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Poli A, Schmitt C, Puy H, Talbi N, Lefebvre T, Gouya L. Erythropoietic protoporphyrias: updates and advances. Trends Mol Med 2024:S1471-4914(24)00128-X. [PMID: 38890030 DOI: 10.1016/j.molmed.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/10/2024] [Accepted: 05/15/2024] [Indexed: 06/20/2024]
Abstract
Protoporphyrias are caused by pathogenic variants in genes encoding enzymes involved in heme biosynthesis. They induce the accumulation of a hydrophobic phototoxic compound, protoporphyrin (PPIX), in red blood cells (RBCs). PPIX is responsible for painful cutaneous photosensitivity, which severely impairs quality of life. Hepatic elimination of PPIX increases the risk of cholestatic liver disease, requiring lifelong monitoring. Treatment options are scarce and mainly limited to supportive care such as protection from visible light. Here, we review the pathophysiology of protoporphyrias, their diagnosis, and current recommendations for medical care. We discuss new therapeutic strategies, some of which are currently undergoing clinical trials and are likely to radically alter the severity of the disease in the years to come.
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Affiliation(s)
- Antoine Poli
- Institut National de la Santé et de la Recherche Médicale U1149, Centre de Recherche sur l'Inflammation, Paris, France; Université Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Centre de Référence Maladies Rares Porphyries, Hôpital Louis Mourier, Colombes, France; Laboratory of excellence Gr-Ex, Paris, France.
| | - Caroline Schmitt
- Institut National de la Santé et de la Recherche Médicale U1149, Centre de Recherche sur l'Inflammation, Paris, France; Université Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Centre de Référence Maladies Rares Porphyries, Hôpital Louis Mourier, Colombes, France; Laboratory of excellence Gr-Ex, Paris, France
| | - Hervé Puy
- Institut National de la Santé et de la Recherche Médicale U1149, Centre de Recherche sur l'Inflammation, Paris, France; Université Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Centre de Référence Maladies Rares Porphyries, Hôpital Louis Mourier, Colombes, France; Laboratory of excellence Gr-Ex, Paris, France
| | - Neila Talbi
- Institut National de la Santé et de la Recherche Médicale U1149, Centre de Recherche sur l'Inflammation, Paris, France
| | - Thibaud Lefebvre
- Institut National de la Santé et de la Recherche Médicale U1149, Centre de Recherche sur l'Inflammation, Paris, France
| | - Laurent Gouya
- Institut National de la Santé et de la Recherche Médicale U1149, Centre de Recherche sur l'Inflammation, Paris, France; Université Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Centre de Référence Maladies Rares Porphyries, Hôpital Louis Mourier, Colombes, France; Laboratory of excellence Gr-Ex, Paris, France
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Levy C, Dickey AK, Wang B, Thapar M, Naik H, Keel SB, Saberi B, Beaven SW, Rudnick SR, Elmariah SB, Erwin AL, Goddu RJ, Hedstrom K, Leaf RK, Kazamel M, Mazepa M, Philpotts LL, Quigley J, Raef H, Ungar J, Anderson KE, Balwani M. Evidence-based consensus guidelines for the diagnosis and management of protoporphyria-related liver dysfunction in erythropoietic protoporphyria and X-linked protoporphyria. Hepatology 2024; 79:731-743. [PMID: 37505211 PMCID: PMC10818013 DOI: 10.1097/hep.0000000000000546] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/13/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL
| | - Amy K. Dickey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Bruce Wang
- Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA
| | - Manish Thapar
- Division of Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Hetanshi Naik
- Department of Genetics, Stanford University School of Medicine, Palo Alto, CA
| | - Siobán B. Keel
- Division of Hematology, University of Washington School of Medicine, Seattle, WA
| | - Behnam Saberi
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Simon W. Beaven
- Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles Medical Center, Los Angeles, CA
| | - Sean R. Rudnick
- Department of Internal Medicine, Section on Gastroenterology and Hepatology, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Sarina B. Elmariah
- Department of Dermatology, University of California San Francisco, San Francisco, CA
| | - Angelika L. Erwin
- Center for Personalized Genetic Healthcare, Cleveland Clinic, Cleveland, OH
| | - Robert J. Goddu
- Division of Continuing Education, University of Colorado Boulder, Boulder, CO
