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Guida CC, Pellegrino AM, Perez Ys ADM, Aucella F. Kidney disease in acute intermittent porphyria: histological features and therapeutic perspectives. J Nephrol 2024; 37:1165-1169. [PMID: 38642240 DOI: 10.1007/s40620-023-01828-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 04/22/2024]
Affiliation(s)
- Claudio Carmine Guida
- Department of Medical Sciences, Division of Nephrology and Dialysis and Pathology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Viale Cappuccini, 71013, San Giovanni Rotondo, Foggia, Italy.
| | - Angela Maria Pellegrino
- Department of Medical Sciences, Division of Nephrology and Dialysis and Pathology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Viale Cappuccini, 71013, San Giovanni Rotondo, Foggia, Italy
| | - Aurora Del Mar Perez Ys
- Department of Medical Sciences, Division of Nephrology and Dialysis and Pathology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Viale Cappuccini, 71013, San Giovanni Rotondo, Foggia, Italy
| | - Filippo Aucella
- Department of Medical Sciences, Division of Nephrology and Dialysis and Pathology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Viale Cappuccini, 71013, San Giovanni Rotondo, Foggia, Italy
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Yang X, Wang S, Sun C, Xia Y. Causal effect of porphyria biomarkers on alcohol-related hepatocellular carcinoma through Mendelian Randomization. PLoS One 2024; 19:e0299536. [PMID: 38507434 PMCID: PMC10954128 DOI: 10.1371/journal.pone.0299536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/12/2024] [Indexed: 03/22/2024] Open
Abstract
PURPOSE According to some cohort studies, an association exists between acute intermittent porphyria (AIP) and liver cancer. However, establishing a definitive causal relationship between porphyria and hepatocellular carcinoma (HCC) remains challenging. Prexisting studies regarding porphyria biomarkers and alcohol-related hepatocellular carcinoma (AR-HCC) make possible an entry point. In this study, we aimed to investigate the causal relationships between biomarkers of two types of porphyria, AIP and congenital erythropoietic porphyria (CEP), and AR-HCC. METHODS Single-nucleotide polymorphisms (SNPs) associated with porphobilinogen deaminase (PBGD) and uroporphyrinogen-III synthase (UROS), along with outcome data on AR-HCC, were extracted from public genome-wide association studies (GWAS). The GWAS data were then used to explore the potential causal relationships via a two-sample Mendelian randomization (MR) analysis. The effect estimates were calculated using the random-effect inverse-variance-weighted (IVW) method. Additionally, the Cochrane's Q test, MR-Egger test, and leave-one-out analysis were conducted to detect heterogeneity and pleiotropy in the MR results. RESULTS Using the IVW method as the primary causal effects model in the MR analyses, we found that both PBGD (effect estimate = 1.51; 95% CI, from 1.08 to 2.11, p = 0.016) and UROS (effect estimate = 1.53; 95% CI, from 1.08 to 2.18, p = 0.018) have a significant causal effect on AR-HCC. CONCLUSION Our findings revealed a causal effect of both PBGD and UROS on AR-HCC, suggesting that both AIP and CEP have a causal association with AR-HCC.
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Affiliation(s)
- Xiaoyu Yang
- Department of Oncology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Department of Oncology, Anhui Public Health Clinical Center, Hefei, Anhui, China
| | - Shuomin Wang
- Department of Oncology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Department of Oncology, Anhui Public Health Clinical Center, Hefei, Anhui, China
| | - Chen Sun
- Department of Oncology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Department of Oncology, Anhui Public Health Clinical Center, Hefei, Anhui, China
| | - Yunhong Xia
- Department of Oncology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Department of Oncology, Anhui Public Health Clinical Center, Hefei, Anhui, China
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Storjord E, Wahlin S, Karlsen BO, Hardersen RI, Dickey AK, Ludviksen JK, Brekke OL. Potential Biomarkers for the Earlier Diagnosis of Kidney and Liver Damage in Acute Intermittent Porphyria. Life (Basel) 2023; 14:19. [PMID: 38276268 PMCID: PMC11154556 DOI: 10.3390/life14010019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/14/2023] [Accepted: 12/19/2023] [Indexed: 01/27/2024] Open
Abstract
Acute intermittent porphyria (AIP) is an inherited metabolic disorder associated with complications including kidney failure and hepatocellular carcinoma, probably caused by elevations in the porphyrin precursors porphobilinogen (PBG) and delta-aminolevulinic acid (ALA). This study explored differences in modern biomarkers for renal and hepatic damage between AIP patients and controls. Urine PBG testing, kidney injury panels, and liver injury panels, including both routine and modern biomarkers, were performed on plasma and urine samples from AIP cases and matched controls (50 and 48 matched pairs, respectively). Regarding the participants' plasma, the AIP cases had elevated kidney injury marker-1 (KIM-1, p = 0.0002), fatty acid-binding protein-1 (FABP-1, p = 0.04), and α-glutathione S-transferase (α-GST, p = 0.001) compared to the matched controls. The AIP cases with high PBG had increased FABP-1 levels in their plasma and urine compared to those with low PBG. In the AIP cases, KIM-1 correlated positively with PBG, CXCL10, CCL2, and TCC, and the liver marker α-GST correlated positively with IL-13, CCL2, and CCL4 (all p < 0.05). In conclusion, KIM-1, FABP-1, and α-GST could represent potential early indicators of renal and hepatic damage in AIP, demonstrating associations with porphyrin precursors and inflammatory markers.
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Affiliation(s)
- Elin Storjord
- Department of Laboratory Medicine, Nordland Hospital Trust, 8092 Bodø, Norway; (B.O.K.); (O.-L.B.)
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Porphyria Centre Sweden, Karolinska Institute and Karolinska University Hospital, 14186 Stockholm, Sweden;
| | - Bård Ove Karlsen
- Department of Laboratory Medicine, Nordland Hospital Trust, 8092 Bodø, Norway; (B.O.K.); (O.-L.B.)
- Research Laboratory, Nordland Hospital Trust, 8092 Bodø, Norway;
| | - Randolf I. Hardersen
- Department of Nephrology, Nordland Hospital Trust, 8092 Bodø, Norway
- Department of Clinical Medicine, UiT-The Arctic University of Norway, 9019 Tromsø, Norway
| | - Amy K. Dickey
- Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA;
- Harvard Medical School, Boston, MA 02115, USA
| | | | - Ole-Lars Brekke
- Department of Laboratory Medicine, Nordland Hospital Trust, 8092 Bodø, Norway; (B.O.K.); (O.-L.B.)
- Department of Clinical Medicine, UiT-The Arctic University of Norway, 9019 Tromsø, Norway
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Brito Avô L, Pereira L, Oliveira A, Ferreira F, Filipe P, Coelho Rodrigues I, Couto E, Ferreira F, Airosa Pardal A, Morgado P, Moreira S. Portuguese Consensus on Acute Porphyrias: Diagnosis, Treatment, Monitoring and Patient Referral. ACTA MEDICA PORT 2023; 36:753-764. [PMID: 37924314 DOI: 10.20344/amp.20323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/11/2023] [Indexed: 11/06/2023]
Abstract
Acute porphyrias are a group of rare genetic metabolic disorders, caused by a defect in one of the enzymes involved in the heme biosynthesis, which results in an abnormally high accumulation of toxic intermediates. Acute porphyrias are characterized by potentially life-threatening attacks and, for some patients, by chronic manifestations that negatively impact daily functioning and quality of life. Clinical manifestations include a nonspecific set of gastrointestinal, neuropsychiatric, and/or cutaneous symptoms. Effective diagnostic methods are widely available, but due to their clinical heterogeneity and non-specificity, many years often elapse from symptom onset to diagnosis of acute porphyrias, delaying the treatment and increasing morbidity. Therefore, increased awareness of acute porphyrias among healthcare professionals is paramount to reducing disease burden. Treatment of acute porphyrias is centered on eliminating the potential precipitants, symptomatic treatment, and suppressing the hepatic heme pathway, through the administration of hemin or givosiran. Moreover, properly monitoring patients with acute porphyrias and their relatives is fundamental to preventing acute attacks, hospitalization, and long-term complications. Considering this, a multidisciplinary panel elaborated a consensus paper, aiming to provide guidance for an efficient and timely diagnosis of acute porphyrias, and evidence-based recommendations for treating and monitoring patients and their families in Portugal. To this end, all authors exhaustively reviewed and discussed the current scientific evidence on acute porphyrias available in the literature, between November 2022 and May 2023.
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Affiliation(s)
- Luís Brito Avô
- Serviço de Medicina Interna. Hospital CUF Tejo. Lisboa; Unidade de Doenças Raras. Hospital CUF Tejo. Lisboa; Nucleo de Estudos de Doenças Raras da Sociedade Portuguesa de Medicina Interna. Lisboa. Portugal
| | - Luísa Pereira
- Nucleo de Estudos de Doenças Raras da Sociedade Portuguesa de Medicina Interna. Lisboa; Unidade de Cuidados Paliativos. Hospital CUF Tejo. Lisboa. Portugal
| | - Anabela Oliveira
- Serviço de Medicina I. Centro de Referência de Doenças Hereditárias do Metabolismo. Centro Hospitalar Universitário Lisboa Norte. Lisboa. Portugal
| | - Filipa Ferreira
- Unidade de Rastreio Neonatal, Metabolismo e Genética. Departamento de Genética Humana. Instituto Nacional de Saúde Doutor Ricardo Jorge. Porto. Portugal
| | - Paulo Filipe
- Unidade de Investigação de Dermatologia. Instituto de Medicina Molecular João Lobo Antunes. Lisboa. Portugal
| | - Inês Coelho Rodrigues
- Serviço de Gastrenterologia. Centro Hospitalar e Universitário de Lisboa Norte. Lisboa. Portugal
| | - Eduarda Couto
- Departamento de Medicina Interna. Serviço de Hematologia Clínica. Centro Hospitalar Póvoa de Varzim - Vila do Conde. Póvoa de Varzim. Portugal
| | - Fátima Ferreira
- Serviço de Hematologia Clínica. Centro Hospitalar e Universitário de São João. Porto. Portugal
| | - André Airosa Pardal
- Serviço de Hematologia Clínica. Centro Hospitalar Universitário de São João. Porto. Portugal
| | - Pedro Morgado
- Instituto de Investigação em Ciências da Vida e Saúde. Escola de Medicina. Universidade do Minho. Braga; Laboratório Associado do Governo Português ICVS/3B's. Braga/Guimarães; Serviço de Psiquiatria. Hospital de Braga. Braga. Portugal
| | - Sónia Moreira
- Nucleo de Estudos de Doenças Raras da Sociedade Portuguesa de Medicina Interna. Lisboa; Serviço de Medicina Interna. Centro de Referência de Doenças Hereditárias do Metabolismo. Centro Hospitalar e Universitário de Coimbra. Coimbra; Faculdade de Medicina. Universidade de Coimbra. Coimbra. . Portugal
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Poli A, Manceau H, Nguyen AL, Moulouel B, Dessendier N, Talbi N, Puy H, Junot C, Gouya L, Schmitt C, Lefebvre T. Quantification of Urine and Plasma Porphyrin Precursors Using LC-MS in Acute Hepatic Porphyrias: Improvement in Routine Diagnosis and in the Monitoring of Kidney Failure Patients. Clin Chem 2023; 69:1186-1196. [PMID: 37608428 DOI: 10.1093/clinchem/hvad117] [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: 03/08/2023] [Accepted: 07/10/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND The quantification of delta-aminolevulinic acid (ALA) and porphobilinogen (PBG) in urine are the first-line tests for diagnosis and monitoring of acute hepatic porphyrias (AHP). Ion-exchange chromatography (IEC), which is time- and staff-consuming and limited to urine, is still the preferred method in many specialized laboratories, despite the development of mass spectrometry-based methods. METHODS We describe a new LC-MS method that allows for rapid and simple quantification of ALA and PBG in urine and plasma with an affordable instrument that was used to analyze 2260 urine samples and 309 blood samples collected in 2 years of routine activity. The results were compared to those obtained with IEC, and urine reference ranges and concentrations in asymptomatic carriers were determined. Plasma concentrations were measured in healthy subjects and subgroups of symptomatic and asymptomatic AHP carriers. RESULTS In urine, the clinical decision limits were not impacted by the change of method despite discrepancies in low absolute concentrations, leading to lower normal values. Two-thirds of asymptomatic AHP carriers (with the exception of coproporphyria carriers) showed an increased urine PBG concentration. Urine and plasma levels showed a good correlation except in patients with kidney disease in whom the urine/plasma ratio was relatively low. CONCLUSION We described an LC-MS based method for the routine diagnosis and monitoring of AHP that allows for the detection of more asymptomatic carriers than the historical method. Blood analysis appears to be particularly relevant for patients with kidney disease, where urine measurement underestimates the increase in ALA and PBG levels.
