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Kirk FT, Munk DE, Swenson ES, Quicquaro AM, Vendelbo MH, Schilsky ML, Ott P, Sandahl TD. Effects of trientine and penicillamine on intestinal copper uptake: A mechanistic 64 Cu PET/CT study in healthy humans. Hepatology 2024; 79:1065-1074. [PMID: 38088886 PMCID: PMC11019997 DOI: 10.1097/hep.0000000000000708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 11/17/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND AND AIMS Trientine (TRI) and D-penicillamine (PEN) are used to treat copper overload in Wilson disease. Their main mode of action is thought to be through the facilitation of urinary copper excretion. In a recent study, TRI was noninferior to PEN despite lower 24-hour urinary copper excretion than PEN. We tested whether TRI and/or PEN also inhibit intestinal copper absorption. APPROACH AND RESULTS Sixteen healthy volunteers were examined with positron emission tomography (PET)/CT 1 and 15 hours after an oral Copper-64 ( 64 Cu) dose. They then received 7 days of either PEN or TRI (trientine tetrahydrochloride), after which the 64 Cu PET/CT scans were repeated. Venous blood samples were also collected. Pretreatment to posttreatment changes of the hepatic 64 Cu uptake reflect the effect of drugs on intestinal absorption. 64 Cu activity was normalized to dose and body weight and expressed as the mean standard uptake value. TRI (n=8) reduced hepatic 64 Cu activity 1 hour after 64 Cu dose from 6.17 (4.73) to 1.47 (2.97) standard uptake value, p <0.02, and after 15 hours from 14.24 (3.09) to 6.19 (3.43), p <0.02, indicating strong inhibition of intestinal 64 Cu absorption. PEN (n=8) slightly reduced hepatic standard uptake value at 15 hours, from 16.30 (5.63) to 12.17 (1.44), p <0.04. CONCLUSIONS In this mechanistic study, we show that TRI inhibits intestinal copper absorption, in addition to its cupriuretic effect. In contrast, PEN has modest effects on the intestinal copper absorption. This may explain why TRI and PEN are equally effective although urinary copper excretion is lower with TRI. The study questions whether the same therapeutic targets for 24-hour urinary excretion apply to both drugs.
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Affiliation(s)
- Frederik Teicher Kirk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Ditte Emilie Munk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Mikkel Holm Vendelbo
- Department of Nuclear Medicine & PET-center, Aarhus University Hospital, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Michael L. Schilsky
- Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Surgery, Section of Transplant and Immunology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Peter Ott
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Kirk FT, Munk DE, Swenson ES, Quicquaro AM, Vendelbo MH, Larsen A, Schilsky ML, Ott P, Sandahl TD. Effects of tetrathiomolybdate on copper metabolism in healthy volunteers and in patients with Wilson disease. J Hepatol 2024; 80:586-595. [PMID: 38081365 DOI: 10.1016/j.jhep.2023.11.023] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/08/2023] [Accepted: 11/23/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND & AIMS In Wilson disease (WD), copper accumulates in the liver and brain causing disease. Bis-choline tetrathiomolybdate (TTM) is a potent copper chelator that may be associated with a lower risk of inducing paradoxical neurological worsening than conventional therapy for neurologic WD. To better understand the mode of action of TTM, we investigated its effects on copper absorption and biliary excretion. METHODS In a double-blind randomized setting, hepatic 64Cu activity was examined after orally administered 64Cu by PET/CT in 16 healthy volunteers before and after seven days of TTM treatment (15 mg/d) or placebo. Oral 64Cu was administered one hour after the final TTM dose. Changes in hepatic 64Cu activity reflected changes in intestinal 64Cu uptake. Additionally, in four patients with WD, the distribution of 64Cu in venous blood, liver, gallbladder, kidney, and brain was followed after i.v. 64Cu dosing for up to 68 hours before and after seven days of TTM (15 mg/day), using PET/MRI. Increased gallbladder 64Cu activity was taken as evidence of increased biliary 64Cu excretion. RESULTS In healthy volunteers, TTM reduced intestinal 64Cu uptake by 82% 15 hours after the oral 64Cu dose. In patients with WD, gallbladder 64Cu activity was negligible before and after TTM, while TTM effectively retained 64Cu in the blood, significantly reduced hepatic 64Cu activity at all time-points and significantly reduced cerebral 64Cu activity two hours after the intravenous 64Cu dose. CONCLUSIONS While we did not show an increase in biliary excretion of 64Cu following TTM administration, we demonstrated that TTM effectively inhibited most intestinal 64Cu uptake and retained 64Cu in the blood stream, limiting the exposure of organs like the liver and brain to 64Cu. IMPACT AND IMPLICATIONS Bis-choline tetrathiomolybdate (TTM) is an investigational copper chelator being developed for the treatment of Wilson disease. In animal models of Wilson disease, TTM has been shown to facilitate biliary copper excretion. In the present human study, TTM surprisingly did not facilitate biliary copper excretion but instead reduced intestinal copper uptake to a clinically significant degree. Our study builds on our understanding of human copper metabolism and the mechanism of action of TTM.
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Affiliation(s)
- Frederik Teicher Kirk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
| | - Ditte Emilie Munk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Mikkel Holm Vendelbo
- Department of Nuclear Medicine & PET-center, Aarhus University Hospital, Aarhus, Denmark; Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Agnete Larsen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Michael L Schilsky
- Department of Medicine, Section of Digestive Diseases, and Department of Surgery, Section of Transplant and Immunology, Yale School of Medicine, New Haven, CT, USA
| | - Peter Ott
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Affiliation(s)
- Eve A Roberts
- From the Departments of Paediatrics, Medicine, and Pharmacology and Toxicology, University of Toronto, and the Hospital for Sick Children Research Institute - both in Toronto; and the History of Science and Technology Programme, University of King's College, Halifax, NS, Canada (E.A.R.); and the Departments of Medicine and Surgery, Yale University School of Medicine, New Haven, CT (M.L.S.)
| | - Michael L Schilsky
- From the Departments of Paediatrics, Medicine, and Pharmacology and Toxicology, University of Toronto, and the Hospital for Sick Children Research Institute - both in Toronto; and the History of Science and Technology Programme, University of King's College, Halifax, NS, Canada (E.A.R.); and the Departments of Medicine and Surgery, Yale University School of Medicine, New Haven, CT (M.L.S.)
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Schilsky ML, Roberts EA, Bronstein JM, Dhawan A, Hamilton JP, Rivard AM, Washington MK, Weiss KH, Zimbrean PC. A multidisciplinary approach to the diagnosis and management of Wilson disease: Executive summary of the 2022 Practice Guidance on Wilson disease from the American Association for the Study of Liver Diseases. Hepatology 2023; 77:1428-1455. [PMID: 36152019 DOI: 10.1002/hep.32805] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 12/08/2022]
Affiliation(s)
- Michael L Schilsky
- Medicine and Surgery , Yale University School of Medicine , New Haven , Connecticut , USA
| | - Eve A Roberts
- Paediatrics, Medicine, Pharmacology and Toxicology , University of Toronto , Toronto , Ontario , Canada
| | - Jeff M Bronstein
- Neurology , University of California Los Angeles , Los Angeles , California , USA
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre and MowatLabs , King's College Hospital , London , UK
| | - James P Hamilton
- Medicine , Johns Hopkins University School of Medicine , Baltimore , Maryland , USA
| | - Anne Marie Rivard
- Food and Nutrition Services , Yale New Haven Hospital , New Haven , Connecticut , USA
| | - Mary Kay Washington
- Pathology, Immunology and Microbiology , Vanderbilt University Medical Center , Nashville , Tennessee , USA
| | | | - Paula C Zimbrean
- Psychiatry , Yale University School of Medicine , New Haven , Connecticut , USA
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Camarata MA, Ala A, Coskun AK, Deng Y, Embel VK, Gonzalez-Peralta R, Maciejewski KR, Patel A, Rubman S, To U, Tomlin R, Schilsky ML, Zimbrean PC. Major Depressive Disorder in an International Multisite Wilson Disease Registry. J Acad Consult Liaison Psychiatry 2023; 64:106-117. [PMID: 36521682 DOI: 10.1016/j.jaclp.2022.12.001] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/13/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Psychiatric symptoms are frequently reported in Wilson disease (WD); however, systematic assessments with validated measures are lacking. OBJECTIVE We aim to report the prevalence and clinical correlates for major depressive disorder (MDD) as resulting from a multisite international WD registry. METHODS All patients enrolled in the WD registry received structured psychiatric evaluations (Mini International Neuropsychiatric Interview, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7 scale, Perceived Stress Scale), laboratory tests, hepatology, and neurological assessments. We present the analysis of the data collected at enrollment for the first 3 years (N = 62). RESULTS Thirty-seven percent (23) had a lifetime history (MDD), and 6% (4) met the criteria for an active major depressive episode. Depression was self-reported in 30.51% (19) at WD diagnosis. Patients with MDD had worse mental health quality-of-life (QOL) scores (median 43 vs 53.6, P = 0.006), higher severe anxiety (13.04% vs 0), higher perceived stress (median 18 vs 9, P < 0.003), and higher levels of neuroticism (median 8 vs 5.0, P = 0.002). We found no significant difference in physical health QOL and severity of neurological or liver disease. There was no significant difference in copper parameters or liver tests in those with MDD and without. The limitations of our study consist of the small sample size, the cross-sectional report, and the lack of brain copper measurements. CONCLUSIONS Lifetime MDD is highly prevalent in WD and associated with worse mental health QOL. We did not find a significant association among liver disease, neurological disease laboratory tests, and MDD. Screening for depression should be considered in patients with WD.
