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Berends M, Brunger AF, Bijzet J, Kroesen BJ, Drost G, Lange F, Teunissen CE, In 't Veld S, Vrancken AF, Gans ROB, Hazenberg BPC, van der Zwaag PA, Nienhuis HLA. Longitudinal analysis of serum neurofilament light chain levels as marker for neuronal damage in hereditary transthyretin amyloidosis. Amyloid 2024; 31:132-141. [PMID: 38477065 DOI: 10.1080/13506129.2024.2327342] [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: 11/14/2023] [Accepted: 02/29/2024] [Indexed: 03/14/2024]
Abstract
OBJECTIVE To evaluate serum neurofilament light chain (sNfL) as biomarker of disease onset, progression and treatment effect in hereditary transthyretin (ATTRv) amyloidosis patients and TTR variant (TTRv) carriers. METHODS sNfL levels were assessed longitudinally in persistently asymptomatic TTRv carriers (N = 12), persistently asymptomatic ATTRv amyloidosis patients (defined as asymptomatic patients but with amyloid detectable in subcutaneous abdominal fat tissue) (N = 8), in TTRv carriers who developed polyneuropathy (N = 7) and in ATTRv amyloidosis patients with polyneuropathy on treatment (TTR-stabiliser (N = 20) or TTR-silencer (N = 18)). Polyneuropathy was confirmed by nerve conduction studies or quantitative sensory testing. sNfL was analysed using a single-molecule array assay. RESULTS sNfL increased over 2 years in persistently asymptomatic ATTRv amyloidosis patients, but did not change in persistently asymptomatic TTRv carriers. In all TTRv carriers who developed polyneuropathy, sNfL increased from 8.4 to 49.8 pg/mL before the onset of symptoms and before polyneuropathy could be confirmed neurophysiologically. In symptomatic ATTRv amyloidosis patients on a TTR-stabiliser, sNfL remained stable over 2 years. In patients on a TTR-silencer, sNfL decreased after 1 year of treatment. CONCLUSION sNfL is a biomarker of early neuronal damage in ATTRv amyloidosis already before the onset of polyneuropathy. Current data support the use of sNfL in screening asymptomatic TTRv carriers and in monitoring of disease progression and treatment effect.
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Affiliation(s)
- Milou Berends
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
| | - Anne F Brunger
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
- Department of Rheumatology & Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Johan Bijzet
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
- Department of Laboratory Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Bart-Jan Kroesen
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
- Department of Laboratory Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Gea Drost
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - Fiete Lange
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - Charlotte E Teunissen
- Department of Laboratory Medicine, Amsterdam Neuroscience, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Sjors In 't Veld
- Department of Laboratory Medicine, Amsterdam Neuroscience, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | | | - Reinold O B Gans
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
| | - Bouke P C Hazenberg
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
- Department of Rheumatology & Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul A van der Zwaag
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
- Department of Medical Genetics, University Medical Center Groningen, Groningen, The Netherlands
| | - Hans L A Nienhuis
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
- Amyloidosis Center of Expertise, University Medical Center Groningen, Groningen, The Netherlands
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Uncini A, Cavallaro T, Fabrizi GM, Manganelli F, Vallat JM. Conduction slowing, conduction block and temporal dispersion in demyelinating, dysmyelinating and axonal neuropathies: Electrophysiology meets pathology. J Peripher Nerv Syst 2024; 29:135-160. [PMID: 38600691 DOI: 10.1111/jns.12625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/02/2024] [Accepted: 03/28/2024] [Indexed: 04/12/2024]
Abstract
Nerve conduction studies are usually the first diagnostic step in peripheral nerve disorders and their results are the basis for planning further investigations. However, there are some commonplaces in the interpretation of electrodiagnostic findings in peripheral neuropathies that, although useful in the everyday practice, may be misleading: (1) conduction block and abnormal temporal dispersion are distinctive features of acquired demyelinating disorders; (2) hereditary neuropathies are characterized by uniform slowing of conduction velocity; (3) axonal neuropathies are simply diagnosed by reduced amplitude of motor and sensory nerve action potentials with normal or slightly slow conduction velocity. In this review, we reappraise the occurrence of uniform and non-uniform conduction velocity slowing, conduction block and temporal dispersion in demyelinating, dysmyelinating and axonal neuropathies attempting, with a translational approach, a correlation between electrophysiological and pathological features as derived from sensory nerve biopsy in patients and animal models. Additionally, we provide some hints to navigate in this complex field.
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Affiliation(s)
- Antonino Uncini
- Department of Neurosciences, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti-Pescara, Italy
| | - Tiziana Cavallaro
- Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
| | - Gian Maria Fabrizi
- Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
| | - Fiore Manganelli
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Jean-Michel Vallat
- Department of Neurology, National Reference Center for "Rare Peripheral Neuropathies", CHU Dupuytren, Limoges, France
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3
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Gentile L, Mazzeo A, Briani C, Casagrande S, De Luca M, Fabrizi GM, Gagliardi C, Gemelli C, Forcina F, Grandis M, Guglielmino V, Iabichella G, Leonardi L, Lozza A, Manganelli F, Mussinelli R, My F, Occhipinti G, Fenu S, Russo M, Romano A, Salvalaggio A, Tagliapietra M, Tozza S, Palladini G, Obici L, Luigetti M. Long-term treatment of hereditary transthyretin amyloidosis with patisiran: multicentre, real-world experience in Italy. Neurol Sci 2024:10.1007/s10072-024-07494-9. [PMID: 38622453 DOI: 10.1007/s10072-024-07494-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 03/23/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Hereditary transthyretin (ATTRv, v for variant) amyloidosis with polyneuropathy is a rare disease caused by mutations in the transthyretin gene. In ATTRv amyloidosis, multisystem extracellular deposits of amyloid cause tissue and organ dysfunction. Patisiran is a small interfering RNA molecule drug that reduces circulating levels of mutant and wild-type TTR proteins. Prior to its regulatory approval, patisiran was available in Italy through a compassionate use programme (CUP). The aim of this study was to analyse the long-term outcomes of patients who entered into the CUP. METHODS This was a multicentre, observational, retrospective study of patients with ATTRv amyloidosis treated with patisiran. The analysis included change from baseline to 12, 24, 36 and 48 months in familial amyloid polyneuropathy (FAP) stage, polyneuropathy disability (PND) class, neuropathy impairment score (NIS), modified body mass index (mBMI), Compound Autonomic Dysfunction Test (CADT), Karnofsky Performance Status (KPS) scale and Norfolk Quality of Life-Diabetic Neuropathy (QoL-DN) questionnaire. Safety data were also analysed. RESULTS Forty patients from 11 Italian centres were enrolled: 23 in FAP 1 (6 in PND 1 and 17 in PND 2) and 17 in FAP 2 (8 in PND 3a and 9 in PND 3b) stage. In this population, the mean NIS at baseline was 71.4 (± 27.8); mBMI, 917.1 (± 207) kg/m2; KPS, 67.1 (± 14.0); Norfolk QoL-DN, 62.2 (± 25.2); and CADT, 13.2 (± 3.3). Statistical analysis showed few significant differences from baseline denoting disease stability. No new safety signals emerged. CONCLUSIONS Patisiran largely stabilised disease in patients with ATTRv amyloidosis.
