Intravenous iron-induced hypophosphatemia and kidney stone disease

Patients with Crohn's disease are at increased risk for symptomatic nephrolithiasis. Stones in these patients are most commonly composed of calcium oxalate monohydrate or mixed calcium-oxalate and calcium-phosphate. Precipitation of both minerals depends on urinary pH, calcium, phosphate and oxalate excretion. The present manuscript reports on two patients with Crohn's disease and bowel resection, in whom the onset of symptomatic urolithiasis occurred after repeated infusions of ferric carboxymaltose - a drug, which is known to cause hyperphosphaturia. The present study shows that ferric carboxymaltose-induced hyperphosphaturia can be associated with kidney stone formation and symptomatic urolithiasis, especially in patients treated with calcitriol. Calcitriol has been shown to mitigate ferric carboxymaltose-induced secondary hyperparathyroidism and hyperphosphaturia, but is known to increase urinary calcium excretion. Chemical analysis of recovered stones revealed that they were mixed calcium oxalate and phosphate stones. Ring-like deposition of iron detected by spatially resolved elemental analysis using laser ablation-inductively coupled plasma mass spectrometry, showed that the stones also contained iron. Based on our findings, we propose that patients with inflammatory bowel disease requiring intravenous iron therapy should be carefully monitored for the development of hypophosphatemia and urolithiasis. If hypophosphatemia occurs in such patients, calcitriol should be used with caution.

Penetrance, cancer incidence and survival in HFE haemochromatosis-A population-based cohort study

BACKGROUND AND AIMS

Haemochromatosis is characterized by progressive iron overload affecting the liver and can cause cirrhosis and hepatocellular carcinoma. Most haemochromatosis patients are homozygous for p.C282Y in HFE, but only a minority of individuals with this genotype will develop the disease. The aim was to assess the penetrance of iron overload, fibrosis, hepatocellular carcinoma and life expectancy.

METHODS

A total of 8839 individuals from the Austrian region of Tyrol were genotyped for the p.C282Y variant between 1997 and 2021. Demographic, laboratory parameters and causes of death were assessed from health records. Penetrance, survival, and cancer incidence were ascertained from diagnosed cases, insurance- and cancer registry data. Outcomes were compared with a propensity score-matched control population.

RESULTS

Median age at diagnosis in 542 p.C282Y homozygous individuals was 47.8 years (64% male). At genotyping, the prevalence of iron overload was 55%. The cumulative penetrance of haemochromatosis defined as the presence of provisional iron overload was 24.2% in males and 10.5% in females aged 60 years or younger. Among p.C282Y homozygotes of the same ages, the cumulative proportion of individuals without fibrosis (FIB-4 score < 1.3) was 92.8% in males and 96.7% in females. Median life expectancy was reduced by 6.8 years in individuals homozygous for p.C282Y when compared with population-matched controls (p = .001). Hepatocellular carcinoma incidence was not significantly higher in p.C282Y homozygotes than in controls matched for age and sex.

CONCLUSION

Reduced survival and the observed age-dependent increase in penetrance among p.C282Y homozygotes call for earlier diagnosis of haemochromatosis to prevent complications.

Long-term follow-up of patients discontinuing bulevirtide treatment upon long-term HDV-RNA suppression

Background & Aims

Bulevirtide (BLV) is a novel antiviral drug licensed for the treatment of chronic hepatitis D. Data on the safety and efficacy of stopping BLV therapy upon long-term HDV-RNA suppression are scarce.

Methods

A total of seven patients (age, 31-68 years, four with cirrhosis) included in a prospective Austrian HDV registry discontinued BLV treatment (duration, 46-141 weeks) upon long-term HDV suppression (HDV-RNA negativity, 12-69 weeks). Pegylated interferon-ɑ2a was used in combination with BLV in two patients. HDV-RNA, alanine aminotransferase, and quantitative HBsAg levels were closely monitored during treatment-free follow-up.

Results

The seven patients were followed up for 14 to 112 weeks. Six patients completed ≥24 weeks of follow-up. HDV-RNA became detectable again in three patients within 24 weeks, whereas one additional patient showed an HDV-RNA relapse after almost 1 year. All patients who relapsed at any point had undergone BLV monotherapy. Meanwhile, HDV-RNA remained undetectable in two patients who were treated with BLV + pegylated interferon-ɑ2a. Only one patient showed significant alanine aminotransferase increases within 24 weeks of follow-up. BLV was reintroduced in three patients after 13-62 BLV-free weeks and was well tolerated, and all patients achieved virologic response again.

