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Jericó D, Córdoba KM, Urigo F, Enríquez de Salamanca R, Anderson KE, Deybach JC, Ávila MA, Fontanellas A. Exploring current and emerging therapies for porphyrias. Liver Int 2024; 44:2174-2190. [PMID: 38813953 DOI: 10.1111/liv.15979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 05/31/2024]
Abstract
Porphyrias are rare, mostly inherited disorders resulting from altered activity of specific enzymes in the haem synthesis pathway that lead to accumulation of pathway intermediates. Photocutaneous symptoms occur when excess amounts of photoreactive porphyrins circulate in the blood to the skin, whereas increases in potentially neurotoxic porphyrin precursors are associated with neurovisceral symptoms. Current therapies are suboptimal and their mechanisms are not well established. As described here, emerging therapies address underlying disease mechanisms by introducing a gene, RNA or other specific molecule with the potential to cure or slow progression of the disease. Recent progress in nanotechnology and nanoscience, particularly regarding particle design and formulation, is expanding disease targets. More secure and efficient drug delivery systems have extended our toolbox for transferring specific molecules, especially into hepatocytes, and led to proof-of-concept studies in animal models. Repurposing existing drugs as molecular chaperones or haem synthesis inhibitors is also promising. This review summarizes key examples of these emerging therapeutic approaches and their application for hepatic and erythropoietic porphyrias.
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Affiliation(s)
- Daniel Jericó
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
| | - Karol M Córdoba
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
| | - Francesco Urigo
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
| | - Rafael Enríquez de Salamanca
- Department of Internal Medicine, Reference Center for Inherited Metabolic Disease-MetabERN, University Hospital 12 de Octubre, UCM, Madrid, Spain
| | - Karl E Anderson
- Porphyria Laboratory and Center, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Jean-Charles Deybach
- French Porphyria Reference Center (CRMR Porphyries France), Université Paris, Paris, France
| | - Matías A Ávila
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Antonio Fontanellas
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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Sandgren JA, Tung ML, Berrebi KG, Saade DN, Bermick JR, Lee SS, Stanford AH. A Severe Reaction After Phototherapy in a Neonate With X-Linked Protoporphyria. Pediatrics 2024; 154:e2023064724. [PMID: 39054943 DOI: 10.1542/peds.2023-064724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 07/27/2024] Open
Abstract
Protoporphyria is a subtype of porphyria characterized primarily by painful phototoxic skin reactions after light exposure at specific wavelengths. Historically, phototherapy is not contraindicated in patients with protoporphyria since there have not been any reports of phototoxic reactions. However, patients with protoporphyria are advised to avoid direct sunlight. In this case report, we describe a neonate not known to have X-linked protoporphyria who received phototherapy for 1 to 2 hours. Within hours after initiation of phototherapy, this neonate developed a life-threatening reaction consisting of rash over the distribution of phototherapy, acute liver failure with coagulopathy, diffuse hypotonia with diaphragmatic failure, and subsequent acute respiratory failure that required mechanical ventilation. As in this case, patients with protoporphyria-related acute liver failure can have signs and symptoms similar to that of an acute hepatic porphyria attack. Neither neonatal reactions to phototherapy nor liver failure temporally associated with phototherapy have been reported in patients with X-linked protoporphyria. Early recognition of this entity is crucial in light of potential life-threatening complications. Therefore, providers must react quickly when neonates have abnormal reactions to phototherapy and consider protoporphyria in the differential diagnosis.
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Affiliation(s)
| | | | - Kristen G Berrebi
- Department of Dermatology and Pediatrics, University of Iowa, Iowa City, Iowa
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Minder AE, Kluijver LG, Barman-Aksözen J, Minder EI, Langendonk JG. Erythropoietic protoporphyrias: Pathogenesis, diagnosis and management. Liver Int 2024. [PMID: 39011756 DOI: 10.1111/liv.16027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 06/22/2024] [Accepted: 06/24/2024] [Indexed: 07/17/2024]
Abstract
The erythropoietic protoporphyrias consist of three ultra-rare genetic disorders of the erythroid heme biosynthesis, including erythropoietic protoporphyria (EPP1), X-linked protoporphyria (XLEPP) and CLPX-protoporphyria (EPP2), which all lead to the accumulation of protoporphyrin IX (PPIX) in erythrocytes. Affected patients usually present from early childhood with episodes of severe phototoxic pain in the skin exposed to visible light. The quantification of PPIX in erythrocytes with a metal-free PPIX ≥3 times the upper limit of normal confirms the diagnosis. Protoporphyria-related complications include liver failure, gallstones, mild anaemia and vitamin D deficiency with reduced bone mineral density. The management is focused on preventing phototoxic reactions and treating the complications. Vitamin D should be supplemented, and DEXA scans in adults should be considered. In EPP1, even in cases of biochemically determined iron deficiency, supplementation of iron may stimulate PPIX production, resulting in an increase in photosensitivity and the risk of cholestatic liver disease. However, for patients with XLEPP, iron supplementation can reduce PPIX levels, phototoxicity and liver damage. Because of its rarity, there is little data on the management of EPP-related liver disease. As a first measure, any hepatotoxins should be eliminated. Depending on the severity of the liver disease, phlebotomies, exchange transfusions and ultimately liver transplantation with subsequent haematopoietic stem cell transplantation (HSCT) are therapeutic options, whereby multidisciplinary management including porphyria experts is mandatory. Afamelanotide, an alpha-melanocyte-stimulating hormone analogue, is currently the only approved specific treatment that increases pain-free sunlight exposure and quality of life.