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Affiliation(s)
- Antoine Poli
- Université de Paris Cité, INSERM U1149, Centre de Recherche sur l'Inflammation, HIROS Team, F-75018 Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, F-92700 Colombes, France
- Laboratory of Excellence, Gr-Ex, Paris, France
- Département Médicaments et Technologies pour La Santé (DMTS), Université Paris-Saclay, CEA, INRAE, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | - Hana Manceau
- Université de Paris Cité, INSERM U1149, Centre de Recherche sur l'Inflammation, HIROS Team, F-75018 Paris, France
- Laboratory of Excellence, Gr-Ex, Paris, France
- Assistance Publique-Hôpitaux de Paris, Laboratoire de Biochimie, Hôpital Beaujon, F-92110 Clichy la Garenne, France
| | - Anvi Laetitia Nguyen
- Département Médicaments et Technologies pour La Santé (DMTS), Université Paris-Saclay, CEA, INRAE, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | - Boualem Moulouel
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, F-92700 Colombes, France
| | - Nathalie Dessendier
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, F-92700 Colombes, France
| | - Neila Talbi
- Université de Paris Cité, INSERM U1149, Centre de Recherche sur l'Inflammation, HIROS Team, F-75018 Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, F-92700 Colombes, France
- Laboratory of Excellence, Gr-Ex, Paris, France
| | - Hervé Puy
- Université de Paris Cité, INSERM U1149, Centre de Recherche sur l'Inflammation, HIROS Team, F-75018 Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, F-92700 Colombes, France
- Laboratory of Excellence, Gr-Ex, Paris, France
| | - Christophe Junot
- Département Médicaments et Technologies pour La Santé (DMTS), Université Paris-Saclay, CEA, INRAE, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | - Laurent Gouya
- Université de Paris Cité, INSERM U1149, Centre de Recherche sur l'Inflammation, HIROS Team, F-75018 Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, F-92700 Colombes, France
- Laboratory of Excellence, Gr-Ex, Paris, France
| | - Caroline Schmitt
- Université de Paris Cité, INSERM U1149, Centre de Recherche sur l'Inflammation, HIROS Team, F-75018 Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, F-92700 Colombes, France
- Laboratory of Excellence, Gr-Ex, Paris, France
| | - Thibaud Lefebvre
- Université de Paris Cité, INSERM U1149, Centre de Recherche sur l'Inflammation, HIROS Team, F-75018 Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, F-92700 Colombes, France
- Laboratory of Excellence, Gr-Ex, Paris, France
- Département Médicaments et Technologies pour La Santé (DMTS), Université Paris-Saclay, CEA, INRAE, MetaboHUB, F-91191 Gif-sur-Yvette, France
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Shramova EI, Frolova AY, Filimonova VP, Deyev SM, Proshkina GM. System for Self-excited Targeted Photodynamic Therapy Based on the Multimodal Protein DARP-NanoLuc-SOPP3. Acta Naturae 2023; 15:100-110. [PMID: 38234600 PMCID: PMC10790359 DOI: 10.32607/actanaturae.27331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/28/2023] [Indexed: 01/19/2024] Open
Abstract
Despite the significant potential of photodynamic therapy (PDT) as a minimally invasive treatment modality, the use of this method in oncology has remained limited due to two serious problems: 1) limited penetration of the excitation light in tissues, which makes it impossible to affect deep-seated tumors and 2) use of chemical photosensitizers that slowly degrade in the body and cause photodermatoses and hyperthermia in patients. To solve these problems, we propose a fully biocompatible targeted system for PDT that does not require an external light source. The proposed system is based on bioluminescent resonance energy transfer (BRET) from the oxidized form of the luciferase substrate to the photosensitizing protein SOPP3. The BRET-activated system is composed of the multimodal protein DARP-NanoLuc-SOPP3, which contains a BRET pair NanoLuc-SOPP3 and a targeting module DARPin. The latter provides the interaction of the multimodal protein with tumors overexpressing tumor-associated antigen HER2 (human epidermal growth factor receptor type II). In vitro experiments in a 2D monolayer cell culture and a 3D spheroid model have confirmed HER2-specific photo-induced cytotoxicity of the system without the use of an external light source; in addition, experiments in animals with subcutaneous HER2-positive tumors have shown selective accumulation of DARP-NanoLuc-SOPP3 on the tumor site. The fully biocompatible system for targeted BRET-induced therapy proposed in this work makes it possible to overcome the following limitations: 1) the need to use an external light source and 2) the side phototoxic effect from aberrant accumulation of chemical photosensitizers. The obtained results demonstrate that the fully protein-based self-excited BRET system has a high potential for targeted PDT.
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Affiliation(s)
- E. I. Shramova
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Moscow, Russian Academy of science, Moscow, 117997 Russian Federation
| | - A. Yu. Frolova
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Moscow, Russian Academy of science, Moscow, 117997 Russian Federation
| | - V. P. Filimonova
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Moscow, Russian Academy of science, Moscow, 117997 Russian Federation
| | - S. M. Deyev
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Moscow, Russian Academy of science, Moscow, 117997 Russian Federation
- ”Biomarker” Research Laboratory, Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, 420008 Russian Federation
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, 119991 Russian Federation
| | - G. M. Proshkina
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Moscow, Russian Academy of science, Moscow, 117997 Russian Federation
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Díaz-Calvillo P, Rodríguez-Pozo JÁ, Martínez-López A, Aguilera-Peiró P, Díaz-de-Heredia C, Arias-Santiago S, Tercedor-Sánchez J. Twelve-year follow-up of bone marrow transplantation in congenital erythropoietic porphyria: lessons learned from a challenging case. Clin Exp Dermatol 2023; 48:1187-1189. [PMID: 37409586 DOI: 10.1093/ced/llad219] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 06/19/2023] [Indexed: 07/07/2023]
Abstract
The only curative treatment for congenital erythropoietic porphyria (CEP) is bone marrow transplantation (BMT), but long-term data on this therapy in CEP are scarce. We present the evolution after 12 years of a case of CEP treated with BMT. The BMT has allowed the young patient to develop adequately and to avoid devastating consequences, but mild skin symptoms along with liver and kidney damage persist.
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Affiliation(s)
- Pablo Díaz-Calvillo
- Dermatology Unit, Hospital Universitario Virgen de las Nieves, Granada, Spain
- TECe19-Investigational and Translational Dermatology Research Group, Instituto de Investigación Biosanitaria (IBS), Granada, Spain
| | - Juan Ángel Rodríguez-Pozo
- Dermatology Unit, Hospital Universitario Virgen de las Nieves, Granada, Spain
- TECe19-Investigational and Translational Dermatology Research Group, Instituto de Investigación Biosanitaria (IBS), Granada, Spain
| | - Antonio Martínez-López
- Dermatology Unit, Hospital Universitario Virgen de las Nieves, Granada, Spain
- TECe19-Investigational and Translational Dermatology Research Group, Instituto de Investigación Biosanitaria (IBS), Granada, Spain
| | | | | | - Salvador Arias-Santiago
- Dermatology Unit, Hospital Universitario Virgen de las Nieves, Granada, Spain
- TECe19-Investigational and Translational Dermatology Research Group, Instituto de Investigación Biosanitaria (IBS), Granada, Spain
- Department of Dermatology, Faculty of Medicine, University of Granada, Granada, Spain
| | - Jesus Tercedor-Sánchez
- Dermatology Unit, Hospital Universitario Virgen de las Nieves, Granada, Spain
- TECe19-Investigational and Translational Dermatology Research Group, Instituto de Investigación Biosanitaria (IBS), Granada, Spain
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8
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Mantel Ä, Vassiliou D, Lissing M, Stephansson O, Wahlin S, Sardh E. Maternal and fetal outcomes in acute hepatic porphyria: A Swedish National Cohort Study. J Inherit Metab Dis 2023; 46:675-686. [PMID: 37078226 DOI: 10.1002/jimd.12616] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/22/2023] [Accepted: 04/19/2023] [Indexed: 04/21/2023]
Abstract
Current knowledge of pregnancy and perinatal outcomes in women with acute hepatic porphyria (AHP) is largely based on biochemical disease models, case reports, and case series. We performed a nationwide, registered-based cohort study to investigate the association between maternal AHP and the risk of adverse pregnancy and perinatal outcomes. All women in the Swedish Porphyria Register with confirmed AHP aged 18 years or older between 1987 and 2015 and matched general population comparators, with at least one registered delivery in the Swedish Medical Birth Register were included. Risk ratios (RRs) of pregnancy complications, delivery mode and perinatal outcomes were estimated and adjusted for maternal age at delivery, area of residency, birth year and parity. Women with acute intermittent porphyria (AIP), the most common form of AHP, were further categorized according to maximal lifetime urinary porphobilinogen (U-PBG) levels. The study included 214 women with AHP and 2174 matched comparators. Women with AHP presented with a higher risk for pregnancy-induced hypertensive disorder (aRR 1.73, 95% CI 1.12-2.68), gestational diabetes (aRR 3.41, 95% CI 1.69-6.89), and small-for-gestational-age birth (aRR 2.08, 95% CI 1.26-3.45). In general, RRs were higher among women with AIP who had high lifetime U-PBG levels. Our study shows an increased risk for pregnancy induced hypertensive disease, gestational diabetes, and small for gestational age births for AHP women, with higher relative risks for women with biochemically active AIP. No increased risk for perinatal death or malformations was observed.
