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Gariballa N, Mohamed F, Badawi S, Ali BR. The double whammy of ER-retention and dominant-negative effects in numerous autosomal dominant diseases: significance in disease mechanisms and therapy. J Biomed Sci 2024; 31:64. [PMID: 38937821 PMCID: PMC11210014 DOI: 10.1186/s12929-024-01054-1] [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: 03/24/2024] [Accepted: 06/20/2024] [Indexed: 06/29/2024] Open
Abstract
The endoplasmic reticulum (ER) employs stringent quality control mechanisms to ensure the integrity of protein folding, allowing only properly folded, processed and assembled proteins to exit the ER and reach their functional destinations. Mutant proteins unable to attain their correct tertiary conformation or form complexes with their partners are retained in the ER and subsequently degraded through ER-associated protein degradation (ERAD) and associated mechanisms. ER retention contributes to a spectrum of monogenic diseases with diverse modes of inheritance and molecular mechanisms. In autosomal dominant diseases, when mutant proteins get retained in the ER, they can interact with their wild-type counterparts. This interaction may lead to the formation of mixed dimers or aberrant complexes, disrupting their normal trafficking and function in a dominant-negative manner. The combination of ER retention and dominant-negative effects has been frequently documented to cause a significant loss of functional proteins, thereby exacerbating disease severity. This review aims to examine existing literature and provide insights into the impact of dominant-negative effects exerted by mutant proteins retained in the ER in a range of autosomal dominant diseases including skeletal and connective tissue disorders, vascular disorders, neurological disorders, eye disorders and serpinopathies. Most crucially, we aim to emphasize the importance of this area of research, offering substantial potential for understanding the factors influencing phenotypic variability associated with genetic variants. Furthermore, we highlight current and prospective therapeutic approaches targeted at ameliorating the effects of mutations exhibiting dominant-negative effects. These approaches encompass experimental studies exploring treatments and their translation into clinical practice.
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Affiliation(s)
- Nesrin Gariballa
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box: 15551, Al-Ain, United Arab Emirates
| | - Feda Mohamed
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box: 15551, Al-Ain, United Arab Emirates
- ASPIRE Precision Medicine Research Institute Abu Dhabi, United Arab Emirates University, Abu Dhabi, United Arab Emirates
| | - Sally Badawi
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box: 15551, Al-Ain, United Arab Emirates
| | - Bassam R Ali
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box: 15551, Al-Ain, United Arab Emirates.
- ASPIRE Precision Medicine Research Institute Abu Dhabi, United Arab Emirates University, Abu Dhabi, United Arab Emirates.
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Hayama M, Maeda Y, Obata S, Tsuda T, Takeda K, Nishida T, Inohara H. Understanding hereditary hemorrhagic telangiectasia: From genetic anomalies to systemic manifestations, quality of life, and epistaxis management-Exploring the otolaryngologist's integral role. Auris Nasus Larynx 2024; 51:305-312. [PMID: 38008660 DOI: 10.1016/j.anl.2023.11.002] [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: 09/11/2023] [Revised: 10/19/2023] [Accepted: 11/07/2023] [Indexed: 11/28/2023]
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Rendu-Weber syndrome, is a rare autosomal dominant disorder characterized by vascular malformations. This comprehensive review aimed to provide an overview and summarize various aspects of HHT, including the genetic abnormalities, complications associated with visceral arteriovenous malformations (AVMs), prognosis of HHT, quality of life (QOL), and treatment of epistaxis. In addition, this review highlights the challenges in diagnosing HHT and emphasizes the critical role of otolaryngologists in the early detection of HHT. Otolaryngologists can refer patients with refractory epistaxis for AVM screening to expedite intervention. Mutation of the genes involved in the transforming growth factor-β signaling pathway leads to the incidence of HHT, resulting in the formation of abnormal blood vessel formation. These vascular malformations commonly manifest as telangiectasia on the skin and mucous membranes; however, epistaxis remains the hallmark symptom of HHT. The impact of HHT goes beyond the visible symptoms and often includes the formation of life-threatening visceral AVMs in the lungs, liver, and brain. The prognosis of patients with HHT is closely related to the development of these complications, necessitating timely diagnosis and intervention. Refractory epistaxis diminishes the QOL of patients with HHT. The management of epistaxis ranges from conservative measures to advanced interventions such as prevention, conservative treatments, ablation, surgical procedures, and the administration of anti-angiogenic agents. However, effective management requires a multidisciplinary approach. The diagnosis of HHT remains challenging due to its variable presentation and lack of awareness among physicians. This review highlights the importance of reducing the duration between symptom onset and diagnosis. Otolaryngologists who are experienced in the management of refractory epistaxis can aid in identifying potential cases of HHT. They can facilitate the initiation of screening for visceral AVMs via prompt recognition of the signs and symptoms of HHT, contributing to improved patient outcomes. Early detection and intervention through screening can extend the life expectancy of patients with HHT to levels comparable with that of the general population. In conclusion, this review provides insight into various aspects of HHT and emphasizes the importance of timely diagnosis and intervention in the mitigation of the potentially life-threatening complications associated with this disorder. Otolaryngologists play a critical role in this process, serving as gatekeepers to the identification of cases of HHT and implementation of appropriate screening and management pathways, thereby improving the life expectancy and QOL of patients.
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Affiliation(s)
- Masaki Hayama
- Department of Otorhinolaryngology, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya City, Hyogo, Japan; Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan.
| | - Yohei Maeda
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan; Department of Otorhinolaryngology, Japan Community Healthcare Organization Osaka Hospital, Osaka City, Osaka, Japan
| | - Sho Obata
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Takeshi Tsuda
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Kazuya Takeda
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Takeo Nishida
- Department of Neurosurgery, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya City, Hyogo, Japan; Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Hidenori Inohara
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
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Seebauer CT, Wiens B, Hintschich CA, Platz Batista da Silva N, Evert K, Haubner F, Kapp FG, Wendl C, Renner K, Bohr C, Kühnel T, Vielsmeier V. Targeting the microenvironment in the treatment of arteriovenous malformations. Angiogenesis 2024; 27:91-103. [PMID: 37733132 PMCID: PMC10881762 DOI: 10.1007/s10456-023-09896-3] [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: 07/12/2023] [Accepted: 09/04/2023] [Indexed: 09/22/2023]
Abstract
Extracranial arteriovenous malformations (AVMs) are regarded as rare diseases and are prone to complications such as pain, bleeding, relentless growth, and high volume of shunted blood. Due to the high vascular pressure endothelial cells of AVMs are exposed to mechanical stress. To control symptoms and lesion growth pharmacological treatment strategies are urgently needed in addition to surgery and interventional radiology. AVM cells were isolated from three patients and exposed to cyclic mechanical stretching for 24 h. Thalidomide and bevacizumab, both VEGF inhibitors, were tested for their ability to prevent the formation of circular networks and proliferation of CD31+ endothelial AVM cells. Furthermore, the effect of thalidomide and bevacizumab on stretched endothelial AVM cells was evaluated. In response to mechanical stress, VEGF gene and protein expression increased in patient AVM endothelial cells. Thalidomide and bevacizumab reduced endothelial AVM cell proliferation. Bevacizumab inhibited circular network formation of endothelial AVM cells and lowered VEGF gene and protein expression, even though the cells were exposed to mechanical stress. With promising in vitro results, bevacizumab was used to treat three patients with unresectable AVMs or to prevent regrowth after incomplete resection. Bevacizumab controlled bleeding, pulsation, and pain over the follow up of eight months with no patient-reported side effects. Overall, mechanical stress increases VEGF expression in the microenvironment of AVM cells. The monoclonal VEGF antibody bevacizumab alleviates this effect, prevents circular network formation and proliferation of AVM endothelial cells in vitro. The clinical application of bevacizumab in AVM treatment demonstrates effective symptom control with no side effects.
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Affiliation(s)
- Caroline T Seebauer
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
| | - Benedikt Wiens
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Constantin A Hintschich
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | | | - Katja Evert
- Institute of Pathology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Frank Haubner
- Department of Otorhinolaryngology, Ludwig Maximilian University of Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Friedrich G Kapp
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, University of Freiburg, Heiliggeiststr. 1, 79106, Freiburg im Breisgau, Germany
| | - Christina Wendl
- Institute of Radiology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Kathrin Renner
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Christopher Bohr
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Thomas Kühnel
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Veronika Vielsmeier
- Department of Otorhinolaryngology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
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Saladino A, Gonzalez ML, Chuliber FA, Serra MM. Glanzmann's thrombasthenia associated with gastrointestinal angiodysplasias successfully treated with bevacizumab. Blood Coagul Fibrinolysis 2023; 34:545-548. [PMID: 37942747 DOI: 10.1097/mbc.0000000000001249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
Glanzmann's Thrombasthenia (GT) is a rare hemorrhagic condition caused by a platelet surface receptor disorder of the glycoprotein (GP) IIb/IIIa. Symptoms of GT are various forms of hemorrhages, such as purpura, epistaxis and menorrhagia. Gastrointestinal bleeding (GIB) is a rare expression of the condition and may occur due to traumas in the GI tract or as a consequence of gastrointestinal angiodysplasia (GIADs). In this case report, we present a middle-aged woman with recurrent GIB consequent to GIADs with persistent melena and iron deficiency anemia. After several unsuccessful therapeutic interventions, the patient was studied by the hereditary hemorrhagic telangiectasia's (HHT - Osler-Weber-Rendu disease) unit, where she received bevacizumab, showing a complete improvement in symptoms as well as a reduction in her GIADs. This case shows that bevacizumab could be a possible line of treatment for patients with coagulation disorders with GIADs.
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Affiliation(s)
- Agustina Saladino
- Hospital Italiano de Buenos Aires
- Argentine Rendu Study Group
- Instituto Universitario Hospital Italiano de Buenos Aires, Argentina
| | - María L Gonzalez
- Hospital Italiano de Buenos Aires
- Argentine Rendu Study Group
- Hereditary Hemorrhagic Telangiectasia Unit
- Gastroenterology Department
- Instituto Universitario Hospital Italiano de Buenos Aires, Argentina
| | | | - Marcelo M Serra
- Hospital Italiano de Buenos Aires
- Argentine Rendu Study Group
- Hereditary Hemorrhagic Telangiectasia Unit
- Internal Medicine Department
- Instituto Universitario Hospital Italiano de Buenos Aires, Argentina
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5
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Ricciardelli AR, Robledo A, Fish JE, Kan PT, Harris TH, Wythe JD. The Role and Therapeutic Implications of Inflammation in the Pathogenesis of Brain Arteriovenous Malformations. Biomedicines 2023; 11:2876. [PMID: 38001877 PMCID: PMC10669898 DOI: 10.3390/biomedicines11112876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/26/2023] Open
Abstract
Brain arteriovenous malformations (bAVMs) are focal vascular lesions composed of abnormal vascular channels without an intervening capillary network. As a result, high-pressure arterial blood shunts directly into the venous outflow system. These high-flow, low-resistance shunts are composed of dilated, tortuous, and fragile vessels, which are prone to rupture. BAVMs are a leading cause of hemorrhagic stroke in children and young adults. Current treatments for bAVMs are limited to surgery, embolization, and radiosurgery, although even these options are not viable for ~20% of AVM patients due to excessive risk. Critically, inflammation has been suggested to contribute to lesion progression. Here we summarize the current literature discussing the role of the immune system in bAVM pathogenesis and lesion progression, as well as the potential for targeting inflammation to prevent bAVM rupture and intracranial hemorrhage. We conclude by proposing that a dysfunctional endothelium, which harbors the somatic mutations that have been shown to give rise to sporadic bAVMs, may drive disease development and progression by altering the immune status of the brain.
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Affiliation(s)
- Ashley R. Ricciardelli
- Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Integrative Physiology, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Ariadna Robledo
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX 77555, USA; (A.R.)
| | - Jason E. Fish
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON M5G 2C4, Canada;
- Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON M5G 2N2, Canada
| | - Peter T. Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX 77555, USA; (A.R.)
| | - Tajie H. Harris
- Department of Neuroscience, University of Virginia School of Medicine, Charlottesville, VA 22903, USA;
- Brain, Immunology, and Glia (BIG) Center, University of Virginia School of Medicine, Charlottesville, VA 22903, USA
| | - Joshua D. Wythe
- Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Integrative Physiology, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Neuroscience, University of Virginia School of Medicine, Charlottesville, VA 22903, USA;
- Brain, Immunology, and Glia (BIG) Center, University of Virginia School of Medicine, Charlottesville, VA 22903, USA
- Department of Cell Biology, University of Virginia School of Medicine, Charlottesville, VA 22903, USA
- Robert M. Berne Cardiovascular Research Center, University of Virginia School of Medicine, Charlottesville, VA 22903, USA
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6
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Tai FWD, Chetcuti-Zammit S, Sidhu R. Small bowel angioectasia-The clinical and cost impact of different management strategies. Clin Res Hepatol Gastroenterol 2023; 47:102193. [PMID: 37553067 DOI: 10.1016/j.clinre.2023.102193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/26/2023] [Accepted: 08/06/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND The management of patients with recurrent anaemia and small bowel angioectasia (SBA) is costly and challenging. AIMS/METHODS In this retrospective cohort study, we examined the clinical and cost implication of a combination therapy of Somatostatin analogues (SA) and endoscopic ablation, endoscopic therapy alone, and conservative management. RESULTS Median number of bleeding episodes reduced from 3.5 (IQR 4) in the year before, to 1 (IQR 2) in the year after starting combination therapy with SA (p = 0.002). There were no differences in number of bed days (13.7 vs. 15.3, p = 0.66) and cost (£10,835 vs £11,653, p = 0.73) in the year before and after starting combination therapy. There was a trend towards a reduction in median number of blood transfusions episodes (17 vs 5, p = 0.07) and therapeutic endoscopies (1 vs. 0, p = 0.05) after starting SA. In patients suitable for endoscopic therapy alone, time spent in hospital was reduced (-3.5 days, p = 0.004), but bleeding episodes, transfusions and cost of treatment were not different. Patients requiring a combination therapy were significantly more co-morbid with a mean (± sd) Charlson comorbidity index (CCI) of 7.1 (± 2.7). Higher CCI (OR 2.1, 95% CI 1.1-3.9) and presence of chronic renal failure (OR 4.1, 95% CI 1.4-12.4) predicted escalation to combination therapy. CONCLUSIONS SAs may be a useful adjunct to endoscopic therapy for transfusion dependent comorbid patients. In the first year they reduce bleeding episodes. Cost in the 1-year before and after adding on SA are no different suggesting additional clinical benefit can be gained without additional cost.
