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Hemostatic Abnormalities in Gaucher Disease: Mechanisms and Clinical Implications. J Clin Med 2022; 11:jcm11236920. [PMID: 36498496 PMCID: PMC9735904 DOI: 10.3390/jcm11236920] [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: 10/14/2022] [Revised: 11/08/2022] [Accepted: 11/20/2022] [Indexed: 11/25/2022] Open
Abstract
Gaucher disease (GD) is a rare inherited lysosomal metabolism disorder, characterized by an accumulation into lysosomes of reticuloendothelial cells, especially in the bone marrow, spleen, and liver of β-glucosylceramide and glucosyl sphingosine, which is its deacylated product. Impaired storage is responsible for a chronic inflammatory state at the sites of accumulation and together represents the pathophysiological cause of GD. GD is a progressive, multi-organ chronic disorder. Type 1 GD is the most prevalent form, with heterogeneous multisystem involvement and different severity of symptoms at any age. Hematological involvement is consistent, and a bleeding tendency is frequent, particularly at diagnosis. Several coagulation and primary hemostasis abnormalities are observed in GD. Bleeding manifestations are rarely severe and usually mucocutaneous. Post-operative, delivery, and post-partum hemorrhages are also common. Thrombocytopenia, platelet function defects, and clotting abnormalities, alone or variably associated, contribute to increase the risk of bleeding in GD. Enzyme replacement therapy (ERT) or substrate reduction therapy (SRT) are the two specific available treatments effective in improving typical hematological symptoms and abnormalities, including those of hemostasis. However, the use of medication to potentiate hemostasis may be also useful in defined clinical situations: recent starting of ERT/SRT, surgery, delivery, and life-threatening bleeding.
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Brain-Derived Neurotrophic Factor (BDNF) Is Associated with Platelet Activity and Bleeding Tendency in Patients with Gaucher Disease. Int J Mol Sci 2022; 23:ijms232213982. [PMID: 36430458 PMCID: PMC9697957 DOI: 10.3390/ijms232213982] [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: 10/20/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Bleeding tendency, a prominent feature of patients with Gaucher disease (GD), is associated with abnormal platelet function. Brain-derived neurotrophic factor (BDNF) is a protein with neuroprotective potential stored in alpha granules of circulating platelets. Here we studied BDNF levels in 50 patients with type I GD (GD1) and their correlation with platelet activity and bleeding tendency. Flow cytometry was used to test unstimulated and stimulated measurement of platelet surface-activated expression of αIIbβ3 integrin, P-selectin and lysosomal-associated membrane protein (LAMP3/CD63). Serum and plasma BDNF levels were quantified using ELISA. The bleeding history was recorded by a bleeding questionnaire. Serum BDNF levels were positively correlated with platelet count and moderately correlated with unstimulated and stimulated platelet P-selectin expression. Patients with more than one bleeding manifestation were shown to have lower serum BDNF levels, albeit similar platelet count. Plasma BDNF levels were significantly elevated in splenectomized patients and showed a moderate positive correlation with stimulated platelet CD63 expression. These observations demonstrate the first association between BDNF levels in the peripheral blood with platelet dysfunction and increased bleeding manifestation. The role of measuring serum BDNF for assessing platelet alpha degranulation defects and bleeding risk in patients with GD and the general population needs further study.
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Giraldo P, Andrade-Campos M. Novel Management and Screening Approaches for Haematological Complications of Gaucher's Disease. J Blood Med 2021; 12:1045-1056. [PMID: 34908889 PMCID: PMC8665828 DOI: 10.2147/jbm.s279756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/23/2021] [Indexed: 12/17/2022] Open
Abstract
Purpose Gaucher disease (GD) is the most common lysosomal storage disorder. The principal manifestations for its diagnosis and further monitoring include haematological manifestations such as anaemia, thrombocytopaenia, spleen enlargement, and bleeding disorders, among others. This review aims to summarise and update the role of haematological complications in GD diagnosis and follow-up, describe their management strategies, and to use these indicators as part of the diagnostic approach. Materials and Methods A systematic review following the recommendations of PRISMA-P 2020 was carried out. Publications indexed in the databases PubMed, Embase, Science Open, Mendeley, and Web of Science were electronically searched by three independent reviewers, and publications up to June 2021 were accessed. A total of 246 publications were initially listed, of which 129 were included for further review and analysis. Case reports were considered if they were representative of a relevant hematologic complication. Results From the first review dated in 1974 to the latest publication in 2021, including different populations confirmed that the haematological manifestations such as thrombocytopaenia and splenomegaly at diagnosis of GD type 1 are the most frequent features of the disease. The incorporation of haematological parameters to diagnosis strategies increases their cost-effectiveness. Hematologic parameters are part of the scoring system for disease assessment and the evaluation of therapeutic outcomes, providing reliable and accessible data to improve the management of GD. However, cytopaenia, underlying coagulation disorders, and platelet dysfunction need to be addressed, especially during pregnancy or surgery. Long-term haematological complications include the risk of neoplasia and immune impairment, an area of unmet need that is currently under research. Conclusion Haematological features are key for GD suspicion, diagnosis, and management. Normalization of hematological parameters is achieved with the treatment; however, there are unmet needs such as the underlying inflammatory status and the long-term risk of hematologic neoplasia.
