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Badminton MN, Anderson KE, Deybach JC, Harper P, Sandberg S, Elder GH. From chemistry to genomics: A concise history of the porphyrias. Liver Int 2024; 44:2144-2155. [PMID: 38767598 DOI: 10.1111/liv.15960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 05/22/2024]
Abstract
We describe developments in understanding of the porphyrias associated with each step in the haem biosynthesis pathway and the role of individuals whose contributions led to major advances over the past 150 years. The first case of erythropoietic porphyria was reported in 1870, and the first with acute porphyria in 1889. Photosensitisation by porphyrin was confirmed by Meyer-Betz, who self-injected haematoporphyrin. Günther classified porphyrias into haematoporphyria acuta, acuta toxica, congenita and chronica. This was revised by Waldenström into porphyria congenita, acuta and cutanea tarda, with the latter describing those with late-onset skin lesions. Waldenström was the first to recognise porphobilinogen's association with acute porphyria, although its structure was not solved until 1953. Hans Fischer was awarded the Nobel prize in 1930 for solving the structure of porphyrins and the synthesis of haemin. After 1945, research by several groups elucidated the pathway of haem biosynthesis and its negative feedback regulation by haem. By 1961, following the work of Watson, Schmid, Rimington, Goldberg, Dean, Magnus and others, aided by the availability of modern techniques of porphyrin separation, six of the porphyrias were identified and classified as erythropoietic or hepatic. The seventh, 5-aminolaevulinate dehydratase deficiency porphyria, was described by Doss in 1979. The discovery of increased hepatic 5-aminolaevulinate synthase activity in acute porphyria led to development of haematin as a treatment for acute attacks. By 2000, all the haem biosynthesis genes were cloned, sequenced and assigned to chromosomes and disease-specific mutations identified in all inherited porphyrias. These advances have allowed definitive family studies and development of new treatments.
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Affiliation(s)
| | - Karl E Anderson
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Jean-Charles Deybach
- French Porphyria Reference Center (CRMR Porphyries France), University Paris, Paris, France
| | - Pauline Harper
- Department of Medical Biochemistry and Biophysics, Centre for inherited Metabolic Diseases, Porphyria Centre Sweden, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sverre Sandberg
- Department of Medical Biochemistry and Biophysics, Centre for inherited Metabolic Diseases, Porphyria Centre Sweden, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Medical Biochemistry and Pharmacology, Norwegian Porphyria Centre, Haukeland University Hospital, Bergen, Norway
- Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital, Bergen, Norway
- Institute of Public Health and Primary Health Care, University of Bergen, Bergen, Norway
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2
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Jericó D, Córdoba KM, Urigo F, Enríquez de Salamanca R, Anderson KE, Deybach JC, Ávila MA, Fontanellas A. Exploring current and emerging therapies for porphyrias. Liver Int 2024; 44:2174-2190. [PMID: 38813953 DOI: 10.1111/liv.15979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 05/31/2024]
Abstract
Porphyrias are rare, mostly inherited disorders resulting from altered activity of specific enzymes in the haem synthesis pathway that lead to accumulation of pathway intermediates. Photocutaneous symptoms occur when excess amounts of photoreactive porphyrins circulate in the blood to the skin, whereas increases in potentially neurotoxic porphyrin precursors are associated with neurovisceral symptoms. Current therapies are suboptimal and their mechanisms are not well established. As described here, emerging therapies address underlying disease mechanisms by introducing a gene, RNA or other specific molecule with the potential to cure or slow progression of the disease. Recent progress in nanotechnology and nanoscience, particularly regarding particle design and formulation, is expanding disease targets. More secure and efficient drug delivery systems have extended our toolbox for transferring specific molecules, especially into hepatocytes, and led to proof-of-concept studies in animal models. Repurposing existing drugs as molecular chaperones or haem synthesis inhibitors is also promising. This review summarizes key examples of these emerging therapeutic approaches and their application for hepatic and erythropoietic porphyrias.
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Affiliation(s)
- Daniel Jericó
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
| | - Karol M Córdoba
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
| | - Francesco Urigo
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
| | - Rafael Enríquez de Salamanca
- Department of Internal Medicine, Reference Center for Inherited Metabolic Disease-MetabERN, University Hospital 12 de Octubre, UCM, Madrid, Spain
| | - Karl E Anderson
- Porphyria Laboratory and Center, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Jean-Charles Deybach
- French Porphyria Reference Center (CRMR Porphyries France), Université Paris, Paris, France
| | - Matías A Ávila
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Antonio Fontanellas
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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3
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Balwani M, Keel S, Meissner P, Sonderup M, Stein P, Yasuda M. Case-based discussion of the acute hepatic porphyrias: Updates on pathogenesis, diagnosis and management. Liver Int 2024. [PMID: 38618923 DOI: 10.1111/liv.15924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/16/2024]
Abstract
The acute hepatic porphyrias (AHPs) include three autosomal dominant disorders, acute intermittent porphyria, variegate porphyria and hereditary coproporphyria, and the ultra-rare autosomal recessive 5-aminolevulinic acid dehydratase-deficient porphyria. All four are characterized by episodic acute neurovisceral attacks that can be life-threatening if left untreated. The attacks are precipitated by factors that induce hepatic 5-aminolevulinic acid synthase 1 (ALAS1), resulting in accumulation of the porphyrin precursors, 5-aminolevulinic acid and porphobilinogen, which are believed to cause neurotoxicity. Diagnosis of these rare disorders is often delayed because the symptoms are non-specific with many common aetiologies. However, once clinical suspicion of an AHP is raised, diagnosis can be made by specialized biochemical testing, particularly during attacks. Moderate or severe attacks are treated with intravenous hemin infusions, together with supportive care to relieve pain and other symptoms. Prophylactic treatments are recommended in patients with confirmed recurrent attacks (≥4 attacks in a maximum period of 12 months), the most effective being givosiran, an RNAi therapeutic targeting hepatocyte ALAS1 mRNA. AHP patients with clinically and/or biochemically active disease are at elevated risk for developing long-term complications, including chronic kidney disease, chronic hypertension and hepatocellular carcinoma, thus, surveillance is recommended. Here, using a case-based format, we provide an update on the pathogenesis, diagnosis and treatment of the AHPs based on literature review and clinical experiences.
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Affiliation(s)
- Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Siobán Keel
- Department of Medicine, Division of Hematology and Oncology, University of Washington, Seattle, Washington, USA
| | - Peter Meissner
- Department of Integrative Biomedical Sciences, Division of Medical Biochemistry and Structural Biology, University of Cape Town, Cape Town, South Africa
| | - Mark Sonderup
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Penelope Stein
- Department of Haematological Medicine, King's College Hospital, London, UK
| | - Makiko Yasuda
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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4
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Mantel Ä, Vassiliou D, Lissing M, Stephansson O, Wahlin S, Sardh E. Maternal and fetal outcomes in acute hepatic porphyria: A Swedish National Cohort Study. J Inherit Metab Dis 2023; 46:675-686. [PMID: 37078226 DOI: 10.1002/jimd.12616] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/22/2023] [Accepted: 04/19/2023] [Indexed: 04/21/2023]
Abstract
Current knowledge of pregnancy and perinatal outcomes in women with acute hepatic porphyria (AHP) is largely based on biochemical disease models, case reports, and case series. We performed a nationwide, registered-based cohort study to investigate the association between maternal AHP and the risk of adverse pregnancy and perinatal outcomes. All women in the Swedish Porphyria Register with confirmed AHP aged 18 years or older between 1987 and 2015 and matched general population comparators, with at least one registered delivery in the Swedish Medical Birth Register were included. Risk ratios (RRs) of pregnancy complications, delivery mode and perinatal outcomes were estimated and adjusted for maternal age at delivery, area of residency, birth year and parity. Women with acute intermittent porphyria (AIP), the most common form of AHP, were further categorized according to maximal lifetime urinary porphobilinogen (U-PBG) levels. The study included 214 women with AHP and 2174 matched comparators. Women with AHP presented with a higher risk for pregnancy-induced hypertensive disorder (aRR 1.73, 95% CI 1.12-2.68), gestational diabetes (aRR 3.41, 95% CI 1.69-6.89), and small-for-gestational-age birth (aRR 2.08, 95% CI 1.26-3.45). In general, RRs were higher among women with AIP who had high lifetime U-PBG levels. Our study shows an increased risk for pregnancy induced hypertensive disease, gestational diabetes, and small for gestational age births for AHP women, with higher relative risks for women with biochemically active AIP. No increased risk for perinatal death or malformations was observed.
