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Lerario S, Monti L, Ambrosetti I, Luglio A, Pietra A, Aiello V, Montanari F, Bellasi A, Zaza G, Galante A, Salera D, Capelli I, La Manna G, Provenzano M. Fabry disease: a rare disorder calling for personalized medicine. Int Urol Nephrol 2024:10.1007/s11255-024-04042-4. [PMID: 38613662 DOI: 10.1007/s11255-024-04042-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/25/2024] [Indexed: 04/15/2024]
Abstract
Fabry Disease (FD) is a genetic disease caused by a deficiency in the activity of lysosomal galactosidase A (α-GalA), an enzyme responsible for the catabolism of globotriaosylceramide (Gb3). Since lysosomes are present throughout the body and play a crucial role in catabolism and recycling of cytosolic compounds, FD can affect multiple organs and result in various symptoms, including renal, cardiovascular, neurological, cutaneous, and ophthalmic manifestations. Due to the nonspecific symptoms and the rarity of FD, it is often diagnosed late in life. However, introducing targeted therapies such as enzyme replacement therapy (ERT) and chaperone therapy has significantly improved FD's natural history and prognosis by restoring α-GalA enzyme activity. Despite the advancements, there are limitations to the currently available therapies, which has prompted research into new potential treatments for FD, including alternative forms of enzyme replacement therapy, substrate reduction therapy, mRNA therapy, and genetic therapy. In this review, we analyze the epidemiology, pathophysiology, and treatment of FD, with particular emphasis on promising therapeutic opportunities that could shift the treatment of this rare disease from a standardized to a personalized approach soon.
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Affiliation(s)
- Sarah Lerario
- Nephrology, Dialysis, and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Luigi Monti
- Medical Genetics Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Irene Ambrosetti
- Medical Genetics Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Agnese Luglio
- Medical Genetics Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Andrea Pietra
- Medical Genetics Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Valeria Aiello
- Nephrology, Dialysis, and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Francesca Montanari
- Medical Genetics Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Antonio Bellasi
- Servizio Di Nefrologia, Ospedale Regionale Di Lugano, Ente Ospedaliero Cantonale, Ospedale CivicoVia Tesserete 46, 6903, Lugano, Switzerland
- Università Della Svizzera Italiana (USI), Lugano, Switzerland
| | - Gianluigi Zaza
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, 87036, Rende, CS, Italy
| | - Antonio Galante
- Università Della Svizzera Italiana (USI), Lugano, Switzerland
| | - Davide Salera
- Servizio Di Nefrologia, Ospedale Regionale Di Lugano, Ente Ospedaliero Cantonale, Ospedale CivicoVia Tesserete 46, 6903, Lugano, Switzerland
| | - Irene Capelli
- Nephrology, Dialysis, and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.
| | - Gaetano La Manna
- Nephrology, Dialysis, and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.
| | - Michele Provenzano
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, 87036, Rende, CS, Italy
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Mignani R, Americo C, Aucella F, Battaglia Y, Cianci V, Sapuppo A, Lanzillo C, Pennacchiotti F, Tartaglia L, Marchi G, Pieruzzi F. Reducing agalsidase beta infusion time in Fabry patients: low incidence of antibody formation and infusion-associated reactions in an Italian multicenter study. Orphanet J Rare Dis 2024; 19:38. [PMID: 38308295 PMCID: PMC10835838 DOI: 10.1186/s13023-024-03049-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/19/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Fabry disease is a rare progressive X-linked lysosomal storage disease caused by mutations in the GLA gene that encodes α-galactosidase A. Agalsidase beta is a recombinant enzyme replacement therapy authorized in Europe at a standard dose of 1.0 mg/kg intravenously every other week at an initial infusion rate of ≤ 0.25 mg/min until patient tolerance is established, after which the infusion rate may be increased gradually. However, specific practical guidance regarding the progressive reduction in infusion time is lacking. This study investigated a new and specific protocol for reducing agalsidase beta infusion time in which a stable dosage of 15 mg/h is infused for the first four months, and the infusion rate is increased progressively from 15 to 35 mg/h for the subsequent four infusions. The shortest infusion time is reached after six months and maintained thereafter. The incidence of infusion-associated reactions (IARs) and the development of anti-drug antibodies were analyzed, and the disease burden and the clinical evolution of the disease at 12 months were evaluated. RESULTS Twenty-five of the 31 patients were naïve to enzyme or chaperone treatment at baseline and six patients had been switched from agalsidase alfa. The reduced infusion time protocol was well tolerated. Only one patient exhibited an IAR, with mild symptoms that resolved with low-dose steroids. Six patients globally seroconverted during treatment (4 with a classic phenotype and 2 with late-onset disease). All but three patients were seronegative at month 12. All patients were stable at the study's end (FAbry STabilization indEX value < 20%); reducing infusion time did not negatively impact clinical outcomes in any patient. The perceived medical assessment showed that the quality of life of all patients improved. CONCLUSIONS The study demonstrates that reducing agalsidase beta infusion time is possible and safe from both an immunogenic and clinical point of view. The use of a low infusion rate in the first months when the probability of onset of the development of antibodies is higher contributed to very limited seroconversion to antibody-positive status.
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Affiliation(s)
- Renzo Mignani
- Nephrology, Dialysis and Transplantation, IRCCS S. Orsola Hospital, University of Bologna, Bologna, Italy.
| | - Claudio Americo
- Nephrology and Dialysis Unit, Pierantoni Hospital, Forlì, Italy
| | - Filippo Aucella
- Nephrology Unit, Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Yuri Battaglia
- Nephrology and Dialysis Unit, St. Anna University Hospital, Ferrara, Italy
| | - Vittoria Cianci
- Regional Epilepsy Centre, Great Metropolitan Hospital, Reggio Calabria, Italy
| | - Annamaria Sapuppo
- Pediatric Clinic, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | | | | | - Luciano Tartaglia
- Nephrology Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Giacomo Marchi
- MetabERN Referral Center for Lysosomal Storage Disorders, Internal Medicine Unit, University of Verona, Verona, Italy
| | - Federico Pieruzzi
- Clinical Nephrology, School of Medicine and Surgery, University of Milano, Bicocca, Italy
- Nephrology and Dialysis Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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Laffer B, Lenders M, Ehlers-Jeske E, Heidenreich K, Brand E, Köhl J. Complement activation and cellular inflammation in Fabry disease patients despite enzyme replacement therapy. Front Immunol 2024; 15:1307558. [PMID: 38304433 PMCID: PMC10830671 DOI: 10.3389/fimmu.2024.1307558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/03/2024] [Indexed: 02/03/2024] Open
Abstract
Defective α-galactosidase A (AGAL/GLA) due to missense or nonsense mutations in the GLA gene results in accumulation of the glycosphingolipids globotriaosylceramide (Gb3) and its deacylated derivate globotriaosylsphingosine (lyso-Gb3) in cells and body fluids. The aberrant glycosphingolipid metabolism leads to a progressive lysosomal storage disorder, i. e. Fabry disease (FD), characterized by chronic inflammation leading to multiorgan damage. Enzyme replacement therapy (ERT) with agalsidase-alfa or -beta is one of the main treatment options facilitating cellular Gb3 clearance. Proteome studies have shown changes in complement proteins during ERT. However, the direct activation of the complement system during FD has not been explored. Here, we demonstrate strong activation of the complement system in 17 classical male FD patients with either missense or nonsense mutations before and after ERT as evidenced by high C3a and C5a serum levels. In contrast to the strong reduction of lyso-Gb3 under ERT, C3a and C5a markedly increased in FD patients with nonsense mutations, most of whom developed anti-drug antibodies (ADA), whereas FD patients with missense mutations, which were ADA-negative, showed heterogenous C3a and C5a serum levels under treatment. In addition to the complement activation, we found increased IL-6, IL-10 and TGF-ß1 serum levels in FD patients. This increase was most prominent in patients with missense mutations under ERT, most of whom developed mild nephropathy with decreased estimated glomerular filtration rate. Together, our findings demonstrate strong complement activation in FD independent of ERT therapy, especially in males with nonsense mutations and the development of ADAs. In addition, our data suggest kidney cell-associated production of cytokines, which have a strong potential to drive renal damage. Thus, chronic inflammation as a driver of organ damage in FD seems to proceed despite ERT and may prove useful as a target to cope with progressive organ damage.
