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Aerts-Kaya F, van Til NP. Gene and Cellular Therapies for Leukodystrophies. Pharmaceutics 2023; 15:2522. [PMID: 38004502 PMCID: PMC10675548 DOI: 10.3390/pharmaceutics15112522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/13/2023] [Accepted: 10/20/2023] [Indexed: 11/26/2023] Open
Abstract
Leukodystrophies are a heterogenous group of inherited, degenerative encephalopathies, that if left untreated, are often lethal at an early age. Although some of the leukodystrophies can be treated with allogeneic hematopoietic stem cell transplantation, not all patients have suitable donors, and new treatment strategies, such as gene therapy, are rapidly being developed. Recent developments in the field of gene therapy for severe combined immune deficiencies, Leber's amaurosis, epidermolysis bullosa, Duchenne's muscular dystrophy and spinal muscular atrophy, have paved the way for the treatment of leukodystrophies, revealing some of the pitfalls, but overall showing promising results. Gene therapy offers the possibility for overexpression of secretable enzymes that can be released and through uptake, allow cross-correction of affected cells. Here, we discuss some of the leukodystrophies that have demonstrated strong potential for gene therapy interventions, such as X-linked adrenoleukodystrophy (X-ALD), and metachromatic leukodystrophy (MLD), which have reached clinical application. We further discuss the advantages and disadvantages of ex vivo lentiviral hematopoietic stem cell gene therapy, an approach for targeting microglia-like cells or rendering cross-correction. In addition, we summarize ongoing developments in the field of in vivo administration of recombinant adeno-associated viral (rAAV) vectors, which can be used for direct targeting of affected cells, and other recently developed molecular technologies that may be applicable to treating leukodystrophies in the future.
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Affiliation(s)
- Fatima Aerts-Kaya
- Department of Stem Cell Sciences, Graduate School of Health Sciences, Center for Stem Cell Research and Development, Hacettepe University, 06100 Ankara, Turkey;
- Advanced Technologies Application and Research Center, Hacettepe University, 06800 Ankara, Turkey
| | - Niek P. van Til
- Amsterdam Leukodystrophy Center, Emma Children’s Hospital, Amsterdam University Medical Centers, Amsterdam Neuroscience, 1081 HV Amsterdam, The Netherlands
- Department of Integrative Neurophysiology, Center for Neurogenomics and Cognitive Research, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
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Laugwitz L, Santhanakumaran V, Spieker M, Boehringer J, Bender B, Gieselmann V, Beck‐Woedl S, Bruchelt G, Harzer K, Kraegeloh‐Mann I, Groeschel S. Extremely low arylsulfatase A enzyme activity does not necessarily cause symptoms: A long-term follow-up and review of the literature. JIMD Rep 2022; 63:292-302. [PMID: 35822086 PMCID: PMC9259399 DOI: 10.1002/jmd2.12293] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/04/2022] [Accepted: 04/19/2022] [Indexed: 01/22/2023] Open
Abstract
Metachromatic leukodystrophy (MLD) is an autosomal recessive lysosomal storage disease caused by deficiency of arylsulfatase A (ARSA). Heterozygous carriers of disease-causing variants and individuals harbouring pseudodeficiency alleles in the ARSA gene exhibit reduced ARSA activity. In the context of these genotypes, low ARSA activity has been suggested to lead to an atypical form of MLD or other neurological abnormalities, but data are limited. The aim of our study was to analyse the impact of low ARSA activity in two subjects who are heterozygous for the ARSA pseudodeficiency allele and a disease-causing variant. Biochemical testing included ARSA activity measurements and urinary sulfatide analysis. Biochemical data of a large cohort of MLD patients, heterozygotes, pseudodeficient individuals and healthy controls were analysed. MRI was performed at 3T using T1- and T2-weighted sequences and MR spectroscopy. We present two long-term follow-ups who are heterozygous for the ARSA pseudodeficiency allele and a disease-causing variant in the ARSA gene in cis. The two related index cases exhibit markedly reduced ARSA activity compared to controls and heterozygous carriers. The neurological evaluation and MRI do not reveal any abnormalities. Our data underline that extremely low enzyme activity due to a pseudodeficiency allele and a disease-causing variant in the ARSA gene even in cis does not lead to clinical symptoms or pre-symptomatic MRI changes suspicious for MLD. The review of literature corroborates that any association of low ARSA activity with disease features remains questionable. It seems important to combine the measurement of ARSA activity with elevated sulfatide as well as genetic testing, as done in current newborn screening approaches. Heterozygosity for metachromatic leukodystrophy and an arylsulfatase A pseudodeficiency allele does not cause neurological or neuropsychiatric features.
