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Pfau K, Lengyel I, Ossewaarde-van Norel J, van Leeuwen R, Risseeuw S, Leftheriotis G, Scholl HPN, Feltgen N, Holz FG, Pfau M. Pseudoxanthoma elasticum - Genetics, pathophysiology, and clinical presentation. Prog Retin Eye Res 2024; 102:101274. [PMID: 38815804 DOI: 10.1016/j.preteyeres.2024.101274] [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: 02/04/2024] [Revised: 05/17/2024] [Accepted: 05/20/2024] [Indexed: 06/01/2024]
Abstract
Pseudoxanthoma elasticum (PXE) is an autosomal-recessively inherited multisystem disease. Mutations in the ABCC6-gene are causative, coding for a transmembrane transporter mainly expressed in hepatocytes, which promotes the efflux of adenosine triphosphate (ATP). This results in low levels of plasma inorganic pyrophosphate (PPi), a critical anti-mineralization factor. The clinical phenotype of PXE is characterized by the effects of elastic fiber calcification in the skin, the cardiovascular system, and the eyes. In the eyes, calcification of Bruch's membrane results in clinically visible lesions, including peau d'orange, angioid streaks, and comet tail lesions. Frequently, patients must be treated for secondary macular neovascularization. No effective therapy is available for treating the cause of PXE, but several promising approaches are emerging. Finding appropriate outcome measures remains a significant challenge for clinical trials in this slowly progressive disease. This review article provides an in-depth summary of the current understanding of PXE and its multi-systemic manifestations. The article offers a detailed overview of the ocular manifestations, including their morphological and functional consequences, as well as potential complications. Lastly, previous and future clinical trials of causative treatments for PXE are discussed.
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Affiliation(s)
- Kristina Pfau
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland; Department of Ophthalmology, University Hospital Bonn, Bonn, Germany.
| | - Imre Lengyel
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom; Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | | | - Redmer van Leeuwen
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Sara Risseeuw
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Georges Leftheriotis
- University Hospital Nice, Vascular Physiology and Medicine Unit, 06000, Nice, France
| | | | - Nicolas Feltgen
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland
| | - Frank G Holz
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
| | - Maximilian Pfau
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland; Institute of Molecular and Clinical Ophthalmology Basel, Basel, Basel-Stadt, Switzerland
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Bartstra JW, van den Beukel T, Kranenburg G, Geurts LJ, den Harder AM, Witkamp T, Wolterink JM, Zwanenburg JJM, van Valen E, Koek HL, Mali WPTM, de Jong PA, Hendrikse J, Spiering W. Increased Intracranial Arterial Pulsatility and Microvascular Brain Damage in Pseudoxanthoma Elasticum. AJNR Am J Neuroradiol 2024; 45:386-392. [PMID: 38548304 DOI: 10.3174/ajnr.a8212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 12/02/2023] [Indexed: 04/10/2024]
Abstract
BACKGROUND AND PURPOSE Carotid siphon calcification might contribute to the high prevalence of cerebrovascular disease in pseudoxanthoma elasticum through increased arterial flow pulsatility. This study aimed to compare intracranial artery flow pulsatility, brain volumes, and small-vessel disease markers between patients with pseudoxanthoma elasticum and controls and the association between arterial calcification and pulsatility in pseudoxanthoma elasticum. MATERIALS AND METHODS Fifty patients with pseudoxanthoma elasticum and 40 age- and sex-matched controls underwent 3T MR imaging, including 2D phase-contrast acquisitions for flow pulsatility in the assessment of ICA and MCA and FLAIR acquisitions for brain volumes, white matter lesions, and infarctions. All patients with pseudoxanthoma elasticum underwent CT scanning to measure siphon calcification. Flow pulsatility (2D phase-contrast), brain volumes, white matter lesions, and infarctions (3D T1 and 3D T2 FLAIR) were compared between patients and controls. The association between siphon calcification and pulsatility in pseudoxanthoma elasticum was tested with linear regression models. RESULTS Patients with pseudoxanthoma elasticum (mean age, 57 [SD, 12] years; 24 men) had significantly higher pulsatility indexes (1.05; range, 0.94-1.21 versus 0.94; range, 0.82-1.04; P = .02), lower mean GM volumes (597 [SD, 53] mL versus 632 [SD, 53] mL; P < .01), more white matter lesions (2.6; range, 0.5-7.5 versus 1.1; range, 0.5-2.4) mL; P = .05), and more lacunar infarctions (64 versus 8, P = .04) than controls (mean age, 58 [SD, 11] years; 20 men). Carotid siphon calcification was associated with higher pulsatility indexes in patients with pseudoxanthoma elasticum (β = 0.10; 95% CI, 0.01-0.18). CONCLUSIONS Patients with pseudoxanthoma elasticum have increased intracranial artery flow pulsatility and measures of small-vessel disease. Carotid siphon calcification might underlie the high prevalence of cerebrovascular disease in pseudoxanthoma elasticum.
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Affiliation(s)
- J W Bartstra
- From the Department of Radiology (J.W.B., T.v.d.B., L.J.G., A.M.d.H., T.W., J.J.M.Z., W.P.T.M.M., P.A.d.J., J.H.), University Medical Center Utrecht, Utrecht /University, the Netherlands
| | - T van den Beukel
- From the Department of Radiology (J.W.B., T.v.d.B., L.J.G., A.M.d.H., T.W., J.J.M.Z., W.P.T.M.M., P.A.d.J., J.H.), University Medical Center Utrecht, Utrecht /University, the Netherlands
| | - G Kranenburg
- Department of Vascular Medicine (G.K., W.S.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - L J Geurts
- From the Department of Radiology (J.W.B., T.v.d.B., L.J.G., A.M.d.H., T.W., J.J.M.Z., W.P.T.M.M., P.A.d.J., J.H.), University Medical Center Utrecht, Utrecht /University, the Netherlands
| | - A M den Harder
- From the Department of Radiology (J.W.B., T.v.d.B., L.J.G., A.M.d.H., T.W., J.J.M.Z., W.P.T.M.M., P.A.d.J., J.H.), University Medical Center Utrecht, Utrecht /University, the Netherlands
| | - T Witkamp
- From the Department of Radiology (J.W.B., T.v.d.B., L.J.G., A.M.d.H., T.W., J.J.M.Z., W.P.T.M.M., P.A.d.J., J.H.), University Medical Center Utrecht, Utrecht /University, the Netherlands
| | - J M Wolterink
- Department of Applied Mathematics (J.M.W., E.v.V., H.L.K.), Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - J J M Zwanenburg
- From the Department of Radiology (J.W.B., T.v.d.B., L.J.G., A.M.d.H., T.W., J.J.M.Z., W.P.T.M.M., P.A.d.J., J.H.), University Medical Center Utrecht, Utrecht /University, the Netherlands
| | - E van Valen
- Department of Applied Mathematics (J.M.W., E.v.V., H.L.K.), Technical Medical Centre, University of Twente, Enschede, the Netherlands
- Department of Geriatrics (E.v.V., H.L.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - H L Koek
- Department of Applied Mathematics (J.M.W., E.v.V., H.L.K.), Technical Medical Centre, University of Twente, Enschede, the Netherlands
- Department of Geriatrics (E.v.V., H.L.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - W P T M Mali
- From the Department of Radiology (J.W.B., T.v.d.B., L.J.G., A.M.d.H., T.W., J.J.M.Z., W.P.T.M.M., P.A.d.J., J.H.), University Medical Center Utrecht, Utrecht /University, the Netherlands
| | - P A de Jong
- From the Department of Radiology (J.W.B., T.v.d.B., L.J.G., A.M.d.H., T.W., J.J.M.Z., W.P.T.M.M., P.A.d.J., J.H.), University Medical Center Utrecht, Utrecht /University, the Netherlands
| | - J Hendrikse
- From the Department of Radiology (J.W.B., T.v.d.B., L.J.G., A.M.d.H., T.W., J.J.M.Z., W.P.T.M.M., P.A.d.J., J.H.), University Medical Center Utrecht, Utrecht /University, the Netherlands
| | - W Spiering
