Simone Wygoda
- KFH Pediatric Kidney Center Leipzig, Delitzscherstr. 14, 04129 Leipzig, Germany.
| | - William Allen Gahl
- National Genome Research Institute (NHGRI), National Institutes of Health, Medical Genetics Branch, 9000 Rockville Pike, Bethesda, MD 20892, USA.
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Clinical and neurophysiological characterization of early neuromuscular involvement in children and adolescents with nephropathic cystinosis. Pediatr Nephrol 2022; 37:1555-1566. [PMID: 34791528 DOI: 10.1007/s00467-021-05343-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 10/16/2021] [Accepted: 10/18/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Nephropathic cystinosis is a rare autosomal recessive lysosomal storage disorder characterized by kidney and extra-renal complications due to the accumulation of cystine crystals in various tissues and organs. Herein, we describe the early neuromuscular complications in a cohort of pediatric nephropathic cystinosis patients. METHODS We prospectively evaluated the clinical, biochemical, and neurophysiological data of 15 cystinosis patients. Neurophysiological evaluation was performed to confirm or exclude presence of neuropathy and/or myopathy. RESULTS Patients' age ranged between 20 and 216 months at time of examination. Nine patients were males. Three patients had early abnormal neurophysiological features consistent with neuromuscular involvement (clinically asymptomatic proximal myopathy with a patchy distribution in one patient and isolated asymptomatic sensory nerve conduction changes in two patients). A fourth patient had mixed abnormal motor and sensory axonal neuropathic changes associated with overt clinical features (predominantly motor symptoms). Patients with abnormal neuromuscular features were significantly older in age than the unaffected group (P = 0.005) and had a diagnosis of cystinosis with subsequent cysteamine therapy at a significantly older age than the unaffected group (P = 0.027 and 0.001, respectively). CONCLUSIONS We expanded the recognized phenotypes of cystinosis neuromuscular complications with early proximal skeletal myopathy and symptomatic motor and sensory axonal neuropathy. Early asymptomatic neuromuscular complications could develop in pediatric patients and would require neurophysiological studies for early detection prior to development of overt clinical manifestations. Prompt diagnosis and timely initiation of cysteamine therapy with recommended dose can delay the development of neuromuscular complications. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Sullivan S, Grant N, Hammond C, David WS, Eichler F, Sadjadi R. Longitudinal dysphagia assessment in adult patients with nephropathic cystinosis using the Modified Barium Swallow Impairment Profile. Muscle Nerve 2022; 66:223-226. [PMID: 35616433 DOI: 10.1002/mus.27642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 11/12/2022]
Abstract
INTRODUCTION/AIMS Nephropathic cystinosis is a lysosomal storage disorder with known myopathic features, including dysphagia. Evaluation of oropharyngeal swallowing physiology can be standardized using the Modified Barium Swallow Impairment Profile (MBSImP), a validated assessment tool used to analyze and rate swallowing across 17 distinct physiologic domains. Our objective was to better characterize swallowing impairments in nephropathic cystinosis using MBSImP analysis. METHODS We retrospectively evaluated 40 video fluoroscopic swallowing studies performed at two time points over 1 y in patients with nephropathic cystinosis with various levels of oral and pharyngeal stage dysphagia. Patients completed two self-administered dysphagia outcome measures (the M. D. Anderson Dysphagia Inventory [MDADI] and the 10-item Eating Assessment Tool [EAT-10]). RESULTS We demonstrated oral stage and pharyngeal stage dysphagia across domains that impacted bolus control, transit, and clearance through both the oral cavity and pharyngeal lumen. Also captured were deficits related to onset and completeness of laryngeal closure that impact airway protection during swallow. There were significant correlations between pharyngeal total score and EAT-10 (r = 0.5, p < 0.001) and between oral total score and EAT-10 (r = 0.7, p < 0.001), MDADI-e (r = -0.6, p < 0.001), MDADI-p (r = -0.5, p < 0.001) and MDADI-c (r = -0.6, p < 0.001). There were no differences in oral or pharyngeal total scores across the 1-y time span. DISCUSSION This study identifies oral and pharyngeal stage dysphagia as crucial to patients with nephropathic cystinosis and paves the path for future studies of treatment targets.
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Affiliation(s)
- Stacey Sullivan
- Department of Speech, Language and Swallowing Disorders, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Natalie Grant
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Colleen Hammond
- Cystinosis Adult Care Excellence Initiative, Reading, Massachusetts, USA
| | - William S David
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Florian Eichler
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Reza Sadjadi
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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10
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Vill K, Müller-Felber W, Landfarth T, Köppl C, Herzig N, Knerr C, Holla H, Steidle G, Harms E, Hohenfellner K. Neuromuscular conditions and the impact of cystine-depleting therapy in infantile nephropathic cystinosis: A cross-sectional analysis of 55 patients. J Inherit Metab Dis 2022; 45:183-191. [PMID: 34888877 DOI: 10.1002/jimd.12464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/12/2021] [Accepted: 12/07/2021] [Indexed: 11/08/2022]
Abstract
Infantile nephropathic cystinosis (INC) is a rare lysosomal storage disease caused by biallelic mutations in the cystinosin gene, leading to cystine accumulation in various organs. The aim of this cross-sectional study was to investigate neuromuscular complications in a cohort of 55 patients (aged 2.8-41.3 years, median 18.5 years) with INC. Clinical examination, jumping mechanography, clinical neurophysiology, and muscle/nerve ultrasound were performed. Physical performance, measured by mechanography, was below average in all patients. However, this reduction in physical performance was not always detected by conventional muscle power assessment. Twenty-eight percent of patients had mostly mild axial weakness of the neck flexors and/or of the abdominal rectus muscles, the latter often presenting during childhood. One adult patient had generalized muscle weakness. Two patients had evidence of specific neuromuscular conditions, which may not have been directly related to cystinosis. 30% of patients presented with mild, 7% with moderate, and 5% with severe weakness of the intrinsic muscles of the hand. Muscle wasting was more pronounced in the older cystinosis patients with multiple organ complications. Sonographic increase in muscle echogenicity corresponded only with severe weakness. Electromyography of the intrinsic hand muscles, performed in selected patients, showed myopathic, neurogenic, or mixed myopathic-neurogenic abnormalities. A particularly important finding of this study is that the neuromuscular complications were largely independent from both the age of initiation of pharmacological cystine-depleting therapy and from adherence to treatment. Significant correlation was observed between better physical performance in jumping and cysteine levels in leukocytes.
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Affiliation(s)
- Katharina Vill
- Department of Pediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, LMU - University of Munich, Munich, Germany
| | - Wolfgang Müller-Felber
- Department of Pediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, LMU - University of Munich, Munich, Germany
| | - Timotheus Landfarth
- Institute for Medical Information Processing, Biometry, and Epidemiology, LMU - University of Munich, Munich, Germany
| | | | - Nadine Herzig
- Schoen Clinic Munich Harlaching, Specialist Centre for Paediatric and Neuro-Orthopaedics, Munich, Germany
| | | | - Heike Holla
- Department of Pediatric Nephrology, Children's Hospital Rosenheim, Rosenheim, Germany
| | | | - Erik Harms
- Formally Chairman (retired) of the Department of Pediatrics, University of Muenster, Münster, Germany
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11
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Adult complications of nephropathic cystinosis: a systematic review. Pediatr Nephrol 2021; 36:223-236. [PMID: 32016627 DOI: 10.1007/s00467-020-04487-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/18/2020] [Accepted: 01/20/2020] [Indexed: 01/13/2023]
Abstract
While nephropathic cystinosis is classically thought of as a childhood disease, with improved treatments, patients are more commonly living into adulthood. We performed a systematic review of the literature available on what complications this population faces as it ages. Nearly every organ system is affected in cystinosis, either from the disease itself or from sequelae of kidney transplantation. While cysteamine is known to delay the onset of end-stage kidney disease, its effects on other complications of cystinosis are less well determined. More common adult-onset complications include myopathy, diabetes, and hypothyroidism. Some less common complications, such as neurologic dysfunction, can still have a profound impact on those with cystinosis. Areas for further research in this area include additional study of the impact of cysteamine on the nonrenal manifestations of cystinosis, as well as possible avenues for new and novel treatments.
