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Keidel LF, Schworm B, Hohenfellner K, Kruse F, Priglinger S, Luft N, Priglinger C. Posterior Segment Involvement in Infantile Nephropathic Cystinosis - A Review. Klin Monbl Augenheilkd 2023; 240:266-275. [PMID: 36977427 DOI: 10.1055/s-0037-1599653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
Cystinosis is a rare lysosomal storage disease with a prevalence of 1 : 100 000 - 1 : 200 000 cases. It is caused by biallelic mutations in the CTNS gene, which encodes cystinosin, that transport cystine out of the lysosomes. Due to its dysfunction, cystine crystals accumulate in the lysosomes and ultimately cause apoptosis of the cell. Since cystinosin is ubiquitously present in the body, cystine crystals are deposited in every body structure and lead to the dysfunction of various organ systems in the course of time. Cystine crystals deposited in the cornea are a clinical hallmark of the disease, while there is less awareness of concomitant posterior segment alterations. Symmetrical pigment epithelial mottling and patches of depigmentation frequently start in the periphery and progress towards the posterior pole and can be encountered upon fundus biomicroscopy. Spectral-domain optical coherence tomography (SD-OCT) is an elegant tool for visualizing chorioretinal cystine crystals at the posterior pole. An SD-OCT-based clinical grading of the severity of the chorioretinal manifestation can potentially be applied as a biomarker for systemic disease status and for monitoring oral therapy adherence in the future. Along with previous histological examinations, it may also give information about the location of cystine crystals in the choroid and retina. This review aims to increase the awareness of vision-threatening retinal and choroidal changes in cystinosis and the concomitant findings in SD-OCT.
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Affiliation(s)
| | - Benedikt Schworm
- Department of Ophthalmology, Ludwig-Maximilians-University Munich, Germany
| | | | - Franziska Kruse
- Department of Ophthalmology, Ludwig-Maximilians-University Munich, Germany
| | | | - Nikolaus Luft
- Department of Ophthalmology, Ludwig-Maximilians-University Munich, Germany
| | - Claudia Priglinger
- Department of Ophthalmology, Ludwig-Maximilians-University Munich, Germany
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Nießl C, Boulesteix AL, Oh J, Palm K, Schlingmann P, Wygoda S, Haffner D, Wühl E, Tönshoff B, Buescher A, Billing H, Hoppe B, Zirngibl M, Kettwig M, Moeller K, Acham-Roschitz B, Arbeiter K, Bald M, Benz M, Galiano M, John-Kroegel U, Klaus G, Marx-Berger D, Moser K, Mueller D, Patzer L, Pohl M, Seitz B, Treikauskas U, von Vigier RO, Gahl WA, Hohenfellner K. Relationship between age at initiation of cysteamine treatment, adherence with therapy, and glomerular kidney function in infantile nephropathic cystinosis. Mol Genet Metab 2022; 136:268-273. [PMID: 35835062 PMCID: PMC9395137 DOI: 10.1016/j.ymgme.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 10/17/2022]
Abstract
Infantile nephropathic cystinosis, due to impaired transport of cystine out of lysosomes, occurs with an incidence of 1 in 100-200,000 live births. It is characterized by renal Fanconi syndrome in the first year of life and glomerular dysfunction progression to end-stage kidney disease by approximately 10 years of age. Treatment with oral cysteamine therapy helps preserve glomerular function, but affected individuals eventually require kidney replacement therapy. This is because glomerular damage had already occurred by the time a child is diagnosed with cystinosis, typically in the second year of life. We performed a retrospective multicenter study to investigate the impact of initiating cysteamine treatment within the first 2 months of life in some infants and comparing two different levels of adherence in patients diagnosed at the typical age. We collected 3983 data points from 55 patients born between 1997 and 2020; 52 patients with 1592 data points could be further evaluated. These data were first analyzed by dividing the patient cohort into three groups: (i) standard treatment start with good adherence, (ii) standard treatment start with less good adherence, and (iii) early treatment start. At every age, mean estimated glomerular filtration rate (eGFR) was higher in early-treated patients than in later-treated patients. Second, a generalized additive mixed model (GAMM) was applied showing that patients with initiation of treatment before 2 months of age are expected to have a 34 ml/min/1.73 m2 higher eGFR than patients with later treatment start while controlling for adherence and patients' age. These data strongly suggest that oral cysteamine treatment initiated within 2 months of birth preserves kidney function in infantile nephropathic cystinosis and provide evidence of the utility of newborn screening for this disease.
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Affiliation(s)
- Christina Nießl
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Working group "Biometry in Molecular Medicine", Ludwig-Maximilians-University of Munich, Marchoninistr. 15, 81377 Munich, Germany.
| | - Anne-Laure Boulesteix
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Working group "Biometry in Molecular Medicine", Ludwig-Maximilians-University of Munich, Marchoninistr. 15, 81377 Munich, Germany.
| | - Jun Oh
- Department of Pediatrics, Pediatric Nephrology, University Center Hamburg/Eppendorf, Martinistr. 52, 20251 Hamburg, Germany.
| | - Katja Palm
- Department of Pediatrics, University Hospital Magdeburg, Leipzigerstr. 44, 39120 Magdeburg, Germany.
| | - Peter Schlingmann
- Department of General Pediatrics, Pediatric Nephrology, University Children's Hospital Münster, Waldeyerstr. 22, 48149 Münster, Germany.