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Affiliation(s)
- Luca Gentile
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Anna Mazzeo
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Chiara Briani
- Department of Neurosciences, Neurology Unit, University of Padova, Padua, Italy
| | - Silvia Casagrande
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Marcella De Luca
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Gian Maria Fabrizi
- Department of Neurological Sciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Christian Gagliardi
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
| | | | - Francesca Forcina
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Marina Grandis
- IRCCS Policlinico San Martino Hospital, Genoa, Italy
- Dipartimento Di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili, Università Di Genova, Genoa, Italy
| | - Valeria Guglielmino
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giacomo Iabichella
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Luca Leonardi
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Alessandro Lozza
- Amyloidosis Research and Treatment Centre, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Fiore Manganelli
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Roberta Mussinelli
- Amyloidosis Research and Treatment Centre, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Filomena My
- Department of Neurology, "Vito Fazzi" Hospital, Lecce, Italy
| | - Giuseppe Occhipinti
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Silvia Fenu
- S.C. Malattie Neurologiche Rare, Dipartimento di Neuroscienze Cliniche, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Massimo Russo
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Angela Romano
- Dipartimento Di Neuroscienze, Organi Di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Matteo Tagliapietra
- Department of Neurological Sciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Stefano Tozza
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Centre, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Laura Obici
- Amyloidosis Research and Treatment Centre, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy.
| | - Marco Luigetti
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento Di Neuroscienze, Organi Di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Tozza S, Palumbo G, Severi D, Iovino A, Spina E, Aruta F, Cassano E, Iodice R, Dubbioso R, Ruggiero L, Nolano M, Santoro L, Manganelli F. Heterogenous electrophysiological features in early stage of hereditary transthyretin amyloidosis neuropathy. Neurol Sci 2024; 45:1685-1689. [PMID: 37870643 PMCID: PMC10942904 DOI: 10.1007/s10072-023-07140-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/14/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Hereditary transthyretin-mediated amyloidosis (ATTRv, v for variant) is a progressive disease caused by mutations in the TTR gene, leading to sensory-motor, axonal and length-dependent neuropathy. However, some patients may show variable electrophysiological pattern. The aim of this study was to evaluate the electrophysiological features of TTR amyloid neuropathy at the time of the first nerve conduction study (NCS) to assess whether there were distinguishing features useful for early diagnosis. METHODS We retrospectively revised the first electrophysiological findings of ATTRv patients, and we categorized the neuropathy based on nerve conduction slowing, type of involved fibres and distribution pattern of PNS involvement. Cluster analysis was performed to evaluate the prevalence of neuropathy features between the early and late stage of disease, based on disease duration and disability burden assessed by NIS. RESULTS We recruited 33 patients (27 males) with mean age 63.9 ± 10.8 years, mean disease duration 2.8 ± 2.4 years and mean NIS 47.6 ± 41.8. Overall, the frequency analysis showed that the most common features of ATTRv neuropathy included the categories of axonal, sensory-motor and neuronopathic-like pattern. This electrophysiological pattern of PNS involvement was constant in patients in late stage of disease, whereas ATTRv patients in early stage of disease displayed variable electrophysiological pattern of PNS involvement. DISCUSSION Our findings demonstrated that ATTRv neuropathy may present at first NCS in a variable way, and it changes over the course of disease. Such heterogeneity makes the suspicion of ATTRv even more challenging at the time of first electrophysiological examination.
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Affiliation(s)
- Stefano Tozza
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Sergio Pansini, 5, 80131, Naples, Italy.
| | - Giovanni Palumbo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Sergio Pansini, 5, 80131, Naples, Italy
| | - Daniele Severi
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Sergio Pansini, 5, 80131, Naples, Italy
| | - Aniello Iovino
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Sergio Pansini, 5, 80131, Naples, Italy
| | - Emanuele Spina
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Sergio Pansini, 5, 80131, Naples, Italy
| | - Francesco Aruta
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Sergio Pansini, 5, 80131, Naples, Italy
| | - Emanuele Cassano
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Sergio Pansini, 5, 80131, Naples, Italy
| | - Rosa Iodice
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Sergio Pansini, 5, 80131, Naples, Italy
| | - Raffaele Dubbioso
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Sergio Pansini, 5, 80131, Naples, Italy
| | - Lucia Ruggiero
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Sergio Pansini, 5, 80131, Naples, Italy
| | - Maria Nolano
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Sergio Pansini, 5, 80131, Naples, Italy
| | - Lucio Santoro
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Sergio Pansini, 5, 80131, Naples, Italy
| | - Fiore Manganelli
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Sergio Pansini, 5, 80131, Naples, Italy
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Di Stefano V, Lupica A, Alonge P, Pignolo A, Augello SM, Gentile F, Gagliardo A, Giglia F, Brinch D, Cappello M, Di Lisi D, Novo G, Borgione E, Scuderi C, Brighina F. Genetic screening for hereditary transthyretin amyloidosis with polyneuropathy in western Sicily: Two years of experience in a neurological clinic. Eur J Neurol 2024; 31:e16065. [PMID: 37725003 DOI: 10.1111/ene.16065] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/21/2023] [Accepted: 08/30/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND AND PURPOSE Hereditary transthyretin amyloidosis with polyneuropathy (ATTRv-PN) is caused by mutations in the TTR gene, leading to misfolded monomers that aggregate generating amyloid fibrils. METHODS A prospective systematic genetic screening for ATTRv-PN was proposed in patients presenting with a sensory-motor idiopathic polyneuropathy and two or more "red flags" among the following: family history of polyneuropathy or cardiopathy, bilateral carpal tunnel syndrome, cardiac insufficiency, renal amyloidosis, lumbar tract stenosis, autonomic dysfunction, idiopathic gastrointestinal disease, amyloid deposits on biopsy, and vitreous opacities. The detection rate was calculated, and nonparametric analyses were carried out to underline differences among screened positive versus negative patients. RESULTS In the first step, 145 suspected patients underwent genetic testing, revealing a diagnosis of ATTRv-PN in 14 patients (10%). Then, cascade screening allowed early recognition of 33 additional individuals (seven symptomatic ATTRv-PN patients and 26 presymptomatic carriers) among 84 first-degree relatives. Patients with a positive genetic test presented a higher frequency of unexplained weight loss, gastrointestinal symptoms, and family history of cardiopathy. CONCLUSIONS A systematic screening for ATTRv-PN yielded an increased recognition of the disease in our neurological clinic. Unexplained weight loss associated with axonal polyneuropathy had the highest predictive value in the guidance of clinical suspicion. A focused approach for the screening of ATTRv-PN could lead to an earlier diagnosis and identification of asymptomatic carriers, who will be promptly treated after a strict follow-up at the clinical onset.
