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Zhang E, Virk ZM, Rodriguez-Lopez J, Al-Samkari H. Hereditary hemorrhagic telangiectasia may be the most morbid inherited bleeding disorder in women. Blood Adv 2024; 8:3166-3172. [PMID: 38593443 PMCID: PMC11225659 DOI: 10.1182/bloodadvances.2023011961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 04/11/2024] Open
Abstract
ABSTRACT Hereditary hemorrhagic telangiectasia (HHT) is the second-most common inherited bleeding disorder (BD) worldwide and remains without approved therapies. HHT causes serious mucosal bleeding resulting in severe iron-deficiency anemia, major psychosocial complications, and visceral arteriovenous malformations in the brain, lung, and liver, which can cause life-threatening hemorrhagic complications. No study has examined the relative morbidity of HHT and von Willebrand disease (VWD), which is the most common inherited BD in women. We performed an observational cohort study of women with HHT or VWD, comparing a representative sample of 100 randomly selected women with HHT to 100 randomly selected age-matched women with VWD. In HHT vs VWD, recurrent epistaxis and gastrointestinal bleeding were more likely (odds ratio [OR], 32.73 [95% confidence interval, 13.81-71.80]; P < .0001 and 5.69 [2.59-12.89]; P < .0001) and heavy menstrual bleeding was less likely (OR, 0.32 [0.18-0.57]; P < .0001). Iron-deficiency anemia was significantly more likely, and the lowest hemoglobin was significantly lower in HHT than in VWD. The odds of iron infusion dependence, requirement for red cell transfusion, and hemostatic surgical procedures were significantly higher-17-fold, threefold, and eightfold higher, respectively-and hospital admissions to manage disease complications were both ∼14 times more frequent in women with HHT vs those with VWD. In conclusion, much higher disease-related morbidity, mortality, and health care use were observed in women with HHT vs VWD, providing evidence that HHT may be the most clinically significant inherited BD in women. Given the vast gap in research funding for HHT compared with both hemophilia (a disease primarily of men) and VWD, these findings have significant implications for gender equity in hematology.
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Affiliation(s)
- Ellen Zhang
- Department of Medicine, Stanford University Medical Center, Palo Alto, CA
| | - Zain M. Virk
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Josanna Rodriguez-Lopez
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, MA
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2
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Gong AJ, Garg T, Khalil A, Gowda PC, Mathai SC, Rowan NR, Merlo CA, Weiss CR. Health-Related Quality of Life Outcome Measures in Individuals With Hereditary Hemorrhagic Telangiectasia: A Scoping Review. Am J Rhinol Allergy 2024; 38:60-76. [PMID: 37855028 DOI: 10.1177/19458924231207123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
BACKGROUND Studies evaluating health-related quality of life (HRQOL) in patients with hereditary hemorrhagic telangiectasia (HHT) have expanded rapidly in the past decade. These studies have evaluated QOL aspects ranging from the general QOL for patients living with HHT to intervention-specific outcomes. However, few tools have been fully validated across the spectrum of disease manifestations and interventions in HHT. OBJECTIVE In this scoping review, we aim to map the literature on HHT-QOL metrics, identify gaps, inform future QOL research, and facilitate future metric development. METHODS We analyzed articles in English that assessed at least 1 measure of general HRQOL, including physical health, mental health, social health, or intervention-specific QOL in patients with HHT. Searches across 2 bibliographic databases (PubMed and Scopus) yielded 186 articles after duplicates were removed. Sixty-three studies met eligibility criteria: 22 prospective studies (34.9%), 20 retrospective studies (31.7%), 12 cross-sectional studies (17.5%), 6 randomized controlled trials or secondary analyses of a randomized controlled trials (9.5%), 2 qualitative studies (3.2%), and 1 case-control study (1.6%). Two additional studies-1 prospective and 1 cross-sectional study-were identified at the October 2022 14th International HHT Conference and included, making a total of 65 studies. RESULTS The 65 eligible studies used 30 QOL instruments. Twenty studies characterized baseline HRQOL, and 45 studies evaluated QOL before and after treatment. Of those 45 studies, 37 evaluated HRQOL before and after therapies targeting epistaxis and nasal symptoms, 4 targeted therapies for liver arteriovenous malformations and high-output heart failure, 3 evaluated therapies for both epistaxis and gastrointestinal bleeding, and 1 evaluated treatment targeting gastrointestinal bleeding alone. CONCLUSIONS Comparison of results across studies remains challenging given the heterogeneity in outcomes measures. Further development of HHT-specific patient-reported outcomes instruments that capture the global illness experience of HHT is needed.
