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Begum F, Nahid KL, Jesmin T, Mazumder MW, Rukunuzzaman M. Could Urinary Copper/Zinc Ratio Be a Newer Tool to Replace 24-Hour Urinary Copper Excretion for Diagnosing Wilson Disease in Children? Pediatr Gastroenterol Hepatol Nutr 2024; 27:53-61. [PMID: 38249640 PMCID: PMC10796261 DOI: 10.5223/pghn.2024.27.1.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/06/2023] [Accepted: 10/25/2023] [Indexed: 01/23/2024] Open
Abstract
Purpose Although the 24-hours urinary copper excretion is useful for the diagnosis of Wilson disease (WD), there are practical difficulties in the accurate and timed collection of urine samples. The purpose of this study was to verify if the spot morning urinary Copper/ Zinc (Cu/Zn) ratio could be used as a replacement parameter of 24-hours urinary copper excretion in the diagnosis of WD. Methods A cross-sectional study was conducted at the Department of Pediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, from June 2019 to May 2021 on 67 children over three years of age who presented with liver disease. Twenty-seven children who fulfilled the inclusion criteria for WD were categorized into the test group, and the remaining forty children were considered to have non-Wilsonian liver disease and were categorized into the control group. Along with other laboratory investigations, spot morning urinary samples were estimated for the urinary Cu/Zn ratio in all patients and were compared to the 24-hour urinary copper excretion. The diagnostic value of the Cu/Zn ratio was then analyzed. Results Correlation of spot morning urinary Cu/Zn ratio with 24-hours urinary copper excretion was found to be significant (r=0.60). The area under ROC curve with 95% confidence interval of morning urinary Cu/Zn ratio measured using 24-hours urine sample was 0.84 (standard error, 0.05; p<0.001). Conclusion Spot morning urinary Cu/Zn ratio seems to be a promising parameter for the replacement of 24-hours urinary copper excretion in the diagnosis of WD.
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Affiliation(s)
- Fahmida Begum
- Department of Paediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
| | - Khan Lamia Nahid
- Department of Paediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
| | - Tahmina Jesmin
- Department of Paediatric Nephrology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
| | - Md. Wahiduzzaman Mazumder
- Department of Paediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
| | - Md. Rukunuzzaman
- Department of Paediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
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Roy S, Ghosh S, Ray J, Ray K, Sengupta M. Missing heritability of Wilson disease: a search for the uncharacterized mutations. Mamm Genome 2023; 34:1-11. [PMID: 36462057 DOI: 10.1007/s00335-022-09971-y] [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: 11/06/2022] [Accepted: 11/24/2022] [Indexed: 12/05/2022]
Abstract
Wilson disease (WD), a copper metabolism disorder caused by mutations in ATP7B, manifests heterogeneous clinical features. Interestingly, in a fraction of clinically diagnosed WD patients, mutations in ATP7B appears to be missing. In this review we discuss the plausible explanations of this missing heritability and propose a workflow that can identify the hidden mutations. Mutation analyses of WD generally includes targeted sequencing of ATP7B exons, exon-intron boundaries, and rarely, the proximal promoter region. We propose that variants in the distal cis-regulatory elements and/or deep intronic variants that impact splicing might well represent the hidden mutations. Heterozygous del/ins that remain refractory to conventional PCR-sequencing method may also represent such mutations. In this review, we also hypothesize that mutations in the key copper metabolism genes, like, ATOX1, COMMD1, and SLC31A1, could possibly lead to a WD-like phenotype. In fact, WD does present overlapping symptoms with other rare genetic disorders; hence, the possibility of a misdiagnosis and thus adding to missing heritability cannot be excluded. In this regard, it seems that whole-genome analysis will provide a comprehensive and rapid molecular diagnosis of WD. However, considering the associated cost for such a strategy, we propose an alternative customized screening schema of WD which include targeted sequencing of ATP7B locus as well as other key copper metabolism genes. Success of such a schema has been tested in a pilot study.
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Affiliation(s)
- Shubhrajit Roy
- S. N. Pradhan Centre for Neurosciences, University of Calcutta, Kolkata, India
- Post-doctoral Fellow, Physiology Department, Johns Hopkins University, Baltimore, USA
| | - Sampurna Ghosh
- Department of Genetics, University of Calcutta, 35 Ballygunge Circular Road, Kolkata, 700019, India
- Department of Biochemistry, Microbiology and Immunology, University of Saskatchewan, Saskatoon, Canada
| | - Jharna Ray
- S. N. Pradhan Centre for Neurosciences, University of Calcutta, Kolkata, India
| | - Kunal Ray
- Ramakrishna Mission Vivekananda Educational and Research Institute, Narendrapur, Kolkata, 700 103, India.
| | - Mainak Sengupta
- Department of Genetics, University of Calcutta, 35 Ballygunge Circular Road, Kolkata, 700019, India.
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3
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Muacevic A, Adler JR. Wilson's Disease Manifestation in Late Adulthood: A Case Report and Literature Review. Cureus 2022; 14:e29797. [PMID: 36340556 PMCID: PMC9618403 DOI: 10.7759/cureus.29797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2022] [Indexed: 11/07/2022] Open
Abstract
Wilson's disease is a rare inherited condition that results in an excessive copper buildup in various organs, especially the liver, brain, and other vital organs, leading to cirrhosis, liver failure, neurological problems like involuntary movements, clumsy gait, speech difficulties, and psychological issues, in addition to other symptoms. It is an ATP7B gene mutation-driven autosomal recessive condition. Although the condition is present from birth, symptoms often start to show up between the ages of five and 35, when the body has accumulated enough copper. Wilson's disease may become fatal if an excessive amount of copper is accumulated in the body. It is treatable and has a good prognosis if diagnosed early. Early identification, however, is not always straightforward since symptoms might resemble those of other diseases and develop later in life when copper is absorbed by food and drink and gradually accumulates in the body's many organs. In addition to medicine, physicians advise people with Wilson's disease to avoid foods and beverages containing copper. Our patient was diagnosed with Wilson’s disease at the age of 16 and was on Cuprimine which helped her to survive. Her younger sister was diagnosed at an early age and was started on a treatment regimen, which is why her sister’s manifestation of Wilson’s disease was less severe than hers.
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Liposome-encapsulated curcumin attenuates HMGB1-mediated hepatic inflammation and fibrosis in a murine model of Wilson's disease. Biomed Pharmacother 2022; 152:113197. [PMID: 35687913 DOI: 10.1016/j.biopha.2022.113197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/21/2022] [Accepted: 05/23/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND AIMS Wilson's disease (WD) is an inherited disorder of copper metabolism with predominant hepatic manifestations. Left untreated, it can be fatal. Current therapies focus on treating copper overload rather than targeting the pathophysiology of copper-induced liver injuries. We sought to investigate whether liposome-encapsulated curcumin (LEC) could attenuate the underlying pathophysiology of WD in a mouse model of WD. APPROACH AND RESULTS Subcutaneous administration in a WD mouse model with ATP7B knockout (Atp7b-/-) resulted in robust delivery of LEC to the liver as determined by in-vitro and in-vivo imaging. Treatment with LEC attenuated hepatic injuries, restored lipid metabolism and decreased hepatic inflammation and fibrosis, and thus hepatosplenomegaly in Atp7b-/- mice. Mechanistically, LEC decreased hepatic immune cell and macrophage infiltration and attenuated the hepatic up-regulation of p65 by preventing cellular translocation of high-mobility group box-1 (HMGB-1). Moreover, decreased translocation of HMGB1 was associated with reduced splenic CD11b+/CD43+/Ly6CHi inflammatory monocyte expansion and circulating level of proinflammatory cytokines. Nevertheless there was no change in expression of oxidative stress-related genes or significant copper chelation effect of LEC in Atp7b-/- mice. CONCLUSION Our results indicate that treatment with subcutaneous LEC can attenuate copper-induced liver injury in an animal model of WD via suppression of HMGB1-mediated hepatic and systemic inflammation. These findings provide important proof-of-principle data to develop LEC as a novel therapy for WD as well as other inflammatory liver diseases.
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Salman HM, Amin M, Syed J, Sarfraz Z, Sarfraz A, Sarfraz M, Farfán Bajaña MJ, Felix M, Cherrez-Ojeda I. Biochemical testing for the diagnosis of Wilson's disease: A systematic review. J Clin Lab Anal 2021; 36:e24191. [PMID: 34951059 PMCID: PMC8842170 DOI: 10.1002/jcla.24191] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/08/2021] [Accepted: 12/08/2021] [Indexed: 11/28/2022] Open
Abstract
Background Wilson's disease (WD) is a rare inherited disorder that leads to copper accumulation in the liver, brain, and other organs. WD is prevalent worldwide, with an occurrence of 1 per 30,000 live births. Currently, there is no gold standard diagnostic test for WD. The objective of this systematic review is to determine the diagnostic accuracy for WD of three biochemical tests, namely hepatic copper, 24‐hour urinary copper, and ceruloplasmin using the Leipzig criteria. Methods Adhering to PRISMA guidelines, databases including PubMed/MEDLINE, CINAHL Plus, Web of Science, and Cochrane were searched. Studies that comprised of confirmed or suspected WD along with normal populations were included with adult and pediatric group. The sensitivity, specificity, negative predictive value and positive predictive value were computed using RevMan 5.4. Results Nine studies were included. The best practice evidence for 24‐hour urinary copper test ranged from a cutoff value of 0.64–1.6 μmol/24 h (N = 268; sensitivity = 75.6%, specificity = 98.3%). Hepatic copper test was optimally cutoff based on the ROC curve analysis at 1.2 μmol/g yielding a power of 96.4% sensitivity and 95.4% specificity (N = 1,150); however, the tried and tested 4 μmol/g cutoff, with 99.4% sensitivity and 96.1% specificity, is more widely accepted. The ceruloplasmin test cutoff value was found to be ranging from 0.14 to 0.2 g/L (N = 4,281; sensitivity = 77.1%–99%, specificity = 55.9%–82.8%). Conclusion This paper provides a large‐scale analysis of current evidence pertaining to the biochemical diagnosis of WD employing the Leipzig criteria. The laboratory values are typically based on specific subgroups based on age, ethnicity, and clinical subgroups. The findings of this systematic review must be used with caution, given the over‐ or under‐estimation of the index tests.
