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Value of Electrocardiography to Distinguish Fabry Disease from Sarcomeric Hypertrophic Cardiomyopathy. Am J Cardiol 2022; 178:131-136. [PMID: 35810008 DOI: 10.1016/j.amjcard.2022.05.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 11/21/2022]
Abstract
Fabry disease (FD) is a rare genetic disorder that leads to left ventricular hypertrophy (LVH), frequently misdiagnosed as hypertrophic cardiomyopathy (HCM). We sought to assess the value of electrocardiography for distinguishing FD from HCM. We retrospectively reviewed and compared standard electrocardiograms and echocardiograms from 26 patients with FD and LVH and 33 sarcomeric patients with HCM, matched for gender, age, and degree of LVH. The mean age of patients with FD was 46 years (interquartile range) (28 to 53) and of HCM 50 (30 to 61) years (p = 0.27). Of them, 16 (61%) and 25 (76%) were male, respectively (p = 0.26). Indexed left ventricular mass was 166 g/m2 in FD versus 181 g/m2 in HCM (p = 0.88). All patients with FD and 30 (91%) with HCM were in sinus rhythm (p = 0.25). A higher prevalence of right bundle branch block (RBBB) was observed in FD (27%) versus HCM (6%) (p = 0.03). The PR interval was shorter in FD, 140 ms (120-160) versus 160 ms (140 to 180) (p = 0.004). P-wave duration was longer in patients with FD, 100 ms (80 to 120) versus 80 ms (80 to 100) (p = 0.01). The PQ interval (PR interval minus P-wave duration) was shorter in patients with FD, 40 ms (20 to 45) versus 80 ms (40 to 80) (p = 0.001). There were no differences regarding P-wave amplitude, QRS complex duration, corrected QT length, conduction or repolarization abnormalities, Sokolow-Lyon index, and Cornell index. After multivariate adjustments for RBBB, PR interval, P-wave duration, and PQ interval, a PQ interval ≤40 ms and RBBB were significantly associated with FD. In conclusion, there are electrocardiogram characteristics, such as the presence of RBBB or a PQ interval ≤40 ms, that may be helpful for screening and reducing the delay in FD diagnosis.
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Electrocardiographic Characteristics and Their Correlation with Echocardiographic Alterations in Fabry Disease. J Cardiovasc Dev Dis 2022; 9:jcdd9010011. [PMID: 35050221 PMCID: PMC8777656 DOI: 10.3390/jcdd9010011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/23/2021] [Accepted: 12/31/2021] [Indexed: 12/24/2022] Open
Abstract
Fabry disease (FD) is an X-linked disorder with α-galactosidase A deficiency. Males (>30 years) and females (>40 years) often present with cardiac manifestations, predominantly left ventricular hypertrophy (LVH). The aim of this study was to evaluate electrocardiographic (ECG) characteristics within FD patients to identify gender related differences, and to additionally explore the association of ECG parameters with structural and functional alterations on transthoracic echocardiography (TTE). Retrospective cross-sectional analysis of 45 FD patients with contemporaneous ECG and TTE was performed and compared to age and gender matched healthy controls. FD patients demonstrated alterations in several ECG parameters particularly in males, including prolonged P-wave duration (91 vs. 81 ms, p = 0.022), prolonged QRS duration (96 vs. 84 ms, p < 0.001), increased R-wave amplitude in lead I (8.1 vs. 5.7 mV, p = 0.047), increased Sokolow–Lyon index (25 vs. 19 mV, p = 0.002) and were more likely to meet LVH criteria (31% vs. 7%, p = 0.006). FD patients with impaired basal longitudinal strain (LS) on TTE were more likely to meet LVH criteria (41% vs. 0%, p = 0.018). Those with more advanced FD (increased LV wall thickness on TTE) were more likely to meet LVH criteria but additionally demonstrated prolonged ventricular depolarization (QRS duration 101 vs. 88 ms, p = 0.044). Therefore, alterations on ECG demonstrating delayed atrial activation, delayed ventricular depolarization and evidence of LVH were more often seen in male FD patients. Impaired basal LS, a TTE marker of early cardiac involvement, correlated with ECG abnormalities. Increased LV wall thickness on TTE, a marker of more advanced FD, was associated with more severe ECG abnormalities.