- Department of Vascular Medicine (G.K., W.S.), University Medical Center Utrecht, Utrecht University, the Netherlands
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Harmsen IM, Visseren FL, Kok M, de Jong PA, Spiering W. Plasma lipids in Pseudoxanthoma Elasticum (PXE) patients: A comparative study with population-based reference values and Non-PXE controls. ATHEROSCLEROSIS PLUS 2024; 55:5-11. [PMID: 38221909 PMCID: PMC10784135 DOI: 10.1016/j.athplu.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/10/2023] [Accepted: 12/04/2023] [Indexed: 01/16/2024]
Abstract
Background and aims - Pseudoxanthoma elasticum (PXE) is a rare genetic disease caused by pathogenic mutations in the ABCC6 gene, resulting in low values of inorganic pyrophosphate (PPi). While low PPi is thought to contribute to arterial calcification, it remains unclear whether this fully explains premature calcification in PXE. It has been hypothesized that the ABCC6 gene could be related to dyslipidemia, which could contribute to vascular calcification seen in PXE. The aim of this study is to evaluate the relation between PXE and plasma lipid concentrations in a large cohort of PXE patients compared with reference values for the general population and compared with non-PXE controls. Methods - The plasma concentrations of total cholesterol, HDL-cholesterol, tiglycerides, and LDL-cholesterol of 312 PXE patients were compared to age- and sex-matched modeled data of the general Dutch population. Differences in median lipid levels were compared with Mann-Whitney-U test. Secondly, plasma lipid concentrations of 44 PXE patients were compared to 44 not-genetically related relatives (spouses or friends), with linear models adjusted for age, sex and BMI. Results - Total cholesterol in PXE patients was 5.6 [IQR 4.6-6.4] mmol/L versus 5.3 [IQR 4.7-6.0] mmol/L (p < 0.01) in the general population; triglycerides were 1.1 [IQR 0.9-1.7] mmol/L versus 1.0 [0.7-1.4] mmol/L (p < 0.01); HDL-c was 1.4 [IQR 1.2-1.7] mmol/L versus 1.5 [IQR 1.2-1.8] mmol/L (p = 0.03) and LDL-c was 3.3 [IQR 2.7-4.1] mmol/L versus 3.2 [IQR 2.7-3.8] mmol/L (p = 0.01). In the patient control analysis with 44 pairs and age, sex and BMI adjusted, comparison with the non-PXE controls only triglycerides were significantly different (mean difference: 0.38 (0.13-0.63)). Conclusion -The lipid profiles of PXE patients are marginally different from the general population or compared to a matched control group, but the differences are unlikely to be clinically relevant. It is therefore unlikely that plasma lipids contribute to the premature vascular calcifications in PXE patients.
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Affiliation(s)
- Iris M. Harmsen
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Frank L.J. Visseren
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Madeleine Kok
- Department of Radiology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Pim A. de Jong
- Department of Radiology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
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Kauffenstein G, Martin L, Le Saux O. The Purinergic Nature of Pseudoxanthoma Elasticum. BIOLOGY 2024; 13:74. [PMID: 38392293 PMCID: PMC10886499 DOI: 10.3390/biology13020074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/13/2024] [Accepted: 01/19/2024] [Indexed: 02/24/2024]
Abstract
Pseudoxanthoma Elasticum (PXE) is an inherited disease characterized by elastic fiber calcification in the eyes, the skin and the cardiovascular system. PXE results from mutations in ABCC6 that encodes an ABC transporter primarily expressed in the liver and kidneys. It took nearly 15 years after identifying the gene to better understand the etiology of PXE. ABCC6 function facilitates the efflux of ATP, which is sequentially hydrolyzed by the ectonucleotidases ENPP1 and CD73 into pyrophosphate (PPi) and adenosine, both inhibitors of calcification. PXE, together with General Arterial Calcification of Infancy (GACI caused by ENPP1 mutations) as well as Calcification of Joints and Arteries (CALJA caused by NT5E/CD73 mutations), forms a disease continuum with overlapping phenotypes and shares steps of the same molecular pathway. The explanation of these phenotypes place ABCC6 as an upstream regulator of a purinergic pathway (ABCC6 → ENPP1 → CD73 → TNAP) that notably inhibits mineralization by maintaining a physiological Pi/PPi ratio in connective tissues. Based on a review of the literature and our recent experimental data, we suggest that PXE (and GACI/CALJA) be considered as an authentic "purinergic disease". In this article, we recapitulate the pathobiology of PXE and review molecular and physiological data showing that, beyond PPi deficiency and ectopic calcification, PXE is associated with wide and complex alterations of purinergic systems. Finally, we speculate on the future prospects regarding purinergic signaling and other aspects of this disease.
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Affiliation(s)
- Gilles Kauffenstein
- UMR INSERM 1260, Regenerative Nanomedicine, University of Strasbourg, 67084 Strasbourg, France
| | - Ludovic Martin
- PXE Consultation Center, MAGEC Nord Reference Center for Rare Skin Diseases, Angers University Hospital, 49000 Angers, France
- MITOVASC-UMR CNRS 6015 INSERM 1083, University of Angers, 49000 Angers, France
| | - Olivier Le Saux
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI 96822, USA
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Kozák E, Bartstra JW, de Jong PA, Mali WPTM, Fülöp K, Tőkési N, Pomozi V, Risseeuw S, Norel JOV, van Leeuwen R, Váradi A, Spiering W. Plasma Level of Pyrophosphate Is Low in Pseudoxanthoma Elasticum Owing to Mutations in the ABCC6 Gene, but It Does Not Correlate with ABCC6 Genotype. J Clin Med 2023; 12:jcm12031047. [PMID: 36769695 PMCID: PMC9917606 DOI: 10.3390/jcm12031047] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/04/2023] [Accepted: 01/22/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Pseudoxanthoma elasticum (PXE), a monogenic disorder resulting in calcification affecting the skin, eyes and peripheral arteries, is caused by mutations in the ABCC6 gene, and is associated with low plasma inorganic pyrophosphate (PPi). It is unknown how ABCC6 genotype affects plasma PPi. METHODS We studied the association of ABCC6 genotype (192 patients with biallelic pathogenic ABCC6 mutations) and PPi levels, and its association with the severity of arterial and ophthalmological phenotypes. ABCC6 variants were classified as truncating or non-truncating, and three groups of the 192 patients were formed: those with truncating mutations on both chromosomes (n = 121), those with two non-truncating mutations (n = 10), and a group who had one truncating and one non-truncating ABCC6 mutation (n = 61). The hypothesis formulated before this study was that there was a negative association between PPi level and disease severity. RESULTS Our findings confirm low PPi in PXE compared with healthy controls (0.53 ± 0.15 vs. 1.13 ± 0.29 µM, p < 0.01). The PPi of patients correlated with increasing age (β: 0.05 µM, 95% CI: 0.03-0.06 per 10 years) and was higher in females (0.55 ± 0.17 vs. 0.51 ± 0.13 µM in males, p = 0.03). However, no association between PPi and PXE phenotypes was found. When adjusted for age and sex, no association between PPi and ABCC6 genotype was found. CONCLUSIONS Our data suggest that the relationship between ABCC6 mutations and reduced plasma PPi may not be as direct as previously thought. PPi levels varied widely, even in patients with the same ABCC6 mutations, further suggesting a lack of direct correlation between them, even though the ABCC6 protein-mediated pathway is responsible for ~60% of this metabolite in the circulation. We discuss potential factors that may perturb the expected associations between ABCC6 genotype and PPi and between PPi and disease severity. Our findings support the argument that predictions of pathogenicity made on the basis of mutations (or on the structure of the mutated protein) could be misleading.