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Affiliation(s)
- Ängla Mantel
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
- Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
- Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Daphne Vassiliou
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Centre for Inherited Metabolic Diseases, Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Lissing
- Hepatology Division, Karolinska University Hospital, Stockholm, Sweden
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
- Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
- Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Staffan Wahlin
- Hepatology Division, Karolinska University Hospital, Stockholm, Sweden
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Eliane Sardh
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Centre for Inherited Metabolic Diseases, Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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9
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Wang B, Bonkovsky HL, Lim JK, Balwani M. AGA Clinical Practice Update on Diagnosis and Management of Acute Hepatic Porphyrias: Expert Review. Gastroenterology 2023; 164:484-491. [PMID: 36642627 DOI: 10.1053/j.gastro.2022.11.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/28/2022] [Accepted: 11/20/2022] [Indexed: 01/17/2023]
Abstract
DESCRIPTION The acute hepatic porphyrias (AHP) are rare, inborn errors of heme-metabolism and include acute intermittent porphyria, hereditary coproporphyria, variegate porphyria, and porphyria due to severe deficiency of 5-aminolevulinic acid dehydratase. Acute intermittent porphyria is the most common type of AHP, with an estimated prevalence of patients with symptoms of approximately 1 in 100,000. The major clinical presentation involves attacks of severe pain, usually abdominal and generalized, without peritoneal signs or abnormalities on cross-sectional imaging. Acute attacks occur mainly in women in their childbearing years. AHP should be considered in the evaluation of all patients, and especially women aged 15-50 years with recurrent severe abdominal pain not ascribable to common causes. The screening tests of choice include random urine porphobilinogen and δ-aminolevulinic acid corrected to creatinine. All patients with elevations in urinary porphobilinogen and/or δ-aminolevulinic acid should initially be presumed to have AHP. The cornerstones of management include discontinuation of porphyrinogenic drugs and chemicals, administration of oral or intravenous dextrose and intravenous hemin, and use of analgesics and antiemetics. Diagnosis of AHP type can be confirmed after initial treatment by genetic testing for pathogenic variants in HMBS, CPOX, PPOX, and ALAD genes. AHP is also associated with chronic symptoms and long-term risk of systemic arterial hypertension, chronic renal and liver disease, and hepatocellular carcinoma. Patients who have recurrent acute attacks (4 or more per year) should be considered for prophylactic therapy with intravenous hemin or subcutaneous givosiran. Liver transplantation is curative and reserved for patients with intractable symptoms who have failed other treatment options. METHODS This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. These Best Practice Advice (BPA) statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these BPA statements do not carry formal ratings of the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Women aged 15-50 years with unexplained, recurrent severe abdominal pain without a clear etiology after an initial workup should be considered for screening for an AHP. BEST PRACTICE ADVICE 2: Initial diagnosis of AHP should be made by biochemical testing measuring δ-aminolevulinic acid, porphobilinogen, and creatinine on a random urine sample. BEST PRACTICE ADVICE 3: Genetic testing should be used to confirm the diagnosis of AHP in patients with positive biochemical testing. BEST PRACTICE ADVICE 4: Acute attacks of AHP that are severe enough to require hospital admission should be treated with intravenous hemin, given daily, preferably into a high-flow central vein. BEST PRACTICE ADVICE 5: In addition to intravenous hemin, management of acute attacks of AHP should include pain control, antiemetics, management of systemic arterial hypertension, tachycardia, and hyponatremia, and hypomagnesemia, if present. BEST PRACTICE ADVICE 6: Patients should be counseled to avoid identifiable triggers that may precipitate acute attacks, such as alcohol and porphyrinogenic medications. BEST PRACTICE ADVICE 7: Prophylactic heme therapy or givosiran, administered in an outpatient setting, should be considered in patients with recurrent attacks (4 or more per year). BEST PRACTICE ADVICE 8: Liver transplantation for AHP should be limited to patients with intractable symptoms and significantly decreased quality of life who are refractory to pharmacotherapy. BEST PRACTICE ADVICE 9: Patients with AHP should be monitored annually for liver disease. BEST PRACTICE ADVICE 10: Patients with AHP, regardless of the severity of symptoms, should undergo surveillance for hepatocellular carcinoma, beginning at age 50 years, with liver ultrasound every 6 months. BEST PRACTICE ADVICE 11: Patients with AHP on treatment should undergo surveillance for chronic kidney disease annually with serum creatinine and estimated glomerular filtration rate. BEST PRACTICE ADVICE 12: Patients should be counseled on the chronic and long-term complications of AHP, including neuropathy, chronic kidney disease, hypertension, and hepatocellular carcinoma, and need for long-term monitoring.
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Affiliation(s)
- Bruce Wang
- Department of Medicine and Division of Gastroenterology, University of California San Francisco, San Francisco, California.
| | - Herbert L Bonkovsky
- Section of Gastroenterology and Hepatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Joseph K Lim
- Section of Digestive Diseases and Yale Liver Center, Yale University School of Medicine, New Haven, Connecticut
| | - Manisha Balwani
- Departments of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
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Bonkovsky HL, Rudnick SP, Ma CD, Overbey JR, Wang K, Faust D, Hallberg C, Hedstrom K, Naik H, Moghe A, Anderson KE. Ledipasvir/Sofosbuvir Is Effective as Sole Treatment of Porphyria Cutanea Tarda with Chronic Hepatitis C. Dig Dis Sci 2023; 68:2738-2746. [PMID: 36811718 PMCID: PMC9945827 DOI: 10.1007/s10620-023-07859-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/28/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND AND AIMS Chronic hepatitis C [CHC] is a risk factor for porphyria cutanea tarda [PCT]. To assess whether ledipasvir/sofosbuvir is effective for treating both PCT and CHC, we treated patients with CHC + PCT solely with ledipasvir/sofosbuvir and followed them for at least 1 year to assess cure of CHC and remission of PCT. METHODS Between September 2017 and May 2020, 15 of 23 screened PCT + CHC patients were eligible and enrolled. All were treated with ledipasvir/sofosbuvir at recommended doses and durations, according to their stage of liver disease. We measured plasma and urinary porphyrins at baseline and monthly for the first 12 months and at 16, 20, and 24 mos. We measured serum HCV RNA at baseline, 8-12, and 20-24 mos. Cure of HCV was defined as no detectable serum HCV RNA ≥ 12 weeks after the end of treatment (EOT). Remission of PCT was defined clinically as no new blisters or bullae and biochemically as urinary uro- plus hepta-carboxyl porphyrins ≤ 100 mcg/g creatinine. RESULTS All 15 patients, 13 of whom were men, were infected with HCV genotype 1. 2/15 withdrew or were lost to follow-up. Of the remaining 13, 12 achieved cure of CHC; 1 had complete virological response, followed by relapse of HCV after ledipasvir/sofosbuvir but was subsequently cured by treatment with sofosbuvir/velpatasvir. Of the 12 cured of CHC, all achieved sustained clinical remission of PCT. CONCLUSIONS Ledipasvir/sofosbuvir [and likely other direct-acting antivirals] is an effective treatment for HCV in the presence of PCT and leads to clinical remission of PCT without additional phlebotomy or low-dose hydroxychloroquine treatment. TRIAL REGISTRATION ClinicalTrials.gov NCT03118674.
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Affiliation(s)
- Herbert L Bonkovsky
- Section On Gastroenterology & Hepatology, Department of Internal Medicine, Wake Forest University School of Medicine, E-112, NRC, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA.
| | - Sean P Rudnick
- Section On Gastroenterology & Hepatology, Department of Internal Medicine, Wake Forest University School of Medicine, E-112, NRC, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Christopher D Ma
- Section On Gastroenterology & Hepatology, Department of Internal Medicine, Wake Forest University School of Medicine, E-112, NRC, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Jessica R Overbey
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Kelly Wang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Denise Faust
- Section On Gastroenterology & Hepatology, Department of Internal Medicine, Wake Forest University School of Medicine, E-112, NRC, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Csilla Hallberg
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, 77555-0655, USA
| | - Karli Hedstrom
- Department of Human Genetics & Genomics, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Hetanshi Naik
- Department of Human Genetics & Genomics, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Akshata Moghe
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, 77555-0655, USA
| | - Karl E Anderson
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, 77555-0655, USA
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Traber GM, Yu AM. RNAi-Based Therapeutics and Novel RNA Bioengineering Technologies. J Pharmacol Exp Ther 2023; 384:133-154. [PMID: 35680378 PMCID: PMC9827509 DOI: 10.1124/jpet.122.001234] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 01/26/2023] Open
Abstract
RNA interference (RNAi) provides researchers with a versatile means to modulate target gene expression. The major forms of RNAi molecules, genome-derived microRNAs (miRNAs) and exogenous small interfering RNAs (siRNAs), converge into RNA-induced silencing complexes to achieve posttranscriptional gene regulation. RNAi has proven to be an adaptable and powerful therapeutic strategy where advancements in chemistry and pharmaceutics continue to bring RNAi-based drugs into the clinic. With four siRNA medications already approved by the US Food and Drug Administration (FDA), several RNAi-based therapeutics continue to advance to clinical trials with functions that closely resemble their endogenous counterparts. Although intended to enhance stability and improve efficacy, chemical modifications may increase risk of off-target effects by altering RNA structure, folding, and biologic activity away from their natural equivalents. Novel technologies in development today seek to use intact cells to yield true biologic RNAi agents that better represent the structures, stabilities, activities, and safety profiles of natural RNA molecules. In this review, we provide an examination of the mechanisms of action of endogenous miRNAs and exogenous siRNAs, the physiologic and pharmacokinetic barriers to therapeutic RNA delivery, and a summary of the chemical modifications and delivery platforms in use. We overview the pharmacology of the four FDA-approved siRNA medications (patisiran, givosiran, lumasiran, and inclisiran) as well as five siRNAs and several miRNA-based therapeutics currently in clinical trials. Furthermore, we discuss the direct expression and stable carrier-based, in vivo production of novel biologic RNAi agents for research and development. SIGNIFICANCE STATEMENT: In our review, we summarize the major concepts of RNA interference (RNAi), molecular mechanisms, and current state and challenges of RNAi drug development. We focus our discussion on the pharmacology of US Food and Drug Administration-approved RNAi medications and those siRNAs and miRNA-based therapeutics that entered the clinical investigations. Novel approaches to producing new true biological RNAi molecules for research and development are highlighted.
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Affiliation(s)
| | - Ai-Ming Yu
- Department of Biochemistry and Molecular Medicine, University of California (UC) Davis School of Medicine, Sacramento, California
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Lefever S, Peersman N, Meersseman W, Cassiman D, Vermeersch P. Development and validation of diagnostic algorithms for the laboratory diagnosis of porphyrias. J Inherit Metab Dis 2022; 45:1151-1162. [PMID: 36053909 DOI: 10.1002/jimd.12545] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 08/04/2022] [Accepted: 08/11/2022] [Indexed: 11/09/2022]
Abstract
Porphyrias are rare metabolic disorders of the haem synthesis. They can present with acute neurovisceral attacks, cutaneous symptoms, or a combination of both. As they present with a wide variety of clinical symptoms, diagnosis is often delayed and correct interpretation of porphyria-related tests remains a challenge for many physicians. We developed and validated two algorithms for the laboratory diagnosis of porphyrias based on presenting symptoms. Based on a literature search and clinical/laboratory expertise, we developed algorithms for acute and cutaneous porphyrias. We validated these algorithms using all porphyria related laboratory test requests between January 1st 2000 and September 30th 2020 in UZ Leuven. In addition, we also evaluated our algorithm using samples from the European porphyria network (EPNET) external quality assessment scheme (2010-2021). Sensitivity of the algorithm for acute porphyria was 100.0% [74.9%-100.0%] (13 acute intermittent porphyria (AIP) and 1 variegate porphyria [VP]) with a specificity of 98.5% [91.0%-100.0%] (65 patients). Sensitivity of the algorithm for cutaneous porphyria was 100% [95.1%-100.0%] (7 VP, 59 porphyria cutanea tarda (PCT), 23 erythropoietic protoporphyria (EPP), 2 X-linked erythropoietic protoporphyria [XLEPP]) with a specificity of 93.9% [82.9%-98.5%]. There were no diagnostic samples of other types of porphyria. The algorithms correctly identified 18 of the 19 EPNET porphyria cases. One of the two hereditary coproporphyria cases was missed. The algorithms for acute and cutaneous porphyria showed high sensitivity and specificity and can be used to aid the clinician in correctly interpreting the laboratory findings of porphyria-related tests.
