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Conceição I. Early diagnosis in ATTRv amyloidosis, how early is enough? How early is possible? Med Clin (Barc) 2024; 162:e70-e73. [PMID: 38614903 DOI: 10.1016/j.medcli.2024.02.013] [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: 10/03/2023] [Revised: 02/15/2024] [Accepted: 02/22/2024] [Indexed: 04/15/2024]
Abstract
Hereditary transthyretin amyloidosis (ATTRv amyloidosis) is a rare, progressive, and debilitating genetic disorder characterized by the deposition of abnormal transthyretin (TTR) protein aggregates in various tissues, leading to organ dysfunction. Early diagnosis of ATTRv amyloidosis is critical for starting timely interventions and improving patient outcomes. This review explores the concepts of "how early is enough" and "how early is possible" in the context of diagnosing ATTRv amyloidosis, highlighting the challenges and opportunities for early recognition.
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Affiliation(s)
- Isabel Conceição
- Departamento de Neurociências e Saúde Mental, Unidade Local de Saúde de Santa Maria, Hospital de Santa Maria, Centro Académico de Medicina de Lisboa, Lisboa, Portugal; Instituto de Fisiologia, Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Portugal.
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Berends M, Brunger AF, Bijzet J, Kroesen BJ, Drost G, Lange F, Teunissen CE, In 't Veld S, Vrancken AF, Gans ROB, Hazenberg BPC, van der Zwaag PA, Nienhuis HLA. Longitudinal analysis of serum neurofilament light chain levels as marker for neuronal damage in hereditary transthyretin amyloidosis. Amyloid 2024; 31:132-141. [PMID: 38477065 DOI: 10.1080/13506129.2024.2327342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/29/2024] [Indexed: 03/14/2024]
Abstract
OBJECTIVE To evaluate serum neurofilament light chain (sNfL) as biomarker of disease onset, progression and treatment effect in hereditary transthyretin (ATTRv) amyloidosis patients and TTR variant (TTRv) carriers. METHODS sNfL levels were assessed longitudinally in persistently asymptomatic TTRv carriers (N = 12), persistently asymptomatic ATTRv amyloidosis patients (defined as asymptomatic patients but with amyloid detectable in subcutaneous abdominal fat tissue) (N = 8), in TTRv carriers who developed polyneuropathy (N = 7) and in ATTRv amyloidosis patients with polyneuropathy on treatment (TTR-stabiliser (N = 20) or TTR-silencer (N = 18)). Polyneuropathy was confirmed by nerve conduction studies or quantitative sensory testing. sNfL was analysed using a single-molecule array assay. RESULTS sNfL increased over 2 years in persistently asymptomatic ATTRv amyloidosis patients, but did not change in persistently asymptomatic TTRv carriers. In all TTRv carriers who developed polyneuropathy, sNfL increased from 8.4 to 49.8 pg/mL before the onset of symptoms and before polyneuropathy could be confirmed neurophysiologically. In symptomatic ATTRv amyloidosis patients on a TTR-stabiliser, sNfL remained stable over 2 years. In patients on a TTR-silencer, sNfL decreased after 1 year of treatment. CONCLUSION sNfL is a biomarker of early neuronal damage in ATTRv amyloidosis already before the onset of polyneuropathy. Current data support the use of sNfL in screening asymptomatic TTRv carriers and in monitoring of disease progression and treatment effect.
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Affiliation(s)
- Milou Berends
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
| | - Anne F Brunger
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
- Department of Rheumatology & Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Johan Bijzet
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
- Department of Laboratory Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Bart-Jan Kroesen
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
- Department of Laboratory Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Gea Drost
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - Fiete Lange
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - Charlotte E Teunissen
- Department of Laboratory Medicine, Amsterdam Neuroscience, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Sjors In 't Veld
- Department of Laboratory Medicine, Amsterdam Neuroscience, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | | | - Reinold O B Gans
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
| | - Bouke P C Hazenberg
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
- Department of Rheumatology & Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul A van der Zwaag
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
- Department of Medical Genetics, University Medical Center Groningen, Groningen, The Netherlands
| | - Hans L A Nienhuis
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
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Cárdenas-Soto K, Dominguez XH, Cortes G, Tsai F, Saniger MDM, Guraieb-Chahin P, Torres-Ocatvo B, Gibbons C, Kelly JW, Freeman R, González-Duarte A. Cutaneous biomarkers of therapeutic efficacy in early treatment of hereditary ATTR amyloid polyneuropathy with tafamidis. J Peripher Nerv Syst 2024; 29:221-231. [PMID: 38706223 DOI: 10.1111/jns.12624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND ATTR (ATTRv) amyloidosis neuropathy is characterized by progressive sensorimotor and autonomic nerve degeneration secondary to amyloid deposition caused by a misfolded transthyretin protein (TTR). Small nerve fiber neuropathy is an early clinical manifestation of this disease resulting from the dysfunction of the Aδ and C small nerve fibers. Tafamidis, a selective TTR stabilizer, has proven its efficacy in the earlier stages of hATTR. OBJECTIVES To evaluate the clinical course and utility of cutaneous pathological biomarkers in patients with ATTR amyloidosis treated with tafamidis compared to control patients. METHODS Forty patients diagnosed with early stages of ATTRv amyloidosis (polyneuropathy disability [PND] scores 0-II) underwent small and large nerve fiber neurological evaluations, and annual skin biopsies for intraepidermal nerve fiber density (IENFD) and amyloid deposition index (ADI) estimation. Thirty patients were allocated to receive tafamidis, and 10 patients served as controls. Tafamidis pharmacokinetics analysis was performed in patients who received the treatment. RESULTS At baseline, 12% of patients in stage PND 0 and 28% in PND I displayed small nerve fiber denervation in the distal thigh, whereas 23% and 38%, respectively, in the distal leg. Similarly, 72% and 84% had amyloid deposition in the distal thigh and 56% and 69% in the distal leg. Following 1 year of treatment, the tafamidis group showed significant clinical improvement compared to the control group, revealed by the following mean differences (1) -9.3 versus -4 points (p = <.00) in the patient's neuropathy total symptom score 6 (NTSS-6) questionnaire, (2) -2.5 versus +2.8 points (p = <.00) in the Utah Early Neuropathy Score (UENS), and (3) +1.2°C versus -0.6 (p = .01) in cold detection thresholds. Among the patients who received tafamidis, 65% had stable or increased IENFD in their distal thigh and 27% in the distal leg. In contrast, all patients in the control group underwent denervation. The ADI either decreased or remained constant in 31% of the biopsies in the distal thigh and in 24% of the biopsies in the distal leg of the tafamidis-treated patients, whereas it rose across all the biopsies in the control group. At the 4-year follow-up, the tafamidis group continued to display less denervation in the distal thigh (mean difference [MD] of -3.0 vs. -9.3 fibers/mm) and the distal leg (mean difference [MD] -4.9 vs. -8.6 fibers/mm). ADI in tafamidis-treated patients was also lower in the distal thigh (10 vs. 30 amyloid/mm2) and the distal leg (23 vs. 40 amyloid/mm2) compared to control patients. Plasma tafamidis concentrations were higher in patients with IENFD improvement and in patients with reduced amyloid deposition. Patients without amyloid deposition in the distal leg at baseline displayed delayed disease progression at 4 years. CONCLUSIONS Cutaneous IENFD and amyloid deposition assessments in the skin of the distal thigh and distal leg are valuable biomarkers for early diagnosis of ATTR amyloidosis and for measuring the progression of small nerve fiber neuropathy. Early treatment with tafamidis slows the clinical progression of the disease, skin denervation, and amyloid deposition in the skin. Higher plasma concentrations of tafamidis are associated with better disease outcomes, suggesting that increasing the drug dose could achieve better plasma concentrations and response rates. This study describes the longest small nerve fiber neuropathy therapeutic trial with tafamidis and is the first to report small fiber symptoms, function, and structural assessments as outcomes.
