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Keeley J, Benson-Goldberg S, Saldaris J, Lariviere J, Leonard H, Marsh ED, Demarest ST, Benke TA, Jacoby P, Downs J. Communication of individuals with CDKL5 deficiency disorder as observed by caregivers: A descriptive qualitative study. Am J Med Genet A 2024; 194:e63570. [PMID: 38425131 PMCID: PMC11161303 DOI: 10.1002/ajmg.a.63570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/02/2024] [Indexed: 03/02/2024]
Abstract
CDKL5 deficiency disorder (CDD) is a genetically caused developmental epileptic encephalopathy that causes severe communication impairments. Communication of individuals with CDD is not well understood in the literature and currently available measures are not well validated in this population. Accurate and sensitive measurement of the communication of individuals with CDD is important for understanding this condition, clinical practice, and upcoming interventional trials. The aim of this descriptive qualitative study was to understand how individuals with CDD communicate, as observed by caregivers. Participants were identified through the International CDKL5 Disorder Database and invited to take part if their child had a pathogenic variant of the CDKL5 gene and they had previously completed the Communication and Symbolic Behavior Checklist (CSBS-DP ITC). The sample comprised caregivers of 23 individuals with CDD, whose ages ranged from 2 to 30 years (median 13 years), 15 were female, and most did not use words. Semistructured interviews were conducted via videoconference and analyzed using a conventional content analysis. Three overarching categories were identified: mode, purpose and meaning, and reciprocal exchanges. These categories described the purposes and mechanism of how some individuals with CDD communicate, including underpinning influential factors. Novel categories included expressing a range of emotions, and reciprocal exchanges (two-way interactions that varied in complexity). Caregivers observed many communication modes for multiple purposes. Understanding how individuals with CDD communicate improves understanding of the condition and will guide research to develop accurate measurement for clinical practice and upcoming medication trials.
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Affiliation(s)
- Jessica Keeley
- Telethon Kids Institute, Perth Western Australia, Australia
| | - Sofia Benson-Goldberg
- Center for Literacy and Disability Studies, Department of Health Sciences, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, United States
| | | | - Judy Lariviere
- Assistive Tech 4 ALL, Inc., Rancho Cordova, California, United States
| | - Helen Leonard
- Telethon Kids Institute, Perth Western Australia, Australia
| | - Eric D. Marsh
- Division of Neurology, Children’s Hospital of Philadelphia, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott T. Demarest
- Department of Pediatrics and Neurology, School of Medicine, University of Colorado Precision Medicine Institute, Children’s Hospital Colorado, USA, Aurora, CO
| | - Tim A. Benke
- Children’s Hospital Colorado, Paediatrics and Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Peter Jacoby
- Telethon Kids Institute, Perth Western Australia, Australia
| | - Jenny Downs
- Telethon Kids Institute, Perth Western Australia, Australia
- Curtin School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
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2
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Saldaris J, Leonard H, Wong K, Jacoby P, Spence M, Marsh ED, Benke TA, Demarest S, Downs J. Validating the Communication and Symbolic Behavior Scales-Developmental Profile Infant-Toddler Checklist (CSBS-DP ITC) Beyond Infancy in the CDKL5 Deficiency Disorder. J Autism Dev Disord 2024; 54:2526-2535. [PMID: 37184758 PMCID: PMC10699574 DOI: 10.1007/s10803-023-06002-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2023] [Indexed: 05/16/2023]
Abstract
CDKL5 deficiency disorder (CDD) results in early-onset epilepsy and lifelong cognitive and motor impairments. With no validated measure for communication in CDD, this study evaluated the psychometric properties of the Communication and Symbolic Behavior Scales-Developmental Profile Infant Toddler Checklist (CSBS-DP ITC). Caregivers (n = 150; affected individuals aged 1-29 years) completed the CSBS-DP ITC. Distribution of scores indicated a floor effect. There was poor divergent validity for the three-factor model but goodness of fit and convergent validity data were satisfactory for the one-factor model. Individuals with poorer overall functional abilities scored lower on the CSBS-DP ITC. Test-retest reliability was excellent. The floor effect could explain the very high reliability, suggesting problems as a sensitive outcome measure in clinical trials for CDD.
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Affiliation(s)
- Jacinta Saldaris
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, PO Box 855, West Perth, WA, 6872, Australia
| | - Helen Leonard
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, PO Box 855, West Perth, WA, 6872, Australia
| | - Kingsley Wong
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, PO Box 855, West Perth, WA, 6872, Australia
| | - Peter Jacoby
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, PO Box 855, West Perth, WA, 6872, Australia
| | - Mary Spence
- Children's Hospital Colorado Therapy Care, Highlands Ranch, CO, USA
| | - Eric D Marsh
- Division of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tim A Benke
- Children's Hospital Colorado, Paediatric Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Scott Demarest
- Children's Hospital Colorado, Paediatric Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jenny Downs
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, PO Box 855, West Perth, WA, 6872, Australia.
- School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia.
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Lombardo A, Sinibaldi L, Genovese S, Catino G, Mei V, Pompili D, Sallicandro E, Falasca R, Liambo MT, Faggiano MV, Roberti MC, Di Donato M, Vitelli A, Russo S, Giannini R, Micalizzi A, Pietrafusa N, Digilio MC, Novelli A, Fusco L, Alesi V. A Case of CDKL5 Deficiency Due to an X Chromosome Pericentric Inversion: Delineation of Structural Rearrangements as an Overlooked Recurrent Pathological Mechanism. Int J Mol Sci 2024; 25:6912. [PMID: 39000022 PMCID: PMC11241409 DOI: 10.3390/ijms25136912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/11/2024] [Accepted: 06/13/2024] [Indexed: 07/14/2024] Open
Abstract
CDKL5 deficiency disorder (CDD) is an X-linked dominant epileptic encephalopathy, characterized by early-onset and drug-resistant seizures, psychomotor delay, and slight facial features. Genomic variants inactivating CDKL5 or impairing its protein product kinase activity have been reported, making next-generation sequencing (NGS) and chromosomal microarray analysis (CMA) the standard diagnostic tests. We report a suspicious case of CDD in a female child who tested negative upon NGS and CMA and harbored an X chromosome de novo pericentric inversion. The use of recently developed genomic techniques (optical genome mapping and whole-genome sequencing) allowed us to finely characterize the breakpoints, with one of them interrupting CDKL5 at intron 1. This is the fifth case of CDD reported in the scientific literature harboring a structural rearrangement on the X chromosome, providing evidence for the hypothesis that this type of anomaly can represent a recurrent pathogenic mechanism, whose frequency is likely underestimated, with it being overlooked by standard techniques. The identification of the molecular etiology of the disorder is extremely important in evaluating the pathological outcome and to better investigate the mechanisms associated with drug resistance, paving the way for the development of specific therapies. Karyotype and genomic techniques should be considered in all cases presenting with CDD without molecular confirmation.
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Affiliation(s)
- Antonietta Lombardo
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Lorenzo Sinibaldi
- Medical Genetics Unit, IRCCS Bambino Gesù Children Hospital, 00165 Rome, Italy
| | - Silvia Genovese
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Giorgia Catino
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Valerio Mei
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Daniele Pompili
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Ester Sallicandro
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Roberto Falasca
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Maria Teresa Liambo
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Maria Vittoria Faggiano
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Maria Cristina Roberti
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Maddalena Di Donato
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Anna Vitelli
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Serena Russo
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Rosalinda Giannini
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Alessia Micalizzi
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
- Medical Genetics Unit, San Pietro Fatebenefratelli Hospital, 00189 Rome, Italy
| | - Nicola Pietrafusa
- Neurology, Epilepsy and Movement Disorders Unit, Bambino Gesù, IRCCS Children's Hospital, 00165 Rome, Italy
| | | | - Antonio Novelli
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Lucia Fusco
- Neurology, Epilepsy and Movement Disorders Unit, Bambino Gesù, IRCCS Children's Hospital, 00165 Rome, Italy
| | - Viola Alesi
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
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Dell'Isola GB, Antonella F, Francesco P, Mario M, Cordelli DM, Piero P, Pasquale P, Alessandro F, Operto FF, Maurizio E, Marco C, Dario P, Sara M, Elisabetta S, Alberto S, Giovanna S, Savasta S, Paolo P, Di Cara G, Fruttini D, Vincenzo S, Pasquale S, Alberto V. CDKL5 deficiency-related neurodevelopmental disorders: a multi-center cohort study in Italy. J Neurol 2024:10.1007/s00415-024-12421-1. [PMID: 38874638 DOI: 10.1007/s00415-024-12421-1] [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: 01/24/2024] [Revised: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 06/15/2024]
Abstract
CDKL5 deficiency disorder (CDD) is a complex clinical condition resulting from non-functional or absent CDKL5 protein, a serine-threonine kinase pivotal for neural maturation and synaptogenesis. The disorder manifests primarily as developmental epileptic encephalopathy, with associated neurological phenotypes, such as hypotonia, movement disorders, visual impairment, and gastrointestinal issues. Its prevalence is estimated at 1 in 40,000-60,000 live births, and it is more prevalent in females due to the lethality of germline mutations in males during fetal development. This Italian multi-center observational study focused on 34 patients with CDKL5-related epileptic encephalopathy, aiming to enhance the understanding of the clinical and molecular aspects of CDD. The study, conducted across 14 pediatric neurology tertiary care centers in Italy, covered various aspects, including phenotypic presentations, seizure types, EEG patterns, treatments, neuroimaging findings, severity of psychomotor delay, and variant-phenotype correlations. The results highlighted the heterogeneity of seizure patterns, with hypermotor-tonic-spasms sequence seizures (HTSS) noted in 17.6% of patients. The study revealed a lack of clear genotype-phenotype correlation within the cohort. The presence of HTSS or HTSS-like at onset resulted a negative prognostic factor for the presence of daily seizures at long-term follow-up in CDD patients. Despite extensive polypharmacotherapy, including medications such as valproic acid, clobazam, cannabidiol, and others, sustained seizure freedom proved elusive, affirming the inherent drug-resistant nature of CDD. The findings underscored the need for further research to explore response rates to different treatments and the potential role of non-pharmacological interventions in managing this challenging disorder.
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Affiliation(s)
| | | | - Pisani Francesco
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences, Sapienza University of Rome, 00185, Rome, Italy
- Department of Neuroscience/Mental Health, Azienda Ospedaliero-Universitaria Policlinico Umberto I, 00161, Rome, Italy
| | - Mastrangelo Mario
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences, Sapienza University of Rome, 00185, Rome, Italy
- Child Neurology Unit, University of Bologna, Bologna, Italy
| | | | - Pavone Piero
- Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Parisi Pasquale
- Pediatrics Unit, Neuroscience, Mental Health and Sense Organs (NESMOS) Department, Faculty of Medicine and Psychology, Sapienza University of Rome, 00189, Rome, Italy
| | - Ferretti Alessandro
- Pediatrics Unit, Neuroscience, Mental Health and Sense Organs (NESMOS) Department, Faculty of Medicine and Psychology, Sapienza University of Rome, 00189, Rome, Italy
| | - Francesca Felicia Operto
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
- Department of Science of Health, School of Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Elia Maurizio
- Unit of Neurology and Clinical Neurophysiopathology, Oasi Research Institute-IRCCS, Troina, Italy
| | - Carotenuto Marco
- Clinic of Child and Adolescent Neuropsychiatry, Department of Mental Health, Physical and Preventive Medicine, Università degli studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Pruna Dario
- Child Neurology and Epileptology Unit, Paediatric Department, ARNAS Brotzu, Cagliari, Italy
| | - Matricardi Sara
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | | | - Spalice Alberto
- Department of Pediatrics, "Sapienza" University of Rome, Rome, Italy
| | - Scorrano Giovanna
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Salvatore Savasta
- Pediatric Clinic and Rare Diseases, Microcythemic Pediatric Hospital "A. Cao", University of Cagliari, Cagliari, Italy
| | - Prontera Paolo
- Medical Genetics Unit, Hospital Santa Maria Della Misericordia, Perugia, Italy
| | | | - Daniela Fruttini
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Salpietro Vincenzo
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- Department of Neuromuscular Diseases, Queen Square Institute of Neurology, University College London, London, UK
| | - Striano Pasquale
- Giannina Gaslini Institute, Scientific Institute for Research and Health Care, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
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5
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Charfi Triki C, Zouari Mallouli S, Ben Jdila M, Ben Said M, Kamoun Feki F, Weckhuysen S, Masmoudi S, Fakhfakh F. First report of Tunisian patients with CDKL5-related encephalopathy. Epilepsia Open 2024; 9:906-917. [PMID: 37701975 PMCID: PMC11145601 DOI: 10.1002/epi4.12824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 09/09/2023] [Indexed: 09/14/2023] Open
Abstract
OBJECTIVE Mutations in the cyclin-dependent kinase-like 5 gene (CDKL5) are associated with a wide spectrum of clinical presentations. Early-onset epileptic encephalopathy (EOEE) is the most recognized phenotype. Here we describe phenotypic features in eight Tunisian patients with CDKL5-related encephalopathy. METHODS We included all cases with clinical features consistent with CDKL5-related encephalopathy: infantile epileptic spasm, acquired microcephaly, movement disorders and visual impairment. We collected data about seizure types, electroencephalogram, magnetic resonance imaging, and metabolic analysis. The diagnosis of CDKL5 mutation was made thanks to Sanger sequencing with an ABI PRISM 3100-Avant automated DNA sequencer using a Big Dye Terminator Cycle Sequencing Reaction Kit v1.1. and Next Generation Sequencing (NGS) since the development of a gene panel responsible for DEE within the framework of "Strengthening the Sfax University Expertise for diagnosis and management of epileptic encephalopathies". RESULTS We collected four boys and four girls aged meanly 6 years old with confirmed mutation on CDKL5 gene. Overall, we identified five de novo CDKL5 mutations including three Frame-shift mutations, one missense mutation, and a splicing variant. The mean age at first seizure onset was 4 months. The first seizure type was infantile epileptic spasm (4/8) followed by tonic (2/8) and myoclonic seizures (2/8). Out of eight cases, four exhibited two stages epileptic course while epilepsy in three other patients progressed on three stages. Regarding development, most cases (6/8) had psychomotor retardation from the start whilst the two others showed psychomotor regression with the onset of seizures. Additional clinical features included visual impairment (7/8), tone abnormalities (7/8), stereotypies (7/8), and acquired microcephaly (6/8). SIGNIFICANCE Our present report delineates an unusual phenotype of CDKL5-related encephalopathy with male gender predominance and delayed onset epilepsy. It interestingly described new phenotypic features and uncommon benign developmental profiles in boys, different patterns of CDKL5-epilepsy, neuroimaging findings, and CDKL5 mutational spectrum.
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Affiliation(s)
- Chahnez Charfi Triki
- Child Neurology Department, Hedi Chaker Sfax University Hospital, and Research Laboratory LR19ES15University of SfaxSfaxTunisia
| | - Salma Zouari Mallouli
- Child Neurology Department, Hedi Chaker Sfax University Hospital, and Research Laboratory LR19ES15University of SfaxSfaxTunisia
| | - Marwa Ben Jdila
- Laboratory of Molecular and Functional Genetics, Faculty of Science of SfaxUniversity of SfaxSfaxTunisia
| | - Mariem Ben Said
- Laboratory of Molecular and Cellular Screening Processes (LPCMC), Center of Biotechnology of SfaxUniversity of SfaxSfaxTunisia
| | - Fatma Kamoun Feki
- Child Neurology Department, Hedi Chaker Sfax University Hospital, and Research Laboratory LR19ES15University of SfaxSfaxTunisia
| | - Sarah Weckhuysen
- Applied & Translational Neurogenomics Group, VIB Center for Molecular Neurology, VIBUniversity of AntwerpAntwerpBelgium
- Department of NeurologyAntwerp University HospitalAntwerpBelgium
- Translational Neurosciences, Faculty of Medicine and Health ScienceUniversity of AntwerpAntwerpBelgium
| | - Sabeur Masmoudi
- Laboratory of Molecular and Cellular Screening Processes (LPCMC), Center of Biotechnology of SfaxUniversity of SfaxSfaxTunisia
| | - Faiza Fakhfakh
- Laboratory of Molecular and Functional Genetics, Faculty of Science of SfaxUniversity of SfaxSfaxTunisia
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Perinelli MG, Naboni C, Balagura G, Amadori E, Vari MS, Capra V, Lentoiou C, Foiadelli T, Sirchia F, Luparia A, Marseglia G, Ramenghi LA, Striano P. Early Developmental Intervention and Enriched Environment in CDKL5 Developmental and Epileptic Encephalopathy: A Case Report. Neurol Clin Pract 2024; 14:e200287. [PMID: 38660576 PMCID: PMC11042840 DOI: 10.1212/cpj.0000000000200287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/07/2024] [Indexed: 04/26/2024]
Abstract
Objectives CDKL5 developmental and epileptic encephalopathy (CDKL5-DEE) is a rare X-linked dominant genetic disorder. Family-centered Early Intervention (EI) programs, which promote axonal plasticity and synaptic reorganization through exposure to an enriched environment, should be integrated into clinical practice. However, there is presently a dearth of dedicated EI protocols for patients with CDKL5-DEE and cerebral visual impairment (CVI). Methods We present a girl with a deletion of the CDKL5 gene (MIM*300203). At the age of 2 months, the child presented with severe epilepsy. The neurologic examination was abnormal, and she had severe CVI. At the first assessment, at 5 months old, her Developmental Quotient (DQ) on the Griffiths Mental Developmental Scales III (GMDS-III) was equivalent to 3-month-old skills (95% CI). The child was enrolled in an EI program for 6 months. Results At 12 months of age, the DQ score was 91. There has been improvement in the neurovisual functions. The findings from the scales show a gradual improvement in neuromotor and psychomotor development, which is in contrast to the expected outcome of the disease. Discussion The case study shows that a family-centered EI and prompt assessment of CVI can promote and enhance neurodevelopment.