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Affiliation(s)
- Anna J Gong
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tushar Garg
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adham Khalil
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Prateek C Gowda
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephen C Mathai
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicholas R Rowan
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christian A Merlo
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Clifford R Weiss
- Division of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Wits M, Becher C, de Man F, Sanchez-Duffhues G, Goumans MJ. Sex-biased TGFβ signalling in pulmonary arterial hypertension. Cardiovasc Res 2023; 119:2262-2277. [PMID: 37595264 PMCID: PMC10597641 DOI: 10.1093/cvr/cvad129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/21/2023] [Accepted: 07/04/2023] [Indexed: 08/20/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare cardiovascular disorder leading to pulmonary hypertension and, often fatal, right heart failure. Sex differences in PAH are evident, which primarily presents with a female predominance and increased male severity. Disturbed signalling of the transforming growth factor-β (TGFβ) family and gene mutations in the bone morphogenetic protein receptor 2 (BMPR2) are risk factors for PAH development, but how sex-specific cues affect the TGFβ family signalling in PAH remains poorly understood. In this review, we aim to explore the sex bias in PAH by examining sex differences in the TGFβ signalling family through mechanistical and translational evidence. Sex hormones including oestrogens, progestogens, and androgens, can determine the expression of receptors (including BMPR2), ligands, and soluble antagonists within the TGFβ family in a tissue-specific manner. Furthermore, sex-related genetic processes, i.e. Y-chromosome expression and X-chromosome inactivation, can influence the TGFβ signalling family at multiple levels. Given the clinical and mechanistical similarities, we expect that the conclusions arising from this review may apply also to hereditary haemorrhagic telangiectasia (HHT), a rare vascular disorder affecting the TGFβ signalling family pathway. In summary, we anticipate that investigating the TGFβ signalling family in a sex-specific manner will contribute to further understand the underlying processes leading to PAH and likely HHT.
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Affiliation(s)
- Marius Wits
- Department of Cell and Chemical Biology, Leiden University Medical Center, Einthovenweg 20, 2333 ZC Leiden, The Netherlands
| | - Clarissa Becher
- Department of Cell and Chemical Biology, Leiden University Medical Center, Einthovenweg 20, 2333 ZC Leiden, The Netherlands
| | - Frances de Man
- Department of Pulmonary Medicine, Amsterdam University Medical Center (UMC) (Vrije Universiteit), 1081 HV Amsterdam, The Netherlands
| | - Gonzalo Sanchez-Duffhues
- Department of Cell and Chemical Biology, Leiden University Medical Center, Einthovenweg 20, 2333 ZC Leiden, The Netherlands
- Nanomaterials and Nanotechnology Research Center (CINN-CSIC), Health Research Institute of Asturias (ISPA), 33011 Oviedo, Spain
| | - Marie-José Goumans
- Department of Cell and Chemical Biology, Leiden University Medical Center, Einthovenweg 20, 2333 ZC Leiden, The Netherlands
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Guilhem A, Dupuis-Girod S, Espitia O, Rivière S, Seguier J, Kerjouan M, Lavigne C, Maillard H, Magro P, Alric L, Lipsker D, Parrot A, Leguy V, Vanlemmens C, Guibaud L, Vikkula M, Eyries M, Valette PJ, Giraud S. Seven cases of hereditary haemorrhagic telangiectasia-like hepatic vascular abnormalities associated with EPHB4 pathogenic variants. J Med Genet 2023; 60:905-909. [PMID: 36813543 DOI: 10.1136/jmg-2022-109107] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/30/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND EPHB4 loss of function is associated with type 2 capillary malformation-arteriovenous malformation syndrome, an autosomal dominant vascular disorder. The phenotype partially overlaps with hereditary haemorrhagic telangiectasia (HHT) due to epistaxis, telangiectases and cerebral arteriovenous malformations, but a similar liver involvement has never been described. METHODS Members of the French HHT network reported their cases of EPHB4 mutation identified after an initial suspicion of HHT. Clinical, radiological and genetic characteristics were analysed. RESULTS Among 21 patients with EPHB4, 15 had a liver imaging, including 7 with HHT-like abnormalities (2 female patients and 5 male patients, ages 43-69 years). Atypical epistaxis and telangiectases were noted in two cases each. They were significantly older than the eight patients with normal imaging (median: 51 vs 20 years, p<0.0006).The main hepatic artery was dilated in all the cases (diameter: 8-11 mm). Six patients had hepatic telangiectases. All kind of shunts were described (arteriosystemic: five patients, arterioportal: two patients, portosystemic: three patients). The overall liver appearance was considered as typical of HHT in six cases.Six EPHB4 variants were classified as pathogenic and one as likely pathogenic, with no specific hot spot. CONCLUSION EPHB4 loss-of-function variants can be associated with HHT-like hepatic abnormalities and should be tested for atypical HHT presentations.