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Affiliation(s)
- Ängla Mantel
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
- Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
- Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Daphne Vassiliou
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Centre for Inherited Metabolic Diseases, Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Lissing
- Hepatology Division, Karolinska University Hospital, Stockholm, Sweden
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
- Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
- Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Staffan Wahlin
- Hepatology Division, Karolinska University Hospital, Stockholm, Sweden
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Eliane Sardh
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Centre for Inherited Metabolic Diseases, Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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5
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Cheng S, Yu E, Garacci Z, Erwin AL, Venkatesan T. Prevalence of Undiagnosed Acute Hepatic Porphyria in Cyclic Vomiting Syndrome and Overlap in Clinical Symptoms. Dig Dis Sci 2022; 68:2107-2114. [PMID: 36380150 DOI: 10.1007/s10620-022-07756-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 10/27/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS Acute hepatic porphyria (AHP) presents with nausea and vomiting and can mimic cyclic vomiting syndrome (CVS). The prevalence of AHP in CVS and overlap in clinical symptomatology is not known. We thus sought to determine the prevalence of pathogenic variants for AHP and characterize symptom overlap between CVS and AHP. METHODS We conducted a cross-sectional study of 234 CVS patients using Rome criteria. Patients were eligible for AHP genetic testing if they had recurrent episodes of severe, diffuse abdominal pain with ≥ 2 of the following-peripheral nervous system (muscle weakness/aching, numbness, tingling), central nervous system (confusion, anxiety, seizures, hallucinations), autonomic nervous system (hyponatremia, tachycardia, hypertension, constipation) symptoms, red/brownish urine, or blistering skin lesions on sun-exposed areas. A family history of AHP or elevated urinary porphobilinogen (PBG)/aminolaevulinic acid (ALA) were also criteria for genetic testing and was performed using a 4-gene panel. RESULTS Mean age was 38.7 ± 14.5 years, 180 (76.9%) were female and 200 (85.5%) were Caucasian. During a CVS attack, 173 (92%) reported abdominal pain, 166 (87.2%) had peripheral nervous system, 164 (86.8%) had central nervous system and 173 (92) % had autonomic symptoms. Ninety-one eligible patients completed genetic testing. None were positive for AHP but two had variants of uncertain significance (VUS) in the HMBS gene. CONCLUSIONS There is a high prevalence of non-gastrointestinal symptoms in CVS, like AHP, which is important for clinicians to recognize. AHP was not detected in this study and larger studies are warranted to ascertain its prevalence.
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Affiliation(s)
- Shanna Cheng
- Department of Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Elliot Yu
- Gastroenterology and Hepatology Fellow, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Zhuping Garacci
- Center for Advancing Population Science, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Angelika L Erwin
- Department of Pediatrics, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Center for Personalized Genetic Healthcare, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Thangam Venkatesan
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University College of Medicine, 395 W 12th Avenue, Columbus, OH, 43210, USA.
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6
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Schulenburg-Brand D, Stewart F, Stein P, Rees D, Badminton M. Update on the diagnosis and management of the autosomal dominant acute hepatic porphyrias. J Clin Pathol 2022; 75:jclinpath-2021-207647. [PMID: 35584894 DOI: 10.1136/jclinpath-2021-207647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 05/04/2022] [Indexed: 11/04/2022]
Abstract
The autosomal dominant acute hepatic porphyrias (AHPs), acute intermittent porphyria, hereditary coproporphyria (HCP) and variegate porphyria (VP), are low penetrance adult onset disorders caused by partial deficiency of enzymes of haem biosynthesis. All are associated with acute neurovisceral attacks, which are a consequence of the increased hepatic demand for haem triggered by hormones, stress, drugs or systemic infections which leads to upregulation of the pathway and overproduction of haem precursors 5-aminolaevulinic acid (ALA) and porphobilinogen (PBG). Acute episodes are characterised by severe abdominal pain, nausea, vomiting, hyponatraemia, hypertension and tachycardia, behavioural disturbance and can progress to include seizures, peripheral motor neuropathy and posterior reversible encephalopathy syndrome if undiagnosed and untreated. VP and HCP may also present with photocutaneous skin lesions either alone or during acute symptoms. Diagnosis involves demonstrating increased excretion of PBG in urine. Treatment focuses on removing or managing triggers, supportive treatment and suppressing the hepatic haem pathway by administering human haemin. Chronic complications include hypertension, chronic kidney disease and hepatocellular carcinoma. A small proportion of symptomatic patients with AHP progress to repeated acute attacks which require preventative therapy. A new RNA interference therapy has recently been licensed and is likely to become the treatment of choice in this situation.
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Affiliation(s)
- Danja Schulenburg-Brand
- Medical Biochemistry and Immunology, University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
| | - Felicity Stewart
- School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Penelope Stein
- Haematological Medicine, King's College London, London, UK
| | - David Rees
- Haematological Medicine, King's College London, London, UK
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Mike Badminton
- Medical Biochemistry and Immunology, University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
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7
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Jericó D, Córdoba KM, Jiang L, Schmitt C, Morán M, Sampedro A, Alegre M, Collantes M, Santamaría E, Alegre E, Culerier C, de Mendoza AEH, Oyarzabal J, Martín MA, Peñuelas I, Ávila MA, Gouya L, Martini PGV, Fontanellas A. mRNA-based therapy in a rabbit model of variegate porphyria offers new insights into the pathogenesis of acute attacks. MOLECULAR THERAPY. NUCLEIC ACIDS 2021; 25:207-219. [PMID: 34458006 PMCID: PMC8368795 DOI: 10.1016/j.omtn.2021.05.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 05/13/2021] [Indexed: 11/28/2022]
Abstract
Variegate porphyria (VP) results from haploinsufficiency of protoporphyrinogen oxidase (PPOX), the seventh enzyme in the heme synthesis pathway. There is no VP model that recapitulates the clinical manifestations of acute attacks. Combined administrations of 2-allyl-2-isopropylacetamide and rifampicin in rabbits halved hepatic PPOX activity, resulting in increased accumulation of a potentially neurotoxic heme precursor, lipid peroxidation, inflammation, and hepatocyte cytoplasmic stress. Rabbits also showed hypertension, motor impairment, reduced activity of critical mitochondrial hemoprotein functions, and altered glucose homeostasis. Hemin treatment only resulted in a slight drop in heme precursor accumulation but further increased hepatic heme catabolism, inflammation, and cytoplasmic stress. Hemin replenishment did protect against hypertension, but it failed to restore action potentials in the sciatic nerve or glucose homeostasis. Systemic porphobilinogen deaminase (PBGD) mRNA administration increased hepatic PBGD activity, the third enzyme of the pathway, and rapidly normalized serum and urine porphyrin precursor levels. All features studied were improved, including those related to critical hemoprotein functions. In conclusion, the VP model recapitulates the biochemical characteristics and some clinical manifestations associated with severe acute attacks in humans. Systemic PBGD mRNA provided successful protection against the acute attack, indicating that PBGD, and not PPOX, was the critical enzyme for hepatic heme synthesis in VP rabbits.