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Junqua N, Legallois D, Segard S, Lairez O, Réant P, Goizet C, Maillard H, Charron P, Milliez P, Labombarda F. The value of electrocardiography and echocardiography in distinguishing Fabry disease from sarcomeric hypertrophic cardiomyopathy. Arch Cardiovasc Dis 2020; 113:542-550. [PMID: 32771348 DOI: 10.1016/j.acvd.2020.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 04/21/2020] [Accepted: 04/23/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Screening for Fabry disease is sub-optimal in non-specialised centres. AIM To assess the diagnostic value of electrocardiographic scores of left ventricular hypertrophy and a combined electrocardiographic and echocardiographic model in Fabry disease. METHODS We retrospectively reviewed the electrocardiograms and echocardiograms of 61 patients (mean age 55.6±11.5 years; 57% men) with Fabry disease and left ventricular hypertrophy, and compared them with those from 59 patients (mean age 44.8±18.3 years; 66% men) with sarcomeric hypertrophic cardiomyopathy. Six electrocardiography criteria for left ventricular hypertrophy were specifically analysed: Sokolow-Lyon voltage index; Cornell voltage index; Gubner index; Romhilt-Estes score; Sokolow-Lyon product (voltage index×QRS duration); and Cornell product (voltage index×QRS duration). RESULTS Right bundle branch block was more frequent in patients with Fabry disease (54% vs. 22%; P=0.001). QRS duration, Gubner score and Sokolow-Lyon product were significantly higher in patients with Fabry disease. Maximal wall thickness was higher in patients with sarcomeric hypertrophic cardiomyopathy (21.9±5.1 vs. 15.5±2.9mm; P<0.001). Indexed sinus of Valsalva diameter was larger in patients with Fabry disease. After multivariable analysis, right bundle branch block, Sokolow-Lyon product, maximal wall thickness and aortic diameter were independently associated with Fabry disease. A model including these four variables yielded an area under the receiver operating characteristic curve of 0.918 (95% confidence interval 0.868-0.968) for Fabry disease. CONCLUSION Our model combining easy-to-assess electrocardiographic and echocardiographic variables may be helpful in improving screening and reducing diagnosis delay in Fabry disease.
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Affiliation(s)
- Nicolas Junqua
- Department of Cardiology, Caen University Hospital, 14000 Caen, France
| | - Damien Legallois
- Department of Cardiology, Caen University Hospital, 14000 Caen, France; EA 4650 (Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique), Medical School, Caen-Normandie University (UNICAEN), Caen University Hospital, 14000 Caen, France
| | - Sophie Segard
- Department of Cardiology, Caen University Hospital, 14000 Caen, France
| | - Olivier Lairez
- Department of Cardiology, Rangueil University Hospital, Rangueil Medical School, University Paul-Sabatier, 31400 Toulouse, France
| | - Patricia Réant
- Department of Cardiology, Bordeaux University Hospital, 33000 Bordeaux, France; INSERM U1045, Bordeaux University, IHU Liryc, 33604 Pessac, France
| | - Cyril Goizet
- Department of Medical Genetics, Bordeaux University Hospital, Laboratoire MRGM, INSERM Unit 1211, University of Bordeaux, 33076 Bordeaux, France
| | - Hélène Maillard
- Department of Internal Medicine, Claude Huriez Hospital, University of Lille, 59000 Lille, France
| | - Philippe Charron
- Centre de référence pour les maladies cardiaques héréditaires, INSERM UMR_S 1166 and Institute for Cardiometabolism and Nutrition (ICAN), Pitié-Salpêtrière University Hospital, Sorbonne University, 75013 Paris, France
| | - Paul Milliez
- Department of Cardiology, Caen University Hospital, 14000 Caen, France; EA 4650 (Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique), Medical School, Caen-Normandie University (UNICAEN), Caen University Hospital, 14000 Caen, France
| | - Fabien Labombarda
- Department of Cardiology, Caen University Hospital, 14000 Caen, France; EA 4650 (Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique), Medical School, Caen-Normandie University (UNICAEN), Caen University Hospital, 14000 Caen, France.
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Shah KB, Mankad AK, Castano A, Akinboboye OO, Duncan PB, Fergus IV, Maurer MS. Transthyretin Cardiac Amyloidosis in Black Americans. Circ Heart Fail 2017; 9:e002558. [PMID: 27188913 DOI: 10.1161/circheartfailure.115.002558] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 02/10/2016] [Indexed: 12/20/2022]
Abstract
Transthyretin-related cardiac amyloidosis is a progressive infiltrative cardiomyopathy that mimics hypertensive and hypertrophic heart disease and often goes undiagnosed. In the United States, the hereditary form disproportionately afflicts black Americans, who when compared with whites with wild-type transthyretin amyloidosis, a phenotypically similar condition, present with more advanced disease despite having a noninvasive method for early identification (genetic testing). Although reasons for this are unclear, this begs to consider the inadequate access to care, societal factors, or a biological basis. In an effort to improve awareness and explore unique characteristics, we review the pathophysiology, epidemiology, and therapeutic strategies for transthyretin amyloidosis and highlight diagnostic pitfalls and clinical pearls for identifying patients with amyloid heart disease.
