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Rösner S, Pardo LM, Bertoli-Avella AM, Skrahina V, Engel P, Schröder S, Zielske S, Bonke V, Kreth J, Westphal G, Reder F, Skobalj S, Zielke S, Bogdanovic X, Grieger P, Rennecke J, Skripuletz T, Patten M, Aßmus B, Hahn K, Rolfs A, Bauer P. Hereditary Transthyretin-Related Amyloidosis Ongoing Observational Study: A Baseline Report of the First 3167 Participants. J Clin Med 2024; 13:6197. [PMID: 39458146 PMCID: PMC11508262 DOI: 10.3390/jcm13206197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2024] [Revised: 10/12/2024] [Accepted: 10/13/2024] [Indexed: 10/28/2024] Open
Abstract
Background: Hereditary transthyretin-related amyloidosis is a clinically heterogeneous autosomal dominant disease caused by pathogenic variants in the TTR gene (hATTR amyloidosis). Objective: The current study describes the demographic, clinical, and genetic characteristics of patients with suspected hATTR amyloidosis. Methods: This study is part of the "Hereditary transthyretin-related amyloidosis and longitudinal monitoring of TTR-positive patients" (TRAMmoniTTR) study. This study included 3167 participants, along with their clinical details. Principal component (PC) analysis was used to analyze their clinical symptomatology. Next-generation sequencing of the TTR gene was performed and genotype-phenotype relationships were investigated. We compared the demographic and clinical characteristics using the principal components (PCs) and also compared participants with and without the TTR pathogenic variants. Results: We identified five main clinical phenotypes out of 22 single symptoms that explained 49% of the variation. The first two PCs referred to polyneuropathy and cardiomyopathy. We found significant differences between gender and PC-polyneuropathy and PC-cardiomyopathy, with male over-representation in the higher quantiles of PC-polyneuropathy and male under-representation in the lowest quantiles of PC-cardiomyopathy. We identified 92 participants with hATTR (3%), exhibiting 17 unique heterozygous TTR variants. The p.Val50Met variant was the most frequent. Furthermore, 503 participants (20%) were identified with ATTR and no relevant TTR variants (ATTRwt). We detected significant differences between the ATTRwt and hATTR groups, with male gender predominance in only the ATTRwt group and a positive family history of polyneuropathy and/or cardiomyopathy among the hATTR participants. Conclusions: The current clinical and genetic characterization of this cohort serves as a foundation for further longitudinal monitoring and assessment.
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Affiliation(s)
- Sabine Rösner
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
| | - Luba M. Pardo
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
| | - Aida M. Bertoli-Avella
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
| | - Volha Skrahina
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
| | - Pierre Engel
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
| | - Sabine Schröder
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
| | - Susan Zielske
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
| | - Valerie Bonke
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
| | - Janett Kreth
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
| | - Gina Westphal
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
| | - Felix Reder
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
| | - Snezana Skobalj
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
| | - Susanne Zielke
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
| | - Xenia Bogdanovic
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
| | - Paula Grieger
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
| | - Jörg Rennecke
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, 30625 Hannover, Germany;
- Amyloidosis Center of Lower Saxony, Hannover Medical School, 30625 Hannover, Germany
| | - Monica Patten
- Department of Cardiology, University Heart and Vascular Center, 20148 Hamburg, Germany;
| | - Birgit Aßmus
- Department of Cardiology and Angiology, University Hospital Giessen and Marburg, 35043 Marburg, Germany;
| | - Katrin Hahn
- Department of Neurology, Charitè–Universitätsmedizin, Amyloidosis Center Charité, 10117 Berlin, Germany;
- Amyloidosis Center Charité Berlin (ACCB), Charité Universitätsmedizin, 10117 Berlin, Germany
| | - Arndt Rolfs
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
- RCV GmbH, Institute for Rare Disease Diagnostics, 10629 Berlin, Germany
| | - Peter Bauer
- CENTOGENE GmbH, 18055 Rostock, Germany; (S.R.); (L.M.P.); (A.M.B.-A.); (V.S.); (P.E.); (S.S.); (S.Z.); (V.B.); (G.W.); (F.R.); (S.S.); (S.Z.); (X.B.); (P.G.); (J.R.); (A.R.)
- Medical Faculty, University Rostock, 18057 Rostock, Germany
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Conceição I, Berk JL, Weiler M, Kowacs PA, Dasgupta NR, Khella S, Chao CC, Attarian S, Kwoh TJ, Jung SW, Chen J, Viney NJ, Yu RZ, Gertz M, Masri A, Cruz MW, Coelho T. Switching from inotersen to eplontersen in patients with hereditary transthyretin-mediated amyloidosis with polyneuropathy: analysis from NEURO-TTRansform. J Neurol 2024; 271:6655-6666. [PMID: 39138650 PMCID: PMC11447117 DOI: 10.1007/s00415-024-12616-6] [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: 06/27/2024] [Revised: 07/23/2024] [Accepted: 07/28/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND The phase 3 NEURO-TTRansform trial showed eplontersen treatment for 65 weeks reduced transthyretin (TTR), halted progression of neuropathy impairment, and improved quality of life (QoL) in adult patients with hereditary TTR-mediated amyloidosis with polyneuropathy (ATTRv-PN), vs. historical placebo. METHODS NEURO-TTRansform enrolled patients with ATTRv-PN. A subset of patients were randomized to receive subcutaneous inotersen 300 mg weekly (Weeks 1-34) and subsequently switched to subcutaneous eplontersen 45 mg every 4 weeks (Weeks 37-81). Change in serum TTR and treatment-emergent adverse events (TEAEs) were evaluated through Week 85. Effects on neuropathy impairment, QoL, and nutritional status were also evaluated. RESULTS Of 24 patients randomized to inotersen, 20 (83%) switched to eplontersen at Week 37 and four discontinued due to AEs/investigator decision. Absolute change in serum TTR was greater after switching from inotersen (-74.3%; Week 35) to eplontersen (-80.6%; Week 85). From the end of inotersen treatment, neuropathy impairment and QoL were stable (i.e., did not progress) while on eplontersen, and there was no deterioration in nutritional status. TEAEs were fewer with eplontersen (Weeks 37-85; 19/20 [95%] patients) compared with inotersen (up to Week 35; 24/24 [100%] patients). Mean platelet counts decreased during inotersen treatment (mean nadir reduction ‒40.7%) and returned to baseline during eplontersen treatment (mean nadir reduction, ‒3.2%). CONCLUSIONS Switching from inotersen to eplontersen further reduced serum TTR, halted disease progression, stabilized QoL, restored platelet count, and improved tolerability, without deterioration in nutritional status. This supports a positive benefit-risk profile for patients with ATTRv-PN who switch from inotersen to eplontersen.
