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Hwu WL. Deciphering the diagnostic dilemma: A comprehensive review of the Taiwanese cardiac variant in Fabry disease. J Formos Med Assoc 2024; 123:738-743. [PMID: 37833114 DOI: 10.1016/j.jfma.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/21/2023] [Accepted: 10/01/2023] [Indexed: 10/15/2023] Open
Abstract
Molecular diagnosis has undergone rapid and significant advancements in recent years. But because molecular diagnosis can be conducted independently of phenotype, it can engender ambiguity and potential misinterpretations in disease diagnosis. Fabry disease, an X-linked lysosomal storage disorder, arises from a deficiency in α-galactosidase A. In 2002, Ishii and colleagues uncovered a variant (IVS4+919G > A) deep within intron 4 of the GLA gene that could lead to aberrant splicing of the GLA mRNA. This variant is present in 1:875 males in Taiwan, and many patients with hypertrophic cardiomyopathy and the IVS4+919G > A variant are currently treated by enzyme replacement therapy, an expensive treatment. Unfortunately, till now only one article published in 2013 described the outcome of treatment. This review summarized the conflicting evidence about the clinical relevance of the IVS4+919G > A variant, and suggest a multifactorial model, rather than a monogenic model, for the involvement of the IVS4+919G > A variant in hypertrophic cardiomyopathy. The diagnostic dilemma for this Taiwanese cardiac variant in Fabry disease clearly emphasizes the need for precise interpretation and application of molecular diagnostic results.
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Affiliation(s)
- Wuh-Liang Hwu
- Department of Pediatrics and Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan.
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2
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Boutin M, Maranda B, Waters PJ. Analysis of Globotriaosylceramide (Gb 3) in Liquid Urine: A Straightforward Assay Using Tandem Mass Spectrometry. Curr Protoc 2024; 4:e1087. [PMID: 38896100 DOI: 10.1002/cpz1.1087] [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] [Indexed: 06/21/2024]
Abstract
Fabry disease (FD) is a lysosomal storage disorder caused by variants in the GLA gene encoding α-galactosidase A, an enzyme required for catabolism of globotriaosylceramide (Gb3). Accumulation of Gb3 in patients' cells, tissues, and biological fluids causes clinical manifestations including ventricular hypertrophy, renal insufficiency, and strokes. This protocol describes a methodology to analyze urinary Gb3 and creatinine. Samples are diluted with an internal standard solution containing Gb3(C17:0) and creatinine-D3, centrifuged, and directly analyzed by ultra-high performance liquid chromatography coupled to tandem mass spectrometry (UHPLC-MS/MS) using an 8.7-min method. Eight Gb3 isoforms [C16:0, C18:0, C20:0, C22:1, C22:0, C24:1, C24:0, and (C24:0)OH] are analyzed and the total is normalized to creatinine. Confirmation ions are monitored to detect potential interferences. The Gb3 limit of quantification is 0.023 µg/ml. Its interday coefficients of variation (3 concentrations measured) are ≤15.4%. This method minimizes matrix effects (≤6.5%) and prevents adsorption or precipitation of Gb3. Urine samples are stable (bias <15%) for 2 days at 21°C, 7 days at 4°C, and 4 freeze/thaw cycles, whereas prepared samples are stable for 5 days at 21°C, and 14 days at 4°C. The Gb3/creatinine age-related upper reference limits (mean + 2 standard deviations) are 29 mg/mol creatinine (<7 years) and 14 mg/mol creatinine (≥7 years). This simple, robust protocol has been fully validated (ISO 15189) and provides a valuable tool for diagnosis and monitoring of FD patients. © 2024 The Authors. Current Protocols published by Wiley Periodicals LLC. Basic Protocol: Analysis of urinary globotriaosylceramide (Gb3) and creatinine by UHPLC-MS/MS Support Protocol 1: Preparation of the urinary quality controls Support Protocol 2: Preparation of the urine matrix used for the Gb3 calibration curve Support Protocol 3: Preparation of the Gb3 calibrators Support Protocol 4: Preparation of the working solution containing the internal standards Support Protocol 5: Preparation of the creatinine calibrators Support Protocol 6: Preparation of the UHPLC solutions and mobile phases.