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Affiliation(s)
- Vincenzo Di Stefano
- Section of Neurology, Department of Biomedicine, Neuroscience, and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Antonino Lupica
- Section of Neurology, Department of Biomedicine, Neuroscience, and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Paolo Alonge
- Section of Neurology, Department of Biomedicine, Neuroscience, and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Antonia Pignolo
- Section of Neurology, Department of Biomedicine, Neuroscience, and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Sofia Maria Augello
- Section of Neurology, Department of Biomedicine, Neuroscience, and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Francesca Gentile
- Section of Neurology, Department of Biomedicine, Neuroscience, and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Andrea Gagliardo
- Section of Neurology, Department of Biomedicine, Neuroscience, and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Francesca Giglia
- Unit of Neurology With Stroke Unit, S. Giovanni di Dio Hospital, Agrigento, Italy
| | - Daniele Brinch
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine, and Medical Specialties, University of Palermo, Palermo, Italy
| | - Maria Cappello
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine, and Medical Specialties, University of Palermo, Palermo, Italy
| | - Daniela Di Lisi
- Section of Cardiology, Department of Health Promotion, Mother and Child Care, Internal Medicine, and Medical Specialties, University of Palermo, Palermo, Italy
| | - Giuseppina Novo
- Section of Cardiology, Department of Health Promotion, Mother and Child Care, Internal Medicine, and Medical Specialties, University of Palermo, Palermo, Italy
| | - Eugenia Borgione
- Unit of Neuromuscular Diseases, Oasi Research Institute, IRCCS, Troina, Italy
| | - Carmela Scuderi
- Unit of Neuromuscular Diseases, Oasi Research Institute, IRCCS, Troina, Italy
| | - Filippo Brighina
- Section of Neurology, Department of Biomedicine, Neuroscience, and Advanced Diagnostics, University of Palermo, Palermo, Italy
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Adams D, Sekijima Y, Conceição I, Waddington-Cruz M, Polydefkis M, Echaniz-Laguna A, Reilly MM. Hereditary transthyretin amyloid neuropathies: advances in pathophysiology, biomarkers, and treatment. Lancet Neurol 2023; 22:1061-1074. [PMID: 37863593 DOI: 10.1016/s1474-4422(23)00334-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 08/08/2023] [Accepted: 08/31/2023] [Indexed: 10/22/2023]
Abstract
Hereditary transthyretin (TTR) amyloid polyneuropathy is an autosomal dominant life-threatening disorder. TTR is produced mainly by the liver but also by the choroid plexus and retinal pigment epithelium. Detailed clinical characterisation, identification of clinical red flags for misdiagnosis, and use of biomarkers enable early diagnosis and treatment. In addition to liver transplantation and TTR stabilisers, three other disease-modifying therapies have regulatory approval: one antisense oligonucleotide (inotersen) and two small interfering RNAs (siRNAs; patisiran and vutrisiran). The siRNAs have been shown to stop progression of neuropathy and improve patients' quality of life. As none of the disease-modifying therapies can cross the blood-brain barrier, TTR deposition in the CNS, which can cause stroke and cognitive impairment, remains an important unaddressed issue. CRISPR-Cas9-based one-time TTR editing therapy is being investigated in a phase 1 clinical study. Identification of the earliest stages of pathogenesis in TTR variant carriers is a major challenge that needs addressing for optimal management.
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Affiliation(s)
- David Adams
- Department of Neurology, Bicêtre Centre Hospitalo Universitaire, AP-HP, INSERM U 1195, University Paris Saclay, Le Kremlin Bicetre, France.
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Isabel Conceição
- Department of Neurosciences and Mental Health, Centro Hospitalar Universitario Lisboas Norte-Hospital de Santa Maria and Centro de Estudos Egas Moniz, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Marcia Waddington-Cruz
- Centro de Estudos em Paramiloidose Antonio Rodrigues de Mello, National Amyloidosis Referral Center, University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Michael Polydefkis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andoni Echaniz-Laguna
- Department of Neurology, Centre Hospitalo Universitaire, AP-HP, INSERM U 1195, University Paris Saclay, Le Kremlin Bicetre Cedex, France
| | - Mary M Reilly
- Department of Neuromuscular Disease, University College London Institute of Neurology and the National Hospital of Neurology and Neurosurgery, London, UK
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7
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Di Stefano V, Prinzi F, Luigetti M, Russo M, Tozza S, Alonge P, Romano A, Sciarrone MA, Vitali F, Mazzeo A, Gentile L, Palumbo G, Manganelli F, Vitabile S, Brighina F. Machine Learning for Early Diagnosis of ATTRv Amyloidosis in Non-Endemic Areas: A Multicenter Study from Italy. Brain Sci 2023; 13:brainsci13050805. [PMID: 37239276 DOI: 10.3390/brainsci13050805] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/12/2023] [Accepted: 05/14/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Hereditary transthyretin amyloidosis with polyneuropathy (ATTRv) is an adult-onset multisystemic disease, affecting the peripheral nerves, heart, gastrointestinal tract, eyes, and kidneys. Nowadays, several treatment options are available; thus, avoiding misdiagnosis is crucial to starting therapy in early disease stages. However, clinical diagnosis may be difficult, as the disease may present with unspecific symptoms and signs. We hypothesize that the diagnostic process may benefit from the use of machine learning (ML). METHODS 397 patients referring to neuromuscular clinics in 4 centers from the south of Italy with neuropathy and at least 1 more red flag, as well as undergoing genetic testing for ATTRv, were considered. Then, only probands were considered for analysis. Hence, a cohort of 184 patients, 93 with positive and 91 (age- and sex-matched) with negative genetics, was considered for the classification task. The XGBoost (XGB) algorithm was trained to classify positive and negative TTR mutation patients. The SHAP method was used as an explainable artificial intelligence algorithm to interpret the model findings. RESULTS diabetes, gender, unexplained weight loss, cardiomyopathy, bilateral carpal tunnel syndrome (CTS), ocular symptoms, autonomic symptoms, ataxia, renal dysfunction, lumbar canal stenosis, and history of autoimmunity were used for the model training. The XGB model showed an accuracy of 0.707 ± 0.101, a sensitivity of 0.712 ± 0.147, a specificity of 0.704 ± 0.150, and an AUC-ROC of 0.752 ± 0.107. Using the SHAP explanation, it was confirmed that unexplained weight loss, gastrointestinal symptoms, and cardiomyopathy showed a significant association with the genetic diagnosis of ATTRv, while bilateral CTS, diabetes, autoimmunity, and ocular and renal involvement were associated with a negative genetic test. CONCLUSIONS Our data show that ML might potentially be a useful instrument to identify patients with neuropathy that should undergo genetic testing for ATTRv. Unexplained weight loss and cardiomyopathy are relevant red flags in ATTRv in the south of Italy. Further studies are needed to confirm these findings.