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Affiliation(s)
| | - Mahwish Amin
- Sir Ganga Ram Hospital, Lahore, Punjab, Pakistan
| | | | | | | | | | - Maria Jose Farfán Bajaña
- Universidad Espíritu Santo, Samborondón, Ecuador.,Respiralab, Respiralab Research Group, Guayaquil, Ecuador
| | - Miguel Felix
- Universidad Espíritu Santo, Samborondón, Ecuador.,Respiralab, Respiralab Research Group, Guayaquil, Ecuador
| | - Ivan Cherrez-Ojeda
- Universidad Espíritu Santo, Samborondón, Ecuador.,Respiralab, Respiralab Research Group, Guayaquil, Ecuador
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6
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Zhi Y, Sun Y, Jiao Y, Pan C, Wu Z, Liu C, Su J, Zhou J, Shang D, Niu J, Hua R, Yin P. HR-MS Based Untargeted Lipidomics Reveals Characteristic Lipid Signatures of Wilson's Disease. Front Pharmacol 2021; 12:754185. [PMID: 34880754 PMCID: PMC8645799 DOI: 10.3389/fphar.2021.754185] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 11/02/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: The diagnosis of Wilson's disease (WD) is challenging by clinical or genetic criteria. A typical early pathological change of WD is the increased liver lipid deposition and lowered serum triglyceride (TG). Therefore, the contents of serum lipids may provide evidence for screening of biomarkers for WD. Methods: 34 WD patients, 31 WD relatives, and 65 normal controls were enrolled in this study. Serum lipidomics data was acquired by an ultra-high-performance liquid chromatography high-resolution mass spectrometry system, and the data were analyzed by multivariate statistical methods. Results: Of all 510 identified lipids, there are 297 differential lipids between the WD and controls, 378 differential lipids between the relatives and controls, and 119 differential lipids between the patients and relatives. In WD, the abundances of most saturated TG were increased, whereas other unsaturated lipids decreased, including phosphatidylcholine (PC), sphingomyelin (SM), lysophosphatidylcholine (LPC), ceramide (Cer), and phosphatidylserine (PS). We also found many serum lipid species may be used as biomarkers for WD. The areas under the receiver operating characteristic curve (AUC) of PS (35:0), PS (38:5), and PS (34:0) were 0.919, 0.843, and 0.907. The AUCs of TG (38:0) and CerG1 (d42:2) were 0.948 and 0.915 and the AUCs of LPC (17:0) and LPC (15:0) were 0.980 and 0.960, respectively. The lipid biomarker panel exhibits good diagnostic performance for WD. The correlation networks were built among the different groups and the potential mechanisms of differential lipids were discussed. Interestingly, similar lipid profile of WD is also found in their relatives, which indicated the changes may also related to the mutation of the ATP7B gene. Conclusions: Lipid deregulation is another important hallmark of WD besides the deposition of copper. Our lipidomic results provide new insights into the diagnostic and therapeutic targets of WD.
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Affiliation(s)
- Yixiao Zhi
- Clinical Laboratory of Integrative Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, China.,Department of Hepatology, The First Hospital of Jilin University, Changchun, China
| | - Yujiao Sun
- Clinical Laboratory of Integrative Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, China.,Institute of Integrative Medicine, Dalian Medical University, Dalian, China
| | - Yonggeng Jiao
- Department of Anesthesiology Jilin Province FAW General Hospital, Changchun, China
| | - Chen Pan
- Clinical Laboratory of Integrative Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, China.,Department of General Surgery, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zeming Wu
- iPhenome biotechnology Inc. Dalian (Yun Pu Kang), Dalian, China
| | - Chang Liu
- Clinical Laboratory of Integrative Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, China.,Institute of Integrative Medicine, Dalian Medical University, Dalian, China
| | - Jie Su
- Department of Hepatology, The First Hospital of Jilin University, Changchun, China
| | - Jie Zhou
- Department of Hepatology, The First Hospital of Jilin University, Changchun, China
| | - Dong Shang
- Clinical Laboratory of Integrative Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, China.,Department of Hepatology, The First Hospital of Jilin University, Changchun, China.,Department of General Surgery, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Junqi Niu
- Department of Hepatology, The First Hospital of Jilin University, Changchun, China
| | - Rui Hua
- Department of Hepatology, The First Hospital of Jilin University, Changchun, China
| | - Peiyuan Yin
- Clinical Laboratory of Integrative Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, China.,Institute of Integrative Medicine, Dalian Medical University, Dalian, China
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7
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Reeve JLV, Twomey PJ, Borovickova I. Environmental causes of copper toxicity should not be forgotten in familial presentations. J Clin Pathol 2021; 74:691. [PMID: 34321224 DOI: 10.1136/jclinpath-2020-207362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 06/08/2021] [Indexed: 11/04/2022]
Affiliation(s)
| | - Patrick J Twomey
- Clinical Chemistry, St Vincent's University Hospital, Dublin, Ireland .,University College Dublin School of Medicine, Dublin, Ireland
| | - Ingrid Borovickova
- Department of Paediatric Laboratory Medicine, Children's Health Ireland at Temple Street, Dublin, Ireland
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8
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Wijayasiri P, Hayre J, Nicholson ES, Kaye P, Wilkes EA, Evans J, Aithal GP, Jones G, Pearce F, Aravinthan AD. Estimating the clinical prevalence of Wilson's disease in the UK. JHEP Rep 2021; 3:100329. [PMID: 34381985 PMCID: PMC8335649 DOI: 10.1016/j.jhepr.2021.100329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/20/2021] [Accepted: 06/28/2021] [Indexed: 11/22/2022] Open
Abstract
Background & Aims The clinical prevalence of Wilson’s disease (WD) in the UK remains unknown. The estimated genetic prevalence in the UK, 142/million, is higher than the clinical prevalence (15/million) reported in other European studies. The aim of this study was to estimate the clinical prevalence of WD utilising readily available laboratory and clinical data. Method Patients with WD who attended Nottingham University Hospital NHS Trust (NUH) between 2011 and 2018 were identified using multiple sources of case ascertainment: serum ceruloplasmin, 24-hour urinary copper, ‘Wilson’ in liver biopsy report, hospital prescription for penicillamine/trientine/zinc and admission coded with ICD-10 Code E83.0 (disorder of copper metabolism). Potential cases were identified using the Leipzig score, diagnosis was confirmed in hospital records and the point prevalence was calculated using the Office for National Statistics mid-2017 population estimates. Results A total of 1,794 patients were identified from ≥1 source; 19 patients had WD, of whom 11 were from within the study catchment area and alive at the time of point prevalence estimation. Twenty-nine patients had a Leipzig score ≥2 without a diagnosis of WD, but none had WD on screening (n = 16). The overall prevalence of WD was 15.5/million; males 16.9/million and females 14.1/million. Conclusion This is the first UK population-based study to assess the clinical prevalence of WD. The reported clinical prevalence is lower than the UK genetic prevalence, but comparable to the clinical prevalence reported in Europe. The case ascertainment approach used in this study may be cost-effective, and similar practises could be adopted nationally. Lay summary Our study estimates the clinical prevalence of Wilson’s disease, a rare genetic disorder of copper metabolism, in the UK. The estimated clinical prevalence is this study is markedly lower than the estimated UK genetic prevalence. The clinical prevalence of Wilson’s disease in the UK is estimated to be 15.5/million (1/64,516). The clinical prevalence is significantly lower than the previously reported genetic prevalence. Routine clinical and laboratory data can be used to not only find existing cases, but also evaluate potential cases. Case ascertainment is potentially a cost-effective approach for Wilson’s disease and other rare diseases.
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Affiliation(s)
- Pramudi Wijayasiri
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, UK.,Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, UK
| | - Jatinder Hayre
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, UK
| | | | - Philip Kaye
- Department of Pathology, Nottingham University Hospitals NHS Trust, UK
| | - Emilie A Wilkes
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, UK
| | - Jonathan Evans
- Department of Neurology, Nottingham University Hospitals NHS Trust, UK
| | - Guruprasad P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, UK.,Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, UK
| | - Gabriela Jones
- Department of Clinical Genetics, Nottingham University Hospitals NHS Trust, UK
| | - Fiona Pearce
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, UK.,Population and Lifespan Sciences, School of Medicine, University of Nottingham, UK
| | - Aloysious D Aravinthan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, UK.,Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, UK
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9
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Collins JF. Copper nutrition and biochemistry and human (patho)physiology. ADVANCES IN FOOD AND NUTRITION RESEARCH 2021; 96:311-364. [PMID: 34112357 DOI: 10.1016/bs.afnr.2021.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The essential trace mineral copper plays important roles in human physiology and pathophysiology. Disruption of copper homeostasis may underlie the development of ischemic heart disease, and connective tissue and neurodegenerative disorders. Copper also likely participates in the host response to bacterial infection and is further implicated more broadly in regulating immunity. Recent studies further associate copper with disruption of lipid homeostasis, as is frequently seen in, for example, non-alcoholic fatty liver disease (NAFLD). Moreover, continuing investigation of copper chaperones has revealed new roles for these intracellular copper-binding proteins. Despite these (and many other) significant advances, many questions related to copper biology remain unanswered. For example, what are the most sensitive and specific biomarkers of copper status, and which ones are useful in marginal (or "sub-clinical" copper deficiency)? Further research on this topic is required to inform future investigations of copper metabolism in humans (so the copper status of study participants can be fully appreciated). Also, are current recommendations for copper intake adequate? Recent studies suggest that overt copper deficiency is more common than once thought, and further, some have suggested that the copper RDAs for adults may be too low. Additional human balance and interventional studies are necessary and could provide the impetus for reconsidering the copper RDAs in the future. These and myriad other unresolved aspects of copper nutrition will undoubtedly be the focus of future investigation.
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Affiliation(s)
- James F Collins
- Food Science and Human Nutrition Department, University of Florida, Gainesville, FL, United States.