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Affiliation(s)
- Michel Boutin
- Division of Medical Genetics, Department of Laboratory Medicine, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada
- Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Bruno Maranda
- Division of Medical Genetics, Department of Laboratory Medicine, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada
- Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Paula J Waters
- Division of Medical Genetics, Department of Laboratory Medicine, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada
- Department of Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Effraimidis G, Feldt-Rasmussen U, Rasmussen ÅK, Lavoie P, Abaoui M, Boutin M, Auray-Blais C. Globotriaosylsphingosine (lyso-Gb 3) and analogues in plasma and urine of patients with Fabry disease and correlations with long-term treatment and genotypes in a nationwide female Danish cohort. J Med Genet 2020; 58:692-700. [PMID: 32963035 DOI: 10.1136/jmedgenet-2020-107162] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/14/2020] [Accepted: 08/03/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Recent studies showed the usefulness of globotriaosylsphingosine (lyso-Gb3) and related analogues, deacylated forms of globotriaosylceramide (Gb3), for high-risk screening, treatment monitoring and follow-up for patients with Fabry disease. METHODS We evaluated Gb3, lyso-Gb3 and analogues using tandem mass spectrometry in 57 women with Fabry disease followed during a period of 15.4 years. Twenty-one women were never treated and 36 received treatment (agalsidase-beta, n=30; agalsidase-alfa, n=5; or migalastat, n=1). Lyso-Gb3 and analogues at m/z (-28), (-2), (+16), (+34) and (+50) were analysed in plasma and urine. Total Gb3 and lyso-Gb3 analogues at m/z (-12) and (+14) were evaluated in urine while the analogue at m/z (+18) was evaluated in plasma. RESULTS A strong correlation between plasma and urine lyso-Gb3 and analogue levels was revealed. Plasma and urine lyso-Gb3 and analogue levels were not statistically different between patients carrying missense (n=49), nonsense (n=6) or deletion mutations (n=2). Never treated patients had lower plasma lyso-Gb3 and analogues at m/z (-28), (-2), (+16), (+34) and the seven urinary lyso-Gb3 analogues compared with pretreatment levels of the treated patients. A significant reduction of plasma lyso-Gb3 and five analogues, as well as urine Gb3 and six lyso-Gb3 analogues, but not lyso-Gb3 and lyso-Gb3 at m/z (+50), was observed post-treatment with agalsidase-beta. The same tendency was observed with agalsidase-alfa. CONCLUSION Women with Fabry disease who started treatment based on clinical manifestations had higher lyso-Gb3 and analogue biomarker levels than never treated women. This indicates that a biomarker cut-off could potentially be a decision tool for treatment initiation in women with Fabry disease.
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Affiliation(s)
| | - Ulla Feldt-Rasmussen
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Endocrinology, Rigshospitalet, Copenhagen, Denmark
| | | | - Pamela Lavoie
- Division of Medical Genetics, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mona Abaoui
- Pediatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Michel Boutin
- Division of Medical Genetics, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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High-risk screening for Fabry disease in a Canadian cohort of chronic kidney disease patients. Clin Chim Acta 2020; 501:234-240. [DOI: 10.1016/j.cca.2019.10.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 11/22/2022]
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Affiliation(s)
- Maria Fuller
- Genetics and Molecular Pathology, SA Pathology at Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Atul Mehta
- Haematology, Royal Free Hospital, London, UK
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Kang JJ, Kaissarian NM, Desch KC, Kelly RJ, Shu L, Bodary PF, Shayman JA. α-galactosidase A deficiency promotes von Willebrand factor secretion in models of Fabry disease. Kidney Int 2018; 95:149-159. [PMID: 30470436 DOI: 10.1016/j.kint.2018.08.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/11/2018] [Accepted: 08/16/2018] [Indexed: 12/14/2022]
Abstract
Fabry disease results from loss of activity of the lysosomal enzyme α-galactosidase A (GLA), leading to the accumulation of globoseries glycosphingolipids in vascular endothelial cells. Thrombosis and stroke are life-threatening complications of Fabry disease; however, the mechanism of the vasculopathy remains unclear. We explored the relationship between GLA deficiency and endothelial cell von Willebrand factor (VWF) secretion in in vivo and in vitro models of Fabry disease. Plasma VWF was significantly higher at two months and increased with age in Gla-null compared to wild-type mice. Disruption of GLA in a human endothelial cell line by siRNA and CRISPR/Cas9 resulted in a 3-fold and 5-fold increase in VWF secretion, respectively. The increase in VWF levels was associated with decreased endothelial nitric oxide synthase (eNOS) activity in both in vitro models. Pharmacological approaches that increase nitric oxide bioavailability or decrease reactive oxygen species completely normalized the elevated VWF secretion in GLA deficient cells. In contrast, the abnormality was not readily reversed by recombinant human GLA or by inhibition of glycosphingolipid synthesis with eliglustat. These results suggest that GLA deficiency promotes VWF secretion through eNOS dysregulation, which may contribute to the vasculopathy of Fabry disease.
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Affiliation(s)
- Justin J Kang
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Nayiri M Kaissarian
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan, USA
| | - Karl C Desch
- Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, Michigan, USA
| | - Robert J Kelly
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan, USA
| | - Liming Shu
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Peter F Bodary
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - James A Shayman
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan, USA.
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Abstract
PURPOSE OF REVIEW This review explores the clinical and pathological features of Fabry disease. New modalities of imaging, biomarkers and long-term treatment effects are discussed. RECENT FINDINGS Fabry disease is clinically heterogeneous, and in women the clinical severity has recently been linked to skewing of X-inactivation. Two phenotypes have been described, one with early onset manifestations is including pain and one with later onset single organ manifestations; however, the cardiac outcomes in these two groups appear similar. Fibrosis is found in renal and cardiac tissues on biopsy and appears to be a critical point in the pathology of Fabry disease after which response to enzyme replacement therapy is more limited. In-vitro studies have suggested that lyso-globotriaosylceramide may have an important role in the generation of fibrosis. Imaging, including cardiac magnetic resonance imaging, may have a role in detection of early stages of the disease. Long-term outcomes for patients treated with enzyme replacement therapy are now being described with some suggestion that patients treated at earlier points in the disease course may have better outcomes. SUMMARY Recent advances in understanding pathology, disease processes and treatment effects may enable future rational targeting of treatment with improved outcomes.