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Affiliation(s)
- Pilar Giraldo
- Haematology, Hospital Quironsalud, Zaragoza, Spain.,Foundation FEETEG, Zaragoza, Spain
| | - Marcio Andrade-Campos
- Foundation FEETEG, Zaragoza, Spain.,Haematology Department, Hospital del Mar, Barcelona, Spain
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4
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Revel-Vilk S, Naamad M, Frydman D, Freund MR, Dinur T, Istaiti M, Becker-Cohen M, Falk R, Broide E, Michelson AD, Frelinger AL, Zimran A. Platelet Activation and Reactivity in a Large Cohort of Patients with Gaucher Disease. Thromb Haemost 2021; 122:951-960. [PMID: 34507369 DOI: 10.1055/a-1642-4206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Patients with Gaucher disease (GD) are at increased risk of bleeding and have varying degrees of thrombocytopenia, making the analysis of platelet function difficult. This study aimed to provide a clinically relevant quantitative assessment of platelet function and determine its relationship with bleeding and GD-related data. METHODS Unstimulated and stimulated platelet function was measured by whole blood flow cytometry of platelet surface-activated αIIbβ3 integrin (detected with monoclonal antibody PAC1), P-selectin (CD62P), and lysosomal-associated membrane protein (LAMP3/CD63) in 149 GD patients. RESULTS GD patients had a higher level of unstimulated CD63 expression than healthy subjects, which was mildly correlated with glucosylsphingosine (lyso-Gb1) levels (r = 0.17, p-value = 0.042). Splenectomized GD patients had a higher level of unstimulated αIIbβ3 integrin and P-selectin expression. Reduced platelet reactivity (-2 standard deviation of reference range) was found in 79 (53%, 95% confidence interval [CI]: 44-61%) patients, of whom 10 (6.7%, 95% CI: 3.3-12%) had more severe platelet dysfunction. In a multivariate model, only lyso-Gb1 levels were associated with the more severe platelet dysfunction. Fifty-four (49%) of 128 adult patients who completed the bleeding tendency questionnaire reported positive bleeding history. In a multivariate logistic model, older age (odds ratio [OR]: 1.05, 95% CI: 1.01-1.1) and low P-selectin reactivity (OR: 2.03, 95% CI: 1.25-3.35) were associated with more than one bleeding manifestation. CONCLUSION Flow cytometry enables the study of platelet function in thrombocytopenic GD patients. A platelet degranulation defect, but not αIIbβ3 integrin activation defect, is associated with clinical bleeding. In vivo increased CD63 expression may be related to GD-related inflammation.
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Affiliation(s)
- Shoshana Revel-Vilk
- Gaucher Unit, Shaare Zedek Medical Center, Jerusalem, Israel.,Pediatric Hematology/Oncology Unit, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Mira Naamad
- Flow Cytometry Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Dafna Frydman
- Gaucher Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Tama Dinur
- Gaucher Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | | | - Roni Falk
- Flow Cytometry Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Eti Broide
- Flow Cytometry Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Alan D Michelson
- Center for Platelet Research Studies, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, United States
| | - Andrew L Frelinger
- Center for Platelet Research Studies, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, United States
| | - Ari Zimran
- Gaucher Unit, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Cohen Y, Frydman D, Rotem R, Kofman R, Zimran A, Revel-Vilk S, Grisaru-Granovsky S. Risk of postpartum hemorrhage in multiparous women with Gaucher disease: A call for reconsidering enzyme replacement therapy in all pregnant patients. J Inherit Metab Dis 2021; 44:1165-1173. [PMID: 33829536 DOI: 10.1002/jimd.12382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 03/09/2021] [Accepted: 04/06/2021] [Indexed: 11/11/2022]
Abstract
For the last three decades, enzyme replacement therapy (ERT) for Gaucher disease (GD) has been available. We aimed to evaluate the effect of ERT on the pregnancy and obstetric outcome in a unique group of multiparous women with type 1 GD (GD1) who had pregnancies with and without ERT. The Gaucher Unit database (1987-2019) was searched for multiparous women who had pregnancies before and after the institution of ERT. Data were collected from the clinic files and study-specific questionnaires. Descriptive, correlation analysis and generalized estimating equations (GEE) were used to study the effect of ERT and confounding variables on study outcomes. We identified 19 women with 105 pregnancies, among which 26 (24.7%) terminated in first-trimester miscarriage. The risk for miscarriage was associated with the severity of GD1 genotype and phenotype, but not with ERT usage. Early postpartum hemorrhage (PPH) was reported in 16 (84%) women after 25 deliveries (31.6%, 95% CI 21.6%-43.1%). The risks of early PPH and red blood cell (RBC) transfusions were significantly lower when ERT was used during pregnancy, OR (95% CI) 0.13 (0.03-0.54) and 0.27 (0.08-0.94), respectively, compared to pregnancies without the use of ERT. Enzyme replacement therapy during pregnancy is risk reducing for early PPH and RBC transfusions in women with GD1. We suggest considering ERT for the benefit of all pregnant women with GD1, including mild GD1.