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Affiliation(s)
- Björn Laffer
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Malte Lenders
- Department of Internal Medicine D, University Hospital Münster, Münster, Germany
| | - Elvira Ehlers-Jeske
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | | | - Eva Brand
- Department of Internal Medicine D, University Hospital Münster, Münster, Germany
| | - Jörg Köhl
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
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Wallace EL, Goker-Alpan O, Wilcox WR, Holida M, Bernat J, Longo N, Linhart A, Hughes DA, Hopkin RJ, Tøndel C, Langeveld M, Giraldo P, Pisani A, Germain DP, Mehta A, Deegan PB, Molnar MJ, Ortiz D, Jovanovic A, Muriello M, Barshop BA, Kimonis V, Vujkovac B, Nowak A, Geberhiwot T, Kantola I, Knoll J, Waldek S, Nedd K, Karaa A, Brill-Almon E, Alon S, Chertkoff R, Rocco R, Sakov A, Warnock DG. Head-to-head trial of pegunigalsidase alfa versus agalsidase beta in patients with Fabry disease and deteriorating renal function: results from the 2-year randomised phase III BALANCE study. J Med Genet 2023:jmg-2023-109445. [PMID: 37940383 DOI: 10.1136/jmg-2023-109445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/10/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Pegunigalsidase alfa is a PEGylated α-galactosidase A enzyme replacement therapy. BALANCE (NCT02795676) assessed non-inferiority of pegunigalsidase alfa versus agalsidase beta in adults with Fabry disease with an annualised estimated glomerular filtration rate (eGFR) slope more negative than -2 mL/min/1.73 m2/year who had received agalsidase beta for ≥1 year. METHODS Patients were randomly assigned 2:1 to receive 1 mg/kg pegunigalsidase alfa or agalsidase beta every 2 weeks for 2 years. The primary efficacy analysis assessed non-inferiority based on median annualised eGFR slope differences between treatment arms. RESULTS Seventy-seven patients received either pegunigalsidase alfa (n=52) or agalsidase beta (n=25). At baseline, mean (range) age was 44 (18-60) years, 47 (61%) patients were male, median eGFR was 74.5 mL/min/1.73 m2 and median (range) eGFR slope was -7.3 (-30.5, 6.3) mL/min/1.73 m2/year. At 2 years, the difference between median eGFR slopes was -0.36 mL/min/1.73 m2/year, meeting the prespecified non-inferiority margin. Minimal changes were observed in lyso-Gb3 concentrations in both treatment arms at 2 years. Proportions of patients experiencing treatment-related adverse events and mild or moderate infusion-related reactions were similar in both groups, yet exposure-adjusted rates were 3.6-fold and 7.8-fold higher, respectively, with agalsidase beta than pegunigalsidase alfa. At the end of the study, neutralising antibodies were detected in 7 out of 47 (15%) pegunigalsidase alfa-treated patients and 6 out of 23 (26%) agalsidase beta-treated patients. There were no deaths. CONCLUSIONS Based on rate of eGFR decline over 2 years, pegunigalsidase alfa was non-inferior to agalsidase beta. Pegunigalsidase alfa had lower rates of treatment-emergent adverse events and mild or moderate infusion-related reactions. TRIAL REGISTRATION NUMBER NCT02795676.
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Affiliation(s)
- Eric L Wallace
- Department of Medicine, Division of Nephrology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ozlem Goker-Alpan
- Lysosomal and Rare Disorders Research and Treatment Center, Inc, Fairfax, Virginia, USA
| | - William R Wilcox
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Myrl Holida
- Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - John Bernat
- Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Nicola Longo
- Department of Pediatrics, Division of Medical Genetics, University of Utah Health, Salt Lake City, Utah, USA
| | - Aleš Linhart
- Department of Internal Medicine, School of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Derralynn A Hughes
- Lysosomal Storage Disorders Unit, Royal Free London NHS Foundation Trust and University College London, London, UK
| | - Robert J Hopkin
- Department of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Camilla Tøndel
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Mirjam Langeveld
- Academisch Medisch Centrum Universiteit van Amsterdam, Amsterdam, The Netherlands
| | - Pilar Giraldo
- Unidad de Investigación Traslacional. Hospital Universitario Miguel Servet, Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER-ISCIII), Zaragoza, Spain
| | - Antonio Pisani
- Department of Public Health, Universita degli Studi di Napoli Federico II, Napoli, Italy
| | | | - Ankit Mehta
- Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Patrick B Deegan
- Lysosmal Disorders Unit, Department of Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Maria Judit Molnar
- Institute of Genomic Medicine and Rare Disorders, Semmelweis University Clinical Center, Budapest, Hungary
| | - Damara Ortiz
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ana Jovanovic
- Mark Holland Metabolic Unit, Northern Care Alliance NHS Foundation Trust, Greater Manchester, UK
| | - Michael Muriello
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Bruce A Barshop
- Department of Pediatrics, University of California San Diego, La Jolla, California, USA
| | - Virginia Kimonis
- Department of Pediatrics, University of California Irvine, Irvine, California, USA
| | - Bojan Vujkovac
- Department of Internal Medicine, General Hospital Slovenj Gradec, Slovenj Gradec, Slovenia
| | - Albina Nowak
- Department of Endocrinology and Clinical Nutrition, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Tarekegn Geberhiwot
- Department of Diabetes, Endocrinology and Metabolism, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Ilkka Kantola
- Division of Medicine, Turku University Hospital, Turku, Finland
| | | | | | - Khan Nedd
- Infusion Associates, Grand Rapids, Michigan, USA
| | - Amel Karaa
- Massachusetts General Hospital for Children, Boston, Massachusetts, USA
| | | | - Sari Alon
- Product Development, Protalix Biotherapeutics, Carmiel, Israel
| | | | | | | | - David G Warnock
- Department of Medicine, Division of Nephrology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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Shiga T, Tsukimura T, Kubota T, Togawa T, Sakuraba H. Profiles of Globotriaosylsphingosine Analogs and Globotriaosylceramide Isoforms Accumulated in Body Fluids from Various Phenotypic Fabry Patients. Intern Med 2023:2493-23. [PMID: 37866916 DOI: 10.2169/internalmedicine.2493-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2023] Open
Abstract
Objectives Fabry disease is characterized by the systemic accumulation of globotriaosylceramide (Gb3) and globotriaosylsphingosine (Lyso-Gb3), which are widely used as biomarkers of the disease. However, few reports have described the relationship of Lyso-Gb3 analogs and Gb3 isoforms with the disease. The present study determined the profiles of Lyso-Gb3 analogs and Gb3 isoforms accumulated in body fluids from various phenotypic Fabry patients to elucidate the basis of the disease. Methods Plasma Lyso-Gb3 and related analogs were measured in 15 classic Fabry men, 6 later-onset Fabry men, 11 Fabry women, and 36 controls, while urinary Gb3 isoforms were measured in 5 classic Fabry men, 5 later-onset Fabry men, 17 Fabry women, and 11 controls, using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Furthermore, these values were monitored for a classic Fabry man, in whom neutralizing anti-drug antibodies had developed following enzyme replacement therapy (ERT). Results The levels of plasma Lyso-Gb3 analogs/urinary Gb3 isoforms were higher in Fabry patients than in controls, especially in classic Fabry men. However, minor differences in the ratio of each Lyso-Gb3 analog and Gb3 isoform with respect to the total Lyso-Gb3 analogs and Gb3 isoforms, respectively, were observed among individual classic Fabry men. Their time courses were well associated with the development and attenuation of anti-drug antibodies in a patient with classic Fabry disease during ERT. Conclusion Quantification of Lyso-Gb3 analogs and Gb3 isoforms provides us with more detailed information about the substrates that accumulated in the body fluids of Fabry patients than does quantification of Lyso-Gb3 and Gb3 alone, so this approach may be useful for elucidating the basis of Fabry disease.
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Affiliation(s)
- Tomoko Shiga
- Department of Clinical Genetics, Meiji Pharmaceutical University, Japan
| | - Takahiro Tsukimura
- Department of Functional Bioanalysis, Meiji Pharmaceutical University, Japan
| | - Takao Kubota
- Department of Nephrology, Tohto Sangenjaya Clinic, Japan
- Department of Nephrology, Self-Defense Forces Central Hospital, Japan
| | - Tadayasu Togawa
- Department of Functional Bioanalysis, Meiji Pharmaceutical University, Japan
| | - Hitoshi Sakuraba
- Department of Clinical Genetics, Meiji Pharmaceutical University, Japan
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Lenders M, Feidicker LM, Brand SM, Brand E. Characterization of pre-existing anti-PEG and anti-AGAL antibodies towards PRX-102 in patients with Fabry disease. Front Immunol 2023; 14:1266082. [PMID: 37818380 PMCID: PMC10561604 DOI: 10.3389/fimmu.2023.1266082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/11/2023] [Indexed: 10/12/2023] Open
Abstract
Polyethylene glycol (PEG)ylated drugs are used for medical treatment, since PEGylation either decreases drug clearance or/and shields the protein from undesirable immunogenicity. PEGylation was implemented in a new enzyme replacement therapy for Fabry disease (FD), pegunigalsidase-alfa (PRX-102). However, exposure to PEG via life-style products and vaccination can result in the formation of anti-PEG antibodies. We demonstrate the de novo formation of functional anti-PEG antibodies in a healthy male after the second mRNA-based vaccination against SARS-CoV-2. Consequently, we analyzed the frequency and inhibitory function of anti-PEG and anti-α-Galactosidase A (AGAL) antibodies in 102 FD patients (46.9% males). We identified 29 out of 87 (33.3%) patients with low anti-PEG titers. Sera from patients without anti-AGAL antibodies [n=70] showed a higher rescued AGAL activity of agalsidase-beta and PRX-102 [both p<0.0001] compared to those with anti-AGAL antibodies [n=15]. Sera from anti-AGAL antibody-negative and -positive patients had less inhibitory effects on PRX-102 (rescued activity: 89 ± 6% versus 85 ± 7% and 49 ± 26% versus 25 ± 32%; both p<0.0001). Enzyme stability assays demonstrated that AUCs in anti-AGAL-negative sera (n=20) were 7.6-fold higher for PRX-102, while AUCs of both enzymes in anti-AGAL-positive sera (n=6) were decreased. However, AUC for PRX-102 was 33% of non-anti-AGAL-positive sera treated PRX-102 and 5-fold higher compared to agalsidase-beta. Anti-PEG antibodies had no significant effects on serum half-life of PRX-102, probably due to low titers. Conceivably, therapy efficacy may be superior under next-generation PRX-102 therapy compared to current enzyme replacement therapies in terms of reduced inhibitory effects of anti-AGAL and minor inhibitory effects of anti-PEG antibodies.