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12
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Iyob-Tessema H, Wang CS, Kennedy S, Reyes L, Shin S, Greenbaum LA, Hogan J. Grip Strength in Adults and Children with Cystinosis. Kidney Int Rep 2020; 6:389-395. [PMID: 33615064 PMCID: PMC7879123 DOI: 10.1016/j.ekir.2020.11.017] [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] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/30/2020] [Accepted: 11/17/2020] [Indexed: 11/05/2022] Open
Abstract
Introduction Chronic kidney disease (CKD) is associated with impaired muscle strength. Patients with cystinosis have an increased risk for impaired muscle strength because of early development of CKD and cystinosis-induced myopathy. This study assesses muscle strength in patients with cystinosis and investigates risk factors of decreased muscle strength. Methods Adult and pediatric patients were recruited from Cystinosis Research Network conferences and a large pediatric nephrology clinic between 2017 and 2019. Patients and caregivers completed questionnaires on demographic characteristics, disease course, daily physical activity, and neuromuscular symptoms. Grip strength was assessed using a dynameter and calculated z-scores for age and sex were assessed for associations with patient characteristics. Results We included 76 patients with a mean grip strength z-score of −2.1 (SD, 1.1), which was lower than seen in patients with CKD without cystinosis. Male sex and delayed cysteamine initiation were independently associated with impaired grip strength. Among adults, a low level of physical activity was associated with lower grip strength z score, but no association was found in children. A third of the patients reported neuromuscular symptoms, with swallowing issues associated with lower grip strength. There was no significant correlation between eGFR and grip strength z-score. Conclusion Patients with cystinosis have impaired muscle strength compared with healthy control subjects and patients with CKD. This impairment is greater in male patients and in patients with late initiation of cysteamine therapy and is associated with lower physical activity. Further studies investigating the effect of different types of physical activities, optimizing cysteamine therapy, and other interventions are needed.
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Affiliation(s)
- Helina Iyob-Tessema
- Department of Pediatrics, Emory School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Chia-Shi Wang
- Department of Pediatrics, Emory School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Sabina Kennedy
- Department of Pediatrics, Emory School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Loretta Reyes
- Department of Pediatrics, Emory School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Stella Shin
- Department of Pediatrics, Emory School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Larry A Greenbaum
- Department of Pediatrics, Emory School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Julien Hogan
- Emory Transplant Center, Department of Surgery, Emory School of Medicine, Atlanta, Georgia, USA.,Pediatric Nephology Department, Robert Debré Hospital, Paris, France
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13
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Sadjadi R, Sullivan S, Grant N, Thomas SE, Doyle M, Hammond C, Corre C, Mello N, David WS, Eichler F. Clinical trial readiness study of distal myopathy and dysphagia in nephropathic cystinosis. Muscle Nerve 2020; 62:681-687. [PMID: 32737993 DOI: 10.1002/mus.27039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/23/2020] [Accepted: 07/27/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Nephropathic cystinosis is a lysosomal storage disorder with late-onset systemic complications, such as myopathy and dysphagia. Currently employed outcome measures lack sensitivity and responsiveness for dysphagia and myopathy, a limitation to clinical trial readiness. METHODS We evaluated 20 patients with nephropathic cystinosis in two visits over the course of a year to identify outcomes sensitive to detect changes over time. Patients also underwent an expiratory muscle strength training program to assess any effects on aspiration and dysphagia. RESULTS There were significant differences in the Timed Up and Go Test (TUG) and Timed 25-Foot Walk (25-FW) between baseline and 1-y follow-up (P < .05). Maximum expiratory pressure (MEP) and peak cough flow (PCF) significantly improved following respiratory training (P < .05). CONCLUSIONS Improved respiratory outcomes may enhance patients ability to expel aspirated material from the airway, stave off pulmonary sequelae associated with chronic aspiration, and yield an overall improvement in physical health and well-being.
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Affiliation(s)
- Reza Sadjadi
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stacey Sullivan
- Department of Speech, Language and Swallowing Disorders, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Natalie Grant
- Center for Rare Neurological Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Susan E Thomas
- Division of Pediatric Nephrology, Department of Pediatrics and Communicable Diseases, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Maya Doyle
- Department of Social Work, School of Health Sciences, Quinnipiac University, Hamden, Connecticut, USA
| | - Colleen Hammond
- Cystinosis Adult Care Excellence Initiative, Reading, Massachusetts, USA
| | - Camille Corre
- Center for Rare Neurological Diseases, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nicholas Mello
- Center for Rare Neurological Diseases, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William S David
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Florian Eichler
- Center for Rare Neurological Diseases, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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14
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Sadjadi R, Sullivan S, Grant N, Thomas SE, Doyle M, Hammond C, Duong R, Corre C, David W, Eichler F. Clinical myopathy in patients with nephropathic cystinosis. Muscle Nerve 2019; 61:74-80. [PMID: 31588568 DOI: 10.1002/mus.26726] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 09/16/2019] [Accepted: 09/17/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Nephropathic cystinosis is a lysosomal storage disorder. Patient survival years after renal transplantation has revealed systemic complications including distal myopathy and dysphagia. METHODS We evaluated 20 adult patients with nephropathic cystinosis using patient-reported and clinical outcome measures. Standard motor measures, video fluoroscopy swallow studies, and tests of respiratory function were performed. We also used Rasch analysis of an initial survey to design a 16-item survey focused on upper and lower extremity function, which was completed by 31 additional patients. RESULTS Distal myopathy and dysphagia were common in patients with nephropathic cystinosis. Muscle weakness ranges from mild involvement of intrinsic hand muscles to prominent distal greater than proximal weakness and contractures. CONCLUSIONS In addition to further characterization of underlying dysphagia and muscle weakness, we propose a new psychometrically devised, disease specific, functional outcome measures for distal myopathy in patients with nephropathic cystinosis.
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Affiliation(s)
- Reza Sadjadi
- Center for Rare Neurological Diseases, Department of Neurology, Massachusetts General Hospital, Massachusetts
| | - Stacey Sullivan
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Natalie Grant
- Center for Rare Neurological Diseases, Department of Neurology, Massachusetts General Hospital, Massachusetts
| | - Susan E Thomas
- Division of Pediatric Nephrology, Department of Pediatrics and Communicable Diseases, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Maya Doyle
- Department of Social Work, School of Health Sciences, Quinnipiac University, Hamden, Connecticut
| | - Colleen Hammond
- Cystinosis Adult Care Excellence Initiative, Reading, Massachusetts
| | - Rachel Duong
- Center for Rare Neurological Diseases, Department of Neurology, Massachusetts General Hospital, Massachusetts
| | - Camille Corre
- Center for Rare Neurological Diseases, Department of Neurology, Massachusetts General Hospital, Massachusetts
| | - William David
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Florian Eichler
- Center for Rare Neurological Diseases, Department of Neurology, Massachusetts General Hospital, Massachusetts
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15
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Hohenfellner K, Rauch F, Ariceta G, Awan A, Bacchetta J, Bergmann C, Bechtold S, Cassidy N, Deschenes G, Elenberg E, Gahl WA, Greil O, Harms E, Herzig N, Hoppe B, Koeppl C, Lewis MA, Levtchenko E, Nesterova G, Santos F, Schlingmann KP, Servais A, Soliman NA, Steidle G, Sweeney C, Treikauskas U, Topaloglu R, Tsygin A, Veys K, v. Vigier R, Zustin J, Haffner D. Management of bone disease in cystinosis: Statement from an international conference. J Inherit Metab Dis 2019; 42:1019-1029. [PMID: 31177550 PMCID: PMC7379238 DOI: 10.1002/jimd.12134] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/02/2019] [Accepted: 06/03/2019] [Indexed: 01/10/2023]
Abstract
Cystinosis is an autosomal recessive storage disease due to impaired transport of cystine out of lysosomes. Since the accumulation of intracellular cystine affects all organs and tissues, the management of cystinosis requires a specialized multidisciplinary team consisting of pediatricians, nephrologists, nutritionists, ophthalmologists, endocrinologists, neurologists' geneticists, and orthopedic surgeons. Treatment with cysteamine can delay or prevent most clinical manifestations of cystinosis, except the renal Fanconi syndrome. Virtually all individuals with classical, nephropathic cystinosis suffer from cystinosis metabolic bone disease (CMBD), related to the renal Fanconi syndrome in infancy and progressive chronic kidney disease (CKD) later in life. Manifestations of CMBD include hypophosphatemic rickets in infancy, and renal osteodystrophy associated with CKD resulting in bone deformities, osteomalacia, osteoporosis, fractures, and short stature. Assessment of CMBD involves monitoring growth, leg deformities, blood levels of phosphate, electrolytes, bicarbonate, calcium, and alkaline phosphatase, periodically obtaining bone radiographs, determining levels of critical hormones and vitamins, such as thyroid hormone, parathyroid hormone, 25(OH) vitamin D, and testosterone in males, and surveillance for nonrenal complications of cystinosis such as myopathy. Treatment includes replacement of urinary losses, cystine depletion with oral cysteamine, vitamin D, hormone replacement, physical therapy, and corrective orthopedic surgery. The recommendations in this article came from an expert meeting on CMBD that took place in Salzburg, Austria, in December 2016.