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Affiliation(s)
- Yael Cohen
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
- The Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Dafna Frydman
- Gaucher Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Reut Rotem
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Roei Kofman
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Ari Zimran
- The Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Gaucher Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Shoshana Revel-Vilk
- The Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Gaucher Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
- The Faculty of Medicine, Hebrew University, Jerusalem, Israel
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Revel-Vilk S, Szer J, Zimran A. Hematological manifestations and complications of Gaucher disease. Expert Rev Hematol 2021; 14:347-354. [PMID: 33759681 DOI: 10.1080/17474086.2021.1908120] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: Gaucher disease (GD), although pan-ethnic and rare (common in Ashkenazi Jews), is of great importance to hematologists both for diagnosis and management. The need for increased awareness of GD is that delayed diagnosis may lead to preventable irreversible complications (mainly skeletal) or unnecessary invasive procedures (e.g. bone marrow biopsy), and the birth of another affected sibling due to lack of genetic consulting.Areas covered: The review outlines the common hematological manifestations of GD, including splenomegaly, thrombocytopenia, and anemia. Other hematological manifestations such as coagulation abnormalities, platelet dysfunction, gammopathy, and other hematological malignancies associated with GD are also discussed. Current and future treatment modalities are delineated, including enzyme replacement and substrate reduction therapy, pharmacological chaperon, and gene therapy. A literature search was conducted to identify original research articles relevant to hematology manifestations and GD published before November 2020.Expert opinion: Patients with GD should be ideally followed and treated in a center of excellence where the GD expert benefits from experienced consultants in relevant disciplines. Due to the availability of several very expensive treatment options, it is important to have an unbiased expert who can select the most suitable management for the individual patients (including withholding prescription in asymptomatic patients).
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Affiliation(s)
- Shoshana Revel-Vilk
- Gaucher Unit, Shaare Zedek Medical Centre, Jerusalem, Israel.,Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jeff Szer
- Clinical Haematology at Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia
| | - Ari Zimran
- Gaucher Unit, Shaare Zedek Medical Centre, Jerusalem, Israel.,Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
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Pawliński Ł, Tobór E, Suski M, Biela M, Polus A, Kieć-Wilk B. Proteomic biomarkers in Gaucher disease. J Clin Pathol 2020; 74:25-29. [PMID: 32409598 DOI: 10.1136/jclinpath-2020-206580] [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: 03/21/2020] [Revised: 04/07/2020] [Accepted: 04/13/2020] [Indexed: 12/28/2022]
Abstract
AIMS The research work was conducted to find new biomarkers and potential drug targets in Gaucher disease type 1 (GDt1) by analysing the serum proteins. METHODS This study was an observational, cross-sectional analysis of a group of 12 adult participants: six Gaucher disease (GD) patients and six healthy control. Fasting venous blood underwent proteomics analysis and molecular tests. Over 400 proteins were analysed, and in case of significantly different concentrations between the study and control group, we checked corresponding genes to confirm changes in their expression and consistency with protein alteration. RESULTS We found 31 proteins that significantly differed in concentration between GDt1 patients and a control group. These were mostly proteins involved in the regulation of the inflammatory processes and haemostasis. The levels of proteins such as alpha-1-acid glycoprotein 2, S100-A8/A9, adenyl cyclase-associated protein 1, haptoglobin or translationally controlled tumour protein related to inflammation process were significantly higher in GD patients than in control group, whereas the levels of some proteins such as heavy constant mu and gamma 4 or complement C3/C4 complex involved in humoral response like immunoglobulins were significantly decreased in GD patients. Alteration in two proteins concentration was confirmed in RNA analysis. CONCLUSIONS The work revealed few new targets for further investigation which may be useful in clinical practice for diagnosis, treatment and monitoring GDt1 patients.