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Affiliation(s)
- Malte Lenders
- Department of Internal Medicine D, and Interdisciplinary Fabry Center (IFAZ), University Hospital Muenster, Muenster, Germany
| | - Lina Marleen Feidicker
- Department of Internal Medicine D, and Interdisciplinary Fabry Center (IFAZ), University Hospital Muenster, Muenster, Germany
| | - Stefan-Martin Brand
- Institute of Sports Medicine, Interdisciplinary Fabry Center (IFAZ), University Hospital Muenster, Muenster, Germany
| | - Eva Brand
- Department of Internal Medicine D, and Interdisciplinary Fabry Center (IFAZ), University Hospital Muenster, Muenster, Germany
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Deng M, Zhou H, He S, Qiu H, Wang Y, Zhao AY, Mu Y, Li F, Zhao AZ. Systematic gene therapy derived from an investigative study of AAV2/8 vector gene therapy for Fabry disease. Orphanet J Rare Dis 2023; 18:275. [PMID: 37670350 PMCID: PMC10481556 DOI: 10.1186/s13023-023-02894-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/26/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Fabry disease (FD) is a progressive multisystemic disease characterized by a lysosomal enzyme deficiency. A lack of α-galactosidase A (α-Gal A) activity results in the progressive systemic accumulation of its substrates, including globotriaosylceramide (Gb3) and globotriaosylsphingosine (Lyso-Gb3), which results in renal, cardiac, and/or cerebrovascular disease and early death. Enzyme replacement therapy (ERT) is the current standard of care for FD; however, it has important limitations, including a low half-life, limited distribution, and requirement of lifelong biweekly infusions of recombinant enzymes. METHODS Herein, we evaluated a gene therapy approach using an episomal adeno-associated viral 2/8 (AAV2/8) vector that encodes the human GLA cDNA driven by a liver-specific expression cassette in a mouse model of FD that lacks α-Gal A activity and progressively accumulates Gb3 and Lyso-Gb3 in plasma and tissues. RESULTS A pharmacology and toxicology study showed that administration of AAV2/8-hGLA vectors (AAV2/8-hGLA) in FD mice without immunosuppression resulted in significantly increased plasma and tissue α-Gal A activity and substantially normalized Gb3 and Lyso-Gb3 content. CONCLUSIONS Moreover, the plasma enzymatic activity of α-Gal A continued to be stably expressed for up to 38 weeks and sometimes even longer, indicating that AAV2/8-hGLA is effective in treating FD mice, and that α-Gal A is continuously and highly expressed in the liver, secreted into plasma, and absorbed by various tissues. These findings provide a basis for the clinical development of AAV2/8-hGLA.
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Affiliation(s)
- Mulan Deng
- The School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou, 510006, Guangdong Province, People's Republic of China
| | - Hongyu Zhou
- The School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou, 510006, Guangdong Province, People's Republic of China
| | - Shaomei He
- The School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou, 510006, Guangdong Province, People's Republic of China
| | - Haoheng Qiu
- The School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou, 510006, Guangdong Province, People's Republic of China
| | - Yanping Wang
- The School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou, 510006, Guangdong Province, People's Republic of China
| | - April Yuanyi Zhao
- The School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou, 510006, Guangdong Province, People's Republic of China
| | - Yunping Mu
- The School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou, 510006, Guangdong Province, People's Republic of China.
| | - Fanghong Li
- The School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou, 510006, Guangdong Province, People's Republic of China.
| | - Allan Zijian Zhao
- The School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou, 510006, Guangdong Province, People's Republic of China.
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Burlina A, Brand E, Hughes D, Kantola I, Krӓmer J, Nowak A, Tøndel C, Wanner C, Spada M. An expert consensus on the recommendations for the use of biomarkers in Fabry disease. Mol Genet Metab 2023; 139:107585. [PMID: 37207471 DOI: 10.1016/j.ymgme.2023.107585] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 04/04/2023] [Accepted: 04/14/2023] [Indexed: 05/21/2023]
Abstract
Fabry disease is an X-linked lysosomal storage disorder caused by the accumulation of glycosphingolipids in various tissues and body fluids, leading to progressive organ damage and life-threatening complications. Phenotypic classification is based on disease progression and severity and can be used to predict outcomes. Patients with a classic Fabry phenotype have little to no residual α-Gal A activity and have widespread organ involvement, whereas patients with a later-onset phenotype have residual α-Gal A activity and disease progression can be limited to a single organ, often the heart. Diagnosis and monitoring of patients with Fabry disease should therefore be individualized, and biomarkers are available to support with this. Disease-specific biomarkers are useful in the diagnosis of Fabry disease; non-disease-specific biomarkers may be useful to assess organ damage. For most biomarkers it can be challenging to prove they translate to differences in the risk of clinical events associated with Fabry disease. Therefore, careful monitoring of treatment outcomes and collection of prospective data in patients are needed. As we deepen our understanding of Fabry disease, it is important to regularly re-evaluate and appraise published evidence relating to biomarkers. In this article, we present the results of a literature review of evidence published between February 2017 and July 2020 on the impact of disease-specific treatment on biomarkers and provide an expert consensus on clinical recommendations for the use of those biomarkers.
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Affiliation(s)
- Alessandro Burlina
- Neurological Unit, St. Bassiano Hospital, Via dei Lotti 40, I-36061 Bassano del Grappa, Italy.
| | - Eva Brand
- Internal Medicine, Department of Nephrology, Hypertension and Rheumatology; Interdisciplinary Fabry Center Münster (IFAZ), University Hospital Münster, Münster, Germany
| | - Derralynn Hughes
- Lysosomal Storage Disorders Unit, Royal Free London NHS Foundation Trust, University College London, United Kingdom
| | - Ilkka Kantola
- Division of Medicine, Turku University Hospital, Turku, Finland
| | - Johannes Krӓmer
- Pediatric Neurology and Metabolism, Department of Pediatrics and Adolescent Medicine, University of Ulm, Ulm, Germany
| | - Albina Nowak
- Department of Endocrinology and Clinical Nutrition, University Hospital of Zurich, Zurich, Switzerland
| | - Camilla Tøndel
- Department of Clinical Science, University of Bergen and Department of Paediatrics, Haukeland University Hospital, Bergen, Norway
| | - Christoph Wanner
- Department of Internal Medicine, Division of Nephrology, Fabry Center for Interdisciplinary Therapy (FAZIT), University Hospital of Würzburg, Würzburg, Germany
| | - Marco Spada
- Department of Pediatrics, University of Torino, Torino, Italy
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9
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van Kuilenburg ABP, Hollak CEM, Travella A, Jacobs M, Gentilini LD, Leen R, der Vlugt KMMGV, Stet FSB, Goorden SMI, van der Veen S, Criscuolo M, Papouchado M. Development of a Biosimilar of Agalsidase Beta for the Treatment of Fabry Disease: Preclinical Evaluation. Drugs R D 2023:10.1007/s40268-023-00421-x. [PMID: 37083901 DOI: 10.1007/s40268-023-00421-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Fabry disease (FD) is a rare lysosomal storage disorder caused by a deficiency of the enzyme α-galactosidase A (aGal A). Since 2001, two different enzyme replacement therapies have been authorized, with agalsidase beta being used in most parts of the Western world. Currently, biosimilars of several expensive enzyme therapies are under development to improve their accessibility for patients. We present the preclinical results of the development of a biosimilar to agalsidase beta. METHODS Produced in a Chinese hamster ovary (CHO)-cell system, the biosimilar aGal A Biosidus (AGABIO), was compared with agalsidase beta with respect to amino acid sequence, glycosylation, specific α-galactosidase activity, stability in plasma, and effects on cultured human Fabry fibroblasts and Fabry mice. RESULTS AGABIO had the same amino acid composition and similar glycosylation, enzymatic activity, and stability as compared with agalsidase beta. After uptake in fibroblasts, α-galactosidase A activity increased in a dose-dependent manner, with maximum uptake observed after 24 h, which remained stable until at least 48 h. Both enzymes were localized to lysosomes. Reduction of accumulated globotriaosylceramide (Gb3) and lysoGb3 in cultured Fabry fibroblasts by AGABIO and agalsidase beta showed comparable dose-response curves. In Fabry knockout mice, after a single injection, both enzymes were rapidly cleared from the plasma and showed equal reductions in tissue and plasma sphingolipids. Repeated dose studies in rats did not raise any safety concerns. Anti-drug antibodies from patients with FD treated with agalsidase beta showed equal neutralization activity toward AGABIO. CONCLUSION These findings support the biosimilarity of AGABIO in comparison with agalsidase beta. The clinical study phase is currently under development.
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Affiliation(s)
- André B P van Kuilenburg
- Amsterdam UMC location University of Amsterdam, Laboratory Genetic Metabolic Diseases F0-220, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands.
| | - Carla E M Hollak
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
- Amsterdam UMC location University of Amsterdam, Endocrinology and Metabolism, Meibergdreef 9, Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam, UMC-University of Amsterdam, Amsterdam, The Netherlands
| | | | | | | | - René Leen
- Amsterdam UMC location University of Amsterdam, Laboratory Genetic Metabolic Diseases F0-220, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Karen M M Ghauharali-van der Vlugt
- Amsterdam UMC location University of Amsterdam, Laboratory Genetic Metabolic Diseases F0-220, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Femke S Beers Stet
- Amsterdam UMC location University of Amsterdam, Laboratory Genetic Metabolic Diseases F0-220, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Susan M I Goorden
- Amsterdam UMC location University of Amsterdam, Laboratory Genetic Metabolic Diseases F0-220, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Sanne van der Veen
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
- Amsterdam UMC location University of Amsterdam, Endocrinology and Metabolism, Meibergdreef 9, Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam, UMC-University of Amsterdam, Amsterdam, The Netherlands
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10
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Abstract
α-Galactosidases are exoglycosidases that are active on galactose-containing side chains in oligosaccharides, polysaccharides, glycolipids, and glycoproteins. α-Galactosidases are gaining increased interest in human medicine, especially in the enzyme replacement therapy for Fabry's disease. α-Galactosidases with regioselectivity toward α-1,3-linked galactose find application in xenotransplantation and blood group transformation. The use of α-galactosidases as a therapeutic agent in alleviating the postprandial symptoms of irritable bowel syndrome is much acclaimed. The excellent therapeutic applications of α-galactosidases have led to an upwelling of worldwide research interventions to identify novel α-galactosidases with improved catalytic efficiency. In addition to these therapeutic applications, α-galactosidases also have interesting applications in the industrial sectors like food, feed, probiotics, sugar, and paper pulp. The current review focuses on the diverse therapeutic applications of α-galactosidases and their prospects.