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Affiliation(s)
- Vincenzo Di Stefano
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy
| | - Francesco Prinzi
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy
| | - Marco Luigetti
- Fondazione Policlinico Universitario A, Gemelli-IRCCS, UOC Neurologia, 00168 Rome, Italy
- Department of Neurosciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Massimo Russo
- Department of Clinical and Experimental Medicine, University of Messina, 98182 Messina, Italy
| | - Stefano Tozza
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", 80131 Naples, Italy
| | - Paolo Alonge
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy
| | - Angela Romano
- Fondazione Policlinico Universitario A, Gemelli-IRCCS, UOC Neurologia, 00168 Rome, Italy
- Department of Neurosciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Maria Ausilia Sciarrone
- Fondazione Policlinico Universitario A, Gemelli-IRCCS, UOC Neurologia, 00168 Rome, Italy
- Department of Neurosciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Francesca Vitali
- Fondazione Policlinico Universitario A, Gemelli-IRCCS, UOC Neurologia, 00168 Rome, Italy
- Department of Neurosciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Anna Mazzeo
- Department of Clinical and Experimental Medicine, University of Messina, 98182 Messina, Italy
| | - Luca Gentile
- Department of Clinical and Experimental Medicine, University of Messina, 98182 Messina, Italy
| | - Giovanni Palumbo
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", 80131 Naples, Italy
| | - Fiore Manganelli
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", 80131 Naples, Italy
| | - Salvatore Vitabile
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy
| | - Filippo Brighina
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy
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8
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Dori A, Arad M, Wasserstrum Y, Pollak A, Nikitin V, Ben-David M, Shamash J, Nahum AH, Shavit-Stein E, Domachevsky L, Kuperstein R, Dominissini D, Shelestovich N, Sadeh M, Pras E, Greenbaum L. Ser77Tyr transthyretin amyloidosis in Israel: Initial manifestations and diagnostic features. Ann Clin Transl Neurol 2023; 10:553-567. [PMID: 36772971 PMCID: PMC10109316 DOI: 10.1002/acn3.51741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 02/12/2023] Open
Abstract
OBJECTIVE Amyloidosis due to the transthyretin Ser77Tyr mutation (ATTRS77Y) is a rare autosomal-dominant disorder, characterized by carpal-tunnel syndrome, poly- and autonomic-neuropathy, and cardiomyopathy. However, related symptoms and signs are often nonspecific and confirmatory tests are required. We describe the age and frequency of early symptoms and diagnostic features among individuals of Jewish Yemenite descent in Israel. METHODS Records of mutation carriers were retrospectively reviewed. ATTRS77Y diagnosis was defined by the presence of amyloid in tissue and/or amyloid-related cardiomyopathy. RESULTS We identified the Ser77Tyr mutation at the heterozygous state in 19 amyloidosis patients (mean age at diagnosis: 62 ± 5.7 years, range 49-70) and 30 amyloid-negative carriers. The probability for disease diagnosis increased from 4.4% at age 49 to 100% at 70 and occurred earlier in males. Initial symptoms preceded diagnosis by 5 ± 3.8 years (range 0-12) and were commonly sensory changes in the extremities. Erectile dysfunction predated these in 8/13 (62%) males. In two patients cardiac preceded neurological symptoms. Two patients declined symptoms. Electrophysiological studies near the time of diagnosis indicated a median neuropathy at the wrist in 18/19 (95%) and polyneuropathy in 13/19 (68%). Skin biopsy revealed epidermal denervation in 15/16 (94%) patients. Cardiomyopathy was identified in 16/19 (84%). Sensory complaints or epidermal denervations were present in 17/30 (57%) of amyloid-negative carriers and co-occurred in 10/30 (33%). INTERPRETATION ATTRS77Y symptoms commonly occur after age 50, but may begin earlier. Median neuropathy, skin denervation and cardiomyopathy are frequently identified. Symptoms may be absent in patients and common in amyloid-negative carriers.
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Affiliation(s)
- Amir Dori
- Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Arad
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Yishay Wasserstrum
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Arthur Pollak
- Department of Cardiology, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Vera Nikitin
- Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Merav Ben-David
- Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jana Shamash
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Ayelet Hashachar Nahum
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Efrat Shavit-Stein
- Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liran Domachevsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Nuclear Medicine, Sheba Medical Center, Tel Hashomer, Israel
| | - Rafael Kuperstein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Dan Dominissini
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The genomics Unit, Sheba Cancer Research Center, Sheba Medical Center, Tel Hashomer, Israel.,Wohl Institute of Translational Medicine, Sheba Medical Center, Tel Hashomer, Israel
| | - Natalia Shelestovich
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Pathology, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Menachem Sadeh
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Neurology, Wolfson Medical Center, Holon, Israel
| | - Elon Pras
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Lior Greenbaum
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel.,The Joseph Sagol Neuroscience Center, Sheba Medical Center, Tel Hashomer, Israel
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9
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Tozza S, Luigetti M, Antonini G, Mazzeo A, Severi D, Di Paolantonio A, Leonardi L, Russo M, Romano A, Forcina F, Gentile L, Nolano M, Mattia C, Manganelli F. Neuropathic pain experience in symptomatic and presymptomatic subjects carrying a transthyretin gene mutation. Front Neurol 2023; 14:1109782. [PMID: 36846120 PMCID: PMC9944934 DOI: 10.3389/fneur.2023.1109782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/23/2023] [Indexed: 02/10/2023] Open
Abstract
Introduction Pain is a common symptom of hereditary transthyretin amyloidosis (ATTRv), however, its occurrence in late-onset ATTRv has not been investigated thoroughly. Our aim was to describe the pain experience and its impact on quality of life (QoL) in symptomatic patients and presymptomatic carriers harboring a transthyretin (TTR) gene mutation with a late-onset phenotype. Materials and methods Study participants (aged ≥18 years) were consecutively recruited from four Italian centers. Clinical disability was assessed using the Familial Amyloid Polyneuropathy (FAP) stage and Neuropathy Impairment Score (NIS). The Norfolk questionnaire evaluated QoL and the Compound Autonomic Dysfunction Test assessed autonomic involvement. Neuropathic pain was screened using the Douleur Neuropathique 4 (DN4) questionnaire, and pain intensity and its impact on daily activity were assessed using the Brief Pain Inventory severity and interference subscores. Data on the type of TTR mutation, presence of cardiomyopathy, treatment, and Body Mass Index (BMI) were collected. Results Overall, 102 subjects with TTR mutations (mean age ± SD 63.6 ± 13.5 years) were recruited, including 78 symptomatic patients (68.1 ± 10.9 years) and 24 presymptomatic carriers (49 ± 10.3 years). Pain was reported by 75.5% of all subjects, but was more frequent in symptomatic patients than in presymptomatic carriers (85.9 vs. 41.6%, respectively). Pain exhibited neuropathic features (DN4≥4) in 69.2% of symptomatic patients and in 8.3% of presymptomatic carriers. Subjects with neuropathic pain were older (p = 0.015) had worse FAP stage (p < 0.001), higher NIS scores (p < 0.001), greater autonomic involvement (p = 0.003), and a lower QoL (p < 0.001) than those without neuropathic pain. Neuropathic pain was associated with higher pain severity (p < 0.001) and had a significant negative impact on daily activities (p < 0.001) Neuropathic pain was not associated with gender, mutation type, TTR therapy, or BMI. Conclusion Approximately 70% of late-onset ATTRv patients complained of neuropathic pain (DN4≥4) that worsened as peripheral neuropathy progressed and increasingly interfered with daily activities and QoL. Notably, 8% of presymptomatic carriers complained of neuropathic pain. These results suggest that assessment of neuropathic pain may be useful to monitor disease progression and identify early manifestations of ATTRv.