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Affiliation(s)
- Martina Giorgia Perinelli
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Cecilia Naboni
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Ganna Balagura
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Elisabetta Amadori
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Maria Stella Vari
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Valeria Capra
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Camelia Lentoiou
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Thomas Foiadelli
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Fabio Sirchia
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Antonella Luparia
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Gianluigi Marseglia
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Luca A Ramenghi
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Pasquale Striano
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
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Amin S, Møller RS, Aledo‐Serrano A, Arzimanoglou A, Bager P, Jóźwiak S, Kluger GJ, López‐Cabeza S, Nabbout R, Partridge C, Schubert‐Bast S, Specchio N, Kälviäinen R. Providing quality care for people with CDKL5 deficiency disorder: A European expert panel opinion on the patient journey. Epilepsia Open 2024; 9:832-849. [PMID: 38450883 PMCID: PMC11145618 DOI: 10.1002/epi4.12914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 01/21/2024] [Indexed: 03/08/2024] Open
Abstract
Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) is a developmental and epileptic encephalopathy caused by variants in the CDKL5 gene. The disorder is characterized by intractable early-onset seizures, severe neurodevelopmental delay, hypotonia, motor disabilities, cerebral (cortical) visual impairment and microcephaly. With no disease-modifying therapies available for CDD, treatment is symptomatic with an initial focus on seizure control. Another unmet need in the management of people with CDD is the lack of evidence to aid standardized care and guideline development. To address this gap, experts in CDD and representatives from patient advocacy groups from Denmark, Finland, France, Germany, Italy, Poland, Spain, and the United Kingdom convened to form an Expert Working Group. The aim was to provide an expert opinion consensus on how to ensure quality care in routine clinical practice within the European setting, including in settings with limited experience or resources for multidisciplinary care of CDD and other developmental and epileptic encephalopathies. By means of one-to-one interviews around the current treatment landscape in CDD, insights from the Expert Working Group were collated and developed into a Europe-specific patient journey for individuals with CDD, which was later validated by the group. Further discussions followed to gain consensus of opinions on challenges and potential solutions for achieving quality care in this setting. The panel recognized the benefit of early genetic testing, a holistic personalized approach to seizure control (taking into consideration various factors such as concomitant medications and comorbidities), and age- and comorbidity-dependent multidisciplinary care for optimizing patient outcomes and quality of life. However, their insights and experiences also highlighted much disparity in management approaches and resources across different European countries. Development of standardized European recommendations is required to align realistic diagnostic criteria, treatment goals, and management approaches that can be adapted for different settings. PLAIN LANGUAGE SUMMARY: Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) is a rare condition caused by a genetic mutation with a broad range of symptoms apparent from early childhood, including epileptic seizures that do not respond to medication and severe delays in development. Due to the lack of guidance on managing CDD, international experts and patient advocates discussed best practices in the care of people with CDD in Europe. The panel agreed that early testing, a personalized approach to managing seizures, and access to care from different disciplines are beneficial. Development of guidelines to ensure that care is standardized would also be valuable.
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Affiliation(s)
- Sam Amin
- University Hospitals BristolBristolUK
| | - Rikke S. Møller
- The Danish Epilepsy Centre, FiladelfiaDianalundDenmark
- Department of Regional Health Research, Faculty of Health SciencesUniversity of Southern DenmarkOdenseDenmark
| | - Angel Aledo‐Serrano
- Vithas Madrid La Milagrosa University HospitalVithas Hospital GroupMadridSpain
| | | | | | | | - Gerhard Josef Kluger
- Epilepsy Center for Children and AdolescentsVogtareuthGermany
- Paracelsus Medical University SalzburgSalzburgAustria
| | | | - Rima Nabbout
- Necker‐Enfants Malades HospitalUniversité Paris Cité, Imagine InstituteParisFrance
| | | | - Susanne Schubert‐Bast
- Center of Neurology and NeurosurgeryEpilepsy Center Frankfurt Rhine‐MainGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER)Goethe‐UniversityFrankfurt am MainGermany
- University Children's HospitalGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
| | | | - Reetta Kälviäinen
- University of Eastern Finland and Epilepsy CenterKuopio University HospitalKuopioFinland
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Daniels C, Greene C, Smith L, Pestana-Knight E, Demarest S, Zhang B, Benke TA, Poduri A, Olson H. CDKL5 deficiency disorder and other infantile-onset genetic epilepsies. Dev Med Child Neurol 2024; 66:456-468. [PMID: 37771170 PMCID: PMC10922313 DOI: 10.1111/dmcn.15747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 07/25/2023] [Accepted: 08/02/2023] [Indexed: 09/30/2023]
Abstract
AIM To differentiate phenotypic features of individuals with CDKL5 deficiency disorder (CDD) from those of individuals with other infantile-onset epilepsies. METHOD We performed a retrospective cohort study and ascertained individuals with CDD and comparison individuals with infantile-onset epilepsy who had epilepsy gene panel testing. We reviewed records, updated variant classifications, and compared phenotypic features. Wilcoxon rank-sum tests and χ2 or Fisher's exact tests were performed for between-cohort comparisons. RESULTS We identified 137 individuals with CDD (110 females, 80.3%; median age at last follow-up 3 year 11 months) and 313 individuals with infantile-onset epilepsies (156 females, 49.8%; median age at last follow-up 5 years 2 months; 35% with genetic diagnosis). Features reported significantly more frequently in the CDD group than in the comparison cohort included developmental and epileptic encephalopathy (81% vs 66%), treatment-resistant epilepsy (95% vs 71%), sequential seizures (46% vs 6%), epileptic spasms (66% vs 42%, with hypsarrhythmia in 30% vs 48%), regression (52% vs 29%), evolution to Lennox-Gastaut syndrome (23% vs 5%), diffuse hypotonia (72% vs 36%), stereotypies (69% vs 11%), paroxysmal movement disorders (29% vs 17%), cerebral visual impairment (94% vs 28%), and failure to thrive (38% vs 22%). INTERPRETATION CDD, compared with other suspected or confirmed genetic epilepsies presenting in the first year of life, is more often characterized by a combination of treatment-resistant epilepsy, developmental and epileptic encephalopathy, sequential seizures, spasms without hypsarrhythmia, diffuse hypotonia, paroxysmal movement disorders, cerebral visual impairment, and failure to thrive. Defining core phenotypic characteristics will improve precision diagnosis and treatment.
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Affiliation(s)
- Carolyn Daniels
- Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
| | - Caitlin Greene
- Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
| | - Lacey Smith
- Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
| | - Elia Pestana-Knight
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott Demarest
- Children’s Hospital Colorado, Aurora, CO, USA
- Department of Pediatrics, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Bo Zhang
- Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
| | - Timothy A Benke
- Children’s Hospital Colorado, Aurora, CO, USA
- Department of Pediatrics, University of Colorado, School of Medicine, Aurora, CO, USA
- Department of Pharmacology, University of Colorado, School of Medicine, Aurora, CO, USA
- Department of Neurology, University of Colorado, School of Medicine, Aurora, CO, USA
- Department of Otolaryngology, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Annapurna Poduri
- Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
- Division of Epilepsy and Clinical Neurophysiology and Epilepsy Genetics Program, Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
- Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Heather Olson
- Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
- Division of Epilepsy and Clinical Neurophysiology and Epilepsy Genetics Program, Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
- Department of Neurology, Harvard Medical School, Boston, MA, USA
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9
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Pestana Knight EM, Olson HE. CDKL5 Deficiency Disorder: Some Lessons Learned 20 Years After the First Description. AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2024; 129:101-109. [PMID: 38411242 DOI: 10.1352/1944-7558-129.2.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Loss of function variants in the Cyclin-dependent kinase-like 5 gene (CDKL5) causes CDKL5 deficiency disorder (CDD). Most cases of CDD are due to a de novo missense or truncating variants. The CDKL5 gene was discovered in 1998 as part of the genomic mapping of the chromosome Xp22 region that led to the discovery of the serine-threonine kinases STK9. Since then, there have been significant advancements in the description of the disease in humans, the understanding of the pathophysiology, and the management of the disease. There have been many lessons learned since the initial description of the condition in humans in 2003. In this article, we will focus on pathophysiology, clinical manifestations, with particular focus on seizures because of its relevance to the medical practitioners and researchers and guidelines for management. We finalize the manuscript with the voice of the parents and caregivers, as discussed with the 2019 meeting with the Food and Drug Administration.
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Saldaris JM, Jacoby P, Marsh ED, Suter B, Leonard H, Olson HE, Rajaraman R, Pestana-Knight E, Weisenberg J, Price D, Drummond C, Benke TA, Demarest S, Downs J. Adapting a measure of gross motor skills for individuals with CDKL5 deficiency disorder: A psychometric study. Epilepsy Res 2024; 200:107287. [PMID: 38237219 DOI: 10.1016/j.eplepsyres.2024.107287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/15/2023] [Accepted: 01/02/2024] [Indexed: 02/23/2024]
Abstract
PURPOSE Validated measures capable of demonstrating meaningful interventional change in the CDKL5 deficiency disorder (CDD) are lacking. The study objective was to modify the Rett Syndrome Gross Motor Scale (RSGMS) and evaluate its psychometric properties for individuals with CDD. METHODS Item and scoring categories of the RSGMS were modified. Caregivers registered with the International CDKL5 Clinical Research Network uploaded motor videos filmed at home to a protected server and completed a feedback questionnaire (n = 70). Rasch (n = 137), known groups (n = 109), and intra- and inter-rater reliability analyses (n = 50) were conducted. RESULTS The age of individuals with CDD ranged from 1.5 to 34.1 years. The modified scale, Gross Motor-Complex Disability (GM-CD), comprised 17 items. There were no floor or ceiling effects and inter- and intra-rater reliability were good. Rasch analysis demonstrated that the items encompassed a large range of performance difficulty, although there was some item redundancy and some disordered categories. One item, Prone Head Position, was a poor fit. Caregiver-reported acceptability was positive. Scores differed by age and functional abilities. SUMMARY GM-CD appears to be a suitable remotely administered measure and psychometrically sound for individuals with CDD. This study provides the foundation to propose the use of GM-CD in CDD clinical trials. Longitudinal evaluation is planned.
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Affiliation(s)
- J M Saldaris
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, WA, Australia
| | - P Jacoby
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, WA, Australia
| | - E D Marsh
- Division of Child Neurology, Children's Hospital of Philadelphia and Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - B Suter
- Department of Pediatrics & Neurology, Baylor College of Medicine, Houston, TX, USA
| | - H Leonard
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, WA, Australia
| | - H E Olson
- Division of Epilepsy and Clinical Neurophysiology and Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - R Rajaraman
- UCLA Mattel Children's Hospital, Los Angeles, CA, USA
| | | | - J Weisenberg
- St. Louis Children's Hospital and Washington University School of Medicine, St Louis, MO, USA
| | - D Price
- NYU Langone Health and Department of Neurology, New York University, New York, NY, USA
| | - C Drummond
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, WA, Australia
| | - T A Benke
- University of Colorado, School of Medicine, Depts Pediatrics, Neurology and Pharmacology and Children's Hospital Colorado, Aurora, CO, USA
| | - S Demarest
- University of Colorado, School of Medicine, Depts Pediatrics, Neurology and Pharmacology and Children's Hospital Colorado, Aurora, CO, USA.
| | - J Downs
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, WA, Australia; Curtin School of Allied Health, Curtin University, Perth, WA, Australia.
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Ziniel SI, Mackie A, Saldaris J, Leonard H, Jacoby P, Marsh ED, Suter B, Pestana-Knight E, Olson HE, Price D, Weisenberg J, Rajaraman R, VanderVeen G, Benke TA, Downs J, Demarest S. The development, content and response process validation of a caregiver-reported severity measure for CDKL5 deficiency disorder. Epilepsy Res 2023; 197:107231. [PMID: 37751639 PMCID: PMC10760432 DOI: 10.1016/j.eplepsyres.2023.107231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/18/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND CDKL5 Deficiency Disorder (CDD) is a severe X-linked developmental and epileptic encephalopathy. Existing developmental outcome measures have floor effects and cannot capture incremental changes in symptoms. We modified the caregiver portion of a CDD clinical severity assessment (CCSA) and assessed content and response-process validity. METHODS We conducted cognitive interviews with 15 parent caregivers of 1-39-year-old children with CDD. Caregivers discussed their understanding and concerns regarding appropriateness of both questions and answer options. Item wording and questionnaire structure were adjusted iteratively to ensure questions were understood as intended. RESULTS The CCSA was refined during three rounds of cognitive interviews into two measures: (1) the CDD Developmental Questionnaire - Caregiver (CDQ-Caregiver) focused on developmental skills, and (2) the CDD Clinical Severity Assessment - Caregiver (CCSA-Caregiver) focused on symptom severity. Branching logic was used to ensure questions were age and skill appropriate. Initial pilot data (n = 11) suggested no floor effects. CONCLUSIONS This study modified the caregiver portion of the initial CCSA and provided evidence for its content and response process validity.
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Affiliation(s)
- Sonja I Ziniel
- University of Colorado School of Medicine Department of Pediatrics, Section of Pediatric Hospital Medicine, 13123 East 16th Avenue, Box 302, Aurora, CO, United States; Children's Hospital Colorado Precision Medicine Institute, 13123 East 16th Avenue, Box 155, Aurora, CO 80045 United States
| | - Alexandra Mackie
- University of Colorado School of Medicine Department of Pediatrics, Section of Neurology, 13123 East 16th Avenue, Box 155, Aurora, CO 80045, United States
| | - Jacinta Saldaris
- University of Western Australia Centre for Child Health Research, Telethon Kids Institute, PO Box 855, West Perth, Western Australia 6872, Australia
| | - Helen Leonard
- University of Western Australia Centre for Child Health Research, Telethon Kids Institute, PO Box 855, West Perth, Western Australia 6872, Australia
| | - Peter Jacoby
- University of Western Australia Centre for Child Health Research, Telethon Kids Institute, PO Box 855, West Perth, Western Australia 6872, Australia
| | - Eric D Marsh
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Bernhard Suter
- Baylor College of Medicine and Texas Children's Hospital, 6701 Fannin St MWT, Suite 1250, Houston, TX 77030, United States
| | - Elia Pestana-Knight
- Cleveland Clinic Neurological Institute, Epilepsy Center, S10-024 9500 Euclid Ave, Cleveland, OH 44195, United States
| | - Heather E Olson
- Boston Children's Hospital Department of Neurology Division of Epilepsy and Clinical Neurophysiology and Epilepsy Genetics Program, 300 Longwood Ave, Boston, MA, United States
| | - Dana Price
- NYU Langone Comprehensive Epilepsy Center, 223 East 34th Street, New York, NY 10016, United States
| | - Judith Weisenberg
- Washington University School of Medicine Department of Neurology, Division of Pediatric Neurology, 660 South Euclid Ave Campus Box 8111, St. Louis, MO 63110 United States
| | - Rajsekar Rajaraman
- David Geffen School of Medicine and UCLA Mattel Children's Hospital Division of Pediatric Neurology, 10833 Le Conte Ave 22-474 MDCC, Los Angeles, CA 90095 United States
| | - Gina VanderVeen
- Children's Hospital Colorado Precision Medicine Institute, 13123 East 16th Avenue, Box 155, Aurora, CO 80045 United States; University of Colorado School of Medicine Department of Pediatrics, Section of Neurology, 13123 East 16th Avenue, Box 155, Aurora, CO 80045, United States
| | - Tim A Benke
- Children's Hospital Colorado Precision Medicine Institute, 13123 East 16th Avenue, Box 155, Aurora, CO 80045 United States; University of Colorado School of Medicine Department of Pediatrics, Section of Neurology, 13123 East 16th Avenue, Box 155, Aurora, CO 80045, United States
| | - Jenny Downs
- University of Western Australia Centre for Child Health Research, Telethon Kids Institute, PO Box 855, West Perth, Western Australia 6872, Australia; Curtin University, Curtin School of Allied Health, GPO Box U1987, Perth, Western Australia 6845, Australia
| | - Scott Demarest
- Children's Hospital Colorado Precision Medicine Institute, 13123 East 16th Avenue, Box 155, Aurora, CO 80045 United States; University of Colorado School of Medicine Department of Pediatrics, Section of Neurology, 13123 East 16th Avenue, Box 155, Aurora, CO 80045, United States.
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12
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Castano A, Silvestre M, Wells CI, Sanderson JL, Ferrer CA, Ong HW, Lang Y, Richardson W, Silvaroli JA, Bashore FM, Smith JL, Genereux IM, Dempster K, Drewry DH, Pabla NS, Bullock AN, Benke TA, Ultanir SK, Axtman AD. Discovery and characterization of a specific inhibitor of serine-threonine kinase cyclin-dependent kinase-like 5 (CDKL5) demonstrates role in hippocampal CA1 physiology. eLife 2023; 12:e88206. [PMID: 37490324 PMCID: PMC10406435 DOI: 10.7554/elife.88206] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/24/2023] [Indexed: 07/26/2023] Open
Abstract
Pathological loss-of-function mutations in cyclin-dependent kinase-like 5 (CDKL5) cause CDKL5 deficiency disorder (CDD), a rare and severe neurodevelopmental disorder associated with severe and medically refractory early-life epilepsy, motor, cognitive, visual, and autonomic disturbances in the absence of any structural brain pathology. Analysis of genetic variants in CDD has indicated that CDKL5 kinase function is central to disease pathology. CDKL5 encodes a serine-threonine kinase with significant homology to GSK3β, which has also been linked to synaptic function. Further, Cdkl5 knock-out rodents have increased GSK3β activity and often increased long-term potentiation (LTP). Thus, development of a specific CDKL5 inhibitor must be careful to exclude cross-talk with GSK3β activity. We synthesized and characterized specific, high-affinity inhibitors of CDKL5 that do not have detectable activity for GSK3β. These compounds are very soluble in water but blood-brain barrier penetration is low. In rat hippocampal brain slices, acute inhibition of CDKL5 selectively reduces postsynaptic function of AMPA-type glutamate receptors in a dose-dependent manner. Acute inhibition of CDKL5 reduces hippocampal LTP. These studies provide new tools and insights into the role of CDKL5 as a newly appreciated key kinase necessary for synaptic plasticity. Comparisons to rodent knock-out studies suggest that compensatory changes have limited the understanding of the roles of CDKL5 in synaptic physiology, plasticity, and human neuropathology.
