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Litwin T, Rędzia-Ogrodnik B, Antos A, Przybyłkowski A, Członkowska A, Bembenek JP. Brain Magnetic Resonance Imaging in Wilson's Disease-Significance and Practical Aspects-A Narrative Review. Brain Sci 2024; 14:727. [PMID: 39061467 PMCID: PMC11274939 DOI: 10.3390/brainsci14070727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 07/10/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024] Open
Abstract
Wilson's disease (WD) is a genetic disorder of copper metabolism with pathological copper accumulation in many organs, resulting in clinical symptoms, mostly hepatic and neuropsychiatric. As copper accumulates in the brain during WD, and almost 50% of WD patients at diagnosis present with neurological symptoms, neuroimaging studies (especially brain magnetic resonance imaging (MRI)) are part of WD diagnosis. The classical sequences (T1, T2, and fluid-attenuated inversion recovery) were used to describe brain MRI; however, with the development of neuroradiology, several papers proposed the use of new MRI sequences and techniques like susceptibility-weighted images, T2*, diffusion MRI, tractography, volumetric assessment and post-processing brain MRI analysis of paramagnetic accumulation-quantitative susceptibility mapping. Based on these neuroradiological data in WD, currently, brain MRI semiquantitative scale and the pathognomonic neuroradiological brain MRI signs in WD were proposed. Further, the volumetric studies and brain iron accumulation MRI analysis suggested brain atrophy and iron accumulation as biomarkers of neurological WD disease severity. All these results highlight the significance of brain MRI examinations in WD. Due to the extreme progress of these studies, based on the available literature, the authors present the current state of knowledge about the significance, practical aspects, and future directions of brain MRI in WD.
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Affiliation(s)
- Tomasz Litwin
- Second Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland; (B.R.-O.); (A.A.); (A.C.)
| | - Barbara Rędzia-Ogrodnik
- Second Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland; (B.R.-O.); (A.A.); (A.C.)
| | - Agnieszka Antos
- Second Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland; (B.R.-O.); (A.A.); (A.C.)
| | - Adam Przybyłkowski
- Department of Gastroenterology, Medical University, Warsaw 02-097, Poland;
| | - Anna Członkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland; (B.R.-O.); (A.A.); (A.C.)
| | - Jan Paweł Bembenek
- Department of Neurophysiology, Institute Psychiatry and Neurology, 02-957 Warsaw, Poland;
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Burghart L, Ferenci P, Petrenko O, Mandorfer M, Schwarz M, Gschwantler M, Trauner M, Reiberger T, Stättermayer AF. Portal hypertension and its prognostic implications in patients with Wilson's disease. Aliment Pharmacol Ther 2024; 60:257-266. [PMID: 38798050 DOI: 10.1111/apt.18060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/20/2023] [Accepted: 05/11/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND AND AIMS Wilson's disease may progress to cirrhosis and clinically significant portal hypertension (CSPH). We aimed to assess the prevalence and prognostic impact of CSPH-related features on hepatic decompensation and transplant-free survival in patients with Wilson's disease. METHODS AND RESULTS About 137 patients with Wilson's disease (Leipzig score ≥4), followed for a median observation period of 9.0 (3.9-17.7) years at the Vienna General Hospital, were included in this retrospective study. Overall, 49 (35.8%) developed features of CSPH: 14 (10.2%) varices, 40 (29.2%) splenomegaly, 20 (14.6%) ascites, 18 (13.1%) hepatic encephalopathy and 3 (2.2%) experienced acute variceal bleeding. Overall, 8 (5.8%) patients died, including three deaths caused by CSPH-related complications. Within 10 years, compensated patients with features of CSPH developed more decompensation events (8.3% vs. 1.5% in patients without CSPH, p = 0.3) and had worse transplant-free-survival (91.7% vs. 98.6%), which further declined in patients with hepatic decompensation (26.7%, log-rank: p < 0.0001). Patients with liver stiffness <15 kPa and normal platelets (≥150 G/L) were less likely to decompensate within 10 years (2.6% vs. 8.4%, p = 0.002) and had a better 10-year transplant-free-survival (97.7% vs. 83.9%, p = 0.006). CONCLUSIONS Patients with Wilson's disease developing features of CSPH are at an increased risk for hepatic decompensation and liver-related mortality, warranting for regular screening and timely initiation of effective CSPH-directed treatments.
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Affiliation(s)
- Lukas Burghart
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
- Department of Internal Medicine IV, Wilhelminenspital, Vienna, Austria
- Sigmund Freud University, Vienna, Austria
| | - Peter Ferenci
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Oleksandr Petrenko
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases (LBI-RUD), Vienna, Austria
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
- Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
| | - Michael Schwarz
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Gschwantler
- Department of Internal Medicine IV, Wilhelminenspital, Vienna, Austria
- Sigmund Freud University, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases (LBI-RUD), Vienna, Austria
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
- Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
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Hu S, Wei T, Li C, Wang X, Nguchu BA, Wang Y, Dong T, Yang Y, Ding Y, Qiu B, Yang W. Abnormalities in subcortical function and their treatment response in Wilson's disease. Neuroimage Clin 2024; 43:103618. [PMID: 38830274 PMCID: PMC11180346 DOI: 10.1016/j.nicl.2024.103618] [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: 01/22/2024] [Revised: 04/22/2024] [Accepted: 05/10/2024] [Indexed: 06/05/2024]
Abstract
Extensive neuroimaging abnormalities in subcortical regions build the pathophysiological basis of Wilson's disease (WD). Yet, subcortical topographic organization fails to articulate, leaving a huge gap in understanding the neural mechanism of WD. Thus, how functional abnormalities of WD subcortical regions influence complex clinical symptoms and response to treatment remain unknown. Using resting-state functional MRI data from 232 participants (including 130 WD patients and 102 healthy controls), we applied a connectivity-based parcellation technique to develop a subcortical atlas for WD. The atlas was further used to investigate abnormalities in subcortical function (ASF) by exploring intrasubcortical functional connectivity (FC) and topographic organization of cortico-subcortical FC. We further used support vector machine (SVM) to integrate these functional abnormalities into the ASF score, which serves as a biomarker for characterizing individual subcortical dysfunction for WD. Finally, the baseline ASF score and one-year treatment data of the follow-up WD patients were used to assess treatment response. A group set of subcortical parcellations was evaluated, in which 26 bilateral regions well recapitulated the anatomical nuclei of the subcortical areas of WD. The results of cortico-subcortical FC and intrasubcortical FC reveal that dysfunction of the somatomotor networks-lenticular nucleus-thalamic pathways is involved in complex symptoms of WD. The ASF score was able to characterize disease progression and was significantly associated with treatment response of WD. Our findings provide a comprehensive elaboration of functional abnormalities of WD subcortical regions and reveal their association with clinical presentations, improving our understanding of the functional neural underpinnings in WD. Furthermore, abnormalities in subcortical function could serve as a potential biomarker for understanding the disease progression and evaluating treatment response of WD.
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Affiliation(s)
- Sheng Hu
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, Anhui, 230031, China; Center for Biomedical Imaging, University of Science and Technology of China, Hefei, Anhui, 2300026, China; School of Medical Information Engineering, Anhui University of Traditional Chinese Medicine, Hefei, Anhui, 230012, China
| | - Taohua Wei
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, Anhui, 230031, China; Key Laboratory of Xin'an Medicine of the Ministry of Education, Anhui University of Traditional Chinese Medicine, Hefei, Anhui, 230031, China
| | - Chuanfu Li
- Medical Imaging Center, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, Anhui, 230031, China.
| | - Xiaoxiao Wang
- Center for Biomedical Imaging, University of Science and Technology of China, Hefei, Anhui, 2300026, China
| | | | - Yanming Wang
- Center for Biomedical Imaging, University of Science and Technology of China, Hefei, Anhui, 2300026, China
| | - Ting Dong
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, Anhui, 230031, China; Key Laboratory of Xin'an Medicine of the Ministry of Education, Anhui University of Traditional Chinese Medicine, Hefei, Anhui, 230031, China
| | - Yulong Yang
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, Anhui, 230031, China
| | - Yufeng Ding
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, Anhui, 230031, China
| | - Bensheng Qiu
- Center for Biomedical Imaging, University of Science and Technology of China, Hefei, Anhui, 2300026, China.
| | - Wenming Yang
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, Anhui, 230031, China; Key Laboratory of Xin'an Medicine of the Ministry of Education, Anhui University of Traditional Chinese Medicine, Hefei, Anhui, 230031, China.
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Deguti MM, Araujo FC, Terrabuio DRB, Araujo TF, Barbosa ER, Porta G, Cançado ELR. Wilson disease: the diagnostic challenge and treatment outcomes in a series of 262 cases. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-9. [PMID: 38811021 DOI: 10.1055/s-0044-1786855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
BACKGROUND Wilson disease (WD) is an autosomal recessive disorder that leads to organ toxicity due to copper overload. Early diagnosis is complicated by the rarity and diversity of manifestations. OBJECTIVE To describe the diagnostic features and response to treatment in our cohort of WD patients. METHODS This was a retrospective analysis of 262 WD patients stratified by clinical presentation, complementary exams, ATP7B genotyping, and response to treatment. RESULTS Symptoms occurred at an average age of 17.4 (7-49) years, and patients were followed up for an average of 9.6 (0-45) years. Patients presented mainly with hepatic (36.3%), neurologic (34.7%), and neuropsychiatric (8.3%) forms. Other presentations were hematologic, renal, or musculoskeletal, and 16.8% of the patients were asymptomatic. Kayser-Fleischer rings occurred in 78.3% of the patients, hypoceruloplasminemia in 98.3%, and elevated cupruria/24h in 73.0%, with an increase after D-penicillamine in 54.0%. Mutations of the ATP7B gene were detected in 84.4% of alleles. Brain magnetic resonance imaging showed abnormalities in the basal ganglia in 77.7% of patients. D-penicillamine was the first choice in 93.6% of the 245 patients, and 21.1% of these patients were switched due to adverse effects. The second-line therapies were zinc and trientine. The therapeutic response did not differ significantly between the drugs (p = 0.2). Nine patients underwent liver transplantation and 82 died. CONCLUSION Wilson disease is diagnosed at a late stage, and therapeutic options are limited. In people under 40 years of age with compatible manifestations, WD could be considered earlier in the differential diagnosis. There is a need to include ATP7B genotyping and therapeutic alternatives in clinical practice.
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Affiliation(s)
- Marta Mitiko Deguti
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, São Paulo SP, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Medicina Tropical, Laboratório de Gastroenterologia e Hepatologia, São Paulo SP, Brazil
| | - Fabiana Cordeiro Araujo
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, São Paulo SP, Brazil
| | | | - Thiago Ferreira Araujo
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Medicina Tropical, Laboratório de Gastroenterologia e Hepatologia, São Paulo SP, Brazil
| | - Egberto Reis Barbosa
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Gilda Porta
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, São Paulo SP, Brazil
| | - Eduardo Luiz Rachid Cançado
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, São Paulo SP, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Medicina Tropical, Laboratório de Gastroenterologia e Hepatologia, São Paulo SP, Brazil
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Berenguer M, Vergara M, Almohalla C, Hernandez A, Blanco S, Testillano M, Girona E, Casado M, García M, Catalina MV, Muñoz C, Gutierrez ML, Molina E, Romero M, Otero A, Hernáez-Alsina T, Bernal-Monterde V, Lorente S, Masnou H, Bonet L, Soto S, Gisbert C, Valer MP, Gomez J, Pacheco G, Morillas J, Gonzalez M, Dominguez N, Lazaro M, Pascual S, Castelló I, Gonzalez R. Significant heterogeneity in the diagnosis and long-term management of Wilson disease: Results from a large multicenter Spanish study. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:577-584. [PMID: 36372257 DOI: 10.1016/j.gastrohep.2022.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/15/2022] [Accepted: 10/24/2022] [Indexed: 11/13/2022]
Abstract
There is uncertainty regarding Wilson's disease (WD) management. OBJECTIVES To assess, in a multicenter Spanish retrospective cohort study, whether the approach to WD is homogeneous among centers. METHODS Data on WD patients followed at 32 Spanish hospitals were collected. RESULTS 153 cases, 58% men, 20.6 years at diagnosis, 69.1% hepatic presentation, were followed for 15.5 years. Discordant results in non-invasive laboratory parameters were present in 39.8%. Intrahepatic copper concentration was pathologic in 82.4%. Genetic testing was only done in 56.6% with positive results in 83.9%. A definite WD diagnosis (Leipzig score ≥4) was retrospectively confirmed in 92.5% of cases. Chelating agents were standard initial therapy (75.2%) with frequent modifications (57%), particularly to maintenance zinc. Enzyme normalization was not achieved by one third, most commonly in the setting of poor compliance, lack of genetic mutations and/or presence of cardiometabolic risk factors. Although not statistically significant, there were trends for sex differences in number of diagnosed cases, age at diagnosis and biochemical response. CONCLUSIONS Significant heterogeneity in diagnosis and management of WD patients emerges from this multicenter study that includes both small and large reference centers. The incorporation of genetic testing will likely improve diagnosis. Sex differences need to be further explored.
