Wilson disease

Living Donor Liver Transplantation for Pediatric Wilson's Disease-related Acute Liver Failure-Hard Work With High Rewards

Background

Liver transplantation (LT) is indicated for children with Wilson's disease (WD) presenting with acute liver failure (ALF) or with chronic liver disease (CLD) that has progressed to decompensation. We present our experience of living donor liver transplantation (LDLT) for pediatric WD, discuss the challenges of managing WD-ALF and compare outcomes of children presenting with WD-ALF with WD-CLD.

Methods

We compared presentation and outcomes of the WD-ALF and WD-CLD cohorts. Fifty-three children (WD-ALF: 28 (53%), WD-CLD: 25 (47%)) underwent LDLT for WD.

Results

WD-ALF group had higher Kings New Wilson Index (KNWI) (15 vs 9, P = 0.001), higher pediatric end-stage liver disease/model for end-stage liver disease score (35 vs 20, P = 0.001), were more frequently encephalopathic (64% vs 4%, P = 0.001), and had ongoing hemolysis (86% vs 28%, <0.001). Preoperative mechanical ventilation, operative continuous renal replacement therapy (CRRT), therapeutic plasma exchange (TPE) was needed in 32%, 46.5%, and 89% of WD-ALF children, respectively. WD-ALF patients had longer postoperative ICU stay (4.5 days vs 3 days, P = 0.001), longer hospital stay (20.5 days vs 14 days, P = 0.001), more major complications (57% vs 20%, P = 0.006). WD-ALF cohort also had more postoperative neurological complications (42.9% vs 8%, P = 0.004) and invasive fungal infections (21.4% vs none, P = 0.024). There were two perioperative (90 day) mortalities in WD-ALF group and none in WD-CLD group. Patient survival of the entire cohort at median follow-up of 26 months was 94.3% and all survivors had good allograft function neurological sequelae. Patient survival was inferior for WD-ALF cohort though the difference was not statistically significant (88.5% vs 100%, log rank test, P = 0.089).

Conclusion

LDLT is a curative treatment for children with WD with excellent short-term and long-term outcomes. WD-ALF patients can have a complicated postoperative course but have good long-term survival.

Challenges and Recent Advances in Diagnosing Wilson Disease

Wilson disease (WD) is a rare autosomal recessive disorder caused by ATP7B gene mutations, leading to pathological copper accumulation that primarily affects the liver, brain, and eyes. Diagnosing WD remains a significant challenge due to its highly variable clinical presentation, which ranges from asymptomatic biochemical abnormalities to acute liver failure and severe neuropsychiatric manifestations. Traditional diagnostic markers, such as serum ceruloplasmin, urinary copper excretion, and liver biopsy, lack sufficient specificity and sensitivity, often leading to delays in diagnosis and misclassification. Additionally, the absence of a single gold-standard test and the overlap with other hepatic and neurological disorders further complicate early detection. Recent advances in diagnostic techniques offer promising solutions to overcome these limitations. Novel biomarkers, including relative exchangeable copper (REC) and ATP7B protein quantification in dried blood spots have demonstrated improved accuracy in distinguishing WD from other conditions. Advanced imaging modalities, such as anterior segment optical coherence tomography (AS-OCT), quantitative susceptibility mapping (QSM), and copper-64 positron emission tomography imaging provide noninvasive tools for detecting early disease-related changes. Furthermore, next-generation sequencing (NGS) enhances genetic screening, facilitating earlier diagnosis, and family screening. A comprehensive approach integrating conventional and emerging diagnostic methodologies is essential for improving early detection and patient outcomes. Greater awareness of the limitations of traditional tests and the incorporation of novel biomarkers and imaging techniques into clinical practice can help refine diagnostic accuracy, reduce delays, and optimize treatment strategies for WD.

Cuproptosis, a potential target for the therapy of diabetic critical limb ischemia

Diabetic patients are considered as the high risk population to develop critical limb ischemia (CLI), a peripheral vascular disease (PVD) resulted from atherosclerosis. Cuproptosis is a novel copper-dependent cell death that has shown the regulatory role in diabetes, while its effect on diabetic CLI has not been explored yet. In this study, Diabetic CLI mice was induced by femoral artery ligation (FAL) on diabetic mice. Endothelial injury in diabetic CLI was mimicked in human microvascular endothelial cells (HMEC-1) via the induction with high glucose (HG) and nutrient deprivation (ND). Besides, copper chelator Ammonium Tetrathiomolybdate (TM), which has shown the anti-cuproptosis property, was administrated to explore its potential effects on diabetic CLI mice and HG/ND-induced HMEC-1 cells. Strikingly, obvious cuproptosis was found in the gastrocnemius muscles of diabetic CLI mice and HG/ND-induced HMEC-1 cells, as evidenced by the copper overload and dysregulated cuproptosis-related proteins (such as Fe-S cluster proteins, copper exporter ATP7A, and copper importer SLC31A1). More importantly, TM protected against the hindlimb ischemic damages in diabetic CLI mice and alleviated cuproptosis-associated cell deaths in HG/ND-induced HMEC-1 cells. In summary, this study indicates the involvements of cuproptosis in diabetic CLI, and provides novel insights into copper chelator TM on diabetic CLI therapy.

The Elements of Life, Photosynthesis and Genomics

I am a Professor of Biochemistry, Biophysics and Structural Biology and Plant and Microbial Biology at the University of California in Berkeley. I was born and raised in India, emigrated to the United States to attend university, earning a B.S. in Molecular Biology and a Ph.D. in Biochemistry at the University of Wisconsin in Madison. Following post-doctoral studies with Lawrence Bogorad at Harvard University where I became interested in genetic control of trace element quotas, I joined the department of Chemistry and Biochemistry at UCLA. One of the first to appreciate essential trace metals as potential regulators of gene expression, I articulated the details of the nutritional Cu regulon in Chlamydomonas. In parallel, I used genetic approaches to discover the genes governing missing steps in tetrapyrrole metabolism, including the attachment of heme to apocytochromes in the thylakoid lumen and the factors catalyzing the formation of ring V in chlorophyll. After biochemistry and classical genetics, I embraced genomics, taking a leadership role on the Joint Genome Institute's efforts on the Chlamydomonas genome and more recently, contributing to high quality assemblies of several genomes in the green algal radiation, and large transcriptomic and proteomic datasets - focusing on the diel metabolic cycle in synchronized cultures and acclimation to key environmental and nutritional stressors - that are well-used and appreciated by the community. A new venture in Berkeley is the promotion of Auxenochlorella protothecoides as the true "green yeast" and as a platform for engineering algae to produce useful bioproducts.

A functional seizure case in Wilson's disease

Wilson's disease (WD) is a rare disorder characterized by abnormal copper metabolism, leading to its accumulation in various tissues, particularly the brain and the liver. Psychiatric and neurological symptoms are common manifestations of WD. We present a case of a 22-year-old woman diagnosed with WD who exhibited neurological symptoms and experienced functional seizures (FS) that were misdiagnosed as epilepsy secondary to WD for almost two years. The patient's history of childhood trauma and interpersonal difficulties underscored the complex interplay between organic and psychogenic factors contributing to FS development. This case highlights the diagnostic challenges associated with the neuropsychiatric manifestations of Wilson's disease, as well as the complexities in differentiating functional seizures from epilepsy. It emphasizes the importance of comprehensive assessment and multidisciplinary care in optimizing patient outcomes.

Advancements in diagnostic approaches for Wilson's disease

Wilson's disease (WD) is a genetic disorder that results in excessive copper build-up in tissues, causing significant liver and neurological damage. Early and accurate diagnosis is crucial for effective management and treatment. Traditional diagnostic methods, including serum ceruloplasmin and urinary copper level monitoring, liver biopsy and genetic testing, are limited by sensitivity, specificity, invasiveness, and accessibility. Recent advances in diagnostic technologies offer new hope for more accurate, rapid, and non-invasive detection of WD. In this regard, nanotechnology-driven formulations hold significant promise for both the early diagnosis and treatment of WD. Through the innovative use of advanced nanomaterials, researchers are developing more effective therapeutic options and highly sensitive diagnostic tools, potentially transforming the management and prognosis of this genetic disorder. This review provides a comprehensive analysis of recent advancements in WD diagnostics, focusing on research published since 2016. It explores the development and application of novel biomarkers, advanced imaging modalities, innovative biosensors, and emerging nanotechnology-based approaches. By integrating these cutting-edge methodologies, the review highlights their potential to enhance early and accurate detection of WD, addressing current diagnostic challenges and improving clinical outcomes.