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Affiliation(s)
- Foong Way David Tai
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
| | | | - Reena Sidhu
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Nip L, Evans N, Bali S, Hopper C, Papadopoulou A, Khalifa M, Hamilton G, Lim CS, Brookes J. Early experience of thalidomide therapy for high-grade peripheral and facial arteriovenous malformations. INT ANGIOL 2023; 42:448-456. [PMID: 37943292 DOI: 10.23736/s0392-9590.23.05111-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
BACKGROUND Arteriovenous malformations (AVMs) are developmental defects in the vascular system with abnormal connections between arteries and veins. A minority of AVMs are characterized by aggressive growth and continue to proliferate despite maximal surgical and interventional therapy. We report our outcomes with the use of thalidomide as the only UK specialist center adopting this novel approach for the management of AVMs refractory to conventional therapy. METHODS This was a retrospective case series which included only complex and proliferative AVM lesions (Schobinger grade III and IV). All patients prescribed thalidomide on a compassionate basis between September 2006 and August 2022 after attempts at embolosclerotherapy without satisfactory response were reviewed. RESULTS Eleven patients were included in our study. The median total duration of thalidomide use was 10 months. Two thirds of patients with pain (six of nine) reported an improvement, three quarters reported a reduction in swelling (six of eight) and all who presented with bleeding reported improvement in overall volume or frequency (four of four). Over the study period, 45% achieved a non-proliferative state with no further target vessel demonstrable on angiography. Mild, tolerable side effects such as fatigue were common (73%). There was only one major adverse reaction (neutropenia) necessitating cessation of therapy. CONCLUSIONS We can conclude that thalidomide is able to reduce the symptom burden for patients with complex and proliferative AVMs that were refractory to established treatment modalities. Adverse effects are common, but the benefit achieved from taking thalidomide in otherwise treatment resistant cases outweighs the risks, most of which are manageable.
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Affiliation(s)
- Lawrence Nip
- Vascular Anomalies Center, Royal Free London NHS Foundation Trust, London, UK
| | - Nicholas Evans
- Vascular Anomalies Center, Royal Free London NHS Foundation Trust, London, UK
| | - Suparna Bali
- Vascular Anomalies Center, Royal Free London NHS Foundation Trust, London, UK
| | - Colin Hopper
- Eastman Dental Institute, University College London, London, UK
| | - Anthie Papadopoulou
- Vascular Anomalies Center, Royal Free London NHS Foundation Trust, London, UK
| | - Mohamed Khalifa
- Vascular Anomalies Center, Royal Free London NHS Foundation Trust, London, UK
| | - George Hamilton
- Vascular Anomalies Center, Royal Free London NHS Foundation Trust, London, UK
| | - Chung S Lim
- Vascular Anomalies Center, Royal Free London NHS Foundation Trust, London, UK -
| | - Jocelyn Brookes
- Vascular Anomalies Center, Royal Free London NHS Foundation Trust, London, UK
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Ielasi L, Tonnini M, Piscaglia F, Serio I. Current guidelines for diagnosis and management of hepatic involvement in hereditary hemorrhagic teleangiectasia. World J Hepatol 2023; 15:675-687. [PMID: 37305373 PMCID: PMC10251273 DOI: 10.4254/wjh.v15.i5.675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/04/2023] [Accepted: 04/12/2023] [Indexed: 05/24/2023] Open
Abstract
Hereditary hemorrhagic teleangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is the most common cause of hepatic vascular malformations in adults. Different vascular shunts (arteriovenous, arterioportal or portovenous) lead to different clinical manifestations. Even though no hepatic-related symptoms are reported in the majority of cases, the severity of liver disease could lead to refractory medical conditions, in some cases requiring liver transplantation. The aim of this manuscript is to provide an updated overview of the current evidence regarding the diagnosis and treatment of HHT liver involvement and liver-related complications.
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Affiliation(s)
- Luca Ielasi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
- Department of Internal Medicine, Ospedale per gli Infermi di Faenza, Faenza 48018, Italy
| | - Matteo Tonnini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Fabio Piscaglia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Ilaria Serio
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
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Liu J, Duan X, Yin J, Yang H, He R, Zhao S. Effective long-term sirolimus treatment in hypoxemia mainly due to intrapulmonary right-to-left shunt in a patient with multiple vascular anomalies. Orphanet J Rare Dis 2023; 18:124. [PMID: 37226169 DOI: 10.1186/s13023-023-02732-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 05/14/2023] [Indexed: 05/26/2023] Open
Abstract
Pulmonary arteriovenous malformations (PAVMs), particularly where feeding artery/arteries to PAVMs ≥ 3 mm can be treated with embolization. The treatment for hypoxemia resulting from multiple small or diffuse PAVMs remains unclear.We report a girl aged 5 years and 10 months presented with cyanosis and decreased activity after exercise (83-85% of pulse oxygen saturation, SpO2). She had 1 skin lesion on her face and 1 suspected hemangioma on her left upper extremity at birth and that gradually disappeared spontaneously. Physical examination revealed clubbed fingers, and abundant vascular networks on her back. Contrast-enhanced lung CT (slice thickness:1.25 mm) with vascular three-dimensional reconstruction and abdominal CT revealed increased bronchovascular bundles, increased diameter of the pulmonary artery and ascending aorta, and intrahepatic portosystemic venous shunts due to patent ductus venosus. Echocardiography revealed increased diameter of aortic and pulmonary artery. Transthoracic contrast echocardiography was highly positive (bubble appearing in the left ventricle after 5 cardiac cycles). Abdominal doppler ultrasound revealed hepatic-portal venous shunt. Magnetic resonance imaging, artery and vein of the brain revealed multiple malformations of venous sinuses. The patient received sirolimus for 2 years and 4 months. Her condition improved significantly. SpO2 gradually increased to 98%. Her finger clubbing gradually normalized.Our report implicates sirolimus might be a potential treatment option in persistent hypoxemia mainly due to intrapulmonary right-to-left shunt even small multiple or diffusive PAVMs in pediatric patients with multiple cutaneous and visceral vascular anomalies.
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Affiliation(s)
- Jinrong Liu
- Department of Respiratory Medicine, National Clinical Research Center of Respiratory Disease, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Xiaomin Duan
- Imaging Center, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Jie Yin
- Imaging Center, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Haiming Yang
- Department of Respiratory Medicine, National Clinical Research Center of Respiratory Disease, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Ruxuan He
- Department of Respiratory Medicine, National Clinical Research Center of Respiratory Disease, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Shunying Zhao
- Department of Respiratory Medicine, National Clinical Research Center of Respiratory Disease, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China.
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10
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Torres-Iglesias R, Mora-Luján JM, Iriarte A, Cerdà P, Alba E, Sánchez-Corral MÁ, Berrozpe A, Cruellas F, Gamundí E, Ribas J, Castellote J, Riera-Mestre A. Long-term use of somatostatin analogs for chronic gastrointestinal bleeding in hereditary hemorrhagic telangiectasia. Front Med (Lausanne) 2023; 10:1146080. [PMID: 37250655 PMCID: PMC10213420 DOI: 10.3389/fmed.2023.1146080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/27/2023] [Indexed: 05/31/2023] Open
Abstract
Background Chronic bleeding due to gastrointestinal (GI) involvement in patients with hemorrhagic hereditary telangiectasia (HHT) can provoke severe anemia with high red blood cells (RBC) transfusion requirements. However, the evidence about how to deal with these patients is scarce. We aimed to assess the long-term efficacy and safety of somatostatin analogs (SA) for anemia management in HHT patients with GI involvement. Methods This is a prospective observational study including patients with HHT and GI involvement attended at a referral center. SA were considered for those patients with chronic anemia. Anemia-related variables were compared in patients receiving SA before and during treatment. Patients receiving SA were divided into responders (patients with minimal hemoglobin levels improvement >10 g/L and maintaining hemoglobin levels ≥80 g/L during treatment), and non-responders. Adverse effects during follow-up were collected. Results Among 119 HHT patients with GI involvement, 67 (56.3%) received SA. These patients showed lower minimal hemoglobin levels (73 [60-87] vs. 99 [70.2-122.5], p < 0.001), and more RBC transfusion requirements (61.2% vs. 38.5%, p = 0.014) than patients without SA therapy. Median treatment period was 20.9 ± 15.2 months. During treatment, there was a statistically significant improvement in minimum hemoglobin levels (94.7 ± 29.8 g/L vs. 74.7 ± 19.7, p < 0.001) and a reduction of patients with minimal hemoglobin levels <80 g/L (39 vs. 61%, p = 0.007) and RBC transfusions requirement (33.9% vs. 59.3%, p < 0.001). Sixteen (23.9%) patients showed mild adverse effects, mostly diarrhea or abdominal pain, leading to treatment discontinuation in 12 (17.9%) patients. Fifty-nine patients were eligible for efficacy assessment and 32 (54.2%) of them were considered responders. Age was associated with non-responder patients, OR 95% CI; 1.070 (1.014-1.130), p = 0.015. Conclusion SA can be considered a long-term effective and safe option for anemia management in HHT patients with GI bleeding. Older age is associated with poorer response.
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Affiliation(s)
- Raquel Torres-Iglesias
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - José María Mora-Luján
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Adriana Iriarte
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Pau Cerdà
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Esther Alba
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Radiology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Miguel Ángel Sánchez-Corral
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Cardiology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Ana Berrozpe
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Department of Digestive Diseases, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Francesc Cruellas
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Enric Gamundí
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Cytology and Hematology Laboratory, Antamomic Pathology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Jesús Ribas
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Pneumology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
| | - Jose Castellote
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Department of Digestive Diseases, Hospital Universitari de Bellvitge, Barcelona, Spain
- Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - Antoni Riera-Mestre
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
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11
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Parrot A, Barral M, Amiot X, Bachmeyer C, Wagner I, Eyries M, Alamowitch S, Ederhy S, Epaud R, Dupuis-Girod S, Cadranel J. [Hereditary hemorrhagic telangiectasia]. Rev Mal Respir 2023; 40:391-405. [PMID: 37062633 DOI: 10.1016/j.rmr.2023.02.007] [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: 12/14/2022] [Accepted: 02/26/2023] [Indexed: 04/18/2023]
Abstract
Hereditary hemorrhagic telangiectasia, also known as Rendu-Osler - Weber disease, is a rare, autosomal dominant vascular disease, with prevalence of 1/5,000. The condition is characterized by muco-cutaneous telangiectasias, which are responsible for a hemorrhagic syndrome of variable severity, as well as arteriovenous malformations (AVMs) appearing in the lungs, the liver, and the nervous system. They can be the source of shunts, which may be associated with high morbidity (neurological ischemic stroke, brain abscess, high-output heart failure, biliary ischemia…). It is therefore crucial to establish a clinical diagnosis using the Curaçao criteria or molecular diagnosis based on genetic analysis of the ENG, ACVRL1, SMAD4 and GDF2 genes. In most cases, multidisciplinary management allows patients to have normal life expectancy. Advances in interventional radiology and better understanding of the pathophysiology of angiogenesis have resulted in improved therapeutic management. Anti-angiogenic treatments, such as bevacizumab (BVZ, an anti-VEGF antibody), have proven to be effective in cases involving bleeding complications and severe liver damage with cardiac repercussions. Other anti-angiogenic agents are currently being investigated, including tyrosine kinase inhibitors.