| | - Karli Hedstrom
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rebecca Karp Leaf
- Harvard Medical School, Boston, MA
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Mohamed Kazamel
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Marshall Mazepa
- Division of Hematology,Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | | | - John Quigley
- Division of Hematology/Oncology, Department of Medicine, University of Illinois Chicago, IL
| | - Haya Raef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of Hematology, University of Washington School of Medicine, Seattle, WA
- Department of Dermatology, University of California San Francisco, San Francisco, CA
| | - Jonathan Ungar
- Department of Dermatology, Mount Sinai Hospital, New York, NY
| | - Karl E. Anderson
- Department of Internal Medicine (Division of Gastroenterology & Hepatology), University of Texas Medical Branch/UTMB Health, Galveston, TX
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
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Tavabie OD, Salehi S, Aluvihare VR. The challenges and potential in developing microRNA associated with regeneration as biomarkers to improve prognostication for liver failure syndromes and hepatocellular carcinoma. Expert Rev Mol Diagn 2024; 24:5-22. [PMID: 38059597 DOI: 10.1080/14737159.2023.2292642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 12/05/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION Determining the need for liver transplantation remains critical in the management of hepatocellular carcinoma (HCC) and liver failure syndromes (including acute liver failure and decompensated cirrhosis states). Conventional prognostic models utilize biomarkers of liver and non-liver failure and have limitations in their application. Novel biomarkers which predict regeneration may fulfil this niche. microRNA are implicated in health and disease and are present in abundance in the circulation. Despite this, they have not translated into mainstream clinical biomarkers. AREAS COVERED We will discuss current challenges in the prognostication of patients with liver failure syndromes as well as for patients with HCC. We will discuss biomarkers implicated with liver regeneration. We then provide an overview of the challenges in developing microRNA into clinically tractable biomarkers. Finally, we will provide a scoping review of microRNA which may have potential as prognostic biomarkers in liver failure syndromes and HCC. EXPERT OPINION Novel biomarkers are needed to improve prognostic models in liver failure syndromes and HCC. Biomarkers associated with liver regeneration are currently lacking and may fulfil this niche. microRNA have the potential to be developed into clinically tractable biomarkers but a consensus on standardizing methodology and reporting is required prior to large-scale studies.
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Affiliation(s)
| | - Siamak Salehi
- Institute of Liver Studies, King's College Hospital, London, UK
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Poli A, Frieri C, Lefebvre T, Delforge J, Mirmiran A, Talbi N, Moulouel B, Six M, Paradis V, Parquet N, Puy H, Schmitt C, Aslangul E, de Fontbrune FS, Gouya L. Management of erythropoietic protoporphyria with cholestatic liver disease: A case report. Mol Genet Metab Rep 2023; 37:101018. [PMID: 38053924 PMCID: PMC10694760 DOI: 10.1016/j.ymgmr.2023.101018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 12/07/2023] Open
Abstract
Erythropoietic protoporphyria (EPP) is a rare metabolic disease of the heme biosynthetic pathway where an enzymatic dysfunction results in protoporphyrin IX (PPIX) accumulation in erythroid cells. The porphyrins are photo-reactive and are responsible for severe photosensitivity in patients, thus drastically decreasing their quality of life. The liver eliminates PPIX and as such, the main and rare complication of EPP is progressive cholestatic liver disease, which can lead to liver failure. The management of this complication is challenging, as it often requires a combination of approaches to promote PPIX elimination and suppress the patient's erythropoiesis. Here we described a 3-year follow-up of an EPP patient, with three episodes of liver involvement, aggravated by the coexistence of a factor VII deficiency. It covers all the different types of intervention available for the management of liver disease, right through to successful allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
- Antoine Poli
- Institut National de la Santé et de la Recherche Médicale U1149, Centre de Recherche sur l'Inflammation, Paris, France