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Affiliation(s)
- Marina Berenguer
- Hepatology - Liver Transplantation Unit, IIS La Fe and CIBER-EHD, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Department of Medicine, Universitat de València, Valencia, Spain.
| | - Mercedes Vergara
- Parc Tauli Sabadell Hospital Universitari, Institut d'Investigació i Innovació Parc Tauli I3PT, Univ Autonoma de Barcelona, Sabadell, Barcelona, Spain; Dept Medicina, Universitat Autonoma de Barcelona and CIBERhed, Insituto Carlos III, Madrid, Spain
| | - Carolina Almohalla
- Servicio de Aparato Digestivo, Unidad de Hepatología, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Alicia Hernandez
- Servicio de Aparato Digestivo, Hospital universitario de Ciudad Real, Ciudad real, Spain
| | - Sonia Blanco
- Servicio de Aparato Digestivo, Hospital Universitario Basurto, Euskadi, Spain
| | - Milagros Testillano
- Servicio de Aparato Digestivo, Unidad de Hepatología, Hospital Universitario Cruces, Bizkaia, Spain
| | - Eva Girona
- Servicio de Aparato Digestivo, Hospital de Elx, Alicante, Spain
| | - Marta Casado
- Servicio de Aparato Digestivo, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Miren García
- Servicio de Aparato Digestivo, Hospital Universitario Virgen de La Victoria, Málaga, Spain
| | - Maria-Vega Catalina
- Servicio de Aparato Digestivo, Unidad de Hepatología, Hospital General Universitario Gregorio Marañon. Madrid, Spain
| | - Carolina Muñoz
- Servicio de Aparato Digestivo, Unidad de Hepatología, Hospital 12 de Octubre, Madrid, Spain
| | - Maria Luisa Gutierrez
- Servicio de Aparato Digestivo, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Esther Molina
- Servicio de Aparato Digestivo, Unidad de Hepatología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Miriam Romero
- Servicio de Aparato Digestivo, Unidad de Hepatología, Hospital La Paz, Madrid, Spain
| | - Alejandra Otero
- Servicio de Aparato Digestivo, Hospital Universitario de A Coruña, Coruña, Spain
| | | | - Vanessa Bernal-Monterde
- Servicio de Aparato Digestivo, Hospital Miguel Servet, Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
| | - Sara Lorente
- Unidad de Hepatología y Trasplante Hepático, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Helena Masnou
- Servei Aparell Digestiu, Unitat de Hepatologia, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Lucia Bonet
- Servicio Aparato Digestivo, Hospital Universitari Son Espases, Spain
| | - Susana Soto
- Servicio de Aparato Digestivo, Hospital del Tajo, Aranjuez, Spain
| | - Concha Gisbert
- Servicio de Medicina Interna, Hospital de Dénia - Marina Salud, Denia, Spain
| | - María-Paz Valer
- Servicio de Aparato Digestivo, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Judith Gomez
- Servicio de Aparato Digestivo, Hospital Universitario de Burgos, Burgos, Spain
| | - Gemma Pacheco
- Servicio de Aparato Digestivo, Hospital Universitario La Ribera, Spain
| | - Julia Morillas
- Servicio de Aparato Digestivo, Hospital Virgen de la Luz, Cuenca, Spain
| | - Martha Gonzalez
- Servicio de Aparato Digestivo, Hospital El Bierzo, Ponferrada, León, Spain
| | - Nuria Dominguez
- Servicio de Aparato Digestivo, Hospital University Infanta Cristina, Parla, Spain
| | - Maria Lazaro
- Servicio de Aparato Digestivo, Hospital General San Jorge, Huesca, Spain
| | - Sonia Pascual
- Servicio de Aparato Digestivo, Unidad Hepática, Hospital General Universitario de Alicante, Alicante, Spain; CiberEHD, Madrid, Spain
| | | | - Rocio Gonzalez
- Servicio de Aparato Digestivo, Hospital Regional Universitario de Málaga, Málaga, Spain
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Patel AH, Ghattu M, Mazzaferro N, Chen A, Catalano K, Minacapelli CD, Rustgi V. Demographics and Outcomes Related to Wilson's Disease Patients: A Nationwide Inpatient Cohort Study. Cureus 2023; 15:e44714. [PMID: 37809179 PMCID: PMC10552679 DOI: 10.7759/cureus.44714] [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] [Accepted: 09/01/2023] [Indexed: 10/10/2023] Open
Abstract
Background and objective Wilson's disease (WD) is a rare autosomal recessive disease caused by mutations in the ATP7B gene, leading to impairment in copper excretion and subsequent accumulation primarily in the liver and brain. There is scarce data in the literature on the outcomes and cost burden of WD. In light of this, we aimed to assess outcomes, mortality rates, and costs associated with WD patients and their management in the United States (US). Methods We conducted a retrospective cohort study based on data in the National Inpatient Sample (NIS) database from 2007 to 2017. A total of 17,713 patients with a diagnosis of WD were identified using the International Classification of Diseases, Ninth or Tenth Revision (ICD-9/10) codes. Bivariate analyses were performed using t-tests for continuous variables and Pearson's chi-square tests for categorical variables, where two-sided p-values <0.05 were considered statistically significant. Results The majority of the 17,713 identified patients were female. The mean age of the WD cohort was 49 years. WD patients had a higher prevalence of Kayser-Fleischer rings, neuropsychiatric symptoms, and liver-related complications including acute hepatitis, liver failure, portal hypertension, and cirrhosis. Peptic ulcer disease, connective tissue disease, and hemolytic anemia were significantly more common in the WD cohort. Compared to the non-WD cohort, the WD cohort had a significantly higher mortality rate, longer length of stay (LOS), and increased hospitalization costs (p<0.0001). A higher proportion of patients who had undergone orthotopic liver transplantation (OLTx) were in the 18-34 and 35-44-year-old subgroups. On the contrary, the highest proportion of patients with WD who had not undergone OLTx were in the 55-89-year-old subgroup. WD patients who had undergone OLTx had a lower degree of comorbidities, decreased mortality rate, and shorter LOS (all p<0.0001) compared to WD patients who had not undergone OLTx. Conclusion Based on our findings, patients with WD had a higher LOS, mean hospitalization costs, and mortality rate compared to the non-WD cohort. Mortality rate and LOS were significantly lower in WD patients who had undergone OLTx.
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Affiliation(s)
- Ankoor H Patel
- Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
| | - Meghana Ghattu
- Medicine, Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical school, New Brunswick, USA
| | - Natale Mazzaferro
- Biostatistics and Epidemiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
| | - Alexander Chen
- Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
| | - Kaitlyn Catalano
- Medicine, Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
| | - Carlos D Minacapelli
- Medicine, Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
| | - Vinod Rustgi
- Medicine, Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
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Antos A, Członkowska A, Bembenek J, Kurkowska-Jastrzębska I, Litwin T. D-Penicillamine-Induced Myasthenia Gravis-A Probable Complication of Wilson's Disease Treatment-A Case Report and Systematic Review of the Literature. Life (Basel) 2023; 13:1715. [PMID: 37629572 PMCID: PMC10455431 DOI: 10.3390/life13081715] [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: 06/23/2023] [Revised: 07/31/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Wilson's disease (WD) is a genetic disorder with copper accumulation in various tissues leading to related clinical symptoms (mainly hepatic and neuropsychiatric) which can be in 85% of patients successfully treated with anti-copper agents. However, during WD treatment neurological deterioration may occur in several patients. D-penicillamine (DPA) is one of the most frequently used drugs in WD treatment. Despite its efficacy, DPA can produce many adverse drug reactions, which should be recognized early. We present the case of a 51-year-old man diagnosed with the hepatic form of WD and initially treated with DPA in whom after 15 months of treatment, diplopia and evening ptosis occurred. WD treatment non-compliance as well as overtreatment were excluded. Supported by neurological symptoms, a positive edrophonium test, and high serum levels of antibodies against acetylcholine receptors (AChR-Abs), as well as low concentrations of antibodies against muscle-specific kinase (MuSK-Abs), the diagnosis of myasthenia gravis (MG), induced by DPA, was established. DPA was stopped; zinc sulfate for WD and pyridostigmine for MG symptoms were introduced. Diplopia and ptosis subsided after a few days, which supported our diagnosis. During a follow-up visit after 6 months, the patient did not present any MG symptoms. AChR-Abs level gradually decreased and MuSK-Abs were no longer detected. Pyridostigmine was stopped, and within 9 months of follow-up, the neurological symptoms of MG did not reoccur. The authors discussed the patient's neurological deterioration, performed a systematic review of DPA-induced MG in WD and concluded that MG is a rare and usually reversible complication of DPA treatment. DPA-induced MG generally occurs 2-12 months after treatment initiation and ocular symptoms predominate. Response to pyridostigmine treatment is good and MG symptoms usually reverse within one year after DPA treatment cessation. However, symptoms may persist in some cases where DPA treatment is only a trigger factor for MG occurrence.
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Affiliation(s)
- Agnieszka Antos
- Second Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland; (A.A.); (A.C.); (I.K.-J.)
| | - Anna Członkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland; (A.A.); (A.C.); (I.K.-J.)
| | - Jan Bembenek
- Department of Clinical Neurophysiology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland;
| | - Iwona Kurkowska-Jastrzębska
- Second Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland; (A.A.); (A.C.); (I.K.-J.)
| | - Tomasz Litwin
- Second Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland; (A.A.); (A.C.); (I.K.-J.)
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Mariño Z, Berenguer M, Peña-Quintana L, Olveira A, Miralpeix A, Sastre I, Reyes-Domínguez A, Castillo P, García-Solà C, Bono A, Romero M, Pérez-Sádaba FJ, Aceituno S, Anguera A. Health-Related Quality of Life in Patients Living with Wilson Disease in Spain: A Cross-Sectional Observational Study. J Clin Med 2023; 12:4823. [PMID: 37510937 PMCID: PMC10381913 DOI: 10.3390/jcm12144823] [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: 06/28/2023] [Revised: 07/12/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
Wilson disease (WD) is a rare copper metabolism disorder caused by mutations in the ATP7B gene. It usually affects young individuals and can produce hepatic and/or neurological involvement, potentially affecting health-related quality of life (HRQoL). We assessed HRQoL in a cohort of Spanish patients with WD and evaluated disease impact on several domains of patients' lives, treatment adherence, drug preference and satisfaction, and healthcare resource utilisation in a cross-sectional, retrospective, multicentric, observational study. A total of 102 patients were included: 81.4% presented isolated liver involvement (group H) and 18.6% presented neurological or mixed involvement (group EH). Up to 30% of patients reported a deteriorated emotional status with anxiety and depression, which was greater in the EH subgroup; the use of neuropsychiatric drugs was high. Over 70% of the patients were satisfied with their current treatment but complained about taking too many pills, stating they would consider switching to another more patient-friendly treatment if available. The Simplified Medication Adherence Questionnaire revealed only 22.5% of patients were fully adherent to therapy, suggesting that alternative therapies are needed. This real-world study, even though is highly enriched with hepatic patients and mild disease, shows that WD impacts patients' HRQoL, especially in the emotional domain.
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Affiliation(s)
- Zoe Mariño
- Liver Unit, Hospital Clínic Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), European Reference Networks (ERN)-RARE Liver, University of Barcelona, 08007 Barcelona, Spain
| | - Marina Berenguer
- Department of Gastroenterology and Hepatology, Hospital Universitari i Politècnic La Fe, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Investigación Sanitaria (IIS La Fe), 46026 Valencia, Spain
| | - Luis Peña-Quintana
- Pediatric Gastroenterology, Hepatoloy and Nutrition Unit, Complejo Hospitalario Universitario Insular Materno-Infantil, 35016 Las Palmas de Gran Canaria, Spain
- Centro de Investigación Biomédica en Red de la Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, University of Las Palmas de Gran Canaria, 35001 Las Palmas de Gran Canaria, Spain
| | - Antonio Olveira
- Department of Gastroenterology, Hospital La Paz, 28046 Madrid, Spain
| | - Anna Miralpeix
- Liver Unit, Hospital Clínic Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), European Reference Networks (ERN)-RARE Liver, University of Barcelona, 08007 Barcelona, Spain
| | - Isabel Sastre
- Department of Gastroenterology and Hepatology, Hospital Universitari i Politècnic La Fe, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Investigación Sanitaria (IIS La Fe), 46026 Valencia, Spain
| | - Ana Reyes-Domínguez
- Pediatric Gastroenterology, Hepatoloy and Nutrition Unit, Complejo Hospitalario Universitario Insular Materno-Infantil, 35016 Las Palmas de Gran Canaria, Spain
| | - Pilar Castillo
- Department of Gastroenterology, Hospital La Paz, 28046 Madrid, Spain
| | - Clàudia García-Solà
- Liver Unit, Hospital Clínic Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), European Reference Networks (ERN)-RARE Liver, University of Barcelona, 08007 Barcelona, Spain
| | - Ariadna Bono
- Department of Gastroenterology and Hepatology, Hospital Universitari i Politècnic La Fe, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Investigación Sanitaria (IIS La Fe), 46026 Valencia, Spain
| | - Miriam Romero
- Department of Gastroenterology, Hospital La Paz, 28046 Madrid, Spain
| | | | | | - Anna Anguera
- Medical Department, Alexion, AstraZeneca Rare Diseases, 08028 Barcelona, Spain
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Litwin T, Dusek P, Antos A, Członkowska A, Bembenek J. Tackling the neurological manifestations in Wilson's disease - currently available treatment options. Expert Rev Neurother 2023; 23:1249-1259. [PMID: 37842984 DOI: 10.1080/14737175.2023.2268841] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/05/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Wilson's disease (WD) is a potentially treatable, inherited disorder resulting from impaired copper metabolism. Pathological copper accumulation causes a range of symptoms, most commonly hepatic and a wide spectrum of neurological symptoms including tremor, dystonia, chorea, parkinsonism, dysphagia, dysarthria, gait and posture disturbances. To reduce copper overload, anti-copper drugs are used that improve liver function and neurological symptoms in up to 85% of patients. However, in some WD patients, treatment introduction leads to neurological deterioration, and in others, neurological symptoms persist with no improvement or improvement only after several years of treatment, severely affecting the patient's quality of life. AREAS COVERED This review appraises the evidence on various pharmacological and non-pharmacological therapies, neurosurgical procedures and liver transplantation for the management of neurological WD symptoms. The authors also discuss the neurological symptoms of WD, causes of deterioration and present symptomatic treatment options. EXPERT OPINION Based on case and series reports, current recommendations and expert opinion, WD treatment is focused mainly on drugs leading to negative copper body metabolism (chelators or zinc salts) and copper-restricted diet. Treatment of WD neurological symptoms should follow general recommendations of symptomatic treatment. Patients should be always considered individually, especially in the case of severe, disabling neurological symptoms.