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Affiliation(s)
- Grace Sathyanesan Anisha
- Post-Graduate and Research Department of Zoology, Government College for Women, Thiruvananthapuram, Kerala, India
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11
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Lenders M, Brand E. Assessment and impact of dose escalation on anti-drug antibodies in Fabry disease. Front Immunol 2022; 13:1024963. [PMID: 36569886 PMCID: PMC9782970 DOI: 10.3389/fimmu.2022.1024963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022] Open
Abstract
Enzyme replacement therapy (ERT) with recombinant α-galactosidase A (AGAL) can lead to the formation of neutralizing anti-drug antibodies (ADA), which significantly limit treatment efficacy in patients with Fabry disease (FD). The effects of dose escalation on ADA titer and plasma globotriaosylsphingosine (lyso-Gb3) level are unknown. We screened 250 FD patients (200 males, 50 females) under ERT for ADAs and assessed the impact of an approved dose escalation in affected patients, focusing on ADA titers and plasma lyso-Gb3. ADA-positive patients were identified by serum-mediated inhibition assays, followed by titration assays to determine the individual inhibitory capacities of ADAs against agalsidase-alfa and agalsidase-beta. 70 (35%) of the male patients were ADA-positive, with a mean inhibitory capacity of 83.5 ± 113.7mg AGAL. Although patients receiving agalsidase-beta showed higher inhibitory capacities (84.7 ± 34.7mg) than patients under agalsidase-alfa (60.3 ± 126.7mg, p<0.001), the "theoretical deficit" to the infused dose was lower in patients receiving agalsidase-beta. In seven patients receiving agalsidase-alfa (0.2 mg/kg) ADAs were saturable by switching patients to agalsidase-beta (1.0 mg/kg). The switch resulted in increasing ADA titers within the first months. In 2 out of 7 (28.6%) therapy switchers, dose escalation could lead to durable ADA saturation. Independent of an increase in ADA titers, lyso-Gb3 levels decrease and cardiac and renal parameters remained stable after dose escalation. Dose escalation results in a heterogeneous, unpredictable ADA response, with more than a quarter of all treatment switchers succeeding in ADA saturation. Longitudinal ADA measurements are required to assess the individual risk of affected patients.
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12
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van der Veen SJ, Langeveld M. Antibodies against recombinant enzyme in the treatment of Fabry disease: Now you see them, now you don’t. Molecular Therapy - Methods & Clinical Development 2022; 27:324-326. [DOI: 10.1016/j.omtm.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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13
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Abstract
Fabry disease is a monogenic disease characterized by a deficiency or loss of the α-galactosidase A (GLA). The resulting impairment in lysosomal GLA enzymatic activity leads to the pathogenic accumulation of enzymatic substrate and, consequently, the progressive appearance of clinical symptoms in target organs, including the heart, kidney, and brain. However, the mechanisms involved in Fabry disease-mediated organ damage are largely ambiguous and poorly understood, which hinders the development of therapeutic strategies for the treatment of this disorder. Although currently available clinical approaches have shown some efficiency in the treatment of Fabry disease, they all exhibit limitations that need to be overcome. In this review, we first introduce current mechanistic knowledge of Fabry disease and discuss potential therapeutic strategies for its treatment. We then systemically summarize and discuss advances in research on therapeutic approaches, including enzyme replacement therapy (ERT), gene therapy, and chaperone therapy, as well as strategies targeting subcellular compartments, such as lysosomes, the endoplasmic reticulum, and the nucleus. Finally, the future development of potential therapeutic strategies is discussed based on the results of mechanistic studies and the limitations associated with these therapeutic approaches.
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Affiliation(s)
- Xi Li
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Xiangyi Ren
- Core Facilities of West China Hospital, Sichuan University, Chengdu, China
| | - Yabing Zhang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Lin Ding
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Minfeng Huo
- Shanghai Tenth People’s Hospital, Shanghai Frontiers Science Center of Nanocatalytic Medicine, School of Medicine, Tongji University, Shanghai, China
- *Correspondence: Qian Li, ; Minfeng Huo,
| | - Qian Li
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
- *Correspondence: Qian Li, ; Minfeng Huo,
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14
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Lenders M, Pollmann S, Terlinden M, Brand E. Pre-existing anti-drug antibodies in Fabry disease show less affinity for pegunigalsidase alfa. Mol Ther Methods Clin Dev 2022; 26:323-30. [PMID: 35990747 DOI: 10.1016/j.omtm.2022.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 07/15/2022] [Indexed: 10/25/2022]
Abstract
We analyzed the cross-reactivity of anti-drug antibodies (ADAs) against agalsidase-alfa and -beta from 49 patients with Fabry disease (FD) against the novel PEGylated enzyme pegunigalsidase-alfa (PRX-102). The affinity of purified anti-AGAL antibodies from pooled patient sera was significantly lower for PRX-102 compared to agalsidase-alfa and -beta (both p < 0.05). Pull-down experiments revealed the presence of masked epitopes on PRX-102, possibly due to PEGylation. ADA titers in serum (μg/mL) and corresponding inhibitory capacities against agalsidase-alfa and -beta were measured in male patients with FD, showing strong correlations (r2 = 0.9978 and 0.4930, both p < 0.001). Affinities of ADAs of individual patients against PRX-102 (Kd: 3.55 ± 2.72 μmol) were significantly lower compared to agalsidase alfa (Kd: 1.99 ± 1.26 μmol) and -beta (Kd: 2.18 ± 1.51 μmol) (both p < 0.0001). Cross-ELISAs supported the presence of masked epitopes on PRX-102. Importantly, inhibition measurements also revealed a 30% reduction in inhibitory capacity of pre-existing ADAs towards PRX-102. Enzyme-uptake experiments in AGAL-deficient EA.hy926 cells demonstrated less effects of ADAs on cellular PRX-102 uptake compared with agalsidase beta. We conclude that due to the reduced affinity of pre-existing ADAs against agalsidase-alfa or -beta, ADA-affected patients might benefit from a therapy switch to PRX-102, which is currently evaluated in clinical trials.
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15
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Abstract
Determining the etiologies of left ventricular hypertrophy (LVH) can be challenging due to the similarities of the different manifestations in clinical presentation and morphological features. Depending on the underlying cause, not only left ventricular mass but also left ventricular cavity size, or both, may increase. Patients with LVH remain asymptomatic for a few years, but disease progression will lead to the development of systolic or diastolic dysfunction and end-stage heart failure. As hypertrophied cardiac muscle disrupts normal conduction, LVH predisposes to arrhythmias. Distinguishing individuals with treatable causes of LVH is important for prevention of cardiovascular events and mortality. Athletic’s heart with physiological LVH does not require treatment. Frequent causes of hypertrophy include etiologies due to pressure/volume overload, such as systemic hypertension, hypertrophic cardiomyopathy, or infiltrative cardiac processes such as amyloidosis, Fabry disease, and sarcoidosis. Hypertension and aortic valve stenosis are the most common causes of LVH. Management of LVH involves lifestyle changes, medications, surgery, and implantable devices. In this review we systematically summarize treatments for the different patterns of cardiac hypertrophy and their impacts on outcomes while informing clinicians on advances in the treatment of LVH due to Fabry disease, cardiac amyloidosis, and hypertrophic cardiomyopathy.
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Affiliation(s)
| | - Ali Oto
- Department of Cardiology, Memorial Ankara Hospital, Ankara, Turkey
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16
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van der Veen SJ, Körver S, Hirsch A, Hollak CEM, Wijburg FA, Brands MM, Tøndel C, van Kuilenburg ABP, Langeveld M. Early start of enzyme replacement therapy in pediatric male patients with classical Fabry disease is associated with attenuated disease progression. Mol Genet Metab 2022; 135:163-169. [PMID: 35033446 DOI: 10.1016/j.ymgme.2021.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/12/2021] [Accepted: 12/13/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Enzyme replacement therapy (ERT) slows disease progression of Fabry disease (FD), especially when initiated before the onset of irreversible organ damage. However, with the clinically asymptomatic progression of renal, cardiac and cerebral disease manifestations spanning decades, optimal timing of ERT initiation remains unclear. METHODS In this cross-sectional retrospective study, seven male FD patients with a classical disease phenotype (cFD) who started treatment with agalsidase-beta in childhood were evaluated after 10 years of treatment (median age at evaluation 24 years, range 14-26). Cardiac imaging (echocardiography and MRI), electrophysiological and biochemical data of these patients were compared to those of untreated male cFD patients (n = 23, median age 22 years, range 13-27). RESULTS Albuminuria was less common and less severe in treated patients (albumin to creatinine ratio, ACR 0-8.8 mg/mmol, median 0.4) compared to untreated patients (ACR 0-248 mg/mmol, median 3.7, p = 0.02). The treated group had a lower left ventricular mass, measured using echocardiography (median 80 g/m2 versus 94 g/m2, p = 0.02) and MRI (median 53 g/m2 versus 68 g/m2, p = 0.02). Myocardial fibrosis was absent in all included patients. eGFR was normal in all treated patients whereas 7/23 (30%) of untreated patients had abnormal eGFR. Cerebral manifestations did not differ. CONCLUSIONS Start of treatment with ERT before age 16, in male cFD patients is associated with reduced occurrence of renal and cardiac manifestations of FD, as assessed by intermediate endpoints. Confirmation that this approach delays or even prevents renal failure and cardiac events requires another decade of follow-up.