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Affiliation(s)
- Keyur B Shah
- From the Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Richmond (K.B.S., A.K.M., P.B.D.); Division of Cardiology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA (A.K.M.); Division of Cardiology, Columbia University Medical Center, New York, NY (A.C., M.S.M.); Queens Heart Institute, Rosedale, NY (O.O.A.); Cardiac Health Management Network, Chester, VA (P.B.D.); and Division of Cardiology, Mount Sinai Medical Center, New York, NY (I.V.F.).
| | - Anit K Mankad
- From the Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Richmond (K.B.S., A.K.M., P.B.D.); Division of Cardiology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA (A.K.M.); Division of Cardiology, Columbia University Medical Center, New York, NY (A.C., M.S.M.); Queens Heart Institute, Rosedale, NY (O.O.A.); Cardiac Health Management Network, Chester, VA (P.B.D.); and Division of Cardiology, Mount Sinai Medical Center, New York, NY (I.V.F.)
| | - Adam Castano
- From the Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Richmond (K.B.S., A.K.M., P.B.D.); Division of Cardiology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA (A.K.M.); Division of Cardiology, Columbia University Medical Center, New York, NY (A.C., M.S.M.); Queens Heart Institute, Rosedale, NY (O.O.A.); Cardiac Health Management Network, Chester, VA (P.B.D.); and Division of Cardiology, Mount Sinai Medical Center, New York, NY (I.V.F.)
| | - Olakunle O Akinboboye
- From the Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Richmond (K.B.S., A.K.M., P.B.D.); Division of Cardiology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA (A.K.M.); Division of Cardiology, Columbia University Medical Center, New York, NY (A.C., M.S.M.); Queens Heart Institute, Rosedale, NY (O.O.A.); Cardiac Health Management Network, Chester, VA (P.B.D.); and Division of Cardiology, Mount Sinai Medical Center, New York, NY (I.V.F.)
| | - Phillip B Duncan
- From the Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Richmond (K.B.S., A.K.M., P.B.D.); Division of Cardiology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA (A.K.M.); Division of Cardiology, Columbia University Medical Center, New York, NY (A.C., M.S.M.); Queens Heart Institute, Rosedale, NY (O.O.A.); Cardiac Health Management Network, Chester, VA (P.B.D.); and Division of Cardiology, Mount Sinai Medical Center, New York, NY (I.V.F.)
| | - Icilma V Fergus
- From the Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Richmond (K.B.S., A.K.M., P.B.D.); Division of Cardiology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA (A.K.M.); Division of Cardiology, Columbia University Medical Center, New York, NY (A.C., M.S.M.); Queens Heart Institute, Rosedale, NY (O.O.A.); Cardiac Health Management Network, Chester, VA (P.B.D.); and Division of Cardiology, Mount Sinai Medical Center, New York, NY (I.V.F.)
| | - Mathew S Maurer
- From the Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Richmond (K.B.S., A.K.M., P.B.D.); Division of Cardiology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA (A.K.M.); Division of Cardiology, Columbia University Medical Center, New York, NY (A.C., M.S.M.); Queens Heart Institute, Rosedale, NY (O.O.A.); Cardiac Health Management Network, Chester, VA (P.B.D.); and Division of Cardiology, Mount Sinai Medical Center, New York, NY (I.V.F.)
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Mankad AK, Sesay I, Shah KB. Light-chain cardiac amyloidosis. Curr Probl Cancer 2017; 41:144-156. [DOI: 10.1016/j.currproblcancer.2016.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/14/2016] [Indexed: 12/17/2022]
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Krämer J, Nordbeck P, Störk S, Ritter C, Ertl G, Wanner C, Weidemann F. Electrical Changes in Resting, Exercise, and Holter Electrocardiography in Fabry Cardiomyopathy. JIMD Rep 2015; 28:19-28. [PMID: 26498960 PMCID: PMC5059213 DOI: 10.1007/8904_2015_502] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/15/2015] [Accepted: 09/18/2015] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND In Fabry cardiomyopathy, little is known about the interaction between its key feature of myocardial replacement fibrosis and changes in resting, Holter, and exercise electrocardiography (-ECG). METHODS AND RESULTS Resting ECG, 24-h Holter ECG, and exercise ECG were performed in 95 patients (50 women) with Fabry disease, staged using cardiac magnetic resonance imaging to measure left ventricular fibrosis. With resting ECG, T alterations were seen in patients with cardiac fibrosis, while time intervals and rhythm were unchanged (except for a longer QRS duration in patients with severe fibrosis). All patients with severe fibrosis showed T inversion, ST alteration, or both. With Holter ECG, maximum and minimum heart rate did not differ with fibrosis severity. Patients without fibrotic tissue showed less ventricular premature beats (VPB) (median 5/24 h) compared to those with mild (median 11/24 h) or severe fibrosis (median 115/24 h; P < 0.05, respectively). Fibrosis was a strong predictor of VPB burden (r 2 = 0.5; P < 0.001). During exercise, patients with severe fibrosis had the least increase in systolic blood pressure (sBP) (47 ± 22 mmHg vs. 62 ± 25 mmHg, P < 0.05) and the lowest maximum heart rate (113 ± 18/min; P < 0.05). Patients with mild fibrosis had a high sBP during exercise (198 ± 37 mmHg; P < 0.05). Decreased diastolic blood pressure (>10 mmHg) occurred in some patients with no (3/41) or mild fibrosis (3/34) but not in patients with severe fibrosis (0/20; P < 0.01). CONCLUSIONS Our data suggest that cardiac replacement fibrosis is responsible for repolarization abnormalities on resting ECG and increased VPB with Holter ECG. During exercise ECG, advanced cardiomyopathy is characterized by chronotropic incompetence with limitations on blood pressure and heart rate increase.