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Affiliation(s)
- Karla Cárdenas-Soto
- Department of Neurology, Instituto Nacional De Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Xel-Ha Dominguez
- Department of Neurology, Instituto Nacional De Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Giovanni Cortes
- Department of Neurology, Instituto Nacional De Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Felix Tsai
- Department of Chemistry, University of Washington, Seattle, Washington, USA
| | | | | | | | - Christopher Gibbons
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffery W Kelly
- Department of Chemical Physiology, Skaggs Institute of Chemical Biology, La Jolla, California, USA
- Department of Chemistry, The Scripps Research Institute, La Jolla, California, USA
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Alejandra González-Duarte
- Department of Neurology, Instituto Nacional De Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Department of Neurology, New York University School of Medicine New York, New York, New York, USA
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Beauvais D, Labeyrie C, Cauquil C, Francou B, Eliahou L, Not A, Echaniz-Laguna A, Adam C, Slama MS, Benmalek A, Leonardi L, Rouzet F, Adams D, Algalarrondo V, Beaudonnet G. Detailed clinical, physiological and pathological phenotyping can impact access to disease-modifying treatments in ATTR carriers. J Neurol Neurosurg Psychiatry 2024; 95:489-499. [PMID: 37875336 PMCID: PMC11103288 DOI: 10.1136/jnnp-2023-332180] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/27/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Hereditary transthyretin amyloidosis is a life-threatening autosomal dominant systemic disease due to pathogenic TTR variants (ATTRv), mostly affecting the peripheral nerves and heart. The disease is characterised by a combination of symptoms, organ involvement and histological amyloid deposition. The available disease-modifying ATTRv treatments (DMTs) are more effective if initiated early. Pathological nerve conduction studies (NCS) results are the cornerstone of large-fibre polyneuropathy diagnosis, but this anomaly occurs late in the disease. We investigated the utility of a multimodal neurological and cardiac evaluation for detecting early disease onset in ATTRv carriers. METHODS We retrospectively analysed a cohort of ATTRv carriers with normal NCS results regardless of symptoms. Multimodal denervation and infiltration evaluations included a clinical questionnaire (Lauria and New York Heart Association (NYHA)) and examination, intra-epidermal nerve fibre density assessment, autonomic assessment based on heart rate variability, Sudoscan, meta-iodo-benzyl-guanidine scintigraphy, cardiac biomarkers, echocardiography, MRI and searches for amyloidosis on skin biopsy and bone scintigraphy. RESULTS We included 130 ATTRv carriers (40.8% men, age: 43.6±13.5 years), with 18 amyloidogenic TTR gene mutations, the majority of which was the late-onset Val30Met variant (42.3%). Amyloidosis was detected in 16.9% of mutation carriers, including 9 (6.9%) with overt disease (Lauria>2 or NYHA>1) and 13 asymptomatic carriers (10%) with organ involvement (small-fibre neuropathy or cardiomyopathy). Most of these patients received DMT. Abnormal test results of unknown significance were obtained for 105 carriers (80.8%). Investigations were normal in only three carriers (2.3%). CONCLUSIONS Multimodal neurological and cardiac investigation of TTRv carriers is crucial for the early detection of ATTRv amyloidosis and initiation of DMT.
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Affiliation(s)
- Diane Beauvais
- AP-HP, Service de neurologie, CHU Bicêtre, Centre de référence national des neuropathies amyloïdes familiales et autres neuropathies périphériques rares, CERAMIC, FILNEMUS Network, Le Kremlin-Bicêtre, France
- Department of Neurology (Nerve-Muscle Unit), AOC National Reference Center for Neuromuscular Disorders, University Hospital of Bordeaux (CHU Pellegrin), Bordeaux, France
| | - Céline Labeyrie
- AP-HP, Service de neurologie, CHU Bicêtre, Centre de référence national des neuropathies amyloïdes familiales et autres neuropathies périphériques rares, CERAMIC, FILNEMUS Network, Le Kremlin-Bicêtre, France
| | - Cécile Cauquil
- AP-HP, Service de neurologie, CHU Bicêtre, Centre de référence national des neuropathies amyloïdes familiales et autres neuropathies périphériques rares, CERAMIC, FILNEMUS Network, Le Kremlin-Bicêtre, France
| | - Bruno Francou
- AP-HP, Laboratoire de Génétique Moléculaire, Pharmacogénétique et Hormonologie, CHU Bicêtre, Le Kremlin-Bicêtre, France
| | | | - Adeline Not
- AP-HP, Service de neurologie, CHU Bicêtre, Centre de référence national des neuropathies amyloïdes familiales et autres neuropathies périphériques rares, CERAMIC, FILNEMUS Network, Le Kremlin-Bicêtre, France
| | - Andoni Echaniz-Laguna
- AP-HP, Service de neurologie, CHU Bicêtre, Centre de référence national des neuropathies amyloïdes familiales et autres neuropathies périphériques rares, CERAMIC, FILNEMUS Network, Le Kremlin-Bicêtre, France
- Université de Paris-Saclay, INSERM U1195, Le Kremlin-Bicêtre, France
| | - Clovis Adam
- AP-HP, Service d'Anatomopathologie Clinique, CHU Bicêtre, Le Kremlin-Bicêtre, France
| | - Michel S Slama
- AP-HP, Département de Cardiologie, CHU Bichat, Paris, France
| | - Anouar Benmalek
- Faculté de Pharmacie, Université Paris-Saclay, Gif-sur-Yvette, France
| | - Luca Leonardi
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sant'Andrea Hospital, Sapienza University of Rome, Roma, Italy
| | - François Rouzet
- AP-HP, Service de Médecine nucléaire, CHU Bichat, Paris, France
| | - David Adams
- AP-HP, Service de neurologie, CHU Bicêtre, Centre de référence national des neuropathies amyloïdes familiales et autres neuropathies périphériques rares, CERAMIC, FILNEMUS Network, Le Kremlin-Bicêtre, France
- Université de Paris-Saclay, INSERM U1195, Le Kremlin-Bicêtre, France
| | - Vincent Algalarrondo
- AP-HP, Département de Cardiologie, CHU Bichat, Paris, France
- Université Paris Cité, Paris, France
| | - Guillemette Beaudonnet
- AP-HP, Service de neurologie, CHU Bicêtre, Centre de référence national des neuropathies amyloïdes familiales et autres neuropathies périphériques rares, CERAMIC, FILNEMUS Network, Le Kremlin-Bicêtre, France
- AP-HP, Unité de Neurophysiologie Clinique et Epileptologie (UNCE), CHU Bicêtre, Le Kremlin-Bicêtre, France
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Romano A, Guglielmino V, Bisogni G, Di Paolantonio A, Truini A, Minnella AM, Sciarrone MA, Vitali F, Maceroni M, Galosi E, Sabatelli M, Luigetti M. Early detection of nerve involvement in presymptomatic TTR mutation carriers: exploring potential markers of disease onset. Neurol Sci 2024; 45:1675-1684. [PMID: 37938457 PMCID: PMC10942905 DOI: 10.1007/s10072-023-07177-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/30/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Hereditary transthyretin (ATTRv) amyloidosis is a heterogeneous, progressive, multisystemic disease with a life-threatening course if left untreated. Given the current availability of effective therapies, close follow-up of presymptomatic TTR mutation carriers is essential to recognize disease onset at the earliest sign. In addition to routine techniques, in recent years several novel tools have been proposed, although a consensus on their use has not been reached yet. In this paper, we aimed to evaluate possible markers of neuropathic disease onset intended to discriminate clinically asymptomatic carriers from early symptomatic patients, thus allowing timely treatment initiation. METHODS Thirty-eight presymptomatic carriers were enrolled. Clinical and electrophysiological findings at first evaluation and follow-up were collected. All carriers underwent an extensive clinical and instrumental evaluation according to the standard clinical practice. One or more non-routine investigations, whose use in this field is not yet validated (henceforth "unconventional"), were additionally assessed in a subgroup of individuals. RESULTS Based on the exclusive use of routine investigations, it was possible to define disease onset in 4/38 carriers during the follow-up. Employing additionally one or more "unconventional" tests, abnormal findings, indicative of a possible "conversion" to symptomatic disease, were detected in further 12 cases. More than half of our study cohort showed findings suggestive of small nerve fiber (SF) involvement at either invasive or non-invasive tests. CONCLUSIONS A close, multidisciplinary monitoring of presymptomatic TTR mutation carriers is fundamental, and diagnostic workup should include both routine and "unconventional" tests. Assessment of SF involvement is important also in non-endemic countries.