- Université Paris Cité, Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
- Laboratory of Excellence Gr-Ex, Paris, France
| | - Camilla Frieri
- Assistance Publique-Hôpitaux de Paris, Service d'hématologie-greffe, Hôpital Saint-Louis, Paris, France
- A.O.R.N. San Giuseppe Moscati Hospital, Avellino, Italy
| | - Thibaud Lefebvre
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
| | - Juliette Delforge
- Assistance Publique-Hôpitaux de Paris, Service de médecine interne, Hôpital Louis Mourier, Colombes, France
| | - Arienne Mirmiran
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
| | - Neila Talbi
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
| | - Boualem Moulouel
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
| | - Marion Six
- Assistance Publique-Hôpitaux de Paris, Service de médecine interne, Hôpital Louis Mourier, Colombes, France
| | - Valérie Paradis
- Assistance Publique-Hôpitaux de Paris, Département de pathologie, Hôpital Beaujon, Clichy, France
| | - Nathalie Parquet
- Assistance Publique-Hôpitaux de Paris, Unité d'Aphérèse Thérapeutique, Hôpital Saint-Louis, Paris, France
| | - Hervé Puy
- Institut National de la Santé et de la Recherche Médicale U1149, Centre de Recherche sur l'Inflammation, Paris, France
- Université Paris Cité, Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
- Laboratory of Excellence Gr-Ex, Paris, France
| | - Caroline Schmitt
- Institut National de la Santé et de la Recherche Médicale U1149, Centre de Recherche sur l'Inflammation, Paris, France
- Université Paris Cité, Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
- Laboratory of Excellence Gr-Ex, Paris, France
| | - Elisabeth Aslangul
- Assistance Publique-Hôpitaux de Paris, Service de médecine interne, Hôpital Louis Mourier, Colombes, France
| | - Flore Sicre de Fontbrune
- Assistance Publique-Hôpitaux de Paris, Service d'hématologie-greffe, Hôpital Saint-Louis, Paris, France
| | - Laurent Gouya
- Institut National de la Santé et de la Recherche Médicale U1149, Centre de Recherche sur l'Inflammation, Paris, France
- Université Paris Cité, Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
- Laboratory of Excellence Gr-Ex, Paris, France
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Portich JP, Ribeiro AS, Rodrigues Taniguchi AN, Backes A, de Souza CFM, Kieling CO, Scherer FF, de Oliveira Poswar F, Leipnitz I, Doederlein Schwartz IV, Sekine L, Rigoni LDC, Marquardt da Silveira L, de Almeida Furlanetto M, Adami MR, Breunig RC, Guedes RR, do Amaral SN, Gonçalves Vieira SM, de Brum Soares T, Silva TO, da Rocha Silla LM, Astigarraga CC, Paz AA, Daudt LE. Consecutive Liver and Bone Marrow Transplantation for Erythropoietic Protoporphyria: Case Report and Literature Review. J Pediatr Hematol Oncol 2023; 45:416-422. [PMID: 37539993 DOI: 10.1097/mph.0000000000002738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/22/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) is a rare inherited disease of heme biosynthesis resulting in the accumulation of protoporphyrin, characterized by liver failure in a minority of cases. Although liver transplant (LT) is the therapeutic strategy for advanced hepatic disease, it does not correct the primary defect, which leads to recurrence in liver graft. Thus, hematopoietic stem cell transplantation (HSCT) is an approach for treating EPP. METHODS We aim to describe the first sequential LT and HSCT for EPP performed in Latin America, besides reviewing the present-day literature. RESULTS The patient, a 13-year-old female with a history of photosensitivity, presented with symptoms of cholestatic and hepatopulmonary syndrome and was diagnosed with EPP. Liver biopsy demonstrated cirrhosis. She was submitted to a successful LT and showed improvement of respiratory symptoms. However, she had disease recurrence on the liver graft. She underwent a myeloablative HSCT using a matched unrelated donor, conditioning with BuCy (busulfan and cyclophosphamide), and GvHD (graft vs. host disease) prophylaxis with ATG (thymoglobulin), tacrolimus and methotrexate. Neutrophil engraftment occurred on D+18. She has presented mixed chimerism, but normalization of PP levels, being 300 days after HSCT, in good state of health and normal liver function. CONCLUSIONS Consecutive LT and HSCT for EPP is a procedure that has been described in 10 cases in the literature and, even though these patients are a highly diversified population, studies have shown favorable results. This concept of treatment should be considered in patients with established liver disease.
