Challenges in Fabry disease: the combination of two individually amenable GLA variants may be nonamenable to migalastat

Fabry disease is a rare lysosomal storage disorder caused by mutations in the GLA gene, resulting in reduced or absent α-Gal A activity. Migalastat is an oral chaperone therapy for Fabry patients with amenable GLA variants. We previously reported a case of a 60-year-old male patient with a classic phenotype of Fabry disease, presenting with two GLA variants: p.R356Q and p.G360R. Herein, we report that, although these two missense variants are individually classified as amenable to migalastat in the validated in vitro human embryonic kidney-293 cell-based assay, their combination precludes the patient to be treated with this oral chaperone. This case illustrates how therapeutic decisions may be challenging and how a good genotypic characterization of Fabry patients is critical for the selection of the correct therapeutic strategy.

Contrast-induced nephropathy following PCI: can we calculate a safe contrast volume?

Introduction

Acute kidney injury (AKI) due to contrast induced nephropathy (CIN) is a common complication after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS), and is associated with prolonged hospitalizations and elevated cardio and renovascular morbidity. Scientific evidence demonstrates that the mean volume of contrast (VolC) and ratio with creatinine clearance (CrCl) (VolC/CrCl) are independent predictors of CIN, but the accepted optimal value remains controversial.

Objective

Population characterization. To evaluate whether the calculation of VolC using the VolC/ClCr ratio <3.7 used in our Cath lab during PCI of ACS allows preventing the development of AKI by CIN, and whether the development of early vs late AKI influences outcomes.

Methods

Retrospective study between 2017/2020, composed of n=378 patients who suffered ACS. Descriptve analysis was carried out regarding the demographic and clinical characteristics of the patients. Chi-Square test was used for categorical variables and the T-Student test for numerical variables, with a significance level of 95%.

Results

A total of 378 patients were identified, with a mean age of 64.5±11.2 years, 78.6% were male. 60.1% had hypertension, 48.4% dyslipidemia, 24.3% diabetes, 2.6% chronic renal failure (CRF) and 1.6% heart failure. Of these, 12.7% developed AKI (<24h in 1.9% vs ≥24h in 10,8%). Indepedent prognostic factors for development of AKI were smokers (AKI ≥24h 7 (4.8%) vs AKI<24h 2 (1.4%), p=0.001), diabetes (AKI≥24h 17 (19%) vs AKI <24h 2 (2.2%), p=0.007), CRF (AKI ≥24h 6 (60%) vs AKI <24h 1 (10%), p=0.001), CrCl (AKI ≥24h 65.8±27.1, p=0.001), ratio VolC/CrCl (AKI ≥24h 3.3±2.5, p=0.001) and LVEF (AKI ≥24h 51.4±9.7, p=0.001). Mortality afected 4.2% of the patients, and was more frequente in AKI subjects (AKI ≥24h 7 (70%) vs AKI <24h 1 (10%), p=0.001). Using a ratio <3.7 allowed to prevent AK <24h but not AKI ≥24h (AKI <24h ratio <3.7 = 3 (1%) vs ratio ≥3.7 = 9 (4.1%), p=0.001) (AKI ≥24 ratio <3.7 = 30 (25%) vs ratio ≥3.7 = 11 (9.7%), p=0.001). A ratio <2.0 allowed to prevent both early and late AKI (AKI <24h ratio <2.0 = 0 (0%) vs ratio ≥2.0 = 7 (4.5%), p=0.001) (AKI ≥24 ratio <2.0 = 11 (5.6%) vs ratio ≥2.0 = 30 (19.1%), p=0.001).

Conclusion

In patients submitted to ACS PCI, the development of AKI increases mortality, especial if AKI emerge after 24h. We report a more suitable ratio VolC/ClCr <2.0, that allow us to calculate a safe VolC that will help to prevent both early and late AKI in selected patients wtih ACS.

Funding Acknowledgement

Type of funding sources: None.

[Asymptomatic aortic dissection with large aneurysm of the ascending and the transverse aorta. Report of a case]

The authors present a cae of asymptomatic type I of the DeBakey aortic dissection with a voluminous aneurysm of the false channel. In the absence of suggestive symptoms, the diagnosis was established by chance through two dimensional echocardiography and later confirmed by magnetic resonance imaging. They ignore the period of time between the beginning of the dissection and the diagnosis, but they consider that it could have exceeded five years. During that time, besides as well tolerated aortic incompetence and aneurysmatic enlargement of the false channel, no other problems were detected. Based on this case, the authors are going through the literature and are discussing the importance of some noninvasive imaging techniques in the diagnosis and follow-up of this patients.

[Pulmonary embolism. A propos of a case treated with APSAC]

One describes the clinical case of a patient suffering from massive pulmonary embolism under a state of shock who was successfully treated with APSAC 30 units in one single bolus. Thrombolytic agents provoke a rapid destruction of thrombi which lead to a very important and fast hemodynamic improvement. These agents have a great improving action, compared to heparin, in the alterations of pulmonary diffusion provoked by embolism. Most of the times, they also avoid surgery and the appearance of cor pulmonale. APSAC seems to be effective and secure.

[Pneumopyopericardium]

Pneumopyopericardium is a rare disease. The most common causes seems to be ulceration or carcinoma in the lower esophagus or upper stomach. We report a case of pneumopiopericardium secondary to a pneumonia in a 60 years-old-woman after the first course of chemotherapy for acute myeloid leukemia. We use this case as a basis for a review of the literature on similar cases. This syndrome can be recognised promptly because of its characteristic physical findings and radiographic features.