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Affiliation(s)
- Tomasz Litwin
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Petr Dusek
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Agnieszka Antos
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Anna Członkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Jan Bembenek
- Department of Clinical Neurophysiology, Institute of Psychiatry and Neurology, Warsaw, Poland
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10
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Sipilä JO, Kytövuori L, Kaasinen V. Clinical spectrum and genotype-phenotype associations in Finnish patients with Wilson's disease. J Neurol Sci 2023; 448:120620. [PMID: 36966606 DOI: 10.1016/j.jns.2023.120620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/11/2023] [Accepted: 03/20/2023] [Indexed: 04/01/2023]
Abstract
Genotype-phenotype correlation data covering all ages of Wilson's disease onset in Caucasian patients are limited. We therefore analyzed genotype-phenotype correlations in a retrospective cohort of Finnish patients. Six homozygous (HoZ) and 11 compound heterozygous (CoHZ) patients were included. There were no differences in the presence/absence of hepatic, neurological, psychiatric or any symptoms at diagnosis (p > 0.30 for all) between HoZ and CoHZ patients, but HoZ patients had an earlier age of diagnosis (median 6.7 versus 34.5; p = 0.003). Severe liver affliction was almost exclusively associated with the p.H1069Q variant. Patients with p.H1069Q had a later mean age of diagnosis (30.2 ± 11.6 vs. 8.7 ± 4.9 years; p < 0.001) compared to those without. There were no differences in the presence/absence of hepatic, neurological, psychiatric or any symptoms at diagnosis between p.H1069Q-positive and p.H1069Q-negative patients (p > 0.54 for all). These results suggest that population-specific factors may partly explain the high clinical variability of Wilson's disease.
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11
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Antos A, Członkowska A, Bembenek J, Skowronska M, Kurkowska-Jastrzębska I, Litwin T. Blood Based Biomarkers of Central Nervous System Involvement in Wilson's Disease. Diagnostics (Basel) 2023; 13:diagnostics13091554. [PMID: 37174946 PMCID: PMC10177361 DOI: 10.3390/diagnostics13091554] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/15/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023] Open
Abstract
Wilson's disease (WD) is an inherited disorder of copper metabolism with clinical symptoms related to pathological copper accumulation, which are mainly hepatic and/or neuropsychiatric. The disease is potentially treatable with pharmacological agents (chelators or zinc salts). As such, key factors for a favorable treatment outcome are early diagnosis and anti-copper treatment initiation as well as appropriate treatment monitoring for safety and efficacy. Despite the generally favorable outcome in most treated patients, almost 10% of the general population of WD patients and about 25% of patients in the group with initial neurological phenotype of disease experience early neurological deterioration. In almost 50% of patients with neurological symptoms, the symptoms persist. A search for new treatment modalities (e.g., gene therapy, molybdenum salts) aims to prevent early neurological deterioration as well as improve treatment outcomes. In addition to evaluating the clinical signs and symptoms of the disease, serum biomarkers for diagnosis and treatment monitoring are very important for WD management. Sensitive serum biomarkers of copper metabolism and liver injury are well described. However, there is a need to establish blood-based biomarkers of central nervous system (CNS) injury to help identify patients at risk of early neurological deterioration and aid in their monitoring. Based on the available literature and studies of WD patients, the authors reviewed serum biomarkers of CNS involvement in WD, as well as their potential clinical significance.
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Affiliation(s)
- Agnieszka Antos
- Second Department of Neurology, Institute of Psychiatry and Neurology, 9 Sobieskiego Str., 02-957 Warsaw, Poland
| | - Anna Członkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, 9 Sobieskiego Str., 02-957 Warsaw, Poland
| | - Jan Bembenek
- Department of Clinical Neurophysiology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland
| | - Marta Skowronska
- Second Department of Neurology, Institute of Psychiatry and Neurology, 9 Sobieskiego Str., 02-957 Warsaw, Poland
| | - Iwona Kurkowska-Jastrzębska
- Second Department of Neurology, Institute of Psychiatry and Neurology, 9 Sobieskiego Str., 02-957 Warsaw, Poland
| | - Tomasz Litwin
- Second Department of Neurology, Institute of Psychiatry and Neurology, 9 Sobieskiego Str., 02-957 Warsaw, Poland
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Schilsky ML, Roberts EA, Bronstein JM, Dhawan A, Hamilton JP, Rivard AM, Washington MK, Weiss KH, Zimbrean PC. A multidisciplinary approach to the diagnosis and management of Wilson disease: 2022 Practice Guidance on Wilson disease from the American Association for the Study of Liver Diseases. Hepatology 2022:01515467-990000000-00207. [PMID: 36151586 DOI: 10.1002/hep.32801] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 01/18/2023]
Affiliation(s)
- Michael L Schilsky
- Medicine and Surgery , Yale University School of Medicine , New Haven , Connecticut , USA
| | - Eve A Roberts
- Paediatrics, Medicine, Pharmacology and Toxicology , University of Toronto , Toronto , Ontario , Canada
| | - Jeff M Bronstein
- Neurology , University of California Los Angeles , Los Angeles , California , USA
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre and MowatLabs , King's College Hospital , London , UK
| | - James P Hamilton
- Medicine , Johns Hopkins University School of Medicine , Baltimore , Maryland , USA
| | - Anne Marie Rivard
- Food and Nutrition Services , Yale New Haven Hospital , New Haven , Connecticut , USA
| | - Mary Kay Washington
- Pathology, Immunology and Microbiology , Vanderbilt University Medical Center , Nashville , Tennessee , USA
| | | | - Paula C Zimbrean
- Psychiatry , Yale University School of Medicine , New Haven , Connecticut , USA
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13
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Daniel-Robin T, Bénichou B, Leboucher C, Blein C, Combal JP. Epidemiology, treatment and burden of Wilson disease in France: A 10-year analysis of the national health insurance database. Clin Res Hepatol Gastroenterol 2022; 46:101992. [PMID: 35793759 DOI: 10.1016/j.clinre.2022.101992] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/20/2022] [Accepted: 07/01/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND & AIMS Wilson disease (WD) is a rare hereditary, debilitating disease that is fatal if untreated. Given its low prevalence, collecting longitudinal information on large cohorts of patients is challenging. Analysis of health insurance databases offers an approach to meet this challenge. The aim of this study was to evaluate longitudinal trends in the presentation and management of patients with WD identified in the French national health insurance database (SNDS). METHODS This retrospective, longitudinal, observational study identified people with WD in the SNDS database through hospitalisation diagnosis codes and long-term illness status between 2009 and 2019 inclusive. For each patient, data were extracted on hospitalisations, liver transplantation, mortality, WD-specific treatments (d-penicillamine, trientine and zinc), disability status and sick leave. RESULTS 1,928 patients with WD were identified, of whom 1,520 (78.8%) were analysed. Prevalence of WD in 2019 was estimated as 2.2 cases per 100,000. Of the 670 patients first documented between 2010 and 2019, 76.1% were hospitalised at least once for a mean duration of 4.63±10.6 days. 152 patients (10.0%) underwent liver transplantation and 205 died (13.5%). The mean age at death was 57.9 ± 23.1 years. 665 patients (43.8%) received a WD-specific treatment at least once. 167 patients (17.1%) received a government disability pension and 624 (41.1%) benefited from long-term illness status due to WD. CONCLUSIONS Unexpectedly, less than half of patients with WD received treatment recommended in practice guidelines, which may contribute to a high disease burden in terms of hospitalisations, disability and reduced life expectancy. Improving treatment rates, building patient awareness of long-term disease impact or developing a new paradigm of treatment could make a significant contribution to reducing the disease burden.
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Lau NSM, Henderson P. Outcomes of paediatric patients with chronic liver disease in early adulthood: A heterogeneous, but representative, regional cohort study. J Paediatr Child Health 2022; 58:1771-1777. [PMID: 35762110 PMCID: PMC9796537 DOI: 10.1111/jpc.16091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/26/2022] [Accepted: 05/22/2022] [Indexed: 01/01/2023]
Abstract
AIM Advances in paediatric hepatology have led to the increasing survival of patients with paediatric-onset chronic hepatobiliary disease into adulthood. Data are lacking with regard to the outcomes of this heterogeneous group of patients and current transition models may be insufficient. This retrospective regional cohort study examined the outcomes of these patients cared for in a paediatric gastroenterology centre following transfer to adult services. METHODS A prospective database of paediatric patients with liver disease identified those already transferred to adult services. Following exclusions, medical notes were examined and health parameters recorded including initial diagnoses, transplant status, fertility and mortality. Descriptive statistics were used to calculate follow-up data and transplant-free survival (TFS). RESULTS Overall, 63 patients (52% male) entered the final analyses with a median follow-up of 27.5 years. The most common diagnosis was biliary atresia (19%); 27 different diagnoses were apparent within the cohort highlighting the heterogeneity within a single centre. Transplant prevalence at adult transfer was 41%; 14% of patients were lost to follow-up including 10% of transplant patients. TFS for biliary atresia was 17% after 37.4 years follow-up and was 54% for the total cohort. There were seven documented pregnancies and the prevalence of any psychological or psychiatric input was 44%. Transplant complications occurred in 38% of patients; there were two cancer diagnoses and two deaths following transfer. CONCLUSIONS Although overall mortality was low, the health-care burden of patients with paediatric-onset chronic liver disease is high. This group is also very heterogeneous, making structured transition to adult services difficult.
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Affiliation(s)
- Nicole SM Lau
- Child Life and HealthUniversity of EdinburghEdinburghUnited Kingdom
| | - Paul Henderson
- Child Life and HealthUniversity of EdinburghEdinburghUnited Kingdom,Department of Paediatric Gastroenterology and NutritionRoyal Hospital for Children and Young PeopleEdinburghUnited Kingdom
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15
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Ziemssen T, Smolinski L, Członkowska A, Akgun K, Antos A, Bembenek J, Kurkowska-Jastrzębska I, Przybyłkowski A, Skowrońska M, Redzia-Ogrodnik B, Litwin T. Serum neurofilament light chain and initial severity of neurological disease predict the early neurological deterioration in Wilson's disease. Acta Neurol Belg 2022:10.1007/s13760-022-02091-z. [PMID: 36098934 PMCID: PMC9469052 DOI: 10.1007/s13760-022-02091-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/01/2022] [Indexed: 12/03/2022]
Abstract
Background In Wilson’s disease (WD), early neurological deterioration after treatment initiation is associated with poor outcomes; however, data on this phenomenon are limited. Our study analysed the frequency and risk factors of early neurological deterioration in WD. Methods Early neurological deterioration, within 6 months from diagnosis, was defined based on the Unified Wilson’s Disease Rating Scale (UWDRS): any increase in part II or an increase of ≥ 4 in part III. In total, 61 newly diagnosed WD patients were included. UWDRS scores, brain magnetic resonance imaging (MRI) scores, copper metabolism parameters, treatment type and serum neuro-filament light chain (sNfL) concentrations at diagnosis were analysed as potential risk factors of early deterioration. Results Early neurological deterioration was observed in 16.3% of all WD patients; all cases of worsening occurred in the neurological phenotype (27.7%). Higher scores were seen in those who deteriorated compared with those who did not for UWDRS part II (4.3 ± 5.0 vs 2.0 ± 5.9; p < 0.05), UWDRS part III (21.5 ± 14.1 vs 9.3 ± 16.4; p < 0.01) and MRI-assessed chronic damage (3.2 ± 1.6 vs 1.4 ± 2.2; p = 0.006); all these variables indicated the initial severity of neurological disease. Pre-treatment sNfL concentrations were significantly higher in patients who deteriorated compared with those who did not (33.2 ± 23.5 vs 27.6 ± 62.7 pg/mL; p < 0.01). In univariate logistic regression amongst all patients, chronic damage MRI scores, UWDRS part III scores and sNfL concentrations predicated early deterioration. In the neurological WD, only sNFL were a significant predictor. In bivariate logistic regression amongst all patients, sNfL remained the only significant predictor of deterioration when corrected for MRI scores. Conclusion sNfL concentrations are a promising biomarker of the risk of early neurological deterioration in WD.
