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Dasgupta NR. Care of Patients With Transthyretin Amyloidosis: the Roles of Nutrition, Supplements, Exercise, and Mental Health. Am J Cardiol 2022; 185 Suppl 1:S35-S42. [PMID: 36549789 DOI: 10.1016/j.amjcard.2022.10.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 12/24/2022]
Abstract
Transthyretin (ATTR) amyloidosis is a debilitating disease that results in organ failure and eventual death. As the disease progresses, patients experience neurologic, gastrointestinal, and cardiovascular symptoms that increasingly compromise their nutritional status and exercise capacity. These symptoms cause considerable emotional stress and mental health challenges for patients and caregivers. This review summarizes common symptoms and mechanisms associated with malnutrition and exercise intolerance, and sources of emotional stress, and offers therapeutic strategies to address these issues. Although earlier diagnosis and disease-specific treatment are central to caring for patients with ATTR amyloidosis, additional attention to symptom-focused treatments to improve nutritional status, maintain exercise tolerance and capacity, and improve and maintain mental health are also important. In conclusion, a team-based approach involving multiple clinicians and providers can offer more comprehensive and coordinated care, support, and education for patients and caregivers.
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Affiliation(s)
- Noel R Dasgupta
- Department of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana.
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Kamperidis N, Nightingale J. Neurological disorders and small bowel dysmotility. Curr Opin Gastroenterol 2022; 38:299-306. [PMID: 35645022 DOI: 10.1097/mog.0000000000000836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Small bowel dysmotility is common in the context of neurological disorders. Overlooking it can have an adverse impact on patient's quality of life and neurological outcomes. This review focuses on describing the mechanisms and effects of enteric dysmotility in neurological patients and providing treatment options. RECENT FINDINGS Small bowel dysmotility is prevalent among neurological patients. The definition and diagnosis of small bowel dysmotility is a challenge; however, up to two-thirds of neurological patients may experience associated symptoms. Small bowel dysmotility can affect the absorption of nutrients and medication, impacts on social and professional function and can result in malnutrition and its associated morbidity and mortality. SUMMARY Small bowel dysmotility due to a neuropathy can result from acute or chronic disorders in the central and peripheral nervous system and includes the cerebral cortex, brain stem, spinal cord, parasympathetic (vagus) and sympathetic nerves and the myenteric and submucosal plexuses of the intestine. Generalized muscle disorders can also cause an enteral myopathy. Generally, the disorders may be degenerative or inflammatory. Both enteric neuropathy and myopathy may cause symptoms of abdominal pain, nausea/vomiting, bloating, constipation or diarrhoea and can cause malnutrition. The symptoms need to be addressed in order of importance to the patient and malnutrition prevented or treated.
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Modified Body Mass Index as a Novel Nutritional and Prognostic Marker in Patients with Cardiac Amyloidosis. CARDIOGENETICS 2022. [DOI: 10.3390/cardiogenetics12020017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The nutritional assessment is gaining clinical relevance since cardiac cachexia and malnutrition are emerging as novel markers of functional status and prognosis in many cardiovascular disorders, including cardiac amyloidosis (CA). This study aimed to evaluate the prognostic role of different nutritional indices for cardiovascular mortality in patients with CA and subgroups. Fifty CA patients (26 AL and 24 ATTR wild-type) were retrospectively analyzed. All patients underwent a comprehensive clinical and laboratory evaluation. Conventional body mass index (cBMI), modified BMI (mBMI), new BMI (nBMI) and prognostic nutritional index (PNI) were analyzed. Multivariate regression analysis was performed to identify the association between nutritional and other clinical-laboratory parameters with cardiovascular death. Compared to ATTRwt patients, those with AL showed lower mBMI values. No significant difference was observed for the other nutritional indices. During a median follow-up of 11.2 months, a lower mBMI quartile was associated with worse survival, in both groups. In multivariate analysis, mBMI emerged as an independent predictor for cardiovascular death. This study showed that mBMI is a novel index of malnutrition and an independent risk factor for cardiovascular mortality in patients with CA in both AL and ATTRwt form.