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Affiliation(s)
- Angela Romano
- UOC Neurologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Valeria Guglielmino
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giulia Bisogni
- Centro Clinico NeMO Adulti, Fondazione Serena Onlus-Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Andrea Truini
- Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Angelo Maria Minnella
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
- UOC Oftalmologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Francesca Vitali
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Martina Maceroni
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
- UOC Oftalmologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Eleonora Galosi
- Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Mario Sabatelli
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
- Centro Clinico NeMO Adulti, Fondazione Serena Onlus-Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marco Luigetti
- UOC Neurologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy.
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy.
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Berends M, Nienhuis HLA, Adams D, Karam C, Luigetti M, Polydefkis M, Reilly MM, Sekijima Y, Hazenberg BPC. Neurofilament Light Chains in Systemic Amyloidosis: A Systematic Review. Int J Mol Sci 2024; 25:3770. [PMID: 38612579 PMCID: PMC11011627 DOI: 10.3390/ijms25073770] [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: 02/17/2024] [Revised: 03/08/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Peripheral and autonomic neuropathy are common disease manifestations in systemic amyloidosis. The neurofilament light chain (NfL), a neuron-specific biomarker, is released into the blood and cerebrospinal fluid after neuronal damage. There is a need for an early and sensitive blood biomarker for polyneuropathy, and this systematic review provides an overview on the value of NfL in the early detection of neuropathy, central nervous system involvement, the monitoring of neuropathy progression, and treatment effects in systemic amyloidosis. A literature search in PubMed, Embase, and Web of Science was performed on 14 February 2024 for studies investigating NfL levels in patients with systemic amyloidosis and transthyretin gene-variant (TTRv) carriers. Only studies containing original data were included. Included were thirteen full-text articles and five abstracts describing 1604 participants: 298 controls and 1306 TTRv carriers or patients with or without polyneuropathy. Patients with polyneuropathy demonstrated higher NfL levels compared to healthy controls and asymptomatic carriers. Disease onset was marked by rising NfL levels. Following the initiation of transthyretin gene-silencer treatment, NfL levels decreased and remained stable over an extended period. NfL is not an outcome biomarker, but an early and sensitive disease-process biomarker for neuropathy in systemic amyloidosis. Therefore, NfL has the potential to be used for the early detection of neuropathy, monitoring treatment effects, and monitoring disease progression in patients with systemic amyloidosis.
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Affiliation(s)
- Milou Berends
- Department of Internal Medicine, Amyloidosis Center of Expertise, University Medical Center Groningen, 9700 RB Groningen, The Netherlands; (M.B.); (H.L.A.N.)
| | - Hans L. A. Nienhuis
- Department of Internal Medicine, Amyloidosis Center of Expertise, University Medical Center Groningen, 9700 RB Groningen, The Netherlands; (M.B.); (H.L.A.N.)
| | - David Adams
- Service de Neurologie, CHU Bicêtre, Assistance Publique—Hôpitaux de Paris, University Paris-Saclay, CERAMIC, Le Kremlin-Bicêtre, 94270 Paris, France;
| | - Chafic Karam
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Marco Luigetti
- UOC Neurologia, Fondazione Policlinico A. Gemelli IRCCS, 00168 Rome, Italy;
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Michael Polydefkis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Mary M. Reilly
- Centre for Neuromuscular Diseases, Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK;
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto 390-8621, Japan;
| | - Bouke P. C. Hazenberg
- Department of Rheumatology & Clinical Immunology, Amyloidosis Center of Expertise, University Medical Center Groningen, 9700 RB Groningen, The Netherlands
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Pinton S, Vacchi E, Chiaro G, Raimondi A, Tzankov A, Gerber B, Gobbi C, Kaelin-Lang A, Melli G. Amyloid detection and typing yield of skin biopsy in systemic amyloidosis and polyneuropathy. Ann Clin Transl Neurol 2023; 10:2347-2359. [PMID: 37849451 PMCID: PMC10723241 DOI: 10.1002/acn3.51924] [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: 08/13/2023] [Revised: 09/26/2023] [Accepted: 09/28/2023] [Indexed: 10/19/2023] Open
Abstract
OBJECTIVE Disease-modifying therapies are available for amyloidosis but are ineffective if end-organ damage is severe. As small fiber neuropathy is an early and common feature of amyloidosis, we assessed detection and typing yield of skin biopsy for amyloid in patients with confirmed systemic amyloidosis and neuropathic symptoms. METHODS In this case-control study, patients with transthyretin and light chain amyloidosis (ATTRv, ATTRwt, and AL) were consecutively recruited. They were sex and age-matched to three control groups (1) non-neuropathic controls (NNC), (2) monoclonal gammopathy of undetermined significance (MGUS), and (3) other neuropathic disease controls (ONC). Patients underwent a double 3 mm skin biopsy in proximal and distal leg. Amyloid index and burden, protein typing by immuno-electron microscopy, intraepidermal nerve fiber density, electroneuromyography, and clinical characteristics were analyzed. RESULTS We studied 15 subjects with confirmed systemic amyloidosis, 20 NNC, 18 MGUS, and 20 ONC. Amyloid was detected in 100% of patients with amyloidosis (87% in ankle and 73% in thigh). It was not detected in any of the control groups. A small fiber neuropathy was encountered in 100% of amyloidosis patients, in 80% of MGUS, and in 78% of ONC. Amyloid burden was higher in ATTRv, followed by AL and ATTRwt. The ultrastructural examination allowed the identification of the precursor protein by immunotyping in most of the cases. INTERPRETATION Skin biopsy is a minimally invasive test with optimal sensitivity for amyloid. It allows amyloid typing by electron microscope to identify the precursor protein. The diagnostic work up of systemic amyloidosis should include a skin biopsy.