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Affiliation(s)
- Michelle A Camarata
- Digestive Diseases, Transplantation and Immunology, Yale University, New Haven, CT; Gastroenterology and Hepatology, Royal Surrey County Hospital, Surrey, United Kingdom
| | - Aftab Ala
- Gastroenterology and Hepatology, Royal Surrey County Hospital, Surrey, United Kingdom; Department of Clinical and Experimental Medicine, University of Surrey, Surrey, United Kingdom; King's College Hospital, Institute of Liver Studies, London, United Kingdom
| | - Ayse K Coskun
- Digestive Diseases, Transplantation and Immunology, Yale University, New Haven, CT
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale University, New Haven, CT
| | - Veysel K Embel
- Digestive Diseases, Transplantation and Immunology, Yale University, New Haven, CT
| | | | | | - Amar Patel
- Neurology, Yale University, New Haven, CT
| | | | - Uyen To
- Digestive Diseases, Transplantation and Immunology, Yale University, New Haven, CT
| | - Ricarda Tomlin
- Digestive Diseases, Transplantation and Immunology, Yale University, New Haven, CT
| | - Michael L Schilsky
- Digestive Diseases, Transplantation and Immunology, Yale University, New Haven, CT
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Schilsky ML, Roberts EA, Bronstein JM, Dhawan A, Hamilton JP, Rivard AM, Washington MK, Weiss KH, Zimbrean PC. A multidisciplinary approach to the diagnosis and management of Wilson disease: 2022 Practice Guidance on Wilson disease from the American Association for the Study of Liver Diseases. Hepatology 2022:01515467-990000000-00207. [PMID: 36151586 DOI: 10.1002/hep.32801] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 01/18/2023]
Affiliation(s)
- Michael L Schilsky
- Medicine and Surgery , Yale University School of Medicine , New Haven , Connecticut , USA
| | - Eve A Roberts
- Paediatrics, Medicine, Pharmacology and Toxicology , University of Toronto , Toronto , Ontario , Canada
| | - Jeff M Bronstein
- Neurology , University of California Los Angeles , Los Angeles , California , USA
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre and MowatLabs , King's College Hospital , London , UK
| | - James P Hamilton
- Medicine , Johns Hopkins University School of Medicine , Baltimore , Maryland , USA
| | - Anne Marie Rivard
- Food and Nutrition Services , Yale New Haven Hospital , New Haven , Connecticut , USA
| | - Mary Kay Washington
- Pathology, Immunology and Microbiology , Vanderbilt University Medical Center , Nashville , Tennessee , USA
| | | | - Paula C Zimbrean
- Psychiatry , Yale University School of Medicine , New Haven , Connecticut , USA
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Schilsky ML, Czlonkowska A, Zuin M, Cassiman D, Twardowschy C, Poujois A, Gondim FDAA, Denk G, Cury RG, Ott P, Moore J, Ala A, D'Inca R, Couchonnal-Bedoya E, D'Hollander K, Dubois N, Kamlin COF, Weiss KH. Trientine tetrahydrochloride versus penicillamine for maintenance therapy in Wilson disease (CHELATE): a randomised, open-label, non-inferiority, phase 3 trial. Lancet Gastroenterol Hepatol 2022; 7:1092-1102. [PMID: 36183738 DOI: 10.1016/s2468-1253(22)00270-9] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Wilson disease is an inherited disorder of copper transport. Whereas penicillamine is used therapeutically to re-establish copper balance, trientine is indicated for patients with penicillamine intolerance. We aimed to compare penicillamine with trientine tetrahydrochloride (TETA4) for maintenance therapy in patients with Wilson disease. METHODS We conducted a randomised, open-label, non-inferiority, phase 3 trial at 15 health-care centres across nine countries (patients were recruited from 13 of these health-care centres across Brazil, Europe, and the USA). We enrolled patients aged 18-75 years with stable Wilson disease who were treated for at least 1 year with penicillamine. Patients entered a 12-week period to determine stability through clinical assessment by site investigators and predefined thresholds for serum non-caeruloplasmin-bound copper (NCC; by an exchangeable copper assay; 25-150 μg/L), 24 h urinary copper excretion (100-900 μg/24 h), and alanine aminotransferase (ALT; <2 × upper limit of normal). Stable patients were randomly assigned (1:1) to continue receiving the maintenance twice daily dose of oral penicillamine or switched mg-for-mg to oral TETA4 centrally with a web-based system using minimisation. The primary endpoint, assessed 24 weeks after randomisation, was NCC by speciation assay. The non-inferiority margin of mean difference in NCC by speciation assay was -50 μg/L, as estimated by a general linear model for repeated visits, adjusted for baseline values. Further data on safety and efficacy were collected during a 24-week extension period. Data were analysed using an intention-to-treat approach. Safety was assessed in all patients who received at least one dose of study treatment. This study is registered with ClinicalTrials.gov, NCT03539952 (active, not recruiting). FINDINGS Between June 4, 2018, and March 10, 2020, 77 patients were screened. 53 patients were randomly assigned (27 to the penicillamine group and 26 to the TETA4 group). After 24 weeks, the mean difference in serum NCC by speciation assay between the penicillamine group and TETA4 group was -9·1 μg/L (95% CI -24·2 to 6·1), with the lower limit of the 95% CI within the defined non-inferiority margin. At 24 weeks, urinary copper excretion was lower with TETA4 than with penicillamine (mean difference 237·5 μg/24 h (99% CI 115·6 to 359·4). At 48 weeks, TETA4 remained non-inferior to penicillamine in terms of NCC by speciation assay (mean difference NCC -15·5 μg/L [95% CI -34·5 to 3·6]). Urinary copper excretion at 48 weeks remained in the expected range for well treated patients in both study groups, and the mean difference (124·8 μg/24 h [99% CI -37·6 to 287·1]) was not significantly different. At 24 weeks and 48 weeks, masked clinical adjudication of stability assessed by three independent clinicians confirmed clinical stability (100%) of all participants, in agreement with the stability seen with the NCC by speciation assay. There were no notable changes in either the Clinical Global Impression of Change or Unified Wilson Disease Rating Scale (neurological assessment) from baseline (pre-randomisation) at weeks 24 and 48. The mean change in serum total copper from baseline to 24 weeks was 17·6 μg/L (99% CI -9·5 to 44·7) with penicillamine and -6·3 μg/L (-34·7 to 22·1) with TETA4, and the mean change in serum total caeruloplasmin from baseline to 24 weeks was 1·8 mg/L (-19·2 to 22·8) with penicillamine and -2·2 mg/L (-6·1 to 1·7) with TETA4. All liver enzymes were similar at 24 weeks and 48 weeks, with the exception of elevated ALT concentration at 48 weeks for patients in the TETA4 group. Penicillamine was associated with three post-randomisation serious adverse events (leukopenia, cholangiocarcinoma, and hepatocellular cancer); none were reported for TETA4. The most common treatment-emergent adverse events were headache for penicillamine (five [19%] of 27 patients vs two [8%] of 26) and abdominal pain for TETA4 (one [4%] vs four [15%]); all treatment-emergent adverse events resolved and were mild to moderate. One patient developed a rash with TETA4 that resolved on discontinuation of therapy. INTERPRETATION The efficacy of TETA4 as oral maintenance therapy was non-inferior to penicillamine and well tolerated in adults with Wilson disease. FUNDING Orphalan.
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Affiliation(s)
- Michael L Schilsky
- Department of Medicine, Section of Digestive Diseases, and Department of Surgery, Section of Transplant and Immunology, Yale School of Medicine, New Haven, CT, USA.
| | - Anna Czlonkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Massimo Zuin
- UO Medicina Generale Epatologia e Gastroenterologia Medica ASST Santi Paolo e Carlo, Milano, Italy
| | - David Cassiman
- Department of Gastroenterology-Hepatology and Department of Chronic Diseases and Metabolism, University Hospitals, Leuven, Belgium
| | | | - Aurelia Poujois
- Département de Neurologie, Centre de Référence de la Maladie de Wilson, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | | | - Gerald Denk
- Medizinische Klinik und Poliklinik II/Transplantation Center, LMU Klinikum, München, Germany
| | - Rubens G Cury
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Peter Ott
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Aftab Ala
- Department of Gastroenterology and Hepatology, Royal Surrey NHS Foundation Trust, Surrey, UK; Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK; Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Renata D'Inca
- UOC Gastroenterologia Azienda Ospedaliera di Padova, Padova, Italy
| | - Eduardo Couchonnal-Bedoya
- Hospices Civils de Lyon - Hôpital Femme Mère Enfant - Hépatologie, Gastroentérologie et Nutrition Pédiatrique, Centre de Référence de la Maladie de Wilson, Bron, France
| | | | | | | | - Karl Heinz Weiss
- Department of Internal Medicine, Salem Medical Center, Heidelberg, Germany
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Pashankar DS, Brown T, Votto P, Follo M, Formica RN, Schilsky ML, Mulligan DC, Khokhar B. Sustained Improvement in Patient Experience by Optimizing Patient Flow in Ambulatory Settings. J Patient Exp 2022; 9:23743735221092610. [PMID: 35402702 PMCID: PMC8990690 DOI: 10.1177/23743735221092610] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Patient experience has become a priority for healthcare institutions as it
affects clinical quality of care, financial reimbursement, provider, and patient
satisfaction. We report our experience of improving patient experience measured
by Press Ganey surveys in a busy multidisciplinary clinic over 65 months. We
optimized patient flow in the clinic by technology-facilitated communication
among the clinic staff and by a modest space redesign. We noted a significant
improvement in “clinic visit” scores from baseline of 82.1 to 84.6 at year 1,
86.1 at year 2, 88.7 at year 3, and 88.9 at year 4
(P < .001). In comparison with previous short-term studies,
we were able to sustain improvement in patient experience scores over 4 years
due to optimized patient flow and monitoring of clinic operations. A similar
approach can be implemented in other ambulatory settings and is likely to cause
a long-term positive impact on patient experience.
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Affiliation(s)
| | - Troy Brown
- Yale New Haven Transplantation Center, Yale School of Medicine, New Haven, CT, USA
| | - Paul Votto
- Clinical Optimization Service, Yale Medicine, New Haven, CT, USA
| | - Marie Follo
- Ambulatory Operations, Yale Medicine, New Haven, CT, USA
| | - Richard N Formica
- Yale New Haven Transplantation Center, Yale School of Medicine, New Haven, CT, USA
| | - Michael L Schilsky
- Yale New Haven Transplantation Center, Yale School of Medicine, New Haven, CT, USA
| | - David C Mulligan
- Yale New Haven Transplantation Center, Yale School of Medicine, New Haven, CT, USA
| | - Babar Khokhar
- Clinical Optimization Service, Yale Medicine, New Haven, CT, USA
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Ge EJ, Bush AI, Casini A, Cobine PA, Cross JR, DeNicola GM, Dou QP, Franz KJ, Gohil VM, Gupta S, Kaler SG, Lutsenko S, Mittal V, Petris MJ, Polishchuk R, Ralle M, Schilsky ML, Tonks NK, Vahdat LT, Van Aelst L, Xi D, Yuan P, Brady DC, Chang CJ. Connecting copper and cancer: from transition metal signalling to metalloplasia. Nat Rev Cancer 2022; 22:102-113. [PMID: 34764459 PMCID: PMC8810673 DOI: 10.1038/s41568-021-00417-2] [Citation(s) in RCA: 431] [Impact Index Per Article: 215.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 12/25/2022]
Abstract
Copper is an essential nutrient whose redox properties make it both beneficial and toxic to the cell. Recent progress in studying transition metal signalling has forged new links between researchers of different disciplines that can help translate basic research in the chemistry and biology of copper into clinical therapies and diagnostics to exploit copper-dependent disease vulnerabilities. This concept is particularly relevant in cancer, as tumour growth and metastasis have a heightened requirement for this metal nutrient. Indeed, the traditional view of copper as solely an active site metabolic cofactor has been challenged by emerging evidence that copper is also a dynamic signalling metal and metalloallosteric regulator, such as for copper-dependent phosphodiesterase 3B (PDE3B) in lipolysis, mitogen-activated protein kinase kinase 1 (MEK1) and MEK2 in cell growth and proliferation and the kinases ULK1 and ULK2 in autophagy. In this Perspective, we summarize our current understanding of the connection between copper and cancer and explore how challenges in the field could be addressed by using the framework of cuproplasia, which is defined as regulated copper-dependent cell proliferation and is a representative example of a broad range of metalloplasias. Cuproplasia is linked to a diverse array of cellular processes, including mitochondrial respiration, antioxidant defence, redox signalling, kinase signalling, autophagy and protein quality control. Identifying and characterizing new modes of copper-dependent signalling offers translational opportunities that leverage disease vulnerabilities to this metal nutrient.