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Affiliation(s)
- Daniel Jericó
- Hepatology Program, Centre for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Karol M Córdoba
- Hepatology Program, Centre for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Lei Jiang
- Moderna Inc., Cambridge, MA 02139, USA
| | - Caroline Schmitt
- Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale U1149, 75018 Paris, France.,Centre Français des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes et Université de Paris, 92701 Colombes, France
| | - María Morán
- Mitochondrial Diseases Laboratory, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), U723, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Ana Sampedro
- Hepatology Program, Centre for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Manuel Alegre
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain.,Department of Clinical Neurophysiology, Clínica Universidad de Navarra (CUN), 31008 Pamplona, Spain
| | - María Collantes
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain.,MicroPET Research Unit, CIMA-CUN, 31008 Pamplona, Spain.,Nuclear Medicine Department, CUN, 31008 Pamplona, Spain
| | - Eva Santamaría
- Hepatology Program, Centre for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Estíbaliz Alegre
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain.,Department of Biochemistry, Service of Biochemistry, Clínica Universidad de Navarra (CUN), 31008 Pamplona, Spain
| | - Corinne Culerier
- Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale U1149, 75018 Paris, France.,Centre Français des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes et Université de Paris, 92701 Colombes, France
| | | | - Julen Oyarzabal
- Small Molecule Discovery Platform, Molecular Therapeutics Program, CIMA-University of Navarra, 31008 Pamplona, Spain
| | - Miguel A Martín
- Mitochondrial Diseases Laboratory, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), U723, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Iván Peñuelas
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain.,MicroPET Research Unit, CIMA-CUN, 31008 Pamplona, Spain.,Nuclear Medicine Department, CUN, 31008 Pamplona, Spain
| | - Matías A Ávila
- Hepatology Program, Centre for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Laurent Gouya
- Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale U1149, 75018 Paris, France.,Centre Français des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes et Université de Paris, 92701 Colombes, France
| | | | - Antonio Fontanellas
- Hepatology Program, Centre for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, 28029 Madrid, Spain
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8
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Di Pierro E, De Canio M, Mercadante R, Savino M, Granata F, Tavazzi D, Nicolli AM, Trevisan A, Marchini S, Fustinoni S. Laboratory Diagnosis of Porphyria. Diagnostics (Basel) 2021; 11:diagnostics11081343. [PMID: 34441276 PMCID: PMC8391404 DOI: 10.3390/diagnostics11081343] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/13/2021] [Accepted: 07/22/2021] [Indexed: 12/13/2022] Open
Abstract
Porphyrias are a group of diseases that are clinically and genetically heterogeneous and originate mostly from inherited dysfunctions of specific enzymes involved in heme biosynthesis. Such dysfunctions result in the excessive production and excretion of the intermediates of the heme biosynthesis pathway in the blood, urine, or feces, and these intermediates are responsible for specific clinical presentations. Porphyrias continue to be underdiagnosed, although laboratory diagnosis based on the measurement of metabolites could be utilized to support clinical suspicion in all symptomatic patients. Moreover, the measurement of enzymatic activities along with a molecular analysis may confirm the diagnosis and are, therefore, crucial for identifying pre-symptomatic carriers. The present review provides an overview of the laboratory assays used most commonly for establishing the diagnosis of porphyria. This would assist the clinicians in prescribing appropriate diagnostic testing and interpreting the testing results.
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Affiliation(s)
- Elena Di Pierro
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Correspondence: ; Tel.: +39-0255036155
| | - Michele De Canio
- Porphyria and Rare Diseases Centre, San Gallicano Dermatological Institute IRCCS, 00144 Rome, Italy;
| | - Rosa Mercadante
- EPIGET-Epidemiology, Epigenetics, and Toxicology Lab, Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (R.M.); (D.T.); (S.F.)
| | - Maria Savino
- Servizio di Medicina Trasfusionale e Laboratorio Analisi, Laboratorio di Immunogenetica, IRCCS Ospedale “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy;
| | - Francesca Granata
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Dario Tavazzi
- EPIGET-Epidemiology, Epigenetics, and Toxicology Lab, Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (R.M.); (D.T.); (S.F.)
| | - Anna Maria Nicolli
- Dipartimento di Scienze Cardio-Toraco-Vascolari e Sanità Pubblica, Università Degli Studi di Padova, 35121 Padova, Italy; (A.M.N.); (A.T.)
| | - Andrea Trevisan
- Dipartimento di Scienze Cardio-Toraco-Vascolari e Sanità Pubblica, Università Degli Studi di Padova, 35121 Padova, Italy; (A.M.N.); (A.T.)
| | - Stefano Marchini
- Laboratorio Malattie Rare-Settore Porfirie, Dipartimento di Scienze Mediche, Chirurgiche, Materno-Infantili e Dell’Adulto, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41125 Modena, Italy;
| | - Silvia Fustinoni
- EPIGET-Epidemiology, Epigenetics, and Toxicology Lab, Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (R.M.); (D.T.); (S.F.)
- Environmental and Industrial Toxicology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
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Kiew CK, Lam ASEL. Unexpected presentation of acute porphyria. BMJ Case Rep 2021; 14:14/6/e241580. [PMID: 34187794 DOI: 10.1136/bcr-2021-241580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute porphyrias are rarely reported in Southeast Asia. They may be underdiagnosed due to their clinical mimicry and lack of awareness among physicians. There is a common cognitive bias to gravitate towards common conditions. In this case report, a 28-year-old woman, who presented with seizures, rhabdomyolysis hyponatraemia and altered mental state, was initially diagnosed as amphetamine overdose. She had presented 3 days prior with abdominal pain, treated for acute cystitis and discharged. On readmission for seizures a day later, she was extensively worked up for altered mental state. Despite normalisation of serum sodium concentration and control of her seizures, she remained unwell. Further investigations later confirmed a diagnosis of acute porphyria. The aim of this case report is to highlight the non-specific nature of presentation of acute porphyria and the importance of considering it as a differential diagnosis in cases of abdominal pain with neuropsychiatric features.
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10
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Vassiliou D, Lindén Hirschberg A, Sardh E. Treatment with assisted reproduction technologies in women with acute hepatic porphyria. Acta Obstet Gynecol Scand 2021; 100:1712-1721. [PMID: 34060066 DOI: 10.1111/aogs.14200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Acute porphyrias are rare disorders of the heme biosynthetic pathway and present with acute neurovisceral symptoms that can be induced by hormonal changes and medications. Women are far more likely to present with clinical symptoms than men, particularly during parts of their lifetime with changes in the level of female sex hormones such as ovulation, menstruation, and pregnancy. Treatment of ovulatory dysfunction and controlled ovarian hyperstimulation require the administration of hormones, which are considered porphyrinogenic. Women with acute hepatic porphyria have therefore been considered unsuitable for such treatments in the past. MATERIAL AND METHODS We report on nine women with acute hepatic porphyria who underwent in vitro fertilization (IVF), preceded by ovarian stimulation. Their mean age at the start of IVF was 33.2 years (range 27-38 years). Two women had been diagnosed with polycystic ovarian syndrome, two were treated for hyperprolactinemia, two had hypothyroidism, of which one also had type 1 diabetes, one had a uterus malformation, one had anovulatory cycles, and one used a sperm donor. RESULTS All patients were able to undergo fertility treatment without experiencing severe porphyria attacks. CONCLUSIONS Women with acute hepatic porphyria considering fertility treatments should be assessed individually for potential risks, treatment should be planned in close collaboration with a porphyria specialist, and biochemical activity should be monitored regularly during ovarian stimulation. As we gather more knowledge, we hope that the porphyrinogenicity of the stimulation agents is re-assessed and that more studies will shed light on the reproductive health of women living with acute hepatic porphyria.
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Affiliation(s)
- Daphne Vassiliou
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden.,Porphyria Center Sweden, Center for Inherited Metabolic Diseases (CMMS), Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Angelica Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Eliane Sardh
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden.,Porphyria Center Sweden, Center for Inherited Metabolic Diseases (CMMS), Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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11
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Abstract
PURPOSE OF REVIEW Acute hepatic porphyrias (AHP) are a group of rare diseases that are characterized by episodic acute neurovisceral pain episodes caused by abnormal accumulation of the neurotoxic porphyrin precursor delta-aminolevulinic acid (ALA). Patient with frequent recurrent acute attacks have been difficult to treat and these patients sometimes require liver transplantation. Recent developments in small interfering RNA (siRNA)-based therapy led to the development of an effective prophylactic treatment for patients with frequent recurrent attacks. This review will describe treatment options for AHP and highlight management in light of new treatment option. RECENT FINDINGS Givosiran is a novel siRNA-based therapy targeted specifically to hepatocytes to inhibit ALA synthase 1, the first and rate-limiting step in heme biosynthesis. Patients with frequent recurrent attacks treated with givosiran had durable normalization of ALA and significantly reduced numbers of acute attacks and need for hemin treatment. The overall safety profile for givosiran was comparable with placebo and the drug was recently approved by the Food and Drug Administration for treatment of AHP patients. SUMMARY Givosiran is an effective treatment for prevention of acute porphyria attacks in AHP patients with frequent recurrent attacks.
