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Schilsky ML, Roberts EA, Bronstein JM, Dhawan A, Hamilton JP, Rivard AM, Washington MK, Weiss KH, Zimbrean PC. A multidisciplinary approach to the diagnosis and management of Wilson disease: 2022 Practice Guidance on Wilson disease from the American Association for the Study of Liver Diseases. Hepatology 2022:01515467-990000000-00207. [PMID: 36151586 DOI: 10.1002/hep.32801] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 01/18/2023]
Affiliation(s)
- Michael L Schilsky
- Medicine and Surgery , Yale University School of Medicine , New Haven , Connecticut , USA
| | - Eve A Roberts
- Paediatrics, Medicine, Pharmacology and Toxicology , University of Toronto , Toronto , Ontario , Canada
| | - Jeff M Bronstein
- Neurology , University of California Los Angeles , Los Angeles , California , USA
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre and MowatLabs , King's College Hospital , London , UK
| | - James P Hamilton
- Medicine , Johns Hopkins University School of Medicine , Baltimore , Maryland , USA
| | - Anne Marie Rivard
- Food and Nutrition Services , Yale New Haven Hospital , New Haven , Connecticut , USA
| | - Mary Kay Washington
- Pathology, Immunology and Microbiology , Vanderbilt University Medical Center , Nashville , Tennessee , USA
| | | | - Paula C Zimbrean
- Psychiatry , Yale University School of Medicine , New Haven , Connecticut , USA
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2
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Nuklearmedizinische Diagnostik beim Morbus Wilson. DER NERVENARZT 2022; 94:327-334. [PMID: 36149458 DOI: 10.1007/s00115-022-01390-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/25/2022] [Indexed: 10/14/2022]
Abstract
Wilson's disease is an autosomal recessive disorder of copper metabolism and is caused by a genetic defect on chromosome 13. Nuclear medicine methods can prove the metabolic defect and contribute to the assessment of central neurological deficits.With high specificity and sensitivity, the intravenous radiocopper test enables the diagnosis to be confirmed as the basis for initiating treatment. The oral radiocopper test is used to monitor zinc treatment.[123I]β-CIT-SPECT and [123I]IBZM-SPECT provide functional information of the nigrostriatal system.[123I]β-CIT-SPECT also allows the determination of SERT availability in the hypothalamus/brain stem as a surrogate parameter of depression.Metabolic parameters of the cortex, basal ganglia and cerebellum can be assessed by [18F]FDG-PET studies.SPECT and [18F]FDG-PET studies show significant differences between neurological and non-neurological Wilson patients. Overall, only noninvasive in vivo nuclear medicine enables a deeper insight into the pathophysiology of neurological processes in Wilson's disease.
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Avan A, Członkowska A, Gaskin S, Granzotto A, Sensi SL, Hoogenraad TU. The Role of Zinc in the Treatment of Wilson’s Disease. Int J Mol Sci 2022; 23:ijms23169316. [PMID: 36012580 PMCID: PMC9409413 DOI: 10.3390/ijms23169316] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/09/2022] [Accepted: 08/15/2022] [Indexed: 02/06/2023] Open
Abstract
Wilson’s disease (WD) is a hereditary disorder of copper metabolism, producing abnormally high levels of non-ceruloplasmin-bound copper, the determinant of the pathogenic process causing brain and hepatic damage and dysfunction. Although the disease is invariably fatal without medication, it is treatable and many of its adverse effects are reversible. Diagnosis is difficult due to the large range and severity of symptoms. A high index of suspicion is required as patients may have only a few of the many possible biomarkers. The genetic prevalence of ATP7B variants indicates higher rates in the population than are currently diagnosed. Treatments have evolved from chelators that reduce stored copper to zinc, which reduces the toxic levels of circulating non-ceruloplasmin-bound copper. Zinc induces intestinal metallothionein, which blocks copper absorption and increases excretion in the stools, resulting in an improvement in symptoms. Two meta-analyses and several large retrospective studies indicate that zinc is equally effective as chelators for the treatment of WD, with the advantages of a very low level of toxicity and only the minor side effect of gastric disturbance. Zinc is recommended as a first-line treatment for neurological presentations and is gaining acceptance for hepatic presentations. It is universally recommended for lifelong maintenance therapy and for presymptomatic WD.