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10
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Przybyłkowski A, Szeligowska J, Januszewicz M, Raszeja-Wyszomirska J, Szczepankiewicz B, Nehring P, Górnicka B, Litwin T, Członkowska A. Evaluation of liver fibrosis in patients with Wilson's disease. Eur J Gastroenterol Hepatol 2021; 33:535-540. [PMID: 32433421 PMCID: PMC8565503 DOI: 10.1097/meg.0000000000001754] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/06/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Staging of fibrosis in chronic liver disease is important for prognosis and treatment planning. Liver biopsy is the gold standard in fibrosis assessment; however, new methods for fibrosis and stiffness measurement exist which have not been evaluated in patients with Wilson's disease. To evaluate the accuracy of collagen proportionate area (CPA), transient elastography and shear wave elastography (SWE) in the assessment of liver fibrosis in adult patients with Wilson's disease. METHODS In this retrospective study of 60 patients with Wilson's disease, results of percutaneous cutting liver biopsy assessed using the Ishak fibrosis score and CPA were compared with liver stiffness measured with transient elastography and SWE. RESULTS CPA correlated with the Ishak score (r = 0.45; P = 0.001) and transient elastography results correlated with SWE measurements (r = 0.80; P = 0.0001). In contrast, transient elastography or SWE did not significantly correlate with the Ishak score or CPA. CONCLUSION Collagen content assessment may be useful for estimation of liver fibrosis in patients with Wilson's disease. However, single time-point elastographic liver stiffness measurements have a limited diagnostic value in Wilson's disease.
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Affiliation(s)
| | | | | | | | | | - Piotr Nehring
- Department of Gastroenterology and Internal Medicine
| | - Barbara Górnicka
- Chair and Department of Pathomorphology, Medical University of Warsaw
| | - Tomasz Litwin
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Anna Członkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
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11
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AlDhaleei W, AlAhmad M, Alhosani I. Wilson's Disease Presenting in Late Adult Life. Case Rep Gastroenterol 2021; 15:142-146. [PMID: 33708062 PMCID: PMC7923729 DOI: 10.1159/000512422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/16/2020] [Indexed: 11/19/2022] Open
Abstract
Wilson's disease (WD) is an autosomal recessive disease affecting the copper metabolism resulting in various clinical presentations. Diagnosis includes the presence of low serum copper and ceruloplasmin concentrations, increased urinary copper excretion, and/or increased hepatic copper concentrations. Yet, genetic testing remains diagnostic. Management includes copper chelating agents and liver transplant in advance cases. We report a case of WD presenting with liver function impairment in late adult life and started on treatment. Therefore, early diagnosis and treatment of WD can prevent related complications.
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Affiliation(s)
- Wafa AlDhaleei
- Gastroenterology Department, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Maryam AlAhmad
- Gastroenterology Department, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Ibrahim Alhosani
- Gastroenterology Department, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
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12
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Effects of Dietary Glucose and Fructose on Copper, Iron, and Zinc Metabolism Parameters in Humans. Nutrients 2020; 12:nu12092581. [PMID: 32854403 PMCID: PMC7551875 DOI: 10.3390/nu12092581] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 08/21/2020] [Accepted: 08/21/2020] [Indexed: 02/07/2023] Open
Abstract
Alterations of transition metal levels have been associated with obesity, hepatic steatosis, and metabolic syndrome in humans. Studies in animals indicate an association between dietary sugars and copper metabolism. Our group has conducted a study in which young adults consumed beverages sweetened with glucose, fructose, high fructose corn syrup (HFCS), or aspartame for two weeks and has reported that consumption of both fructose- and HFCS-sweetened beverages increased cardiovascular disease risk factors. Baseline and intervention serum samples from 107 participants of this study were measured for copper metabolism (copper, ceruloplasmin ferroxidase activity, ceruloplasmin protein), zinc levels, and iron metabolism (iron, ferritin, and transferrin) parameters. Fructose and/or glucose consumption were associated with decreased ceruloplasmin ferroxidase activity and serum copper and zinc concentrations. Ceruloplasmin protein levels did not change in response to intervention. The changes in copper concentrations were correlated with zinc, but not with iron. The decreases in copper, ceruloplasmin ferroxidase activity, ferritin, and transferrin were inversely associated with the increases in metabolic risk factors associated with sugar consumption, specifically, apolipoprotein CIII, triglycerides, or post-meal glucose, insulin, and lactate responses. These findings are the first evidence that consumption of sugar-sweetened beverages can alter clinical parameters of transition metal metabolism in healthy subjects.
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13
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Pearce JMS. Historical note: The Kayser–Fleischer ring. ADVANCES IN CLINICAL NEUROSCIENCE & REHABILITATION 2020. [DOI: 10.47795/xcrj9055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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14
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Oe S, Honma Y, Yabuki K, Morino K, Kumamoto K, Hayashi T, Kusanaga M, Ogino N, Minami S, Shibata M, Abe S, Harada M. Importance of a Liver Biopsy in the Management of Wilson Disease. Intern Med 2020; 59:77-81. [PMID: 31511488 PMCID: PMC6995705 DOI: 10.2169/internalmedicine.3440-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
A 37-year-old Wilson disease patient treated with D-penicillamine visited our hospital for the evaluation of his liver function. Laboratory data showed a low serum copper level and ceruloplasmin. The ratio of urinary copper to urinary creatinine in a spot urinary analysis after 4 days' cessation of D-penicillamine was under 0.1. We concluded that the copper chelation was excessive and changed D-penicillamine to zinc acetate. However, his liver function test results did not normalize. We performed a liver biopsy and discovered a high copper content. The liver dysfunction was improved after resuming chelating therapy. Accurate measurement of the hepatic copper content via a biopsy is important for the adequate management of this disease.
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Affiliation(s)
- Shinji Oe
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Yuichi Honma
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Kei Yabuki
- Department of Pathology and Oncology, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Kahori Morino
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Keiichiro Kumamoto
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
- Department of Pathology and Cell Biology, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Tsuguru Hayashi
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Masashi Kusanaga
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Noriyoshi Ogino
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Sota Minami
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Michihiko Shibata
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Shintaro Abe
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Masaru Harada
- Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
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Liu WL, Li F, Liu L, Chen W, He ZX, Gu H, Ai R. A novel gross deletion and breakpoint junction sequence analysis of ATP7B in a Chinese family with Wilson disease using next‑generation sequencing and Sanger sequencing. Mol Med Rep 2019; 21:517-523. [PMID: 31746411 PMCID: PMC6896306 DOI: 10.3892/mmr.2019.10830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 10/15/2019] [Indexed: 11/15/2022] Open
Abstract
Wilson disease (WD) is a rare autosomal recessive genetic disorder that causes abnormal copper metabolism, resulting in pathological accumulation of copper in the liver, brain and other organs. Mutations in the ATPase copper transporter 7B (ATP7B) gene, which encodes a membrane P-type adenosine triphosphatase, have been identified as being responsible for WD. The present study analyzed clinical data and collected DNA samples from a pediatric patient with WD and her healthy parents. Mutation screening for ATP7B was performed using direct sequencing, multiplex ligation-dependent probe amplification(MLPA), next-generation sequencing (NGS) and Sanger sequencing of the breakpoint junction sequence. The patient (age, 2.7 years) presented with early-onset hepatic disease. The present study identified compound heterozygous mutations of ATP7B, including a heterozygous mutation (p.Arg1,041Trp) and a novel heterozygous gross deletion of a 57,771 bp fragment (chr13: 52490972-52548742) (GRCh37) from partial exon2- exon21 to external ATP7B sequence (15.833bp) in the patient. Analysis of the family members of the patient showed that the missense mutation and the gross deletion mutation were inherited from her mother and father, respectively. Microhomology and inverted repeat sequences, which may mediate the deletion mutation, were identified through sequence analysis on both sides of the breakpoints of this deletion. The present study provided additional information on the genotypic spectrum of the ATP7B gene, particularly with regard to early onset hepatic disease, as observed in the present patient with WD. The identification of the precise breakpoint junction sequence warrants further investigation of DNA break and recombination mechanisms. In detecting precise deletions, the NGS associated with Sanger sequencing of breakpoint junction sequence have been found to have more advantages than MLPA.
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Affiliation(s)
- Wei-Liang Liu
- Department of Pediatrics, Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou 550004, P.R. China
| | - Fang Li
- Department of Ophthalmology, Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou 550004, P.R. China
| | - Lu Liu
- Department of Ophthalmology, Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou 550004, P.R. China
| | - Wei Chen
- Department of Ophthalmology, Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou 550004, P.R. China
| | - Zhi-Xu He
- Department of Pediatrics, Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou 550004, P.R. China
| | - Hao Gu
- Department of Ophthalmology, Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou 550004, P.R. China
| | - Rong Ai
- Department of Pediatrics, Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou 550004, P.R. China
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16
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Porlas RV, de Castillo LLC, Dioquino CPC. Neurologic Wilson disease: case series on a diagnostic and therapeutic emergency. DIALOGUES IN CLINICAL NEUROSCIENCE 2019. [PMID: 30936772 PMCID: PMC6436958 DOI: 10.31887/dcns.2018.20.4/rporlas] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Wilson disease is a rare genetic disease causing pathologic deposition of copper in the liver, brain, cornea, kidney, and cardiac muscles. Presented are two cases of neurologic Wilson disease with progressive movement disorder and Kayser-Fleischer rings with low serum copper, low ceruloplasmin, and increased 24-hour urine copper against a background of normal transaminases. Cranial imaging revealed symmetric basal ganglia hyperintensities in T2/FLAIR. More often than not, these cases go unnoticed and misdiagnosed because of its rarity and varied presentation. Extensive workup is necessary to confirm the diagnosis. As for management, the earlier the intervention is initiated, the better prognosis would be for recovery. There are several treatment options which should be tailored to every patient with neurologic Wilson disease. Neurologic Wilson disease is considered as a copper toxicity; immediate diagnostic evaluation and early treatment initiation is a must.
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Affiliation(s)
- Romeo V Porlas
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines, Manila
| | - Lennie Lynn C de Castillo
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines, Manila
| | - Carissa Paz C Dioquino
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines, Manila; National Poison Management and Control Center, Philippine General Hospital, University of the Philippines, Manila, Philippines
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17
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Wang S, Yu G, Ma Y, Yang Z, Liu Y, Wang J, Chen X. Ratiometric Photoacoustic Nanoprobe for Bioimaging of Cu 2. ACS APPLIED MATERIALS & INTERFACES 2019; 11:1917-1923. [PMID: 30575388 DOI: 10.1021/acsami.8b20113] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Aberrant copper contents implicate numerous diseases including Alzheimer's disease and Wilson's disease. Conventional copper detection technologies are difficult to offer non-invasive and accurate deep tissue detection of copper. Here, we report a photoacoustic (PA) nanoprobe (NRh-IR-NMs) for ratiometric PA imaging of Cu2+. The nanoprobe consists of a selective Cu2+-responsive probe (NRh) as the indicator and a nonresponsive dye (IR) as the internal reference. In the presence of Cu2+, a selective Cu2+-induced structure change of NRh would take place, resulting in the increase of PA signal intensity increment at 716 nm (ΔPA716). However, the ΔPA834 which attributes to IR shows negligible change. Therefore, the ratiometric PA signal (ΔPA716/ΔPA834) could be used as an indicator for Cu2+ detection. This ratiometric PA detection method offers a noninvasive technology with high selectivity and tissue penetration depth, which is a promising tool for deep-tissue detection of Cu2+ in living organisms.