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Affiliation(s)
| | | | | | | | | | - Carlos Oscar Kieling
- Children Liver Transplantation Program
- Digestive Surgery Service, Hospital de Clínicas de Porto Alegre
| | | | | | - Ian Leipnitz
- Hemotherapy
- Digestive Surgery Service, Hospital de Clínicas de Porto Alegre
| | | | - Leo Sekine
- Post-Graduation Program in Child's Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Luciana Marquardt da Silveira
- Departments of Bone Marrow Transplantation
- Post-Graduation Program in Child's Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Marina Rossato Adami
- Children Liver Transplantation Program
- Digestive Surgery Service, Hospital de Clínicas de Porto Alegre
| | - Raquel Cristine Breunig
- Post-Graduation Program in Child's Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Renata Rostirola Guedes
- Children Liver Transplantation Program
- Digestive Surgery Service, Hospital de Clínicas de Porto Alegre
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Minder AE, Schneider-Yin X, Zulewski H, Minder CE, Minder EI. Afamelanotide Is Associated with Dose-Dependent Protective Effect from Liver Damage Related to Erythropoietic Protoporphyria. Life (Basel) 2023; 13:life13041066. [PMID: 37109595 PMCID: PMC10143433 DOI: 10.3390/life13041066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 03/29/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
In animal models, melanocyte-stimulating hormones (MSHs) protect the liver from various injuries. Erythropoietic protoporphyria (EPP), a metabolic disorder, leads to the accumulation of protoporphyrin (PPIX). In addition to the most prominent symptom of incapacitating phototoxic skin reactions, 20% of EPP patients exhibit disturbed liver functioning and 4% experience terminal liver failure caused by the hepatobiliary elimination of excess PPIX. Skin symptoms are mitigated through the application of the controlled-release implant afamelanotide, an α-MSH analog, every sixty days. Recently, we showed that liver function tests (LFTs) improved during afamelanotide treatment when compared to before treatment. The present study investigated whether this effect is dose-dependent, as the evidence of dose dependency would support a beneficial influence of afamelanotide. METHODS In this retrospective observational study, we included 2933 liver-function tests, 1186 PPIX concentrations and 1659 afamelanotide implant applications in 70 EPP patients. We investigated whether the number of days since the preceding afamelanotide dose or the number of doses during the preceding 365 days had an effect on LFTs and PPIX levels. In addition, we assessed the effect of global radiation. RESULTS Inter-patient differences exerted the most prominent effect on PPIX and LFTs. In addition, PPIX increased significantly with an increase in the number of days since the last afamelanotide implant (p < 0.0001). ALAT and bilirubin decreased significantly with an increasing number of afamelanotide doses in the preceding 365 days (p = 0.012, p = 0.0299, respectively). Global radiation only influenced PPIX (p = 0.0113). CONCLUSIONS These findings suggest that afamelanotide ameliorates both PPIX concentrations and LFTs in EPP in a dose-dependent manner.