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Affiliation(s)
- Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, University Clinic Carl Gustav Carus and Dresden University of Technology, Dresden, Germany
| | - Lukasz Smolinski
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957, Warsaw, Poland
| | - Anna Członkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957, Warsaw, Poland
| | - Katja Akgun
- Center of Clinical Neuroscience, Department of Neurology, University Clinic Carl Gustav Carus and Dresden University of Technology, Dresden, Germany
| | - Agnieszka Antos
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957, Warsaw, Poland
| | - Jan Bembenek
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957, Warsaw, Poland
| | - Iwona Kurkowska-Jastrzębska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957, Warsaw, Poland
| | - Adam Przybyłkowski
- Department of Gastroenterology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Marta Skowrońska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957, Warsaw, Poland
| | | | - Tomasz Litwin
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957, Warsaw, Poland.
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ATP7B Genotype and Chronic Liver Disease Treatment Outcomes in Wilson Disease: Worse Survival With Loss-of-Function Variants. Clin Gastroenterol Hepatol 2022; 21:1323-1329.e4. [PMID: 36096368 DOI: 10.1016/j.cgh.2022.08.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 08/22/2022] [Accepted: 08/27/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Although a good genotype-phenotype correlation has not been established in Wilson disease (WD), patients with loss-of-function (LOF) ATP7B variants demonstrate different clinical and biochemical characteristics. We aim to describe long-term treatment outcomes in the chronic liver disease (CLD) phenotype and evaluate an association with LOF variants. METHODS This was a single-center retrospective review of WD patients with at least 1 variant in ATP7B. Demographic, biochemical, genetic, and clinical parameters were obtained. The composite clinical endpoint of liver transplantation or death was used for probands with CLD phenotype on chelators. RESULTS Of 117 patients with hepatic WD: 71 had CLD, 27 had fulminant hepatic failure requiring urgent liver transplantation, and 19 were diagnosed through family screening. Median age at diagnosis was 13.1 (interquartile range, 9.7-17.6) years. In total, 91 variants in ATP7B were identified in the study population. At least 1 LOF variant was present in 60 (51.3%) patients. During median follow-up of 10.7 (interquartile range, 6.7-18.9) years, 10 (14.1%) of the probands with CLD reached the composite endpoint. There was a worse transplant-free survival for patients prescribed chelation therapy in patients with at least 1 LOF variant (P = .03). CONCLUSIONS Patients with WD and CLD phenotype on chelators, who have at least 1 LOF variant in ATP7B, have a worse prognosis during long-term follow up. This subgroup of patients requires close monitoring for signs of progressive liver disease. Sequencing of ATP7B may be used in the diagnosis of WD, and in addition, it may provide useful prognostic information for patients with hepatic WD.
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Rędzia-Ogrodnik B, Członkowska A, Bembenek J, Antos A, Kurkowska-Jastrzębska I, Skowrońska M, Smoliński Ł, Litwin T. Brain magnetic resonance imaging and severity of neurological disease in Wilson's disease - the neuroradiological correlations. Neurol Sci 2022; 43:4405-4412. [PMID: 35275318 DOI: 10.1007/s10072-022-06001-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 03/06/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Wilson's disease (WD) is a genetic disorder with pathological copper accumulation and associated clinical symptoms in various organs, particularly the liver and brain. Neurological disease is assessed with the clinical Unified Wilson's Disease Rating Scale (UWDRS). There is a lack of quantitative objective markers evaluating brain involvement. Recently, a semiquantitative brain magnetic resonance imaging (MRI) scale has been proposed, which combines acute toxicity and chronic damage measures into a total score. The relationship between MRI brain pathology and the MRI scale with disease form and neurological severity was studied in a large cohort. METHODS We retrospectively assessed 100 newly diagnosed treatment-naïve patients with WD with respect to brain MRI pathology and MRI scores (acute toxicity, chronic damage, and total) and analyzed the relationship with disease form and UWDRS part II (functional impairment) and part III (neurological deficits) scores. RESULTS Most patients had the neurological form of WD (55%) followed by hepatic (31%) and presymptomatic (14%). MRI examination revealed WD-typical abnormalities in 56% of patients, with higher pathology rates in neurological cases (83%) than in hepatic (29%) and presymptomatic (7%) cases. UWDRS part II and III scores correlated with the MRI acute toxicity score (r = 0.55 and 0.55, respectively), chronic damage score (r = 0.39 and 0.45), and total score (0.45 and 0.52) (all P < 0.01). CONCLUSIONS Brain MRI changes may be present even in patients without neurological symptoms, although not frequently. The semiquantitative MRI scale correlated with the UWDRS and appears to be a complementary tool for severity of brain injury assessment in WD patients.
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Affiliation(s)
| | - Anna Członkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957, Warsaw, Poland
| | - Jan Bembenek
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957, Warsaw, Poland
| | - Agnieszka Antos
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957, Warsaw, Poland
| | - Iwona Kurkowska-Jastrzębska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957, Warsaw, Poland
| | - Marta Skowrońska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957, Warsaw, Poland
| | - Łukasz Smoliński
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957, Warsaw, Poland
| | - Tomasz Litwin
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957, Warsaw, Poland.
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Kitagawa D, Ominami M, Taira K, Tanoue K, Higashimori A, Maruyama H, Itani S, Nishida Y, Nadatani Y, Fukunaga S, Otani K, Hosomi S, Tanaka F, Nagami Y, Kamata N, Kuwae Y, Watanabe T, Ohsawa M, Fujiwara Y. Lustrous White Erosions Surrounded by an Erythematous Mucosa: A Novel Endoscopic Finding of Gastric Lesions in Patients with Wilson Disease. Intern Med 2022; 61:1835-1841. [PMID: 34866098 PMCID: PMC9259810 DOI: 10.2169/internalmedicine.8076-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Wilson disease is an inherited copper metabolism disorder. We herein report a novel endoscopic finding in three men with Wilson disease. These patients underwent upper endoscopy due to gastrointestinal symptoms or during follow-up. In each case, endoscopy revealed lustrous white erosions surrounded by an erythematous mucosa in the greater curvature of the gastric body. A biopsy of the lesions showed orcein-positive tissue, indicating copper deposition, in the interstitial stroma and fundic glands of the mucosa. All patients had been receiving treatment with zinc acetate. These endoscopic findings might have been related to the cytotoxicity of the accumulated copper and zinc acetate.
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Affiliation(s)
- Daiki Kitagawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Koichi Taira
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Kojiro Tanoue
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Akira Higashimori
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Hirotsugu Maruyama
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Shigehiro Itani
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Yu Nishida
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Yuji Nadatani
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Shusei Fukunaga
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Koji Otani
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Shuhei Hosomi
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Noriko Kamata
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Yuko Kuwae
- Department of Diagnostic Pathology, Osaka City University Graduate School of Medicine, Japan
| | - Toshio Watanabe
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
| | - Masahiko Ohsawa
- Department of Diagnostic Pathology, Osaka City University Graduate School of Medicine, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Japan
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Shribman S, Marjot T, Sharif A, Vimalesvaran S, Ala A, Alexander G, Dhawan A, Dooley J, Gillett GT, Kelly D, McNeill A, Warner TT, Wheater V, Griffiths W, Bandmann O. Investigation and management of Wilson's disease: a practical guide from the British Association for the Study of the Liver. Lancet Gastroenterol Hepatol 2022; 7:560-575. [PMID: 35429442 DOI: 10.1016/s2468-1253(22)00004-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 02/07/2023]
Abstract
Wilson's disease is an autosomal-recessive disorder of copper metabolism with hepatic, neurological, psychiatric, ophthalmological, haematological, renal, and rheumatological manifestations. Making a diagnosis can be challenging given that no single test can confirm or exclude the disease, and diagnostic delays are common. Treatment protocols vary and adverse effects, including paradoxical neurological worsening, can occur. In this Review, we provide a practical guide to the diagnosis of Wilson's disease. We include recommendations on indications for testing, how to interpret results, and when additional investigations are required. We also cover treatment initiation, ideally under the guidance of a specialist centre for Wilson's disease, and the principles behind long-term management. This guidance was developed by a multidisciplinary group of Wilson's disease experts formed through the British Association for the Study of the Liver. The guidance has been endorsed by the British Society of Gastroenterology and approved by the Association of British Neurologists.
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Affiliation(s)
- Samuel Shribman
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, London, UK
| | - Thomas Marjot
- Oxford Liver Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Abubakar Sharif
- Liver Unit, Birmingham Women and Children's Hospital, Birmingham, UK
| | - Sunitha Vimalesvaran
- Paediatric Liver, GI and Nutrition Centre and Mowat Labs, King's College Hospital, Denmark Hill, London, UK
| | - Aftab Ala
- Department of Gastroenterology and Hepatology, Royal Surrey NHS Foundation Trust, Guildford; Institute of Liver Studies, King's College Hospital, London, UK
| | - Graeme Alexander
- University College London Institute of Liver and Digestive Health, London, UK
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre and Mowat Labs, King's College Hospital, Denmark Hill, London, UK
| | - James Dooley
- University College London Institute of Liver and Digestive Health, London, UK
| | - Godfrey T Gillett
- Laboratory Medicine, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Deirdre Kelly
- Liver Unit, Birmingham Women and Children's Hospital, Birmingham, UK
| | | | - Thomas T Warner
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, London, UK
| | | | | | - Oliver Bandmann
- Sheffield Institute for Translational Neuroscience (SITraN), Department of Neuroscience, University of Sheffield, UK.
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20
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Litwin T, Bembenek J, Antos A, Przybyłkowski A, Skowrońska M, Kurkowska-Jastrzębska I, Członkowska A. Liver transplantation as a treatment for Wilson's disease with neurological presentation: a systematic literature review. Acta Neurol Belg 2022; 122:505-518. [PMID: 35080708 PMCID: PMC8986686 DOI: 10.1007/s13760-022-01872-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 01/13/2022] [Indexed: 12/15/2022]
Abstract
Introduction Wilson’s disease (WD) is a potentially treatable, genetic disorder of copper metabolism, with survival similar to healthy populations if controlled. However, in almost 50% of WD patients, neurological symptoms persist despite treatment, and in up to 10% of patients, neurological deterioration is irreversible. International guidelines on WD treatment do not recommend liver transplantation (LT) as a treatment for neurological symptoms in WD. However, such treatment has been assessed in retrospective analyses, case and series reports. We aimed to systematically assess all available evidence on the effectiveness and safety of LT in WD patients with neurological presentation. Methods This systematic literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were identified by searching the PubMed database (up to 6 April 2021) and by screening reference lists. Results Based on the systematic literature review, 48 articles were identified, showing outcomes of LT in 302 WD patients with neurological symptoms. Of these patients, major improvement was found in 215 cases (71.2%), with no difference in neurological status before and after LT in 21 cases (6.9%). There were 29 deaths (9.6%), neurological worsening in 24 cases (7.9%), and 13 cases (4.3%) were lost to follow-up. Conclusions The results suggest that LT is a promising method of WD management in patients with severe, neurological symptoms, particularly if the patient has not responded to pharmacological de-coppering treatment. Further studies of LT in these patients are warranted. Supplementary Information The online version contains supplementary material available at 10.1007/s13760-022-01872-w.
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21
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Tang S, Bai L, Hou W, Hu Z, Chen X, Zhao J, Liang C, Zhang W, Duan Z, Zheng S. Comparison of the Effectiveness and Safety of d-Penicillamine and Zinc Salt Treatment for Symptomatic Wilson Disease: A Systematic Review and Meta‐Analysis. Front Pharmacol 2022; 13:847436. [PMID: 35370752 PMCID: PMC8975209 DOI: 10.3389/fphar.2022.847436] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 01/31/2022] [Indexed: 12/21/2022] Open
Abstract
Background: Pharmacological therapy is currently the main treatment method for patients with Wilson disease (WD). We aimed to evaluate the efficacy and safety of the common treatment regimens in these patients. Methods: We conducted a systemic review and meta-analysis by searching multiple databases for studies from inception to October 2021. Outcomes of interest were the improved rate and safety of d-penicillamine and zinc salts treatment in WD patients. Two independent reviewers performed the study selection and data extraction. Results: Sixteen studies were included in this meta-analysis. The pooled improved rate for all included symptomatic WD patients was 78.0% (95% CI: 70.8%–85.2%). In symptomatic hepatic WD patients, there is no difference in the treatment efficiency of d-penicillamine and zinc salts (RR: 0.98, 95% CI: 0.86%–1.12%; p = 0.765). In neurological WD patients, the pooled improved rate of those who received d-penicillamine and zinc salts was 56.3% (95% CI: 37.5%–75.1%) and 80.2% (95% CI: 67.2%–93.2%), respectively. The incidence of adverse effects (RR: 2.42, 95% CI: 1.20%–4.88%; p = 0.014) and neurological deterioration (RR: 1.96, 95% CI: 1.31%–2.93%; p = 0.001) in all symptomatic WD patients treated with d-penicillamine was both higher than that of patients treated with zinc salts. Conclusion: Our analysis suggests that symptomatic WD patients treated with d-penicillamine have higher incidence of adverse effects and neurological deterioration than that of zinc salts. The therapeutic effectiveness of these two regimens does not seem to be significantly different, and these results must be interpreted with caution. Systematic Review Registration: PROSPERO registration, identifier CRD 42021287126.