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Affiliation(s)
- S J van der Veen
- Amsterdam UMC, University of Amsterdam, Department of Endocrinology and Metabolism, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Lysosome Center "Sphinx", Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - S Körver
- Amsterdam UMC, University of Amsterdam, Department of Endocrinology and Metabolism, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Lysosome Center "Sphinx", Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - A Hirsch
- Department of Cardiology and Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Room Rg-419, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands
| | - C E M Hollak
- Amsterdam UMC, University of Amsterdam, Department of Endocrinology and Metabolism, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Lysosome Center "Sphinx", Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - F A Wijburg
- Amsterdam UMC, University of Amsterdam, Department of Pediatric Metabolic Diseases, Emma Children's Hospital, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Lysosome Center "Sphinx", Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - M M Brands
- Amsterdam UMC, University of Amsterdam, Department of Pediatric Metabolic Diseases, Emma Children's Hospital, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Lysosome Center "Sphinx", Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - C Tøndel
- Haukeland University Hospital, Department of Paediatrics and University of Bergen, Department of Clinical Medicine, Bergen, Norway
| | - A B P van Kuilenburg
- Amsterdam UMC, University of Amsterdam, Department of Clinical Chemistry, Gastroenterology & Metabolism, Laboratory Genetic Metabolic Diseases, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - M Langeveld
- Amsterdam UMC, University of Amsterdam, Department of Endocrinology and Metabolism, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Lysosome Center "Sphinx", Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
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17
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Lenders M, Brand E. Mechanisms of Neutralizing Anti-drug Antibody Formation and Clinical Relevance on Therapeutic Efficacy of Enzyme Replacement Therapies in Fabry Disease. Drugs 2021; 81:1969-1981. [PMID: 34748189 PMCID: PMC8602155 DOI: 10.1007/s40265-021-01621-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
Abstract
Fabry disease (FD) is a rare X-linked lysosomal storage disorder caused by mutations in the α-galactosidase A (AGAL/GLA) gene. The lysosomal accumulation of the substrates globotriaosylceramide (Gb3) and globotriaosylsphingosine (lyso-Gb3) results in progressive renal failure, cardiomyopathy associated with cardiac arrhythmia, and recurrent strokes, significantly limiting life expectancy in affected patients. Current treatment options for FD include recombinant enzyme-replacement therapies (ERTs) with intravenous agalsidase-α (0.2 mg/kg body weight) or agalsidase-β (1 mg/kg body weight) every 2 weeks, facilitating cellular Gb3 clearance and an overall improvement of disease burden. However, ERT can lead to infusion-associated reactions, as well as the formation of neutralizing anti-drug antibodies (ADAs) in ERT-treated males, leading to an attenuation of therapy efficacy and thus disease progression. In this narrative review, we provide a brief overview of the clinical picture of FD and diagnostic confirmation. The focus is on the biochemical and clinical significance of neutralizing ADAs as a humoral response to ERT. In addition, we provide an overview of different methods for ADA measurement and characterization, as well as potential therapeutic approaches to prevent or eliminate ADAs in affected patients, which is representative for other ERT-treated lysosomal storage diseases.
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Affiliation(s)
- Malte Lenders
- Department of Internal Medicine D, Nephrology, Hypertension and Rheumatology, Interdisciplinary Fabry Center Münster (IFAZ), University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.
| | - Eva Brand
- Department of Internal Medicine D, Nephrology, Hypertension and Rheumatology, Interdisciplinary Fabry Center Münster (IFAZ), University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
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18
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Carr WW, Jain N, Sublett JW. Immunogenicity of Botulinum Toxin Formulations: Potential Therapeutic Implications. Adv Ther 2021; 38:5046-64. [PMID: 34515975 DOI: 10.1007/s12325-021-01882-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/02/2021] [Indexed: 12/21/2022]
Abstract
Botulinum neurotoxins (BoNTs) are proteins produced by bacteria of the Clostridium family. Upon oral ingestion, BoNT causes the neuroparalytic syndrome botulism. There are seven serotypes of BoNT (serotypes A-G); BoNT-A and BoNT-B are the botulinum toxin serotypes utilized for therapeutic applications. Treatment with BoNT injections is used to manage chronic medical conditions across multiple indications. As with other biologic drugs, immunogenicity after long-term treatment with BoNT formulations may occur, and repeated use can elicit antibody formation leading to clinical nonresponsiveness. Thus, approaching BoNT treatment of chronic conditions with therapeutic formulations that minimize stimulating the host immune response while balancing patient responsiveness to therapy is ideal. Immunogenicity is a clinical limitation in many settings that use biologic drugs for treatment, and clinically relevant immunogenicity reduction has been achieved through engineering smaller protein constructs and reducing unnecessary formulation components. A similar approach has influenced the evolution of BoNT formulations. Three BoNT-A products and one BoNT-B product have been approved by the Food and Drug Administration (FDA) for therapeutic use: onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, and rimabotulinumtoxinB; a fourth BoNT-A product, daxibotulinumtoxinA, is currently under regulatory review. Additionally, prabotulinumtoxinA is a BoNT-A product that has been approved for aesthetic indications but not therapeutic use. Here, we discuss the preclinical and clinical immunogenicity data that exist within the scientific literature and provide a perspective for considering immunogenicity as a key factor in choice of BoNT formulation.
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Azevedo O, Cordeiro F, Gago MF, Miltenberger-Miltenyi G, Ferreira C, Sousa N, Cunha D. Fabry Disease and the Heart: A Comprehensive Review. Int J Mol Sci 2021; 22:4434. [PMID: 33922740 DOI: 10.3390/ijms22094434] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 12/17/2022] Open
Abstract
Fabry disease (FD) is an X-linked lysosomal storage disorder caused by mutations of the GLA gene that result in a deficiency of the enzymatic activity of α-galactosidase A and consequent accumulation of glycosphingolipids in body fluids and lysosomes of the cells throughout the body. GB3 accumulation occurs in virtually all cardiac cells (cardiomyocytes, conduction system cells, fibroblasts, and endothelial and smooth muscle vascular cells), ultimately leading to ventricular hypertrophy and fibrosis, heart failure, valve disease, angina, dysrhythmias, cardiac conduction abnormalities, and sudden death. Despite available therapies and supportive treatment, cardiac involvement carries a major prognostic impact, representing the main cause of death in FD. In the last years, knowledge has substantially evolved on the pathophysiological mechanisms leading to cardiac damage, the natural history of cardiac manifestations, the late-onset phenotypes with predominant cardiac involvement, the early markers of cardiac damage, the role of multimodality cardiac imaging on the diagnosis, management and follow-up of Fabry patients, and the cardiac efficacy of available therapies. Herein, we provide a comprehensive and integrated review on the cardiac involvement of FD, at the pathophysiological, anatomopathological, laboratory, imaging, and clinical levels, as well as on the diagnosis and management of cardiac manifestations, their supportive treatment, and the cardiac efficacy of specific therapies, such as enzyme replacement therapy and migalastat.
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20
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Lenders M, Scharnetzki D, Heidari A, Di Iorio D, Wegner SV, Brand E. Generation and Characterization of a Polyclonal Human Reference Antibody to Measure Anti-Drug Antibody Titers in Patients with Fabry Disease. Int J Mol Sci 2021; 22:2680. [PMID: 33800950 PMCID: PMC7961705 DOI: 10.3390/ijms22052680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 02/26/2021] [Accepted: 03/03/2021] [Indexed: 12/31/2022] Open
Abstract
Male patients with Fabry disease (FD) are at high risk for the formation of antibodies to recombinant α-galactosidase A (AGAL), used for enzyme replacement therapy. Due to the rapid disease progression, the identification of patients at risk is highly warranted. However, currently suitable references and standardized protocols for anti-drug antibodies (ADA) determination do not exist. Here we generate a comprehensive patient-derived antibody mixture as a reference, allowing ELISA-based quantification of antibody titers from individual blood samples. Serum samples of 22 male patients with FD and ADAs against AGAL were pooled and purified by immune adsorption. ADA-affinities against agalsidase-α, agalsidase-β and Moss-AGAL were measured by quartz crystal microbalance with dissipation monitoring (QCM-D). AGAL-specific immune adsorption generated a polyclonal ADA mixture showing a concentration-dependent binding and inhibition of AGAL. Titers in raw sera and from purified total IgGs (r2 = 0.9063 and r2 = 0.8952, both p < 0.0001) correlated with the individual inhibitory capacities of ADAs. QCM-D measurements demonstrated comparable affinities of the reference antibody for agalsidase-α, agalsidase-β and Moss-AGAL (KD: 1.94 ± 0.11 µM, 2.46 ± 0.21 µM, and 1.33 ± 0.09 µM, respectively). The reference antibody allows the ELISA-based ADA titer determination and quantification of absolute concentrations. Furthermore, ADAs from patients with FD have comparable affinities to agalsidase-α, agalsidase-β and Moss-AGAL.
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Affiliation(s)
- Malte Lenders
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, Interdisciplinary Fabry Center Muenster (IFAZ), University Hospital Muenster, 48149 Muenster, Germany; (D.S.); (E.B.)
| | - David Scharnetzki
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, Interdisciplinary Fabry Center Muenster (IFAZ), University Hospital Muenster, 48149 Muenster, Germany; (D.S.); (E.B.)
| | - Ali Heidari
- Institute of Physiological Chemistry and Pathobiochemistry, University of Muenster, 48149 Muenster, Germany; (A.H.); (D.D.I.); (S.V.W.)
| | - Daniele Di Iorio
- Institute of Physiological Chemistry and Pathobiochemistry, University of Muenster, 48149 Muenster, Germany; (A.H.); (D.D.I.); (S.V.W.)
| | - Seraphine Valeska Wegner
- Institute of Physiological Chemistry and Pathobiochemistry, University of Muenster, 48149 Muenster, Germany; (A.H.); (D.D.I.); (S.V.W.)
| | - Eva Brand
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, Interdisciplinary Fabry Center Muenster (IFAZ), University Hospital Muenster, 48149 Muenster, Germany; (D.S.); (E.B.)