| | - Simone Wygoda
- KFH Pediatric Kidney Center Leipzig, Delitzscherstr. 14, 04129 Leipzig, Germany.
| | - Dieter Haffner
- Department of Pediatrics, Department of Pediatric Kidney, Liver and Metabolic Diseases, Medical School, Carl-Neuberg-str. 1, 30625 Hannover, Germany.
| | - Elke Wühl
- Department of Pediatrics I, Division of Pediatric Nephrology, University Children 's Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
| | - Burkhard Tönshoff
- Department of Pediatrics I, Division of Pediatric Nephrology, University Children 's Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Anja Buescher
- Department of Pediatrics II, University Hospital of Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany.
| | - Heiko Billing
- Department of Pediatrics, Riedstraße 12, 74321 Bietigheim-Bissingen, Germany.
| | - Bernd Hoppe
- KNZ - Kindernierenzentrum Bonn, Im Mühlenbach 2B, 53127 Bonn, Germany.
| | - Matthias Zirngibl
- Department of General Pediatrics/Hematology/Oncology, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany.
| | - Matthias Kettwig
- Department of Pediatrics, University Hospital Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany.
| | - Kristina Moeller
- Department of Pediatrics, Gesundheit Nord, Klinikverbund Bremen, Kürfürstenallee 130, 28211 Bremen, Germany.
| | - Birgit Acham-Roschitz
- Department of Pediatrics, Medical University of Graz, Auenbruggerplatz 34, 8036 Graz, Austria.
| | - Klaus Arbeiter
- Pediatric Dialysis Unit, Clinic of Pediatric and Adolescent Medicine, Department of Pediatric Nephrology and Gastroenterology, Medical University Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Martin Bald
- Department of Pediatric Nephrology Olgahospital, Clinics of Stuttgart, Kriegsbergstr. 62, 70174 Stuttgart, Germany.
| | - Marcus Benz
- Pediatric Nephrology Dachau, Schleißheimerstr. 12, 85221 Dachau, Germany.
| | - Matthias Galiano
- Pediatric Nephrology, Department of Pediatrics and Adolescent Medicine, University Hospital of Erlangen, Loschgestr. 15, 91052 Erlangen, Germany.
| | - Ulrike John-Kroegel
- Department of Pediatric Nephrology, University Children's hospital Jena, Kastanienstr. 1, 07747 Jena, Germany.
| | - Guenter Klaus
- Pediatric Rheumatology, University Children's hospital, Philipps University of Marburg, Baldingerstr, 35043 Marburg, Germany.
| | - Daniela Marx-Berger
- Children's Hospital of Eastern Switzerland, Claudiusstr. 6, 9006 St. Gallen, Switzerland.
| | - Katja Moser
- Children's Hospital Aschaffenburg, Am Hasenkopf 1, 63739 Aschaffenburg, Germany.
| | - Dirk Mueller
- Department of Neonatology and Pediatrics, Gesundheit Nordhessen, Mönchebergstraße 41-43, 34125 Kassel, Germany.
| | - Ludwig Patzer
- Department of Pediatric Nephrology, Department of Pediatrics, Krankenhaus Halle Saale, Mauerstr. 5, 06110 Halle Saale, Germany.
| | - Martin Pohl
- Department of Pediatric Nephrology, Department of Pediatrics, University Children 's Hospital Freiburg, Mathildenstr. 1, 79106 Freiburg, Germany.
| | - Barbara Seitz
- KFH Pediatric Kidney Center Munich, Parzivalstr. 16, 80804 Munich, Germany.
| | - Ulrike Treikauskas
- Department of Pediatric Nephrology, Department of Pediatrics, RoMed Kliniken, Pettenkoferstr. 10, 83022 Rosenheim, Germany.
| | - Rodo O von Vigier
- Pediatric Clinic, Wildermeth Children's Hospital, Vogelsang 84, 2502 Biel-Bienne, Switzerland.
| | - William Allen Gahl
- National Genome Research Institute (NHGRI), National Institutes of Health, Medical Genetics Branch, 9000 Rockville Pike, Bethesda, MD 20892, USA.
| | - Katharina Hohenfellner
- Department of Pediatric Nephrology, Department of Pediatrics, RoMed Kliniken, Pettenkoferstr. 10, 83022 Rosenheim, Germany.
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Cavaliere GA, Murali N, Bontempo LJ, Dezman ZDW. 19-year-old Woman with Intermittent Weakness. Clin Pract Cases Emerg Med 2021; 5:276-282. [PMID: 34437031 PMCID: PMC8373190 DOI: 10.5811/cpcem.2021.4.52011] [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: 02/01/2021] [Accepted: 04/01/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction Systemic weakness is a common chief complaint of patients presenting to the emergency department (ED). A well thought out approach to the assessment and workup of these patients is key to diagnostic accuracy and definitive therapy. Case Presentation In this case, a 19-year-old female presented to the ED with generalized weakness and near syncope. She had global weakness in her extremities and multiple electrolyte abnormalities. Discussion This case takes the reader through the differential diagnosis and evaluation of a patient with weakness and profound electrolyte derangements. It includes a discussion of the diagnostic studies and calculations that ultimately led to the patient’s diagnosis.