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Affiliation(s)
- Eva J Ge
- Department of Chemistry, University of California, Berkeley, Berkeley, CA, USA
| | - Ashley I Bush
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC, Australia
| | - Angela Casini
- Chair of Medicinal and Bioinorganic Chemistry, Department of Chemistry, Technical University of Munich, Garching, Germany
| | - Paul A Cobine
- Department of Biological Sciences, Auburn University, Auburn, AL, USA
| | - Justin R Cross
- Donald B. and Catherine C. Marron Cancer Metabolism Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gina M DeNicola
- Department of Cancer Physiology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Q Ping Dou
- Department of Oncology, School of Medicine, Wayne State University, Detroit, MI, USA
- Department of Pharmacology, School of Medicine, Wayne State University, Detroit, MI, USA
- Department of Pathology, School of Medicine, Wayne State University, Detroit, MI, USA
- Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | | | - Vishal M Gohil
- Department of Biochemistry and Biophysics, Texas A&M University, College Station, TX, USA
| | - Sanjeev Gupta
- Department of Medicine, Albert Einstein College of Medicine, New York, NY, USA
- Department of Pathology, Albert Einstein College of Medicine, New York, NY, USA
- Marion Bessin Liver Research Center, Albert Einstein College of Medicine, New York, NY, USA
- Diabetes Research Center, Albert Einstein College of Medicine, New York, NY, USA
- Irwin S. and Sylvia Chanin Institute for Cancer Research, Albert Einstein College of Medicine, New York, NY, USA
- Ruth L. and David S. Gottesman Institute for Stem Cell and Regenerative Medicine Research, Albert Einstein College of Medicine, New York, NY, USA
| | - Stephen G Kaler
- Center for Gene Therapy, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
| | - Svetlana Lutsenko
- Department of Physiology, Johns Hopkins Medical Institutes, Baltimore, MD, USA
| | - Vivek Mittal
- Department of Cardiothoracic Surgery, Neuberger Berman Foundation Lung Cancer Research Center, Weill Cornell Medicine, New York, NY, USA
- Department of Cell and Developmental Biology, Weill Cornell Medicine, New York, NY, USA
| | - Michael J Petris
- Department of Biochemistry, University of Missouri, Columbia, MO, USA
- Department of Ophthalmology, University of Missouri, Columbia, MO, USA
- Genetics Area Program, University of Missouri, Columbia, MO, USA
- Christopher S. Bond Life Science Center, University of Missouri, Columbia, MO, USA
| | | | - Martina Ralle
- Department of Molecular and Medical Genetics, Oregon Health and Sciences University, Portland, OR, USA
| | - Michael L Schilsky
- Section of Transplantation and Immunology, Division of Digestive Diseases, Department of Medicine and Surgery, Yale University Medical Center, New Haven, CT, USA
| | | | - Linda T Vahdat
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Dan Xi
- National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Peng Yuan
- Center for the Investigation of Membrane Excitability Diseases, Washington University School of Medicine, St Louis, MI, USA
- Department of Cell Biology and Physiology, Washington University School of Medicine, St Louis, MI, USA
| | - Donita C Brady
- Department of Cancer Biology, University of Pennsylvania, Philadelphia, PA, USA.
- Abramson Family Cancer Research Institute, University of Pennsylvania, Philadelphia, PA, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Christopher J Chang
- Department of Chemistry, University of California, Berkeley, Berkeley, CA, USA.
- Department of Molecular and Cell Biology, University of California, Berkeley, Berkeley, CA, USA.
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10
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Ott P, Ala A, Askari FK, Czlonkowska A, Hilgers R, Poujois A, Roberts EA, Sandahl TD, Weiss KH, Ferenci P, Schilsky ML. Designing Clinical Trials in Wilson's Disease. Hepatology 2021; 74:3460-3471. [PMID: 34320232 PMCID: PMC9291486 DOI: 10.1002/hep.32074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/29/2021] [Accepted: 07/14/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Wilson's disease (WD) is an autosomal-recessive disorder caused by ATP7B gene mutations leading to pathological accumulation of copper in the liver and brain. Adoption of initial treatments for WD was based on empirical observations. These therapies are effective, but there are still unmet needs for which treatment modalities are being developed. An increase of therapeutical trials is anticipated. APPROACH AND RESULTS The first Wilson Disease Aarhus Symposium (May 2019) included a workshop on randomized clinical trial design. The authors of the article were organizers or presented during this workshop, and this article presents their consensus on the design of clinical trials for WD, addressing trial population, treatment comparators, inclusion and exclusion criteria, and treatment endpoints. To achieve adequate recruitment of patients with this rare disorder, the study groups should include all clinical phenotypes and treatment-experienced as well as treatment-naïve patients. CONCLUSIONS The primary study endpoint should be clinical or a composite endpoint until appropriate surrogate endpoints are validated. Standardization of clinical trials will permit pooling of data and allow for better treatment comparisons, as well as reduce the future numbers of patients needed per trial.
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Affiliation(s)
- Peter Ott
- Department of Hepatology and GastroenterologyAarhus UniversityAarhusDenmark
| | - Aftab Ala
- Department of Gastroenterology and HepatologyThe Royal Surrey NHS Foundation TrustGuildfordUnited Kingdom,Department of Clinical and Experimental MedicineUniversity of SurreyGuildfordUnited Kingdom,Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | | | - Anna Czlonkowska
- Second Department of NeurologyInstitute of Psychiatry and NeurologyWarsawPoland
| | | | - Aurélia Poujois
- Neurology Department and National Reference Centre for Wilson’s DiseaseRothschild Foundation HospitalParisFrance
| | - Eve A. Roberts
- Departments of Paediatrics, Medicine, and Pharmacology and ToxicologyUniversity of TorontoTorontoOntarioCanada
| | | | - Karl Heinz Weiss
- Salem Medical CenterHeidelbergGermany,Department of Internal MedicineIV at University Hospital HeidelbergHeidelbergGermany
| | - Peter Ferenci
- Department of Gastroenterology and HepatologyMedical University of ViennaViennaAustria
| | - Michael L. Schilsky
- Departments of Medicine and SurgeryYale University Medical CenterNew HavenCTUSA
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11
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Ala A, Wilder J, Jonassaint NL, Coffin CS, Brady C, Reynolds A, Schilsky ML. COVID-19 and the Uncovering of Health Care Disparities in the United States, United Kingdom and Canada: Call to Action. Hepatol Commun 2021; 5:1791-1800. [PMID: 34558861 PMCID: PMC8426700 DOI: 10.1002/hep4.1790] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/14/2021] [Accepted: 06/18/2021] [Indexed: 12/24/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic created a crisis that disproportionately affected populations already disadvantaged with respect to access to health care systems and adequate medical care and treatments. Understanding how and where health care disparities are most widespread is an important starting point for exploring opportunities to mitigate such disparities, especially within our patient population with liver disease. In a webinar in LiverLearning, we discussed the impact of the pandemic on the United States, United Kingdom and Canada, highlighting the disproportionate effects on infection rates and death for certain ethnic minorities, those socioeconomically disadvantaged and living in higher density areas, and those working in health care and other essential jobs. We set forth a "call to action" for members of the American Association for the Study of Liver Diseases and the larger community of providers of liver disease care to generate viable solutions to improve access to care and vaccination rates of our patients against COVID-19, and in general help reduce health care disparities and improve the health of disadvantaged populations within their communities. Solutions will likely involve personalized interventions and messaging for communities that honor local leaders and embrace the diverse needs and different cultural sensitivities of our unique patient populations.
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Affiliation(s)
- Aftab Ala
- Institute of Liver StudiesKings College HospitalLondonUnited Kingdom.,Department of Gastroenterology and HepatologyRoyal Surrey NHS Foundation TrustGuildfordUnited Kingdom.,Department of Clinical and Experimental MedicineFHMSUniversity of SurreyGuildfordUnited Kingdom
| | - Julius Wilder
- Department of MedicineDivision of GastroenterologyDuke UniversityDurhamNCUSA
| | | | - Carla S Coffin
- Department of MedicineCumming School of MedicineUniversity of CalgaryCalgaryALCanada
| | - Carla Brady
- Department of MedicineDivision of GastroenterologyDuke UniversityDurhamNCUSA
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12
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Fix OK, Blumberg EA, Chang KM, Chu J, Chung RT, Goacher EK, Hameed B, Kaul DR, Kulik LM, Kwok RM, McGuire BM, Mulligan DC, Price JC, Reau NS, Reddy KR, Reynolds A, Rosen HR, Russo MW, Schilsky ML, Verna EC, Ward JW, Fontana RJ. American Association for the Study of Liver Diseases Expert Panel Consensus Statement: Vaccines to Prevent Coronavirus Disease 2019 Infection in Patients With Liver Disease. Hepatology 2021; 74:1049-1064. [PMID: 33577086 PMCID: PMC8014184 DOI: 10.1002/hep.31751] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 02/06/2023]
Abstract
The aim of this document is to provide a concise scientific review of the currently available COVID-19 vaccines and those in development, including mRNA, adenoviral vectors, and recombinant protein approaches. The anticipated use of COVID-19 vaccines in patients with chronic liver disease (CLD) and liver transplant (LT) recipients is reviewed and practical guidance is provided for health care providers involved in the care of patients with liver disease and LT about vaccine prioritization and administration. The Pfizer and Moderna mRNA COVID-19 vaccines are associated with a 94%-95% vaccine efficacy compared to placebo against COVID-19. Local site reactions of pain and tenderness were reported in 70%-90% of clinical trial participants, and systemic reactions of fever and fatigue were reported in 40%-70% of participants, but these reactions were generally mild and self-limited and occurred more frequently in younger persons. Severe hypersensitivity reactions related to the mRNA COVID-19 vaccines are rare and more commonly observed in women and persons with a history of previous drug reactions for unclear reasons. Because patients with advanced liver disease and immunosuppressed patients were excluded from the vaccine licensing trials, additional data regarding the safety and efficacy of COVID-19 vaccines are eagerly awaited in these and other subgroups. Remarkably safe and highly effective mRNA COVID-19 vaccines are now available for widespread use and should be given to all adult patients with CLD and LT recipients. The online companion document located at https://www.aasld.org/about-aasld/covid-19-resources will be updated as additional data become available regarding the safety and efficacy of other COVID-19 vaccines in development.