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Affiliation(s)
- Eszter Kozák
- Institute of Enzymology, Research Center for Natural Sciences, Hungarian Academy of Sciences Center of Excellence, 1117 Budapest, Hungary
| | - Jonas W. Bartstra
- Department of Radiology, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Pim A. de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Willem P. T. M. Mali
- Department of Radiology, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Krisztina Fülöp
- Institute of Enzymology, Research Center for Natural Sciences, Hungarian Academy of Sciences Center of Excellence, 1117 Budapest, Hungary
| | - Natália Tőkési
- Institute of Enzymology, Research Center for Natural Sciences, Hungarian Academy of Sciences Center of Excellence, 1117 Budapest, Hungary
| | - Viola Pomozi
- Institute of Enzymology, Research Center for Natural Sciences, Hungarian Academy of Sciences Center of Excellence, 1117 Budapest, Hungary
| | - Sara Risseeuw
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | | | - Redmer van Leeuwen
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - András Váradi
- Institute of Enzymology, Research Center for Natural Sciences, Hungarian Academy of Sciences Center of Excellence, 1117 Budapest, Hungary
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
- Correspondence: ; Tel.: +31-88-7571188
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6
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Verwer MC, Hazenberg CEVB, Spiering W, de Borst GJ. Peripheral Interventions in Patients with Pseudoxanthoma Elasticum (PXE). Eur J Vasc Endovasc Surg 2023; 65:142-148. [PMID: 35977696 DOI: 10.1016/j.ejvs.2022.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 07/30/2022] [Accepted: 08/06/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Pseudoxanthoma elasticum (PXE) is an autosomal recessive metabolic disorder that may be associated with a high prevalence of peripheral artery disease (PAD) and related symptoms. However, the evidence supporting this association is weak, as only small cohort studies are available. Furthermore, limited data are available on the outcome of lower limb peripheral arterial interventions (PAI) in patients with PXE. It was the aim of this study to clarify the prevalence of PAD, and the occurrence and outcome of PAI in patients with PXE. METHODS This was a retrospective review of prospectively collected data from the Dutch Expertise Centre for PXE database. Clinical data of consecutive patients with a definitive diagnosis of PXE were examined. The primary endpoint was the prevalence of PAD (defined as an ankle brachial index of < 0.9). The secondary endpoint was to report an overview of PAI and target lesion revascularisations. RESULTS In 285 PXE patients (median age 58 years), 50.9% of patients (n = 145) met the criteria for PAD. Seventeen patients underwent a PAI, mostly for intermittent claudication, at a median age of 51 years. The incidence of PAI was 2.25 per 1 000 patient years in patients with PAD and PXE. A total of 58 interventions was recorded, of which 35 were target lesion revascularisations in nine patients. Twenty one revascularisations were performed within a year following the primary intervention, in 16 cases due to an acute occlusion. CONCLUSION Within a well phenotyped and large PXE cohort, the diagnosis of PAD was prevalent in one in two patients. The observed rate of peripheral interventions was low, while the re-intervention rate was unfavourable after endovascular or bypass surgical procedures, with over half of these re-interventions indicated within a year.
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Affiliation(s)
- Maarten C Verwer
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Constantijn E V B Hazenberg
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, Division of Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands.
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Pelttari S, Väärämäki S, Vanakker O, Verschuere S, Uusitalo H, Huhtala H, Hinkka T, Pörsti I, Nevalainen PI. Various vascular malformations are prevalent in Finnish pseudoxanthoma elasticum (PXE) patients: a national registry study. Orphanet J Rare Dis 2022; 17:185. [PMID: 35525997 PMCID: PMC9077871 DOI: 10.1186/s13023-022-02341-6] [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: 12/06/2021] [Accepted: 04/26/2022] [Indexed: 11/26/2022] Open
Abstract
Background Pseudoxanthoma elasticum (PXE, OMIM# 264800) is an inborn error of metabolism causing ectopic soft tissue calcification due to low plasma pyrophosphate concentration. We aimed to assess the prevalence of PXE in Finland and to characterize the Finnish PXE population. A nationwide registry search was performed to identify patients with ICD-10 code Q82.84. Information was gathered from available medical records which were requisitioned from hospitals and health centers. Misdiagnosed patients and patients with insufficient records were excluded. Results The prevalence of PXE in Finland was 1:260,000 with equal sex distribution. Patients with high conventional cardiovascular risk had more visual and vascular complications than patients with low risk. Four patients (19%) had at least one vascular malformation. A high proportion (33%) of ABCC6 genotypes were of the common homozygous c.3421C > T, p.Arg1141Ter variant. Nine other homozygous or compound heterozygous allelic variants were found. Conclusions The prevalence of diagnosed PXE appears to be lower in Finland than in estimates from other countries. Decreased visual acuity is the most prevalent complication. We suggest that various vascular malformations may be an unrecognized feature of PXE.
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Affiliation(s)
- Saku Pelttari
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
| | - Suvi Väärämäki
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Olivier Vanakker
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Shana Verschuere
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Hannu Uusitalo
- SILK, Department of Ophthalmology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Tays Eye Centre, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Tero Hinkka
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
| | - Ilkka Pörsti
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland.,Department of Internal Medicine, Tampere University Hospital, Teiskontie 35, 33521, Tampere, Finland
| | - Pasi I Nevalainen
- Department of Internal Medicine, Tampere University Hospital, Teiskontie 35, 33521, Tampere, Finland.
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Leftheriotis G, Navasiolava N, Clotaire L, Duranton C, Le Saux O, Bendahhou S, Laurain A, Rubera I, Martin L. Relationships between Plasma Pyrophosphate, Vascular Calcification and Clinical Severity in Patients Affected by Pseudoxanthoma Elasticum. J Clin Med 2022; 11:jcm11092588. [PMID: 35566717 PMCID: PMC9100273 DOI: 10.3390/jcm11092588] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/28/2022] [Accepted: 04/30/2022] [Indexed: 12/10/2022] Open
Abstract
Pseudoxanthoma elasticum (PXE; OMIM 264800) is an autosomal recessive metabolic disorder characterized by progressive calcification in the skin, the Bruch’s membrane, and the vasculature. Calcification in PXE results from a low level of circulating pyrophosphate (PPi) caused by ABCC6 deficiency. In this study, we used a cohort of 107 PXE patients to determine the pathophysiological relationship between plasma PPi, coronary calcification (CAC), lower limbs arterial calcification (LLAC), and disease severity. Overall, our data showed a deficit in plasma PPi in PXE patients compared to controls. Remarkably, affected females showed higher PPi levels than males, but a lower LLAC. There was a strong correlation between age and PPi in PXE patients (r = 0.423, p < 0.0001) but not in controls (r = 0.059, p = 0.828). A weak correlation was found between PPi and CAC (r = 0.266, p < 0.02); however, there was no statistically significant connection with LLAC (r = 0.068, p = 0.518) or a severity score (r = 0.077, p = 0.429). Surprisingly, we found no significant correlation between plasma alkaline phosphatase activity and PPi (r = 0.113, p = 0.252) or between a 10-year cardiovascular risk score and all other variables. Multivariate analysis confirmed that LLAC and CAC were strongly dependent on age, but not on PPi. Our data showed that arterial calcification is only weakly linked to circulating PPi levels and that time (i.e., age) appears to be the major determinant of disease severity and calcification in PXE. These data are important to better understand the natural history of this disease but also for the follow-up and management of patients, and the design of future clinical trials. Our results also show that PPi is not a good biomarker for the evaluation of disease severity and progression.
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Affiliation(s)
- Georges Leftheriotis
- University Hospital Nice, Vascular Physiology and Medicine Unit, 06000 Nice, France
- Université Côte d’Azur, LP2M, UMR CNRS 7370, LabEx ICST, 06107 Nice, France; (L.C.); (C.D.); (S.B.); (A.L.); (I.R.)