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Affiliation(s)
- Garrett A Cavaliere
- University of Maryland Medical Center, Department of Emergency Medicine, Baltimore, Maryland
| | - Neeraja Murali
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Laura J Bontempo
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Zachary D W Dezman
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland.,University of Maryland School of Medicine, Department of Epidemiology and Public Health, Baltimore, Maryland
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Keidel L, Elhardt C, Hohenfellner K, Priglinger S, Schworm B, Wertheimer C, Priglinger C, Luft N, Bechtold Dalla Pozza S, Bergmann C, Buss M, Dosch R, Erler J, Getzinger T, Herzig N, Hohenfellner K, Holla H, Knerr C, Koeppl C, Ockert C, Passow M, Rohayem J, Steidle G, Thiele A, Treikauskas U, Vill K, Weber R, Weitzel D. Establishing an objective biomarker for corneal cystinosis using a threshold-based Spectral domain optical coherence tomography imaging algorithm. Acta Ophthalmol 2021; 99:e189-e195. [PMID: 32833325 DOI: 10.1111/aos.14569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/24/2020] [Accepted: 07/02/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE The purpose of the present study was to establish a semi-automated threshold-based image segmentation algorithm to detect and objectively quantify corneal cystine crystal deposition in ocular cystinosis with anterior segment optical coherence tomography (AS-OCT). METHODS This prospective, observational, comparative study included 88 eyes of 45 patients from the German Cystinosis Registry Study as well as 68 eyes of 35 healthy control subjects. All eyes were imaged with AS-OCT (Cirrus HD-OCT 5000, Carl Zeiss Meditec AG, Jena, Germany). As an initial step, B-scan images were subjectively analysed for typical changes in morphology in comparison to healthy controls. Based on the experience gained, an objective semi-automated B-scan image segmentation algorithm was developed using a grey scale value-based threshold method to automatically quantify corneal crystals. RESULTS On AS-OCT B-scans, corneal crystals appeared as hyperreflective deposits within the corneal stroma. The crystals were distributed either in all stromal layers (43 eyes, 49%) or confined to the anterior (23 eyes, 26%) or posterior stroma (22 eyes, 25%), respectively. The novel automatic B-scan image segmentation algorithm was most efficient in delineating corneal crystals at higher grey scale thresholds (e.g. 226 of a maximum of 255). Significant differences in suprathreshold grey scale pixels were observable between cystinosis patients and healthy controls (p < 0.001). In addition, the algorithm was able to detect an age-dependent depth distribution profile of crystal deposition. CONCLUSION Objective quantification of corneal cystine crystal deposition is feasible with AS-OCT and can serve as a novel biomarker for ocular disease control and topical treatment monitoring.
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Affiliation(s)
- Leonie Keidel
- Department of Ophthalmology Ludwig‐Maximilians‐University Munich Germany
| | - Carolin Elhardt
- Department of Ophthalmology Ludwig‐Maximilians‐University Munich Germany
| | | | | | - Benedikt Schworm
- Department of Ophthalmology Ludwig‐Maximilians‐University Munich Germany
| | | | - Claudia Priglinger
- Department of Ophthalmology Ludwig‐Maximilians‐University Munich Germany
| | - Nikolaus Luft
- Department of Ophthalmology Ludwig‐Maximilians‐University Munich Germany
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Sousa-Neves F, Ribeiro AC, Saraiva E, Ribeiro L, Sequeira J, Varandas R. Ocular manifestations of intermediate cystinosis: To treat or not to treat? Eur J Ophthalmol 2019; 30:NP7-NP10. [PMID: 31074291 DOI: 10.1177/1120672119848899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To report a case of intermediate cystinosis with an atypical presentation in which a delayed non-treatment decision has been proved right over a large period of time. METHODS This is a unique case report of a patient who underwent full ophthalmologic evaluations including anterior chamber optical coherence tomography on a regular basis during a 7-year follow-up period. RESULTS A 30-year-old woman with photophobia was being studied by the Department of Nephrology with a suspicion of Alport syndrome. Slit-lamp examination showed iridescent deposits throughout the corneal anterior stroma and the inferior tarsal conjunctiva bilaterally. Anterior chamber optical coherence tomography showed stromal hyperreflectivity. CTNS gene was found to be positive for c.416C>T (Ser139Phe) mutation. The patient was offered oral and topical cysteamine which was refused. After a period of 5 years of follow-up, general health status remained stable, corneal disease showed no progression and photophobia complaints diminished. However, the patient was advised to start systemic and topical cysteamine because of the unknown development of the disease. CONCLUSION In this reported case, a delayed non-treatment decision has been proved right contrary to published evidence of active treatment of photophobia. The decision whether to treat or not to treat corneal involvement of the disease is not straightforward. Besides biomicroscopic evaluations, patients' complaints and expectations should be taken into account.