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Affiliation(s)
- Sheng Wang
- Department of Nuclear Medicine, Xijing Hospital , Fourth Military Medical University , Xi'an 710032 , China
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering , National Institutes of Health , Bethesda , Maryland 20892 , United States
| | - Guocan Yu
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering , National Institutes of Health , Bethesda , Maryland 20892 , United States
| | - Ying Ma
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering , National Institutes of Health , Bethesda , Maryland 20892 , United States
| | - Zhen Yang
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering , National Institutes of Health , Bethesda , Maryland 20892 , United States
| | - Yi Liu
- School of Engineering , China Pharmaceutical University , Nanjing 210009 , China
| | - Jing Wang
- Department of Nuclear Medicine, Xijing Hospital , Fourth Military Medical University , Xi'an 710032 , China
| | - Xiaoyuan Chen
- Laboratory of Molecular Imaging and Nanomedicine, National Institute of Biomedical Imaging and Bioengineering , National Institutes of Health , Bethesda , Maryland 20892 , United States
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18
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Shah B, Limbu S. A Case Report of Misdiagnosis of Psychotic Symptoms Predominant Wilson's Disease. J Neurosci Rural Pract 2018; 9:616-618. [PMID: 30271060 PMCID: PMC6126283 DOI: 10.4103/jnrp.jnrp_515_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Wilson's disease is an autosomal recessive disease of abnormal copper metabolism. Psychosis is a rare manifestation of Wilson's disease. Few cases of misdiagnosing Wilson's disease as an etiology of psychosis were reported in the literature. We report a case of a 42-year-old patient, who was diagnosed with a schizoaffective disorder and treated with antipsychotics for 3 years with no significant improvement. On reevaluation, we the patient was diagnosed to have Wilson's disease. The patient's symptoms improved significantly with chelation therapy.
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Affiliation(s)
- Bhupendra Shah
- Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Suren Limbu
- Department of Psychiatry, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
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19
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Madakshira MG, Das A, Umairv M, Dutta U. Liver histology and histochemistry in Wilson disease. AUTOPSY AND CASE REPORTS 2018; 8:e2018026. [PMID: 30101132 PMCID: PMC6066266 DOI: 10.4322/acr.2018.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 06/04/2018] [Indexed: 12/14/2022] Open
Affiliation(s)
- Manoj Gopal Madakshira
- Postgraduate Institute of Medical Education and Research, Department of Histopathology. Chandigarh, India
| | - Ashim Das
- Postgraduate Institute of Medical Education and Research, Department of Histopathology. Chandigarh, India
| | - Mohammed Umairv
- Postgraduate Institute of Medical Education and Research, Department of Gastroenterology. Chandigarh, India
| | - Usha Dutta
- Postgraduate Institute of Medical Education and Research, Department of Gastroenterology. Chandigarh, India
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20
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Gong G, Jiang L, Lin Q, Liu W, He MF, Zhang J, Feng F, Qu W, Xie N. In vivo toxic effects of 4-methoxy-5-hydroxy-canthin-6-one in zebrafish embryos via copper dyshomeostasis and oxidative stress. Comp Biochem Physiol C Toxicol Pharmacol 2018; 204:79-87. [PMID: 29208543 DOI: 10.1016/j.cbpc.2017.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 10/24/2017] [Accepted: 11/29/2017] [Indexed: 11/23/2022]
Abstract
Dysfunction of copper homeostasis can lead to a host of disorders, which might be toxic sometimes. 4-Methoxy-5-hydroxy-canthin-6-one (CAN) is one of the major constituents from Picrasma quassioides and responsible for its therapeutic effects. In this work, we evaluated the toxic effect of CAN (7.5μM) on zebrafish embryos. CAN treatment decreased survival, delayed hatching time and induced malformations (loss of pigmentation, pericardial edema, as well as hematologic and neurologic abnormalities). Besides, exogenous copper supplementation rescued the pigmentation and cardiovascular defects in CAN-treated embryos. Further spectroscopic studies revealed a copper-chelating activity of CAN. Then its regulation on the expressions of copper homeostasis related genes also be analyzed. In addition, CAN lowered the total activity of SOD, elevated the ROS production and altered the oxidative related genes transcriptions, which led to oxidative stress. In conclusion, we demonstrated that CAN (7.5μM) might exert its toxic effects in zebrafish embryos by causing copper dyshomeostasis and oxidative stress. It will give insight into the risk assessment and prevention of CAN-mediated toxicity.
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Affiliation(s)
- Guiyi Gong
- Department of Natural Medicinal Chemistry, China Pharmaceutical University, Nanjing 210009, China
| | - Lingling Jiang
- Institute of Translational Medicine, College of Biotechnology and Pharmaceutical Engineering, Nanjing Tech University, Nanjing 211800, China
| | - Qinghua Lin
- Department of Natural Medicinal Chemistry, China Pharmaceutical University, Nanjing 210009, China
| | - Wenyuan Liu
- Department of Pharmaceutical Analysis, China Pharmaceutical University, 24 Tongjiaxiang, Nanjing 210009, China; Key Laboratory of Drug Quality Control and Pharmacovigilance (China Pharmaceutical University), Ministry of Education, China Pharmaceutical University, 24 Tongjiaxiang, Nanjing 210009, China
| | - Ming-Fang He
- Institute of Translational Medicine, College of Biotechnology and Pharmaceutical Engineering, Nanjing Tech University, Nanjing 211800, China
| | - Jie Zhang
- Department of Natural Medicinal Chemistry, China Pharmaceutical University, Nanjing 210009, China; Key Laboratory of Biomedical Functional Materials, China Pharmaceutical University, Nanjing 211198, China
| | - Feng Feng
- Department of Natural Medicinal Chemistry, China Pharmaceutical University, Nanjing 210009, China; Key Laboratory of Biomedical Functional Materials, China Pharmaceutical University, Nanjing 211198, China.
| | - Wei Qu
- Department of Natural Medicinal Chemistry, China Pharmaceutical University, Nanjing 210009, China; Key Laboratory of Biomedical Functional Materials, China Pharmaceutical University, Nanjing 211198, China.
| | - Ning Xie
- State Key Laboratory of Innovative Natural Medicines and TCM Injections, Jiangxi Qingfeng Pharmaceutical Co., Ltd., Ganzhou 341000, Jiangxi, China
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21
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Abstract
Essential tremor (ET) is a progressive and highly prevalent neurologic disease. Along with the tremors, mild to moderate gait ataxia and other signs of cerebellar dysfunction may occur (i.e., subtle saccadic eye movement abnormalities and abnormalities of motor timing) as well as cognitive features, some of which may be due to cerebellar dysfunction. Numerous neuroimaging studies indicate the presence of functional, metabolic, and structural abnormalities in the cerebellum of a patient with ET. In tandem with these clinical and imaging studies, which were gathering increasing support for the notion that the cerebellum and/or cerebellar systems seemed to be at the root of ET, a growing postmortem literature is for the first time beginning to identify microscopic abnormalities in the ET brain, most of which are centered on the Purkinje cells and connected neuronal populations, and are likely to be degenerative. In terms of treatment, most of these pharmacotherapeutic agents serve to enhance GABAergic neurotransmission, further bolstering the notion that ET may very well be a disorder with a primary Purkinje cell dysfunction resulting in reduced cerebellar cortical inhibition. Similarly, the interruption of presumably abnormal cerebellar outflow pathways to the thalamus is the mechanism of deep-brain stimulation surgery, which is highly effective in treating ET.
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Affiliation(s)
- Elan D Louis
- Department of Neurology and Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, Yale University, New Haven, CT, United States; Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale University, New Haven, CT, United States.
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22
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Olson JC. Acute-on-chronic and Decompensated Chronic Liver Failure: Definitions, Epidemiology, and Prognostication. Crit Care Clin 2017; 32:301-9. [PMID: 27339672 DOI: 10.1016/j.ccc.2016.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Chronic liver disease is the fifth leading cause of death worldwide and represents a major burden for the health care community. Cirrhosis is a progressive disease resulting in end-stage liver failure, which in the absence of liver transplantation is fatal. Acute-on-chronic liver failure carries high short-term mortality but is potentially reversible. Viral hepatitis, alcohol, and nonalcoholic fatty liver disease remain the principal causes of liver disease. Though treatments exist for hepatitis B and C, they remain unavailable to many with these diseases. This article reviews the epidemiology of advanced liver disease and the concept of acute-on-chronic liver failure.
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Affiliation(s)
- Jody C Olson
- Hepatology and Critical Care Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 1023, Kansas City, KS 66160, USA.
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23
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Demily C, Parant F, Cheillan D, Broussolle E, Pavec A, Guillaud O, Restier L, Lachaux A, Bost M. Screening of Wilson's disease in a psychiatric population: difficulties and pitfalls. A preliminary study. Ann Gen Psychiatry 2017; 16:19. [PMID: 28392828 PMCID: PMC5379609 DOI: 10.1186/s12991-017-0142-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 03/25/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Wilson's disease (WD) is a rare autosomal-recessive, inherited disorder caused by a mutation in the copper-transporting gene ATP7B affecting the liver and nervous system. About 30% of patients with WD may initially present with psychiatric symptoms, and diagnosis can be difficult to establish. The objectives of the present preliminary study were [1] to evaluate the relevance of serum copper (Cu) and ceruloplasmin (Cp) measures in hospitalized patients with psychiatric disorders; and [2] to identify possible mutations in the ATP7B gene in patients with abnormal biological copper profile. METHODS All psychiatric patients who participated in this study were hospitalized in Saint-Jean de Dieu Hospital (Lyon, France). Cp was measured by immunoturbidimetry and serum Cu by inductively coupled plasma-optical emission spectrometry. When Cp and serum Cu levels were inferior to, respectively, 0.18 g/L and 0.88 mg/L in combination with atypical psychiatric presentations, complete clinical examinations were performed by multidisciplinary physicians specialized in WD. In addition, mutation detection in the ATP7B gene was performed. RESULTS A total of 269 patients completed the study. (1) 51 cases (19%) showed both decreased Cp and Cu concentrations. (2) Molecular genetic tests were performed in 29 patients, and one ATP7B mutation (heterozygous state) was found in four patients. We identified three different missense mutations: p.His1069Gln, c.3207C>A (exon 14), p.Pro1379Ser, c.4135C>T (exon 21) and p.Thr1434Met, c.4301C>T (exon 21). No pathogenic mutation on either ATP7B allele was detected. CONCLUSION Results of Cp and/or serum Cu concentrations below the normal limits are common in patients with psychiatric disorders and nonrelevant and/or informative for the WD diagnosis. WD diagnosis is based on a combination of clinical and biological arguments. Psychiatric patients with suspicion of WD should be evaluated in a reference center. Trial registration CPP Lyon Sud-Est IVNo 10/044, CNIL No DR-2011-470, Afssaps No B100832-40 and CCTIRS No 10.612 bis, registered 8 June 2010.