- Correspondence: or
| | - Nastassia Navasiolava
- PXE Reference Center, MAGEC Nord, University Hospital of Angers, 49000 Angers, France; (N.N.); (L.M.)
| | - Laetitia Clotaire
- Université Côte d’Azur, LP2M, UMR CNRS 7370, LabEx ICST, 06107 Nice, France; (L.C.); (C.D.); (S.B.); (A.L.); (I.R.)
| | - Christophe Duranton
- Université Côte d’Azur, LP2M, UMR CNRS 7370, LabEx ICST, 06107 Nice, France; (L.C.); (C.D.); (S.B.); (A.L.); (I.R.)
| | - Olivier Le Saux
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI 96817, USA;
| | - Saïd Bendahhou
- Université Côte d’Azur, LP2M, UMR CNRS 7370, LabEx ICST, 06107 Nice, France; (L.C.); (C.D.); (S.B.); (A.L.); (I.R.)
| | - Audrey Laurain
- Université Côte d’Azur, LP2M, UMR CNRS 7370, LabEx ICST, 06107 Nice, France; (L.C.); (C.D.); (S.B.); (A.L.); (I.R.)
| | - Isabelle Rubera
- Université Côte d’Azur, LP2M, UMR CNRS 7370, LabEx ICST, 06107 Nice, France; (L.C.); (C.D.); (S.B.); (A.L.); (I.R.)
| | - Ludovic Martin
- PXE Reference Center, MAGEC Nord, University Hospital of Angers, 49000 Angers, France; (N.N.); (L.M.)
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9
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Therapy of Pseudoxanthoma Elasticum: Current Knowledge and Future Perspectives. Biomedicines 2021; 9:biomedicines9121895. [PMID: 34944710 PMCID: PMC8698611 DOI: 10.3390/biomedicines9121895] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/05/2021] [Accepted: 12/07/2021] [Indexed: 12/24/2022] Open
Abstract
Pseudoxanthoma elasticum (PXE) is a rare, genetic, metabolic disease with an estimated prevalence of between 1 per 25,000 and 56,000. Its main hallmarks are characteristic skin lesions, development of choroidal neovascularization, and early-onset arterial calcification accompanied by a severe reduction in quality-of-life. Underlying the pathology are recessively transmitted pathogenic variants of the ABCC6 gene, which results in a deficiency of ABCC6 protein. This results in reduced levels of peripheral pyrophosphate, a strong inhibitor of peripheral calcification, but also dysregulation of blood lipids. Although various treatment options have emerged during the last 20 years, many are either already outdated or not yet ready to be applied generally. Clinical physicians often are left stranded while patients suffer from the consequences of outdated therapies, or feel unrecognized by their attending doctors who may feel uncertain about using new therapeutic approaches or not even know about them. In this review, we summarize the broad spectrum of treatment options for PXE, focusing on currently available clinical options, the latest research and development, and future perspectives.
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10
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Bartstra JW, Risseeuw S, de Jong PA, van Os B, Kalsbeek L, Mol C, Baas AF, Verschuere S, Vanakker O, Florijn RJ, Hendrikse J, Mali W, Imhof S, Ossewaarde-van Norel J, van Leeuwen R, Spiering W. Genotype-phenotype correlation in pseudoxanthoma elasticum. Atherosclerosis 2021; 324:18-26. [PMID: 33812167 DOI: 10.1016/j.atherosclerosis.2021.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/26/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Pseudoxanthoma elasticum (PXE) is caused by variants in the ABCC6 gene. It results in calcification in the skin, peripheral arteries and the eyes, but has considerable phenotypic variability. We investigated the association between the ABCC6 genotype and calcification and clinical phenotypes in these different organs. METHODS ABCC6 sequencing was performed in 289 PXE patients. Genotypes were grouped as two truncating, mixed, or two non-truncating variants. Arterial calcification mass was quantified on whole body, low dose CT scans; and peripheral arterial disease was measured with the ankle brachial index after treadmill test. The presence of pseudoxanthoma in the skin was systematically scored. Ophthalmological phenotypes were the length of angioid streaks as a measure of Bruchs membrane calcification, the presence of choroidal neovascularizations, severity of macular atrophy and visual acuity. Regression models were built to test the age and sex adjusted genotype-phenotype association. RESULTS 158 patients (median age 51 years) had two truncating variants, 96 (median age 54 years) a mixed genotype, 18 (median age 47 years) had two non-truncating variants. The mixed genotype was associated with lower peripheral (β: 0.39, 95%CI:-0.62;-0.17) and total (β: 0.28, 95%CI:-0.47;-0.10) arterial calcification mass scores, and lower prevalence of choroidal neovascularizations (OR: 0.41 95%CI:0.20; 0.83) compared to two truncating variants. No association with pseudoxanthomas was found. CONCLUSIONS PXE patients with a mixed genotype have less severe arterial and ophthalmological phenotypes than patients with two truncating variants in the ABCC6 gene. Research into environmental and genetic modifiers might provide further insights into the unexplained phenotypic variability.
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Affiliation(s)
- Jonas W Bartstra
- Department of Radiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Sara Risseeuw
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Pim A de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Bram van Os
- Department of Radiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Lianne Kalsbeek
- Department of Radiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Chris Mol
- Department of Radiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Annette F Baas
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Shana Verschuere
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Olivier Vanakker
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Ralph J Florijn
- Department of Clinical Genetics, Academic Medical Center, Amsterdam, the Netherlands
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Willem Mali
- Department of Radiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Saskia Imhof
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | | | - Redmer van Leeuwen
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands.
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11
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Brampton C, Pomozi V, Chen LH, Apana A, McCurdy S, Zoll J, Boisvert WA, Lambert G, Henrion D, Blanchard S, Kuo S, Leftheriotis G, Martin L, Le Saux O. ABCC6 deficiency promotes dyslipidemia and atherosclerosis. Sci Rep 2021; 11:3881. [PMID: 33594095 PMCID: PMC7887252 DOI: 10.1038/s41598-021-82966-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 01/25/2021] [Indexed: 02/08/2023] Open
Abstract
ABCC6 deficiency promotes ectopic calcification; however, circumstantial evidence suggested that ABCC6 may also influence atherosclerosis. The present study addressed the role of ABCC6 in atherosclerosis using Ldlr-/- mice and pseudoxanthoma elasticum (PXE) patients. Mice lacking the Abcc6 and Ldlr genes were fed an atherogenic diet for 16 weeks before intimal calcification, aortic plaque formation and lipoprotein profile were evaluated. Cholesterol efflux and the expression of several inflammation, atherosclerosis and cholesterol homeostasis-related genes were also determined in murine liver and bone marrow-derived macrophages. Furthermore, we examined plasma lipoproteins, vascular calcification, carotid intima-media thickness and atherosclerosis in a cohort of PXE patients with ABCC6 mutations and compared results to dysmetabolic subjects with increased cardiovascular risk. We found that ABCC6 deficiency causes changes in lipoproteins, with decreased HDL cholesterol in both mice and humans, and induces atherosclerosis. However, we found that the absence of ABCC6 does not influence overall vascular mineralization induced with atherosclerosis. Decreased cholesterol efflux from macrophage cells and other molecular changes such as increased pro-inflammation seen in both humans and mice are likely contributors for the phenotype. However, it is likely that other cellular and/or molecular mechanisms are involved. Our study showed a novel physiological role for ABCC6, influencing plasma lipoproteins and atherosclerosis in a haploinsufficient manner, with significant penetrance.