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Affiliation(s)
- Filipe Sousa-Neves
- Department of Ophthalmology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Ana Clara Ribeiro
- Department of Ophthalmology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Eduardo Saraiva
- Department of Ophthalmology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Lígia Ribeiro
- Department of Ophthalmology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Joaquim Sequeira
- Department of Ophthalmology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Rosário Varandas
- Department of Ophthalmology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
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6
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Kovach JL, Isildak H, Sarraf D. Crystalline retinopathy: Unifying pathogenic pathways of disease. Surv Ophthalmol 2019; 64:1-29. [DOI: 10.1016/j.survophthal.2018.08.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 08/01/2018] [Accepted: 08/06/2018] [Indexed: 01/02/2023]
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Personalized Pharmacoperones for Lysosomal Storage Disorder: Approach for Next-Generation Treatment. ADVANCES IN PROTEIN CHEMISTRY AND STRUCTURAL BIOLOGY 2015; 102:225-65. [PMID: 26827607 DOI: 10.1016/bs.apcsb.2015.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Lysosomal storage disorders (LSDs) are a collection of inborn errors of metabolic disorders affected by mutations in lysosome functional genes, commonly acid hydrolases. From the past decades, many approaches like enzyme replacement therapy, substrate reduction therapy are followed to treat these conditions. However, all these approaches have their own limitations. Proof-of-concept studies on pharmacological chaperone therapy (PCT) is now transformed into clinical practice to treat LSDs. Furthermore, it is narrowed with individuals to chaperone sensitive, specific mutations. Hence, personalizing the PCT will be a new direction to combat LSDs. In this review, we have discussed the available clinical strategies and pointed the light on how pharmacological chaperones can be personalized and hopeful to be a next-generation approach to address LSDs.
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Shams F, Livingstone I, Oladiwura D, Ramaesh K. Treatment of corneal cystine crystal accumulation in patients with cystinosis. Clin Ophthalmol 2014; 8:2077-84. [PMID: 25336909 PMCID: PMC4199850 DOI: 10.2147/opth.s36626] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Cystinosis is a rare autosomal recessive disorder characterized by the accumulation of cystine within the cells of different organs. Infantile nephropathic cystinosis is the most common and severe phenotype. With the success of renal transplantation, these patients are now living longer and thus more long-term complications within different organs are becoming apparent. Ophthalmic manifestations range from corneal deposits of cystine crystals to pigmentary retinopathy. With increasing age, more severe ocular complications have been reported. Photophobia is a prominent symptom for patients. With prolonged survival and increasing age, this symptom, along with corneal erosions and blepharospasm, can become debilitating. This review revisits the basic pathogenesis of cystinosis, the ocular manifestations of the disease, and the treatment of corneal crystals.
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Affiliation(s)
- Fatemeh Shams
- Department of Ophthalmology, Gartnavel General Hospital, Glasgow, Scotland
| | - Iain Livingstone
- Department of Ophthalmology, Gartnavel General Hospital, Glasgow, Scotland
| | - Dilys Oladiwura
- Department of Ophthalmology, Gartnavel General Hospital, Glasgow, Scotland
| | - Kanna Ramaesh
- Department of Ophthalmology, Gartnavel General Hospital, Glasgow, Scotland
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9
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Nesterova G, Gahl WA. Cystinosis: the evolution of a treatable disease. Pediatr Nephrol 2013; 28:51-9. [PMID: 22903658 PMCID: PMC3505515 DOI: 10.1007/s00467-012-2242-5] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 06/07/2012] [Accepted: 06/08/2012] [Indexed: 11/01/2022]
Abstract
Cystinosis is a rare autosomal recessive disorder involving lysosomal storage of the amino acid cystine due to a defect in the membrane transport protein, cystinosin. Since the introduction of kidney transplants and the availability of cystine-depleting medical therapy, this previously fatal disease was transformed into a treatable disorder. Renal allografts and medical therapy targeting the basic metabolic defect have altered the natural hisotry of cystinosis so drastically that patients have a life expectancy extending past 50 years. Consequently, early diagnosis and appropriate therapy are critically important. In this article, we offer a review of the manifestations of cystinosis, including the proximal tubular dysfunction of renal Fanconi syndrome, and discuss the prevention and treatment of the disorder's systemic complications. We focus on the nephropathic forms of cystinosis, aiming to assist nephrologists and other physicians to develop early recognition and appropriate management of cystinosis patients.
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Affiliation(s)
- Galina Nesterova
- NHGRI, Medical Biochemical Genetic Section, National Institutes of Health, Bethesda, MD, USA.
| | - William A. Gahl
- NHGRI, Medical Biochemical Genetic Section, National Institutes of Health, Bethesda, MD USA
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10
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Retinal Manifestations of Renal and Connective Tissue Diseases. Clin Ophthalmol 2012; 52:93-105. [DOI: 10.1097/iio.0b013e31823bbb32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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11
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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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12
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Cystine accumulation in the CNS results in severe age-related memory deficits. Neurobiol Aging 2009; 30:987-1000. [DOI: 10.1016/j.neurobiolaging.2007.09.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2007] [Revised: 08/21/2007] [Accepted: 09/18/2007] [Indexed: 11/22/2022]
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13
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Nesterova G, Gahl W. Nephropathic cystinosis: late complications of a multisystemic disease. Pediatr Nephrol 2008; 23:863-78. [PMID: 18008091 DOI: 10.1007/s00467-007-0650-8] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Revised: 09/24/2007] [Accepted: 09/24/2007] [Indexed: 11/29/2022]
Abstract
Cystinosis is a rare autosomal recessive disorder due to impaired transport of cystine out of cellular lysosomes. Its estimated incidence is 1 in 100,000 live births. End-stage renal disease (ESRD) is the most prominent feature of cystinosis and, along with dehydration and electrolyte imbalance due to renal tubular Fanconi syndrome, has accounted for the bulk of deaths from this disorder. Prior to renal transplantation and cystine-depleting therapy with cysteamine for children with nephropathic cystinosis, their lifespan was approximately 10 years. Now, cystinotic patients have survived through their fifth decade, but the unremitting accumulation of cystine has created significant non-renal morbidity and mortality. In this article we review the classic presentation of nephropathic cystinosis and the natural history, diagnosis, and treatment of the disorder's systemic involvement. We also emphasize the role of oral cysteamine therapy in preventing the late complications of cystinosis.