Conclusions

BLV discontinuation upon long-term HDV-RNA suppression seems safe. Retreatment with BLV was effective in case of virologic relapse. These findings are within a limited number of patients, and future studies are needed to define stopping rules and further investigate the safety of stopping BLV.

Impact and Implications

Limited data exist on stopping bulevirtide (BLV) treatment in patients who achieve long-term HDV-RNA suppression. In a small cohort of seven Austrian patients discontinuing BLV therapy, HDV-RNA relapses were observed in four patients during long-term follow-up, whereas significant alanine aminotransferase increases were recorded in only one. Retreatment with BLV was effective in relapsers. The safety and efficacy of stopping BLV needs to be further studied in larger cohorts.

Synonymous mutation in adenosine triphosphatase copper-transporting beta causes enhanced exon skipping in Wilson disease

Wilson disease (WD) is caused by biallelic pathogenic variants in adenosine triphosphatase copper-transporting beta (ATP7B); however, genetic testing identifies only one or no pathogenic ATP7B variant in a number of patients with WD. Synonymous single-nucleotide sequence variants have been recognized as pathogenic in individual families. The aim of the present study was to evaluate the prevalence and disease mechanism of the synonymous variant c.2292C>T (p.Phe764=) in WD. A cohort of 280 patients with WD heterozygous for a single ATP7B variant was investigated for the presence of c.2292C>T (p.Phe764=). In this cohort of otherwise genetically unexplained WD, the allele frequency of c.2292C>T (p.Phe764=) was 2.5% (14 of 560) compared to 7.1 × 10^-6 in the general population (2 of 280,964 in the Genome Aggregation Database; p < 10^-5 ; Fisher exact test). In an independent United Kingdom (UK) cohort, 2 patients with WD homozygous for p.Phe764= were identified. RNA analysis of ATP7B transcripts from patients homozygous or heterozygous for c.2292C>T and control fibroblasts showed that this variant caused high expression of an ATP7B transcript variant lacking exon 8. Conclusion: The synonymous ATP7B variant c.2292C>T (p.Phe764=) causes abnormal messenger RNA processing of ATP7B transcripts and is associated with WD in compound heterozygotes and homozygotes.

Response-guided long-term treatment of chronic hepatitis D patients with bulevirtide-results of a "real world" study

BACKGROUND AND AIM

Bulevirtide (BLV) blocks the uptake of the hepatitis D virus (HDV) into hepatocytes via the sodium/bile acid cotransporter NTCP. BLV was conditionally approved by the EMA but real-life data on BLV efficacy are limited.

METHODS

Patients were treated with BLV monotherapy. Patients who did not achieve further decreases in HDV-RNA after 24 weeks were offered PEG-IFN as an add-on therapy in a response-guided manner.

RESULTS

Twenty-three patients (m: 10, f: 13; mean age: 47.9 years, cirrhosis: 16; median ALT: 71 IU/ml; median HDV-RNA: 2.1 × 10⁵ copies/ml) started BLV monotherapy (2 mg/day: 22; 10 mg/day: 1). Twenty-two completed ≥24 weeks of treatment (24-137 weeks): Ten (45%) were classified as BLV responders at week 24. BLV was stopped in two patients with >6 months HDV-RNA undetectability, but both became HDV-RNA positive again. One patient was transplanted at week 25. One patient terminated treatment because of side effects at week 60. Ten patients are still on BLV monotherapy. Adding PEG-IFN in eight patients induced an HDV-RNA decrease in all (1.29 ± 0.19 [SD] log within 12 weeks). HDV-RNA decreased by >2log or became undetectable in 45%(10/22), 55%(11/20), 65% (13/20) and 69% (9/13); and ALT levels normalised in 64% (14/22), 85% (17/20), 90% (18/20) and in 92% (12/13) patients at weeks 24, 36, 48 and 60, respectively. Portal pressure decreased in 40% (2/5) of patients undergoing repeated measurement under BLV therapy.