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Affiliation(s)
- Bruce Wang
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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12
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Abstract
The acute hepatic porphyrias (AHP) are a group of four inherited diseases of heme biosynthesis. They present with similar severe, episodic, acute neurovisceral symptoms due to abnormally elevated levels of porphyrin precursors delta-aminolevulinic acid (ALA). Recently genetic screening indicates that the prevalence of mutation carrier state is more common than previously thought, occurring in 1 in 1,500, though the clinical penetrance of symptomatic AHP is low at ~1%. Symptomatic attacks occur primarily in females during their reproductive years. In an acute porphyria attack, the primary symptom is abdominal pain, due to intestinal dysmotility from autonomic nerve injury. Other manifestations include seizures, weakness and mood changes, point to injury involving peripheral and central nervous system. Due to the non-specific nature of the symptoms and signs in AHP, the diagnosis is often delayed by many years. The diagnosis of AHP depends on biochemical evidence of elevated ALA and PBG levels in urine during symptomatic attacks. Genetic testing is used for confirmation of the gene involved and the exact mutation. Treatment involves administration of heme, which downregulates production of ALA. Long-term management centers on educating genetic carriers on avoiding triggers that increase the risk of acute attacks and screening family members.
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Affiliation(s)
- Bruce Wang
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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13
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Acute hepatic porphyria and anaesthesia: a practical approach to the prevention and management of acute neurovisceral attacks. BJA Educ 2020; 21:66-74. [PMID: 33889432 DOI: 10.1016/j.bjae.2020.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 11/20/2022] Open
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14
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Bustad HJ, Toska K, Schmitt C, Vorland M, Skjærven L, Kallio JP, Simonin S, Letteron P, Underhaug J, Sandberg S, Martinez A. A Pharmacological Chaperone Therapy for Acute Intermittent Porphyria. Mol Ther 2019; 28:677-689. [PMID: 31810863 PMCID: PMC7001003 DOI: 10.1016/j.ymthe.2019.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 11/26/2022] Open
Abstract
Mutations in hydroxymethylbilane synthase (HMBS) cause acute intermittent porphyria (AIP), an autosomal dominant disease where typically only one HMBS allele is mutated. In AIP, the accumulation of porphyrin precursors triggers life-threatening neurovisceral attacks and at long-term, entails an increased risk of hepatocellular carcinoma, kidney failure, and hypertension. Today, the only cure is liver transplantation, and a need for effective mechanism-based therapies, such as pharmacological chaperones, is prevailing. These are small molecules that specifically stabilize a target protein. They may be developed into an oral treatment, which could work curatively during acute attacks, but also prophylactically in asymptomatic HMBS mutant carriers. With the use of a 10,000 compound library, we identified four binders that further increased the initially very high thermal stability of wild-type HMBS and protected the enzyme from trypsin digestion. The best hit and a selected analog increased steady-state levels and total HMBS activity in human hepatoma cells overexpressing HMBS, and in an Hmbs-deficient mouse model with a low-expressed wild-type-like allele, compared to untreated controls. Moreover, the concentration of porphyrin precursors decreased in liver of mice treated with the best hit. Our findings demonstrate the great potential of these hits for the development of a pharmacological chaperone-based corrective treatment of AIP by enhancing wild-type HMBS function independently of the patients’ specific mutation.
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Affiliation(s)
- Helene J Bustad
- Department of Biomedicine, University of Bergen, 5020 Bergen, Norway
| | - Karen Toska
- Norwegian Porphyria Centre (NAPOS), Laboratory for Clinical Biochemistry, Haukeland University Hospital, 5021 Bergen, Norway
| | - Caroline Schmitt
- Assistance Publique Hôpitaux de Paris (AP-HP), Centre Français des Porphyries, Hôpital Louis Mourier, 92700 Colombes, France; INSERM U1149, Center for Research on Inflammation (CRI), Université de Paris, 75018 Paris, France
| | - Marta Vorland
- Norwegian Porphyria Centre (NAPOS), Laboratory for Clinical Biochemistry, Haukeland University Hospital, 5021 Bergen, Norway
| | - Lars Skjærven
- Department of Biomedicine, University of Bergen, 5020 Bergen, Norway
| | - Juha P Kallio
- Department of Biomedicine, University of Bergen, 5020 Bergen, Norway
| | - Sylvie Simonin
- Assistance Publique Hôpitaux de Paris (AP-HP), Centre Français des Porphyries, Hôpital Louis Mourier, 92700 Colombes, France; INSERM U1149, Center for Research on Inflammation (CRI), Université de Paris, 75018 Paris, France
| | - Philippe Letteron
- INSERM U1149, Center for Research on Inflammation (CRI), Université de Paris, 75018 Paris, France
| | - Jarl Underhaug
- Department of Chemistry, University of Bergen, 5020 Bergen, Norway
| | - Sverre Sandberg
- Norwegian Porphyria Centre (NAPOS), Laboratory for Clinical Biochemistry, Haukeland University Hospital, 5021 Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, 5020 Bergen, Norway; The Norwegian Quality Improvement of Primary Care Laboratories, Haraldsplass Deaconess Hospital, 5009 Bergen, Norway
| | - Aurora Martinez
- Department of Biomedicine, University of Bergen, 5020 Bergen, Norway.
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15
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Anderson KE. Acute hepatic porphyrias: Current diagnosis & management. Mol Genet Metab 2019; 128:219-227. [PMID: 31311713 PMCID: PMC6911835 DOI: 10.1016/j.ymgme.2019.07.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 05/27/2019] [Accepted: 07/04/2019] [Indexed: 12/19/2022]
Abstract
Each of the four acute hepatic porphyrias is due to mutation of an enzyme in the heme biosynthetic pathway. The accumulation of pathway intermediates that occur most notably when these diseases are active is the basis for screening and establishing a biochemical diagnosis of these rare disorders. Measurement of enzyme activities and especially DNA testing also are important for diagnosis. Suspicion of the diagnosis and specific testing, particularly measurement of urinary porphobilinogen, are often delayed because the symptoms are nonspecific, even when severe. Urinary porphyrins are also measured, but their elevation is much less specific. If porphobilinogen is elevated, second line testing will establish the type of acute porphyria. DNA testing identifies the familial mutation and enables screening of family members. Management includes removal of triggering factors whenever possible. Intravenous hemin is the most effective treatment for acute attacks. Carbohydrate loading is sometimes used for mild attacks. Cyclic attacks, if frequent, can be prevented by a GnRH analogue. Frequent noncyclic attacks are sometime preventable by scheduled (e.g. weekly) hemin infusions. Long term complications may include chronic pain, renal impairment and liver cancer. Other treatments, including RNA interference, are under development.
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Affiliation(s)
- Karl E Anderson
- The University of Texas Medical Branch, Department of Preventive Medicine and Community Health and Internal Medicine, 301 University Boulevard, Galveston, TX 77555-1109, United States of America.
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16
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Stölzel U, Doss MO, Schuppan D. Clinical Guide and Update on Porphyrias. Gastroenterology 2019; 157:365-381.e4. [PMID: 31085196 DOI: 10.1053/j.gastro.2019.04.050] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 04/07/2019] [Accepted: 04/10/2019] [Indexed: 12/24/2022]
Abstract
Physicians should be aware of porphyrias, which could be responsible for unexplained gastrointestinal, neurologic, or skin disorders. Despite their relative rarity and complexity, most porphyrias can be easily defined and diagnosed. They are caused by well-characterized enzyme defects in the complex heme biosynthetic pathway and are divided into categories of acute vs non-acute or hepatic vs erythropoietic porphyrias. Acute hepatic porphyrias (acute intermittent porphyria, variegate porphyria, hereditary coproporphyria, and aminolevulinic acid dehydratase deficient porphyria) manifest in attacks and are characterized by overproduction of porphyrin precursors, producing often serious abdominal, psychiatric, neurologic, or cardiovascular symptoms. Patients with variegate porphyria and hereditary coproporphyria can present with skin photosensitivity. Diagnosis relies on measurement of increased urinary 5-aminolevulinic acid (in patients with aminolevulinic acid dehydratase deficient porphyria) or increased 5-aminolevulinic acid and porphobilinogen (in patients with other acute porphyrias). Management of attacks requires intensive care, strict avoidance of porphyrinogenic drugs and other precipitating factors, caloric support, and often heme therapy. The non-acute porphyrias are porphyria cutanea tarda, erythropoietic protoporphyria, X-linked protoporphyria, and the rare congenital erythropoietic porphyria. They lead to the accumulation of porphyrins that cause skin photosensitivity and occasionally severe liver damage. Secondary elevated urinary or blood porphyrins can occur in patients without porphyria, for example, in liver diseases, or iron deficiency. Increases in porphyrin precursors and porphyrins are also found in patients with lead intoxication. Patients with porphyria cutanea tarda benefit from iron depletion, hydroxychloroquine therapy, and, if applicable, elimination of the hepatitis C virus. An α-melanocyte-stimulating hormone analogue can reduce sunlight sensitivity in patients with erythropoietic protoporphyria or X-linked protoporphyria. Strategies to address dysregulated or dysfunctional steps within the heme biosynthetic pathway are in development.