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Nakov R, Suhr OB, Ianiro G, Kupcinskas J, Segal JP, Dumitrascu DL, Heinrich H, Mikolasevic I, Stojkovic-Lalosevic M, Barbov I, Sarafov S, Tournev I, Nakov V, Wixner J. Recommendations for the diagnosis and management of transthyretin amyloidosis with gastrointestinal manifestations. Eur J Gastroenterol Hepatol 2021; 33:613-622. [PMID: 33394808 DOI: 10.1097/meg.0000000000002030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Transthyretin amyloid (ATTR) amyloidosis is an adult-onset, rare systemic disorder characterized by the accumulation of misfolded fibrils in the body, including the peripheral nerves, the heart and the gastrointestinal tract. Gastrointestinal manifestations are common in hereditary (ATTRv) amyloidosis and are present even before the onset of the polyneuropathy in some cases. Delays in diagnosis of ATTRv amyloidosis with gastrointestinal manifestations commonly occur because of fragmented knowledge among gastroenterologists and general practitioners, as well as a shortage of centers of excellence and specialists dedicated to disease management. Although the disease is becoming well-recognized in the societies of Neurology and Cardiology, it is still unknown for most gastroenterologists. This review presents the recommendations for ATTRv amyloidosis with gastrointestinal manifestations elaborated by a working group of European gastroenterologists and neurologists, and aims to provide digestive health specialists with an overview of crucial aspects of ATTRv amyloidosis diagnosis to help facilitate rapid and accurate identification of the disease by focusing on disease presentation, misdiagnosis and management of gastrointestinal symptoms.
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Affiliation(s)
- Radislav Nakov
- Department of Gastroenterology, Clinic of Gastroenterology, Tsaritsa Joanna University Hospital, Medical University of Sofia, Sofia, Bulgaria
| | - Ole B Suhr
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Gianluca Ianiro
- Department of Gastroenterology, Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Juozas Kupcinskas
- Department of Gastroenterology and Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jonathon P Segal
- Department of Gastroenterology and Hepatology, St Mary's Hospital, London, UK
| | - Dan L Dumitrascu
- Second Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Henriette Heinrich
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | | | | | - Ivan Barbov
- Department of Neurology, University Clinic for Neurology, Skopje, Republic of North Macedonia
| | - Stayko Sarafov
- Department of Neurology, Expert Center for Hereditary Neurological and Metabolic Disorders, ATTR Amyloidosis Expert Center, Clinic of Nervous Diseases, Alexandrovska University Hospital, Medical University of Sofia
| | - Ivailo Tournev
- Department of Neurology, Expert Center for Hereditary Neurological and Metabolic Disorders, ATTR Amyloidosis Expert Center, Clinic of Nervous Diseases, Alexandrovska University Hospital, Medical University of Sofia
- Department of Cognitive Science and Psychology, New Bulgarian University, Sofia, Bulgaria
| | - Ventsislav Nakov
- Department of Gastroenterology, Clinic of Gastroenterology, Tsaritsa Joanna University Hospital, Medical University of Sofia, Sofia, Bulgaria
| | - Jonas Wixner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Abstract
The extrinsic and autonomic nervous system intricately controls the major functions of the gastrointestinal tract through the enteric nervous system; these include motor, secretory, sensory, storage, and excretory functions. Disorders of the nervous system affecting gastrointestinal tract function manifest primarily as abnormalities in motor (rather than secretory) functions. Common gastrointestinal symptoms in neurologic disorders include sialorrhea, dysphagia, gastroparesis, intestinal pseudo-obstruction, constipation, diarrhea, and fecal incontinence. Diseases of the entire neural axis ranging from the cerebral hemispheres to the peripheral autonomic nerves can result in gastrointestinal motility disorders. The most common neurologic diseases affecting gastrointestinal function are stroke, parkinsonism, multiple sclerosis, and diabetic neuropathy. Diagnosis involves identification of the neurologic disease and its distribution, and documentation of segmental gut dysfunction, typically using noninvasive imaging, transit measurements, or intraluminal measurements of pressure activity and coordination of motility. Apart from treatment of the underlying neurologic disease, management focuses on restoration of normal hydration and nutrition and pharmacologic treatment of the gut neuromuscular disorder.