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Affiliation(s)
- Anna Castano
- Department of Pharmacology, University of Colorado School of MedicineAuroraUnited States
| | - Margaux Silvestre
- Kinases and Brain Development Laboratory, The Francis Crick InstituteLondonUnited Kingdom
| | - Carrow I Wells
- Structural Genomics Consortium, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel HillChapel HillUnited States
| | - Jennifer L Sanderson
- Department of Pharmacology, University of Colorado School of MedicineAuroraUnited States
| | - Carla A Ferrer
- Structural Genomics Consortium, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel HillChapel HillUnited States
| | - Han Wee Ong
- Structural Genomics Consortium, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel HillChapel HillUnited States
| | - Yi Lang
- Structural Genomics Consortium, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel HillChapel HillUnited States
| | - William Richardson
- Centre for Medicines Discovery, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | - Josie A Silvaroli
- Division of Pharmaceutics and Pharmacology, College of Pharmacy and Comprehensive Cancer Center, The Ohio State UniversityColumbusUnited States
| | - Frances M Bashore
- Structural Genomics Consortium, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel HillChapel HillUnited States
| | - Jeffery L Smith
- Structural Genomics Consortium, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel HillChapel HillUnited States
| | - Isabelle M Genereux
- Structural Genomics Consortium, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel HillChapel HillUnited States
| | - Kelvin Dempster
- Kinases and Brain Development Laboratory, The Francis Crick InstituteLondonUnited Kingdom
| | - David H Drewry
- Structural Genomics Consortium, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel HillChapel HillUnited States
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina at Chapel HillChapel HillUnited States
| | - Navlot S Pabla
- Division of Pharmaceutics and Pharmacology, College of Pharmacy and Comprehensive Cancer Center, The Ohio State UniversityColumbusUnited States
| | - Alex N Bullock
- Centre for Medicines Discovery, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | - Tim A Benke
- Departments of Pediatrics, Pharmacology, Neurology and Otolaryngology, University of Colorado School of MedicineAuroraUnited States
| | - Sila K Ultanir
- Kinases and Brain Development Laboratory, The Francis Crick InstituteLondonUnited Kingdom
| | - Alison D Axtman
- Structural Genomics Consortium, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel HillChapel HillUnited States
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13
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Sun X, Wang T. Research progress on the pathogenesis of CDKL5 pathogenic variants and related encephalopathy. Eur J Pediatr 2023:10.1007/s00431-023-05006-z. [PMID: 37166538 DOI: 10.1007/s00431-023-05006-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/12/2023]
Abstract
Cyclin-dependent kinase-like 5 (CDKL5) is a gene encoding a serine/threonine kinase that possesses an N-terminal catalytic domain and a large C-terminal domain and is located on the short arm of the X-chromosome at position 22 (Xp22). CDKL5 regulates neuronal migration, axonal growth, dendritic morphogenesis, and synaptic development and affects synaptic function. Pathogenic variants include deletions, truncations, splice variants, and missense variants. The specificity of CDKL5 is mainly determined by the shared sequence of amino acid residues, which is the phosphorylation site of the target protein with the motif Arg-Pro-X-Ser/Thr-Ala/Pro/Gly/Ser (R-P-X-[S/T]-[A/G/P/S]). Developmental encephalopathy caused by pathogenic variants of CDKL5 has a variety of nervous system symptoms, such as epilepsy, hypotonia, growth retardation, dyskinesia, cortical visual impairment, sleep disorders, and other clinical symptoms. This review summarizes the mechanism of CDKL5-induced allogeneic lesions in the nervous system and the clinical manifestations of related encephalopathy. Conclusion: This review clarifies CDKL5's participation in neurodevelopmental diseases as well as its crucial function in dividing cells, cultured neurons, knockout mice, and human iPSC-derived neurons. CDKL5 variants help identify clinical diagnostic biomarkers. Although a few direct substrates of CDKL5 have been identified, more must be found in order to fully comprehend the signaling pathways connected to CDKL5 in the brain and the mechanisms that underlie its activities.
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Affiliation(s)
- Xuyan Sun
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, 730000, China
| | - Tiancheng Wang
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, 730000, China.
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14
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Castano A, Silvestre M, Wells CI, Sanderson JL, Ferrer CA, Ong HW, Liang Y, Richardson W, Silvaroli JA, Bashore FM, Smith JL, Genereux IM, Dempster K, Drewry DH, Pabla NS, Bullock AN, Benke TA, Ultanir SK, Axtman AD. Discovery and characterization of a specific inhibitor of serine-threonine kinase cyclin dependent kinase-like 5 (CDKL5) demonstrates role in hippocampal CA1 physiology. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.04.24.538049. [PMID: 37162893 PMCID: PMC10168277 DOI: 10.1101/2023.04.24.538049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Pathological loss-of-function mutations in cyclin-dependent kinase-like 5 ( CDKL5 ) cause CDKL5 deficiency disorder (CDD), a rare and severe neurodevelopmental disorder associated with severe and medically refractory early-life epilepsy, motor, cognitive, visual and autonomic disturbances in the absence of any structural brain pathology. Analysis of genetic variants in CDD have indicated that CDKL5 kinase function is central to disease pathology. CDKL5 encodes a serine-threonine kinase with significant homology to GSK3β, which has also been linked to synaptic function. Further, Cdkl5 knock-out rodents have increased GSK3β activity and often increased long-term potentiation (LTP). Thus, development of a specific CDKL5 inhibitor must be careful to exclude cross-talk with GSK3β activity. We synthesized and characterized specific, high-affinity inhibitors of CDKL5 that do not have detectable activity for GSK3β. These compounds are very soluble in water but blood-brain barrier penetration is low. In rat hippocampal brain slices, acute inhibition of CDKL5 selectively reduces post-synaptic function of AMPA-type glutamate receptors in a dose-dependent manner. Acute inhibition of CDKL5 reduces hippocampal LTP. These studies provide new tools and insights into the role of CDKL5 as a newly appreciated, key kinase necessary for synaptic plasticity. Comparisons to rodent knock-out studies suggest that compensatory changes have limited the understanding of the roles of CDKL5 in synaptic physiology, plasticity and human neuropathology.
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15
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Factors influencing the attainment of major motor milestones in CDKL5 deficiency disorder. Eur J Hum Genet 2023; 31:169-178. [PMID: 35978140 PMCID: PMC9905550 DOI: 10.1038/s41431-022-01163-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/22/2022] [Accepted: 07/21/2022] [Indexed: 11/09/2022] Open
Abstract
This study investigated the influence of factors at birth and in infancy on the likelihood of achieving major motor milestones in CDKL5 Deficiency Disorder (CDD). Data on 350 individuals with a pathogenic CDKL5 variant was sourced from the International CDKL5 Disorder Database. A first model included factors available at birth (e.g., sex, variant group and mosaicism) and the second additionally included factors available during infancy (e.g., age at seizure onset, number of anti-seizure medications used, experience of a honeymoon period and formal therapy). Cox regression was used to model the time to achieve the milestones. The probability of attaining the outcomes at specific ages was estimated by evaluating the time-to-event function at specific covariate values. Independent sitting and walking were achieved by 177/350 and 57/325 children respectively. By seven years of age, 67.1% of females but only 37.3% of males could sit independently. About a quarter each of females and males achieved independent walking by eight and six years, respectively. When observed from birth, female gender, a late truncating variant and mosaicism impacted most positively on the likelihood of independent sitting. When observed from one year, later seizure onset and experiencing a honeymoon period also improved the likelihood of independent sitting. Factors that favoured sitting (except gender) also improved walking. Having a truncating variant between aa178 and aa781 reduced the likelihood of achieving independent sitting and walking. It is possible to utilise factors occurring early in life to inform the likelihood of future motor development in CDD.
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Saldaris JM, Jacoby P, Leonard H, Benke TA, Demarest S, Marsh ED, Downs J. Psychometric properties of QI-Disability in CDKL5 Deficiency Disorder: Establishing readiness for clinical trials. Epilepsy Behav 2023; 139:109069. [PMID: 36634535 PMCID: PMC9899310 DOI: 10.1016/j.yebeh.2022.109069] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 12/23/2022] [Accepted: 12/23/2022] [Indexed: 01/12/2023]
Abstract
CDKL5 Deficiency Disorder (CDD) is a rare genetic disorder with symptoms of epilepsy, developmental impairments, and other comorbidities. Currently, there are no outcome measures for CDD with comprehensive evidence of validation. This study aimed to evaluate the psychometric properties of the Quality of Life Inventory-Disability (QI-Disability) in CDD. Quality of Life Inventory-Disability was administered to 152 parent caregivers registered with the International CDKL5 Disorder Database (ICDD). Confirmatory factor analysis was conducted and the goodness of fit of the factor structure was assessed. Fixed-effects linear regression models examined the responsiveness of QI-Disability to reported changes in child health. A subset of parent caregivers (n = 56) completed QI-Disability, as well as additional health-related questions, on two occasions separated by four weeks to evaluate test-retest reliability. Test-retest reliability was assessed using intra-class correlations (ICCs) calculated from QI-Disability scores. Based upon adjustments for changes in child health, ICCs were recalculated to estimate responsiveness to change. Confirmatory factor analysis, internal consistency, and divergent validity were mostly satisfactory, except divergent validity was not satisfactory for the Social Interactions and Independence domains. The Physical Health, Social Interactions, Leisure, and Total scores responded to changes in the child's Physical health, and the Negative Emotions and Leisure domains responded to changes in the child's behavior. Unadjusted and adjusted ICC values were above 0.8 for the Positive Emotions, Negative Emotions, Social Interactions, Leisure, Independence domains and Total score, and above 0.6 for the Physical Health domain. Findings suggest that QI-Disability is suitable to assess the quality of life of children and adults with CDD and could be of value for upcoming clinical trials.
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Affiliation(s)
- Jacinta M Saldaris
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Peter Jacoby
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Helen Leonard
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Tim A Benke
- Children's Hospital Colorado, Pediatric Neurology, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Scott Demarest
- Children's Hospital Colorado, Pediatric Neurology, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Eric D Marsh
- Division of Child Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia; School of Allied Health, Curtin University, Perth, Western Australia, Australia.
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17
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Morkous SS. Quality Of Life in Individuals with CDKL5 Deficiency Disorder. Pediatr Neurol Briefs 2022. [DOI: 10.15844/pedneurbriefs-36-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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18
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Keehan L, Haviland I, Gofin Y, Swanson LC, El Achkar CM, Schreiber J, VanNoy GE, O’Heir E, O’Donnell-Luria A, Lewis RA, Magoulas P, Tran A, Azamian MS, Chao HT, Pham L, Samaco RC, Elsea S, Thorpe E, Kesari A, Perry D, Lee B, Lalani SR, Rosenfeld JA, Olson HE, Burrage LC. Wide range of phenotypic severity in individuals with late truncations unique to the predominant CDKL5 transcript in the brain. Am J Med Genet A 2022; 188:3516-3524. [PMID: 35934918 PMCID: PMC9669137 DOI: 10.1002/ajmg.a.62940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/10/2022] [Accepted: 06/19/2022] [Indexed: 01/31/2023]
Abstract
Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) is caused by heterozygous or hemizygous variants in CDKL5 and is characterized by refractory epilepsy, cognitive and motor impairments, and cerebral visual impairment. CDKL5 has multiple transcripts, of which the longest transcripts, NM_003159 and NM_001037343, have been used historically in clinical laboratory testing. However, the transcript NM_001323289 is the most highly expressed in brain and contains 170 nucleotides at the 3' end of its last exon that are noncoding in other transcripts. Two truncating variants in this region have been reported in association with a CDD phenotype. To clarify the significance and range of phenotypes associated with late truncating variants in this region of the predominant transcript in the brain, we report detailed information on two individuals, updated clinical information on a third individual, and a summary of published and unpublished individuals reported in ClinVar. The two new individuals (one male and one female) each had a relatively mild clinical presentation including periods of pharmaco-responsive epilepsy, independent walking and limited purposeful communication skills. A previously reported male continued to have a severe phenotype. Overall, variants in this region demonstrate a range of clinical severity consistent with reports in CDD but with the potential for milder presentation.
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Affiliation(s)
- Laura Keehan
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Isabel Haviland
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
| | - Yoel Gofin
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Lindsay C. Swanson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
| | - Christelle Moufawad El Achkar
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
| | - John Schreiber
- Division of Epilepsy, Neurophysiology, and Critical Care Neurology, 8404 Children's National Hospital, Washington, DC, USA
| | - Grace E. VanNoy
- Center for Mendelian Genomics, Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Emily O’Heir
- Center for Mendelian Genomics, Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Anne O’Donnell-Luria
- Center for Mendelian Genomics, Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Genetics and Genomics, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard A. Lewis
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
- Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, TX, USA
| | - Pilar Magoulas
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Alyssa Tran
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Mahshid S. Azamian
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Hsiao-Tuan Chao
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
- Departments of Neuroscience and Pediatrics, Division of Neurology and Developmental Neuroscience, BCM, Houston, TX, USA
- Jan and Dan Duncan Neurological Research Institute, Texas Children's Hospital, Houston, TX, USA
- McNair Medical Institute at the Robert and Janice McNair Foundation, Houston, TX, USA
| | - Lisa Pham
- The Meyer Center for Developmental Pediatrics, Texas Children’s Hospital, Houston, TX, USA
| | - Rodney C. Samaco
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- Jan and Dan Duncan Neurological Research Institute, Texas Children's Hospital, Houston, TX, USA
| | - Sarah Elsea
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | | | | | | | | | - Brendan Lee
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Seema R. Lalani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Jill A. Rosenfeld
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Heather E. Olson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
- Equal contributions
| | - Lindsay C. Burrage
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
- Equal contributions
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Leonard H, Whitehouse A, Jacoby P, Benke T, Demarest S, Saldaris J, Wong K, Reddihough D, Williams K, Downs J. Quality of life beyond diagnosis in intellectual disability - Latent profiling. RESEARCH IN DEVELOPMENTAL DISABILITIES 2022; 129:104322. [PMID: 35939908 PMCID: PMC9792277 DOI: 10.1016/j.ridd.2022.104322] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/26/2022] [Accepted: 07/31/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To compare quality of life (QOL) across diagnoses associated with intellectual disability, construct QOL profiles and evaluate membership by diagnostic group, function and comorbidities. METHOD Primary caregivers of 526 children with intellectual disability (age 5-18 years) and a diagnosis of cerebral palsy, autism spectrum disorder, Down syndrome, CDKL5 deficiency disorder or Rett syndrome completed the Quality of Life Inventory-Disability (QI-Disability) questionnaire. Latent profile analysis of the QI-Disability domain scores was conducted. RESULTS The mean (SD) total QOL score was 67.8 (13.4), ranging from 60.3 (14.6) for CDD to 77.5 (11.7) for Down syndrome. Three classes describing domain scores were identified: Class 1 was characterised by higher domain scores overall but poorer negative emotions scores; Class 2 by average to high scores for most domains but low independence scores; and Class 3 was characterised by low positive emotions, social interaction, and leisure and the outdoors scores, and extremely low independence scores. The majority of individuals with autism spectrum disorder and Down syndrome belonged to Class 1 and the majority with CDKL5 deficiency disorder belonged to Class 3. Those with better functional abilities (verbal communication and independent walking were predominately members of Class 1 and those with frequent seizures were more often members of Class 2 and 3. CONCLUSION The profiles illustrated variation in QOL across a diverse group of children. QOL evaluations illustrate areas where interventions could improve QOL and provide advice to families as to where efforts may be best directed.
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Affiliation(s)
- Helen Leonard
- Telethon Kids Institute, Child Disability, The University of Western Australia, Perth, Western Australia, Australia
| | - Andrew Whitehouse
- Telethon Kids Institute, CliniKids Autism Research, Perth, Western Australia, Australia
| | - Peter Jacoby
- Telethon Kids Institute, Child Disability, The University of Western Australia, Perth, Western Australia, Australia
| | - Tim Benke
- Children's Hospital Colorado, Paediatric Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Scott Demarest
- Children's Hospital Colorado, Paediatric Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jacinta Saldaris
- Telethon Kids Institute, Child Disability, The University of Western Australia, Perth, Western Australia, Australia
| | - Kingsley Wong
- Telethon Kids Institute, Child Disability, The University of Western Australia, Perth, Western Australia, Australia
| | - Dinah Reddihough
- Royal Children's Hospital, Parkville, Victoria, Australia; Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia
| | - Katrina Williams
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia; Paediatric Education and Research, Monash University, Melbourne, Victoria, Australia; Developmental Paediatrics, Monash Children's Hospital, Australia
| | - Jenny Downs
- Telethon Kids Institute, Child Disability, The University of Western Australia, Perth, Western Australia, Australia; Curtin University, School of Physiotherapy and Exercise Science, Perth, Western Australia, Australia.