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Affiliation(s)
- Ulrich Stölzel
- Saxony Porphyria Center, Department of Internal Medicine II, Klinikum Chemnitz, Chemnitz, Germany
| | - Manfred O Doss
- German Competence Center for Porphyria Diagnosis and Consultation, Marburg, Germany; Institute of Translational Immunology and Research Center for Immune Therapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Detlef Schuppan
- Institute of Translational Immunology and Research Center for Immune Therapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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17
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Williams GR, Nerenz RD. Not Your Ordinary Rash. Clin Chem 2019; 65:733-737. [PMID: 31138547 DOI: 10.1373/clinchem.2018.291344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 09/04/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Grace R Williams
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH.,The Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Robert D Nerenz
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH; .,The Geisel School of Medicine at Dartmouth, Hanover, NH
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18
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Borrero Corte MJ, Jara Rubio F, Morán Jiménez MJ, Díaz Díaz S, Castelbón Fernandez FJ, García Pastor I, Enríquez de Salamanca R, Méndez M. Molecular analysis of 19 Spanish patients with mixed porphyrias. Eur J Med Genet 2018; 62:103589. [PMID: 30476629 DOI: 10.1016/j.ejmg.2018.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 11/12/2018] [Accepted: 11/22/2018] [Indexed: 01/07/2023]
Abstract
Porphyrias are rare diseases caused by alterations in the heme biosynthetic pathway. Depending on the afected enzyme, porphyrin precursors or porphyrins are overproduced, causing acute neurovisceral attacks or dermal photosensitivity, respectively. Hereditary Coproporphyria (HCP) and Variegate Porphyria (VP) are mixed porphyrias since they can present acute and/or cutaneous symptoms. These diseases are caused by a deficiency of coproporphyrinogen oxidase (CPOX) in HCP, and protoporphyrinogen oxidase (PPOX) in VP. Herein, we studied nineteen unrelated Spanish patients with mixed porphyrias. The diagnosis of either, HCP or VP was made on the basis of clinical symptoms, biochemical findings and the identification of the mutation responsible in the CPOX or PPOX genes. Two patients presented both acute and cutaneous symptoms. In most patients, the biochemical data allowed the diagnosis. Among eleven patients with HCP, ten CPOX mutations were identified, including six novel ones: two frameshift (c.32delG and c.1102delC), two nonsense (p.Cys239Ter and p.Tyr365Ter), one missense (p.Trp275Arg) and one amino acid deletion (p.Gly336del). Moreover, seven previously described PPOX mutations were identified in eight patients with VP. The impacts of CPOX mutations p.Trp275Arg and p.Gly336del, were evaluated using prediction softwares and their functional consequences were studied in a prokaryotic expression system. Both alterations were predicted as deleterious by in silico analysis. Aditionally, when these alleles were expressed in E. coli, only p.Trp275Arg retained some residual activity. These results emphasize the usefulness of integrated the biochemical tests and molecular studies in the diagnosis. Furthermore, they extend knowledge on the molecular heterogeneity of mixed porphyrias in Spain.
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Affiliation(s)
| | | | | | - Silvia Díaz Díaz
- Servicio de Análisis Clínicos, Hospital 12 de Octubre, Madrid, Spain
| | | | | | | | - Manuel Méndez
- Instituto de Investigación Hospital 12 de Octubre, Madrid, Spain.
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19
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Kakoullis L, Louppides S, Papachristodoulou E, Panos G. Porphyrias and photosensitivity: pathophysiology for the clinician. Postgrad Med 2018; 130:673-686. [PMID: 30296862 DOI: 10.1080/00325481.2018.1533380] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Porphyrias are disorders caused by defects in the biosynthetic pathway of heme. Their manifestations can be divided into three distinct syndromes, each attributable to the accumulation of three distinct classes of molecules. The acute neurovisceral syndrome is caused by the accumulation of the neurotoxic porphyrin precursors, delta aminolevulinic acid, and porphobilinogen; the syndrome of immediate painful photosensitivity is caused by the lipid-soluble protoporphyrin IX and, the syndrome of delayed blistering photosensitivity, caused by the water-soluble porphyrins, uroporphyrin, and coproporphyrin. Porphyrias can manifest with one, or with a combination, of these syndromes, depending on whether one or more types of molecules are being accumulated. Iron plays a significant role in some of these conditions, as evidenced by improvements in both clinical manifestations and laboratory parameters, following iron depletion in porphyria cutanea tarda, or iron administration in some cases of X-linked erythropoietic protoporphyria. While the pathophysiology of a specific type of porphyrias, the protoporphyrias, appears to favor the administration of zinc, results so far have been conflicting, necessitating further studies in order to assess its potential benefit. The pathways involved in each disease, as well as insights into their pathobiological processes are presented, with an emphasis on the development of photosensitivity reactions.
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Affiliation(s)
- Loukas Kakoullis
- a Department of Internal Medicine , Nicosia General Hospital, University of Cyprus Medical School , Nicosia , Cyprus
| | - Stylianos Louppides
- a Department of Internal Medicine , Nicosia General Hospital, University of Cyprus Medical School , Nicosia , Cyprus
| | - Eleni Papachristodoulou
- a Department of Internal Medicine , Nicosia General Hospital, University of Cyprus Medical School , Nicosia , Cyprus
| | - George Panos
- a Department of Internal Medicine , Nicosia General Hospital, University of Cyprus Medical School , Nicosia , Cyprus.,b Department of Internal Medicine, Section of Infectious Diseases , Patras University General Hospital, University of Patras School of Medicine , Patras , Greece
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20
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21
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Oosthuizen NM, Olivier J, Martins J, Schutte C, Pillay TS. Red-Brown Urine in a Patient with Chronic HIV Infection and Quadriparesis. Clin Chem 2018; 62:1181-4. [PMID: 27573452 DOI: 10.1373/clinchem.2015.250746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/29/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Nicholette M Oosthuizen
- Department of Chemical Pathology, Faculty of Health Sciences, University of Pretoria & NHLS-Tshwane Academic Division (TAD), Pretoria, South Africa
| | - Janine Olivier
- Department of Chemical Pathology, Faculty of Health Sciences, University of Pretoria & NHLS-Tshwane Academic Division (TAD), Pretoria, South Africa
| | - Janine Martins
- Department of Chemical Pathology, Faculty of Health Sciences, University of Pretoria & NHLS-Tshwane Academic Division (TAD), Pretoria, South Africa
| | - Clara Schutte
- Department of Neurology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Tahir S Pillay
- Department of Chemical Pathology, Faculty of Health Sciences, University of Pretoria & NHLS-Tshwane Academic Division (TAD), Pretoria, South Africa; Division of Chemical Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
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22
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Abstract
Acute porphyrias are rare inherited disorders due to deficiencies of haem synthesis enzymes. To date, all UK cases have been one of the three autosomal dominant forms, although penetrance is low and most gene carriers remain asymptomatic. Clinical presentation is typically with acute neurovisceral attacks characterised by severe abdominal pain, vomiting, tachycardia and hypertension. Severe attacks may be complicated by hyponatraemia, peripheral neuropathy sometimes causing paralysis, seizures and psychiatric features. Attacks are triggered by prescribed drugs, alcohol, hormonal changes, fasting or stress. The diagnosis is made by finding increased porphobilinogen excretion in a light-protected random urine sample. Management includes administration of intravenous human haemin and supportive treatment with non-porphyrinogenic drugs. A few patients develop recurrent attacks, a chronic illness requiring specialist management. Late complications include chronic pain, hepatocellular carcinoma, chronic renal failure and hypertension. In the UK, the National Acute Porphyria Service provides clinical advice and supplies haemin when indicated.