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Affiliation(s)
- Oren K Fix
- Elson S. Floyd College of MedicineWashington State UniversitySpokaneWAUSA
| | | | - Kyong-Mi Chang
- University of PennsylvaniaPhiladelphiaPAUSA.,The Corporal Michael J. Crescenz VA Medical CenterPhiladelphiaPAUSA
| | - Jaime Chu
- Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mark W Russo
- Atrium HealthCarolinas Medical CenterCharlotteNCUSA
| | | | | | - John W Ward
- Coalition for Global Hepatitis EliminationDecaturGAUSA
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13
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Stravitz RT, Fontana RJ, Meinzer C, Durkalski V, Hanje AJ, Olson J, Koch D, Hamid B, Schilsky ML, McGuire B, Ganger D, Liou I, Karvellas CJ, Rule JA, Lisman T, Clasen K, Reuben A, Cripps MW, Lee WM. Coagulopathy, Bleeding Events, and Outcome According to Rotational Thromboelastometry in Patients With Acute Liver Injury/Failure. Hepatology 2021; 74:937-949. [PMID: 33636020 PMCID: PMC10668528 DOI: 10.1002/hep.31767] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/01/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Patients with acute liver injury or failure (ALI/ALF) experience bleeding complications uncommonly despite an abnormal hemostatic profile. Rotational thromboelastometry (ROTEM), which assesses clot formation in whole blood, was used to determine the nature of abnormal hemostasis and whether it contributes to bleeding events, illness severity, or survival. APPROACH AND RESULTS A total of 200 patients were recruited from sites of the ALF Study Group. Blood collected daily for up to 5 days was analyzed using ROTEM delta devices. Consistent with standard laboratory evidence of hypocoagulability (median international normalized ratio = 2.9 and platelet count = 144 × 109 /L), patients frequently exhibited ROTEM parameters outside the normal range (73% and 62% had abnormalities in clot formation from extrinsic and intrinsic clotting cascades, respectively); however, measures of clot stability were generally normal. Eighteen patients (9%) experienced bleeding events, in whom clot initiation, assembly, and firmness were more severely deranged than patients without bleeding. Abnormal ROTEM parameters were more frequently observed in patients with non-acetaminophen ALI/ALF than those with acetaminophen ALI/ALF (clot initiation [P < 0.001], assembly [P = 0.02], firmness at 10 minutes [P = 0.05], and maximal firmness [P = 0.06]). Patients with more severe systemic complications (high-grade hepatic encephalopathy and need for renal replacement therapy) also had a higher incidence of abnormal ROTEM parameters. Finally, more hypocoagulable ROTEM parameters (clot initiation (P = 0.005), stiffness at 10 minutes (P = 0.05), and maximal stiffness by fibrin assembly (P = 0.004)) were observed in patients who died or underwent liver transplantation than those who survived with their native liver. CONCLUSIONS In patients with ALI/ALF, abnormal ROTEM parameters are frequent and proportional to disease severity. Whether the increased bleeding risk associated with abnormal ROTEM indicates hemostatic failure or is a proxy for disease severity requires additional study.
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Affiliation(s)
- RT Stravitz
- Hume-Lee Transplant Center of Virginia Commonwealth University, Richmond, VA
| | - RJ Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - C Meinzer
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - V Durkalski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - AJ Hanje
- Department of Medicine, The Ohio State University, Columbus, OH
| | - J Olson
- Division of Gastroenterology, University of Kansas Medical Center, Kansas City, KS
| | - D Koch
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - B Hamid
- Department of Medicine, University of California at San Francisco, San Francisco, CA
| | - ML Schilsky
- Divisions of Digestive Disease and Transplant and Immunology, Yale University, New Haven, CT
| | - B McGuire
- Division of Gastroenterology, University of Alabama, Birmingham, AL
| | - D Ganger
- Division of Gastroenterology, Northwestern University, Chicago, IL
| | - I Liou
- Department of Medicine, University of Washington, Seattle, WA
| | - CJ Karvellas
- Division of Gastroenterology (Liver Unit) and Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - JA Rule
- Department of Internal Medicine, University of Texas, Southwestern Medical Center, Dallas, TX
| | - T Lisman
- Department of Surgery, University of Groningen, Groningen, The Netherlands
| | - K Clasen
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - A Reuben
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - MW Cripps
- Department of Surgery, University of Texas, Southwestern Medical Center, Dallas, TX
| | - WM Lee
- Department of Internal Medicine, University of Texas, Southwestern Medical Center, Dallas, TX
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14
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Collins CJ, Yi F, Dayuha R, Duong P, Horslen S, Camarata M, Coskun AK, Houwen RHJ, Pop TL, Zoller H, Yoo HW, Jung SW, Weiss KH, Schilsky ML, Ferenci P, Hahn SH. Direct Measurement of ATP7B Peptides Is Highly Effective in the Diagnosis of Wilson Disease. Gastroenterology 2021; 160:2367-2382.e1. [PMID: 33640437 PMCID: PMC8243898 DOI: 10.1053/j.gastro.2021.02.052] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/09/2021] [Accepted: 02/21/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Both existing clinical criteria and genetic testing have significant limitations for the diagnosis of Wilson disease (WD), often creating ambiguities in patient identification and leading to delayed diagnosis and ineffective management. ATP7B protein concentration, indicated by direct measurement of surrogate peptides from patient dried blood spot samples, could provide primary evidence of WD. ATP7B concentrations were measured in patient samples from diverse backgrounds, diagnostic potential is determined, and results are compared with biochemical and genetic results from individual patients. METHODS Two hundred and sixty-four samples from biorepositories at 3 international and 2 domestic academic centers and 150 normal controls were obtained after Institutional Review Board approval. Genetically or clinically confirmed WD patients with a Leipzig score >3 and obligate heterozygote (carriers) from affected family members were included. ATP7B peptide measurements were made by immunoaffinity enrichment mass spectrometry. RESULTS Two ATP7B peptides were used to measure ATP7B protein concentration. Receiver operating characteristics curve analysis generates an area under the curve of 0.98. ATP7B peptide analysis of the sequence ATP7B 887 was found to have a sensitivity of 91.2%, specificity of 98.1%, positive predictive value of 98.0%, and a negative predictive value of 91.5%. In patients with normal ceruloplasmin concentrations (>20 mg/dL), 14 of 16 (87.5%) were ATP7B-deficient. In patients without clear genetic results, 94% were ATP7B-deficient. CONCLUSIONS Quantification of ATP7B peptide effectively identified WD patients in 92.1% of presented cases and reduced ambiguities resulting from ceruloplasmin and genetic analysis. Clarity is brought to patients with ambiguous genetic results, significantly aiding in noninvasive diagnosis. A proposed diagnostic score and algorithm incorporating ATP7B peptide concentrations can be rapidly diagnostic and supplemental to current Leipzig scoring systems.
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Affiliation(s)
| | - Fan Yi
- Seattle Children's Research Institute, Seattle, Washington
| | | | - Phi Duong
- Seattle Children's Research Institute, Seattle, Washington
| | - Simon Horslen
- University of Washington School of Medicine, Seattle, Washington
| | | | - Ayse K Coskun
- Yale University School of Medicine, New Haven, Connecticut
| | - Roderick H J Houwen
- Wilhelmina Children's Hospital, University Medical Center, Utrecht, The Netherlands
| | - Tudor L Pop
- Second Pediatric Clinic, University of Medicine and Pharmacy, Iuliu Hatieganu, Cluj-Napoca, Romania
| | - Heinz Zoller
- Medical University of Innsbruck, Innsbruck, Austria
| | | | - Sung Won Jung
- Gachon University School of Medicine, Incheon, Korea
| | - Karl H Weiss
- Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Si Houn Hahn
- Seattle Children's Research Institute, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington.
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15
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Abstract
Wilson disease (WD) is rare genetic disorder that presents with varied phenotype that can at times make the diagnosis challenging. Medical treatments are available, but there are still unmet needs for patients. Since life-long therapy is necessary, adherence to medical therapy and best practices for monitoring and individualizing therapy continue to evolve. Studies are ongoing that address some of these issues. In the current review we focused our attention to recent advances in the diagnosis of WD, current medical treatments, future potential therapies and treatment monitoring. We include discussion of new methodology for detection and quantitation of ophthalmologic signs of WD, new brain imaging modalities for early detection of neurologic involvement in patients and potential new diagnostic methodology using blood samples that may be applicable to newborn screening and adult disease diagnosis. In addition, there are new strategies aimed at improving adherence and outcomes with currently available therapies, including once daily chelation dosing and discussion of the efficacy of different zinc salt compounds. With respect to new therapies with different mechanisms of action, we discuss studies on Bis-choline tetrathiomolybdate (TTM) in patients, pre-clinical studies of a novel chelator methanobactin and other animal studies exploring cures for WD with gene therapy using adeno-associated vectors (AAVs) that introduce ATP7B into liver cells. There are also promising advances in the more accurate measurement of non-ceruloplasmin bound copper and exchangeable copper in the circulation which would potentially help with monitoring and individualization of treatment and possibly play a role in future disease diagnosis.
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Affiliation(s)
- Maryam Moini
- Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Division of Gastroenterology, University of Toronto, Toronto, Canada
| | - Uyen To
- Department of Medicine and Surgery, Division of Digestive Diseases and Transplantation and Immunology, Yale University, New Haven CT, USA
| | - Michael L Schilsky
- Department of Medicine and Surgery, Division of Digestive Diseases and Transplantation and Immunology, Yale University, New Haven CT, USA
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16
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17
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Merola J, Schilsky ML, Mulligan DC. The Impact of COVID-19 on Organ Donation, Procurement, and Liver Transplantation in the United States. Hepatol Commun 2021; 5:5-11. [PMID: 33043228 PMCID: PMC7537114 DOI: 10.1002/hep4.1620] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/15/2020] [Accepted: 09/19/2020] [Indexed: 12/18/2022] Open
Abstract
The coronavirus disease 2019 pandemic has had an impact on all facets of our health care system, including life-saving procedures like organ transplantation. Concerns for potential exposure to the causative severe acute respiratory syndrome coronavirus type 2 have profoundly altered the process of organ donation and recovery that is vital to the execution of organ transplantation. Issues regarding adequate donor evaluation and consent, organ recovery, organ procurement organization, and donor hospital resources as well as the transplant center's acceptance of organ offers for their candidates have all required new practice paradigms. Consequently, the ability to treat patients with organ failure, in particular patients with end-stage liver disease in whom no temporizing treatments exist, and to obtain expected excellent outcomes for new liver transplant recipients has been challenged during this time. Conclusion: We summarize some of the negative effects of the current pandemic on organ recovery and liver transplantation as well as offer considerations and strategies for their mitigation that could have a lasting impact on the field even after the coronavirus disease 2019 has waned.