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Affiliation(s)
- Sandra Pinton
- Neurology Department, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Neurodegenerative disorders lab, Laboratories for Translational Research, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Elena Vacchi
- Neurology Department, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Neurodegenerative disorders lab, Laboratories for Translational Research, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Giacomo Chiaro
- Neurology Department, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Neurodegenerative disorders lab, Laboratories for Translational Research, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Andrea Raimondi
- Institute for Research in Biomedicine, Università della Svizzera italiana, Bellinzona, Switzerland
- Experimental Imaging Centre, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alexandar Tzankov
- Histopathology, Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Claudio Gobbi
- Neurology Department, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Alain Kaelin-Lang
- Neurology Department, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Neurodegenerative disorders lab, Laboratories for Translational Research, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Giorgia Melli
- Neurology Department, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Neurodegenerative disorders lab, Laboratories for Translational Research, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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Adams D, Algalarrondo V, Echaniz-Laguna A. Hereditary transthyretin amyloidosis in the era of RNA interference, antisense oligonucleotide, and CRISPR-Cas9 treatments. Blood 2023; 142:1600-1612. [PMID: 37624911 DOI: 10.1182/blood.2023019884] [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: 03/13/2023] [Revised: 08/08/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
Hereditary transthyretin amyloidosis (ATTRv) is a rare autosomal dominant adult-onset disorder caused by point mutations in the transthyretin (TTR) gene encoding TTR, also known as prealbumin. ATTRv survival ranges from 3 to 10 years, and peripheral nervous system and heart are usually the 2 main tissues affected, although central nervous system and eye may also be involved. Because the liver is the main TTR protein secretor organ, it has been the main target of treatments developed these last years, including liver transplantation, which has been shown to significantly increase survival in a subset of patients carrying the so-called "early-onset Val30Met" TTR gene mutation. More recently, treatments targeting hepatic TTR RNA have been developed. Hepatic TTR RNA targeting is performed using RNA interference (RNAi) and antisense oligonucleotide (ASO) technologies involving lipid nanoparticle carriers or N-acetylgalactosamine fragments. RNAi and ASO treatments induce an 80% decrease in TTR liver production for a period of 1 to 12 weeks. ASO and RNAi phase 3 trials in patients with TTR-related polyneuropathy have shown a positive impact on neuropathy clinical scores and quality of life end points, and delayed RNAi treatment negatively affects survival. Clinical trials specifically investigating RNAi therapy in TTR cardiomyopathy are underway. Hepatic RNA targeting has revolutionized ATTRv treatment and may allow for the transforming a fatal disease into a treatable disorder. Because retina and choroid plexus secrete limited quantities of TTR protein, both tissues are now seen as the next targets for fully controlling the disease.
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Affiliation(s)
- David Adams
- Neurology Department, Bicêtre Hospital, INSERM U 1195, CERAMIC, Assistance Publique-Hôpitaux de Paris, University of Paris Saclay, Paris, France
| | - Vincent Algalarrondo
- Cardiology Department, CERAMIC, Bichat Claude Bernard Hospital, University of Paris-Cité, Paris, France
| | - Andoni Echaniz-Laguna
- Neurology Department, Bicêtre Hospital, INSERM U 1195, CERAMIC, Assistance Publique-Hôpitaux de Paris, University of Paris Saclay, Paris, France
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9
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Adams D, Sekijima Y, Conceição I, Waddington-Cruz M, Polydefkis M, Echaniz-Laguna A, Reilly MM. Hereditary transthyretin amyloid neuropathies: advances in pathophysiology, biomarkers, and treatment. Lancet Neurol 2023; 22:1061-1074. [PMID: 37863593 DOI: 10.1016/s1474-4422(23)00334-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 08/08/2023] [Accepted: 08/31/2023] [Indexed: 10/22/2023]
Abstract
Hereditary transthyretin (TTR) amyloid polyneuropathy is an autosomal dominant life-threatening disorder. TTR is produced mainly by the liver but also by the choroid plexus and retinal pigment epithelium. Detailed clinical characterisation, identification of clinical red flags for misdiagnosis, and use of biomarkers enable early diagnosis and treatment. In addition to liver transplantation and TTR stabilisers, three other disease-modifying therapies have regulatory approval: one antisense oligonucleotide (inotersen) and two small interfering RNAs (siRNAs; patisiran and vutrisiran). The siRNAs have been shown to stop progression of neuropathy and improve patients' quality of life. As none of the disease-modifying therapies can cross the blood-brain barrier, TTR deposition in the CNS, which can cause stroke and cognitive impairment, remains an important unaddressed issue. CRISPR-Cas9-based one-time TTR editing therapy is being investigated in a phase 1 clinical study. Identification of the earliest stages of pathogenesis in TTR variant carriers is a major challenge that needs addressing for optimal management.
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Affiliation(s)
- David Adams
- Department of Neurology, Bicêtre Centre Hospitalo Universitaire, AP-HP, INSERM U 1195, University Paris Saclay, Le Kremlin Bicetre, France.