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Affiliation(s)
- Abolfazl Avan
- Department of Public Health, School of Medicine, Mashhad University of Medical Sciences, Mashhad 93518-88415, Iran
- Correspondence:
| | - Anna Członkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland
| | - Susan Gaskin
- Department of Civil Engineering, McGill University, Montreal, QC H3A 0C3, Canada
| | - Alberto Granzotto
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Department of Neuroscience, Imaging, and Clinical Sciences (DNISC), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Sue and Bill Gross Stem Cell Research Center, University of California-Irvine, Irvine, CA 92697, USA
| | - Stefano L. Sensi
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Department of Neuroscience, Imaging, and Clinical Sciences (DNISC), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Institute for Advanced Biomedical Technologies (ITAB), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Tjaard U. Hoogenraad
- Department of Neurology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
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Zinc monotherapy for young patients with oligosymptomatic Wilson disease: A single center, retrospective study. Clin Res Hepatol Gastroenterol 2021; 45:101623. [PMID: 33662781 DOI: 10.1016/j.clinre.2021.101623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/24/2020] [Accepted: 12/29/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Few studies have focused on the treatment failure of zinc monotherapy for oligosymptomatic Wilson disease (WD) patients. Therefore, we aimed to evaluate the long-term efficacy of zinc monotherapy in oligosymptomatic patients and to analyze the possible factors that may influence the outcome of this treatment. METHODS We retrospectively reviewed the medical records of oligosymptomatic WD patients who received zinc monotherapy from the time of diagnosis. Then, the characteristics of patients who were treated with zinc monotherapy successfully and those who experienced treatment failure were investigated. RESULTS Forty oligosymptomatic WD patients were identified that have received zinc monotherapy as initial treatment, with a median age of 3.83 years at the time of diagnosis. 36 (90%) patients had abnormal alanine transaminase/aspartate transaminase levels at baseline. None of the patients became symptomatic during zinc monotherapy. 28 (70%, Group 1) patients were treated with zinc monotherapy successfully for a median period of 2.4 years. In Group 1, serum aminotransferase levels significantly decreased 6 and 12 months after zinc therapy compared to the baseline levels (P < 0.05). 12 (30%, Group 2) patients experienced treatment failure with zinc monotherapy due to uncontrolled serum liver enzyme levels, and d-penicillamine was combined. The baseline 24-hour urine copper levels before treatment were significantly higher in Group 2 compared to that in Group 1 (182.5 vs 90.92 μg /day, P = 0.018). Comparing the age at onset; ceruloplasmin, serum copper, ALT, and AST levels; and proportions of abdominal ultrasonography abnormality at baseline between Group 1 and 2 revealed no statistically significant differences. CONCLUSIONS We found that high initial 24 -h urinary copper levels may lead to treatment failure of zinc monotherapy in oligosymptomatic WD patients. It might be reasonable to follow up liver function tests more closely during zinc monotherapy and to begin combination treatment with chelators early in patients with high level of 24 -h urinary copper.
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Coni P, Pichiri G, Lachowicz JI, Ravarino A, Ledda F, Fanni D, Gerosa C, Piras M, Coghe F, Gibo Y, Cau F, Castagnola M, Van Eyken P, Saba L, Piludu M, Faa G. Zinc as a Drug for Wilson's Disease, Non-Alcoholic Liver Disease and COVID-19-Related Liver Injury. Molecules 2021; 26:6614. [PMID: 34771023 PMCID: PMC8587580 DOI: 10.3390/molecules26216614] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 10/29/2021] [Indexed: 02/07/2023] Open
Abstract
Zinc is the second most abundant trace element in the human body, and it plays a fundamental role in human physiology, being an integral component of hundreds of enzymes and transcription factors. The discovery that zinc atoms may compete with copper for their absorption in the gastrointestinal tract let to introduce zinc in the therapy of Wilson's disease, a congenital disorder of copper metabolism characterized by a systemic copper storage. Nowadays, zinc salts are considered one of the best therapeutic approach in patients affected by Wilson's disease. On the basis of the similarities, at histological level, between Wilson's disease and non-alcoholic liver disease, zinc has been successfully introduced in the therapy of non-alcoholic liver disease, with positive effects both on insulin resistance and oxidative stress. Recently, zinc deficiency has been indicated as a possible factor responsible for the susceptibility of elderly patients to undergo infection by SARS-CoV-2, the coronavirus responsible for the COVID-19 pandemic. Here, we present the data correlating zinc deficiency with the insurgence and progression of Covid-19 with low zinc levels associated with severe disease states. Finally, the relevance of zinc supplementation in aged people at risk for SARS-CoV-2 is underlined, with the aim that the zinc-based drug, classically used in the treatment of copper overload, might be recorded as one of the tools reducing the mortality of COVID-19, particularly in elderly people.
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Affiliation(s)
- Pierpaolo Coni
- Department of Medical Sciences and Public Health, University of Cagliari, 09042 Monserrato, Italy; (P.C.); (A.R.); (F.L.); (D.F.); (C.G.); (M.P.); (F.C.); (G.F.)
| | - Giuseppina Pichiri
- Department of Medical Sciences and Public Health, University of Cagliari, 09042 Monserrato, Italy; (P.C.); (A.R.); (F.L.); (D.F.); (C.G.); (M.P.); (F.C.); (G.F.)
| | - Joanna Izabela Lachowicz
- Department of Medical Sciences and Public Health, University of Cagliari, 09042 Monserrato, Italy; (P.C.); (A.R.); (F.L.); (D.F.); (C.G.); (M.P.); (F.C.); (G.F.)
