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Loser V, Baumgartner T, Legardeur H, Panchaud A, Théaudin M. Patisiran exposure in early pregnancy: a case report. Ther Adv Neurol Disord 2024; 17:17562864241239755. [PMID: 38532802 PMCID: PMC10964446 DOI: 10.1177/17562864241239755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/28/2024] [Indexed: 03/28/2024] Open
Abstract
We describe here the first case of exposure to patisiran treatment, a small interfering RNA molecule, during early pregnancy of a 36-year-old woman with symptomatic hereditary transthyretin-related amyloidosis. There were no major complications during pregnancy and delivery, except for a postpartum hemorrhage due to uterine atony. Vitamin A levels had to be closely monitored during pregnancy, and vitamin A substitution adapted accordingly. There was no sign of minor or major congenital abnormalities of the baby. One month after delivery, the patient showed slight clinical and electrophysiological signs of neuropathy progression due to patisiran treatment withdrawal. Patisiran infusions were resumed 3 months after delivery. Due to the unknown teratogenic potential of patisiran, the risk of neuropathy worsening associated with withholding treatment must of course be weighed against a potential teratogenic risk of treatment during pregnancy. Vitamin A levels need to be closely assessed, and substitution must be adapted accordingly, to avoid embryofetal adverse outcome due to vitamin A deficiency or toxicity.
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Affiliation(s)
- Valentin Loser
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 44, Lausanne 1011, Switzerland
| | - Thomas Baumgartner
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Hélène Legardeur
- Woman–Mother–Child Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Alice Panchaud
- Service of Pharmacy, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - Marie Théaudin
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Casasnovas C, Lladó L, Borrachero C, Pérez-Santamaría PV, Muñoz-Beamud F, Losada-López IA, Baliellas-Comellas MC, González-Moreno J. A narrative review and expert recommendations on the assessment of the clinical manifestations, follow-up, and management of post-OLT patients with ATTRv amyloidosis. Ther Adv Neurol Disord 2023; 16:17562864231191590. [PMID: 37655225 PMCID: PMC10467168 DOI: 10.1177/17562864231191590] [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: 03/15/2023] [Accepted: 07/17/2023] [Indexed: 09/02/2023] Open
Abstract
Orthotopic liver transplantation (OLT) was the first treatment able to modify the natural course of hereditary transthyretin (ATTRv) amyloidosis, which is a rare and fatal disorder caused by the accumulation of misfolded transthyretin (TTR) variants in different organs and tissues and which leads to a progressive and multisystem dysfunction. Because the liver is the main source of TTR, OLT dramatically reduces the production of the pathogenic TTR variant, which should prevent amyloid formation and halt disease progression. However, amyloidosis progression may occur after OLT due to wild-type TTR deposition, especially in the nerves and heart. In this review, we discuss the disease features influencing OLT outcomes and the clinical manifestations of ATTRv amyloidosis progression post-OLT to improve our understanding of disease worsening after OLT and optimize the follow-up and clinical management of these patients. By conducting a literature review on the PubMed database, we identified patient characteristics that have been associated with worse post-OLT outcomes, including late-onset V50M and non-V50M variants, age >40 years, long disease duration, advanced neuropathy and autonomic dysfunction, and malnutrition. Regarding post-OLT mortality, deaths occurring within the first year after OLT were mainly associated with fatal graft complications and infectious diseases, whereas cardiovascular-related deaths usually occurred later. Considering the diverse clinical manifestations of ATTRv amyloidosis progression post-OLT, including worsening neuropathy and/or cardiomyopathy, autonomic dysfunction, and oculoleptomeningeal involvement, we present advice on the most relevant tests for assessing disease progression post-OLT. Finally, we discuss the use of new therapies based on TTR stabilizers and TTR mRNA silencers for the treatment of ATTRv amyloidosis patients post-OLT.