Hypoxia inducible factor-1α drives cancer resistance to cuproptosis

Cuproptosis represents a new type of cell death that intricately associated with copper homeostasis and protein lipoylation. The cuproptosis suppression has been characterized in the hypoxic tumor microenvironment (TME). Here we reveal that hypoxia inducible factor-1α (HIF-1α) is a driver of cuproptosis resistance in solid tumor. We found that HIF-1α activates pyruvate dehydrogenase kinase 1 and 3 (PDK1/3), resulting in decreased expression of dihydrolipoamide S-acetyltransferase (DLAT) (target of copper), and promotes the accumulation of metallothionein, which sequesters mitochondrial copper, leading to resistance to cuproptosis under hypoxic conditions. Furthermore, we discovered that high levels of copper reduce ubiquitination and increase the stability of HIF-1α protein without affecting its mRNA levels. Inhibition of HIF-1α increases the susceptibility of cancer to cuproptosis in vivo. This study unveils the multifaceted role of HIF-1α in cuproptosis and demonstrates the molecular mechanism of hypoxia-promoted carcinogenesis.

Photoactivated in-situ engineered-bacteria as an efficient H2S generator to enhance photodynamic immunotherapy via remodeling the tumor microenvironment

Based on the unique biological advantages of bacteria and their derivatives, biosynthetic nanomaterials have been widely used in the field of tumor therapy. Although conventional bacterial treatments demonstrate potential in activating tumor immunity, their efficacy in inhibiting tumor growth remains constrained. In this study, a photoactivated hydrogen sulfide (H2S) generator was successfully prepared by in-situ engineering of bacteria, after Pt/MoS2 nanocomposites were in-situ generated by Escherichia coli (E. coli) and loaded with photosensitizer Ce6. This engineered-bacteria has been proved to have good tumor targeting ability and can enhance the effect of photodynamic therapy in the hypoxic tumor microenvironment. While reactive oxygen species (ROS) is effectively released, the fragmentation of bacteria can accelerate the release of abundant H2S, and promote tumor-specific H2S gas therapy, which can effectively remodel the tumor microenvironment and promote the activation of anti-tumor immunotherapy. This engineered bacteria not only improves the tumor specificity and effectiveness of H2S treatment, but also provides a new idea for nanomaterials in bacterial-mediated synergistic cancer treatment.

Current Management of Neurological Wilson's Disease

Wilson's disease (WD) is a disorder of copper metabolism due to variants in the ATP7B gene. This autosomal recessively inherited disorder is characterized by the accumulation of copper in various body parts, mainly the liver, brain, and kidneys. Initially, WD was described to involve the hepatic and neurological systems. Subsequently, diverse presentations have been reported with skeletal and hematological manifestations and various constellations of symptoms. Neurological manifestations of WD are varied, ranging from asymptomatic neurological state to refractory dystonia. Earlier, the diagnosis was based only on measuring serum ceruloplasmin levels, urinary copper levels, and imaging. Advanced genetic testing has provided an additional mode of diagnosis in the patient, screening of the family members and, a way to better understand the genotype-phenotype associations of the disease if there are any. In the last few decades, the treatment of WD has evolved from symptomatic treatment and chelation therapy to many new advanced measures for both copper chelation and symptomatic relief. With a better understanding of the genetic aspects of WD in recent years, there has been more focus on gene therapy, novel therapies targeting ATP7B genes, and therapies targeting mutant proteins to prevent copper accumulation. This article highlights the advances in diagnostic methods and treatment modalities in WD.

Novel Mutation at Cys225 in GNAO1-Associated Developmental and Epileptic Encephalopathies: Clinical, Molecular, and Pharmacological Profiling of Case Studies

GNAO1-associated disorders have a large spectrum of neurological symptoms, from early-onset developmental and epileptic encephalopathies (DEE) to late-onset movement disorders. First reported in 2013 and now identified in around 400 cases worldwide, this disease is caused by dominant, mostly de novo missense mutations in GNAO1, the gene encoding the major neuronal G protein Gαo. Being the immediate transducer of a number of neuronal G protein-coupled receptors, Gαo plays crucial functions in brain development and physiology. Here, we discover a novel mutation site in GNAO1, Cys225 mutated to Tyr or Arg in pediatric individuals from France and China (p.(Cys225Tyr) and p.(Cys225Arg), respectively), leading to severe early-onset DEE. Molecular investigations characterize the novel pathogenic variants as deficient in the interactions with guanine nucleotides and physiological cellular partners of Gαo, with reduced stability and plasma membrane localization and a strong neomorphic interaction with the chaperone Ric8A. Salts of zinc, emerging as a promising targeted therapy for GNAO1-associated disorders, impose a previously unseen effect on the mutant Gαo, accelerating the loss of its ability to interact with guanine nucleotides. Our study, combining clinical, cellular, molecular, and modeling approaches, describes deep insights into molecular etiology and treatment perspectives of the novel form of GNAO1-associated disorders.

Free Water MRI of White Matter in Wilson's Disease

BACKGROUND

Diffusion tensor imaging (DTI) is susceptible to partial volume effects from free water, which can be corrected by using bi-tensor free water imaging (FWI). This approach may improve the evaluation of microstructural changes associated with Wilson's disease (WD).

PURPOSE

To investigate microstructural changes in white matter of WD using DTI and FWI.

STUDY TYPE

Prospective.

SUBJECTS

Nineteen neurological WD (7 female, 31.68 ± 7.89 years), 10 hepatic WD (3 female, 29.67 ± 13.37 years), and 25 healthy controls (13 female, 29.5 ± 7.7 years).

FIELD STRENGTH/SEQUENCE

3-T, spin-echo echo-planar imaging diffusion-weighted imaging, T1-weighted, T2-weighted, fluid-attenuated inversion recovery.

ASSESSMENT

Various diffusion metrics, including mean diffusivity (MD), radial diffusivity (RD), fractional anisotropy (FA), axial diffusivity (AD), free water, and free water-corrected metrics (MDT, RDT, FAT, and ADT) were estimated and compared across entire white matter skeleton among neurological WD, hepatic WD, and controls. Voxel-wise tract-based spatial statistics and region of interest (ROI) analysis based on white matter atlas were performed. Additionally, partial correlation analysis was conducted to assess the relationship between FWI indices in ROIs and clinical indicators.

STATISTICAL TESTS

One-way analysis of variance, family-wise error correction for multiple comparisons, and Bonferroni correction for post hoc comparisons. A P-value <0.05, corrected for multiple comparisons, was considered statistically significant.

RESULTS

Our study found significantly lower FA and higher MD, AD, and RD across most of white matter skeleton in neurological WD. Decreased FAT and increased MDT, ADT, and RDT were observed only in limited white matter areas compared to DTI indices. Additionally, a significant relationship was found between Unified WD Rating Scale neurological subscale of neurological WD and free water (r = 0.613) in middle cerebellar peduncle, ADT (r = -0.555) in superior cerebellar peduncle, RDT (r = 0.655), and FAT (r = -0.660) in posterior limb in internal capsule.

DATA CONCLUSION

FWI may allow a more precise evaluation of microstructural changes in WD than conventional DTI, with FWI metrics potentially correlating with clinical severity scores of WD patients.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 2.

The physiological role of copper: Dietary sources, metabolic regulation, and safety concerns

Copper plays an important physiological role in the body, with both deficiency and excess potentially impacting overall health. The body maintains a stringent copper metabolism mechanism to oversee absorption, utilization, storage, and elimination. Dietary consumption serves as the principal source of copper. The dietary factors may interfere with the absorption and metabolism of copper, leading to fluctuation of copper levels in the body. However, these dietary factors can also be strategically employed to facilitate the precise regulation of copper. This paper delved into the advancements in research concerning copper in food processing, including dietary sources of copper, the regulatory processes of copper metabolism and health implications of copper. The safety and its underlying mechanisms of excess copper were also highlighted. In particular, the paper examines the influence of dietary factors on the absorption and metabolism of copper, aiming to provide direction for accurate copper regulation and the creation of functional foods and pharmaceuticals.

Copper in cancer: friend or foe? Metabolism, dysregulation, and therapeutic opportunities

Copper, one of the essential nutrients for the human body, acts as an electron relay in multiple pathways due to its redox properties. Both deficiencies and excesses of copper lead to cellular fragility. Therefore, it can manifest pro- and anti-cancer properties in tumors. Therefore, it is crucial to clarify the copper activity within the cell. We have thoughtfully summarized the metabolic activities of copper from a macro and micro perspective. Cuproptosis, as well as other forms of cell death, is directly or indirectly interfered with by Cu2+, causing cancer cell death. Meanwhile, we did pan-cancer analysis of cuproptosis-related genes to further clarify the roles of these genes. In addition, copper has been found to be involved in multiple pathways within the metastasis of cancer cells. Given the complexity of copper's role, we are compelled to ask: is copper a friend or a foe? Up to now, copper has been used in various clinical applications, including protocols for measurement of copper concentration and bioimaging of radioactive 64Cu. But therapeutically it is still a continuation of the old medicine, and new possibilities need to be explored, such as the use of nanomaterials. Some studies have also shown that copper has considerable interventional power in metabolic cancers, which provides the great applications potential of copper therapy in specific cancer types. This paper reviews the dual roles played by cuproptosis in cancer from the new perspectives of oxidative stress, cell death, and tumor metastasis, and points out the value of its application in specific cancer types, summarizes the value of its testing and imaging from the perspective of clinical application as well as the current feasible options for the new use of the old drugs, and emphasizes the prospects for the application of nano-copper.