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Affiliation(s)
| | - Frank Rauch
- Shriners Hospital for Children, McGill UniversityMontrealCanada
| | - Gema Ariceta
- Service of Pediatric NephrologyUniversity Hospital Vall d’ HebronBarcelonaSpain
| | - Atif Awan
- Department of NephrologyChildren's University HospitalDublinIreland
| | - Justine Bacchetta
- Référence Center for Rare Renal DiseasesHôpital Femme‐Mère‐EnfantBronFrance
| | - Carsten Bergmann
- Department of MedicineUniversity Hospital FreiburgFreiburgGermany
| | - Susanne Bechtold
- Division of Pediatric EndocrinologyChildren's Hospital and Polyclinic iSPZ, Dr. v. Haunerschen Kinderspital, University Hospital MunichMunichGermany
| | - Noelle Cassidy
- Department of Orthopaedic SurgeryChildren's University HospitalDublinIreland
| | - Geroges Deschenes
- Department of Pediatric NephrologyHôpital Robert‐Debré and University of Paris DiderotParisFrance
| | - Ewa Elenberg
- Department of PediatricsBaylor College of Medicine and Texas Children's HospitalHoustonTexas
| | - William A. Gahl
- National Human Genome Research InstituteNational Institutes of Health Undiagnosed Diseases ProgramBethesdaMaryland
| | - Oliver Greil
- Department of Diagnostic and Interventional RadiologyKlinikum TraunsteinTraunsteinGermany
| | - Erik Harms
- Children‘s University Hospital MuensterMuensterGermany
| | - Nadine Herzig
- Schoen Clinic Munich HarlachingSpecialist Centre for Paediatric and Neuro‐OrthopaedicsMunichGermany
| | - Bernd Hoppe
- Division of Pediatric NephrologyUniversity Children's HospitalBonnGermany
| | - Christian Koeppl
- Kliniken Südostbayern AG, Sozialpädiatrisches ZentrumTraunsteinGermany
| | - Malcolm A. Lewis
- Department of NephrologyChildren's University HospitalDublinIreland
| | - Elena Levtchenko
- Department of Pediatrics & Development and RegenerationUniversity Hospitals Leuven & Katholieke Universiteit LeuvenLeuvenBelgium
| | - Galina Nesterova
- National Institutes of Health, National Human Genome Research Institute (NHGRI)BethesdaMaryland
| | - Fernando Santos
- Hospital Universitario Central de AsturiasPediatríaOviedoSpain
| | - Karl P. Schlingmann
- Department of General PediatricsUniversity Children's Hospital MünsterMünsterGermany
| | - Aude Servais
- Reference Center of Inherited Metabolic Diseases, Nephrology Unit, Hospital Necker Enfants Malades, APHPUniversity Paris DescartesParisFrance
| | - Neveen A. Soliman
- Department of Pediatrics, Center of Pediatric Nephrology and Transplantation (CPNT), Kasr Al Ainy Faculty of MedicineCairo UniversityCairoEgypt
| | - Guenther Steidle
- Kliniken Südostbayern AG, Sozialpädiatrisches ZentrumTraunsteinGermany
| | - Clodagh Sweeney
- Department of NephrologyChildren's University HospitalDublinIreland
| | - Ulrike Treikauskas
- Department of Pediatrics, Department of Pediatric NephrologyRo‐Med KlinikenRosenheimGermany
| | - Rezan Topaloglu
- Department of Pediatric NephrologyHacettepe University Faculty of MedicineAnkaraTurkey
| | - Alexey Tsygin
- Department of NephrologyNational Medical and Research Center for Children's HealthMoscowRussia
| | - Koenraad Veys
- Department of Pediatrics & Development and RegenerationUniversity Hospitals Leuven & Katholieke Universiteit LeuvenLeuvenBelgium
| | - Rodo v. Vigier
- Pediatric ClinicWildermeth Children's HospitalBiel‐BienneSwitzerland
| | - Jozef Zustin
- Institute of Osteology and BiomechanicsUniversity Medical Center Hamburg‐Eppendorf, University of HamburgHamburgGermany
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic DiseasesHannover Medical SchoolHannoverGermany
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16
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Sürmeli Döven S, Delibaş A, Kayacan UR, Ünal S. Short-cut diagnostic tool in cystinosis: Bone marrow aspiration. Pediatr Int 2017; 59:1178-1182. [PMID: 28871612 DOI: 10.1111/ped.13416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 01/13/2017] [Accepted: 08/07/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cystinosis is a rare metabolic genetic disorder caused by a mutation in cystinosin lysosomal cystine transporter (CTNS). The diagnosis of nephropathic cystinosis (NC) is made by observing corneal cystine crystals and/or measuring the cystine content of leukocytes. CTNS mutation analysis confirms the diagnosis of cystinosis, but leukocyte cystine measurement and CTNS analysis have not been widely available, and cystine crystals in the cornea may not be apparent in the first months of life. Cystine crystal deposition can be seen in the bone marrow earlier than corneal deposition, in patients with NC. METHODS Ten patients with cystinosis diagnosis were enrolled in the study. Medical records were reviewed retrospectively to collect demographic and clinical data such as age at diagnosis, disease presentation, parental consanguinity, family history, corneal cystine deposition, leukocyte cystine level, bone marrow cystine deposition, presence of renal failure, follow-up time and prognosis. RESULTS Cystine crystals were seen in all of the patients' fresh bone marrow aspiration samples. Eight patients had corneal cystine deposition. Leukocyte cystine measurement could have been performed in four patients who had come from another center. Complications such as pulmonary hypertension and idiopathic intracranial hypertension (IIH) were observed in two patients. CONCLUSIONS Bone marrow aspiration might be an easy and short-cut diagnostic tool for NC especially when it is not possible to measure fibroblast cystine content. Additionally some rare complications such as pulmonary hypertension and IIH can be encountered during the course of NC.
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Affiliation(s)
- Serra Sürmeli Döven
- Department of Pediatric Nephrology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Ali Delibaş
- Department of Pediatric Nephrology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Uğur Raşit Kayacan
- Department of Pediatrics, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Selma Ünal
- Department of Pediatric Hematology, Mersin University Faculty of Medicine, Mersin, Turkey
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17
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Sadeghipour F, Basiratnia M, Derakhshan A, Fardaei M. Mutation analysis of the CTNS gene in Iranian patients with infantile nephropathic cystinosis: identification of two novel mutations. Hum Genome Var 2017; 4:17038. [PMID: 28983406 PMCID: PMC5628181 DOI: 10.1038/hgv.2017.38] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/07/2017] [Accepted: 07/09/2017] [Indexed: 12/02/2022] Open
Abstract
Nephropathic cystinosis is an inherited lysosomal transport disorder caused by mutations in the CTNS gene that encodes for a lysosomal membrane transporter, cystinosin. Dysfunction in this protein leads to cystine accumulation in the cells of different organs. The accumulation of cystine in the kidneys becomes apparent with renal tubular Fanconi syndrome between 6 and 12 months of age and leads to renal failure in the first decade of life. The aim of this study was to analyze the CTNS mutations in 20 Iranian patients, from 20 unrelated families, all of whom were afflicted with infantile nephropathic cystinosis. In these patients, seven different mutant alleles were found, including two new mutations, c.517T>C; p.Y173H and c.492_515del, that have not been previously reported. In addition, we observed that c.681G>A, the common Middle Eastern mutation, was the most common mutation in our patients. Moreover, a new minisatellite or variable number of tandem repeat marker (KX499495) was identified at the CTNS gene. Seven different alleles were found for this marker, and its allele frequency and heterozygosity degree were calculated in cystinosis patients and healthy individuals.