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Affiliation(s)
- Stefano Tozza
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples “Federico II”, Naples, Italy
| | - Marco Luigetti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurologia, Rome, Italy,Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Antonini
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University, Rome, Italy
| | - Anna Mazzeo
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Daniele Severi
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples “Federico II”, Naples, Italy
| | - Andrea Di Paolantonio
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy,U.O. Neurologia, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Luca Leonardi
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University, Rome, Italy
| | - Massimo Russo
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Angela Romano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurologia, Rome, Italy,Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesca Forcina
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University, Rome, Italy
| | - Luca Gentile
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Maria Nolano
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples “Federico II”, Naples, Italy,Neurology Department, Skin Biopsy Laboratory, Istituti Clinici Scientifici Maugeri IRCCS, Telese Terme, Italy
| | - Consalvo Mattia
- Department of Medical and Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, “Sapienza” University of Rome, Rome, Italy,Anesthesia, Intensive Care and Pain Unit, ICOT-Polo Pontino, Latina, Italy
| | - Fiore Manganelli
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples “Federico II”, Naples, Italy,*Correspondence: Fiore Manganelli ✉
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10
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Lee LY, Tan CY, Wong KT, Goh KJ, Shahrizaila N. Diagnostic yield of nerve biopsy in the evaluation of peripheral neuropathies. J Clin Neurosci 2023; 107:40-47. [PMID: 36502780 DOI: 10.1016/j.jocn.2022.11.017] [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: 09/09/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND With progress made in neurogenetics and neuroinflammation, the indications and value of nerve biopsies in the diagnostic evaluation of peripheral neuropathies are less clear. In this study, we aimed to evaluate the diagnostic yield of nerve biopsies in patients with peripheral neuropathies. METHODS We performed a retrospective review of nerve biopsy reports from April 1998 to June 2021 of patients with peripheral neuropathies presenting to the Department of Pathology, University of Malaya Medical Centre, Kuala Lumpur, Malaysia. The diagnostic value of the biopsies was determined based on the criteria by Midroni and Bilbao as follows: contributive (essential and helpful), non-contributive and inadequate. RESULTS A total of 107 nerve biopsies were analysed. Sixty-four (60 %) were males and the mean age was 52 years, ranging from 13 to 86 years. Ninety-four (88 %) were sural nerve biopsies; and only one patient (1 %) each had superficial peroneal and superficial radial nerve biopsy. The indications for the procedure were vasculitis (34 %), peripheral neuropathy of unknown aetiology (34 %), amyloidosis (14 %) and chronic inflammatory demyelinating polyneuropathy (10 %). In 68 (63 %) biopsies, the diagnostic value was contributive. Of these, 28 (26 %) were essential and 40 (37 %) were helpful. In contrast, 35 (33 %) biopsies were non-contributive and 4 (4 %) were inadequate. In 66 % (71/107) of cases, the nerve biopsy did not reveal a definite pathological diagnosis. However, in the remainder, a diagnosis of vasculitis (18 %, 19/107), followed by amyloidosis (10 %, 11/107) could be determined. For 32/71 biopsies with undetermined pathological diagnosis, neuropathy remained cryptogenic in 22 % (7/32) upon follow up. CONCLUSIONS With the exception of vasculitis and amyloidosis, there is limited value in performing nerve biopsies in the evaluation of patients with peripheral neuropathy. However, this should be interpreted with caution as the number of patients with a clinical diagnosis of vasculitis and amyloidosis were relatively larger than patients with other diagnosis. Refinement and careful selection of cases are required to increase the diagnostic yield of nerve biopsy.
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Affiliation(s)
- Ling Yi Lee
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Cheng Yin Tan
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Kum Thong Wong
- Department of Pathology, University of Malaya, Kuala Lumpur, Malaysia
| | - Khean Jin Goh
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nortina Shahrizaila
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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11
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Tozza S, Severi D, Palumbo G, Provitera V, Ruggiero L, Dubbioso R, Iodice R, Nolano M, Manganelli F. Quantitative Sensory Testing in Late-Onset ATTRv Presymptomatic Subjects: A Single Center Experience. Biomedicines 2022; 10:2877. [PMID: 36359398 PMCID: PMC9687694 DOI: 10.3390/biomedicines10112877] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 11/09/2023] Open
Abstract
Backgrounds Hereditary transthyretin amyloidosis (ATTRv) presymptomatic subjects undergo multidisciplinary evaluation to detect, as early as possible, a subclinical involvement of multisystem disease. Quantitative sensory testing (QST) that investigates and discriminates the function of C, Aδ and Aβ fibers is included as an instrumental test to monitor nerve fiber function. The purpose of this study was to evaluate the role of QST in the context of the multidisciplinary evaluation in late onset carriers. Methods Four-teen presymptomatic (namely carriers) were enrolled. Subjects underwent thermal [cold and warm detection threshold (CDT, WDT), cold and heat pain (CP and HP)] and tactile QST in four body sites: foot dorsum, distal lateral leg, distal thigh, hand dorsum. Results Overall, presymptomatic subject showed a significant difference in all thermal QST findings compared to the control group. All subjects had at least one altered thermal QST finding; the sites more frequently altered were foot and leg, whilst the thermal modalities which were more frequently abnormal were CDT, WDT and CP. Conclusions Our study highlights the importance of performing thermal QST in subjects carrying TTR mutation, given the high frequency of abnormal findings. Notably, performing both innocuous and painful stimulation in foot and/or leg increases the chance of detecting nerve fiber dysfunction. Moreover, the investigation of the hand may provide useful information in monitoring disease progression before the Predicted Age of Disease Onset (PADO).
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Affiliation(s)
- Stefano Tozza
- Department of Neuroscience, Reproductive Science and Odonstomatology, University “Federico II”, 80131 Naples, Italy
| | - Daniele Severi
- Department of Neuroscience, Reproductive Science and Odonstomatology, University “Federico II”, 80131 Naples, Italy
| | - Giovanni Palumbo
- Department of Neuroscience, Reproductive Science and Odonstomatology, University “Federico II”, 80131 Naples, Italy
| | - Vincenzo Provitera
- Neurology Department, Skin Biopsy Laboratory, Istituti Clinici Scientifici Maugeri IRCCS, 82037 Telese Terme, Italy
| | - Lucia Ruggiero
- Department of Neuroscience, Reproductive Science and Odonstomatology, University “Federico II”, 80131 Naples, Italy
| | - Raffaele Dubbioso
- Department of Neuroscience, Reproductive Science and Odonstomatology, University “Federico II”, 80131 Naples, Italy
| | - Rosa Iodice
- Department of Neuroscience, Reproductive Science and Odonstomatology, University “Federico II”, 80131 Naples, Italy
| | - Maria Nolano
- Department of Neuroscience, Reproductive Science and Odonstomatology, University “Federico II”, 80131 Naples, Italy
- Neurology Department, Skin Biopsy Laboratory, Istituti Clinici Scientifici Maugeri IRCCS, 82037 Telese Terme, Italy
| | - Fiore Manganelli
- Department of Neuroscience, Reproductive Science and Odonstomatology, University “Federico II”, 80131 Naples, Italy
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12
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Freeman R, Gonzalez-Duarte A, Barroso F, Campagnolo M, Rajan S, Garcia J, Kim JY, Wang N, Orellana L, Gibbons C. Cutaneous amyloid is a biomarker in early ATTRv neuropathy and progresses across disease stages. Ann Clin Transl Neurol 2022; 9:1370-1383. [PMID: 35945901 PMCID: PMC9463946 DOI: 10.1002/acn3.51636] [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: 04/29/2022] [Revised: 06/22/2022] [Accepted: 07/14/2022] [Indexed: 11/06/2022] Open
Abstract
Objective To determine the sensitivity and specificity of cutaneous amyloid deposition in relation to patient‐reported measures in the earliest disease stage of hereditary ATTR amyloidosis (ATTRv). Methods In a cross‐sectional study, we analyzed 88 individuals with TTR mutations, 47 of whom were in the earliest disease stage and without clinically evident neuropathy, 12 healthy controls, and 13 disease controls with diabetes. All participants' neuropathy symptoms and signs were assessed using validated patient and clinician‐reported measures and 3‐mm skin punch biopsies were immunostained using protein gene product 9.5 and Congo Red. Results Amyloid can be detected in the earliest disease stages in up to 86% of patients with ATTRv amyloidosis. Amyloid was not detected in healthy individuals or individuals with diabetic peripheral neuropathy supporting a sensitivity of 86% and a specificity of 100%. The cutaneous deposition of amyloid correlates with neuropathy sensory symptoms, measured with the Neuropathy Total Symptom Score‐6 (R = 0.46, p < 0.01); pain measured with the Brief Pain Symptom Inventory (R = 0.44, p < 0.05); autonomic symptoms, measured with the Boston Autonomic Symptom Questionnaire (R = 0.38, p < 0.05); and quality of life measured with the Norfolk Diabetic Neuropathy Quality of Life Questionnaire (R = 0.44, p < 0.05). Individuals with amyloid deposition were more likely to have sensory symptoms, pain, autonomic impairment, and reduced quality of life than ATTRv patients without amyloid deposition. Interpretation These findings have implications for understanding the earliest manifestations of the clinical phenotype of ATTRv‐associated neuropathy, for the pathophysiological construct of disease staging, and for timing the introduction of disease‐modifying therapy.