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Affiliation(s)
- Galina Nesterova
- Section on Human Biochemical Genetics, Human Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892-1851, USA
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Kalatzis V, Serratrice N, Hippert C, Payet O, Arndt C, Cazevieille C, Maurice T, Hamel C, Malecaze F, Antignac C, Müller A, Kremer EJ. The ocular anomalies in a cystinosis animal model mimic disease pathogenesis. Pediatr Res 2007; 62:156-62. [PMID: 17597652 DOI: 10.1203/pdr.0b013e31809fda89] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cystinosis is a lysosomal storage disorder characterized by abnormal accumulation of cystine, which forms crystals at high concentrations. The causative gene CTNS encodes cystinosin, the lysosomal cystine transporter. The eye is one of the first organs affected (corneal lesions and photophobia in the first and visual impairment in the second decade of life). We characterized the ocular anomalies of Ctns-/- mice to determine whether they mimic those of patients. The most dramatic cystine accumulation was seen in the iris, ciliary body, and cornea of Ctns-/- mice. Consistently, Ctns-/- mice had a low intraocular pressure (IOP) and seemed mildly photophobic. Retinal cystine levels were elevated but increased less dramatically with age. Consistently, the retina was intact and electroretinogram (ERG) profiles were normal in mice younger than 19 mo; beyond this age, retinal crystals and lesions appeared. Finally, the lens contained the lowest cystine levels and crystals were not seen. The temporospatial pattern of cystine accumulation in Ctns-/- mice parallels that of patients and validates the mice as a model for the ocular anomalies of cystinosis. This work is a prerequisite step to the testing of novel ocular cystine-depleting therapies.
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15
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Tsilou E, Zhou M, Gahl W, Sieving PC, Chan CC. Ophthalmic manifestations and histopathology of infantile nephropathic cystinosis: report of a case and review of the literature. Surv Ophthalmol 2007; 52:97-105. [PMID: 17212992 PMCID: PMC1850966 DOI: 10.1016/j.survophthal.2006.10.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Cystinosis is a rare autosomal recessive metabolic disorder characterized by the intracellular accumulation of cystine, the disulfide of the amino acid cysteine, in many organs and tissues. Infantile nephropathic cystinosis is the most severe phenotype. Corneal crystal accumulation and pigmentary retinopathy were originally the most commonly described ophthalmic manifestations, but successful kidney transplantation significantly changed the natural history of the disease. As cystinosis patients now live longer, long-term complications in extrarenal tissues, including the eye, have become apparent. A case of an adult patient with infantile nephropathic cystinosis is reported. He presented with many long-term ocular complications of cystinosis. After 4 years of follow-up, the patient died from sepsis. Pathology of the phthisical eyes demonstrated numerous electron-transparent polygonal spaces, bounded by single membrane, in corneal cells, retinal pigment epithelial cells, and even choroidal endothelial cells. The ophthalmic manifestations and pathology of infantile nephropathic cystinosis are discussed and reviewed in light of the current report and other cases in the literature.
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Affiliation(s)
- Ekaterini Tsilou
- Ophthalmic Genetics and Visual Function Branch, National Eye Institute, National Institutes of Health, Bethesda, MD 20892, USA
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16
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Affiliation(s)
- William R Wilcox
- Division of Medical Genetics, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.
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Assadi FK, Sandler RH, Wong PW, Salem M, Simenauer L. Infantile cystinosis presenting as chronic constipation. Am J Kidney Dis 2002; 39:E24. [PMID: 12046055 DOI: 10.1053/ajkd.2002.33415] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An infant presented with persistent constipation as the first clinical symptom of cystinosis before evidence of renal Fanconi's syndrome. The history of muscle weakness, failure to thrive, polydipsia, and polyuria prompted subsequent clinical and laboratory evaluations, leading to the correct diagnosis of cystinosis. Primary and persistent constipation as an initial manifestation of cystinosis has not been reported previously. Although rare, cystinosis should be considered in the differential diagnosis of constipation if other suggestive signs or symptoms are present.
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Affiliation(s)
- Farahnak K Assadi
- Department of Pediatrics, Rush Presbyterian St. Luke's Medical Center, Rush University Medical College, Chicago, IL, USA.
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18
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Tsilou ET, Rubin BI, Reed GF, Iwata F, Gahl W, Kaiser-Kupfer MI. Age-related prevalence of anterior segment complications in patients with infantile nephropathic cystinosis. Cornea 2002; 21:173-6. [PMID: 11862089 DOI: 10.1097/00003226-200203000-00009] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE As a result of successful renal transplantation, patients with nephropathic cystinosis are now living into adulthood. As these patients age, anterior segment ocular complications, other than deposition of corneal crystals, become more evident. With our experience with 172 patients followed up at the National Institutes of Health between 1976 and 2000, the prevalence of anterior segment complications in nephropathic cystinosis was determined. METHODS A cross-sectional examination of age-specific prevalence was performed with logistic regression analysis of prevalence change with age. RESULTS Besides the corneal crystals apparent in all age groups, superficial punctate keratopathy, filamentary keratopathy, severe peripheral corneal neovascularization, band keratopathy, and posterior synechiae with iris thickening and transillumination were noted in the older age groups. The prevalence increased with age for each complication. CONCLUSIONS As patients with cystinosis grow older, more severe ophthalmic manifestations become evident. It remains to be seen how the prevalence of these complications will be altered by early initiation of oral and topical cysteamine therapy.