Novel hypothesis and therapeutic interventions for irritable bowel syndrome: interplay between metal dyshomeostasis, gastrointestinal dysfunction, and neuropsychiatric symptoms

Irritable bowel syndrome is a gastrointestinal disorder due to multiple pathologies. While patients with this condition experience anxiety and depressed mood more frequently than healthy individuals, it is unclear how gastrointestinal dysfunction interacts with such neuropsychiatric symptoms. Data suggest that irritable bowel syndrome patients predominantly display a lower zinc intake, which presumably impairs enterochromaffin cells producing 5-hydroxytryptamine, gut bacteria fermenting short-chain fatty acids, and barrier system in the intestine, with the accompanying constipation, diarrhea, low-grade mucosal inflammation, and visceral pain. Dyshomeostasis of copper and zinc concentrations as well as elevated pro-inflammatory cytokine levels in the blood can disrupt blood-cerebrospinal fluid barrier function, leading to locus coeruleus neuroinflammation and hyperactivation with resultant amygdalar overactivation and dorsolateral prefrontal cortex hypoactivation as found in neuropsychiatric disorders. The dysregulation between the dorsolateral prefrontal cortex and amygdala is likely responsible for visceral pain-related anxiety, depressed mood caused by anticipatory anxiety, and visceral pain catastrophizing due to catastrophic thinking or cognitive distortion. Collectively, these events can result in a spiral of gastrointestinal symptoms and neuropsychiatric signs, prompting the progression of irritable bowel syndrome. Given that the negative feedback mechanism in regulation of the hypothalamic-pituitary-adrenal axis is preserved in a subset of neuropsychiatric cases, dorsolateral prefrontal cortex abnormality accompanied by neuropsychiatric symptoms may be a more significant contributing factor in brain-gut axis malfunction than activation of the hypothalamic corticotropin-releasing hormone system. The proposed mechanistic model could predict novel therapeutic interventions for comorbid irritable bowel syndrome and neuropsychiatric disorders.

Clinical significance of platelet-to-white blood cell ratio in patients with Wilson disease: a retrospective cohort study

Objective

To assess the correlation between the platelet-to-white blood cell ratio (PWR) and the severity of liver dysfunction, hepatic complications, and prognosis in Wilson disease (WD) patients.

Methods

A retrospective analysis was conducted on medical records from January 1, 2016, to March 30, 2022. Both univariate and multivariate analyses were performed to examine the impact of a low PWR (<26.3) on WD severity, liver complications, and disease progression. Additionally, the effect of splenectomy on PWR was evaluated.

Results

The study included 315 patients with WD, among whom 105 had a low PWR and 210 had a high PWR. Those with low PWR exhibited significantly elevated levels of bilirubin, international normalized ratio, prothrombin time, procollagen type-III N-terminal propeptide, type IV collagen, hyaluronic acid, and portal vein diameter. Conversely, they had lower levels of albumin, total cholesterol, low-density lipoprotein cholesterol, and triglycerides (all P < 0.05). A low PWR correlated with a greater incidence of splenomegaly/hypersplenism, esophagogastric varices, and ascites (all P < 0.05). Furthermore, low PWR independently predicted hepatic decompensation (P < 0.05), and splenectomy led to a marked increase in PWR among WD patients (P < 0.001).

Conclusion

A low PWR in WD patients is linked to heightened disease severity, increased risk of liver complications, and rapid progression to decompensation. The results imply that splenectomy, by enhancing PWR, may serve as a viable strategy to slow WD progression.

Clinical Characteristics, Treatment Effects and Risk Factors of Liver Cirrhosis in Patients with Wilson's Disease Hepatic Type

Background and Aims

Wilson's disease (WD) is a rare autosomal recessive genetic disorder that can be treated with medications. The lack of a single, specific diagnostic indicator leads to diagnostic difficulties, which may result in disease progression to cirrhosis and even liver cancer. Thus, this study aimed to analyze the clinical data, imaging, histopathological manifestations, genetic testing results, and treatment effects of patients with WD hepatic type, and to explore the factors related to WD cirrhosis.

Methods

A single-center retrospective study was performed. 48 WD patients with a Leipzig score ≥ 4 were divided into a cirrhosis group and a non-cirrhosis group based on the presence of cirrhosis. Logistic regression analysis and odds ratios were used to describe the strength of association between risk factors and cirrhosis. The predictive value of the model for cirrhosis occurrence was evaluated by calculating the area under the receiver operating characteristic curve and the cutoff value.

Results

All 48 patients diagnosed with WD had liver damage, with males accounting for 54.17%. The median age at diagnosis was 28 years (range: 10.25-40.5 years), and 39.58% of patients had cirrhosis. The most prevalent mutation was c.2333G>T (p.Arg778Leu), found in 41.30% (19/46) of cases. Imaging revealed fatty liver in 31.25% (15/48) of patients and "honeycomb-like" cirrhosis nodules in 73.68% (14/19). Compared with the non-cirrhosis group, the cirrhosis group had a higher positive rate for the Kayser-Fleischer (K-F) ring, older age at diagnosis, and higher levels of immunoglobulin G, but lower levels of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, white blood cells, and platelets (p < 0.05). Age at diagnosis (odds ratio = 1.072, 95% confidence interval = 1.007-1.142, p = 0.03) and the K-F ring (odds ratio = 18.657, 95% confidence interval = 1.451-239.924, p = 0.025) were independent risk factors for WD-related cirrhosis. The best values of area under the receiver operating characteristic curve for age at diagnosis combined with the K-F ring in predicting WD cirrhosis were 0.909. The average follow-up time for 33 patients was 48.6 months (range: 12-72 months). The biochemical recovery rate was over 60% after 12-72 months of treatment with zinc gluconate and/or penicillamine.

Conclusions

Age at diagnosis, combined with the K-F ring, is a simple and effective risk factor for WD-related cirrhosis. Zinc gluconate and penicillamine are safe and effective treatments.

Mechanistic Insights Into GDFMD-Mediated Inhibition of Liver Fibrosis via miRNA-29b-3p Upregulation in Wilson's Disease

Background: Wilson's disease (WD) is an abnormal copper metabolism disease. GanDouFuMu decoction (GDFMD) is a traditional Chinese medicine, whicn has shown good therapeutic effects in clinical treatment of WD liver fibrosis;but its regulatory mechanism is still unclear. Methods: The serum of WD patients before and after GDFMD treatment were collected, the four items of liver fibrosis were detected by ELISA. The hepatic stellate cell (HSC) activities were assesed via CCK8 assay. The mRNA levels were evaluated by qPCR. The protein levels were checked by western blot. The autophygosomes were observed by transmission electron microscope (TEM). The transdifferentiation ability of HSCs into myofibroblasts was evaluated with anti-α-SMA antibody by immunofluorescence (IF). In copper-laden rats with WD, the autophagy levels, and fibrosis level were observed by IF. Results: The four items of liver fibrosis levels were decreased. GDFMD could increase the HSCs cell activity. GDFMD could increase miRNA-29b-3p levels, which was decreased by TGF-β1. miRNA-29b-3p inhibitors could reversed the suppression response of GDFMD on the the protein expression of ULK1, beclin1, LC3, α-SMA, and Col1. GDFMD blocked the transdifferentiation of HSCs into myofibroblasts, inhibited liver fibrosis. Conclusion: GDFMD blocked the transdifferentiation of HSCs into myofibroblasts by upregulating miRNA-29b-3p, and then inhibited liver fibrosis in WD.

From severe aplastic anemia with TERT variant to Wilson disease - associations or not

Severe aplastic anemia is a life-threatening ineffective hematopoiesis, arising from inherited or acquired traits. Wilson disease is a rare congenital metabolic disorder with copper accumulation. Here we report a rare case of a 15-year-old boy, who presented with bone marrow failure. Whole exome sequencing revealed several gene mutations in ATP7B and TERT. Based on the phenotypes, telomere lengths and pedigree of his family, the patient was diagnosed with severe aplastic anemia accompanied by Wilson disease. Allogeneic hematopoietic stem cell transplantation and anti-copper therapy helped him achieve transfusion independence and restore relatively normal copper metabolism. We discussed the possible associations between the two rare conditions and optimal management in this situation.

Emerging roles of cuproptosis in liver diseases

Intracellular copper levels should be maintained within a controlled range to obtain copper homeostasis. Cuproptosis, a newly discovered form of cell death, occurs when excessive copper ions bind to the lipoylated enzymes in the tricarboxylic acid cycle, which leads to lipoylated protein aggregation, proteotoxic stress, and ultimately cell death. Herein, we summarize the current knowledge regarding copper metabolism, the discovery and molecular mechanism of cuproptosis. In addition, we discuss the implications of cuproptosis in the pathogenesis of various liver diseases, including hepatocellular carcinoma (HCC), Wilson disease (WD), metabolic-associated fatty liver disease (MAFLD), liver fibrosis, hepatic ischemia-reperfusion injury (HIRI) and drug-induced liver injury (DILI). Understanding the mechanism of cuproptosis can not only provide deeper insights into the pathogenesis of liver diseases but also open up new avenues for the development of targeted therapies.

