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Jabiry-Zieniewicz Z, Stelmach DA, Jasak K, Knap-Wielgus W, Szumska A, Raszeja-Wyszomirska J, Szpotanska-Sikorska M. Pregnancies in Women After Liver Transplant due to Wilson's Disease-Case Series. Transplant Proc 2024:S0041-1345(24)00249-5. [PMID: 38729835 DOI: 10.1016/j.transproceed.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 04/14/2024] [Accepted: 04/17/2024] [Indexed: 05/12/2024]
Abstract
Wilson's disease is a rare autosomal recessive disorder. Due to a defect in membrane copper transporter, copper is not excreted in the bile and accumulates in the tissues. The only treatment for acute liver failure in Wilson's disease is a liver transplant. AIM Assessment of the course of pregnancies and comparison of obstetric outcomes in female liver transplant recipients in the course of Wilson's disease. METHODOLOGY Retrospective analysis of data of women, who were pregnant and gave birth in the years: 2017 to 2023. Evaluation of their liver function used pharmacotherapy and obstetric outcomes. RESULTS We recorded 11 pregnancies in liver transplantation recipients due to Wilson's disease. Ten single pregnancies and 1 twin (DCDA) were observed. In all pregnancies, graft functions and immunosuppressive drug concentrations were monitored. Three women suffered from epilepsy, one was diagnosed with psychiatric disorder. Two were diagnosed with cholestasis, and another 2 with gestational diabetes. Two of them were treated for pregnancy-induced hypertension and 2 developed preeclampsia. Deterioration of liver function parameters in pregnancy was observed in 2 cases. In total, 8 full-term babies were born and 4 late-preterm, including twins at 35 weeks of gestation. Seven pregnancies were delivered by caesarean section and 4 delivered vaginally. No complications in early postpartum period have been reported. CONCLUSIONS Women with Wilson's disease treated with organ transplantation have a chance of successful pregnancies and deliveries.
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Affiliation(s)
| | - Daria Ada Stelmach
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Kamil Jasak
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Weronika Knap-Wielgus
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Agnieszka Szumska
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Raszeja-Wyszomirska
- Department of Hepatology, Transplantology, and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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Bailey KM, Sahota N, To U, Hedera P. "Because it is a rare disease…it needs to be brought to attention that there are things out of the norm": a qualitative study of patient and physician experiences of Wilson disease diagnosis and management in the US. Orphanet J Rare Dis 2023; 18:158. [PMID: 37349760 PMCID: PMC10288732 DOI: 10.1186/s13023-023-02778-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 06/18/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Wilson disease (WD) is a genetic disorder of copper metabolism that leads to copper accumulation in various organs, primarily the liver and brain, resulting in heterogenous hepatic, neurologic, and psychiatric symptoms. Diagnosis can occur at any age, requiring lifelong treatment, which can involve liver transplantation. This qualitative study aims to understand the wider patient and physician experience of the diagnosis and management of WD in the US. METHODS Primary data were collected from 1:1 semi structured interviews with US-based patients and physicians and thematically analyzed with NVivo. RESULTS Twelve WD patients and 7 specialist WD physicians (hepatologists and neurologists) were interviewed. Analysis of the interviews revealed 18 themes, which were organized into 5 overarching categories: (1) Diagnosis journey, (2) Multidisciplinary approach, (3) Medication, (4) The role of insurance, and (5) Education, awareness, and support. Patients who presented with psychiatric or neurological symptoms reported longer diagnostic journeys (range 1 to 16 years) than those presenting with hepatic symptoms or through genetic screening (range 2 weeks to 3 years). All were also affected by geographical proximity to WD specialists and access to comprehensive insurance. Exploratory testing was often burdensome for patients, but receipt of a definitive diagnosis led to relief for some. Physicians emphasized the importance of multidisciplinary teams beyond hepatology, neurology, and psychiatry and recommended a combination of chelation, zinc, and a low-copper diet; however, only half the patients in this sample were on a chelator, and some struggled to access prescription zinc due to insurance issues. Caregivers often advocated for and supported adolescents with their medication and dietary regimen. Patients and physicians recommended more education and awareness for the healthcare community. CONCLUSIONS WD requires the coordination of care and medication among several specialists due to its complex nature, but many patients do not have access to multiple specialties due to geographical or insurance barriers. Because some patients cannot be treated in Centers of Excellence, easy access to reliable and up-to-date information is important to empower physicians, patients, and their caregivers in managing the condition, along with general community outreach programs.
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Affiliation(s)
| | | | - Uyen To
- Yale University, New Haven, Connecticut, United States
| | - Peter Hedera
- University of Louisville, Louisville, KY, USA.
- Department of Neurology Institution, University of Louisville, 220 Abraham Flexner Way, Suite 606, Louisville, KY, 40202, USA.