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Affiliation(s)
- Ekaterini T Tsilou
- Ophthalmic Genetics and Visual Function Branch, Division of Biometry and Epidemiology, National Eye Institute, National Institutes of Health, 10 Center Drive, Bldg 10,Rm 10N226, Bethesda, MD 20892, U.S.A.
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19
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Chang BY, George ND. Early blindness due to retinopathy of infantile cystinosis. Eye (Lond) 2000; 14 Pt 5:804-5. [PMID: 11116719 DOI: 10.1038/eye.2000.218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Abstract
Incidence and prevalence, the measures of "frequency, " are often confused. While in a nonhereditary situation, the useful parameter is the incidence rate, evaluating the impact of an etiologic factor, it is prevalence that is considered useful in a hereditary disease. Prevalence may concern either the whole population or a fraction of this population, that is, males or females or individuals at a given age, for example, at birth. Pathologic phenotype and morbid genotype prevalences have to be clearly differentiated. In this article, we review the epidemiologic surveys allowing an estimation of the distribution of major single-gene kidney diseases progressing to renal failure in different populations. In order to compare their results, the geographic/ethnic composition of the population, the determination of its size, the choice and mode of calculation of the epidemiologic measure, the definition of the disease and modes of diagnosis, the inclusion of cases, the sources of ascertainment and the possible causes of underascertainment, and the period of time during which events were counted should be analyzed accurately. Although their impact in terms of morbidity, hospitalizations, mortality, and cost to society is high, this review shows that information on the prevalence of single-gene kidney diseases is far from complete. To date, the data essentially apply to large populations of European origin. A part of the variation among prevalence data may be due to methodological differences. Not representative are the small populations in which some rare diseases, especially recessive, are found with a high prevalence.
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Affiliation(s)
- M Levy
- Unité INSERM 535 Génétique épidémiologique et structure des populations humaines, Bâtiment INSERM Gregory Pincus,Le Kremlin Bicêtre, and Laboratoire d'anthropologie, case 7041, Université Paris VII, Paris, France.
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21
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Bonsib SM, Horvath F. Multinucleated podocytes in a child with nephrotic syndrome and Fanconi's syndrome: A unique clue to the diagnosis. Am J Kidney Dis 1999; 34:966-71. [PMID: 10561159 DOI: 10.1016/s0272-6386(99)70060-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- S M Bonsib
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
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22
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Kastrup O, Koeppen S, Schwechheimer K, Keidel M, Diener HC. Myopathy in two siblings with nephropathic cystinosis. Eur J Neurol 1998; 5:609-612. [PMID: 10210897 DOI: 10.1046/j.1468-1331.1998.560609.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Nephropathic cystinosis is a hereditary disorder characterized by a specific defect in the transport of cystine across the lysosomal membrane, leading to an accumulation of protein-free cystine in tissues, including conjunctiva, liver, bone marrow and kidney. Renal transplantation is necessary because of renal failure. With improved life-expectancy, neurological complications have been reported, including cases of distal myopathy diagnosed ante- and post-mortem. We report on two further rare cases of two siblings suffering from cystinosis who developed a predominantly distal myopathy, proven electrophysiologically and on biopsy during life. The reported clinical picture of a distal atrophy resembling a neurogenic disease, confirms a picture apparently typical in cystinosis. Possible effects of cysteamine therapy on the course of the myopathy are discussed. Copyright 1998 Lippincott Williams & Wilkins
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Affiliation(s)
- O Kastrup
- Department of Neurology, University of Essen, Hufelandstr. 55, D-45122, Essen, Germany
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23
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Assadi FK, Mullin JJ, Beckman DA. Evaluation of the reproductive and developmental safety of cysteamine in the rat: effects on female reproduction and early embryonic development. TERATOLOGY 1998; 58:88-95. [PMID: 9802188 DOI: 10.1002/(sici)1096-9926(199809/10)58:3/4<88::aid-tera4>3.0.co;2-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cystinosis is an autosomal recessive metabolic disease in which the amino acid cystine accumulates in lysosomes due to a defect in lysosomal cystine transport. Cystinosis in infancy is associated with poor growth, muscle wastage, and death at about age 10 due to kidney failure. Treatment with cysteamine and kidney transplantation enables cystinotic girls to reach reproductive age and to be healthy enough to permit pregnancy. It is not known whether exposure to cysteamine will have adverse effects on reproduction in the human. It is also possible that some of the complications seen in cystinotic children could be avoided if a pregnant woman carrying a cystinotic fetus were given cysteamine. However, this treatment is not likely to occur until therapeutic exposures to cysteamine are judged to present no increased risk to the human fetus. As part of a larger investigation assessing the reproductive and developmental safety of cysteamine (as phosphocysteamine) using the rat, the two studies reported herein were performed. The first, a dose-finding study, led to the selection of 150 mg/kg/day as the highest dose of cysteamine used for the second and primary focus of this report. The second study involved the exposure of female rats to cysteamine from premating through day 6.5 postconception and assessment of female fertility and early embryonic development. Cysteamine was administered orally in doses of 0, 37.5, 75, 100, or 150 mg/kg/day. There were no clinical signs of maternal toxicity during the exposures of 2 to 5 weeks before successful mating. Animals in the 150 mg/kg/day group experienced a nonsignificant decrease in body weight gain during pregnancy to day 6.5 postconception, a significant increase in liver and spleen weights, and a significant increase in days to coitus--suggesting that a low level of toxicity was manifested. However, there were no adverse effects on reproductive performance with respect to conception and early embryonic development.