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Affiliation(s)
- Caroline Demily
- GénoPsy, Center for the Detection and Management of Psychiatric Disorders of Genetic Origin, Pôle Ouest, Hôpital le Vinatier & UMR 5229 (CNRS & Lyon University), 95 Bld Pinel, 69677 Bron cedex, France
- National Reference Center for Wilson’s disease, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - François Parant
- Pharmaco-Toxicology, Biochemistry and Molecular Biology Unit, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - David Cheillan
- Laboratory of Inherited Metabolic Diseases, Centre de Biologie Est, Hospices Civils de Lyon, Bron, France
| | - Emmanuel Broussolle
- National Reference Center for Wilson’s disease, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
- Neurology Unit C, Cognitive Neurosciences Center, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon; Claude Bernard-Lyon 1 University; CNRS UMR 5229, Bron, France
| | | | - Olivier Guillaud
- National Reference Center for Wilson’s disease, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
- Hepato-Gastroenterology Department, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Lioara Restier
- National Reference Center for Wilson’s disease, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
- Gastroenterology, Hepatology and Pediatric Nutrition Department, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Alain Lachaux
- National Reference Center for Wilson’s disease, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
- Gastroenterology, Hepatology and Pediatric Nutrition Department, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Muriel Bost
- Laboratory of Inherited Metabolic Diseases, Centre de Biologie Est, Hospices Civils de Lyon, Bron, France
- National Reference Center for Wilson’s disease, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
- Pharmaco-Toxicology, Biochemistry and Molecular Biology Unit, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
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24
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Abstract
Wilson disease (WD) is an autosomal-recessive disorder of hepatocellular copper deposition caused by pathogenic variants in the copper-transporting gene, ATP7B. Early detection and treatment are critical to prevent lifelong neuropsychiatric, hepatic, and systemic disabilities. Due to the marked heterogeneity in age of onset and clinical presentation, the diagnosis of Wilson disease remains challenging to physicians today. Direct sequencing of the ATP7B gene is the most sensitive and widely used confirmatory testing method, and concurrent biochemical testing improves diagnostic accuracy. More than 600 pathogenic variants in ATP7B have been identified, with single-nucleotide missense and nonsense mutations being the most common, followed by insertions/deletions, and, rarely, splice site mutations. The prevalence of Wilson disease varies by geographic region, with higher frequency of certain mutations occurring in specific ethnic groups. Wilson disease has poor genotype-phenotype correlation, although a few possible modifiers have been proposed. Improving molecular genetic studies continue to advance our understanding of the pathogenesis, diagnosis, and screening for Wilson disease.
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Affiliation(s)
- Irene J Chang
- Division of Medical Genetics, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Si Houn Hahn
- Division of Genetic Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, USA.
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25
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Duncan A, Yacoubian C, Beetham R, Catchpole A, Bullock D. The role of calculated non-caeruloplasmin-bound copper in Wilson's disease. Ann Clin Biochem 2016; 54:649-654. [PMID: 27742851 DOI: 10.1177/0004563216676843] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background US and European guidelines suggest the use of calculated non-caeruloplasmin-bound copper (free copper index) for the diagnosis and management of Wilson's Disease. However, there is concern that the required analytical measurements of caeruloplasmin and copper may not be sufficiently robust at the concentrations usually found. Methods Aliquots of six plasma specimens were sent to laboratories participating in the UK National External Quality Assessment Scheme for copper and caeruloplasmin. The variability of these two reported measurements and the calculated non-caeruloplasmin-bound copper concentrations were compared. The variability of caeruloplasmin reference ranges quoted by laboratories was also investigated. Results No laboratories use the required enzymatic methods in the calculation of non-caeruloplasmin-bound copper. The interlaboratory variations in caeruloplasmin concentrations and calculated non-caeruloplasmin-bound copper concentrations were very considerable so making clinical interpretation unreliable. Wide differences in the caeruloplasmin reference ranges used were also found. Conclusions Such variations of the calculated non-caeruloplasmin-bound copper concentrations and the predominant use of immunological methods for measuring caeruloplasmin preclude a clinical role for this calculated value in the investigation of Wilson's disease.
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Affiliation(s)
- Andrew Duncan
- 1 Scottish Trace Element and Micronutrient Diagnostic and Research Laboratory, Department of Clinical Biochemistry, Royal Infirmary, Glasgow, UK
| | - Calum Yacoubian
- 1 Scottish Trace Element and Micronutrient Diagnostic and Research Laboratory, Department of Clinical Biochemistry, Royal Infirmary, Glasgow, UK
| | - Robert Beetham
- 2 Department of Clinical Biochemistry, North Bristol NHS Trust, Bristol, UK
| | - Anthony Catchpole
- 1 Scottish Trace Element and Micronutrient Diagnostic and Research Laboratory, Department of Clinical Biochemistry, Royal Infirmary, Glasgow, UK
| | - David Bullock
- 3 UK National External Quality Assessment Scheme, Birmingham, UK
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26
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Abstract
PURPOSE to prospectively investigate the incidence and prevalence of Wilson disease (Wd) in Chinese han population in anhui province, to analyze the genetic mutations in individuals with Wd, and to provide basic epidemiological data regarding Wd in this Chinese han population. METHODS between november 2008 and June 2010, individuals aged from 7 to 75 years were screened for the cornea K-f ring in both eyes using slit lamp examination and random sampling methods based on age stratification and cluster level 1. the participants were from anhui province’s hanshan County, Jinzhai County, and lixin County. the clinical manifestations of the brain, liver, kidney, skin, and other organs in each individual were also determined. individuals with positive K-f rings and clinical manifestations indicative of Wd underwent copper biochemistry evaluations, abdominal ultrasound testing, and ATP7B gene mutation screening to confirm or exclude the diagnosis of Wd. RESULTS of 153,370 individuals investigated in this study, nine were diagnosed with Wd. in these Wd individuals, three cases had neurological symptoms, one has hepatic symptoms, one was hepatic and neurological combined, and the other four cases were presymptomatic. of the eight individuals in whom genetic mutations were detected, seven individuals had mutations in the ATP7B gene. the other individual had no ATP7B gene mutations but her copper biochemical test results met the diagnostic criteria for Wd. the incidence and prevalence of Wd in this population were approximately 1.96/100,000 and 5.87/100,000 respectively. CONCLUSION the Chinese han population had a higher average prevalence of Wd than the populations of the united States or europe.
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27
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Amvrosiadou M, Petropoulou M, Poulou M, Tzetis M, Kanavakis E, Christopoulos TK, Ioannou PC. Multi-allele genotyping platform for the simultaneous detection of mutations in the Wilson disease related ATP7B gene. J Chromatogr B Analyt Technol Biomed Life Sci 2015; 1006:201-208. [PMID: 26580967 DOI: 10.1016/j.jchromb.2015.10.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 10/20/2015] [Accepted: 10/23/2015] [Indexed: 11/30/2022]
Abstract
Wilson's disease is an inherited disorder of copper transport in the hepatocytes with a wide range of genotype and phenotype characteristics. Mutations in the ATP7B gene are responsible for the disease. Approximately, over 500 mutations in the ATP7B gene have been described to date. We report a method for the simultaneous detection of the ten most common ATP7B gene mutations in Greek patients. The method comprises 3 simple steps: (i) multiplex PCR amplification of fragments in the ATP7B gene flanking the mutations (ii) multiplex primer extension reaction of the unpurified amplification products using allele-specific primers and (iii) visual detection of the primer extension reaction products within minutes by means of dry-reagent multi-allele dipstick assay using anti-biotin conjugated gold nanoparticles. Optimization studies on the efficiency and specificity of the PEXT reaction were performed. The method was evaluated by genotyping 46 DNA samples of known genotype and 34 blind samples. The results were fully concordant with those obtained by reference methods. The method is simple, rapid, cost-effective and it does not require specialized instrumentation or highly qualified personnel.
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Affiliation(s)
- Maria Amvrosiadou
- Laboratory of Analytical Chemistry, Department of Chemistry, Athens University, Athens 15771, Greece
| | - Margarita Petropoulou
- Laboratory of Analytical Chemistry, Department of Chemistry, Athens University, Athens 15771, Greece
| | - Myrto Poulou
- Laboratory of Medical Genetics, Athens University, Athens 11527, Greece
| | - Maria Tzetis
- Laboratory of Medical Genetics, Athens University, Athens 11527, Greece
| | | | - Theodore K Christopoulos
- Department of Chemistry, University of Patras, Patras 26500, Greece; Foundation for Research and Technology Hellas, Institute of Chemical Engineering and High Temperature Chemical Processes (FORTH/ICE-HT), Patras 26504, Greece
| | - Penelope C Ioannou
- Laboratory of Analytical Chemistry, Department of Chemistry, Athens University, Athens 15771, Greece.