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Shamsi BH, Chatoo M, Xu XK, Xu X, Chen XQ. Versatile Functions of Somatostatin and Somatostatin Receptors in the Gastrointestinal System. Front Endocrinol (Lausanne) 2021; 12:652363. [PMID: 33796080 PMCID: PMC8009181 DOI: 10.3389/fendo.2021.652363] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/19/2021] [Indexed: 01/03/2023] Open
Abstract
Somatostatin (SST) and somatostatin receptors (SSTRs) play an important role in the brain and gastrointestinal (GI) system. SST is produced in various organs and cells, and the inhibitory function of somatostatin-containing cells is involved in a range of physiological functions and pathological modifications. The GI system is the largest endocrine organ for digestion and absorption, SST-endocrine cells and neurons in the GI system are a critical effecter to maintain homeostasis via SSTRs 1-5 and co-receptors, while SST-SSTRs are involved in chemo-sensory, mucus, and hormone secretion, motility, inflammation response, itch, and pain via the autocrine, paracrine, endocrine, and exoendocrine pathways. It is also a power inhibitor for tumor cell proliferation, severe inflammation, and post-operation complications, and is a first-line anti-cancer drug in clinical practice. This mini review focuses on the current function of producing SST endocrine cells and local neurons SST-SSTRs in the GI system, discusses new development prognostic markers, phosphate-specific antibodies, and molecular imaging emerging in diagnostics and therapy, and summarizes the mechanism of the SST family in basic research and clinical practice. Understanding of endocrines and neuroendocrines in SST-SSTRs in GI will provide an insight into advanced medicine in basic and clinical research.
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Affiliation(s)
- Bilal Haider Shamsi
- Department of Neurobiology, Department of Neurology of the Second Affiliated Hospital, School of Brain Science and Brain Medicine, Hangzhou, China
| | - Mahanand Chatoo
- Department of Neurobiology, Department of Neurology of the Second Affiliated Hospital, School of Brain Science and Brain Medicine, Hangzhou, China
| | - Xiao Kang Xu
- Department of Neurobiology, Department of Neurology of the Second Affiliated Hospital, School of Brain Science and Brain Medicine, Hangzhou, China
| | - Xun Xu
- College of Renji, Wenzhou Medical University, Wenzhou, China
| | - Xue Qun Chen
- Department of Neurobiology, Department of Neurology of the Second Affiliated Hospital, School of Brain Science and Brain Medicine, Hangzhou, China
- National Health Commission (NHC) and Chinese Academy of Medical Sciences (CAMS) Key Laboratory of Medical Neurobiology, Ministry of Education (MOE), Frontier Science Center for Brain Research and Brain Machine Integration, School of Brain Science and Brain Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Xue Qun Chen,
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Nakov R, Sarafov S, Nakov V, Gospodinova M, Tournev I. Fecal calprotectin concentrations in patients with hereditary transthyretin amyloidosis and gastrointestinal symptoms. Eur J Gastroenterol Hepatol 2020; 32:664. [PMID: 32251206 DOI: 10.1097/meg.0000000000001655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Radislav Nakov
- Clinic of Gastroenterology, Tsaritsa Yoanna University Hospital, Medical University of Sofia
| | - Stayko Sarafov
- Clinic of Nervous Diseases, Alexandrovska University Hospital, Medical University of Sofia
| | - Ventsislav Nakov
- Clinic of Gastroenterology, Tsaritsa Yoanna University Hospital, Medical University of Sofia
| | | | - Ivailo Tournev
- Clinic of Gastroenterology, Tsaritsa Yoanna University Hospital, Medical University of Sofia.,Department of Cognitive Science and Psychology, New Bulgarian University, Sofia, Bulgaria
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Schwartzlow C, Kazamel M. Hereditary Transthyretin Amyloidosis: Clinical Presentation and Management Updates. J Clin Neuromuscul Dis 2020; 21:144-156. [PMID: 32073460 DOI: 10.1097/cnd.0000000000000270] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Hereditary transthyretin amyloidosis, once a rare progressive neuropathy and/or cardiomyopathy, is now recognized with increasing worldwide frequency, various phenotypes, and over 130 gene mutations identified to date. This inherited disorder develops as a result of mutated transthyretin amyloid aggregation and systematic deposition throughout the body. With increasing knowledge about the pathophysiology of this disease, new disease-modifying therapies are being developed. In addition to slowing progression, these new agents were found to improve quality of life and reduce the severity of neuropathic symptoms. Two new gene-modifying therapies recently received Food and Drug Administration approval following the positive results from phase III trials. These include an antisense oligonucleotide, inotersen, and small interfering RNA, patisiran, which were reported to reduce the production of transthyretin and had promising safety profiles. Additional novel therapies are being explored with hopes to prolong survival. Therefore, early diagnosis of this treatable disorder has become increasingly important in clinical practice.