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Affiliation(s)
- Alexandre Guilhem
- Service de Génétique, Centre de Référence pour la maladie de Rendu-Osler, CHU Lyon, Lyon, France
| | - Sophie Dupuis-Girod
- Service de Génétique, Centre de Référence pour la maladie de Rendu-Osler, CHU Lyon, Lyon, France
- Laboratory Biology of Cancer and Infection, CEA de Grenoble, Grenoble, France
| | - Olivier Espitia
- Department of Internal and Vascular Medicine, CHU Nantes, Nantes, France
| | - Sophie Rivière
- Médecine Interne et Maladies Multi-Organiques, CHU Montpellier, Montpellier, France
| | - Julie Seguier
- Département de Médecine Interne, Hôpital de la Timone, Marseille, France
| | | | | | - Hélène Maillard
- Service de Médecine Interne et Immunologie Clinique, CHU Lille, Lille, France
| | - Pascal Magro
- Service de Pneumologie, Hôpital Bretonneau, Tours, France
| | - Laurent Alric
- Médecine Interne, Département des Maladies Digestives, CHU Toulouse, Toulouse, France
| | - Dan Lipsker
- Clinique Dermatologique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - Vanessa Leguy
- Service de Médecine Interne et Immunologie Clinique, CHU Dijon, Dijon, France
| | - Claire Vanlemmens
- Service Hépatologie et soins intensifs digestifs, CHU Besancon, Besancon, France
| | - Laurent Guibaud
- Service d'Imagerie Médicale Pédiatrique et Foetale, CHU Lyon, Lyon, France
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, Bruxelles, Belgium
| | - Melanie Eyries
- Genetics, Groupe Hospitalier Pitié-Salpétrière, AP-HP, Paris, France
| | | | - Sophie Giraud
- Service de Génétique, Centre de Référence pour la maladie de Rendu-Osler, CHU Lyon, Lyon, France
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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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6
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Aguilera C, Padró-Miquel A, Esteve-Garcia A, Cerdà P, Torres-Iglesias R, Llecha N, Riera-Mestre A. Improving Hereditary Hemorrhagic Telangiectasia Molecular Diagnosis: A Referral Center Experience. Genes (Basel) 2023; 14:genes14030772. [PMID: 36981042 PMCID: PMC10048779 DOI: 10.3390/genes14030772] [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: 02/28/2023] [Revised: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a rare vascular disease inherited in an autosomal dominant manner. Disease-causing variants in endoglin (ENG) and activin A receptor type II-like 1 (ACVRL1) genes are detected in more than 90% of the patients undergoing molecular testing. The identification of variants of unknown significance is often seen as a challenge in clinical practice that makes family screening and genetic counseling difficult. Here, we show that the implementation of cDNA analysis to assess the effect of splice site variants on mRNA splicing is a powerful tool. METHODS Gene panel sequencing of genes associated with HHT and other arteriovenous malformation-related syndromes was performed. To evaluate the effect of the splice site variants, cDNA analysis of ENG and ACVRL1 genes was carried out. RESULTS three novel splice site variants were identified in ENG (c.68-2A > T and c.1311+4_1311+8del) and ACVLR1 (c.526-6C > G) genes correspondingly in three individuals with HHT that met ≥ 3 Curaçao criteria. All three variants led to an aberrant splicing inducing exon skipping (ENG:c.68-2A > T and ACVRL1:c.526-6C > G) or intron retention (ENG:c.1311+4_1311+8del) allowing the confirmation of the predicted effect on splicing and the reclassification from unknown significance to pathogenic/likely pathogenic of two of them. CONCLUSIONS RNA analysis should be performed to assess and/or confirm the impact of variants on splicing. The molecular diagnosis of HHT patients is crucial to allow family screening and accurate genetic counseling. A multidisciplinary approach including clinicians and geneticists is crucial when dealing with patients with rare diseases.
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Affiliation(s)
- Cinthia Aguilera
- Hereditary Hemorrhagic Telangiectasia Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
- Genetics Laboratory, Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
| | - Ariadna Padró-Miquel
- Hereditary Hemorrhagic Telangiectasia Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
- Genetics Laboratory, Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
| | - Anna Esteve-Garcia
- Hereditary Hemorrhagic Telangiectasia Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
- Clinical Genetics Unit, Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
| | - Pau Cerdà
- Hereditary Hemorrhagic Telangiectasia Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
| | - Raquel Torres-Iglesias
- Hereditary Hemorrhagic Telangiectasia Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
| | - Núria Llecha
- Genetics Laboratory, Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
- Clinical Genetics Unit, Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
| | - Antoni Riera-Mestre
- Hereditary Hemorrhagic Telangiectasia Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), 08907 L'Hospitalet de Llobregat, Spain
- Faculty of Medicine and Health Sciences, Universitat de Barcelona, 08907 L'Hospitalet de Llobregat, Spain
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Zanetto A, Cossiga V, Shalaby S, Guarino M, Invernizzi F, Lapenna L, Becchetti C, Morisco F, Morelli MC, Merli M, Toniutto P, Burra P. Vascular liver diseases: A sex-oriented analysis of the literature. Dig Liver Dis 2023; 55:178-186. [PMID: 35906168 DOI: 10.1016/j.dld.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 02/01/2023]
Abstract
Vascular liver diseases are an heterogenous group of diseases that collectively represent an important health issue in the field of liver diseases. This narrative review was elaborated by the Special Interest Group (SIG) "Gender in Hepatology" of the Italian Association for the Study of the Liver (AISF). We aimed to review the current knowledge regarding the potential role of biological sex in patients with vascular liver diseases such as splanchnic vein thrombosis, hepatic vein thrombosis, porto-sinusoidal vascular disorder, and hereditary hemorrhagic telangiectasia. As vascular liver diseases commonly affect young individuals, including women in childbearing age, we also included a specific section on the management of pregnancy in these challenging patients.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Valentina Cossiga
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples "Federico II", Naples, Italy
| | - Sarah Shalaby
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Maria Guarino
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples "Federico II", Naples, Italy
| | - Federica Invernizzi
- Center for Liver Disease, Division of Internal Medicine and Hepatology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Lucia Lapenna
- Department of Translational and Precision Medicine, University of Rome Sapienza, Rome, Italy
| | - Chiara Becchetti
- Hepatology and Gastroenterology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Filomena Morisco
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples "Federico II", Naples, Italy
| | | | - Manuela Merli
- Center for Liver Disease, Division of Internal Medicine and Hepatology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Pierluigi Toniutto
- Hepatology and Liver Transplantation Unit, Academic Hospital, University of Udine, Udine, Italy
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy.