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Affiliation(s)
- Stefanie Lefever
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Nele Peersman
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Wouter Meersseman
- Center of Metabolic Diseases, University Hospitals Leuven, Leuven, Belgium
| | - David Cassiman
- Center of Metabolic Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Vermeersch
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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Plasma porphyrins among end stage renal disease patients and cutaneous symptoms- is there still an association? Mol Genet Metab Rep 2022; 33:100928. [PMID: 36281443 PMCID: PMC9587357 DOI: 10.1016/j.ymgmr.2022.100928] [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] [Received: 08/19/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction Several abnormalities of porphyrin metabolism leading to Porphyria Cutanea Tarda (PCT) have been described in early studies of End Stage Renal Disease (ESRD) patients, with a reported prevalence of 5-18%. We aimed to evaluate porphyrin levels and correlation to skin manifestations in modern dialysis era. Methods The study cohort included adult hemodialysis patients from a single center tertiary medical center. All patients underwent a full skin examination, completed the Dermatology Life Quality Index questioner, and provided a blood sample for porphyrin levels assessment. Results A total of 94 adult hemodialysis patients were recruited to the study. No clinical PCT was diagnosed. Porphyrin levels did not correlate with any clinical or dialysis quality parameters. Conclusions In modern hemodialysis era, possibly due to improved porphyrins' metabolism and dialysis removal, PCT is much less prevalent among hemodialysis patients than previously reported in the past.
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Wang B, Ventura P, Takase KI, Thapar M, Cassiman D, Kubisch I, Liu S, Sweetser MT, Balwani M. Disease burden in patients with acute hepatic porphyria: experience from the phase 3 ENVISION study. Orphanet J Rare Dis 2022; 17:327. [PMID: 36028858 PMCID: PMC9419398 DOI: 10.1186/s13023-022-02463-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/24/2022] [Indexed: 11/29/2022] Open
Abstract
Background Acute hepatic porphyria (AHP) is a family of four rare genetic diseases, each involving deficiency in a hepatic heme biosynthetic enzyme. Resultant overproduction of the neurotoxic intermediates δ-aminolevulinic acid (ALA) and porphobilinogen (PBG) leads to disabling acute neurovisceral attacks and progressive neuropathy. We evaluated the AHP disease burden in patients aged ≥ 12 years in a post hoc analysis of the Phase 3, randomized, double-blind, placebo-controlled ENVISION trial of givosiran (NCT03338816), an RNA interference (RNAi) therapeutic that targets the enzyme ALAS1 to decrease ALA and PBG production. We analyzed baseline AHP severity via chronic symptoms between attacks, comorbidities, concomitant medications, hemin-associated complications, and quality of life (QOL) and evaluated givosiran (2.5 mg/kg monthly) in patients with and without prior hemin prophylaxis on number and severity of attacks and pain scores during and between attacks. Results Participants (placebo, n = 46; givosiran, n = 48) included patients with low and high annualized attack rates (AARs; range 0–46). At baseline, patients reported chronic symptoms (52%), including nausea, fatigue, and pain; comorbidities, including neuropathy (38%) and psychiatric disorders (47%); concomitant medications, including chronic opioids (29%); hemin-associated complications (eg, iron overload); and poor QOL (low SF-12 and EuroQol visual analog scale scores). A linear relationship between time since diagnosis and AAR with placebo suggested worsening of disease over time without effective treatment. Givosiran reduced the number and severity of attacks, days with worst pain scores above baseline, and opioid use versus placebo. Conclusions Patients with AHP, regardless of annualized attack rates, have considerable disease burden that may partly be alleviated with givosiran.
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Affiliation(s)
- Bruce Wang
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, 94143, USA.
| | - Paolo Ventura
- University of Modena and Reggio Emilia, Modena, Italy
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Dental and Periodontal Health in Acute Intermittent Porphyria. Life (Basel) 2022; 12:life12081270. [PMID: 36013449 PMCID: PMC9410213 DOI: 10.3390/life12081270] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/09/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
In the inherited metabolic disorder acute intermittent porphyria (AIP), high sugar intake prevents porphyric attacks due to the glucose effect and the following high insulin levels that may lower AIP disease activity. Insulin resistance is a known risk factor for periodontitis and sugar changes diabetogenic hormones and affects dental health. We hypothesized differences in homeostasis model assessment (HOMA) scores for insulin resistance in AIP cases vs. controls and in those with periodontitis. Our aim was to systematically study dental health in AIP as poor dental health was previously only described in case reports. Further, we aimed to examine if poor dental health and kidney failure might worsen AIP as chronic inflammation and kidney failure might increase disease activity. In 47 AIP cases and 47 matched controls, X-rays and physical examination of clinical attachment loss (CAL), probing pocket depth (PPD), and decayed missing filled teeth (DMFT) were performed. Dietary intake was evaluated through a diet logbook. Plasma cytokines and diabetogenic hormones were measured using multiplex technology and urine porphobilinogen and kidney and liver function by routine methods. An excel spreadsheet from the University of Oxford was used to estimate HOMA scores; beta cell function, HOMA%B (%B), insulin sensitivity, HOMA%S (%S), and insulin resistance HOMA-IR (IR), based on glucose and plasma (P) C-peptide. The Wilcoxon matched-pairs signed rank test, the Mann−Whitney U-test, and Spearman’s non-parametric correlation were used. Insulin (p = 0.007) and C-peptide (p = 0.006) were higher in the AIP cases with periodontitis versus those without. In AIP patients, the liver fibrosis index 4 correlated with DMFT (p < 0.001) and CAL ≥4 mm (p = 0.006); the estimated glomerular filtration rate correlated with DMFT (p < 0.001) and CAL ≥4 mm (p = 0.02). CAL ≥4 mm was correlated with chemokine ligand 11 and interleukin (IL)-13 (p = 0.04 for both), and PPD >5 mm was correlated with plasminogen activator inhibitor-1 (p = 0.003) and complement component 3 (p = 0.02). In conclusion, dental health in AIP cases was correlated with insulin resistance, inflammatory markers, and biomarkers of kidney and liver function, demonstrating that organ damage in the kidney and liver are associated with poorer dental health.
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Endothelial Dysfunction in Acute Hepatic Porphyrias. Diagnostics (Basel) 2022; 12:diagnostics12061303. [PMID: 35741113 PMCID: PMC9221615 DOI: 10.3390/diagnostics12061303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/21/2022] [Accepted: 05/22/2022] [Indexed: 12/12/2022] Open
Abstract
Background Acute hepatic porphyrias (AHPs) are a group of rare diseases caused by dysfunctions in the pathway of heme biosynthesis. Although acute neurovisceral attacks are the most dramatic manifestations, patients are at risk of developing long-term complications, several of which are of a vascular nature. The accumulation of non-porphyrin heme precursors is deemed to cause most clinical symptoms. Aim We measured the serum levels of endothelin-1 (ET-1) and nitric oxide (NO) to assess the presence of endothelial dysfunction (ED) in patients with AHPs. Forty-six patients were classified, according to their clinical phenotype, as symptomatic (AP-SP), asymptomatic with biochemical alterations (AP-BA), and asymptomatic without biochemical alterations (AP-AC). Results Even excluding those under hemin treatment, AP-SP patients had the lowest NO and highest ET-1 levels, whereas no significant differences were found between AP-BA and AP-AC patients. AP-SP patients had significantly more often abnormal levels of ED markers. Patients with the highest heme precursor urinary levels had the greatest alterations in ED markers, although no significant correlation was detected. Conclusions ED is more closely related to the clinical phenotype of AHPs than to their classical biochemical alterations. Some still undefined disease modifiers may possibly determine the clinical picture of AHPs through an effect on endothelial functions.
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Ventura P, Ricci A. Givosiran for the treatment of acute hepatic porphyria. Expert Rev Clin Pharmacol 2022; 15:383-393. [DOI: 10.1080/17512433.2022.2075848] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Paolo Ventura
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Ricci
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Modena, Italy
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Sardh E, Harper P. RNAi therapy with givosiran significantly reduces attack rates in acute intermittent porphyria. J Intern Med 2022; 291:593-610. [PMID: 35067977 DOI: 10.1111/joim.13443] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Acute hepatic porphyria (AHP) is a group of inherited metabolic disorders that affect hepatic heme biosynthesis. They are associated with attacks of neurovisceral manifestations that can be life threatening and constitute what is considered an acute porphyria attack. Until recently, the sole specific treatment for acute porphyria attacks consisted of the intravenous administration of hemin. Although attacks are often sporadic, some patients develop recurrent acute attacks, with devastating effects on quality of life. Liver transplantation has historically been the sole curative treatment option. The clinical manifestations of AHP are attributed to the accumulation of the heme precursor 5-aminolevulinic acid (ALA) and porphobilinogen (PBG). Advances in molecular engineering have provided new therapeutic possibilities for modifying the heme synthetic pathway. We reviewed the background and current status of AHP treatment using liver-directed small interfering RNA targeting ALAS1. The therapeutic aim was to normalize the levels of ALAS1, which is highly upregulated during acute porphyria attacks. Givosiran is now an approved drug for use in adults and adolescents aged 12 years and older. The results of clinical trials have shown that givosiran treatment leads to a rapid and sustained reduction of ALAS1 mRNA, decreased heme precursor levels, and a decreased rate of acute attacks compared with placebo. The clinical trials (phases I, II, and III) were all randomized and placebo controlled. Many patients enrolled in the initial clinical trials have continued treatment in open label extension and extended/compassionate-use programs in countries where givosiran is not yet commercially available.
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Affiliation(s)
- Eliane Sardh
- Department of Molecular Medicine and Surgery, Centre for Inherited Metabolic Diseases, Porphyria Centre Sweden, Department of Endocrinology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Pauline Harper
- Department of Medical Biochemistry and Biophysics, Centre for inherited Metabolic Diseases, Porphyria Centre Sweden., Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Marcacci M, Ricci A, Cuoghi C, Marchini S, Pietrangelo A, Ventura P. Challenges in diagnosis and management of acute hepatic porphyrias: from an uncommon pediatric onset to innovative treatments and perspectives. Orphanet J Rare Dis 2022; 17:160. [PMID: 35392955 PMCID: PMC8991793 DOI: 10.1186/s13023-022-02314-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/28/2022] [Indexed: 12/17/2022] Open
Abstract
Acute hepatic porphyrias (AHPs) are a family of four rare genetic diseases resulting from a deficiency in one of the enzymes involved in heme biosynthesis. AHP patients can experience potentially life-threatening acute attacks, characterized by severe abdominal pain, along with other signs and symptoms including nausea, mental confusion, hyponatraemia, hypertension, tachycardia and muscle weakness. Some patients also experience chronic manifestations and long-term complications, such as chronic pain syndrome, neuropathy and porphyria-associated kidney disease. Most symptomatic patients have only a few attacks in their lifetime; nevertheless, some experience frequent attacks that result in ongoing symptoms and a significant negative impact on their quality of life (QoL). Initial diagnosis of AHP can be made with a test for urinary porphobilinogen, \documentclass[12pt]{minimal}
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\begin{document}$$\delta$$\end{document}δ-aminolaevulinic acid and porphyrins using a single random (spot) sample. However, diagnosis is frequently missed or delayed, often for years, because the clinical symptoms of AHP are non-specific and mimic other more common disorders. Delayed diagnosis is of concern as some commonly used medications can trigger or exacerbate acute attacks, and untreated attacks can become severe, potentially leading to permanent neurological damage or fatality. Other attack triggers include hormonal fluctuations in women, stress, alcohol and low-calorie diets, which should be avoided in patients where possible. For the management of attacks, intravenous hemin is approved, whereas new therapeutic approaches are currently being investigated as a baseline therapy for prevention of attacks and improvement of QoL. Among these, a novel siRNA-based agent, givosiran, has shown very promising results in a recently concluded Phase III trial and has been approved for the management of AHPs. Here, we propose a challenging case study-with a very unusual pediatric onset of variegate porphyria-as a starting point to summarize the main clinical aspects (namely, clinical manifestations, diagnostic challenges, and therapeutic management) of AHPs, with a focus on the latest therapeutic innovations.