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Affiliation(s)
- Forough Sadeghipour
- Department of Medical Genetics, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mitra Basiratnia
- Department of Pediatric Nephrology, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Derakhshan
- Department of Pediatric Nephrology, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Majid Fardaei
- Department of Medical Genetics, Shiraz University of Medical Sciences, Shiraz, Iran.,Transgenic Technology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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18
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Abstract
Nephropathic cystinosis is an autosomal recessive lysosomal disease in which cystine cannot exit the lysosome to complete its degradation in the cytoplasm, thus accumulating in tissues. Some patients develop a distal myopathy involving mainly hand muscles. Myopathology descriptions from only 5 patients are available in the literature. We present a comprehensive clinical, pathological and genetic description of 3 patients from 2 families with nephropathic cystinosis. Intrafamiliar variability was detected in one family in which one sibling developed a severe distal myopathy while the other sibling did not show any signs of skeletal muscle involvement. One of the patients was on treatment with Cysteamine for over 12 years but still developed the usual complications of nephropathic cystinosis in his twenties. Novel pathological findings consisting in sarcoplasmic deposits reactive for slow myosin were identified. Three previously known and one novel mutation are reported. Nephropathic cystinosis should be included in the differential diagnosis of distal myopathies in those with early renal failure. Novel clinical and pathological features are reported here contributing to the characterization of the muscle involvement in nephropathic cystinosis.
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19
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Abstract
PURPOSE OF REVIEW Over the past few decades, cystinosis, a rare lysosomal storage disorder, has evolved into a treatable metabolic disease. The increasing understanding of its pathophysiology has made cystinosis a prototype disease, delivering new insights into several fundamental biochemical and cellular processes. RECENT FINDINGS In this review, we aim to provide an overview of the latest advances in the pathogenetic, clinical, and therapeutic aspects of cystinosis. SUMMARY The development of alternative therapeutic monitoring strategies and new systemic and ocular cysteamine formulations might improve outcome of cystinosis patients in the near future. With the dawn of stem cell based therapy and new emerging gene-editing technologies, novel tools have become available in the search for a cure for cystinosis.
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20
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Abstract
Cystinosis is a rare, autosomal recessive inherited lysosomal storage disease. It is the most frequent and potentially treatable cause of the inherited renal Fanconi syndrome. If left untreated, renal function rapidly deteriorates towards end-stage renal disease by the end of the first decade of life. Due to its rarity and non-specific presentation, the entity is often not promptly recognized resulting in delayed diagnosis. Two major milestones in cystinosis management, cystine-depleting therapy with cysteamine and renal allograft transplantation, have had a considerable impact on the natural history and prognosis of cystinosis patients. However, due to its significant side effects and a strict 6-hourly dosing regimen, non-adherence to the immediate release of cysteamine bitartrate formulation (Cystagon®) is a major issue that might affect long-term outcome. Recently, a new twice-daily administered delayed-release enteric-coated formula of cysteamine bitartrate (Procysbi(TM)) has been approved by the European Medical Agency for the treatment of cystinosis, and has been shown to be safe and effective. This delayed-release cysteamine has the potential to improve compliance and hence prognosis, through its better dosing regimen, positive impact on quality of life and possibly less side-effects, and is now tested in an ongoing long-term clinical trial. Longer survival of patients with cystinosis makes transition from pediatric to adult-oriented care another challenge in cystinosis management and requires an extended multidisciplinary approach.
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Affiliation(s)
- Koenraad R P Veys
- a Department of Pediatrics, Pediatric Nephrology , University Hospitals Leuven , Belgium
| | - Martine T P Besouw
- b Department of Pediatric Nephrology , University Hospital Ghent , Belgium
| | | | - Maria Van Dyck
- a Department of Pediatrics, Pediatric Nephrology , University Hospitals Leuven , Belgium
| | - Ingele Casteels
- c Department of Ophthalmology , University Hospitals Leuven , Belgium
| | - Elena N Levtchenko
- a Department of Pediatrics, Pediatric Nephrology , University Hospitals Leuven , Belgium
- d Department of Growth & Regeneration , Katholieke Universiteit Leuven , Belgium
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Elmonem MA, Veys KR, Soliman NA, van Dyck M, van den Heuvel LP, Levtchenko E. Cystinosis: a review. Orphanet J Rare Dis 2016; 11:47. [PMID: 27102039 PMCID: PMC4841061 DOI: 10.1186/s13023-016-0426-y] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 04/15/2016] [Indexed: 01/01/2023] Open
Abstract
Cystinosis is the most common hereditary cause of renal Fanconi syndrome in children. It is an autosomal recessive lysosomal storage disorder caused by mutations in the CTNS gene encoding for the carrier protein cystinosin, transporting cystine out of the lysosomal compartment. Defective cystinosin function leads to intra-lysosomal cystine accumulation in all body cells and organs. The kidneys are initially affected during the first year of life through proximal tubular damage followed by progressive glomerular damage and end stage renal failure during mid-childhood if not treated. Other affected organs include eyes, thyroid, pancreas, gonads, muscles and CNS. Leucocyte cystine assay is the cornerstone for both diagnosis and therapeutic monitoring of the disease. Several lines of treatment are available for cystinosis including the cystine depleting agent cysteamine, renal replacement therapy, hormonal therapy and others; however, no curative treatment is yet available. In the current review we will discuss the most important clinical features of the disease, advantages and disadvantages of the current diagnostic and therapeutic options and the main topics of future research in cystinosis.
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Affiliation(s)
- Mohamed A Elmonem
- Department of Pediatric Nephrology & Growth and Regeneration, University Hospitals Leuven & KU Leuven, UZ Herestraat 49-3000, Leuven, Belgium.,Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Koenraad R Veys
- Department of Pediatric Nephrology & Growth and Regeneration, University Hospitals Leuven & KU Leuven, UZ Herestraat 49-3000, Leuven, Belgium
| | - Neveen A Soliman
- Department of Pediatrics, Center of Pediatric Nephrology and Transplantation (CPNT), Faculty of Medicine, Cairo University, Cairo, Egypt.,EGORD, Egyptian group of orphan renal diseases, Cairo, Egypt
| | - Maria van Dyck
- Department of Pediatric Nephrology & Growth and Regeneration, University Hospitals Leuven & KU Leuven, UZ Herestraat 49-3000, Leuven, Belgium
| | - Lambertus P van den Heuvel
- Department of Pediatric Nephrology & Growth and Regeneration, University Hospitals Leuven & KU Leuven, UZ Herestraat 49-3000, Leuven, Belgium.,Department of Pediatric Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Elena Levtchenko
- Department of Pediatric Nephrology & Growth and Regeneration, University Hospitals Leuven & KU Leuven, UZ Herestraat 49-3000, Leuven, Belgium.
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La cystinose chez l’adulte : une maladie systémique. Nephrol Ther 2015; 11:152-9. [DOI: 10.1016/j.nephro.2014.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 12/15/2014] [Accepted: 12/15/2014] [Indexed: 11/23/2022]
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Cistinosis en pacientes adolescentes y adultos: Recomendaciones para la atención integral de la cistinosis. Nefrologia 2015. [DOI: 10.1016/j.nefro.2015.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Ariceta G, Camacho JA, Fernández-Obispo M, Fernández-Polo A, Gamez J, García-Villoria J, Lara Monteczuma E, Leyes P, Martín-Begué N, Oppenheimer F, Perelló M, Morell GP, Torra R, Santandreu AV, Güell A. Cystinosis in adult and adolescent patients: Recommendations for the comprehensive care of cystinosis. Nefrologia 2015; 35:304-321. [PMID: 26523297 DOI: 10.1016/j.nefroe.2015.06.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023] Open
Abstract
INTRODUCTION Cystinosis is a rare lysosomal systemic disease that mainly affects the kidney and the eye. Patients with cystinosis begin renal replacement therapy during the first decade of life in absence of treatment. Prognosis of cystinosis depends on early diagnosis, and prompt starting and good compliance with cysteamine treatment. Kidney disease progression, extra-renal complications and shorter life expectancy are more pronounced in those patients that do not follow treatment. The objective of this work was to elaborate recommendations for the comprehensive care of cystinosis and the facilitation of patient transition from paediatric to adult treatment, based on clinical experience. The goal is to reduce the impact of the disease, and to improve patient quality of life and prognosis. METHODS Bibliographic research and consensus meetings among a multidisciplinary professional team of experts in the clinical practice, with cystinotic patients (T-CiS.bcn group) from 5 hospitals located in Barcelona. RESULTS This document gathers specific recommendations for diagnosis, treatment and multidisciplinary follow-up of cystinotic patients in the following areas: nephrology, dialysis,renal transplant, ophthalmology, endocrinology, neurology, laboratory, genetic counselling,nursing and pharmacy. CONCLUSIONS A reference document for the comprehensive care of cystinosis represents a support tool for health professionals who take care of these patients. It is based on the following main pillars: (a) a multi-disciplinary approach, (b) appropriate disease monitoring and control of intracellular cystine levels in leukocytes, (c) the importance of adherence to treatment with cysteamine, and (d) the promotion of patient self-care by means of disease education programmes. All these recommendations will lead us, in a second phase, to create a coordinated transition model between paediatric and adult care services which will contemplate the specific needs of cystinosis.