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20
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Downs J, Jacoby P, Saldaris J, Leonard H, Benke T, Marsh E, Demarest S. Negative impact of insomnia and daytime sleepiness on quality of life in individuals with the cyclin-dependent kinase-like 5 deficiency disorder. J Sleep Res 2022; 31:e13600. [PMID: 35415902 PMCID: PMC9489598 DOI: 10.1111/jsr.13600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/15/2022] [Accepted: 03/21/2022] [Indexed: 12/30/2022]
Abstract
Cyclin-dependent kinase-like 5 (CDKL5) gene pathogenic variants result in CDKL5 deficiency disorder (CDD). Early onset intractable epilepsy and severe developmental delays are prominent symptoms of CDD. Comorbid sleep disturbances are a major concerning symptom for families. We aimed to explore the relationship between insomnia, daytime sleepiness, sleep medications and quality of life in children with CDD. Caregivers of 129 children with CDD in the International CDKL5 Disorder Database completed the Quality-of-Life Inventory-Disability (QI-Disability) questionnaire and "Disorders of Maintaining Sleep" (DIMS) and the "Disorders of Excessive Somnolence" (DOES) items of the Sleep Disturbance Scale for Children. Adjusting for covariates, a unit increase in DOES score was associated with reduced quality of life total (coefficient -3.06, 95% confidence interval [CI] 1.35-7.80), physical health (coefficient -7.20, 95% CI -10.64, -3.76) and negative emotions (coefficient -3.90, 95% CI -7.38, -0.42) scores. Adjusting for covariates, a unit increase in DIMS score was associated with reduced negative emotions (coefficient -6.02, 95% CI -10.18, -2.86). Use of sleep medications had small influences on the effect sizes. This study highlights the importance of sleep problems as a determinant of quality of life in children with CDD, consistent with effects observed for other groups of children with intellectual disability. Excessive daytime sleepiness was particularly associated with detrimental effects on quality of life. Further research in optimal behavioural and pharmaceutical management of sleep problems for this population is required.
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Affiliation(s)
- Jenny Downs
- Telethon Kids Institute, Centre for Child Health ResearchThe University of Western AustraliaPerthAustralia,Curtin School of Allied HealthCurtin UniversityPerthAustralia
| | - Peter Jacoby
- Telethon Kids Institute, Centre for Child Health ResearchThe University of Western AustraliaPerthAustralia
| | - Jacinta Saldaris
- Telethon Kids Institute, Centre for Child Health ResearchThe University of Western AustraliaPerthAustralia
| | - Helen Leonard
- Telethon Kids Institute, Centre for Child Health ResearchThe University of Western AustraliaPerthAustralia
| | - Tim Benke
- Children's Hospital Colorado, Paediatric NeurologyUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Eric Marsh
- Division of Neurology, Children's Hospital of Philadelphia, School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Scott Demarest
- Children's Hospital Colorado, Paediatric NeurologyUniversity of Colorado School of MedicineAuroraColoradoUSA
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21
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CDKL5 deficiency disorder: molecular insights and mechanisms of pathogenicity to fast-track therapeutic development. Biochem Soc Trans 2022; 50:1207-1224. [PMID: 35997111 PMCID: PMC9444073 DOI: 10.1042/bst20220791] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/28/2022] [Accepted: 07/28/2022] [Indexed: 12/02/2022]
Abstract
CDKL5 deficiency disorder (CDD) is an X-linked brain disorder of young children and is caused by pathogenic variants in the cyclin-dependent kinase-like 5 (CDKL5) gene. Individuals with CDD suffer infantile onset, drug-resistant seizures, severe neurodevelopmental impairment and profound lifelong disability. The CDKL5 protein is a kinase that regulates key phosphorylation events vital to the development of the complex neuronal network of the brain. Pathogenic variants identified in patients may either result in loss of CDKL5 catalytic activity or are hypomorphic leading to partial loss of function. Whilst the progressive nature of CDD provides an excellent opportunity for disease intervention, we cannot develop effective therapeutics without in-depth knowledge of CDKL5 function in human neurons. In this mini review, we summarize new findings on the function of CDKL5. These include CDKL5 phosphorylation targets and the consequence of disruptions on signaling pathways in the human brain. This new knowledge of CDKL5 biology may be leveraged to advance targeted drug discovery and rapid development of treatments for CDD. Continued development of effective humanized models will further propel our understanding of CDD biology and may permit the development and testing of therapies that will significantly alter CDD disease trajectory in young children.
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22
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Jacoby P, Whitehouse A, Leonard H, Saldaris J, Demarest S, Benke T, Downs J. Devising a Missing Data Rule for a Quality of Life Questionnaire-A Simulation Study. J Dev Behav Pediatr 2022; 43:e414-e418. [PMID: 35075044 PMCID: PMC9308825 DOI: 10.1097/dbp.0000000000001061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 12/30/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to devise an evidence-based missing data rule for the Quality of Life Inventory-Disability (QI-Disability) questionnaire specifying how many missing items are permissible for domain and total scores to be calculated using simple imputation. We sought a straightforward rule that can be used in both research and clinical monitoring settings. METHOD A simulation study was conducted involving random selection of missing items from a complete data set of questionnaire responses. This comprised 520 children with intellectual disability from 5 diagnostic groups. We applied a simple imputation scheme, and the simulated distribution of errors induced by imputation was compared with the previously estimated standard error of measurement (SEM) for each domain. RESULTS Using a stringent criterion, which requires that the 95th percentile of absolute error be less than the SEM, 1 missing item should be permitted for 2 of the 6 QI-Disability subdomain scores to be calculated and 1 missing item per domain for the total score to be calculated. Other, less stringent criteria would allow up to 2 missing items per domain. CONCLUSION Empirical evidence about the impact of imputing missing questionnaire responses can be gathered using simulation methods applied to a complete data set. We recommend that such evidence be used in devising a rule that specifies how many items can be imputed for a valid score to be calculated.
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Affiliation(s)
- Peter Jacoby
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Andrew Whitehouse
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Helen Leonard
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Jacinta Saldaris
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Scott Demarest
- Children’s Hospital Colorado, Paediatric Neurology, University of Colorado School of Medicine, Aurora, Colorado
| | - Tim Benke
- Children’s Hospital Colorado, Paediatric Neurology, University of Colorado School of Medicine, Aurora, Colorado
| | - Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
- School of Allied Health, Curtin University, Perth, Western Australia, Australia
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Ta D, Downs J, Baynam G, Wilson A, Richmond P, Schmidt A, Decker A, Leonard H. Development of an International Database for a Rare Genetic Disorder: The MECP2 Duplication Database (MDBase). CHILDREN 2022; 9:children9081111. [PMID: 35892614 PMCID: PMC9332564 DOI: 10.3390/children9081111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022]
Abstract
The natural history of MECP2 duplication syndrome (MDS), a rare X-linked neurodevelopmental disorder with an estimated birth prevalence of 1/150,000 live births, is poorly understood due to a lack of clinical data collected for research. Such information is critical to the understanding of disease progression, therapeutic endpoints and outcome measures for clinical trials, as well as the development of therapies and orphan products. This clinical information can be systematically collected from caregivers through data collation efforts—yet, no such database has existed for MDS before now. Here, in this methodological study, we document the development, launch and management of the international MECP2 Duplication Database (MDBase). The MDBase consists of an extensive family questionnaire that collects information on general medical history, system-specific health problems, medication and hospitalisation records, developmental milestones and function, and quality of life (for individuals with MDS, and their caregivers). Launched in 2020, in its first two years of operation the MDBase has collected clinical data from 154 individuals from 26 countries—the largest sample size to date. The success of this methodology for the establishment and operation of the MDBase may provide insight and aid in the development of databases for other rare neurodevelopmental disorders.
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Affiliation(s)
- Daniel Ta
- Telethon Kids Institute, University of Western Australia, Perth, WA 6009, Australia; (D.T.); (J.D.); (G.B.); (A.W.); (P.R.)
| | - Jenny Downs
- Telethon Kids Institute, University of Western Australia, Perth, WA 6009, Australia; (D.T.); (J.D.); (G.B.); (A.W.); (P.R.)
- Curtin School of Allied Health, Curtin University, Bentley, WA 6102, Australia
| | - Gareth Baynam
- Telethon Kids Institute, University of Western Australia, Perth, WA 6009, Australia; (D.T.); (J.D.); (G.B.); (A.W.); (P.R.)
- Rare Care Centre, Perth Children’s Hospital, Nedlands, WA 6009, Australia
- Western Australian Register of Developmental Anomalies, King Edward Memorial Hospital, Subiaco, WA 6904, Australia
| | - Andrew Wilson
- Telethon Kids Institute, University of Western Australia, Perth, WA 6009, Australia; (D.T.); (J.D.); (G.B.); (A.W.); (P.R.)
- Curtin School of Allied Health, Curtin University, Bentley, WA 6102, Australia
- North Entrance, Perth Children’s Hospital, 15 Hospital Ave, Nedlands, WA 6009, Australia
- Discipline of Paediatrics, School of Medicine, University of Western Australia, Perth, WA 6009, Australia
| | - Peter Richmond
- Telethon Kids Institute, University of Western Australia, Perth, WA 6009, Australia; (D.T.); (J.D.); (G.B.); (A.W.); (P.R.)
- North Entrance, Perth Children’s Hospital, 15 Hospital Ave, Nedlands, WA 6009, Australia
- Discipline of Paediatrics, School of Medicine, University of Western Australia, Perth, WA 6009, Australia
| | - Aron Schmidt
- MECP2 Duplication Foundation, Tuscon, AZ 85724, USA; (A.S.); (A.D.)
| | - Amelia Decker
- MECP2 Duplication Foundation, Tuscon, AZ 85724, USA; (A.S.); (A.D.)
- Department of Paediatrics, University of Arizona College of Medicine, Tuscon, AZ 85724, USA
| | - Helen Leonard
- Telethon Kids Institute, University of Western Australia, Perth, WA 6009, Australia; (D.T.); (J.D.); (G.B.); (A.W.); (P.R.)
- Correspondence:
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24
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Amin S, Monaghan M, Aledo-Serrano A, Bahi-Buisson N, Chin RF, Clarke AJ, Cross JH, Demarest S, Devinsky O, Downs J, Pestana Knight EM, Olson H, Partridge CA, Stuart G, Trivisano M, Zuberi S, Benke TA. International Consensus Recommendations for the Assessment and Management of Individuals With CDKL5 Deficiency Disorder. Front Neurol 2022; 13:874695. [PMID: 35795799 PMCID: PMC9251467 DOI: 10.3389/fneur.2022.874695] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
CDKL5 Deficiency Disorder (CDD) is a rare, X-linked dominant condition that causes a developmental and epileptic encephalopathy (DEE). The incidence is between ~ 1:40,000 and 1:60,000 live births. Pathogenic variants in CDKL5 lead to seizures from infancy and severe neurodevelopmental delay. During infancy and childhood, individuals with CDD suffer impairments affecting cognitive, motor, visual, sleep, gastrointestinal and other functions. Here we present the recommendations of international healthcare professionals, experienced in CDD management, to address the multisystem and holistic needs of these individuals. Using a Delphi method, an anonymous survey was administered electronically to an international and multidisciplinary panel of expert clinicians and researchers. To provide summary recommendations, consensus was set, a priori, as >70% agreement for responses. In the absence of large, population-based studies to provide definitive evidence for treatment, we propose recommendations for clinical management, influenced by this proposed threshold for consensus. We believe these recommendations will help standardize, guide and improve the medical care received by individuals with CDD.
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Affiliation(s)
- Sam Amin
- Department of Paediatric Neurology, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Marie Monaghan
- Department of Paediatric Neurology, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Angel Aledo-Serrano
- Epilepsy Program, Department of Neurology, Ruber Internacional Hospital, Madrid, Spain
| | - Nadia Bahi-Buisson
- Pediatric Neurology, Necker Enfants Malades, Université de Paris, Paris, France
| | - Richard F. Chin
- Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom
| | - Angus J. Clarke
- University Hospital of Wales, Cardiff University, Cardiff, United Kingdom
| | - J. Helen Cross
- Developmental Neurosciences, UCL NIHR BRC Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Scott Demarest
- Departments of Pediatrics and Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, United States
| | - Orrin Devinsky
- Department of Neurology, New York University, New York, NY, United States
| | - Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
- School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia
| | - Elia M. Pestana Knight
- Cleveland Clinic Epilepsy Center, Cleveland Clinic Learner College of Medicine, Cleveland, OH, United States
| | - Heather Olson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, MA, United States
| | | | - Graham Stuart
- Bristol Heart Institute, Bristol Royal Hospital for Children, University of Bristol, Bristol, United Kingdom
| | - Marina Trivisano
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sameer Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, United Kingdom
- College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom
| | - Tim A. Benke
- Department of Pediatrics, Pharmacology, Neurology, and Otolaryngology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, United States
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25
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Leonard H, Downs J, Benke TA, Swanson L, Olson H, Demarest S. CDKL5 deficiency disorder: clinical features, diagnosis, and management. Lancet Neurol 2022; 21:563-576. [PMID: 35483386 PMCID: PMC9788833 DOI: 10.1016/s1474-4422(22)00035-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 12/19/2021] [Accepted: 01/18/2022] [Indexed: 12/25/2022]
Abstract
CDKL5 deficiency disorder (CDD) was first identified as a cause of human disease in 2004. Although initially considered a variant of Rett syndrome, CDD is now recognised as an independent disorder and classified as a developmental epileptic encephalopathy. It is characterised by early-onset (generally within the first 2 months of life) seizures that are usually refractory to polypharmacy. Development is severely impaired in patients with CDD, with only a quarter of girls and a smaller proportion of boys achieving independent walking; however, there is clinical variability, which is probably genetically determined. Gastrointestinal, sleep, and musculoskeletal problems are common in CDD, as in other developmental epileptic encephalopathies, but the prevalence of cerebral visual impairment appears higher in CDD. Clinicians diagnosing infants with CDD need to be familiar with the complexities of this disorder to provide appropriate counselling to the patients' families. Despite some benefit from ketogenic diets and vagal nerve stimulation, there has been little evidence that conventional antiseizure medications or their combinations are helpful in CDD, but further treatment trials are finally underway.
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Affiliation(s)
- Helen Leonard
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia.
| | - Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia; Curtin School of Allied Health, Curtin University, Perth, WA, Australia
| | - Tim A Benke
- Department of Neurology, Children's Hospital Colorado, Aurora, CO, USA; Department of Pediatrics, University of Colorado at Denver, Aurora, CO, USA; Department of Pharmacology, University of Colorado at Denver, Aurora, CO, USA; Department of Neurology, University of Colorado at Denver, Aurora, CO, USA; Department of Otolaryngology, University of Colorado at Denver, Aurora, CO, USA
| | - Lindsay Swanson
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Heather Olson
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Scott Demarest
- Department of Neurology, Children's Hospital Colorado, Aurora, CO, USA; Department of Pediatrics, University of Colorado at Denver, Aurora, CO, USA; Department of Neurology, University of Colorado at Denver, Aurora, CO, USA
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26
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CDKL5 Deficiency Disorder-Related Epilepsy: A Review of Current and Emerging Treatment. CNS Drugs 2022; 36:591-604. [PMID: 35633486 PMCID: PMC9876658 DOI: 10.1007/s40263-022-00921-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2022] [Indexed: 01/27/2023]
Abstract
Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) is a developmental and epileptic encephalopathy with infantile-onset epilepsy. Most individuals with CDD develop refractory epilepsy with multiple seizure types. Management of seizures in CDD remains challenging for clinicians given the highly refractory nature of seizures and the limited number of disease-specific studies that offer a high level of evidence. Epileptic spasms are the most common seizure type in CDD and are more often refractory to standard first-line treatment than are spasms of other etiologies. In other seizure types, the effectiveness of antiseizure medications is limited and wanes over time. Ketogenic diet and palliative surgical treatments have both had mixed results in observational studies. When treating refractory seizures in CDD, we recommend carefully balancing seizure control and treatment-related side effects to optimize each individual's overall quality of life. Clinical trials of medications targeting epilepsy in CDD have been conducted, and additional investigational small molecules, gene therapy, and other disease-modifying therapies are in development for CDD.
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27
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Demarest S, Marsh R, Treat L, Fisher MP, Dempsey A, Junaid M, Downs J, Leonard H, Benke T, Morris MA. The Lived Experience of Parents' Receiving the Diagnosis of CDKL5 Deficiency Disorder for Their Child. J Child Neurol 2022; 37:451-460. [PMID: 35196159 DOI: 10.1177/08830738221076285] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
CDKL5 deficiency disorder (CDD), a severe developmental and epileptic encephalopathy, is being diagnosed earlier with improved access to genetic testing, but this may also have unanticipated impacts on parents' experience receiving the diagnosis. This study explores the lived experience of parents receiving a diagnosis of CDD for their child using mixed methods. Thirty-seven semistructured interviews were conducted with parents of children with a diagnosis of CDD, which were coded and analyzed to identify themes. Grief was a nearly universal theme expressed among participants. Parents of younger children discussed grief in the context of receiving the diagnosis, whereas parents of older children indicated they were at different stages along the grieving journey when they received the diagnosis. Parents with less understanding of their child's prognosis (poorer prognostic awareness) connected their grief to receiving the diagnosis as this brought a clear understanding of the prognosis. Several themes suggested what providers did well to improve the diagnostic experience for parents, much of which aligns with existing literature around how to provide serious news. Additionally, parents identified long-term benefits of having a diagnosis for their child's medical problems. Although interview data were concordant with a survey of parents' diagnostic experience from a large international cohort, most participants in this study were relatively affluent, white mothers and further research is needed to better understand if other groups of parents have a different diagnostic experience. This study gives context of parental experience that providers should be aware of when conveying new genetic diagnoses to families.