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Affiliation(s)
| | - Michael L Schilsky
- Department of SurgeryYale School of MedicineNew HavenCTUSA.,Department of MedicineYale School of MedicineNew HavenCTUSA
| | - David C Mulligan
- Department of SurgeryYale School of MedicineNew HavenCTUSA.,United Network for Organ SharingRichmondVAUSA
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18
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Tinaz S, Arora J, Nalamada K, Vives-Rodriguez A, Sezgin M, Robakis D, Patel A, Constable RT, Schilsky ML. Structural and functional brain changes in hepatic and neurological Wilson disease. Brain Imaging Behav 2020; 15:2269-2282. [PMID: 33244627 DOI: 10.1007/s11682-020-00420-5] [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] [Accepted: 11/09/2020] [Indexed: 12/14/2022]
Abstract
Wilson disease (WD) can manifest with hepatic or neuropsychiatric symptoms. Our understanding of the in vivo brain changes in WD, particularly in the hepatic phenotype, is limited. Thirty subjects with WD and 30 age- and gender-matched controls participated. WD group underwent neuropsychiatric assessment. Unified WD Rating Scale neurological exam scores were used to determine neurological (WDN, score > 0) and hepatic-only (WDH, score 0) subgroups. All subjects underwent 3 Tesla anatomical and resting-state functional MRI. Diffusion tensor imaging (DTI) and susceptibility-weighted imaging (SWI) were performed only in the WD group. Volumetric, DTI, and functional connectivity analyses were performed to determine between-group differences. WDN and WDH groups were matched in demographic and psychiatric profiles. The entire WD group compared to controls showed significant thinning in the bilateral superior frontal cortex. The WDN group compared to control and WDH groups showed prominent structural brain changes including significant striatal and thalamic atrophy, more subcortical hypointense lesions on SWI, and diminished white matter integrity in the bilateral anterior corona radiata and corpus callosum. However, the WDH group also showed significant white matter volume loss compared to controls. The functional connectivity between the frontostriatal nodes was significantly reduced in the WDN group, whereas that of the hippocampus was significantly increased in the WDH group compared to controls. In summary, structural and functional brain changes were present even in neurologically non-manifesting WD patients in this cross-sectional study. Longitudinal brain MRI scans may be useful as biomarkers for prognostication and optimization of treatment strategies in WD.
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Affiliation(s)
- Sule Tinaz
- Department of Neurology, Yale University School of Medicine, 15 York St, LCI Suite 710, New Haven, CT, 06510, USA. .,Clinical Neurosciences Imaging Center, Yale University School of Medicine, New Haven, CT, USA.
| | - Jagriti Arora
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Keerthana Nalamada
- Department of Neurology, Yale University School of Medicine, 15 York St, LCI Suite 710, New Haven, CT, 06510, USA
| | - Ana Vives-Rodriguez
- Department of Neurology, Yale University School of Medicine, 15 York St, LCI Suite 710, New Haven, CT, 06510, USA
| | - Mine Sezgin
- Department of Neurology, Yale University School of Medicine, 15 York St, LCI Suite 710, New Haven, CT, 06510, USA.,Istanbul Faculty of Medicine, Department of Neurology, Istanbul University, Istanbul, Turkey
| | - Daphne Robakis
- Department of Neurology, Yale University School of Medicine, 15 York St, LCI Suite 710, New Haven, CT, 06510, USA.,Department of Neurology, State University of New York Downstate College of Medicine, Brooklyn, NY, USA
| | - Amar Patel
- Department of Neurology, Yale University School of Medicine, 15 York St, LCI Suite 710, New Haven, CT, 06510, USA
| | - R Todd Constable
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Michael L Schilsky
- Departments of Medicine and Surgery, Sections of Digestive Diseases and Transplant and Immunology, Yale University School of Medicine, New Haven, CT, USA
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19
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Glavind E, Gotthardt DN, Pfeiffenberger J, Sandahl TD, Bashlekova T, Willemoe GL, Hasselby JP, Weiss KH, Møller HJ, Vilstrup H, Lee WM, Schilsky ML, Ott P, Grønbæk H. The macrophage activation marker soluble CD163 is elevated and associated with liver disease phenotype in patients with Wilson's disease. Orphanet J Rare Dis 2020; 15:173. [PMID: 32615997 PMCID: PMC7331244 DOI: 10.1186/s13023-020-01452-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 04/05/2020] [Accepted: 06/23/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Macrophages play a significant role in liver disease development and progression. The macrophage activation marker soluble (s)CD163 is associated with severity and prognosis in a number of different acute and chronic liver diseases but has been only sparsely examined in Wilson's disease (WD). We investigated sCD163 levels in patients with acute and chronic WD and hypothesized associations with liver disease phenotype and biochemical markers of liver injury. METHODS We investigated sCD163 in two independent cohorts of WD patients: 28 patients with fulminant WD from the US Acute Liver Failure (ALF) Study Group registry and 147 patients with chronic disease from a German WD registry. We included a control group of 19 healthy individuals. Serum sCD163 levels were measured by ELISA. Liver CD163 expression was determined by immunohistochemistry. RESULTS In the ALF cohort, median sCD163 was 10-fold higher than in healthy controls (14.6(2.5-30.9) vs. 1.5(1.0-2.7) mg/L, p < 0.001). In the chronic cohort, median sCD163 was 2.6(0.9-24.9) mg/L. There was no difference in sCD163 according to subgroups based on initial clinical presentation, i.e. asymptomatic, neurologic, hepatic, or mixed. Patients with cirrhosis at the time of diagnosis had higher sCD163 compared with those without cirrhosis (3.0(1.2-24.9) vs. 2.3(0.9-8.0) mg/L, p < 0.001); and both cohorts significantly lower than the ALF patients. Further, sCD163 correlated positively with ALT, AST, GGT and INR (rho = 0.27-0.53); and negatively with albumin (rho = - 0.37), (p ≤ 0.001, all). We observed immunohistochemical CD163 expression in liver tissue from ALF patients. CONCLUSIONS Although sCD163 is not specific for WD, it was elevated in WD patients, especially in those with ALF. Further, sCD163 was higher in patients with cirrhosis compared to patients without cirrhosis and associated with biochemical markers of liver injury and hepatocellular function. Thus, macrophage activation is evident in WD and associates with liver disease phenotype and biochemical parameters of liver disease. Our findings suggest that sCD163 may be used as a marker of liver disease severity in WD patients.
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Affiliation(s)
- Emilie Glavind
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 99 Palle Juul-Jensens Boulevard, DK-8200, Aarhus N, Denmark.
| | - Daniel N Gotthardt
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Jan Pfeiffenberger
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Damgaard Sandahl
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 99 Palle Juul-Jensens Boulevard, DK-8200, Aarhus N, Denmark
| | - Teodora Bashlekova
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Gro Linno Willemoe
- Department of Pathology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jane Preuss Hasselby
- Department of Pathology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Karl Heinz Weiss
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Holger Jon Møller
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 99 Palle Juul-Jensens Boulevard, DK-8200, Aarhus N, Denmark
| | - William M Lee
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center at Dallas, Dallas, TX, USA
| | | | - Peter Ott
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 99 Palle Juul-Jensens Boulevard, DK-8200, Aarhus N, Denmark
| | - Henning Grønbæk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 99 Palle Juul-Jensens Boulevard, DK-8200, Aarhus N, Denmark
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20
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Fix OK, Hameed B, Fontana RJ, Kwok RM, McGuire BM, Mulligan DC, Pratt DS, Russo MW, Schilsky ML, Verna EC, Loomba R, Cohen DE, Bezerra JA, Reddy KR, Chung RT. Clinical Best Practice Advice for Hepatology and Liver Transplant Providers During the COVID-19 Pandemic: AASLD Expert Panel Consensus Statement. Hepatology 2020; 72:287-304. [PMID: 32298473 PMCID: PMC7262242 DOI: 10.1002/hep.31281] [Citation(s) in RCA: 394] [Impact Index Per Article: 98.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/13/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS Coronavirus disease 2019 (COVID-19), the illness caused by the SARS-CoV-2 virus, is rapidly spreading throughout the world. Hospitals and healthcare providers are preparing for the anticipated surge in critically ill patients, but few are wholly equipped to manage this new disease. The goals of this document are to provide data on what is currently known about COVID-19, and how it may impact hepatologists and liver transplant providers and their patients. Our aim is to provide a template for the development of clinical recommendations and policies to mitigate the impact of the COVID-19 pandemic on liver patients and healthcare providers. APPROACH AND RESULTS This article discusses what is known about COVID-19 with a focus on its impact on hepatologists, liver transplant providers, patients with liver disease, and liver transplant recipients. We provide clinicians with guidance for how to minimize the impact of the COVID-19 pandemic on their patients' care. CONCLUSIONS The situation is evolving rapidly, and these recommendations will need to evolve as well. As we learn more about how the COVID-19 pandemic impacts the care of patients with liver disease, we will update the online document available at https://www.aasld.org/about-aasld/covid-19-and-liver.
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Affiliation(s)
| | - Bilal Hameed
- University of California San FranciscoSan FranciscoCA
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21
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Jaffe A, Schilsky ML, Deshpande R, Batra R. Liver Transplantation in the Time of COVID19: Barriers and Ethical considerations for Management and Next Steps. Hepatol Commun 2020; 4:1242-1256. [PMID: 32838103 PMCID: PMC7361607 DOI: 10.1002/hep4.1568] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/04/2020] [Accepted: 06/19/2020] [Indexed: 12/15/2022] Open
Abstract
The recent outbreak of the novel virus severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2), which causes the corona virus disease of 2019 (COVID19), has spread globally and affects millions of people. This pandemic has taxed our health care system and disrupted normal operations, even life‐saving procedures, such as liver transplants. During these unprecedented times, providers and patients are imperiled and resources for diagnosis and care may be limited. Continuing to perform resource‐intense advanced procedures is challenging, as is caring for patients with end‐stage liver disease or patients with urgent needs for liver tumor control. Liver transplantation, in particular, requires critical resources, like blood products and critical care beds, which are fairly limited in the COVID19 pandemic. The potential of COVID19 infections in posttransplant recipients on immunosuppression and staff contacts further adds to the complexity. Therefore, transplant programs must reevaluate the ethicality, feasibility, and safety of performing liver transplants during this pandemic. Herein, we discuss the clinical and ethical challenges posed by performing liver transplants and offer guidance for managing patients with end‐stage liver disease during the COVID19 pandemic.