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Low frequency of Fabry disease in patients with common heart disease. Genet Med 2017; 20:754-759. [PMID: 29227985 DOI: 10.1038/gim.2017.175] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 09/05/2017] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To test the hypothesis that undiagnosed patients with Fabry disease exist among patients affected by common heart disease. METHODS Globotriaosylceramide in random whole urine using tandem mass spectroscopy, α-galactosidase A activity in dried blood spots, and next-generation sequencing of pooled or individual genomic DNA samples supplemented by Sanger sequencing. RESULTS We tested 2,256 consecutive patients: 852 women (median age 65 years (19-95)) and 1,404 men (median age 65 years (21-92)). The primary diagnoses were coronary artery disease (n = 994), arrhythmia (n = 607), cardiomyopathy (n = 138), and valvular disease (n = 568). Urinary globotriaosylceramide was elevated in 15% of patients and 15 males had low α-galactosidase A activity. GLA variants found included R118C (n = 2), D83N, and D313Y (n = 7); IVS6-22 C>T, IVS4-16 A>G, IVS2+990C>A, 5'UTR-10 C>T (n = 4), IVS1-581 C>T, IVS1-1238 G>A, 5'UTR-30 G>A, IVS2+590C>T, IVS0-12 G>A, IVS4+68A>G, IVS0-10 C>T, IVS2-81-77delCAGCC, IVS2-77delC. Although the pathogenicity of several of these missense mutations and complex intronic haplotypes has been controversial, none of the patients screened in this study were diagnosed definitively with Fabry disease. CONCLUSION This population of patients with common heart disease did not contain a substantial number of patients with undiagnosed Fabry disease. GLA gene sequencing is superior to urinary globotriaosylceramide or α-galactosidase A activity in the screening for Fabry disease.
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Schiffmann R, Hughes DA, Linthorst GE, Ortiz A, Svarstad E, Warnock DG, West ML, Wanner C, Christensen EI, Correa-Rotter R, Elliott PM, Feriozzi S, Fogo AB, Germain DP, Hollak CE, Hopkin RJ, Johnson J, Kantola I, Kopp JB, Kröner J, Linhart A, Martins AM, Matern D, Mehta AB, Mignani R, Najafian B, Narita I, Nicholls K, Obrador GT, Oliveira JP, Pisani A, Politei J, Ramaswami U, Ries M, Terryn W, Tøndel C, Torra R, Vujkovac B, Waldek S, Walter J. Screening, diagnosis, and management of patients with Fabry disease: conclusions from a "Kidney Disease: Improving Global Outcomes" (KDIGO) Controversies Conference. Kidney Int 2016; 91:284-293. [PMID: 27998644 DOI: 10.1016/j.kint.2016.10.004] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/08/2016] [Accepted: 10/13/2016] [Indexed: 01/16/2023]
Abstract
Patients with Fabry disease (FD) are at a high risk for developing chronic kidney disease and cardiovascular disease. The availability of specific but costly therapy has elevated the profile of this rare condition. This KDIGO conference addressed controversial areas in the diagnosis, screening, and management of FD, and included enzyme replacement therapy and nonspecific standard-of-care therapy for the various manifestations of FD. Despite marked advances in patient care and improved overall outlook, there is a need to better understand the pathogenesis of this glycosphingolipidosis and to determine the appropriate age to initiate therapy in all types of patients. The need to develop more effective specific therapies was also emphasized.
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Affiliation(s)
- Raphael Schiffmann
- Institute of Metabolic Disease, Baylor Research Institute, Dallas, Texas, USA.
| | - Derralynn A Hughes
- Department of Haematology, Royal Free London NHS Foundation Trust, & University College London, UK
| | - Gabor E Linthorst
- Department of Endocrinology and Metabolism, Academic Medical Center, Amsterdam, Netherlands
| | - Alberto Ortiz
- Unidad de Dialisis, IIS-Fundacion Jimenez Diaz/UAM, IRSIN, Madrid, Spain
| | - Einar Svarstad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - David G Warnock
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael L West
- Department of Medicine, Dalhousie University, Halifax, Canada
| | - Christoph Wanner
- Department of Medicine, Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany.
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Abstract
BACKGROUND Fabry disease, an X-linked disorder of glycosphingolipids, markedly increases the risk of systemic vasculopathy, ischemic stroke, small-fiber peripheral neuropathy, cardiac dysfunction, and chronic kidney disease. METHODS We performed an extensive PubMed search on the topic of Fabry disease and drew from our cumulative 43 years of experience. RESULTS Most of these complications are nonspecific in nature and clinically indistinguishable from similar abnormalities that occur in the context of more common disorders in the general population. This disease is caused by variants of the GLA gene, and its incidence may have been underestimated. However, one must also guard against overdiagnosis of Fabry disease and unjustified enzyme replacement therapy, because some of the gene variants are benign. Specific therapy for Fabry disease has been developed in the last few years, but its clinical effect has been modest. Novel therapeutic agents are being developed. Standard "nonspecific" medical and surgical therapy is necessary and effective in slowing deterioration or compensating for organ failure in patients with Fabry disease. CONCLUSIONS Fabry disease is a treatable and modifiable genetic risk factor for a myriad of clinical organ complications. Fabry disease may be frequently overlooked but on occasion overdiagnosed.