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Affiliation(s)
- F K Assadi
- Department of Pediatrics, Alfred I. duPont Hospital for Children, Wilmington, Delaware 19899, USA
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24
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Abstract
The reproductive and developmental safety of cysteamine has become an important issue to children with cystinosis because renal transplants and treatment with cysteamine reduce the complications associated with cystinosis and increase the lifespan of the affected children. In addition, there is the potential to decrease the severity or the incidence of renal Fanconi syndrome with administration of cysteamine to pregnant women carrying fetuses with cystinosis, and to ease significantly the burden of this disease throughout their lives. If cysteamine increases significantly the risk of fetal death, growth retardation or birth defects at doses used to treat women with cystinosis, treatment of the affected female should cease during pregnancy and would not be considered for fetal treatment. The goal of this study was to assess the developmental safety of exposure in utero to cysteamine in the rat. Pregnant rats were given cysteamine (as phosphocysteamine) from day 6.5 through day 18.5 postconception and fetuses were assessed for survival, growth, and structural abnormalities on day 20.5. Cysteamine was administered orally in doses of 0, 37.5, 75, 100, or 150 mg/kg/day. Cysteamine produced dose-dependent developmental toxicity with an apparent no adverse effect observed level of 75 mg/kg/day. Specific malformations were associated with this effect (cleft palate, kyphosis), as well as intrauterine growth retardation and fetal death at 100-150 mg/kg/day, without signs of maternal toxicity. Investigations continue into the mechanism for the developmental toxicity of cysteamine.
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Affiliation(s)
- D A Beckman
- Division of Developmental Biology, Nemours Research Programs, Alfred I. duPont Hospital for Children, Wilmington, Delaware 19899, USA.
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Crook M, Swaminathan R. Disorders of plasma phosphate and indications for its measurement. Ann Clin Biochem 1996; 33 ( Pt 5):376-96. [PMID: 8888972 DOI: 10.1177/000456329603300502] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- M Crook
- Department of Chemical Pathology, Guy's Hospital, London, UK
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Aly AM, Arai M, Hoyer LW. Cysteamine enhances the procoagulant activity of Factor VIII-East Hartford, a dysfunctional protein due to a light chain thrombin cleavage site mutation (arginine-1689 to cysteine). J Clin Invest 1992; 89:1375-81. [PMID: 1569180 PMCID: PMC443005 DOI: 10.1172/jci115725] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
We have recently identified the molecular defect responsible for cross-reacting material-positive hemophilia A in two unrelated patients in which the substitution of cysteine for arginine-1689 (Factor VIII-East Hartford[FVIII-EH]) abolishes a critical Factor VIII light chain thrombin cleavage site. As other mutant proteins with a cysteine for arginine substitution have been modified in the presence of cysteamine, we have determined the effect of this and other reducing agents on FVIII-EH function. Cysteamine concentrations between 0.1 and 10 mM caused dose- and time-dependent increases in FVIII-EH VIII:C activity, as much as 14-fold (to 35 and 62 U/dl for the two patients tested). Comparable data were obtained in a standard one-stage VIII:C coagulation assay and in a chromogenic substrate assay measuring Factor Xa generation. Thrombin cleavage of the FVIII-EH light chain in the presence of cysteamine was documented by immunoadsorption and analysis. Cystamine and cysteamine-S-phosphate, similar compounds that do not possess a free thiol group, had no effect. Cysteamine augmentation of FVIII-EH VIII:C was abolished by the simultaneous addition of N-ethyl maleimide or iodoacetamide, but these sulfhydryl blocking agents did not prevent the VIII:C increase and light chain cleavage by thrombin if the plasma samples were dialyzed to remove the inhibitors before adding the cysteamine. However, incubation with DTT before iodoacetamide prevented the cysteamine effect after dialysis. These data suggest that when isolated from patient plasma, FVIII-EH cysteine-1689 is present in a disulfide bond. This bond is cleaved by cysteamine to form a new mixed disulfide, a pseudolysine that restores a thrombin cleavage site that is essential for procoagulant function.
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Affiliation(s)
- A M Aly
- Holland Laboratory, American Red Cross Blood Services, Rockville, Maryland 20855
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Bradbury JA, Danjoux JP, Voller J, Spencer M, Brocklebank T. A randomised placebo-controlled trial of topical cysteamine therapy in patients with nephropathic cystinosis. Eye (Lond) 1991; 5 ( Pt 6):755-60. [PMID: 1800180 DOI: 10.1038/eye.1991.139] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Five patients with nephropathic cystinosis were evaluated to assess the ability of topical cysteamine to clear corneal cystine crystals. All patients were randomised to receive topical cysteamine 0.2% six times a day in one eye with normal saline in the other eye as a control. All five patients showed some improvement in visual symptoms (photophobia, blepharospasm and visual acuity) together with an improvement in corneal crystal density. Three of these also had an improvement in Snellen visual acuity and contrast sensitivity.