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Affiliation(s)
- Christopher Brampton
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii, 651 Ilalo St. BSB222E, Honolulu, HI, USA
- Bio-Rad Laboratories, Inc., Hercules, CA, USA
| | - Viola Pomozi
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii, 651 Ilalo St. BSB222E, Honolulu, HI, USA
| | - Li-Hsieh Chen
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii, 651 Ilalo St. BSB222E, Honolulu, HI, USA
| | - Ailea Apana
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii, 651 Ilalo St. BSB222E, Honolulu, HI, USA
| | - Sara McCurdy
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
- Department of Medicine, University of California San Diego, San Diego, USA
| | - Janna Zoll
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii, 651 Ilalo St. BSB222E, Honolulu, HI, USA
| | - William A Boisvert
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Gilles Lambert
- University of La Réunion Medical School (France) INSERM UMR1188 DéTROI, Ste Clotilde, La Réunion, France
| | - Daniel Henrion
- MITOVASC Institute - UMR CNRS 6015 INSERM U1083, University of Angers, Angers, France
| | - Simon Blanchard
- Département d'Immunologie et d'Allergologie, University Hospital of Angers, 49000, Angers, France
- Inserm U1232, CRCINA, University of Angers, 44000, Nantes, France
| | - Sheree Kuo
- Department of Pediatrics Kapi'olani Medical Center for Women and Children, University of Hawaii, Honolulu, HI, USA
| | - Georges Leftheriotis
- Faculty of Medicine, University of Nice-Sophia Antipolis, 06107, Nice, France
- Laboratory of Physiology and Molecular Medicine (LP2M) UMR CNRS 7073, 06107, Nice, France
| | - Ludovic Martin
- PXE Consultation Center, MAGEC Reference Center for Rare Skin Diseases, Angers University Hospital, Angers, France
- BNMI, CNRS 6214/INSERM 1083, University Bretagne-Loire, Angers, France
| | - Olivier Le Saux
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii, 651 Ilalo St. BSB222E, Honolulu, HI, USA.
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12
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Rutsch F, Buers I, Nitschke Y. Hereditary Disorders of Cardiovascular Calcification. Arterioscler Thromb Vasc Biol 2020; 41:35-47. [PMID: 33176451 DOI: 10.1161/atvbaha.120.315577] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Arterial calcification is a common phenomenon in the elderly, in patients with atherosclerosis or renal failure and in diabetes. However, when present in very young individuals, it is likely to be associated with an underlying hereditary disorder of arterial calcification. Here, we present an overview of the few monogenic disorders presenting with early-onset cardiovascular calcification. These disorders can be classified according to the function of the respective disease gene into (1) disorders caused by an altered purine and phosphate/pyrophosphate metabolism, (2) interferonopathies, and (3) Gaucher disease. The finding of arterial calcification in early life should alert the clinician and prompt further genetic work-up to define the underlying genetic defect, to establish the correct diagnosis, and to enable appropriate therapy.
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Affiliation(s)
- Frank Rutsch
- Department of General Pediatrics, Muenster University Children's Hospital, Germany
| | - Insa Buers
- Department of General Pediatrics, Muenster University Children's Hospital, Germany
| | - Yvonne Nitschke
- Department of General Pediatrics, Muenster University Children's Hospital, Germany
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13
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Omarjee L, Mention PJ, Janin A, Kauffenstein G, Le Pabic E, Meilhac O, Blanchard S, Navasiolava N, Leftheriotis G, Couturier O, Jeannin P, Lacoeuille F, Martin L. Assessment of Inflammation and Calcification in Pseudoxanthoma Elasticum Arteries and Skin with 18F-FluroDeoxyGlucose and 18F-Sodium Fluoride Positron Emission Tomography/Computed Tomography Imaging: The GOCAPXE Trial. J Clin Med 2020; 9:jcm9113448. [PMID: 33120982 PMCID: PMC7692997 DOI: 10.3390/jcm9113448] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/12/2020] [Accepted: 10/19/2020] [Indexed: 01/27/2023] Open
Abstract
Background: Pseudoxanthoma elasticum (PXE) is an inherited metabolic disease characterized by elastic fiber fragmentation and ectopic calcification. There is growing evidence that vascular calcification is associated with inflammatory status and is enhanced by inflammatory cytokines. Since PXE has never been considered as an inflammatory condition, no incidence of chronic inflammation leading to calcification in PXE has been reported and should be investigated. In atherosclerosis and aortic stenosis, positron emission tomography combined with computed tomographic (PET-CT) imaging has demonstrated a correlation between inflammation and calcification. The purpose of this study was to assess skin/artery inflammation and calcification in PXE patients. Methods: 18F-FluroDeoxyGlucose (18F-FDG) and 18F-Sodium Fluoride (18F-NaF) PET-CT, CT-imaging and Pulse wave velocity (PWV) were used to determine skin/vascular inflammation, tissue calcification, arterial calcium score (CS) and stiffness, respectively. In addition, inorganic pyrophosphate, high-sensitive C-reactive protein and cytokines plasma levels were monitored. Results: In 23 PXE patients, assessment of inflammation revealed significant 18F-FDG uptake in diseased skin areas contrary to normal regions, and exclusively in the proximal aorta contrary to the popliteal arteries. There was no correlation between 18F-FDG uptake and PWV in the aortic wall. Assessment of calcification demonstrated significant 18F-NaF uptake in diseased skin regions and in the proximal aorta and femoral arteries. 18F-NaF wall uptake correlated with CS in the femoral arteries, and aortic wall PWV. Multivariate analysis indicated that aortic wall 18F-NaF uptake is associated with diastolic blood pressure. There was no significant correlation between 18F-FDG and 18F-NaF uptake in any of the artery walls. Conclusion: In the present cross-sectional study, inflammation and calcification were not correlated. PXE would appear to more closely resemble a chronic disease model of ectopic calcification than an inflammatory condition. To assess early ectopic calcification in PXE patients, 18F-NaF-PET-CT may be more relevant than CT imaging. It potentially constitutes a biomarker for disease-modifying anti-calcifying drug assessment in PXE.
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Affiliation(s)
- Loukman Omarjee
- Vascular Medicine Department, French National Health and Medical Research (Inserm), Clinical Investigation Center (CIC) 1414, University of Rennes 1, 35033 Rennes, France
- Pseudoxanthoma Elasticum (PXE) Clinical and Research Vascular Center, CHU Rennes, 35033 Rennes, France
- NuMeCan Institute, Exogenous and Endogenous Stress and Pathological Responses in Hepato-Gastrointestinal Diseases (EXPRES) team, French national health and medical research (Inserm) U1241, University of Rennes 1, 35033 Rennes, France
- Correspondence: or ; Tel.: +33-(0)-62-749-7051
| | - Pierre-Jean Mention
- Department of Nuclear Medicine, Angers University Hospital, 49100 Angers, France; (P.-J.M.); (O.C.); (F.L.)
| | - Anne Janin
- Sorbonne University Paris Nord, INSERM, U942, Cardiovascular Markers in Stressed Conditions, MASCOT, F- 93000 Bobigny, France;
| | - Gilles Kauffenstein
- MitoVasc Institute Mixed Research Unit: National Centre for Scientific Research, CNRS 6015, French National Health and Medical Research, Inserm U1083, Angers University, 49100 Angers, France; (G.K.); (N.N.); (L.M.)
| | - Estelle Le Pabic
- CHU Rennes, French National Health and Medical Research (Inserm), Clinical Investigation Center (CIC) 1414, 35000 Rennes, France;
| | - Olivier Meilhac
- University of Reunion Island, INSERM, UMR 1188 Reunion, Indian Ocean diabetic atherothrombosis therapies (DéTROI), CHU de La Réunion, 97400 Saint-Denis de La Réunion, France;
| | - Simon Blanchard
- Regional Center for Research in Cancerology and Immunology Nantes/Angers, CRCINA, Angers University, 49100 Angers, France; (S.B.); (P.J.)
- Immunology and Allergology Department, CHU Angers, Angers University, 49100 Angers, France
| | - Nastassia Navasiolava
- MitoVasc Institute Mixed Research Unit: National Centre for Scientific Research, CNRS 6015, French National Health and Medical Research, Inserm U1083, Angers University, 49100 Angers, France; (G.K.); (N.N.); (L.M.)
