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Pilotte J, Huang AS, Khoury S, Zhang X, Tafreshi A, Vanderklish P, Sarraf ST, Pulido JS, Milman T. Detection of TTR Amyloid in the Conjunctiva Using a Novel Fluorescent Ocular Tracer. Transl Vis Sci Technol 2024; 13:11. [PMID: 38359019 PMCID: PMC10876017 DOI: 10.1167/tvst.13.2.11] [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: 08/15/2023] [Accepted: 12/15/2023] [Indexed: 02/17/2024] Open
Abstract
Background Transthyretin amyloidosis (ATTR) is a significant cause of cardiomyopathy and other morbidities in the elderly and Black Americans. ATTR can be treated with new disease-modifying therapies, but large shortfalls exist in its diagnosis. The objective of this study was to test whether TTR amyloid can be detected and imaged in the conjunctiva using a novel small-molecule fluorescent ocular tracer, with the implication that ATTR might be diagnosable by a simple eye examination. Methods Three approaches were used in this study. First, AMDX-9101 was incubated with in vitro aggregated TTR protein, and changes in its excitation and emission spectra were quantified. Second, a cadaver eye from a patient with familial amyloid polyneuropathy type II TTR mutation and a vitrectomy sample from an hATTR patient were incubated with AMDX-9101 and counterstained with Congo Red and antibodies to TTR to determine whether AMDX-9101 labels disease-related TTR amyloid deposits in human conjunctiva and eye. Last, imaging of in vitro aggregated TTR amyloid labeled with AMDX-9101 was tested in a porcine ex vivo model, using a widely available clinical ophthalmic imaging device. Results AMDX-9101 hyper-fluoresced in the presence of TTR amyloid in vitro, labeled TTR amyloid deposits in postmortem human conjunctiva and other ocular tissues and could be detected under the conjunctiva of a porcine eye using commercially available ophthalmic imaging equipment. Conclusions AMDX-9101 enabled detection of TTR amyloid in the conjunctiva, and the fluorescent binding signal can be visualized using commercially available ophthalmic imaging equipment. Translational Relevance AMDX-9101 detection of TTR amyloid may provide a potential new and noninvasive test for ATTR that could lead to earlier ATTR diagnosis, as well as facilitate development of new therapeutics.
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Affiliation(s)
| | - Alex S. Huang
- Hamilton Glaucoma Center, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, CA, USA
| | | | - Xiaowei Zhang
- Hamilton Glaucoma Center, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, CA, USA
| | | | | | | | - Jose S. Pulido
- Vickie and Jack Farber Vision Research Center and MidAtlantic Retina Service, Wills Eye Hospital, Philadelphia, PA, USA
| | - Tatyana Milman
- Vickie and Jack Farber Vision Research Center and MidAtlantic Retina Service, Wills Eye Hospital, Philadelphia, PA, USA
- Pathology Department, Wills Eye Hospital, Philadelphia, PA, USA
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Razvi Y, Ioannou A, Patel RK, Chacko L, Karia N, Riefolo M, Porcari A, Rauf MU, Starr N, Ganesananthan S, Blakeney I, Kaza N, Filisetti S, Bolhuis RE, Rowczenio D, Gilbertson J, Hutt D, Mahmood S, Lachmann HJ, Wechalekar AD, Kotecha T, Knight DS, Coghlan JG, Petrie A, Whelan CJ, Venneri L, Martinez-Naharro A, Hawkins P, Fontana M, Gillmore JD. Deep phenotyping of p.(V142I)-associated variant transthyretin amyloid cardiomyopathy: Distinct from wild-type transthyretin amyloidosis? Eur J Heart Fail 2024; 26:383-393. [PMID: 37953725 DOI: 10.1002/ejhf.3088] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/26/2023] [Accepted: 11/09/2023] [Indexed: 11/14/2023] Open
Abstract
AIMS Transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly recognized cause of heart failure. A total of 3-4% of individuals of African descent carry a TTR gene mutation encoding the p.(V142I) variant, a powerful risk factor for development of variant ATTR-CM (ATTRv-CM); this equates to 1.6 million carriers in the United States. We undertook deep phenotyping of p.(V142I)-ATTRv-CM and comparison with wild-type ATTR-CM (ATTRwt-CM). METHODS AND RESULTS A retrospective study of 413 patients with p.(V142I) ATTRv-CM who attended the UK National Amyloidosis Centre (NAC) was conducted. Patients underwent evaluation at time of diagnosis, including clinical, echocardiography, and biomarker analysis; a subgroup had cardiac magnetic resonance (CMR) imaging. A total of 413 patients with ATTRwt-CM, matched for independent predictors of prognosis (age, NAC Stage, decade of first presentation), were used as a comparator group. At time of diagnosis, patients with ATTRv-CM had significant functional impairment by New York Heart Association classification (NHYA class ≥ III; 38%) and 6-min walk test distance (median 276 m). Median 5-year survival in ATTRv-CM patients was 31 versus 59 months in matched patients with ATTRwt-CM (p < 0.001). Patients with ATTRv-CM had significant impairment of functional parameters by echocardiography including biventricular impairment, high burden of regurgitant valvular disease and low cardiac output. Multivariable analysis revealed the prognostic importance of right ventricular dysfunction. CMR and histological analysis revealed myocyte atrophy and widespread myocardial infiltration in ATTRv-CM. CONCLUSION p.(V142I)-ATTRv-CM has an aggressive phenotype characterized by myocyte loss and widespread myocardial infiltration which may account for frequent biventricular failure and poor prognosis in this ATTR-CM genotypic subgroup.