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Affiliation(s)
- Lucia Laugwitz
- Institute of Medical Genetics and Applied GenomicsUniversity of TübingenTübingenGermany
- Department of Neuropediatrics, Developmental Neurology and Social PaediatricsUniversity of TübingenTübingenGermany
| | - Vidiyaah Santhanakumaran
- Department of Neuropediatrics, Developmental Neurology and Social PaediatricsUniversity of TübingenTübingenGermany
| | - Mareike Spieker
- Department of Neuropediatrics, Developmental Neurology and Social PaediatricsUniversity of TübingenTübingenGermany
| | - Judith Boehringer
- Department of Neuropediatrics, Developmental Neurology and Social PaediatricsUniversity of TübingenTübingenGermany
| | - Benjamin Bender
- Diagnostic and Interventional NeuroradiologyRadiologic Clinics, University of TübingenTübingenGermany
| | - Volkmar Gieselmann
- Institute of Biochemistry and Molecular BiologyUniversity of BonnBonnGermany
| | - Stefanie Beck‐Woedl
- Institute of Medical Genetics and Applied GenomicsUniversity of TübingenTübingenGermany
| | - Gernot Bruchelt
- Department of Neuropediatrics, Developmental Neurology and Social PaediatricsUniversity of TübingenTübingenGermany
| | - Klaus Harzer
- Department of Neuropediatrics, Developmental Neurology and Social PaediatricsUniversity of TübingenTübingenGermany
| | - Ingeborg Kraegeloh‐Mann
- Department of Neuropediatrics, Developmental Neurology and Social PaediatricsUniversity of TübingenTübingenGermany
| | - Samuel Groeschel
- Department of Neuropediatrics, Developmental Neurology and Social PaediatricsUniversity of TübingenTübingenGermany
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Beck‐Wödl S, Kehrer C, Harzer K, Haack TB, Bürger F, Haas D, Rieß A, Groeschel S, Krägeloh‐Mann I, Böhringer J. Long-term disease course of two patients with multiple sulfatase deficiency differs from metachromatic leukodystrophy in a broad cohort. JIMD Rep 2021; 58:80-88. [PMID: 33728250 PMCID: PMC7932862 DOI: 10.1002/jmd2.12189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/27/2020] [Accepted: 11/12/2020] [Indexed: 12/16/2022] Open
Abstract
Multiple sulfatase deficiency (MSD) is a lysosomal storage disease caused by a deficiency of formylglycine-generating enzyme due to SUMF1 defects. MSD may be misdiagnosed as metachromatic leukodystrophy (MLD), as neurological and neuroimaging findings are similar, and arylsulfatase A (ARSA) deficiency and enhanced urinary sulfatide excretion may also occur. While ARSA deficiency seems a cause for neurological symptoms and later neurodegenerative disease course, deficiency of other sulfatases results in clinical features such as dysmorphism, dysostosis, or ichthyosis. We report on a girl and a boy of the same origin presenting with severe ARSA deficiency and neurological and neuroimaging features compatible with MLD. However, exome sequencing revealed not yet described homozygosity of the missense variant c.529G > C, p.Ala177Pro in SUMF1. We asked whether dynamics of disease course differs between MSD and MLD. Comparison to a cohort of 59 MLD patients revealed different disease course concerning onset and disease progression in both MSD patients. The MSD patients showed first gross motor symptoms earlier than most patients with juvenile MLD (<10th percentile of Gross-Motor-Function in MLD [GMFC-MLD] 1). However, subsequent motor decline was more protracted (75th and 90th percentile of GMFC-MLD 2 (loss of independent walking) and 75th percentile of GMFC-MLD 5 (loss of any locomotion)). Language decline started clearly after 50th percentile of juvenile MLD and progressed rapidly. Thus, dynamics of disease course may be a further clue for the characterization of MSD. These data may contribute to knowledge of natural course of ultra-rare MSD and be relevant for counseling and therapy.
