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Xiong X, Wei H, Zhu Y, Zhou X, Zhao Z, Chen Q. Wilson disease in pregnancy: A case series. Medicine (Baltimore) 2023; 102:e32968. [PMID: 36800617 PMCID: PMC9936009 DOI: 10.1097/md.0000000000032968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
RATIONALE Hepatolenticular degeneration, also known as Wilson disease (WD), is an autosomal recessive inherited disease characterized by copper metabolism, which has complex clinical manifestations, and mainly including liver and nervous system lesions. Pregnancy combined with WD is extremely harmful to mothers and children, with high miscarriage rates, and premature birth rates and perinatal mortality. PATIENT CONCERNS Here we introduced the basic information of 4 pregnant women with WD. The first pregnant woman had a 16-year history of WD, stopped taking penicillamine 1 year before pregnancy. The second woman had a 3-year history of WD and was taking penicillamine regularly, unintended pregnancy occurred 1 month after stopping the drug. The third woman had a history of WD for 5 years with penicillamine treatment. The 4th woman was found to have WD due to repeated missed miscarriage with abnormal liver function, after which penicillamine was regularly taken. Fortunately, she was pregnant again a year later. DIAGNOSES The pregnant women in case 1 and case 2 were diagnosed with decompensated cirrhosis with coagulation dysfunction during pregnancy. The pregnant woman in case 3 was found to have liver cirrhosis by ultrasound, and the pregnant woman in case 4 did not have liver abnormalities during pregnancy. INTERVENTIONS The pregnant woman in case 1 began to take copper-removing drugs and take a low-copper diet after finding the aggravation of the disease in the early stage of pregnancy, and had good compliance during pregnancy. The pregnant woman in case 2 had poor compliance during pregnancy and did not receive any treatment. The pregnant woman in case 3 refused to use copper elimination drugs during pregnancy, but took a low copper diet. The pregnant woman in case 4 had good compliance during pregnancy, and she was treated with drugs and low copper diet during the whole pregnancy. OUTCOMES Three of the four pregnant women got a healthy baby but premature, and only the pregnant woman in case 2 had spontaneous abortion at 25 weeks. LESSONS After comprehensive monitoring and multidisciplinary management of professional medical staff before and after pregnancy, WD pregnant women still have the opportunity to obtain a better pregnancy outcome and improve quality of life.
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Affiliation(s)
- Xiali Xiong
- Department of Obstetrics, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Hong Wei
- Department of Obstetrics, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Yunxia Zhu
- Department of Obstetrics, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Xin Zhou
- Department of Obstetrics, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Zhiqiang Zhao
- Department of Obstetrics, Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Qiang Chen
- China Academy of Chinese Medical Sciences Eye Hospital, Beijing, China
- * Correspondence: Qiang Chen, China Academy of Chinese Medical Sciences Eye Hospital, No. 33 Lu Gu Road, Shi Jing Shan District, Beijing 100040, China (e-mail: )
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Litwin T, Bembenek J, Antos A, Kurkowska-Jastrzębska I, Przybyłkowski A, Skowrońska M, Smoliński Ł, Członkowska A. The Maternal and Fetal Outcomes of Pregnancy in Wilson’s Disease: A Systematic Literature Review and Meta-Analysis. Biomedicines 2022; 10:biomedicines10092072. [PMID: 36140172 PMCID: PMC9495510 DOI: 10.3390/biomedicines10092072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/17/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Wilson’s disease (WD) is a rare, treatable genetic disorder with multi-organ symptoms related mainly to copper accumulation. Most patients become aware of the disease as young adults, thus knowledge on fertility, pregnancy course and outcome is very important both for patients and physicians. The aim of this study was to perform a systematic review and meta-analysis of pregnancy outcomes in women with WD. This systematic literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were identified by searching the PubMed database (up to 12 January 2022) and by screening reference lists. We found 49 publications, including 13 retrospective studies and 36 series and case reports on pregnancy outcomes in WD patients. In total, descriptions of 449 pregnant women with 822 pregnancies were retrieved. Successful deliveries were achieved in 78.3% (644/822) of all pregnancies. Spontaneous abortions were observed in 21.7% (178/822) of pregnancies, more frequently in patients who were untreated 68.6% (96/140). Analyzing maternal outcome, 2.2% (18/822) of pregnancies were associated with the aggravation of neurological symptoms. Symptoms of hepatic deterioration were observed in 4.6% (38/822) of cases. These were usually transient and recovered after pregnancy; however, death due to liver failure was observed in 0.2% (2/822) of cases. Birth defects occurred in 4.7% (39/822) of pregnancies. The available meta-analysis showed statistically significant positive associations between anti-copper treatment and pregnancy outcome. Our results document the significance of anti-copper treatment as the main factor leading to successful pregnancy, as well as positive outcomes for women with WD.