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Affiliation(s)
- Scott Demarest
- Adult and Child Consortium for Health Outcomes Research Science, University of Colorado.,Department of Pediatrics, University of Colorado.,2932Children's Hospital Colorado
| | - Rebekah Marsh
- Adult and Child Consortium for Health Outcomes Research Science, University of Colorado
| | - Lauren Treat
- Department of Pediatrics, University of Colorado.,2932Children's Hospital Colorado
| | - Michael P Fisher
- Department of Health Sciences, 1492Towson University, Towson, MD, USA
| | - Amanda Dempsey
- Adult and Child Consortium for Health Outcomes Research Science, University of Colorado.,Department of Pediatrics, University of Colorado.,2932Children's Hospital Colorado
| | - Mohammed Junaid
- 117610Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Jenny Downs
- 117610Telethon Kids Institute, Nedlands, Western Australia, Australia.,Curtin School of Allied Health, Curtin University, Bentley, Western Australia, Australia
| | - Helen Leonard
- 117610Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Tim Benke
- Adult and Child Consortium for Health Outcomes Research Science, University of Colorado.,Department of Pediatrics, University of Colorado.,Department of Medicine.,Department of Pharmacology
| | - Megan A Morris
- Adult and Child Consortium for Health Outcomes Research Science, University of Colorado.,Department of Medicine
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28
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Saldaris J, Leonard H, Jacoby P, Marsh ED, Benke TA, Demarest S, Downs J. Initial Validation and Reliability of the CDKL5 Deficiency Disorder Hand Function Scale (CDD-Hand). J Child Neurol 2022; 37:541-547. [PMID: 35422141 PMCID: PMC9149062 DOI: 10.1177/08830738221091044] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pathogenic variants in the CDKL5 gene result in CDKL5 deficiency disorder (CDD), which is characterized by early-onset epilepsy, severe developmental delay, and often, cortical visual impairment. Validated clinical outcome measures are needed for future clinical trials to be successful. This study aimed to adapt the Rett Syndrome Hand Function Scale for CDKL5 deficiency disorder and evaluate its feasibility, acceptability, content validity, and reliability. Consultation with a cortical visual impairment experienced specialist and the Consumer Reference Group informed modifications to the instructions of the Rett Syndrome Hand Function Scale for children with CDKL5 deficiency disorder (CDD-Hand). Eighty-six families registered with the International CDKL5 Disorder Database provided video clips of their child's hand function and provided feedback about the measure. Video data were coded by 2 researchers to evaluate intra- and interrater reliability. This study provides initial evidence of validation and reliability. The scale appears to be suitable for a range of ages and functional abilities for CDKL5 deficiency disorder.
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Affiliation(s)
- Jacinta Saldaris
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, Australia
| | - Helen Leonard
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, Australia
| | - Peter Jacoby
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, Australia
| | - Eric D. Marsh
- Division of Neurology, Children’s Hospital of Philadelphia, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tim A. Benke
- Children’s Hospital Colorado, Paediatric Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Scott Demarest
- Children’s Hospital Colorado, Paediatric Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jenny Downs
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, Australia.,School of Allied Health, Curtin University, Perth, Australia
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29
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Knight EMP, Amin S, Bahi-Buisson N, Benke TA, Cross JH, Demarest ST, Olson HE, Specchio N, Fleming TR, Aimetti AA, Gasior M, Devinsky O. Safety and efficacy of ganaxolone in patients with CDKL5 deficiency disorder: results from the double-blind phase of a randomised, placebo-controlled, phase 3 trial. Lancet Neurol 2022; 21:417-427. [PMID: 35429480 DOI: 10.1016/s1474-4422(22)00077-1] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 02/01/2022] [Accepted: 02/09/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND CDKL5 deficiency disorder (CDD) is a rare, X-linked, developmental and epileptic encephalopathy characterised by severe global developmental impairment and seizures that can begin in the first few months after birth and are often treatment refractory. Ganaxolone, an investigational neuroactive steroid, reduced seizure frequency in an open-label, phase 2 trial that included patients with CDD. We aimed to further assess the efficacy and safety of ganaxolone in patients with CDD-associated refractory epilepsy. METHODS In the double-blind phase of this randomised, placebo-controlled, phase 3 trial, done at 39 outpatient clinics in eight countries (Australia, France, Israel, Italy, Poland, Russia, the UK, and the USA), patients were eligible if they were aged 2-21 years with a pathogenic or probably pathogenic CDKL5 variant and at least 16 major motor seizures (defined as bilateral tonic, generalised tonic-clonic, bilateral clonic, atonic, or focal to bilateral tonic-clonic) per 28 days in each 4-week period of an 8-week historical period. After a 6-week prospective baseline period, patients were randomly assigned (1:1) via an interactive web response system to receive either enteral adjunctive ganaxolone or matching enteral adjunctive placebo (maximum dose 63 mg/kg per day for patients weighing ≤28 kg or 1800 mg/day for patients weighing >28 kg) for 17 weeks. Patients, caregivers, investigators (including those analysing data), trial staff, and the sponsor (other than the investigational product manager) were masked to treatment allocation. The primary efficacy endpoint was percentage change in median 28-day major motor seizure frequency from the baseline period to the 17-week double-blind phase and was analysed (using a Wilcoxon-rank sum test) in all patients who received at least one dose of trial treatment and for whom baseline data were available. Safety (compared descriptively across groups) was analysed in all patients who received at least one dose of trial treatment. This study is registered with ClinicalTrials.gov, NCT03572933, and the open-label extension phase is ongoing. FINDINGS Between June 25, 2018, and July 2, 2020, 114 patients were screened for eligibility, of whom 101 (median age 6 years [IQR 3 to 10]) were randomly assigned to receive either ganaxolone (n=50) or placebo (n=51). All patients received at least one dose of a study drug, but seizure frequency for one patient in the ganaxolone group was not recorded at baseline and so the primary endpoint was analysed in a population of 100 patients. There was a median percentage change in 28-day major motor seizure frequency of -30·7% (IQR -49·5 to -1·9) in the ganaxolone group and of -6·9% (-24·1 to 39·7) in the placebo group (p=0·0036). The Hodges-Lehmann estimate of median difference in responses to ganaxolone versus placebo was -27·1% (95% CI -47·9 to - 9·6). Treatment-emergent adverse events occurred in 43 (86%) of 50 patients in the ganaxolone group and in 45 (88%) of 51 patients in the placebo group. Somnolence, pyrexia, and upper respiratory tract infections occurred in at least 10% of patients in the ganaxolone group and more frequently than in the placebo group. Serious adverse events occurred in six (12%) patients in the ganaxolone group and in five (10%) patients in the placebo group. Two (4%) patients in the ganaxolone group and four (8%) patients in the placebo group discontinued the trial. There were no deaths in the double-blind phase. INTERPRETATION Ganaxolone significantly reduced the frequency of CDD-associated seizures compared with placebo and was generally well tolerated. Results from what is, to our knowledge, the first controlled trial in CDD suggest a potential treatment benefit for ganaxolone. Long-term treatment is being assessed in the ongoing open-label extension phase of this trial. FUNDING Marinus Pharmaceuticals.
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Affiliation(s)
- Elia M Pestana Knight
- Epilepsy Center, Cleveland Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Sam Amin
- Pediatric Neurology, University Hospitals Bristol and Weston, Bristol, UK
| | - Nadia Bahi-Buisson
- Pediatric Neurology, Necker Enfants Malades University Hospital, Paris, France
| | - Tim A Benke
- Department of Pediatrics and Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - J Helen Cross
- UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK
| | - Scott T Demarest
- Department of Pediatrics and Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Heather E Olson
- Division of Epilepsy and Clinical Neurophysiology and Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Thomas R Fleming
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | | | - Orrin Devinsky
- New York University Langone Comprehensive Epilepsy Center, New York, NY, USA
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30
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Frasca A, Pavlidou E, Bizzotto M, Gao Y, Balestra D, Pinotti M, Dahl HA, Mazarakis ND, Landsberger N, Kinali M. Not Just Loss-of-Function Variations: Identification of a Hypermorphic Variant in a Patient With a CDKL5 Missense Substitution. Neurol Genet 2022; 8:e666. [PMID: 35280940 PMCID: PMC8906656 DOI: 10.1212/nxg.0000000000000666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 12/21/2021] [Indexed: 11/15/2022]
Abstract
Background and Objectives CDKL5 deficiency disorder (CDD) is a neurodevelopmental encephalopathy characterized by early-onset epilepsy and impaired psychomotor development. Variations in the X-linked CDKL5 gene coding for a kinase cause CDD. Molecular genetics has proved that almost all pathogenic missense substitutions localize in the N-terminal catalytic domain, therefore underlining the importance for brain development and functioning of the kinase activity. CDKL5 also features a long C-terminal domain that acts as negative regulator of the enzymatic activity and modulates its subcellular distribution. CDD is generally attributed to loss-of-function variations, whereas the clinical consequences of increased CDKL5 activity remain uncertain. We have identified a female patient characterized by mild epilepsy and neurologic symptoms, harboring a novel c.2873C>G nucleotide substitution, leading to the missense variant p.(Thr958Arg). To increase our comprehension of genetic variants in CDKL5-associated neurologic disorders, we have characterized the molecular consequences of the identified substitution. Methods MRI and video EEG telemetry were used to describe brain activity and capture seizure. The Bayley III test was used to evaluate the patient development. Reverse transcriptase PCR was used to analyze whether the identified nucleotide variant affects messenger RNA stability and/or splicing. The X chromosome inactivation pattern was analyzed determining the DNA methylation status of the androgen receptor (AR) gene and by sequencing of expressed alleles. Western blotting was used to investigate whether the novel Thr958Arg substitution affects the stability and/or enzymatic activity of CDKL5. Immunofluorescence was used to define whether CDKL5 subcellular distribution is affected by the Thr958Arg substitution. Results Our data suggested that the proband tends toward a skewed X chromosome inactivation pattern in favor of the novel variant. The molecular investigation revealed that the p.(Thr958Arg) substitution leads to a significant increase in the autophosphorylation of both the TEY motif and residue Tyr171 of CDKL5, as well as in the phosphorylation of the target protein MAP1S, indicating an hyperactivation of CDKL5. This occurs without evidently affecting the kinase subcellular distribution. Discussion Our data provide a strong indication that the c.2873C>G nucleotide substitution represents an hypermorphic pathogenic variation of CDKL5, therefore highlighting the importance of a tight control of CDKL5 activity in the brain.
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Affiliation(s)
- Angelisa Frasca
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Efterpi Pavlidou
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Matteo Bizzotto
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Yunan Gao
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Dario Balestra
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Mirko Pinotti
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Hans Atli Dahl
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Nicholas D Mazarakis
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Nicoletta Landsberger
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Maria Kinali
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
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31
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Leonard H, Junaid M, Wong K, Aimetti AA, Pestana Knight E, Downs J. Influences on the trajectory and subsequent outcomes in CDKL5 deficiency disorder. Epilepsia 2021; 63:352-363. [PMID: 34837650 DOI: 10.1111/epi.17125] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 10/28/2021] [Accepted: 11/02/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The study investigated the effect of seizure and medication burden at initial contact with the International CDKL5 Disorder Database on subsequent development and clinical severity and compared quality of life among those whose development progressed, remained stable, or regressed between baseline and follow-up. METHODS The effects of seizure and medication burden at baseline (high or low) on the CDKL5 Disorder Severity Scores and CDKL5 Developmental Score (CDS) at follow-up were assessed using linear and negative binomial regressions, respectively, with adjustment for age at baseline, gender, and follow-up duration with and without genotype. Seizure and medication burden were defined by average daily seizure count (high, ≥5/day; low, <5/day) and number of antiseizure medications (high, ≥3/day; low, <3/day), respectively. The effects of change in CDS over time (improved, stable, or deteriorated) on Quality of Life Inventory-Disability (QI-Disability) total and domain scores at follow-up were assessed in those aged at least 3 years at follow-up using linear regression models with adjustment for baseline CDS, gender, and follow-up duration. RESULTS The expected follow-up CDS was lower for individuals with high compared to low seizure burden at baseline (β = -.49, 95% confidence interval [CI] = -.84 to -.13). The average total QI-Disability score was 5.6 (95% CI = -.2 to 11.5) points higher among those with improved compared with stable or deteriorating CDS and 8.5 (95% CI = 3.1-13.8) points lower for those with deteriorating compared to stable or improved CDS. SIGNIFICANCE Our finding that later development showed slight improvement in those with better earlier seizure control even after adjustment for genotype suggests that the trajectory for an individual child is not necessarily predetermined and could possibly be influenced by optimal seizure management. This has implications for children's quality of life.
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Affiliation(s)
- Helen Leonard
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia.,Faculty of Health and Medical Sciences, Centre of Child Health Research, University of Western Australia, Nedlands, Western Australia, Australia
| | - Mohammed Junaid
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
| | - Kingsley Wong
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
| | | | - Elia Pestana Knight
- Pediatric Epilepsy Section, Epilepsy Center, Cleveland Clinic, Neurological Institute, Cleveland, Ohio, USA
| | - Jenny Downs
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
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32
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Olson HE, Costantini JA, Swanson LC, Kaufmann WE, Benke TA, Fulton AB, Hansen R, Poduri A, Heidary G. Cerebral visual impairment in CDKL5 deficiency disorder: vision as an outcome measure. Dev Med Child Neurol 2021; 63:1308-1315. [PMID: 34028805 PMCID: PMC8782241 DOI: 10.1111/dmcn.14908] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 11/30/2022]
Abstract
AIM To characterize the neuro-ophthalmological phenotype of cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) and assess visual acuity as a reproducible, quantitative outcome measure. METHOD We retrospectively analyzed clinical data from patients with CDD. Complete neuro-ophthalmological assessments, including visual acuity, were evaluated. RESULTS Of 26 patients (22 females, four males; median age 4y, interquartile range 2y 1mo-7y 10mo), cerebral visual impairment (CVI), defined as visual dysfunction in the absence of ocular or anterior visual pathway abnormalities, was diagnosed in all those over 2 years of age. Ophthalmological examinations revealed nystagmus in 10 patients and strabismus in 24 patients. Visual acuity was measured in 24 patients, by preferential looking in all and by sweep visual evoked potential in 13. Visual acuities were lower than age expectations and demonstrated improvement in the first 3 years. Adjusting for age and sex, average preferential looking visual acuity after 2 years of age was higher in patients with intact mobility than in those who were non-mobile. INTERPRETATION CVI was observed in patients with CDD. Visual acuity improved over time and correlated with mobility. Visual acuity, as a quantifiable measure of visual function, should be considered as an outcome measure in pre-clinical and clinical studies for CDD. What this paper adds Cerebral visual impairment is highly prevalent in cyclin-dependent kinase-like 5 deficiency disorder (CDD). Visual acuity is a measurable quantitative outcome measure in CDD. Visual acuity in CDD correlates with gross motor ability.
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Affiliation(s)
- Heather E. Olson
- Division of Epilepsy and Clinical Neurophysiology and
Epilepsy Genetics Program, Department of Neurology, Boston Children’s
Hospital and Harvard Medical School, Boston, MA, USA,CDKL5 Center of Excellence, Department of Neurology, Boston
Children’s Hospital, Boston, MA, USA
| | - Julia A. Costantini
- CDKL5 Center of Excellence, Department of Neurology, Boston
Children’s Hospital, Boston, MA, USA
| | - Lindsay C. Swanson
- CDKL5 Center of Excellence, Department of Neurology, Boston
Children’s Hospital, Boston, MA, USA
| | - Walter E. Kaufmann
- Department of Human Genetics, Emory University School of
Medicine, Atlanta, GA, USA
| | - Timothy A. Benke
- Children’s Hospital Colorado, University of Colorado
School of Medicine Departments of Pediatrics, Neurology, Pharmacology and
Otolaryngology, Aurora, Colorado, USA
| | - Anne B. Fulton
- Department of Ophthalmology, Boston Children’s
Hospital and Harvard Medical School, Boston, MA, USA
| | - Ronald Hansen
- Department of Ophthalmology, Boston Children’s
Hospital and Harvard Medical School, Boston, MA, USA
| | - Annapurna Poduri
- Division of Epilepsy and Clinical Neurophysiology and
Epilepsy Genetics Program, Department of Neurology, Boston Children’s
Hospital and Harvard Medical School, Boston, MA, USA
| | - Gena Heidary
- CDKL5 Center of Excellence, Department of Neurology, Boston
Children’s Hospital, Boston, MA, USA,Department of Ophthalmology, Boston Children’s
Hospital and Harvard Medical School, Boston, MA, USA
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33
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Saldaris J, Weisenberg J, Pestana-Knight E, Marsh ED, Suter B, Rajaraman R, Heidary G, Olson HE, Devinsky O, Price D, Jacoby P, Leonard H, Benke TA, Demarest S, Downs J. Content Validation of Clinician-Reported Items for a Severity Measure for CDKL5 Deficiency Disorder. J Child Neurol 2021; 36:998-1006. [PMID: 34378447 PMCID: PMC8458223 DOI: 10.1177/08830738211019576] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
CDKL5 deficiency disorder (CDD) results in early-onset seizures and severe developmental impairments. A CDD clinical severity assessment (CCSA) was previously developed with clinician and parent-report items to capture information on a range of domains. Consistent with US Food and Drug Administration (FDA) guidelines, content validation is the first step in evaluating the psychometric properties of an outcome measure. The aim of this study was to validate the content of the clinician-reported items in the CCSA (CCSA-Clinician). Eight neurologists leading the USA CDD Center of Excellence clinics were interviewed using the "think aloud" technique to critique 26 clinician-reported items. Common themes were aggregated, and a literature search of related assessments informed item modifications. The clinicians then participated in 2 consensus meetings to review themes and finalize the items. A consensus was achieved for the content of the CCSA-Clinician. Eight of the original items were omitted, 11 items were added, and the remaining 18 items were revised. The final 29 items were classified into 2 domains: functioning and neurologic impairments. This study enabled refinement of the CCSA-Clinician and provided evidence for its content validity. This preliminary validation is essential before field testing and further validation, in order to advance the instrument toward clinical trial readiness.