Quantitative vessel density around foveal avascular zone as a potential imaging biomarker for detecting central nervous system injury in Wilson's disease: an optical coherence tomography angiography study

Background

Studies have confirmed that optical coherence tomography angiography (OCTA) can detect early retinal microvascular impairment in many diseases. However, as far as we know, only one study has found retinal and optic disc microcirculation changes in Wilson's disease (WD) by OCTA. The purpose of our study was to evaluate the OCTA parameters in WD.

Methods

We performed a cross-sectional study at the First Affiliated Hospital of Guangdong Pharmaceutical University between June 2021 and April 2022. A total of 42 WD patients and 40 gender- and age-matched healthy controls (HEC) were recruited in this study. WD patients were divided into neurological form (NWD) and hepatic form (HWD) of the disease. All participants underwent retinal OCTA to assess the superficial vessel density (VD), deep VD, and foveal avascular zone (FAZ) parameters. The FAZ parameters included the area in mm2, perimeter in mm, and VD of the 300 µm-width annulus surrounding FAZ (FD-300). Statistical tests used in this study included Chi-squared test, one-way analysis, correlation analysis, and t-test or Mann-Whitney U test.

Results

WD patients comprised 21 females and 21 males, with mean age of 30.54±9.83 years. HEC comprised 16 females and 24 males, with mean age of 30.42±7.37 years. NWD had smaller FD-300 (51.67%±5.29% vs. 55.87%±3.85%, P<0.01) than HEC and smaller FD-300 (51.67%±5.29% vs. 55.42%±4.09%, P<0.05) than HWD. There was no significant difference in OCTA parameters between HWD and HEC.

Conclusions

Our study indicated that OCTA may be a useful tool for detecting central nervous system (CNS) injury in WD. We speculate that the decrease of FD-300 may be a sign of CNS injury in WD.

Intrathecal Baclofen Therapy Improves Refractory Status Dystonicus in Neuro-hepatic Wilson's Disease: A Case Report

Wilson's disease is an autosomal recessive disorder of copper metabolism. A current unresolved issue is the worsening of neurological symptoms during the initial treatment phase, particularly with chelation therapy. This phenomenon, termed "early neurological worsening," is attributed to the rapid mobilization and redistribution of copper during treatment initiation. We report the case of a 10-year-old boy, with neuro-hepatic Wilson's disease who developed treatment-refractory generalized dystonia, which improved with intrathecal baclofen therapy. The patient experienced walking discomfort 5 months before referral to our hospital, with rapid progression to dysphagia and a 3 kg weight loss. Initially, he presented with dystonia, including foot inversion. Wilson's disease was diagnosed based on physiological, clinical, and imaging findings, with confirmation of a homozygous mutation in the ATP7B gene. The patient was treated with trientine hydrochloride, followed by zinc monotherapy. Despite appropriate chelation therapy, dystonia progressed to severe axial torsion involving the trunk. His condition deteriorated to status dystonicus, with high-grade fever, elevated creatine phosphokinase levels, and dehydration, requiring midazolam sedation. These symptoms were attributed to "early neurological worsening." A trial of intrathecal baclofen injection provided symptom relief, leading to the implantation of a baclofen pump, which significantly reduced the status dystonicus. At discharge, the patient had a modified Rankin Scale score of 5. Three years later, although wheelchair-dependent, his oral intake and speech are progressively improving with training. This is the first reported case of status dystonicus in Wilson's disease successfully treated with intrathecal baclofen, highlighting its potential as a viable treatment option for Wilson's disease-associated debilitating dystonia.

Association between Copper Exposure and Cognitive Function: A Cross-Sectional Study in a County, Guangxi, China

There has been growing attention to the impact of copper exposure on cognitive function; however, current research on the specific information regarding urinary copper and cognitive function is limited, particularly detailed analyses in the Chinese adult population. This study aimed to explore the association between copper exposure and cognitive function in a cross-sectional design. A total of 2617 participants in a county, Guangxi Zhuang Autonomous Region (Guangxi), China, were included. The mini-mental state examination (MMSE) was used to assess cognitive function, and inductively coupled plasma mass spectrometry was used to measure urinary metal levels. Spearman's rank correlation was used to analyze the correlation between urinary copper levels and various cognitive function assessment indices. After adjusting for potential confounders, binary logistic regression was used to explore the association between urinary copper levels and the risk of cognitive impairment (CI) as revealed by MMSE, and restricted cubic spline regression was further used to explore the dose-response relationship. The results showed a negative correlation between urinary copper levels and orientation, attention and calculation, memory, language ability, and MMSE total scores (P < 0.05). Compared with the low copper exposure group, the high exposure group showed a 58.5% increased risk of CI (OR = 1.585, 95%CI: 1.125 to 2.235, P = 0.008). A significant linear dose-response relationship was observed between urinary copper levels and the risk of CI (P overall = 0.045, P nonlinearity = 0.081). Our findings suggest that higher copper exposure may be associated with CI in the population of a county, Guangxi, China.

Review of the Efficacy and Mechanisms of Traditional Chinese Medicine for Treating Multi-Organ Damage in Wilson's Disease

Wilson's disease (WD) is an autosomal recessive disorder characterized by abnormal copper metabolism. Disruptions in copper metabolism lead to excessive copper deposition in the liver, nervous system, kidneys, heart, and other organs, thereby inducing a range of pathological manifestations and clinical symptoms. Traditional Chinese Medicine (TCM) has demonstrated significant therapeutic efficacy and excellent safety profiles. When integrated with effective Western anti-copper therapies, it can yield superior therapeutic outcomes. Consequently, TCM has exhibited unique advantages in managing WD, particularly when combined with multiple systemic damages. This paper discusses the pathological mechanisms and TCM etiology and pathogenesis of WD combined with multiple organ damage. It also summarizes the clinical efficacy and mechanism of TCM in treating WD combined with multiple organ damage, aiming to provide a reference for further studies on the role and potential mechanisms of TCM interventions in WD.

Gut Akkermansia enhances liver protection and facilitates copper removal during D-penicillamine treatment in a Wilson's disease model

Patients afflicted with Wilson's disease (WD) may encounter hepatic and extraneous manifestations due to the progressive accumulation of copper in the liver and other subsequent organs. Copper-chelating agents, such as D-penicillamine (DPA), are commonly utilized in the medical treatment of copper overload in WD. Manipulating the composition of gut microbiota appropriately can enhance drug efficacy and safety. This study aims to investigate how targeted intervention on gut microbiota influences the effectiveness of copper removal in a WD model during DPA treatment. First, following a 4-week treatment of DPA, the liver copper concentration and gut microbial composition were assessed in the WD mice model to identify potential candidates for targeted regulation of gut microbiota. Second, after 8 weeks of manipulating the gut microbiota during DPA treatment, various parameters including blood liver function indicators, tissue copper load, hepatic histopathological features, and gut microbiota were investigated in WD mice. The findings demonstrated that the presence of Akkermansia significantly enhances the efficacy of DPA, leading to a more efficient elimination of copper from tissues and a greater improvement in liver injury, liver dysfunction, and gut dysbiosis. In contrast, Butyricimonas has an antagonistic effect. The results of gene function prediction analysis indicated that the altered gut microbial function by DPA and Akk is primarily linked to energy generation/utilization, amino acid, fatty acid, lipid, and nucleic acid metabolisms. To summarize, this study provides experimental evidence for the potential application of targeted regulation of gut microbiota in the adjunctive therapy of copper dysregulation disease.IMPORTANCECopper is an essential element in virtually all living organisms. Wilson's disease (WD) is a representative disorder caused by the disruption of copper homeostasis. Oral-chelating agents are the first-line treatment for copper-overloaded diseases, with D-penicillamine (DPA) being the prototypical drug. However, the efficacy and adverse effects of DPA remain challenging in its use for WD treatment. In our study, the supplementation of Akkermansia muciniphila (Akk), a key gut microbe, along with DPA was demonstrated to enhance copper removal, ameliorate liver injury and dysfunction, and restore gut dysbiosis in a mouse model of WD. These findings highlight the significant potential applications of targeted modulation of gut microbiota as "pharmacomicrobiomics" in adjunctive therapy for disorders involving copper dysregulation.