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Isabel Conceição
- Department of Neurosciences and Mental Health, Centro Hospitalar Universitario Lisboas Norte-Hospital de Santa Maria and Centro de Estudos Egas Moniz, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Marcia Waddington-Cruz
- Centro de Estudos em Paramiloidose Antonio Rodrigues de Mello, National Amyloidosis Referral Center, University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Michael Polydefkis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andoni Echaniz-Laguna
- Department of Neurology, Centre Hospitalo Universitaire, AP-HP, INSERM U 1195, University Paris Saclay, Le Kremlin Bicetre Cedex, France
| | - Mary M Reilly
- Department of Neuromuscular Disease, University College London Institute of Neurology and the National Hospital of Neurology and Neurosurgery, London, UK
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10
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Ando Y, Waddington-Cruz M, Sekijima Y, Koike H, Ueda M, Konishi H, Ishii T, Coelho T. Optimal practices for the management of hereditary transthyretin amyloidosis: real-world experience from Japan, Brazil, and Portugal. Orphanet J Rare Dis 2023; 18:323. [PMID: 37828588 PMCID: PMC10571420 DOI: 10.1186/s13023-023-02910-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 09/05/2023] [Indexed: 10/14/2023] Open
Abstract
Hereditary transthyretin (ATTRv) amyloidosis is a rare and autosomal dominant disorder associated with mutations in the transthyretin gene. Patients present with diverse symptoms related to sensory, motor, and autonomic neuropathy, as well as gastrointestinal, ocular, cardiac, renal and orthopedic symptoms, resulting from the deposition of transthyretin amyloid fibrils in multiple organs. The progressive nature of ATTRv amyloidosis necessitates pre- and post-onset monitoring of the disease. This review article is primarily based on a collation of discussions from a medical advisory board meeting in August 2021. In this article, we summarize the best practices in amyloidosis centers in three major endemic countries for ATTRv amyloidosis (Japan, Brazil, and Portugal), where most patients carry the Val30Met mutation in the transthyretin gene and the patients' genetic background was proven to be the same. The discussions highlighted the similarities and differences in the management of asymptomatic gene mutation carriers among the three countries in terms of the use of noninvasive tests and tissue biopsies and timing of starting the investigations. In addition, this article discusses a set of practical tests and examinations for monitoring disease progression applicable to neurologists working in diverse medical settings and generalizable in non-endemic countries and areas. This set of assessments consists of periodic (every 6 to 12 months) evaluations of patients' nutritional status and autonomic, renal, cardiac, ophthalmologic, and neurological functions. Physical examinations and patient-reported outcome assessments should be also scheduled every 6 to 12 months. Programs for monitoring gene mutation carriers and robust referral networks can aid in appropriate patient management in pre- to post-onset stages. For pre- and post-symptom onset testing for ATTRv amyloidosis, various noninvasive techniques are available; however, their applicability differs depending on the medical setting in each country and region, and the optimal option should be selected in view of the clinical settings, medical environment, and available healthcare resources in each region.
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Affiliation(s)
- Yukio Ando
- Department of Amyloidosis Research, Faculty of Pharmaceutical Sciences, Nagasaki International University, 2825-7 Huis Ten Bosch Machi, Sasebo City, Nagasaki, 859-3298, Japan.
| | - Marcia Waddington-Cruz
- Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | | | | | - Teresa Coelho
- Andrade's Center for Familial Amyloidosis, Hospital Santo António, Centro Hospitalar Universitário Do Porto, Porto, Portugal
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11
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Leonardi L, Costanzo R, Forcina F, Morino S, Antonini G, Salvetti M, Luigetti M, Romano A, Primiano G, Guglielmino V, Fionda L, Garibaldi M, Lauletta A, Rossini E, Tufano L, Ceccanti M, Esposito N, Falco P, di Pietro G, Truini A, Galosi E. Quantitative sensory testing and skin biopsy findings in late-onset ATTRv presymptomatic carriers: Relationships with predicted time of disease onset (PADO). J Peripher Nerv Syst 2023; 28:390-397. [PMID: 37535421 DOI: 10.1111/jns.12586] [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: 06/14/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Hereditary transthyretin amyloidosis polyneuropathy (ATTRv-PN) presymptomatic carriers often show preclinical abnormalities at small fiber-related diagnostic tests. However, no validated biomarker is currently available to use for presymptomatic carriers' follow-up, thus helping therapeutic decision making. Our study aimed at assessing nerve conduction study (NCS), quantitative sensory testing (QST), and skin biopsy parameters in a large cohort of late-onset ATTRv presymptomatic carriers and to evaluate whether they correlated with predicted age of disease onset (PADO). METHODS Late-onset ATTRv presymptomatic carriers were consecutively enrolled and underwent NCS, QST, and skin biopsy with intraepidermal nerve fiber density (IENFD) evaluation from a distal and a proximal site. Douleur Neuropathique-4 (DN4) and Small Fiber Neuropathy-Symptoms Inventory (SFN-SIQ) were used to assess painful and small fiber neuropathy-related symptoms. PADO and time-to-PADO (delta-PADO) were estimated for each carrier, and correlations with diagnostic test measures were analyzed. RESULTS Forty presymptomatic ATTRv subjects were enrolled. Twenty carriers (50%) had distal IENFD reduction, with a non-length-dependent distribution in 73% of cases. Eleven subjects (27.5%) had cold and/or warm detection threshold (CDT and/or WDT) abnormalities at QST. Delta-PADO positively correlated with sural sensory nerve action potential (SNAP) amplitude (r = .416, p = .004), and z-values of QST parameters like CDT (r = .314, p = .028), WDT (r = -.294, p = .034), and mechanical detection threshold (MDT; r = -.382, p = .012). Simple linear regression models showed a linear relation between delta-PADO and sural SAP, CDT, and MDT. CONCLUSIONS Our findings confirm that IENFD reduction and QST abnormalities may occur early in ATTRv presymptomatic carriers, often with a non-length-dependent pattern. However, only sural SAP amplitude and QST parameters correlated with delta-PADO, suggesting that serial combined QST and NCS evaluation could be useful in ATTRv presymptomatic carriers' follow-up.
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Affiliation(s)
- Luca Leonardi
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Rocco Costanzo
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Francesca Forcina
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Stefania Morino
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Giovanni Antonini
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Marco Salvetti
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
- Neuromed Institute IRCCS, Pozzilli, Isernia, Italy
| | - Marco Luigetti
- UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore. Sede di Roma, Rome, Italy
| | - Angela Romano
- UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Guido Primiano
- UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valeria Guglielmino
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore. Sede di Roma, Rome, Italy
| | - Laura Fionda
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Matteo Garibaldi
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Antonio Lauletta
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Elena Rossini
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Laura Tufano
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Marco Ceccanti
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Nicoletta Esposito
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Pietro Falco
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Giuseppe di Pietro
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Andrea Truini
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Eleonora Galosi
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
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12
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Ullah R, Lee EJ. Advances in Amyloid-β Clearance in the Brain and Periphery: Implications for Neurodegenerative Diseases. Exp Neurobiol 2023; 32:216-246. [PMID: 37749925 PMCID: PMC10569141 DOI: 10.5607/en23014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/25/2023] [Accepted: 08/23/2023] [Indexed: 09/27/2023] Open
Abstract
This review examines the role of impaired amyloid-β clearance in the accumulation of amyloid-β in the brain and the periphery, which is closely associated with Alzheimer's disease (AD) and cerebral amyloid angiopathy (CAA). The molecular mechanism underlying amyloid-β accumulation is largely unknown, but recent evidence suggests that impaired amyloid-β clearance plays a critical role in its accumulation. The review provides an overview of recent research and proposes strategies for efficient amyloid-β clearance in both the brain and periphery. The clearance of amyloid-β can occur through enzymatic or non-enzymatic pathways in the brain, including neuronal and glial cells, blood-brain barrier, interstitial fluid bulk flow, perivascular drainage, and cerebrospinal fluid absorption-mediated pathways. In the periphery, various mechanisms, including peripheral organs, immunomodulation/immune cells, enzymes, amyloid-β-binding proteins, and amyloid-β-binding cells, are involved in amyloid-β clearance. Although recent findings have shed light on amyloid-β clearance in both regions, opportunities remain in areas where limited data is available. Therefore, future strategies that enhance amyloid-β clearance in the brain and/or periphery, either through central or peripheral clearance approaches or in combination, are highly encouraged. These strategies will provide new insight into the disease pathogenesis at the molecular level and explore new targets for inhibiting amyloid-β deposition, which is central to the pathogenesis of sporadic AD (amyloid-β in parenchyma) and CAA (amyloid-β in blood vessels).