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Affiliation(s)
| | - Judith Weisenberg
- St. Louis Children’s Hospital and Washington University School of Medicine, St Louis, Missouri, USA
| | | | - Eric D. Marsh
- Division of Neurology, Children’s Hospital of Philadelphia and School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bernhard Suter
- Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas, USA
| | | | - Gena Heidary
- Department of Ophthalmology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Heather E. Olson
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Orrin Devinsky
- NYU Langone Health and Department of Neurology, New York University, New York, New York, USA
| | - Dana Price
- NYU Langone Health and Department of Neurology, New York University, New York, New York, USA
| | - Peter Jacoby
- Telethon Kids Institute, Perth, Western Australia, Australia
| | - Helen Leonard
- Telethon Kids Institute, Perth, Western Australia, Australia,The University of Western Australia, Perth, Western Australia, Australia
| | - Tim A. Benke
- Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Scott Demarest
- Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jenny Downs
- Telethon Kids Institute, Perth, Western Australia, Australia,The School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
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34
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Olson HE, Daniels CI, Haviland I, Swanson LC, Greene CA, Denny AMM, Demarest ST, Pestana-Knight E, Zhang X, Moosa AN, Fidell A, Weisenberg JL, Suter B, Fu C, Neul JL, Percy AK, Marsh ED, Benke TA, Poduri A. Current neurologic treatment and emerging therapies in CDKL5 deficiency disorder. J Neurodev Disord 2021; 13:40. [PMID: 34530725 PMCID: PMC8447578 DOI: 10.1186/s11689-021-09384-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 08/16/2021] [Indexed: 12/05/2022] Open
Abstract
Background CDKL5 deficiency disorder (CDD) is associated with refractory infantile onset epilepsy, global developmental delay, and variable features that include sleep, behavioral disturbances, and movement disorders. Current treatment is primarily symptom-based and informed by experience in caring for this population. Methods We describe medication and non-medication approaches to treatment of epilepsy and additional key neurologic symptoms (sleep disturbances, behavioral issues, movement disorders, and swallowing dysfunction) in a cohort of 177 individuals meeting criteria for CDD, 154 evaluated at 4 CDKL5 Centers of Excellence in the USA and 40 identified through the NIH Natural History Study of Rett and Related Disorders. Results The four most frequently prescribed anti-seizure medications were broad spectrum, prescribed in over 50% of individuals. While the goal was not to ascertain efficacy, we obtained data from 86 individuals regarding response to treatment, with 2-week response achieved in 14–48% and sustained 3-month response in 5–36%, of those with known response. Additional treatments for seizures included cannabis derivatives, tried in over one-third of individuals, and clinical trial medications. In combination with pharmacological treatment, 50% of individuals were treated with ketogenic diet for attempted seizure control. Surgical approaches included vagus nerve stimulators, functional hemispherectomy, and corpus callosotomy, but numbers were too limited to assess response. Nearly one-third of individuals received pharmacologic treatment for sleep disturbances, 13% for behavioral dysregulation and movement disorders, and 43% had gastrostomy tubes. Conclusions Treatment for neurologic features of CDD is currently symptom-based and empiric rather than CDD-specific, though clinical trials for CDD are emerging. Epilepsy in this population is highly refractory, and no specific anti-seizure medication was associated with improved seizure control. Ketogenic diet is commonly used in patients with CDD. While behavioral interventions are commonly instituted, information on the use of medications for sleep, behavioral management, and movement disorders is sparse and would benefit from further characterization and optimization of treatment approaches. The heterogeneity in treatment approaches highlights the need for systematic review and guidelines for CDD. Additional disease-specific and disease-modifying treatments are in development. Supplementary Information The online version contains supplementary material available at 10.1186/s11689-021-09384-z.
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Affiliation(s)
- Heather E Olson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA.
| | - Carolyn I Daniels
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA
| | - Isabel Haviland
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA
| | - Lindsay C Swanson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA
| | - Caitlin A Greene
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA
| | - Anne Marie M Denny
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA.,Division of Pediatric Neurology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Scott T Demarest
- Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, CO, USA.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Elia Pestana-Knight
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaoming Zhang
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahsan N Moosa
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andrea Fidell
- Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, CO, USA.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Judith L Weisenberg
- Department of Pediatric Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Bernhard Suter
- Division of Child Neurology, Texas Children's Hospital, Departments of Neurology and Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Cary Fu
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey L Neul
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alan K Percy
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Eric D Marsh
- Division of Child Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy A Benke
- Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, CO, USA.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, CO, USA.,Departments of Pharmacology, Neurology, and Otolaryngology, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Annapurna Poduri
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Mailstop 3063, Boston, MA, 02115, USA
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35
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Dale T, Downs J, Wong K, Leonard H. The perceived effects of cannabis products in the management of seizures in CDKL5 Deficiency Disorder. Epilepsy Behav 2021; 122:108152. [PMID: 34148781 DOI: 10.1016/j.yebeh.2021.108152] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 05/29/2021] [Accepted: 06/02/2021] [Indexed: 01/10/2023]
Abstract
INTRODUCTION CDKL5 Deficiency Disorder (CDD) is a severe treatment-resistant form of early-onset epilepsy. Current treatment options are often ineffective and associated with adverse effects, forcing families to seek alternative therapies for their children including products derived from cannabis. Reportsof miraculous cures and a public preferencefor 'natural' therapies have resulted in considerable public interest, and so this study aimed to characterize the use of cannabis in these individuals, as well as compare caregiver perceptions of efficacy and safety to objective evidence of seizure control and number of antiepileptic drugs used. METHODS Families from the International CDKL5 Disorder Database were invited to complete questionnaires which included data relating to their child's current and past treatments, including use of any cannabis-derived preparations. Perceived effects on seizure control, as well as additional benefits and adverse effects were reported. Seizure frequency and number of antiepileptic drugs were compared between those actively using cannabis products and those who were not. Longitudinal analysis was performed on a subset of the study population to compare these same variables at pre-treatment and post-treatment time points. RESULTS Three hundred and twelve caregivers answered questions regarding their child's use of antiepileptic medications. Of these, 82 (26%) described use of cannabis preparations either at present, or in the past, with the most common being cannabidiol. Of 70 caregivers that described their perceived effect on seizure control, more than two thirds reported an improvement in seizure control, either temporary (16%) or lasting (54%). Additional benefits included improvements in attention, cognition, and sleep. The majority of responses (78%) described adverse effects as 'none', though some reported an increase in sedation and gastrointestinal upset. There was no reduction in the median seizure frequency nor the number of different antiepileptic drugs, for those who were actively using cannabis products compared to those who were not. Similarly, individuals who were not using cannabis products at an initial time point had no differences in seizure frequency nor number of antiepileptic drugs at a second timepoint when they had started using this treatment. CONCLUSIONS Although this is an observational study, limited by potential participation bias and the unreliable nature of unblinded self-assessment, it suggests that caregivers perceive cannabis products, especially cannabidiol, to have a tolerable adverse effect profile and adequate efficacy. Despite this, cannabis was not associated with a reduction in seizure frequency nor number of antiepileptic drugs when compared to non-users or when compared to pre-treatment. Randomized controlled trials are urgently needed to more reliably assess this treatment's safety and efficacy.
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Affiliation(s)
- Tristan Dale
- The Faculty of Health, Medical Sciences, University of Western Australia, Perth, Western Australia, Australia; Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Jenny Downs
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia; School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Kingsley Wong
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Helen Leonard
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.
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36
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Siri B, Varesio C, Freri E, Darra F, Gana S, Mei D, Porta F, Fontana E, Galati G, Solazzi R, Niceta M, Veggiotti P, Alfei E. CDKL5 deficiency disorder in males: Five new variants and review of the literature. Eur J Paediatr Neurol 2021; 33:9-20. [PMID: 33989939 DOI: 10.1016/j.ejpn.2021.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 04/18/2021] [Accepted: 04/24/2021] [Indexed: 11/30/2022]
Abstract
The X-linked Cyclin-Dependent Kinase-Like 5 (CDKL5) gene encodes a serine-threonine kinase highly expressed in the developing brain. Loss of function of CDKL5 is pointed out to underlie the CDKL5 Deficiency Disorder (CDD), an X-linked dominant disease characterized by early-onset epileptic encephalopathy and developmental delay, usually affecting females more than males. To the best to our knowledge, only 45 males with CDD have been reported so far. Type and position of CDKL5 variants with different impact on the protein are reported to influence the clinical presentation. X-chromosome inactivation occurring in females and post-zygotic mosaicism in males are also believed to contribute to this variability. Based on these issues, genotype-phenotype correlations are still challenging. Here, we describe clinical features of five additional affected males with unreported CDKL5 variants, expanding the molecular spectrum of the disorder. We also reviewed the clinical profile of the previously reported 45 males with molecularly confirmed CDD. Severe developmental delay, cortical visual impairment, and early-onset refractory epilepsy characterize the CDD picture in males. By assessing the molecular spectrum, we confirm that germ-line truncating CDKL5 variants, equally distributed across the coding sequence, are the most recurrent mutations in CDD, and cause the worsen phenotype. While recurrence and relevance of missense substitutions within C-terminal remain still debated, disease-causing missense changes affecting the N-terminal catalytic domain correlate to a severe clinical phenotype. Finally, our data provide evidence that post-zygotic CDKL5 mosaicism may result in milder phenotypes and, at least in a subset of subjects, in variable response to antiepileptic treatments.
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Affiliation(s)
- Barbara Siri
- Department of Paediatrics, Ospedale Infantile Regina Margherita, University of Torino, Italy; Division of Metabolism, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Costanza Varesio
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Italy; Department of Brain and Behavioral Sciences, University of Pavia, Italy.
| | - Elena Freri
- Department of Paediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesca Darra
- Child Neuropsychiatry, Department of Surgical Sciences, Dentistry, Gynecology and Paediatrics, University of Verona, AOUI Verona, Verona, Italy
| | - Simone Gana
- Medical Genetics Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Davide Mei
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Children's Hospital A. Meyer-University of Florence, Italy
| | - Francesco Porta
- Department of Paediatrics, AOU Città della Salute e della Scienza di Torino, University of Torino, Italy
| | - Elena Fontana
- Child Neuropsychiatry, Department of Surgical Sciences, Dentistry, Gynecology and Paediatrics, University of Verona, AOUI Verona, Verona, Italy
| | - Giulia Galati
- Child Neuropsychiatry, Department of Surgical Sciences, Dentistry, Gynecology and Paediatrics, University of Verona, AOUI Verona, Verona, Italy
| | - Roberta Solazzi
- Department of Paediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Marcello Niceta
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Pierangelo Veggiotti
- L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy; Paediatric Neurology Unit V. Buzzi Children's Hospital Milan, Italy
| | - Enrico Alfei
- Paediatric Neurology Unit V. Buzzi Children's Hospital Milan, Italy
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37
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Kluckova D, Kolnikova M, Medova V, Bognar C, Foltan T, Svecova L, Gnip A, Kadasi L, Soltysova A, Ficek A. Clinical manifestation of CDKL5 deficiency disorder and identified mutations in a cohort of Slovak patients. Epilepsy Res 2021; 176:106699. [PMID: 34229227 DOI: 10.1016/j.eplepsyres.2021.106699] [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: 01/05/2021] [Revised: 06/06/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022]
Abstract
CDKL5 deficiency disorder (CDD) is an independent clinical entity associated with early-onset encephalopathy, which is often considered the type of epileptic encephalopathy with CDKL5 mutation also found in children diagnosed with early-onset seizure (Hanefeld) type of Rett syndrome, epileptic spasms, West syndrome, Lennox-Gastaut syndrome, or autism. Since early seizure onset is a prominent feature, in this study, a cohort of 54 unrelated patients consisting of 26 males and 28 females was selected for CDKL5 screening, with seizures presented before 12 months of age being the only clinical criterion. Five patients were found to have pathogenic or likely pathogenic variants in CDKL5 while 1 was found to have a variant of uncertain significance (p.L522V). Although CDKL5 variants are more frequently identified in female patients, we identified three male and three female patients (11.1 %, 6/54) in this study. Missense variant with unknown inheritance (p.L522V), de novo missense variant (p.E60 K), two de novo splicing (IVS15 + 1G > A, IVS16 + 2 T > A), and one de novo nonsense variant p.W125* were identified using Sanger sequencing. Whole exome analysis approach revealed de novo frameshift variant c.1247_1248delAG in a mosaic form in one of the males. Patient clinical features are reviewed and compared to those previously described in related literature. Variable clinical features were presented in CDKL5 positive patients characterised in this study. In addition to more common features, such as early epileptic seizures, severe intellectual disability, and gross motor impairment, inappropriate laughing/screaming spells and hypotonia appeared at the age of 1 year in all patients, regardless of the type of CDKL5 mutation or sex. All three CDKL5 positive males from our cohort were initially diagnosed with West syndrome, which suggests that the CDKL5 gene mutations are a significant cause of West syndrome phenotype, and also indicate the overlapping characteristics of these two clinical entities.
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Affiliation(s)
- Daniela Kluckova
- Department of Molecular Biology, Faculty of Natural Sciences, Comenius University, Ilkovicova 6, Bratislava, 842 15, Slovakia
| | - Miriam Kolnikova
- Department of Paediatric Neurology, Faculty of Medicine, Comenius University and National Institute of Children's Diseases, Limbova 1, 833 40, Bratislava, Slovakia
| | - Veronika Medova
- Institute for Clinical and Translational Research, Biomedical Research Centre, Slovak Academy of Sciences, Dubravska cesta 9, 845 05, Bratislava, Slovakia
| | - Csaba Bognar
- Department of Molecular Biology, Faculty of Natural Sciences, Comenius University, Ilkovicova 6, Bratislava, 842 15, Slovakia
| | - Tomas Foltan
- Department of Paediatric Neurology, Faculty of Medicine, Comenius University and National Institute of Children's Diseases, Limbova 1, 833 40, Bratislava, Slovakia
| | - Lucia Svecova
- Department of Paediatric Neurology, Faculty of Medicine, Comenius University and National Institute of Children's Diseases, Limbova 1, 833 40, Bratislava, Slovakia
| | - Andrej Gnip
- Medirex a.s., MEDIREX GROUP, Holubyho 35, 902 01, Pezinok, Slovakia
| | - Ludevit Kadasi
- Department of Molecular Biology, Faculty of Natural Sciences, Comenius University, Ilkovicova 6, Bratislava, 842 15, Slovakia; Institute for Clinical and Translational Research, Biomedical Research Centre, Slovak Academy of Sciences, Dubravska cesta 9, 845 05, Bratislava, Slovakia
| | - Andrea Soltysova
- Department of Molecular Biology, Faculty of Natural Sciences, Comenius University, Ilkovicova 6, Bratislava, 842 15, Slovakia; Institute for Clinical and Translational Research, Biomedical Research Centre, Slovak Academy of Sciences, Dubravska cesta 9, 845 05, Bratislava, Slovakia
| | - Andrej Ficek
- Department of Molecular Biology, Faculty of Natural Sciences, Comenius University, Ilkovicova 6, Bratislava, 842 15, Slovakia.
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38
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La Montanara P, Hervera A, Baltussen LL, Hutson TH, Palmisano I, De Virgiliis F, Kong G, Chadwick J, Gao Y, Bartus K, Majid QA, Gorgoraptis N, Wong K, Downs J, Pizzorusso T, Ultanir SK, Leonard H, Yu H, Millar DS, Istvan N, Mazarakis ND, Di Giovanni S. Cyclin-dependent-like kinase 5 is required for pain signaling in human sensory neurons and mouse models. Sci Transl Med 2021; 12:12/551/eaax4846. [PMID: 32641489 DOI: 10.1126/scitranslmed.aax4846] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 12/10/2019] [Accepted: 04/05/2020] [Indexed: 12/19/2022]
Abstract
Cyclin-dependent-like kinase 5 (CDKL5) gene mutations lead to an X-linked disorder that is characterized by infantile epileptic encephalopathy, developmental delay, and hypotonia. However, we found that a substantial percentage of these patients also report a previously unrecognized anamnestic deficiency in pain perception. Consistent with a role in nociception, we found that CDKL5 is expressed selectively in nociceptive dorsal root ganglia (DRG) neurons in mice and in induced pluripotent stem cell (iPS)-derived human nociceptors. CDKL5-deficient mice display defective epidermal innervation, and conditional deletion of CDKL5 in DRG sensory neurons impairs nociception, phenocopying CDKL5 deficiency disorder in patients. Mechanistically, CDKL5 interacts with calcium/calmodulin-dependent protein kinase II α (CaMKIIα) to control outgrowth and transient receptor potential cation channel subfamily V member 1 (TRPV1)-dependent signaling, which are disrupted in both CDKL5 mutant murine DRG and human iPS-derived nociceptors. Together, these findings unveil a previously unrecognized role for CDKL5 in nociception, proposing an original regulatory mechanism for pain perception with implications for future therapeutics in CDKL5 deficiency disorder.