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Affiliation(s)
- Johannes Krämer
- Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
- Department of Pediatrics and Adolescent Medicine, University of Ulm, Ulm, Germany
| | - Peter Nordbeck
- Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
- Department of Internal Medicine I, University of Würzburg, Würzburg, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
- Department of Internal Medicine I, University of Würzburg, Würzburg, Germany
| | - Christian Ritter
- Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
- Department of Internal Medicine I, University of Würzburg, Würzburg, Germany
| | - Georg Ertl
- Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
- Department of Internal Medicine I, University of Würzburg, Würzburg, Germany
| | - Christoph Wanner
- Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
- Department of Internal Medicine I, University of Würzburg, Würzburg, Germany
| | - Frank Weidemann
- Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany.
- Department of Internal Medicine II, Katharinen-Hospital Unna, Unna, Germany.
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Kampmann C, Perrin A, Beck M. Effectiveness of agalsidase alfa enzyme replacement in Fabry disease: cardiac outcomes after 10 years' treatment. Orphanet J Rare Dis 2015; 10:125. [PMID: 26416388 PMCID: PMC4587871 DOI: 10.1186/s13023-015-0338-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 09/06/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND To explore long-term effects of agalsidase alfa on Fabry disease cardiomyopathy in adults. METHODS Retrospective analysis of prospectively collected data at a single center in Mainz, Germany, revealed that 45 adult patients (21 men, 24 women) had received agalsidase alfa for approximately 10 years. Data were extracted for cardiac and heart failure status, echocardiographic evaluations of cardiac structure and function, and renal function at treatment start and during agalsidase alfa treatment. RESULTS After 10 years of agalsidase alfa treatment, heart failure classification had improved by at least 1 class in 22/42 patients, and angina scores were stable or improved in 41/42 patients. During treatment, no patients without left ventricular hypertrophy (LVH) at treatment initiation developed LVH, and no patients with LVH at treatment initiation showed a decline in left ventricular mass. CONCLUSIONS Approximately 10 years of agalsidase alfa treatment appeared to have beneficial effects for controlling progression and improving some symptoms of Fabry-associated cardiomyopathy.
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Affiliation(s)
- Christoph Kampmann
- Section Head for Congenital Heart Defects, Center for Pediatric and Adolescent Medicine, University Medical Center, University of Mainz, Langenbeckstr. 1, Mainz, DE-55101, Germany.
| | - Amandine Perrin
- Statistical Programmer, Rare Diseases Business Unit, Global Outcomes Research, Shire, Zug, Switzerland.
| | - Michael Beck
- Professor Emeritus, Department of Pediatrics, University Medical Center, University of Mainz, Mainz, Germany.
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Niemann M, Hartmann T, Namdar M, Breunig F, Beer M, Machann W, Herrmann S, Ertl G, Wanner C, Weidemann F. Cross-sectional baseline analysis of electrocardiography in a large cohort of patients with untreated Fabry disease. J Inherit Metab Dis 2013; 36:873-9. [PMID: 23053470 DOI: 10.1007/s10545-012-9540-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 08/21/2012] [Accepted: 08/30/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Morphology and function of Fabry cardiomyopathy has been previously studied by echocardiography and cardiac magnetic resonance (CMR). However, the value of electrocardiography (ECG) in relation to these two techniques remains largely unknown. METHODS One hundred fifty genetically confirmed Fabry patients were investigated using a comprehensive clinical workup comprising 12-lead ECG, echocardiography, and CMR. RESULTS ECG parameters at rest [PR, P wave, QT, QTc, QT dispersion and time interval from the peak to the end of the T wave (Tpeak to Tend)] were normal in the entire cohort and did not distinguish between males and females or stages of cardiomyopathy. A significant positive correlation was found between left ventricular (LV) mass on CMR and both the QRS duration and the LV Sokolow index, with the highest values in male patients with an advanced cardiomyopathy stage. No prediction of late enhancement on CMR (a sign for replacement fibrosis) was possible by a single ECG parameter. However, the absence of ST or T alterations (in 37 of 38 patients) specifically excluded late enhancement on CMR. CONCLUSION Our data in a large cohort of Fabry patients, including all cardiomyopathy stages, show, in contrast to former assumptions, that ECG parameters are not suitable to stage Fabry cardiomoypathy. Most ECG parameters were normal in the complete cohort. However, the absence of ST or T alterations seems to almost exclude late enhancement on CMR in these patients.