| | - Alberto Ravarino
- Department of Medical Sciences and Public Health, University of Cagliari, 09042 Monserrato, Italy; (P.C.); (A.R.); (F.L.); (D.F.); (C.G.); (M.P.); (F.C.); (G.F.)
| | - Francesca Ledda
- Department of Medical Sciences and Public Health, University of Cagliari, 09042 Monserrato, Italy; (P.C.); (A.R.); (F.L.); (D.F.); (C.G.); (M.P.); (F.C.); (G.F.)
| | - Daniela Fanni
- Department of Medical Sciences and Public Health, University of Cagliari, 09042 Monserrato, Italy; (P.C.); (A.R.); (F.L.); (D.F.); (C.G.); (M.P.); (F.C.); (G.F.)
| | - Clara Gerosa
- Department of Medical Sciences and Public Health, University of Cagliari, 09042 Monserrato, Italy; (P.C.); (A.R.); (F.L.); (D.F.); (C.G.); (M.P.); (F.C.); (G.F.)
| | - Monica Piras
- Department of Medical Sciences and Public Health, University of Cagliari, 09042 Monserrato, Italy; (P.C.); (A.R.); (F.L.); (D.F.); (C.G.); (M.P.); (F.C.); (G.F.)
| | - Ferdinando Coghe
- Dipartimento Servizi di Diagnosi e Cura, Azienda Ospedaliero-Universitaria di Cagliari (A.O.U.), University of Cagliari, 09024 Cagliari, Italy;
| | - Yukio Gibo
- Hepatology Clinic, 1-34-20 Muraimachiminami, Matsumoto, Nagano 399-0036, Japan;
| | - Flaviana Cau
- Department of Medical Sciences and Public Health, University of Cagliari, 09042 Monserrato, Italy; (P.C.); (A.R.); (F.L.); (D.F.); (C.G.); (M.P.); (F.C.); (G.F.)
| | - Massimo Castagnola
- Laboratorio di Proteomica e Metabonomica-Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Santa Lucia, 00013 Rome, Italy;
| | - Peter Van Eyken
- Department of Pathology, Genk Regional Ziekenhuis, 3600 Genk, Belgium;
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari—Polo di Monserrato s.s. 554, 09045 Monserrato, Italy;
| | - Marco Piludu
- Department of Biomedical Sciences, University of Cagliari, 09042 Monserrato, Italy;
| | - Gavino Faa
- Department of Medical Sciences and Public Health, University of Cagliari, 09042 Monserrato, Italy; (P.C.); (A.R.); (F.L.); (D.F.); (C.G.); (M.P.); (F.C.); (G.F.)
- UOC Anatomia Patologica, AOU Cagliari, University of Cagliari, 09124 Cagliari, Italy
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Cai S, Gong JY, Yang J, Wang JS. Anemia following zinc treatment for Wilson's disease: a case report and literature review. BMC Gastroenterol 2019; 19:120. [PMID: 31288754 PMCID: PMC6617635 DOI: 10.1186/s12876-019-1038-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 06/24/2019] [Indexed: 12/18/2022] Open
Abstract
Background Zinc therapy is considered an effective and safe treatment for Wilson’s disease. Hypocupremia-related anemia is rarely reported after long-term zinc administration or combination therapy with copper-chelating agent. Case presentation We herein report a 12-year-old girl with pre-symptomatic Wilson’s disease diagnosed 5 years ago who presented with severe anemia after high-dose oral zinc for 4 years and 4 months. Her hemoglobin was gradually restored to the normal range after the adjustment of zinc dose and diet therapy for 4 months. A review of the literature revealed eight patients with hypocupremia-associated anemia following zinc therapy for Wilson’s disease, including 7 adults and 1 child. The only child patient was a 16-year-old boy, in whom the zinc therapy was succession to penicillamine administration. Conclusions This is the first report worldwide that a child developed severe anemia following high-dose single zinc administration for Wilson’s disease. It highlights the importance of regular follow-up during zinc treatment and the involvement of specialists in the long-term management of Wilson’s disease. We hope that this will alert pediatricians the issue of zinc over-treatment.
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Affiliation(s)
- Sha Cai
- Department of Pediatrics, Jinshan Hospital of Fudan University, 1508 Longhang Road, Jinshan District, Shanghai, 201508, China
| | - Jing-Yu Gong
- Department of Pediatrics, Jinshan Hospital of Fudan University, 1508 Longhang Road, Jinshan District, Shanghai, 201508, China
| | - Jing Yang
- Department of Pediatrics, Jinshan Hospital of Fudan University, 1508 Longhang Road, Jinshan District, Shanghai, 201508, China
| | - Jian-She Wang
- Department of Pediatrics, Jinshan Hospital of Fudan University, 1508 Longhang Road, Jinshan District, Shanghai, 201508, China. .,Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, Shanghai, 201102, China.