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Affiliation(s)
- Penelope E Stein
- Department of Haematological Medicine, King's College Hospital, London, UK
| | - Michael N Badminton
- Department of Medical Biochemistry and Immunology, University Hospital of Wales, Cardiff, UK
| | - David C Rees
- Department of Haematological Medicine, King's College Hospital, London, UK
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23
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Schulenburg-Brand D, Katugampola R, Anstey AV, Badminton MN. The Cutaneous Porphyrias. Dermatol Clin 2014; 32:369-84, ix. [DOI: 10.1016/j.det.2014.03.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Ferrer MD, Tauler P, Sureda A, Palacín C, Tur JA, Pons A. Antioxidants restore protoporphyrinogen oxidase in variegate porphyria patients. Eur J Clin Invest 2013; 43:668-78. [PMID: 23601071 DOI: 10.1111/eci.12091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 03/15/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Variegate porphyria (VP) is the result of decreased protoporphyrinogen oxidase (PPOX) activity and results in the accumulation of porphyrins and porphyrin precursors. Our aims were to analyse the basal antioxidant defences and oxidative damage markers and the effects of a diet supplementation with vitamins E and C on the oxidant/antioxidant status and PPOX gene expression in lymphocytes of variegate porphyria (VP) patients. MATERIALS AND METHODS Twelve women affected by VP and 12 control women participated in a randomized and double-blind crossover study. Each participant took either 50 mg/day vitamin E and 150 mg/day vitamin C or a placebo for 6 months. RESULTS Lymphocyte PPOX gene expression, together with catalase and glutathione peroxidase activities, was reduced in VP women. No differences were observed in the levels of malondialdehyde and protein carbonyl derivatives. Stimulated lymphocyte H2 O2 production was higher in porphyric women. Supplementation with antioxidant vitamins increased PPOX expression in VP patients. Glutathione reductase (GRd) and superoxide dismutase (SOD) activities were higher in the treatment groups. CONCLUSIONS Lymphocytes from VP patients show reduced PPOX expression and present a greater susceptibility to producing H2 O2 and impaired H2 O2 detoxifying mechanisms. Supplementation with vitamins E and C restores PPOX expression in VP patients and enhances GRd and SOD activity, suggesting the potential benefits of a diet rich in vitamins E and C in these patients.
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Affiliation(s)
- Miguel D Ferrer
- Laboratori de Ciències de l'Activitat Física, Departament de Biologia Fonamental i Ciències de la Salut, Grup de Nutrició Comunitaria i Estrés Oxidatiu, IUNICS, Universitat de les Illes Balears, Palma de Mallorca, Spain
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26
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Barbaro M, Kotajärvi M, Harper P, Floderus Y. Partial protoporphyrinogen oxidase (PPOX) gene deletions, due to different Alu-mediated mechanisms, identified by MLPA analysis in patients with variegate porphyria. Orphanet J Rare Dis 2013; 8:13. [PMID: 23324528 PMCID: PMC3554555 DOI: 10.1186/1750-1172-8-13] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 01/09/2013] [Indexed: 11/10/2022] Open
Abstract
Variegate porphyria (VP) is an autosomal dominantly inherited hepatic porphyria. The genetic defect in the PPOX gene leads to a partial defect of protoporphyrinogen oxidase, the penultimate enzyme of heme biosynthesis. Affected individuals can develop cutaneous symptoms in sun-exposed areas of the skin and/or neuropsychiatric acute attacks. The identification of the genetic defect in VP families is of crucial importance to detect the carrier status which allows counseling to prevent potentially life threatening neurovisceral attacks, usually triggered by factors such as certain drugs, alcohol or fasting.In a total of 31 Swedish VP families sequence analysis had identified a genetic defect in 26. In the remaining five families an extended genetic investigation was necessary. After the development of a synthetic probe set, MLPA analysis to screen for single exon deletions/duplications was performed.We describe here, for the first time, two partial deletions within the PPOX gene detected by MLPA analysis. One deletion affects exon 5 and 6 (c.339-197_616+320del1099) and has been identified in four families, most probably after a founder effect. The other extends from exon 5 to exon 9 (c.339-350_987+229del2609) and was found in one family. We show that both deletions are mediated by Alu repeats.Our findings emphasize the usefulness of MLPA analysis as a complement to PPOX gene sequencing analysis for comprehensive genetic diagnostics in patients with VP.
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Affiliation(s)
- Michela Barbaro
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital, Stockholm, Sweden
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27
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Abstract
Porphyric neuropathy often poses a diagnostic dilemma; it is typically associated with the hepatic porphyrias, characterized by acute life-threatening attacks of neurovisceral symptoms that mimic a range of acute medical and psychiatric conditions. The development of acute neurovisceral attacks is responsive to environmental factors, including drugs, hormones, and diet. This chapter reviews the clinical manifestations, genetics, pathophysiology, and mechanisms of neurotoxicity of the acute hepatic porphyrias. While the etiology of the neurological manifestations in the acute porphyrias remains undefined, the main hypotheses include toxicity of porphyrin precursors and deficiency of heme synthesis. These hypotheses will be discussed with reference to novel experimental models of porphyric neuropathy.
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Affiliation(s)
- Cindy Shin-Yi Lin
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia.
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Simon NG, Herkes GK. The neurologic manifestations of the acute porphyrias. J Clin Neurosci 2011; 18:1147-53. [DOI: 10.1016/j.jocn.2011.01.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 01/11/2011] [Accepted: 01/26/2011] [Indexed: 12/17/2022]
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Barbaro M, Kotajärvi M, Harper P, Floderus Y. Identification of an AluY-mediated deletion of exon 5 in the CPOX gene by MLPA analysis in patients with hereditary coproporphyria. Clin Genet 2011; 81:249-56. [PMID: 21231929 DOI: 10.1111/j.1399-0004.2011.01628.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hereditary coproporphyria (HCP) is an autosomal dominantly inherited hepatic porphyria, caused by a mutation in the coproporphyrinogen oxidase (CPOX) gene. The genetic defect leads to a partial defect of CPOX, the sixth enzyme involved in haem biosynthesis. Affected individuals can develop acute life-threatening attacks of neurovisceral symptoms and/or more rarely cutaneous symptoms such as skin fragility and blistering. The identification of the genetic defect in HCP families is of crucial importance to detect the carrier status which allows counselling to prevent possible triggering factors, e.g. certain drugs, alcohol, or fasting. In a total of nine Swedish HCP families, routine gene sequence analysis had identified a causative mutation in only five. In the present study, using an in-house developed synthetic probe set for multiplex ligation-dependent probe amplification (MLPA) analysis, we detected a deletion of the fifth exon in the CPOX gene in the remaining four families. The deletion is 3381 bp in size and has originated by an Alu-mediated mechanism. This finding emphasizes the usefulness of MLPA analysis as a complement to gene sequencing for comprehensive genetic diagnostics in HCP patients.
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Affiliation(s)
- M Barbaro
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Zschocke J. Dominant versus recessive: molecular mechanisms in metabolic disease. J Inherit Metab Dis 2008; 31:599-618. [PMID: 18932014 DOI: 10.1007/s10545-008-1016-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2008] [Revised: 08/13/2008] [Accepted: 08/14/2008] [Indexed: 12/17/2022]
Abstract
Inborn errors of metabolism used to be regarded as simple monogenic traits, but a closer look at how different alleles of a gene determine different phenotypes shows that the molecular mechanisms in the individual case are often complicated. Most metabolic disorders represent a spectrum of phenotypes from normal via attenuated to severe (and sometimes prenatally fatal), and disease manifestation is often influenced by other specific genetic or exogenous factors. The terms 'dominant' or 'recessive' relate to the functional consequences of differing alleles in the (compound) heterozygous individual; the terms are irrelevant for homozygous individuals and inappropriate for X-linked disorders. Mutations affecting the same amino acid residue may be associated with different inheritance patterns. True dominant inheritance in metabolism is rare; it may be found e.g. in tightly regulated biosynthetic pathways or when minor changes in metabolite concentrations have a functional effect. Some disorders such as erythropoietic protoporphyria show pseudodominant inheritance due to prevalent loss-of-function polymorphisms in the general population and are better acknowledged as recessive traits. The term 'variable expressivity' is not helpful with regard to autosomal recessive disorders when variable phenotypes are explained by different mutations in the respective gene. Clonal unmasking of a heterozygous mutation through somatic loss of the second allele, the main pathomechanism in inherited tumour predisposition syndromes, is rare in metabolic disorders, but focal congenital hyperinsulinism is a notable exception. Somatic mosaicism for an OTC gene mutation is given as an example of an apparently heterozygous mutation pattern in a boy with an X-linked disease.
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Affiliation(s)
- Johannes Zschocke
- Institute of Human Genetics, Heidelberg University, Heidelberg, Germany.