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Affiliation(s)
- Łukasz Pawliński
- Metabolic Diseases and Diabetology Department, Szpital Uniwersytecki w Krakowie, Kraków, małopolskie, Poland
| | - Ewa Tobór
- Metabolic Diseases and Diabetology Department, Szpital Uniwersytecki w Krakowie, Kraków, małopolskie, Poland
| | - Maciej Suski
- Department of Pharmacology, Jagiellonian University in Krakow Medical College Faculty of Medicine, Krakow, Poland
| | - Maria Biela
- Department of Clinical Biochemistry, Jagiellonian University in Krakow Medical College Faculty of Medicine, Krakow, Poland
| | - Anna Polus
- Department of Clinical Biochemistry, Jagiellonian University in Krakow Medical College Faculty of Medicine, Krakow, Poland
| | - Beata Kieć-Wilk
- Metabolic Diseases and Diabetology Department, Szpital Uniwersytecki w Krakowie, Kraków, małopolskie, Poland
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Serratrice C, Cherin P, Lidove O, Noel E, Masseau A, Leguy-Seguin V, Jaussaud R, Marie I, Lavigne C, Maillot F. Coagulation Parameters in Adult Patients With Type-1 Gaucher Disease. J Hematol 2019; 8:121-124. [PMID: 32300455 PMCID: PMC7153659 DOI: 10.14740/jh543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 08/16/2019] [Indexed: 02/05/2023] Open
Abstract
Background Gaucher disease is a rare inborn error of lysosomal metabolism, characterized by lysosomal storage of the β-glucosylceramide. Bleedings observed in type-1 Gaucher disease (GD1) are commonly attributed to a low platelet count, but they can also occur when the platelet count is normal or slightly low. Abnormal platelet function has been described and deficiencies in coagulation factors too, such as factors II, V, VII, VIII, IX, X, XI, XII, and von Willebrand factor. However, studies are few in number, involving few patients and having varying conclusions. The aim of this study was to analyze clotting factor deficiencies in a larger cohort of French patients with GD1. Methods This is an observational national study. The coagulation parameters were collected during routine GD1 monitoring and described retrospectively. Results We highlighted low levels of various coagulation factors in 46% of the patients with GD1. The most frequent coagulation abnormalities encountered were factor V, X, XI, and XII deficiencies. Deficits were usually mild and coagulation abnormalities tended to be more frequent in non-splenectomized patients. Conclusions In conclusion, frequent and varied coagulation abnormalities were found in a high proportion of GD1 patients.
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Affiliation(s)
- Christine Serratrice
- Department of Internal Medicine of the Aged, University Hospital of Geneva, 1226 Thonex, Switzerland
| | - Patrick Cherin
- Department of Internal Medicine, Pitie-Salpetriere Hospital Group, 75013 Paris, France
| | - Olivier Lidove
- Internal Medicine Department, Groupe Hospitalier Diaconesses Croix Saint Simon, 75020 Paris, France
| | - Esther Noel
- Department of Internal Medicine, University Hospital of Strasbourg, 67091 Strasbourg, France
| | - Agathe Masseau
- Internal Medicine Department, University Hospital Hotel Dieu, 44093 Nantes, France
| | - Vanessa Leguy-Seguin
- Department of Internal Medicine and Clinical Immunology, University Hospital of Dijon, 21079, Dijon, France
| | - Roland Jaussaud
- Department of Internal Medicine, CHRU Nancy, 54511 Vandoeuvre les Nancy, France
| | - Isabelle Marie
- Department of Internal Medicine, University Hospital of Rouen, INSERM U 905, 76031 Rouen, France
| | - Christian Lavigne
- Internal Medicine and Vascular Diseases Department, Angers University Hospital, 49933 Angers, France
| | - Francois Maillot
- Internal Medicine Department, Tours University Hospital, University of Tours, UMR INSERM 1253, 37044 Tours, France
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9
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Acquired platelet function disorders. Thromb Res 2019; 196:561-568. [PMID: 31229273 DOI: 10.1016/j.thromres.2019.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 06/08/2019] [Accepted: 06/14/2019] [Indexed: 12/16/2022]
Abstract
The possibility of an acquired platelet function disorder should be considered in patients who present with recent onset muco-cutaneous bleeding. Despite the availability of newer and faster platelet function assays, light transmission aggregometry (LTA) remains the preferred diagnostic test. This review examines and discusses the causes of acquired platelet dysfunction; most commonly drugs, dietary factors, medical disorders and procedures. In addition to well-known antiplatelet therapies, clinicians should be alert for newer drugs which can affect platelets, such as ibrutinib. There is little clinical trial evidence to guide the management of acquired platelet function defects, but we summarise commonly employed strategies, which include addressing the underlying cause, antifibrinolytic agents, desmopressin infusions, and in selected patients, platelet transfusions.
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Abstract
OBJECTIVE The objective of this article was to demonstrate that Gaucher disease (GD) patients with refractory hypersplenism and massive splenomegaly may successfully undergo hand-assisted laparoscopic splenectomy (HALS). METHODS This was a retrospective audit conducted at the Gaucher clinic at a national referral center over a 10-year period. PATIENT POPULATION This study included 8 GD patients who underwent hand-assisted or conventional laparoscopic splenectomy for massive or complicated splenomegaly between the years 2007 and 2017. RESULTS Seven patients underwent an elective HALS procedure because of refractory hypersplenism, whereas 1 patient underwent an urgent conventional laparoscopic splenectomy because of torsion of a wandering spleen. Only 1 patient required conversion to open surgery because of multiple adhesions from a previous partial splenectomy. The mean weight of the removed spleens was 2373 g (range, 480 to 4900 g), mean craniocaudal length of the removed spleens was 25 cm (range, 20 to 33.5 cm), and mean operating time was 150 minutes (range, 96 to 280 min). Postoperative complications were limited to 2 patients and included thrombosis of the splenic vein stump in 1 patient, and propagation of a preoperative splenic vein thrombus to the portal system, as well as an accumulation of an intra-abdominal hematoma in another patient. There was no mortality. Mean length of hospital stay was 5 days (range, 2 to 11 d). CONCLUSION HALS for GD patients with refractory hypersplenism and massive splenomegaly is safe and feasible in experienced hands.