- PXE Reference Center (MAGEC Nord), University Hospital of Angers, 49100 Angers, France
| | | | - Olivier Couturier
- Department of Nuclear Medicine, Angers University Hospital, 49100 Angers, France; (P.-J.M.); (O.C.); (F.L.)
- GLIAD Team (Design and Application of Innovative Local Treatments in Glioblastoma), INSERM UMR 1232, CRCINA, CEDEX 9, 49933 Angers, France
| | - Pascale Jeannin
- Regional Center for Research in Cancerology and Immunology Nantes/Angers, CRCINA, Angers University, 49100 Angers, France; (S.B.); (P.J.)
- Immunology and Allergology Department, CHU Angers, Angers University, 49100 Angers, France
| | - Franck Lacoeuille
- Department of Nuclear Medicine, Angers University Hospital, 49100 Angers, France; (P.-J.M.); (O.C.); (F.L.)
- GLIAD Team (Design and Application of Innovative Local Treatments in Glioblastoma), INSERM UMR 1232, CRCINA, CEDEX 9, 49933 Angers, France
| | - Ludovic Martin
- MitoVasc Institute Mixed Research Unit: National Centre for Scientific Research, CNRS 6015, French National Health and Medical Research, Inserm U1083, Angers University, 49100 Angers, France; (G.K.); (N.N.); (L.M.)
- PXE Reference Center (MAGEC Nord), University Hospital of Angers, 49100 Angers, France
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14
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D'Marco L, Lima-Martínez M, Karohl C, Chacín M, Bermúdez V. Pseudoxanthoma Elasticum: An Interesting Model to Evaluate Chronic Kidney Disease-Like Vascular Damage without Renal Disease. KIDNEY DISEASES 2020; 6:92-97. [PMID: 32309291 DOI: 10.1159/000505026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/26/2019] [Indexed: 12/20/2022]
Abstract
Background Pseudoxanthoma elasticum (PXE; OMIM 264800) is an inherited multisystem disorder associated with accumulation of mineralized and fragmented elastic fibers in the skin, vascular walls, and brush membrane in the eye. Carriers exhibit characteristic lesions in the cardiovascular system, and peripheral and coronary arterial disease as well as mitral valvulopathy often present as a cardiovascular feature of this disease. PXE and chronic kidney disease (CKD) share some common patterns in the vascular damage and in therapeutic approaches as well. Summary To date, treating PXE has focused more on careful follow-up examinations with retinal specialists and cardiologist, avoiding long-term anticoagulation. Like CKD, maintaining a low-calcium diet, increasing dietary magnesium, and administering phosphate binders such as aluminum hydroxide or sevelamer may yield a modest benefit. Recently, 4-phenylbutyrate acid (4-PBA) has demonstrated a maturation of ABCC6 mutant effects into the plasma membrane. Moreover, in a humanized mouse model of PXE, 4-PBA administration restored the physiological function of ABCC6 mutants, resulting in enhanced calcification inhibition and thus a promising strategy for allele-specific therapy of ABCC6-associated calcification disorders. Key Message Vascular compromise in PXE patients share some components similar to CKD.
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Affiliation(s)
- Luis D'Marco
- Nephrology Department, Hospital Clinico Universitario, INCLIVA, Valencia, Spain
| | - Marcos Lima-Martínez
- Department of Physiological Sciences, Universidad de Oriente, Bolívar, Venezuela
| | - Cristina Karohl
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Porto Alegre, Brazil
| | - Maricarmen Chacín
- Universidad Simón Bolívar, Facultad de Ciencias de la Salud, Barranquilla, Colombia
| | - Valmore Bermúdez
- Universidad Simón Bolívar, Facultad de Ciencias de la Salud, Barranquilla, Colombia
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15
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Pseudoxanthoma Elasticum, Kidney Stones and Pyrophosphate: From a Rare Disease to Urolithiasis and Vascular Calcifications. Int J Mol Sci 2019; 20:ijms20246353. [PMID: 31861118 PMCID: PMC6940945 DOI: 10.3390/ijms20246353] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/09/2019] [Accepted: 12/11/2019] [Indexed: 12/11/2022] Open
Abstract
Pseudoxanthoma elasticum is a rare disease mainly due to ABCC6 gene mutations and characterized by ectopic biomineralization and fragmentation of elastic fibers resulting in skin, cardiovascular and retinal calcifications. It has been recently described that pyrophosphate (a calcification inhibitor) deficiency could be the main cause of ectopic calcifications in this disease and in other genetic disorders associated to mutations of ENPP1 or CD73. Patients affected by Pseudoxanthoma Elasticum seem also prone to develop kidney stones originating from papillary calcifications named Randall’s plaque, and to a lesser extent may be affected by nephrocalcinosis. In this narrative review, we summarize some recent discoveries relative to the pathophysiology of this mendelian disease responsible for both cardiovascular and renal papillary calcifications, and we discuss the potential implications of pyrophosphate deficiency as a promoter of vascular calcifications in kidney stone formers and in patients affected by chronic kidney disease.
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16
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Mowafy KA, Soliman M, Hammoda AM, Soliman RM. Bilateral Lower Limb Disabling Claudication in a Young Man: A Case of Mönckeberg’s Arteriosclerosis. VASCULAR AND ENDOVASCULAR REVIEW 2019. [DOI: 10.15420/ver.2018.20.3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Mönckeberg’s arteriosclerosis, also called medial calcific sclerosis or Mönckeberg’s sclerosis, is a form of vessel hardening due to increased calcium deposits in the tunica media layer. There is disagreement over its clinical significance and aetiology and its relation to atherosclerosis and vascular calcification. Its clinical presentations and treatment are still debated. More effort should be directed on attempting to distinguish between atherosclerotic lesions and Mönckeberg’s lesions on the basis of age, location and the pattern of calcifications where there is considerable overlap between intimal or medial and involvement of the internal elastic lamina border between those planes. In-depth research is still needed to create consensus guidelines for the diagnosis and management of this condition. This article includes a review of the literature and a case report of a 22-year-old man with the condition.
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Affiliation(s)
- Khalid Abdelaziz Mowafy
- Vascular and Endovascular Surgery Department, Mansoura College of Medicine, Mansoura University, Egypt
| | - Mosaad Soliman
- Vascular and Endovascular Surgery Department, Mansoura College of Medicine, Mansoura University, Egypt
| | - Ahmed Magdy Hammoda
- Vascular and Endovascular Surgery Department, Mansoura College of Medicine, Mansoura University, Egypt
| | - Reem Mosaad Soliman
- Vascular and Endovascular Surgery Department, Mansoura College of Medicine, Mansoura University, Egypt
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17
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Letavernier E, Kauffenstein G, Huguet L, Navasiolava N, Bouderlique E, Tang E, Delaitre L, Bazin D, de Frutos M, Gay C, Perez J, Verpont MC, Haymann JP, Pomozi V, Zoll J, Le Saux O, Daudon M, Leftheriotis G, Martin L. ABCC6 Deficiency Promotes Development of Randall Plaque. J Am Soc Nephrol 2018; 29:2337-2347. [PMID: 29991491 DOI: 10.1681/asn.2017101148] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 05/28/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Pseudoxanthoma elasticum (PXE) is a genetic disease caused by mutations in the ABCC6 gene that result in low pyrophosphate levels and subsequent progressive soft tissue calcifications. PXE mainly affects the skin, retina, and arteries. However, many patients with PXE experience kidney stones. We determined the prevalence of this pathology in patients with PXE and examined the possible underlying mechanisms in murine models. METHODS We conducted a retrospective study in a large cohort of patients with PXE and analyzed urine samples and kidneys from Abcc6-/- mice at various ages. We used Yasue staining, scanning electron microscopy, electron microscopy coupled to electron energy loss spectroscopy, and Fourier transform infrared microspectroscopy to characterize kidney calcifications. RESULTS Among 113 patients with PXE, 45 (40%) had a past medical history of kidney stones. Five of six computed tomography scans performed showed evidence of massive papillary calcifications (Randall plaques). Abcc6-/- mice spontaneously developed kidney interstitial apatite calcifications with aging. These calcifications appeared specifically at the tip of the papilla and formed Randall plaques similar to those observed in human kidneys. Compared with controls, Abcc6-/- mice had low urinary excretion of pyrophosphate. CONCLUSIONS The frequency of kidney stones and probably, Randall plaque is extremely high in patients with PXE, and Abcc6-/- mice provide a new and useful model in which to study Randall plaque formation. Our findings also suggest that pyrophosphate administration should be evaluated for the prevention of Randall plaque and kidney stones.