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Ajioka RS, Phillips JD, Kushner JP. Biosynthesis of heme in mammals. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2006; 1763:723-36. [PMID: 16839620 DOI: 10.1016/j.bbamcr.2006.05.005] [Citation(s) in RCA: 341] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2006] [Revised: 05/10/2006] [Accepted: 05/11/2006] [Indexed: 11/30/2022]
Abstract
Most iron in mammalian systems is routed to mitochondria to serve as a substrate for ferrochelatase. Ferrochelatase inserts iron into protoporphyrin IX to form heme which is incorporated into hemoglobin and cytochromes, the dominant hemoproteins in mammals. Tissue-specific regulatory features characterize the heme biosynthetic pathway. In erythroid cells, regulation is mediated by erythroid-specific transcription factors and the availability of iron as Fe/S clusters. In non-erythroid cells the pathway is regulated by heme-mediated feedback inhibition. All of the enzymes in the heme biosynthetic pathway have been crystallized and the crystal structures have permitted detailed analyses of enzyme mechanisms. All of the genes encoding the heme biosynthetic enzymes have been cloned and mutations of these genes are responsible for a group of human disorders designated the porphyrias and for X-linked sideroblastic anemia. The biochemistry, structural biology and the mechanisms of tissue-specific regulation are presented in this review along with the key features of the porphyric disorders.
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Affiliation(s)
- Richard S Ajioka
- Department of Internal Medicine, Division of Hematology, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
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von und zu Fraunberg M, Timonen K, Mustajoki P, Kauppinen R. Clinical and biochemical characteristics and genotype-phenotype correlation in Finnish variegate porphyria patients. Eur J Hum Genet 2002; 10:649-57. [PMID: 12357337 DOI: 10.1038/sj.ejhg.5200860] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2001] [Revised: 06/18/2002] [Accepted: 06/19/2002] [Indexed: 11/09/2022] Open
Abstract
Variegate porphyria (VP) is an inherited metabolic disease resulting from the partial deficiency of protoporphyrinogen oxidase, the penultimate enzyme in the heme biosynthetic pathway. We have evaluated the clinical and biochemical outcome of 103 Finnish VP patients diagnosed between 1966 and 2001. Fifty-two per cent of patients had experienced clinical symptoms: 40% had photosensitivity, 27% acute attacks and 14% both manifestations. The proportion of patients with acute attacks has decreased dramatically from 38 to 14% in patients diagnosed before and after 1980, whereas the prevalence of skin symptoms had decreased only subtly from 45 to 34%. We have studied the correlation between PPOX genotype and clinical outcome of 90 patients with the three most common Finnish mutations I12T, R152C and 338G-->C. The patients with the I12T mutation experienced no photosensitivity and acute attacks were rare (8%). Therefore, the occurrence of photosensitivity was lower in the I12T group compared to the R152C group (P=0.001), whereas no significant differences between the R152C and 338G-->C groups could be observed. Biochemical abnormalities were significantly milder suggesting a milder form of the disease in patients with the I12T mutation. In all VP patients, normal excretion of protoporphyrin in faeces in adulthood predicted freedom from both skin symptoms and acute attacks. The most valuable test predicting an increased risk of symptoms was urinary coproporphyrin, but only a substantially increased excretion exceeding 1,000 nmol/day was associated with an increased risk of both skin symptoms and acute attacks. All patients with an excretion of more than 1,000 nmol/day experienced either skin symptoms, acute attacks, or both.
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Affiliation(s)
- Mikael von und zu Fraunberg
- Department of Medicine, Division of Endocrinology, University Central Hospital of Helsinki, Biomedicum Helsinki, Helsinki, Finland.
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Affiliation(s)
- S Twaddle
- Kings College School of Medicine, Department of Clinical Biochemistry, London, UK
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Abstract
Current models for regulation of heme synthesis during erythropoiesis propose that the first enzyme of the pathway, 5-aminolevulinate synthase (ALAS), is the rate-limiting enzyme. We have examined cellular porphyrin excretion in differentiating murine erythroleukemia cells to determine in situ rate-limiting steps in heme biosynthesis. The data demonstrate that low levels of coproporphyrin and protoporphyrin accumulate in the culture medium under normal growth conditions and that during erythroid differentiation the level of excretion of coproporphyrin increases approximately 100-fold. Iron supplementation lowered, but did not eliminate, porphyrin accumulation. While ALAS induction is necessary for increased heme synthesis, these data indicate that other enzymes, in particular coproporphyrinogen oxidase, represent down-stream rate-limiting steps.
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Affiliation(s)
- S I Woodard
- Department of Microbiology, University of Georgia, Athens 30602, USA
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Abstract
Porphyrias are divided into erythropoietic and hepatic manifestations. Erythropoietic porphyrias are characterized by cutaneous symptoms and appear in early childhood. Erythropoietic protoporphyria is complicated by cholestatic liver cirrhosis and progressive hepatic failure in 10%, of patients. Acute hepatic porphyrias (delta-aminolaevulinic acid dehydratase deficiency porphyria, acute intermittent porphyria, hereditary coproporphyria and variegate porphyria) are characterized by variable extrahepatic gastrointestinal, neurological-psychiatric and cardiovascular manifestations requiring early diagnosis to avoid life-threatening complications. Acute hepatic porphyrias are pharmacogenetic and molecular regulatory diseases (without porphyrin accumulation) mainly induced by drugs, sex hormones, fasting or alcohol. The disease process depends on the derepression of hepatic delta-aminolaevulinic acid synthase following haem depletion. In contrast to the acute porphyrias, nonacute, chronic hepatic porphyrias such as porphyria cutanea tarda are porphyrin accumulation disorders leading to cutaneous symptoms associated with liver disease, especially caused by alcohol or viral hepatitis. Alcohol, oestrogens, haemodialysis, hepatitis C and AIDS are triggering factors. Porphyria cutanea tarda is the most common porphyria, followed by acute intermittent porphyria and erythropoietic protoporphyria. The molecular genetics of the porphyrias is very heterogenous. Nearly every family has its own mutation. The mutations identified account for the corresponding enzymatic deficiencies, which may remain clinically silent throughout life. Thus, the recognition of the overt disorder with extrahepatic manifestations depends on the demonstration of biochemical abnormalities due to these primary defects and compensatory hepatic overexpression of hepatic delta-aminolaevulinic acid synthase in the acute porphyrias. Consequently, haem precursors are synthesized in excess. The increased metabolites upstream of the enzymatic defect are excreted into urine and faeces. The diagnosis is based on their evaluation. Primary enzymatic or molecular analyses are noncontributary and may be misleading. Acute polysymptomatic exacerbations accompany a high excretory constellation of porphyrin precursors delta-aminolaevulinic acid and porphobilinogen. Homozygous or compound heterozygous variants of acute hepatic porphyrias may already manifest in childhood.
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MESH Headings
- Animals
- Humans
- Porphyria Cutanea Tarda/diagnosis
- Porphyria Cutanea Tarda/genetics
- Porphyria Cutanea Tarda/physiopathology
- Porphyria Cutanea Tarda/therapy
- Porphyria, Acute Intermittent/diagnosis
- Porphyria, Acute Intermittent/genetics
- Porphyria, Acute Intermittent/physiopathology
- Porphyria, Acute Intermittent/therapy
- Porphyria, Erythropoietic/diagnosis
- Porphyria, Erythropoietic/genetics
- Porphyria, Erythropoietic/physiopathology
- Porphyria, Erythropoietic/therapy
- Porphyrias, Hepatic/diagnosis
- Porphyrias, Hepatic/genetics
- Porphyrias, Hepatic/physiopathology
- Porphyrias, Hepatic/therapy
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Affiliation(s)
- U Gross
- Division of Clinical Biochemistry, Faculty of Medicine, Philipps University, Marburg, Germany.