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Affiliation(s)
- Markus Niemann
- Department of Internal Medicine I, University of Würzburg, Würzburg, Germany
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Roshan VD, Hosseinzadeh M, Saravi M. The effects of dehydration and rehydration on electrocardiographic and echocardiographic parameters in Greco-Roman wrestlers. Eur J Sport Sci 2012. [DOI: 10.1080/17461391.2010.536584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Lysosomal storage diseases: Diagnostic confirmation and management of presymptomatic individuals. Genet Med 2011; 13:457-84. [DOI: 10.1097/gim.0b013e318211a7e1] [Citation(s) in RCA: 158] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Gambarin FI, Disabella E, Narula J, Diegoli M, Grasso M, Serio A, Favalli BMEV, Agozzino M, Tavazzi L, Fraser AG, Arbustini E. When should cardiologists suspect Anderson-Fabry disease? Am J Cardiol 2010; 106:1492-9. [PMID: 21059442 DOI: 10.1016/j.amjcard.2010.07.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 07/13/2010] [Accepted: 07/13/2010] [Indexed: 11/16/2022]
Abstract
Anderson-Fabry disease is a lysosomal storage disorder caused by α-galactosidase defects and progressive intracellular accumulation of globotriaosylceramide. The disease can be specifically treated with enzyme replacement therapy. Hemizygous men and heterozygous women can develop cardiac disease. Whereas men experience the most severe clinical phenotype, clinical presentation in women varies from asymptomatic to severely symptomatic. The characteristic cardiac phenotype is left ventricular hypertrophy mimicking sarcomeric hypertrophic cardiomyopathy or hypertensive heart disease. Early or prehypertrophy cardiac involvement may escape detection, unless electrocardiographic clues are present. The cardiac markers that raise suspicion of Anderson-Fabry disease include a short PR interval without a δ wave and a prolonged QRS interval, supraventricular and ventricular arrhythmias, and concentric left ventricular hypertrophy. Extracardiac features include renal failure, corneal deposits, and nervous, gastrointestinal, and cutaneous manifestations. Useful family data include cardiac and extracardiac traits in relatives and absence of male-to-male transmission. Symptoms are subtle, and the interval between the onset of symptoms and diagnosis may be as long as 20 years. As such, the diagnosis is typically late. Endomyocardial biopsy shows optically empty myocytes on light microscopy and dense osmiophilic bodies constituted of globotriaosylceramide on electron microscopy. Alpha-galactosidase A activity is reduced in hemizygous men but not in heterozygous women. Genetic testing is the gold standard for the diagnosis. In conclusion, a correct and timely diagnosis offers the possibility of disease-specific treatment that leads to sustained clinical benefits for cardiac and noncardiac signs and symptoms.
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Affiliation(s)
- Fabiana I Gambarin
- Centre for Inherited Cardiovascular Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Sheppard MN, Cane P, Florio R, Kavantzas N, Close L, Shah J, Lee P, Elliott P. A detailed pathologic examination of heart tissue from three older patients with Anderson–Fabry disease on enzyme replacement therapy. Cardiovasc Pathol 2010; 19:293-301. [DOI: 10.1016/j.carpath.2009.05.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Revised: 04/16/2009] [Accepted: 05/22/2009] [Indexed: 10/20/2022] Open
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13
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Constantin T, Székely A, Ponyi A, Gulácsy V, Ambrus C, Kádár K, Vastagh I, Dajnoki A, Tóth B, Bokrétás G, Müller V, Katona M, Medvecz M, Fiedler O, Széchey R, Varga E, Rudas G, Kertész A, Molnár S, Kárpáti S, Nagy V, Magyar P, Mahdi M, Rákóczi É, Németh K, Bereczki D, Garami M, Erdős M, Maródi L, Fekete G. Management of Fabry disease. Orv Hetil 2010; 151:1243-51. [DOI: 10.1556/oh.2010.28796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A Fabry-kór a lizoszomális tárolási betegségek csoportjába tartozó, X-kromoszómához kötötten, recesszív módon öröklődő betegség, amely a globotriaozilceramid felhalmozódásához vezet a szervezet legkülönbözőbb szöveteiben. A betegség első tünetei többnyire gyermekkorban jelentkeznek, a progresszió során a betegek súlyos szervi károsodásokkal és korai halálozással számolhatnak. Elsősorban férfiak érintettek, azonban a betegség tüneteit heterozigóta nők esetében is megfigyelhetjük, de náluk a kórkép súlyossága változó, általában enyhébb lefolyású. Az enzimpótló kezelések megjelenése szükségessé tette, hogy részletes diagnosztikus és terápiás protokollt dolgozzunk ki. A jelen dolgozatban megjelenő ajánlásokat egy, a magyarországi Fabry-kóros betegek kezelésében részt vevő orvosokból, a diagnosztika területén dolgozó biológosukból és egyéb szakemberekből álló multidiszciplináris munkacsoport foglalta össze. A munkacsoport áttekintette a korábbi klinikai tanulmányokat, a publikált vizsgálatokat és a közelmúltban megjelent nemzetközi és nemzeti útmutatókat.