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Affiliation(s)
- Anna-Elisabeth Minder
- Division of Endocrinology, Diabetology, and Porphyria, Stadtspital Zürich Triemli, Zurich, Switzerland
- Swiss Reference Centre for Porphyrias, Stadtspital Zürich Triemli, Zurich, Switzerland
| | - Louisa G Kluijver
- Department of Internal Medicine, Porphyria Center Rotterdam, Center for Lysosomal and Metabolic Disease, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Jasmin Barman-Aksözen
- Swiss Reference Centre for Porphyrias, Stadtspital Zürich Triemli, Zurich, Switzerland
- Institute of Laboratory Medicine, Stadtspital Zürich Triemli, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Elisabeth I Minder
- Division of Endocrinology, Diabetology, and Porphyria, Stadtspital Zürich Triemli, Zurich, Switzerland
- Swiss Reference Centre for Porphyrias, Stadtspital Zürich Triemli, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Janneke G Langendonk
- Department of Internal Medicine, Porphyria Center Rotterdam, Center for Lysosomal and Metabolic Disease, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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4
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Lindemann H, Diehl-Wiesenecker E, Gerischer L, Frank J. [An overview of porphyrias]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024; 75:539-547. [PMID: 38902527 DOI: 10.1007/s00105-024-05370-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 06/22/2024]
Abstract
Porphyrias are predominantly genetic metabolic disorders caused by dysregulation of specific enzymes in porphyrin-heme biosynthesis. The enzymatic dysfunction leads to formation and excretion of intermediate metabolic products in the form of porphyrins and/or their precursors δ‑aminolevulinic acid and porphobilinogen, which have cyto- and tissue-toxic properties. Clinically, porphyrias are extremely diverse, with symptoms ranging from skin changes on light-exposed areas of the body to potentially life-threatening neurovisceral attacks. Biochemical tests in urine, blood and stool are used for diagnosis, which can be supplemented by molecular genetic analyses. Treatment of the various forms of porphyria is complex and often requires close interdisciplinary cooperation between different medical specialties.
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Affiliation(s)
- Hanna Lindemann
- Klinik für Dermatologie und Allergologie, Universitätsspital Basel, Basel, Schweiz
| | - Eva Diehl-Wiesenecker
- Innere Medizin mit Gastroenterologie und Nephrologie, Zentrale Notaufnahme, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Lea Gerischer
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Jorge Frank
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsmedizin Göttingen, Robert Koch Str. 40, 37075, Göttingen, Deutschland.
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Barman-Aksözen J, Minder AE, Schuppan D, Stölzel U. Letter to the Editor: Contrasting effect of iron supplementation in protoporphyria. Hepatology 2024; 79:E87-E88. [PMID: 37862552 DOI: 10.1097/hep.0000000000000633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 10/22/2023]
Affiliation(s)
- Jasmin Barman-Aksözen
- Institute of Laboratory Medicine, Municipal Hospital Zurich Triemli, Zurich, Switzerland
- Swiss Reference Centre for Porphyrias, Municipal Hospital Zurich Triemli, Zurich, Switzerland
| | - Anna-Elisabeth Minder
- Swiss Reference Centre for Porphyrias, Municipal Hospital Zurich Triemli, Zurich, Switzerland
- Division for Endocrinology, Diabetology and Porphyria, Municipal Hospital Zurich Triemli, Zurich, Switzerland
| | - Detlef Schuppan
- Institute of Translational Immunology and Research Center for Immune Therapy, University Medical Centre, Johannes Gutenberg University, Mainz, Germany
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ulrich Stölzel
- Porphyria Centre, Department of Internal Medicine II, Klinikum Chemnitz, Chemnitz, Germany
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Levy C, Dickey AK, Anderson KE, Keel SB, Balwani M. Reply: Contrasting effect of iron supplementation in protoporphyria. Hepatology 2024; 79:E89-E90. [PMID: 37862462 DOI: 10.1097/hep.0000000000000640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 09/11/2023] [Indexed: 10/22/2023]
Affiliation(s)
- Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Amy K Dickey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Karl E Anderson
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, University of Texas Medical Branch/UTMB Health, Galveston, Texas, USA
| | - Sioban B Keel
- Division of Hematology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Mann AK, Allan L, Wheeden KP, Dickey AK, Levy C. Diagnosis and management of protoporphyria-related liver dysfunction in erythropoietic protoporphyria and x-linked protoporphyria: A patient-friendly summary of the 2023 evidence-based consensus guidelines. Clin Liver Dis (Hoboken) 2024; 23:e0133. [PMID: 38487349 PMCID: PMC10939578 DOI: 10.1097/cld.0000000000000133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/10/2024] [Indexed: 03/17/2024] Open
Affiliation(s)
- Anna K. Mann
- United Porphyrias Association, Bethesda, Maryland, USA
| | - Liz Allan
- United Porphyrias Association, Bethesda, Maryland, USA
| | | | - Amy K. Dickey
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Cynthia Levy
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami, Miami, Florida, USA
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