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Affiliation(s)
- Roy Freeman
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Fabio Barroso
- Raúl Carrea Institute for Neurological Research, FLENI, Ciudad Autónoma de Buenos Aires, Argentina
| | - Marta Campagnolo
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sharika Rajan
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer Garcia
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jee Young Kim
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ningshan Wang
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lucas Orellana
- Raúl Carrea Institute for Neurological Research, FLENI, Ciudad Autónoma de Buenos Aires, Argentina
| | - Christopher Gibbons
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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13
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Luigetti M, Guglielmino V, Romozzi M, Romano A, Di Paolantonio A, Bisogni G, Sabatelli E, Modoni A, Sabatelli M, Servidei S, Lo Monaco M. Nerve Conduction Studies of Dorsal Sural Nerve: Normative Data and Its Potential Application in ATTRv Pre-Symptomatic Subjects. Brain Sci 2022; 12:brainsci12081037. [PMID: 36009100 PMCID: PMC9406159 DOI: 10.3390/brainsci12081037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 11/16/2022] Open
Abstract
The objective of the study is to provide age-related normative values for dorsal sural nerve (DSN) and to analyse its application during follow-up of hereditary transthyretin amyloidosis (ATTRv) pre-symptomatic subjects. We consecutively recruited ATTRv pre-symptomatic carriers in which clinical examination, cardiological evaluation, and nerve conduction studies of the sural nerve and DSN were performed. To provide normative data of DSN, neurophysiologic parameters from healthy controls referred to our service were entered into linear regression analyses to check the relative influence of age and height. A correction grid was then derived. We collected 231 healthy subjects: the mean DSN sensory nerve action potential (SNAP) amplitude was 9.99 ± 5.48 μV; the mean conduction velocity was 49.01 ± 5.31 m/s. Significant correlations were found between age and height with DSN SNAP amplitude. Fifteen ATTRv pre-symptomatic carriers were examined. Sural nerve NCS were normal in 12/15 and revealed low/borderline values in three subjects. Considering our correction grid, we found an abnormal DNS amplitude in 9/15 subjects and low/borderline values in 2/15. In ATTRv, early detection of peripheral nerve damage is crucial to start a disease-modifying treatment. DSN may be easily and reliably included in the routine neurophysiological follow-up of ATTRv pre-symptomatic subjects.
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Affiliation(s)
- Marco Luigetti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurologia, 00168 Rome, Italy
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-06-30154435
| | - Valeria Guglielmino
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Marina Romozzi
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Angela Romano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurologia, 00168 Rome, Italy
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Andrea Di Paolantonio
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giulia Bisogni
- Centro Clinico NEMO, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy
| | - Eleonora Sabatelli
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Anna Modoni
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurologia, 00168 Rome, Italy
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Mario Sabatelli
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Centro Clinico NEMO, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy
| | - Serenella Servidei
- Dipartimento Di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurofisiopatologia, 00168 Rome, Italy
| | - Mauro Lo Monaco
- MiA Onlus (“Miotonici in Associazione”), 80055 Portici, Italy
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14
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Du K, Chu X, Tang Y, Zhao X, Yu M, Zheng Y, Deng J, Lv H, Zhang W, Wang Z, Yuan Y, Meng L. Patterns of myelinated nerve fibers loss in transthyretin amyloid polyneuropathy and mimics. Ann Clin Transl Neurol 2022; 9:1059-1068. [PMID: 35665499 PMCID: PMC9268867 DOI: 10.1002/acn3.51599] [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: 02/15/2022] [Revised: 05/02/2022] [Accepted: 05/12/2022] [Indexed: 11/10/2022] Open
Abstract
Objective The present study was intended to analyze the characteristics of myelinated nerve fibers density (MFD) of transthyretin amyloid polyneuropathy (ATTR‐PN) and other similar neuropathies. Methods A total of 41 patients with ATTR‐PN, 58 patients of other common peripheral neuropathies, and 17 age‐and gender‐matched controls who visited the First Hospital of Peking University and performed sural nerve biopsy between June 2007 and August 2021 were included for analysis of MFD. Results Except the vasculitic neuropathy group, the total and small MFD of patients in the ATTR‐PN group were significantly lower than those of other disease groups. There was an obvious negative correlation between the total MFD and the disease course in the ATTR‐PN group. The disease course of early‐onset and late‐onset symptoms was similar, but the loss of large myelinated nerve fibers (MF) was more severe for the latter. In addition, all late‐onset and most early‐onset patients had severely reduced MFD after a 2 years' disease course. The MFD in ATTR‐PN patients was negatively correlated with Neuropathy Impairment Score (NIS) and Norfolk Quality of life‐diabetic neuropathy (Norfolk QOL‐DN) score. Conclusion MF is lost differently in ATTR‐PN and in other common peripheral neuropathies. The late‐onset and early‐onset ATTR‐PN patients have different patterns of loss of large and small MF.