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Affiliation(s)
- A Parrot
- Service de pneumologie, centre de compétence de la maladie de Rendu-Osler, hôpital Tenon, AP-HP, 75020 Paris, France.
| | - M Barral
- Service de radiologie, hôpital Tenon, AP-HP, 75020 Paris, France; UFR médecine, Sorbonne université, 75006 Paris, France
| | - X Amiot
- Service de gastroentérologie, hôpital Tenon, AP-HP, 75020 Paris, France
| | - C Bachmeyer
- Service de médecine interne, hôpital Tenon, AP-HP, 75020 Paris, France
| | - I Wagner
- Service d'ORL, hôpital Tenon, AP-HP, 75020 Paris, France
| | - M Eyries
- Service de génétique, hôpital de la Pitié-Salpetrière, AP-HP, 75020 Paris, France
| | - S Alamowitch
- Service des urgences cérébrovasculaires, hôpital de la Pitié-Salpetrière, AP-HP, 75020 Paris, France
| | - S Ederhy
- Service de cardiologie et GRC no 27, hôpital Saint-Antoine, AP-HP, 75020 Paris, France
| | - R Epaud
- Service de pédiatrie, centre intercommunaux de Créteil, Créteil, France
| | - S Dupuis-Girod
- Service de génétique, centre de référence pour la maladie de Rendu-Osler, hospices civils de Lyon, hôpital Mère-Enfant, 69500 Bron, France
| | - J Cadranel
- Service de pneumologie, centre de compétence de la maladie de Rendu-Osler, hôpital Tenon, AP-HP, 75020 Paris, France; UFR médecine, Sorbonne université, 75006 Paris, France
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12
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Matti E, Maiorano E, Nacu B, Luceri A, Sovardi F, Siragusa V, Ferrauto A, Spinozzi G, Olivieri C, Benazzo M, Pagella F. Silicone septal splint for recurrent epistaxis in HHT patients: experience of a national referral centre. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2023; 43:S28-S33. [PMID: 37698097 PMCID: PMC10159634 DOI: 10.14639/0392-100x-suppl.1-43-2023-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 09/13/2023]
Abstract
Objective To report our experience in the use of silicone septal splint for recurrent severe epistaxis in hereditary haemorrhagic telangiectasia patients (HHT). Methods This is a descriptive analysis carried out at the Otorhinolaryngology Department of Fondazione IRCCS Policlinico San Matteo in Pavia, a reference centre for the treatment and diagnosis of HHT. We retrospectively evaluated HHT patients who underwent silicone septal splint positioning after the endoscopic surgical treatment of epistaxis from 2000 to 2022. Results Of the 506 patients surgically treated in the period of analysis, 74 patients underwent silicone septal splint positioning and 37 were post-operatively interviewed. With a mean of 2.4 previous surgical treatments and a mean epistaxis severity of 7.38, the majority of patients presented with septal perforation (71.6%). On average, patients maintained the splint in place for 54.5 months, with a good tolerability and a significant reduction in epistaxis severity, need for blood transfusion and improvement of haemoglobin levels. Conclusions In HHT patients with recurrent severe epistaxis and with septal perforation, the placement of septal splints offers a useful additional strategy in the management of nosebleeds.
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Affiliation(s)
- Elina Matti
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Eugenia Maiorano
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Bogdan Nacu
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - Andrea Luceri
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - Fabio Sovardi
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Vera Siragusa
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- University of Pavia, Pavia, Italy
| | | | - Giuseppe Spinozzi
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carla Olivieri
- Molecular Medicine Department, General Biology and Medical Genetics Unit, University of Pavia, Pavia, Italy
| | - Marco Benazzo
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - Fabio Pagella
- Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- University of Pavia, Pavia, Italy
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13
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Szmygin M, Szmygin P, Drelich K, Pustelniak O, Pech M, Jargiełło T. The role of interventional radiology in treatment of patients with hereditary hemorrhagic telangiectasia. Eur J Radiol 2023; 162:110769. [PMID: 36933496 DOI: 10.1016/j.ejrad.2023.110769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) also known as Osler-Weber-Rendu disease is a rare autosomal dominant, multi-organ disorder that leads to formation of abnormal vascular connections resulting in devastating and life-threatening complications. Due to its multisystem character, wide range of clinical manifestations and variable expressivity, HHT remains a diagnostic challenge and requires close cooperation of specialists from various medical fields. Interventional radiology plays a key role in the management of this disease, helping maintain the health of HHT patients and minimize the risk of fatal complications. The aim of this article is to review clinical manifestations, diagnostic guidelines and criteria of HHT as well as to present the means of endovascular therapy in the management of HHT patients.
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Affiliation(s)
- Maciej Szmygin
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Lublin, Poland.
| | - Paweł Szmygin
- Medical University of Lublin, Department of Neurosurgery, Lublin, Poland
| | - Katarzyna Drelich
- Medical University of Lublin, Students' Scientific Society at the Department of Interventional Radiology and Neuroradiology, Lublin, Poland
| | - Olga Pustelniak
- Medical University of Lublin, Students' Scientific Society at the Department of Interventional Radiology and Neuroradiology, Lublin, Poland
| | - Maciej Pech
- Medical University of Magdeburg, Department of Radiology and Nuclear Medicine, Magdeburg, Germany
| | - Tomasz Jargiełło
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Lublin, Poland
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14
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Hereditary Hemorrhagic Telangiectasia in Pediatric Age: Focus on Genetics and Diagnosis. Pediatr Rep 2023; 15:129-142. [PMID: 36810341 PMCID: PMC9944132 DOI: 10.3390/pediatric15010011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
Hereditary Hemorrhagic Telangiectasia (HHT) or Rendu-Osler-Weber Syndrome (ROW) is an autosomal dominant vascular disease, with an estimated prevalence of 1:5000. Genes associated with HHT are ACVRL1, ENG, SMAD4, and GDF2, all encoding for proteins involved in the TGFβ/BMPs signaling pathway. The clinical diagnosis of HHT is made according to the "Curaçao Criteria," based on the main features of the disease: recurrent and spontaneous epistaxis, muco-cutaneous telangiectases, arteriovenous malformations in the lungs, liver, and brain, and familiarity. Since the clinical signs of HHT can be misinterpreted, and the primary symptom of HHT, epistaxis, is common in the general population, the disease is underdiagnosed. Although HHT exhibits a complete penetrance after the age of 40, young subjects may also present symptoms of the disease and are at risk of severe complications. Here we review the literature reporting data from clinical, diagnostic, and molecular studies on the HHT pediatric population.
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15
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Quintin S, Figg JW, Mehkri Y, Hanna CO, Woolridge MG, Lucke-Wold B. Arteriovenous Malformations: An Update on Models and Therapeutic Targets. JOURNAL OF NEUROSCIENCE AND NEUROLOGICAL SURGERY 2023; 13:250. [PMID: 36846724 PMCID: PMC9956274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Arteriovenous malformations (AVMs) are an anomaly of the vascular system where feeding arteries are directly connected to the venous drainage network. While AVMs can arise anywhere in the body and have been described in most tissues, brain AVMs are of significant concern because of the risk of hemorrhage which carries significant morbidity and mortality. The prevalence of AVM's and the mechanisms underlying their formation are not well understood. For this reason, patients who undergo treatment for symptomatic AVM's remain at increased risk of subsequent bleeds and adverse outcomes. The cerebrovascular network is delicate and novel animal models continue to provide insight into its dynamics in the context of AVM's. As the molecular players in the formation of familial and sporadic AVM's are better understood, novel therapeutic approaches have been developed to mitigate their associated risks. Here we discuss the current literature surrounding AVM's including the development of models and therapeutic targets which are currently being investigated.
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Affiliation(s)
- Stephan Quintin
- College of Medicine, University of Florida, Gainesville, Florida 32610, USA
| | - John W Figg
- Department of Neurosurgery, University of Florida, Gainesville, Florida 32610, USA
| | - Yusuf Mehkri
- College of Medicine, University of Florida, Gainesville, Florida 32610, USA
| | - Chadwin O Hanna
- College of Medicine, University of Florida, Gainesville, Florida 32610, USA
| | | | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida 32610, USA
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16
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Nguyen HL, Boon LM, Vikkula M. Trametinib as a promising therapeutic option in alleviating vascular defects in an endothelial KRAS-induced mouse model. Hum Mol Genet 2023; 32:276-289. [PMID: 35972810 DOI: 10.1093/hmg/ddac169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/27/2022] [Accepted: 07/18/2022] [Indexed: 01/18/2023] Open
Abstract
Somatic activating Kirsten rat sarcoma viral oncogene homologue (KRAS) mutations have been reported in patients with arteriovenous malformations. By producing LSL-Kras (G12D); Cdh5 (PAC)-CreERT2 [iEC-Kras (G12D*)] mice, we hoped to activate KRAS within vascular endothelial cells (ECs) to generate an arteriovenous malformation mouse model. Neonatal mice were treated daily with tamoxifen from postnatal (PN) days 1-3. Mortality and phenotypes varied amongst iEC-Kras (G12D*) pups, with only 31.5% surviving at PN14. Phenotypes (focal lesions, vessel dilations) developed in a consistent manner, although with unpredictable severity within multiple soft tissues (such as the brain, liver, heart and brain). Overall, iEC-Kras (G12D*) pups developed significantly larger vascular lumen areas compared with control littermates, beginning at PN8. We subsequently tested whether the MEK inhibitor trametinib could effectively alleviate lesion progression. At PN16, iEC-Kras (G12D*) pup survival improved to 76.9%, and average vessel sizes were closer to controls than in untreated and vehicle-treated mutants. In addition, trametinib treatment helped normalize iEC-Kras (G12D*) vessel morphology in PN14 brains. Thus, trametinib could act as an effective therapy for KRAS-induced vascular malformations in patients.
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Affiliation(s)
- Ha-Long Nguyen
- Human Molecular Genetics, de Duve Institute, University of Louvain, 1200 Brussels, Belgium
| | - Laurence M Boon
- Human Molecular Genetics, de Duve Institute, University of Louvain, 1200 Brussels, Belgium.,Center for Vascular Anomalies, Division of Plastic Surgery, VASCERN VASCA European Reference Centre, Saint Luc University Hospital, 1200 Brussels, Belgium
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, 1200 Brussels, Belgium.,Center for Vascular Anomalies, Division of Plastic Surgery, VASCERN VASCA European Reference Centre, Saint Luc University Hospital, 1200 Brussels, Belgium
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17
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DeMaio A, New C, Bergmann S. Medical Treatment of Vascular Anomalies. Dermatol Clin 2022; 40:461-471. [DOI: 10.1016/j.det.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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18
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Viteri-Noël A, González-García A, Patier JL, Fabregate M, Bara-Ledesma N, López-Rodríguez M, Gómez del Olmo V, Manzano L. Hereditary Hemorrhagic Telangiectasia: Genetics, Pathophysiology, Diagnosis, and Management. J Clin Med 2022; 11:jcm11175245. [PMID: 36079173 PMCID: PMC9457069 DOI: 10.3390/jcm11175245] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/30/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia is an inherited disease related to an alteration in angiogenesis, manifesting as cutaneous telangiectasias and epistaxis. As complications, it presents vascular malformations in organs such as the lung, liver, digestive tract, and brain. Currently, diagnosis can be made using the Curaçao criteria or by identifying the affected gene. In recent years, there has been an advance in the understanding of the pathophysiology of the disease, which has allowed the use of new therapeutic strategies to improve the quality of life of patients. This article reviews some of the main and most current evidence on the pathophysiology, clinical manifestations, diagnostic approach, screening for complications, and therapeutic options, both pharmacological and surgical.
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Affiliation(s)
- Adrian Viteri-Noël
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, 28034 Madrid, Spain
- Faculty of Medicine and Health Sciences, Universidad de Alcalá (UAH), 28801 Alcalá de Henares, Spain
- Correspondence:
| | - Andrés González-García
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, 28034 Madrid, Spain
- Faculty of Medicine and Health Sciences, Universidad de Alcalá (UAH), 28801 Alcalá de Henares, Spain
| | - José Luis Patier
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, 28034 Madrid, Spain
- Faculty of Medicine and Health Sciences, Universidad de Alcalá (UAH), 28801 Alcalá de Henares, Spain
| | - Martin Fabregate
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, 28034 Madrid, Spain
| | - Nuria Bara-Ledesma
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, 28034 Madrid, Spain
| | - Mónica López-Rodríguez
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, 28034 Madrid, Spain
- Faculty of Medicine and Health Sciences, Universidad de Alcalá (UAH), 28801 Alcalá de Henares, Spain
| | - Vicente Gómez del Olmo
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, 28034 Madrid, Spain
| | - Luis Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, IRYCIS, 28034 Madrid, Spain
- Faculty of Medicine and Health Sciences, Universidad de Alcalá (UAH), 28801 Alcalá de Henares, Spain
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Dupuis-Girod S, Shovlin CL, Kjeldsen AD, Mager HJ, Sabba C, Droege F, Fargeton AE, Fialla AD, Gandolfi S, Hermann R, Lenato GM, Manfredi G, Post MC, Rennie C, Suppressa P, Sure U, Crocione C, Blom R, Botella LM, Brocca F, Coxall C, Druckman KT, Erasme D, Federici P, Grabowski C, Lundgren M, Søderman T, Woods D, E B. European Reference Network for Rare Vascular Diseases (VASCERN): When and how to use intravenous bevacizumab in Hereditary Haemorrhagic Telangiectasia (HHT)? Eur J Med Genet 2022; 65:104575. [DOI: 10.1016/j.ejmg.2022.104575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 06/09/2022] [Accepted: 07/20/2022] [Indexed: 11/25/2022]
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20
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Joyce KE, Onabanjo E, Brownlow S, Nur F, Olupona K, Fakayode K, Sroya M, Thomas GA, Ferguson T, Redhead J, Millar CM, Cooper N, Layton DM, Boardman-Pretty F, Caulfield MJ, Shovlin CL. Whole genome sequences discriminate hereditary hemorrhagic telangiectasia phenotypes by non-HHT deleterious DNA variation. Blood Adv 2022; 6:3956-3969. [PMID: 35316832 PMCID: PMC9278305 DOI: 10.1182/bloodadvances.2022007136] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/21/2022] [Indexed: 11/20/2022] Open
Abstract
The abnormal vascular structures of hereditary hemorrhagic telangiectasia (HHT) often cause severe anemia due to recurrent hemorrhage, but HHT causal genes do not predict the severity of hematological complications. We tested for chance inheritance and clinical associations of rare deleterious variants in which loss-of-function causes bleeding or hemolytic disorders in the general population. In double-blinded analyses, all 104 patients with HHT from a single reference center recruited to the 100 000 Genomes Project were categorized on new MALO (more/as-expected/less/opposite) sub-phenotype severity scales, and whole genome sequencing data were tested for high impact variants in 75 HHT-independent genes encoding coagulation factors, or platelet, hemoglobin, erythrocyte enzyme, and erythrocyte membrane constituents. Rare variants (all gnomAD allele frequencies <0.003) were identified in 56 (75%) of these 75 HHT-unrelated genes. Deleteriousness assignments by Combined Annotation Dependent Depletion (CADD) scores >15 were supported by gene-level mutation significance cutoff scores. CADD >15 variants were identified in 38/104 (36.5%) patients with HHT, found for 1 in 10 patients within platelet genes; 1 in 8 within coagulation genes; and 1 in 4 within erythrocyte hemolytic genes. In blinded analyses, patients with greater hemorrhagic severity that had been attributed solely to HHT vessels had more CADD-deleterious variants in platelet (Spearman ρ = 0.25; P = .008) and coagulation (Spearman ρ = 0.21; P = .024) genes. However, the HHT cohort had 60% fewer deleterious variants in platelet and coagulation genes than expected (Mann-Whitney test P = .021). In conclusion, patients with HHT commonly have rare variants in genes of relevance to their phenotype, offering new therapeutic targets and opportunities for informed, personalized medicine strategies.