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Affiliation(s)
- Matteo Marcacci
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Andrea Ricci
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Chiara Cuoghi
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Stefano Marchini
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Antonello Pietrangelo
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Paolo Ventura
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy.
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Poli A, Schmitt C, Moulouel B, Mirmiran A, Talbi N, Rivière S, Cerutti D, Bouchoule I, Faivre A, Grobost V, Douillard C, Duchêne F, Fiorentino V, Dupré T, Manceau H, Peoc'h K, Puy H, Lefebvre T, Gouya L. Givosiran in acute intermittent porphyria: A personalized medicine approach. Mol Genet Metab 2022; 135:206-214. [PMID: 35058124 DOI: 10.1016/j.ymgme.2022.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 11/30/2021] [Accepted: 01/07/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND In patients with acute intermittent porphyria (AIP), induction of delta aminolevulinic acid synthase 1 (ALAS1) leads to haem precursor accumulation that may cause recurring acute attacks. In a recent phase III trial, givosiran significantly reduced the attack rate in severe AIP patients. Frequent adverse events were injection-site reaction, fatigue, nausea, chronic kidney disease and increased alanine aminotransferase. OBJECTIVES To describe the efficacy and safety of givosiran based on a personalized medical approach. METHODS We conducted a retrospective patient file study in 25 severe AIP patients treated with givosiran in France. We collected data on clinical and biochemical efficacy along with reports of adverse events. RESULTS Givosiran drastically reduced the attack rate in our cohort, as 96% were attack-free at the time of the study. The sustained efficacy of givosiran in most patients allowed us to personalize dosing frequency. In 42%, givosiran was only given when haem precursor levels were increasing. Our data suggest that givosiran is most effective when given early in the disease course. We confirmed a high prevalence of adverse events. One patient discontinued treatment due to acute pancreatitis. All patients had hyperhomocysteinemia, and all patients with initial homocysteine levels available showed an increase under treatment. In this context, one patient was diagnosed with pulmonary embolism. CONCLUSION The sustained effect of givosiran allowed a decrease in dosing frequency without compromising treatment efficacy. The high prevalence of adverse events emphasizes the importance of restricting the treatment to severe AIP and administering the minimum effective dose for each patient.
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Affiliation(s)
- Antoine Poli
- Université de Paris, INSERM U1149, Centre de Recherche sur l’Inflammation, F-75018 Paris, France
- AP-HP, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
- Laboratory of Excellence Gr-Ex, Paris
| | - Caroline Schmitt
- Université de Paris, INSERM U1149, Centre de Recherche sur l’Inflammation, F-75018 Paris, France
- AP-HP, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
- Laboratory of Excellence Gr-Ex, Paris
| | - Boualem Moulouel
- AP-HP, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
| | - Arienne Mirmiran
- AP-HP, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
| | - Neila Talbi
- AP-HP, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
| | - Sophie Rivière
- CHU Montpellier, Médecine interne, Hôpital St Eloi, Montpellier, France
| | - Diane Cerutti
- CH Toulon, Médecine polyvalente, La Seyne-sur-Mer, France
| | - Isabelle Bouchoule
- CHI Elbeuf Louviers Val de Reuil, Néphrologie, Saint-Aubin-lès-Elbeuf, France
| | | | | | - Claire Douillard
- CHRU Lille, Endocrinologie-diabétologie-métabolisme-nutrition, hôpital Huriez, Lille, France
| | - Francis Duchêne
- Hôpital Nord Franche-Comté, Médecine interne, Trévenans, France
| | - Valeria Fiorentino
- Université de Paris, INSERM U1149, Centre de Recherche sur l’Inflammation, F-75018 Paris, France
| | - Thierry Dupré
- Université de Paris, INSERM U1149, Centre de Recherche sur l’Inflammation, F-75018 Paris, France
| | - Hana Manceau
- Université de Paris, INSERM U1149, Centre de Recherche sur l’Inflammation, F-75018 Paris, France
- AP-HP, Biochimie, Hôpital Beaujon, Clichy, France
| | - Katell Peoc'h
- Université de Paris, INSERM U1149, Centre de Recherche sur l’Inflammation, F-75018 Paris, France
- AP-HP, Biochimie, Hôpital Beaujon, Clichy, France
| | - Hervé Puy
- Université de Paris, INSERM U1149, Centre de Recherche sur l’Inflammation, F-75018 Paris, France
- AP-HP, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
- Laboratory of Excellence Gr-Ex, Paris
| | - Thibaud Lefebvre
- Université de Paris, INSERM U1149, Centre de Recherche sur l’Inflammation, F-75018 Paris, France
- AP-HP, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
| | - Laurent Gouya
- Université de Paris, INSERM U1149, Centre de Recherche sur l’Inflammation, F-75018 Paris, France
- AP-HP, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
- Laboratory of Excellence Gr-Ex, Paris
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Sirch C, Khanna N, Frassetto L, Bianco F, Artero ML. Diagnosis of acute intermittent porphyria in a renal transplant patient: A case report. World J Transplant 2022; 12:8-14. [PMID: 35096552 PMCID: PMC8771597 DOI: 10.5500/wjt.v12.i1.8] [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: 08/11/2021] [Revised: 11/16/2021] [Accepted: 01/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute intermittent porphyria (AIP) is an inherited disorder of porphyrin metabolism with a worldwide distribution and a prevalence ranging from 1 to 9 per million population. AIP is caused by an autosomal dominant-inherited mutation of low penetrance resulting in a deficiency of porphobilinogen deaminase (PBGD) activity. Acute attacks are provoked by stressors such as certain medications, alcohol, and infection. We herein present the first case report of AIP detected in a post-renal transplant patient. CASE SUMMARY The patient was a 65-year-old man who underwent transplantation 2 years previously for suspected nephroangiosclerosis and chronic interstitial nephro-pathy. He subsequently developed diabetes mellitus which required insulin therapy. He had been treated in the recent past with local mesalamine for proctitis. He presented with classic but common symptoms of AIP including intense abdominal pain, hypertension, and anxiety. He had multiple visits to the emergency room over a 6-mo period for these same symptoms before the diagnosis of AIP was entertained. His urinary postprandial blood glucose level was 60 mg/24 h (normal, < 2 mg/24 h). He was placed on a high carbohydrate diet, and his symptoms slowly improved. CONCLUSION This case report describes a common presentation of an uncommon disease, in which post-transplant complications and medications may have contributed to precipitating the previously undiagnosed AIP. We hypothesize that the low-carbohydrate diet and insulin with which our patient was treated may have led to the attacks of AIP. Alternatively, our patient's mesalamine treatment for proctitis may have led to an acute AIP crisis. A high index of suspicion is needed to consider the diagnosis of a heme synthesis disorder, which presents with the common symptoms of abdominal pain, high blood pressure, and anxiety.
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Affiliation(s)
- Cristina Sirch
- Nefrologia e Dialisi, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste 34100, Italy
| | - Niloufar Khanna
- Medicine, California Northstate University, Elk Grove, CA 95757, United States
| | - Lynda Frassetto
- Internal Medicine, Division of Nephrology, University of California San Francisco, San Francisco, CA 94193, United States
| | - Francesco Bianco
- Nefrologia e Dialisi, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste 34100, Italy
| | - Mary Louise Artero
- Nefrologia e Dialisi, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste 34100, Italy
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22
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Anderson KE, Desnick RJ, Stewart MF, Ventura P, Bonkovsky HL. Acute Hepatic Porphyrias: "Purple Flags"-Clinical Features That Should Prompt Specific Diagnostic Testing. Am J Med Sci 2022; 363:1-10. [PMID: 34606756 DOI: 10.1016/j.amjms.2021.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 06/15/2021] [Accepted: 09/28/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Porphyrias are a group of rare diseases leading to dysregulation in heme biosynthesis and the accumulation of heme precursors, including porphyrinogens, which in their oxidized states [porphyrins] are reddish or purple. Acute hepatic porphyrias (AHP) comprise four diseases that cause acute debilitating neurovisceral attacks. Despite diagnostic advances, AHP is often undiagnosed or misdiagnosed due to a lack of disease awareness, low clinical suspicion, variable presentation, and nonspecific symptoms that mimic more common diseases. Delays in diagnosis and treatment increase the risk of serious acute and chronic complications. METHODS In order to assess whether symptoms alone or in combination might be utilized as important indicators or "purple flags" that, when present, should alert clinicians to suspect AHP and pursue specific diagnostic testing, we conducted a comprehensive review of the literature on AHP, including cohort studies and case reports over two epochs, from 1980 to 2006 and from 2012 to 2018. RESULTS We found that severe abdominal pain, with or without acute central nervous system manifestations and peripheral neuropathy, continues to be the most frequent symptom. Hyponatremia, change in urine color, and certain chronic symptoms were also identified as features that should raise suspicion of AHP. To improve diagnosis of AHP, clinicians need to take a broad perspective, including demographic data and medical history, into consideration. CONCLUSIONS The clinical features of AHP continue to be severe pain, especially pain in the abdomen. Other features that should raise suspicion are autonomic, peripheral, or central neuropathies, hyponatremia, and red-purple urine color.
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Affiliation(s)
- Karl E Anderson
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Robert J Desnick
- Department of Genetics and Genomic Medicine, Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - M Felicity Stewart
- Salford Royal NHS Foundation Trust, Salford, UK; Division of Medical Education, University of Manchester, Manchester, UK
| | - Paolo Ventura
- Internal Medicine Unit, Policlinico Hospital, Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Herbert L Bonkovsky
- Section on Gastroenterology & Hepatology, Department of Medicine, Wake Forest University School of Medicine/North Carolina Baptist Hospital, Nutrition Research Center, Winston-Salem, NC, USA..
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23
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Ricci A, Guida CC, Manzini P, Cuoghi C, Ventura P. Kidney Involvement in Acute Hepatic Porphyrias: Pathophysiology and Diagnostic Implications. Diagnostics (Basel) 2021; 11:2324. [PMID: 34943561 PMCID: PMC8700387 DOI: 10.3390/diagnostics11122324] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/06/2021] [Accepted: 12/08/2021] [Indexed: 12/27/2022] Open
Abstract
Porphyrias are a group of rare disorders originating from an enzyme dysfunction in the pathway of heme biosynthesis. Depending on the specific enzyme involved, porphyrias manifest under drastically different clinical pictures. The most dramatic presentation of the four congenital acute hepatic porphyrias (AHPs: acute intermittent porphyria-AIP, ALAD deficiency, hereditary coproporphyria-HCP, and porphyria variegata-VP) consists of potentially life-threatening neurovisceral attacks, for which givosiran, a novel and effective siRNA-based therapeutic, has recently been licensed. Nonetheless, the clinical manifestations of acute porphyrias are multifaceted and do not limit themselves to acute attacks. In particular, porphyria-associated kidney disease (PAKD) is a distinct, long-term degenerating condition with specific pathological and clinical features, for which a satisfactory treatment is not available yet. In PAKD, chronic tubule-interstitial damage has been most commonly reported, though other pathologic features (e.g., chronic fibrous intimal hyperplasia) are consistent findings. Given the relevant role of the kidney in porphyrin metabolism, the mechanisms possibly intervening in causing renal damage in AHPs are different: among others, δ-aminolevulinic acid (ALA)-induced oxidative damage on mitochondria, intracellular toxic aggregation of porphyrins in proximal tubular cells, and derangements in the delicate microcirculatory balances of the kidney might be implicated. The presence of a variant of the human peptide transporter 2 (PEPT2), with a greater affinity to its substrates (including ALA), might confer a greater susceptibility to kidney damage in patients with AHPs. Furthermore, a possible effect of givosiran in worsening kidney function has been observed. In sum, the diagnostic workup of AHPs should always include a baseline evaluation of renal function, and periodic monitoring of the progression of kidney disease in patients with AHPs is strongly recommended. This review outlines the role of the kidney in porphyrin metabolism, the available evidence in support of the current etiologic and pathogenetic hypotheses, and the known clinical features of renal involvement in acute hepatic porphyrias.
