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Joseph MW, Stein DR, Stein AC. Gastrointestinal challenges in nephropathic cystinosis: clinical perspectives. Pediatr Nephrol 2024:10.1007/s00467-023-06211-6. [PMID: 38393360 DOI: 10.1007/s00467-023-06211-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 02/25/2024]
Abstract
Gastrointestinal (GI) sequelae, such as vomiting, hyperacidity, dysphagia, dysmotility, and diarrhea, are nearly universal among patients with nephropathic cystinosis. These complications result from disease processes (e.g., kidney disease, cystine crystal accumulation in the GI tract) and side effects of treatments (e.g., cysteamine, immunosuppressive therapy). GI involvement can negatively impact patient well-being and jeopardize disease outcomes by compromising drug absorption and patient adherence to the strict treatment regimen required to manage cystinosis. Given improved life expectancy due to advances in kidney transplantation and the transformative impact of cystine-depleting therapy, nephrologists are increasingly focused on addressing extra-renal complications and quality of life in patients with cystinosis. However, there is a lack of clinical data and guidance to inform GI-related monitoring, interventions, and referrals by nephrologists. Various publications have examined the prevalence and pathophysiology of selected GI complications in cystinosis, but none have summarized the full picture or provided guidance based on the literature and expert experience. We aim to comprehensively review GI sequelae associated with cystinosis and its treatments and to discuss approaches for monitoring and managing these complications, including the involvement of gastroenterology and other disciplines.
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Affiliation(s)
- Mark W Joseph
- Pediatric Nephrology, Oregon Health & Science University and OHSU Doernbecher Children's Hospital, Portland, OR, USA.
| | - Deborah R Stein
- Pediatric Nephrology, Harvard Medical School and Boston Children's Hospital, Boston, MA, USA
| | - Adam C Stein
- Gastroenterology, Northwestern University and Northwestern Medicine, Chicago, IL, USA
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Lenz B, Brink A, Mihatsch MJ, Altmann B, Niederhauser U, Steinhuber B, Wyttenbach N, Fischer H. Multiorgan Crystal Deposition of an Amphoteric Drug in Rats Due to Lysosomal Accumulation and Conversion to a Poorly Soluble Hydrochloride Salt. Toxicol Sci 2021; 180:383-394. [PMID: 33454789 PMCID: PMC8041455 DOI: 10.1093/toxsci/kfaa191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Poor solubility of drug candidates mainly affects bioavailability, but poor solubility of drugs and metabolites can also lead to precipitation within tissues, particularly when high doses are tested. RO0728617 is an amphoteric compound bearing basic and acidic moieties that has previously demonstrated good solubility at physiological pH but underwent widespread crystal deposition in multiple tissues in rat toxicity studies. The aim of our investigation was to better characterize these findings and their underlying mechanism(s), and to identify possible screening methods in the drug development process. Main microscopic features observed in rat RO0728617 toxicity studies were extensive infiltrates of crystal-containing macrophages in multiple organs. Matrix-assisted laser desorption/ionization Fourier transform ion cyclotron resonance mass spectrometry revealed that these crystals contained the orally administered parent compound, and locality was confirmed to be intracytoplasmic and partly intralysosomal by electron microscopic examination. Crystal formation was explained by lysosomal accumulation of the compound followed by precipitation of the hydrochloride salt under physiological conditions in the lysosomes, which have a lower pH and higher chloride concentration in comparison to the cytosol. This study demonstrates that risk of drug precipitation can be assessed by comparing the estimated lysosomal drug concentration at a given dose with the solubility of the compound at lysosomal conditions.
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Affiliation(s)
- Barbara Lenz
- Roche Pharma Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, 4070 Basel, Switzerland
| | - Andreas Brink
- Roche Pharma Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, 4070 Basel, Switzerland
| | - Michael J Mihatsch
- Pathology, Institute of Medical Genetics and Pathology, University Hospital of Basel, University of Basel, 4031 Basel, Switzerland
| | - Bernd Altmann
- Roche Pharma Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, 4070 Basel, Switzerland
| | - Urs Niederhauser
- Roche Pharma Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, 4070 Basel, Switzerland
| | - Bernd Steinhuber
- Roche Pharma Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, 4070 Basel, Switzerland
| | - Nicole Wyttenbach
- Roche Pharma Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, 4070 Basel, Switzerland
| | - Holger Fischer
- Roche Pharma Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, 4070 Basel, Switzerland
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Chiari I Malformation in Nephropathic Cystinosis. J Pediatr 2015; 167:1126-9. [PMID: 26265281 PMCID: PMC4661060 DOI: 10.1016/j.jpeds.2015.07.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 06/09/2015] [Accepted: 07/22/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the relative incidence of Chiari I malformations in children with cystinosis compared with those in the general population. STUDY DESIGN Magnetic resonance imaging scans were performed on 53 patients with nephropathic cystinosis and 120 controls, age range 3-18 years. RESULTS Ten of 53 (18.9%) patients with cystinosis had Chiari I or tonsillar ectopia, and only 2 of 120 controls (1.6%) had a similar finding. At least 2 of the patients had symptoms or signs thought to be related to the malformation, and one had surgical decompression. Two had an associated cervical syrinx. CONCLUSIONS Children with cystinosis have a 12-fold higher prevalence of Chiari I malformations than the general pediatric population. Chiari I malformations should be high on the differential diagnosis when individuals with cystinosis develop neurologic signs and symptoms, and magnetic resonance imaging scans should be performed on children with cystinosis who present with new-onset headache, ataxia, incontinence, or other unexplained neurologic symptoms.