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11
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Revel-Vilk S, Szer J, Mehta A, Zimran A. How we manage Gaucher Disease in the era of choices. Br J Haematol 2018; 182:467-480. [PMID: 29808905 DOI: 10.1111/bjh.15402] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Treatment of Gaucher Disease (GD) is now beset with the abundance of therapeutic options for an individual patient, making the choice of therapy complex for both expert and non-expert clinicians. The pathogenesis of all disease manifestations is a gene mutation-driven deficiency of glucocerebrosidase, but the clinical expression and response of each of the clinical manifestations to different therapies can be difficult to predict. Enzyme replacement therapy has been available since 1991 and is well-established, with known efficacy and minimal toxicity. Of interest, the three available enzymes are distinct molecules and were registered as new products, not biosimilars. Oral substrate reduction therapy has undergone a revitalisation with a newly approved agent in this class for which some efficacy and toxicity questions have been raised. Herein we present our approach to the management of GD in the era of choices, including a new algorithm for how to manage a newly diagnosed patient.
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Affiliation(s)
- Shoshana Revel-Vilk
- Gaucher Clinic, Shaare Zedek Medical Centre, Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - Jeff Szer
- Royal Melbourne Hospital and Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Atul Mehta
- Department of Haematology, Royal Free Hospital, London, UK
| | - Ari Zimran
- Gaucher Clinic, Shaare Zedek Medical Centre, Hadassah-Hebrew University Medical School, Jerusalem, Israel
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12
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Adar T, Ilan Y, Elstein D, Zimran A. Liver involvement in Gaucher disease – Review and clinical approach. Blood Cells Mol Dis 2018; 68:66-73. [DOI: 10.1016/j.bcmd.2016.10.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/17/2016] [Indexed: 02/07/2023]
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13
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Stirnemann J, Belmatoug N, Camou F, Serratrice C, Froissart R, Caillaud C, Levade T, Astudillo L, Serratrice J, Brassier A, Rose C, Billette de Villemeur T, Berger MG. A Review of Gaucher Disease Pathophysiology, Clinical Presentation and Treatments. Int J Mol Sci 2017; 18:ijms18020441. [PMID: 28218669 PMCID: PMC5343975 DOI: 10.3390/ijms18020441] [Citation(s) in RCA: 411] [Impact Index Per Article: 58.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 02/09/2017] [Accepted: 02/10/2017] [Indexed: 01/18/2023] Open
Abstract
Gaucher disease (GD, ORPHA355) is a rare, autosomal recessive genetic disorder. It is caused by a deficiency of the lysosomal enzyme, glucocerebrosidase, which leads to an accumulation of its substrate, glucosylceramide, in macrophages. In the general population, its incidence is approximately 1/40,000 to 1/60,000 births, rising to 1/800 in Ashkenazi Jews. The main cause of the cytopenia, splenomegaly, hepatomegaly, and bone lesions associated with the disease is considered to be the infiltration of the bone marrow, spleen, and liver by Gaucher cells. Type-1 Gaucher disease, which affects the majority of patients (90% in Europe and USA, but less in other regions), is characterized by effects on the viscera, whereas types 2 and 3 are also associated with neurological impairment, either severe in type 2 or variable in type 3. A diagnosis of GD can be confirmed by demonstrating the deficiency of acid glucocerebrosidase activity in leukocytes. Mutations in the GBA1 gene should be identified as they may be of prognostic value in some cases. Patients with type-1 GD-but also carriers of GBA1 mutation-have been found to be predisposed to developing Parkinson's disease, and the risk of neoplasia associated with the disease is still subject to discussion. Disease-specific treatment consists of intravenous enzyme replacement therapy (ERT) using one of the currently available molecules (imiglucerase, velaglucerase, or taliglucerase). Orally administered inhibitors of glucosylceramide biosynthesis can also be used (miglustat or eliglustat).