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Affiliation(s)
- Tomasz Litwin
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957 Warsaw, Poland
- Correspondence: ; Tel.: +48-22-4582537; Fax: +48-22-8424023
| | - Jan Bembenek
- Department of Clinical Neurophysiology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957 Warsaw, Poland
| | - Agnieszka Antos
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957 Warsaw, Poland
| | | | - Adam Przybyłkowski
- Department of Gastroenterology and Internal Medicine, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
| | - Marta Skowrońska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957 Warsaw, Poland
| | - Łukasz Smoliński
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957 Warsaw, Poland
| | - Anna Członkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957 Warsaw, Poland
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Nicastro E, Iascone M, Di Giorgio A, Brecelj J, Petruzzelli R, Polishchuk RS, Deheragoda M, Wagner BE, Sonzogni A, Bonanomi E, D’Antiga L. Infantile ATP7B-Related End-Stage Liver Disease: An Exceptional Wilson Disease Phenotype From Consecutive Generations. JPGN REPORTS 2021; 2:e112. [PMID: 37205945 PMCID: PMC10191499 DOI: 10.1097/pg9.0000000000000112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/02/2021] [Indexed: 05/21/2023]
Abstract
Wilson disease (WD) is a rare autosomal recessive disorder of copper metabolism typically presenting after 3 years of age. We describe a girl presenting with neonatal cholestasis rapidly progressing to end-stage liver disease. She presented hepatosplenomegaly, neurological impairment, Coombs-negative hemolytic anemia, central hypothyroidism. A patient-parents whole exome sequencing identified a homozygous state for ATP7B mutations causing WD in the proband (p.Gln7fs/p.His1069Gln) and her mother (p.His1069Gln/p.His1069Gln), who was then confirmed to have cirrhotic WD. A causative role of copper toxicity due to ATP7B loss of function was indicated by the presence of extrahepatic features of WD, consistent tests of copper metabolism-including a 7-fold increase in liver copper-and similarity of patient's liver gene expression profile and ultrastructure with that of WD models. This exceptionally early presentation could result from the combination of the ATP7B impairment and the intrauterine copper overload due to maternal undiagnosed WD.
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Affiliation(s)
- Emanuele Nicastro
- From the Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Maria Iascone
- Medical Genetics Laboratory, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Angelo Di Giorgio
- From the Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Jernej Brecelj
- Departments of Gastroenterology, Hepatology and Nutrition and Pediatrics, Medical Faculty Ljubljana, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | | | - Maesha Deheragoda
- Institute of Liver Studies, King’s College Hospital, London, United Kingdom
| | - Bart E. Wagner
- Histopathology Department, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | | | - Ezio Bonanomi
- Pediatric Intensive Care Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Lorenzo D’Antiga
- From the Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
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4
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Roseira J, Lopes R, Silva MJ, Vieira AM, Sampaio M, Calinas F. Gynecological history up to diagnosis and pregnancy outcomes in diagnosed Wilson's disease under therapy - a bicentric matched control cohort study. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 114:198-203. [PMID: 33393331 DOI: 10.17235/reed.2020.7444/2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction Most studies narrowly focus on pregnancy outcomes comparisons between Wilson Disease (WD) patients on and off treatment. We aimed to identify menses irregularities in untreated WD and evaluate pregnancy outcomes in treated WD compared with matched controls (with and without liver disease). Methods Women with WD, women with Hepatitis C (liver disease controls), and women with other gastrointestinal conditions (controls without liver disease), were identified from two tertiary hospital gastroenterology departments. Gynecological and obstetric data was retrospectively collected. Comparison of gynecological and obstetric outcomes between groups was performed, and regression models were used to further assess obstetric outcomes. Results We identified 18 women with WD, comprising 19 pregnancies under treatment in 11 patients, and 20 women for each control group. Age and liver disease stage between groups was adjusted. The incidence of menses irregularities was higher for WD (late menarche, 83% vs. 10% vs. 10%, p<0.01; irregular cycles, 100% vs. 20% vs. 20%, p<0.01; amenorrhea, 67% vs. 10% vs. 5%, p<0.01). Logistic regression models identified WD as a predictor of miscarriage and low birth weight (OR 6.0; IC 1.1-33.3; p<0.05), but not of birth defects. Neither therapies (D-Pencillamine 300mg or zinc acetate 150mg) nor disease presentation (hepatic or/and neurological) were associated with obstetric complications in WD. Conclusion There was a higher incidence of menses irregularities in untreated women with WD. Additionally, our data suggests that treated WD still carries a higher risk of spontaneous abortion and low birth weight, compared to matched control groups with and without liver disease.