CONCLUSION

Long-term BLV monotherapy is safe and effectively decreases HDV-RNA and ALT-even in patients with cirrhosis. The optimal duration of BLV treatment alone or in combination with PEG-IFN remains to be established. An algorithm for a response-guided BLV treatment approach is proposed.

MRI-Based Iron Phenotyping and Patient Selection for Next-Generation Sequencing of Non-Homeostatic Iron Regulator Hemochromatosis Genes

BACKGROUND AND AIMS

High serum ferritin is frequent among patients with chronic liver disease and commonly associated with hepatic iron overload. Genetic causes of high liver iron include homozygosity for the p.Cys282Tyr variant in homeostatic iron regulator (HFE) and rare variants in non-HFE genes. The aims of the present study were to describe the landscape and frequency of mutations in hemochromatosis genes and determine whether patient selection by noninvasive hepatic iron quantification using MRI improves the diagnostic yield of next-generation sequencing (NGS) in patients with hyperferritinemia.

APPROACH AND RESULTS

A cohort of 410 unselected liver clinic patients with high serum ferritin (defined as ≥200 μg/L for women and ≥300 μg/L for men) was investigated by HFE genotyping and abdominal MRI R2*. Forty-one (10%) patients were homozygous for the p.Cys282Tyr variant in HFE. Of the remaining 369 patients, 256 (69%) had high transferrin saturation (TSAT; ≥45%) and 199 (53%) had confirmed hepatic iron overload (liver R2* ≥70 s^-1 ). NGS of hemochromatosis genes was carried out in 180 patients with hepatic iron overload, and likely pathogenic variants were identified in 68 of 180 (38%) patients, mainly in HFE (79%), ceruloplasmin (25%), and transferrin receptor 2 (19%). Low spleen iron (R2* <50 s^-1 ), but not TSAT, was significantly associated with the presence of mutations. In 167 patients (93%), no monogenic cause of hepatic iron overload could be identified.

CONCLUSIONS

In patients without homozygosity for p.Cys282Tyr, coincident pathogenic variants in HFE and non-HFE genes could explain hyperferritinemia with hepatic iron overload in a subset of patients. Unlike HFE hemochromatosis, this type of polygenic hepatic iron overload presents with variable TSAT. High ferritin in blood is an indicator of the iron storage disease, hemochromatosis. A simple genetic test establishes this diagnosis in the majority of patients affected. MRI of the abdomen can guide further genetic testing.

Neurodegeneration in Hepatic and Neurologic Wilson's Disease

Clinical presentation of Wilson disease (WD) includes hepatic and neurologic manifestations. This study compares subcortical brain regions by magnetic resonance imaging in patients with WD and without neurological symptoms. Distinct atrophy affecting the basal ganglia, accumbens, and hippocampus was present in neurological WD. Cerebellar atrophy was observed in hepatic WD without neurological symptoms.

Reduced iron export associated with hepcidin resistance can explain the iron overload spectrum in ferroportin disease

BACKGROUND & AIMS

Ferroportin disease (FD) and hemochromatosis type 4 (HH4) are associated with variants in the ferroportin-encoding gene SLC40A1. Both phenotypes are characterized by iron overload despite being caused by distinct variants that either mediate reduced cellular iron export in FD or resistance against hepcidin-induced inactivation of ferroportin in HH4. The aim of this study was to assess if reduced iron export also confers hepcidin resistance and causes iron overload in FD associated with the R178Q variant.

METHODS

The ferroportin disease variants R178Q andA77D and the HH4-variant C326Y were overexpressed in HEK-293T cells and subcellular localization was characterized by confocal microscopy and flow cytometry. Iron export and cytosolic ferritin were measured as markers of iron transport and radioligand binding studies were performed. The hepcidin-ferroportin axis was assessed by ferritin/hepcidin correlation in patients with different iron storage diseases.

RESULTS

In the absence of hepcidin, the R178Q and A77D variants exported less iron when compared to normal and C326Y ferroportin. In the presence of hepcidin, the R178Q and C326Y, but not the A77D-variant, exported more iron than cells expressing normal ferroportin. Regression analysis of serum hepcidin and ferritin in patients with iron overload are compatible with hepcidin deficiency in HFE hemochromatosis and hepcidin resistance in R178Q FD.