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Affiliation(s)
- Jérôme Stirnemann
- Department of Internal Medicine, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève, Switzerland.
| | - Nadia Belmatoug
- Department of Internal Medicine, Reference Center for Lysosomal Storage Diseases, Hôpitaux Universitaires Paris Nord Val de Seine, site Beaujon, Assistance Publique-Hôpitaux de Paris, 100 boulevard du Général Leclerc, F-92110 Clichy la Garenne, France.
| | - Fabrice Camou
- Réanimation Médicale, Hôpital Saint André, CHU de Bordeaux, 1 rue Jean Burguet, F-33075 Bordeaux, France.
| | - Christine Serratrice
- Department of Internal Medicine, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève, Switzerland.
| | - Roseline Froissart
- Service de Biochimie et Biologie Moléculaire Grand Est, unité des Maladies Héréditaires du Métabolisme et Dépistage Néonatal, Centre de Biologie et de Pathologie Est, Hospices Civils de Lyon, F-69677 Bron, France.
| | - Catherine Caillaud
- Inserm U1151, Institut Necker Enfants Malades, Université Paris Descartes, Laboratoire de Biochimie, Métabolomique et Protéomique, Hôpital Universitaire Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, 149 rue de Sèvres, F-75005 Paris, France.
| | - Thierry Levade
- Institut National de la Santé et de la Recherche Médicale (INSERM) UMR1037, Centre de Recherches en Cancérologie de Toulouse (CRCT), Université Paul Sabatier, Laboratoire de Biochimie Métabolique, Institut Fédératif de Biologie, CHU Purpan, F-31059 Toulouse, France.
| | - Leonardo Astudillo
- Institut National de la Santé et de la Recherche Médicale (INSERM) UMR1037, Equipe Labellisée Ligue Contre le Cancer 2013, Centre de Recherches en Cancerologie de Toulouse (CRCT), Université de Toulouse, Service de Médecine Interne, CHU Purpan, F-31059 Toulouse, France.
| | - Jacques Serratrice
- Department of Internal Medicine, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève, Switzerland.
| | - Anaïs Brassier
- Centre de Référence des Maladies Héréditaires du Métabolisme de l'Enfant et de l'Adulte (MaMEA), Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Institut Imagine, F-75012 Paris, France.
| | - Christian Rose
- Service d'onco-hématologie, Saint-Vincent de Paul Hospital, Boulevard de Belfort, Université Catholique de Lille, Univ. Nord de France, F-59000 Lille, France.
| | - Thierry Billette de Villemeur
- Service de Neuropédiatrie, Pathologie du développement, Sorbonne Université, Reference Center for Lysosomal Diseases, Hôpital Trousseau, Assistance Publique-Hôpitaux de Paris, 24 Avenue du docteur Arnold Netter, F-75012 Paris, France.
| | - Marc G Berger
- CHU Estaing et Université Clermont Auvergne, Hematology (Biology) et EA 7453 CHELTER, F-63000 Clermont-Ferrand, France.
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Ioscovich A, Fadeev D, Kenet G, Naamad M, Schtrechman G, Zimran A, Elstein D. Thromboelastography as a Surrogate Marker of Perisurgical Hemostasis in Gaucher Disease. Clin Appl Thromb Hemost 2016; 22:693-7. [DOI: 10.1177/1076029615578165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Thromboelastography (TEG) has long been available for routine monitoring of perisurgical and postpartum hemostasis, especially at point of care. The purpose of this study is to retrospectively compare TEG parameters to concomitant standard clotting test results in an unselected cohort of patients with Gaucher disease to ascertain whether TEG values are specific and sensitive enough to substitute for classic coagulation tests for decision making. This remains a cogent concern because of high incidence of thrombocytopenia in patients with Gaucher disease. Thromboelastography values were compared to concomitant platelet counts, partial thromboplastin time, international normalization ratio, and plasma fibrinogen. Demographic characteristics were collected from patients’ files. There were 22 patients with Gaucher disease (2 children; 12.5%) for whom there were 24 TEG results at the same time as classic coagulation test results and 30% performed platelet function tests. The current study shows linear and/or monotonic relationships between platelet counts and several TEG values that were significant over a range of platelet counts including severe thrombocytopenia. The fibrinogen component, correlating only with the rate of clot lysis, played a lesser role. Based on these preliminary results albeit in a small cohort with only 1 case of hemorrhage, there is putative support for the intention to treat patients with Gaucher disease based on TEG results using the same TEG protocol as for other patients undergoing comparable procedures in our institution.