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Affiliation(s)
- Coreen Schwartzlow
- Department of Neurology, The University of Alabama at Birmingham, Birmingham, AL
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Nakov R, Sarafov S, Nakov V, Gospodinova M, Ianiro G, Todorov T, Todorova A, Tournev I. Fecal calprotectin levels are elevated in transthyretin amyloidosis patients with gastrointestinal manifestations. Medicine (Baltimore) 2020; 99:e19509. [PMID: 32176096 PMCID: PMC7440347 DOI: 10.1097/md.0000000000019509] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Transthyretin amyloid (ATTR) amyloidosis is a rare systemic disorder characterized by amyloid deposits formed by misfolded monomers of the transthyretin. Gastrointestinal (GI) manifestations are common in ATTR amyloidosis; however, their pathogenesis is not fully elucidated. In the present study, we aim to evaluate the diagnostic role of fecal calprotectin (FC) in ATTR amyloidosis patients with GI manifestations.We recruited 21 consecutive ATTR amyloidosis patients and 42 sex and age-matched healthy controls. The presentation of GI symptoms and the severity of peripheral neuropathy were evaluated. Colonoscopy and FC assessment were performed in all subjects.Mean levels of FC in ATTR amyloidosis patients (184 μg/g [30-430]) were significantly higher thаn those of controls (40 μg/g [30-70]), P < .001. Receiver operating characteristic curve analysis indicated a FC cut-off level of 71 μg/g, which differentiates ATTR amyloidosis with GI manifestations from healthy subjects with 91% sensitivity, 100% specificity, 100% positive predictive value, 95% negative predictive value and 97% overall accuracy. FC values were significantly associated with the presence of neutrophilic granulocytic infiltration in the colonic mucosa (P = .002), with the presence of amyloid deposits in rectal mucosa (P = .007) and the presence of diarrhea (P = .046).FC levels are elevated in patients with ATTR amyloidosis with GI manifestations, which suggests an inflammatory component in the pathogenesis of the disease. The presence of elevated FC concentrations could help gastroenterologists to include ATTR amyloidosis in their diagnostic work-up.