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Yunus H, Amin S, Haq FU, Ali W, Hamid T, Ali W, Ullah B, Bai P. Case report: Diagnosis of hereditary hemorrhagic telangiectasia (Osler Weber Rendu Syndrome) in a 23-year-old male presented with anemia and thrombocytopenia and its response to bevacizumab. Front Med (Lausanne) 2022; 9:1001695. [PMID: 36262274 PMCID: PMC9575171 DOI: 10.3389/fmed.2022.1001695] [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: 07/23/2022] [Accepted: 09/12/2022] [Indexed: 11/22/2022] Open
Abstract
Osler Weber Rendu Syndrome (OWS) is characterized by the development of abnormally dilated blood vessels, which manifest as arteriovenous shunts (pulmonary, gastrointestinal, hepatic, and cerebral) and mucocutaneous telangiectasias (lips, tongue, and fingertips). It is an autosomal dominant disease with a defect in transforming growth factor beta superfamily genes. This defect results in increased angiogenesis and disruption of vessel wall integrity. The disease remains underreported, with occasional history of recurrent epistaxis, iron deficiency anemia, and gastrointestinal bleeding in moderate to severe cases. Diagnosis is based on clinical presentation and confirmed by genetic testing. Various local (nasal saline, air humidification, laser ablation, and electric cauterization for epistaxis and endoscopic Argon Plasma Coagulation-APC for active GI bleeding), surgical, and systemic (tranexamic acid and antiangiogenic agents like bevacizumab and thalidomide) treatment options are used depending upon disease severity. Here, we present a case with recurrent gastrointestinal bleeding refractory to endoscopic APC ablation and thalidomide and severe symptomatic anemia requiring multiple packed red cell transfusions. The patient was ultimately started on bevacizumab, to which he had a good response and has remained in remission for 8 months as of now. This case emphasizes the need to have a low threshold of suspicion to diagnose HHT and start targeted therapy like bevacizumab early on in moderate to severe cases of HHT rather than just relying on temporizing palliative measures like ablation, cauterization, and tranexamic acid.
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Affiliation(s)
- Hamza Yunus
- Internal Medicine, Hayatabad Medical Complex, Peshawar, KPK, Pakistan,*Correspondence: Hamza Yunus,
| | - Said Amin
- Internal Medicine, Hayatabad Medical Complex, Peshawar, KPK, Pakistan
| | - Furqan Ul Haq
- Internal Medicine, Hayatabad Medical Complex, Peshawar, KPK, Pakistan
| | - Waqar Ali
- Internal Medicine, Mardan Medical Complex, Mardan, KPK, Pakistan
| | - Tanveer Hamid
- Internal Medicine, Sligo General Hospital, Sligo, Ireland
| | - Wajid Ali
- Internal Medicine, Hayatabad Medical Complex, Peshawar, KPK, Pakistan
| | - Basharat Ullah
- Pediatric Oncology, Shaukat Khanum Memorial Hospital and Research Centre, Peshawar, KPK, Pakistan
| | - Payal Bai
- Peoples University of Medical and Health Sciences (PUMHS), Nawabshah, Pakistan
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9
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Perioperative Complications and Long-Term Follow-Up of Liver Transplantation in Hemorrhagic Hereditary Telangiectasia: Report of Three Cases and Systematic Review. J Clin Med 2022; 11:jcm11195624. [PMID: 36233492 PMCID: PMC9573297 DOI: 10.3390/jcm11195624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/11/2022] [Accepted: 09/19/2022] [Indexed: 11/17/2022] Open
Abstract
The aim was to describe three patients with hemorrhagic hereditary telangiectasia (HHT) requiring liver transplantation (LT) and to perform a systematic review focusing on surgical complications and long-term follow-up. Unrestricted searches of the Medline and Embase databases were performed through February 2022. Forty-five studies were selected including 80 patients plus the three new reported patients, 68 (81.9%) were female and mean age was 50 (27–72) years. Main indications for LT were high-output cardiac failure (n = 40; 48.2%), ischemic cholangitis (n = 19; 22.9%), and a combination of both conditions (n = 13;15.6%). Mean cold ischemic time and red blood cell units transfused during LT were 554 (300–941) minutes and 11.4 (0–88) units, respectively. Complications within 30 days were described in 28 (33.7%) patients, mainly bleeding complications in 13 patients, hepatic artery (HA) thrombosis in four and hepatic vein thrombosis in one. Mean follow-up was 76.4 (1–288) months, and during it, four new patients developed thrombotic complications in HA, HA aneurysm, celiac artery, and the portal–splenic–mesenteric vein. HHT relapse in the transplant allograft was detected in 13 (17.1%) patients after 1–19 years (including two fatal recurrences). Overall mortality was 12%. In conclusion, previous assessment of HA anatomy and hyperdynamic circulatory state could reduce LT complications. The risk of relapse in the hepatic graft supports a multidisciplinary follow-up for HHT patients with LT.