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Affiliation(s)
- Isabel Conceição
- ULS Santa Maria, CAML, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal.
| | - John L Berk
- Boston University School of Medicine, Boston, MA, USA
| | - Markus Weiler
- Amyloidosis Center and Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Pedro A Kowacs
- Instituto de Neurologia de Curitiba, Curitiba, Paraná, Brazil
| | - Noel R Dasgupta
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sami Khella
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | - Shahram Attarian
- Neuromuscular Disorders and ALS Department, Centre Hospitalier Universitaire La Timone, Marseille, France
| | - T Jesse Kwoh
- Clinical Development, Ionis Pharmaceuticals, Inc., Carlsbad, CA, USA
| | - Shiangtung W Jung
- Clinical Development, Ionis Pharmaceuticals, Inc., Carlsbad, CA, USA
| | - Jersey Chen
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MA, USA
| | - Nicholas J Viney
- Clinical Development, Ionis Pharmaceuticals, Inc., Carlsbad, CA, USA
| | - Rosie Z Yu
- Preclinical Development, Ionis Pharmaceuticals, Inc, Carlsbad, CA, USA
| | | | - Ahmad Masri
- OHSU Center for Hypertrophic Cardiomyopathy and Amyloidosis, Portland, OR, USA
| | - Márcia Waddington Cruz
- CEPARM, Amyloidosis Center, University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Teresa Coelho
- Centro Hospitalar Universitário de Santo António, Porto, Portugal
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Chompoopong P, Mauermann ML, Siddiqi H, Peltier A. Amyloid Neuropathy: From Pathophysiology to Treatment in Light-Chain Amyloidosis and Hereditary Transthyretin Amyloidosis. Ann Neurol 2024; 96:423-440. [PMID: 38923548 DOI: 10.1002/ana.26965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 03/20/2024] [Accepted: 05/02/2024] [Indexed: 06/28/2024]
Abstract
Amyloid neuropathy is caused by deposition of insoluble β-pleated amyloid sheets in the peripheral nervous system. It is most common in: (1) light-chain amyloidosis, a clonal non-proliferative plasma cell disorder in which fragments of immunoglobulin, light or heavy chain, deposit in tissues, and (2) hereditary transthyretin (ATTRv) amyloidosis, a disorder caused by autosomal dominant mutations in the TTR gene resulting in mutated protein that has a higher tendency to misfold. Amyloid fibrils deposit in the endoneurium of peripheral nerves, often extensive in the dorsal root ganglia and sympathetic ganglia, leading to atrophy of Schwann cells in proximity to amyloid fibrils and blood-nerve barrier disruption. Clinically, amyloid neuropathy is manifested as a length-dependent sensory predominant neuropathy associated with generalized autonomic failure. Small unmyelinated nerves are involved early and prominently in early-onset Val30Met ATTRv, whereas other ATTRv and light-chain amyloidosis often present with large- and small-fiber involvement. Nerve conduction studies, quantitative sudomotor axon testing, and intraepidermal nerve fiber density are useful tools to evaluate denervation. Amyloid deposition can be demonstrated by tissue biopsy of the affected organ or surrogate site, as well as bone-avid radiotracer cardiac imaging. Treatment of light-chain amyloidosis has been revolutionized by monoclonal antibodies and stem cell transplantation with improved 5-year survival up to 77%. Novel gene therapy and transthyretin stabilizers have revolutionized treatment of ATTRv, improving the course of neuropathy (less change in the modified Neuropathy Impairment Score + 7 from baseline) and quality of life. With great progress in amyloidosis therapies, early diagnosis and presymptomatic testing for ATTRv family members has become paramount. ANN NEUROL 2024;96:423-440.