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21
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Nowak A, Haddad G, Kistler AD, Nlandu-Khodo S, Beuschlein F, Wüthrich RP, Lorenzen JM, Kölling M. Circular RNA-based biomarkers in blood of patients with Fabry disease and related phenotypes. J Med Genet 2021; 59:279-286. [PMID: 33547137 DOI: 10.1136/jmedgenet-2020-107086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Fabry disease is a rare X-linked lysosomal storage disease caused by mutations in the galactosidase α gene. Deficient activity of α-galactosidase A leads to glycosphingolipid accumulations in multiple organs. Circular RNAs represent strong regulators of gene expression. Their circular structure ensures high stability in blood. We hypothesised that blood-based circular RNA profiles improve phenotypic assignment and therapeutic monitoring of Fabry disease. METHODS A genome-wide circular RNA expression analysis was performed in blood of genetically diagnosed patients with Fabry disease (n=58), age-matched and sex-matched healthy volunteers (n=14) and disease control patients with acute kidney injury (n=109). Most highly dysregulated circular RNAs were validated by quantitative real-time PCR. Circular RNA biomarker sensitivity, specificity, predictive values and area under the curve (AUC) were determined. Linear regression analyses were conducted for validated circular RNA biomarkers and clinical patient characteristics. RESULTS A distinct circular RNA transcriptome signature identified patients with Fabry disease. Level of circular RNAs hsa_circ_0006853 (AUC=0.73), hsa_circ_0083766 (AUC=0.8) and hsa_circ_0002397 (AUC=0.8) distinguished patients with Fabry disease from both healthy controls and patients with acute kidney injury. Hsa_circ_0002397 was, furthermore, female-specifically expressed. Circular RNA level were significantly related to galactosidase α gene mutations, early symptoms, phenotypes, disease severities, specific therapies and long-term complications of Fabry disease. CONCLUSION The discovery of circular RNA-based and Fabry disease-specific biomarkers may advance future diagnosis of Fabry disease and help to distinguish related phenotypes.
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Affiliation(s)
- Albina Nowak
- Department of Endocrinology, University Hospital Zurich, Zurich, Switzerland.,Department of Internal Medicine, Psychiatric Hospital of the University of Zurich, Zurich, Switzerland
| | - George Haddad
- Department of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Andreas D Kistler
- Department of Medicine, Frauenfeld Cantonal Hospital, Frauenfeld, Switzerland
| | | | - Felix Beuschlein
- Department of Endocrinology, University Hospital Zurich, Zurich, Switzerland
| | - Rudolf P Wüthrich
- Department of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Johan M Lorenzen
- Department of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Malte Kölling
- Department of Nephrology, University Hospital Zurich, Zurich, Switzerland.,Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
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22
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Azevedo O, Gago MF, Miltenberger-Miltenyi G, Sousa N, Cunha D. Fabry Disease Therapy: State-of-the-Art and Current Challenges. Int J Mol Sci 2020; 22:ijms22010206. [PMID: 33379210 PMCID: PMC7794923 DOI: 10.3390/ijms22010206] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/18/2020] [Accepted: 12/21/2020] [Indexed: 12/13/2022] Open
Abstract
Fabry disease (FD) is a lysosomal storage disorder caused by mutations of the GLA gene that lead to a deficiency of the enzymatic activity of α-galactosidase A. Available therapies for FD include enzyme replacement therapy (ERT) (agalsidase alfa and agalsidase beta) and the chaperone migalastat. Despite the large body of literature published about ERT over the years, many issues remain unresolved, such as the optimal dose, the best timing to start therapy, and the clinical impact of anti-drug antibodies. Migalastat was recently approved for FD patients with amenable GLA mutations; however, recent studies have raised concerns that "in vitro" amenability may not always reflect "in vivo" amenability, and some findings on real-life studies have contrasted with the results of the pivotal clinical trials. Moreover, both FD specific therapies present limitations, and the attempt to correct the enzymatic deficiency, either by enzyme exogenous administration or enzyme stabilization with a chaperone, has not shown to be able to fully revert FD pathology and clinical manifestations. Therefore, several new therapies are under research, including new forms of ERT, substrate reduction therapy, mRNA therapy, and gene therapy. In this review, we provide an overview of the state-of-the-art on the currently approved and emerging new therapies for adult patients with FD.
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Affiliation(s)
- Olga Azevedo
- Cardiology Department, Reference Center on Lysosomal Storage Disorders, Hospital Senhora da Oliveira, 4835-044 Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal; (M.F.G.); (G.M.-M.); (N.S.); (D.C.)
- ICVS/3Bs PT Government Associate Laboratory, 4805-017 Braga/Guimarães, Portugal
- Correspondence: ; Tel.: +351-253-540-330; Fax: +351-253-513-592
| | - Miguel Fernandes Gago
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal; (M.F.G.); (G.M.-M.); (N.S.); (D.C.)
- ICVS/3Bs PT Government Associate Laboratory, 4805-017 Braga/Guimarães, Portugal
- Neurology Department, Reference Center on Lysosomal Storage Disorders, Hospital Senhora da Oliveira, 4835-044 Guimarães, Portugal
| | - Gabriel Miltenberger-Miltenyi
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal; (M.F.G.); (G.M.-M.); (N.S.); (D.C.)
- ICVS/3Bs PT Government Associate Laboratory, 4805-017 Braga/Guimarães, Portugal
- Genetics Department, Reference Center on Lysosomal Storage Disorders, Hospital Senhora da Oliveira, 4835-044 Guimarães, Portugal
| | - Nuno Sousa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal; (M.F.G.); (G.M.-M.); (N.S.); (D.C.)
- ICVS/3Bs PT Government Associate Laboratory, 4805-017 Braga/Guimarães, Portugal
| | - Damião Cunha
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal; (M.F.G.); (G.M.-M.); (N.S.); (D.C.)
- ICVS/3Bs PT Government Associate Laboratory, 4805-017 Braga/Guimarães, Portugal
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23
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Tsukimura T, Tayama Y, Shiga T, Hirai K, Togawa T, Sakuraba H. Anti-drug antibody formation in Japanese Fabry patients following enzyme replacement therapy. Mol Genet Metab Rep 2020; 25:100650. [PMID: 33072516 PMCID: PMC7548986 DOI: 10.1016/j.ymgmr.2020.100650] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/13/2020] [Indexed: 02/06/2023] Open
Abstract
Enzyme replacement therapy (ERT) for Fabry disease (deficiency of α-galactosidase A, α-Gal) with recombinant α-Gals (agalsidase alfa and agalsidase beta) is widely available and improves some of the clinical manifestations and biochemical findings. However, recent reports suggest that recurrent administration of recombinant enzymes often induces the formation of anti-drug antibodies, which may have a negative impact on the outcome of the therapy. We examined the formation of anti-drug antibodies using blood samples from 97 Japanese Fabry patients following ERT and tried to characterize them by means of enzyme-linked immunosorbent assay (ELISA), serum-mediated α-Gal inhibition, and immunochromatographic (IC) assay, followed by GLA gene analysis and measurement of plasma globotriaosylsphingosine (lyso-Gb3). ELISA revealed that 20/35 (57%) classic Fabry males were antibody (Immunoglobulin G, IgG) -positive (Ab+) at 6 months after the initiation of ERT, although only two of the seventeen (12%) later-onset Fabry males and none of the 45 Fabry females were. The Ab+ state was maintained at least until 24 months after the initiation of ERT in most of the cases, the exceptions being two patients who acquired immune tolerance during ERT. As many Ab+ patients have nonsense mutations, attention should be paid to the formation of anti-drug antibodies in Fabry patients harboring such gene mutations, who hardly produce α-Gal protein. Serum-mediated α-Gal inhibition was seen in most of the Ab+ patients and the antibodies affected the reduction of the plasma lyso-Gb3 level following ERT, suggesting that the antibodies inhibit the enzyme activity. There was a correlation between the results of the IC test and those of the ELISA. As the former is easy and rapid, it should be useful as a bed-side test. The anti-drug antibodies formed in Fabry patients during ERT were characterized. Serum-mediated α-Gal inhibition was seen in most of the antibody-positive patients. The immunochromatographic test is easy, rapid, and useful as a bed-side test.
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Affiliation(s)
- Takahiro Tsukimura
- Department of Functional Bioanalysis, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo 204-8588, Japan
| | - Yuya Tayama
- Department of Functional Bioanalysis, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo 204-8588, Japan
| | - Tomoko Shiga
- Department of Clinical Genetics, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo 204-8588, Japan
| | - Kanako Hirai
- Department of Clinical Genetics, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo 204-8588, Japan
| | - Tadayasu Togawa
- Department of Functional Bioanalysis, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo 204-8588, Japan
| | - Hitoshi Sakuraba
- Department of Clinical Genetics, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo 204-8588, Japan
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24
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van der Veen SJ, Hollak CEM, van Kuilenburg ABP, Langeveld M. Developments in the treatment of Fabry disease. J Inherit Metab Dis 2020; 43:908-921. [PMID: 32083331 PMCID: PMC7540041 DOI: 10.1002/jimd.12228] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 02/10/2020] [Accepted: 02/17/2020] [Indexed: 12/19/2022]
Abstract
Enzyme replacement therapy (ERT) with recombinant α-galactosidase A (r-αGAL A) for the treatment of Fabry disease has been available for over 15 years. Long-term treatment may slow down disease progression, but cardiac, renal, and cerebral complications still develop in most patients. In addition, lifelong intravenous treatment is burdensome. Therefore, several new treatment approaches have been explored over the past decade. Chaperone therapy (Migalastat; 1-deoxygalactonojirimycin) is the only other currently approved therapy for Fabry disease. This oral small molecule aims to improve enzyme activity of mutated α-galactosidase A and can only be used in patients with specific mutations. Treatments currently under evaluation in (pre)clinical trials are second generation enzyme replacement therapies (Pegunigalsidase-alfa, Moss-aGal), substrate reduction therapies (Venglustat and Lucerastat), mRNA- and gene-based therapy. This review summarises the knowledge on currently available and potential future options for the treatment of Fabry disease.