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Affiliation(s)
- Anna-Elisabeth Minder
- Division of Endocrinology, Diabetology, Porphyria and Clinical Nutrition, Stadtspital Zürich, Triemli, 8063 Zurich, Switzerland
- Swiss Reference Centre for Porphyrias, Stadtspital Zürich, Triemli, 8063 Zurich, Switzerland
| | - Xiaoye Schneider-Yin
- Swiss Reference Centre for Porphyrias, Stadtspital Zürich, Triemli, 8063 Zurich, Switzerland
- Institute of Laboratory Medicine, Stadtspital Zürich, Triemli, 8063 Zurich, Switzerland
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
| | - Henryk Zulewski
- Division of Endocrinology, Diabetology, Porphyria and Clinical Nutrition, Stadtspital Zürich, Triemli, 8063 Zurich, Switzerland
- Department of Biosystems Science and Engineering (D-BSSE), ETH, 8092 Zurich, Switzerland
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
| | - Christoph E Minder
- Department of Social and Preventive Medicine, University of Bern, 3012 Bern, Switzerland
| | - Elisabeth I Minder
- Division of Endocrinology, Diabetology, Porphyria and Clinical Nutrition, Stadtspital Zürich, Triemli, 8063 Zurich, Switzerland
- Swiss Reference Centre for Porphyrias, Stadtspital Zürich, Triemli, 8063 Zurich, Switzerland
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
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Pastore LM, Sun CW, Hsu S. Erythropoietic Protoporphyria: You May Not Have Seen It, but It May Have Seen You. Cureus 2022; 14:e23253. [PMID: 35449677 PMCID: PMC9012550 DOI: 10.7759/cureus.23253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/05/2022] Open
Abstract
Erythropoietic protoporphyria is a rare skin condition that commonly presents in childhood. We report a case of a 35-year-old Hispanic male with a history of sun sensitivity, presenting with complaints of immediate burning and itching of the skin on his face and upper extremities upon sun exposure. On examination, there was minimal face erythema and calluses over the knuckles. Laboratory workup demonstrated substantially increased protoporphyrin (over 10 times the upper limit of normal) along with elevated liver enzyme levels. Liver biopsy confirmed stage 4 cirrhosis. Our patient’s cutaneous manifestations were the primary complaint that led to the diagnosis of his terminal hepatic illness. We recommend screening for erythropoietic protoporphyria in patients who present with a life-long history of non-blistering, burning and itching of the skin, which begins immediately upon sun exposure.
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Di Pierro E, Granata F, De Canio M, Rossi M, Ricci A, Marcacci M, De Luca G, Sarno L, Barbieri L, Ventura P, Graziadei G. Recognized and Emerging Features of Erythropoietic and X-Linked Protoporphyria. Diagnostics (Basel) 2022; 12:diagnostics12010151. [PMID: 35054318 PMCID: PMC8775248 DOI: 10.3390/diagnostics12010151] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/31/2021] [Accepted: 01/06/2022] [Indexed: 02/06/2023] Open
Abstract
Erythropoietic protoporphyria (EPP) and X-linked protoporphyria (XLP) are inherited disorders resulting from defects in two different enzymes of the heme biosynthetic pathway, i.e., ferrochelatase (FECH) and delta-aminolevulinic acid synthase-2 (ALAS2), respectively. The ubiquitous FECH catalyzes the insertion of iron into the protoporphyrin ring to generate the final product, heme. After hemoglobinization, FECH can utilize other metals like zinc to bind the remainder of the protoporphyrin molecules, leading to the formation of zinc protoporphyrin. Therefore, FECH deficiency in EPP limits the formation of both heme and zinc protoporphyrin molecules. The erythroid-specific ALAS2 catalyses the synthesis of delta-aminolevulinic acid (ALA), from the union of glycine and succinyl-coenzyme A, in the first step of the pathway in the erythron. In XLP, ALAS2 activity increases, resulting in the amplified formation of ALA, and iron becomes the rate-limiting factor for heme synthesis in the erythroid tissue. Both EPP and XLP lead to the systemic accumulation of protoporphyrin IX (PPIX) in blood, erythrocytes, and tissues causing the major symptom of cutaneous photosensitivity and several other less recognized signs that need to be considered. Although significant advances have been made in our understanding of EPP and XLP in recent years, a complete understanding of the factors governing the variability in clinical expression and the severity (progression) of the disease remains elusive. The present review provides an overview of both well-established facts and the latest findings regarding these rare diseases.
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Affiliation(s)
- Elena Di Pierro
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (G.D.L.); (G.G.)