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Affiliation(s)
- Tamás Constantin
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar II. Gyermekgyógyászati Klinika Budapest Tűzoltó u. 7–9. 1094
| | - Annamária Székely
- 2 Debreceni Egyetem, Általános Orvostudományi Kar Infektológiai és Gyermekimmunológiai Tanszék Debrecen
| | - Andrea Ponyi
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar II. Gyermekgyógyászati Klinika Budapest Tűzoltó u. 7–9. 1094
| | - Vera Gulácsy
- 2 Debreceni Egyetem, Általános Orvostudományi Kar Infektológiai és Gyermekimmunológiai Tanszék Debrecen
| | - Csaba Ambrus
- 3 Semmelweis Egyetem, Általános Orvostudományi Kar I. Belgyógyászati Klinika Budapest
| | | | - Ildikó Vastagh
- 5 Semmelweis Egyetem, Általános Orvostudományi Kar Neurológiai Klinika Budapest
| | - Angéla Dajnoki
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar II. Gyermekgyógyászati Klinika Budapest Tűzoltó u. 7–9. 1094
| | - Beáta Tóth
- 2 Debreceni Egyetem, Általános Orvostudományi Kar Infektológiai és Gyermekimmunológiai Tanszék Debrecen
| | - Gergely Bokrétás
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar II. Gyermekgyógyászati Klinika Budapest Tűzoltó u. 7–9. 1094
| | - Veronika Müller
- 6 Semmelweis Egyetem, Általános Orvostudományi Kar Pulmonológiai Klinika Budapest
| | - Mária Katona
- 7 Semmelweis Egyetem, Általános Orvostudományi Kar Bőrgyógyászati Klinika Budapest
| | - Márta Medvecz
- 7 Semmelweis Egyetem, Általános Orvostudományi Kar Bőrgyógyászati Klinika Budapest
| | - Orsolya Fiedler
- 8 Semmelweis Egyetem, Általános Orvostudományi Kar Szemészeti Klinika Budapest
| | - Rita Széchey
- 8 Semmelweis Egyetem, Általános Orvostudományi Kar Szemészeti Klinika Budapest
| | | | - Gábor Rudas
- 9 Semmelweis Egyetem Tudásközpont, MR-labor Budapest
| | - Attila Kertész
- 10 Debreceni Egyetem, Általános Orvostudományi Kar Kardiológiai Klinika Debrecen
| | - Sándor Molnár
- 11 Debreceni Egyetem, Általános Orvostudományi Kar Neurológiai Klinika Debrecen
| | - Sarolta Kárpáti
- 7 Semmelweis Egyetem, Általános Orvostudományi Kar Bőrgyógyászati Klinika Budapest
| | - Viktor Nagy
- 4 Gottsegen György Országos Kardiológiai Intézet Budapest
| | - Pál Magyar
- 6 Semmelweis Egyetem, Általános Orvostudományi Kar Pulmonológiai Klinika Budapest
| | - Mohamed Mahdi
- 2 Debreceni Egyetem, Általános Orvostudományi Kar Infektológiai és Gyermekimmunológiai Tanszék Debrecen
| | - Éva Rákóczi
- 2 Debreceni Egyetem, Általános Orvostudományi Kar Infektológiai és Gyermekimmunológiai Tanszék Debrecen
| | - Krisztina Németh
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar II. Gyermekgyógyászati Klinika Budapest Tűzoltó u. 7–9. 1094
| | - Dániel Bereczki
- 5 Semmelweis Egyetem, Általános Orvostudományi Kar Neurológiai Klinika Budapest
| | - Miklós Garami
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar II. Gyermekgyógyászati Klinika Budapest Tűzoltó u. 7–9. 1094
| | - Melinda Erdős
- 2 Debreceni Egyetem, Általános Orvostudományi Kar Infektológiai és Gyermekimmunológiai Tanszék Debrecen
| | - László Maródi
- 2 Debreceni Egyetem, Általános Orvostudományi Kar Infektológiai és Gyermekimmunológiai Tanszék Debrecen
| | - György Fekete
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar II. Gyermekgyógyászati Klinika Budapest Tűzoltó u. 7–9. 1094
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Cardiac challenges in patients with Fabry disease. Int J Cardiol 2010; 141:3-10. [DOI: 10.1016/j.ijcard.2009.08.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Revised: 06/15/2009] [Accepted: 08/11/2009] [Indexed: 11/24/2022]
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Clarke JTR, West ML, Bultas J, Schiffmann R. The pharmacology of multiple regimens of agalsidase alfa enzyme replacement therapy for Fabry disease. Genet Med 2009; 9:504-9. [PMID: 17700388 DOI: 10.1097/gim.0b013e318133fb1b] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE This 10-week study was conducted to determine the pharmacokinetics of varying doses of agalsidase alfa and evaluate the effect of dose and dosing frequency on plasma Gb3 levels. METHODS Eighteen adult male Fabry patients, naive to enzyme replacement therapy, were randomized to one of five regimens: 0.1, 0.2, or 0.4 mg/kg weekly; 0.2 mg/kg every other week (the approved dose); or 0.4 mg/kg every other week. Intravenous infusion rate was 0.1 mg/kg per 20 minutes. Plasma Gb3 levels were assessed at baseline and periodically during the study. RESULTS The mean half-life was 56-76 minutes, and the mean volume of distribution at steady state was 17%-18% of body weight, with no significant association between dose and half-life, clearance, or volume of distribution at steady state. The area under the curve was linearly proportional to the dose from 0.1 to 0.4 mg/kg. Baseline average plasma Gb3 was 9.12 +/- 2.61 nmol/mL and after 10 weeks of treatment was significantly reduced by about 50% in each group with no statistically significant differences between groups. CONCLUSIONS Reduction of plasma Gb3 levels was independent of dose or dose frequency in the range tested. These observations, coupled with the clinical trial experience of both agalsidase alfa and agalsidase beta, indicate that the standard dose of agalsidase alfa is sufficient to maximally reduce plasma Gb3. However, because plasma Gb3 is not a validated surrogate of disease severity in Fabry disease, further clinical study will be required to determine the optimal dosing regimen for providing maximal clinical benefit.