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Affiliation(s)
- Stefanie Beck‐Wödl
- Institute of Medical Genetics and Applied GenomicsUniversity of TübingenTübingenGermany
| | - Christiane Kehrer
- Department of NeuropediatricsUniversity Children's HospitalTübingenGermany
| | - Klaus Harzer
- Department of NeuropediatricsUniversity Children's HospitalTübingenGermany
| | - Tobias B. Haack
- Institute of Medical Genetics and Applied GenomicsUniversity of TübingenTübingenGermany
| | | | - Dorothea Haas
- Metabolic CentreUniversity Children's HospitalHeidelbergGermany
| | - Angelika Rieß
- Institute of Medical Genetics and Applied GenomicsUniversity of TübingenTübingenGermany
| | - Samuel Groeschel
- Department of NeuropediatricsUniversity Children's HospitalTübingenGermany
| | | | - Judith Böhringer
- Department of NeuropediatricsUniversity Children's HospitalTübingenGermany
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Seker Yilmaz B, Davison J, Jones SA, Baruteau J. Novel therapies for mucopolysaccharidosis type III. J Inherit Metab Dis 2021; 44:129-147. [PMID: 32944950 PMCID: PMC8436764 DOI: 10.1002/jimd.12316] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 12/11/2022]
Abstract
Mucopolysaccharidosis type III (MPS III) or Sanfilippo disease is an orphan inherited lysosomal storage disease and one of the most common MPS subtypes. The classical presentation is an infantile-onset neurodegenerative disease characterised by intellectual regression, behavioural and sleep disturbances, loss of ambulation, and early death. Unlike other MPS, no disease-modifying therapy has yet been approved. Here, we review the numerous approaches of curative therapy developed for MPS III from historical ineffective haematopoietic stem cell transplantation and substrate reduction therapy to the promising ongoing clinical trials based on enzyme replacement therapy or adeno-associated or lentiviral vectors mediated gene therapy. Preclinical studies are presented alongside the most recent translational first-in-man trials. In addition, we present experimental research with preclinical mRNA and gene editing strategies. Lessons from animal studies and clinical trials have highlighted the importance of an early therapy before extensive neuronal loss. A disease-modifying therapy for MPS III will undoubtedly mandate development of new strategies for early diagnosis.
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Affiliation(s)
- Berna Seker Yilmaz
- Genetics and Genomic Medicine, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- Department of Paediatric Metabolic MedicineMersin UniversityMersinTurkey
| | - James Davison
- Metabolic Medicine DepartmentGreat Ormond Street Hospital for Children NHS Foundation TrustLondonUK
| | - Simon A. Jones
- Metabolic MedicineManchester University NHS Foundation TrustManchesterUK
| | - Julien Baruteau
- Genetics and Genomic Medicine, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- Metabolic Medicine DepartmentGreat Ormond Street Hospital for Children NHS Foundation TrustLondonUK
- National Institute of Health Research Great Ormond Street Hospital Biomedical Research CentreLondonUK
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Beschle J, Döring M, Kehrer C, Raabe C, Bayha U, Strölin M, Böhringer J, Bevot A, Kaiser N, Bender B, Grimm A, Lang P, Müller I, Krägeloh-Mann I, Groeschel S. Early clinical course after hematopoietic stem cell transplantation in children with juvenile metachromatic leukodystrophy. Mol Cell Pediatr 2020; 7:12. [PMID: 32910272 PMCID: PMC7483683 DOI: 10.1186/s40348-020-00103-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 08/09/2020] [Indexed: 02/06/2023] Open
Abstract
Background Long-term outcomes of hematopoietic stem cell transplantation (HSCT) in children with juvenile metachromatic leukodystrophy (MLD) have been investigated systematically, while short-term effects of HSCT on the course of the disease remain to be elucidated. Results In this study, the clinical course was evaluated over the first 24 months following HSCT, conducted at our center in 12 children with juvenile MLD (mean follow-up 6.75 years, range 3–13.5) and compared with 35 non-transplanted children with juvenile MLD. Motor function (GMFM-88 and GMFC-MLD), cognitive function (FSIQ), peripheral neuropathy (tibial nerve conduction velocity), and cerebral changes (MLD-MR severity score) were tested prospectively. Seven children remained neurologically stable over a long period, five exhibited rapid disease progression over the first 12 to 18 months after transplantation. In the latter, time from first gross motor symptoms to loss of independent walking was significantly shorter compared with non-transplanted patients at the same stage of disease (p < 0.02). Positive prognostic factors were good motor function (GMFM = 100%, GMFC-MLD = 0) and a low MR severity score (≤ 17) at the time of HSCT. Conclusions Our results show that if disease progression occurs, this happens early on after HSCT and proceeds faster than in non-transplanted children with juvenile MLD, indicating that HSCT may trigger disease progression.
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Affiliation(s)
- Judith Beschle
- Department for Pediatric Neurology, University Children's Hospital, Tübingen, Germany
| | - Michaela Döring
- Department for General Pediatrics, Hematology/Oncology, University Children's Hospital, Tübingen, Germany
| | - Christiane Kehrer
- Department for Pediatric Neurology, University Children's Hospital, Tübingen, Germany
| | - Christa Raabe
- Department for Pediatric Neurology, University Children's Hospital, Tübingen, Germany
| | - Ute Bayha
- Department for Pediatric Neurology, University Children's Hospital, Tübingen, Germany
| | - Manuel Strölin
- Department for Pediatric Neurology, University Children's Hospital, Tübingen, Germany
| | - Judith Böhringer
- Department for Pediatric Neurology, University Children's Hospital, Tübingen, Germany
| | - Andrea Bevot
- Department for Pediatric Neurology, University Children's Hospital, Tübingen, Germany
| | - Nadja Kaiser
- Department for Pediatric Neurology, University Children's Hospital, Tübingen, Germany
| | - Benjamin Bender
- Department of Diagnostic and Interventional Neuroradiology, Tübingen, Germany
| | | | - Peter Lang
- Department for General Pediatrics, Hematology/Oncology, University Children's Hospital, Tübingen, Germany
| | - Ingo Müller
- Department of Pediatric Hematology and Oncology, University Hospital Eppendorf, Hamburg, Germany
| | | | - Samuel Groeschel
- Department for Pediatric Neurology, University Children's Hospital, Tübingen, Germany.