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Affiliation(s)
- Joana Roseira
- Gastroenterology, Algarve Universitary Hospital Center, Portugal
| | - Rita Lopes
- Medicine Faculty - University of the Algarve, Portugal, Portugal
| | - Mário Jorge Silva
- Gastroenterology , Central Lisbon Universitary Hospital Center, Portugal - Capuchos Hospital, Portugal
| | | | | | - Filipe Calinas
- Gastroenterology, Central Lisbon Universitary Hospital Center, Portugal - Capuchos Hospital, Portugal
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5
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Luo J, Hao S, Zhao L, Shi F, Ye G, He C, Lin J, Zhang W, Liang H, Wang X, Guo H, He R, Tang H, Li Y. Oral exposure of pregnant rats to copper nanoparticles caused nutritional imbalance and liver dysfunction in fetus. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2020; 206:111206. [PMID: 32889309 DOI: 10.1016/j.ecoenv.2020.111206] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 06/11/2023]
Abstract
Copper nanoparticles (Cu NPs) are increasingly used as an animal feed additive in China. In previous studies, it was determined that Cu NPs can penetrate the placental barrier, however, its toxic effects on the fetus have not yet been elucidated. Therefore, in this study, we investigated the potential fetal toxic effects of Cu NPs. Cu NPs were orally administered to pregnant Sprague-Dawley rats from gestation days (GDs) 3-18 at a dose of 60, 120, and 180 mg/kg/day. Cesarean sections were conducted on GD 19. During fetal examination, no toxicities were observed regarding general clinical signs, however, Cu NPs significantly decreased fetal body weight, body length, and liver weights. Cu ions and Cu MPs exhibited similar effects on the fetal development. Cu NPs increased the liver concentration of Cu, and decreased protein levels and Fe in fetuses. Cu NPs also increased oxidative stress and inflammation in the fetus after pregnant rats were exposed to high doses of Cu NPs. Oral exposure to Cu NPs during pregnancy increased Cu concentrations in the fetus, which not only affected fetal development, but also significantly induced oxidative stress and inflammatory responses in fetal liver. Taken together, these findings are valuable to evaluate fetal risk assessment after oral exposure of Cu NPs during pregnancy. Additional comprehensive toxicity studies are deemed necessary to clarify the underlying mechanisms involved.
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Affiliation(s)
- Jie Luo
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China; National Ethnic Affairs Commission Key Open Laboratory of Traditional Chinese Veterinary Medicine, Tongren Polytechnic College, Tongren, 554300, China
| | - Suqi Hao
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
| | - Ling Zhao
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
| | - Fei Shi
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
| | - Gang Ye
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
| | - Changliang He
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
| | - Juchun Lin
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
| | - Wei Zhang
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
| | - Hao Liang
- National Ethnic Affairs Commission Key Open Laboratory of Traditional Chinese Veterinary Medicine, Tongren Polytechnic College, Tongren, 554300, China
| | - Xun Wang
- College of Animal Science, Sichuan Agricultural University, Chengdu, 611130, China
| | - Hongrui Guo
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
| | - Ran He
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
| | - Huaqiao Tang
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China.
| | - Yinglun Li
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China.
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Pfeiffenberger J, Beinhardt S, Gotthardt DN, Haag N, Freissmuth C, Reuner U, Gauss A, Stremmel W, Schilsky ML, Ferenci P, Weiss KH. Pregnancy in Wilson's disease: Management and outcome. Hepatology 2018; 67:1261-1269. [PMID: 28859232 DOI: 10.1002/hep.29490] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 07/12/2017] [Accepted: 08/29/2017] [Indexed: 12/19/2022]
Abstract
UNLABELLED Wilson's disease (WD) is a rare inherited disorder of copper metabolism causing toxic hepatic and neural copper accumulation. Clinical symptoms vary widely, from asymptomatic disease to acute liver failure or chronic liver disease with or without neuropsychiatric symptoms. Continuation of specific medical treatment for WD is recommended during pregnancy, but reports of pregnancy outcomes in WD patients are sparse. In a retrospective, multicenter study, 282 pregnancies in 136 WD patients were reviewed. Age at disease onset, age at conception, and WD-specific treatments were recorded. Maternal complications during pregnancy, rate of spontaneous abortions, and birth defects were analyzed with respect to medical treatment during pregnancy. Worsening of liver function tests was evident during 16 of 282 (6%) pregnancies and occurred in undiagnosed patients as well as in those under medical treatment. Liver test abnormalities resolved in all cases after delivery. Aggravation of neurological symptoms during pregnancy was rare (1%), but tended to persist after delivery. The overall spontaneous abortion rate in the study cohort was 73 of 282 (26%). Patients with an established diagnosis of WD receiving medical treatment experienced significantly fewer spontaneous abortions than patients with undiagnosed WD (odds ratio, 2.853 [95% confidence interval, 1.634-4.982]). Birth defects occurred in 7 of 209 (3%) live births. CONCLUSION Pregnancy in WD patients on anticopper therapy is safe. The spontaneous abortion rate in treated patients was lower than that in therapy-naïve patients. Although the teratogenic potential of copper chelators is a concern, the rate of birth defects in our cohort was low. Treatment for WD should be maintained during pregnancy, and patients should be monitored closely for hepatic and neurological symptoms. (Hepatology 2018;67:1261-1269).
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Affiliation(s)
- Jan Pfeiffenberger
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sandra Beinhardt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Daniel N Gotthardt
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Nicola Haag
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Clarissa Freissmuth
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Ulrike Reuner
- Department of Neurology, University Hospital Dresden, Dresden, Germany
| | - Annika Gauss
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Wolfgang Stremmel
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael L Schilsky
- Sections of Digestive Disease and Transplantation and Immunology, Departments of Medicine and Surgery, Yale University School of Medicine, New Haven, CT
| | - Peter Ferenci
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Karl Heinz Weiss
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
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Abstract
PURPOSE OF REVIEW This review discusses movement disorders that occur during pregnancy, the treatment of preexisting movement disorders, and the influence the pregnant state has on movement disorders symptoms, in order to guide clinicians in providing better counseling for female patients who are pregnant or considering pregnancy. RECENT FINDINGS Unique considerations for movement disorders during pregnancy include investigations and their safety during pregnancy and the impact of treatment on both the pregnant patient and her fetus. SUMMARY The most common movement disorders arising in pregnancy are restless leg syndrome and chorea gravidarum. Preexisting movement disorders in women who become pregnant may also be seen.