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El-Naggari MA, Elnour I, Al-Kindy H, Al-Shahrabally A, Abdelmogheth AA. Successful management of a neglected case of nephropathic cystinosis. Sultan Qaboos Univ Med J 2014; 14:e245-e248. [PMID: 24790750 PMCID: PMC3997544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 12/30/2013] [Accepted: 01/26/2014] [Indexed: 06/03/2023] Open
Abstract
Cystinosis is a rare metabolic disorder characterised by lysosomal cystine accumulation leading to multi-organ damage; clinically, the kidneys are the first organ affected. Respiratory insufficiency caused by overall respiratory muscle myopathy is a life-threatening complication. Treatment with cysteamine should be initiated rapidly and continued lifelong to prolong renal function and protect the extra-renal organs. We report the case of a four-year-old Omani girl, diagnosed with infantile nephropathic cystinosis at 21 months. Cysteamine was prescribed but with no compliance to medications. She presented to the Child Health Department of Sultan Qaboos University Hospital, Oman, two years later with severe failure to thrive, electrolyte disturbance and respiratory failure. The hypoventilation and early respiratory dysfunction, due to intercostal and diaphragm myopathy, was treated by non-invasive positive-pressure ventilation. The patient was discharged after four months of intensive rehabilitation with no ventilator support. No standard treatment options have yet been established for respiratory dysfunction in cystinosis.
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Al-Haggar M. Cystinosis as a lysosomal storage disease with multiple mutant alleles: Phenotypic-genotypic correlations. World J Nephrol 2013; 2:94-102. [PMID: 24255892 PMCID: PMC3832870 DOI: 10.5527/wjn.v2.i4.94] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 10/18/2013] [Indexed: 02/06/2023] Open
Abstract
Cystinosis is an autosomal recessive lysosomal storage disease with an unclear enzymatic defect causing lysosomal cystine accumulation with no corresponding elevation of plasma cystine levels leading to multisystemic dysfunction. The systemic manifestations include a proximal renal tubular defect (Fanconi-like), endocrinal disturbances, eye involvements, with corneal, conjunctival and retinal depositions, and neurological manifestations in the form of brain and muscle dysfunction. Most of the long-term ill effects of cystinosis are observed particularly in patients with long survival as a result of a renal transplant. Its responsible CTNS gene that encodes the lysosomal cystine carrier protein (cystinosin) has been mapped on the short arm of chromosome 17 (Ch17 p13). There are three clinical forms based on the onset of main symptoms: nephropathic infantile form, nephropathic juvenile form and non-nephropathic adult form with predominant ocular manifestations. Avoidance of eye damage from sun exposure, use of cystine chelators (cysteamine) and finally renal transplantation are the main treatment lines. Pre-implantation genetic diagnosis for carrier parents is pivotal in the prevention of recurrence.
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Brodin-Sartorius A, Tête MJ, Niaudet P, Antignac C, Guest G, Ottolenghi C, Charbit M, Moyse D, Legendre C, Lesavre P, Cochat P, Servais A. Cysteamine therapy delays the progression of nephropathic cystinosis in late adolescents and adults. Kidney Int 2011; 81:179-89. [PMID: 21900880 DOI: 10.1038/ki.2011.277] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Nephropathic cystinosis is a multisystem autosomal recessive disease caused by cystine accumulation, which is usually treated by oral cysteamine. In order to determine long-term effects of this therapy, we enrolled 86 adult patients (mean age 26.7 years) diagnosed with nephropathic cystinosis, 75 of whom received cysteamine. Therapy was initiated at a mean age of 9.9 years with a mean duration of 17.4 years. By last follow-up, 78 patients had end-stage renal disease (mean age 11.1 years), 62 had hypothyroidism (mean age 13.4), 48 developed diabetes (mean age 17.1 years), and 32 had neuromuscular disorders (mean age 23.3 years). Initiating cysteamine therapy before 5 years of age significantly decreased the incidence and delayed the onset of end-stage renal disease, and significantly delayed the onset of hypothyroidism, diabetes, and neuromuscular disorders. The development of diabetes and hypothyroidism was still significantly delayed, however, in patients in whom therapy was initiated after 5 years of age, compared with untreated patients. The life expectancy was significantly improved in cysteamine-treated versus untreated patients. Thus, cysteamine decreases and delays the onset of complications and improves life expectancy in cystinosis. Hence, cysteamine therapy should be introduced as early as possible during childhood and maintained lifelong.
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Cystinosis: practical tools for diagnosis and treatment. Pediatr Nephrol 2011; 26:205-15. [PMID: 20734088 PMCID: PMC3016220 DOI: 10.1007/s00467-010-1627-6] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2010] [Revised: 07/05/2010] [Accepted: 07/07/2010] [Indexed: 02/07/2023]
Abstract
Cystinosis is the major cause of inherited Fanconi syndrome, and should be suspected in young children with failure to thrive and signs of renal proximal tubular damage. The diagnosis can be missed in infants, because not all signs of renal Fanconi syndrome are present during the first months of life. In older patients cystinosis can mimic idiopathic nephrotic syndrome due to focal and segmental glomerulosclerosis. Measuring elevated white blood cell cystine content is the corner stone for the diagnosis. The diagnosis is confirmed by molecular analysis of the cystinosin gene. Corneal cystine crystals are invariably present in all patients with cystinosis after the age of 1 year. Treatment with the cystine depleting drug cysteamine should be initiated as soon as possible and continued lifelong to prolong renal function survival and protect extra-renal organs. This educational feature provides practical tools for the diagnosis and treatment of cystinosis.
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Berger JR, Dillon DA, Young BA, Goldstein SJ, Nelson P. Cystinosis of the brain and spinal cord with associated vasculopathy. J Neurol Sci 2009; 284:182-5. [DOI: 10.1016/j.jns.2009.03.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 03/16/2009] [Accepted: 03/20/2009] [Indexed: 11/30/2022]
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Developmental changes in cerebral white matter microstructure in a disorder of lysosomal storage. Cortex 2009; 46:206-16. [PMID: 19427638 DOI: 10.1016/j.cortex.2009.03.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2008] [Revised: 02/26/2009] [Accepted: 03/03/2009] [Indexed: 11/22/2022]
Abstract
The goal of this work was to study white matter (WM) integrity in children with cystinosis, a rare lysosomal storage disorder resulting in cystine accumulation in peripheral and central nervous system tissue. Based on previous reports of cystine crystal formation in myelin precursors as well as evidence for specific cognitive deficits in visuospatial functioning, diffusion tensor imaging (DTI) was applied to 24 children with cystinosis (age 3-7 years) and to 24 typically developing age-matched controls. Scalar diffusion indices, fractional anisotropy (FA) and mean diffusivity (MD), were examined in manually defined regions of interest within the parietal and inferior temporal lobes. Diffusion indices were correlated with performance on measures of visuospatial cognition and with white blood cell cystine levels. Bilaterally decreased FA and increased MD were evident in the inferior and superior parietal lobules in children with cystinosis, with comparable FA and MD to controls in inferior temporal WM, and implicate a dissociation of the dorsal and ventral visual pathways. In older cystinosis children (age>5), diminutions in visuospatial performance were associated with reduced FA in the right inferior parietal lobule. In addition, increased MD was found in the presence of high cystine levels in all children with cystinosis. This study provides new information that the average diffusion properties in children with cystinosis deviate from typically developing children. Findings suggest the presence of early microstructural WM changes in addition to a secondary effect of cystine accumulation. These alterations may impact the development of efficient fiber networks important for visuospatial cognition.
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Ahmed I, Phan TT, Lipkin GW, Frenneaux M. Ventricular noncompaction in a female patient with nephropathic cystinosis: a case report. J Med Case Rep 2009; 3:31. [PMID: 19178729 PMCID: PMC2649139 DOI: 10.1186/1752-1947-3-31] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 01/29/2009] [Indexed: 01/25/2023] Open
Abstract
Introduction We report an unusual and interesting case of a 24-year-old woman with nephropathic cystinosis in association with concomitant isolated noncompaction of the left ventricle. Left ventricular noncompaction usually presents with reduced exercise tolerance as a consequence of ventricular dysfunction, the result of embolus or with palpitations and syncope due to arrhythmia. There is no specific treatment directed at isolated noncompaction. Treatment is focused on the cause of presentation, with medication aimed at improving ventricular dysfunction, as well as treating and preventing thrombosis and arrhythmia. Case presentation Our patient presented with an episode of decompensated heart failure. Trans-thoracic echocardiography demonstrated excessive trabeculation with inter-trabecular recesses in the left ventricle typical of noncompaction of the left ventricle. The patient's admission was complicated by a cardiac arrest precipitated by ventricular tachycardia for which she subsequently underwent implantation of an automatic implantable cardioverter defibrillator. Conclusion This is, as far as we know, the first case report of the co-existence of nephropathic cystinosis and isolated noncompaction of the left ventricle. It highlights the importance of being vigilant to the diagnosis of left ventricular noncompaction.