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Affiliation(s)
- Katie E. Joyce
- Imperial College School of Medicine, Imperial College, London, United Kingdom
- Genomics England Respiratory Clinical Interpretation Partnership (GeCIP), London, United Kingdom
| | - Ebun Onabanjo
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Sheila Brownlow
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fadumo Nur
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Kike Olupona
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Kehinde Fakayode
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Manveer Sroya
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | | | - Teena Ferguson
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Julian Redhead
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Carolyn M. Millar
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College, London, United Kingdom
| | - Nichola Cooper
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College, London, United Kingdom
| | - D. Mark Layton
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College, London, United Kingdom
| | | | - Mark J. Caulfield
- Genomics England Research Consortium, Genomics England, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; and
| | | | - Claire L. Shovlin
- Genomics England Respiratory Clinical Interpretation Partnership (GeCIP), London, United Kingdom
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
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21
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Coulie J, Boon L, Vikkula M. Molecular Pathways and Possible Therapies for Head and Neck Vascular Anomalies. J Oral Pathol Med 2022; 51:878-887. [PMID: 35610188 DOI: 10.1111/jop.13318] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 05/05/2022] [Indexed: 11/29/2022]
Abstract
Vascular Anomalies are a heterogenous group of vascular lesions that can be divided, according to the International Society for the Study of Vascular Anomalies Classification, into two main groups : Vascular Tumors and Vascular Malformations. Vascular Malformations can be further subdivided into slow-flow and fast-flow malformations. This clinical and radiological classification allows for a better understanding of vascular anomalies and aims to offer a more precise final diagnosis. Correct diagnosis is essential to propose the best treatment, which traditionally consists of surgery, embolization or sclerotherapy. Since a few years, medical treatment has become an important part of multidisciplinary treatment. Genetic and molecular knowledge of vascular anomalies are increasing rapidly and opens the door for a molecular classification of vascular anomalies according to the underlying pathways involved. The main pathways seem to be: PI3K/AKT/mTOR (PIKopathies) and RAS/RAF/MEK/ERK (RASopathies). Knowing the underlying molecular cascades allows us to use targeted medical therapies. The first part of this article aims to review the vascular anomalies seen in the head and neck region and their underlying molecular causes and involved pathways. The second part will propose an overview of the available targeted therapies based on the affected molecular cascade. This article summarizes theragnostic treatments available in vascular anomalies.
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Affiliation(s)
- Julien Coulie
- Center for Vascular Anomalies, Division of Plastic Surgery, VASCERN VASCA European Reference Centre, Saint Luc University Hospital, Brussels, Belgium.,Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium
| | - Laurence Boon
- Center for Vascular Anomalies, Division of Plastic Surgery, VASCERN VASCA European Reference Centre, Saint Luc University Hospital, Brussels, Belgium.,Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium
| | - Miikka Vikkula
- Center for Vascular Anomalies, Division of Plastic Surgery, VASCERN VASCA European Reference Centre, Saint Luc University Hospital, Brussels, Belgium.,Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium
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22
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Egido-Turrión C, Rossi E, Ollauri-Ibáñez C, Pérez-García ML, Sevilla MA, Bastida JM, González-Porras JR, Rodríguez-Barbero A, Bernabeu C, Lopez-Novoa JM, Pericacho M. Functional Alterations Involved in Increased Bleeding in Hereditary Hemorrhagic Telangiectasia Mouse Models. Front Med (Lausanne) 2022; 9:871903. [PMID: 35665360 PMCID: PMC9160577 DOI: 10.3389/fmed.2022.871903] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/06/2022] [Indexed: 12/11/2022] Open
Abstract
Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal-dominant genetic disorder involving defects in two predominant genes known as endoglin (ENG; HHT-1) and activin receptor-like kinase 1 (ACVRL1/ALK1; HHT-2). It is characterized by mucocutaneous telangiectases that, due to their fragility, frequently break causing recurrent epistaxis and gastrointestinal bleeding. Because of the severity of hemorrhages, the study of the hemostasis involved in these vascular ruptures is critical to find therapies for this disease. Our results demonstrate that HHT patients with high bleeding, as determined by a high Epistaxis Severity Score (ESS), do not have prolonged clotting times or alterations in clotting factors. Considering that coagulation is only one of the processes involved in hemostasis, the main objective of this study was to investigate the overall mechanisms of hemostasis in HHT-1 (Eng+/−) and HHT-2 (Alk1+/−) mouse models, which do not show HHT vascular phenotypes in the meaning of spontaneous bleeding. In Eng+/− mice, the results of in vivo and in vitro assays suggest deficient platelet-endothelium interactions that impair a robust and stable thrombus formation. Consequently, the thrombus could be torn off and dragged by the mechanical force exerted by the bloodstream, leading to the reappearance of hemorrhages. In Alk1+/− mice, an overactivation of the fibrinolysis system was observed. These results support the idea that endoglin and Alk1 haploinsufficiency leads to a common phenotype of impaired hemostasis, but through different mechanisms. This contribution opens new therapeutic approaches to HHT patients' epistaxis.
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Affiliation(s)
- Cristina Egido-Turrión
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Elisa Rossi
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, Paris, France
| | - Claudia Ollauri-Ibáñez
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - María L. Pérez-García
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Internal Medicine, Complejo Asistencial Universitario de Salamanca (CAUSA)-SACYL, Salamanca, Spain
| | - María A. Sevilla
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - José María Bastida
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Hematology, Complejo Asistencial Universitario de Salamanca (CAUSA)-SACYL, Salamanca, Spain
| | - José Ramón González-Porras
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Hematology, Complejo Asistencial Universitario de Salamanca (CAUSA)-SACYL, Salamanca, Spain
| | - Alicia Rodríguez-Barbero
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Carmelo Bernabeu
- Centro de Investigaciones Biológicas Margarita Salas, Consejo Superior de Investigaciones Científicas (CSIC), Madrid, Spain
| | - José M. Lopez-Novoa
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Miguel Pericacho
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- *Correspondence: Miguel Pericacho
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23
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De Leacy R, Ansari SA, Schirmer CM, Cooke DL, Prestigiacomo CJ, Bulsara KR, Hetts SW. Endovascular treatment in the multimodality management of brain arteriovenous malformations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee. J Neurointerv Surg 2022; 14:1118-1124. [PMID: 35414599 DOI: 10.1136/neurintsurg-2021-018632] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/07/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The purpose of this review is to summarize the data available for the role of angiography and embolization in the comprehensive multidisciplinary management of brain arteriovenous malformations (AVMs METHODS: We performed a structured literature review for studies examining the indications, efficacy, and outcomes for patients undergoing endovascular therapy in the context of brain AVM management. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS The multidisciplinary evaluation and treatment of brain AVMs continues to evolve. Recommendations include: (1) Digital subtraction catheter cerebral angiography (DSA)-including 2D, 3D, and reformatted cross-sectional views when appropriate-is recommended in the pre-treatment assessment of cerebral AVMs. (I, B-NR) . (2) It is recommended that endovascular embolization of cerebral arteriovenous malformations be performed in the context of a complete multidisciplinary treatment plan aiming for obliteration of the AVM and cure. (I, B-NR) . (3) Embolization of brain AVMs before surgical resection can be useful to reduce intraoperative blood loss, morbidity, and surgical complexity. (IIa, B-NR) . (4) The role of primary curative embolization of cerebral arteriovenous malformations is uncertain, particularly as compared with microsurgery and radiosurgery with or without adjunctive embolization. Further research is needed, particularly with regard to risk for AVM recurrence. (III equivocal, C-LD) . (5) Targeted embolization of high-risk features of ruptured brain AVMs may be considered to reduce the risk for recurrent hemorrhage. (IIb, C-LD) . (6) Palliative embolization may be useful to treat symptomatic AVMs in which curative therapy is otherwise not possible. (IIb, B-NR) . (7) The role of AVM embolization as an adjunct to radiosurgery is not well-established. Further research is needed. (III equivocal, C-LD) . (8) Imaging follow-up after apparent cure of brain AVMs is recommended to assess for recurrence. Although non-invasive imaging may be used for longitudinal follow-up, DSA remains the gold standard for residual or recurrent AVM detection in patients with concerning imaging and/or clinical findings. (I, C-LD) . (9) Improved national and international reporting of patients of all ages with brain AVMs, their treatments, side effects from treatment, and their long-term outcomes would enhance the ability to perform clinical trials and improve the rigor of research into this rare condition. (I, C-EO) . CONCLUSIONS Although the quality of evidence is lower than for more common conditions subjected to multiple randomized controlled trials, endovascular therapy has an important role in the management of brain AVMs. Prospective studies are needed to strengthen the data supporting these recommendations.
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Affiliation(s)
- Reade De Leacy
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sameer A Ansari
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Daniel L Cooke
- Radiology and Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | | | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Steven W Hetts
- Radiology and Biomedical Imaging, University California San Francisco, San Francisco, California, USA
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24
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Al-Samkari H. Systemic Antiangiogenic Therapies for Bleeding in Hereditary Hemorrhagic Telangiectasia: A Practical, Evidence-Based Guide for Clinicians. Semin Thromb Hemost 2022; 48:514-528. [PMID: 35226946 DOI: 10.1055/s-0042-1743467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Management of bleeding in hereditary hemorrhagic telangiectasia (HHT), the second most common hereditary bleeding disorder in the world, is currently undergoing a paradigm shift. Disease-modifying antiangiogenic therapies capable of achieving durable hemostasis via inducing telangiectasia regression have emerged as a highly effective and safe modality to treat epistaxis and gastrointestinal bleeding in HHT. While evidence to date is incomplete and additional studies are ongoing, patients presently in need are being treated with antiangiogenic agents off-label. Intravenous bevacizumab, oral pazopanib, and oral thalidomide are the three targeted primary angiogenesis inhibitors, with multiple studies describing both reassuring safety and impressive effectiveness in the treatment of moderate-to-severe HHT-associated bleeding. However, at present there is a paucity of guidance in the literature, including the published HHT guidelines, addressing the practical aspects of antiangiogenic therapy for HHT in clinical practice. This review article and practical evidence-based guide aims to fill this unaddressed need, synthesizing published data on the use of antiangiogenic agents in HHT, relevant data for their use outside of HHT, and expert guidance where evidence is lacking. After a brief review of principles of bleeding therapy in HHT, guidance on hematologic support with iron and blood products, and alternatives to antiangiogenic therapy, this article examines each of the aforementioned antiangiogenic agents in detail, including patient selection, initiation, monitoring, toxicity management, and discontinuation. With proper, educated use of antiangiogenic therapies in HHT, patients with even the most severe bleeding manifestations can achieve durable hemostasis with minimal side-effects, dramatically improving health-related quality of life and potentially altering the disease course.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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25
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Gariballa N, Kizhakkedath P, Akawi N, John A, Ali BR. Endoglin Wild Type and Variants Associated With Hereditary Hemorrhagic Telangiectasia Type 1 Undergo Distinct Cellular Degradation Pathways. Front Mol Biosci 2022; 9:828199. [PMID: 35281255 PMCID: PMC8916587 DOI: 10.3389/fmolb.2022.828199] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/27/2022] [Indexed: 02/05/2023] Open
Abstract
Endoglin, also known as cluster of differentiation 105 (CD105), is an auxiliary receptor in the TGFβ signaling pathway. It is predominantly expressed in endothelial cells as a component of the heterotetrameric receptor dimers comprising type I, type II receptors and the binding ligands. Mutations in the gene encoding Endoglin (ENG) have been associated with hereditary hemorrhagic telangiectasia type 1 (HHT1), an autosomal dominant inherited disease that is generally characterized by vascular malformation. Secretory and many endomembrane proteins synthesized in the Endoplasmic reticulum (ER) are subjected to stringent quality control mechanisms to ensure that only properly folded and assembled proteins are trafficked forward through the secretory pathway to their sites of action. We have previously demonstrated that some Endoglin variants causing HHT1 are trapped in the ER and fail to traffic to their normal localization in plasma membrane, which suggested the possible involvement of ER associated protein degradation (ERAD) in their molecular pathology. In this study, we have investigated, for the first time, the degradation routes of Endoglin wild type and two mutant variants, P165L and V105D, and previously shown to be retained in the ER. Stably transfected HEK293 cells were treated with proteasomal and lysosomal inhibitors in order to elucidate the exact molecular mechanisms underlying the loss of function phenotype associated with these variants. Our results have shown that wild type Endoglin has a relatively short half-life of less than 2 hours and degrades through both the lysosomal and proteasomal pathways, whereas the two mutant disease-causing variants show high stability and predominantly degrades through the proteasomal pathway. Furthermore, we have demonstrated that Endoglin variants P165L and V105D are significantly accumulated in HEK293 cells deficient in HRD1 E3 ubiquitin ligase; a major ERAD component. These results implicate the ERAD mechanism in the pathology of HHT1 caused by the two variants. It is expected that these results will pave the way for more in-depth research studies that could provide new windows for future therapeutic interventions.