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Hardman B, Luff S, Ackland M. Differential intracellular localisation of the Menkes and Wilson copper transporting ATPases in the third trimester human placenta. Placenta 2011; 32:79-85. [DOI: 10.1016/j.placenta.2010.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Revised: 10/07/2010] [Accepted: 11/03/2010] [Indexed: 10/18/2022]
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Young T, Downey G, Maheshwari MB, Nicholl DJ. A cupric pregnancy - thirteenth time lucky. JRSM SHORT REPORTS 2010; 1:51. [PMID: 21234114 PMCID: PMC2994355 DOI: 10.1258/shorts.2010.010069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Terence Young
- City Hospital , Dudley Road, Birmingham B18 7QH , UK
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Kranick SM, Mowry EM, Colcher A, Horn S, Golbe LI. Movement disorders and pregnancy: A review of the literature. Mov Disord 2010; 25:665-71. [DOI: 10.1002/mds.23071] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Uriu-Adams JY, Scherr RE, Lanoue L, Keen CL. Influence of copper on early development: prenatal and postnatal considerations. Biofactors 2010; 36:136-52. [PMID: 20232410 DOI: 10.1002/biof.85] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Copper (Cu) is an essential nutrient whose requirement is increased during pregnancy and lactation. These represent times of critical growth and development, and the fetus and neonate are particularly vulnerable to deficiencies of this nutrient. Genetic mutations that predispose the offspring to inadequate stores of Cu can be life threatening as is observed in children with Menkes disease. During the last decade, severe Cu deficiency, once thought to be a rare condition, has been reported in the literature at an increasing frequency. Secondary Cu deficiencies can be induced by a variety of ways such as excessive zinc or iron intake, certain drugs, and bariatric surgery. Premature and low birth weight infants can be born with low Cu stores. A number of mechanisms can contribute to the teratogenicity of Cu including decreased activity of select cuproenzymes, increased oxidative stress, decreased nitric oxide availability, altered iron metabolism, abnormal extracellular matrix protein crosslinking, decreased angiogenesis and altered cell signaling among others. The brain, heart, and vessels as well as tissues such as lung, skin and hair, and systems including the skeletal, immune, and blood systems, are negatively affected by suboptimal Cu during development. Additionally, persistent structural, biochemical, and functional adverse effects in the offspring are noted even when Cu supplementation is initiated after birth, supporting the concept that adequate Cu nutriture during pregnancy and lactation is critical for normal development. Although Cu-containing IUDs are an effective method for increasing intrauterine Cu concentrations and for reducing the risk of pregnancy, high amounts of dietary Cu are not thought to represent a direct developmental risk.
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Affiliation(s)
- Janet Y Uriu-Adams
- Department of Nutrition, University of California, Davis, Davis, CA 95616, USA.
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12
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Hanukoglu A, Curiel B, Berkowitz D, Levine A, Sack J, Lorberboym M. Hypothyroidism and dyshormonogenesis induced by D-penicillamine in children with Wilson's disease and healthy infants born to a mother with Wilson's disease. J Pediatr 2008; 153:864-6. [PMID: 19014823 DOI: 10.1016/j.jpeds.2008.06.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2007] [Revised: 05/12/2008] [Accepted: 06/17/2008] [Indexed: 12/22/2022]
Abstract
Two siblings born to a mother with Wilson's disease, who was taking D-penicillamine, developed transient goitrous hypothyroidism. A prospective evaluation of 5 patients with Wilson's disease taking and not taking D-penicillamine for as long as 9.5 years showed subclinical hypothyroidism. D-penicillamine probably inhibited thyroperoxidase activity in utero in healthy infants and during childhood in patients with Wilson's disease.
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Affiliation(s)
- Aaron Hanukoglu
- Division of Pediatric Endocrinology, E. Wolfson Medical Center, Holon, Israel; Tel-Aviv University, Sackler School of Medicine, Israel
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13
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Lutsenko S, Barnes NL, Bartee MY, Dmitriev OY. Function and regulation of human copper-transporting ATPases. Physiol Rev 2007; 87:1011-46. [PMID: 17615395 DOI: 10.1152/physrev.00004.2006] [Citation(s) in RCA: 536] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Copper-transporting ATPases (Cu-ATPases) ATP7A and ATP7B are evolutionarily conserved polytopic membrane proteins with essential roles in human physiology. The Cu-ATPases are expressed in most tissues, and their transport activity is crucial for central nervous system development, liver function, connective tissue formation, and many other physiological processes. The loss of ATP7A or ATP7B function is associated with severe metabolic disorders, Menkes disease, and Wilson disease. In cells, the Cu-ATPases maintain intracellular copper concentration by transporting copper from the cytosol across cellular membranes. They also contribute to protein biosynthesis by delivering copper into the lumen of the secretory pathway where metal ion is incorporated into copper-dependent enzymes. The biosynthetic and homeostatic functions of Cu-ATPases are performed in different cell compartments; targeting to these compartments and the functional activity of Cu-ATPase are both regulated by copper. In recent years, significant progress has been made in understanding the structure, function, and regulation of these essential transporters. These studies raised many new questions related to specific physiological roles of Cu-ATPases in various tissues and complex mechanisms that control the Cu-ATPase function. This review summarizes current data on the structural organization and functional properties of ATP7A and ATP7B as well as their localization and functions in various tissues, and discusses the current models of regulated trafficking of human Cu-ATPases.