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Affiliation(s)
- Ibrar Ahmed
- Department of Cardiovascular Medicine, Medical School, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
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DeVilliers P, Gutta R, Szymela VF. Cystinosis, Fanconi syndrome, and odontogenic cysts. ACTA ACUST UNITED AC 2008; 106:866-71. [PMID: 18926732 DOI: 10.1016/j.tripleo.2008.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2007] [Revised: 07/31/2008] [Accepted: 08/14/2008] [Indexed: 10/21/2022]
Abstract
Cystinosis is a multisystemic genetic storage disorder characterized by a mutation in the transporter system of cystine. The disease particularly affects the renal system by causing deposition of cystine crystals leading to, if untreated, Fanconi syndrome and end-stage renal disease. This disease also affects the ocular system, central nervous system, endocrine system, hepatobiliary system, and musculoskeletal system. We present the first case of cystine crystal deposition within an odontogenic cyst, confirmed by the correlation of the clinical, radiographic, and histologic findings on this patient.
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Affiliation(s)
- Patricia DeVilliers
- Department of Anatomic Pathology, University of Alabama, Birmingham, Alabama 35249, USA.
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Müller M, Baumeier A, Ringelstein EB, Husstedt IW. Long-term tracking of neurological complications of encephalopathy and myopathy in a patient with nephropathic cystinosis: a case report and review of the literature. J Med Case Rep 2008; 2:235. [PMID: 18644104 PMCID: PMC2491650 DOI: 10.1186/1752-1947-2-235] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Accepted: 07/18/2008] [Indexed: 11/30/2022] Open
Abstract
Introduction Cystinosis is a hereditary storage disease resulting in intracellular accumulation of cystine and crystal formation that causes deterioration of the function of many organs. The major clinical symptom is renal failure, which progresses and necessitates renal transplantation at the beginning of the second decade of life. Encephalopathy and distal myopathy are important neurological long-term complications with a major impact on the quality of life of these patients. Application of cysteamine is the only specific therapy available; it decreases the intracellular cystine level and delays or may even prevent the failure of organ functions. Case presentation We present the case of a 38-year-old woman with cystinosis and the long-term tracking of her neurological symptoms under cysteamine treatment. Conclusion This case report describes a long observation period of neurological complications in a person with cystinosis who had strikingly different courses of encephalopathy and myopathy while on cysteamine treatment. Although encephalopathy was initially suspected, this did not develop, but distal myopathy progressed continuously despite specific therapy.
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Affiliation(s)
- Marcus Müller
- Department of Neurology, Universitätsklinikum Münster, Albert-Schweitzer-Strasse, Münster, Germany.
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Nesterova G, Gahl W. Nephropathic cystinosis: late complications of a multisystemic disease. Pediatr Nephrol 2008; 23:863-78. [PMID: 18008091 DOI: 10.1007/s00467-007-0650-8] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Revised: 09/24/2007] [Accepted: 09/24/2007] [Indexed: 11/29/2022]
Abstract
Cystinosis is a rare autosomal recessive disorder due to impaired transport of cystine out of cellular lysosomes. Its estimated incidence is 1 in 100,000 live births. End-stage renal disease (ESRD) is the most prominent feature of cystinosis and, along with dehydration and electrolyte imbalance due to renal tubular Fanconi syndrome, has accounted for the bulk of deaths from this disorder. Prior to renal transplantation and cystine-depleting therapy with cysteamine for children with nephropathic cystinosis, their lifespan was approximately 10 years. Now, cystinotic patients have survived through their fifth decade, but the unremitting accumulation of cystine has created significant non-renal morbidity and mortality. In this article we review the classic presentation of nephropathic cystinosis and the natural history, diagnosis, and treatment of the disorder's systemic involvement. We also emphasize the role of oral cysteamine therapy in preventing the late complications of cystinosis.
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Affiliation(s)
- Galina Nesterova
- Section on Human Biochemical Genetics, Human Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892-1851, USA
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Shelton GD, Sturges BK, Lyons LA, Williams DC, Aleman M, Jiang Y, Mizisin AP. Myopathy with tubulin-reactive inclusions in two cats. Acta Neuropathol 2007; 114:537-42. [PMID: 17393175 DOI: 10.1007/s00401-007-0217-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2007] [Revised: 03/05/2007] [Accepted: 03/06/2007] [Indexed: 10/23/2022]
Abstract
Many types of inclusions have been described in human myopathies including but not limited to nemaline rod bodies, cylindrical spirals, tubular aggregates, cytoplasmic bodies, reducing bodies, and fingerprint bodies, and hyaline inclusions in myofibrillar myopathy and inclusion body myositis. There are very few reports describing inclusions in spontaneously occurring myopathies in cats, and these reports are limited to nemaline rod myopathy. A myopathy with tubulin-reactive crystalline inclusions has recently been reported in a human patient with a clinical presentation of myalgia and fatigue. Similarly, a myopathy with chronic, slowly progressive muscle weakness has been identified here in two unrelated cats. Inclusions were the only pathological change in skeletal muscle biopsies and, ultrastructurally, groups of crystalline structures were evident that had a subsarcolemmal or central location, rhomboid or rectangular shapes, lacked orientation, and were not membrane bound. The crystalline structures reacted positively with an antibody against tubulin. This feline myopathy may be the equivalent of the human myopathy with tubulin-positive crystalline inclusions.
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Affiliation(s)
- G Diane Shelton
- Department of Pathology 0709, University of California, San Diego, La Jolla, CA 92093-0709, USA.
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Kessler A, Biasibetti M, da Silva Melo DA, Wajner M, Dutra-Filho CS, de Souza Wyse ÂT, Wannmacher CMD. Antioxidant Effect of Cysteamine in Brain Cortex of Young Rats. Neurochem Res 2007; 33:737-44. [DOI: 10.1007/s11064-007-9486-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Accepted: 08/21/2007] [Indexed: 10/22/2022]
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Abstract
In children, dilated coronary arteries are usually caused by Kawasaki's disease. We report four children with dilated coronary arteries and nephropathic cystinosis.
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Affiliation(s)
- S Olgar
- Department of Pediatric Cardiology, Faculty of Medicine, Istanbul University, Istanbul 34200, Turkey.
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O'Brien K, Hussain N, Warady BA, Kleiner DE, Kleta R, Bernardini I, Heller T, Gahl WA. Nodular regenerative hyperplasia and severe portal hypertension in cystinosis. Clin Gastroenterol Hepatol 2006; 4:387-94. [PMID: 16527704 DOI: 10.1016/j.cgh.2005.12.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Cystinosis is a rare autosomal-recessive disorder characterized by the intralysosomal accumulation of cystine, which is responsible for widespread tissue destruction. Liver biopsy specimens of patients with cystinosis show cystine crystal formation in Kupffer cells. However, significant liver disease and portal hypertension is not a common complication of cystinosis. We report the case histories of 2 young men with poorly treated nephropathic cystinosis who developed noncirrhotic portal hypertension with evidence of nodular regenerative hyperplasia (NRH). METHODS Liver biopsy examinations, upper and lower endoscopy with biopsy examination, imaging studies, venous pressure measurements, and laboratory investigations were used to evaluate the causes of the liver disease and portal hypertension. RESULTS Histologic examination of liver biopsy specimens from both patients showed changes characteristic of NRH with portal hypertension documented by measurement of pressure gradients. In addition, endoscopy in the first patient showed varices and portal hypertensive gastropathy. CONCLUSIONS NRH was confirmed by histologic examination of the liver in both patients and is the likely cause of their portal hypertension. NRH may represent a rare, late complication of cystinosis, although the mechanism remains undefined.