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Affiliation(s)
- Sanne J. van der Veen
- Department of Endocrinology and MetabolismAmsterdam UMC, University of AmsterdamAZAmsterdamThe Netherlands
| | - Carla E. M. Hollak
- Department of Endocrinology and MetabolismAmsterdam UMC, University of AmsterdamAZAmsterdamThe Netherlands
| | - André B. P. van Kuilenburg
- Department of Clinical Chemistry, Gastroenterology & MetabolismAmsterdam UMC, University of AmsterdamAZAmsterdamThe Netherlands
| | - Mirjam Langeveld
- Department of Endocrinology and MetabolismAmsterdam UMC, University of AmsterdamAZAmsterdamThe Netherlands
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25
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Scharnetzki D, Stappers F, Lenders M, Brand E. Detailed epitope mapping of neutralizing anti-drug antibodies against recombinant α-galactosidase A in patients with Fabry disease. Mol Genet Metab 2020; 131:229-234. [PMID: 32888778 DOI: 10.1016/j.ymgme.2020.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/21/2020] [Accepted: 08/21/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Fabry disease (FD) is a lysosomal storage disease, treatable by enzyme replacement therapy (ERT) that substitutes deficient α-galactosidase A (AGAL). The formation of neutralizing anti-drug antibodies (ADA) inhibiting AGAL activity is associated with disease progression in affected male patients. In the current study, we performed a detailed epitope mapping of ADAs from antibody-positive males against infused AGAL. METHODS A detailed epitope mapping for 34 male FD patients with neutralizing ADAs against AGAL was performed. Based on this data, in silico analyses were used to identify potential epitope clusters and mapped surface-located or buried epitopes. ELISA-based assays against α-galactosidase B (NAGA) were performed to identify ADAs that potentially recognize shared epitopes of AGAL and NAGA. A subset of 20 patients was analyzed to assess if NAGA-recognizing ADAs against AGAL might affect long-term outcomes under ERT. RESULTS Thirty percent of the AGAL active site was recognized by patients' ADAs. No differences between buried and surface-located epitopes were observed. Dependent on the epitopes, ADAs against AGAL were also able to recognize human NAGA. Patients with NAGA recognizing anti-AGAL antibodies presented with lower plasma NAGA activities. The presence of NAGA-recognizing ADAs had no effect on disease progression. CONCLUSION In conclusion, our current data underline previous reports demonstrating a large variation of antibody epitopes against AGAL. Detailed epitope mapping in affected patients might be the first step for the generation of patient-specific blocking peptides and/or immune adsorption columns for an individually tailored anti-antibody strategy.
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Affiliation(s)
- David Scharnetzki
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, Interdisciplinary Fabry Center Münster (IFAZ), University Hospital Muenster, 48149 Muenster, Germany
| | - Franciska Stappers
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, Interdisciplinary Fabry Center Münster (IFAZ), University Hospital Muenster, 48149 Muenster, Germany
| | - Malte Lenders
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, Interdisciplinary Fabry Center Münster (IFAZ), University Hospital Muenster, 48149 Muenster, Germany.
| | - Eva Brand
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, Interdisciplinary Fabry Center Münster (IFAZ), University Hospital Muenster, 48149 Muenster, Germany
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26
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van der Veen SJ, Vlietstra WJ, van Dussen L, van Kuilenburg AB, Dijkgraaf MGW, Lenders M, Brand E, Wanner C, Hughes D, Elliott PM, Hollak CEM, Langeveld M. Predicting the Development of Anti-Drug Antibodies against Recombinant alpha-Galactosidase A in Male Patients with Classical Fabry Disease. Int J Mol Sci 2020; 21:5784. [PMID: 32806627 PMCID: PMC7460974 DOI: 10.3390/ijms21165784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/03/2020] [Accepted: 08/06/2020] [Indexed: 12/17/2022] Open
Abstract
Fabry Disease (FD) is a rare, X-linked, lysosomal storage disease that mainly causes renal, cardiac and cerebral complications. Enzyme replacement therapy (ERT) with recombinant alpha-galactosidase A is available, but approximately 50% of male patients with classical FD develop inhibiting anti-drug antibodies (iADAs) that lead to reduced biochemical responses and an accelerated loss of renal function. Once immunization has occurred, iADAs tend to persist and tolerization is hard to achieve. Here we developed a pre-treatment prediction model for iADA development in FD using existing data from 120 classical male FD patients from three European centers, treated with ERT. We found that nonsense and frameshift mutations in the α-galactosidase A gene (p = 0.05), higher plasma lysoGb3 at baseline (p < 0.001) and agalsidase beta as first treatment (p = 0.006) were significantly associated with iADA development. Prediction performance of a Random Forest model, using multiple variables (AUC-ROC: 0.77) was compared to a logistic regression (LR) model using the three significantly associated variables (AUC-ROC: 0.77). The LR model can be used to determine iADA risk in individual FD patients prior to treatment initiation. This helps to determine in which patients adjusted treatment and/or immunomodulatory regimes may be considered to minimize iADA development risk.
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27
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Yasuda M, Huston MW, Pagant S, Gan L, St Martin S, Sproul S, Richards D, Ballaron S, Hettini K, Ledeboer A, Falese L, Cao L, Lu Y, Holmes MC, Meyer K, Desnick RJ, Wechsler T. AAV2/6 Gene Therapy in a Murine Model of Fabry Disease Results in Supraphysiological Enzyme Activity and Effective Substrate Reduction. Mol Ther Methods Clin Dev 2020; 18:607-619. [PMID: 32775495 PMCID: PMC7396970 DOI: 10.1016/j.omtm.2020.07.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 07/02/2020] [Indexed: 01/14/2023]
Abstract
Fabry disease is an X-linked lysosomal storage disorder caused by mutations in the alpha-galactosidase A (GLA) gene, which encodes the exogalactosyl hydrolase, alpha-galactosidase A (α-Gal A). Deficient α-Gal A activity results in the progressive, systemic accumulation of its substrates, globotriaosylceramide (Gb3) and globotriaosylsphingosine (Lyso-Gb3), leading to renal, cardiac, and/or cerebrovascular disease and early demise. The current standard treatment for Fabry disease is enzyme replacement therapy, which necessitates lifelong biweekly infusions of recombinant enzyme. A more long-lasting treatment would benefit Fabry patients. Here, a gene therapy approach using an episomal adeno-associated viral 2/6 (AAV2/6) vector that encodes the human GLA cDNA driven by a liver-specific expression cassette was evaluated in a Fabry mouse model that lacks α-Gal A activity and progressively accumulates Gb3 and Lyso-Gb3 in plasma and tissues. A detailed 3-month pharmacology and toxicology study showed that administration of a clinical-scale-manufactured AAV2/6 vector resulted in markedly increased plasma and tissue α-Gal A activities, and essentially normalized Gb3 and Lyso-Gb3 at key sites of pathology. Further optimization of vector design identified the clinical lead vector, ST-920, which produced several-fold higher plasma and tissue α-Gal A activity levels with a good safety profile. Together, these studies provide the basis for the clinical development of ST-920.
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Affiliation(s)
- Makiko Yasuda
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Silvere Pagant
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lin Gan
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Scott Sproul
- Sangamo Therapeutics, Inc., Brisbane, CA 94005, USA
| | | | | | | | | | | | - Liching Cao
- Sangamo Therapeutics, Inc., Brisbane, CA 94005, USA
| | - Yanmei Lu
- Sangamo Therapeutics, Inc., Brisbane, CA 94005, USA
| | | | | | - Robert J Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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28
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Seemann S, Ernst M, Cimmaruta C, Struckmann S, Cozma C, Koczan D, Knospe AM, Haake LR, Citro V, Bräuer AU, Andreotti G, Cubellis MV, Fuellen G, Hermann A, Giese AK, Rolfs A, Lukas J. Proteostasis regulators modulate proteasomal activity and gene expression to attenuate multiple phenotypes in Fabry disease. Biochem J 2020; 477:359-80. [PMID: 31899485 DOI: 10.1042/BCJ20190513] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 12/17/2019] [Accepted: 01/02/2020] [Indexed: 12/22/2022]
Abstract
The lysosomal storage disorder Fabry disease is characterized by a deficiency of the lysosomal enzyme α-Galactosidase A. The observation that missense variants in the encoding GLA gene often lead to structural destabilization, endoplasmic reticulum retention and proteasomal degradation of the misfolded, but otherwise catalytically functional enzyme has resulted in the exploration of alternative therapeutic approaches. In this context, we have investigated proteostasis regulators (PRs) for their potential to increase cellular enzyme activity, and to reduce the disease-specific accumulation of the biomarker globotriaosylsphingosine in patient-derived cell culture. The PRs also acted synergistically with the clinically approved 1-deoxygalactonojirimycine, demonstrating the potential of combination treatment in a therapeutic application. Extensive characterization of the effective PRs revealed inhibition of the proteasome and elevation of GLA gene expression as paramount effects. Further analysis of transcriptional patterns of the PRs exposed a variety of genes involved in proteostasis as potential modulators. We propose that addressing proteostasis is an effective approach to discover new therapeutic targets for diseases involving folding and trafficking-deficient protein mutants.