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Affiliation(s)
- Carlos Casasnovas
- Neuromuscular Unit, Department of Neurology, Bellvitge University Hospital-IDIBELL, C/ Feixa Llarga s/n, 08906 l’Hospitalet de Llobregat, Barcelona, Spain
| | - Laura Lladó
- Liver Transplant Unit, Department of Surgery, Bellvitge University Hospital, IDIBELL, Barcelona, Spain
| | - Cristina Borrachero
- ATTRv Unit, Department of Internal Medicine, Juan Ramón Jiménez Hospital, Huelva, Spain
| | | | | | | | | | - Juan González-Moreno
- Department of Internal Medicine, Son Llàtzer University Hospital, Palma de Mallorca, Spain
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Lorenzoni PJ, Giugno VR, Ducci RDP, Werneck LC, Kay CSK, Scola RH. Genetic screening for transthyretin familial amyloid polyneuropathy to avoid misdiagnosis in patients with polyneuropathy associated with high protein in the cerebrospinal fluid. Acta Neurol Belg 2023:10.1007/s13760-023-02215-z. [PMID: 36840806 DOI: 10.1007/s13760-023-02215-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/13/2023] [Indexed: 02/26/2023]
Affiliation(s)
- Paulo José Lorenzoni
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, 80060-900, Brazil.
| | - Vinicius Riegel Giugno
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, 80060-900, Brazil
| | - Renata Dal-Prá Ducci
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, 80060-900, Brazil
| | - Lineu Cesar Werneck
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, 80060-900, Brazil
| | - Claudia Suemi Kamoi Kay
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, 80060-900, Brazil
| | - Rosana Herminia Scola
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, 80060-900, Brazil
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Castro J, Miranda B, de Castro I, Conceição I. Changes in nerve conduction studies predate clinical symptoms onset in early onset Val30Met hereditary ATTR amyloidosis. Eur J Neurol 2021; 29:826-832. [PMID: 34751997 DOI: 10.1111/ene.15176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/02/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Hereditary amyloidosis related to transthyretin (ATTR) is a rare and progressive disease that, despite the phenotypic heterogeneity, a length-dependent sensorimotor axonal neuropathy (ATTR-PN) is the classic hallmark. Timely diagnosis is paramount for early treatment implementation. METHODS Sixty-nine asymptomatic gene carriers (Val30Met) were assessed during a 4-year period to identify those remaining asymptomatic versus those converting to ATTRV30M-PN. Conversion to symptomatic was defined as presenting with two definite symptoms of ATTRV30M-PN. Composite neurophysiological scores of sensory (SNS), motor (MNS), and sympathetic skin response (SSRS) amplitudes were used to assess neuropathy progression. We used mixed-effects modeling and ordinal logistic regression to assess neurophysiological evolution over time. RESULTS Of all asymptomatic gene carriers, 55.1% (n = 38/69) converted over the period of this analysis. The progression of the SNS relative to baseline was different between groups (asymptomatic gene carriers vs. converters), the decline being greater in the converter group (time × group interaction p = 0.040), starting about 2 years before symptom onset. No significant change occurred regarding MNS or SSRS. Moreover, the percentage of cases with an annual decline on the SNS of at least 25%, gradually and significantly increased in the converter group, representing a 1.92 increase in risk of developing symptoms for those with such reduction on the last evaluation. CONCLUSIONS A simple composite neurophysiological sum score can predict the onset of ATTRV30M-PN symptoms by as much as 2 years, highlighting the importance of a systematic follow-up of asymptomatic gene carriers, allowing a timely diagnosis, and management of symptomatic disease.