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Orchard PJ. Cellular Therapy in Rare Childhood Neurologic Disease: Lessons, Outcomes, and Access. J Child Neurol 2018; 33:877-881. [PMID: 30203711 DOI: 10.1177/0883073818797875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Paul J Orchard
- 1 Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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7
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Boucher AA, Miller W, Shanley R, Ziegler R, Lund T, Raymond G, Orchard PJ. Long-term outcomes after allogeneic hematopoietic stem cell transplantation for metachromatic leukodystrophy: the largest single-institution cohort report. Orphanet J Rare Dis 2015; 10:94. [PMID: 26245762 PMCID: PMC4545855 DOI: 10.1186/s13023-015-0313-y] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 07/29/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Metachromatic Leukodystrophy (MLD) is a rare, fatal demyelinating disorder with limited treatment options. Published outcomes after hematopoietic stem cell transplantation (HSCT) are scant and mixed. We report survival and function following HSCT for a large, single-center MLD cohort. METHODS Transplant-related data, survival and serial measures (brain MRI, nerve conduction velocity (NCV), neurologic and neuropsychology evaluations) were reviewed. When possible, parental interviews informed current neurologic status, quality-of-life, and adaptive functioning. Gross motor and expressive functions for late-infantile (LI-MLD) and juvenile (J-MLD) patients were described using previously reported, MLD-specific scales. RESULTS Forty patients with confirmed MLD have undergone HSCT at our center. Twenty-one (53 %) survive at a median 12 years post-HSCT. Most deaths (n = 17) were treatment-related; two died from disease progression. Survival did not depend upon MLD subtype or symptom status at transplant. LI-MLD patients survive beyond reported life expectancy in untreated disease. Abnormal brain MRI and peripheral nerve conduction velocities (NCV) were common before HSCT. Following transplant, fewer patients experienced MRI progression compared to NCV deterioration. Sixteen LI-MLD and J-MLD survivors were evaluable for long-term gross motor and/or expressive language functioning using existing MLD clinical scoring systems. While most J-MLD patients regressed, the aggregate cohort demonstrated superior retention of function compared to published natural history. Seventeen LI-MLD, J-MLD and adult subtype (A-MLD) survivors were evaluable for long-term adaptive functioning, activities of daily living, and/or cognition. Relative cognitive sparing was observed despite overall global decline. Five sibling pairs (one LI-MLD and four J-MLD), in which at least one underwent transplant in our cohort, were evaluable. Within each familial dyad, survival or function was superior for the treated sibling, or if both siblings were transplanted, for the pre-symptomatic sibling. CONCLUSIONS HSCT is a viable treatment option for MLD, but has significant limitations. Later-onset phenotypes may benefit most from early, pre-symptomatic transplant. Until superior, novel treatment strategies are demonstrated, MLD patients should be carefully considered for HSCT.
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Affiliation(s)
- Alexander A Boucher
- Department of Internal Medicine and Pediatrics, University of Minnesota, Minneapolis, MN, 55455, USA.
| | - Weston Miller
- Division of Pediatric Blood and Marrow Transplantation, 420 Delaware Street SE, MMC 484, Minneapolis, MN, 55455, USA.
| | - Ryan Shanley
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, 55455, USA.
| | - Richard Ziegler
- Division of Pediatric Clinical Neurosciences, University of Minnesota, Minneapolis, MN, 55455, USA.
| | - Troy Lund
- Division of Pediatric Blood and Marrow Transplantation, 420 Delaware Street SE, MMC 484, Minneapolis, MN, 55455, USA.
| | - Gerald Raymond
- Division of Pediatric Clinical Neurosciences, University of Minnesota, Minneapolis, MN, 55455, USA.
| | - Paul J Orchard
- Division of Pediatric Blood and Marrow Transplantation, 420 Delaware Street SE, MMC 484, Minneapolis, MN, 55455, USA.
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Abstract
Developing therapies for the brain is perhaps the greatest challenge facing modern medicine today. While a great many potential therapies show promise in animal models, precious few make it to approval or are even studied in human patients. The particular challenges to the translation of neurotherapeutics to the clinic are many, but a major barrier is difficulty in delivering therapeutics into the brain. The goal of this workshop was to present ways to deliver therapeutics to the brain, including the limitations of each method, and describe ways to track their delivery, safety, and efficacy. Solving the problem of delivery will aid translation of therapeutics for patients suffering from neurodegeneration and other disorders of the brain.