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Affiliation(s)
- Emmanuel Letavernier
- Unité Mixte de Recherche S 1155, Sorbonne Universités, Université Pierre et Marie Curie-Paris 06, Paris, France; .,Unité Mixte de Recherche S 1155, Institut National de la Santé et de la Recherche Médicale, Paris, France.,Department of Physiology, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | - Gilles Kauffenstein
- Institut des maladies mitochondriales, du coeur et des vaisseaux-MITOVASC, Centre National de la Recherche Scientifique 6015, Institut National de la Santé et de la Recherche Médicale U1083, Angers University, Angers, France
| | - Léa Huguet
- Unité Mixte de Recherche S 1155, Sorbonne Universités, Université Pierre et Marie Curie-Paris 06, Paris, France.,Unité Mixte de Recherche S 1155, Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Nastassia Navasiolava
- Department of Dermatology, PseudoXanthoma Elasticum Consultation center, Reference Center for rare skin diseases, Angers University Hospital, France
| | - Elise Bouderlique
- Unité Mixte de Recherche S 1155, Sorbonne Universités, Université Pierre et Marie Curie-Paris 06, Paris, France.,Unité Mixte de Recherche S 1155, Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Ellie Tang
- Unité Mixte de Recherche S 1155, Sorbonne Universités, Université Pierre et Marie Curie-Paris 06, Paris, France.,Unité Mixte de Recherche S 1155, Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Léa Delaitre
- Department of Dermatology, PseudoXanthoma Elasticum Consultation center, Reference Center for rare skin diseases, Angers University Hospital, France
| | - Dominique Bazin
- Unité Mixte de Recherche 8502, Laboratoire de Physique des Solides, Centre National de la Recherche Scientifique, Université Paris Sud XI, Orsay, France
| | - Marta de Frutos
- Unité Mixte de Recherche 8502, Laboratoire de Physique des Solides, Centre National de la Recherche Scientifique, Université Paris Sud XI, Orsay, France
| | - Clément Gay
- Unité Mixte de Recherche 8502, Laboratoire de Physique des Solides, Centre National de la Recherche Scientifique, Université Paris Sud XI, Orsay, France
| | - Joëlle Perez
- Unité Mixte de Recherche S 1155, Sorbonne Universités, Université Pierre et Marie Curie-Paris 06, Paris, France.,Unité Mixte de Recherche S 1155, Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Marie-Christine Verpont
- Unité Mixte de Recherche S 1155, Sorbonne Universités, Université Pierre et Marie Curie-Paris 06, Paris, France.,Unité Mixte de Recherche S 1155, Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Jean-Philippe Haymann
- Unité Mixte de Recherche S 1155, Sorbonne Universités, Université Pierre et Marie Curie-Paris 06, Paris, France.,Unité Mixte de Recherche S 1155, Institut National de la Santé et de la Recherche Médicale, Paris, France.,Department of Physiology, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | - Viola Pomozi
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii; and
| | - Janna Zoll
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii; and
| | - Olivier Le Saux
- Department of Cell and Molecular Biology, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii; and
| | - Michel Daudon
- Unité Mixte de Recherche S 1155, Sorbonne Universités, Université Pierre et Marie Curie-Paris 06, Paris, France.,Unité Mixte de Recherche S 1155, Institut National de la Santé et de la Recherche Médicale, Paris, France.,Department of Physiology, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | - Georges Leftheriotis
- Department of Physiology and Molecular Medicine, Unité Mixte de Recherche 7370, Centre National de la Recherche Scientifique, University of Nice, Nice, France
| | - Ludovic Martin
- Institut des maladies mitochondriales, du coeur et des vaisseaux-MITOVASC, Centre National de la Recherche Scientifique 6015, Institut National de la Santé et de la Recherche Médicale U1083, Angers University, Angers, France.,Department of Dermatology, PseudoXanthoma Elasticum Consultation center, Reference Center for rare skin diseases, Angers University Hospital, France
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18
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[Unexplained diffuse arteriosclerosis in a 26-year-old patient]. Ann Cardiol Angeiol (Paris) 2018; 67:106-109. [PMID: 29506748 DOI: 10.1016/j.ancard.2018.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 01/30/2018] [Indexed: 11/21/2022]
Abstract
Arteriosclerosis is an alteration of the blood vessels whose walls calcify, lose their elasticity and thicken. The result is a decrease in circulating blood flow and ischemic manifestations. Calcification of the arteries is a physiological phenomenon in the elderly but young subjects may also be affected. Indeed, certain risk factors can favor the formation of plaques at the level of the vessels. These include classic cardiovascular risk factors, as well as systemic inflammatory diseases, connective tissue diseases, chronic hypercalcemia… We report the case of a 26-year-old female patient with diffuse arteriosclerosis discovered accidentally, and whose exhaustive etiological investigation remained negative.
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19
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Kranenburg G, Visseren FLJ, de Borst GJ, de Jong PA, Spiering W. Arterial stiffening and thickening in patients with pseudoxanthoma elasticum. Atherosclerosis 2018; 270:160-165. [PMID: 29432933 DOI: 10.1016/j.atherosclerosis.2018.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 01/25/2018] [Accepted: 02/02/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS Patients with pseudoxanthoma elasticum (PXE), a monogenetic calcification disease, are at high vascular risk. Although the precise arterial phenotype remains unestablished, it is hypothesized that PXE predominantly affects the medial arterial layer leading to arterial stiffening. We aimed to test this hypothesis by measuring arterial wall characteristics in PXE and comparisons with the general population and diabetes mellitus type 2 (DM2), a condition typically associated with mixed intimal and medial arterial disease. METHODS Extensive arterial wall characterization was performed in 203 PXE patients involving intima-media thickness (IMT), pulse wave velocity (PWV) and pulse pressure (PP) measurements. IMT and PWV in PXE were compared with the general population using age, sex and mean arterial pressure corrected values for each PXE patient. IMT and PP were compared between PXE and DM2 independently of sex, age and systolic blood pressure, using data of DM2 patients (n = 1033) from the Second Manifestations of ARTerial disease (SMART) cohort. RESULTS PXE patients had significantly higher IMT (mean difference 0.09 mm; 95% CI 0.07-0.12 mm) and PWV (mean difference 2.5 m/s; 95% CI 1.9-3.0 m/s) compared to the general population. IMT in PXE was lower compared to DM2 (0.72 mm; 95% CI 0.68-0.75 mm vs. 0.85 mm; 95% CI 0.83-0.87 mm, p-value<0.01), whereas PP in PXE was higher compared to DM2 (60 mmHg; 95% CI 59-62 vs. 57 mmHg; 95% CI 57-58 mmHg, p-value<0.01). CONCLUSIONS PXE patients have thicker arterial walls than the general population, but thinner arterial walls than DM2 patients at similar age. Arterial stiffening is more pronounced in PXE patients compared to DM2 patients.
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Affiliation(s)
- Guido Kranenburg
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Gert Jan de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Pim A de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, The Netherlands.