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Affiliation(s)
- Raphael Schiffmann
- Institute of Metabolic Disease, Baylor Research Institute, Dallas, Texas.
| | - Markus Ries
- Department of Pediatric Neurology and Metabolic Medicine, Center for Rare Disorders, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
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Abaoui M, Boutin M, Lavoie P, Auray-Blais C. High-Risk Screening of Fabry Disease: Analysis of Fifteen Urinary Methylated and Non-Methylated Gb 3 Isoforms Using Tandem Mass Spectrometry. CURRENT PROTOCOLS IN HUMAN GENETICS 2016; 91:17.24.1-17.24.11. [PMID: 27727434 DOI: 10.1002/cphg.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Fabry disease is a multisystemic, X-linked lysosomal storage disorder caused by mutations in the GLA gene, leading to α-galactosidase A deficiency and resulting in the accumulation of glycosphingolipids in different tissues and biological fluids. Glycosphingolipid biomarkers, such as globotriaosylceramide (Gb3 ) isoforms, globotriaosylsphingosine (lyso-Gb3 ) and related analogs, and galabiosylceramide (Ga2 ) isoforms and analogs, are found to be abnormally increased in urine and in plasma of Fabry patients and have the potential to be used as specific biomarkers of the disease. This unit presents a protocol for the relative quantification of fifteen urinary isoforms of Gb3 analyzed simultaneously with creatinine by ultra-performance liquid chromatography (UPLC) coupled to tandem mass spectrometry (MS/MS). In order to purify urine samples, a liquid-liquid extraction is performed and samples are analyzed by MS/MS in positive electrospray ionization mode. These biomarkers are useful for screening, diagnosis, and long-term monitoring of Fabry disease patients. We have shown that the methylated Gb3 isoforms are particularly useful for screening Fabry patients who present with late-onset cardiac variant mutations. © 2016 by John Wiley & Sons, Inc.
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Affiliation(s)
- Mona Abaoui
- Division of Medical Genetics, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Centre de Recherche-CHUS, Sherbrooke, Quebec, Canada
| | - Michel Boutin
- Division of Medical Genetics, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Centre de Recherche-CHUS, Sherbrooke, Quebec, Canada
| | - Pamela Lavoie
- Division of Medical Genetics, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Centre de Recherche-CHUS, Sherbrooke, Quebec, Canada
| | - Christiane Auray-Blais
- Division of Medical Genetics, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Centre de Recherche-CHUS, Sherbrooke, Quebec, Canada
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Schiffmann R, Fuller M, Clarke LA, Aerts JM. Is it Fabry disease? Genet Med 2016; 18:1181-1185. [DOI: 10.1038/gim.2016.55] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 03/16/2016] [Indexed: 11/09/2022] Open
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Dynamic Assessment of Functional Lipidomic Analysis in Human Urine. Lipids 2016; 51:875-86. [PMID: 27038173 DOI: 10.1007/s11745-016-4142-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 03/06/2016] [Indexed: 01/12/2023]
Abstract
The development of enabling mass spectrometry platforms for the quantification of diverse lipid species in human urine is of paramount importance for understanding metabolic homeostasis in normal and pathophysiological conditions. Urine represents a non-invasive biofluid that can capture distinct differences in an individual's physiological status. However, currently there is a lack of quantitative workflows to engage in high throughput lipidomic analysis. This study describes the development of a MS/MS(ALL) shotgun lipidomic workflow and a micro liquid chromatography-high resolution tandem mass spectrometry (LC-MS/MS) workflow for urine structural and mediator lipid analysis, respectively. This workflow was deployed to understand biofluid sample handling and collection, extraction efficiency, and natural human variation over time. Utilization of 0.5 mL of urine for structural lipidomic analysis resulted in reproducible quantification of more than 600 lipid molecular species from over 20 lipid classes. Analysis of 1 mL of urine routinely quantified in excess of 55 mediator lipid metabolites comprised of octadecanoids, eicosanoids, and docosanoids generated by lipoxygenase, cyclooxygenase, and cytochrome P450 activities. In summary, the high-throughput functional lipidomics workflow described in this study demonstrates an impressive robustness and reproducibility that can be utilized for population health and precision medicine applications.
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Gaggl M, Lajic N, Heinze G, Voigtländer T, Sunder-Plassmann R, Paschke E, Fauler G, Sunder-Plassmann G, Mundigler G. Screening for Fabry Disease by Urinary Globotriaosylceramide Isoforms Measurement in Patients with Left Ventricular Hypertrophy. Int J Med Sci 2016; 13:340-6. [PMID: 27226774 PMCID: PMC4879766 DOI: 10.7150/ijms.14997] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 03/21/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Left ventricular hypertrophy (LVH) is a frequent echocardiographic feature in Fabry disease (FD) and in severe cases may be confused with hypertrophic cardiomyopathy (HCM) of other origin. The prevalence of FD in patients primarily diagnosed with HCM varies considerably in screening and case finding studies, respectively. In a significant proportion of patients, presenting with only mild or moderate LVH and unspecific clinical signs FD may remain undiagnosed. Urinary Gb3 isoforms have been shown to detect FD in both, women and men. We examined whether this non-invasive method would help to identify new FD cases in a non-selected cohort of patients with various degree of LVH. METHODS AND RESULTS Consecutive patients older than 18 years with a diastolic interventricular septal wall thickness of ≥12mm determined by echocardiography were included. Referral diagnosis was documented and spot urine was collected. Gb3 was measured by mass spectroscopy. Subjects with an elevated Gb3-24:18 ratio were clinically examined for signs of FD, α-galactosidase-A activity in leukocytes was determined and GLA-mutation-analysis was performed. We examined 2596 patients. In 99 subjects urinary Gb3 isoforms excretion were elevated. In these patients no new cases of FD were identified by extended FD assessment. In two of three patients formerly diagnosed with FD Gb3-24:18 ratio was elevated and would have led to further diagnostic evaluation. CONCLUSION Measurement of urinary Gb3 isoforms in a non-selected cohort with LVH was unable to identify new cases of FD. False positive results may be prevented by more restricted inclusion criteria and may improve diagnostic accuracy of this method.