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Affiliation(s)
- Shan Tang
- The First Unit, Department of Hepatology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Li Bai
- The Fourth Unit, Department of Hepatology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Beijing, China
| | - Wei Hou
- The First Unit, Department of Hepatology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Zhongjie Hu
- The First Unit, Department of Hepatology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Xinyue Chen
- The First Unit, Department of Hepatology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Jing Zhao
- The First Unit, Department of Hepatology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Chen Liang
- The First Unit, Department of Hepatology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Wei Zhang
- The First Unit, Department of Hepatology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Zhongping Duan
- The Fourth Unit, Department of Hepatology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Sujun Zheng
- The First Unit, Department of Hepatology, Beijing YouAn Hospital, Capital Medical University, Beijing, China
- *Correspondence: Sujun Zheng,
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Li N, Krishna SG, Hinton A, Conwell DL, Mumtaz K. Characteristics and outcomes of hospitalized patients with Wilson's disease in the United States: A national survey. Ann Hepatol 2022; 25:100362. [PMID: 34144249 DOI: 10.1016/j.aohep.2021.100362] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Wilson's disease (WD) is a rare genetic disorder characterized by excessive copper disposition predominantly in the liver and brain. Hospitalization data on patients with WD are scarce. Hence, we sought to examine the inpatient characteristics and outcomes of patients with WD. PATIENTS AND METHODS We utilized the National Inpatient Database (2006-2011) and analyzed all adult patients with a diagnosis of WD. RESULTS There were 9046 hospitalizations during the study period. The leading etiologies for admissions were chronic liver disease (8.58%), WD (6.49%) and infections (septicemia 3.10% and pneumonia 2.50%). The overall inpatient mortality rate for WD patients was 2.58%. Independent predictors of mortality in WD patients were acute respiratory failure (OR: 4.53; 95% CI: 2.44-8.42), acute renal failure (OR: 4.09; 95% CI: 2.19-7.65), decompensated liver disease or liver failure (OR: 3.37; 95% CI: 1.72-6.59), and advanced age (every 10 year increase, OR: 1.48; 95% CI: 1.25-1.75). Propensity-score matched analysis revealed better inpatient survival in WD patients compared to matched non-WD patients (2.84% vs. 4.67%, p = 0.01). CONCLUSIONS Our study demonstrated the clinical characteristics and outcomes of hospitalized patients with WD. These findings add important knowledge to our understanding of the healthcare utilization and outcomes of this rare disease in the United States.
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Affiliation(s)
- Na Li
- Division of Gastroenterology, Hepatology, & Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology, & Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Alice Hinton
- Division of Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology, & Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Khalid Mumtaz
- Division of Gastroenterology, Hepatology, & Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Ziemssen T, Akgun K, Członkowska A, Antos A, Bembenek J, Kurkowska-Jastrzębska I, Przybyłkowski A, Skowrońska M, Smolinski L, Litwin T. Serum Neurofilament Light Chain as a Biomarker of Brain Injury in Wilson's Disease: Clinical and Neuroradiological Correlations. Mov Disord 2022; 37:1074-1079. [PMID: 35114010 DOI: 10.1002/mds.28946] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 01/11/2022] [Accepted: 01/14/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Clinical scales and neuroimaging are used to monitor nervous system injury in Wilson's disease, while data on serum markers are scarce. OBJECTIVE To investigate whether serum concentrations of neurofilament light chain (sNfL) correlate with brain injury in Wilson's disease patients. METHODS In 61 treatment-naïve patients, the Unified Wilson's Disease Rating Scale and a validated semiquantitative brain magnetic resonance imaging scale were compared with concentrations of sNfL. RESULTS Concentrations of sNfL were significantly higher in patients with neurological disease compared with patients presenting with other forms (39.7 ± 73.4 pg/mL vs. 13.3 ± 9.2 pg/mL; P < 0.01). Moreover, the sNfL concentration positively correlated with neurological severity scores and with acute and chronic brain damage based on the neuroimaging scale. CONCLUSIONS Neurofilament light chain concentrations may be used as a marker of brain injury in Wilson's disease, in addition to the clinical and neuroimaging disease severity scales. © 2022 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, University Clinic Carl Gustav Carus & Dresden University of Technology, Dresden, Germany
| | - Katja Akgun
- Center of Clinical Neuroscience, Department of Neurology, University Clinic Carl Gustav Carus & Dresden University of Technology, Dresden, Germany
| | - Anna Członkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Agnieszka Antos
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Jan Bembenek
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | | | - Adam Przybyłkowski
- Department of Gastroenterology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Marta Skowrońska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Lukasz Smolinski
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Tomasz Litwin
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
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24
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Sinha S, Aruna R, Mariyappa N, Nagappa M, Velmurugan J, Saini J, Bindu PS, Mathuranath PS, Thennarasu K, Satishchandra P, Taly AB. Insights from Magnetic Evoked Field Analysis in Patients with Wilson's Disease. Neurol India 2022; 70:1963-1970. [DOI: 10.4103/0028-3886.359230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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25
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Ott P, Ala A, Askari FK, Czlonkowska A, Hilgers R, Poujois A, Roberts EA, Sandahl TD, Weiss KH, Ferenci P, Schilsky ML. Designing Clinical Trials in Wilson's Disease. Hepatology 2021; 74:3460-3471. [PMID: 34320232 PMCID: PMC9291486 DOI: 10.1002/hep.32074] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/29/2021] [Accepted: 07/14/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Wilson's disease (WD) is an autosomal-recessive disorder caused by ATP7B gene mutations leading to pathological accumulation of copper in the liver and brain. Adoption of initial treatments for WD was based on empirical observations. These therapies are effective, but there are still unmet needs for which treatment modalities are being developed. An increase of therapeutical trials is anticipated. APPROACH AND RESULTS The first Wilson Disease Aarhus Symposium (May 2019) included a workshop on randomized clinical trial design. The authors of the article were organizers or presented during this workshop, and this article presents their consensus on the design of clinical trials for WD, addressing trial population, treatment comparators, inclusion and exclusion criteria, and treatment endpoints. To achieve adequate recruitment of patients with this rare disorder, the study groups should include all clinical phenotypes and treatment-experienced as well as treatment-naïve patients. CONCLUSIONS The primary study endpoint should be clinical or a composite endpoint until appropriate surrogate endpoints are validated. Standardization of clinical trials will permit pooling of data and allow for better treatment comparisons, as well as reduce the future numbers of patients needed per trial.
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Affiliation(s)
- Peter Ott
- Department of Hepatology and GastroenterologyAarhus UniversityAarhusDenmark
| | - Aftab Ala
- Department of Gastroenterology and HepatologyThe Royal Surrey NHS Foundation TrustGuildfordUnited Kingdom,Department of Clinical and Experimental MedicineUniversity of SurreyGuildfordUnited Kingdom,Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | | | - Anna Czlonkowska
- Second Department of NeurologyInstitute of Psychiatry and NeurologyWarsawPoland
| | | | - Aurélia Poujois
- Neurology Department and National Reference Centre for Wilson’s DiseaseRothschild Foundation HospitalParisFrance
| | - Eve A. Roberts
- Departments of Paediatrics, Medicine, and Pharmacology and ToxicologyUniversity of TorontoTorontoOntarioCanada
| | | | - Karl Heinz Weiss
- Salem Medical CenterHeidelbergGermany,Department of Internal MedicineIV at University Hospital HeidelbergHeidelbergGermany
| | - Peter Ferenci
- Department of Gastroenterology and HepatologyMedical University of ViennaViennaAustria
| | - Michael L. Schilsky
- Departments of Medicine and SurgeryYale University Medical CenterNew HavenCTUSA
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Seetharaman J, Sarma MS. Chelation therapy in liver diseases of childhood: Current status and response. World J Hepatol 2021; 13:1552-1567. [PMID: 34904029 PMCID: PMC8637676 DOI: 10.4254/wjh.v13.i11.1552] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 05/07/2021] [Accepted: 08/20/2021] [Indexed: 02/06/2023] Open
Abstract
Chelation is the mainstay of therapy in certain pediatric liver diseases. Copper and iron related disorders require chelation. Wilson’s disease (WD), one of the common causes of cirrhosis in children is treated primarily with copper chelating agents like D-penicillamine and trientine. D-Penicillamine though widely used due its high efficacy in hepatic WD is fraught with frequent adverse effects resulting discontinuation. Trientine, an alternative drug has comparable efficacy in hepatic WD but has lower frequency of adverse effects. The role of ammonium tetra-thiomolybdate is presently experimental in hepatic WD. Indian childhood cirrhosis is related to excessive copper ingestion, rarely seen in present era. D-Penicillamine is effective in the early part of this disease with reversal of clinical status. Iron chelators are commonly used in secondary hemochromatosis of liver in hemolytic anemias. There are strict chelation protocols during bone marrow transplant. The role of iron chelation in neonatal hemochromatosis is presently not in vogue due to its poor efficacy and availability of other modalities of therapy. Hereditary hemochromatosis is rare in children and the use of iron chelators in this condition is limited.
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Affiliation(s)
- Jayendra Seetharaman
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
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27
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Wilson's Disease: An Update on the Diagnostic Workup and Management. J Clin Med 2021; 10:jcm10215097. [PMID: 34768617 PMCID: PMC8584493 DOI: 10.3390/jcm10215097] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/18/2021] [Accepted: 10/27/2021] [Indexed: 02/08/2023] Open
Abstract
Wilson's disease (WD) is a rare autosomal recessive disorder of hepatocellular copper deposition. The diagnostic approach to patients with WD may be challenging and is based on a complex set of clinical findings that derive from patient history, physical examination, as well as laboratory and imaging testing. No single examination can unequivocally confirm or exclude the disease. Timely identification of signs and symptoms using novel biomarkers and modern diagnostic tools may help to reduce treatment delays and improve patient prognosis. The proper way of approaching WD management includes, firstly, early diagnosis and prompt treatment introduction; secondly, careful and lifelong monitoring of patient compliance and strict adherence to the treatment; and, last but not least, screening for adverse effects and evaluation of treatment efficacy. Liver transplantation is performed in about 5% of WD patients who present with acute liver failure at first disease presentation or with signs of decompensation in the course of liver cirrhosis. Increasing awareness of this rare inherited disease among health professionals, emphasizing their training to consider early signs and symptoms of the illness, and strict monitoring are vital strategies for the patient safety and efficacy of WD therapy.
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Socha P, Czlonkowska A, Janczyk W, Litwin T. Wilson's disease- management and long term outcomes. Best Pract Res Clin Gastroenterol 2021; 56-57:101768. [PMID: 35331405 DOI: 10.1016/j.bpg.2021.101768] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/01/2021] [Accepted: 10/08/2021] [Indexed: 01/31/2023]
Abstract
Wilson's disease (WD) is an autosomal recessive genetic disorder of copper metabolism leading to liver or brain injury due to accumulation of copper. Diagnosis is based on: clinical features, biochemical tests including plasma ceruloplasmin concentration, 24h urinary copper excretion, copper content in the liver, and molecular analysis. Pharmacological therapy comprises chelating agents (penicillamine, trientine) and zinc salts which seem to be very effective. Still, poor compliance is a major problem. Adolescents and patients with psychiatric disorders usually have problems with adherence to treatment. As transition is a vulnerable period transition ''training'' should start before the planned transfer, preferably already in early adolescence in cooperation between adult and pediatric clinics. Response to treatment is assessed based on physical examination, normal liver function tests and monitoring of copper metabolism markers. Liver transplantation has a well-defined role in Wilsonian acute hepatic failure according to the prognostic score. The long-term survival in WD patients seems to be very similar as for the general population if disease is early diagnosed and correctly treated. WD patients with a longer delay from diagnosis to therapy and who present with neurological and psychiatric symptoms have worse quality of life.
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Affiliation(s)
- Piotr Socha
- The Children's Memorial Health Institute, Warsaw, Poland.
| | | | | | - Tomasz Litwin
- Institute of Psychiatry and Neurology, Warsaw, Poland
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Pediatric Wilson's Disease: Phenotypic, Genetic Characterization and Outcome of 182 Children in France. J Pediatr Gastroenterol Nutr 2021; 73:e80-e86. [PMID: 34091542 DOI: 10.1097/mpg.0000000000003196] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To describe a cohort of Wilson disease (WD) pediatric cases, and to point out the diagnostic particularities of this age group and the long-term outcome. METHODS Clinical data of 182 pediatric patients included in the French WD national registry from 01/03/1995 to 01/06/2019 were gathered. RESULTS Diagnosis of WD was made at a mean age of 10.7 ± 4.2 years (range 1-18 years). At diagnosis, 154 patients (84.6%) had hepatic manifestations, 19 (10.4%) had neurological manifestations, and 9 patients (4.9%) were asymptomatic. The p.His1069Gln mutation was the most frequently encountered (14% of patients).Neurological patients were diagnosed at least 1 year after they presented their first symptoms. At diagnosis, the median urinary copper excretion (UCE) was 4.2 μmol/24 hours (0.2-253). The first-line treatment was d-penicillamine (DP) for 131 (72%) patients, zinc salts for 24 (13%) patients, and Trientine for 17 (9%) patients. Liver transplantation was performed in 39 (21.4%) patients, for hepatic indications in 33 of 39 patients or for neurological deterioration in 6 of 39 patients, mean Unified Wilson's Disease Rating Scale of the latter went from 90 ± 23.1 before liver transplantation (LT) to 26.8 ± 14.1 (P < 0.01) after a mean follow-up of 4.3 ± 2.5 years. Overall survival rate at 20 years of follow-up was 98%, patient and transplant-free combined survival was 84% at 20 years. CONCLUSION Diagnosis of WD can be challenging in children, particularly at the early stages of liver disease and in case of neurological presentation; hence the support of clinical scores and genetic testing is essential. Diagnosis at early stages and proper treatment ensure excellent outcomes, subject to good long-term treatment compliance. LT is a valid option for end-stage liver disease not responding to treatment and can be discussed for selected cases of neurological deterioration.