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Affiliation(s)
- Nesrin Gariballa
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Praseetha Kizhakkedath
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Nadia Akawi
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Anne John
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Bassam R Ali
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.,Zayed Center for Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
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26
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Shovlin CL, Buscarini E, Sabbà C, Mager HJ, Kjeldsen AD, Pagella F, Sure U, Ugolini S, Torring PM, Suppressa P, Rennie C, Post MC, Patel MC, Nielsen TH, Manfredi G, Lenato GM, Lefroy D, Kariholu U, Jones B, Fialla AD, Eker OF, Dupuis O, Droege F, Coote N, Boccardi E, Alsafi A, Alicante S, Dupuis-Girod S. The European Rare Disease Network for HHT Frameworks for management of hereditary haemorrhagic telangiectasia in general and speciality care. Eur J Med Genet 2022; 65:104370. [PMID: 34737116 DOI: 10.1016/j.ejmg.2021.104370] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/24/2021] [Accepted: 10/26/2021] [Indexed: 12/22/2022]
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a complex, multisystemic vascular dysplasia affecting approximately 85,000 European Citizens. In 2016, eight founding centres operating within 6 countries, set up a working group dedicated to HHT within what became the European Reference Network on Rare Multisystemic Vascular Diseases. By launch, combined experience exceeded 10,000 HHT patients, and Chairs representing 7 separate specialties provided a median of 24 years' experience in HHT. Integrated were expert patients who focused discussions on the patient experience. Following a 2016-2017 survey to capture priorities, and underpinned by more than 40 monthly meetings, and new data acquisitions, VASCERN HHT generated position statements that distinguish expert HHT care from non-expert HHT practice. Leadership was by specialists in the relevant sub-discipline(s), and 100% consensus was required amongst all clinicians before statements were published or disseminated. One major set of outputs targeted all healthcare professionals and their HHT patients, and include the new Orphanet definition; Do's and Don'ts for common situations; Outcome Measures suitable for all consultations; COVID-19; and anticoagulation. The second output set span aspects of vascular pathophysiology where greater understanding will assist organ-specific specialist clinicians to provide more informed care to HHT patients. These cover cerebral vascular malformations and screening; mucocutaneous telangiectasia and differential diagnosis; anti-angiogenic therapies; circulatory interplays between anaemia and arteriovenous malformations; and microbiological strategies to counteract loss of normal pulmonary capillary function. Overall, the integrated outputs, and documented current practices, provide frameworks for approaches that augment the health and safety of HHT patients in diverse health-care settings.
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Affiliation(s)
- C L Shovlin
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK; National Heart and Lung Institute, Imperial College London, UK.
| | - E Buscarini
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy.
| | - C Sabbà
- VASCERN HHT Reference Centre, Centro Sovraziendale Malattie Rare, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Italy.
| | - H J Mager
- VASCERN HHT Reference Centre, St Antonius Ziekenhuis, Nieuwegein, Netherlands.
| | - A D Kjeldsen
- VASCERN HHT Reference Centre, Odense University Hospital, Syddansk Universitet, Odense, Denmark.
| | - F Pagella
- VASCERN HHT Reference Centre, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy.
| | - U Sure
- VASCERN HHT Reference Centre, Essen University Hospital, Essen, Germany; Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany.
| | - S Ugolini
- VASCERN HHT Reference Centre, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy.
| | - P M Torring
- VASCERN HHT Reference Centre, Odense University Hospital, Syddansk Universitet, Odense, Denmark.
| | - P Suppressa
- VASCERN HHT Reference Centre, Centro Sovraziendale Malattie Rare, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Italy.
| | - C Rennie
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - M C Post
- VASCERN HHT Reference Centre, St Antonius Ziekenhuis, Nieuwegein, Netherlands; Department of Cardiology, University Medical Center Utrecht, The Netherlands.
| | - M C Patel
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - T H Nielsen
- VASCERN HHT Reference Centre, Odense University Hospital, Syddansk Universitet, Odense, Denmark.
| | - G Manfredi
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy.
| | - G M Lenato
- VASCERN HHT Reference Centre, Centro Sovraziendale Malattie Rare, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Italy.
| | - D Lefroy
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - U Kariholu
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - B Jones
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - A D Fialla
- VASCERN HHT Reference Centre, Odense University Hospital, Syddansk Universitet, Odense, Denmark.
| | - O F Eker
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France.
| | - O Dupuis
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France.
| | - F Droege
- VASCERN HHT Reference Centre, Essen University Hospital, Essen, Germany; Department of ENT Surgery, University Hospital Essen, Germany.
| | - N Coote
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - E Boccardi
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy; Niguarda Hospital, Milan, Italy.
| | - A Alsafi
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - S Alicante
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy.
| | - S Dupuis-Girod
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France.
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27
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Murray E, Taylor J, Hountras P. A Case of High-Output Heart Failure. Chest 2022; 161:e23-e28. [DOI: 10.1016/j.chest.2021.07.2180] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/29/2021] [Accepted: 07/15/2021] [Indexed: 11/25/2022] Open
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28
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Cusumano LR, Tesoriero JA, Wilsen CB, Sayre J, Quirk M, McWilliams JP. Predictors of heart failure symptoms in hereditary hemorrhagic telangiectasia patients with hepatic arteriovenous malformations. Orphanet J Rare Dis 2021; 16:478. [PMID: 34794458 PMCID: PMC8600745 DOI: 10.1186/s13023-021-02109-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hepatic arteriovenous malformations (AVMs) in hereditary hemorrhagic telangiectasia (HHT) patients are most commonly hepatic artery to hepatic venous shunts which can result in high-output heart failure. This condition can be debilitating and is a leading cause of liver transplantation in HHT patients. However, it is not known what characteristics can discriminate between asymptomatic patients and those who will develop heart failure symptoms. RESULTS 176 patients with HHT were evaluated with computed tomography angiography (CTA) between April 2004 and February 2019 at our HHT Center of Excellence. 63/176 (35.8%) patients were found to have hepatic AVMs on CTA. 18 of these patients were excluded because of the presence of another condition which could confound evaluation of heart failure symptoms. In the remaining 45 patients included in our cohort, 25/45 (55.6%) patients were classified as asymptomatic and 20/45 (44.4%) were classified as symptomatic, and these groups were compared. In symptomatic patients, mean common hepatic artery (CHA) diameter was significantly higher (11.1 versus 8.4 mm) and mean hemoglobin levels were significantly lower (10.7 vs 12.6 g/dL). A stepwise multiple logistic regression analysis demonstrated that both CHA diameter and hemoglobin level were independent predictors of heart failure symptoms with ORs of 2.554 (95% CI 1.372-4.754) and 0.489 (95% CI 0.299-0.799), respectively. The receiver operator characteristic (ROC) curve of our analysis demonstrated an AUC of 0.906 (95% CI 0.816-0.996), sensitivity 80.0% (95% CI 55.7-93.4%), and specificity 75.0% (95% CI 52.9-89.4%). CONCLUSIONS CTA is an effective and easily reproducible method to evaluate hepatic involvement of HHT. Utilizing CTA, clinical, and laboratory data we determined CHA diameter and hemoglobin level were independent predictors of heart failure symptoms.
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Affiliation(s)
- Lucas R Cusumano
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, 2nd Floor, Room 2125, Los Angeles, CA, 90095, USA
| | - Joseph A Tesoriero
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, 2nd Floor, Room 2125, Los Angeles, CA, 90095, USA
| | - Craig B Wilsen
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, 2nd Floor, Room 2125, Los Angeles, CA, 90095, USA
| | - James Sayre
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Matthew Quirk
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, 2nd Floor, Room 2125, Los Angeles, CA, 90095, USA
| | - Justin P McWilliams
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, 2nd Floor, Room 2125, Los Angeles, CA, 90095, USA.
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29
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Green RJ, Swift AC. Hereditary haemorrhagic telangiectasia: an overview from an ear, nose and throat perspective. Br J Hosp Med (Lond) 2021; 82:1-9. [PMID: 34817255 DOI: 10.12968/hmed.2020.0560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Patients with hereditary haemorrhagic telangiectasia can present with a multitude of symptoms caused by telangiectasia and arteriovenous malformations in the nose, brain, gastrointestinal tract, liver and spinal cord. Clinicians should be aware of the potential diagnosis of hereditary haemorrhagic telangiectasia and how to manage these patients both in the acute and chronic setting. Identifying these patients and optimising their management can help reverse the reduced life expectancy back to that of the normal population. The management of these patients is complex and often requires a multidisciplinary approach, with difficult discussions to be had around screening for arteriovenous malformations and genetic testing. The stepwise management ladder can be used in both the medical and surgical strategies; there are multiple pharmacological and surgical options available, all with their own side effects and risks. Patient education is key to help informed decision making. This article outlines the clinical characteristics of the disease and management options available.
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Affiliation(s)
- Richard J Green
- Department of Otolaryngology, Ninewells Hospital, Dundee, UK
| | - Andrew C Swift
- Liverpool Head and Neck Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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30
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Seebauer CT, Freigang V, Schwan FE, Fischer R, Bohr C, Kühnel TS, Andorfer KEC. Hereditary Hemorrhagic Telangiectasia: Success of the Osler Calendar for Documentation of Treatment and Course of Disease. J Clin Med 2021; 10:jcm10204720. [PMID: 34682843 PMCID: PMC8541180 DOI: 10.3390/jcm10204720] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/04/2021] [Accepted: 10/10/2021] [Indexed: 12/28/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT; Rendu-Osler-Weber syndrome) affects the capillary and larger vessels, leading to arteriovenous shunts. Epistaxis is the main symptom impairing quality of life. The aim of the Osler Calendar is to offer information about the extent of the systemic disease and the current state of treatment. A care plan with information on the rare disease and self-treatment of epistaxis was created. Organ examinations and ongoing treatments were recorded. A questionnaire documents the treatment success, including patient satisfaction, frequency of hemorrhage and hemoglobin levels. The patients using the Osler Calendar for at least one year (n = 54) were surveyed. Eighty-five percent of patients (n = 46) used the calendar to gain information about HHT. Seventy-two percent (n = 39) used the Osler Calendar for instructions on the self-treatment of nosebleeds. The calendar increased patients’ understanding for the need for organ screenings from 48% (n = 26) to 81% (n = 44). Seventy-nine percent (n = 43) of patients confirmed that the Osler Calendar documented their therapeutic process either well or very well. Fifty-two percent (n = 28) saw an improvement in the therapeutic process due to the documentation. The Osler Calendar records the individual intensity of the disease and facilitates the communication between attending physicians. It is a tool for specialists to review treatment strategies. Furthermore, the calendar enhances patients’ comprehension of their condition.
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Affiliation(s)
- Caroline T. Seebauer
- Department of Otorhinolaryngology, Regensburg University Medical Center, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (F.E.S.); (R.F.); (C.B.); (T.S.K.); (K.E.C.A.)
- Correspondence:
| | - Viola Freigang
- Department of Trauma, Regensburg University Medical Center, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany;
| | - Franziska E. Schwan
- Department of Otorhinolaryngology, Regensburg University Medical Center, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (F.E.S.); (R.F.); (C.B.); (T.S.K.); (K.E.C.A.)
| | - René Fischer
- Department of Otorhinolaryngology, Regensburg University Medical Center, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (F.E.S.); (R.F.); (C.B.); (T.S.K.); (K.E.C.A.)
| | - Christopher Bohr
- Department of Otorhinolaryngology, Regensburg University Medical Center, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (F.E.S.); (R.F.); (C.B.); (T.S.K.); (K.E.C.A.)
| | - Thomas S. Kühnel
- Department of Otorhinolaryngology, Regensburg University Medical Center, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (F.E.S.); (R.F.); (C.B.); (T.S.K.); (K.E.C.A.)
| | - Kornelia E. C. Andorfer
- Department of Otorhinolaryngology, Regensburg University Medical Center, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (F.E.S.); (R.F.); (C.B.); (T.S.K.); (K.E.C.A.)
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Thangavelu K, Köhnlein S, Eivazi B, Gurschi M, Stuck BA, Geisthoff U. [Epistaxis-overview and current aspects]. HNO 2021; 69:931-942. [PMID: 34643746 DOI: 10.1007/s00106-021-01110-4] [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] [Accepted: 09/15/2021] [Indexed: 11/27/2022]
Abstract
Nosebleeds (epistaxis) are usually minor. Medical intervention is only necessary in about 6% of cases. The source of bleeding is frequently located in the anterior region of the nose (Kiesselbach's plexus). The estimated lifetime prevalence of epistaxis is 60%. Diffuse epistaxis is often a manifestation of systemic disease. Epistaxis is the leading symptom of Rendu-Osler-Weber disease (hereditary hemorrhagic telangiectasia, HHT). If intervention is required, the first-choice of treatment is bidigital compression for several minutes. Common therapeutic measures include local hemostasis using electrocoagulation or chemical agents, e.g., silver nitrate. Resorbable anterior nasal tampons or tampons with a smooth surface are also frequently employed. In case of failed surgical closure of the sphenopalatine artery, angiographic embolization is the method of choice.