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Affiliation(s)
- Andrea Ricci
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, Regional Reference Centre for Diagnosing and Management of Porphyrias, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico of Modena, Largo del Pozzo 71, 41124 Modena, Italy; (A.R.); (C.C.)
| | - Claudio Carmine Guida
- Interregional Reference Center for the Prevention, Surveillance, Diagnosis and Treatment of Porphyria, Nephrology and Dialysis Unit, Scientific Institute for Research and Health Care, Viale Cappuccini, San Giovanni Rotondo, 71013 Foggia, Italy;
| | - Paola Manzini
- Transfusion Medicine and Blood Establishment, Regional Reference Centre for Diagnosis and Management of Porphyrias, University Hospital City of Science and Health of Torino, 10126 Torino, Italy;
| | - Chiara Cuoghi
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, Regional Reference Centre for Diagnosing and Management of Porphyrias, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico of Modena, Largo del Pozzo 71, 41124 Modena, Italy; (A.R.); (C.C.)
| | - Paolo Ventura
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, Regional Reference Centre for Diagnosing and Management of Porphyrias, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico of Modena, Largo del Pozzo 71, 41124 Modena, Italy; (A.R.); (C.C.)
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24
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Østergaard MGØ, Erlandsen EJ, Thomsen HH, Randers E. Peritoneal dialysis resulting in discontinuance of recurring attacks of acute intermittent porphyria: A case report. Semin Dial 2021; 35:93-95. [PMID: 34558740 DOI: 10.1111/sdi.13025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 09/03/2021] [Accepted: 09/09/2021] [Indexed: 11/27/2022]
Abstract
Acute intermittent porphyria is one of eight disorders arising from disturbances in heme biosynthesis where the precursors, 5-aminolevulinate and porphobilinogen, are elevated in plasma and urine. Attacks are characterized by severe abdominal pain, vomiting and/or obstipation, neurological manifestations, and psychological disturbances. The mainstay of treatment is hemin infusion to induce the negative feedback of heme synthesis. Hemodialysis is casuistically suggested as an alternative treatment. We present a case report of a 78-year-old male with acute intermittent porphyria and renal failure treated with peritoneal dialysis resulting in complete discontinuance of longstanding painful and disabling porphyria attacks.
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Affiliation(s)
| | | | - Henrik Holm Thomsen
- Department of Internal Medicine, Viborg Regional Hospital, Viborg, Denmark.,Research Unit of Multimorbidity, Viborg Regional Hospital, Viborg, Denmark
| | - Else Randers
- Department of Internal Medicine, Viborg Regional Hospital, Viborg, Denmark.,Research Unit of Multimorbidity, Viborg Regional Hospital, Viborg, Denmark
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25
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Gilles A, Vermeersch S, Vermeersch P, Wolff F, Cotton F, Tilleux S, Cassiman D. Expert consensus statement on acute hepatic porphyria in Belgium. Acta Clin Belg 2021; 77:735-741. [PMID: 34369323 DOI: 10.1080/17843286.2021.1961056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acute hepatic porphyrias (AHP) are a group of four different rare to ultra-rare, severely debilitating, and sometimes fatal diseases that significantly impact patients' lives: 5-aminolevulinic acid (ALA) dehydratase deficiency porphyria (ADP), acute intermittent porphyria (AIP), hereditary coproporphyria (HCP), and variegate porphyria (VP). Based on literature estimates, a conservative estimate of the number of AHP patients in Belgium requiring treatment, defined as patients experiencing recurrent attacks and/or chronic debilitating symptoms, is likely limited to 11-34 patients. These patients face a considerable unmet need, as there is currently no pharmaceutical treatment available that effectively prevents attacks and has an impact on other chronic symptoms of the disease.A panel consisting of the two European Porphyria Network1 (EPNet) centers in Belgium (Center for inborn errors of metabolism of UZ Leuven and the 'Centre Belge des Porphyries' of Erasme Hospital and LHUB-ULB) participated in an advisory board on 24 January 2020. Representatives of the sponsoring pharmaceutical company, Alnylam Pharmaceuticals, organized and attended the meeting. The objective of the meeting was to obtain expert input on the state-of-the-art clinical practice of AHP in Belgium. Following this meeting, this expert consensus statement was drafted, in collaboration with and coordinated by the EPNet centers in Belgium. This statement provides an overview of the state-of-the art in AHP, by means of a concise overview of AHP pathophysiology, clinical manifestations, and burden of disease, (Belgian) epidemiology, treatments, and proposed organization of care.
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Affiliation(s)
- Axelle Gilles
- Dept of Clinical Hematology, Cliniques universitaires de Bruxelles, Erasme Hospital
| | | | | | - Fleur Wolff
- Department of Clinical Chemistry, Laboratoire Hospitalier Universitaire de Bruxelles (LHUB-ULB), Université Libre de Bruxelles (ULB), Brussels, Belgium
- Centre Belge de Porphyries, Erasme Hospital, Université Libre de Bruxelles
| | - Frederic Cotton
- Department of Clinical Chemistry, Laboratoire Hospitalier Universitaire de Bruxelles (LHUB-ULB), Université Libre de Bruxelles (ULB), Brussels, Belgium
- Centre Belge de Porphyries, Erasme Hospital, Université Libre de Bruxelles
| | | | - David Cassiman
- Dienst Maag-Darm-Leverziekten en Metabool Centrum, UZ Leuven, Belgium
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To-Figueras J, Wijngaard R, García-Villoria J, Aarsand AK, Aguilera P, Deulofeu R, Brunet M, Gómez-Gómez À, Pozo OJ, Sandberg S. Dysregulation of homocysteine homeostasis in acute intermittent porphyria patients receiving heme arginate or givosiran. J Inherit Metab Dis 2021; 44:961-971. [PMID: 33861472 DOI: 10.1002/jimd.12391] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 12/16/2022]
Abstract
Acute intermittent porphyria (AIP) is a rare metabolic disease caused by mutations within the hydroxymethylbilane synthase gene. Previous studies have reported increased levels of plasma total homocysteine (tHcy) in symptomatic AIP patients. In this study, we present long-term data for tHcy and related parameters for an AIP patient cohort (n = 37) in different clinical disease-states. In total, 25 patients (68%) presented with hyperhomocysteinemia (HHcy; tHcy > 15 μmol/L) during the observation period. HHcy was more frequent in AIP patients with recurrent disease receiving heme arginate, than in nonrecurrent (median tHcy: 21.6 μmol/L; range: 10-129 vs median tHcy: 14.5 μmol/L; range 6-77). Long-term serial analyses showed a high within-person tHcy variation, especially among the recurrent patients (coefficient of variation: 16.4%-78.8%). HHcy was frequently associated with low blood concentrations of pyridoxal-5'-phosphate and folate, while cobalamin concentration and the allele distribution of the methylene-tetrahydrofolate-reductase gene were normal. Strikingly, 6 out of the 9 recurrent patients who were later included in a regime of givosiran, a small-interfering RNA that effectively reduced recurrent attacks, showed further increased tHcy (median tHcy in 9 patients: 105 μmol/L; range 16-212). Screening of amino acids in plasma by liquid-chromatography showed co-increased levels of methionine (median 71 μmol/L; range 23-616; normal <40), suggestive of acquired deficiency of cystathionine-β-synthase. The kynunerine/tryptophan ratio in plasma was, however, normal, indicating a regular metabolism of tryptophan by heme-dependent enzymes. In conclusion, even if HHcy was observed in AIP patients receiving heme arginate, givosiran induced an aggravation of the dysregulation, causing a co-increase of tHcy and methionine resembling classic homocystinuria.
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Affiliation(s)
- Jordi To-Figueras
- Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Robin Wijngaard
- Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Judit García-Villoria
- Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Aasne K Aarsand
- Norwegian Porphyria Centre (NAPOS), Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Norwegian Organization for Quality Improvement of Laboratory Examinations, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Paula Aguilera
- Dermatology Department, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Ramon Deulofeu
- Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Mercè Brunet
- Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Àlex Gómez-Gómez
- Integrative Pharmacology and Systems Neuroscience Group, Institut Municipal Investigació Mèdica (IMIM), Hospital del Mar, Barcelona, Spain
| | - Oscar J Pozo
- Integrative Pharmacology and Systems Neuroscience Group, Institut Municipal Investigació Mèdica (IMIM), Hospital del Mar, Barcelona, Spain
| | - Sverre Sandberg
- Norwegian Porphyria Centre (NAPOS), Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Norwegian Organization for Quality Improvement of Laboratory Examinations, Haraldsplass Deaconess Hospital, Bergen, Norway
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27
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Lissing M, Nowak G, Adam R, Karam V, Boyd A, Gouya L, Meersseman W, Melum E, Ołdakowska‐Jedynak U, Reiter FP, Colmenero J, Sanchez R, Herden U, Langendonk J, Ventura P, Isoniemi H, Boillot O, Braun F, Perrodin S, Mowlem E, Wahlin S. Liver Transplantation for Acute Intermittent Porphyria. Liver Transpl 2021; 27:491-501. [PMID: 37160035 PMCID: PMC8248103 DOI: 10.1002/lt.25959] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 10/19/2020] [Accepted: 11/03/2020] [Indexed: 12/14/2022]
Abstract
Recurrent attacks of acute intermittent porphyria (AIP) result in poor quality of life and significant risks of morbidity and mortality. Liver transplantation (LT) offers a cure, but published data on outcomes after LT are limited. We assessed the pretransplant characteristics, complications, and outcomes for patients with AIP who received a transplant. Data were collected retrospectively from the European Liver Transplant Registry and from questionnaires sent to identified transplant and porphyria centers. We studied 38 patients who received transplants in 12 countries from 2002 to 2019. Median age at LT was 37 years (range, 18-58), and 34 (89%) of the patients were women. A total of 9 patients died during follow-up, and 2 patients were retransplanted. The 1-year and 5-year overall survival rates were 92% and 82%, which are comparable with other metabolic diseases transplanted during the same period. Advanced pretransplant neurological impairment was associated with increased mortality. The 5-year survival rate was 94% among 19 patients with moderate or no neuropathy at LT and 83% among 10 patients with severe neuropathy (P = 0.04). Pretransplant renal impairment was common. A total of 19 (51%) patients had a GFR < 60 mL/minute. Although few patients improved their renal function after LT, neurological impairments improved, and no worsening of neurological symptoms was recorded. No patient had AIP attacks after LT, except for a patient who received an auxiliary graft. LT is a curative treatment option for patients with recurrent attacks of AIP. Severe neuropathy and impaired renal function are common and increase the risk for poor outcomes. If other treatment options fail, an evaluation for LT should be performed early.