CONCLUSIONS

These results support a novel concept that in certain FD variants reduced iron export and hepcidin resistance could be interlinked. Evasion of mutant ferroportin from hepcidin-mediated regulation could result in uncontrolled iron absorption and iron overload despite reduced transport function.

Anxiety, depression and quality of life of cancer patients undergoing radiation therapy: a cross-sectional study in a community hospital outpatient centre

The purpose of the present study is to determine the impact of illness characteristics and psychopathological comorbidity on the quality of life (QoL) of radio-oncological patients in health-related and individual dimensions. Sixty-three of 93 eligible patients (40 women and 23 men) were included in the study during their radiation therapy visit to an outpatient centre annexed to a community hospital in Southern Bavaria, Germany. In a semi-structured interview, we elicited individually relevant life domains rated by the patients according to the 'Schedule for the Evaluation of Individual Quality of Life - Direct Weighting'. In addition, the participants completed the 'European Organization for Research and Treatment of Cancer (EORTC) QoL Questionnaire Core 30' and the 'Hospital Anxiety and Depression Scale'. We also assessed the demand for psychotherapy and utilization of psycho-oncological services. In total, 9.5% of the examined patients suffer from clinically relevant anxiety and/or depression [total Hospital Anxiety and Depression Scale (HADS) score >19]. There was a weak positive correlation between Karnofsky's Performance Status and QoL. Anxiety and depression were significantly correlated with impaired QoL, especially with impaired individual QoL. There was no association between psychopathological comorbidity and the requirement for psycho-oncological support. Conversely, patients who report difficulties in accepting help had a significantly lower QoL. Psychopathological comorbidity has a considerable influence on QoL of patients undergoing radiotherapy. Measuring the individual QoL appears as an adapted needs assessment and helps the psychotherapist in focusing on the patient's problems and desires. Furthermore, the patient's QoL is a main target in providing or planning mental health care in non-university oncological services.

Porphyrias associated with malignant tumors: results of treatment with ionizing irradiation

BACKGROUND

Porphyrin metabolism disorders, known as porphyria, represent inherited or acquired diseases. The development of porphyria due to light sensibility occurs especially with exposure to wavelengths in the range of 300-700 nm. Skin reactions and neurovisceral dysfunctions are known side effects of ionizing irradiation. It can be postulated that during or after ionizing irradiation treatment of patients affected with tumor and porphyria, severe side effects might appear, in contrast to patients without porphyria. This paper describes the treatment of 2 patients affected with tumor and concomitant porphyria.

PATIENTS

One female patient suffering from intermittent porphyria and breast cancer and one male patient suffering from porphyria cutanea tarda and bladder cancer were treated with ionizing irradiation (electrons and photons). No abnormalities nor any severe general or local side effects could be observed.

CONCLUSION

Radiation therapy is not a 'stimulating' factor in activating porphyria symptoms.

Quantitative radioluminography of (125)Iodine whole-body autoradiograms

Radioluminography (RLG) was applied for the quantitation of (125)iodine ((125)I) autoradiograms using the bioimaging analyzer BAS 2000. RLG was performed on 50-microm sections of sagittal whole-body sections of rats and (125)I-radiolabeled erythrocyte calibration scales. Linearity, sensitivity, accuracy, and reproducibility were investigated in comparison to direct (125)I radioactivity measurement. RLG is demonstrated to be a simple, reproducible, and precise analytical tool. However, the spatial resolution of quantitative (125)I RLG is limited by the relatively high average free path of gamma-radiation and X rays.

[The prognostic factors following the simultaneous radiochemotherapy of anal canal carcinoma in a multicenter series of 139 patients]

PURPOSE

Evaluation of prognostic variables, results and toxicity after chemo-radiation (CRT) of anal canal carcinoma (ACC).

MATERIAL AND METHODS

Between 1982 and 1992, 139 patients with epidermoid carcinoma of the anal canal were treated by radiation and chemotherapy with 5-fluorouracil (5-Fu) and mitomycin C (MMC). 99 patients belonged to a prospectively designed trial (50 Gy, 2 courses of chemotherapy) and 40 to a historical control group (40 Gy, 1 course of chemotherapy). The female/male ratio was 116/23. Median age was 62 years. Staging (UICC 1987): T1: 16.5%; T2: 49%; T3: 23%; T4: 9.4%; unknown: 2.1%. Abnormal regional nodes were present in 15% of the patients.