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Zimny S, Bourhis H, Weber S, Reiter FP, Hohenester S, Kraft E, Mohr I, Merle U, Weiss KH, Denk G. Medical care of patients with Wilson disease in Germany: a multidisciplinary survey among university centers. Orphanet J Rare Dis 2023; 18:122. [PMID: 37226184 DOI: 10.1186/s13023-023-02731-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 05/14/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Wilson disease (WD) is a rare, hereditary disorder of copper metabolism. Due to its variable symptoms and manifestations, diagnosis remains challenging. Affected patients must obtain lifelong medical treatment, as the disease is fatal if untreated. Patients require continuous monitoring, but little is known about the care of these patients in Germany. Therefore, we analyzed the medical care of WD patients at German university centers. We sent a questionnaire containing 20 questions to a total of 108 departments of pediatrics, neurology and gastroenterology in 36 university hospitals. Our questions referred to the characteristics of WD patients at the different sites and internal procedures regarding diagnosis, therapy and follow-up. A descriptive statistical analysis was performed. RESULTS Sixty-three departments (58%) returned our questionnaire. In total, approximately one-third of the estimated WD patients in Germany are seen annually in the outpatient clinics of these departments (approx. 950 patients). There are only a few departments which treat patients in a multidisciplinary setting (12%). Our survey revealed that for diagnosis, 51% of all departments used an algorithm based on the Leipzig score as recommended by international guidelines. Most departments apply essential parameters recommended by WD guidelines. Routine monitoring is performed at least biannually by 84% of the departments, and standard investigations for monitoring are regularly applied. A routine family screening is performed by 84% of all departments. A reduction in medical therapy during pregnancy is recommended by 46% of the departments. Only 14% suggested that WD patients should not breastfeed. Liver transplantation (LT) due to WD is a rare but repeatedly occurring event. Most departments of gastroenterology (72%) reported at least one patient with LT within the last decade. CONCLUSIONS Medical care of WD patients at German university centers follows the recommendations set forth by international guidelines, but only a few centers treat significant numbers of patients. The surveillance of patients does not follow specified standards, but most departments adhere to the accepted guidelines. The formation of central units and networks in a multidisciplinary setting should be evaluated to improve the care of WD patients.
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Affiliation(s)
- Sebastian Zimny
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.
| | - Hélène Bourhis
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Sabine Weber
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Florian Paul Reiter
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
- Department of Medicine II, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Simon Hohenester
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Eduard Kraft
- Department of Physical Medicine and Rehabilitation, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Isabelle Mohr
- Department of Internal Medicine IV, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Uta Merle
- Department of Internal Medicine IV, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Karl Heinz Weiss
- Internal Medicine, Salem Medical Center, Zeppelinstraße 11 - 33, 69121, Heidelberg, Germany
| | - Gerald Denk
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
- Transplant Center, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
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Schilsky ML, Roberts EA, Bronstein JM, Dhawan A, Hamilton JP, Rivard AM, Washington MK, Weiss KH, Zimbrean PC. A multidisciplinary approach to the diagnosis and management of Wilson disease: 2022 Practice Guidance on Wilson disease from the American Association for the Study of Liver Diseases. Hepatology 2022:01515467-990000000-00207. [PMID: 36151586 DOI: 10.1002/hep.32801] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 01/18/2023]
Affiliation(s)
- Michael L Schilsky
- Medicine and Surgery , Yale University School of Medicine , New Haven , Connecticut , USA
| | - Eve A Roberts
- Paediatrics, Medicine, Pharmacology and Toxicology , University of Toronto , Toronto , Ontario , Canada
| | - Jeff M Bronstein
- Neurology , University of California Los Angeles , Los Angeles , California , USA
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre and MowatLabs , King's College Hospital , London , UK
| | - James P Hamilton
- Medicine , Johns Hopkins University School of Medicine , Baltimore , Maryland , USA
| | - Anne Marie Rivard
- Food and Nutrition Services , Yale New Haven Hospital , New Haven , Connecticut , USA
| | - Mary Kay Washington
- Pathology, Immunology and Microbiology , Vanderbilt University Medical Center , Nashville , Tennessee , USA
| | | | - Paula C Zimbrean
- Psychiatry , Yale University School of Medicine , New Haven , Connecticut , USA
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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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Wilson's Disease: An Update on the Diagnostic Workup and Management. J Clin Med 2021; 10:jcm10215097. [PMID: 34768617 PMCID: PMC8584493 DOI: 10.3390/jcm10215097] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/18/2021] [Accepted: 10/27/2021] [Indexed: 02/08/2023] Open
Abstract
Wilson's disease (WD) is a rare autosomal recessive disorder of hepatocellular copper deposition. The diagnostic approach to patients with WD may be challenging and is based on a complex set of clinical findings that derive from patient history, physical examination, as well as laboratory and imaging testing. No single examination can unequivocally confirm or exclude the disease. Timely identification of signs and symptoms using novel biomarkers and modern diagnostic tools may help to reduce treatment delays and improve patient prognosis. The proper way of approaching WD management includes, firstly, early diagnosis and prompt treatment introduction; secondly, careful and lifelong monitoring of patient compliance and strict adherence to the treatment; and, last but not least, screening for adverse effects and evaluation of treatment efficacy. Liver transplantation is performed in about 5% of WD patients who present with acute liver failure at first disease presentation or with signs of decompensation in the course of liver cirrhosis. Increasing awareness of this rare inherited disease among health professionals, emphasizing their training to consider early signs and symptoms of the illness, and strict monitoring are vital strategies for the patient safety and efficacy of WD therapy.
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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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