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Affiliation(s)
- Joe T R Clarke
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.
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16
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Kampmann C, Linhart A, Baehner F, Palecek T, Wiethoff CM, Miebach E, Whybra C, Gal A, Bultas J, Beck M. Onset and progression of the Anderson-Fabry disease related cardiomyopathy. Int J Cardiol 2008; 130:367-73. [PMID: 18572264 DOI: 10.1016/j.ijcard.2008.03.007] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Revised: 02/26/2008] [Accepted: 03/01/2008] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cardiac involvement is responsible for substantial morbidity and mortality in Anderson-Fabry disease (AFD). We sought to document its onset and progression in a population of male and female AFD patients. METHODS We performed a cross sectional echocardiographic study of a cohort of 177 male and female AFD patients with subsequent longitudinal follow-up of 76 patients (38 males and 38 females; mean follow-up 4.5 years) who did not receive enzyme replacement therapy. RESULTS In this population, aged 3.3 to 70.8 years, a strong correlation between age and left ventricular mass indexed (LVMi, g/m(2.7)) was found in both males and females (P<0.0001 for both). At the initial examination 48.6% of the male patients and 36.4% of the female patients were classified as having left ventricular hypertrophy (LVH). The cumulative prevalence of LVH peaked at age 40 years in males and 60 years in females. In patients with longitudinal follow-up, LVMi increased by 4.07+/-1.03 g/m(2.7) per year in males and by 2.31+/-0.81 g/m(2.7) in females (P<0.01, Wilcoxon rank sum). In patients with LVH at baseline, the median progression rate was 5.52 g/m(2.7) per year in males and by 1.80 g/m(2.7) in females (P=0.12). CONCLUSION AFD is associated with high prevalence of LVH in both genders. However, the age of onset is delayed in females and progression rate slower.
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17
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Clavelou P, Besson G, Elziere C, Ferrier A, Pinard JM, Hermier M, Artigou JY, Germain DP. [Neurological aspects of Fabry's disease]. Rev Neurol (Paris) 2006; 162:569-80. [PMID: 16710123 DOI: 10.1016/s0035-3787(06)75051-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Fabry disease is a rare X-linked disorder caused by deficient activity of the lysosomal enzyme alpha-galactosidase A. Progressive accumulation in lysosomes of the undegraded glycosphingolipids leads to a multi-system disease with dermatological, ocular, renal, cardiac, and neurological manifestations. Peripheral nerve involvement, neuropathic pain and chronic acroparesthesiae, are frequent and early-onset signs revealing the disease. They are due to the involvement of small nerve fiber, thus explaining the normality of electroneuromyography. Cochleo-vestibular and autonomic nervous system involvement is frequent. Besides rare aseptic meningitis, central nervous system involvement is essentially represented by cerebrovascular events (stroke, transient ischemic attack). Affecting essentially the posterior circulation, their etiologies have to be clarified: progressive stenosis of small vessels with globotriasocylceramide deposits, arterial remodeling, endothelial dysfunction, pro-thrombotic state, cerebral hypoperfusion consecutive to dysautonaumy, cardiac embolism. MRI shows numerous silent lesions, increasing with age, mainly in small perforant arteries (periventricular white matter, brainstem, cerebellum, basal ganglia). Pulvinar calcifications, due to an increase in cerebral hyperperfusion, could be specific of Fabry disease. Positon tomography analysis shows a reduced cerebral flow velocity and impaired cerebral autoregulation, secondary to the glycosphingolipid storage in vascular endothelial cells. Enzyme replacement therapy has to be carefully monitored.
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Affiliation(s)
- P Clavelou
- Service de Neurologie, CHU Montpied, Clermont-Ferrand.