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Affiliation(s)
- Svetlana Lutsenko
- Department of Biochemistry and Molecular Biology, Oregon Health & Science University, Portland, Oregon 97239, USA.
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14
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Donadio S, Alfaidy N, De Keukeleire B, Micoud J, Feige JJ, Challis JRG, Benharouga M. Expression and Localization of Cellular Prion and COMMD1 Proteins in Human Placenta throughout Pregnancy. Placenta 2007; 28:907-11. [PMID: 17254632 DOI: 10.1016/j.placenta.2006.11.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2006] [Revised: 11/20/2006] [Accepted: 11/21/2006] [Indexed: 11/30/2022]
Abstract
Copper is an essential trace element for successful pregnancy. However, the mechanisms by which copper is transported from maternal circulation to the fetus have not been clearly elucidated. Two proteins, cellular prion (PrP(C)) and COMMD1, are known to be responsible for prion diseases and canine copper toxicosis, respectively, and are thought to play a role in copper homeostasis. However, their placental expression and localization throughout human gestation are still unknown. In this study, we used quantitative RT-PCR, western blotting and immunohistochemistry to investigate in detail the expression and localization of PrP(C) and COMMD1 proteins in human placenta throughout pregnancy. Our results show that both proteins are expressed in human placenta. PrP(C) showed the highest mRNA and protein expression levels during the first trimester of pregnancy. PrP(C) and COMMD1 proteins are similarly localized within the placental villi. Both proteins are present in the syncytiotrophoblast, the cytotrophoblast, vascular endothelial cells and Hofbauer cells. These data offer some insights into possible roles for PrP(C) and COMMD1 within the placenta.
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Affiliation(s)
- S Donadio
- CEA Grenoble, UMR 5090 CEA/CNRS/Université Joseph Fourier, Département Réponse et Dynamique Cellulaire, Laboratoire de Biophysique Moléculaire et Cellulaire, 17 rue des Martyrs, 38054 Grenoble Cedex 9, France
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15
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La Fontaine S, Mercer JFB. Trafficking of the copper-ATPases, ATP7A and ATP7B: Role in copper homeostasis. Arch Biochem Biophys 2007; 463:149-67. [PMID: 17531189 DOI: 10.1016/j.abb.2007.04.021] [Citation(s) in RCA: 292] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2007] [Revised: 04/18/2007] [Accepted: 04/18/2007] [Indexed: 01/05/2023]
Abstract
Copper is essential for human health and copper imbalance is a key factor in the aetiology and pathology of several neurodegenerative diseases. The copper-transporting P-type ATPases, ATP7A and ATP7B are key molecules required for the regulation and maintenance of mammalian copper homeostasis. Their absence or malfunction leads to the genetically inherited disorders, Menkes and Wilson diseases, respectively. These proteins have a dual role in cells, namely to provide copper to essential cuproenzymes and to mediate the excretion of excess intracellular copper. A unique feature of ATP7A and ATP7B that is integral to these functions is their ability to sense and respond to intracellular copper levels, the latter manifested through their copper-regulated trafficking from the transGolgi network to the appropriate cellular membrane domain (basolateral or apical, respectively) to eliminate excess copper from the cell. Research over the last decade has yielded significant insight into the enzymatic properties and cell biology of the copper-ATPases. With recent advances in elucidating their localization and trafficking in human and animal tissues in response to physiological stimuli, we are progressing rapidly towards an integrated understanding of their physiological significance at the level of the whole animal. This knowledge in turn is helping to clarify the biochemical and cellular basis not only for the phenotypes conferred by individual Menkes and Wilson disease patient mutations, but also for the clinical variability of phenotypes associated with each of these diseases. Importantly, this information is also providing a rational basis for the applicability and appropriateness of certain diagnostic markers and therapeutic regimes. This overview will provide an update on the current state of our understanding of the localization and trafficking properties of the copper-ATPases in cells and tissues, the molecular signals and posttranslational interactions that govern their trafficking activities, and the cellular basis for the clinical phenotypes associated with disease-causing mutations.
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Affiliation(s)
- Sharon La Fontaine
- Centre for Cellular and Molecular Biology, School of Life and Environmental Sciences, 221 Burwood Highway, Burwood, Vic. 3125, Australia.