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Affiliation(s)
| | | | - Hasan Siddiqi
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda Peltier
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
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De Lillo A, Pathak GA, Low A, De Angelis F, Abou Alaiwi S, Miller EJ, Fuciarelli M, Polimanti R. Clinical spectrum of Transthyretin amyloidogenic mutations among diverse population origins. Hum Genomics 2024; 18:31. [PMID: 38523305 PMCID: PMC10962184 DOI: 10.1186/s40246-024-00596-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/08/2024] [Indexed: 03/26/2024] Open
Abstract
PURPOSE Coding mutations in the Transthyretin (TTR) gene cause a hereditary form of amyloidosis characterized by a complex genotype-phenotype correlation with limited information regarding differences among worldwide populations. METHODS We compared 676 diverse individuals carrying TTR amyloidogenic mutations (rs138065384, Phe44Leu; rs730881165, Ala81Thr; rs121918074, His90Asn; rs76992529, Val122Ile) to 12,430 non-carriers matched by age, sex, and genetically-inferred ancestry to assess their clinical presentations across 1,693 outcomes derived from electronic health records in UK biobank. RESULTS In individuals of African descent (AFR), Val122Ile mutation was linked to multiple outcomes related to the circulatory system (fold-enrichment = 2.96, p = 0.002) with the strongest associations being cardiac congenital anomalies (phecode 747.1, p = 0.003), endocarditis (phecode 420.3, p = 0.006), and cardiomyopathy (phecode 425, p = 0.007). In individuals of Central-South Asian descent (CSA), His90Asn mutation was associated with dermatologic outcomes (fold-enrichment = 28, p = 0.001). The same TTR mutation was linked to neoplasms in European-descent individuals (EUR, fold-enrichment = 3.09, p = 0.003). In EUR, Ala81Thr showed multiple associations with respiratory outcomes related (fold-enrichment = 3.61, p = 0.002), but the strongest association was with atrioventricular block (phecode 426.2, p = 2.81 × 10- 4). Additionally, the same mutation in East Asians (EAS) showed associations with endocrine-metabolic traits (fold-enrichment = 4.47, p = 0.003). In the cross-ancestry meta-analysis, Val122Ile mutation was associated with peripheral nerve disorders (phecode 351, p = 0.004) in addition to cardiac congenital anomalies (fold-enrichment = 6.94, p = 0.003). CONCLUSIONS Overall, these findings highlight that TTR amyloidogenic mutations present ancestry-specific and ancestry-convergent associations related to a range of health domains. This supports the need to increase awareness regarding the range of outcomes associated with TTR mutations across worldwide populations to reduce misdiagnosis and delayed diagnosis of TTR-related amyloidosis.
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Affiliation(s)
- Antonella De Lillo
- Department of Psychiatry, Yale University School of Medicine, 60 Temple, Suite 7A, New Haven, CT, 06510, USA
- Department of Biology, University of Rome "Tor Vergata", Rome, Italy
| | - Gita A Pathak
- Department of Psychiatry, Yale University School of Medicine, 60 Temple, Suite 7A, New Haven, CT, 06510, USA
- VA CT Healthcare Center, West Haven, CT, USA
| | - Aislinn Low
- Department of Psychiatry, Yale University School of Medicine, 60 Temple, Suite 7A, New Haven, CT, 06510, USA
- VA CT Healthcare Center, West Haven, CT, USA
| | - Flavio De Angelis
- Department of Psychiatry, Yale University School of Medicine, 60 Temple, Suite 7A, New Haven, CT, 06510, USA
- Department of Physical and Mental Health, and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Sarah Abou Alaiwi
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Maria Fuciarelli
- Department of Biology, University of Rome "Tor Vergata", Rome, Italy
| | - Renato Polimanti
- Department of Psychiatry, Yale University School of Medicine, 60 Temple, Suite 7A, New Haven, CT, 06510, USA.
- VA CT Healthcare Center, West Haven, CT, USA.
- Wu Tsai Institute, Yale University, New Haven, CT, USA.
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Fargeot G, Echaniz-Laguna A, Labeyrie C, Svahn J, Camdessanché JP, Cintas P, Chanson JB, Esselin F, Piedvache C, Verstuyft C, Genestet S, Lagrange E, Magy L, Péréon Y, Sacconi S, Signate A, Nadaj-Pakleza A, Taithe F, Viala K, Tard C, Poinsignon V, Cauquil C, Attarian S, Adams D. Hereditary transthyretin amyloidosis in middle-aged and elderly patients with idiopathic polyneuropathy: a nationwide prospective study. Amyloid 2024; 31:62-69. [PMID: 37855400 DOI: 10.1080/13506129.2023.2270661] [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: 06/15/2023] [Accepted: 10/05/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Hereditary transthyretin amyloidosis (ATTRv) is an adult-onset autosomal dominant disease resulting from TTR gene pathogenic variants. ATTRv often presents as a progressive polyneuropathy, and effective ATTRv treatments are available. METHODS In this 5 year-long (2017-2021) nationwide prospective study, we systematically analysed the TTR gene in French patients with age >50 years with a progressive idiopathic polyneuropathy. RESULTS 553 patients (70% males) with a mean age of 70 years were included. A TTR gene pathogenic variant was found in 15 patients (2.7%), including the Val30Met TTR variation in 10 cases. In comparison with patients with no TTR gene pathogenic variants (n = 538), patients with TTR pathogenic variants more often presented with orthostatic hypotension (53 vs. 21%, p = .007), significant weight loss (33 vs 11%, p = .024) and rapidly deteriorating nerve conduction studies (26 vs. 8%, p = .03). ATTRv diagnosis led to amyloid cardiomyopathy diagnosis in 11 cases, ATTRv specific treatment in all cases and identification of 15 additional ATTRv cases among relatives. CONCLUSION In this nationwide prospective study, we found ATTRv in 2.7% of patients with age >50 years with a progressive polyneuropathy. These results are highly important for the early identification of patients in need of disease-modifying treatments.