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Affiliation(s)
- Patricia I Dickson
- Division of Medical Genetics, Department of Pediatrics, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1124 W. Carson Street, HH1, Torrance, CA, 90502, USA,
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Boelens JJ, Orchard PJ, Wynn RF. Transplantation in inborn errors of metabolism: current considerations and future perspectives. Br J Haematol 2014; 167:293-303. [DOI: 10.1111/bjh.13059] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Jaap Jan Boelens
- Paediatric Blood and Marrow Transplantation Programme; University Medical Centre Utrecht; Utrecht The Netherlands
- Laboratory Translational Immunology; University Medical Centre Utrecht; Utrecht The Netherlands
| | - Paul J. Orchard
- Program in Blood and Marrow Transplantation; Department of Pediatrics; University of Minnesota; Minneapolis MN USA
| | - Robert F. Wynn
- Department of Haematology/BMT; Royal Manchester Children's Hospital; Manchester UK
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Hematopoietic SCT: a useful treatment for late metachromatic leukodystrophy. Bone Marrow Transplant 2014; 49:1046-51. [PMID: 24797185 DOI: 10.1038/bmt.2014.93] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 03/10/2014] [Accepted: 03/13/2014] [Indexed: 11/08/2022]
Abstract
In metachromatic leukodystrophy (MLD), the deficiency of the lysosomal enzyme arylsulfatase A (ARSA) leads to demyelination in the central and peripheral nervous system and ultimately to death. Allogeneic hematopoietic SCT (HSCT) is currently the only treatment for adult and late-onset juvenile MLD, although it is still in question because of insufficient follow-up. We wanted to determine whether HSCT could halt the progression of adult and late-onset juvenile MLD. Four treated unrelated patients and three untreated siblings were included in the study, and followed regularly for up to 18 years after transplantation. The patients were assessed from clinical examination, ARSA enzyme levels, magnetic resonance imaging of the brain and neuropsychological and neurophysiological tests. In the treated patients, ARSA levels were normal up to 18 years after transplantation. The parameters evaluated stabilized and remained stable after a latency period of 12-24 months. Two patients live normal lives, partially in a protected environment. The other two patients stabilized at a low cognitive and functional level. One of the controls is demented, one is in a vegetative state and one died. We conclude that, in comparison with their untreated siblings, HSCT halted the progression of the disease in our treated patients.
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Kehrer C, Groeschel S, Kustermann-Kuhn B, Bürger F, Köhler W, Kohlschütter A, Bley A, Steinfeld R, Gieselmann V, Krägeloh-Mann I. Language and cognition in children with metachromatic leukodystrophy: onset and natural course in a nationwide cohort. Orphanet J Rare Dis 2014; 9:18. [PMID: 24499656 PMCID: PMC3922034 DOI: 10.1186/1750-1172-9-18] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 01/10/2014] [Indexed: 12/02/2022] Open
Abstract
Background Metachromatic leukodystrophy (MLD) is a rare, genetic neurodegenerative disease. It leads to progressive demyelination resulting in regression of development and early death. With regard to experimental therapies, knowledge of the natural course of the disease is highly important. We aimed to analyse onset and character of first symptoms in MLD and to provide detailed natural course data concerning language and cognition. Methods Patients with MLD were recruited nationwide within the scope of the German research network LEUKONET. 59 patients’ questionnaires (23 late-infantile, 36 juvenile) were analysed. Results Time from first symptoms (at a median age of 1.5 years in late-infantile and 6 years in juvenile MLD) to diagnosis took one year in late-infantile and two years in juvenile patients on average. Gait disturbances and abnormal movement patterns were first signs in all patients with late-infantile and in most with juvenile MLD. Onset in the latter was additionally characterized by problems in concentration, behaviour and fine motor function (p = 0.0011, p < 0.0001, and p = 0.0012). Half of late-infantile patients did not learn to speak in complete sentences after an initially normal language acquisition. They showed a rapid language decline with first language difficulties at a median age of 2.5 years and complete loss of expressive language within several months (median age 32, range 22–47 months). This was followed by total loss of communication at a median age of around four years. In juvenile patients, language decline was more protracted, and problems in concentration and behaviour were followed by decline in skills for reading, writing and calculating around four years after disease onset. Conclusions Our data reflect the natural course of decline in language and cognition in late-infantile and juvenile MLD in a large cohort over a long observation period. This is especially relevant to juvenile patients where the disease course is protracted and prospective studies are hardly feasible. Knowledge of first symptoms may lead to earlier diagnosis and subsequently to a better outcome following therapeutic intervention. Our data may serve as a reference for individual treatment decisions and for evaluation of clinical outcome after treatment intervention.