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Hardman B, Michalczyk A, Greenough M, Camakaris J, Mercer J, Ackland M. Hormonal regulation of the Menkes and Wilson copper-transporting ATPases in human placental Jeg-3 cells. Biochem J 2007; 402:241-50. [PMID: 17109627 PMCID: PMC1798443 DOI: 10.1042/bj20061099] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Copper deficiency during pregnancy results in early embryonic death and foetal structural abnormalities including skeletal, pulmonary and cardiovascular defects. During pregnancy, copper is transported from the maternal circulation to the foetus by mechanisms which have not been clearly elucidated. Two copper-transporting ATPases, Menkes (ATP7A; MNK) and Wilson (ATP7B; WND), are expressed in the placenta and both are involved in placental copper transport, as copper accumulates in the placenta in both Menkes and Wilson disease. The regulatory mechanisms of MNK and WND and their exact role in the placenta are unknown. Using a differentiated polarized Jeg-3 cell culture model of placental trophoblasts, MNK and WND were shown to be expressed within these cells. Distinct roles for MNK and WND are suggested on the basis of their opposing responses to insulin. Insulin and oestrogen increased both MNK mRNA and protein levels, altered the localization of MNK towards the basolateral membrane in a copper-independent manner, and increased the transport of copper across this membrane. In contrast, levels of WND were decreased in response to insulin, and the protein was located in a tight perinuclear region, with a corresponding decrease in copper efflux across the apical membrane. These results are consistent with a model of copper transport in the placenta in which MNK delivers copper to the foetus and WND returns excess copper to the maternal circulation. Insulin and oestrogen stimulate copper transport to the foetus by increasing the expression of MNK and reducing the expression of WND. These data show for the first time that MNK and WND are differentially regulated by the hormones insulin and oestrogen in human placental cells.
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Affiliation(s)
- Belinda Hardman
- *Centre for Cellular and Molecular Biology, School of Life and Environmental Sciences, Deakin University, Melbourne Campus, 221 Burwood Highway, Burwood, Victoria 3125, Australia
| | - Agnes Michalczyk
- *Centre for Cellular and Molecular Biology, School of Life and Environmental Sciences, Deakin University, Melbourne Campus, 221 Burwood Highway, Burwood, Victoria 3125, Australia
| | - Mark Greenough
- †Department of Genetics, Melbourne University, Melbourne, Victoria 3010, Australia
| | - James Camakaris
- †Department of Genetics, Melbourne University, Melbourne, Victoria 3010, Australia
| | - Julian F. B. Mercer
- *Centre for Cellular and Molecular Biology, School of Life and Environmental Sciences, Deakin University, Melbourne Campus, 221 Burwood Highway, Burwood, Victoria 3125, Australia
| | - M. Leigh Ackland
- *Centre for Cellular and Molecular Biology, School of Life and Environmental Sciences, Deakin University, Melbourne Campus, 221 Burwood Highway, Burwood, Victoria 3125, Australia
- To whom correspondence should be addressed (email )
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Suzuki Y, Watanabe I, Tanabe S, Kuno K. Trace elements accumulation and their variations with growth, sex and habitat: effects on Formosan squirrel (Callosciurus erythraeus). CHEMOSPHERE 2006; 64:1296-310. [PMID: 16494926 DOI: 10.1016/j.chemosphere.2005.12.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Revised: 12/27/2005] [Accepted: 12/28/2005] [Indexed: 05/06/2023]
Abstract
Formosan squirrels are considered a useful bio-indicator because their habitat exists within that of humans. Therefore, concentrations of 19 trace elements were determined in tissues of this species for assessment of environmental pollution in urban Kamakura and rural Izuohshima. Results of analyses revealed high Cu concentrations in the livers of Formosan squirrels. Moreover, concentrations of some trace elements from automobile exhausts-V, Zn, Cu and As-in the specimens from Kamakura were higher than those from Izuohshima. These results reflect the presence of pollution caused by human activities in Kamakura.
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Affiliation(s)
- Yoshinari Suzuki
- United Graduate School of Agricultural Science, Tokyo University of Agriculture and Technology, Fuchu 183-8509, Japan
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Christensen RD, Alder SC, Richards SC, Horn JT, Lambert DK, Baer VL. A pilot trial testing the feasibility of administering D-penicillamine to extremely low birth weight neonates. J Perinatol 2006; 26:120-4. [PMID: 16407960 DOI: 10.1038/sj.jp.7211440] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We enterally administered a 14-day course of 3-mercapto-D-valine (D-penicillamine) to five extremely low birth weight (ELBW) neonates, as a step toward assessing this therapy as a means of reducing the incidence or severity of retinopathy of prematurity (ROP). METHODS The study drug (100 mg/ml) was given by nasogastric tube at a dose of 100 mg/k every 8 h for three days, and then 50 mg/k once per day for 11 additional days. Logbooks were maintained by the bedside nurses to record signs of possible immediate intolerance. Laboratory tests assessed hepatic, renal, and hematologic toxicity. ROP was scored according to the ICROP guidelines. Comparisons were with a cohort of 139 consecutive recent neonates of the same birth weight and gestational age range. RESULTS Five neonates were enrolled in the study, and all received the full course of study drug as planned. Signs of immediate intolerance of the study drug were not observed in any. The study patients did not have a higher incidence, than that of the cohort group, in creatinine elevation, thrombocytopenia, neutropenia, hyperbilirubinemia, or abnormal liver function test. Four of the five had no ROP and one developed transient stage 1, compared with a 54% occurrence of ROP in the cohort. CONCLUSIONS It is feasible to enterally administer a 14-day course of 3-mercapto-D-valine to ELBW neonates and the suspension appears to be well tolerated. These results suggest that phase II safety and preliminary efficacy trials can be undertaken.