HISTOLOGY

Squamous cell carcinoma: 68%; cloacogenic carcinoma: 31%; unknown: 1%. External beam radiation (ERT) was given to the primary tumour including perirectal, inguinal and iliac nodes by a 3 to 4 field box technique (50 patients) or parallel opposed fields (89 patients). Median single fraction and total dose were 1.8 Gy and 50 Gy. An additional boost to the involved sites was delivered by ERT (32 cases; median dose 16 Gy) or interstitial brachytherapy (BT) in 28 cases with a median dose 14 Gy. 84 patients (60%) received 2 or more cycles, 50 patients (36%) 1 cycle, 5 patients (4%) no chemotherapy.

RESULTS

The survival rate, NED-survival rate and local tumour control rate were 78%, 64% and 69% at 5 years. Anorectal function was retained in 94 of 139 patients (68%). Multivariate analysis indicated that T-stage (p = 0.037) and belonging to the historical control group (p = 0.003) were significant variables for local tumour control. T-stage was a marginally significant factor (p = 0.09) for NED-survival. Acute toxicity of grade 3 and 4 (WHO) was observed in 36%, severe late toxicity (grade 3 Eschwege) in 3% of the patients.

CONCLUSIONS

CRT with 2 courses 5-FU, MMC and ERT to a total dose of 45 to 50 Gy is a safe and effective treatment for ACC. Intensification of treatment is recommended in advanced stages T3/4.

Digital storage phosphor radiography for treatment verification in radiotherapy

The potential of digital storage phosphor radiography (SR) to improve image quality of portal radiographs is evaluated. Conventional film radiographs (FR) and corresponding SR verification images of an anthropomorphic phantom and various irradiation ports of patients were obtained with high-energy photon beams. For both techniques conventional films and storage phosphor screens were placed into a cassette with steel screens. Images were evaluated according to contrast and spatial resolution, delineation of anatomical structures, position of shielding blocks and accuracy of field alignments. Evaluation of 33 pairs of SR and FR portal images yielded a superior contrast resolution of SR in 47% (contrast air-soft tissue) and 37% (bone-soft tissue). Thus SR allows quick and easy detectability of anatomical structures as well as a better definition of block positions and field alignments. Shorter exposure times for computed images may result in a reduction of motion artefacts. SR images are indispensable in modern radiation therapy units, as they are instantly available in a computerized network for further image processing and analysis.

[Multiple admissions to the psychiatric hospital--a study of the status of so-called "revolving door patients"]

The graph of the frequency distribution of rehospitalization shows a constant exponential decline without demarking a particular population of so-called "revolving-door" patients. Patients with at least four admissions to a regional psychiatry hospital within a time span of two years are compared to a control group of the total clinic population. Multiple admission patients suffer significantly more often from diseases with an unfavourable prognosis, the illness has started earlier in their lives, and the course of illness is marked by unstable dynamic states with frequent crises of suicide. A demographic analysis shows the group under survey to be younger and less often married; participation in the world of labour has been lost more often, schizophrenics who have frequently stayed in hospitals even loose their former autonomy in housing. Guardianships are significantly more often installed, but they have not proved to be an efficient form of help. The therapeutic care of this problem patients is rather unsatisfactory. The offered ambulatory services are not claimed and in hospital the special treatment units fail to reach these patients. Lack of therapeutic continuity and compliance determines the course of treatment and complicates therapeutic strategies.

Persistent cortisol non-suppression after clinical recovery predicts symptomatic relapse in unipolar depression

We assessed the length and the quality of remission of 13 unipolar endogenous depressed patients, DST non-suppressors before treatment, in a 2-year prospective study. During this period, we recorded stressful life events. Persistent dexamethasone non-suppression, after treatment and complete clinical recovery, correlated highly with early clinical relapse. All six non-normalizers but only one normalizer were rehospitalized within the following 2 years for a major depressive relapse. Persistent DST non-suppression was unrelated to any impact of drug discontinuation, the occurrence of stressful life events or the length of illness-free intervals in the patient's prior course of illness. Persistent DST non-suppression appears to have significant prognostic value.