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Affiliation(s)
- Kang Du
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Xujun Chu
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Yuwei Tang
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Xutong Zhao
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Meng Yu
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Yiming Zheng
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Jianwen Deng
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - He Lv
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Wei Zhang
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Zhaoxia Wang
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Yun Yuan
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
- Beijing Key Laboratory of Neurovascular Disease Discovery Beijing 100034 China
| | - Lingchao Meng
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
- Beijing Key Laboratory of Neurovascular Disease Discovery Beijing 100034 China
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Di Stefano V, Fava A, Gentile L, Guaraldi P, Leonardi L, Poli L, Tagliapietra M, Vastola M, Fanara S, Ferrero B, Giorgi M, Perfetto F, Russo M, Russo D. Italian Real-Life Experience of Patients with Hereditary Transthyretin Amyloidosis Treated with Patisiran. Pharmgenomics Pers Med 2022; 15:499-514. [PMID: 35592550 PMCID: PMC9113125 DOI: 10.2147/pgpm.s359851] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/22/2022] [Indexed: 12/02/2022] Open
Abstract
Hereditary transthyretin amyloidosis (ATTRv) is a multisystemic, rare, inherited, progressive and adult-onset disease, affecting the sensorimotor nerves, heart, autonomic function and other organs. The actual scenario of pharmaceutical approaches for ATTRv amyloidosis includes five main groups: TTR stabilizers, TTR mRNA silencers, TTR fibril disruptors, inhibitor of TTR fibril seeding and gene therapy. Patisiran is a small, double-stranded interfering RNA encapsulated in a lipid nanoparticle, able to penetrate into hepatocytes, where it selectively targets TTR mRNA, reducing TTR production. We report and discuss 9 cases of different patients with ATTRv amyloidosis successfully managed with patisiran in the real clinical practice. Literature data, as well as the above presented case reports, show that this drug is effective and safe in improving both neurological and cardiovascular symptoms of ATTRv amyloidosis, and to maintain a good QoL, independently form the stage of the disease and the involved mutation. Recent studies correlated improved functional and biochemical outcomes with a regression of amyloid burden, especially at the cardiac level. Today, patisiran can be considered a valid therapeutic option for the management of patients with ATTRv amyloidosis and polyneuropathy and cardiovascular symptoms.
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Affiliation(s)
- Vincenzo Di Stefano
- Department of Biomedicine, Neuroscience and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
- Correspondence: Vincenzo Di Stefano, Department of Biomedicine, Neuroscience and advanced Diagnostic (BIND), University of Palermo Palermo, Italy, Via del Vespro 143, Palermo, 90127, Italy, Tel +39 3285781786, Fax +390916552974, Email
| | - Antonella Fava
- Division of Cardiology, Heart Vascular and Thoracic Department, Città della Salute e della Scienza (Molinette Hospital- University of Turin), Turin, Italy
| | - Luca Gentile
- Unit of Neurology and Neuromuscular Disease, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Pietro Guaraldi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Luca Leonardi
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome Sant’Andrea Hospital, Rome, Italy
| | - Loris Poli
- Department of Neurology, ASST Spedali Civili, Brescia, Italy
| | - Matteo Tagliapietra
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Michele Vastola
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
- Neurosciences Department, Florence University, Rome, Italy
| | - Salvatore Fanara
- Department of Biomedicine, Neuroscience and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - Bruno Ferrero
- SC Neurology 2U, Department of Neuroscience “Rita Levi Montalcini”, Città della Salute e della Scienza (Molinette Hospital -University of Turin), Turin, Italy
| | - Mauro Giorgi
- Division of Cardiology, Heart Vascular and Thoracic Department, Città della Salute e della Scienza (Molinette Hospital- University of Turin), Turin, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Massimo Russo
- Unit of Neurology and Neuromuscular Disease, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Domitilla Russo
- Division of Cardiology, Department of Clinical and Molecular Medicine, St. Andrea Hospital, Sapienza University, Rome, Italy
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A compound score to screen patients with hereditary transthyretin amyloidosis. J Neurol 2022; 269:4281-4287. [PMID: 35279758 PMCID: PMC9293821 DOI: 10.1007/s00415-022-11056-4] [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: 12/01/2021] [Revised: 02/26/2022] [Accepted: 02/28/2022] [Indexed: 11/16/2022]
Abstract
Background Hereditary transthyretin amyloidosis (ATTRv) is a rare, debilitating and fatal disease, mostly characterized by progressive axonal peripheral neuropathy. Diagnosis is still challenging and diagnostic delay in non-endemic area is about 3–4 years. The aim of this study was to arrange a clinical and electrophysiological score to select patients with axonal neuropathy that deserve screening for TTR mutation. Methods Thirty-five ATTRv patients and 55 patients with chronic idiopathic axonal polyneuropathy (CIAP) were retrospectively analyzed. Clinical and electrophysiological findings at first evaluation were collected. Based on significant results between the two groups, a compound (clinical and electrophysiological) score was arranged, and ROC analysis was performed to identify the ideal cut-off able to discriminate between the two groups. Results ATTRv patients presented a later age at onset, more frequent muscle weakness and carpal tunnel syndrome history. On the other hand, electrophysiological analysis showed that ATTRv patients had lower CMAP and SAP amplitude in all examined nerves. We arranged a compound score constituted by 7 total items, ranging from 0 to 12. ROC analysis showed an Area Under the Curve = 0.8655 and we set the cut-off ≥ 5 points to discriminate ATTRv patients with a sensitivity of 96.6% and a specificity of 63.6%. Conclusion Our study demonstrated that our compound score with cut-off ≥ 5 allows to discriminate ATTRv patients among subject affected by axonal polyneuropathy with a sensitivity > 95%. Thus, our compound score is a quick, easy and effective screening tool.
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Khan FA, Rohatgi S, Nirhale S, Manohar P, Rao P, Naphade P, Dave D, Sravya Kotaru VV, Gupta S, Gitay A, Dubey P. Novel transthyretin gene mutation in familial amyloid neuropathy in India: Case. Ann Afr Med 2022; 21:296-298. [DOI: 10.4103/aam.aam_260_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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18
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The Value of Nerve Biopsy in Transthyretin Amyloidosis with Competing Comorbidities. Can J Neurol Sci 2021; 49:725-727. [PMID: 34275504 DOI: 10.1017/cjn.2021.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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19
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Leonardi L, Galosi E, Vanoli F, Fasolino A, Di Pietro G, Luigetti M, Sabatelli M, Fionda L, Garibaldi M, Alfieri G, Lauletta A, Morino S, Salvetti M, Truini A, Antonini G. Skin biopsy and quantitative sensory assessment in an Italian cohort of ATTRv patients with polyneuropathy and asymptomatic carriers: possible evidence of early non-length dependent denervation. Neurol Sci 2021; 43:1359-1364. [PMID: 34189665 DOI: 10.1007/s10072-021-05434-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/24/2021] [Indexed: 12/29/2022]
Abstract
AIM Study of intraepidermal nerve fiber density (IENFD) by skin biopsy represents a promising tool in the evaluation of patients with ATTRv polyneuropathy (ATTRv-PN). Herein, we retrospectively analyze intraepidermal innervation and quantitative sensory test (QST) data from an Italian cohort of Italian ATTRv-PN patients and asymptomatic carriers aimed to provide insights into early nerve pathological and functional changes in this disease. METHODS IENFD and QST data of 14 ATTRv-PN patients and 14 asymptomatic carriers were retrospectively analyzed together with clinical and paraclinical data such as disease stage and severity, neuropathic pain scales, and sural SNAP amplitude. RESULTS Given an estimated time to the predicted age of onset of symptomatic disease of 20.27 + / - 7.9 years, small nerve fiber loss seems to be unexpectedly early in carriers. Moreover, carriers showed skin denervation at the proximal (thigh) site, suggesting a non-length-dependent neuropathic process. IENFD at ankle correlated with disease severity and other paraclinical variables such as sural nerve potential amplitude and QST parameters. Patients at earlier stages of the disease did not show significant differences in ankle IENFD compared with asymptomatic carriers, but significant differences in terms of QST parameters, small fiber neuropathy symptoms, and neuropathic pain. CONCLUSIONS Skin biopsy can disclose an early non-length-dependent small fiber loss in ATTRv-PN and, together with QST, could provide a useful insight disease onset and progression.