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Affiliation(s)
- Radislav Nakov
- Clinic of Gastroenterology, Tsaritsa Yoanna University Hospital
| | - Stayko Sarafov
- Clinic of Nervous Diseases, Alexandrovska University Hospital, Medical University, Sofia, Bulgaria
| | | | - Mariana Gospodinova
- Clinic of Cardiology, Medical Institute of Ministry of Interior, Sofia, Bulgaria
| | - Gianluca Ianiro
- Digestive Disease Center, Gastroenterology and Oncology Area, IRCCS Fondazione Policlinico Universitario “A. Gemelli”, Rome, Italy
| | - Tihomir Todorov
- Genetic and Medico-diagnostic Laboratory “Genica”, Sofia, Bulgaria
| | - Albena Todorova
- Genetic and Medico-diagnostic Laboratory “Genica”, Sofia, Bulgaria
- Department of Medical Chemistry and Biochemistry, Medical University
| | - Ivailo Tournev
- Clinic of Nervous Diseases, Alexandrovska University Hospital, Medical University, Sofia, Bulgaria
- Department of Cognitive Science and Psychology, New Bulgarian University, Sofia, Bulgaria
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Gertz MA, Mauermann ML, Grogan M, Coelho T. Advances in the treatment of hereditary transthyretin amyloidosis: A review. Brain Behav 2019; 9:e01371. [PMID: 31368669 PMCID: PMC6749475 DOI: 10.1002/brb3.1371] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/01/2019] [Accepted: 07/03/2019] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Amyloid transthyretin amyloidosis (ATTR) is a progressive and often fatal disease caused by the buildup of mutated (hereditary ATTR [hATTR]; also known as ATTR variant [ATTRv]) or normal transthyretin (wild-type ATTR) throughout the body. Two new therapies-inotersen, an antisense oligonucleotide therapy, and patisiran, an RNA interference therapy-received marketing authorization and represent a significant advance in the treatment of amyloidosis. Herein, we describe the clinical presentation of ATTR, commonly used procedures in its diagnosis, and current treatment landscape for ATTR, with a focus on hATTR. METHODS A PubMed search from 2008 to September 2018 was conducted to review the literature on ATTR. RESULTS Until recently, there have been few treatment options for polyneuropathy of hATTR. Inotersen and patisiran substantially reduce the amyloidogenic precursor protein transthyretin and have demonstrated efficacy in patients with early- and late-stage disease and in slowing or improving neuropathy progression. In contrast, established therapies, such as liver transplantation, typically reserved for patients with early-stage disease, and tafamidis, indicated for the treatment of early-stage disease in Europe, or diflunisal, a nonsteroidal anti-inflammatory drug that is used off-label, are associated with side effects and/or unclear efficacy in certain patient populations. Thus, inotersen and patisiran are positioned to be the preferred therapeutic modalities. CONCLUSIONS Important differences between inotersen and patisiran, including formulation, dosing, requirements for premedications, and safety monitoring, require an understanding and knowledge of each treatment for informed decision making.
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Affiliation(s)
| | | | | | - Teresa Coelho
- Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
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Obici L, Suhr OB. Diagnosis and treatment of gastrointestinal dysfunction in hereditary TTR amyloidosis. Clin Auton Res 2019; 29:55-63. [PMID: 31452022 PMCID: PMC6763516 DOI: 10.1007/s10286-019-00628-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 08/02/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE To review the management of gastrointestinal symptoms in patients with hereditary transthyretin amyloidosis, discussing diagnostic evaluations, assessment of disease progression and therapeutic strategies that could be implemented in routine practice. METHODS Literature review. Key search terms included "gastrointestinal symptoms", "autonomic neuropathy", "hereditary transthyretin amyloidosis" and "familial amyloid polyneuropathy". RESULTS Gastrointestinal disturbances are a common and serious manifestation of hereditary transthyretin amyloidosis, with significant effects on patients' quality of life and demonstrating a strong association with mortality. Gastrointestinal involvement is more often subclinical in the early stages of the disease, although in some patients gastric and/or bowel abnormalities may be the inaugural symptoms. In both cases, under-recognition, delayed investigation and suboptimal treatment frequently occur. A clear understanding of the mechanisms underlying gastrointestinal dysfunction in hereditary transthyretin amyloidosis is still lacking, but similar to diabetic enteropathy, multiple pathophysiological alterations seem to play a role. CONCLUSIONS Early detection and treatment of gastrointestinal disturbances is key to the successful treatment of this devastating disease. Gastroenterologists play a valuable role in both the diagnosis and the timely management of gastrointestinal symptoms in hereditary transthyretin amyloidosis and should, therefore, be part of a multidisciplinary and comprehensive approach to this disorder.
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Affiliation(s)
- Laura Obici
- Amyloidosis Research and Treatment Centre, Fondazione IRCCS Policlinico San Matteo, Viale Golgi, 19, 27100, Pavia, Italy.
| | - Ole B Suhr
- Department of Medicine, Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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