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Affiliation(s)
- José Castro
- Department of Neurosciences and Mental Health, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal.,Faculdade de Medicina, Instituto de Fisiologia, Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisbon, Portugal
| | - Bruno Miranda
- Faculdade de Medicina, Instituto de Fisiologia, Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisbon, Portugal
| | - Isabel de Castro
- Department of Neurosciences and Mental Health, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal.,Faculdade de Medicina, Instituto de Fisiologia, Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisbon, Portugal
| | - Isabel Conceição
- Department of Neurosciences and Mental Health, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal.,Faculdade de Medicina, Instituto de Fisiologia, Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisbon, Portugal
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Obici L, Mussinelli R. Current and Emerging Therapies for Hereditary Transthyretin Amyloidosis: Strides Towards a Brighter Future. Neurotherapeutics 2021; 18:2286-2302. [PMID: 34850359 PMCID: PMC8804119 DOI: 10.1007/s13311-021-01154-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 12/19/2022] Open
Abstract
The past few years have witnessed an unprecedented acceleration in the clinical development of novel therapeutic options for hereditary transthyretin amyloidosis. Recently approved agents and drugs currently under investigation not only represent a major breakthrough in this field but also provide validation of the therapeutic potential of innovative approaches, like RNA interference and CRISPR-Cas9-mediated gene editing, in rare inherited disorders. In this review, we describe the evolving therapeutic landscape for hereditary transthyretin amyloidosis and discuss how this highly disabling and fatal condition is turning into a treatable disease. We also provide an overview of the molecular mechanisms involved in transthyretin (TTR) amyloid formation and regression, to highlight how a deeper understanding of these processes has contributed to the identification of novel treatment targets. Finally, we focus on major areas of uncertainty and unmet needs that deserve further efforts to improve long-term patients' outcomes and allow for a brighter future.
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Affiliation(s)
- Laura Obici
- Amyloidosis Research and Treatment Centre, IRCCS Fondazione Policlinico San Matteo, Viale Golgi, 19, 27100, Pavia, Italy.
| | - Roberta Mussinelli
- Amyloidosis Research and Treatment Centre, IRCCS Fondazione Policlinico San Matteo, Viale Golgi, 19, 27100, Pavia, Italy
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Follow-up in transthyretin familial amyloid polyneuropathy: Useful investigations. J Neurol Sci 2020; 413:116776. [PMID: 32203746 DOI: 10.1016/j.jns.2020.116776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/10/2020] [Accepted: 03/13/2020] [Indexed: 11/21/2022]
Abstract
Patients with transthyretin amyloid polyneuropathy (TTR-FAP) and asymptomatic mutation-carriers have to be regularly followed-up in order to identify disease progression and the time point for starting or modifying therapy. In this case series we describe the potential suitability of different variables as progression markers. We retrospectively analyzed the follow-up charts of 10 TTR-FAP patients. Clinical examination included the Neuropathy Impairment Score of Lower Limb (NIS-LL), temperature perception thresholds, nerve conduction and autonomic function tests. The NIS-LL had the greatest value for a sensitive and correct follow-up for all TTR-FAP stages. All other examinations provided useful additional information but they were either less suited for advanced TTR-FAP, or had a higher test-retest variability. The results of this study provide preliminary evidence that a good clinical investigation is mandatory in TTR-FAP follow-up. Simple neuropathy scores like the NIS-LL might be as useful as technical investigations for TTR-FAP follow-up.
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Abstract
Transthyretin (TTR) related cardiomyopathy is an underdiagnosed cause of heart failure but is increasingly recognized in various settings - from patients admitted with heart failure to symptomatic aortic stenosis - and is rapidly becoming the most frequent form of systemic amyloidosis. Following the recent publication of the landmark ATTR-ACT trial that showed tafamidis to be the first treatment to improve survival in patients with TTR-related cardiac amyloidosis and heart failure, we reviewed the drug's rationale, characteristics and evidence supporting its use in TTR amyloidosis.
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Affiliation(s)
- Massimiliano Lorenzini
- University College London Institute for Cardiovascular Science & Barts Heart Centre, St Bartholomew's Hospital, London, UK.,Cardiology, Department of Experimental, Diagnostic & Specialty Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Perry M Elliott
- University College London Institute for Cardiovascular Science & Barts Heart Centre, St Bartholomew's Hospital, London, UK
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