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Affiliation(s)
- Luca Leonardi
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sant'Andrea Hospital, Sapienza University of Rome, 1035-39 Grottarossa St., Rome, Italy.
| | - Eleonora Galosi
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Fiammetta Vanoli
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sant'Andrea Hospital, Sapienza University of Rome, 1035-39 Grottarossa St., Rome, Italy
| | | | - Giuseppe Di Pietro
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Marco Luigetti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurologia, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mario Sabatelli
- Università Cattolica del Sacro Cuore, Rome, Italy.,Centro Clinico NEMO, Rome, Italy
| | - Laura Fionda
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sant'Andrea Hospital, Sapienza University of Rome, 1035-39 Grottarossa St., Rome, Italy
| | - Matteo Garibaldi
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sant'Andrea Hospital, Sapienza University of Rome, 1035-39 Grottarossa St., Rome, Italy
| | - Girolamo Alfieri
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sant'Andrea Hospital, Sapienza University of Rome, 1035-39 Grottarossa St., Rome, Italy
| | - Antonio Lauletta
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sant'Andrea Hospital, Sapienza University of Rome, 1035-39 Grottarossa St., Rome, Italy
| | - Stefania Morino
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sant'Andrea Hospital, Sapienza University of Rome, 1035-39 Grottarossa St., Rome, Italy
| | - Marco Salvetti
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sant'Andrea Hospital, Sapienza University of Rome, 1035-39 Grottarossa St., Rome, Italy
| | - Andrea Truini
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Giovanni Antonini
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sant'Andrea Hospital, Sapienza University of Rome, 1035-39 Grottarossa St., Rome, Italy
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20
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Tozza S, Severi D, Spina E, Iovino A, Aruta F, Ruggiero L, Dubbioso R, Iodice R, Nolano M, Manganelli F. The neuropathy in hereditary transthyretin amyloidosis: A narrative review. J Peripher Nerv Syst 2021; 26:155-159. [PMID: 33960565 PMCID: PMC8360044 DOI: 10.1111/jns.12451] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/26/2021] [Accepted: 05/01/2021] [Indexed: 01/10/2023]
Abstract
Hereditary transthyretin amyloidosis (ATTRv) is a condition with adult onset, caused by mutation of the transthyretin (TTR) gene and characterized by extracellular deposition of amyloid fibrils in tissue, especially in the peripheral nervous system (PNS) and heart. PNS involvement leads to a rapidly progressive and disabling sensory‐motor axonal neuropathy. Although awareness among neurologists increased in recent years thanks to new treatment options, ATTRv is frequently misdiagnosed, and thus a correct diagnosis can be delayed by several years. This review aims to draw the history and features of polyneuropathy in ATTRv based on pathological and electrophysiological correlates. We assessed original articles and case reports based on their relevance to ATTRv neuropathy and we included those appropriate for the scheme of this narrative review. Amyloid fibrils initially deposit in ganglia, causing an axonal neuropathy without amyloid deposits in distal segments (eg, sural nerve biopsy). Over time, amyloid fibrils spread along the nerves, leading to some demyelinating features in the context of severe axonal loss. This review highlights how the features of neuropathy change based on type of ATTRv (early vs late onset) and stage of disease.
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Affiliation(s)
- Stefano Tozza
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Daniele Severi
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Emanuele Spina
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Aniello Iovino
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Francesco Aruta
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Lucia Ruggiero
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Raffaele Dubbioso
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Rosa Iodice
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Maria Nolano
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Fiore Manganelli
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
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Nerve Biopsy in Peripheral Neuropathies: Not All Water Is under the Bridge. Brain Sci 2021; 11:brainsci11050550. [PMID: 33925500 PMCID: PMC8145769 DOI: 10.3390/brainsci11050550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/22/2021] [Indexed: 11/24/2022] Open
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22
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Patisiran in hATTR Amyloidosis: Six-Month Latency Period before Efficacy. Brain Sci 2021; 11:brainsci11040515. [PMID: 33921571 PMCID: PMC8073153 DOI: 10.3390/brainsci11040515] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 01/29/2023] Open
Abstract
Hereditary amyloidosis associated with mutations in the transthyretin gene (hATTR) is a progressive devastating disease, with a fatal outcome occurring within 10years after onset. In recent years, TTR gene silencing therapy appeared as a promising therapeutic strategy, showing evidence that disease progression can be slowed and perhaps reversed. We report here 18 subjects affected by hATTR amyloidosis treated with patisiran, a small interfering RNA acting as TTR silencer, and evaluated with a PND score, the NIS and NIS-LL scale, and a Norfolk QOL-DN questionnaire at baseline and then every 6 months. A global clinical stabilizationwas observed for the majority of the patients, with mild-moderate improvements in some cases, even in advanced disease stage (PND score > 2). Analysis of NIS, NIS-LL and Norfolk QOL-DN results, and PND score variation suggest the possible presence of a 6-month latency period prior to benefit of treatment.
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Mechanisms of Nerve Damage in Neuropathies Associated with Hematological Diseases: Lesson from Nerve Biopsies. Brain Sci 2021; 11:brainsci11020132. [PMID: 33498362 PMCID: PMC7909400 DOI: 10.3390/brainsci11020132] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 12/15/2022] Open
Abstract
Despite the introduction of non-invasive techniques in the study of peripheral neuropathies, sural nerve biopsy remains the gold standard for the diagnosis of several neuropathies, including vasculitic neuropathy and neurolymphomatosis. Besides its diagnostic role, sural nerve biopsy has helped to shed light on the pathogenic mechanisms of different neuropathies. In the present review, we discuss how pathological findings helped understand the mechanisms of polyneuropathies complicating hematological diseases.
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Advances in Treatment of ATTRv Amyloidosis: State of the Art and Future Prospects. Brain Sci 2020; 10:brainsci10120952. [PMID: 33316911 PMCID: PMC7763612 DOI: 10.3390/brainsci10120952] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/05/2020] [Accepted: 12/07/2020] [Indexed: 02/07/2023] Open
Abstract
Hereditary amyloid transthyretin (ATTRv) amyloidosis with polyneuropathy is a progressive disease that is transmitted as an autosomal dominant trait and characterized by multiple organ failure, including axonal sensory-motor neuropathy, cardiac involvement, and autonomic dysfunction. Liver transplantation (LT) and combined heart-liver transplantation, introduced in the 1990s, have been the only therapies for almost two decades. In 2011, tafamidis meglumine became the first specific drug approved by regulatory agencies, since then the attention toward this disease has progressively increased and several drugs with different mechanisms of action are now available. This review describes the drugs already on the market, those that have shown interesting results although not yet approved, and those currently being tested.
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