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Elmonem MA, Makar SH, van den Heuvel L, Abdelaziz H, Abdelrahman SM, Bossuyt X, Janssen MC, Cornelissen EA, Lefeber DJ, Joosten LA, Nabhan MM, Arcolino FO, Hassan FA, Gaide Chevronnay HP, Soliman NA, Levtchenko E. Clinical utility of chitotriosidase enzyme activity in nephropathic cystinosis. Orphanet J Rare Dis 2014; 9:155. [PMID: 25407738 PMCID: PMC4269071 DOI: 10.1186/s13023-014-0155-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 09/30/2014] [Indexed: 01/02/2023] Open
Abstract
Background Nephropathic cystinosis is an inherited autosomal recessive lysosomal storage disorder characterized by the pathological accumulation and crystallization of cystine inside different cell types. WBC cystine determination forms the basis for the diagnosis and therapeutic monitoring with the cystine depleting drug (cysteamine). The chitotriosidase enzyme is a human chitinase, produced by activated macrophages. Its elevation is documented in several lysosomal storage disorders. Although, about 6% of Caucasians have enzyme deficiency due to homozygosity of 24-bp duplication mutation in the chitotriosidase gene, it is currently established as a screening marker and therapeutic monitor for Gaucher’s disease. Methods Plasma chitotriosidase activity was measured in 45 cystinotic patients, and compared with 87 healthy controls and 54 renal disease patients with different degrees of renal failure (CKD1-5). Chitotriosidase levels were also correlated with WBC cystine in 32 treated patients. Furthermore, we incubated control human macrophages in-vitro with different concentrations of cystine crystals and monitored the response of tumor necrosis factor-alpha (TNF-α) and chitotriosidase activity. We also compared plasma chitotriosidase activity in cystinotic knocked-out (n = 10) versus wild-type mice (n = 10). Results Plasma chitotriosidase activity in cystinotic patients (0–3880, median 163 nmol/ml/h) was significantly elevated compared to healthy controls (0–90, median 18 nmol/ml/h) and to CKD patients (0–321, median 52 nmol/ml/h), P < 0.001 for both groups. Controls with decreased renal function had mild to moderate chitotriosidase elevations; however, their levels were significantly lower than in cystinotic patients with comparable degree of renal insufficiency. Chitotriosidase activity positively correlated with WBC cystine content for patients on cysteamine therapy (r = 0.8), P < 0.001. In culture, human control macrophages engulfed cystine crystals and released TNF-α into culture supernatant in a crystal concentration dependent manner. Chitotriosidase activity was also significantly increased in macrophage supernatant and cell-lysate. Furthermore, chitotriosidase activity was significantly higher in cystinotic knocked-out than in the wild-type mice, P = 0.003. Conclusions This study indicates that cystine crystals are potent activators of human macrophages and that chitotriosidase activity is a useful marker for this activation and a promising clinical biomarker and therapeutic monitor for nephropathic cystinosis.
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Affiliation(s)
- Mohamed A Elmonem
- Department of Clinical and Chemical Pathology, Inherited Metabolic Disorder Laboratory (IMDL), Cairo University, Cairo, Egypt.
| | - Samuel H Makar
- Department of Pediatrics, Center of Pediatric Nephrology and Transplantation (CPNT), Cairo University, Cairo, Egypt. .,EGORD, Egyptian group of orphan renal diseases, Cairo, Egypt.
| | - Lambertus van den Heuvel
- Department of Pediatric Nephrology & Growth and Regeneration, University Hospital Leuven, Catholic University of Leuven, Leuven, Belgium. .,Department of Pediatric Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Hanan Abdelaziz
- Department of Pediatrics, Center of Pediatric Nephrology and Transplantation (CPNT), Cairo University, Cairo, Egypt. .,EGORD, Egyptian group of orphan renal diseases, Cairo, Egypt.