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Affiliation(s)
- Yousuf Razvi
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Adam Ioannou
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Rishi K Patel
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Liza Chacko
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | | | - Mattia Riefolo
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Muhammad Umaid Rauf
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Neasa Starr
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | | | - Iona Blakeney
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | | | - Stefano Filisetti
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Roos Eline Bolhuis
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Dorota Rowczenio
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Janet Gilbertson
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - David Hutt
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Helen J Lachmann
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | | | | | | | - Aviva Petrie
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Carol J Whelan
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Lucia Venneri
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Phillip Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
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Skrahina V, Grittner U, Beetz C, Skripuletz T, Juenemann M, Krämer HH, Hahn K, Rieth A, Schaechinger V, Patten M, Tanislav C, Achenbach S, Assmus B, Knebel F, Gingele S, Skrahin A, Hartkamp J, Förster TM, Roesner S, Pereira C, Rolfs A. Hereditary transthyretin-related amyloidosis is frequent in polyneuropathy and cardiomyopathy of no obvious aetiology. Ann Med 2021; 53:1787-1796. [PMID: 34658264 PMCID: PMC8525987 DOI: 10.1080/07853890.2021.1988696] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 09/28/2021] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Hereditary Transthyretin-Related Amyloidosis, a clinically heterogeneous autosomal dominant disease caused by pathogenic variants in the TTR gene, is characterized by the deposition of insoluble misfolded protein fibrils. The diagnosis, especially in non-endemic areas, is typically delayed by 4-5 years; a misdiagnosis due to clinical heterogeneity is common. The study objective was to define the prevalence of Hereditary Transthyretin-Related Amyloidosis in patients with polyneuropathy and/or cardiomyopathy of no obvious aetiology. METHOD A multicenter observational "Epidemiological analysis for the hereditary Transthyretin-Related AMyloidosis"-TRAM study was performed in Germany, Austria, and Switzerland. RESULTS A total of 5141 participants were recruited by 50 neurologic and 27 cardiologic specialized centres. Genetic analysis demonstrated a 1.1% Hereditary Transthyretin-Related Amyloidosis positivity rate among patients with polyneuropathy and/or cardiomyopathy of not obvious aetiology. Twenty-one various TTR variants (TTR-positive) were identified. Body Mass Index was lower in the TTR-positive patients as an indicator for the involvement of the autonomic nervous system; the age of onset of clinical manifestations was higher in TTR-positive patients. There were no other genotype-phenotype correlations or the prevalence of specific clinical manifestations in TTR-positive patients. CONCLUSIONS Our data support the fact that Hereditary Transthyretin-Related Amyloidosis is underdiagnosed in polyneuropathy and cardiomyopathy patients. Routine implementation of genetic testing is recommended in patients with unexplained polyneuropathy and/or cardiomyopathy to accelerate the earlier diagnosis and the time-sensitive treatment initiation.KEY MESSAGESMore than 5.000 participants with CM and/or PNP of no obvious aetiology were recruited in the observational "Epidemiological analysis for the hereditary Transthyretin-Related AMyloidosis" TRAM study and screened for pathogenic TTR variants.The study demonstrated >1% of patients with CM and/or PNP of unclear aetiology are positive for a pathogenic TTR variant.Routine genetic testing is recommended in patients with unexplained CM and/or PNP to accelerate the initial diagnosis and timely treatment initiation.