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Affiliation(s)
- Alexander Ioscovich
- Department of Anesthesiology, Perioperative Medicine & Pain Treatment, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Dmitri Fadeev
- Department of Anesthesiology, Perioperative Medicine & Pain Treatment, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Gili Kenet
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer affiliated with the Sackler Medical School of the Tel Aviv University, Tel Aviv, Israel
| | - Mira Naamad
- Blood Bank, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Gal Schtrechman
- Department of Anesthesiology, Perioperative Medicine & Pain Treatment, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Ari Zimran
- Gaucher Clinic, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Deborah Elstein
- Gaucher Clinic, Shaare Zedek Medical Center, Jerusalem, Israel
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Linari S, Castaman G. Hematological manifestations and complications of Gaucher disease. Expert Rev Hematol 2015; 9:51-8. [DOI: 10.1586/17474086.2016.1112732] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Gaucher disease (GD) is an inherited lysosomal disorder, originating from deficient activity of the lysosomal enzyme glucocerebrosidase (GCase). Normally, GCase hydrolyzes glucocerebroside (GC) to glucose and ceramide; however, impaired activity of this enzyme leads to the accumulation of GC in macrophages, termed "Gaucher cells." Gaucher disease is associated with hepatosplenomegaly, cytopenias, skeletal complications and in some forms involves the central nervous system. Coagulation abnormalities are common among GD patients due to impaired production and chronic consumption of coagulation factors. Bleeding phenomena are variable (as are other symptoms of GD) and include mucosal and surgical hemorrhages. FOUR MAIN ETIOLOGICAL FACTORS ACCOUNT FOR THE HEMOSTATIC DEFECT IN GD: thrombocytopenia, abnormal platelet function, reduced production of coagulation factors, and activation of fibrinolysis. Thrombocytopenia relates not only to hypersplenism and decreased megakaryopoiesis by the infiltrated bone marrow but also to immune thrombocytopenia. Autoimmunity, especially the induction of platelet antibody production, might cause persistent thrombocytopenia. Enzyme replacement therapy reverses only part of the impaired coagulation system in Gaucher disease. Other therapeutic and supportive measures should be considered to prevent and/or treat bleeding in GD. Gaucher patients should be evaluated routinely for coagulation abnormalities especially prior to surgery and dental and obstetric procedures.
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Affiliation(s)
- Hanna Rosenbaum
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel and ; Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Mitrovic M, Elezovic I, Grujicic D, Miljic P, Suvajdzic N. Complex haemostatic abnormalities as a cause of bleeding after neurosurgery in a patient with Gaucher disease. Platelets 2014; 26:260-2. [PMID: 24749498 DOI: 10.3109/09537104.2014.903471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We report a treatment-naïve patient with Gaucher disease (GD) who experienced repeated bleeding after three neurosurgeries for a brain tumour, identified as an oligoastrocytoma. The patient had normal values on basic haemostatic tests: prothrombin time, 75-105%; activated partial thromboplastin time, 30.3-34 s; and mild thrombocytopaenia, 96-115 × 10(9 )cells/l. However, additional tests showed mild von Willebrand factor (vWF) deficiency (vWF antigen, 56%; vWF ristocetin cofactor, 49%; factor VIII [FVIII], 54%) and abnormal collagen-mediated platelet aggregation (0.45-0.55). Bleeding control was achieved after vWF/FVIII concentrate and platelet transfusions. This case raises questions about the safe platelet count and basic haemostatic tests for assessing bleeding risk in patients with GD prior to surgery. In patients with GD, a minimum haemostatic evaluation should include platelet count and basic haemostatic tests such as fibrinogen, prothrombin time, activated partial thromboplastin time as well as platelet function tests and assessing vWF and FVIII levels. Specific coagulation factors or platelet function deficiencies should be corrected with factor concentrates or platelet transfusions.
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Mitrovic M, Elezovic I, Miljic P, Suvajdzic N. Acquired von Willebrand syndrome in patients with Gaucher disease. Blood Cells Mol Dis 2014; 52:205-7. [DOI: 10.1016/j.bcmd.2013.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Revised: 10/05/2013] [Accepted: 10/26/2013] [Indexed: 11/27/2022]
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Thomas AS, Mehta A, Hughes DA. Gaucher disease: haematological presentations and complications. Br J Haematol 2014; 165:427-40. [PMID: 24588457 DOI: 10.1111/bjh.12804] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Gaucher disease (GD) is an autosomal recessive lysosomal storage disease, caused by deficiency of the enzyme glucocerebrosidase, required for the degradation of glycosphingolipids. Clinical manifestations include hepatosplenomegaly, thrombocytopenia, bone disease and a bleeding diathesis, frequently resulting in presentation to haematologists. Historically managed by splenectomy, transfusions and orthopaedic surgery, the development of specific therapy in the form of intravenous enzyme replacement therapy in the 1990s has resulted in dramatic improvements in haematological and visceral disease. Recognition of complications, including multiple myeloma and Parkinson disease, has challenged the traditional macrophage-centric view of the pathophysiology of this disorder. The pathways by which enzyme deficiency results in the clinical manifestations of this disorder are poorly understood; altered inflammatory cytokine profiles, bioactive sphingolipid derivatives and alterations in the bone marrow microenvironment have been implicated. Further elucidating these pathways will serve to advance our understanding not only of GD, but of associated disorders.