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Affiliation(s)
- Ariel Jaffe
- Yale University School of Medicine New Haven United States
| | | | | | - Ramesh Batra
- Yale University School of Medicine New Haven United States
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22
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Camarata MA, Gottfried M, Rule JA, Ala A, Lee WM, Stravitz RT, Schilsky ML. Outcomes of Acute Liver Injury in Adults Due to Wilson's Disease: Is Survival Without Transplant Possible? Liver Transpl 2020; 26:330-336. [PMID: 31838773 PMCID: PMC10668501 DOI: 10.1002/lt.25703] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/26/2019] [Indexed: 12/12/2022]
Abstract
Wilson's disease (WD) is a rare cause of acute liver failure (ALF) that is thought to have a uniformly fatal outcome without liver transplantation (LT). Previous studies proposed diagnostic and prognostic criteria for WD-ALF. It is not known whether these apply to WD patients presenting as severe acute liver injury (ALI) without encephalopathy. From 2008 to 2018, 822 patients with ALI in the US Acute Liver Failure Study Group (ALFSG) registry were enrolled and prospectively followed. The diagnosis of WD-ALI was confirmed in 8 patients. Serum biochemical diagnostic ratios predicting WD-ALF (alkaline phosphatase [ALP]:total bilirubin(TB) and aspartate aminotransferase [AST]:alanine aminotransferase [ALT]) were determined in these patients, and predictors of prognosis for WD-ALI were evaluated. Of these 8 ALI-WD patients, 5 received an LT. Ratios of both ALP:TB of <4 and AST:ALT of >2.2 on study admission were met in 4 LT patients. All LT patients were female. The Model for End-Stage Liver Disease scores on admission were generally higher in LT patients. All transplanted patients had an initial revised WD score of >11 (>10 predicting poor outcome without LT in WD-ALF), whereas in non-LT patients, 2 had scores of 9, and 1 a score of 13. Also, 3 LT patients were started on chelation therapy, 2 were started on plasmapheresis, and 1 was started on Molecular Adsorbent Recirculating System therapy. All non-LT patients were treated with chelation. At 21 days, all patients were alive and discharged from the hospital. In conclusion, some patients with ALI due to WD may survive without LT. Revised Wilson index scores >10 predict poor outcome in most patients with WD-ALI, as they do for WD-ALF, and they correlate positively with the ALI model in this cohort. Biochemical ratios for WD diagnosis appear more applicable to ALF compared with WD-ALI.
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Affiliation(s)
- Michelle A. Camarata
- Digestive Diseases and Transplantation and Immunology, Department of Medicine and Surgery, Yale University Medical Center, New Haven, CT
- Department of Gastroenterology and Hepatology, Royal Surrey County Hospital, Guildford, United Kingdom
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, United Kingdom
| | - Michelle Gottfried
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Jody A. Rule
- Division of Digestive and Liver Disease, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Aftab Ala
- Department of Gastroenterology and Hepatology, Royal Surrey County Hospital, Guildford, United Kingdom
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, United Kingdom
- Institute of Liver Studies, King’s College Hospital, London, United Kingdom
| | - William M. Lee
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC
| | - R. Todd Stravitz
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Michael L. Schilsky
- Digestive Diseases and Transplantation and Immunology, Department of Medicine and Surgery, Yale University Medical Center, New Haven, CT
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23
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Camarata MA, Ala A, Schilsky ML. Zinc Maintenance Therapy for Wilson Disease: A Comparison Between Zinc Acetate and Alternative Zinc Preparations. Hepatol Commun 2019; 3:1151-1158. [PMID: 31388634 PMCID: PMC6671772 DOI: 10.1002/hep4.1384] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 05/06/2019] [Indexed: 12/15/2022] Open
Abstract
We evaluate Wilson disease (WD) treatment with zinc acetate (U.S. Food and Drug Administration approved) and alternative zinc salts. Studies examining zinc therapy in WD are few, and data on alternative zinc salts are limited. We describe one of the largest recent studies of zinc therapy in WD. First, we conducted a single‐center retrospective review of 59 patients with WD (age 6‐88 years, 32 female patients) treated with zinc (50‐150 mg) for 0.8 to 52 years (median, 26 years); most were on prior chelation therapy (n = 39). Second, we developed a survey to explore patients' zinc therapy experience. Primary endpoints were alamine aminotransferase (ALT) and urine copper excretion (µg/24 hours). Urine copper was categorized as low <25 μg (possible overtreatment), target 25‐100 μg, or elevated >100 μg (possible noncompliance or treatment failure). The target range was reached in 81% of patients on zinc acetate, 73% on zinc gluconate, and 57% on alternative zinc. Low urine copper was not associated with a high ALT. ALT was normal in 77% of patients with target urine copper but only in 16% with urine copper >100 µg. ALT elevations were not significantly different between zinc salts (Kruskal‐Wallis, P = 0.26). Our survey demonstrated the mean age of starting zinc was 26.8 years (3.5‐65 years); most were treated with zinc acetate (45%) and zinc gluconate (42%). Before zinc treatment, 45% of patients were symptomatic; the majority of patients (80%) were asymptomatic on zinc. Gastrointestinal side effects were the predominant reason for changing zinc salts (38%), but most reported no side effects on current zinc therapy (67%). Conclusion: Effective treatment with zinc is possible in many patients with WD. The potential for treatment failure suggests close monitoring and consideration of alternative treatments are paramount for those without both a normal serum ALT and appropriate urine copper excretion. We describe one of the largest recent studies of Zn therapy in WD and include data on alternative Zn salts which is lacking thus far. In clinical practice, due to issues of intolerance and increased cost of WD medications, many patients have gravitated towards alternative Zn salts, some purchasing non‐prescription Zn over‐the‐counter. An understanding of the potential utility of different Zn preparations and required monitoring will provide benefit in expanding and optimizing treatment options for patients with WD.
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Affiliation(s)
- Michelle A Camarata
- Departments of Medicine and Surgery, Division of Digestive Diseases and Transplantation and Immunology Yale University Medical Center New Haven CT.,Department of Clinical and Experimental Medicine University of Surrey Guildford United Kingdom.,Department of Gastroenterology and Hepatology Royal Surrey County Hospital National Health Service Foundation Trust Guildford United Kingdom
| | - Aftab Ala
- Department of Clinical and Experimental Medicine University of Surrey Guildford United Kingdom.,Department of Gastroenterology and Hepatology Royal Surrey County Hospital National Health Service Foundation Trust Guildford United Kingdom.,Institute of Liver Studies King's College Hospital London United Kingdom
| | - Michael L Schilsky
- Departments of Medicine and Surgery, Division of Digestive Diseases and Transplantation and Immunology Yale University Medical Center New Haven CT
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24
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Abstract
Three guidelines in Wilson disease (WD) have been issued to date: by the American Association for the Study of Liver Diseases (AASLD) in 2003 with revision in 2008, by the European Association for the Study of the Liver (EASL) in 2012, and most recently by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) in 2018. The following review aims to compare and contrast the approach to diagnosis and management of WD outlined in each guidance. Diagnostic criteria for WD are variable, with the AASLD proposing a clinical/biochemical algorithmic approach, while EASL and ESPGHAN favor use of the Leipzig score. Screening of first-degree relatives differs in modality: clinical and genetic testing in AASLD and ESPGHAN, versus genetic testing alone in EASL. There is general consensus regarding treatment of WD, though ESPGHAN favors zinc over chelators in maintenance phase and for asymptomatic patients. Liver transplantation is indicated in cases of acute liver failure (ALF) due to WD, but not primarily for neuropsychiatric disease in all guidelines. EASL and ESPGHAN advocate for use of the revised King's score to guide transplant listing. There are limited recommendations on special circumstances including pregnancy, surgery, and malignancy risk in WD. Though current recommendations address the management of liver disease due to WD, future guidelines may include a more detailed discussion of neurological and psychiatric manifestations of WD.
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Affiliation(s)
- Chiara Saroli Palumbo
- Department of Medicine and Surgery, Division of Digestive Diseases, Section of Transplantation and Immunology, Yale University Medical Center, New Haven, CT, USA
| | - Michael L Schilsky
- Department of Medicine and Surgery, Division of Digestive Diseases, Section of Transplantation and Immunology, Yale University Medical Center, New Haven, CT, USA
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25
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Abstract
Wilson disease (WD) is a potentially treatable, inherited disorder of copper metabolism that is characterized by the pathological accumulation of copper. WD is caused by mutations in ATP7B, which encodes a transmembrane copper-transporting ATPase, leading to impaired copper homeostasis and copper overload in the liver, brain and other organs. The clinical course of WD can vary in the type and severity of symptoms, but progressive liver disease is a common feature. Patients can also present with neurological disorders and psychiatric symptoms. WD is diagnosed using diagnostic algorithms that incorporate clinical symptoms and signs, measures of copper metabolism and DNA analysis of ATP7B. Available treatments include chelation therapy and zinc salts, which reverse copper overload by different mechanisms. Additionally, liver transplantation is indicated in selected cases. New agents, such as tetrathiomolybdate salts, are currently being investigated in clinical trials, and genetic therapies are being tested in animal models. With early diagnosis and treatment, the prognosis is good; however, an important issue is diagnosing patients before the onset of serious symptoms. Advances in screening for WD may therefore bring earlier diagnosis and improvements for patients with WD.
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Affiliation(s)
- Anna Członkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland.