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18
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Ramaswami U, Whybra C, Parini R, Pintos-Morell G, Mehta A, Sunder-Plassmann G, Widmer U, Beck M. Clinical manifestations of Fabry disease in children: data from the Fabry Outcome Survey. Acta Paediatr 2006; 95:86-92. [PMID: 16498740 DOI: 10.1080/08035250500275022] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Fabry disease is a rare X-linked disorder caused by deficient activity of the enzyme alpha-galactosidase A. This produces progressive lysosomal accumulation of globotriaosylceramide throughout the body, leading to organ failure and premature death. AIM Here, we present the clinical manifestations of Fabry disease in children enrolled in FOS--the Fabry Outcome Survey--a European database of the natural history of Fabry disease and the effects of enzyme replacement therapy with agalsidase alfa (Replagal). METHODS Currently, there are 545 patients in FOS, from 11 European countries. We analysed the baseline demographic and clinical characteristics of 82 of these patients (40 boys, 42 girls) who were below 18 y of age. The median age at evaluation (defined as the median age at entry into FOS) was 12.5 and 13.2 y for boys and girls, respectively. RESULTS The most frequent early clinical manifestations of Fabry disease were neurological (acroparaesthesiae, altered temperature sensitivity) and gastrointestinal symptoms (altered bowel habits and abdominal pain), which were documented in about 80% and 60% of patients, respectively, at the time of evaluation and subsequent entry into FOS. Tinnitus, vertigo, fatigue and angiokeratoma were present in over 40% of patients. Symptoms were noted in early childhood and occurred with similar frequency in boys and girls, although the onset of symptoms was 2-5 y later in girls than in boys. There was an approximately 3-y delay from onset of symptoms to diagnosis, and patients were frequently misdiagnosed. CONCLUSION Although the life-threatening complications of Fabry disease, such as stroke and renal and heart failure, are not seen in children, the present analysis shows that other symptoms are common and may have an impact on quality of life.
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Affiliation(s)
- Uma Ramaswami
- Department of Paediatric Endocrinology, Diabetes and Metabolism, Addenbrooke's Hospital, Cambridge, UK.
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Schiffmann R, Rapkiewicz A, Abu-Asab M, Ries M, Askari H, Tsokos M, Quezado M. Pathological findings in a patient with Fabry disease who died after 2.5 years of enzyme replacement. Virchows Arch 2005; 448:337-43. [PMID: 16315019 PMCID: PMC2288734 DOI: 10.1007/s00428-005-0089-x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2005] [Accepted: 08/31/2005] [Indexed: 10/25/2022]
Abstract
We describe the postmortem findings of a 47-year-old man with Fabry disease, an X-linked glycolipid storage disorder, who was on enzyme replacement therapy with recombinant alpha-galactosidase A for more than 2 years. The patient had widespread atherosclerotic coronary artery disease that culminated in a massive acute myocardial infarction. Atherosclerotic lesions were seen in the right and left coronary systems, aorta, and the basilar artery. Typical Fabry cardiomyopathy and glomerular nephropathy were found. With the exception of vascular endothelial cells, extensive glycolipid storage deposits were seen in all vascular and nonvascular cells and organ systems. We conclude that, at least in this patient, repeated infusions with alpha-galactosidase A over a prolonged period did not appreciably clear storage material in cells other than vascular endothelial cells. These findings also illustrate accelerated atherosclerosis in susceptible patients with Fabry disease.
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Affiliation(s)
- Raphael Schiffmann
- Developmental and Metabolic Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
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Schiffmann R, Ries M, Timmons M, Flaherty JT, Brady RO. Long-term therapy with agalsidase alfa for Fabry disease: safety and effects on renal function in a home infusion setting. Nephrol Dial Transplant 2005; 21:345-54. [PMID: 16204287 DOI: 10.1093/ndt/gfi152] [Citation(s) in RCA: 194] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Fabry disease is an X-linked disorder of glycosphingolipid catabolism that is the result of an intracellular deficiency in the lysosomal enzyme alpha-galactosidase A (alpha-Gal A). This enzymatic defect results in the accumulation of globotriaosylceramide (Gb(3)) within cells and causes progressive neurological, cardiovascular and renal dysfunction. Our objective is to describe the safety and renal effects of long-term enzyme replacement therapy. METHODS This was a single centre, prospective open-label treatment trial in 25 adult male Fabry patients who had completed a 6-month randomized placebo-controlled study and subsequently enrolled in an open-label extension study. Patients were treated every other week with agalsidase alfa (0.2 mg/kg) infused intravenously over 40 min. The main outcome measures were safety, antibody response and renal glomerular filtration rate (GFR). RESULTS During the 4-4.5 years of enzyme replacement therapy, all eligible subjects were able to transition to home therapy. Eight patients developed persistent IgG antibodies to agalsidase alfa, but IgE antibodies were not detected in any patient. The development of IgG antibodies appeared not to affect any clinical end points. Estimated GFR remained stable in subgroups of patients with Stage I (GFR >90 ml/min) or Stage II (GFR 60-89 ml/min) chronic kidney disease at baseline. In contrast, in the subgroup of patients with Stage III chronic kidney disease (GFR 30-59 ml/min), the slope of the decline in GFR was reduced compared with comparable historical controls, suggesting that enzyme replacement therapy was slowing the decline of renal function in this susceptible population. CONCLUSIONS Long-term enzyme replacement therapy with agalsidase alfa is safe and may slow the progressive decline in renal function that was commonly observed in adult males with Fabry disease.
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Affiliation(s)
- Raphael Schiffmann
- Developmental and Metabolic Neurology Branch, National Institute of Neurological Disorders and Stroke National Institutes of Health, Bethesda, MD 20892-1260, USA.
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