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Affiliation(s)
- Guillaume Fargeot
- Neurology Department, CHU de Bicêtre, AP-HP, Le-Kremlin-Bicêtre, France
| | - Andoni Echaniz-Laguna
- Neurology Department, CHU de Bicêtre, AP-HP, Le-Kremlin-Bicêtre, France
- French National Reference Center for Rare Neuropathies (NNERF), Le-Kremlin-Bicêtre, France
- Inserm U1195, Paris-Saclay University, Le-Kremlin-Bicêtre, France
| | - Céline Labeyrie
- Neurology Department, CHU de Bicêtre, AP-HP, Le-Kremlin-Bicêtre, France
- French National Reference Center for Rare Neuropathies (NNERF), Le-Kremlin-Bicêtre, France
| | - Juliette Svahn
- Electroneuromyography and Neuromuscular Department, Pierre Wertheimer Hospital, Hospices Civils de Lyon, Lyon, France
| | | | - Pascal Cintas
- Department of Neurology, AOC (Atlantique-Occitanie-Caraïbes) Reference Centre for Neuromuscular Diseases, Pierre Paul Riquet Hospital, CHU Toulouse, Toulouse, France
| | - Jean-Baptiste Chanson
- Neurology Department, CHU de Strasbourg, Strasbourg, and Neuromuscular Reference Center Nord/Est/Ile de France (NEIF), Strasbourg, France
| | - Florence Esselin
- Explorations Neurologiques et Centre SLA, CHU et Université de Montpellier, INSERM, Montpellier, France
| | - Céline Piedvache
- Unité de Recherche Clinique Paris-Saclay, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Céline Verstuyft
- Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Centre de Ressources Biologiques Paris Saclay, AP-HP, GH Paris Saclay, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Steeve Genestet
- Reference Centre for Neuromuscular Diseases AOC, University Hospital of Brest, Brest, France
| | - Emmeline Lagrange
- Department of Neurology, Grenoble Alpes University Hospital, Grenoble, France
| | - Laurent Magy
- Service de Neurologie, Centre de Référence Neuropathies Périphériques Rares, NNerf, UR 20218 NeurIT, CHU de Limoges, Hôpital Dupuytren, Limoges, France
| | - Yann Péréon
- CHU Nantes, Reference Centre for Neuromuscular Diseases AOC, Hôtel-Dieu, Filnemus, Euro-NMD, Nantes, France
| | - Sabrina Sacconi
- Department of Clinical Neurosciences, Neuromuscular Diseases Centre, University Hospital of Nice (CHU), Nice, France
| | - Aissatou Signate
- Department of Neurology, CHU Martinique (University Hospital of Martinique), Fort de France, France
| | - Aleksandra Nadaj-Pakleza
- Neurology Department, CHU de Strasbourg, Strasbourg, and Neuromuscular Reference Center Nord/Est/Ile de France (NEIF), Strasbourg, France
| | - Frédéric Taithe
- Department of Neurology, University Hospital of Clermont-Ferrand (CHU Clermont-Ferrand - Gabriel Montpied Hospital), Clermont-Ferrand, FT, France
| | - Karine Viala
- Neurophysiology Department, AP-HP, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Céline Tard
- Centre de référence des maladies Neuromusculaires Nord/Est/Ile-de-France, U1172, CHU de Lille, Lille, France
| | - Vianney Poinsignon
- Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie de Bicêtre, Hôpitaux Universitaires Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
| | - Cécile Cauquil
- Neurology Department, CHU de Bicêtre, AP-HP, Le-Kremlin-Bicêtre, France
- French National Reference Center for Rare Neuropathies (NNERF), Le-Kremlin-Bicêtre, France
| | - Shahram Attarian
- Centre de Référence des Maladies Neuromusculaires et de la SLA, APHM, CHU Timone, Marseille, France
| | - David Adams
- Neurology Department, CHU de Bicêtre, AP-HP, Le-Kremlin-Bicêtre, France
- French National Reference Center for Rare Neuropathies (NNERF), Le-Kremlin-Bicêtre, France
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Adams D, Sekijima Y, Conceição I, Waddington-Cruz M, Polydefkis M, Echaniz-Laguna A, Reilly MM. Hereditary transthyretin amyloid neuropathies: advances in pathophysiology, biomarkers, and treatment. Lancet Neurol 2023; 22:1061-1074. [PMID: 37863593 DOI: 10.1016/s1474-4422(23)00334-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 08/08/2023] [Accepted: 08/31/2023] [Indexed: 10/22/2023]
Abstract
Hereditary transthyretin (TTR) amyloid polyneuropathy is an autosomal dominant life-threatening disorder. TTR is produced mainly by the liver but also by the choroid plexus and retinal pigment epithelium. Detailed clinical characterisation, identification of clinical red flags for misdiagnosis, and use of biomarkers enable early diagnosis and treatment. In addition to liver transplantation and TTR stabilisers, three other disease-modifying therapies have regulatory approval: one antisense oligonucleotide (inotersen) and two small interfering RNAs (siRNAs; patisiran and vutrisiran). The siRNAs have been shown to stop progression of neuropathy and improve patients' quality of life. As none of the disease-modifying therapies can cross the blood-brain barrier, TTR deposition in the CNS, which can cause stroke and cognitive impairment, remains an important unaddressed issue. CRISPR-Cas9-based one-time TTR editing therapy is being investigated in a phase 1 clinical study. Identification of the earliest stages of pathogenesis in TTR variant carriers is a major challenge that needs addressing for optimal management.
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Affiliation(s)
- David Adams
- Department of Neurology, Bicêtre Centre Hospitalo Universitaire, AP-HP, INSERM U 1195, University Paris Saclay, Le Kremlin Bicetre, France.