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Affiliation(s)
- Martina Gaggl
- 1. Department of Medicine II, Division of Cardiology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.; 2. Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Natalija Lajic
- 1. Department of Medicine II, Division of Cardiology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Georg Heinze
- 3. Center of Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Till Voigtländer
- 4. Department of Clinical Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Raute Sunder-Plassmann
- 5. Department of Laboratory Medicine, Laboratory for Molecular Diagnostics, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Eduard Paschke
- 6. Department of Pediatrics, Medical University of Graz, Auenbruggerplatz, 8036 Graz, Austria
| | - Günter Fauler
- 7. Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Auenbruggerplatz, 8036 Graz, Austria
| | - Gere Sunder-Plassmann
- 2. Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Gerald Mundigler
- 1. Department of Medicine II, Division of Cardiology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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Abaoui M, Boutin M, Lavoie P, Auray-Blais C. Tandem mass spectrometry multiplex analysis of methylated and non-methylated urinary Gb3 isoforms in Fabry disease patients. Clin Chim Acta 2015; 452:191-8. [PMID: 26593248 DOI: 10.1016/j.cca.2015.11.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 11/15/2015] [Accepted: 11/18/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Fabry disease is a lysosomal storage disorder leading to the accumulation of glycosphingolipids in biological fluids and tissues. Globotriaosylceramide (Gb3) and globotriaosylsphingosine (lyso-Gb3) are currently used for Fabry screening and diagnosis. However, these biomarkers are not always increased in Fabry patients with residual enzyme activity. We recently identified 7 urinary methylated Gb3-related isoforms. The aims of this study were (1) to develop and validate a novel LC-MS/MS method for the relative quantification of methylated and non-methylated Gb3 isoforms normalized to creatinine, (2) to evaluate these biomarkers in Fabry patients and healthy controls, and (3) to assess correlations between biomarker urinary excretion with age, gender, treatment and genotype of patients. METHODS Urine samples from 150 Fabry patients and 95 healthy controls were analyzed. Samples were purified and injected in the tandem mass spectrometer working in positive electrospray ionization. Relative quantification was performed for 15 methylated and non-methylated Gb3 isoforms. RESULTS Significant correlations (p<0.001) were established between Gb3 isoform concentrations, gender and treatment. Five patients with the late-onset cardiac mutation p.N215S showed abnormal concentrations of methylated Gb3 isoforms compared to their non-methylated homologues. CONCLUSIONS Methylated Gb3 isoforms might be helpful urinary biomarkers for Fabry patients with late-onset cardiac variant mutations.
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Affiliation(s)
- Mona Abaoui
- Division of Medical Genetics, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, Quebec J1H 5N4, Canada
| | - Michel Boutin
- Division of Medical Genetics, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, Quebec J1H 5N4, Canada
| | - Pamela Lavoie
- Division of Medical Genetics, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, Quebec J1H 5N4, Canada
| | - Christiane Auray-Blais
- Division of Medical Genetics, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, Quebec J1H 5N4, Canada.
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Ferreira S, Auray-Blais C, Boutin M, Lavoie P, Nunes JP, Martins E, Garman S, Oliveira JP. Variations in the GLA gene correlate with globotriaosylceramide and globotriaosylsphingosine analog levels in urine and plasma. Clin Chim Acta 2015; 447:96-104. [PMID: 26070511 PMCID: PMC4793778 DOI: 10.1016/j.cca.2015.06.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 06/03/2015] [Indexed: 12/14/2022]
Abstract
Recent data have shown that lyso-Gb3, the deacylated derivative of globotriaosylceramide (Gb3), is possibly involved in the pathogenesis of Fabry disease (FD) and might be a clinically useful biomarker of its metabolic load. To test this hypothesis, we assayed Gb3 and lyso-Gb3 and related analogs in plasma and/or urine samples of 12 clinically well-characterized subjects carrying several different GLA variant alleles associated with a wide range of residual α-galactosidase A activities. Urinary Gb3 was measured by HPLC-MS/MS; plasma and urinary lyso-Gb3 and related analogs were measured by UPLC-MS/MS. Individual profiles of Gb3 and lyso-Gb3 and related analogs closely correlated with the phenotypic data for each subject, discerning the classical FD patient from the two patients carrying cardiac variants as well as those from all the others without FD. The lyso-Gb3 analog at m/z 836 was found at increased levels only in patients manifesting clinically severe heart disease, irrespective of the pathogenicity of the GLA variant they carried. This finding suggests that this lyso-Gb3 analog might be an earlier biomarker of progressive heart disease, non-specific of the FD cardiomyopathy. The possibility that urinary Gb3 is a specific marker of kidney involvement in FD deserves further study.