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HHT-Related Epistaxis and Pregnancy-A Retrospective Survey and Recommendations for Management from an Otorhinolaryngology Perspective. J Clin Med 2022; 11:jcm11082178. [PMID: 35456271 PMCID: PMC9025602 DOI: 10.3390/jcm11082178] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/22/2022] [Accepted: 04/11/2022] [Indexed: 02/07/2023] Open
Abstract
Appropriate management of hereditary hemorrhagic telangiectasia (HHT) is of particular importance in females, as HHT-mediated modifications of the vascular bed and circulation are known to increase the risk of complications during pregnancy and delivery. This study was undertaken to evaluate female HHT patients’ awareness of and experience with HHT during pregnancy and delivery, with a focus on epistaxis. In this retrospective study, 46 females (median age: 60 years) with confirmed HHT completed a 17-item questionnaire assessing knowledge of HHT and its pregnancy-associated complications, the severity of epistaxis during past pregnancies and deliveries, and the desire for better education and counselling regarding HHT and pregnancy. Results revealed that 85% of participants were unaware of their disease status prior to the completion of all pregnancies. Further, 91% reported no knowledge of increased pregnancy-related risk due to HHT. In regard to epistaxis, 61% of respondents reported experiencing nosebleeds during pregnancy. Finally, approximately a third of respondents suggested that receiving counseling on the risks of HHT in pregnancy could have been helpful. Findings suggest that awareness of HHT and its potential for increasing pregnancy-related risk is poor. Best practices in HHT management should be followed to minimize negative effects of the disorder.
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11
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Medina-Jover F, Riera-Mestre A, Viñals F. Rethinking growth factors: the case of BMP9 during vessel maturation. VASCULAR BIOLOGY (BRISTOL, ENGLAND) 2022; 4:R1-R14. [PMID: 35350597 PMCID: PMC8942324 DOI: 10.1530/vb-21-0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 02/07/2022] [Indexed: 12/21/2022]
Abstract
Angiogenesis is an essential process for correct development and physiology. This mechanism is tightly regulated by many signals that activate several pathways, which are constantly interacting with each other. There is mounting evidence that BMP9/ALK1 pathway is essential for a correct vessel maturation. Alterations in this pathway lead to the development of hereditary haemorrhagic telangiectasias. However, little was known about the BMP9 signalling cascade until the last years. Recent reports have shown that while BMP9 arrests cell cycle, it promotes the activation of anabolic pathways to enhance endothelial maturation. In light of this evidence, a new criterion for the classification of cytokines is proposed here, based on the physiological objective of the activation of anabolic routes. Whether this activation by a growth factor is needed to sustain mitosis or to promote a specific function such as matrix formation is a critical characteristic that needs to be considered to classify growth factors. Hence, the state-of-the-art of BMP9/ALK1 signalling is reviewed here, as well as its implications in normal and pathogenic angiogenesis.