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Affiliation(s)
- Rahat Ullah
- Neuroregeneration and Stem Cell Programs, Institute for Cell Engineering, School of Medicine, The Johns Hopkins University, Baltimore, MD 21205, USA
- Department of Neurology, School of Medicine, The Johns Hopkins University, Baltimore, MD 21205, USA
| | - Eun Jeong Lee
- Department of Brain Science, Ajou University School of Medicine, Suwon 16499, Korea
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13
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Gottschalk CG, Whelan R, Peterson D, Roy A. Detection of Elevated Level of Tetrahydrobiopterin in Serum Samples of ME/CFS Patients with Orthostatic Intolerance: A Pilot Study. Int J Mol Sci 2023; 24:ijms24108713. [PMID: 37240059 DOI: 10.3390/ijms24108713] [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: 04/10/2023] [Revised: 05/02/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
Myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS) is a multisystem chronic illness characterized by severe muscle fatigue, pain, dizziness, and brain fog. Many patients with ME/CFS experience orthostatic intolerance (OI), which is characterized by frequent dizziness, light-headedness, and feeling faint while maintaining an upright posture. Despite intense investigation, the molecular mechanism of this debilitating condition is still unknown. OI is often manifested by cardiovascular alterations, such as reduced cerebral blood flow, reduced blood pressure, and diminished heart rate. The bioavailability of tetrahydrobiopterin (BH4), an essential cofactor of endothelial nitric oxide synthase (eNOS) enzyme, is tightly coupled with cardiovascular health and circulation. To explore the role of BH4 in ME/CFS, serum samples of CFS patients (n = 32), CFS patients with OI only (n = 10; CFS + OI), and CFS patients with both OI and small fiber polyneuropathy (n = 12; CFS + OI + SFN) were subjected to BH4 ELISA. Interestingly, our results revealed that the BH4 expression is significantly high in CFS, CFS + OI, and CFS + OI + SFN patients compared to age-/gender-matched controls. Finally, a ROS production assay in cultured microglial cells followed by Pearson correlation statistics indicated that the elevated BH4 in serum samples of CFS + OI patients might be associated with the oxidative stress response. These findings suggest that the regulation of BH4 metabolism could be a promising target for understanding the molecular mechanism of CFS and CFS with OI.
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Affiliation(s)
- Carl Gunnar Gottschalk
- Simmaron Research Institute, 948 Incline Way, Incline Village, NV 89451, USA
- Simmaron Research and Development Laboratory, Chemistry Building, University of Wisconsin-Milwaukee, 3210 N Cramer Street, Suite # 214, Milwaukee, WI 53211, USA
| | - Ryan Whelan
- Simmaron Research Institute, 948 Incline Way, Incline Village, NV 89451, USA
| | - Daniel Peterson
- Simmaron Research Institute, 948 Incline Way, Incline Village, NV 89451, USA
- Sierra Internal Medicine, 920 Incline Way, Incline Village, NV 89451, USA
| | - Avik Roy
- Simmaron Research Institute, 948 Incline Way, Incline Village, NV 89451, USA
- Simmaron Research and Development Laboratory, Chemistry Building, University of Wisconsin-Milwaukee, 3210 N Cramer Street, Suite # 214, Milwaukee, WI 53211, USA
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14
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Zampino S, Sheikh FH, Vaishnav J, Judge D, Pan B, Daniel A, Brown E, Ebenezer G, Polydefkis M. Phenotypes Associated With the Val122Ile, Leu58His, and Late-Onset Val30Met Variants in Patients With Hereditary Transthyretin Amyloidosis. Neurology 2023; 100:e2036-e2044. [PMID: 36941075 PMCID: PMC10186220 DOI: 10.1212/wnl.0000000000207158] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 01/20/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Hereditary transthyretin amyloidosis (hATTR) is a rare autosomal dominant systemic disease with variable penetrance and heterogeneous clinical presentation. Several effective treatments can reduce mortality and disability, though diagnosis remains challenging, especially in the United States where disease is nonendemic. Our aim is to describe the neurologic and cardiac characteristics of common US ATTR variants V122I, L58H, and late-onset V30M at presentation. METHODS We conducted a retrospective case series of patients with a new diagnosis of ATTRv between January 2008 and January 2020 to characterize features of prominent US variants. The neurologic (examination, EMG, and skin biopsy), cardiac (echo), and laboratory assessments (pro b-type natriuretic peptide [proBNP] and reversible neuropathy screens) are described. RESULTS A total of 56 patients with treatment-naïve ATTRv with symptoms/signs of peripheral neuropathy (PN) or cardiomyopathy and confirmatory genetic testing presenting with Val122Ile (N = 31), late-onset Val30Met (N = 12), and Leu58His ATTRv (N = 13) were included. The age at onset and sex distributions were similar (V122I: 71.5 ± 8.0, V30M: 64.8 ± 2.6, and L58H: 62.4 ± 9.8 years; 26, 25, 31% female). Only 10% of patients with V122I and 17% of patients with V30M were aware of an ATTRv family history, while 69% of patients with L58H were aware. PN was present in all 3 variants at diagnosis (90%, 100%, and 100%), though neurologic impairment scores differed: V122I: 22 ± 16, V30M: 61 ± 31, and L58H: 57 ± 25. Most points (deficits) were attributed to loss of strength. Carpal tunnel syndrome (CTS) and a positive Romberg sign were common across all groups (V122I: 97%, 39%; V30M: 58%, 58%; and L58H: 77%, 77%). ProBNP levels and interventricular septum thickness were highest among patients with V122I (5,939 ± 962 pg/mL, 1.70 ± 0.29 cm), followed by V30M (796 ± 970 pg/mL, 1.42 ± 0.38 cm) and L58H (404 ± 677 pg/mL, 1.23 ± 0.36 cm). Atrial fibrillation was present among 39% of cases with V122I and only 8% of cases with V30M and L58H. Gastrointestinal symptoms were rare (6%) among patients with V122I and common in patients with V30M (42%) and L58H (54%). DISCUSSION Important clinical differences exist between ATTRv genotypes. While V122I is perceived to be a cardiac disease, PN is common and clinically relevant. Most patients with V30M and V122I were diagnosed de novo and therefore require clinical suspicion for diagnosis. A history of CTS and a positive Romberg sign are helpful diagnostic clues.