- Correspondence: or ; Tel.: +39-0255036155
| | - Francesca Granata
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (G.D.L.); (G.G.)
| | - Michele De Canio
- Porphyria and Rare Diseases Centre, San Gallicano Dermatological Institute IRCCS, 00144 Rome, Italy; (M.D.C.); (L.B.)
| | - Mariateresa Rossi
- Department of Dermatology, ASST Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy; (M.R.); (L.S.)
| | - Andrea Ricci
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, University of Modena e Reggio Emilia, 41124 Modena, Italy; (A.R.); (M.M.); (P.V.)
| | - Matteo Marcacci
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, University of Modena e Reggio Emilia, 41124 Modena, Italy; (A.R.); (M.M.); (P.V.)
| | - Giacomo De Luca
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (G.D.L.); (G.G.)
| | - Luisa Sarno
- Department of Dermatology, ASST Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy; (M.R.); (L.S.)
| | - Luca Barbieri
- Porphyria and Rare Diseases Centre, San Gallicano Dermatological Institute IRCCS, 00144 Rome, Italy; (M.D.C.); (L.B.)
| | - Paolo Ventura
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, University of Modena e Reggio Emilia, 41124 Modena, Italy; (A.R.); (M.M.); (P.V.)
| | - Giovanna Graziadei
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (G.D.L.); (G.G.)
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9
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Severe aplastic anemia in a patient with erythropoietic protoporphyria successfully treated by avatrombopag. Ann Hematol 2021; 101:1361-1363. [PMID: 34825961 DOI: 10.1007/s00277-021-04726-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/13/2021] [Indexed: 12/18/2022]
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10
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Zhao C, Guan JX, Hui DY, Zhang NN, Lu LR, Tang LY, Shao CK, Chen JN. Liver involvement in patients with erythropoietic protoporphyria: retrospective analysis of clinicopathological features of 5 cases. Ann Diagn Pathol 2021; 56:151859. [PMID: 34844099 DOI: 10.1016/j.anndiagpath.2021.151859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/11/2021] [Indexed: 01/24/2023]
Abstract
Erythropoietic protoporphyria (EPP) is a rare inherited disease whose morbidity is about 1:75,000 to 1:200,000. It is caused by the deficiency of porphyrin ferrochelatase (FECH). Liver involvement in EPP is even rarer. The diagnosis of EPP with liver involvement mainly relies on clinical manifestations, laboratory examinations, histopathological examinations and genetic testing, which is still a huge challenge for both clinicians and pathologists. Here, 5 cases of EPP with liver injury were collected, and the clinicopathological features of these patients were analyzed. The clinical manifestations and laboratory examinations varied from person to person, whereas the liver biopsies showed that there were dark brown deposits within the hepatocytes, Kupffer cells, bile canaliculi and the lumen of bile ducts, which was a constant finding by histopathological examination. Gene tests were conducted in two of the five cases, and the results confirmed the diagnosis. Fully understanding of the diseases can help us reduce the rate of missed diagnosis and provide proper treatment as early as possible.
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Affiliation(s)
- Chang Zhao
- Department of Pathology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510000, China
| | - Jie-Xia Guan
- Department of Pathology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510000, China
| | - Da-Yang Hui
- Department of Pathology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510000, China
| | - Na-Na Zhang
- Department of Pathology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510000, China
| | - Li-Rong Lu
- Department of Special Inspection, Guangzhou KingMed Center for Clinical Laboratory Co., Ltd., Guangzhou 510000, China
| | - Lu-Ying Tang
- Department of Pathology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510000, China
| | - Chun-Kui Shao
- Department of Pathology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510000, China.
| | - Jian-Ning Chen
- Department of Pathology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510000, China.