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Affiliation(s)
- Susana Ferreira
- Department of Genetics, Faculty of Medicine, University of Porto, Alameda Hernâni Monteiro, 4200-319 Porto, Portugal.
| | - Christiane Auray-Blais
- Division of Medical Genetics, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, Quebec J1H 5N4, Canada.
| | - Michel Boutin
- Division of Medical Genetics, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, Quebec J1H 5N4, Canada.
| | - Pamela Lavoie
- Division of Medical Genetics, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, Quebec J1H 5N4, Canada.
| | - José Pedro Nunes
- Service of Cardiology, São João Hospital Centre, Alameda Hernâni Monteiro, 4200-319 Porto, Portugal.
| | - Elisabete Martins
- Service of Cardiology, São João Hospital Centre, Alameda Hernâni Monteiro, 4200-319 Porto, Portugal.
| | - Scott Garman
- Department of Biochemistry and Molecular Biology, University of Massachusetts Amherst, Amherst, MA 01003, USA.
| | - João Paulo Oliveira
- Department of Genetics, Faculty of Medicine, University of Porto, Alameda Hernâni Monteiro, 4200-319 Porto, Portugal; Medical Genetics Outpatient Clinic, São João Hospital Centre, Alameda Hernâni Monteiro, 4200-319 Porto, Portugal.
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Interfering parameters in the determination of urinary globotriaosylceramide (Gb3) in patients with chronic kidney disease. J Nephrol 2015; 28:679-89. [PMID: 25857295 DOI: 10.1007/s40620-015-0193-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 03/20/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Globotriaosylceramide (Gb3, CD77) represents a pivotal part of the cell membrane. Measuring the urinary Gb3 content can be used to screen patients with chronic kidney disease (CKD) for Fabry disease, a disorder caused by hampered Gb3 degradation. However, little is known about factors influencing urinary Gb3 excretion other than Fabry disease. The aim of the present study was to identify routine diagnostic parameters as predictors of urinary Gb3 excretion in patients with CKD. METHODS Our study included 609 subjects with CKD stage I-V. We analyzed the influence of age, gender, renal function, urinary cell content and chemical characteristics on urinary Gb3 concentrations (total Gb3, Gb3-24 isoform, and Gb3-24:18 isoform ratio), determined by direct electrospray ionization mass spectrometry. RESULTS In 609 subjects the median total urinary Gb3 was 233 ng/mg and the Gb3-24:18 isoform ratio was 1.2. Twenty-one patients, none of whom had Fabry disease, had a Gb3-24:18 isoform ratio ≥2.3. Females excreted a higher total amount of Gb3, but the Gb3-24:18 isoform ratio was comparable to males. Renal function and age had no influence on total Gb3, Gb3 isoforms or the ratio. Only a distinct load of bacteria and leukocytes was associated with an increased Gb3 excretion. Urinary leukocytes, erythrocytes, bacteria, or protein content did not affect the Gb3-24:18 isoform ratio. CONCLUSION The Gb3-24:18 isoform ratio is unaffected by several potential influencing variables and may thus be applied for screening for Fabry disease in unselected cohorts of patients presenting with CKD.
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A Hyphenated Technique based on High-Performance Thin Layer Chromatography for Determining Neutral Sphingolipids: A Proof of Concept. CHROMATOGRAPHY 2015. [DOI: 10.3390/chromatography2020167] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Ferreira S, Ortiz A, Germain DP, Viana-Baptista M, Caldeira-Gomes A, Camprecios M, Fenollar-Cortés M, Gallegos-Villalobos Á, Garcia D, García-Robles JA, Egido J, Gutiérrez-Rivas E, Herrero JA, Mas S, Oancea R, Péres P, Salazar-Martín LM, Solera-Garcia J, Alves H, Garman SC, Oliveira JP. The alpha-galactosidase A p.Arg118Cys variant does not cause a Fabry disease phenotype: data from individual patients and family studies. Mol Genet Metab 2015; 114:248-58. [PMID: 25468652 PMCID: PMC4423738 DOI: 10.1016/j.ymgme.2014.11.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 10/31/2014] [Accepted: 11/01/2014] [Indexed: 10/24/2022]
Abstract
Lysosomal α-galactosidase A (α-Gal) is the enzyme deficient in Fabry disease (FD), an X-linked glycosphingolipidosis caused by pathogenic mutations affecting the GLA gene. The early-onset, multi-systemic FD classical phenotype is associated with absent or severe enzyme deficiency, as measured by in vitro assays, but patients with higher levels of residual α-Gal activity may have later-onset, more organ-restricted clinical presentations. A change in the codon 118 of the wild-type α-Gal sequence, replacing basic arginine by a potentially sulfhydryl-binding cysteine residue - GLA p.(Arg118Cys) -, has been recurrently described in large FD screening studies of high-risk patients. Although the Cys118 allele is associated with high residual α-Gal activity in vitro, it has been classified as a pathogenic mutation, mainly on the basis of theoretical arguments about the chemistry of the cysteine residue. However its pathogenicity has never been convincingly demonstrated by pathology criteria. We reviewed the clinical, biochemical and histopathology data obtained from 22 individuals of Portuguese and Spanish ancestry carrying the Cys118 allele, including 3 homozygous females. Cases were identified either on the differential diagnosis of possible FD manifestations and on case-finding studies (n=11; 4 males), or on unbiased cascade screening of probands' close relatives (n=11; 3 males). Overall, those data strongly suggest that the GLA p.(Arg118Cys) variant does not segregate with FD clinical phenotypes in a Mendelian fashion, but might be a modulator of the multifactorial risk of cerebrovascular disease. The Cys118 allelic frequency in healthy Portuguese adults (n=696) has been estimated as 0.001, therefore not qualifying for "rare" condition.