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Stappers F, Scharnetzki D, Schmitz B, Manikowski D, Brand SM, Grobe K, Lenders M, Brand E. Neutralising anti-drug antibodies in Fabry disease can inhibit endothelial enzyme uptake and activity. J Inherit Metab Dis 2020; 43:334-347. [PMID: 31587315 DOI: 10.1002/jimd.12176] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/22/2019] [Accepted: 09/24/2019] [Indexed: 11/10/2022]
Abstract
Fabry disease (FD) is a lysosomal storage disease, treatable by enzyme replacement therapy (ERT) that substitutes deficient α-galactosidase A (AGAL). The formation of neutralising anti-drug antibodies (ADA) inhibiting AGAL activity during infusion is associated with disease progression in affected male patients. In this study we analysed if ADAs also inhibit endothelial enzyme uptake as well as intracellular enzyme activity. Therefore, fluorescence-labelled AGAL in combination with ADA-positive sera from FD patients (n = 8) was used to analyse enzyme uptake in endothelial and FD-specific cells. Furthermore, immune adsorption and a comprehensive ADA epitope mapping were performed. Pre-incubation of AGAL with ADAs significantly inhibited intracellular enzyme activity, which was rescued by immune adsorption (both P < .01). ADAs from some patients also inhibited enzyme uptake. ADA epitope mapping identified an epitope at position 121 to 140 aa potentially responsible for uptake inhibition for these patients. Further analyses revealed the presence of stable AGAL/ADA-immune complexes at pH 4.5 and decreased intracellular enzyme activity in endothelial cells (P < .001). Finally, the pre-incubation of AGAL with ADAs resulted in a reduced depletion of intracellular globotriaosylceramide in patient-derived AGAL-deficient cells, demonstrating a direct negative impact of ADAs on intracellular clearance. Neutralising ADAs may not only inhibit infused AGAL activity, but according to their epitopes can also inhibit endothelial AGAL uptake. Indeed, internalised AGAL/ADA-complexes may not dissociate, underlining the importance of novel therapeutic approaches for ADA reduction and prevention to increase therapy efficiency in affected patients.
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Affiliation(s)
- Franciska Stappers
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, University Hospital Muenster, Muenster, Germany
| | - David Scharnetzki
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, University Hospital Muenster, Muenster, Germany
| | - Boris Schmitz
- Institute of Sports Medicine, Molecular Genetics of Cardiovascular Disease, University Hospital Muenster, Muenster, Germany
| | - Dominique Manikowski
- Institute of Physiological Chemistry and Pathobiochemistry and Cells-in-Motion Cluster of Excellence (EXC1003-CiM), University of Muenster, Muenster, Germany
| | - Stefan-Martin Brand
- Institute of Sports Medicine, Molecular Genetics of Cardiovascular Disease, University Hospital Muenster, Muenster, Germany
| | - Kay Grobe
- Institute of Physiological Chemistry and Pathobiochemistry and Cells-in-Motion Cluster of Excellence (EXC1003-CiM), University of Muenster, Muenster, Germany
| | - Malte Lenders
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, University Hospital Muenster, Muenster, Germany
| | - Eva Brand
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, University Hospital Muenster, Muenster, Germany
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30
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Lukas J, Cimmaruta C, Liguori L, Pantoom S, Iwanov K, Petters J, Hund C, Bunschkowski M, Hermann A, Cubellis MV, Rolfs A. Assessment of Gene Variant Amenability for Pharmacological Chaperone Therapy with 1-Deoxygalactonojirimycin in Fabry Disease. Int J Mol Sci 2020; 21:ijms21030956. [PMID: 32023956 PMCID: PMC7037350 DOI: 10.3390/ijms21030956] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 01/20/2020] [Accepted: 01/29/2020] [Indexed: 01/21/2023] Open
Abstract
Fabry disease is one of the most common lysosomal storage disorders caused by mutations in the gene encoding lysosomal α-galactosidase A (α-Gal A) and resultant accumulation of glycosphingolipids. The sugar mimetic 1-deoxygalactonojirimycin (DGJ), an orally available pharmacological chaperone, was clinically approved as an alternative to intravenous enzyme replacement therapy. The decision as to whether a patient should be treated with DGJ depends on the genetic variant within the α-galactosidase A encoding gene (GLA). A good laboratory practice (GLP)-validated cell culture-based assay to investigate the biochemical responsiveness of the variants is currently the only source available to obtain pivotal information about susceptibility to treatment. Herein, variants were defined amenable when an absolute increase in enzyme activity of ≥3% of wild type enzyme activity and a relative increase in enzyme activity of ≥1.2-fold was achieved following DGJ treatment. Efficacy testing was carried out for over 1000 identified GLA variants in cell culture. Recent data suggest that about one-third of the variants comply with the amenability criteria. A recent study highlighted the impact of inter-assay variability on DGJ amenability, thereby reducing the power of the assay to predict eligible patients. This prompted us to compare our own α-galactosidase A enzyme activity data in a very similar in-house developed assay with those from the GLP assay. In an essentially retrospective approach, we reviewed 148 GLA gene variants from our former studies for which enzyme data from the GLP study were available and added novel data for 30 variants. We also present data for 18 GLA gene variants for which no data from the GLP assay are currently available. We found that both differences in experimental biochemical data and the criteria for the classification of amenability cause inter-assay discrepancy. We conclude that low baseline activity, borderline biochemical responsiveness, and inter-assay discrepancy are alarm signals for misclassifying a variant that must not be ignored. Furthermore, there is no solid basis for setting a minimum response threshold on which a clinical indication with DGJ can be justified.
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Affiliation(s)
- Jan Lukas
- Translational Neurodegeneration Section “Albrecht-Kossel“, Department of Neurology, University Medical Center Rostock, 18147 Rostock, Germany; (C.C.); (S.P.); (K.I.); (J.P.); (C.H.); (A.H.)
- Center for Transdisciplinary Neurosciences Rostock (CTNR), University Medical Center Rostock, University of Rostock, 18147 Rostock, Germany
- Correspondence: ; Tel.: +49-0381-494-4894
| | - Chiara Cimmaruta
- Translational Neurodegeneration Section “Albrecht-Kossel“, Department of Neurology, University Medical Center Rostock, 18147 Rostock, Germany; (C.C.); (S.P.); (K.I.); (J.P.); (C.H.); (A.H.)
| | - Ludovica Liguori
- Dipartimento di Scienze e Tecnologie Ambientali, Biologiche e Farmaceutiche, Università degli Studi della Campania “Luigi Vanvitelli”, 81100 Caserta, Italy;
- Institute of Biomolecular Chemistry, CNR, 80078 Pozzuoli, Italy;
| | - Supansa Pantoom
- Translational Neurodegeneration Section “Albrecht-Kossel“, Department of Neurology, University Medical Center Rostock, 18147 Rostock, Germany; (C.C.); (S.P.); (K.I.); (J.P.); (C.H.); (A.H.)
| | - Katharina Iwanov
- Translational Neurodegeneration Section “Albrecht-Kossel“, Department of Neurology, University Medical Center Rostock, 18147 Rostock, Germany; (C.C.); (S.P.); (K.I.); (J.P.); (C.H.); (A.H.)
| | - Janine Petters
- Translational Neurodegeneration Section “Albrecht-Kossel“, Department of Neurology, University Medical Center Rostock, 18147 Rostock, Germany; (C.C.); (S.P.); (K.I.); (J.P.); (C.H.); (A.H.)
| | - Christina Hund
- Translational Neurodegeneration Section “Albrecht-Kossel“, Department of Neurology, University Medical Center Rostock, 18147 Rostock, Germany; (C.C.); (S.P.); (K.I.); (J.P.); (C.H.); (A.H.)
| | | | - Andreas Hermann
- Translational Neurodegeneration Section “Albrecht-Kossel“, Department of Neurology, University Medical Center Rostock, 18147 Rostock, Germany; (C.C.); (S.P.); (K.I.); (J.P.); (C.H.); (A.H.)
- Center for Transdisciplinary Neurosciences Rostock (CTNR), University Medical Center Rostock, University of Rostock, 18147 Rostock, Germany
- German Center for Neurodegenerative Diseases (DZNE) Rostock/Greifswald, 18147 Rostock, Germany
| | - Maria Vittoria Cubellis
- Institute of Biomolecular Chemistry, CNR, 80078 Pozzuoli, Italy;
- Department of Biology, University Federico II, 80126 Naples, Italy
| | - Arndt Rolfs
- Centogene AG, 18055 Rostock, Germany; (M.B.); (A.R.)
- University Medical Center Rostock, University of Rostock, 18057 Rostock, Germany
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Miller JJ, Kanack AJ, Dahms NM. Progress in the understanding and treatment of Fabry disease. Biochim Biophys Acta Gen Subj 2019; 1864:129437. [PMID: 31526868 DOI: 10.1016/j.bbagen.2019.129437] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Fabry disease is caused by α-galactosidase A deficiency. Substrates of this lysosomal enzyme accumulate, resulting in cellular dysfunction. Patients experience neuropathic pain, kidney failure, heart disease, and strokes. SCOPE OF REVIEW The clinical picture and molecular features of Fabry disease are described, along with updates on disease mechanisms, animal models, and therapies. MAJOR CONCLUSIONS How the accumulation of α-galactosidase A substrates, mainly glycosphingolipids, leads to organ damage is incompletely understood. Enzyme replacement and chaperone therapies are clinically available to patients, while substrate reduction, mRNA-based, and gene therapies are on the horizon. Animal models exist to optimize these therapies and elucidate disease mechanisms for novel treatments. GENERAL SIGNIFICANCE Recent newborn screening studies demonstrate that Fabry disease is the most common lysosomal storage disease. As many countries now include Fabry disease in their screening panels, the number of identified patients is expected to increase significantly. Better knowledge of disease pathogenesis is needed to improve treatment options.
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Affiliation(s)
- James J Miller
- Department of Biochemistry, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Adam J Kanack
- Department of Biochemistry, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Nancy M Dahms
- Department of Biochemistry, Medical College of Wisconsin, Milwaukee, WI, United States of America.
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