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Minder AE, Barman-Aksoezen J, Schmid M, Minder EI, Zulewski H, Minder CE, Schneider-Yin X. Beyond pigmentation: signs of liver protection during afamelanotide treatment in Swiss patients with erythropoietic protoporphyria, an observational study. THERAPEUTIC ADVANCES IN RARE DISEASE 2021; 2:26330040211065453. [PMID: 37181106 PMCID: PMC10032460 DOI: 10.1177/26330040211065453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 11/18/2021] [Indexed: 05/16/2023]
Abstract
Erythropoietic protoporphyria (EPP) is an ultra-rare inherited disorder with overproduction of protoporphyrin in maturating erythroblasts. This excess protoporphyrin leads to incapacitating phototoxic burns in sunlight exposed skin. Its biliary elimination causes cholestatic liver injury in 20% and terminal liver failure in 4% of EPP patients. Thereby, the risk of liver injury increases with increasing erythrocyte protoporphyrin concentrations. Afamelanotide, an α-melanocyte-stimulating hormone (MSH) analog inducing skin pigmentation, was shown to improve sunlight tolerance in EPP. Beyond this well-known effect on pigmentation, the MSHs have liver-protective effects and improve survival of maturating erythroblasts, effects described in animal or in vitro models to date only. We investigated whether afamelanotide treatment in EPP has effects on erythropoiesis, protoporphyrin concentrations, and liver injury by analyzing retrospectively our long-term safety data. Methods From the 47 Swiss EPP-patients treated at our center since 2006, we included those 38 patients in the current analysis who received at least one afamelanotide dose between 2016 and 2018 and underwent regular laboratory testing before and during the treatment. We compared the means of pretreatment measurements with those during the treatment. Results Protoporphyrin concentrations dropped from 21.39 ± 11.12 (mean ± SD) before afamelanotide to 16.83 ± 8.24 µmol/L (p < .0001) during treatment. Aspartate aminotransferase decreased from 26.67 ± 13.16 to 22.9 ± 7.76 IU/L (p = .0146). For both entities, patients with higher values showed a more progressive decrease, indicating a risk reduction of EPP-related liver disease. The pre-existing hypochromia and broad mean red-cell distribution width were further augmented under afamelanotide. This was more likely due to an influence of afamelanotide on maturating erythroblasts than due to an exacerbated iron deficiency, as mean zinc-protoporphyrin decreased significantly and ferritin remained unchanged. No serious afamelanotide-related adverse events were observed for a total of 240 treatment years. Conclusion Our findings point to a protective effect of afamelanotide on erythroblast maturation and protoporphyrin-induced liver injury. Plain Language summary Afamelanotide, a skin tanning hormone, may protect patients with erythropoietic protoporphyria not only from skin burns, but also from liver injury associated with the disease. Patients with erythropoietic protoporphyria (EPP), an inherited metabolic disease, suffer from light-induced skin burns and liver injury elicited by the accumulated light sensitizer protoporphyrin. The excess protoporphyrin is produced in red cell precursors in the bone marrow, and it is eliminated from the body via the liver and bile. A high protoporphyrin excretion burden damages the liver cells, the risk for this increases with higher protoporphyrin concentrations. About 20% of EPP patients show some sign of liver injury and 4% develop life-threatening liver dysfunction.Afamelanotide, closely related to natural α-melanocyte stimulating hormone (MSH), induces skin tanning. This effect protects EPP patients from light-induced skin burns as shown in previous studies. We have treated Swiss EPP patients with afamelanotide since 2006, and we regularly perform safety tests of this treatment.Recent in vitro and animal studies demonstrated α-MSH effects other than skin tanning, including an improved synthesis of red blood cell precursors in the bone-marrow and protection of the liver from experimentally induced damage. Until now, it is unknown whether afamelanotide has similar effects in the human organism.To study this question, we analyzed retrospectively the safety laboratory data of 38 Swiss patients, who received at least one dose of afamelanotide from 2016 to 2019. We found that both, the average protoporphyrin concentrations and aspartate aminotransferase, a test for liver function, improved during afamelanotide treatment as compared to before.We concluded that afamelanotide applied to EPP patients to protect them from light-induced skin burns also may reduce their risk of liver injury.
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Affiliation(s)
- Anna-Elisabeth Minder
- Division of Endocrinology, Diabetology,
Porphyria, Stadtspital Zürich, Birmensdorferstrasse 497, 8063 Zurich,
Switzerland
| | | | - Mathias Schmid
- Department of Hematology and Oncology,
Stadtspital Zürich, Zurich, Switzerland
| | - Elisabeth I. Minder
- Division of Endocrinology, Diabetology,
Porphyria, Stadtspital Zürich, Zurich, Switzerland
| | - Henryk Zulewski
- Division of Endocrinology, Diabetology,
Porphyria, Stadtspital Zürich, Zurich, Switzerland
| | - Christoph E. Minder
- Department of Social and Preventive Medicine,
University of Bern, Bern, Switzerland
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