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Affiliation(s)
- R D Christensen
- Department of Women and Newborn, Intermountain Health Care and the McKay-Dee Hospital Center, Ogden, UT 84403, USA.
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Abstract
Movement disorders are not particularly common during pregnancy, with a few exceptions. RLS occurs most commonly followed by CG. Currently, with the incidence of rheumatic fever lower than previously, any woman who develops CG should be checked for illness other than rheumatic heart disease. The differential includes systemic lupus erythromatosis and antiphospholipid antibody syndrome. Regarding the use of dopaminergic agents, the dopamine agonist, pergolide, can be maintained during pregnancy for the treatment of PD, Segawa disease, and RLS. The use of levodopa and ropinirole should be limited during pregnancy because of the possible teratogenic effects. Amantadine is contraindicated during pregnancy. The data on selegiline are controversial; animal studies show possible serotonergic effects and teratogenic effects. If treatment is indicated in patients who have Tourette syndrome, the high potency neuroleptics drugs (haloperidol) are preferred to treat associated symptoms. Depression is a common comorbidity in patients who have PD, HD,Tourette syndrome, or other chronic neurologic diseases. Depression treatment during pregnancy is covered by Levy et al elsewhere in this issue. As discussed previously, most of the data on the use of drugs during pregnancy, especially the dopaminergic agents, are limited to animal studies and case reports. Therefore, it is in part left to the neurologist to decide on treatment based on the individual patient, clinical judgment, and inferences from animal studies and limited case reports.
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Pinter R, Hogge WA, McPherson E. Infant with severe penicillamine embryopathy born to a woman with Wilson disease. Am J Med Genet A 2005; 128A:294-8. [PMID: 15216551 DOI: 10.1002/ajmg.a.10871] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We report a chromosomally normal infant boy with congenital diffuse cutis laxa, severe micrognathia, contractures of all limbs, and central nervous system abnormalities including agenesis of the corpus callosum, born to a woman taking D-penicillamine (DP) for Wilson disease (WD) throughout her pregnancy. His postnatal course was remarkable for chronic lung disease, profound developmental delays, and probable cortical blindness, as well as resolution of his cutis laxa. Embryopathy is a rare complication in babies born to pregnant women treated with DP, and there have been only seven previous reports of birth defects in exposed infants (three of which had favorable postnatal outcomes). The etiology of the severe outcome in this boy is unclear, but prenatal measurement of maternal copper and zinc levels may be indicated for management.
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Affiliation(s)
- R Pinter
- Department of Genetics, Magee-Women's Hospital, Pittsburgh, Pennsylvania, USA.
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Hardman B, Manuelpillai U, Wallace EM, van de Waasenburg S, Cater M, Mercer JFB, Ackland ML. Expression and Localization of Menkes and Wilson Copper Transporting ATPases in Human Placenta. Placenta 2004; 25:512-7. [PMID: 15135234 DOI: 10.1016/j.placenta.2003.11.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2003] [Revised: 11/17/2003] [Accepted: 11/26/2003] [Indexed: 10/26/2022]
Abstract
Copper is an essential trace element necessary for normal growth and development. During pregnancy, copper is transported from the maternal circulation to the fetus by mechanisms which have not been clearly elucidated. Two copper transporting ATPases, Menkes (ATP7A; MNK) and Wilson (ATP7B; WND) are known to be expressed in the placenta and are thought to have a role in copper transport to the fetus. In this study, the expression and localization of the MNK and WND proteins in the human placenta were investigated in detail using immunoperoxidase and double-label immunohistochemistry. MNK and WND are differentially localized within the placenta. MNK is present in the syncytiotrophoblast, the cytotrophoblast and the fetal vascular endothelial cells whereas WND is only in the syncytiotrophoblast. Placental levels of both proteins, measured by Western blot analysis, did not change across pregnancy. These data offer some insights into possible roles for MNK and WND within the placenta.
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Affiliation(s)
- B Hardman
- School of Biological and Chemical Sciences, Centre for Cellular and Molecular Biology, Deakin University, 221 Burwood Highway, Burwood Campus, Burwood, Melbourne, Victoria 3125, Australia
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Abstract
Copper is a trace element, important for the function of many cellular enzymes. Copper ions can adopt distinct redox states oxidized Cu(II) or reduced (I), allowing the metal to play a pivotal role in cell physiology as a catalytic cofactor in the redox chemistry of enzymes, mitochondrial respiration, iron absorption, free radical scavenging and elastin cross-linking. If present in excess, free copper ions can cause damage to cellular components and a delicate balance between the uptake and efflux of copper ions determines the amount of cellular copper. In biological systems, copper homeostasis has been characterized at the molecular level. It is coordinated by several proteins such as glutathione, metallothionein, Cu-transporting P-type ATPases, Menkes and Wilson proteins and by cytoplasmic transport proteins called copper chaperones to ensure that it is delivered to specific subcellular compartments and thereby to copper-requiring proteins.