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Affiliation(s)
- Ferran Medina-Jover
- Program Against Cancer Therapeutic Resistance (ProCURE), Institut Català d’Oncologia, Hospital Duran i Reynals, L’Hospitalet de Llobregat, Barcelona, Spain
- Molecular Mechanisms and Experimental Therapy in Oncology Program (Oncobell), Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain
- Departament de Ciències Fisiològiques, Facultat de Medicina i Ciències de la Salut (Campus de Bellvitge), Universitat de Barcelona, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Antoni Riera-Mestre
- Hereditary Hemorrhagic Telangiectasia Unit, Internal Medicine Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
- Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain
- Faculty of Medicine and Health Sciences, Universitat de Barcelona, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Francesc Viñals
- Program Against Cancer Therapeutic Resistance (ProCURE), Institut Català d’Oncologia, Hospital Duran i Reynals, L’Hospitalet de Llobregat, Barcelona, Spain
- Molecular Mechanisms and Experimental Therapy in Oncology Program (Oncobell), Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain
- Departament de Ciències Fisiològiques, Facultat de Medicina i Ciències de la Salut (Campus de Bellvitge), Universitat de Barcelona, L’Hospitalet de Llobregat, Barcelona, Spain
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12
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Cubiró X, Garcia-Melendo C, Morales-Munera CE, Roé-Crespo E, Riera-Mestre A, Mora-Luján JM, Iriarte A, Puig L, Baselga E. Satisfactory treatment of mucocutaneous lesions in hereditary hemorrhagic telangiectasia patients with dual pulsed dye laser and neodymium: yttrium-aluminum-garnet. Dermatol Ther 2021; 34:e15124. [PMID: 34486206 DOI: 10.1111/dth.15124] [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: 02/04/2021] [Revised: 08/26/2021] [Accepted: 09/02/2021] [Indexed: 11/27/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is characterized by telangiectasia and larger arteriovenous malformations (AVM) in different organs. Mucocutaneous telangiectasia can bleed and cause stigmatization, but the best treatment approach has not been defined yet. The aim of the study was to evaluate the efficacy and safety of dual pulsed dye laser and neodymium: yttrium-aluminum-garnet (PDL-Nd:YAG) laser treatment for mucocutaneous telangiectasia in HHT patients. It is a retrospective case series, where clinical files of all HHT patients treated with PDL-Nd:YAG laser at our Department between December 2010 and July 2019 were reviewed. Demographic, clinical, and treatment characteristics were recorded. The severity and degree of improvement were evaluated by three blinded examiners scoring pretreatment and posttreatment pictures on a 5-point scale. Patient satisfaction and procedure pain were assessed using an ordinal scale (0-10). Forty-three treatment areas from 26 patients were analyzed. Lesions were predominantly located on the lower lip and cheeks. The median number of laser sessions per patient was 3 (interquartile range [IQR] 2-4). The median global severity score at baseline was 2 and became 0 at endpoint (p < 0.0001), with a median improvement rate of 4 (IQR 3-4). All patients reported a high degree of satisfaction (median 9) and tolerable pain (median 5). In conclusion, dual PDL-Nd: YAG laser is a convenient, safe, and effective treatment option for mucocutaneous telangiectasia in HHT patients.
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Affiliation(s)
- Xavier Cubiró
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cristina Garcia-Melendo
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Caridad Elena Morales-Munera
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Esther Roé-Crespo
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antoni Riera-Mestre
- Hereditary Hemorrhagic Telangiectasia Unit, Department of Internal Medicine, Hospital Universitari de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.,Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - José María Mora-Luján
- Hereditary Hemorrhagic Telangiectasia Unit, Department of Internal Medicine, Hospital Universitari de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Adriana Iriarte
- Hereditary Hemorrhagic Telangiectasia Unit, Department of Internal Medicine, Hospital Universitari de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Lluís Puig
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eulàlia Baselga
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Dermatology, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
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13
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Dunphy L, Talwar A, Patel N, Evans A. Hereditary haemorrhagic telangiectasia and pulmonary arteriovenous malformations. BMJ Case Rep 2021; 14:14/1/e238385. [PMID: 33419752 PMCID: PMC7799076 DOI: 10.1136/bcr-2020-238385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) also known as Osler-Weber-Rendu syndrome is an autosomal dominant disorder affecting 1 in 8000 individuals. The eponym recognises the 19th-century physicians William Osler, Henri Jules Louis Marie Rendu and Frederick Parkes Weber who each independently described the disease. It is characterised by epistaxis, telangiectasia and visceral arteriovenous malformations. Individuals with HHT have been found to have abnormal plasma concentrations of transforming growth factor beta and vascular endothelial growth factor secondary to mutations in ENG, ACVRL1 and MADH4. Pulmonary artery malformations (PAVMs) are abnormal communications between pulmonary arteries and veins and are found in up to 50% of individuals with HHT. The clinical features suggestive of PAVMs are stigmata of right to left shunting such as dyspnoea, hypoxaemia, cyanosis, cerebral embolism and unexplained haemoptysis or haemothorax. The authors present the case of a 33-year-old woman presenting with progressive dyspnoea during the COVID-19 pandemic. She had a typical presentation of HHT with recurrent epistaxis, telangiectasia and pulmonary arteriovenous malformations. Although rare, PAVM should be considered in individuals presenting to the emergency department with dyspnoea and hypoxaemia. Delayed diagnosis can result in fatal embolic and haemorrhagic complications.