Advances in copper-containing biomaterials for managing bone-related diseases

Bone-related diseases pose a major challenge in contemporary society, with significant implications for both health and economy. Copper, a vital trace metal in the human body, facilitates a wide range of physiological processes by being crucial for the function of proteins and enzymes. Numerous studies have validated copper's role in bone regeneration and protection, particularly in the development and expansion of bone collagen. Owing to copper's numerous biological advantages, an increasing number of scientists are endeavoring to fabricate novel, multifunctional copper-containing biomaterials as an effective treatment strategy for bone disorders. This review integrates the current understanding regarding the biological functions of copper from the molecular and cellular levels, highlighting its potential for bone regeneration and protection. It also reviews the novel fabrication techniques for developing copper-containing biomaterials, including copper-modified metals, calcium phosphate bioceramics, bioactive glasses, bone cements, hydrogels and biocomposites. The fabrication strategies and various applications of these biomaterials in addressing conditions such as fractures, bone tumors, osteomyelitis, osteoporosis, osteoarthritis and osteonecrosis are carefully elaborated. Moreover, the long-term safety and toxicity assessments of these biomaterials are also presented. Finally, the review addresses current challenges and future prospects, in particular the regulatory challenges and safety issues faced in clinical implementation, with the aim of guiding the strategic design of multifunctional copper-based biomaterials to effectively manage bone-related diseases.

Pathogenicity analysis of ATP7B in pediatric patients with Wilson's disease and functional verification of alternative splice variants

BACKGROUND

Wilson's disease (WD) is an autosomal recessive inherited disease caused by ATP7B gene mutations. Some mutations in ATP7B are presumed to be pathogenic by altering pre-mRNA splicing, while most have not been functionally verified. This study aimed to perform functional studies to verify the pathogenicity of variants that may affect pre-mRNA splicing.

METHODS

We recruited 42 pediatric patients who were clinically diagnosed with WD (Leipzig score ≥ 4) and underwent ATP7B gene sequencing. We leveraged in silico analysis and prioritized seven splice genic variants in ATP7B. Minigene assays were used to evaluate the effects of the selected variants on transcript splicing. Total RNA was extracted from peripheral blood mononuclear cells (PBMCs), and Reverse Transcription-Polymerase Chain Reaction (RT-PCR) was performed on samples from several patients to verify the splicing alterations.

RESULTS

This study screened 42 distinct mutations for their potential effects on splicing based on in silico analysis and functional verification. Five intronic variants (c.1286-1delG, c.1543 + 1G > T, c.1708-1G > C, c.1870-8A > G, and c.2121 + 3A > T) and one missense variant (c.2120A > G) were proved to alter the splicing of ATP7B transcription by minigene assays. The transcript assays demonstrated splicing changes in vivo in patient PBMCs for c.3993 T > G. The altered transcription products resulting from c.2570_2572del were confirmed by sequencing.

CONCLUSIONS

This study adds experimental evidence to genetic diagnosis based on assessing the genetic defects of 42 pediatric WD patients and provides new insights into the pathogenicity of the splicing variants.

Evaluation of efficacy and safety of AAV8-ΔC4ATP7B gene therapy in a mutant mouse model of Wilson's disease

Wilson's disease (WD) is an autosomal recessive disorder caused by pathogenic variants in the ATP7B gene, resulting in the toxic accumulation of copper (Cu). Impaired Cu homeostasis in WD is characterized by low serum ceruloplasmin, excess hepatic Cu, and elevated urinary Cu. WD often presents with hepatic and/or neurological diseases and is fatal if untreated. Adeno-associated virus (AAV)-mediated gene therapy holds promise for WD, but challenges remain in efficacy and safety. Here, we established an Atp7b R780L knockin (KI) mouse model corresponding to the human ATP7B R778L variant and investigated the therapeutic efficacy and safety of liver-targeted AAV8-mediated ATP7B (AAV8-ΔC4ATP7B) gene therapy in this model. The results demonstrated the Atp7b KI/KI mice recapitulated key features of impaired Cu metabolism in WD but had mild liver disease. Ten-week-old Atp7b KI/KI mice received a single-dose of AAV8-ΔC4ATP7B and were sacrificed at 8 or 30 weeks after treatment. Treated Atp7b KI/KI mice showed normalization of serum ceruloplasmin, reduced hepatic Cu, decreased urinary Cu, and reversed liver histopathology. Serum transaminases had a transient increase at 8 weeks after treatment but returned to normal at 30 weeks after treatment. These data provide evidence for the efficacy and safety of AAV8-ΔC4ATP7B in animals, supporting clinical translation to patients with WD.

Case report: Co-occurrence of Wilson's and Alexander's diseases revealed by genetic analysis

Wilson's disease (WD) and Alexander's disease (AxD) are two prevalent genetic illnesses in clinical practice. However, cases of concurrent WD and AxD have not been reported. A mutation in the ATP7B gene causes improper copper metabolism, whereas AxD is caused by a mutation in the GFAP gene, which causes glial fibrillary acidic protein to accumulate in astrocytes. We present the first instance of concurrent WD and AxD in order to increase the diagnosis accuracy of this type of disease and provide a more precise treatment plan for the patient. A 10-year-old girl who appeared with diminished speech, limb weakness, trouble walking, and mental behavioral problems within the last 2 months. The patient's copper biochemistry results and clinical manifestations supported the diagnosis of WD, however her uncommon bilateral frontal lobe cerebral white matter with considerable high signal in MRI differed from the normal neuroimaging presentations of WD. To clarify the patient's diagnosis, we did whole-exome sequencing testing. To further clarify the patient's diagnosis, we performed whole exome sequencing tests on the patient and her father and detected a single heterozygous mutation in the GFAP gene and a double heterozygous mutation in the ATP7B gene, with the two variant loci located on the same allele. Combined with the Leipzig score and characteristic MRI changes, the patient was diagnosed with co-morbid WD and AxD. The overlapping presentation of the two diseases on MRI suggests the importance of clinicians recognizing the features of both diseases. A comprehensive diagnostic strategy including genetic testing, neuroimaging, and detailed clinical evaluation is required.

Hepatic progenitor cells reprogrammed from mouse fibroblasts repopulate hepatocytes in Wilson's disease mice

BACKGROUND

Wilson's disease (WD) is a genetic disorder that impairs the excretion of copper in hepatocytes and results in excessive copper deposition in multiple organs. The replacement of disordered hepatocytes with functional hepatocytes can serve as a lifelong therapeutic strategy for the treatment of WD. The aim of this study was to determine the hepatocyte repopulation effects of fibroblast-derived hepatic progenitor cells in the treatment of WD.

METHODS

Induced hepatic progenitor cells (iHPCs) were generated through direct reprogramming of adult mouse fibroblasts infected with lentivirus carrying both the Foxa3 and Hnf4α genes. These iHPCs were subsequently identified and transplanted into copper-overload WD mice with the Atp7b (H1071Q) mutation via caudal vein injection.

RESULTS

After lentivirus infection, the fibroblasts transformed into Foxa3- and Hnf4α-overexpressing cobblestone-like cells with reduced expression of fibroblast markers and increased expression of epithelial cell and hepatic progenitor cell markers, i.e., iHPCs. Sixteen weeks after transplantation into WD mice, approximately 2% of hepatocytes were derived from iHPCs, and these iHPC-derived hepatocytes expressed a tight junction-associated protein of the bile canal, tight junction protein 1 (Zo1). There was a decrease in the serum copper concentration and relative activity of serum ceruloplasmin at weeks 4 and 8 after iHPCs transplantation compared with those of WD fed mice administered saline or fibroblasts. Furthermore, iHPC transplantation markedly reduced the proportion of CD8+ T lymphocytes and natural killer cells compared with those in fibroblast-transplanted WD mice and downregulated the transcription of the inflammatory cytokines, including tumor necrosis factor α (Tnfα), interleukin 1β (IL-1β), and IL-6, compared with those in WD mice and in fibroblast-transplanted WD mice.

CONCLUSION

iHPCs reprogrammed from adult fibroblasts can repopulate hepatocytes and exert therapeutic effects in WD mice, representing a potential replacement therapy for clinical application.

Evaluation of salivary ceruloplasmin for the diagnosis of Wilson's disease

The serum ceruloplasmin assay is the most commonly used test for diagnosing Wilson's disease (WD). Despite the utility of non-invasive tests for diagnosing WD, no such tests have been developed. Therefore, we aimed to identify a safe and non-invasive assay and determine the factors associated with salivary ceruloplasmin. The sample comprised 167 participants: 130 patients with WD (experimental group) and 37 individuals without WD (control group). Salivary ceruloplasmin's diagnostic performance was assessed using a receiver operating characteristic curve analysis, and the diagnostic thresholds were determined. The Mann-Whitney U test for independent samples was used to compare intergroup variability between the control and WD groups. We used Pearson's correlation coefficient to determine intergroup correlations between the blood and salivary ceruloplasmin levels of patients with WD. Salivary ceruloplasmin levels were significantly lower in the WD group than in the control group. Serum and salivary ceruloplasmin levels were positively correlated. The area under the curve for salivary ceruloplasmin was 0.9977. The critical value of salivary ceruloplasmin was 8.885 ng/mL, with a sensitivity of 99.23% and specificity of 100%. Evidently, salivary ceruloplasmin has substantial diagnostic value. Therefore, saliva analysis can be used as a non-invasive alternative to serum analysis for diagnosing WD.