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Affiliation(s)
| | - Ulrike Grittner
- CENTOGENE GmbH, Rostock, Germany
- Institute of Biometry and Clinical Epidemiology, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | | | | | - Martin Juenemann
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Heidrun H. Krämer
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Katrin Hahn
- Department of Neurology, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Rieth
- Department of Cardiology, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | | | - Monica Patten
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
| | - Christian Tanislav
- Department of Neurology, Evangelisches Jung Stilling Krankenhaus GmbH, Siegen, Germany
| | - Stephan Achenbach
- Department of Cardiology, Erlangen University Hospital, Erlangen, Germany
| | - Birgit Assmus
- Division of Cardiology and Angiology, University Hospital Giessen and Marburg, Giessen, Germany
| | - Fabian Knebel
- Berlin Institute of Health, Berlin, Germany
- Medizinische Klinik mit Schwerpunkt Kardiologie und Angiologie, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research, Berlin, Germany
| | - Stefan Gingele
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | | | | | | | | | - Arndt Rolfs
- CENTOGENE GmbH, Rostock, Germany
- University Medicine, University Rostock, Rostock, Germany
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Cioffi CL, Muthuraman P, Raja A, Varadi A, Racz B, Petrukhin K. Discovery of Bispecific Antagonists of Retinol Binding Protein 4 That Stabilize Transthyretin Tetramers: Scaffolding Hopping, Optimization, and Preclinical Pharmacological Evaluation as a Potential Therapy for Two Common Age-Related Comorbidities. J Med Chem 2020; 63:11054-11084. [DOI: 10.1021/acs.jmedchem.0c00996] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Christopher L. Cioffi
- Departments of Basic and Clinical Sciences and Pharmaceutical Sciences, Albany College of Pharmacy and Health Sciences, 106 New Scotland Avenue, Albany, New York 12208, United States
| | - Parthasarathy Muthuraman
- Departments of Basic and Clinical Sciences and Pharmaceutical Sciences, Albany College of Pharmacy and Health Sciences, 106 New Scotland Avenue, Albany, New York 12208, United States
| | - Arun Raja
- Departments of Basic and Clinical Sciences and Pharmaceutical Sciences, Albany College of Pharmacy and Health Sciences, 106 New Scotland Avenue, Albany, New York 12208, United States
| | - Andras Varadi
- Department of Ophthalmology, Columbia University Medical Center, New York, New York 10032, United States
| | - Boglarka Racz
- Department of Ophthalmology, Columbia University Medical Center, New York, New York 10032, United States
| | - Konstantin Petrukhin
- Department of Ophthalmology, Columbia University Medical Center, New York, New York 10032, United States
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Miller M, Pal A, Albusairi W, Joo H, Pappas B, Haque Tuhin MT, Liang D, Jampala R, Liu F, Khan J, Faaij M, Park M, Chan W, Graef I, Zamboni R, Kumar N, Fox J, Sinha U, Alhamadsheh M. Enthalpy-Driven Stabilization of Transthyretin by AG10 Mimics a Naturally Occurring Genetic Variant That Protects from Transthyretin Amyloidosis. J Med Chem 2018; 61:7862-7876. [PMID: 30133284 DOI: 10.1021/acs.jmedchem.8b00817] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Transthyretin (TTR) amyloid cardiomyopathy (ATTR-CM) is a fatal disease with no available disease-modifying therapies. While pathogenic TTR mutations (TTRm) destabilize TTR