| | - Safaa M Abdelrahman
- Department of Pediatrics, Center of Pediatric Nephrology and Transplantation (CPNT), Cairo University, Cairo, Egypt. .,EGORD, Egyptian group of orphan renal diseases, Cairo, Egypt.
| | - Xavier Bossuyt
- University Hospitals Leuven & Department of Microbiology and Immunology, Laboratory Medicine, Catholic University of Leuven, Leuven, Belgium.
| | - Mirian C Janssen
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Elisabeth Am Cornelissen
- Department of Pediatric Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Dirk J Lefeber
- Department of Neurology, Laboratory for Genetic, Endocrine and Metabolic Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Leo Ab Joosten
- Department of Pediatric Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Marwa M Nabhan
- Department of Pediatrics, Center of Pediatric Nephrology and Transplantation (CPNT), Cairo University, Cairo, Egypt. .,EGORD, Egyptian group of orphan renal diseases, Cairo, Egypt.
| | - Fanny O Arcolino
- Department of Pediatric Nephrology & Growth and Regeneration, University Hospital Leuven, Catholic University of Leuven, Leuven, Belgium.
| | - Fayza A Hassan
- Department of Clinical and Chemical Pathology, Inherited Metabolic Disorder Laboratory (IMDL), Cairo University, Cairo, Egypt.
| | | | - Neveen A Soliman
- Department of Pediatrics, Center of Pediatric Nephrology and Transplantation (CPNT), Cairo University, Cairo, Egypt. .,EGORD, Egyptian group of orphan renal diseases, Cairo, Egypt.
| | - Elena Levtchenko
- Department of Pediatric Nephrology & Growth and Regeneration, University Hospital Leuven, Catholic University of Leuven, Leuven, Belgium.
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Klusmann M, Van't Hoff W, Monsell F, Offiah AC. Progressive destructive bone changes in patients with cystinosis. Skeletal Radiol 2013; 43:387-391. [PMID: 24077756 DOI: 10.1007/s00256-013-1735-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 08/29/2013] [Accepted: 09/02/2013] [Indexed: 02/02/2023]
Abstract
Nephropathic cystinosis is an autosomal recessive lysosomal storage disorder in which intracellular cystine accumulates. It is caused by mutations in the CTNS gene. Clinical manifestations include renal tubular Fanconi syndrome in the first year of life, rickets, hypokalaemia, polyuria, dehydration and acidosis, growth retardation, hypothyroidism, photophobia and renal glomerular deterioration. Late complications include myopathy, pancreatic insufficiency and retinal blindness. Skeletal manifestations described in these patients include failure to thrive, osteomalacia, rickets and short stature. This paper describes progressive bony abnormalities in three unrelated patients with nephropathic cystinosis that have not been reported previously.
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Affiliation(s)
- Maria Klusmann
- Radiology, Imaging Department, University College Hospital, London, UK
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Abstract
Cystinosis is an autosomal recessive disease that results in a defective integral membrane protein responsible for the transport of cystine out of lysosomes. This results in the accumulation of cystine in the lysosomes of almost every tissue, with subsequent formation of damaging crystals. The cystinotic process may affect every system of the body, but is particularly damaging to the kidneys and eyes. We discuss the perioperative care of a cystinotic patient with renal insufficiency, Fanconi's syndrome, and photophobia. Other organ systems affected by the cystinotic process are also discussed, with suggestions for the perioperative management of each. Issues of primary concern during perioperative care include preservation of renal function and maintenance of fluid and electrolyte homeostasis.
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Affiliation(s)
- Theresa L Ray
- Department of Child Health, The Division of Pediatric Critical Care/Pediatric Anesthesiology, The University of Missouri, Columbia, MO, USA
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Abstract
After the important advances that have been made in the diagnosis of inherited lysosomal disorders with the help of biochemical-enzymic methods, the importance of electron microscopy for the identification and study of these conditions has apparently declined. Nevertheless, numerous specimens continue to be submitted for ultrastructural examination when lysosomal storage diseases are suspected. The article summarizes the present role of electron microscopy in this area and depicts typical specific findings in comparison with suggestive and nonspecific lysosomal changes. It is concluded that ultrastructural examination remains a useful and occasionally compulsory diagnostic method. In addition, it contributes to the identification of new diseases, the study of animal models of storage diseases, and the assessment of novel therapeutic methods such as bone marrow transplantation.
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Affiliation(s)
- T C Iancu
- Department of Pediatrics, Carmel Hospital, Haifa, Israel
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