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7
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Abstract
The availability of effective therapies distinguishes Wilson disease (WD) from other inherited neurometabolic diseases. The cause of hepatic, neurologic or psychiatric symptoms is copper overload and subsequent copper toxicity. Diagnosed WD patients require life-long pharmacologic therapy that is focused on reversal of copper overload with maintenance of a long-term negative copper balance. This is associated with the rapid control of free or non-ceruloplasmin bound copper that is mostly responsible for acute cytotoxic effects. Currently available therapies can be divided into chelators and zinc salts. They have different mechanisms of action and the onset of efficacy that influences their selection in acute and chronic stages of therapy. We review the use of D-penicillamine and trientine for chelation therapies, including the required monitoring of therapy for its efficacy and possible overtreatment with iatrogenic copper deficiency. Additionally, the use of zinc salts is also discussed, including a possibility of its use for the initial therapy in an acute stage of the disease. Supportive and symptomatic therapies for liver failure and neuropsychiatric symptoms are also reviewed.
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Affiliation(s)
- Peter Hedera
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
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Aggarwal A, Bhatt M. Advances in Treatment of Wilson Disease. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2018. [PMID: 29520330 PMCID: PMC5840318 DOI: 10.7916/d841881d] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Wilson disease (WD) is an inherited neurometabolic disorder that results in excessive copper deposition in the liver and the brain, affecting children and young adults. Without treatment the disease is invariably fatal. Though treatments for WD have been available since the 1950s, the disease continues to be associated with considerable morbidity and mortality because of missed diagnosis, and delayed or inadequate treatment. In this paper we survey WD-related literature in order to review recent advances in WD treatment. Methods We performed a literature search using the PubMed database for articles relating to WD and its medical treatment. We reviewed the articles, and cross-references of relevant articles, to summarize the current practices for treatment of WD. Results The survey shows that if WD is properly treated, in most patients the liver can be stabilized, even severe neurological disability reversed, and patients can resume normal lives. Discussion Medical treatment for WD includes use of copper chelators (penicillamine, trientine, dimercaprol, dimercaptopropane sulfonate, and ammonium tetrathiomolybdate) and drugs that decrease gastrointestinal copper absorption. Our knowledge of the treatment approaches has benefited from the large systematic clinical studies that have been conducted over the last decade. For each drug used to treat WD, we surveyed its development, indication for use, dosing, efficacy, and adverse effects.
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Affiliation(s)
- Annu Aggarwal
- Wilson Disease Clinic, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India
| | - Mohit Bhatt
- Wilson Disease Clinic, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India
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Li LY, Chen HZ, Bao YC, Yu QS, Yang WM. Successful Treatment of Hypersplenism in Wilson's Disease by Partial Splenic Embolization. J INVEST SURG 2017; 31:75-81. [PMID: 28135891 DOI: 10.1080/08941939.2016.1278058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Liang-Yong Li
- Department of Neurology, the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, China
| | - Huai-Zhen Chen
- Department of Neurology, the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, China
| | - Yuan-Cheng Bao
- Department of Neurology, the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, China
| | - Qing-Sheng Yu
- Department of General Surgery, the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, China
| | - Wen-Ming Yang
- Department of Neurology, the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, China
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Li LY, Yang WM, Chen HZ, Wu YH, Fang X, Zhang J, Wang Z, Han YS, Wang Y. Successful Splenectomy for Hypersplenism in Wilson's Disease: A Single Center Experience from China. PLoS One 2015; 10:e0124569. [PMID: 25910248 PMCID: PMC4409367 DOI: 10.1371/journal.pone.0124569] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 03/16/2015] [Indexed: 02/06/2023] Open
Abstract
Splenomegaly and pancytopenia are common in Wilson's disease (WD) and splenectomy is one of the conventional treatments for splenomegaly and the associated pancytopenia. However, splenectomy remained controversial for hypersplenism in WD as it was reported that splenectomy leaded to serious emotional and neurological deterioration in WD patients with hypersplenism. In the current study, we present our experiences in 70 WD patients with hypersplenism who had undergone splenectomy, outlining the safety and efficacy of splenectomy in WD. The clinical database of 70 WD patients with hypersplenism who had undergone splenectomy in our hospital between 2009 and 2013 were reviewed and followed-up regularly. Before splenectomy, all the patients accepted a short period of anti-copper treatment with intravenous sodium 2, 3-dimercapto-1-propane sulfonate (DMPS). All the patients demonstrated a marked improvement in platelet and leucocyte counts after splenectomy. No severe postoperative complication was observed. In particular, none of the 37 patients with mixed neurologic and hepatic presentations experienced neurological deterioration after splenectomy, and none of the patients with only hepatic presentations newly developed neurological symptoms. During the one year follow-up period, no patient presented hepatic failure or hepatic encephalopathy, no hepatic patient newly developed neurological presentations, and only 3 patients with mixed neurologic and hepatic presentations suffered neurological deterioration and these 3 patients had poor compliance of anti-copper treatment. Quantative analysis of the neurological symptoms in the 37 patients using the Unified Wilson's Disease Rating Scale (UWDRS) showed that the neurological symptoms were not changed in a short-term of one week after splenectomy but significantly improved in a long-term of one year after splenectomy. Additionally, compared to that before splenectomy, the esophageal gastric varices in most patients significantly improved one year after splenectomy. Thus, we may conclude that splenectomy is a safe and effective therapeutic measure for hypersplenism in WD patients who had been preoperatively treated with DMPS for powerful anti-copper therapy.