Effect of methotrexate on perfusion and nitrogen-13 glutamate uptake in the Walker-256 carcinosarcoma

The tissue uptake of [13N]glutamate (glu) was related to that of [11C]butanol (but), a highly diffusible perfusion tracer. In 25 rats bearing Walker-256 carcinomas tumor-to-muscle glu uptake averaged 6.34 +/- 2.84 (s.d.) prior to interventions and the respective uptake of but was 6.79 +/- 3.08 (y = 0.03 + 0.94x). One hour after selective intraarterial administration of methotrexate (mtx), glu uptake fell by 47%, whereas blood flow remained within the pretreatment range (N = 9). Four hours after mtx, perfusion was reduced by approximately 40%, and 2 days later both perfusion and glu uptake reached extremely low levels. No significant difference in the effect of 10 and 50 mg/kg mtx was observed. Regional tissue mtx uptake estimations using 77Br-labeled bromomethotrexate did not reveal any significant uptake in muscle. The relationship between tumor-to-muscle uptake of glu and but (13N/11C-index) was 0.94 +/- 0.015 (s.e.m., N = 25) before intervention. After methotrexate (1 hr, 4 hr, and 2 days) this index was 0.58 +/- 0.06 (N = 9), and 0.85 +/- 0.04 (N = 11) and 1.03 +/- 0.05 (N = 5), respectively. These values demonstrate an early mtx-induced uncoupling of glu uptake with respect to perfusion.

Nitrogen-13 glutamate uptake and perfusion in Walker 256 carcinosarcoma before and after single-dose irradiation

Nitrogen-13 (13N) glutamate uptake was recorded in 18 anesthetized rats, both before and at least once after intervention. Each investigation was immediately followed by imaging of blood flow distribution using [11C]butanol. All animals had Walker 256 carcinosarcoma implants in one hind leg. Tumors were locally irradiated with a dose of 800 rad in 14 rats; in four rats, the vasoactive substance 5-hydroxytryptamine (5-HT) was administered. Prior to interventions, the [13N]glutamate tumor-to-muscle uptake showed a linear correlation with blood flow close to identity (y = 0.117 + 0.915x, r = 0.97). After irradiation, a discordant pattern was observed: blood flow tended to increase, while [13N]glutamate tumor-to-muscle uptake dropped from 4.30 +/- 0.66 (s.e.m.) to 3.06 +/- 0.36 (p less than 0.005) during 30 min and attained 4.04 +/- 0.67 2 days later. If [13N]glutamate tumor-to-muscle uptake was related to that of [11C] butanol in each individual animal, this index dropped from 0.93 +/- 0.03 (s.e.m.) to 0.62 +/- 0.04 (p less than 0.001) 30 min after irradiation and attained 0.90 +/- 0.09 after 2 days. In animals treated with 5-HT, [13N]glutamate and [11C]butanol showed a parallel drop from 6.60 +/- 0.84 to 2.10 +/- 0.60 (p less than 0.05) and from 6.8 +/- 0.78 to 2.08 +/- 0.74 (p less than 0.05), respectively. Thus, single-dose irradiation causes [13N]glutamate uptake to be uncoupled with respect to flow, while [13N]glutamate uptake in untreated tumors is flow-limited and responds together with flow on vasomotion.

Whole-body autoradiographic studies in rats with gadolinium-diethylenetriaminepentaacetic acid, a new contrast agent for magnetic resonance imaging

The time course of the distribution of radiolabel in organs and tissues was investigated after intravenous administration of 0.5 mmol/kg of 14C-labelled gadolinium-diethylenetriaminepentaacetic acid (Gd-14C-DTPA) and of 153Gd-DTPA to pregnant rats (18th day p.c.) and after intragastric administration of 30 mumol/kg of Gd-14C-DTPA to male rats by whole-body autoradiographic technique. After intravenous administration Gd-DTPA was rapidly distributed within the organism. The distribution pattern was similar to that of classical X-ray contrast agents like diatrizoate and iotalamic acid. Gd-DTPA was not able to pass blood-brain and placental barriers. There was no indication of a dissociation of Gd-DTPA complex. 24 h after i.v. injection most of the radiolabel left the body. Only very small amounts were found in the kidney, the placenta and in the contents of the intestine. No specific and long-lasting retention of radioactivity was observed in any organ and tissue. After intragastric administration Gd-DTPA was not absorbed.