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Affiliation(s)
- Louise Dunphy
- Department of Acute Medicine, The Royal Berkshire Hospital, Reading, UK
| | - Ambika Talwar
- Department of Acute Medicine, The Royal Berkshire Hospital, Reading, UK
| | - Neil Patel
- Department of Acute Medicine, The Royal Berkshire Hospital, Reading, UK
| | - Alex Evans
- Department of Acute Medicine, The Royal Berkshire Hospital, Reading, UK
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14
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Mei-Zahav M, Gendler Y, Bruckheimer E, Prais D, Birk E, Watad M, Goldschmidt N, Soudry E. Topical Propranolol Improves Epistaxis Control in Hereditary Hemorrhagic Telangiectasia (HHT): A Randomized Double-Blind Placebo-Controlled Trial. J Clin Med 2020; 9:jcm9103130. [PMID: 32998220 PMCID: PMC7601781 DOI: 10.3390/jcm9103130] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/18/2020] [Accepted: 09/26/2020] [Indexed: 02/07/2023] Open
Abstract
Epistaxis is a common debilitating manifestation in hereditary hemorrhagic telangiectasia (HHT), due to mucocutaneous telangiectases. The epistaxis can be difficult to control despite available treatments. Dysregulated angiogenesis has been shown to be associated with telangiectases formation. Topical propranolol has demonstrated antiangiogenic properties. We performed a two-phase study, i.e., a double-blind placebo-controlled phase, followed by an open-label phase. The aim of the study was assessment of safety and efficacy of nasal propranolol gel in HHT-related epistaxis. Twenty participants with moderate-severe HHT-related epistaxis were randomized to eight weeks of propranolol gel 1.5%, or placebo 0.5 cc, applied to each nostril twice daily; and continued propranolol for eight weeks in an open-label study. For the propranolol group, the epistaxis severity score (ESS) improved significantly (-2.03 ± 1.7 as compared with -0.35 ± 0.68 for the placebo group, p = 0.009); hemoglobin levels improved significantly (10.5 ± 2.6 to 11.4 ± 2.02 g/dL, p = 0.009); and intravenous iron and blood transfusion requirement decreased. The change in nasal endoscopy findings was not significant. During the open-label period, the ESS score improved significantly in the former placebo group (-1.99 ± 1.41, p = 0.005). The most common adverse event was nasal mucosa burning sensation. No cardiovascular events were reported. Our results suggest that topical propranolol gel is safe and effective in HHT-related epistaxis.
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Affiliation(s)
- Meir Mei-Zahav
- Pulmonary Institute, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel; (Y.G.); (D.P.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
- The National HHT Center, Pulmonary Institute, Schneider CMCI, 14 Kaplan St., Petach Tikva 49202, Israel
- Correspondence:
| | - Yulia Gendler
- Pulmonary Institute, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel; (Y.G.); (D.P.)
- The Department of Nursing, Ariel University, Ariel 40700, Israel
| | - Elchanan Bruckheimer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
- Cardiology Department, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
| | - Dario Prais
- Pulmonary Institute, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel; (Y.G.); (D.P.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
- The National HHT Center, Pulmonary Institute, Schneider CMCI, 14 Kaplan St., Petach Tikva 49202, Israel
| | - Einat Birk
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
- Cardiology Department, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
| | - Muhamad Watad
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
| | - Neta Goldschmidt
- Department of Hematology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel;
| | - Ethan Soudry
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (E.B.); (E.B.); (M.W.); (E.S.)
- Department of Otolaryngology Head and Neck Surgery, Rabin Medical Center, Petah Tikva 49202, Israel
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15
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Giraud S, Bardel C, Dupuis-Girod S, Carette MF, Gilbert-Dussardier B, Riviere S, Saurin JC, Eyries M, Patri S, Decullier E, Calender A, Lesca G. Sequence variations of ACVRL1 play a critical role in hepatic vascular malformations in hereditary hemorrhagic telangiectasia. Orphanet J Rare Dis 2020; 15:254. [PMID: 32962750 PMCID: PMC7507685 DOI: 10.1186/s13023-020-01533-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/07/2020] [Indexed: 11/23/2022] Open
Abstract
Background Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal dominant disorder characterized by multiple telangiectases and caused by germline disease-causing variants in the ENG (HHT1), ACVRL1 (HHT2) and, to a lesser extent MADH4 and GDF2, which encode proteins involved in the TGF-β/BMP9 signaling pathway. Common visceral complications of HHT are caused by pulmonary, cerebral, or hepatic arteriovenous malformations (HAVMs). There is large intrafamilial variability in the severity of visceral involvement, suggesting a role for modifier genes. The objective of the present study was to investigate the potential role of ENG, ACVRL1, and of other candidate genes belonging to the same biological pathway in the development of HAVMs. Methods We selected 354 patients from the French HHT patient database who had one disease causing variant in either ENG or ACVRL1 and who underwent hepatic exploration. We first compared the distribution of the different types of variants with the occurrence of HAVMs. Then, we genotyped 51 Tag-SNPs from the Hap Map database located in 8 genes that encode proteins belonging to the TGF-β/BMP9 pathway (ACVRL1, ENG, GDF2, MADH4, SMAD1, SMAD5, TGFB1, TGFBR1), as well as in two additional candidate genes (PTPN14 and ADAM17). We addressed the question of a possible genetic association with the occurrence of HAVMs. Results The proportion of patients with germline ACVRL1 variants and the proportion of women were significantly higher in HHT patients with HAVMs. In the HHT2 group, HAVMs were more frequent in patients with truncating variants. Six SNPs (3 in ACVRL1, 1 in ENG, 1 in SMAD5, and 1 in ADAM17) were significantly associated with HAVMs. After correction for multiple testing, only one remained significantly associated (rs2277383). Conclusions In this large association study, we confirmed the strong relationship between ACVRL1 and the development of HAVMs. Common polymorphisms of ACVRL1 may also play a role in the development of HAVMs, as a modifying factor, independently of the disease-causing variants.