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Isabel Conceição
- Department of Neurosciences and Mental Health, Centro Hospitalar Universitario Lisboas Norte-Hospital de Santa Maria and Centro de Estudos Egas Moniz, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Marcia Waddington-Cruz
- Centro de Estudos em Paramiloidose Antonio Rodrigues de Mello, National Amyloidosis Referral Center, University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Michael Polydefkis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andoni Echaniz-Laguna
- Department of Neurology, Centre Hospitalo Universitaire, AP-HP, INSERM U 1195, University Paris Saclay, Le Kremlin Bicetre Cedex, France
| | - Mary M Reilly
- Department of Neuromuscular Disease, University College London Institute of Neurology and the National Hospital of Neurology and Neurosurgery, London, UK
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7
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Coelho T, Marques W, Dasgupta NR, Chao CC, Parman Y, França MC, Guo YC, Wixner J, Ro LS, Calandra CR, Kowacs PA, Berk JL, Obici L, Barroso FA, Weiler M, Conceição I, Jung SW, Buchele G, Brambatti M, Chen J, Hughes SG, Schneider E, Viney NJ, Masri A, Gertz MR, Ando Y, Gillmore JD, Khella S, Dyck PJB, Waddington Cruz M. Eplontersen for Hereditary Transthyretin Amyloidosis With Polyneuropathy. JAMA 2023; 330:1448-1458. [PMID: 37768671 PMCID: PMC10540057 DOI: 10.1001/jama.2023.18688] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023]
Abstract
Importance Transthyretin gene silencing is an emerging treatment strategy for hereditary transthyretin (ATTRv) amyloidosis. Objective To evaluate eplontersen, an investigational ligand-conjugated antisense oligonucleotide, in ATTRv polyneuropathy. Design, Setting, and Participants NEURO-TTRansform was an open-label, single-group, phase 3 trial conducted at 40 sites across 15 countries (December 2019-April 2023) in 168 adults with Coutinho stage 1 or 2 ATTRv polyneuropathy, Neuropathy Impairment Score 10-130, and a documented TTR variant. Patients treated with placebo from NEURO-TTR (NCT01737398; March 2013-November 2017), an inotersen trial with similar eligibility criteria and end points, served as a historical placebo ("placebo") group. Interventions Subcutaneous eplontersen (45 mg every 4 weeks; n = 144); a small reference group received subcutaneous inotersen (300 mg weekly; n = 24); subcutaneous placebo weekly (in NEURO-TTR; n = 60). Main Outcomes and Measures Primary efficacy end points at week 65/66 were changes from baseline in serum transthyretin concentration, modified Neuropathy Impairment Score +7 (mNIS+7) composite score (scoring range, -22.3 to 346.3; higher scores indicate poorer function), and Norfolk Quality of Life Questionnaire-Diabetic Neuropathy (Norfolk QoL-DN) total score (scoring range, -4 to 136; higher scores indicate poorer quality of life). Analyses of efficacy end points were based on a mixed-effects model with repeated measures adjusted by propensity score weights. Results Among 144 eplontersen-treated patients (mean age, 53.0 years; 69% male), 136 (94.4%) completed week-66 follow-up; among 60 placebo patients (mean age, 59.5 years; 68% male), 52 (86.7%) completed week-66 follow-up. At week 65, adjusted mean percentage reduction in serum transthyretin was -81.7% with eplontersen and -11.2% with placebo (difference, -70.4% [95% CI, -75.2% to -65.7%]; P < .001). Adjusted mean change from baseline to week 66 was lower (better) with eplontersen vs placebo for mNIS+7 composite score (0.3 vs 25.1; difference, -24.8 [95% CI, -31.0 to -18.6; P < .001) and for Norfolk QoL-DN (-5.5 vs 14.2; difference, -19.7 [95% CI, -25.6 to -13.8]; P < .001). Adverse events by week 66 that led to study drug discontinuation occurred in 6 patients (4%) in the eplontersen group vs 2 (3%) in the placebo group. Through week 66, there were 2 deaths in the eplontersen group consistent with known disease-related sequelae (cardiac arrhythmia; intracerebral hemorrhage); there were no deaths in the placebo group. Conclusions and Relevance In patients with ATTRv polyneuropathy, the eplontersen treatment group demonstrated changes consistent with significantly lowered serum transthyretin concentration, less neuropathy impairment, and better quality of life compared with a historical placebo. Trial Registration ClinicalTrials.gov Identifier: NCT04136184; EU Clinical Trials Register: EudraCT 2019-001698-10.
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Affiliation(s)
- Teresa Coelho
- Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Wilson Marques
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, Brazil
| | | | | | - Yeşim Parman
- İstanbul Üniversitesi–Istanbul Tıp Fakültesi, Istanbul, Turkey
| | | | | | - Jonas Wixner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Long-Sun Ro
- Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | | | - Pedro A. Kowacs
- Instituto de Neurologia de Curitiba, Curitiba, Paraná, Brazil
| | - John L. Berk
- Boston University School of Medicine, Boston, Massachusetts
| | - Laura Obici
- Amyloidosis Research and Treatment Centre, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | | | - Markus Weiler
- Amyloidosis Center and Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Isabel Conceição
- Centro Hospitalar Universitário Lisboa-Norte, Hospital de Santa Maria, Lisbon, Portugal
| | | | | | | | - Jersey Chen
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland
| | | | | | | | - Ahmad Masri
- OHSU Center for Hypertrophic Cardiomyopathy and Amyloidosis, Portland, Oregon
| | | | - Yukio Ando
- Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Julian D. Gillmore
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Sami Khella
- University of Pennsylvania School of Medicine, Philadelphia
| | | | - Márcia Waddington Cruz
- Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Jin PH. Localization and Diagnostic Evaluation of Peripheral Nerve Disorders. Continuum (Minneap Minn) 2023; 29:1312-1326. [PMID: 37851032 DOI: 10.1212/con.0000000000001333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE This article provides a framework for the initial evaluation of patients with suspected peripheral nerve disease. The key clinical elements of peripheral nerve diseases can help the practicing neurologist differentiate among peripheral neuropathies with similar presentations. LATEST DEVELOPMENTS The wide range of peripheral nerve diseases with similar clinical presentations can pose a diagnostic challenge. The large array of available testing modalities (including imaging and electrodiagnostic, autonomic, laboratory, biopsy, and genetic testing) further complicates clinical decision making. Recent developments (eg, discovery of new autoantibodies, genetic variations, and histopathologic techniques) across the peripheral neuropathy spectrum have resulted in an increased need to evaluate patients logically and with a tailored diagnostic approach. ESSENTIAL POINTS A careful approach that focuses on key clinical elements combined with an understanding of purposeful diagnostic testing can lead to a successful diagnosis of peripheral nerve diseases.