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Affiliation(s)
- Christiane Kehrer
- Department of Paediatric Neurology and Developmental Medicine, University Children's Hospital, Hoppe-Seyler-Strasse 1, 72076 Tübingen, Germany.
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Kohlschütter A, Eichler F. Childhood leukodystrophies: a clinical perspective. Expert Rev Neurother 2014; 11:1485-96. [DOI: 10.1586/ern.11.135] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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14
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Krägeloh-Mann I, Groeschel S, Kehrer C, Opherk K, Nägele T, Handgretinger R, Müller I. Juvenile metachromatic leukodystrophy 10 years post transplant compared with a non-transplanted cohort. Bone Marrow Transplant 2013; 48:369-75. [PMID: 22941383 DOI: 10.1038/bmt.2012.155] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 07/12/2012] [Accepted: 07/13/2012] [Indexed: 11/08/2022]
Abstract
Metachromatic leukodystrophy (MLD) is a rare inborn error of metabolism leading to severe neurological symptoms and early death. Hematopoietic SCT (HSCT) is considered a treatment option, but results are inconsistent and comparison with natural history is practically missing. We compare a girl with juvenile MLD 10 years after allogeneic HSCT not only with her untreated sister, but also with a large cohort of untreated patients. The girl received HSCT at the age of 5 years when first motor signs appeared. Over 10 years she was stable with respect to her clinical course and gained cognitive abilities. Magnetic resonance imaging (MRI) showed clear regression of white matter changes and magnetic resonance spectroscopy (MRS) demonstrated a reversal of the initial choline increase and N-acetyl-aspartate (NAA) decrease. Only axonal demyelinating neuropathy showed some progression. Her gross motor function and MRI-scores were clearly better compared with her sister and the cohort of untreated patients. Difference to her sister became apparent only 4 years after HSCT. We conclude that HSCT, early in the course of disease, can lead to stabilization of juvenile MLD with a course clearly different from the natural history. HSCT may prevent disease progression, if performed sufficient time before loss of walking, which typically initiates rapid deterioration.
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Affiliation(s)
- I Krägeloh-Mann
- Department for Pediatric Neurology, University Children's Hospital, Tübingen, Germany
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Batzios SP, Zafeiriou DI. Developing treatment options for metachromatic leukodystrophy. Mol Genet Metab 2012; 105:56-63. [PMID: 22078456 DOI: 10.1016/j.ymgme.2011.10.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 10/10/2011] [Accepted: 10/10/2011] [Indexed: 12/25/2022]
Abstract
Metachromatic leukodystrophy (MLD) represents a devastating lysosomal storage disease characterized by intralysosomal accumulation of the sphingolipid sulfatide in various tissues. Three types of the disease are currently distinguished: the late-infantile, which is the most commonly observed, the juvenile and the adult type. Demyelination represents the main histopathological feature of the disorder, leading to neurological impairment with no curative treatment currently available. Nevertheless, the increased scientific interest on the disease has led to the experimental use of innovative therapeutic approaches in animal models, aiming to provide an effective therapeutic regimen for human patients, as well. This paper provides an overview of developing treatment options among patients with MLD. Apart from hematopoietic stem cell transplantation, already in use for decades, other recent data discussed includes umbilical cord blood and stem cell transplantation, enzyme replacement therapy, gene therapy and autologous hematopoietic transplantation of genetically modified stem cells. Gene therapy with oligodedroglial, neural progenitor, embryonic and microencapsulated recombinant cells represents add-on treatment options still on experimental level.
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Affiliation(s)
- Spyros P Batzios
- 1st Department of Paediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Ding XQ, Bley A, Kohlschütter A, Fiehler J, Lanfermann H. Long-term neuroimaging follow-up on an asymptomatic juvenile metachromatic leukodystrophy patient after hematopoietic stem cell transplantation: evidence of myelin recovery and ongoing brain maturation. Am J Med Genet A 2011; 158A:257-60. [PMID: 22140054 DOI: 10.1002/ajmg.a.34389] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 10/25/2011] [Indexed: 11/07/2022]
Affiliation(s)
- Xiao-Qi Ding
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany.
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18
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Cable C, Finkel RS, Lehky TJ, Biassou NM, Wiggs EA, Bunin N, Pierson TM. Unrelated umbilical cord blood transplant for juvenile metachromatic leukodystrophy: a 5-year follow-up in three affected siblings. Mol Genet Metab 2011; 102:207-9. [PMID: 21035368 PMCID: PMC3053057 DOI: 10.1016/j.ymgme.2010.10.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Accepted: 10/04/2010] [Indexed: 11/17/2022]
Abstract
Unrelated umbilical cord blood transplantation (UCBT) was used to treat three siblings with juvenile metachromatic leukodystrophy (jMLD). The efficacy of this therapy was measured over a 5-year period with serial neurological examinations, neuroimaging, nerve conduction studies (NCS), and neuropsychological evaluations (NPE). Outcomes were a function of disease stage at time of UCBT with alteration of disease course occurring in the first 2 years after UCBT and then subsequent halting of progression and stabilization of symptoms and disease.