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Affiliation(s)
- Paolo La Montanara
- Department of Brain Sciences, Division of Neuroscience, Imperial College London, London W12 0NN, UK.
| | - Arnau Hervera
- Department of Brain Sciences, Division of Neuroscience, Imperial College London, London W12 0NN, UK.,Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology, 08028 Barcelona, Spain.,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), 28031 Madrid, Spain.,Department of Cell Biology, Physiology and Immunology, Faculty of Biology & Institute of Neuroscience, Universitat de Barcelona, 08028 Barcelona, Spain
| | - Lucas L Baltussen
- Kinases and Brain Development Laboratory, Francis Crick Institute, London NW1 1AT, UK
| | - Thomas H Hutson
- Department of Brain Sciences, Division of Neuroscience, Imperial College London, London W12 0NN, UK
| | - Ilaria Palmisano
- Department of Brain Sciences, Division of Neuroscience, Imperial College London, London W12 0NN, UK
| | - Francesco De Virgiliis
- Department of Brain Sciences, Division of Neuroscience, Imperial College London, London W12 0NN, UK
| | - Guiping Kong
- Department of Brain Sciences, Division of Neuroscience, Imperial College London, London W12 0NN, UK
| | - Jessica Chadwick
- Department of Brain Sciences, Division of Neuroscience, Imperial College London, London W12 0NN, UK
| | - Yunan Gao
- Gene Therapy, Centre for Neuroinflammation and Neurodegeneration, Division of Brain Sciences, Department of Medicine, Imperial College London, London W12 0NN, UK
| | - Katalin Bartus
- Wolfson Centre for Age-Related Diseases, King's College London, Guy's Campus, London Bridge, London SE1 1UL, UK
| | - Qasim A Majid
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK
| | - Nikos Gorgoraptis
- Department of Brain Sciences, Division of Neuroscience, Imperial College London, London W12 0NN, UK
| | - Kingsley Wong
- Telethon Kids Institute, University of Western Australia, Perth, WA 6009, Australia
| | - Jenny Downs
- Telethon Kids Institute, University of Western Australia, Perth, WA 6009, Australia
| | - Tommaso Pizzorusso
- Institute of Neuroscience, National Research Council (CNR), I-56124 Pisa, Italy.,Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, I-50135 Florence, Italy
| | - Sila K Ultanir
- Gene Therapy, Centre for Neuroinflammation and Neurodegeneration, Division of Brain Sciences, Department of Medicine, Imperial College London, London W12 0NN, UK
| | - Helen Leonard
- Telethon Kids Institute, University of Western Australia, Perth, WA 6009, Australia
| | - Hongwei Yu
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - David S Millar
- Institute of Cancer and Genetics, Cardiff University, Cardiff F14 4ED, UK
| | - Nagy Istvan
- Nociception, Section of Anesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London W12 0NN, UK
| | - Nicholas D Mazarakis
- Gene Therapy, Centre for Neuroinflammation and Neurodegeneration, Division of Brain Sciences, Department of Medicine, Imperial College London, London W12 0NN, UK
| | - Simone Di Giovanni
- Department of Brain Sciences, Division of Neuroscience, Imperial College London, London W12 0NN, UK.
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Van Bergen NJ, Massey S, Stait T, Ellery M, Reljić B, Formosa LE, Quigley A, Dottori M, Thorburn D, Stroud DA, Christodoulou J. Abnormalities of mitochondrial dynamics and bioenergetics in neuronal cells from CDKL5 deficiency disorder. Neurobiol Dis 2021; 155:105370. [PMID: 33905871 DOI: 10.1016/j.nbd.2021.105370] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/01/2021] [Accepted: 04/20/2021] [Indexed: 01/29/2023] Open
Abstract
CDKL5 deficiency disorder (CDD) is a rare neurodevelopmental disorder caused by pathogenic variants in the Cyclin-dependent kinase-like 5 (CDKL5) gene, resulting in dysfunctional CDKL5 protein. It predominantly affects females and causes seizures in the first few months of life, ultimately resulting in severe intellectual disability. In the absence of targeted therapies, treatment is currently only symptomatic. CDKL5 is a serine/threonine kinase that is highly expressed in the brain, with a critical role in neuronal development. Evidence of mitochondrial dysfunction in CDD is gathering, but has not been studied extensively. We used human patient-derived induced pluripotent stem cells with a pathogenic truncating mutation (p.Arg59*) and CRISPR/Cas9 gene-corrected isogenic controls, differentiated into neurons, to investigate the impact of CDKL5 mutation on cellular function. Quantitative proteomics indicated mitochondrial defects in CDKL5 p.Arg59* neurons, and mitochondrial bioenergetics analysis confirmed decreased activity of mitochondrial respiratory chain complexes. Additionally, mitochondrial trafficking velocity was significantly impaired, and there was a higher percentage of stationary mitochondria. We propose mitochondrial dysfunction is contributing to CDD pathology, and should be a focus for development of targeted treatments for CDD.
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Affiliation(s)
- Nicole J Van Bergen
- Brain and Mitochondrial Research Group, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Sean Massey
- Brain and Mitochondrial Research Group, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
| | - Tegan Stait
- Brain and Mitochondrial Research Group, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
| | - Molly Ellery
- Brain and Mitochondrial Research Group, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
| | - Boris Reljić
- Department of Biochemistry and Molecular Biology, The Bio21 Molecular Science and Biotechnology Institute, The University of Melbourne, Parkville, Victoria 3010, Australia
| | - Luke E Formosa
- Department of Biochemistry and Molecular Biology, Monash Biomedicine Discovery Institute, Monash University, Melbourne, VIC 3800, Australia
| | - Anita Quigley
- Electrical and Biomedical Engineering, College of Science, Engineering and Health, RMIT University, Melbourne, Victoria 3000, Australia; Department of Medicine, University of Melbourne, St Vincent's Hospital Melbourne, Fitzroy, Victoria 3065, Australia; BioFab3D@ACMD, St Vincent's Hospital Melbourne, Fitzroy, Victoria 3065, Australia
| | - Mirella Dottori
- Centre for Neural Engineering, The University of Melbourne, Carlton, VIC 3010, Australia; Illawarra Health and Medical Research Institute, Centre for Molecular and Medical Bioscience, University of Wollongong, Wollongong, New South Wales 2500, Australia
| | - David Thorburn
- Brain and Mitochondrial Research Group, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - David A Stroud
- Department of Biochemistry and Molecular Biology, The Bio21 Molecular Science and Biotechnology Institute, The University of Melbourne, Parkville, Victoria 3010, Australia
| | - John Christodoulou
- Brain and Mitochondrial Research Group, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Discipline of Child & Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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Ciccia LM, Scalia B, Venti V, Pizzo F, Pappalardo MG, La Mendola FMC, Falsaperla R, Praticò AD. CDKL5 Gene: Beyond Rett Syndrome. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1727141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Abstract
CDKL5 is a gene located in the X-chromosome (Xp22) encoding a serine/threonine kinase involved in various signaling pathways, implicated in cell proliferation, axon development, dendrite growth, synapse formation, and maintenance. Mutations occurring in this gene have been associated with drug-resistant early-onset epilepsy, with multiple seizures type, and deep cognitive and motor development delay with poor or absent speech, ataxic gait or inability to walk, hand stereotypies and in a few cases decrement of head growth. Many aspects remain unclear about the CDKL5 deficiency disorders, research will be fundamental to better understand the pathogenesis of neurological damage and consequently developed more targeted and profitable therapies, as there is not, at the present, a gene-based treatment and the seizures are in most of the cases drug resistant. In this article, we summarize the actual knowledge about CDKL5 gene function and mostly the consequence given by its dysfunction, also examining the possible therapeutic approaches.
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Affiliation(s)
- Lina Maria Ciccia
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Bruna Scalia
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Valeria Venti
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Francesco Pizzo
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Maria Grazia Pappalardo
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | | | - Raffaele Falsaperla
- Unit of Pediatrics and Pediatric Emergency, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
- Unit of Neonatal Intensive Care and Neonatology, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
| | - Andrea D. Praticò
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Catania, Italy
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Kobayashi Y, Tohyama J, Takahashi Y, Goto T, Haginoya K, Inoue T, Kubota M, Fujita H, Honda R, Ito M, Kishimoto K, Nakamura K, Sakai Y, Takanashi JI, Tanaka M, Tanda K, Tominaga K, Yoshioka S, Kato M, Nakashima M, Saitsu H, Matsumoto N. Clinical manifestations and epilepsy treatment in Japanese patients with pathogenic CDKL5 variants. Brain Dev 2021; 43:505-514. [PMID: 33436160 DOI: 10.1016/j.braindev.2020.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/12/2020] [Accepted: 12/15/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Patients with pathogenic cyclin-dependent kinase-like-5 gene (CDKL5) variants are designated CDKL5 deficiency disorder (CDD). This study aimed to delineate the clinical characteristics of Japanese patients with CDD and elucidate possible appropriate treatments. METHODS We recruited patients with pathogenic or likely pathogenic CDKL5 variants from a cohort of approximately 1,100 Japanese patients with developmental and epileptic encephalopathies, who underwent genetic analysis. We retrospectively reviewed clinical, electroencephalogram, neuroimaging, and genetic information. RESULTS We identified 29 patients (21 females, eight males). All patients showed severe developmental delay, especially in males. Involuntary movements were observed in 15 patients. No antiepileptic drugs (AEDs) achieved seizure freedom by monotherapy. AEDs achieving ≥ 50% reduction in seizure frequency were sodium valproate in two patients, vigabatrin in one, and lamotrigine in one. Seizure aggravation was observed during the use of lamotrigine, potassium bromide, and levetiracetam. Adrenocorticotrophic hormone (ACTH) was the most effective treatment. The ketogenic diet (KD), corpus callosotomy and vagus nerve stimulation did not improve seizure frequency in most patients, but KD was remarkably effective in one. The degree of brain atrophy on magnetic resonance imaging (MRI) reflected disease severity. Compared with females, males had lower levels of attained motor development and more severe cerebral atrophy on MRI. CONCLUSION Our patients showed more severe global developmental delay than those in previous studies and had intractable epilepsy, likely because previous studies had lower numbers of males. Further studies are needed to investigate appropriate therapy for CDD, such as AED polytherapy or combination treatment involving ACTH, KD, and AEDs.
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Affiliation(s)
- Yu Kobayashi
- Department of Child Neurology, NHO Nishiniigata Chuo Hospital, Niigata, Japan.
| | - Jun Tohyama
- Department of Child Neurology, NHO Nishiniigata Chuo Hospital, Niigata, Japan
| | - Yukitoshi Takahashi
- National Epilepsy Center, NHO Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Tomohide Goto
- Division of Neurology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Kazuhiro Haginoya
- Department of Pediatric Neurology, Miyagi Children's Hospital, Sendai, Japan
| | - Takeshi Inoue
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | - Masaya Kubota
- Division of Neurology, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroshi Fujita
- Department of Pediatrics, NHO Aomori Hospital, Aomori, Japan
| | - Ryoko Honda
- Department of Pediatrics, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Masahiro Ito
- Department of Pediatrics, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Kanako Kishimoto
- Department of Pediatrics, Osaka Hospital, Japan Community Healthcare Organization (JCHO), Osaka, Japan
| | - Kazuyuki Nakamura
- Department of Pediatrics, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Yasunari Sakai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun-Ichi Takanashi
- Department of Pediatrics, Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo, Japan
| | - Manabu Tanaka
- Division of General Pediatrics, Saitama Children's Medical Center, Saitama, Japan
| | - Koichi Tanda
- Department of Pediatrics, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Koji Tominaga
- Department of Pediatrics, Graduate School of Medicine, Osaka University, Suita, Japan
| | | | - Mitsuhiro Kato
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
| | - Mitsuko Nakashima
- Department of Biochemistry, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hirotomo Saitsu
- Department of Biochemistry, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naomichi Matsumoto
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Leonard H, Junaid M, Wong K, Demarest S, Downs J. Exploring quality of life in individuals with a severe developmental and epileptic encephalopathy, CDKL5 Deficiency Disorder. Epilepsy Res 2020; 169:106521. [PMID: 33341033 DOI: 10.1016/j.eplepsyres.2020.106521] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/02/2020] [Accepted: 11/29/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND CDKL5 Deficiency Disorder (CDD) is a rare genetic disorder caused by a mutation in the cyclin-dependent kinase-like 5 (CDKL5) gene. It is now considered to be a developmental and epileptic encephalopathy because of the early onset of seizures in association with severe global delay. Other features include cortical visual impairment, sleep and gastro-intestinal problems. Progress in clinical understanding, especially regarding the spectrum of functional ability, seizure patterns, and other comorbidities was initially slow but accelerated in 2012 with the establishment of the International CDKL5 Database (ICDD). Our aim was to use this data source to investigate quality of life (QOL) and associated factors in this disorder. METHOD A follow-up questionnaire was administered in 2018 to parents of children registered with the ICDD who had a pathogenic CDKL5 variant. QOL was assessed using QI Disability, an instrument, specifically developed to measure total and specific domains of QOL (physical health, positive emotions, negative emotions, social interaction, leisure and the outdoors (leisure) and independence) in children with intellectual disability. Associations with functional abilities, physical health, mental health and family factors were investigated, initially using univariate analyses followed by multivariate analyses for each of these groups with a final composite model which included the important variables identified from previous models. RESULTS Questionnaires were returned by 129/160 families with a child aged >3 years. Functional impairment, including lack of ability to sit, use hands and communicate had the greatest adverse impact on QOL. There were also some relationships with major genotype groupings. Individuals using three or more anti-epileptic medications had poorer QOL than those on one or no medication, particularly in the physical health domain. There was also variation by geographical region with those living in North America typically having the best QOL and those living in middle or lower income countries poorer QOL. CONCLUSION Although lower functional abilities were associated with poorer quality of life further research is needed to understand how environmental supports might mitigate this deficit. Comprehensive care and support for both the child and family have important roles to play in helping families to thrive despite the severity of CDD.
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Affiliation(s)
- Helen Leonard
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia.
| | - Mohammed Junaid
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - Kingsley Wong
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | | | - Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
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MacKay CI, Wong K, Demarest ST, Benke TA, Downs J, Leonard H. Exploring genotype-phenotype relationships in the CDKL5 deficiency disorder using an international dataset. Clin Genet 2020; 99:157-165. [PMID: 33047306 DOI: 10.1111/cge.13862] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/20/2020] [Accepted: 10/09/2020] [Indexed: 12/24/2022]
Abstract
Characterized by early-onset seizures, global developmental delay and severe motor deficits, CDKL5 deficiency disorder is caused by pathogenic variants in the cyclin-dependent kinase-like 5 gene. Previous efforts to investigate genotype-phenotype relationships have been limited due to small numbers of recurrent mutations and small cohort sizes. Using data from the International CDKL5 Disorder Database we examined genotype-phenotype relationships for 13 recurrent CDKL5 variants and the previously analyzed historic variant groupings. We have applied the CDKL5 Developmental Score (CDS) and an adapted version of the CDKL5 Clinical Severity Assessment (CCSA), to grade the severity of phenotype and developmental outcomes for 285 individuals with CDKL5 variants. Comparisons of adapted CCSA and CDS between recurrent variants and variant groups were performed using multiple linear regression adjusting for age and sex. Individuals with the missense variant, p.Arg178Trp, had the highest mean adapted CCSA and lowest mean developmental scores. Other variants producing severe phenotypes included p.Arg559* and p.Arg178Gln. Variants producing milder phenotypes included p.Arg134*, p.Arg550*, and p.Glu55Argfs*20. There are observed differences in phenotype severity and developmental outcomes for individuals with different CDKL5 variants. However, the historic variant groupings did not seem to reflect differences in phenotype severity or developmental outcomes as clearly as analyzed by individual variants.
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Affiliation(s)
- Conor I MacKay
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Kingsley Wong
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Scott T Demarest
- Children's Hospital Colorado, Aurora, Colorado, USA.,Departments of Pediatrics and Neurology, University of Colorado at Denver, Aurora, Colorado, USA
| | - Tim A Benke
- Children's Hospital Colorado, Aurora, Colorado, USA.,Departments of Pediatrics, Pharmacology, Neurology and Otolaryngology, University of Colorado at Denver, Aurora, Colorado, USA
| | - Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Helen Leonard
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
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Gao Y, Irvine EE, Eleftheriadou I, Naranjo CJ, Hearn-Yeates F, Bosch L, Glegola JA, Murdoch L, Czerniak A, Meloni I, Renieri A, Kinali M, Mazarakis ND. Gene replacement ameliorates deficits in mouse and human models of cyclin-dependent kinase-like 5 disorder. Brain 2020; 143:811-832. [DOI: 10.1093/brain/awaa028] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 11/15/2019] [Accepted: 12/13/2019] [Indexed: 01/04/2023] Open
Abstract
Abstract
Cyclin-dependent kinase-like 5 disorder is a severe neurodevelopmental disorder caused by mutations in the X-linked cyclin-dependent kinase-like 5 (CDKL5) gene. It predominantly affects females who typically present with severe early epileptic encephalopathy, global developmental delay, motor dysfunction, autistic features and sleep disturbances. To develop a gene replacement therapy, we initially characterized the human CDKL5 transcript isoforms expressed in the brain, neuroblastoma cell lines, primary astrocytes and embryonic stem cell-derived cortical interneurons. We found that the isoform 1 and to a lesser extent the isoform 2 were expressed in human brain, and both neuronal and glial cell types. These isoforms were subsequently cloned into recombinant adeno-associated viral (AAV) vector genome and high-titre viral vectors were produced. Intrajugular delivery of green fluorescence protein via AAV vector serotype PHP.B in adult wild-type male mice transduced neurons and astrocytes throughout the brain more efficiently than serotype 9. Cdkl5 knockout male mice treated with isoform 1 via intrajugular injection at age 28–30 days exhibited significant behavioural improvements compared to green fluorescence protein-treated controls (1012 vg per animal, n = 10 per group) with PHP.B vectors. Brain expression of the isoform 1 transgene was more abundant in hindbrain than forebrain and midbrain. Transgene brain expression was sporadic at the cellular level and most prominent in hippocampal neurons and cerebellar Purkinje cells. Correction of postsynaptic density protein 95 cerebellar misexpression, a major fine cerebellar structural abnormality in Cdkl5 knockout mice, was found in regions of high transgene expression within the cerebellum. AAV vector serotype DJ efficiently transduced CDKL5-mutant human induced pluripotent stem cell-derived neural progenitors, which were subsequently differentiated into mature neurons. When treating CDKL5-mutant neurons, isoform 1 expression led to an increased density of synaptic puncta, while isoform 2 ameliorated the calcium signalling defect compared to green fluorescence protein control, implying distinct functions of these isoforms in neurons. This study provides the first evidence that gene therapy mediated by AAV vectors can be used for treating CDKL5 disorder.