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Affiliation(s)
- Liang-Yong Li
- Department of Neurology, the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei 230031, China
| | - Wen-Ming Yang
- Department of Neurology, the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei 230031, China
| | - Huai-Zhen Chen
- Department of Neurology, the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei 230031, China
| | - Yun-Hu Wu
- Department of Neurology, the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei 230031, China
| | - Xiang Fang
- Department of Neurology, the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei 230031, China
| | - Jing Zhang
- Department of Neurology, the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei 230031, China
| | - Zhen Wang
- Department of General Surgery, the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei 230031, China
| | - Yong-Sheng Han
- Institute of Neurology, Anhui University of Traditional Chinese Medicine, Hefei 230061, China
| | - Yu Wang
- Department of Neurology, the First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
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11
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Abstract
Wilson disease (WD) is an inherited disorder of chronic copper toxicosis characterized by excessive copper deposition in the body, primarily in the liver and the brain. It is a progressive disease and fatal if untreated. Excessive copper accumulation results from the inability of liver to excrete copper in bile. Copper is an essential trace metal and has a crucial role in many metabolic processes. Almost all of the body copper is protein bound. In WD, the slow but relentless copper accumulation overwhelms the copper chaperones (copper-binding proteins), resulting in high levels of free copper and copper-induced tissue injury. Liver is the central organ for copper metabolism, and copper is initially accumulated in the liver but over time spills to other tissues. WD has protean clinical manifestations mainly attributable to liver, brain, and osseomuscular impairment. Diagnosis of WD is challenging and based on combination of clinical features and laboratory tests. Identification of various high-frequency mutations identified in different population studies across the world has revived interest in developing DNA chips for rapid genetic diagnosis of WD. All symptomatic and all presymptomatic patients require lifelong decoppering with careful clinical tracking. Decoppering ensures that presymptomatic individuals remain symptom free. With judicious decoppering, given time, even patients with severe neurological disability improve and can return to normal life and resume school or work at par with their peers. Treatment regimens and tracking patients using the WD-specific Global Assessment Scale for WD (GAS for WD) are discussed.
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12
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Zinc mono-therapy in pre-symptomatic Chinese children with Wilson disease: a single center, retrospective study. PLoS One 2014; 9:e86168. [PMID: 24475083 PMCID: PMC3901685 DOI: 10.1371/journal.pone.0086168] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Accepted: 12/06/2013] [Indexed: 01/02/2023] Open
Abstract
Background There is no official consensus regarding zinc therapy in pre-symptomatic children with Wilson Disease (WD); more data is needed. Objective To investigate the safety and efficacy of zinc gluconate therapy for Chinese children with pre-symptomatic WD. Methods We retrospectively analyzed pre-symptomatic children receiving zinc gluconate in a single Chinese center specialized in pediatric hepatology. Short-term follow-up data on safety and efficacy were presented, and effects of different zinc dosages were compared. Results 30 children (21 males) aged 2.7 to 16.8 years were followed for up to 4.4 years; 26 (87%) children had abnormal ALT at baseline. Most patients (73%) received higher than the currently recommended dose of elemental zinc. Zinc gluconate significantly reduced mean ALT (p<0.0001), AST (p<0.0001), GGT (p<0.0001) levels after 1 month, and urinary copper excretion after 6 months (p<0.0054). Mean direct bilirubin levels dropped significantly at 1 month (p = 0.0175), 3 months (p = 0.0010), and 6 months (p = 0.0036). Serum zinc levels gradually increased and reached a significantly higher level after 6 months (p<0.0026), reflecting good compliance with the therapy. Complete blood count parameters did not change throughout the analysis period. 8 children experienced mild and transient gastrointestinal side effects. The higher zinc dose did not affect treatment response and was not associated with different or increased side effects when compared to conventional zinc dose. Conclusion In our cohort, zinc gluconate therapy for Chinese children with pre-symptomatic WD was effective, and higher initial dose of elemental zinc had the same level of efficacy as the conventional dose.
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13
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Bruguera M, Abraldes JG. [Common problems in the diagnosis and treatment of Wilson's disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:316-25. [PMID: 23570841 DOI: 10.1016/j.gastrohep.2012.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 10/16/2012] [Indexed: 12/16/2022]
Abstract
The present article aims to provide answers to questions frequently asked by physicians attending patients with Wilson's disease (WD) or those with a suspected diagnosis of WD. The article is divided into 2 parts: a first part with answers to questions relating to the diagnosis of this entity and a second with answers to questions concerning treatment. A brief appendix is included with responses to questions not falling into either of these 2 categories.
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Affiliation(s)
- Miguel Bruguera
- Servicio de Hepatología, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Barcelona, España.