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Affiliation(s)
- Susana Ferreira
- Departamento de Genética, Faculdade de Medicina, Universidade do Porto, 4200-319 Porto, Portugal.
| | - Alberto Ortiz
- Servicio de Nefrología, Instituto de Investigación Sanitaria IIS-Fundación Jiménez Diaz, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain.
| | - Dominique P Germain
- University of Versailles, UFR des sciences de la santé Simone Veil, Division of Medical Genetics, 78180 Montigny, France.
| | - Miguel Viana-Baptista
- Serviço de Neurologia, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Centro de Estudo de Doenças Crónicas (CEDOC), Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal.
| | | | - Marta Camprecios
- Servicio de Cardiología, Hospital Moisès Broggi, Sant Joan Despí, Barcelona, Spain
| | - Maria Fenollar-Cortés
- Laboratorio de Genética Clínica, Servicio de Análisis Clínicos, Hospital Clínico Universitario San Carlos, Madrid, Spain.
| | - Ángel Gallegos-Villalobos
- Servicio de Nefrología, Instituto de Investigación Sanitaria IIS-Fundación Jiménez Diaz, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain.
| | - Diego Garcia
- Health In Code, Hospital Marítimo de Oza, A Coruña, Spain
| | | | - Jesús Egido
- Servicio de Nefrología, Instituto de Investigación Sanitaria IIS-Fundación Jiménez Diaz, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain.
| | | | - José Antonio Herrero
- Servicio de Nefrología, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Sebastián Mas
- Servicio de Nefrología, Instituto de Investigación Sanitaria IIS-Fundación Jiménez Diaz, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain.
| | - Raluca Oancea
- Laboratorio de Genética Clínica, Servicio de Análisis Clínicos, Instituto de Investigación Sanitaria, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Paloma Péres
- Servicio de Cardiología, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - Jesús Solera-Garcia
- Instituto de Genética Médica y Molecular, Instituto de Investigación Sanitaria del Hospital Universitario La Paz, Madrid, Spain
| | - Helena Alves
- Centro de Histocompatibilidade do Norte, Porto, Portugal.
| | - Scott C Garman
- Department of Biochemistry and Molecular Biology, University of Massachusetts, Amherst, MA, USA.
| | - João Paulo Oliveira
- Departamento de Genética, Faculdade de Medicina, Universidade do Porto, 4200-319 Porto, Portugal; Serviço de Nefrologia, Centro Hospitalar de São João, 4200-319 Porto, Portugal; Consulta de Genética Médica, Centro Hospitalar de São João, 4200-319 Porto, Portugal.
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van der Tol L, Svarstad E, Ortiz A, Tøndel C, Oliveira JP, Vogt L, Waldek S, Hughes DA, Lachmann RH, Terryn W, Hollak CE, Florquin S, van den Bergh Weerman MA, Wanner C, West ML, Biegstraaten M, Linthorst GE. Chronic kidney disease and an uncertain diagnosis of Fabry disease: approach to a correct diagnosis. Mol Genet Metab 2015; 114:242-7. [PMID: 25187469 DOI: 10.1016/j.ymgme.2014.08.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 08/13/2014] [Accepted: 08/13/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Screening for Fabry disease (FD), an X-linked lysosomal storage disorder, reveals a significant number of individuals with a genetic variant of unknown significance without classical FD manifestations; these variants in the α-galactosidase A gene often result in a high residual leukocyte α-galactosidase A and it is unclear whether these individuals suffer from FD. Therefore, a structured diagnostic approach is warranted. We present a diagnostic algorithm on how to approach adults with chronic kidney disease and an uncertain diagnosis of FD nephropathy. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS A modified Delphi procedure was conducted to reach consensus among 11 FD experts. A systematic review was performed to identify possible criteria that could confirm or exclude FD nephropathy. RESULTS The gold standard for FD nephropathy was defined as characteristic storage on electron microscopy (EM) in a kidney biopsy in the absence of medication that may induce similar storage. The suggested criteria to confirm FD nephropathy are as follows: 'renal cysts', 'Maltese cross sign', 'immunohistochemical staining of Gb3 in urine' and 'high urinary Gb3'; and to exclude FD nephropathy: 'absence of renal cysts', 'small kidneys' and 'high protein excretion' were rejected because of low or uncertain specificity. Urinary Gb3 may be increased in other kidney diseases and there was no agreement on this criterion, although a third of the panel indicated that it is sufficient to diagnose FD nephropathy. The 'Maltese cross sign' and 'high urinary Gb3' were selected as red flags to suggest the possibility of FD nephropathy, but are not sufficient for a definite diagnosis of FD nephropathy. CONCLUSIONS In adults with chronic kidney disease, an α-galactosidase A gene variant and an uncertain diagnosis of FD, a kidney biopsy with EM analysis should be performed to confirm or reject the diagnosis of FD nephropathy. Other criteria currently cannot substitute for a biopsy in these cases.