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Affiliation(s)
- Alison S Thomas
- Lysosomal Storage Disorders Unit, Royal Free Hospital, London, UK
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Abstract
Gaucher disease is the commonest lysosomal storage disease seen in India and worldwide. It should be considered in any child or adult with an unexplained splenohepatomegaly and cytopenia which are seen in the three types of Gaucher disease. Type 1 is the non-neuronopathic form and type 2 and 3 are the neuronopathic forms. Type 2 is a more severe neuronopathic form leading to mortality by 2 years of age. Definitive diagnosis is made by a blood test-the glucocerebrosidase assay. There is no role for histological examination of the bone marrow, liver or spleen for diagnosis of the disease. Molecular studies for mutations are useful for confirming diagnosis, screening family members and prognosticating the disease. A splenectomy should not be performed except for palliation or when there is no response to enzyme replacement treatment or no possibility of getting any definitive treatment. Splenectomy may worsen skeletal and lung manifestations in Gaucher disease. Enzyme replacement therapy (ERT) has completely revolutionized the prognosis and is now the standard of care for patients with this disease. Best results are seen in type 1 disease with good resolution of splenohepatomegaly, cytopenia and bone symptoms. Neurological symptoms in type 3 disease need supportive care. ERT is of no benefit in type 2 disease. Monitoring of patients on ERT involves evaluation of growth, blood counts, liver and spleen size and biomarkers such as chitotriosidase which reflect the disease burden. Therapy with ERT is very expensive and though patients in India have so far got the drug through a charitable access programme, there is a need for the government to facilitate access to treatment for this potentially curable disease. Bone marrow transplantation is an inferior option but may be considered when access to expensive ERT is not possible.
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Key Words
- ACE, angiotensin converting enzyme
- DEXA, dual energy X-ray absorptiometry
- EEG, electroencephalography
- ERT, enzyme replacement therapy
- GBA, acid beta-glucosidase/glucocerebrosidase
- GD, Gaucher disease
- GD1, Gaucher disease type 1
- GD2, Gaucher disease type 2
- GD3, Gaucher disease type 3
- ICGC, International Collaborative Gaucher Group
- INCAP, India Charitable Access Programme
- IQ, intelligence quotient
- LSD, lysosomal storage disorders
- MRI, magnetic resonance imaging
- SF-36, short form 36
- TRAP, tartarate resistant acid phosphatase
- USG, ultrasonography
- enzyme replacement therapy
- glucocerebrosidase
- lysosomal storage disorder
- splenomegaly
- thrombocytopenia
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Razek AAKA, Abdalla A, Fathy A, Megahed A. Apparent diffusion coefficient of the vertebral bone marrow in children with Gaucher's disease type I and III. Skeletal Radiol 2013; 42:283-7. [PMID: 22718272 DOI: 10.1007/s00256-012-1464-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 05/29/2012] [Accepted: 05/30/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess apparent diffusion coefficient (ADC) as a quantitative parameter for detection of vertebral bone marrow infiltration in children with Gaucher's disease type I and III. MATERIAL AND METHODS Prospective study was conducted on 20 infants and children (14 M, 6 F; aged 31-61 months; mean age 46 months) with Gaucher's disease type I (n = 13) and III (n = 7), and 20 age and sex matched controls. They underwent routine and diffusion-weighted MR imaging of the lumbar spine using echo planar imaging with b value of 0, 500 and 1000 sec/mm2. The ADC value of the lumbar vertebral bone marrow was compared in different phenotypes and genotypes; and correlated with bone marrow burden score (BMB), chitotriosidase level, hemoglobin and platelet count. RESULTS The mean ADC value of marrow infiltration in patients with Gaucher's disease (0.39 ± 0.06 × 10(-3) mm(2)/s) was significantly lower (P = 0.001) than that of vertebral bone marrow in controls (0.54 ± 0.05 × 10(-3) mm(2)/s). The cut-off ADC value used to differentiate patients with Gaucher's disease from controls was (0.47 × 10(-3) mm(2)/s); with sensitivity of 95 %; specificity of 95 % and area under the curve of 0.986. The L444P/L444P mutation had significantly lower ADC value compared to other mutations (P = 0.001). The mean ADC value of the bone marrow negatively correlated with BMB (r = -0.831; P = 0.001), and biomarkers of disease activity including chitotriosidase (r = -0.542; P = 0.014), hemoglobin (r = -0.727; P = 0.001) and platelets (r = -0.698; P = 0.001). CONCLUSION We concluded that there is significant difference in the ADC value of vertebral bone marrow between children with Gaucher's disease and controls, and the ADC value correlated well with genotyping and some biomarkers of disease activity.
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Mitrovic M, Sumarac Z, Antic D, Bogdanovic A, Elezovic I, Vukosavljevic D, Ignjatovic S, Majkic-Singh N, Suvajdzic N. Markers of coagulation activation and enhanced fibrinolysis in Gaucher type 1 patient: Effects of enzyme replacement therapy. Blood Cells Mol Dis 2012; 49:58-9. [DOI: 10.1016/j.bcmd.2012.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Revised: 12/04/2011] [Accepted: 02/25/2012] [Indexed: 11/30/2022]
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