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Affiliation(s)
- Kruthika Thangavelu
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland.
| | - Sabine Köhnlein
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland
| | - Behfar Eivazi
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland
- MED-HNO, Schwerpunktpraxis für HNO-Heilkunde, Kopf-Hals-Chirurgie und Plastische Operationen am Alice Hospital Darmstadt, Darmstadt, Deutschland
| | - Mariana Gurschi
- Klinik für Neuroradiologie, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Marburg, Deutschland
| | - Boris A Stuck
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland
| | - Urban Geisthoff
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland
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Xu L, Xu F, Wang Q, Ke X. Hereditary hemorrhagic telangiectasia with liver cirrhosis: a case report. BMC Gastroenterol 2021. [PMID: 34488642 DOI: 10.1186/s12876-021-01913-3.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia is an autosomal dominant hereditary hemorrhagic disease. Its main feature is an abnormal structure of the blood vessel wall. Cirrhosis of the liver is a common chronic progressive disease with one or more causes in which diffuse liver damage occurs after long-term or repeated injury. Liver cirrhosis can cause dilation of gastrointestinal capillaries. Many patients with hereditary hemorrhagic telangiectasia accompanied by gastrointestinal vascular malformations and liver cirrhosis may be diagnosed only with liver cirrhosis if the clinician does not pay attention to physical examination findings and family history. Moreover, general treatment measures, such as blood transfusion, iron supplementation, and application of hemostatic drugs, are less effective for bleeding in patients with hereditary hemorrhagic telangiectasia than in those with liver cirrhosis alone. CASE PRESENTATION Here, we report the rare case of a 75-year-old Chinese man who was admitted to the hospital with repeated melena and epistaxis. He was diagnosed with unexplained liver cirrhosis, which was later confirmed as hereditary hemorrhagic telangiectasia. Subsequently, we implemented the treatment intervention of oral thalidomide combined with gastrointestinal argon plasma coagulation. A follow-up of more than 8 months showed that the treatment effect was excellent. CONCLUSIONS If patients with liver cirrhosis and gastrointestinal vascular malformations also have a family history of epistaxis, special attention should be paid to targeted physical examination results, and the possibility of hereditary hemorrhagic telangiectasia should be considered. Moreover, for patients with hereditary hemorrhagic telangiectasia and both gastrointestinal bleeding caused by gastrointestinal capillaries and repeated epistaxis, when other general treatment measures are ineffective, thalidomide combined with gastrointestinal argon plasma coagulation may be an effective intervention.
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Affiliation(s)
- Linxia Xu
- Department of Gastroenterology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233004, Anhui, China
| | - Feng Xu
- Department of Gastroenterology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233004, Anhui, China
| | - Qizhi Wang
- Department of Gastroenterology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233004, Anhui, China
| | - Xiquan Ke
- Department of Gastroenterology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233004, Anhui, China.
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Xu L, Xu F, Wang Q, Ke X. Hereditary hemorrhagic telangiectasia with liver cirrhosis: a case report. BMC Gastroenterol 2021; 21:343. [PMID: 34488642 PMCID: PMC8422673 DOI: 10.1186/s12876-021-01913-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/17/2021] [Indexed: 11/30/2022] Open
Abstract
Background Hereditary hemorrhagic telangiectasia is an autosomal dominant hereditary hemorrhagic disease. Its main feature is an abnormal structure of the blood vessel wall. Cirrhosis of the liver is a common chronic progressive disease with one or more causes in which diffuse liver damage occurs after long-term or repeated injury. Liver cirrhosis can cause dilation of gastrointestinal capillaries. Many patients with hereditary hemorrhagic telangiectasia accompanied by gastrointestinal vascular malformations and liver cirrhosis may be diagnosed only with liver cirrhosis if the clinician does not pay attention to physical examination findings and family history. Moreover, general treatment measures, such as blood transfusion, iron supplementation, and application of hemostatic drugs, are less effective for bleeding in patients with hereditary hemorrhagic telangiectasia than in those with liver cirrhosis alone. Case presentation Here, we report the rare case of a 75-year-old Chinese man who was admitted to the hospital with repeated melena and epistaxis. He was diagnosed with unexplained liver cirrhosis, which was later confirmed as hereditary hemorrhagic telangiectasia. Subsequently, we implemented the treatment intervention of oral thalidomide combined with gastrointestinal argon plasma coagulation. A follow-up of more than 8 months showed that the treatment effect was excellent. Conclusions If patients with liver cirrhosis and gastrointestinal vascular malformations also have a family history of epistaxis, special attention should be paid to targeted physical examination results, and the possibility of hereditary hemorrhagic telangiectasia should be considered. Moreover, for patients with hereditary hemorrhagic telangiectasia and both gastrointestinal bleeding caused by gastrointestinal capillaries and repeated epistaxis, when other general treatment measures are ineffective, thalidomide combined with gastrointestinal argon plasma coagulation may be an effective intervention.
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Affiliation(s)
- Linxia Xu
- Department of Gastroenterology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233004, Anhui, China
| | - Feng Xu
- Department of Gastroenterology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233004, Anhui, China
| | - Qizhi Wang
- Department of Gastroenterology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233004, Anhui, China
| | - Xiquan Ke
- Department of Gastroenterology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, 233004, Anhui, China.
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Davieson CD, Joyce KE, Sharma L, Shovlin CL. DNA variant classification-reconsidering "allele rarity" and "phenotype" criteria in ACMG/AMP guidelines. Eur J Med Genet 2021; 64:104312. [PMID: 34411772 DOI: 10.1016/j.ejmg.2021.104312] [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: 03/11/2021] [Revised: 07/12/2021] [Accepted: 08/15/2021] [Indexed: 10/20/2022]
Abstract
Recent guidance suggested modified DNA variant pathogenicity assignments based on genome-wide allele rarity. Different a priori probabilities of pathogenicity operate where patients already have clinical diagnoses, and are found to have a very rare variant in a gene known to cause their disease, compared to predictive testing of a clinically unaffected individual. We tested new recommendations from the ClinGen Sequence Variant Interpretation Working Group for ClinVar-listed, loss-of-function variants meeting the very strong evidence of pathogenicity criterion [PVS1] in genes for 3 specific diseases where causal gene identification can modify clinical care of an individual- Von Willebrand disease, cystic fibrosis and hereditary haemorrhagic telangiectasia. Across these diseases, current rules leave 20/1,278 (1.6%) of loss-of-function variants as variants of uncertain significance (VUS that may not be reported to clinicians), and 207/1,278 (17.2%) as likely pathogenic. Applying the new ClinGen rule enabling PVS1 and the allele rarity criterion PM2 to delineate likely pathogenicity still left 8/1,278 (0.9%) as VUS (reflecting non-PVS1 calls by the submitters), and the majority of null alleles meeting PVS1 as merely likely pathogenic. We favour an approach whereby, for PVS1 variants in patients who personally meet the phenotypic PP4 criterion for a disease where casual variants are commonly family-specific, that PM2 is upgraded to permit a pathogenic call. Of 1,278 ClinVar-listed frameshift, nonsense and canonical splice site variants that met PVS1 in the 3 conditions, 16.0% (204/1,278) would be newly designated as pathogenic, avoiding misinterpretation outside of clinical genetics communities. We suggest further discussion around variant assessment across different clinical applications, potentially guided by PP4 alerts to distinguish personal versus family phenotypic history.
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Affiliation(s)
- Connor D Davieson
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Katie E Joyce
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Lakshya Sharma
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Claire L Shovlin
- National Heart and Lung Institute, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK.
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35
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Watson N, Al-Samkari H. Thrombotic and bleeding risk of angiogenesis inhibitors in patients with and without malignancy. J Thromb Haemost 2021; 19:1852-1863. [PMID: 33928747 DOI: 10.1111/jth.15354] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/13/2021] [Accepted: 04/26/2021] [Indexed: 01/06/2023]
Abstract
Over the past two decades, therapies targeting angiogenesis have developed into a major class of cancer therapeutics. The vascular endothelial growth factor (VEGF) family of signaling proteins, a group of potent angiogenic growth factors, and their receptors represent the main targets of this therapeutic class. To date, 16 antiangiogenic agents have been approved in the United States for the treatment of cancer and several more are in development. An important consideration with antiangiogenic therapy is toxicity, in particular thrombotic and bleeding risks. These complications have emerged as a major clinical concern that may affect the use of these agents in patients both with and without cancer who may already have an elevated risk of thrombosis and bleeding. Although these agents are frequently considered together as a class when contemplating their bleeding and thrombotic risks, in fact the risks for venous thromboembolism, arterial thrombosis, and bleeding vary significantly between different classes of antiangiogenic agents and even among different agents within a class. In this narrative review, we describe the literature investigating the venous and arterial thrombotic and bleeding risks associated with the currently available antiangiogenic drugs. In addition, we discuss these specific complications in the context of both cancer therapy as well as the management of nonmalignant disorders now managed with antiangiogenic agents, including hereditary hemorrhagic telangiectasia and neovascular age-related macular degeneration.
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Affiliation(s)
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA, USA
- Division of Hematology, Massachusetts General Hospital, Boston, MA, USA
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36
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Al-Samkari H, Kasthuri RS, Parambil JG, Albitar HA, Almodallal YA, Vázquez C, Serra MM, Dupuis-Girod S, Wilsen CB, McWilliams JP, Fountain EH, Gossage JR, Weiss CR, Latif MA, Issachar A, Mei-Zahav M, Meek ME, Conrad M, Rodriguez-Lopez J, Kuter DJ, Iyer VN. An international, multicenter study of intravenous bevacizumab for bleeding in hereditary hemorrhagic telangiectasia: the InHIBIT-Bleed study. Haematologica 2021; 106:2161-2169. [PMID: 32675221 PMCID: PMC8327711 DOI: 10.3324/haematol.2020.261859] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT, Osler-Weber-Rendu disease) is a rare multisystem vascular disorder that causes chronic gastrointestinal bleeding, epistaxis, and severe anemia. Bevacizumab, an anti-vascular endothelial growth factor antibody, may be effective to treat bleeding in HHT. This international, multicenter, retrospective study evaluated the use of systemic bevacizumab to treat HHTassociated bleeding and anemia at 12 HHT treatment centers. Hemoglobin, Epistaxis Severity Score (ESS), red cell units transfused, and intravenous iron infusions before and after treatment were evaluated using paired means testing and mixed-effects linear models. Bevacizumab was given to 238 HHT patients for a median of 12 (range, 1-96) months. Compared with pretreatment, bevacizumab increased mean hemoglobin by 3.2 g/dL (95% confidence interval: 2.9-3.5 g/dL); i.e., from a mean hemoglobin of 8.6 (8.5-8.8) g/dL to 11.8 (11.5-12.1) g/dL; P<0.0001) and decreased the ESS by 3.4 (3.2-3.7) points (mean ESS 6.8 [6.6-7.1] versus 3.4 [3.2-3.7]; P<0.0001) during the first year of treatment. Compared with 6 months before treatment, the number of red blood cell units transfused decreased by 82% (median of 6.0 [interquartile range, 0.0-13.0] units versus 0 [0.0-1.0] units; P<0.0001) and iron infusions decreased by 70% (median of 6.0 [1.0-18.0] infusions versus 1.0 [0.0-4.0] infusions, P<0.0001) during the first 6 months of bevacizumab treatment. Outcomes were similar regardless of the underlying pathogenic mutation. Following initial induction infusions, continuous/scheduled bevacizumab maintenance achieved higher hemoglobin and lower ESS than intermittent/as-needed maintenance but with more drug exposure. Bevacizumab was well tolerated: hypertension, fatigue, and proteinuria were the most common adverse events. Venous thromboembolism occurred in 2% of patients. In conclusion, systemic bevacizumab was safe and effective for managing chronic bleeding and anemia in HHT.
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Affiliation(s)
- Hanny Al-Samkari
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Raj S Kasthuri
- Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Hasan A Albitar
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Carolina Vázquez
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Marcelo M Serra
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Sophie Dupuis-Girod
- Centre de Reference pour la maladie de Rendu-Osler, Hospices Civils de Lyon, Lyon, France
| | - Craig B Wilsen
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Justin P McWilliams
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Evan H Fountain
- Division of Pulmonary, Critical Care, and Sleep Medicine, Augusta University, Augusta, GA, USA
| | - James R Gossage
- Division of Pulmonary, Critical Care, and Sleep Medicine, Augusta University, Augusta, GA, USA
| | - Clifford R Weiss
- Div. of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Muhammad A Latif
- Div. of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Assaf Issachar
- Schneider Children's Medical Center of Israel, Tel Aviv University, Israel
| | - Meir Mei-Zahav
- Schneider Children's Medical Center of Israel, Tel Aviv University, Israel
| | - Mary E Meek
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Miles Conrad
- Dept. of Radiology, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Josanna Rodriguez-Lopez
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David J Kuter
- Division of Hematology, Massachusetts General Hospital, Boston, MA, USA
| | - Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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Parambil JG, Gossage JR, McCrae KR, Woodard TD, Menon KVN, Timmerman KL, Pederson DP, Sprecher DL, Al-Samkari H. Pazopanib for severe bleeding and transfusion-dependent anemia in hereditary hemorrhagic telangiectasia. Angiogenesis 2021; 25:87-97. [PMID: 34292451 PMCID: PMC8295629 DOI: 10.1007/s10456-021-09807-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a rare angiogenic disorder causing chronic gastrointestinal bleeding, epistaxis, and severe anemia. Pazopanib is an oral multi-kinase angiogenesis inhibitor with promise to treat bleeding in HHT. We analyzed outcomes of HHT patients with the most severe bleeding causing RBC transfusion dependence treated on a predefined institutional pazopanib treatment pathway (with data collected retrospectively). The primary endpoint was achievement of transfusion independence. Secondary endpoints included hemoglobin, epistaxis severity score, RBC transfusion and iron infusion requirements, number of local hemostatic procedures, ferritin and transferrin saturation, compared using paired and repeated measures mean tests. Thirteen transfusion-dependent HHT patients received pazopanib [median (range) dose 150 (25–300) mg daily)] for a median of 22 months. All patients achieved transfusion independence. Compared with pretreatment, pazopanib increased mean hemoglobin by 4.8 (95% CI, 3.6–5.9) g/dL (7.8 vs. 12.7 g/dL, P < 0.0001) and decreased mean epistaxis severity score by 4.77 (3.11–6.44) points (7.20 vs. 2.43 points, P < 0.0001) after 12 months of treatment. Compared with 3 months of pretreatment, RBC transfusions decreased by 93% (median of 16.0 vs. 0.0 units, P < 0.0001) and elemental iron infusion decreased by 92% (median of 4500 vs. 0 mg, P = 0.005) during the first 3 months of treatment; improvements were maintained over time. Pazopanib was well-tolerated: hypertension, lymphocytopenia, and fatigue were the most common TEAEs. In conclusion, pazopanib was safe and effective to manage severe bleeding in HHT, liberating all patients from transfusion dependence and normalizing hematologic parameters at doses lower than used to treat malignancies. These findings require confirmation in a randomized trial.