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20
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Martin L, Hoppé E, Kauffenstein G, Omarjee L, Navasiolava N, Henni S, Willoteaux S, Leftheriotis G. Early arterial calcification does not correlate with bone loss in pseudoxanthoma elasticum. Bone 2017; 103:88-92. [PMID: 28658601 DOI: 10.1016/j.bone.2017.06.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 06/14/2017] [Accepted: 06/22/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Pseudoxanthoma elasticum (PXE; OMIM 264800, prevalence 1/25,000 to 1/50,000) is an autosomal recessive multisystem disease due to deficiency in ABCC6, an ATP-binding cassette, sub-family C transporter. The PXE phenotype is mainly characterized by progressive ectopic calcification of connective tissues (namely skin, retinal Bruch's membrane and peripheral arteries) but the impact of PXE on bone structure is currently unknown. The present study sought to investigate bone mineralization and its potential link with vascular calcification in a large cohort of PXE patients with inherited mutations of the ABCC6 gene. METHODS AND RESULTS 96 patients (61 women) matching the PXE criteria participated in this study. Their clinical history and status and bone biological markers were collected. Bone mineral density (BMD) was measured by dual energy X-ray absorptiometry and expressed as T- and Z-scores. Osteoporotic fractures were identified by X-ray, and coronary (CAC) and lower limb arterial calcification (LLAC) scores were determined by CT scan. RESULTS 44% of the women were menopausal. Osteopenia was disclosed in 46% (17 women) while 23% (9 women) exhibited osteoporosis, 3 with severe osteoporosis. Fractures of an osteoporotic nature were authenticated in 3 patients (1 woman). Markers of bone remodelling processes (CTX, BSAP and osteocalcin) were within the normal range for our laboratory standards. Severe vitamin D deficiency (<25nmol/L) was found in 15%, while 51% exhibited no vitamin D deficiency (vitamin D≥50nmol/L). LLAC and CAC scores were significantly higher in the patients with a low T- and/or Z-score, although this difference disappeared in multivariate analysis with age as a confounding factor. There was no significant difference in LLAC and CAC between PXE patients with and without osteoporotic fractures. There was no statistically significant association between BMD, LLAC and CAC and any of the bone remodelling factors. CONCLUSIONS This is the first report on the bone mineralization process in PXE patients. Our data shows that PXE patients are not markedly prone to exaggerated bone demineralization and fracture risk, and prevalence of osteoporosis remains within the normal range for the general population. Furthermore, the relationships between LLAC, but not CAC, and BMD with age are similar to those observed in the general population. Therefore, despite its pivotal role in ectopic calcification, ABCC6 deficiency does not interfere with the bone-vascular axis. The lack of PXE-related disturbances between BMD and arterial calcification also supports vitamin D supplementation in PXE patients with vitamin D deficiency. ClinicalTrials.gov Identifier: NCT01446393.
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Affiliation(s)
- Ludovic Martin
- PXE Health and Research Center, University Hospital of Angers, Angers, France; MitoVasc, UMR CNRS 6015 - Inserm 1083, School of Medicine, UBL University, Angers, France
| | - Emmanuel Hoppé
- Department of Rheumatology, University Hospital of Angers, Angers, France
| | - Gilles Kauffenstein
- MitoVasc, UMR CNRS 6015 - Inserm 1083, School of Medicine, UBL University, Angers, France
| | - Loukman Omarjee
- PXE Health and Research Center, University Hospital of Angers, Angers, France; MitoVasc, UMR CNRS 6015 - Inserm 1083, School of Medicine, UBL University, Angers, France
| | | | - Samir Henni
- PXE Health and Research Center, University Hospital of Angers, Angers, France; MitoVasc, UMR CNRS 6015 - Inserm 1083, School of Medicine, UBL University, Angers, France
| | - Serge Willoteaux
- PXE Health and Research Center, University Hospital of Angers, Angers, France; UPRES 3860, School of Medicine, UBL University, Angers, France
| | - Georges Leftheriotis
- PXE Health and Research Center, University Hospital of Angers, Angers, France; MitoVasc, UMR CNRS 6015 - Inserm 1083, School of Medicine, UBL University, Angers, France; Laboratory of Physiology and Molecular Medicine - LP2M, and University Hospital of Nice, Nice, France.
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21
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Abstract
Pseudoxanthoma elasticum (PXE) is a genetic metabolic disease with autosomal recessive inheritance caused by mutations in the ABCC6 gene. The lack of functional ABCC6 protein leads to ectopic mineralization that is most apparent in the elastic tissues of the skin, eyes and blood vessels. The clinical prevalence of PXE has been estimated at between 1 per 100,000 and 1 per 25,000, with slight female predominance. The first clinical sign of PXE is almost always small yellow papules on the nape and sides of the neck and in flexural areas. The papules coalesce, and the skin becomes loose and wrinkled. The mid-dermal elastic fibers are short, fragmented, clumped and calcified. Dystrophic calcification of Bruch's membrane, revealed by angioid streaks, may trigger choroidal neovascularization and, ultimately, loss of central vision and blindness in late-stage disease. Lesions in small and medium-sized artery walls may result in intermittent claudication and peripheral artery disease. Cardiac complications (myocardial infarction, angina pectoris) are thought to be relatively rare but merit thorough investigation. Ischemic strokes have been reported. PXE is a metabolic disease in which circulating levels of an anti-mineralization factor are low. There is good evidence to suggest that the factor is inorganic pyrophosphate (PPi), and that the circulating low levels of PPi and decreased PPi/Pi ratio result from the lack of ATP release by hepatocytes harboring the mutant ABCC6 protein. However, the substrate(s) bound, transported or modulated by the ABCC6 protein remain unknown. More than 300 sequence variants of the ABCC6 gene have been identified. There is no cure for PXE; the main symptomatic treatments are vascular endothelial growth factor inhibitor therapy (for ophthalmic manifestations), lifestyle, lipid-lowering and dietary measures (for reducing vascular risk factors), and vascular surgery (for severe cardiovascular manifestations). Future treatment options may include gene therapy/editing and pharmacologic chaperone therapy.
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Affiliation(s)
- Dominique P Germain
- Division of Medical Genetics, University of Versailles - Saint Quentin en Yvelines, Paris-Saclay University, 2 avenue de la source de la Bièvre, F-78180, Montigny, France.
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Kranenburg G, de Jong PA, Mali WP, Attrach M, Visseren FL, Spiering W. Prevalence and severity of arterial calcifications in pseudoxanthoma elasticum (PXE) compared to hospital controls. Novel insights into the vascular phenotype of PXE. Atherosclerosis 2017; 256:7-14. [DOI: 10.1016/j.atherosclerosis.2016.11.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/27/2016] [Accepted: 11/10/2016] [Indexed: 01/23/2023]
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Kullo IJ, Leeper NJ. The genetic basis of peripheral arterial disease: current knowledge, challenges, and future directions. Circ Res 2015; 116:1551-60. [PMID: 25908728 DOI: 10.1161/circresaha.116.303518] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Several risk factors for atherosclerotic peripheral arterial disease (PAD), such as dyslipidemia, diabetes mellitus, and hypertension, are heritable. However, predisposition to PAD may be influenced by genetic variants acting independently of these risk factors. Identification of such genetic variants will provide insights into underlying pathophysiologic mechanisms and facilitate the development of novel diagnostic and therapeutic approaches. In contrast to coronary heart disease, relatively few genetic variants that influence susceptibility to PAD have been discovered. This may be, in part, because of greater clinical and genetic heterogeneity in PAD. In this review, we (1) provide an update on the current state of knowledge about the genetic basis of PAD, including results of family studies and candidate gene, linkage as well as genome-wide association studies; (2) highlight the challenges in investigating the genetic basis of PAD and possible strategies to overcome these challenges; and (3) discuss the potential of genome sequencing, RNA sequencing, differential gene expression, epigenetic profiling, and systems biology in increasing our understanding of the molecular genetics of PAD.
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Affiliation(s)
- Iftikhar J Kullo
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (I.J.K.); and Department of Vascular Surgery, Stanford, Stanford, CA (N.J.L.).
| | - Nicholas J Leeper
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (I.J.K.); and Department of Vascular Surgery, Stanford, Stanford, CA (N.J.L.)
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