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Carabantes-Rueda J, Ruiz-Serrato A, Utrilla-Ayala C, Almodovar-Pulido M, Infantes-Ramos R. Hipertransaminasemia persistente en el adulto: una situación frecuente como presentación de la enfermedad de Wilson. Semergen 2015; 41:e65-6. [DOI: 10.1016/j.semerg.2014.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Revised: 07/22/2014] [Accepted: 07/28/2014] [Indexed: 11/16/2022]
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Cheng N, Wang H, Dong J, Pan S, Wang X, Han Y, Han Y, Yang R. Elevated serum brain natriuretic peptide and matrix metalloproteinases 2 and 9 in Wilson's disease. Metab Brain Dis 2015; 30:1087-91. [PMID: 26077744 DOI: 10.1007/s11011-015-9685-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 05/15/2015] [Indexed: 01/17/2023]
Abstract
Wilson's disease (WD) is a disease of copper metabolism characterized by excessive copper deposition in the body. It is reported abnormal copper metabolism has been associated with cardiovascular disease. BNP and MMP2/9 were biomarkers of congestive heart failure (CHF). There is rare study to explore whether serum concentrations of BNP, MMP2, and or MMP9 are altered in patients with WD. In this study we determine whether serum concentrations of brain natriuretic peptide (BNP) and matrix metalloproteinases (MMP) 2 and 9 are increased in patients with WD. Serum BNP, MMP2 and MMP9 were measured by an ELISA in 34 patients with hepatic WD, in 68 patients with neurological WD, and in 33 healthy controls. We found serum BNP levels were higher in patients with neurological WD than in healthy controls (p = 0.033). Serum MMP2 levels were higher in patients with hepatic (p = 0.009) and neurologic (p = 0.0004) WD than in controls. Serum MMP9 levels were higher in patients with neurologic WD than in patients with hepatic WD (p = 0.002) and controls (p = 0.00005), and were higher in patients with hepatic WD than in controls (p = 0.03). Serum BNP levels were negatively correlated with ceruloplasmin (p = 0.017, r = -0.215), while serum (p = 0.019, r = -0.221) and MMP9 (p = 0.011, r = -0.231) in patients with WD were negatively correlated with ceruloplasmin. BNP, MMP2, and MMP9 may reflect the deposition of copper in the heart.
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Affiliation(s)
- Nan Cheng
- Wilson Disease Centre, Hospital Affiliated to Anhui Chinese Medical University, No. 357, Changjiangzhong Road, Hefei, Anhui, China
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Paradisi I, De Freitas L, Arias S. Most frequent mutation c.3402delC (p.Ala1135GlnfsX13) among Wilson disease patients in Venezuela has a wide distribution and two old origins. Eur J Med Genet 2014; 58:59-65. [PMID: 25497208 DOI: 10.1016/j.ejmg.2014.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 12/04/2014] [Indexed: 01/09/2023]
Abstract
Wilson disease is an infrequent autosomal recessive disorder caused by mutations in the ATP7B gene (13q14.3) producing pathologic phenotypes due to copper accumulation in critical tissues. The aim of the research was to probe Wilson disease genetic epidemiology in Venezuela, through the identification in diagnosed index cases, of ATP7B locus mutations, their geographic distribution, frequency, in-phase haplotypes and probable ethnic ancestry. During the last three decades 33 independent Wilson disease families from the country at large were ascertained and diagnosed through severely reduced ceruloplasmin activity, higher urinary copper excretion, and specific clinical signs. Molecular studies of the ATP7B gene were accomplished in 26 of the families. Disease prevalence was estimated as 1:94,000 families between 1985 and 2013, showing geographic aggregation in the state of Zulia with 1:27,000 families in it. DNA analysis in 26 families revealed 13 different mutations. The c.3402delC was the most frequent one (26.9%), presenting two independent in-phase haplotypes, both of likely European descent; which is followed by the not previously reported p.G691V (9.6%) and by the frequent European H1069Q (7.7%). Known mutations c.51 + 4A > T, c.1285 + 5G > T, M645R, T788I, V845SfsX28, T977M, L1088X, T1220M, R1319X and a novel P767L showed frequencies between 5.8 and 1.9%. Despite the ample mutation heterogeneity for Wilson disease in the country, the findings provide a diagnostic algorithm to ease mutation assessment in new patients; the predominant c.3402delC displayed wide geographic distribution and two genetic origins.
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Affiliation(s)
- Irene Paradisi
- Laboratorio de Genética Humana, Instituto Venezolano de Investigaciones Científicas (IVIC), Caracas, Venezuela.
| | - Laura De Freitas
- Laboratorio de Genética Humana, Instituto Venezolano de Investigaciones Científicas (IVIC), Caracas, Venezuela; Departamento de Ciencias Fisiológicas, Laboratorio de Genética Molecular, Universidad de Carabobo (UC), Valencia, Venezuela
| | - Sergio Arias
- Laboratorio de Genética Humana, Instituto Venezolano de Investigaciones Científicas (IVIC), Caracas, Venezuela
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Li Z, Yu X, Shen J, Liang J. Congential scoliosis in Wilson's disease: case report and review of the literature. BMC Surg 2014; 14:71. [PMID: 25252715 PMCID: PMC4177382 DOI: 10.1186/1471-2482-14-71] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 09/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Wilson's disease (WD) is an autosomal recessive disorder of copper metabolism, which leads to the accumulation of this metal in liver, brain, cornea and kidney. Little is reported about spinal deformity associated with this syndrome. This study is to present a case of thoracic kyphosis occurring in the setting of Wilson'disease and explore the possible association between the two diseases. CASE PRESENTATION Case report and literature review. A previously unreported thoracic kyphosis in Wislon's disease is decribed. The patient was a 7-year-old Chinese female that underwent a posterior correction, using the Moss-SI spinal system performed at Thoracic 9-Lumbar 1 (T9-L1) levels. At 16-month follow-up, the patient was clinically pain free and well balanced. Plain radiographs showed solid spine fusion with no loss of deformity correction. After evaluating 211 WD patients referred to Peking Union Medical College Hospital from February 1991 to February 2012, the prevalence of congential scoliosis among patients with WD was 5.21% (11/211), much higher than that among general population (1/1000). CONCLUSIONS To the best of our knowledge, this is the first report of WD with thoracic kyphosis. During sugery, surgeons and anesthesiologists must pay particular attention to the abnormal liver and brain function associated with WD. The prevalence of scoliosis is much higher among patients with WD, indicating a potential association between congential scoliosis and WD. However, the exact mechanism how copper-chelating agents induce scoliosis is unclear.
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Affiliation(s)
| | | | - Jianxiong Shen
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, China.
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Abstract
Wilson disease (WD) is an inherited disorder of chronic copper toxicosis characterized by excessive copper deposition in the body, primarily in the liver and the brain. It is a progressive disease and fatal if untreated. Excessive copper accumulation results from the inability of liver to excrete copper in bile. Copper is an essential trace metal and has a crucial role in many metabolic processes. Almost all of the body copper is protein bound. In WD, the slow but relentless copper accumulation overwhelms the copper chaperones (copper-binding proteins), resulting in high levels of free copper and copper-induced tissue injury. Liver is the central organ for copper metabolism, and copper is initially accumulated in the liver but over time spills to other tissues. WD has protean clinical manifestations mainly attributable to liver, brain, and osseomuscular impairment. Diagnosis of WD is challenging and based on combination of clinical features and laboratory tests. Identification of various high-frequency mutations identified in different population studies across the world has revived interest in developing DNA chips for rapid genetic diagnosis of WD. All symptomatic and all presymptomatic patients require lifelong decoppering with careful clinical tracking. Decoppering ensures that presymptomatic individuals remain symptom free. With judicious decoppering, given time, even patients with severe neurological disability improve and can return to normal life and resume school or work at par with their peers. Treatment regimens and tracking patients using the WD-specific Global Assessment Scale for WD (GAS for WD) are discussed.
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Lu CX, Qing Lin, Huang WQ, Tzeng CM. New mutations and polymorphisms of the ATP7B gene in sporadic Wilson disease. Eur J Med Genet 2014; 57:498-502. [PMID: 24878384 DOI: 10.1016/j.ejmg.2014.04.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 04/28/2014] [Indexed: 01/01/2023]
Abstract
Wilson's disease (WD) is a rare autosomal recessive genetic disorder of copper metabolism resulting in brain damage, liver failure, and neurological impairment and psychiatric disturbances, as a result of excessive copper accumulation in the brain, liver, kidneys and eyes. ATP7B, encoding a copper transporter P-ATPase was identified as the causative gene of WD. Mutations in the ATP7B gene lead to the defection of the transmembrane transporter so that it can not metabolize copper effectively. We reported the clinical and molecular features of three unrelated and non-consanguineous WD patients. We performed molecular genetic analysis of the ATP7B gene in all cases by DNA sequencing, and revealed 7 novel single nucleotide polymorphisms (SNPs) and 8 well known mutations. Among them, that novel SNP (c. -520 C>T) and two well known mutations (c. 2310 C>G/p. Leu700Leu, c. 2333 G>T/A/p. Arg778Leu/Gln) coexisted in all patients and they were heterozygous and homozygous in the youngest case, respectively, indicating that they may be correlated to the pathogenesis and potentially used as a genetic biomarker for early WD diagnosis.
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Affiliation(s)
- Cong-Xia Lu
- Department of Neurology, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian 361003, China
| | - Qing Lin
- Department of Neurology, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian 361003, China; Translational Medicine Research Center, School of Pharmaceutical Sciences & Institute for Biomedical Research, Xiamen University, Xiamen, Fujian 361102, China
| | - Wen-Qing Huang
- Translational Medicine Research Center, School of Pharmaceutical Sciences & Institute for Biomedical Research, Xiamen University, Xiamen, Fujian 361102, China
| | - Chi-Meng Tzeng
- Translational Medicine Research Center, School of Pharmaceutical Sciences & Institute for Biomedical Research, Xiamen University, Xiamen, Fujian 361102, China.
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Abstract
Copper (Cu) is an essential redox active metal that is potentially toxic in excess. Multicellular organisms acquire Cu from the diet and must regulate uptake, storage, distribution and export of Cu at both the cellular and organismal levels. Systemic Cu deficiency can be fatal, as seen in Menkes disease patients. Conversely Cu toxicity occurs in patients with Wilson disease. Cu dyshomeostasis has also been implicated in neurodegenerative disorders such as Alzheimer's disease. Over the last decade, the fly Drosophila melanogaster has become an important model organism for the elucidation of eukaryotic Cu regulatory mechanisms. Gene discovery approaches with Drosophila have identified novel genes with conserved protein functions relevant to Cu homeostasis in humans. This review focuses on our current understanding of Cu uptake, distribution and export in Drosophila and the implications for mammals.
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Affiliation(s)
- Adam Southon
- Department of Genetics, University of Melbourne, Parkville, Australia.