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Affiliation(s)
- Kevin O'Brien
- Section on Human Biochemical Genetics, Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland 20892-1851, USA
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Ueda M, O'Brien K, Rosing DR, Ling A, Kleta R, McAreavey D, Bernardini I, Gahl WA. Coronary artery and other vascular calcifications in patients with cystinosis after kidney transplantation. Clin J Am Soc Nephrol 2006; 1:555-62. [PMID: 17699259 DOI: 10.2215/cjn.01431005] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Cystinosis, an autosomal recessive disorder of lysosomal cystine accumulation, results from mutations in the CTNS gene that encodes the lysosomal cystine transporter, cystinosin. Renal tubular Fanconi syndrome occurs in infancy, followed by rickets, growth retardation, photophobia, and renal failure, which requires renal transplantation at approximately 10 yr of age. Treatment with cysteamine decreases cellular cystine levels, retards renal deterioration, and allows for normal growth. Patients with a history of inadequate cystine depletion therapy may survive, after renal transplantation, into the third to fifth decades but will experience other, extrarenal complications of the disease. Routine chest and head computed tomography scans of 41 posttransplantation patients with cystinosis were reviewed for vascular calcification. The radiologic procedures had been performed to examine lung and brain parenchyma, so there was little ascertainment bias. Thirteen of the 41 patients had vascular calcification, including 11 with coronary artery calcification. One 25-yr-old man required three-vessel coronary artery bypass graft surgery. There were no significant differences between the 13 patients with calcification and the 28 without calcification in the following parameters: Time on dialysis, frequency of transplantation, hypertension, hypercholesterolemia, homozygosity for the 57-kb deletion in CTNS, serum creatinine, and calcium-phosphate product. However, the finding of vascular calcification correlated directly with duration of life without cysteamine therapy and inversely with duration of life under good cystine-depleting therapy. The accumulation of intracellular cystine itself maybe a risk factor for vascular calcifications, and older patients with cystinosis should be screened for this complication.
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Affiliation(s)
- Masako Ueda
- Section on Human Biochemical Genetics, Medical Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, MD 20892-1851, USA
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Fleck RMM, Rodrigues Junior V, Giacomazzi J, Parissoto D, Dutra-Filho CS, de Souza Wyse AT, Wajner M, Wannmacher CMD. Cysteamine prevents and reverses the inhibition of creatine kinase activity caused by cystine in rat brain cortex. Neurochem Int 2005; 46:391-7. [PMID: 15737437 DOI: 10.1016/j.neuint.2004.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2004] [Revised: 11/15/2004] [Accepted: 11/27/2004] [Indexed: 11/15/2022]
Abstract
Cystinosis is a disorder associated with lysosomal cystine accumulation caused by defective cystine efflux. Cystine accumulation provokes a variable degree of symptoms depending on the involved tissues. Adult patients may present brain cortical atrophy. However, the mechanisms by which cystine is toxic to the tissues are not fully understood. Considering that brain damage may be developed by energy deficiency, creatine kinase is a thiolic enzyme crucial for energy homeostasis, and disulfides like cystine may alter thiolic enzymes by thiol/disulfide exchange, the main objective of the present study was to investigate the effect of cystine on creatine kinase activity in total homogenate, cytosolic and mitochondrial fractions of the brain cortex from 21-day-old Wistar rats. We performed kinetic studies and investigated the effects of GSH, a biologically occurring thiol group protector, and cysteamine, the drug used for cystinosis treatment, to better understand the effect of cystine on creatine kinase activity. Results showed that cystine inhibited the enzyme activity non-competitively in a dose- and time-dependent way. GSH partially prevented and reversed CK inhibition caused by cystine and cysteamine fully prevented and reversed this inhibition, suggesting that cystine inhibits creatine kinase activity by interaction with the sulfhydryl groups of the enzyme. Considering that creatine kinase is a crucial enzyme for brain cortex energy homeostasis, these results provide a possible mechanism for cystine toxicity and also a new possible beneficial effect for the use of cysteamine in cystinotic patients.
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Affiliation(s)
- Rochele M Müller Fleck
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2600 - Anexo, CEP 90.035-003 Porto Alegre, RS, Brazil
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Sonies BC, Almajid P, Kleta R, Bernardini I, Gahl WA. Swallowing dysfunction in 101 patients with nephropathic cystinosis: benefit of long-term cysteamine therapy. Medicine (Baltimore) 2005; 84:137-146. [PMID: 15879904 DOI: 10.1097/01.md.0000164204.00159.d4] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Nephropathic cystinosis is a rare, autosomal recessive lysosomal storage disorder caused by mutations in the CTNS gene that codes for a cystine transporter in the lysosomal membrane. Affected patients store 50-100 times the normal amounts of cystine in their cells, and suffer renal tubular and glomerular disease, growth retardation, photophobia, and other systemic complications, including a myopathy and swallowing dysfunction. Using videofluoroscopy and ultrasound examinations, we assessed the swallowing function of 101 patients with nephropathic cystinosis on their most recent admission to the National Institutes of Health Clinical Center between 1987 and 2004. These patients ranged in age from 6 to 45 years; more than half had significant complaints of swallowing difficulty. On examination of barium swallow, the oral, pharyngeal, and esophageal phases of swallowing were abnormal in 24%, 51%, and 73% of patients, respectively. The frequency of dysfunction increased with age for each phase of swallowing. Both the Swallowing Severity Score (a measure of dysfunction on barium swallow) and the Oral Muscle Composite Score (a reflection of vocal strength, oral-facial movement, and tongue and lip function) increased (that is, worsened) with the number of years that a patient was not receiving treatment with cysteamine, the cystine-depleting agent of choice in cystinosis. The severity scores decreased with the number of years on cysteamine therapy. The Swallowing Severity Score varied directly with the severity of muscle disease, but was not correlated with the presence or absence of the 57-kb CTNS deletion that commonly occurs in nephropathic cystinosis patients. We conclude that swallowing dysfunction in cystinosis presents a risk of fatal aspiration, correlates with the presence of muscle atrophy, and, based on cross-sectional data, increases in frequency with age and number of years without cysteamine treatment. Cystine-depleting therapy with cysteamine should be considered the treatment of choice for both pre- and posttransplant cystinosis patients.
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Affiliation(s)
- Barbara C Sonies
- From Oral Motor Function Section (BCS, PA), Physical Disabilities Branch, Rehabilitation Medicine Department, Warren Grant Magnuson Clinical Center; Section on Human Biochemical Genetics (RK, IB, WAG), Medical Genetics Branch, National Human Genome Research Institute; and Intramural Office of Rare Diseases (RK), Office of the Director; National Institutes of Health, Bethesda, Maryland
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Kleta R, Gahl WA. Pharmacological treatment of nephropathic cystinosis with cysteamine. Expert Opin Pharmacother 2004; 5:2255-62. [PMID: 15500372 DOI: 10.1517/14656566.5.11.2255] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cystinosis, clinically recognised since 1903, is an autosomal recessive lysosomal storage disease caused by mutations in CTNS. This gene codes for a lysosomal cystine transporter, whose absence leads to intracellular cystine crystals, widespread cellular destruction, renal Fanconi syndrome in infancy, renal glomerular failure in later childhood and other systemic complications. Before the availability of kidney transplantation, patients affected with cystinosis uniformly died during childhood. After solid organ transplantations became successful in the 1960s, cystinosis patients survived, but eventually developed life-threatening consequences of the disease (e.g., swallowing disorders). Since the introduction of cysteamine into the pharmacological management of cystinosis, well-treated adolescent and young adult patients have experienced normal growth and maintenance of renal glomerular function. Oral cysteamine therapy is given at doses of 60 - 90 mg/kg/day q.i.d. every 6 h, and generally achieves approximately 90% depletion of cellular cystine, as measured in circulating leucocytes. Cysteamine (and kidney transplantation) have commuted the death sentence of cystinosis into a nearly normal life with a chronic disease. Because treatment with oral cysteamine can prevent, or significantly delay, the complications of cystinosis, early and accurate diagnosis, as well as proper treatment, is critical.
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Affiliation(s)
- Robert Kleta
- NHGRI, Building 10, Room 10C-107, MSC 1851, 10 Center Drive, Bethesda, MD 20892, USA.
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Dogulu CF, Tsilou E, Rubin B, Fitzgibbon EJ, Kaiser-Kupper MI, Rennert OM, Gahl WA. Idiopathic intracranial hypertension in cystinosis. J Pediatr 2004; 145:673-8. [PMID: 15520772 DOI: 10.1016/j.jpeds.2004.06.080] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To report a high frequency of idiopathic intracranial hypertension (IIH) in patients with cystinosis and to speculate on the relationship between these two disorders. STUDY DESIGN Retrospective case series and review of the literature regarding risk factors for the development of IIH in cystinosis. RESULTS Eight patients with cystinosis had documented papilledema, normal neuroimaging of the brain, cerebrospinal fluid (CSF) opening pressure greater than 200 mm of H2O, and normal CSF composition. No common medication, condition, or disease except cystinosis was found in these persons. Six of the patients had received prednisone, growth hormone, cyclosporine, oral contraceptives, vitamin D, or levothyroxine at the time of onset of IIH. Five patients had previous renal transplants. CONCLUSION No single risk factor for the development of IIH linked IIH to cystinosis in our patients. However, thrombosis susceptibility as a result of renal disease or impaired CSF reabsorption in the arachnoid villi as a result of cystine deposition might lead to the development of IIH in cystinosis.