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Affiliation(s)
- Serena Zampino
- From the Department of Neurology (S.Z., B.P., A.D., G.E., M.P.), Johns Hopkins University School of Medicine, Baltimore, MD; Cardiology (F.H.S.), MedStar Medical Group, Washington, DC; Division of Cardiology (J.V., D.J., E.B.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Cardiology (D.J.), Medical University of South Carolina, Charleston
| | - Farooq H Sheikh
- From the Department of Neurology (S.Z., B.P., A.D., G.E., M.P.), Johns Hopkins University School of Medicine, Baltimore, MD; Cardiology (F.H.S.), MedStar Medical Group, Washington, DC; Division of Cardiology (J.V., D.J., E.B.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Cardiology (D.J.), Medical University of South Carolina, Charleston
| | - Joban Vaishnav
- From the Department of Neurology (S.Z., B.P., A.D., G.E., M.P.), Johns Hopkins University School of Medicine, Baltimore, MD; Cardiology (F.H.S.), MedStar Medical Group, Washington, DC; Division of Cardiology (J.V., D.J., E.B.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Cardiology (D.J.), Medical University of South Carolina, Charleston
| | - Daniel Judge
- From the Department of Neurology (S.Z., B.P., A.D., G.E., M.P.), Johns Hopkins University School of Medicine, Baltimore, MD; Cardiology (F.H.S.), MedStar Medical Group, Washington, DC; Division of Cardiology (J.V., D.J., E.B.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Cardiology (D.J.), Medical University of South Carolina, Charleston
| | - Baohan Pan
- From the Department of Neurology (S.Z., B.P., A.D., G.E., M.P.), Johns Hopkins University School of Medicine, Baltimore, MD; Cardiology (F.H.S.), MedStar Medical Group, Washington, DC; Division of Cardiology (J.V., D.J., E.B.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Cardiology (D.J.), Medical University of South Carolina, Charleston
| | - Amrita Daniel
- From the Department of Neurology (S.Z., B.P., A.D., G.E., M.P.), Johns Hopkins University School of Medicine, Baltimore, MD; Cardiology (F.H.S.), MedStar Medical Group, Washington, DC; Division of Cardiology (J.V., D.J., E.B.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Cardiology (D.J.), Medical University of South Carolina, Charleston
| | - Emily Brown
- From the Department of Neurology (S.Z., B.P., A.D., G.E., M.P.), Johns Hopkins University School of Medicine, Baltimore, MD; Cardiology (F.H.S.), MedStar Medical Group, Washington, DC; Division of Cardiology (J.V., D.J., E.B.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Cardiology (D.J.), Medical University of South Carolina, Charleston
| | - Gigi Ebenezer
- From the Department of Neurology (S.Z., B.P., A.D., G.E., M.P.), Johns Hopkins University School of Medicine, Baltimore, MD; Cardiology (F.H.S.), MedStar Medical Group, Washington, DC; Division of Cardiology (J.V., D.J., E.B.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Cardiology (D.J.), Medical University of South Carolina, Charleston
| | - Michael Polydefkis
- From the Department of Neurology (S.Z., B.P., A.D., G.E., M.P.), Johns Hopkins University School of Medicine, Baltimore, MD; Cardiology (F.H.S.), MedStar Medical Group, Washington, DC; Division of Cardiology (J.V., D.J., E.B.), Johns Hopkins University School of Medicine, Baltimore, MD; and Department of Cardiology (D.J.), Medical University of South Carolina, Charleston.
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15
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Dori A, Arad M, Wasserstrum Y, Pollak A, Nikitin V, Ben-David M, Shamash J, Nahum AH, Shavit-Stein E, Domachevsky L, Kuperstein R, Dominissini D, Shelestovich N, Sadeh M, Pras E, Greenbaum L. Ser77Tyr transthyretin amyloidosis in Israel: Initial manifestations and diagnostic features. Ann Clin Transl Neurol 2023; 10:553-567. [PMID: 36772971 PMCID: PMC10109316 DOI: 10.1002/acn3.51741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 02/12/2023] Open
Abstract
OBJECTIVE Amyloidosis due to the transthyretin Ser77Tyr mutation (ATTRS77Y) is a rare autosomal-dominant disorder, characterized by carpal-tunnel syndrome, poly- and autonomic-neuropathy, and cardiomyopathy. However, related symptoms and signs are often nonspecific and confirmatory tests are required. We describe the age and frequency of early symptoms and diagnostic features among individuals of Jewish Yemenite descent in Israel. METHODS Records of mutation carriers were retrospectively reviewed. ATTRS77Y diagnosis was defined by the presence of amyloid in tissue and/or amyloid-related cardiomyopathy. RESULTS We identified the Ser77Tyr mutation at the heterozygous state in 19 amyloidosis patients (mean age at diagnosis: 62 ± 5.7 years, range 49-70) and 30 amyloid-negative carriers. The probability for disease diagnosis increased from 4.4% at age 49 to 100% at 70 and occurred earlier in males. Initial symptoms preceded diagnosis by 5 ± 3.8 years (range 0-12) and were commonly sensory changes in the extremities. Erectile dysfunction predated these in 8/13 (62%) males. In two patients cardiac preceded neurological symptoms. Two patients declined symptoms. Electrophysiological studies near the time of diagnosis indicated a median neuropathy at the wrist in 18/19 (95%) and polyneuropathy in 13/19 (68%). Skin biopsy revealed epidermal denervation in 15/16 (94%) patients. Cardiomyopathy was identified in 16/19 (84%). Sensory complaints or epidermal denervations were present in 17/30 (57%) of amyloid-negative carriers and co-occurred in 10/30 (33%). INTERPRETATION ATTRS77Y symptoms commonly occur after age 50, but may begin earlier. Median neuropathy, skin denervation and cardiomyopathy are frequently identified. Symptoms may be absent in patients and common in amyloid-negative carriers.
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Affiliation(s)
- Amir Dori
- Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Arad
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Yishay Wasserstrum
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Arthur Pollak
- Department of Cardiology, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Vera Nikitin
- Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Merav Ben-David
- Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jana Shamash
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Ayelet Hashachar Nahum
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Efrat Shavit-Stein
- Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liran Domachevsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Nuclear Medicine, Sheba Medical Center, Tel Hashomer, Israel
| | - Rafael Kuperstein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Dan Dominissini
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The genomics Unit, Sheba Cancer Research Center, Sheba Medical Center, Tel Hashomer, Israel.,Wohl Institute of Translational Medicine, Sheba Medical Center, Tel Hashomer, Israel
| | - Natalia Shelestovich
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Pathology, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Menachem Sadeh
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Neurology, Wolfson Medical Center, Holon, Israel
| | - Elon Pras
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Lior Greenbaum
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel.,The Joseph Sagol Neuroscience Center, Sheba Medical Center, Tel Hashomer, Israel
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16
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Conceição I, de Castro I, Diaz A, Castro J. Quantitative sensory testing: a good tool to identify subclinical neuropathy in ATTRV30M amyloidosis patients? Amyloid 2022:1-5. [PMID: 36519495 DOI: 10.1080/13506129.2022.2155132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Quantitative sensory testing (QST) has been one of the neurophysiological tools used for follow-up and disease progression assessment in ATTRv amyloidosis. We aimed to detect the utility of QST in identifying subclinical neuropathic involvement in ATTRV30M amyloidosis carriers. METHODS A cohort of ATTRV30M amyloidosis carriers were assessed with vibratory (VDT) and cooling (CDT) detection thresholds and heat pain responses. Subjects were divided into asymptomatic carriers (Group 1), paucisymptomatic carriers (Group 2) and stage 1 ATTRv-PN patients (Group 3). Nonparametric statistics were used for group comparisons. RESULTS A total of 207 ATTRV30M amyloidosis carriers (83 males) were included. Of these, 113 subjects were asymptomatic and 94 symptomatic carriers. In asymptomatic carriers, CDT and Heat Pain (HP 5.0 and HP 0.5) were significantly lower when compared to both group of symptomatic carriers (p ≤ 0.005). In Group 3, VDT, CDT and HP 5.0 were significantly higher, when compared to Group 2 (p < 0.05). CONCLUSIONS QST, in particular CDT, HP 5 and HP 0.5 modalities, seems a good tool to identify subclinical neuropathy in ATTRv amyloidosis carriers, with CDT showing a higher sensitivity to detect and early neuropathic involvement.