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Affiliation(s)
- Joseph G Parambil
- Cleveland Clinic, Respiratory Institute, 9500 Euclid Avenue A-90, Cleveland, OH, 44195, USA.
| | - James R Gossage
- Division of Pulmonary, Critical Care and Sleep Medicine, Augusta University, Augusta, GA, USA
| | - Keith R McCrae
- Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH, USA
| | - Troy D Woodard
- Cleveland Clinic, Head and Neck Institute, Cleveland, OH, USA
| | | | - Kasi L Timmerman
- Cleveland Clinic, Respiratory Institute, 9500 Euclid Avenue A-90, Cleveland, OH, 44195, USA
| | - Douglas P Pederson
- Cleveland Clinic, Respiratory Institute, 9500 Euclid Avenue A-90, Cleveland, OH, 44195, USA
| | | | - Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Zero Emerson Pl Suite 118, Office 112, Boston, MA, 02114, USA.
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Hereditary hemorrhagic telangiectasia: systemic therapies, guidelines, and an evolving standard of care. Blood 2021; 137:888-895. [PMID: 33171488 DOI: 10.1182/blood.2020008739] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/03/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) management is evolving because of the emergence and development of antiangiogenic therapies to eliminate bleeding telangiectasias and achieve hemostasis. This progress is reflected in recent clinical recommendations published in the Second International Guidelines for the Diagnosis and Treatment of HHT, in which systemic therapies including antiangiogenics and antifibrinolytics are now recommended as standard treatment options for bleeding. This review highlights the new recommendations especially relevant to hematologists in managing bleeding, anticoagulation, and anemia in patients with HHT.
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Management of Refractory Gastrointestinal Bleeding in Hereditary Hemorrhagic Telangiectasia with Bevacizumab. Case Rep Gastrointest Med 2021; 2021:2242178. [PMID: 34306771 PMCID: PMC8263270 DOI: 10.1155/2021/2242178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/17/2021] [Accepted: 06/23/2021] [Indexed: 11/18/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder resulting in vascular malformations of several organs including the pulmonary, cerebral, and gastrointestinal systems. One sequela is recurrent gastrointestinal (GI) bleeding. Bevacizumab (Bev) is emerging as an effective treatment of recurrent gastrointestinal bleeding in HHT. Bev is a recombinant monoclonal antibody that inhibits vascular endothelial growth factor (VEGF), an integral part of angiogenesis.
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40
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Marziano C, Genet G, Hirschi KK. Vascular endothelial cell specification in health and disease. Angiogenesis 2021; 24:213-236. [PMID: 33844116 PMCID: PMC8205897 DOI: 10.1007/s10456-021-09785-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 03/17/2021] [Indexed: 02/08/2023]
Abstract
There are two vascular networks in mammals that coordinately function as the main supply and drainage systems of the body. The blood vasculature carries oxygen, nutrients, circulating cells, and soluble factors to and from every tissue. The lymphatic vasculature maintains interstitial fluid homeostasis, transports hematopoietic cells for immune surveillance, and absorbs fat from the gastrointestinal tract. These vascular systems consist of highly organized networks of specialized vessels including arteries, veins, capillaries, and lymphatic vessels that exhibit different structures and cellular composition enabling distinct functions. All vessels are composed of an inner layer of endothelial cells that are in direct contact with the circulating fluid; therefore, they are the first responders to circulating factors. However, endothelial cells are not homogenous; rather, they are a heterogenous population of specialized cells perfectly designed for the physiological demands of the vessel they constitute. This review provides an overview of the current knowledge of the specification of arterial, venous, capillary, and lymphatic endothelial cell identities during vascular development. We also discuss how the dysregulation of these processes can lead to vascular malformations, and therapeutic approaches that have been developed for their treatment.
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Affiliation(s)
- Corina Marziano
- Department of Cell Biology, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA.,Cardiovascular Research Center, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | - Gael Genet
- Department of Cell Biology, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA.,Cardiovascular Research Center, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | - Karen K Hirschi
- Department of Cell Biology, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA. .,Cardiovascular Research Center, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA. .,Department of Medicine, Yale Cardiovascular Research Center, Yale University School of Medicine, New Haven, CT, 06520, USA.
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Mutational and phenotypic characterization of hereditary hemorrhagic telangiectasia. Blood 2021; 136:1907-1918. [PMID: 32573726 DOI: 10.1182/blood.2019004560] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 05/17/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular dysplasia. Care delivery for HHT patients is impeded by the need for laborious, repeated phenotyping and gaps in knowledge regarding the relationships between causal DNA variants in ENG, ACVRL1, SMAD4 and GDF2, and clinical manifestations. To address this, we analyzed DNA samples from 183 previously uncharacterized, unrelated HHT and suspected HHT cases using the ThromboGenomics high-throughput sequencing platform. We identified 127 rare variants across 168 heterozygous genotypes. Applying modified American College of Medical Genetics and Genomics Guidelines, 106 variants were classified as pathogenic/likely pathogenic and 21 as nonpathogenic (variant of uncertain significance/benign). Unlike the protein products of ACVRL1 and SMAD4, the extracellular ENG amino acids are not strongly conserved. Our inferences of the functional consequences of causal variants in ENG were therefore informed by the crystal structure of endoglin. We then compared the accuracy of predictions of the causal gene blinded to the genetic data using 2 approaches: subjective clinical predictions and statistical predictions based on 8 Human Phenotype Ontology terms. Both approaches had some predictive power, but they were insufficiently accurate to be used clinically, without genetic testing. The distributions of red cell indices differed by causal gene but not sufficiently for clinical use in isolation from genetic data. We conclude that parallel sequencing of the 4 known HHT genes, multidisciplinary team review of variant calls in the context of detailed clinical information, and statistical and structural modeling improve the prognostication and treatment of HHT.
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Droege F, Dingemann J, Thangavelu K, Kuerten CHL, Dahlfrancis PM, Kaiser C, Kaster F, Zioga E, Meyer C, Lueb C, Sure U, Lang S, Geisthoff U. [Implementation and development of a center for hereditary hemorrhagic telangiectasia]. Laryngorhinootologie 2021; 100:372-381. [PMID: 33723832 DOI: 10.1055/a-1402-0543] [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
OBJECTIVE Hereditary Hemorrhagic Telangiectasia (HHT) is a rare and systemic disorder which is characterized by recurrent epistaxis, mucocutaneous telangiectases, and visceral arteriovenous malformations (AVM). An interdisciplinary concept is recommended. MATERIAL AND METHODS We performed a retrospective review of consecutive patients who were referred to our newly established HHT Center of Excellence (HHT COE) for evaluation and treatment between April 2014 and August 2019. RESULTS A network of over 20 departments was established at the University Hospital Essen. In 261 of the 282 patients (93 %), who were referred to the hospital's COE, the HHT diagnosis was at least possible. Most patients suffered from several symptoms (epistaxis and / or telangiectasia: > 80 %, visceral involvement: 65 %) and received a variety of treatments, often in a multidisciplinary setting. Alongside this direct treatment, the COE leader manages the coordination of the center and its public relations, which involves more than 900 e-mails per year. International collaboration and exchanges of expertise within the European Reference Network on Rare Multisystemic Vascular Diseases (VASCERN) can improve the treatment of patients with HHT particularly where these cases are complex. CONCLUSIONS An HHT COE provides an interdisciplinary network where highly specialized diagnostic and therapeutic processes can be updated and optimized continuously.
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Affiliation(s)
- Freya Droege
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Julia Dingemann
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Kruthika Thangavelu
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Gießen und Marburg - Standort Marburg, Germany
| | | | | | - Christina Kaiser
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Friederike Kaster
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Eleni Zioga
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Corinna Meyer
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Carolin Lueb
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Ulrich Sure
- Klinik für Neurochirurgie, Universitätsklinikum Essen, Germany
| | - Stephan Lang
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Urban Geisthoff
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Gießen und Marburg - Standort Marburg, Germany
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Tortora A, Marmo C, Gasbarrini A, Costamagna G, Riccioni ME. Management of Gastrointestinal Bleeding in Rendu-Osler Disease. Rev Recent Clin Trials 2021; 15:321-327. [PMID: 32493201 DOI: 10.2174/1574887115666200603160033] [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: 02/29/2020] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT, or Rendu-Osler-Weber disease) is a rare inherited syndrome, characterized by artero-venous malformations (AVMs or telangiectasia) with autosomal dominant transmission. AVMs can occur in any organ of the body but most commonly it occurs in the nose, pulmonary, hepatic and cerebral circulations. In patients with HHT, we report teleangectasia of mucosa of the gastrointestinal tract. METHODS Research and online content related to HHT online activity is reviewed, and DOC writing excerpts are used to illustrate key themes. RESULTS Patients with HHT have a high rate of complications related to bleeding; of them gastrointestinal bleeding accounts for 10.8%. Several therapies, both medical and endoscopic, were utilized to reduce the need for transfusions and hospitalization. CONCLUSION A combination of medical and endoscopic therapy is probably the best option.
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Affiliation(s)
- Annalisa Tortora
- Department of Gastroenterological, Fondazione Policlinico Gemelli IRCCS, Endocrino-Metabolic, and Nefro-urological Science, Rome, Italy
| | - Clelia Marmo
- Department of Gastroenterological, Fondazione Policlinico Gemelli IRCCS, Endocrino-Metabolic, and Nefro-urological Science, Rome, Italy
| | - Antonio Gasbarrini
- Department of Gastroenterological, Fondazione Policlinico Gemelli IRCCS, Endocrino-Metabolic, and Nefro-urological Science, Rome, Italy
| | - Guido Costamagna
- Department of Gastroenterological, Fondazione Policlinico Gemelli IRCCS, Endocrino-Metabolic, and Nefro-urological Science, Rome, Italy
| | - Maria Elena Riccioni
- Department of Gastroenterological, Fondazione Policlinico Gemelli IRCCS, Endocrino-Metabolic, and Nefro-urological Science, Rome, Italy
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Faughnan ME, Mager JJ, Hetts SW, Palda VA, Lang-Robertson K, Buscarini E, Deslandres E, Kasthuri RS, Lausman A, Poetker D, Ratjen F, Chesnutt MS, Clancy M, Whitehead KJ, Al-Samkari H, Chakinala M, Conrad M, Cortes D, Crocione C, Darling J, de Gussem E, Derksen C, Dupuis-Girod S, Foy P, Geisthoff U, Gossage JR, Hammill A, Heimdal K, Henderson K, Iyer VN, Kjeldsen AD, Komiyama M, Korenblatt K, McDonald J, McMahon J, McWilliams J, Meek ME, Mei-Zahav M, Olitsky S, Palmer S, Pantalone R, Piccirillo JF, Plahn B, Porteous MEM, Post MC, Radovanovic I, Rochon PJ, Rodriguez-Lopez J, Sabba C, Serra M, Shovlin C, Sprecher D, White AJ, Winship I, Zarrabeitia R. Second International Guidelines for the Diagnosis and Management of Hereditary Hemorrhagic Telangiectasia. Ann Intern Med 2020; 173:989-1001. [PMID: 32894695 DOI: 10.7326/m20-1443] [Citation(s) in RCA: 202] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
DESCRIPTION Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease with an estimated prevalence of 1 in 5000 that is characterized by the presence of vascular malformations (VMs). These result in chronic bleeding, acute hemorrhage, and complications from shunting through VMs. The goal of the Second International HHT Guidelines process was to develop evidence-based consensus guidelines for the management and prevention of HHT-related symptoms and complications. METHODS The guidelines were developed using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) framework and GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. The guidelines expert panel included expert physicians (clinical and genetic) in HHT from 15 countries, guidelines methodologists, health care workers, health care administrators, patient advocacy representatives, and persons with HHT. During the preconference process, the expert panel generated clinically relevant questions in 6 priority topic areas. A systematic literature search was done in June 2019, and articles meeting a priori criteria were included to generate evidence tables, which were used as the basis for recommendation development. The expert panel subsequently convened during a guidelines conference to conduct a structured consensus process, during which recommendations reaching at least 80% consensus were discussed and approved. RECOMMENDATIONS The expert panel generated and approved 6 new recommendations for each of the following 6 priority topic areas: epistaxis, gastrointestinal bleeding, anemia and iron deficiency, liver VMs, pediatric care, and pregnancy and delivery (36 total). The recommendations highlight new evidence in existing topics from the first International HHT Guidelines and provide guidance in 3 new areas: anemia, pediatrics, and pregnancy and delivery. These recommendations should facilitate implementation of key components of HHT care into clinical practice.