Functional characterisation of missense ceruloplasmin variants and real-world prevalence assessment of Aceruloplasminemia using population data

BACKGROUND

Aceruloplasminemia (ACP) is a rare recessive disease caused by loss of ceruloplasmin activity due to pathogenic variants in the ceruloplasmin (CP) gene. ACP causes iron accumulation in various organs, leading to neurodegeneration, anaemia, and diabetes. Estimating ACP prevalence is challenging, particularly as missense variants are not readily identified as pathogenic.

METHODS

Heterozygous missense variants likely to impact function were mapped in gnomAD and representative examples analysed for effects on CP activity. This knowledge was complemented by prediction of destabilizing effects of potentially pathogenic missense variants and integrated with loss-of-function mutations. Global ACP prevalence was predicted and compared with a more traditional method.

FINDINGS

Several as yet uncharacterised missense CP variants of pathogenic interest were identified by structure-function in-silico analysis. A representative subset was functionally validated, together with known ACP missense variants. Insights on the relative importance of copper ions coordinating centres in CP and its substrate specificity were discovered. Overall, a destabilizing effect was predicted for 130 missense CP variants. This information, integrated with known ACP missense and loss-of-function CP variants in gnomAD, allowed an estimation of ACP prevalence of 12.6/106. An alternative analysis based on minor allele frequency ≤0.01 resulted in an ACP prevalence as high as 8/106.

INTERPRETATION

These prevalence estimates for ACP are 20-25-fold higher than previously estimated and underscore the applicability of structure-function based analyses of real-world genetic variability to provide an alternative method for representing the frequency of rare disease variants.

FUNDING

REACT-EU PON 2014-2021, Kedrion S.p.A.

The interactive toxic effect of homocysteine and copper on cardiac microvascular endothelial cells during ischemia-reperfusion injury

Hyperhomocysteinemia (HHcy) is associated with the development and progression of chronic cardiovascular diseases through the deleterious effects of high levels of homocysteine (Hcy) on the cardiovascular system. However, the exact mechanism of action of Hcy on the acute injury of the cardiovascular system following ischemia/reperfusion (I/R) remains unclear. The present study demonstrated that copper mobilization occurs during cardiac I/R, and the interactive toxic effect of Hcy and mobile Cu2+ during cardiac I/R induces necroptosis of cardiac microvascular endothelial cells (CMECs) and thus enhances cardiac dysfunction. In the present study, we utilized three cardiac I/R model: isolated rat heart, in vivo model as well as cell culture, and demonstrated that copper mobilization occurs during cardiac I/R, and the interactive toxic effect of Hcy and mobile Cu2+ during cardiac I/R induces necroptosis of cardiac microvascular endothelial cells (CMECs) and thus enhances cardiac dysfunction. Furthermore, we proved that the Cu2+ chelator TTM significantly mitigated the deleterious effects of Hcy and Cu2+ on CMECs and cardiac function both in vitro and in vivo. Mechanismly, the combinative effect of Hcy and Cu2+ are associated with the production of reactive oxygen species (ROS) and nitric oxide (NO) by NADPH oxidase (NOX) and endothelial nitric oxide synthase (eNOS), respectively. Subsequently, the overproduction of toxic peroxynitrite (ONOO-) induces CMECs necroptosis. The application of ROS scavengers in CMECs resulted in a notable reduction in necroptosis mediated by Hcy and Cu2+ under hypoxia/reperfusion (H/R) condition. These findings indicate that the mechanism by which Hcy and Cu2+ enhances cardiac dysfunction under I/R condition may be attributed to the stimulation of both NOX and eNOS activity, resulting in the generation of excessive ONOO- and subsequent necroptosis of CMECs.

EASL-ERN Clinical Practice Guidelines on Wilson's disease

Wilson's disease is an autosomal recessive disorder of copper metabolism which affects the liver, brain and other organs. Diagnosis is based on: clinical features; biochemical tests, including plasma ceruloplasmin concentration, 24-h urinary copper excretion, copper content in the liver; and molecular analysis. Leipzig score and additionally relative exchangeable copper determination are recommended for diagnosis. Pharmacological therapy comprises chelating agents (penicillamine, trientine) and zinc salts, while only chelators are recommended for significant liver disease. Monitoring is based on clinical symptoms, liver tests and copper metabolism (urinary copper excretion, exchangeable copper) to detect poor compliance and over/under-treatment. Acute liver failure is challenging as making a diagnosis is difficult and pharmacological therapy may not be sufficient to save life. Liver transplantation has a well-defined role in Wilsonian acute hepatic failure but may also be considered in neurological disease.

Genetic therapies for movement disorders - current status

Movement disorders are a group of heterogeneous neurological conditions associated with alterations of tone, posture and voluntary movement. They may either occur in isolation or as part of a multisystemic condition. More recently, the advent of next generation sequencing technologies has facilitated better understanding of the underlying causative genes and molecular pathways, thereby identifying targets for genetic therapy. In this review, we summarize the advances in genetic therapy approaches for both hyperkinetic and hypokinetic movement disorders, including Parkinson's Disease, Huntington's Disease and rarer monogenic conditions of childhood onset. While there have been significant advances in the field, multiple challenges remain, related to safety, toxicity, efficacy and brain biodistribution, which will need to be addressed by the next generation of genetic therapies.

Activity-based sensing reveals elevated labile copper promotes liver aging via hepatic ALDH1A1 depletion

Oxidative stress plays a key role in aging and related diseases, including neurodegeneration, cancer, and organ failure. Copper (Cu), a redox-active metal ion, generates reactive oxygen species (ROS), and its dysregulation contributes to aging. Here, we develop activity-based imaging probes for the sensitive detection of Cu(I) and show that labile hepatic Cu activity increases with age, paralleling a decline in ALDH1A1 activity, a protective hepatic enzyme. We also observe an age-related decrease in hepatic glutathione (GSH) activity through noninvasive photoacoustic imaging. Using these probes, we perform longitudinal studies in aged mice treated with ATN-224, a Cu chelator, and demonstrate that this treatment improves Cu homeostasis and preserves ALDH1A1 activity. Our findings uncover a direct link between Cu dysregulation and aging, providing insights into its role and offering a therapeutic strategy to mitigate its effects.

Prion protein promotes copper toxicity in Wilson disease

Copper (Cu) is a vitally important micronutrient, whose balance between essential and toxic levels requires a tightly regulated network of proteins. Dysfunction in key components of this network leads to the disruption of Cu homeostasis, resulting in fatal disorders such as Wilson disease, which is caused by mutations in the hepatic Cu efflux transporter ATP7B. Unfortunately, the molecular targets for normalizing Cu homeostasis in Wilson disease remain poorly understood. Here, using genome-wide screening, we identified the cellular prion protein (PrP) as an important mediator of Cu toxicity in WD. Loss of ATP7B stimulates hepatic expression of PrP, which promotes endocytic Cu uptake, leading to toxic Cu overload. Suppression of PrP significantly reduces Cu toxicity in cell and animal models of Wilson disease. These findings highlight the critical regulatory role of PrP in copper metabolism and open new avenues for exploring the therapeutic potential of PrP suppression in Wilson disease.

Liver diseases: epidemiology, causes, trends and predictions

As a highly complex organ with digestive, endocrine, and immune-regulatory functions, the liver is pivotal in maintaining physiological homeostasis through its roles in metabolism, detoxification, and immune response. Various factors including viruses, alcohol, metabolites, toxins, and other pathogenic agents can compromise liver function, leading to acute or chronic injury that may progress to end-stage liver diseases. While sharing common features, liver diseases exhibit distinct pathophysiological, clinical, and therapeutic profiles. Currently, liver diseases contribute to approximately 2 million deaths globally each year, imposing significant economic and social burdens worldwide. However, there is no cure for many kinds of liver diseases, partly due to a lack of thorough understanding of the development of these liver diseases. Therefore, this review provides a comprehensive examination of the epidemiology and characteristics of liver diseases, covering a spectrum from acute and chronic conditions to end-stage manifestations. We also highlight the multifaceted mechanisms underlying the initiation and progression of liver diseases, spanning molecular and cellular levels to organ networks. Additionally, this review offers updates on innovative diagnostic techniques, current treatments, and potential therapeutic targets presently under clinical evaluation. Recent advances in understanding the pathogenesis of liver diseases hold critical implications and translational value for the development of novel therapeutic strategies.

Low penetrance of frequent ATP7B mutations explains the low prevalence of Wilson disease. Lessons from real-life registries

BACKGROUND & AIMS

Wilson disease (WD) is a copper metabolism disorder caused by mutations in ATP7B gene, with significant clinical variability. Several studies have analyzed the prevalence and penetrance of mutations. We evaluated both characteristics for our more frequent mutations.

METHODS

Evaluation of 260 patients from the National Registry: clinical, analytical and genetic data. Estimation of homozygotes and total cases according to Hardy-Weinberg equilibrium and comparison with Registry records.