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Kotze MJ, De Villiers JN, Groenewald JZ, Rooney RN, Loubser O, Thiart R, Oosthuizen CJ, van Niekerk MM, Groenewald IM, Retief AE, Warnich L. Molecular analysis reveals a high mutation frequency in the first untranslated exon of the PPOX gene and largely excludes variegate porphyria in a subset of clinically affected Afrikaner families. Mol Cell Probes 1998; 12:293-300. [PMID: 9778454 DOI: 10.1006/mcpr.1998.0188] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A subset of probands from 11 South African families with clinical and/or biochemical features of variegate porphyria (VP), but without the known protoporphyrinogen oxidase (PPOX) gene defects identified previously in the South African population, were subjected to mutation analysis. Disease-related mutation(s) could not be identified after screening virtually the entire PPOX gene by heteroduplex single-strand conformation polymorphism analysis (HEX-SSCP), although three new sequence variants were detected in exon 1 of the gene in three normal controls. The presence of these single base changes at nucleotide positions 22 (C/G), 27 (C/A) and 127 (C/A), in addition to the known exon 1 polymorphisms I-26 and I-150, indicates that this untranslated region of the PPOX gene is particularly mutation-prone. Furthermore, microsatellite markers flanking the PPOX and alpha-1 antitrypsin (PI) gene, on chromosomes 1 and 14, respectively, were used to assess the probability of involvement of these loci in disease presentation. Common alleles transmitted from affected parent to affected child were determined where possible in the mutation-negative index cases. Allelic frequencies of these <<disease-associated>> alleles were compared to findings in the normal population, but no predominant disease-associated allele could be identified. Co-segregation of a specific haplotype with the disease phenotype could also not be demonstrated in a large Afrikaner family. It is concluded that further studies are warranted to determine the genetic factor(s) underlying the autosomal dominant pattern of inheritance in molecularly uncharacterized cases showing clinical symptoms of an acute porphyria.
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Affiliation(s)
- M J Kotze
- Division of Human Genetics, Faculty of Medicine, University of Stellenbosch, Tygerberg
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Affiliation(s)
- M B Poh-Fitzpatrick
- Department of Dermatology, Columbia University College of Physicians and Surgeons, New York, NY 10019, USA
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Cardalda CA, Juknat AA, Princ FG, Batlle A. Rat harderian gland porphobilinogen deaminase: characterization studies and regulatory action of protoporphyrin IX. Arch Biochem Biophys 1997; 347:69-77. [PMID: 9344466 DOI: 10.1006/abbi.1997.0310] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Properties of purified porphobilinogen deaminase (PBG-D; EC 4.3.1.8) from rat harderian gland are here presented. The enzyme behaves as a monomer of Mr 38 +/- 2 kDa and is optimally active at pH 8.0-8.2. Its activation energy, determined by an Arrhenius plot, is 76.1 kJ/mol. Initial velocity studies showed a linear progress curve for uroporphyringen I formation and a hyperbolic dependence of the initial rate on substrate concentration, indicating the existence of a sequential displacement mechanism. Apparent kinetic constants, Km and Vm, calculated at 37 degrees C and pH 8.0 were 1.1 microM and 170 pmol/min mg, respectively. The pH dependence of the apparent kinetic parameters revealed the ionization of residues with pKAES and pKBES of 7.4 +/- 0.1 and 8.6 +/- 0.1, respectively, and a pKE value of 8.0 +/- 0.1. Incubation of PBG-D with 5.0 mM N-ethylmaleimide and 5.0 mM 5,5'-dithiobis(2-nitrobenzoic acid) at pH 8.0 led to inhibitions of 70 and 50%, respectively. The effect of pH, as well as the effect of thiol reagents, on enzyme activity strongly suggests the involvement of cysteine residue(s) in the mechanism of uroporphyrinogen I biosynthesis, in both the catalytic reaction and the substrate binding. Rat harderian gland PBG-D activity decreased with increasing concentrations of protoporphyrin IX, reaching a 40% inhibition at the in vivo concentration of the porphyrin and 7 microM PBG. Even at saturating concentrations of substrate, inhibition by protoporphyrin was not completely reversed. So, accumulated porphyrin may act as an regulator of PBG-D activity in rat harderian gland.
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Affiliation(s)
- C A Cardalda
- Departamento de Quimica Biologica, Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires Ciudad Universitaria, 1428 Buenos Aires, Argentina
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Krijt J, Stranska P, Maruna P, Vokurka M, Sanitrak J. Herbicide-induced experimental variegate prophyria in mice: tissue porphyrinogen accumulation and response to porphyrogenic drugs. Can J Physiol Pharmacol 1997. [DOI: 10.1139/y97-149] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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40
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Meissner PN, Dailey TA, Hift RJ, Ziman M, Corrigall AV, Roberts AG, Meissner DM, Kirsch RE, Dailey HA. A R59W mutation in human protoporphyrinogen oxidase results in decreased enzyme activity and is prevalent in South Africans with variegate porphyria. Nat Genet 1996; 13:95-7. [PMID: 8673113 DOI: 10.1038/ng0596-95] [Citation(s) in RCA: 150] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Variegate porphyria (VP), a low-penetrant autosomal dominant inherited disorder of haem metabolism, is characterised by photosensitivity (Fig. 1) and a propensity to develop acute neuropsychiatric attacks with abdominal pain, vomiting, constipation, tachycardia, hypertension, psychiatric symptoms and, in the worst cases, quadriplegia. Acute attacks, often precipitated by inappropriate drug therapy, are potentially fatal. While earlier workers thought the distal haem biosynthetic enzyme ferrochelatase may be involved in the genesis of VP, it was shown in the early 1980's, and is now accepted, that VP is associated with decreased protoporphyrinogen oxidase activity (PPO) (E.C.1.3.3.4). VP prevalence is much higher in South Africa than elsewhere; probably due to a founder effect with patients descending from a 17th century Dutch immigrant. PPO cDNAs from Bacillus subtilis, Myxococcus xanthus, human placenta and mouse liver have been cloned, sequenced and expressed. Human and mouse cDNAs consist of open reading frames 1431 nucleotides long, encoding a 477 amino acid protein. The human PPO gene contains thirteen exons, spanning approximately 4.5 kb. We have identified a C to T transition in codon 59 (in exon 3) resulting in an arginine to tryptophan substitution (R59W). A protein expressed from an in vitro-mutagenized PPO construct exhibits substantially less activity than the wild type. The R59W mutation was present in 43 of 45 patients with VP from 26 of 27 South African families investigated, but not in 34 unaffected relatives or 9 unrelated British patients with PPO deficiency. Since at least one of these families is descended from the founder of South African VP, this defect may represent the founder gene defect associated causally with VP in South Africa.
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Affiliation(s)
- P N Meissner
- Lennox Eales Porphyria Laboratories, MRC/UCT Liver Research Centre, University of Cape Town Dept. of Medicine, South Africa
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Warnich L, Meissner PN, Hift RJ, Louw JH, van Heerden CJ, Retief AE. Mapping of the variegate porphyria (VP) gene: contradictory evidence for linkage between VP and microsatellite markers at chromosome 14q32. Hum Genet 1996; 97:690-2. [PMID: 8655155 DOI: 10.1007/bf02281885] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The gene for variegate porphyria (VP), an autosomal dominant disease with a high prevalance in South Africa, evidently due to a founder effect, was previously mapped to chromosome 14q32. In the current study this localization was evaluated by linkage and haplotype analyses using microsatellite markers spanning a region of more than 20 cM on chromosome 14q32. In many recent studies linkage disequilibrium between disease and marker loci has been utilized to map genes in founder populations, but we could not find any association between VP and the markers used in this study. Our data suggest that the allocation of VP to chromosome 14q32 may be incorrect.
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Affiliation(s)
- L Warnich
- Department of Genetics, University of Stellenbosch, South Africa
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Abstract
To summarize recent information about acute porphyrias and to provide clinicians with a practical diagnostic and management approach, we reviewed the pertinent literature and our clinical experience. The acute porphyrias are characterized by recurrent attacks of abdominal pain with or without additional manifestations of autonomic dysfunction or neuropsychiatric symptoms. On the basis of the potential of these disorders to affect the skin, they are further subdivided into neuroporphyrias and neurocutaneous porphyrias. During acute attacks, acute porphyria is always associated with increased levels of urinary porphyrin precursors. Between attacks, patients with neurocutaneous porphyrias may have normal urinary porphyrins; therefore, stool porphyrins, which are invariably increased, are the most helpful. Latent disease can be detected by the measurement of either urinary and stool porphyrins or cellular enzyme activity. Specific intravenous therapy with hematin has resulted in biochemical remissions, but its clinical benefit remains controversial. Measurement of urinary and stool porphyrins or porphyrin precursors is critical for the diagnosis of clinically overt acute porphyria. Enzyme assays are helpful in supporting the diagnosis but are best used to identify family members with latent disease. Preventive measures and supportive therapy are the mainstays of current management of patients with porphyria.
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Affiliation(s)
- A Tefferi
- Division of Hematology and Internal Medicine, Mayo Clinic Rochester, MN 55905
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Affiliation(s)
- A Tefferi
- Division of Hematology and Internal Medicine, Mayo Clinic Rochester, MN 55905
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