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Affiliation(s)
- Yunan Gao
- Gene Therapy, Section of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, London W12 0NN, UK
| | - Elaine E Irvine
- Metabolic Signalling Group, MRC London Institute of Medical Sciences, Imperial College London, London W12 0NN, UK
| | - Ioanna Eleftheriadou
- Gene Therapy, Section of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, London W12 0NN, UK
| | - Carlos Jiménez Naranjo
- Gene Therapy, Section of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, London W12 0NN, UK
| | - Francesca Hearn-Yeates
- Gene Therapy, Section of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, London W12 0NN, UK
| | - Leontien Bosch
- Gene Therapy, Section of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, London W12 0NN, UK
| | - Justyna A Glegola
- Metabolic Signalling Group, MRC London Institute of Medical Sciences, Imperial College London, London W12 0NN, UK
| | - Leah Murdoch
- CBS Imperial College London, Hammersmith Campus, London W12 0NN, UK
| | | | - Ilaria Meloni
- Medical Genetics, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Alessandra Renieri
- Medical Genetics, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Maria Kinali
- The Portland Hospital, 205-209 Great Portland Street, London, W1W 5AH, UK
| | - Nicholas D Mazarakis
- Gene Therapy, Section of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, London W12 0NN, UK
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45
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CDKL5 Deficiency Disorder-A Complex Epileptic Encephalopathy. Brain Sci 2020; 10:brainsci10020107. [PMID: 32079229 PMCID: PMC7071516 DOI: 10.3390/brainsci10020107] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 02/11/2020] [Accepted: 02/13/2020] [Indexed: 12/31/2022] Open
Abstract
CDKL5 deficiency disorder (CDD) is a complex of clinical symptoms resulting from the presence of non-functional CDKL5 protein, i.e., serine-threonine kinase (previously referred to as STK9), or its complete absence. The clinical picture is characterized by epileptic seizures (that start within the first three months of life and most often do not respond to pharmacological treatment), epileptic encephalopathy secondary to seizures, and retardation of psychomotor development, which are often observed already in the first months of life. Due to the fact that CDKL5 is located on the X chromosome, the prevalence of CDD among women is four times higher than in men. However, the course is usually more severe among male patients. Recently, many clinical centers have analyzed this condition and provided knowledge on the function of CDKL5 protein, the natural history of the disease, therapeutic options, and their effectiveness and prognosis. The International CDKL5 Disorder Database was established in 2012, which focuses its activity on expanding knowledge related to this condition and disseminating such knowledge to the families of patients.
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46
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MacKay CI, Bick D, Prokop JW, Muñoz I, Rouse J, Downs J, Leonard H. Expanding the phenotype of the CDKL5 deficiency disorder: Are seizures mandatory? Am J Med Genet A 2020; 182:1217-1222. [DOI: 10.1002/ajmg.a.61504] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/03/2019] [Accepted: 01/17/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Conor I. MacKay
- Telethon Kids InstituteThe University of Western Australia Perth Western Australia Australia
| | - David Bick
- HudsonAlpha Institute for Biotechnology Huntsville Alabama
| | - Jeremy W. Prokop
- Department of Pediatrics and Human Development, College of Human MedicineMichigan State University Grand Rapids Michigan
| | - Ivan Muñoz
- MRC Protein Phosphorylation and Ubiquitylation Unit, School of Life SciencesUniversity of Dundee Dundee Scotland
| | - John Rouse
- MRC Protein Phosphorylation and Ubiquitylation Unit, School of Life SciencesUniversity of Dundee Dundee Scotland
| | - Jenny Downs
- Telethon Kids InstituteThe University of Western Australia Perth Western Australia Australia
- School of Physiotherapy and Exercise ScienceCurtin University Perth Western Australia Australia
| | - Helen Leonard
- Telethon Kids InstituteThe University of Western Australia Perth Western Australia Australia
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Fuchs C, Gennaccaro L, Ren E, Galvani G, Trazzi S, Medici G, Loi M, Conway E, Devinsky O, Rimondini R, Ciani E. Pharmacotherapy with sertraline rescues brain development and behavior in a mouse model of CDKL5 deficiency disorder. Neuropharmacology 2019; 167:107746. [PMID: 31469994 DOI: 10.1016/j.neuropharm.2019.107746] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/27/2019] [Accepted: 08/21/2019] [Indexed: 12/15/2022]
Abstract
Mutations in the X-linked cyclin-dependent kinase-like 5 (CDKL5) gene cause a severe neurodevelopmental disorder, CDKL5 deficiency disorder (CDD). CDKL5 is fundamental for correct brain development and function, but the molecular mechanisms underlying aberrant neurologic dysfunction in CDD are incompletely understood. Here we show a dysregulation of hippocampal and cortical serotonergic (5-HT) receptor expression in heterozygous Cdkl5 knockout (KO) female mice, suggesting that impaired 5-HT neurotransmission contributes to CDD. We demonstrate that targeting impaired 5-HT signaling via the selective serotonin reuptake inhibitor (SSRI) sertraline rescues CDD-related neurodevelopmental and behavioral defects in heterozygous Cdkl5 KO female mice. In particular, chronic treatment with sertraline normalized locomotion, stereotypic and autistic-like features, and spatial memory in Cdkl5 KO mice. These positive behavioral effects were accompanied by restored neuronal survival, dendritic development and synaptic connectivity. At a molecular level, sertraline increased brain-derived neurotrophic factor (BDNF) expression and restored abnormal phosphorylation levels of tyrosine kinase B (TrkB) and its downstream target the extracellular signal-regulated kinase (ERK1/2). Since sertraline is an FDA-approved drug with an extensive safety and tolerability data package, even for children, our findings suggest that sertraline may improve neurodevelopment in children with CDD. This article is part of the special issue entitled 'Serotonin Research: Crossing Scales and Boundaries'.
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Affiliation(s)
- Claudia Fuchs
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy.
| | - Laura Gennaccaro
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Elisa Ren
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Giuseppe Galvani
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Stefania Trazzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Giorgio Medici
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Manuela Loi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Erin Conway
- Department of Neurology, NYU Langone Health, New York, USA
| | - Orrin Devinsky
- Department of Neurology, NYU Langone Health, New York, USA
| | - Roberto Rimondini
- Department of Medical and Clinical Sciences, University of Bologna, Italy
| | - Elisabetta Ciani
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy.
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48
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Demarest S, Pestana-Knight EM, Olson HE, Downs J, Marsh ED, Kaufmann WE, Partridge CA, Leonard H, Gwadry-Sridhar F, Frame KE, Cross JH, Chin RFM, Parikh S, Panzer A, Weisenberg J, Utley K, Jaksha A, Amin S, Khwaja O, Devinsky O, Neul JL, Percy AK, Benke TA. Severity Assessment in CDKL5 Deficiency Disorder. Pediatr Neurol 2019; 97:38-42. [PMID: 31147226 PMCID: PMC6659999 DOI: 10.1016/j.pediatrneurol.2019.03.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pathologic mutations in cyclin-dependent kinase-like 5 cause CDKL5 deficiency disorder, a genetic syndrome associated with severe epilepsy and cognitive, motor, visual, and autonomic disturbances. This disorder is a relatively common genetic cause of early-life epilepsy. A specific severity assessment is lacking, required to monitor the clinical course and needed to define the natural history and for clinical trial readiness. METHODS A severity assessment was developed based on clinical and research experience from the International Foundation for CDKL5 Research Centers of Excellence consortium and the National Institutes of Health Rett and Rett-Related Disorders Natural History Study consortium. An initial draft severity assessment was presented and reviewed at the annual CDKL5 Forum meeting (Boston, 2017). Subsequently it was iterated through four cycles of a modified Delphi process by a group of clinicians, researchers, industry, patient advisory groups, and parents familiar with this disorder until consensus was achieved. The revised version of the severity assessment was presented for review, comment, and piloting to families at the International Foundation for CDKL5 Research-sponsored family meeting (Colorado, 2018). Final revisions were based on this additional input. RESULTS The final severity assessment comprised 51 items that comprehensively describe domains of epilepsy; motor; cognition, behavior, vision, and speech; and autonomic functions. Parental ratings of therapy effectiveness and child and family functioning are also included. CONCLUSIONS A severity assessment was rapidly developed with input from multiple stakeholders. Refinement through ongoing validation is required for future clinical trials. The consensus methods employed for the development of severity assessment may be applicable to similar rare disorders.
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Affiliation(s)
- Scott Demarest
- Children's Hospital Colorado and University of Colorado School of Medicine Aurora, Colorado; Department of Pediatrics, Aurora, Colorado
| | - Elia M Pestana-Knight
- Cleveland Clinic, Neurological Institute Cleveland, Ohio; Epilepsy Center, Cleveland, Ohio
| | - Heather E Olson
- Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Boston Children's Hospital Boston, Massachusetts
| | - Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia; School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Eric D Marsh
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Walter E Kaufmann
- M.I.N.D. Institute, Department of Neurology, University of California Davis Health System, Sacramento, California; Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia
| | | | - Helen Leonard
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Femida Gwadry-Sridhar
- Department of Computer Science, University of Western Ontario and Pulse Infoframe, London, Ontario, Canada
| | | | - J Helen Cross
- UCL Great Ormond Street Institute of Child Health & NIHR GOSH BRC, London, UK
| | - Richard F M Chin
- University of Edinburgh and Royal Hospital for Sick Children, Edinburgh, UK
| | | | | | - Judith Weisenberg
- Neurology, Division of Pediatric Neurology, Epilepsy Section, Washington University School of Medicine, St. Louis Children's Hospital, St Louis, Missouri
| | - Karen Utley
- International Foundation for CDKL5 Research, Wadwsorth, Ohio
| | - Amanda Jaksha
- International Foundation for CDKL5 Research, Wadwsorth, Ohio
| | | | - Omar Khwaja
- Roche Innovation Center Basel, Roche Pharmaceutical Research and Early Development NORD, Basel, Switzerland
| | - Orrin Devinsky
- Department of Neurology, New York University, New York, New York
| | - Jeffery L Neul
- Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Tennessee
| | - Alan K Percy
- University of Alabama at Birmingham, Pediatrics, Neurology, Neurobiology, Genetics, and Psychology, Birmingham, Alabama
| | - Tim A Benke
- Children's Hospital Colorado and University of Colorado School of Medicine Aurora, Colorado; Department of Pediatrics, Aurora, Colorado; Department of Pharmacology, Aurora, Colorado; Department of Neurology, Aurora, Colorado; Department of Otolaryngology, Aurora, Colorado.
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49
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Demarest ST, Olson HE, Moss A, Pestana-Knight E, Zhang X, Parikh S, Swanson LC, Riley KD, Bazin GA, Angione K, Niestroj LM, Lal D, Juarez-Colunga E, Benke TA. CDKL5 deficiency disorder: Relationship between genotype, epilepsy, cortical visual impairment, and development. Epilepsia 2019; 60:1733-1742. [PMID: 31313283 PMCID: PMC7098045 DOI: 10.1111/epi.16285] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 06/20/2019] [Accepted: 06/20/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The cyclin-dependent kinase like 5 (CDKL5) gene is a known cause of early onset developmental and epileptic encephalopathy, also known as CDKL5 deficiency disorder (CDD). We sought to (1) provide a description of seizure types in patients with CDD, (2) provide an assessment of the frequency of seizure-free periods and cortical visual impairment (CVI), (3) correlate these features with genotype and gender, and (4) correlate these features with developmental milestones. METHODS This is a cohort study of patients with CDD. Phenotypic features were explored and correlated with gene variant grouping and gender. A developmental score was created based on achieving seven primary milestones. Phenotypic variables were correlated with the developmental score to explore markers of better developmental outcomes. Multivariate linear regression was used to account for age at last visit. RESULTS Ninety-two patients with CDD were seen during the enrollment period. Eighteen were male (19%); median age at last visit was 5 years (interquartile range = 2.0-11.0). Eighty-one percent of patients developed epileptic spasms, but only 47% of those also had hypsarrhythmia. Previously described hypermotor-tonic-spasms sequence was seen in only 24% of patients, but 56% of patients had seizures with multiple phases (often tonic and spasms). Forty-three percent of patients experienced a seizure-free period ranging from 1 to >12 months, but only 6% were still seizure-free at the last visit. CVI was present in 75% of all CDD patients. None of these features was associated with genotype group or gender. CVI was correlated with reduced milestone achievement after adjusting for age at last visit and a history of hypsarrhythmia. SIGNIFICANCE The most common seizure types in CDD are epileptic spasms (often without hypsarrhythmia) and tonic seizures that may cluster together. CVI is a common feature in CDD and is correlated with achieving fewer milestones.
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Affiliation(s)
- Scott T Demarest
- Children's Hospital Colorado, Aurora, Colorado
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
- University of Colorado School of Medicine, Aurora, Colorado
- Department of Pediatrics, Colorado School of Public Health, Aurora, Colorado
- Department of Neurology, Colorado School of Public Health, Aurora, Colorado
| | - Heather E Olson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Angela Moss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
| | - Elia Pestana-Knight
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Neurology, Lerner Research Institute, Cleveland, Ohio
- Genomic Medicine Institute, Lerner Research Institute, Cleveland, Ohio
| | - Xiaoming Zhang
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Neurology, Lerner Research Institute, Cleveland, Ohio
- Genomic Medicine Institute, Lerner Research Institute, Cleveland, Ohio
| | - Sumit Parikh
- Genomic Medicine Institute, Lerner Research Institute, Cleveland, Ohio
- Department of Neurogenetics, Lerner Research Institute, Cleveland, Ohio
| | - Lindsay C Swanson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Katherine D Riley
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Grace A Bazin
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Katie Angione
- Children's Hospital Colorado, Aurora, Colorado
- University of Colorado School of Medicine, Aurora, Colorado
| | | | - Dennis Lal
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
- Genomic Medicine Institute, Lerner Research Institute, Cleveland, Ohio
- Cologne Center for Genomics, University of Cologne, Cologne, Germany
- Cleveland Clinic Children's, Cleveland, Ohio
- Stanley Center for Psychiatric Research, Cambridge, Massachusetts
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Elizabeth Juarez-Colunga
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Tim A Benke
- Children's Hospital Colorado, Aurora, Colorado
- University of Colorado School of Medicine, Aurora, Colorado
- Department of Pediatrics, Colorado School of Public Health, Aurora, Colorado
- Department of Neurology, Colorado School of Public Health, Aurora, Colorado
- Department of Pharmacology, Colorado School of Public Health, Aurora, Colorado
- Department of Otolaryngology, Colorado School of Public Health, Aurora, Colorado
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Olson HE, Demarest ST, Pestana-Knight EM, Swanson LC, Iqbal S, Lal D, Leonard H, Cross JH, Devinsky O, Benke TA. Cyclin-Dependent Kinase-Like 5 Deficiency Disorder: Clinical Review. Pediatr Neurol 2019; 97:18-25. [PMID: 30928302 PMCID: PMC7120929 DOI: 10.1016/j.pediatrneurol.2019.02.015] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 01/21/2019] [Accepted: 02/16/2019] [Indexed: 01/08/2023]
Abstract
Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) is a developmental encephalopathy caused by pathogenic variants in the gene CDKL5. This unique disorder includes early infantile onset refractory epilepsy, hypotonia, developmental intellectual and motor disabilities, and cortical visual impairment. We review the clinical presentations and genetic variations in CDD based on a systematic literature review and experience in the CDKL5 Centers of Excellence. We propose minimum diagnostic criteria. Pathogenic variants include deletions, truncations, splice variants, and missense variants. Pathogenic missense variants occur exclusively within the kinase domain or affect splice sites. The CDKL5 protein is widely expressed in the brain, predominantly in neurons, with roles in cell proliferation, neuronal migration, axonal outgrowth, dendritic morphogenesis, and synapse development. The molecular biology of CDD is revealing opportunities in precision therapy, with phase 2 and 3 clinical trials underway or planned to assess disease specific and disease modifying treatments.
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Affiliation(s)
- Heather E Olson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts.
| | - Scott T Demarest
- Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, Colorado; Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado
| | - Elia M Pestana-Knight
- Cleveland Clinic Neurological Institute Epilepsy Center, Cleveland Clinic Neurological Institute Pediatric Neurology Department, Neurogenetics, Cleveland Clinic Children's, Cleveland, Ohio
| | - Lindsay C Swanson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Sumaiya Iqbal
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, Massachusetts; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Dennis Lal
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, Massachusetts; Genomic Medicine Institute, Cleveland Clinic, Cleveland, Ohio; Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Helen Leonard
- Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - J Helen Cross
- UCL Great Ormond Street NIHR BRC Institute of Child Health, London, UK
| | - Orrin Devinsky
- Department of Neurology, NYU Langone Health, New York, New York
| | - Tim A Benke
- Children's Hospital Colorado, University of Colorado, School of Medicine, Aurora, Colorado; Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado; Department of Pharmacology, University of Colorado, School of Medicine, Aurora, Colorado; Department of Neurology, University of Colorado, School of Medicine, Aurora, Colorado; Department of Otolaryngology, University of Colorado, School of Medicine, Aurora, Colorado
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