RESULTS

The estimated number of homozygotes were higher than registered: p.Met645Arg (1949/6), p.His1069Gln (20/8), p.Leu708Pro (63/24) and p.Gly869Arg (147/0). p.Met645Arg homozygotes presented less cirrhosis at diagnosis, extrahepatic disease and Kayser-Fleischer ring (KFR) and more presymptomatic cases and diagnosis after 40 years of age than p.Leu708Pro and p.His1069Gln homozygotes. p.Met645Arg homozygotes presented more late diagnosis than p.Met645Arg compound heterozygotes. Compound heterozygotes carrying p.Met645Arg or p.Gly869Arg showed less cirrhosis at diagnosis, KFR and neurological symptoms and more hepatic and presymptomatic cases, despite clearly low ceruloplasmin levels. The estimated prevalence was 1:3.785, predicting more than 10.500 patients.

CONCLUSIONS

The widespread mutations p.Met645Arg and p.Gly869Arg show low penetrance. WD might be underdiagnosed in Spain due to less severe phenotype of the most frequent mutations, a crucial fact to avoid misdiagnosis and to offer early therapy.

Involvement of copper in cell death and cancer

Copper (cu) is an essential micronutrient required for numerous metabolic processes. It plays a crucial role in cellular respiration by participating in the electron transport chain and facilitating numerous biological reactions. Various diseases, including cancer, demonstrate localized elevation of copper levels and/or alterations in the overall distribution of copper. Modulating local or systemic copper levels as a novel therapeutic approach for treating and ameliorating diseases has emerged as a prominent trend in disease management, particularly in the realm of cancer therapy, which is currently under investigation. The objective of this review is to offer a thorough examination of copper metabolism in both physiological and pathological contexts. Specifically, it delves into how copper ions can effectively target and stimulate tumor cell death via the process known as cuproptosis in cancer patients. Furthermore, this review explores the utilization of three categories of anticancer medications (copper ion carriers, copper complexes, and copper chelating agents) pertaining to copper metabolism within the realm of cancer therapy, elucidating on the distinct mechanisms through which they exert their effects.

Targeted and non-targeted proteomics to identify the urinary protein biomarkers for Wilson disease

BACKGROUND

Wilson disease (WD) is a genetic disorder of copper metabolism. Early diagnosis of WD is inherently challenging due to the absence of typical symptoms. This study aimed to identify urinary protein biomarkers for WD using targeted and nontargeted mass spectrometry-based approaches.

METHODS

Exploratory urinary proteomic research on WD patients was initially conducted and revealed some potential biomarkers (alpha-2-macroglobulin, alpha-1-antitrypsin, complement C3, prothrombin, and complement factor B). A multiple reaction monitoring (MRM) assay was subsequently developed and applied to an independent WD cohort for protein candidate validation. Finally, a Random Forest (RF) model constructed with five proteins was evaluated for its diagnostic capacity.

RESULTS

The linear range of the MRM assay extended from 0.025 ng/L to 155 ng/L and the limit of quantification (LOQ) ranged from 0.0095 ng/L to 9.2308 ng/L. Alpha-2-macroglobulin, alpha-1-antitrypsin, and complement C3 exhibited significant increases (p < 0.05) in WD patients compared to the controls, whereas prothrombin and complement factor B only showed variations in concentration. The physiology reference intervals (RIs) for alpha-2-macroglobulin, alpha-1-antitrypsin, complement C3, prothrombin, and complement factor B were estimated as 0-12.50, 0-123.08, 0-5.20, 0-16.59, 0-4.85 ng/mol Cr, while the pathology RIs were 0-114.86, 0-600.98, 0-12.62, 0-22.16, and 0-10.83 ng/mol Cr, respectively. The RF model demonstrated an area under the curve (AUC) of 0.99 for the training data and 0.83 for the testing data.

CONCLUSIONS

Based on the proteomic results, the quantitative method was successfully applied for the validation of protein candidates in WD. Using supervised machine learning, the five-protein panel exhibited excellent accuracy in non-invasive diagnosis of WD.

Spectrum and classification of ATP7B variants with clinical correlation in children with Wilson disease

OBJECTIVES

To study the spectrum and classification of ATP7B variants in Iraqi children with Wilson disease by direct gene sequencing with clinical correlation.

METHODS

Fifty-five unrelated children with a clinical diagnosis of Wilson disease (WD) were recruited. Deoxyribonucleic acid was extracted from peripheral blood samples, and variants in the ATP7B gene were identified using next-generation sequencing.

RESULTS

Seventy-six deleterious variants were detected in 97 out of 110 alleles of the ATP7B gene. Thirty (54.5%) patients had 2 disease-causing variants (15 homozygous and 15 compound heterozygous). Twelve (21.8%) patients had one disease-causing variant and one variant of uncertain significance (VUS) with potential pathogenicity. Thirteen (23.6%) patients were carriers of a single disease-causing variant. The most frequent variants, c.3305T>C and c.956delC, were detected in 4 alleles each, followed by c.3741-3742dupCA and c.3694A>C, which were detected in 3 alleles each. Among the 76 variants, 42 were missense, 13 were stop-gain, 9 were frameshift, 1 was an in-frame deletion, and 11 were intronic variants. Notably, the globally common variant H1069Q was not detected in this study.

CONCLUSION

The mutational spectrum of ATP7B in the Iraqi population is diverse, despite the high rates of consanguinity. It differs from that of neighboring countries. We provided evidence for ten VUS to be reclassified as deleterious, raising questions about the diagnostic criteria for patients with higher Leipzig scores and a single deleterious variant.

Wilson's disease in two siblings from Ecuador: Two case reports

BACKGROUND

Wilson's disease (WD) is a rare metabolic disorder of copper accumulation in organs such as liver, brain, and cornea. Diagnoses and treatments are challenging in settings, where advanced diagnostic tests are unavailable, copper chelating agents are frequently scarce, healthcare professionals lack disease awareness, and medical follow-ups are limited. Prompt diagnoses and treatments help prevent complications, improve patients' quality of life, and ensure a normal life expectancy. The clinical presentations and outcomes of WD can vary within a single family.

CASE SUMMARY

We present the cases of two siblings (19 and 27 years) from a consanguineous family in rural Ecuador, diagnosed as having WD during a family screening. The male patient, diagnosed at age 19 after his brother's death from acute liver failure, presented with compensated cirrhosis, neurological symptoms, and bilateral Kayser-Fleischer rings. He developed progressive neurological deterioration during an irregular treatment with D-penicillamine due to medication shortages. His condition improved upon switching to trientine tetrahydrochloride, and his neurological symptoms improved over an 8-year period of follow-ups. The female patient, diagnosed at age 10, exhibited only biochemical alterations. Her treatment history was similar; however, she remained asymptomatic without disease progression over the same follow-up period. We discuss the potential influence of epigenetic mechanisms and modifier genes on the various phenotypes, emphasizing the need for research in these areas to optimize therapeutic strategies.

CONCLUSION

Our patients' medical histories show how early diagnosis and treatment can prevent disease progression; and, how suboptimal treatments impact disease outcomes.

Copper-Based biomaterials for anti-tumor therapy: Recent advances and perspectives

Copper, an essential trace element, is integral to numerous metabolic pathways across biological systems. In recent years, copper-based biomaterials have garnered significant interest due to their superior biocompatibility and multifaceted functionalities, particularly in the treatment of malignancies such as sarcomas and cancers. On the one hand, these copper-based materials serve as efficient carriers for a range of therapeutic agents, including chemotherapeutic drugs, small molecule inhibitors, and antibodies, allowing them for precise delivery and controlled release triggered by specific modifications and stimuli. On the other hand, they can induce cell death through mechanisms such as ferroptosis, cuproptosis, apoptosis, and pyroptosis, or inhibit the proliferation and invasion of cancer cells via their outstanding properties. Furthermore, advanced design approaches enable these materials to support tumor imaging and immune activation. Despite this progress, the full scope of their functional capabilities remains to be fully elucidated. This review provides an overview of the anti-tumor functions, underlying mechanisms, and design strategies of copper-based biomaterials, along with their advantages and limitations. The aim is to provide insights into the design, study, and development of novel multifunctional biomaterials, with the ultimate goal of accelerating the clinical application of copper-based nanomaterials in cancer therapy. STATEMENT OF SIGNIFICANCE: This study explores the groundbreaking potential of copper-based biomaterials in cancer therapy, uniquely combining biocompatibility with diverse therapeutic mechanisms such as targeted drug delivery and inhibition of cancer cells through specific cell death pathways. By enhancing tumor imaging and immune activation, copper-based nanomaterials have opened new avenues for cancer treatment. This review examines these multifunctional biomaterials, highlighting their advantages and current limitations while addressing gaps in existing research. The findings aim to accelerate clinical applications of these materials in the field of oncology, providing valuable insights for the design of next-generation copper-based therapies. Therefore, this work is highly relevant to researchers and practitioners focused on innovative cancer treatments.