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Matern D, Oglesbee D, Tortorelli S. Newborn screening for lysosomal storage disorders and other neuronopathic conditions. ACTA ACUST UNITED AC 2014; 17:247-53. [PMID: 23798012 DOI: 10.1002/ddrr.1117] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 05/17/2012] [Indexed: 01/14/2023]
Abstract
Newborn screening (NBS) is a public health program aimed at identifying treatable conditions in presymptomatic newborns to avoid premature mortality, morbidity, and disabilities. Currently, every newborn in the Unites States is screened for at least 29 conditions where evidence suggests that early detection is possible and beneficial. With new or improved treatment options and development of high-throughput screening tests, additional conditions have been proposed for inclusion into NBS programs. Among those are several conditions with a strong neuronopathic component. Some of these conditions have already been added to a few national and international screening programs, whereas others are undergoing pilot studies to determine the test performance metrics. Here, we review the current state of NBS for 13 lysosomal storage disorders, X-adrenoleukodystrophy, Wilson disease, and Friedreich ataxia.
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Affiliation(s)
- Dietrich Matern
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
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Forbes N, Goodwin S, Woodward K, Morgan DG, Brady L, Coulthart MB, Tarnopolsky MA. Evidence for synergistic effects of PRNP and ATP7B mutations in severe neuropsychiatric deterioration. BMC MEDICAL GENETICS 2014; 15:22. [PMID: 24555712 PMCID: PMC3996179 DOI: 10.1186/1471-2350-15-22] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 02/12/2014] [Indexed: 11/13/2022]
Abstract
Background Wilson’s disease (WD), a rare cause of neuropsychiatric deterioration, is associated with mutations in the ATP7B gene. Prion diseases are also rare causes of neuropsychiatric deterioration that can occur sporadically without an identifiable cause, or can be attributed to mutations in the PRNP gene. Case presentation Here we describe a biological “experiment of nature” in which a patient presented with severe neuropsychiatric decline and strong biochemical evidence of WD. Genetic analysis revealed that he was a compound heterozygote for two ATP7B sequence variants (c.2165dupT, p.Arg723Glufs*32; and c.4039G > A, p.Gly1347Ser), the first having been reported once previously, and the second being novel. In addition, the patient was heterozygous for a PRNP variant, c.160G > A, p.Gly54Ser, that has been reported in a neuropsychiatric patient only once previously in association with a similarly severe clinical course of neuropsychiatric disease and early age of onset, but no accompanying information on ATP7B genotype. Of particular interest was the observation that the patient’s older sister, who carried the same ATP7B genotype and laboratory evidence for biochemical WD but was clinically asymptomatic, lacked the PRNP variant allele. Conclusions We propose that synergism may occur between at least some allelic variants of ATP7B and PRNP, possibly exerted through effects on cellular copper metabolism.
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Abstract
Wilson disease, also known as hepatolenticular degeneration, is a disorder in the liver that results in the improper metabolism of copper, which leads to accumulation of excessive amounts of this vital trace element in the liver, brain, eyes, and other organs. Although copper is essential for normal physiologic function, it can become toxic and life-threatening when too much is present within critical organs, especially the liver and the brain. There is no cure for Wilson disease, and patients affected with this disorder face a lifetime of treatment. Fortunately, the disease is very treatable if diagnosed before significant damage to the liver or brain occurs. This article presents a case study on Wilson disease and the role of sonography in helping diagnose and monitor patients with this condition.
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Affiliation(s)
- Bethany Mills
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Anthony L. Baker
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ella C. Whitney
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Abstract
An analysis of 321 case notes of patients with Wilson's disease seen between 1955 and 2000 and one case seen in 1949 has revealed that 22 patients presented with a haemolytic crisis. This study was not a specific research project but a retrospective analysis of 321 patients with Wilson's disease seen between 1949 and 2000. All investigations were carried out in the best interests of diagnosis and management of patients referred to my clinic. The delay in diagnosis in 18 cases resulted in progression to severe hepatic disease in 14 cases and to neurological disease in 4 cases. One patient had no symptoms at the time her sister's illness was diagnosed as Wilson's disease. In a second patient, with liver disease, the diagnosis was also made when a sister was found to have Wilson's disease. There was a female to male ratio of 15:7. The average age of onset was 12.6 years and the incidence 6.9%. Delay in diagnosis resulted in nine deaths. Three patients, late in the series, were admitted in the acute phase, two female and one male; of these two responded to chelation therapy, the third required liver transplantation. Haemolysis appeared to be extravascular, and possible mechanisms of the haemolysis are discussed.
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Fenu M, Liggi M, Demelia E, Sorbello O, Civolani A, Demelia L. Kayser-Fleischer ring in Wilson's disease: a cohort study. Eur J Intern Med 2012; 23:e150-6. [PMID: 22863441 DOI: 10.1016/j.ejim.2012.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 03/04/2012] [Accepted: 04/10/2012] [Indexed: 10/28/2022]
Abstract
AIMS To evaluate Wilson's disease (WD) features in Sardinian patients with Kayser-Fleischer (KF) ring and to evaluate correlations between modifications in KF and anti-copper therapy and systemic WD evolution. PATIENTS AND METHODS Sixty-seven WD patients (35 m/32 f; mean age 41 years) were retrospectively studied. At diagnosis and during follow up comprehensive ophthalmologic and neurologic examinations, brain RMN and ECD SPECT, detailed objective laboratory studies and hepatic histological examination were performed on all patients for analysis. All patients were given anti-copper therapy with d-Penicillamine in mono-therapy or in combination with Zinc Salts. RESULTS At diagnosis, KF was observed in 27% of patients with equal distribution in all age groups. Significant correlations between KF at diagnosis, neuro-psychiatric manifestations and pathologic features in brain RMN and in brain ECD SPECT were found at diagnosis. During follow up, a decrease in, or regression of KF was seen in 14% of patients. Anti-copper therapy leads to KF regression and prevents the appearance of KF. No significant correlations were observed between KF regression and clinical neurological or neuro-imaging improvement nor between KF modifications and clinical hepatic improvement. CONCLUSIONS Our study highlights the peculiar features of Sardinian WD patients: low representation of KF, its equal distribution in all age groups, significant correlation between KF at diagnosis and clinical neurological manifestations, pathologic brain RMN and brain ECD-SPECT are highlighted by our study. Anti-copper therapy induces KF regression and prevents its onset. Therefore, KF ring does appear to be a predictive factor in the neurological and hepatic evolution of WD.
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Affiliation(s)
- M Fenu
- UOC of Gastroenterology, Azienda Ospedaliero - Universitaria, Cagliari, Italy
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Kodama H, Fujisawa C, Bhadhprasit W. Inherited copper transport disorders: biochemical mechanisms, diagnosis, and treatment. Curr Drug Metab 2012; 13:237-50. [PMID: 21838703 PMCID: PMC3290776 DOI: 10.2174/138920012799320455] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 03/07/2011] [Accepted: 05/16/2011] [Indexed: 12/14/2022]
Abstract
Copper is an essential trace element required by all living organisms. Excess amounts of copper, however, results in cellular damage. Disruptions to normal copper homeostasis are hallmarks of three genetic disorders: Menkes disease, occipital horn syndrome, and Wilson's disease. Menkes disease and occipital horn syndrome are characterized by copper deficiency. Typical features of Menkes disease result from low copper-dependent enzyme activity. Standard treatment involves parenteral administration of copper-histidine. If treatment is initiated before 2 months of age, neurodegeneration can be prevented, while delayed treatment is utterly ineffective. Thus, neonatal mass screening should be implemented. Meanwhile, connective tissue disorders cannot be improved by copper-histidine treatment. Combination therapy with copper-histidine injections and oral administration of disulfiram is being investigated. Occipital horn syndrome characterized by connective tissue abnormalities is the mildest form of Menkes disease. Treatment has not been conducted for this syndrome. Wilson's disease is characterized by copper toxicity that typically affects the hepatic and nervous systems severely. Various other symptoms are observed as well, yet its early diagnosis is sometimes difficult. Chelating agents and zinc are effective treatments, but are inefficient in most patients with fulminant hepatic failure. In addition, some patients with neurological Wilson's disease worsen or show poor response to chelating agents. Since early treatment is critical, a screening system for Wilson's disease should be implemented in infants. Patients with Wilson's disease may be at risk of developing hepatocellular carcinoma. Understanding the link between Wilson's disease and hepatocellular carcinoma will be beneficial for disease treatment and prevention.
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Affiliation(s)
- Hiroko Kodama
- Department of health Dietetics, Teikyo Heisei University, Toshima-ku, Tokyo.
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Morgan SM, Zantek ND. Therapeutic plasma exchange for fulminant hepatic failure secondary to Wilson's disease. J Clin Apher 2012; 27:282-6. [DOI: 10.1002/jca.21239] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 05/28/2012] [Indexed: 12/18/2022]
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Abstract
Changes in the liver biochemical profile are normal in pregnancy. However, up to 3% to 5% of all pregnancies are complicated by liver dysfunction. It is important that liver disease during pregnancy is recognized because early diagnosis may improve maternal and fetal outcomes, with resultant decreased morbidity and mortality. Liver diseases that occur in pregnancy can be divided into 3 different groups: liver diseases that are unique to pregnancy, liver diseases that are not unique to pregnancy but can be revealed or exacerbated by pregnancy, and liver diseases that are unrelated to but occur coincidentally during pregnancy.