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9
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Plantone D, Primiano G, Righi D, Romano A, Luigetti M, De Stefano N. Current Evidence Supporting the Role of Immune Response in ATTRv Amyloidosis. Cells 2023; 12:2383. [PMID: 37830598 PMCID: PMC10572348 DOI: 10.3390/cells12192383] [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: 08/16/2023] [Revised: 09/23/2023] [Accepted: 09/27/2023] [Indexed: 10/14/2023] Open
Abstract
Hereditary transthyretin (ATTRv) amyloidosis with polyneuropathy, also known as familial amyloid polyneuropathy (FAP), represents a progressive, heterogeneous, severe, and multisystemic disease caused by pathogenic variants in the TTR gene. This autosomal-dominant neurogenetic disorder has an adult onset with variable penetrance and an inconstant phenotype, even among subjects carrying the same mutation. Historically, ATTRv amyloidosis has been viewed as a non-inflammatory disease, mainly due to the absence of any mononuclear cell infiltration in ex vivo tissues; nevertheless, a role of inflammation in its pathogenesis has been recently highlighted. The immune response may be involved in the development and progression of the disease. Fibrillary TTR species bind to the receptor for advanced glycation end products (RAGE), probably activating the nuclear factor κB (NF-κB) pathway. Moreover, peripheral blood levels of several cytokines, including interferon (IFN)-gamma, IFN-alpha, IL-6, IL-7, and IL-33, are altered in the course of the disease. This review summarizes the current evidence supporting the role of the immune response in ATTRv amyloidosis, from the pathological mechanisms to the possible therapeutic implications.
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Affiliation(s)
- Domenico Plantone
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (D.R.); (N.D.S.)
| | - Guido Primiano
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (A.R.); (M.L.)
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Delia Righi
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (D.R.); (N.D.S.)
| | - Angela Romano
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (A.R.); (M.L.)
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Marco Luigetti
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (A.R.); (M.L.)
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Nicola De Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (D.R.); (N.D.S.)
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10
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Khella SL. Noncardiac Manifestations of Hereditary Amyloidosis. Am J Cardiol 2022; 185 Suppl 1:S17-S22. [PMID: 36369035 DOI: 10.1016/j.amjcard.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/19/2022] [Accepted: 10/03/2022] [Indexed: 11/11/2022]
Abstract
The most common forms of cardiac amyloidosis are progressive, life threatening, and underrecognized. Symptoms affect a variety of organs and overlap with those of more common conditions, complicating and postponing diagnosis. Cardiac disease generally determines mortality, but noncardiac manifestations typically surface before cardiac symptoms, often several years before diagnosis. Familiarity with noncardiac manifestations may lead to early diagnosis, enabling treatment and improving prognosis.
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Affiliation(s)
- Sami L Khella
- Department of Neurology, Penn Presbyterian Medical Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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11
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Samuelsson K, Jovanovic A, Egervall K, Anan I, Wixner J, Press R. Hereditary transthyretin amyloidosis in Sweden: Comparisons between a non-endemic and an endemic region. Amyloid 2022; 29:220-227. [PMID: 35438016 DOI: 10.1080/13506129.2022.2065191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Hereditary transthyretin amyloidosis (ATTRv) is endemic in northern Sweden (Västerbotten). The awareness of ATTRv amyloidosis is lower in Stockholm, a non-endemic region in Sweden. The aim of this study was to compare the possible differences in diagnostic delay, disease phenotypes, treatment and survival between a non-endemic and an endemic region in Sweden. METHODS The in- and outpatient diagnosis registry at the Department of Neurology at Karolinska University Hospital and the Amyloidosis Centre at University Hospital of Umeå were used to identify patients between January 2006 and November 2017. RESULTS In total, 21 patients in Stockholm and 134 patients in Västerbotten were included. The time between symptom onset to time-point of diagnosis was significantly longer in Stockholm vs Västerbotten. This corresponded to a longer median time between first visit at amyloidosis centre to time-point of diagnosis in Stockholm vs in Västerbotten. The most common reason for a diagnostic delay was negative tissue biopsies. CONCLUSION There was a diagnostic-, but no patient-delay in non-endemic Stockholm vs endemic Västerbotten. Despite a more severe neuropathic phenotype in Stockholm at the onset, the systemic affection over the course of disease and of survival seems not to be influenced by the diagnosis delay in Stockholm.