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14
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Weiss KH, Stremmel W. Evolving perspectives in Wilson disease: diagnosis, treatment and monitoring. Curr Gastroenterol Rep 2012; 14:1-7. [PMID: 22083169 DOI: 10.1007/s11894-011-0227-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Wilson disease (WD), the autosomal recessively inherited copper overload disorder, remains a diagnostic and therapeutic challenge. In the last decade, direct sequencing of the affected gene ATP7B became commercially available, but interpretation of the results still requires careful attention. Thus, a combination of tests reflecting the disturbed copper metabolism is needed to make the final diagnosis. Because of the low disease frequency, the existing treatment concepts are not based on controlled trails. Here, recent outcome reports of larger cohort studies challenge the recommended therapies and call for individualized treatment strategies. The notion, that certain medical regimens may either be insufficient to upkeep copper homeostasis or may lead to a clinically relevant overtreatment, demand a continuous monitoring of patients even after decades of therapy. In this article, we review current diagnostic and therapeutic approaches in WD.
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Affiliation(s)
- Karl Heinz Weiss
- University Hospital Heidelberg, Internal Medicine IV, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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Abstract
In the almost 100 years since Wilson's description of the illness that now bears his name, tremendous advances have been made in our understanding of this disorder. The genetic basis for Wilson's disease - mutation within the ATP7B gene - has been identified. The pathophysiologic basis for the damage resulting from the inability to excrete copper via the biliary system with its consequent gradual accumulation, first in the liver and ultimately in the brain and other organs and tissues, is now known. This has led to the development of effective diagnostic and treatment modalities that, although they may not eliminate the disorder, do provide the means for efficient diagnosis and effective amelioration if carried out in a dedicated and persistent fashion. Nevertheless, Wilson's disease remains both a diagnostic and treatment challenge for physician and patient. Its protean clinical manifestations make diagnosis difficult. Appropriate diagnostic evaluations to confirm the diagnosis and institute treatment can be confusing. In this chapter, the clinical manifestations, diagnostic evaluation, and treatment approaches for Wilson's disease are discussed.
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Affiliation(s)
- Ronald F Pfeiffer
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
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Weiss KH, Gotthardt DN, Klemm D, Merle U, Ferenci-Foerster D, Schaefer M, Ferenci P, Stremmel W. Zinc monotherapy is not as effective as chelating agents in treatment of Wilson disease. Gastroenterology 2011; 140:1189-1198.e1. [PMID: 21185835 DOI: 10.1053/j.gastro.2010.12.034] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2010] [Revised: 10/27/2010] [Accepted: 12/10/2010] [Indexed: 12/26/2022]
Abstract
BACKGROUND & AIMS Wilson disease is a genetic disorder that affects copper storage, leading to liver failure and neurologic deterioration. Patients are treated with copper chelators and zinc salts, but it is not clear what approach is optimal because there have been few studies of large cohorts. We assessed long-term outcomes of different treatments. METHODS Patients in tertiary care centers were retrospectively analyzed (n = 288; median follow-up time, 17.1 years) for adherence to therapy, survival, treatment failure, and adverse events from different treatment regimens (chelators, zinc, or a combination). Hepatic treatment failure was defined as an increase in activity of liver enzymes (aspartate aminotransferase, alanine aminotransferase, and γ-glutamyltransferase) >2-fold the upper limit of normal or >100% of baseline with an increase in urinary copper excretion. RESULTS The median age at onset of Wilson disease was 17.5 years. Hepatic and neuropsychiatric symptoms occurred in 196 (68.1%) and 99 (34.4%) patients, respectively. Hepatic treatment failure occurred more often from zinc therapy (14/88 treatments) than from chelator therapy (4/313 treatments; P < .001). Actuarial survival, without transplantation, showed an advantage for chelating agents (P < .001 vs zinc). Changes in treatment resulted mostly from adverse events, but the frequency did not differ between groups. Patients who did not respond to zinc therapy showed hepatic improvement after reintroduction of a chelating agent. CONCLUSIONS Treatments with chelating agents or zinc salt are effective in most patients with Wilson disease; chelating agents are better at preventing hepatic deterioration. It is important to identify patients who do not respond to zinc therapy and have increased activities of liver enzymes, indicating that a chelating agent should be added to the therapeutic regimen.
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Affiliation(s)
- Karl Heinz Weiss
- Department of Gastroenterology, University Hospital Heidelberg, Heidelberg, Germany.