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Affiliation(s)
- J A Bradbury
- Department of Ophthalmology, St James University Hospital, Leeds
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28
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Charnas LR, Bernardini I, Rader D, Hoeg JM, Gahl WA. Clinical and laboratory findings in the oculocerebrorenal syndrome of Lowe, with special reference to growth and renal function. N Engl J Med 1991; 324:1318-25. [PMID: 2017228 DOI: 10.1056/nejm199105093241904] [Citation(s) in RCA: 104] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The oculocerebrorenal syndrome of Lowe is an X-linked disorder whose clinical manifestations include congenital cataracts, mental retardation, and renal tubular dysfunction. We investigated growth, renal function, and serum chemistry values in patients with the oculocerebrorenal syndrome to determine the natural history of the disorder and its heterogeneity with respect to these characteristics. METHODS Twenty-three patients with the oculocerebrorenal syndrome, ranging in age from 4 months to 31 years, were examined. Height was compared with bone age. Renal function was assessed by measurements of proteinuria, urinary volume, and fractional excretions of potassium, phosphate, carnitine, and amino acids. Creatinine clearance was determined as a measure of glomerular function. RESULTS In the oculocerebrorenal syndrome, linear growth decreases after one year of age; bone age lies between chronologic age and height age. Renal dysfunction occurs in the first year of life, characterized by proteinuria (mean [+/- SD], 1.38 +/- 0.77 g of urinary protein per square meter of body-surface area per day; normal, less than or equal to 0.10), generalized aminoaciduria (mean, 686 +/- 505 mumol of urinary amino acid per kilogram of body weight per day; normal, 94 +/- 45), carnitine wasting (mean fractional excretion, 0.10 +/- 0.05; normal, 0.03 +/- 0.01), and phosphaturia progressing into the third decade. Urinary wasting of individual amino acids is milder than in cystinosis, and branched-chain amino acids are relatively spared. Reciprocal serum creatinine levels fall linearly with age, predicting renal failure in the fourth decade. Concentrations of the muscle enzymes creatine kinase, aspartate aminotransferase, and lactate dehydrogenase, as well as of total serum protein, serum alpha 2-globulin, and high-density lipoprotein cholesterol, are elevated. CONCLUSIONS Renal glomerular deterioration is slowly progressive in the oculocerebrorenal syndrome. Renal tubular dysfunction begins early and persists; most patients require alkalinization therapy, and many benefit from supplemental potassium, phosphate, calcium, or carnitine. Serum enzyme elevations suggest muscle involvement in the oculocerebrorenal syndrome.
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Affiliation(s)
- L R Charnas
- Unit on Neurogenetics, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892
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Sonies BC, Ekman EF, Andersson HC, Adamson MD, Kaler SG, Markello TC, Gahl WA. Swallowing dysfunction in nephropathic cystinosis. N Engl J Med 1990; 323:565-70. [PMID: 2381441 DOI: 10.1056/nejm199008303230903] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Nephropathic cystinosis causes renal failure in most patients at approximately 10 years of age. This can be prevented or retarded by cystine-depleting therapy with oral cysteamine. Many patients who do not receive adequate cysteamine therapy undergo renal transplantation, but the accumulation of cystine continues in other organs, resulting in various clinical abnormalities. We report age-related swallowing dysfunction in patients with nephropathic cystinosis. METHODS We studied 43 patients with cystinosis (24 who had received a renal transplant and 19 who had not), 3 to 31 years of age. Oral motor function was assessed by a cranial-nerve oral sensorimotor examination, and an oral motor index was calculated for each patient. The oral phase of swallowing was assessed by ultrasonography, and the pharyngeal and esophageal phases were evaluated by videofluoroscopy. RESULTS Approximately half the patients were slow eaters. Oral motor dysfunction, reflected by a higher oral motor index, increased with age. Speech, oral structure and anatomy, and tongue and lip strength were particularly affected. Seven of nine patients 21 to 31 years old had abnormalities in all three phases of swallowing; the deficits were variable in younger patients. In 28 patients with cystinosis, the mean (+/- SD) duration of oropharyngeal swallowing for a dry swallow (3.06 +/- 1.06 seconds) was longer than in 14 normal subjects (1.89 +/- 0.57 seconds; P less than 0.001). This prolongation reflected impairment of the initiation phase of swallowing. CONCLUSIONS Swallowing dysfunction is a late complication of nephropathic cystinosis, probably related to muscular dysfunction. Changes in the consistency of foods, swallowing exercises, and long-term cysteamine therapy should be considered for patients with cystinosis who have difficulty in swallowing.
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Affiliation(s)
- B C Sonies
- Department of Rehabilitation Medicine, Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, MD 20892
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Gahl WA, Dalakas MC, Charnas L, Chen KT, Pezeshkpour GH, Kuwabara T, Davis SL, Chesney RW, Fink J, Hutchison HT. Myopathy and cystine storage in muscles in a patient with nephropathic cystinosis. N Engl J Med 1988; 319:1461-4. [PMID: 3185663 DOI: 10.1056/nejm198812013192206] [Citation(s) in RCA: 68] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- W A Gahl
- Section on Human Biochemical Genetics, National Institute of Child Health and Human Development, Bethesda, MD 20892
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