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Affiliation(s)
- Kristin Samuelsson
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ana Jovanovic
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Karl Egervall
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Intissar Anan
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Jonas Wixner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Rayomand Press
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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12
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Amiloidosis cardiaca y cierre de aurícula izquierda. Estudio CAMYLAAC. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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13
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Amat-Santos IJ, Delgado-Arana JR, Cruz-González I, Gutiérrez H, García-Bolao I, Millán X, Tirado-Conte G, Ruiz-Nodar JM, Mohandes M, Palazuelos J, Torres Saura F, Del Valle R, Valero Picher E, Núñez García JC, Gómez I, Albarrán Rincón R, Arzamendi D, Nombela-Franco L, Korniiko L, Barrero A, Santos-Martínez S, Serrador A, San Román JA. Cardiac amyloidosis and left atrial appendage closure. The CAMYLAAC Study. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022:S1885-5857(22)00208-0. [PMID: 35934294 DOI: 10.1016/j.rec.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 07/27/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION AND OBJECTIVES Transthyretin cardiac amyloidosis (ATTR-CA) patients often have atrial fibrillation and increased bleeding/thrombogenic risks. We aimed to evaluate outcomes of left atrial appendage closure (LAAC) compared with patients without a known diagnosis of CA. METHODS Comparison at long-term of patients diagnosed with ATTR-CA who underwent LAAC between 2009 and 2020 and those without a known diagnosis of CA. RESULTS We studied a total of 1159 patients. Forty patients (3.5%) were diagnosed with ATTR-CA; these patients were older and had more comorbidities, higher HAS-BLED and CHA2DS2-VASc scores, and lower left ventricular function. Successful LAAC was achieved in 1137 patients (98.1%) with no differences between groups. Regarding in-hospital and follow-up complications, there were no differences between the groups in ischemic stroke (5% vs 2.5% in those without a known diagnosis of CA; P=.283), hemorrhagic stroke (2.5% and 0.8% in the control group; P=.284), major or minor bleeding. At the 2-year follow-up, there were no significant differences in mortality (ATTR-CA: 20% vs those without known CA: 13.6%, 0.248); however, the at 5-year follow-up, ATTR-CA patients had higher mortality (40% vs 19.2%; P <.001) but this difference was unrelated to hemorrhagic complications or ischemic stroke. CONCLUSIONS LAAC could reduce the risk of bleeding complications and ischemic cerebrovascular events without increasing the rate of early or mid-term complications. Although long-term survival was impaired in ATTR-CA patients, it was comparable to that of patients without a known diagnosis of CA at the 2-year follow-up, suggesting that LAAC for patients with ATTR-CA might not be futile.
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Affiliation(s)
- Ignacio J Amat-Santos
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.
| | - José R Delgado-Arana
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Ignacio Cruz-González
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Complejo Asistencial Universitario de Salamanca, Spain
| | - Hipólito Gutiérrez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Ignacio García-Bolao
- Servicio de Cardiología, Clínica Universitaria de Navarra, Pamplona, Navarra, Spain
| | - Xavier Millán
- Servicio de Cardiología, Hospital Universitario Sant Pau, Barcelona, Spain
| | | | - Juan Miguel Ruiz-Nodar
- Servicio de Cardiología, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Mohsen Mohandes
- Servicio de Cardiología, Hospital Universitario Joan XXIII, Tarragona, Spain
| | - Jorge Palazuelos
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain; Servicio de Cardiología, Hospital La luz, Madrid, Spain
| | | | - Raquel Del Valle
- Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Ernesto Valero Picher
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | - Itziar Gómez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Dabit Arzamendi
- Servicio de Cardiología, Hospital Universitario Sant Pau, Barcelona, Spain
| | | | - Liza Korniiko
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Alejandro Barrero
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Sandra Santos-Martínez
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Ana Serrador
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - J Alberto San Román
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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Antonopoulos AS, Panagiotopoulos I, Kouroutzoglou A, Koutsis G, Toskas P, Lazaros G, Toutouzas K, Tousoulis D, Tsioufis K, Vlachopoulos C. Prevalence and Clinical Outcomes of Transthyretin Amyloidosis: A Systematic Review and Meta-analysis. Eur J Heart Fail 2022; 24:1677-1696. [PMID: 35730461 DOI: 10.1002/ejhf.2589] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 06/10/2022] [Accepted: 06/18/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Systematic evidence on the prevalence and clinical outcome of transthyretin amyloidosis (ATTR) is missing. We explored: a) the prevalence of cardiac amyloidosis in various patient subgroups, b) survival estimates for ATTR subtypes and c) the effects of novel therapeutics on the natural course of disease. METHODS A systematic review of literature published in Medline before 31/12/2021 was performed for the prevalence of cardiac amyloidosis & all-cause mortality of ATTR patients. Extracted data included sample size, age, sex, and all-cause mortality at 1, 2 and 5-years. Subgroup analyses were performed for ATTR subtype i.e., wild type ATTR (wtATTR) vs. hereditary ATTR (htATTR), htATTR genotypes and treatment subgroups. RESULTS We identified a total of 62 studies (n=277,882 individuals) reporting the prevalence of cardiac amyloidosis, which was high among patients with a hypertrophic cardiomyopathy phenotype, HFpEF, and elderly with aortic stenosis. Data on ATTR mortality were extracted from 95 studies (n=18,238 ATTR patients). Patients with wtATTR were older (p=7x10-10 ) and more frequently male (p=5x10-20 ) vs. htATTR. The 2-year survival of ATTR was 73.3% (95%CI 71.6-76.2); for non-subtyped ATTR 70.4% (95%CI 66.9-73.9), for wtATTR (76.0%, 95%CI: 73.0-78.9) and for htATTR (77.2%, 95%CI: 74.0-80.4); in meta-regression analysis wtATTR was associated with higher survival after adjusting for confounders. There was an interaction between survival and htATTR genotypes (p=10-15 , Val30Met having the lowest and Val122Ile/Thr60Ala the highest mortality). ATTR 2-year survival was higher on tafamidis/patisiran compared to natural disease course (79.9%, 95%CI: 74.4-85.3 vs. 72.4%, 95%CI 69.8-74.9, p<0.05). CONCLUSIONS We report the prevalence of ATTR in various population subgroups and provide survival estimates for the natural course of disease and the effects of novel therapeutics. Important gaps in worldwide epidemiology research in ATTR were identified. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Alexios S Antonopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Ioannis Panagiotopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Alexandrina Kouroutzoglou