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Affiliation(s)
- Casey Cable
- Neurogenetics Branch, National Institute of Neurological Disorders and Stroke/NIH, Bethesda, MD 20892, USA
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19
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Smith NJ, Marcus RE, Sahakian BJ, Kapur N, Cox TM. Haematopoietic stem cell transplantation does not retard disease progression in the psycho-cognitive variant of late-onset metachromatic leukodystrophy. J Inherit Metab Dis 2010; 33 Suppl 3:S471-5. [PMID: 21080229 DOI: 10.1007/s10545-010-9240-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 10/19/2010] [Accepted: 10/21/2010] [Indexed: 12/12/2022]
Abstract
Haematopoietic stem cell transplantation has an unproven role in the management of late-onset metachromatic leukodystrophy: theoretically justified through the engraftment of enzyme-replete haematopoietic progenitors and restoration of capacity for sulphatide catabolism in neural tissue through enzyme recapture, the long-term outcome is unknown. The rarity of the psycho-cognitive variant and slow progression of late-onset disease impairs evaluation of treatment. We report detailed clinical and neuropsychological assessments after haematopoietic stem-cell transplantation in a patient with a late-onset psycho-cognitive form of metachromatic leukodystrophy. Cognitive decline, indistinguishable from the natural course of the disease, was serially documented over 11 years despite complete donor chimaerism and correction of leukocyte arylsulphatase A to wild type values; subtle motor deterioration was similarly noted and progressive cerebral volume loss was evident upon magnetic resonance imaging. Sensory nerve conduction deteriorated 17 months post-transplantation with apparent stabilisation at 11-year review. Haematopoietic stem-cell transplantation was ineffective for this rare attenuated variant of metachromatic leukodystrophy. In the few patients identified pre-symptomatically or with early-phase disease, clear recommendations are lacking; when transplantation is considered, umbilical cord blood grafts from enzyme-replete donors with adjunctive mesenchymal stem cell infusions from the same source may be preferable. Improved outcomes will depend on enhanced awareness and early diagnosis of the disease, so that promising interventions such as genetically modified, autologous stem cell transplantation have the best opportunity of success.
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Affiliation(s)
- Nicholas J Smith
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Box 157, Cambridge , CB2 0QQ, UK.
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20
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Kemp K, Mallam E, Scolding N, Wilkins A. Stem cells in genetic myelin disorders. Regen Med 2010; 5:425-39. [DOI: 10.2217/rme.10.10] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The genetic myelin disorders are a range of diseases that manifest with severe neurological problems, often from infancy. It has been postulated for some time that stem cells might be an effective treatment for these disorders, primarily as agents to restore dysfunctional or lost myelin. Stem cells, however, may offer a wider range of therapeutic potential, for instance as vehicles to replace abnormal enzymes or genes, or to provide trophic support for residual CNS tissue. This article will review several of the more common genetic myelin disorders and currently available therapies, including bone marrow transplantation for adrenoleukodystrophy. Specific stem cell subtypes and their relevance to potential therapeutic use will be discussed and stem cell transplantation in animal model studies will also be reviewed.
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Affiliation(s)
- Kevin Kemp
- MS & Stem Cell Laboratories, Burden Centre, Frenchay Hospital, Bristol, UK
- Department of Neurology, Frenchay Hospital, Bristol, UK
| | - Elizabeth Mallam
- MS & Stem Cell Laboratories, Burden Centre, Frenchay Hospital, Bristol, UK
- Department of Neurology, Frenchay Hospital, Bristol, UK
| | - Neil Scolding
- MS & Stem Cell Laboratories, Burden Centre, Frenchay Hospital, Bristol, UK
- Department of Neurology, Frenchay Hospital, Bristol, UK
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21
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Mahmood A, Berry J, Wenger DA, Escolar M, Sobeih M, Raymond G, Eichler FS. Metachromatic leukodystrophy: a case of triplets with the late infantile variant and a systematic review of the literature. J Child Neurol 2010; 25:572-80. [PMID: 20038527 PMCID: PMC4301611 DOI: 10.1177/0883073809341669] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Metachromatic leukodystrophy is a rare disorder with great clinical variability. We report the first case of triplets with the late infantile form of the disease and their systematic progression of symptoms. We reviewed the literature and identified all human studies that reported new cases since 1921. We analyzed survival by decade to assess the impact of historical changes in the management of care. Mean age at death and the 5-year survival from onset of symptoms for late infantile, juvenile, and adult phenotypes were 4.2 years and 24.9%, 17.4 years and 70.3%, and 43.1 years and 88.6%, respectively. The 5-year survival of cases reported after 1990 was significantly better than cases reported before 1970 in all subtypes of metachromatic leukodystrophy (late infantile: 52% vs 14%, juvenile: 100% vs 46%, adult: 95% vs 67%). Survival in the late infantile subtype was worse than that in other subtypes. Survival significantly improved over time in all subtypes.