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland.
| | - Tomasz Litwin
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Petr Dusek
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Peter Ferenci
- Internal Medicine 3, Department of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Svetlana Lutsenko
- Department of Physiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Valentina Medici
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA
| | - Janusz K Rybakowski
- Department of Adult Psychiatry, Poznań University of Medical Sciences, Poznań, Poland
| | - Karl Heinz Weiss
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael L Schilsky
- Section of Digestive Diseases and Transplantation and Immunology, Department of Medicine and Surgery, Yale University School of Medicine, New Haven, CT, USA
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26
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Schilsky ML. Getting Better With Age and Time: A Look Back at the European Experience for Liver Transplantation for Pediatric Patients With Wilson's Disease. Liver Transpl 2018; 24:1169-1170. [PMID: 30021047 DOI: 10.1002/lt.25306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 07/09/2018] [Indexed: 01/13/2023]
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27
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Pfeiffenberger J, Beinhardt S, Gotthardt DN, Haag N, Freissmuth C, Reuner U, Gauss A, Stremmel W, Schilsky ML, Ferenci P, Weiss KH. Pregnancy in Wilson's disease: Management and outcome. Hepatology 2018; 67:1261-1269. [PMID: 28859232 DOI: 10.1002/hep.29490] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 07/12/2017] [Accepted: 08/29/2017] [Indexed: 12/19/2022]
Abstract
UNLABELLED Wilson's disease (WD) is a rare inherited disorder of copper metabolism causing toxic hepatic and neural copper accumulation. Clinical symptoms vary widely, from asymptomatic disease to acute liver failure or chronic liver disease with or without neuropsychiatric symptoms. Continuation of specific medical treatment for WD is recommended during pregnancy, but reports of pregnancy outcomes in WD patients are sparse. In a retrospective, multicenter study, 282 pregnancies in 136 WD patients were reviewed. Age at disease onset, age at conception, and WD-specific treatments were recorded. Maternal complications during pregnancy, rate of spontaneous abortions, and birth defects were analyzed with respect to medical treatment during pregnancy. Worsening of liver function tests was evident during 16 of 282 (6%) pregnancies and occurred in undiagnosed patients as well as in those under medical treatment. Liver test abnormalities resolved in all cases after delivery. Aggravation of neurological symptoms during pregnancy was rare (1%), but tended to persist after delivery. The overall spontaneous abortion rate in the study cohort was 73 of 282 (26%). Patients with an established diagnosis of WD receiving medical treatment experienced significantly fewer spontaneous abortions than patients with undiagnosed WD (odds ratio, 2.853 [95% confidence interval, 1.634-4.982]). Birth defects occurred in 7 of 209 (3%) live births. CONCLUSION Pregnancy in WD patients on anticopper therapy is safe. The spontaneous abortion rate in treated patients was lower than that in therapy-naïve patients. Although the teratogenic potential of copper chelators is a concern, the rate of birth defects in our cohort was low. Treatment for WD should be maintained during pregnancy, and patients should be monitored closely for hepatic and neurological symptoms. (Hepatology 2018;67:1261-1269).
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Affiliation(s)
- Jan Pfeiffenberger
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sandra Beinhardt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Daniel N Gotthardt
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Nicola Haag
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Clarissa Freissmuth
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Ulrike Reuner
- Department of Neurology, University Hospital Dresden, Dresden, Germany
| | - Annika Gauss
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Wolfgang Stremmel
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael L Schilsky
- Sections of Digestive Disease and Transplantation and Immunology, Departments of Medicine and Surgery, Yale University School of Medicine, New Haven, CT
| | - Peter Ferenci
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Karl Heinz Weiss
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
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28
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DeMartini KS, Schilsky ML, Palmer A, Fehon DC, Zimbrean P, O'Malley SS, Lee HB, Toll BA. Text Messaging to Reduce Alcohol Relapse in Prelisting Liver Transplant Candidates: A Pilot Feasibility Study. Alcohol Clin Exp Res 2018; 42:761-769. [PMID: 29498753 DOI: 10.1111/acer.13603] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 07/26/2017] [Accepted: 01/22/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Many liver transplantation programs require documented alcohol sobriety prior to United Network for Organ Sharing (UNOS) listing. This pilot study examined the feasibility of the first mobile, alcohol relapse prevention intervention for liver transplant patients with alcoholic liver disease (ALD). METHODS This was a randomized 8-week pilot feasibility trial of a text message-based alcohol intervention. In-treatment assessment was conducted at 4 weeks (4W), and immediate posttreatment assessment was conducted at 8W. Participants were liver transplant candidates (N = 15) diagnosed with ALD who reported at least 1 drinking episode in the past year. Primary feasibility outcomes were percent of messages responded to and posttreatment intervention satisfaction ratings. Preliminary clinical efficacy outcomes were any biologically confirmed alcohol consumption, stress, abstinence self-efficacy, and alcohol craving. RESULTS On feasibility outcomes, participants responded to 81% of messages received and reported high rates of intervention satisfaction, looked forward to receiving the messages, and found it easy to complete the intervention. On preliminary efficacy outcomes, zero participants in the text message (TM) had positive urine alcohol tests at 8W. Two of the 6 participants in standard care (SC) tested positive at 8W. No effects were seen on craving. For stress, a condition × time interaction emerged. TM participants had less stress at 4W and 8W compared with SC at baseline. They maintained their stress level during the intervention. For self-efficacy, a trend for condition effect emerged. TM participants had higher self-efficacy than SC participants. CONCLUSIONS Participants reported high satisfaction with the intervention, looked forward to the messages, and found it easy to complete. Participants who received the intervention had better treatment outcomes than those who received standard care. They maintained higher levels of self-efficacy and lower stress. Mobile alcohol interventions may hold significant promise to help ALD liver transplant patients maintain sobriety.
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Affiliation(s)
- Kelly S DeMartini
- Department of Psychiatry, Smilow Cancer Hospital at Yale, Yale School of Medicine, New Haven, Connecticut
| | - Michael L Schilsky
- Departments of Medicine and Surgery, Divisions of Digestive Diseases and Transplantation and Immunology, Yale-New Transplantation Center, Yale School of Medicine, New Haven, Connecticut
| | - Amanda Palmer
- Moffitt Cancer Center, University of South Florida, Tampa, Florida
| | - Dwain C Fehon
- Liver Transplantation Center, Yale-New Haven Hospital, New Haven, Connecticut
| | - Paula Zimbrean
- Liver Transplantation Center, Yale-New Haven Hospital, New Haven, Connecticut
| | | | - Hochang B Lee
- Department of Psychological Medicine, Yale-New Haven Hospital, New Haven, Connecticut
| | - Benjamin A Toll
- Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina
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29
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30
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Torres-Landa S, Muñoz-Abraham AS, Fortune BE, Gurung A, Pollak J, Emre SH, Rodriguez-Davalos MI, Schilsky ML. De-novo hepatocellular carcinoma after pediatric living donor liver transplantation. World J Hepatol 2017; 9:1361-1366. [PMID: 29359020 PMCID: PMC5756726 DOI: 10.4254/wjh.v9.i36.1361] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/22/2017] [Accepted: 12/08/2017] [Indexed: 02/06/2023] Open
Abstract
De-novo malignancies carry an incidence ranging between 3%-26% after transplant and account for the second highest cause of post-transplant mortality behind cardiovascular disease. While the majority of de-novo malignancies after transplant usually consist of skin cancers, there has been an increasing rate of solid tumor cancers over the last 15 years. Although, recurrence of hepatocellular carcinoma (HCC) is well understood among patients transplanted for HCC, there are increasing reports of de-novo HCC in those transplanted for a non-HCC indication. The proposed pathophysiology for these cases has been mainly connected to the presence of advanced graft fibrosis or cirrhosis and always associated with the presence of hepatitis B or C virus. We report the first known case of de-novo HCC in a recipient, 14 years after a pediatric living related donor liver transplantation for end-stage liver disease due to biliary atresia without the presence of hepatitis B or C virus before and after transplant. We present this case report to increase the awareness of this phenomenon and address on the utility for screening and surveillance of hepatocellular carcinoma among these individuals. One recommendation is to use similar guidelines for screening, diagnosis, and treatment for HCC as those used for primary HCC in the pre-transplant patient, focusing on those recipients who have advanced fibrosis in the allograft, regardless of etiology.
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Affiliation(s)
- Samuel Torres-Landa
- Department of Gastrointestinal Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States
| | | | - Brett E Fortune
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY 10021, United States
| | - Ananta Gurung
- Department of Pathology, Royal Columbian Hospital, New Westminster, British Columbia V3L 3W7, Canada
| | - Jeffrey Pollak
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT 06510, United States
| | - Sukru H Emre
- Department of Surgery, Yale University School of Medicine, New Haven, CT 06510, United States
| | | | - Michael L Schilsky
- Division of Digestive Diseases and Transplant and Immunology, Department of Medicine and Surgery, Yale University School of Medicine, New Haven, CT 06510, United States
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31
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Abstract
Consideration of a diagnosis of Wilson disease is still the critical factor in testing for and establishing disease diagnosis. In association with other clinical and biochemical tests, liver biopsy results and molecular genetic testing can also be used to generate a score for diagnosing Wilson disease. Medical therapy is effective for most patients; liver transplant can rescue those with acute liver failure or those with advanced liver disease who fail to respond to or discontinue medical therapy. Treatment monitoring must be done at regular intervals and includes clinical evaluation, liver tests and blood counts, and copper metabolic parameters.
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Affiliation(s)
- Michael L Schilsky
- Yale University Medical Center, 333 Cedar Street, LMP 1080, New Haven CT 06520, USA.