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Wang LC, Wang JD, Tsai CR, Cheng SB, Lin CC. Clinical features and therapeutic response in Taiwanese children with Wilson's disease: 12 years of experience in a single center. Pediatr Neonatol 2010; 51:124-9. [PMID: 20417464 DOI: 10.1016/s1875-9572(10)60022-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Revised: 08/20/2009] [Accepted: 08/28/2009] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Wilson's disease (WD) is an autosomal recessive defect of cellular copper export. Early diagnosis in children is difficult due to its obscure clinical presentations. The efficacy of zinc salts is well documented, although there are limited data concerning zinc use in pediatric patients with WD. METHODS We performed a retrospective analysis of clinical features, laboratory results and treatment responses in children with WD diagnosed at Taichung Veterans General Hospital between 1996 and 2008. Diagnosis was established by low serum ceruloplasmin, high 24-hour urinary copper excretion, presence of Kayser-Fleischer rings, and mutation analysis. RESULTS Eleven children were included in this study. The main initial presentations were impaired liver function tests (6/11) and hemolytic anemia (2/11). Gene studies in seven children showed six different mutations (G934D, R778Q, C490X, 304insC, IVS4-1 G > C, P992I) and one possible novel mutation (L1181P). All patients had improved liver function tests and hemoglobin levels after treatment with D-penicillamine, trientine and zinc supplement therapy. During a mean period of 3.4 +/- 2.1 years with zinc therapy, six patients had serum zinc levels above the normal limit, and seven patients had serum copper levels below the normal range. CONCLUSION Serum ceruloplasmin and 24-hour urinary copper examinations could be used to rule out WD in children with chronic hepatitis and hemolytic anemia. Gene analysis is helpful for prompt diagnosis of asymptomatic siblings and patients with atypical features. Zinc treatment is generally safe in pediatric patients with WD. However, its adverse effects should be monitored.
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Affiliation(s)
- Li-Ching Wang
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan.
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Bradley WG, Mash DC. Beyond Guam: the cyanobacteria/BMAA hypothesis of the cause of ALS and other neurodegenerative diseases. ACTA ACUST UNITED AC 2010; 10 Suppl 2:7-20. [PMID: 19929726 DOI: 10.3109/17482960903286009] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Excitement about neurogenetics in the last two decades has diverted attention from environmental causes of sporadic ALS. Fifty years ago endemic foci of ALS with a frequency one hundred times that in the rest of the world attracted attention since they offered the possibility of finding the cause for non-endemic ALS throughout the world. Research on Guam suggested that ALS, Parkinson's disease and dementia (the ALS/PDC complex) was due to a neurotoxic non-protein amino acid, beta-methylamino-L-alanine (BMAA), in the seeds of the cycad Cycas micronesica. Recent discoveries that found that BMAA is produced by symbiotic cyanobacteria within specialized roots of the cycads; that the concentration of protein-bound BMAA is up to a hundred-fold greater than free BMAA in the seeds and flour; that various animals forage on the seeds (flying foxes, pigs, deer), leading to biomagnification up the food chain in Guam; and that protein-bound BMAA occurs in the brains of Guamanians dying of ALS/PDC (average concentration 627 microg/g, 5 mM) but not in control brains have rekindled interest in BMAA as a possible trigger for Guamanian ALS/PDC. Perhaps most intriguing is the finding that BMAA is present in brain tissues of North American patients who had died of Alzheimer's disease (average concentration 95 microg/g, 0.8mM); this suggests a possible etiological role for BMAA in non-Guamanian neurodegenerative diseases. Cyanobacteria are ubiquitous throughout the world, so it is possible that all humans are exposed to low amounts of cyanobacterial BMAA, that protein-bound BMAA in human brains is a reservoir for chronic neurotoxicity, and that cyanobacterial BMAA is a major cause of progressive neurodegenerative diseases including ALS worldwide. Though Montine et al., using different HPLC method and assay techniques from those used by Cox and colleagues, were unable to reproduce the findings of Murch et al., Mash and colleagues using the original techniques of Murch et al. have recently confirmed the presence of protein-bound BMAA in the brains of North American patients dying with ALS and Alzheimer's disease (concentrations >100 microg/g) but not in the brains of non-neurological controls or Huntington's disease. We hypothesize that individuals who develop neurodegenerations may have a genetic susceptibility because of inability to prevent BMAA accumulation in brain proteins and that the particular pattern of neurodegeneration that develops depends on the polygenic background of the individual.
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Affiliation(s)
- Walter G Bradley
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14 Street, Miami, FL 33136, USA.
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Bradley WG. Possible therapy for ALS based on the cyanobacteria/BMAA hypothesis. ACTA ACUST UNITED AC 2010; 10 Suppl 2:118-23. [PMID: 19929743 DOI: 10.3109/17482960903285951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Although the cyanobacteria/BMAA hypothesis of the cause of ALS and other age-related neurodegenerative diseases remains to be proven, it is not too early to ask whether treatment would be possible if the hypothesis were correct. This paper reviews the possible ways that chronic BMAA neurotoxicity could be prevented or treated.
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Affiliation(s)
- Walter G Bradley
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14 Street, Miami, Florida 33136, USA.
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Wilson’s disease: two treatment modalities. Correlations to pretreatment and posttreatment brain MRI. Neuroradiology 2009; 51:627-33. [DOI: 10.1007/s00234-009-0536-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Accepted: 05/12/2009] [Indexed: 12/13/2022]
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Affiliation(s)
- Eve A Roberts
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, and Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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Affiliation(s)
- Eve A Roberts
- Division of Gastroenterology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada.