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Affiliation(s)
- Marie E Faughnan
- St. Michael's Hospital, Li Ka Shing Knowledge Institute, and University of Toronto, Toronto, Ontario, Canada (M.E.F.)
| | | | - Steven W Hetts
- University of California, San Francisco, San Francisco, California (S.W.H., M.C.)
| | | | | | | | - Erik Deslandres
- Centre Hospitalier de l'Université de Montréal, Hôtel-Dieu, Montreal, Quebec, Canada (E.D.)
| | - Raj S Kasthuri
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (R.S.K., J.D.)
| | - Andrea Lausman
- St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada (A.L., R.P.)
| | - David Poetker
- Froedtert and Medical College of Wisconsin, Milwaukee, Wisconsin (D.P., P.F.)
| | - Felix Ratjen
- The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada (F.R.)
| | - Mark S Chesnutt
- VA Portland Health Care System and Oregon Health & Science University, Portland, Oregon (M.S.C.)
| | | | - Kevin J Whitehead
- University of Utah Medical Center, Salt Lake City, Utah (K.J.W., J.M.)
| | - Hanny Al-Samkari
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (H.A.)
| | - Murali Chakinala
- Washington University School of Medicine, St. Louis, Missouri (M.C., K.K., J.F.P., A.J.W.)
| | - Miles Conrad
- University of California, San Francisco, San Francisco, California (S.W.H., M.C.)
| | - Daniel Cortes
- St. Michael's Hospital and Unity Health Toronto, Toronto, Canada (D.C.)
| | | | - Jama Darling
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (R.S.K., J.D.)
| | | | | | | | - Patrick Foy
- Froedtert and Medical College of Wisconsin, Milwaukee, Wisconsin (D.P., P.F.)
| | - Urban Geisthoff
- University Hospital of Marburg and Phillips University Marburg, Marburg, Germany (U.G.)
| | | | - Adrienne Hammill
- Cincinnati Children's Hospital and University of Cincinnati, Cincinnati, Ohio (A.H.)
| | - Ketil Heimdal
- Oslo University Hospital, Rikshospitalet, Oslo, Norway (K.H.)
| | | | | | | | | | - Kevin Korenblatt
- Washington University School of Medicine, St. Louis, Missouri (M.C., K.K., J.F.P., A.J.W.)
| | - Jamie McDonald
- University of Utah Medical Center, Salt Lake City, Utah (K.J.W., J.M.)
| | | | - Justin McWilliams
- University of California, Los Angeles, Los Angeles, California (J.M.)
| | - Mary E Meek
- University of Arkansas for Medical Sciences, Little Rock, Arkansas (M.E.M.)
| | - Meir Mei-Zahav
- Schneider Children's Medical Center of Israel and Sackler School of Medicine of Tel Aviv University, Tel Aviv, Israel (M.M.)
| | | | | | - Rose Pantalone
- St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada (A.L., R.P.)
| | - Jay F Piccirillo
- Washington University School of Medicine, St. Louis, Missouri (M.C., K.K., J.F.P., A.J.W.)
| | | | | | - Marco C Post
- St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht, the Netherlands (M.C.P.)
| | - Ivan Radovanovic
- Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada (I.R.)
| | - Paul J Rochon
- University of Colorado Hospital, Aurora, Colorado (P.J.R.)
| | | | | | - Marcelo Serra
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina (M.S.)
| | | | | | - Andrew J White
- Washington University School of Medicine, St. Louis, Missouri (M.C., K.K., J.F.P., A.J.W.)
| | - Ingrid Winship
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia (I.W.)
| | - Roberto Zarrabeitia
- Hospital Sierrallana (Servicio Cántabro de Salud), Torrelavega, Spain (R.Z.)
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45
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Olsen LB, Kjeldsen AD, Poulsen MK, Kjeldsen J, Fialla AD. High output cardiac failure in 3 patients with hereditary hemorrhagic telangiectasia and hepatic vascular malformations, evaluation of treatment. Orphanet J Rare Dis 2020; 15:334. [PMID: 33243256 PMCID: PMC7691053 DOI: 10.1186/s13023-020-01583-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 10/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This report addresses how patients with hereditary hemorrhagic telangiectasia (HHT) and high output cardiac failure (HOCF) due to hepatic vascular malformations, should be evaluated and could be treated. HHT is a genetic disorder, leading to vascular abnormalities with potentially serious clinical implications. In the liver, arteriovenous malformations occur in more than 70% of patients, but only about 8% present clinical symptoms such as HOCF with pulmonary hypertension and less commonly portal hypertension, biliary ischemia and hepatic encephalopathy. RESULTS Three female patients with HHT type 2 and HOCF caused by severe arteriovenous malformations in the liver are presented in this case series. The patients were seen at the HHT-Centre at Odense University Hospital. Treatment with either orthotopic liver transplantation (one patient) or bevacizumab (two patients) was initiated. All patients experienced marked symptom relief and objective improvement. New York Heart Association-class were improved, ascites, peripheral edema and hence diuretic treatment was markedly reduced or discontinued in all three patients. Bevacizumab also resulted in notable effects on epistaxis and anemia. CONCLUSION Our findings substantiate the importance of identification of symptomatic arteriovenous malformations in the liver in patients with HHT. Bevacizumab may possibly, as suggested in this case series and supported by previous case studies, postpone the time to orthotopic liver transplantation or even make it unnecessary. Bevacizumab represents a promising new treatment option, which should be investigated further in clinical trials.
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Affiliation(s)
- Lilian B Olsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark
| | - Anette D Kjeldsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark.,Department of Otorhinolaryngology Head and Neck Surgery, Odense, Denmark.,Institute of Clinical Research, Odense, Denmark
| | - Mikael K Poulsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark.,Department of Cardiology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, Odense, Denmark
| | - Jens Kjeldsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark.,Department of Medical Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, Odense, Denmark
| | - Annette D Fialla
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark. .,Department of Medical Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark. .,Institute of Clinical Research, Odense, Denmark.
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46
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Harwin J, Sugi MD, Hetts SW, Conrad MB, Ohliger MA. The Role of Liver Imaging in Hereditary Hemorrhagic Telangiectasia. J Clin Med 2020; 9:jcm9113750. [PMID: 33233377 PMCID: PMC7700186 DOI: 10.3390/jcm9113750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 01/01/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular disorder characterized by spontaneous epistaxis, telangiectasia, and visceral vascular malformations. Hepatic vascular malformations are common, though a minority are symptomatic. Symptoms are dependent on the severity and exact type of shunting caused by the hepatic malformation: Arteriosystemic shunting leads to manifestations of high output cardiac failure, and arterioportal shunting leads to portal hypertension. Radiologic imaging, including ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), is an important tool for assessing liver involvement. Doppler ultrasonography is the first-line screening modality for HHT-related liver disease, and it has a standardized scale. Imaging can determine whether shunting is principally to the hepatic vein or the portal vein, which can be a key determinant of patients’ symptoms. Liver-related complications can be detected, including manifestations of portal hypertension, focal liver masses as well as ischemic cholangiopathy. Ultrasound and MRI also have the ability to quantify blood flow through the liver, which in the future may be used to determine prognosis and direct antiangiogenic therapy.
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Affiliation(s)
- Joelle Harwin
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143, USA; (J.H.); (M.D.S.); (S.W.H.); (M.B.C.)
| | - Mark D. Sugi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143, USA; (J.H.); (M.D.S.); (S.W.H.); (M.B.C.)
- Department of Radiology, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Steven W. Hetts
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143, USA; (J.H.); (M.D.S.); (S.W.H.); (M.B.C.)
- Department of Radiology, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Miles B. Conrad
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143, USA; (J.H.); (M.D.S.); (S.W.H.); (M.B.C.)
- Department of Radiology, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Michael A. Ohliger
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143, USA; (J.H.); (M.D.S.); (S.W.H.); (M.B.C.)
- Department of Radiology, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Correspondence:
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Potential Second-Hits in Hereditary Hemorrhagic Telangiectasia. J Clin Med 2020; 9:jcm9113571. [PMID: 33167572 PMCID: PMC7694477 DOI: 10.3390/jcm9113571] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant genetic disorder that presents with telangiectases in skin and mucosae, and arteriovenous malformations (AVMs) in internal organs such as lungs, liver, and brain. Mutations in ENG (endoglin), ACVRL1 (ALK1), and MADH4 (Smad4) genes account for over 95% of HHT. Localized telangiectases and AVMs are present in different organs, with frequencies which differ among affected individuals. By itself, HHT gene heterozygosity does not account for the focal nature and varying presentation of the vascular lesions leading to the hypothesis of a “second-hit” that triggers the lesions. Accumulating research has identified a variety of triggers that may synergize with HHT gene heterozygosity to generate the vascular lesions. Among the postulated second-hits are: mechanical trauma, light, inflammation, vascular injury, angiogenic stimuli, shear stress, modifier genes, and somatic mutations in the wildtype HHT gene allele. The aim of this review is to summarize these triggers, as well as the functional mechanisms involved.
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Gariballa N, Ali BR. Endoplasmic Reticulum Associated Protein Degradation (ERAD) in the Pathology of Diseases Related to TGFβ Signaling Pathway: Future Therapeutic Perspectives. Front Mol Biosci 2020; 7:575608. [PMID: 33195419 PMCID: PMC7658374 DOI: 10.3389/fmolb.2020.575608] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/29/2020] [Indexed: 02/05/2023] Open
Abstract
The transforming growth factor signaling pathway (TGFβ) controls a wide range of cellular activities in adulthood as well as during embryogenesis including cell growth, differentiation, apoptosis, immunological responses and other cellular functions. Therefore, germline mutations in components of the pathway have given rise to a heterogeneous spectrum of hereditary diseases with variable phenotypes associated with malformations in the cardiovascular, muscular and skeletal systems. Our extensive literature and database searches revealed 47 monogenic diseases associated with germline mutations in 24 out of 41 gene variant encoding for TGFβ components. Most of the TGFβ components are membrane or secretory proteins and they are therefore expected to pass through the endoplasmic reticulum (ER), where fidelity of proteins folding is stringently monitored via the ER quality control machineries. Elucidation of the molecular mechanisms of mutant proteins’ folding and trafficking showed the implication of ER associated protein degradation (ERAD) in the pathogenesis of some of the diseases. For example, hereditary hemorrhagic telangiectasia types 1 and 2 (HHT1 and HHT2) and familial pulmonary arterial hypertension (FPAH) associated with mutations in Endoglin, ALK1 and BMPR2 components of the signaling pathway, respectively, have all exhibited loss of function phenotype as a result of ER retention of some of their disease-causing variants. In some cases, this has led to premature protein degradation through the proteasomal pathway. We anticipate that ERAD will be involved in the mechanisms of other TGFβ signaling components and therefore warrants further research. In this review, we highlight advances in ER quality control mechanisms and their modulation as a potential therapeutic target in general with particular focus on prospect of their implementation in the treatment of monogenic diseases associated with TGFβ components including HHT1, HHT2, and PAH. In particular, we emphasis the need to establish disease mechanisms and to implement such novel approaches in modulating the molecular pathway of mutant TGFβ components in the quest for restoring protein folding and trafficking as a therapeutic approach.
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Affiliation(s)
- Nesrin Gariballa
- Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.,Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Bassam R Ali
- Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.,Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.,Zayed Bin Sultan Center for Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
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49
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Differential Expression of Circulating Plasma miRNA-370 and miRNA-10a from Patients with Hereditary Hemorrhagic Telangiectasia. J Clin Med 2020; 9:jcm9092855. [PMID: 32899377 PMCID: PMC7565099 DOI: 10.3390/jcm9092855] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/23/2020] [Accepted: 08/31/2020] [Indexed: 02/06/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant, vascular disorder that presents with telangiectases and arteriovenous malformations. HHT is a genetically heterogeneous disorder, involving mutations in endoglin (ENG; HHT1) and activin receptor-like kinase 1 (ACVRL1/ALK1; HHT2) genes that account for over 85% of all HHT patients. The current diagnosis of HHT patients remains at the clinical level, but many suspected patients do not have a clear HHT diagnosis or do not show pathogenic mutations in HHT genes. This situation has prompted the search for biomarkers to help in the early diagnosis of the disease. We have analyzed the plasma levels in HHT patients of selected micro-RNAs (miRNAs), small single-stranded RNAs that regulate gene expression at the transcriptional level by interacting with specific RNA targets. A total of 16 HHT1 and 17 HHT2 plasma samples from clinically confirmed patients and 16 controls were analyzed in this study. Total RNA was purified from plasma, and three selected miRNAs (miRNA-10a, miRNA-214, and miRNA-370), related to the pathobiology of cardiovascular diseases and potentially targeting ENG or ALK1, were measured by quantitative polymerase chain reaction. Compared with controls, levels of miRNA-370, whose putative target is ENG, were significantly downregulated in HHT1, but not in HHT2, whereas the levels of miRNA-10a, whose putative target is ALK1, were significantly upregulated in HHT2, but not in HHT1. In addition, the levels of miRNA-214, potentially targeting ENG and ALK1, did not change in either HHT1 or HHT2 patients versus control samples. While further studies are warranted, these results suggest that dysregulated plasma levels of miRNA-370 or miRNA-10a could help to identify undiagnosed HHT1 or HHT2 patients, respectively.
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50
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Dupuis-Girod S. Intravenous Bevacizumab in Hereditary Hemorrhagic Telangiectasia: A Role That Is Still to Be Defined. Mayo Clin Proc 2020; 95:1565-1566. [PMID: 32753127 DOI: 10.1016/j.mayocp.2020.06.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/24/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Sophie Dupuis-Girod
- Hôpital Femme-Mère-Enfants, Service de Génétique et Centre de Référence National pour la maladie de Rendu-Osler, Bron, France.
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