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Affiliation(s)
- Asif Mahmood
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA
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22
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Abstract
Hematopoietic stem cell transplantation (HSCT) has been used for three decades as therapy for lysosomal storage diseases. Stable engraftment following transplantation has the potential to provide a source of an enzyme for the life of a patient. Recombinant enzyme is available for disorders that do not have a primary neurologic component. However, for diseases affecting the central nervous system (CNS), intravenous enzyme is ineffective due to its inability to cross the blood-brain barrier. For selected lysosomal disorders, including metachromatic leukodystrophy and globoid cell leukodystrophy, disease phenotype and the extent of disease at the time of transplantation are of fundamental importance in determining outcomes. Adrenoleukodystrophy is an X-linked, peroxisomal disorder, and in approximately 40% of cases a progressive, inflammatory condition develops in the CNS. Early in the course of the disease, allogeneic transplantation can arrest the disease process in cerebral adrenoleukodystrophy, while more advanced patients do poorly. In many of these cases, the utilization of cord blood grafts allows expedient transplantation, which can be critical in achieving optimal outcomes.
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Affiliation(s)
- Paul J Orchard
- Department of Pediatrics, Division of Hematopoietic Stem Cell Transplantation, University of Minnesota, Minneapolis, MN 55455, USA
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23
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Prasad VK, Kurtzberg J. Cord blood and bone marrow transplantation in inherited metabolic diseases: scientific basis, current status and future directions. Br J Haematol 2009; 148:356-72. [PMID: 19919654 DOI: 10.1111/j.1365-2141.2009.07974.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Progressive degeneration of the central nervous system leading to the loss of neuromotor, neurophysiological and cognitive abilities is the fundamental clinical problem in patients with many inherited metabolic diseases (IMD). Worldwide experience shows that morbidity, quality of life, and survival in these patients can be improved by allogeneic haematopoietic stem cell transplantation (HSCT), particularly when performed early in the course of the disease. At present, while available for some conditions, exogenous enzyme replacement therapy is unable to correct cognitive and central nervous system disease because of its inability to cross the blood-brain barrier. In contrast, HSCT allows donor-derived, enzyme-producing cells to migrate to the brain and other organs providing a permanent enzyme replacement therapy. HSCT may also mediate non-hematopoietic cell regeneration or repair. Traditionally, bone marrow has been the graft source for IMD patients. However, in the last 5 years many studies utilizing unrelated donor umbilical cord blood (UCB) as a graft source have demonstrated that UCB provides rapid and increased access to transplantation with favourable outcomes. This review describes preclinical studies and past and present clinical treatment approaches and discusses current controversies and future directions of this promising field.
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Affiliation(s)
- Vinod K Prasad
- Division of Pediatric Blood and Marrow Transplantation, Box 3350, Duke University Medical Center, Durham, NC 27710, USA.
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24
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Metachromatic leukodystrophy: an overview of current and prospective treatments. Bone Marrow Transplant 2008; 42 Suppl 2:S2-6. [DOI: 10.1038/bmt.2008.275] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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25
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Platt FM, Lachmann RH. Treating lysosomal storage disorders: current practice and future prospects. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2008; 1793:737-45. [PMID: 18824038 DOI: 10.1016/j.bbamcr.2008.08.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Revised: 08/07/2008] [Accepted: 08/22/2008] [Indexed: 12/22/2022]
Abstract
There are over 40 human disease states that are caused by defects in various aspects of lysosomal function. Over the past two decades there has been dramatic progress in the development and evaluation of therapies for lysosomal storage disorders, several of which are now in routine clinical use or in clinical trials. The greatest current challenge is in developing effective therapies for treating the CNS manifestations of these complex disorders. In this article, we will review the current therapies/approaches being considered for treating lysosomal storage diseases and give a perspective on the scientific, medical, social and ethical issues they raise.
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Affiliation(s)
- Frances M Platt
- Department of Pharmacology, University of Oxford, Mansfield Road, Oxford, OX1 3QT, UK.
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26
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Gärtner J, Kohlschütter A, Gieselmann V. Netzwerkprojekte für die Erforschung von Leukodystrophien, einer Gruppe seltener Erkrankungen der weißen Substanz des Nervensystems. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2007; 50:1531-40. [DOI: 10.1007/s00103-007-0388-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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