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Strausak D, Mercer JF, Dieter HH, Stremmel W, Multhaup G. Copper in disorders with neurological symptoms: Alzheimer's, Menkes, and Wilson diseases. Brain Res Bull 2001; 55:175-85. [PMID: 11470313 DOI: 10.1016/s0361-9230(01)00454-3] [Citation(s) in RCA: 307] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Copper is an essential element for the activity of a number of physiologically important enzymes. Enzyme-related malfunctions may contribute to severe neurological symptoms and neurological diseases: copper is a component of cytochrome c oxidase, which catalyzes the reduction of oxygen to water, the essential step in cellular respiration. Copper is a cofactor of Cu/Zn-superoxide-dismutase which plays a key role in the cellular response to oxidative stress by scavenging reactive oxygen species. Furthermore, copper is a constituent of dopamine-beta-hydroxylase, a critical enzyme in the catecholamine biosynthetic pathway. A detailed exploration of the biological importance and functional properties of proteins associated with neurological symptoms will have an important impact on understanding disease mechanisms and may accelerate development and testing of new therapeutic approaches. Copper binding proteins play important roles in the establishment and maintenance of metal-ion homeostasis, in deficiency disorders with neurological symptoms (Menkes disease, Wilson disease) and in neurodegenerative diseases (Alzheimer's disease). The Menkes and Wilson proteins have been characterized as copper transporters and the amyloid precursor protein (APP) of Alzheimer's disease has been proposed to work as a Cu(II) and/or Zn(II) transporter. Experimental, clinical and epidemiological observations in neurodegenerative disorders like Alzheimer's disease and in the genetically inherited copper-dependent disorders Menkes and Wilson disease are summarized. This could provide a rationale for a link between severely dysregulated metal-ion homeostasis and the selective neuronal pathology.
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Affiliation(s)
- D Strausak
- Center for Cellular and Molecular Biology, School of Biological and Chemical Sciences, Deakin University, Burwood, Victoria, Australia
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Castilla-Higuero L, Romero-Gomez M, Suarez E, Castro M. Acute hepatitis after starting zinc therapy in a patient with presymptomatic Wilson's disease. Hepatology 2000; 32:877. [PMID: 11041690 DOI: 10.1053/jhep.2000.17917] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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Abstract
During the last 90 years, Wilson's hepatolenticular degeneration has evolved from a disease presenting insurmountable challenges to the clinician's diagnostic acumen to a metabolic disorder which is diagnosable woth certainty, treatable successfully, and even preventable. It may be long before the genetic defect becomes amenable to correction and a cure of the disease becomes possible.
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Affiliation(s)
- I Sternlieb
- Department of Medicine, Albert Einstein College of Medicine, Yeshiva University, Bronx, New York, USA.
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Affiliation(s)
- J M Walshe
- The Reta Lila Weston Institute of Neurological Studies, University College, London, UK
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Abstract
Wilson disease is a recessively inherited disorder of copper transport. Clinical features are highly variable, with any combination of neurological, hepatic or psychiatric illness. The age of onset varies from 3 to 50 years of age. Diagnosis is challenging because no specific combination of clinical or biochemical features is necessarily definitive. The genetic defect is due to a variety of abnormalities in a copper-transporting membrane ATPase. Most of the more than 80 mutations are present at a low frequency, and mutations differ between ethnic groups. At least two mutations are sufficiently common to aid in rapid diagnosis, in European and Asian populations respectively. Molecular analysis can provide a definitive diagnosis for asymptomatic sibs. Treatment, using chelating agents or zinc, is most effective when started before permanent tissue damage occurs.
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Affiliation(s)
- E A Roberts
- Division of Gastroenterology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada
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Czlonkowska A, Gajda J, Rodo M. Effects of long-term treatment in Wilson's disease with D-penicillamine and zinc sulphate. J Neurol 1996; 243:269-73. [PMID: 8936358 DOI: 10.1007/bf00868525] [Citation(s) in RCA: 136] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The results of treatment with D-penicillamine (D-P) or zinc sulphate (Zn) in 67 newly diagnosed cases of Wilson's disease have been compared. All patients (7 with hepatic, 1 with psychiatric and 59 with neurological or preclinical forms) were fully compliant. During 12 years of observation, 34 patients received d-P and 33 Zn as the primary treatment. Fifteen patients (44%) discontinued D-P, in 10 cases owing to side effects. Four (12%) patients discontinued Zn, in 2 cases because of side-effects. One patient who received Zn deteriorated during the first few months after the initiation of therapy. The effectiveness of long-term treatment with D-P and Zn was similar in those patients who were able to continue the initial therapy. Zn was tolerated better than D-P; we suggest, therefore, that it may be recommended as an initial therapy for patients in the preclinical stage of Wilson's disease or with neurological presentation of the disease. More observation is needed for patients with the hepatic and psychiatric forms of the disease.
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Affiliation(s)
- A Czlonkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
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