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Affiliation(s)
- Sophie Giraud
- Hospices Civils de Lyon, Service de Génétique, Groupement Hospitalier Est, 69677, Bron, France
| | - Claire Bardel
- Service de Biostatistique-Bioinformatique, plateforme de séquençage à haut débit, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Université de Lyon, Villeurbanne, France.,CNRS UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biotatistique-Santé, F-69100, Villeurbanne, France
| | - Sophie Dupuis-Girod
- Hospices Civils de Lyon, Service de Génétique, Groupement Hospitalier Est, 69677, Bron, France.,Centre de Référence National pour la maladie de Rendu-Osler, Groupement Hospitalier Est, Bron, France
| | | | | | - Sophie Riviere
- CHU de Montpellier, Service de Médecine Interne, Hôpital St Eloi, Montpellier, France
| | - Jean-Christophe Saurin
- Université Claude Bernard Lyon 1, Université de Lyon, Villeurbanne, France.,Hospices Civils de Lyon, Service de Gastro-Entérologie, Hôpital E. Herriot, Lyon, France
| | - Mélanie Eyries
- Assistance Publique-Hôpitaux de Paris, Département de Génétique, GH Pitié-Salpêtrière, Paris, France
| | - Sylvie Patri
- CHU la Milétrie, Laboratoire de Génétique, Poitiers, France
| | - Evelyne Decullier
- Unité de recherche clinique du pole IMER of the Hospices Civils de Lyon, Lyon, France
| | - Alain Calender
- Hospices Civils de Lyon, Service de Génétique, Groupement Hospitalier Est, 69677, Bron, France.,Université Claude Bernard Lyon 1, Université de Lyon, Villeurbanne, France.,Equipe EA7426, Immunopathologie des voies respiratoires, Université Lyon 1, Lyon, France
| | - Gaëtan Lesca
- Hospices Civils de Lyon, Service de Génétique, Groupement Hospitalier Est, 69677, Bron, France. .,Université Claude Bernard Lyon 1, Université de Lyon, Villeurbanne, France.
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16
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Beckman JD, Li Q, Hester ST, Leitner O, Smith KL, Kasthuri RS. Integration of clinical parameters, genotype and epistaxis severity score to guide treatment for hereditary hemorrhagic telangiectasia associated bleeding. Orphanet J Rare Dis 2020; 15:185. [PMID: 32660636 PMCID: PMC7359017 DOI: 10.1186/s13023-020-01453-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/29/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Hereditary Hemorrhagic Telangiectasia (HHT) is a rare inherited disorder characterized by development of mucocutaneous telangiectases and visceral organ arteriovenous malformations, which can lead to recurrent, spontaneous bleeding and development of iron deficiency anemia. The primary objective of this study was to ascertain the relationship between epistaxis severity scores (ESS), laboratory values, genotype, and phenotype in HHT. Our secondary objective was to assess efficacy of systemic antifibrinolytic therapy in reducing ESS in HHT. METHODOLOGY We conducted a retrospective review of patients seen at the UNC HHT Center from January 1, 2009 to February 28, 2015. ESS, demographics, and results of genetic testing were abstracted from the medical record. Response to antifibrinolytic therapy was evaluated by comparing pre-post ESS. RESULTS One hundred and forty nine patients were eligible with 116 having genetic testing and 33 without. Age, hemoglobin and ferritin levels were predictive of ESS. Of the 116 patients that underwent genetic testing: 63 had an ACVRL1 mutation, 40 had an ENG mutation, 2 had a SMAD4 mutation, and 11 patients had no pathologic HHT genetic variation detected. Compared to patients without a detectable HHT-associated genetic variation, patients with a HHT-associated genetic variation had higher ESS scores (p < 0.05). Neither ESS nor genotype was predictive of pulmonary or brain AVMs. Twenty-four HHT patients with ESS > 4 were started on antifibrinolytic therapy (tranexamic acid or aminocaproic acid) and had a post-treatment ESS recorded. All patients had a decrease in ESS of > 0.71 (minimal meaningful difference), but patients taking antifibrinolytics displayed larger decreases. No patients on antifibrinolytics experienced a VTE with median follow up of 13 months. CONCLUSIONS We demonstrate that the ESS correlates with age, hemoglobin and ferritin. Additionally, we demonstrate that HHT patients with genetic mutations have higher ESS scores. Our data demonstrate that antifibrinolytics are effective in decreasing epistaxis severity and safe with long-term use in HHT patients.
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Affiliation(s)
- Joan D Beckman
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Quefeng Li
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Samuel T Hester
- Department of Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ofri Leitner
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Karen L Smith
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, CB#7035, 8206B Mary Ellen Jones Bldg, 116 Manning Drive, Chapel Hill, NC, 27599, USA
| | - Raj S Kasthuri
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, CB#7035, 8206B Mary Ellen Jones Bldg, 116 Manning Drive, Chapel Hill, NC, 27599, USA.
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