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Combined dimercaptosuccinic acid and zinc treatment in neurological Wilson's disease patients with penicillamine-induced allergy or early neurological deterioration. Biosci Rep 2021; 40:225324. [PMID: 32809015 PMCID: PMC7435022 DOI: 10.1042/bsr20200654] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/22/2020] [Accepted: 06/02/2020] [Indexed: 01/22/2023] Open
Abstract
The clinical data of safety and efficacy of a combined treatment with dimercaptosuccinic acid (DMSA) and Zinc with 2 years’ follow-up in 60 neurological Wilson’s disease (WD) patients was retrospectively analyzed. All the patients included in the present study were newly diagnosed and initialized with D-penicillamine (DPA) treatment but were found to have either neurological deterioration or allergy, and their treatment was switched to a combined treatment of DMSA and Zinc. Fifty-one patients (85%) had the neurological symptoms improved 1 and 2 years after treatment, 7 (11.67%) experienced a stable neurological condition, and 2 (3.33%) suffered deterioration of neurological symptoms. No early neurological deterioration was observed in all patients. Twenty-five percent patients experienced mild adverse reactions which did not require a discontinuation of the DMSA and Zinc treatment. Our study confirmed the safety and efficacy of the combined DMSA and Zinc therapy as an initial and probably long-term treatment in neurological WD patients.
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Copper Toxicity Is Not Just Oxidative Damage: Zinc Systems and Insight from Wilson Disease. Biomedicines 2021; 9:biomedicines9030316. [PMID: 33804693 PMCID: PMC8003939 DOI: 10.3390/biomedicines9030316] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/13/2021] [Accepted: 03/17/2021] [Indexed: 12/13/2022] Open
Abstract
Essential metals such as copper (Cu) and zinc (Zn) are important cofactors in diverse cellular processes, while metal imbalance may impact or be altered by disease state. Cu is essential for aerobic life with significant functions in oxidation-reduction catalysis. This redox reactivity requires precise intracellular handling and molecular-to-organismal levels of homeostatic control. As the central organ of Cu homeostasis in vertebrates, the liver has long been associated with Cu storage disorders including Wilson Disease (WD) (heritable human Cu toxicosis), Idiopathic Copper Toxicosis and Endemic Tyrolean Infantile Cirrhosis. Cu imbalance is also associated with chronic liver diseases that arise from hepatitis viral infection or other liver injury. The labile redox characteristic of Cu is often discussed as a primary mechanism of Cu toxicity. However, work emerging largely from the study of WD models suggests that Cu toxicity may have specific biochemical consequences that are not directly attributable to redox activity. This work reviews Cu toxicity with a focus on the liver and proposes that Cu accumulation specifically impacts Zn-dependent processes. The prospect that Cu toxicity has specific biochemical impacts that are not entirely attributable to redox may promote further inquiry into Cu toxicity in WD and other Cu-associated disorders.
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Dong Y, Wang RM, Yang GM, Yu H, Xu WQ, Xie JJ, Zhang Y, Chen YC, Ni W, Wu ZY. Role for Biochemical Assays and Kayser-Fleischer Rings in Diagnosis of Wilson's Disease. Clin Gastroenterol Hepatol 2021; 19:590-596. [PMID: 32485301 DOI: 10.1016/j.cgh.2020.05.044] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 05/17/2020] [Accepted: 05/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Wilson disease is an autosomal recessive disorder that impairs copper homeostasis and is caused by homozygous or compound heterozygous mutations in ATP7B, which encodes a copper-transporting P-type ATPase. Patients have variable clinical manifestations and laboratory test results, resulting in diagnostic dilemmas. We aimed to identify factors associated with symptoms and features of Wilson disease from a large cohort, over 15 years. METHODS We collected data from 715 patients (529 with symptoms, 146 without symptoms, and 40 uncategorized) and a genetic confirmation of Wilson's disease (mean age of diagnosis, 18.84 years), recruited from 3 hospitals in China from 2004 through 2019. We analyzed clinical data along with serum levels of ceruloplasmin (available from 636 patients), 24-hr urinary copper excretion (collected from 131 patients), Kayser-Fleisher rings (copper accumulation in eyes, with neurologic data from 355 patients), and magnetic resonance imaging (MRI) abnormalities. Differences among the groups were analyzed using 1-way analysis of variance followed by Tukey multiple comparison test. RESULTS Of the 529 patients with symptoms, 121 had hepatic features, 355 had neurologic features, 28 had osteomuscular features (premature osteoarthritis, skeletal deformities, and pathological bone fractures), and 25 had psychiatric symptoms. Age of onset was significantly younger in patients with hepatic (16.94 ± 1.03 years; P = .0105) or osteomuscular features (13 ± 1.33 years; P = .0001) than patients with neurological features (19.48 ± 0.46 years). Serum levels of ceruloplasmin differed among asymptomatic patients and patients with osteomuscular or neurologic symptoms of Wilson disease. Serum levels of ceruloplasmin ranged from 18.93 mg/L to approximately 120.00 mg/L (quantiles of 0.025 to approximately 0.975). Fifty-one of 131 patients (39%) had urinary copper excretion levels below 100 μg/24 hr; there was significant variation in levels of urinary copper excretion between patients older than 14 years vs 14 years or younger. Of the 355 patients with neurologic features, 244 patients (69%) had abnormal findings from MRI and Kayser-Fleisher rings; only 1 patient with abnormal findings from brain MRI was negative for Kayser-Fleisher rings. CONCLUSIONS Serum level of ceruloplasmin, 24-hour urinary copper excretion, and Kayser-Fleisher rings can be used to identify patients who might have Wilson disease. Patients with serum levels of ceruloplasmin below 120 mg/L and children with urinary copper excretion above 40 μg should undergo genetic testing for Wilson's disease. Patients with movement disorders and brain MRI abnormalities without Kayser-Fleisher rings are not likely to have Wilson disease.
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Affiliation(s)
- Yi Dong
- Department of Neurology and Research Center of Neurology in Second Affiliated Hospital, and Key Laboratory of Medical Neurobiology of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Rou-Min Wang
- Department of Neurology and Research Center of Neurology in Second Affiliated Hospital, and Key Laboratory of Medical Neurobiology of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Guo-Min Yang
- Department of Neurology and Research Center of Neurology in Second Affiliated Hospital, and Key Laboratory of Medical Neurobiology of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Hao Yu
- Department of Neurology and Research Center of Neurology in Second Affiliated Hospital, and Key Laboratory of Medical Neurobiology of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Wan-Qing Xu
- Department of Neurology and Research Center of Neurology in Second Affiliated Hospital, and Key Laboratory of Medical Neurobiology of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Juan-Juan Xie
- Department of Neurology and Research Center of Neurology in Second Affiliated Hospital, and Key Laboratory of Medical Neurobiology of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Yue Zhang
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yu-Chao Chen
- Department of Neurology, First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wang Ni
- Department of Neurology and Research Center of Neurology in Second Affiliated Hospital, and Key Laboratory of Medical Neurobiology of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhi-Ying Wu
- Department of Neurology and Research Center of Neurology in Second Affiliated Hospital, and Key Laboratory of Medical Neurobiology of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China.
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Hu S, Xu C, Dong T, Wu H, Wang Y, Wang A, Kan H, Li C. Structural and Functional Changes Are Related to Cognitive Status in Wilson's Disease. Front Hum Neurosci 2021; 15:610947. [PMID: 33716691 PMCID: PMC7947794 DOI: 10.3389/fnhum.2021.610947] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/20/2021] [Indexed: 11/13/2022] Open
Abstract
Patients with Wilson’s disease (WD) suffer from prospective memory (PM) impairment, and some of patients develop cognitive impairment. However, very little is known about how brain structure and function changes effect PM in WD. Here, we employed multimodal neuroimaging data acquired from 22 WD patients and 26 healthy controls (HC) who underwent three-dimensional T1-weighted, diffusion tensor imaging (DTI), and resting state functional magnetic resonance imaging (RS-fMRI). We investigated gray matter (GM) volumes with voxel-based morphometry, DTI metrics using the fiber tractography method, and RS-fMRI using the seed-based functional connectivity method. Compared with HC, WD patients showed GM volume reductions in the basal ganglia (BG) and occipital fusiform gyrus, as well as volume increase in the visual association cortex. Moreover, whiter matter (WM) tracks of WD were widely impaired in association and limbic fibers. WM tracks in association fibers are significant related to PM in WD patients. Relative to HC, WD patients showed that the visual association cortex functionally connects to the thalamus and hippocampus, which is associated with global cognitive function in patients with WD. Together, these findings suggested that PM impairment in WD may be modulated by aberrant WM in association fibers, and that GM volume changes in the association cortex has no direct effect on cognitive status, but indirectly affect global cognitive function by its aberrant functional connectivity (FC) in patients with WD. Our findings may provide a new window to further study how WD develops into cognitive impairment, and deepen our understanding of the cognitive status and neuropathology of WD.
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Affiliation(s)
- Sheng Hu
- Center for Biomedical Engineering, University of Science and Technology of China, Hefei, China.,School of Medical Information Engineering, Anhui University of Chinese Medicine, Hefei, China
| | - Chunsheng Xu
- Center for Biomedical Engineering, University of Science and Technology of China, Hefei, China.,Medical Imaging Center, First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
| | - Ting Dong
- Medical Imaging Center, First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
| | - Hongli Wu
- School of Medical Information Engineering, Anhui University of Chinese Medicine, Hefei, China
| | - Yi Wang
- School of Medical Information Engineering, Anhui University of Chinese Medicine, Hefei, China
| | - Anqin Wang
- Medical Imaging Center, First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
| | - Hongxing Kan
- School of Medical Information Engineering, Anhui University of Chinese Medicine, Hefei, China
| | - Chuanfu Li
- Medical Imaging Center, First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
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Pal P, Stezin A, Reddam V, Hegde S, Yadav R, Saini J. Morphometric mapping of the macrostructural abnormalities of midsagittal corpus callosum in Wilson’s disease. ANNALS OF MOVEMENT DISORDERS 2021; 4:60-65. [PMID: 35936213 PMCID: PMC7613241 DOI: 10.4103/aomd.aomd_41_20] [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] [Indexed: 11/12/2022] Open
Abstract
Background and Purpose The corpus callosum (CC) consists of topographically arranged white matter (WM) fibers. Previous studies have indicated the CC to be discretely involved in WD. In this study, we strived to characterize the macrostructural properties of the CC using midsagittal cross-sectional area and thickness profile measurements. Materials and Methods This study was performed using archived magnetic resonance imaging (MRI) scans of 14 patients with WD and 14 age- and gender-matched healthy controls. Using an automated software pipeline for morphometric profiling, the midsagittal CC was segmented into five sub-regions (CC1–5) according to the Hofer–Frahm scheme. The mean thickness and area of different CC segments and their clinical and cognitive correlates were identified. Results The mean area was significantly different only in CC2 segment (94.2 ± 25.5 vs. 118.6 ± 19.7 mm2, corrected P < 0.05). The mean thickness was significantly different in CC1 (5.06 ± 1.15 vs. 6.93 ± 0.89 mm, corrected P < 0.05), CC2 (3.73 ± 0.96 vs. 4.87 ± 1.01 mm, corrected P < 0.05), and CC3 segments (3.42 ± 0.84 vs. 3.94 ± 0.72 mm, corrected P < 0.05). The age at onset of neurological symptoms and MMSE score was significantly correlated with the morphometric changes of CC1 and CC2 segments. Conclusion Morphological changes of the CC are discrete in WD. Morphometric loss of CC was associated with an earlier onset of neurological symptoms and cognitive dysfunction in WD.