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Georgios Koutsis
- Neurogenetics Unit, 1st Department of Neurology, National and Kapodistrian University of Athens, Eginition University Hospital, Athens, Greece
| | - Pantelis Toskas
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Georgios Lazaros
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Charalambos Vlachopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
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15
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Cardiac amyloidosis-interdisciplinary approach to diagnosis and therapy. Herz 2022; 47:324-331. [PMID: 35674775 DOI: 10.1007/s00059-022-05122-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2022] [Indexed: 11/04/2022]
Abstract
The vast majority of cardiac amyloidosis (CA) cases are caused by light chain (AL) or transthyretin (ATTR) amyloidosis. The latter is divided into hereditary (ATTRv) and wild-type forms (ATTRwt). The incidence of ATTRwt amyloidosis has significantly increased, particularly due to the improved diagnosis of cardiac manifestations, with relevant proportions in patient populations with heart failure (HF) and preserved ejection fraction (HFpEF). Cardiac amyloidosis should be suspected in HF with indicative clinical scenarios/"red flags" with typical signs of CA in echocardiography. Further noninvasive imaging (cardiovascular magnetic resonance imaging, scintigraphy) and specific laboratory diagnostics are important for the diagnosis and typing of CA into the underlying main forms of ATTR and AL amyloidosis. The histopathologic analysis of an endomyocardial biopsy is necessary if noninvasive diagnostic methods do not enable reliable typing of CA. This is crucial for initiating specific therapy. Therapy of HF in CA is largely limited to the use of diuretics in the absence of evidence on the benefit of classic HF therapy with neurohormonal modulators. Innovative therapies have been developed for amyloidosis with improvement in organ protection, prognosis, and quality of life. These include specific cytoreductive therapies for monoclonal light-chain disease in AL amyloidosis and pharmacologic stabilization or inhibition of transthyretin expression in ATTR amyloidosis. Since the CA underlying amyloidosis is a systemic disease also affecting other organ systems, close interdisciplinary cooperation is crucial for rapid and effective diagnosis and therapy.
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Ostojic M, Gill SS, Avila JD, Carry BJ. A Rare Case of I127V Heterozygous Transthyretin Amyloidosis With Atypical Transthoracic Echocardiogram Findings Presenting As Upper Extremity Sensorimotor Polyneuropathy. Cureus 2022; 14:e25259. [PMID: 35637921 PMCID: PMC9128760 DOI: 10.7759/cureus.25259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 11/15/2022] Open
Abstract
Hereditary transthyretin amyloidosis (hATTR) is a class of disorders with various systemic clinical manifestations, most often cardiac and neurologic in origin. The I127V mutation is a known but uncommon type of hATTR that typically affects males in their sixth or seventh decade of life. We present a case of this rare genetic variant with an atypical presentation of upper, followed by lower extremity sensorimotor polyneuropathy, with an uncharacteristic transthoracic echocardiogram (TTE) pattern but strongly positive pyrophosphate (PYP) scan, confirming the amyloidosis (AL) diagnosis.
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Affiliation(s)
- Maja Ostojic
- Internal Medicine, Geisinger Medical Center, Danville, USA
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Schilling M. [Gene therapy options for hereditary transthyretin-related amyloidosis]. DER NERVENARZT 2022; 93:557-565. [PMID: 35419654 DOI: 10.1007/s00115-022-01288-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
Abstract
Hereditary transthyretin-related amyloidosis (ATTRv) is a rare autosomal dominant disease and is fatal if left untreated. It is caused by mutations in the transthyretin gene. All known mutations induce misfolding of the tetrameric transthyretin molecule and protein deposits in multiple organs. In peripheral nerves this result in sensorimotor and autonomic polyneuropathy and in cardiac muscle it causes cardiomyopathy. Untreated ATTRv is characterized by an irreversible and progressive course and death 7-11 years after symptom onset. Treatment options consist of TTR stabilizing drugs, such as tafamidis and active agents that selectively interfere at the mRNA level, the so-called gene silencers patisiran and inotersen. All forms of treatment aim to prevent amyloid tissue deposition in tissues and organ dysfunction. Patisiran works by RNA interference on endogenous mechanisms of gene expression. It results in the cleavage of TTR-mRNA using the cytoplasmatic RNA-induced silencing complex. Inotersen, an antisense oligonucleotide, degrades TTR-mRNA via activation of nuclear RNase H. Both mechanisms result in a significant reduction of TTR protein serum levels. The efficacy could be demonstrated by slowing or improving neuropathy progression in the phase III study APOLLO (patisiran) or the NEURO-TTR study (inotersen). Furthermore, the use of both agents led to an improvement in the quality of life in patients with ATTRv. Both forms of treatment are approved in Germany since August 2018 for polyneuropathy stages 1 and 2 according to Coutinho. The choice of treatment should be carried out individually considering drug formulation, contraindications and the necessary safety monitoring controls.
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Affiliation(s)
- Matthias Schilling
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland.
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