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Affiliation(s)
- Mattias Lissing
- Hepatology DivisionDepartment of Upper GI DiseasesPorphyria Centre SwedenKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | - Greg Nowak
- Department of Clinical Science, Intervention and Technology (CLINTEC)Karolinska Institutet and Karolinska University HospitalStockholmSweden
| | - René Adam
- Paul Brousse HospitalUniversity Paris‐SudInserm U935VillejuifFrance
| | - Vincent Karam
- Paul Brousse HospitalUniversity Paris‐SudInserm U935VillejuifFrance
| | | | - Laurent Gouya
- Centre Francais des PorphyriesHôpital Louis MourierAssistance Publique‐Hôpitaux de ParisParisFrance
| | - Wouter Meersseman
- Department of General Internal MedicineUniversitair Ziekenhuis (UZ) LeuvenLeuvenBelgium
| | - Espen Melum
- Section for GastroenterologyNorwegian Primary Sclerosing Cholangitis (PSC) Research CenterDepartment of Transplantation MedicineResearch Institute of Internal MedicineDivision of SurgeryInflammatory Diseases and TransplantationOslo University Hospital RikshospitaletHybrid Technology Hub‐Centre of ExcellenceInstitute of Basic Medical SciencesInstitute of Clinical MedicineFaculty of MedicineUniversity of OsloOsloNorway
| | | | - Florian P. Reiter
- Liver Center MunichDepartment of Medicine IIUniversity HospitalLudwig Maximilian University (LMU) MunichMunichGermany
| | - Jordi Colmenero
- Liver Transplant UnitHospital Clínic de BarcelonaInstitut d'Investigacions Biomèdiques August Pi i SunyerCentro de Investigación Biomédica en Red en Enfermedades Hepáticas y DigestivasUniversitat de BarcelonaBarcelonaSpain
| | - Rosario Sanchez
- Institute of Sanitary and Biomedical Investigation of AlicanteAlicanteSpain
| | - Uta Herden
- Department of Visceral Transplant SurgeryUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Janneke Langendonk
- Erasmus MCUniversity Medical Center RotterdamPorphyria Center RotterdamRotterdamThe Netherlands
| | - Paolo Ventura
- Department of Medical and Surgical Sciences for Children and AdultsUniversity of Modena and Reggio EmiliaUnit of Internal MedicinePoliclinico Hospital of ModenaModenaItaly
| | - Helena Isoniemi
- Department of Transplantation and Liver SurgeryHelsinki University HospitalHelsinkiFinland
| | | | - Felix Braun
- Department of General, Visceral, Thoracic, Transplantation and Pediatric SurgeryUniversitätsklinikum Schleswig‐Holstein (UKSH)Campus KielKielGermany
| | - Stéphanie Perrodin
- Department of Visceral Surgery and MedicineInselspital University Hospital of BernBernSwitzerland
| | - Elizabeth Mowlem
- The Liver UnitAddenbrooke's HospitalCambridge University HospitalsCambridgeUK
| | - Staffan Wahlin
- Hepatology DivisionDepartment of Upper GI DiseasesPorphyria Centre SwedenKarolinska Institutet and Karolinska University HospitalStockholmSweden
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Zhang MM, Bahal R, Rasmussen TP, Manautou JE, Zhong XB. The growth of siRNA-based therapeutics: Updated clinical studies. Biochem Pharmacol 2021; 189:114432. [PMID: 33513339 DOI: 10.1016/j.bcp.2021.114432] [Citation(s) in RCA: 245] [Impact Index Per Article: 81.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/14/2021] [Accepted: 01/19/2021] [Indexed: 12/11/2022]
Abstract
More than two decades after the natural gene-silencing mechanism of RNA interference was elucidated, small interfering RNA (siRNA)-based therapeutics have finally broken into the pharmaceutical market. With three agents already approved and many others in advanced stages of the drug development pipeline, siRNA drugs are on their way to becoming a standard modality of pharmacotherapy. The majority of late-stage candidates are indicated for rare or orphan diseases, whose patients have an urgent need for novel and effective therapies. Additionally, there are agents that have the potential to meet the need of a broader population. Inclisiran, for instance, is being developed for hypercholesterolemia and has shown benefit in patients who are uncontrolled even after maximal statin therapy. This review provides a brief overview of mechanisms of siRNA action, physiological barriers to its delivery and activity, and the most common chemical modifications and delivery platforms used to overcome these barriers. Furthermore, this review presents comprehensive profiles of the three approved siRNA drugs (patisiran, givosiran, and lumasiran) and the seven other siRNA candidates in Phase 3 clinical trials (vutrisiran, nedosiran, inclisiran, fitusiran, teprasiran, cosdosiran, and tivanisiran), summarizing their modifications and delivery strategies, disease-specific mechanisms of action, updated clinical trial status, and future outlooks.
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Affiliation(s)
- M May Zhang
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, CT 06269, USA
| | - Raman Bahal
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, CT 06269, USA
| | - Theodore P Rasmussen
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, CT 06269, USA
| | - José E Manautou
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, CT 06269, USA
| | - Xiao-Bo Zhong
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Connecticut, Storrs, CT 06269, USA.
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Linenberger M, Fertrin KY. Updates on the diagnosis and management of the most common hereditary porphyrias: AIP and EPP. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:400-410. [PMID: 33275677 PMCID: PMC7727547 DOI: 10.1182/hematology.2020000124] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
The porphyrias are a family of metabolic disorders caused by defects in the activity of one of the enzymes in the heme biosynthetic pathway. Acute intermittent porphyria (AIP), caused by autosomal dominant mutations in the gene encoding hydroxymethylbilane synthase, can lead to hepatocyte overaccumulation and systemic distribution of the proximal porphyrin precursors, 5-aminolevulinic acid (ALA) and porphobilinogen (PBG). ALA and PBG are toxic to neurons and extrahepatic tissue and cause the neurovisceral clinical manifestations of AIP. Management of AIP includes awareness and avoidance of triggering factors, infusions of hemin for severe acute attacks, and, if indicated for chronic suppressive therapy, maintenance treatment with hemin or givosiran, a small interfering RNA molecule that antagonizes ALA synthase 1 transcripts. Erythropoietic protoporphyria (EPP) is most commonly caused by autosomal recessive mutations in the gene encoding ferrochelatase (FECH), the heme pathway terminal enzyme. FECH deficiency leads to erythrocyte overaccumulation and high plasma levels of lipophilic protoporphyrins that photoactivate in the skin, causing burning pain and erythema. Protoporphyrins excreted in the bile can cause gallstones, cholestasis, fibrosis, and ultimately liver failure. Management of EPP includes skin protection and afamelanotide, an α-melanocyte stimulating hormone analog that increases melanin pigment and reduces photoactivation. Liver transplantation may be necessary for severe EPP-induced liver complications. Because AIP and EPP arise from defects in the heme biosynthetic pathway, hematologists are often consulted to evaluate and manage suspected or proven porphyrias. A working knowledge of these disorders increases our confidence and effectiveness as consultants and medical providers.
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Affiliation(s)
| | | | - Alberto Ortíz
- Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
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Ortiz A. Ckj consolidation among Q1 Urology and Nephrology journals. Clin Kidney J 2020; 13:723-727. [PMID: 33123351 PMCID: PMC7577766 DOI: 10.1093/ckj/sfaa197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 12/21/2022] Open
Abstract
The Clinical Kidney Journal (ckj) impact factor from Clarivate’s Web of Science for 2019 was 3.388. This consolidates ckj among journals in the top 25% (first quartile, Q1) in the Urology and Nephrology field according to the journal impact factor. The manuscripts contributing the most to the impact factor focused on chronic kidney disease (CKD) epidemiology and evaluation, CKD complications and their management, cost-efficiency of renal replacement therapy, pathogenesis of CKD, familial kidney disease and the environment–genetics interface, onconephrology, technology, SGLT2 inhibitors and outcome prediction. We provide here an overview of the hottest and most impactful topics for 2017–19.
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Affiliation(s)
- Alberto Ortiz
- IIS-Fundación Jiménez Diaz, Department of Medicine, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain.,Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
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Kim EH, Park S, Kim YK, Moon M, Park J, Lee KJ, Lee S, Kim YP. Self-luminescent photodynamic therapy using breast cancer targeted proteins. SCIENCE ADVANCES 2020; 6:eaba3009. [PMID: 32917700 PMCID: PMC7486108 DOI: 10.1126/sciadv.aba3009] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 07/23/2020] [Indexed: 05/10/2023]
Abstract
Despite the potential of photodynamic therapy (PDT), its comprehensive use in cancer treatment has not been achieved because of the nondegradable risks of photosensitizing drugs and limits of light penetration and instrumentation. Here, we present bioluminescence (BL)-induced proteinaceous PDT (BLiP-PDT), through the combination of luciferase and a reactive oxygen species (ROS)-generating protein (Luc-RGP), which is self-luminescent and degradable. After exposure to coelenterazine-h as a substrate for luciferase without external light irradiation, Luc-RGP fused with a small lead peptide-induced breast cancer cell death through the generation of BL-sensitive ROS in the plasma membrane. Even with extremely low light energy, BLiP-PDT exhibited targeted effects in primary breast cancer cells from patients and in in vivo tumor xenograft mouse models. These findings suggest that BLiP-PDT is immediately useful as a promising theranostic approach against various cancers.
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Affiliation(s)
- Eun Hye Kim
- Department of Life Science, Hanyang University, Seoul 04763, Korea
| | - Sangwoo Park
- Gwangju Center, Korea Basic Science Institute (KBSI), Gwangju 61186, Korea
| | - Yun Kyu Kim
- Department of Convergence Medicine, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Minwoo Moon
- Department of Life Science, Hanyang University, Seoul 04763, Korea
| | - Jeongwon Park
- Gwangju Center, Korea Basic Science Institute (KBSI), Gwangju 61186, Korea
| | - Kyung Jin Lee
- Department of Convergence Medicine, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea.
- Research Institute for Natural Sciences, Hanyang University, Seoul 04763, Korea
| | - Seongsoo Lee
- Gwangju Center, Korea Basic Science Institute (KBSI), Gwangju 61186, Korea.
| | - Young-Pil Kim
- Department of Life Science, Hanyang University, Seoul 04763, Korea.
- Research Institute for Natural Sciences, Hanyang University, Seoul 04763, Korea
- Research Institute for Convergence of Basic Sciences, Hanyang University, Seoul 04763, Korea
- Institute of Nano Science and Technology, Hanyang University, Seoul 04763, Korea
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Halloy F, Iyer P, Ćwiek P, Ghidini A, Barman-Aksözen J, Wildner-Verhey van Wijk N, Theocharides APA, Minder E, Schneider-Yin X, Schümperli D, Hall J. Delivery of oligonucleotides to bone marrow to modulate ferrochelatase splicing in a mouse model of erythropoietic protoporphyria. Nucleic Acids Res 2020; 48:4658-4671. [PMID: 32313951 PMCID: PMC7229840 DOI: 10.1093/nar/gkaa229] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/25/2020] [Accepted: 04/09/2020] [Indexed: 12/17/2022] Open
Abstract
Erythropoietic protoporphyria (EPP) is a rare genetic disease in which patients experience acute phototoxic reactions after sunlight exposure. It is caused by a deficiency in ferrochelatase (FECH) in the heme biosynthesis pathway. Most patients exhibit a loss-of-function mutation in trans to an allele bearing a SNP that favors aberrant splicing of transcripts. One viable strategy for EPP is to deploy splice-switching oligonucleotides (SSOs) to increase FECH synthesis, whereby an increase of a few percent would provide therapeutic benefit. However, successful application of SSOs in bone marrow cells is not described. Here, we show that SSOs comprising methoxyethyl-chemistry increase FECH levels in cells. We conjugated one SSO to three prototypical targeting groups and administered them to a mouse model of EPP in order to study their biodistribution, their metabolic stability and their FECH splice-switching ability. The SSOs exhibited distinct distribution profiles, with increased accumulation in liver, kidney, bone marrow and lung. However, they also underwent substantial metabolism, mainly at their linker groups. An SSO bearing a cholesteryl group increased levels of correctly spliced FECH transcript by 80% in the bone marrow. The results provide a promising approach to treat EPP and other disorders originating from splicing dysregulation in the bone marrow.