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Affiliation(s)
- Isabel Conceição
- Department of Neurosciences and Mental Health, Hospital de Santa Maria- CHULN, Lisbon, Portugal.,Instituto de Fisiologia, IMM João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Centro de Estudos Egas Moniz, Universidade de Lisboa, Lisbon, Portugal
| | - Isabel de Castro
- Department of Neurosciences and Mental Health, Hospital de Santa Maria- CHULN, Lisbon, Portugal.,Instituto de Fisiologia, IMM João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Centro de Estudos Egas Moniz, Universidade de Lisboa, Lisbon, Portugal
| | - Andrés Diaz
- Departamento de Neurologia, Clinica Reina Sofia-Keralty, Bogota, Colombia
| | - José Castro
- Department of Neurosciences and Mental Health, Hospital de Santa Maria- CHULN, Lisbon, Portugal.,Instituto de Fisiologia, IMM João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Centro de Estudos Egas Moniz, Universidade de Lisboa, Lisbon, Portugal
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17
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Freeman R, Gonzalez-Duarte A, Barroso F, Campagnolo M, Rajan S, Garcia J, Kim JY, Wang N, Orellana L, Gibbons C. Cutaneous amyloid is a biomarker in early ATTRv neuropathy and progresses across disease stages. Ann Clin Transl Neurol 2022; 9:1370-1383. [PMID: 35945901 PMCID: PMC9463946 DOI: 10.1002/acn3.51636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/22/2022] [Accepted: 07/14/2022] [Indexed: 11/06/2022] Open
Abstract
Objective To determine the sensitivity and specificity of cutaneous amyloid deposition in relation to patient‐reported measures in the earliest disease stage of hereditary ATTR amyloidosis (ATTRv). Methods In a cross‐sectional study, we analyzed 88 individuals with TTR mutations, 47 of whom were in the earliest disease stage and without clinically evident neuropathy, 12 healthy controls, and 13 disease controls with diabetes. All participants' neuropathy symptoms and signs were assessed using validated patient and clinician‐reported measures and 3‐mm skin punch biopsies were immunostained using protein gene product 9.5 and Congo Red. Results Amyloid can be detected in the earliest disease stages in up to 86% of patients with ATTRv amyloidosis. Amyloid was not detected in healthy individuals or individuals with diabetic peripheral neuropathy supporting a sensitivity of 86% and a specificity of 100%. The cutaneous deposition of amyloid correlates with neuropathy sensory symptoms, measured with the Neuropathy Total Symptom Score‐6 (R = 0.46, p < 0.01); pain measured with the Brief Pain Symptom Inventory (R = 0.44, p < 0.05); autonomic symptoms, measured with the Boston Autonomic Symptom Questionnaire (R = 0.38, p < 0.05); and quality of life measured with the Norfolk Diabetic Neuropathy Quality of Life Questionnaire (R = 0.44, p < 0.05). Individuals with amyloid deposition were more likely to have sensory symptoms, pain, autonomic impairment, and reduced quality of life than ATTRv patients without amyloid deposition. Interpretation These findings have implications for understanding the earliest manifestations of the clinical phenotype of ATTRv‐associated neuropathy, for the pathophysiological construct of disease staging, and for timing the introduction of disease‐modifying therapy.
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Affiliation(s)
- Roy Freeman
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Fabio Barroso
- Raúl Carrea Institute for Neurological Research, FLENI, Ciudad Autónoma de Buenos Aires, Argentina
| | - Marta Campagnolo
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sharika Rajan
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer Garcia
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jee Young Kim
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ningshan Wang
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lucas Orellana
- Raúl Carrea Institute for Neurological Research, FLENI, Ciudad Autónoma de Buenos Aires, Argentina
| | - Christopher Gibbons
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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18
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Hou Y, Gao Y, Guo S, Zhang Z, Chen R, Zhang X. Applications of spatially resolved omics in the field of endocrine tumors. Front Endocrinol (Lausanne) 2022; 13:993081. [PMID: 36704039 PMCID: PMC9873308 DOI: 10.3389/fendo.2022.993081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 12/15/2022] [Indexed: 01/11/2023] Open
Abstract
Endocrine tumors derive from endocrine cells with high heterogeneity in function, structure and embryology, and are characteristic of a marked diversity and tissue heterogeneity. There are still challenges in analyzing the molecular alternations within the heterogeneous microenvironment for endocrine tumors. Recently, several proteomic, lipidomic and metabolomic platforms have been applied to the analysis of endocrine tumors to explore the cellular and molecular mechanisms of tumor genesis, progression and metastasis. In this review, we provide a comprehensive overview of spatially resolved proteomics, lipidomics and metabolomics guided by mass spectrometry imaging and spatially resolved microproteomics directed by microextraction and tandem mass spectrometry. In this regard, we will discuss different mass spectrometry imaging techniques, including secondary ion mass spectrometry, matrix-assisted laser desorption/ionization and desorption electrospray ionization. Additionally, we will highlight microextraction approaches such as laser capture microdissection and liquid microjunction extraction. With these methods, proteins can be extracted precisely from specific regions of the endocrine tumor. Finally, we compare applications of proteomic, lipidomic and metabolomic platforms in the field of endocrine tumors and outline their potentials in elucidating cellular and molecular processes involved in endocrine tumors.
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Affiliation(s)
- Yinuo Hou
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
| | - Yan Gao
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
| | - Shudi Guo
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
| | - Zhibin Zhang
- General Surgery, Tianjin First Center Hospital, Tianjin, China
- *Correspondence: Zhibin Zhang, ; Ruibing Chen, ; Xiangyang Zhang,
| | - Ruibing Chen
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
- *Correspondence: Zhibin Zhang, ; Ruibing Chen, ; Xiangyang Zhang,
| | - Xiangyang Zhang
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
- *Correspondence: Zhibin Zhang, ; Ruibing Chen, ; Xiangyang Zhang,
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