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Choe EJ, Choi JW, Kang M, Lee YK, Jeon HH, Park BK, Won SY, Cho YS, Seo JH, Lee CK, Chung JB. A population-based epidemiology of Wilson's disease in South Korea between 2010 and 2016. Sci Rep 2020; 10:14041. [PMID: 32820224 PMCID: PMC7441316 DOI: 10.1038/s41598-020-70976-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 08/10/2020] [Indexed: 12/11/2022] Open
Abstract
Very few population-based studies have examined the epidemiology of Wilson's disease (WD). We investigated the epidemiology of WD using the National Health Insurance Service (NHIS) database in South Korea. We analyzed not only the statistical variables of WD, but also those of WD-related diseases. WD patients were identified with the relevant International Classification of Diseases-10 code out of 50.5 million people. We used the NHIS database from 2009 to 2016 and analyzed the incidence rate, prevalence, and clinical symptoms of WD. A total of 1,333 patients were identified. The average annual incidence rate was 3.8 per million person-years. The prevalence was 38.7 per million people. The mean diagnostic age was 26.1 ± 17.2 with earlier diagnosis in men (P = 0.0003). Among the patients, 988 (74.1%) had hepatic symptoms, 510 (38.3%) had neurologic symptoms, and 601 (45.1%) had psychiatric symptoms. Before the diagnosis of WD, 350 (26.3%) had neurologic symptoms, and 427 (32%) had psychiatric symptoms. The annual mortality rate was 0.7%. Age, liver cirrhosis, and liver failure correlated with a fatal prognosis (P < 0.05). Many patients showed neurologic and psychiatric symptoms before they were diagnosed with WD. Prognosis correlated with age, liver cirrhosis, and liver failure.
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Affiliation(s)
- Eun Ju Choe
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jong Won Choi
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea.
| | - Minjin Kang
- Research Institute, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Yong Kang Lee
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Han Ho Jeon
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Byung Kyu Park
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sun Young Won
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Yong Suk Cho
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jeong Hun Seo
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Chun Kyon Lee
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jae Bock Chung
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
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Leng Y, Li P, Zhou L, Xiao L, Liu Y, Zheng Z, Qin F, Hao Q, Xu H, Yao S, Dong B. Long-Term Correction of Copper Metabolism in Wilson's Disease Mice with AAV8 Vector Delivering Truncated ATP7B. Hum Gene Ther 2020; 30:1494-1504. [PMID: 31668086 DOI: 10.1089/hum.2019.148] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Wilson's disease (WD) is an autosomal recessive disorder of copper metabolism caused by mutations in the ATP7B gene encoding a liver active copper transport enzyme. Gene therapy with adeno-associated virus (AAV) carrying full-length ATP7B, which is about 4.4 kb, was shown to rescue copper metabolism disorder in WD mouse model. However, due to its relatively large size, the AAV vector containing full-length ATP7B could be oversized for its packaging capacity, which could lead to inefficient packaging. To this purpose, we engineered a truncated ATP7B mutant (tATP7B) that is about 3.3 kb in length and used for AAV gene therapy for WD mice. In vitro test showed that the excretion of copper outside the cells could be achieved with tATP7B as efficient as the full-length ATP7B. In vivo delivery of tATP7B to WD mice by AAV8 vectors corrected their copper metabolisms and significantly rescued copper accumulation-related syndromes, including reduced urinary copper excretion, increased serum ceruloplasmin, and improved liver damages. Thus, our study demonstrated that AAV gene therapy based on truncated ATP7B is a promising strategy in the treatment of WD.
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Affiliation(s)
- Yingying Leng
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ping Li
- National Clinical Research Center for Geriatrics, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lifang Zhou
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lin Xiao
- National Clinical Research Center for Geriatrics, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu Liu
- National Clinical Research Center for Geriatrics, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhaoyue Zheng
- National Clinical Research Center for Geriatrics, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fengming Qin
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qiukui Hao
- National Clinical Research Center for Geriatrics, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Heng Xu
- National Clinical Research Center for Geriatrics, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Shaohua Yao
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Biao Dong
- National Clinical Research Center for Geriatrics, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Paternostro R, Pfeiffenberger J, Ferenci P, Stättermayer AF, Stauber RE, Wrba F, Longerich T, Lackner K, Trauner M, Ferlitsch A, Reiberger T, Weiss KH. Non-invasive diagnosis of cirrhosis and long-term disease monitoring by transient elastography in patients with Wilson disease. Liver Int 2020; 40:894-904. [PMID: 31898387 PMCID: PMC7187206 DOI: 10.1111/liv.14368] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/05/2019] [Accepted: 12/30/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The value of liver stiffness measurement (LSM) by transient elastography (TE) for non-invasive fibrosis staging and disease monitoring has not been established in patients with Wilson disease (WD). METHODS Liver stiffness measurement by TE and non-invasive fibrosis scores (APRI, FIB-4) were analysed from 188 WD patients with liver biopsy (LBX). Longitudinal LSM was performed in 128 (68.1%) patients. RESULTS One hundred and eighty-eight patients (mean age: 35 ± 14 years, 54.8% women; 27.1% with histological cirrhosis) were studied. Forty-four[23.4%] patients were recently diagnosed with WD, while 144[76.6%] were previously diagnosed (>1 year between LBX and LSM). Overall, LSM (11.3 vs 6.1 kPa, P < .001), APRI (0.72 vs 0.38, P < .001) and FIB-4 (1.54 vs 0.89, P < .001) were higher in cirrhotic than in non-cirrhotic patients. This was even more pronounced in recently diagnosed patients (35.2 kPa vs 6.4 kPa, P < .001). Accuracy for diagnosing cirrhosis at an LSM cut-off ≥9.9 kPa was better in recently diagnosed (PPV: 74%, NPV: 100%) vs previously diagnosed (PPV: 53%, NPV: 82%) patients. Recently diagnosed patients had higher Area Under the Curve (AUC) for APRI (0.79 vs 0.61) and FIB-4 (0.84 vs 0.65) than previously diagnosed patients. At APRI <1.5 and FIB-4 <3.25 cirrhosis was ruled out with a specificity of 93% and 95% respectively. During a median follow-up of 46 (24-66) months, only 5.9% (5/85) of non-cirrhotic WD patients showed progression to cirrhotic LSM values, while 30.8% (4/13) of cirrhotic WD patients showed LSM suggestive of cirrhosis regression. CONCLUSION TE-based LSM ≥9.9 kPa accurately identifies cirrhosis in WD patients. Next to TE-LSM <9.9 kPa, APRI <1.5 and FIB-4 <3.25 values assist to non-invasively rule out cirrhosis. LSM remains stable in most non-cirrhotic patients on WD therapy, while one-third of cirrhotic patients present clinically relevant decreases in LSM.
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Affiliation(s)
- Rafael Paternostro
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Jan Pfeiffenberger
- Department of Internal Medicine IVUniversity Hospital HeidelbergHeidelbergGermany
| | - Peter Ferenci
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Albert F. Stättermayer
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Rudolf E. Stauber
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineMedical University of GrazGrazAustria
| | - Fritz Wrba
- Department of PathologyMedical University of ViennaViennaAustria
| | - Thomas Longerich
- Institute of PathologyUniversity Hospital HeidelbergHeidelbergGermany
| | | | - Michael Trauner
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Arnulf Ferlitsch
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Thomas Reiberger
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria,Ludwig Boltzmann Institute for Rare and Undiagnosed DiseasesViennaAustria,CeMM Research Center for Molecular Medicine of the Austrian Academy of SciencesViennaAustria
| | - Karl Heinz Weiss
- Department of Internal Medicine IVUniversity Hospital HeidelbergHeidelbergGermany
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A study of susceptibility-weighted imaging in patients with Wilson disease during the treatment of metal chelator. J Neurol 2020; 267:1643-1650. [DOI: 10.1007/s00415-020-09746-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 01/12/2023]
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Sandahl TD, Laursen TL, Munk DE, Vilstrup H, Weiss KH, Ott P. The Prevalence of Wilson's Disease: An Update. Hepatology 2020; 71:722-732. [PMID: 31449670 DOI: 10.1002/hep.30911] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 08/21/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS In 1984, Scheinberg and Sternlieb estimated the prevalence of Wilson's disease to be 1:30,000 based on the limited available data. This suggested a large number of overlooked cases with potentially fatal consequences. The "Scheinberg-Sternlieb Estimate" is still widely used, although more recent clinical and genetic studies of higher quality are now available. In the present study, we included these data to update the prevalence estimate. APPROACH AND RESULTS A MEDLINE Ovid, Science Citation Index Expanded, and PubMed systematic search for all relevant studies on the prevalence of Wilson's disease was conducted. In total, 59 studies (50 clinical and 9 population-based genetic) were included in the final analysis. We identified 4 recent clinical studies based on nationwide databases of high quality, providing prevalence estimates from 1:29,000 to 1:40,000. Higher frequency populations do exist because of frequent first-cousin marriages and/or a higher mutation frequency. When calculating prevalence from the incidence related to number of births, estimates were 1:40,000-1:50,000. Clinical screening studies, including examination for Kayser-Fleischer rings or ceruloplasmin, did not improve these estimates because of insufficient sample size or selection biases. Population-based genetic studies in US and UK populations were not in disagreement with the clinically based estimates. At the same time, studies from France and Sardinia suggested that the genetic prevalence may be 3-4 times higher than the clinical disease prevalence. This raises the question whether the penetrance is indeed 100% as generally assumed. CONCLUSIONS The original prevalence estimate from 1984 of 1:30,000-1:50,000 still appears valid, at least for the United States, Europe, and Asia. In some population-based studies, the genetic prevalence was 3-4 times higher than clinically based estimates. The question of penetrance needs further evaluation.
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Affiliation(s)
| | - Tea Lund Laursen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Ditte Emilie Munk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Karl Heinz Weiss
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Ott
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Appenzeller-Herzog C, Mathes T, Heeres MLS, Weiss KH, Houwen RHJ, Ewald H. Comparative effectiveness of common therapies for Wilson disease: A systematic review and meta-analysis of controlled studies. Liver Int 2019; 39:2136-2152. [PMID: 31206982 DOI: 10.1111/liv.14179] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/16/2019] [Accepted: 06/04/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Wilson disease (WD) is a rare disorder of copper metabolism. The objective of this systematic review was to determine the comparative effectiveness and safety of common treatments of WD. METHODS We included WD patients of any age or stage and the study drugs D-penicillamine, zinc salts, trientine and tetrathiomolybdate. The control could be placebo, no treatment or any other treatment. We included prospective, retrospective, randomized and non-randomized studies. We searched Medline and Embase via Ovid, the Cochrane Central Register of Controlled Trials, and screened reference lists of included articles. Where possible, we applied random-effects meta-analyses. RESULTS The 23 included studies reported on 2055 patients and mostly compared D-penicillamine to no treatment, zinc, trientine or succimer. One study compared tetrathiomolybdate and trientine. Post-decoppering maintenance therapy was addressed in one study only. Eleven of 23 studies were of low quality. When compared to no treatment, D-penicillamine was associated with a lower mortality (odds ratio 0.013; 95% CI 0.0010 to 0.17). When compared to zinc, there was no association with mortality (odds ratio 0.73; 95% CI 0.16 to 3.40) and prevention or amelioration of clinical symptoms (odds ratio 0.84; 95% CI 0.48 to 1.48). Conversely, D-penicillamine may have a greater impact on side effects and treatment discontinuations than zinc. CONCLUSIONS There are some indications that zinc is safer than D-penicillamine therapy while being similarly effective in preventing or reducing hepatic or neurological WD symptoms. Study quality was low warranting cautious interpretation of our findings.
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Affiliation(s)
| | - Tim Mathes
- Institute for Research in Operative Medicine, Faculty of Health, School of Medicine, Witten/Herdecke University, Cologne, Germany
| | - Marlies L S Heeres
- Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Karl Heinz Weiss
- Department of Internal Medicine IV, Medical University of Heidelberg, Heidelberg, Germany
| | - Roderick H J Houwen
- Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Hannah Ewald
- University Medical Library, University of Basel, Basel, Switzerland.,Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
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Litwin T, Dusek P, Skowrońska M, Członkowska A. Treatment of Wilson’s disease – an update. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1638248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Tomasz Litwin
- 2nd Department of Neurology, Institute Psychiatry and Neurology, Warsaw, Poland
| | - Petr Dusek
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Marta Skowrońska
- 2nd Department of Neurology, Institute Psychiatry and Neurology, Warsaw, Poland
| | - Anna Członkowska
- 2nd Department of Neurology, Institute Psychiatry and Neurology, Warsaw, Poland
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Poujois A, Woimant F. Challenges in the diagnosis of Wilson disease. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S67. [PMID: 31179304 PMCID: PMC6531657 DOI: 10.21037/atm.2019.02.10] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 01/31/2019] [Indexed: 01/17/2023]
Abstract
The understanding and management of Wilson disease (WD) have dramatically improved since the first description of the disease by K. Wilson more than a century ago. However, the persistent long delay between the first symptoms and diagnosis emphasizes challenges in diagnosing earlier this copper overload disorder. As a treatable disease, WD should be detected early in the course of the disease by any health professionals at any care level, but the rare prevalence of the disease explains the lack of awareness of referring physicians. The most important challenge is to train physicians to recognize atypical or rare symptoms of WD that will lead to discuss the diagnosis more systematically. Atypia can come from the age of onset, the liver [non-alcoholic steatohepatitis (NASH) presentation], the central or peripheral nervous system (neuropathy, epilepsy, sleep disorders…) or may be due to lesions of other organs (renal manifestations, osteo-articular disorders or endocrine disturbances). Isolated biological anomalies, rare radiological findings or inadequate interpretation of copper test may also lead to misdiagnosis. The second challenge is to confirm the diagnosis faster and more effectively so as not to delay the initiation of treatment, and expand family screening as the genetic prevalence is higher than previously expected. Generalization of the exchangeable copper assay and the next generation sequencing (NGS) are two promising ways to overcome this ultimate challenge. By drawing attention to the earliest and rare symptoms and to new biomarkers and diagnostic tools, we hope that this article will increase diagnostic awareness and reduce delays so that patients can start their treatment earlier in the course of the illness and thus have a better disease prognosis.