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Affiliation(s)
- Arjmand R Mufti
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medical Center, IL 60637, USA
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Vieira J, Oliveira PV, Juliano Y, Warde KRJ, Deguti MM, Barbosa ER, Carrilho FJ, Cancado ELR. Urinary copper excretion before and after oral intake of d-penicillamine in parents of patients with Wilson's disease. Dig Liver Dis 2012; 44:323-7. [PMID: 22169274 DOI: 10.1016/j.dld.2011.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Revised: 10/14/2011] [Accepted: 11/01/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Urinary copper excretion higher than 100 μg/24 h is useful for diagnosing Wilson's disease. d-Penicillamine challenge test may produce higher levels than 1400 μg/24 h, allowing for better diagnostic accuracy. This study investigated whether heterozygotes reach this value and compared copper serum levels, ceruloplasmin, and urinary copper excretion before and after administering d-penicillamine to the parents of Wilson's disease patients. METHODS Fifty parents of adult patients were enrolled to obtain copper serum levels and ceruloplasmin along with 24-h urinary copper excretion before and after administering 1g d-penicillamine. RESULTS Serum ceruloplasmin and copper levels were significantly lower in fathers than in mothers (mean 21.8×27.8 mg%; 71.4×88.0 μg%; p ≤ 0.001). The mean of basal 24-h urinary copper excretion was higher in fathers (26.2×18.7 μg/24 h, p=0.01), but did not differ between the genders after d-penicillamine (521.7×525.3, range 31.6-1085.1 μg/24h, p=0.8). CONCLUSIONS The mean values of serum copper, ceruloplasmin, and basal urinary copper excretion were different between males and females. The current diagnostic threshold of 24-h urinary copper excretion after d-penicillamine was not reached by heterozygotes. The increased urinary copper excretion after d-penicillamine challenge was much higher than fivefold the upper limit of normal urinary copper excretion in the majority of heterozygotes and should not be taken into account when diagnosing Wilson's disease.
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Affiliation(s)
- Jakeliny Vieira
- Department of Gastroenterology of University of Sao Paulo School of Medicine, Brazil
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Micronutrient (Zn, Cu, Fe)-gene interactions in ageing and inflammatory age-related diseases: implications for treatments. Ageing Res Rev 2012; 11:297-319. [PMID: 22322094 DOI: 10.1016/j.arr.2012.01.004] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Revised: 01/20/2012] [Accepted: 01/23/2012] [Indexed: 02/07/2023]
Abstract
In ageing, alterations in inflammatory/immune response and antioxidant capacity lead to increased susceptibility to diseases and loss of mobility and agility. Various essential micronutrients in the diet are involved in age-altered biological functions. Micronutrients (zinc, copper, iron) play a pivotal role either in maintaining and reinforcing the immune and antioxidant performances or in affecting the complex network of genes (nutrigenomic approach) involved in encoding proteins for a correct inflammatory/immune response. By the other side, the genetic inter-individual variability may affect the absorption and uptake of the micronutrients (nutrigenetic approach) with subsequent altered effects on inflammatory/immune response and antioxidant activity. Therefore, the individual micronutrient-gene interactions are fundamental to achieve healthy ageing. In this review, we report and discuss the role of micronutrients (Zn, Cu, Fe)-gene interactions in relation to the inflammatory status and the possibility of a supplement in the event of a micronutrient deficiency or chelation in presence of micronutrient overload in relation to specific polymorphisms of inflammatory proteins or proteins related of the delivery of the micronutriemts to various organs and tissues. In this last context, we report the protein-metal speciation analysis in order to have, coupled with micronutrient-gene interactions, a more complete picture of the individual need in micronutrient supplementation or chelation to achieve healthy ageing and longevity.
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Czaja AJ. Cryptogenic chronic hepatitis and its changing guise in adults. Dig Dis Sci 2011; 56:3421-38. [PMID: 21647651 DOI: 10.1007/s10620-011-1769-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Accepted: 05/20/2011] [Indexed: 12/11/2022]
Abstract
Cryptogenic chronic hepatitis is a disease that is unexplained by conventional clinical, laboratory and histological findings, and it can progress to cirrhosis, develop hepatocellular carcinoma, and require liver transplantation. The goals of this review are to describe the changing phenotype of cryptogenic chronic hepatitis in adults, develop a diagnostic algorithm appropriate to current practice, and suggest treatment options. The frequency of cryptogenic hepatitis is estimated at 5.4%. Cryptogenic cirrhosis is diagnosed in 5-30% of patients with cirrhosis, and it is present in 3-14% of adults awaiting liver transplantation. Nonalcoholic fatty liver disease has been implicated in 21-63% of patients, and autoimmune hepatitis is a likely diagnosis in 10-54% of individuals. Viral infections, hereditary liver diseases, celiac disease, and unsuspected alcohol or drug-induced liver injury are recognized infrequently in the current cryptogenic population. Manifestations of the metabolic syndrome heighten the suspicion of nonalcoholic fatty liver disease, and the absence of hepatic steatosis does not discount this possibility. The diagnostic scoring system of the International Autoimmune Hepatitis Group can support the diagnosis of autoimmune hepatitis in some patients. Certain genetic mutations may have disease-specificity, and they suggest that some patients may have an independent and uncharacterized disease. Corticosteroid therapy is effective in patients with autoimmune features, and life-style changes and specific therapies for manifestations of the metabolic syndrome are appropriate for all obese patients. The 1- and 5-year survivals after liver transplantation have ranged from 72-85% to 58-73%, respectively.
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Affiliation(s)
- Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First Street S.W., Rochester, MN 55905, USA.
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El Balkhi S, Trocello JM, Poupon J, Chappuis P, Massicot F, Girardot-Tinant N, Woimant F. Relative exchangeable copper: a new highly sensitive and highly specific biomarker for Wilson's disease diagnosis. Clin Chim Acta 2011; 412:2254-60. [PMID: 21878323 DOI: 10.1016/j.cca.2011.08.019] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 08/05/2011] [Accepted: 08/11/2011] [Indexed: 01/18/2023]
Abstract
Wilson disease (WD) is an autosomal recessive inherited disorder of copper metabolism. Failure to diagnose WD can be dramatic leading to irreversible damages. The molecular genetic analysis of ATP7B gene is the reference test for diagnosis but the number of reported mutations of the ATP7B gene is on the rise. The analysis is cumbersome and requires tedious work. Other clinical and biological tests are proposed but it is often difficult to interpret some patients' results. A rapid and reliable biological test for WD diagnosis is still needed. Analytical reliability of Exchangeable copper (CuEXC) determination procedure is examined by studying the repeatability, the short term stability and stability in frozen serum. Relative exchangeable copper (REC=CuEXC/total copper%) is proposed and evaluated as a new diagnostic test and compared to classic tests used for WD diagnosis. Sixteen new Wilson disease patients were diagnosed in our institution between January 2009 and May 2011. The different biological tests used for WD diagnosis yielded lower sensitivity and specificity compared to our new biomarker, the REC. We show that REC is an excellent discriminatory tool for the diagnosis of WD offering 100% sensitivity and 100% specificity.
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Affiliation(s)
- Souleiman El Balkhi
- Laboratoire de toxicologie biologique, AP-HP, Hopital Lariboisière, 2, rue Ambroise Paré, 75475 Paris cedex 10, France
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Abstract
In the almost 100 years since Wilson's description of the illness that now bears his name, tremendous advances have been made in our understanding of this disorder. The genetic basis for Wilson's disease - mutation within the ATP7B gene - has been identified. The pathophysiologic basis for the damage resulting from the inability to excrete copper via the biliary system with its consequent gradual accumulation, first in the liver and ultimately in the brain and other organs and tissues, is now known. This has led to the development of effective diagnostic and treatment modalities that, although they may not eliminate the disorder, do provide the means for efficient diagnosis and effective amelioration if carried out in a dedicated and persistent fashion. Nevertheless, Wilson's disease remains both a diagnostic and treatment challenge for physician and patient. Its protean clinical manifestations make diagnosis difficult. Appropriate diagnostic evaluations to confirm the diagnosis and institute treatment can be confusing. In this chapter, the clinical manifestations, diagnostic evaluation, and treatment approaches for Wilson's disease are discussed.
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Affiliation(s)
- Ronald F Pfeiffer
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
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Kodama H, Fujisawa C, Bhadhprasit W. Pathology, clinical features and treatments of congenital copper metabolic disorders--focus on neurologic aspects. Brain Dev 2011; 33:243-51. [PMID: 21112168 DOI: 10.1016/j.braindev.2010.10.021] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Revised: 10/13/2010] [Accepted: 10/21/2010] [Indexed: 02/09/2023]
Abstract
Genetic disorders of copper metabolism, including Menkes kinky hair disease (MD), occipital horn syndrome (OHS) and Wilson's disease (WD) are reviewed with a focus on the neurological aspects. MD and OHS are X-linked recessive disorders characterized by a copper deficiency. Typical features of MD, such as neurologic disturbances, connective tissue disorders and hair abnormalities, can be explained by the abnormally low activity of copper-dependent enzymes. The current standard-of-care for treatment of MD is parenteral administration of copper-histidine. When the treatment is initiated in newborn babies, neurologic degeneration can be prevented, but delayed treatment is considerably less effective. Moreover, copper-histidine treatment does not improve connective tissue disorders. Novel treatments targeting neurologic and connective tissue disorders need to be developed. OHS is the mildest form of MD and is characterized by connective tissue abnormalities. Although formal trials have not been conducted for OHS, OHS patients are typically treated in a similar manner to MD. WD is an autosomal recessive disorder characterized by the toxic effects of chronic exposure to high levels of copper. Although the hepatic and nervous systems are typically most severely affected, initial symptoms are variable, making an early diagnosis difficult. Because early treatments are often critical, especially in patients with neurologic disorders, medical education efforts for an early diagnosis should target primary care physicians. Chelating agents and zinc are effective for the treatment of WD, but neurologic symptoms become temporarily worse just after treatment with chelating agents. Neurologic worsening in patients treated with tetrathiomolybdate has been reported to be lower than rates of neurologic worsening when treating with other chelating agents.
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Affiliation(s)
- Hiroko Kodama
- Department of Pediatrics, Teikyo University School of Medicine, Tokyo, Japan.
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Abstract
Tremor is the most common movement disorder presenting to an outpatient neurology practice and is defined as a rhythmical, involuntary oscillatory movement of a body part. The authors review the clinical examination, classification, and diagnosis of tremor. The pathophysiology of the more common forms of tremor is outlined, and treatment options are discussed. Essential tremor is characterized primarily by postural and action tremors, may be a neurodegenerative disorder with pathologic changes in the cerebellum, and can be treated with a wide range of pharmacologic and nonpharmacologic methods. Tremor at rest is typical for Parkinson's disease, but may arise independently of a dopaminergic deficit. Enhanced physiologic tremor, intention tremor, and dystonic tremor are discussed. Further differential diagnoses described in this review include drug- or toxin-induced tremor, neuropathic tremor, psychogenic tremor, orthostatic tremor, palatal tremor, tremor in Wilson's disease, and tremor secondary to cerebral lesions, such as Holmes' tremor (midbrain tremor). An individualized approach to treatment of tremor patients is important, taking into account the degree of disability, including social embarrassment, which the tremor causes in the patient's life.
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