Metal Ion Signaling in Biomedicine

Complex multicellular organisms are composed of distinct tissues involving specialized cells that can perform specific functions, making such life forms possible. Species are defined by their genomes, and differences between individuals within a given species directly result from variations in their genetic codes. While genetic alterations can give rise to disease-causing acquisitions of distinct cell identities, it is now well-established that biochemical imbalances within a cell can also lead to cellular dysfunction and diseases. Specifically, nongenetic chemical events orchestrate cell metabolism and transcriptional programs that govern functional cell identity. Thus, imbalances in cell signaling, which broadly defines the conversion of extracellular signals into intracellular biochemical changes, can also contribute to the acquisition of diseased cell states. Metal ions exhibit unique chemical properties that can be exploited by the cell. For instance, metal ions maintain the ionic balance within the cell, coordinate amino acid residues or nucleobases altering folding and function of biomolecules, or directly catalyze specific chemical reactions. Thus, metals are essential cell signaling effectors in normal physiology and disease. Deciphering metal ion signaling is a challenging endeavor that can illuminate pathways to be targeted for therapeutic intervention. Here, we review key cellular processes where metal ions play essential roles and describe how targeting metal ion signaling pathways has been instrumental to dissecting the biochemistry of the cell and how this has led to the development of effective therapeutic strategies.

Zinc for GNAO1 encephalopathy: Preclinical profiling and a clinical case

BACKGROUND

De novo pathogenic variants in GNAO1-the gene encoding the major neuronal G protein Gαo-cause pediatric encephalopathies and other neurological deficiencies largely refractory to available therapies. Zn2+ emerged to restore guanosine triphosphate hydrolysis and cellular interactions of pathogenic Gαo; dietary zinc salt supplementation improves lifespan and motoric function in a Drosophila disease model.

METHODS

Using biochemical, animal, and first-in-human studies, we provide support for the patient stratification and application of zinc acetate in GNAO1-associated disorders.

FINDINGS

We show that 16 different pathogenic missense variants cluster in three distinct groups in their responsiveness to Zn2+, and we provide the safety study in a mouse disease model. We further describe treatment of a 3-year-old patient with the common pathogenic GNAO1 variant c607G>A, p.Gly203Arg with oral 50 mg zinc (in the form of zinc acetate) daily, as applied in Wilson's disease. During 11 months of treatment, the patient shows cessation of daily dyskinetic crises, improved Burke-Fahn Marsden Dystonia Rating Scale movement score, reduction in epileptic seizures, and an excellent safety profile.

CONCLUSIONS

Our findings warrant a large-scale clinical trial and might set the new standard of care for GNAO1-related disorders.

FUNDING

This work was funded by the Russian Science Foundation (grant #21-15-00138) and GNAO1 España.

Targeting the initiator to activate both ferroptosis and cuproptosis for breast cancer treatment: progress and possibility for clinical application

Breast cancer is the most commonly diagnosed cancer worldwide. Metal metabolism is pivotal for regulating cell fate and drug sensitivity in breast cancer. Iron and copper are essential metal ions critical for maintaining cellular function. The accumulation of iron and copper ions triggers distinct cell death pathways, known as ferroptosis and cuproptosis, respectively. Ferroptosis is characterized by iron-dependent lipid peroxidation, while cuproptosis involves copper-induced oxidative stress. They are increasingly recognized as promising targets for the development of anticancer drugs. Recently, compelling evidence demonstrated that the interplay between ferroptosis and cuproptosis plays a crucial role in regulating breast cancer progression. This review elucidates the converging pathways of ferroptosis and cuproptosis in breast cancer. Moreover, we examined the value of genes associated with ferroptosis and cuproptosis in the clinical diagnosis and treatment of breast cancer, mainly outlining the potential for a co-targeting approach. Lastly, we delve into the current challenges and limitations of this strategy. In general, this review offers an overview of the interaction between ferroptosis and cuproptosis in breast cancer, offering valuable perspectives for further research and clinical treatment.

Acute Encephalopathy and Refractory Hypokalemia in a 12-Year-Old Boy

Wilson disease is an inherited disorder characterized by copper accumulation in various organs, leading to a wide range of clinical manifestations depending on the deposition site. Typically, symptoms of Wilson disease emerge between the ages of 5 and 35 years, primarily presenting with neurological and hepatic symptoms. This case report describes a 12-year-old boy diagnosed with Wilson disease based on low serum ceruloplasmin levels and elevated 24-hour urinary copper levels. His initial presentation included acute encephalopathy and tubulopathy with persistent hypokalemia. This case highlights the importance of a thorough evaluation, including neurological and renal assessments, to determine the underlying cause of acute encephalopathy, such as Wilson disease. Furthermore, this case shows that Wilson disease can manifest with neurological and kidney presentations despite a normal hepatic evaluation.

Mesenchymal stem cell therapy as a game-changer in liver diseases: review of current clinical trials

Chronic liver diseases, including cirrhosis and liver failure, remain formidable challenges due to their complex progression and limited therapeutic options. Mesenchymal stem cell (MSC) therapy has emerged as a game-changing approach, leveraging its potent immunomodulatory, anti-fibrotic, and regenerative capabilities, along with the ability to transdifferentiate into hepatocytes. This review delves into the latest advances in MSC-based treatments for chronic and end-stage liver diseases, as highlighted in current clinical trials. MSCs derived from bone marrow and umbilical cord have shown remarkable promise in reversing liver damage, improving liver function, and providing hope for patients who do not respond to conventional therapies. When administered through hepatic, portal, or peripheral veins, MSCs have significantly improved liver histology, reduced fibrosis, and restored functional capacity. Furthermore, MSC-derived materials, such as extracellular vesicles and exosomes, are emerging as cutting-edge tools for treating liver failure and mitigating post-transplant complications. While autologous MSC-derived hepatocytes hold promise for non-fatal cirrhosis, allogeneic MSCs are being applied in more severe conditions, including liver failure and transplantation cases. Despite these promising early outcomes, larger trials and long-term studies are essential to fully harness MSCs as a transformative, off-the-shelf alternative to liver transplantation, heralding a new era in regenerative liver therapies.

Epidemiology and economic burden of Wilson disease in France: A nationwide population-based study

Wilson disease (WD) is a rare inherited copper metabolism disorder characterized by progressive pathological deposition of copper, primarily in the liver and brain. This longitudinal retrospective study conducted using the French national claims (Système National des Données de Santé [SNDS]) database assessed WD prevalence in France, described patients' characterizations and healthcare resource use and associated costs. Patients with WD were identified from SNDS using the International Classification of Diseases, 10th Revision code E83.0 for copper metabolism disorder or a long-term disease (affection de longue durée [ALD]) associated with this code between 2010 and 2019. Patients were categorized into hepatic, neurological, and psychiatric sub-cohorts. We identified 2287 patients with WD yielding a crude prevalence of 1 case per 33 898 individuals in 2019. The mean age at inclusion was 39.9 (standard deviation [SD] 22.8) years, 11 years more than that of the incident cohort (28.6, SD 20.3) identified via ALD, and 1180 (51.6%) patients were male. The crude mortality was 3.2% (in total 370 patients died). Overall, 1011 (44.2%), 754 (33.0%), and 414 (18.1%) patients experienced hepatic, neurological, and psychiatric manifestations, respectively. In total, 922 (40.3%) patients were reimbursed for WD-specific treatment, the most common being D-penicillamine (74.8%), and 201 (8.8%) underwent liver transplantation. The average annual hospitalization cost per patient was 4273.7€ (SD 11916.0). At least one sick leave was reported for 533 (23.3%) patients, with an annual average cost of 788.7€ (SD 1328.6). Our findings provide an updated understanding of the prevalence of WD, and indicate a considerable level of morbidity in this population, as well as a high level of direct/indirect costs associated with WD.

Global Knowledge Map and Emerging Research Trends in Induced Pluripotent Stem Cells and Hereditary Diseases: A CiteSpace-based Visualization and Analysis

The rise of induced pluripotent stem cells (iPSCs) technology has ushered in a landmark shift in the study of hereditary diseases. However, there is a scarcity of reports that offer a comprehensive and objective overview of the current state of research at the intersection of iPSCs and hereditary diseases. Therefore, this study endeavors to categorize and synthesize the publications in this field over the past decade through bibliometric methods and visual knowledge mapping, aiming to visually analyze their research focus and clinical trends. The English language literature on iPSCs and hereditary diseases, published from 2014 to 2023 in the Web of Science Core Collection (WoSCC), was examined. The CiteSpace (version 6.3.R1) software was utilized to visualize and analyze country/region, institution, scholar, co-cited authors, and co-cited journals. Additionally, the co-occurrence, clustering, and bursting of co-cited references were displayed. Analysis of 347 articles that met the inclusion criteria revealed a steady increase in the number of published articles and citation frequency in the field over the past decade. With regard to the countries/regions, institutions, scholars, and journals where the articles were published, the highest numbers were found in the USA, the University of California System, Suren M. Zakian, and Stem Cell Research, respectively. The current research is focused on the construction of disease models, both before and after correction, as well as drug target testing for single-gene hereditary diseases. Chromosome transplantation genomic therapy for hereditary diseases with abnormal chromosome structures may emerge as a future research hotspot in this field.