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Affiliation(s)
- Aurélia Poujois
- Neurology Department, AP-HP, Lariboisière University Hospital, Paris, France
- National Reference Centre for Wilson Disease, AP-HP, Lariboisière University Hospital, Paris, France
| | - France Woimant
- Neurology Department, AP-HP, Lariboisière University Hospital, Paris, France
- National Reference Centre for Wilson Disease, AP-HP, Lariboisière University Hospital, Paris, France
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Litwin T, Dzieżyc K, Członkowska A. Wilson disease-treatment perspectives. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S68. [PMID: 31179305 DOI: 10.21037/atm.2018.12.09] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Wilson disease (WD) is a genetic disorder caused by pathological tissue copper accumulation with secondary damage of affected organs (mainly, but not limited to, the liver and brain). The main clinical symptoms of WD are, in concordance with the pathogenesis, hepatic and/or neuropsychiatric. Current treatment options for WD, based on drugs leading to negative copper body balance like chelators or zinc salts, were introduced more than 40 years ago and are generally effective in the majority of WD cases if used lifelong. However, especially in neurological patients, treatment may lead to neurological deterioration, which is often irreversible. Further, almost 50% of neurologically affected WD patients present with persistent neurological deficits despite the use of anti-copper treatment. In addition, up to 30% of patients treated with the widely used drug, d-penicillamine, present with adverse events related to treatment, which often leads to treatment discontinuation. Finally, almost 25% of WD patients do not adhere with anti-copper treatment, partially due to drug-related adverse events and complex treatment regimens (3 times daily, before meals, etc.). These limitations with current treatments have led to the search for other WD treatment possibilities. Currently, research is mainly focused on: (I) new agents with better safety profiles and less neurological deterioration properties compared with traditional chelators, e.g., tetrathiomolybdate salts or central nervous system-penetrable trientine, with the aim to provide more effective copper removal from brain tissue; (II) other non-chelating drugs that lead to removal of copper from cells [e.g., methanobactin (currently in preclinical studies)]; (III) cell and gene therapy. In this article, current research on future treatments for WD is reviewed.
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Affiliation(s)
- Tomasz Litwin
- Second Department of Neurology, Institute Psychiatry and Neurology, Warsaw, Poland
| | - Karolina Dzieżyc
- Second Department of Neurology, Institute Psychiatry and Neurology, Warsaw, Poland
| | - Anna Członkowska
- Second Department of Neurology, Institute Psychiatry and Neurology, Warsaw, Poland
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Mohr I, Weiss KH. Current anti-copper therapies in management of Wilson disease. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S69. [PMID: 31179306 DOI: 10.21037/atm.2019.02.48] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In Wilson disease (WD) severity of disease can vary widely, depending on time of diagnosis. Early treatment can prevent the development of symptoms in patients. In all patients, lifelong medical treatment is indicated. Currently available medical regimens include the copper chelators for example D-penicillamine (DPA) or trientine (TETA), acting to increase copper excretion and zinc salts (ZS), which reduce copper uptake. In this chapter, we discuss considerations regarding choice of drug and safety limitations.
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Affiliation(s)
- Isabelle Mohr
- Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Karl Heinz Weiss
- Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
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Członkowska A, Dzieżyc-Jaworska K, Kłysz B, Barbara RO, Litwin T. Difficulties in diagnosis and treatment of Wilson disease-a case series of five patients. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S73. [PMID: 31179310 DOI: 10.21037/atm.2019.02.37] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Wilson disease (WD) may present symptomatically at any age. There is great variability in the neurological symptoms present, in the clinical state of WD patients, and in the response to decoppering therapy. Early diagnosis and compliance with anti-copper therapy are essential. Here we present five different WD cases to illustrate different problems encountered during diagnosis and treatment. The first case demonstrates that decoppering therapy may be very effective even with severe neurological symptoms. In addition, we see the importance of family screening, especially among the proband's siblings. Case 2 shows that we must be very careful during diagnosis. In the reported family, WD was diagnosed in the father of the proband although her brother had liver pathology but not caused by WD. Other cases teach us that decoppering therapy with d-penicillamine must be introduced slowly because of the high risk of neurological deterioration, especially in patients with typical WD brain changes even without neurological signs. We also have to consider concomitant therapies in WD patients. Neuroleptics may cause exacerbation and should be used at a low dose and for the shortest period possible. A full consideration for the issues surrounding the diagnosis and treatment of WD can lead to optimised care with reduced risk of progression and disability.
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Affiliation(s)
- Anna Członkowska
- Second Department of Neurology, Institute Psychiatry and Neurology, Warsaw, Poland.,Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
| | | | - Bożena Kłysz
- Second Department of Neurology, Institute Psychiatry and Neurology, Warsaw, Poland
| | | | - Tomasz Litwin
- Second Department of Neurology, Institute Psychiatry and Neurology, Warsaw, Poland
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Shribman S, Warner TT, Dooley JS. Clinical presentations of Wilson disease. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S60. [PMID: 31179297 DOI: 10.21037/atm.2019.04.27] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The main presenting features of Wilson disease, many of which mimic common hepatic and neurologic disorders, are discussed. There is a need for specialists in these and related fields to be aware of hints from within and, more importantly, outside their area of expertise that should alert them to consider the diagnosis. Delayed diagnosis and treatment are potentially damaging for the patient. The importance of recognising and promptly investigating Wilson disease at the initial presentation should be understood by all those who assess patients with hepatic or neurologic disorders and/or train others in their specialty.
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Affiliation(s)
- Samuel Shribman
- Reta Lila Weston Institute of Neurological Studies, UCL Queen Square Institute of Neurology, London, UK
| | - Thomas T Warner
- Reta Lila Weston Institute of Neurological Studies, UCL Queen Square Institute of Neurology, London, UK
| | - James S Dooley
- UCL Institute for Liver and Digestive Health, Division of Medicine, Royal Free Campus, London, UK
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Abstract
Wilson disease (WD) is an autosomal recessively-inherited disorder of copper metabolism and characterised by a pathological accumulation of copper. The ATP7B gene encodes for a transmembrane copper transporter essential for biliary copper excretion. Depending on time of diagnosis, severity of disease can vary widely. Almost all patients show evidence of progressive liver disease. Neurological impairments or psychiatric symptoms are common in WD patients not diagnosed during adolescence. WD is a treatable disorder, and early treatment can prevent the development of symptoms in patients diagnosed while still asymptomatic. This is why the early diagnosis of WD is crucial. The diagnosis is based on clinical symptoms, abnormal measures of copper metabolism and DNA analysis. Available treatment includes chelators and zinc salts which increase copper excretion and reduce copper uptake. In severe cases, liver transplantation is indicated and accomplishes a phenotypic correction of the hepatic gene defect. Recently, clinical development of the new copper modulating agent tetrathiomolybdate has started and direct genetic therapies are being tested in animal models. The following review focuses especially on biochemical markers and how they can be utilised in diagnosis and drug monitoring.
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Wilson Disease Presenting With Acute on Chronic Liver Failure: A Single-Center Experience of Outcome and Predictors of Mortality in 68 Patients. J Clin Exp Hepatol 2019; 9:569-573. [PMID: 31695246 PMCID: PMC6823726 DOI: 10.1016/j.jceh.2019.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 02/06/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIMS Acute on chronic liver failure (ACLF) is an emerging entity whose unique pathogenesis, presentation, and outcome are different from those with decompensated cirrhosis. Patients with Wilson disease (WD) often present with ACLF. The outcome in this setting and predictors of mortality have not been well delineated. We describe the clinical features, laboratory characteristics, and prognostic factors in patients with WD with ACLF. We compared the outcome in those without criteria for ACLF. PATIENTS AND METHODS We analyzed the admission characteristics of 68 patients with WD presenting with features of ACLF among a cohort of WD patients from 1997 to 2017. WD was diagnosed as per European association for the study of the liver (EASL)/Leipzig criteria and ACLF by the Asia-Pacific Association of Study of Liver and World Gastroenterology Organization consensus criteria. Factors associated with mortality were analyzed by univariate followed by multivariate analysis and receiver operating characteristic curve. RESULTS Of the 272 patients with WD, 68 fulfilled criteria for ACLF. The mean age was 14.4 years (Range 5-42 years). Males constituted 38/68 (56%). Acute viral or drug induced hepatitis as precipitating factors was seen in 11.7%. Forty-nine patients (49/67; 73%) died including 30/32 (93.8%) with encephalopathy and 45/62 (72.6%) with ascites. Prognostic factors on univariate analysis significant for mortality included encephalopathy, international normalized ratio, white blood cell count and model for end-stage liver disease (MELD) score. On multivariate analysis, only encephalopathy was significant with 82% accuracy in differentiating survivors versus non-survivors. Post mortem liver biopsy in 21 patients and explant biopsy in 2 patients showed features of cirrhosis in all. CONCLUSIONS WD with ACLF is associated with a high mortality Precipitating factors such as viral and drug-induced hepatitis was seen in 11.7% patients. Liver histology in patients subjected to biopsy showed cirrhosis in all. Only encephalopathy is a prognostic marker of non-survival with an accuracy of 82%.
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Członkowska A, Litwin T, Dusek P, Ferenci P, Lutsenko S, Medici V, Rybakowski JK, Weiss KH, Schilsky ML. Wilson disease. Nat Rev Dis Primers 2018; 4:21. [PMID: 30190489 PMCID: PMC6416051 DOI: 10.1038/s41572-018-0018-3] [Citation(s) in RCA: 417] [Impact Index Per Article: 69.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Wilson disease (WD) is a potentially treatable, inherited disorder of copper metabolism that is characterized by the pathological accumulation of copper. WD is caused by mutations in ATP7B, which encodes a transmembrane copper-transporting ATPase, leading to impaired copper homeostasis and copper overload in the liver, brain and other organs. The clinical course of WD can vary in the type and severity of symptoms, but progressive liver disease is a common feature. Patients can also present with neurological disorders and psychiatric symptoms. WD is diagnosed using diagnostic algorithms that incorporate clinical symptoms and signs, measures of copper metabolism and DNA analysis of ATP7B. Available treatments include chelation therapy and zinc salts, which reverse copper overload by different mechanisms. Additionally, liver transplantation is indicated in selected cases. New agents, such as tetrathiomolybdate salts, are currently being investigated in clinical trials, and genetic therapies are being tested in animal models. With early diagnosis and treatment, the prognosis is good; however, an important issue is diagnosing patients before the onset of serious symptoms. Advances in screening for WD may therefore bring earlier diagnosis and improvements for patients with WD.
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Affiliation(s)
- Anna Członkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland.
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland.
| | - Tomasz Litwin
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Petr Dusek
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Peter Ferenci
- Internal Medicine 3, Department of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Svetlana Lutsenko
- Department of Physiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Valentina Medici
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA
| | - Janusz K Rybakowski
- Department of Adult Psychiatry, Poznań University of Medical Sciences, Poznań, Poland
| | - Karl Heinz Weiss
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael L Schilsky
- Section of Digestive Diseases and Transplantation and Immunology, Department of Medicine and Surgery, Yale University School of Medicine, New Haven, CT, USA
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Litwin T, Dusek P, Szafrański T, Dzieżyc K, Członkowska A, Rybakowski JK. Psychiatric manifestations in Wilson's disease: possibilities and difficulties for treatment. Ther Adv Psychopharmacol 2018; 8:199-211. [PMID: 29977520 PMCID: PMC6022881 DOI: 10.1177/2045125318759461] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/02/2018] [Indexed: 12/14/2022] Open
Abstract
Wilson's disease (WD) is an inherited metabolic disorder related to disturbances of copper metabolism, and predominantly presents with liver and neuropsychiatric symptoms. In most cases it can be successfully treated with anti-copper agents, and both liver function and neuropsychiatric symptoms typically improve. Treatment guidelines for WD include recommendations for anti-copper treatment as well as for the treatment of liver failure symptoms. Recently, recommendations for treatment of the neurological symptoms of WD have also been proposed. Although most WD patients present with psychiatric symptoms at some stage of the disease, currently there are no guidelines for the treatment of the psychiatric manifestations. Treatment of the psychiatric symptoms of WD is often guided by general psychiatric experience, which typically glosses over the specificity of WD, and can result in severe neurological and/or hepatic complications. Here we review and discuss the possible treatments available for the mood disturbances, psychosis, behavioral and cognitive disorders that can occur in WD, as well as their efficacy.
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Affiliation(s)
- Tomasz Litwin
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957 Warsaw, Polandc
| | - Petr Dusek
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Prague, Czech Republic
- Department of Radiology, First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | | | - Karolina Dzieżyc
- Second Department of Neurology, Institute Psychiatry and Neurology, Warsaw, Poland
| | - Anna Członkowska
- Second Department of Neurology, Institute Psychiatry and Neurology, Warsaw, Poland
| | - Janusz K. Rybakowski
- Department of Adult Psychiatry, Poznan University of Medical Sciences, Poznan, Poland
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