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Affiliation(s)
- H Tapiero
- Université de Paris - Faculté de Pharmacie CNRS UMR 8612, 5, rue Jean-Baptiste-Clément, 94200, Chatenay-Malabry, France.
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Abstract
This article thoroughly updates the authors' previous review of nutritional assessment and support during pregnancy. After briefly reviewing nutrient metabolism and requirements, the authors discuss the nutritional assessment of the pregnant woman and review the nutritional support principles in hyperemesis gravidarum and other conditions that can compromise the nutritional health of mother or fetus.
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Affiliation(s)
- Elie Hamaoui
- Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219, USA.
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24
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Abstract
Copper is an essential trace element that can be extremely toxic in excess due to the pro-oxidant activity of copper ions. Inherited disorders of copper transport, Menkes disease (copper deficiency), and Wilson disease (copper toxicosis) are caused by mutations of two closely related Cu transporting-ATPases, and demonstrate the essentiality and potential toxicity of copper. Other copper toxicosis conditions in humans and animals have been described, but are not well understood at a molecular level. Copper homeostatic mechanisms are being discovered. One such mechanism is copper-induced trafficking of the Cu-ATPases, which allows cells to provide copper to secreted cupro-proteins but also to efflux excess copper. Oxidative damage induced by copper may be involved in the pathogenesis of neurodegenerative conditions such as Alzheimer's disease, familial amyotrophic lateral sclerosis, and prion diseases.
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Affiliation(s)
- Roxana M Llanos
- Centre for Cellular and Molecular Biology, School of Biological and Chemical Sciences, Deakin University, Melbourne, Australia
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Furman B, Bashiri A, Wiznitzer A, Erez O, Holcberg G, Mazor M. Wilson's disease in pregnancy: five successful consecutive pregnancies of the same woman. Eur J Obstet Gynecol Reprod Biol 2001; 96:232-4. [PMID: 11384817 DOI: 10.1016/s0301-2115(00)00456-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Wilson's disease is an autosomal recessive disorder of copper metabolism characterized mainly by liver cirrhosis and neurological disorders. Appropriate treatment with chelating agents allows normal fertility function. We report five consecutive successful pregnancies of the same woman, treated in the high-risk unit at our medical center. The management dilemmas and treatment options are discussed.
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Affiliation(s)
- B Furman
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Abstract
The reported concentrations of iron and copper in breast milk show a wide variation. Research published over the past 50 y has reported median values of 0.47 and 0.32 mg/L for iron and copper, respectively. The levels of both metals decrease with the progress of lactation. The calculated iron-to-copper ratio of reported means differs from 0.25 to 6.29 (median = 1.18). Maternal constitutional variables such as undernutrition, iron and copper body reserves, stage of lactation, adolescent motherhood, gestation length, and infection and environmental variables such as iron and copper dietary intake, in addition to supplementation, smoking, vegetarianism, and prolonged use of hormonal contraceptives before and during lactation did not consistently affect the concentrations of iron and copper in breast milk. Extreme cases of either low or high levels of body metal availability or altered metabolism due to chelating therapy or illnesses such as Wilson's disease and infections did not affect metal transfer from blood serum to breast milk. There is no clinical or scientific support for the need of extra iron or copper, besides the quantities provided by milk in the full-term breast-fed infant, at least during the first 6 mo.
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Affiliation(s)
- J G Dorea
- Department of Nutrition, University of Brazil, Brasilia, Brazil
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Abstract
Proper nutrition during pregnancy is critically important to mother and fetus. For most healthy women, the only nutritional intervention required may be adequate iron and folate intake; however, for others, who begin pregnancy in a malnourished state or whose nutritional intake deteriorates during pregnancy, invasive nutritional support, including tube feeding or parenteral nutrition, may be indicated. To guide nutritional therapy and to avoid its potential complications, it is necessary to evaluate the patient's nutritional state. Such evaluation must focus not only on body composition and substrate reserves but also on the patient's changing nutrient requirements and any impediments to the patient's capacity to ingest and assimilate food.
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Affiliation(s)
- E Hamaoui
- Metabolic Support Service, Maimonides Medical Center, Brooklyn, New York, USA
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Berghella V, Steele D, Spector T, Cambi F, Johnson A. Successful pregnancy in a neurologically impaired woman with Wilson's disease. Am J Obstet Gynecol 1997; 176:712-4. [PMID: 9077636 DOI: 10.1016/s0002-9378(97)70577-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Patients with treated Wilson's disease and no residual impairments should have successful pregnancies. We report a case of a neurologically impaired patient with Wilson's disease who had a successful pregnancy with no complications. This is the first case to document that compliance with penicillamine therapy as low as 500 mg/day avoids placental and fetal copper accumulation.
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Affiliation(s)
- V Berghella
- Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Abstract
Wilson's disease, genetic and neonatal hemochromatosis, protoporphyria, tyrosinemia, and alpha1-antitrypsin deficiency are updated. Cost effectiveness of screening is discussed. Current therapies are evaluated, including the role of transplantation. The molecular biologic technique PCR is covered. Gene therapy is introduced.
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Affiliation(s)
- S J Schwarzenberg
- Department of Pediatrics, University of Minnesota Hospital and Clinics, Minneapolis 55445, USA
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