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Affiliation(s)
- François Halloy
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Switzerland
| | - Pavithra S Iyer
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Switzerland
| | - Paulina Ćwiek
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Switzerland
| | - Alice Ghidini
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Switzerland
| | | | | | - Alexandre P A Theocharides
- Department of Medical Oncology and Hematology, University Hospital and University of Zurich, Zurich, Switzerland
| | | | | | - Daniel Schümperli
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Switzerland
| | - Jonathan Hall
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Switzerland
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Gouya L, Ventura P, Balwani M, Bissell DM, Rees DC, Stölzel U, Phillips JD, Kauppinen R, Langendonk JG, Desnick RJ, Deybach J, Bonkovsky HL, Parker C, Naik H, Badminton M, Stein PE, Minder E, Windyga J, Bruha R, Cappellini MD, Sardh E, Harper P, Sandberg S, Aarsand AK, Andersen J, Alegre F, Ivanova A, Talbi N, Chan A, Querbes W, Ko J, Penz C, Liu S, Lin T, Simon A, Anderson KE. EXPLORE: A Prospective, Multinational, Natural History Study of Patients with Acute Hepatic Porphyria with Recurrent Attacks. Hepatology 2020; 71:1546-1558. [PMID: 31512765 PMCID: PMC7255459 DOI: 10.1002/hep.30936] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 09/04/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Acute hepatic porphyria comprises a group of rare genetic diseases caused by mutations in genes involved in heme biosynthesis. Patients can experience acute neurovisceral attacks, debilitating chronic symptoms, and long-term complications. There is a lack of multinational, prospective data characterizing the disease and current treatment practices in severely affected patients. APPROACH AND RESULTS EXPLORE is a prospective, multinational, natural history study characterizing disease activity and clinical management in patients with acute hepatic porphyria who experience recurrent attacks. Eligible patients had a confirmed acute hepatic porphyria diagnosis and had experienced ≥3 attacks in the prior 12 months or were receiving prophylactic treatment. A total of 112 patients were enrolled and followed for at least 6 months. In the 12 months before the study, patients reported a median (range) of 6 (0-52) acute attacks, with 52 (46%) patients receiving hemin prophylaxis. Chronic symptoms were reported by 73 (65%) patients, with 52 (46%) patients experiencing these daily. During the study, 98 (88%) patients experienced a total of 483 attacks, 77% of which required treatment at a health care facility and/or hemin administration (median [range] annualized attack rate 2.0 [0.0-37.0]). Elevated levels of hepatic δ-aminolevulinic acid synthase 1 messenger ribonucleic acid levels, δ-aminolevulinic acid, and porphobilinogen compared with the upper limit of normal in healthy individuals were observed at baseline and increased further during attacks. Patients had impaired quality of life and increased health care utilization. CONCLUSIONS Patients experienced attacks often requiring treatment in a health care facility and/or with hemin, as well as chronic symptoms that adversely influenced day-to-day functioning. In this patient group, the high disease burden and diminished quality of life highlight the need for novel therapies.
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Affiliation(s)
- Laurent Gouya
- Centre de Référence Maladies Rares PorphyriesColombesFrance
- University of ParisParisFrance
- Laboratory of Excellence GR‐ExParisFrance
| | - Paolo Ventura
- Università degli Studi di Modena e Reggio EmiliaEmilia‐RomagnaItaly
| | | | | | - David C. Rees
- King’s College HospitalKing’s College LondonLondonUK
| | | | | | | | - Janneke G. Langendonk
- Porphyria CenterCenter for Lysosomal and Metabolic DiseaseDepartment of Internal MedicineErasmus MCUniversity Medical Center Rotterdamthe Netherlands
| | | | - Jean‐Charles Deybach
- Centre de Référence Maladies Rares PorphyriesColombesFrance
- University of ParisParisFrance
- Laboratory of Excellence GR‐ExParisFrance
| | - Herbert L. Bonkovsky
- Section on Gastroenterology & HepatologyWake Forest University/NC Baptist Medical CenterWinston‐SalemNC
| | | | | | | | | | | | - Jerzy Windyga
- Department of Hemostatic Disorders and Internal MedicineInstitute of Hematology and Transfusion MedicineWarsawPoland
| | - Radan Bruha
- 4th Internal ClinicGeneral University HospitalCharles UniversityPragueCzech Republic
| | | | - Eliane Sardh
- Porphyria Centre Sweden, Centre for Inherited Metabolic DiseasesKarolinska Institutet, Karolinska University HospitalStockholmSweden
| | - Pauline Harper
- Porphyria Centre Sweden, Centre for Inherited Metabolic DiseasesKarolinska Institutet, Karolinska University HospitalStockholmSweden
| | - Sverre Sandberg
- Norwegian Porphyria CentreHaukeland University HospitalBergenNorway
| | - Aasne K. Aarsand
- Norwegian Porphyria CentreHaukeland University HospitalBergenNorway
| | - Janice Andersen
- Norwegian Porphyria CentreHaukeland University HospitalBergenNorway
| | | | | | - Neila Talbi
- Centre de Référence Maladies Rares PorphyriesColombesFrance
- University of ParisParisFrance
- Laboratory of Excellence GR‐ExParisFrance
| | - Amy Chan
- Alnylam PharmaceuticalsCambridgeMA
| | | | - John Ko
- Alnylam PharmaceuticalsCambridgeMA
| | | | | | - Tim Lin
- Alnylam PharmaceuticalsCambridgeMA
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Harte J, Chapagain A, Sarkany RP, Chaudhri S. The Case | Bullous eruptions in end-stage renal failure. Kidney Int 2020; 97:1067-1068. [DOI: 10.1016/j.kint.2019.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 10/28/2019] [Accepted: 11/04/2019] [Indexed: 10/24/2022]
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Abstract
El término 'porfiria' proviene del griego 'porphyra' y alude a un grupo heterogéneo de trastornos metabólicos causados por una deficiencia enzimática en la biosíntesis del grupo hemo. La causa de la porfiria intermitente aguda es la deficiencia de la enzima deaminasa del porfobilinógeno. Se presenta el caso de una mujer de 40 años que presentó dolor abdominal de 10 días de evolución, trastorno hidroelectrolítico grave debido a hiponatremia e hipopotasemia, taquicardia e hipertensión arterial sistémica persistentes, por lo cual fue sometida a una laparotomía en la que no se encontró ninguna afección de origen quirúrgico, A los siete días del examen inicial, la paciente desarrolló cuadriparesia flácida aguda y presentó una crisis convulsiva tónico-clónica generalizada. Los estudios neurofisiológicos evidenciaron una polineuropatía axonal mixta, y los valores de porfobilinógeno y porfirinas en orina eran elevados. Tras diagnosticarse porfiria intermitente aguda, esta se trató con hemina, lo que estabilizó los signos clínicos y normalizó el porfobilinógeno. La prevalencia de esta enfermedad es de 1 en 2.000 personas. Tiene un patrón de herencia autosómico dominante y se manifiesta principalmente en mujeres con edades entre los 20 y los 40 años. La enfermedad cursa con síntomas neurológicos y viscerales, y se trata con la administración de hemina y dextrosa, evitando las soluciones hipotónicas por el riesgo de exacerbar la hiponatremia.
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Bronisch O, Stauch T, Haverkamp T, Beykirch MK, Petrides PE. Acute porphyrias: a German monocentric study of the biochemical, molecular genetic, and clinical data of 62 families. Ann Hematol 2019; 98:2683-2691. [DOI: 10.1007/s00277-019-03831-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/24/2019] [Indexed: 12/17/2022]
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Jaramillo-Calle DA, Solano JM, Rabinstein AA, Bonkovsky HL. Porphyria-induced posterior reversible encephalopathy syndrome and central nervous system dysfunction. Mol Genet Metab 2019; 128:242-253. [PMID: 31706631 DOI: 10.1016/j.ymgme.2019.10.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIM An association between neuropsychiatric manifestations and neuroimaging suggestive of posterior reversible encephalopathy syndrome (PRES) during porphyric attacks has been described in numerous case reports. We aimed to systematically review clinical-radiological features and likely pathogenic mechanisms of PRES in patients with acute hepatic porphyrias (AHP) and porphyric attacks. METHODS PubMed, Scopus, Ovid MEDLINE, and Google Scholar were searched (July 30, 2019). We included articles describing patients with convincing evidence of an AHP, confirmed porphyric attacks, and PRES in neuroimaging. RESULTS Forty-three out of 269 articles were included, which reported on 46 patients. Thirty-nine (84.8%) patients were women. The median age was 24 ± 13.8 years. 52.2% had unspecified AHP, 41.3% acute intermittent porphyria, 4.3% hereditary coproporphyria, and 2.2% variegate porphyria. 70.2% had systemic arterial hypertension. Seizures, mental changes, arterial hypertension, and hyponatremia occurred more frequently than expected for porphyric attacks (p < .001). Seizures and hyponatremia were also more frequent than expected for PRES. The most common distributions of brain lesions were occipital (81.4%), parietal (65.1%), frontal (60.5%), subcortical (40%), and cortical (32.5%). Cerebral vasoconstriction was demonstrated in 41.7% of the patients who underwent angiography. 19.6% of the patients had ischemic lesions, and 4.3% developed long-term sequelae (cognitive decline and focal neurological deficits). CONCLUSIONS Brain edema, vasoconstriction, and ischemia in the context of PRES likely account for central nervous symptoms in some porphyric attacks.
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Affiliation(s)
- Daniel A Jaramillo-Calle
- IPS Universitaria, Universidad de Antioquia, Medellin, Colombia; Institute of Medical Research, Universidad de Antioquia, School of Medicine, Medellin, Colombia.
| | - Juan M Solano
- Department of Neurology, Universidad de Antioquia, School of Medicine, Medellin, Colombia
| | | | - Herbert L Bonkovsky
- Section on Gastroenterology & Hepatology, Wake Forest University School of Medicine/NC Baptist Hospital, Winston-Salem, United States of America..
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Granata F, Mendez M, Brancaleoni V, Castelbon FJ, Graziadei G, Ventura P, Di Pierro E. Molecular characterization, by digital PCR analysis of four HMBS gene mutations affecting the ubiquitous isoform of Porphobilinogen Deaminase (PBGD) in patients with Acute Intermittent Porphyria (AIP). Mol Genet Metab 2018; 125:295-301. [PMID: 30201327 DOI: 10.1016/j.ymgme.2018.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/03/2018] [Accepted: 09/03/2018] [Indexed: 12/12/2022]
Abstract
Genetic variants in promoters and alternative-splicing lesions require to be experimentally tested in order to validate them as causatives of a disease. The digital PCR (dPCR) approach, which is an alternative to the classical qPCR, is an innovative and a more sensitive method for the detection and quantification of nucleic acids. In the present study, we identified four HMBS gene mutations affecting the ubiquitous isoform of porphobilinogen deaminase (PBGD) and established a dPCR protocol which would be able to detect the different transcripts of this gene. With the application of this method, we were able to characterize the functional roles of these four genetic variants, demonstrating that all these mutations were causatives of the non-erythroid variant of the acute intermittent porphyria (AIP) disease.
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Affiliation(s)
- Francesca Granata
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, U.O.C. Medicina Generale, Milano, Italy
| | - Manuel Mendez
- Instituto de Investigación, Hospital 12 de Octubre, Madrid, Spain
| | - Valentina Brancaleoni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, U.O.C. Medicina Generale, Milano, Italy
| | | | - Giovanna Graziadei
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, U.O.C. Medicina Generale, Milano, Italy
| | - Paolo Ventura
- Division of Internal Medicine 2 - Centre for Porphyrias, Dept. of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Policlinico Hospital, Modena, Italy
| | - Elena Di Pierro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, U.O.C. Medicina Generale, Milano, Italy.
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