tetramers, the T119M variant stabilizes TTRm and prevents disease. A comparison of potency for leading TTR stabilizers in clinic and structural features important for effective TTR stabilization is lacking. Here, we found that molecular interactions reflected in better binding enthalpy may be critical for development of TTR stabilizers with improved potency and selectivity. Our studies provide mechanistic insights into the unique binding mode of the TTR stabilizer, AG10, which could be attributed to mimicking the stabilizing T119M variant. Because of the lack of animal models for ATTR-CM, we developed an in vivo system in dogs which proved appropriate for assessing the pharmacokinetics-pharmacodynamics profile of TTR stabilizers. In addition to stabilizing TTR, we hypothesize that optimizing the binding enthalpy could have implications for designing therapeutic agents for other amyloid diseases.
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Affiliation(s)
- Mark Miller
- Department of Pharmaceutics & Medicinal Chemistry , University of the Pacific , Stockton , California 95211 , United States
| | - Arindom Pal
- Department of Pharmaceutics & Medicinal Chemistry , University of the Pacific , Stockton , California 95211 , United States
| | - Wabel Albusairi
- Department of Pharmaceutics & Medicinal Chemistry , University of the Pacific , Stockton , California 95211 , United States
| | - Hyun Joo
- Department of Pharmaceutics & Medicinal Chemistry , University of the Pacific , Stockton , California 95211 , United States
| | - Beverly Pappas
- Department of Pharmaceutics & Medicinal Chemistry , University of the Pacific , Stockton , California 95211 , United States
| | - Md Tariqul Haque Tuhin
- Department of Pharmaceutics & Medicinal Chemistry , University of the Pacific , Stockton , California 95211 , United States
| | - Dengpan Liang
- Department of Pharmaceutics & Medicinal Chemistry , University of the Pacific , Stockton , California 95211 , United States
| | - Raghavendra Jampala
- Department of Pharmaceutics & Medicinal Chemistry , University of the Pacific , Stockton , California 95211 , United States
| | - Fang Liu
- Department of Pharmaceutics & Medicinal Chemistry , University of the Pacific , Stockton , California 95211 , United States
| | - Jared Khan
- Department of Pharmaceutics & Medicinal Chemistry , University of the Pacific , Stockton , California 95211 , United States
| | - Marjon Faaij
- Department of Pharmaceutics & Medicinal Chemistry , University of the Pacific , Stockton , California 95211 , United States
| | - Miki Park
- Department of Pharmaceutics & Medicinal Chemistry , University of the Pacific , Stockton , California 95211 , United States
| | - William Chan
- Department of Pharmaceutics & Medicinal Chemistry , University of the Pacific , Stockton , California 95211 , United States
| | - Isabella Graef
- Department of Pathology , Stanford University , Stanford , California 94305 , United States
| | - Robert Zamboni
- Eidos Therapeutics, Inc. , San Francisco , California 94101 , United States
| | - Neil Kumar
- Eidos Therapeutics, Inc. , San Francisco , California 94101 , United States
| | - Jonathan Fox
- Eidos Therapeutics, Inc. , San Francisco , California 94101 , United States
| | - Uma Sinha
- Eidos Therapeutics, Inc. , San Francisco , California 94101 , United States
| | - Mamoun Alhamadsheh
- Department of Pharmaceutics & Medicinal Chemistry , University of the Pacific , Stockton , California 95211 , United States
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