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Affiliation(s)
- Linda van der Tol
- Department of Endocrinology and Metabolism, Academic Medical Center, Amsterdam Lysosome Center 'Sphinx', Amsterdam, Netherlands
| | - Einar Svarstad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Alberto Ortiz
- Unidad de Dialisis, IIS-Fundacion Jimenez Diaz/UAM, IRSIN, Madrid, Spain
| | - Camilla Tøndel
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - João Paulo Oliveira
- Medical Genetics, Hospital São João, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Liffert Vogt
- Department of Nephrology, Academic Medical Center, Amsterdam, Netherlands
| | | | - Derralynn A Hughes
- Department of Haematology, Royal Free London NHS Foundation Trust, & University College London, UK
| | - Robin H Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Wim Terryn
- Department of Internal Medicine, Division of Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Carla E Hollak
- Department of Endocrinology and Metabolism, Academic Medical Center, Amsterdam Lysosome Center 'Sphinx', Amsterdam, Netherlands
| | - Sandrine Florquin
- Department of Pathology, Academic Medical Center, Amsterdam, Netherlands
| | | | - Christoph Wanner
- Department of Medicine, Division of Nephrology, University of Würzburg, Würzburg, Germany
| | - Michael L West
- Department of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Marieke Biegstraaten
- Department of Endocrinology and Metabolism, Academic Medical Center, Amsterdam Lysosome Center 'Sphinx', Amsterdam, Netherlands
| | - Gabor E Linthorst
- Department of Endocrinology and Metabolism, Academic Medical Center, Amsterdam Lysosome Center 'Sphinx', Amsterdam, Netherlands.
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22
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Kolodny E, Fellgiebel A, Hilz MJ, Sims K, Caruso P, Phan TG, Politei J, Manara R, Burlina A. Cerebrovascular Involvement in Fabry Disease. Stroke 2015; 46:302-13. [PMID: 25492902 DOI: 10.1161/strokeaha.114.006283] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Edwin Kolodny
- From the Department of Neurology, New York University School of Medicine (E.K.); Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany (A.F.); Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany (M.J.H.); Center for Human Genetic Research and Neurology Department (K.S.), Division of Neuroradiology, Department of Radiology (P.C.), Harvard Medical School, Massachusetts General Hospital, Boston; Stroke Unit, Department of Neurosciences,
| | - Andreas Fellgiebel
- From the Department of Neurology, New York University School of Medicine (E.K.); Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany (A.F.); Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany (M.J.H.); Center for Human Genetic Research and Neurology Department (K.S.), Division of Neuroradiology, Department of Radiology (P.C.), Harvard Medical School, Massachusetts General Hospital, Boston; Stroke Unit, Department of Neurosciences,
| | - Max J. Hilz
- From the Department of Neurology, New York University School of Medicine (E.K.); Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany (A.F.); Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany (M.J.H.); Center for Human Genetic Research and Neurology Department (K.S.), Division of Neuroradiology, Department of Radiology (P.C.), Harvard Medical School, Massachusetts General Hospital, Boston; Stroke Unit, Department of Neurosciences,
| | - Katherine Sims
- From the Department of Neurology, New York University School of Medicine (E.K.); Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany (A.F.); Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany (M.J.H.); Center for Human Genetic Research and Neurology Department (K.S.), Division of Neuroradiology, Department of Radiology (P.C.), Harvard Medical School, Massachusetts General Hospital, Boston; Stroke Unit, Department of Neurosciences,
| | - Paul Caruso
- From the Department of Neurology, New York University School of Medicine (E.K.); Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany (A.F.); Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany (M.J.H.); Center for Human Genetic Research and Neurology Department (K.S.), Division of Neuroradiology, Department of Radiology (P.C.), Harvard Medical School, Massachusetts General Hospital, Boston; Stroke Unit, Department of Neurosciences,
| | - Thanh G. Phan
- From the Department of Neurology, New York University School of Medicine (E.K.); Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany (A.F.); Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany (M.J.H.); Center for Human Genetic Research and Neurology Department (K.S.), Division of Neuroradiology, Department of Radiology (P.C.), Harvard Medical School, Massachusetts General Hospital, Boston; Stroke Unit, Department of Neurosciences,
| | - Juan Politei
- From the Department of Neurology, New York University School of Medicine (E.K.); Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany (A.F.); Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany (M.J.H.); Center for Human Genetic Research and Neurology Department (K.S.), Division of Neuroradiology, Department of Radiology (P.C.), Harvard Medical School, Massachusetts General Hospital, Boston; Stroke Unit, Department of Neurosciences,
| | - Renzo Manara
- From the Department of Neurology, New York University School of Medicine (E.K.); Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany (A.F.); Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany (M.J.H.); Center for Human Genetic Research and Neurology Department (K.S.), Division of Neuroradiology, Department of Radiology (P.C.), Harvard Medical School, Massachusetts General Hospital, Boston; Stroke Unit, Department of Neurosciences,
| | - Alessandro Burlina
- From the Department of Neurology, New York University School of Medicine (E.K.); Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany (A.F.); Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany (M.J.H.); Center for Human Genetic Research and Neurology Department (K.S.), Division of Neuroradiology, Department of Radiology (P.C.), Harvard Medical School, Massachusetts General Hospital, Boston; Stroke Unit, Department of Neurosciences,
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