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Affiliation(s)
- Cigdem F Dogulu
- Laboratory of Clinical Genomics, National Institute of Child Health and Development, Opthalmic Clinical Genetics Section, National Institutes of Health, Bethesda, MD 20892-4429, USA.
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Abstract
We report the excellent clinical outcomes of siblings with nephropathic cystinosis treated diligently with cysteamine starting at 20 months and 2 months of age. Now 15 and 8 years old, they have glomerular filtration rates of 78 and 105 mL/min/1.73m 2 , respectively. These cases illustrate the critical importance of early diagnosis and treatment.
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Abstract
Cystinosis is an autosomal recessive disease that results in a defective integral membrane protein responsible for the transport of cystine out of lysosomes. This results in the accumulation of cystine in the lysosomes of almost every tissue, with subsequent formation of damaging crystals. The cystinotic process may affect every system of the body, but is particularly damaging to the kidneys and eyes. We discuss the perioperative care of a cystinotic patient with renal insufficiency, Fanconi's syndrome, and photophobia. Other organ systems affected by the cystinotic process are also discussed, with suggestions for the perioperative management of each. Issues of primary concern during perioperative care include preservation of renal function and maintenance of fluid and electrolyte homeostasis.
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Affiliation(s)
- Theresa L Ray
- Department of Child Health, The Division of Pediatric Critical Care/Pediatric Anesthesiology, The University of Missouri, Columbia, MO, USA
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Rosa TG, de Souza Wyse AT, Wajner M, Wannmacher CMD. Cysteamine prevents and reverses the inhibition of pyruvate kinase activity caused by cystine in rat heart. Biochim Biophys Acta Mol Basis Dis 2004; 1689:114-9. [PMID: 15196592 DOI: 10.1016/j.bbadis.2004.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2003] [Revised: 02/24/2004] [Accepted: 02/27/2004] [Indexed: 10/26/2022]
Abstract
Cystinosis is a disorder associated with excessive lysosomal cystine accumulation secondary to defective cystine efflux. Patients affected by this disease develop a variable degree of symptoms depending on the involved tissues. Accumulation of cystine in myocardium may lead to heart failure. However, the mechanisms by which cystine is toxic to the tissues are not fully understood. Considering that thiolic enzymes like pyruvate kinase (PK) may be altered by disulfides like cystine, the main objective of the present study was to investigate the effect of cystine on PK activity in the heart of developing rats. We performed kinetic studies and investigated the effects of reduced glutathione (GSH), a biologically occurring thiol groups protector, and cysteamine, the drug used for cystinosis treatment, on the enzyme activity. We observed that cystine inhibited the enzyme activity non-competitively in a dose- and time-dependent way. We also observed that GSH and cysteamine fully prevented and reversed the inhibition caused by cystine, suggesting that cystine inhibits PK activity by oxidation of the sulfhydryl groups of the enzyme. Although there is no definite proof of cystine within cytoplasm, there is indirect proof t it is able to escape lysosomes and come in contact with PK. Considering that cysteamine is used in patients with cystinosis because it causes parenchymal organ cystine depletion, the present data provide a possible new effect for this drug.
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Affiliation(s)
- Tatiana Galetto Rosa
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, UFRGS, Rua Ramiro Barcelos 2600-Anexo, CEP 90.035-003, Porto Alegre, RS, Brazil
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Kalatzis V, Antignac C. New aspects of the pathogenesis of cystinosis. Pediatr Nephrol 2003; 18:207-15. [PMID: 12644911 DOI: 10.1007/s00467-003-1077-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2002] [Revised: 11/04/2002] [Accepted: 11/08/2002] [Indexed: 10/25/2022]
Abstract
Cystinosis is a lysosomal transport disorder characterized by an intra-lysosomal accumulation of cystine, the disulfide of the amino acid cysteine. It is the most common inherited cause of the renal Fanconi syndrome. There are various clinical forms, infantile, juvenile, and ocular, based on age of onset and severity of symptoms. The first clinical description appeared in the early 1900s, but it was not until 1998 that the causative gene, CTNS, was identified. CTNS encodes cystinosin, a novel seven transmembrane domain (TM) protein. Cystinosin is a lysosomal membrane protein that requires two lysosomal targeting signals: a classic GYDQL motif in its C-terminal tail and a novel conformational motif, the core of which is YFPQA, situated in the fifth inter-TM loop. Cystinosin is the lysosomal cystine transporter and its activity is H(+)-driven. A mouse model of cystinosis was recently generated and Ctns(-/-) mice accumulate cystine in all tissues. A high level of cystine accumulates in the kidney, but these mice do not present with proximal tubulopathy or renal dysfunction. The Ctns(-/-) mouse model may provide clues to the cause of the Fanconi syndrome associated with cystinosis, the origin of which remains poorly understood.
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Dixit MP, Greifer I. Nephropathic cystinosis associated with cardiomyopathy: a 27-year clinical follow-up. BMC Nephrol 2002; 3:8. [PMID: 12425721 PMCID: PMC137602 DOI: 10.1186/1471-2369-3-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2002] [Accepted: 11/09/2002] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Nephropathic cystinosis is an autosomal recessive disease resulting from intracellular accumulation of cystine leading to multiple organ failure. CASE REPORT We describe the clinical course of a patient managed from the age of six until his death at the age of 33 years. He underwent multiple surgery, including two renal transplants, developed transplant renal artery stenosis that was managed medically, and progressive heart failure at the age of 33 years. His death from a ruptured pseudoaneurysm associated with a restrictive cardiomyopathy is noteworthy. A limited cardiac autopsy revealed the presence of cystine crystals in interstitial cardiac histiocytes and one myocardial cell, along with 1000-fold higher tissue cystine content of the left ventricular myocardium compared to patients without cystinosis, suggesting the possibility of direct cystine mediated metabolic injury.
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Affiliation(s)
- Mehul P Dixit
- Division of Nephrology, Department of Pediatrics, University of Arizona, Tucson, USA
| | - Ira Greifer
- Division of Nephrology, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, USA
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Cherqui S, Sevin C, Hamard G, Kalatzis V, Sich M, Pequignot MO, Gogat K, Abitbol M, Broyer M, Gubler MC, Antignac C. Intralysosomal cystine accumulation in mice lacking cystinosin, the protein defective in cystinosis. Mol Cell Biol 2002; 22:7622-32. [PMID: 12370309 PMCID: PMC135682 DOI: 10.1128/mcb.22.21.7622-7632.2002] [Citation(s) in RCA: 136] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cystinosis is an autosomal recessive disorder characterized by an accumulation of intralysosomal cystine. The causative gene, CTNS, encodes cystinosin, a seven-transmembrane-domain protein, which we recently showed to be a lysosomal cystine transporter. The most severe and frequent form of cystinosis, the infantile form, appears around 6 to 12 months, with a proximal tubulopathy (de Toni-Debré-Fanconi syndrome) and ocular damage. End-stage renal failure is reached by 10 years of age. Accumulation of cystine in all tissues eventually leads to multisystemic disease. Treatment with cysteamine, which reduces the concentration of intracellular cystine, delays disease progression but has undesirable side effects. We report the first Ctns knockout mouse model generated using a promoter trap approach. We replaced the last four Ctns exons by an internal ribosome entry site-betagal-neo cassette and showed that the truncated protein was mislocalized and nonfunctional. Ctns(-/-) mice accumulated cystine in all organs tested, and cystine crystals, pathognomonic of cystinosis, were observed. Ctns(-/-) mice developed ocular changes similar to those observed in affected individuals, bone defects and behavioral anomalies. Interestingly, Ctns(-/-) mice did not develop signs of a proximal tubulopathy, or renal failure. A preliminary therapeutic trial using an oral administration of cysteamine was carried out and demonstrated the efficiency of this treatment for cystine clearance in Ctns(-/-) mice. This animal model will prove an invaluable and unique tool for testing emerging therapeutics for cystinosis.
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Affiliation(s)
- William A Gahl
- Heritable Disorders Branch, National Institute of Child Health and Human Development, Bethesda, Md 20892-1830, USA.
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