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32
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Weiss KH, Askari FK, Czlonkowska A, Ferenci P, Bronstein JM, Bega D, Ala A, Nicholl D, Flint S, Olsson L, Plitz T, Bjartmar C, Schilsky ML. Bis-choline tetrathiomolybdate in patients with Wilson's disease: an open-label, multicentre, phase 2 study. Lancet Gastroenterol Hepatol 2017; 2:869-876. [PMID: 28988934 DOI: 10.1016/s2468-1253(17)30293-5] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 08/15/2017] [Accepted: 08/21/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Wilson's disease is a genetic disorder in which copper accumulates in the liver, brain, and other tissues. Therapies are limited by efficacy, safety concerns, and multiple daily dosing. Bis-choline tetrathiomolybdate (WTX101) is an oral first-in-class copper-protein-binding molecule that targets hepatic intracellular copper and reduces plasma non-ceruloplasmin-bound copper (NCC) by forming tripartite complexes with albumin and increasing biliary copper excretion. We aimed to assess the efficacy and safety of WTX101 in the initial or early treatment of patients with Wilson's disease. METHODS We did this open-label, phase 2 study at 11 hospitals in the USA and Europe. We enrolled patients (≥18 years) with Wilson's disease who were untreated or had received no more than 24 months of treatment with chelators or zinc, had a Leipzig score of 4 or more, and had NCC concentrations above the lower limit of the normal reference range (≥0·8 μmol/L). Eligible patients received WTX101 monotherapy at a starting dose of 15-60 mg/day on the basis of baseline NCC concentrations for the first 4-8 weeks, with response-guided individualised dosing for the remaining weeks up to week 24. Investigators, other hospital personnel, and patients were aware of the identity of the treatment. The primary endpoint was change in baseline NCC concentrations corrected for copper in tetrathiomolybdate-copper-albumin complexes (NCCcorrected) at 24 weeks, with treatment success defined as achievement or maintenance of normalised NCCcorrected (≤2·3 μmol/L [upper limit of normal]) or achievement of at least a 25% reduction in NCCcorrected from baseline at 24 weeks. This study is registered with ClinicalTrials.gov, number NCT02273596. FINDINGS Between Nov 24, 2014, and April 27, 2016, 28 patients were enrolled and received WTX101; 22 (79%) patients completed the study up to week 24. At 24 weeks, 20 (71%, 95% CI 51·3-86·8; p<0·0001) of 28 patients met the criteria for treatment success: 16 (57%) treated with WTX101 either achieved or maintained normalised NCCcorrected concentrations and 4 (14%) had at least a 25% reduction from baseline NCCcorrected. Mean NCCcorrected was reduced by 72% from baseline to week 24 (least squares mean difference -2·4 μmol/L [SE 0·4], 95% CI -3·2 to -1·6; p<0·0001). No cases of paradoxical drug-related neurological worsening were recorded. Liver function was stable in all patients, although reversible increased concentrations of asymptomatic alanine or aspartate aminotransferase, or γ-glutamyltransferase, without increased bilirubin, occurred in 11 (39%) of 28 patients who received at least 30 mg/day. 11 serious adverse events were reported in seven (25%) patients and included psychiatric disorders (six events in four patients), gait disturbance (one event), elevated liver aminotransferases (two events in two patients, one with agranulocytosis), and decline in neurological functioning (one event, likely due to natural disease progression although causality could not be ruled out). The seven serious adverse events categorised as psychiatric disorders and as gait disturbance were assessed as unlikely to be related to the study drug, whereas the remaining four events were possibly or probably related. INTERPRETATION Our findings indicate that WTX101 might be a promising new therapeutic approach for Wilson's disease, with a unique mode of action. In view of its once-daily dose and favourable safety profile, WTX101 could improve the treatment of patients with this debilitating condition. FUNDING Wilson Therapeutics AB.
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Affiliation(s)
- Karl Heinz Weiss
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Anna Czlonkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Peter Ferenci
- Department of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Jeff M Bronstein
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, USA
| | - Danny Bega
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Aftab Ala
- Department of Gastroenterology and Hepatology, The Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK; Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, UK
| | - David Nicholl
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | | | | | | | - Michael L Schilsky
- Department of Medicine and Surgery, Yale University Medical Center, New Haven, CT, USA.
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Abstract
Patient support groups serve an important function for those affected by a disease but especially for people with a rare disease. Because of the complexity of Wilson disease there are some unique and difficult problems faced by groups that advocate for these patients. We give a comparative overview of the differences between groups that support people with more common diseases and groups that serve the rare disease population. The history and current status of the Wilson Disease Association and other worldwide Wilson disease groups are described and information about other organizations that support Wilson disease in additional ways is explained. The specific challenges faced in the support of Wilson disease patients are outlined and possible solutions proposed. Drawing from experience in speaking with many patients, we discuss some of the most common questions that are asked by patients who are seeking a possible diagnosis or are already on treatment. There are many options for improving patient advocacy efforts in the future that we hope will be accomplished.
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Affiliation(s)
| | - Michael L Schilsky
- Section of Digestive Diseases and Transplantation and Immunology, Department of Medicine and Surgery, Yale University School of Medicine, New Haven, CT, USA.
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Członkowska A, Schilsky ML. Preface. Handb Clin Neurol 2017; 142:ix. [PMID: 28433115 DOI: 10.1016/b978-0-444-63625-6.09985-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Affiliation(s)
| | - Xiaoyue M Guo
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Matthew Schrag
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Shivani Ghoshal
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Michael L Schilsky
- Section of Digestive Disease and Transplant and Immunology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Lauren A Beslow
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, United States
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Karvellas CJ, Tillman H, Leung AA, Lee WM, Schilsky ML, Hameed B, Stravitz RT, McGuire BM, Fix OK. Acute liver injury and acute liver failure from mushroom poisoning in North America. Liver Int 2016; 36:1043-50. [PMID: 26837055 DOI: 10.1111/liv.13080] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [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] [Received: 10/07/2015] [Accepted: 01/25/2016] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Published estimates of survival associated with mushroom (amatoxin)-induced acute liver failure (ALF) and injury (ALI) with and without liver transplant (LT) are highly variable. We aimed to determine the 21-day survival associated with amatoxin-induced ALI (A-ALI) and ALF (A-ALF) and review use of targeted therapies. METHODS Cohort study of all A-ALI/A-ALF patients enrolled in the US ALFSG registry between 01/1998 and 12/2014. RESULTS Of the 2224 subjects in the registry, 18 (0.8%) had A-ALF (n = 13) or A-ALI (n = 5). At admission, ALF patients had higher lactate levels (5.2 vs. 2.2 mm, P = 0.06) compared to ALI patients, but INR (2.8 vs. 2.2), bilirubin (87 vs. 26 μm) and MELD scores (28 vs. 24) were similar (P > 0.2 for all). Of the 13 patients with ALF, six survived without LT (46%), five survived with LT (39%) and two died without LT (15%). Of the five patients with ALI, four (80%) recovered and one (20%) survived post-LT. Comparing those who died/received LT (non-spontaneous survivors [NSS]) with spontaneous survivors (SS), N-acetylcysteine was used in nearly all patients (NSS 88% vs. SS 80%); whereas, silibinin (25% vs. 50%), penicillin (50% vs. 25%) and nasobiliary drainage (0 vs. 10%) were used less frequently (P > 0.15 for all therapies). CONCLUSION Patients with mushroom poisoning with ALI have favourable survival, while around half of those presenting with ALF may eventually require LT. Further study is needed to define optimal management (including the use of targeted therapies) to improve survival, particularly in the absence of LT.
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Affiliation(s)
- Constantine J Karvellas
- Divisions of Hepatology and Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Holly Tillman
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Alexander A Leung
- Division of Endocrinology and Metabolism, University of Calgary, Calgary, AB, Canada
| | - William M Lee
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael L Schilsky
- Division of Digestive Diseases and Transplant and Immunology, Yale University School of Medicine, New Haven, CT, USA
| | - Bilal Hameed
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, CA, USA
| | - R Todd Stravitz
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University, Richmond, VA, USA
| | - Brendan M McGuire
- Division of Gastroenterology and Hepatology, University of Alabama, Birmingham, AL, USA
| | - Oren K Fix
- Organ Transplant Program, Swedish Medical Center, Seattle, WA, USA
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Boga S, Munoz-Abraham AS, Rodriguez-Davalos MI, Emre SH, Jain D, Schilsky ML. Host factors are dominant in the development of post-liver transplant non-alcoholic steatohepatitis. World J Hepatol 2016; 8:659-664. [PMID: 27239259 PMCID: PMC4876289 DOI: 10.4254/wjh.v8.i15.659] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 03/30/2016] [Accepted: 05/09/2016] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a recognized problem in patients after orthotopic liver transplantation and may lead to recurrent graft injury. As the increased demand for liver allografts fail to match the available supply of donor organs, split liver transplantation (SLT) has emerged as an important technique to increase the supply of liver grafts. SLT allows two transplants to occur from one donor organ, and provides a unique model for observing the pathogenesis of NAFLD with respect to the role of recipient environmental and genetic factors. Here we report on two recipients of a SLT from the same deceased donor where only one developed non-alcoholic steatohepatitis (NASH), suggesting that host factors are critical for the development of NASH.
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Abstract
With the growing number of patients in need of liver transplantation, there is a need for adopting new and modifying existing allocation policies that prioritize patients for liver transplantation. Policy should ensure fair allocation that is reproducible and strongly predictive of best pre and post transplant outcomes while taking into account the natural history of the potential recipients liver disease and its complications. There is wide acceptance for allocation policies based on urgency in which the sickest patients on the waiting list with the highest risk of mortality receive priority. Model for end-stage liver disease and Child-Turcotte-Pugh scoring system, the two most universally applicable systems are used in urgency-based prioritization. However, other factors must be considered to achieve optimal allocation. Factors affecting pre-transplant patient survival and the quality of the donor organ also affect outcome. The optimal system should have allocation prioritization that accounts for both urgency and transplant outcome. We reviewed past and current liver allocation systems with the aim of generating further discussion about improvement of current policies.
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Boga S, Jain D, Schilsky ML. Trientine induced colitis during therapy for Wilson disease: a case report and review of the literature. BMC Pharmacol Toxicol 2015; 16:30. [PMID: 26589720 PMCID: PMC4654910 DOI: 10.1186/s40360-015-0031-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 11/12/2015] [Indexed: 12/16/2022] Open
Abstract
Background Wilson disease (WD) is an autosomal recessive disorder of human copper metabolism characterized by copper accumulation in the liver due to impaired excretion of copper into the bile. Brain accumulation of copper may cause neuropsychiatric symptoms. Trientine (triethylenetetramine dihydrochloride) is a copper-chelating agent used to treat patients with WD. Trientine has been considered an option for initial treatment and maintentance therapy of WD due to its safety profile. Case presentation A 40 year old female with a recent diagnosis of WD was started on treatment with trientine for her WD. Within one month she developed profound bloody diarrhea unresponsive to medical treatment. Trientine was discontinued and a colonoscopy with biopsy showed moderately active ileitis and moderate to severe pancolitis, consistent with a drug induced mucosal injury. The colitis improved immediately upon withdrawal of trientine, and recurred when medication was rechallenged because of worsened WD symptoms. After second compulsory discontinuation of trientine, she remained on zinc therapy for her WD and her colitis resolved by time. Conclusion Drug induced colitis is a very rare side effect of trientine. Although trientine therapy is well tolerated and less side effects are reported with this medication than penicillamine, colitis can occur during trientine treatment. Zinc therapy may be an effective alternative for treatment of WD in patients experiencing side effects from chelation therapy.
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Affiliation(s)
- Salih Boga
- Division of Digestive Diseases and Section of Transplantation and Immunology, Department of Medicine and Surgery, Yale University School of Medicine, Yale University Medical Center, 333 Cedar Street, LMP 1080, New Haven, CT, 06520, USA.
| | - Dhanpat Jain
- Department of Pathology, Yale University School of Medicine, 310 Cedar Street, P.O. Box 208023, New Haven, CT, 06520-8023, USA.
| | - Michael L Schilsky
- Division of Digestive Diseases and Section of Transplantation and Immunology, Department of Medicine and Surgery, Yale University School of Medicine, Yale University Medical Center, 333 Cedar Street, LMP 1080, New Haven, CT, 06520, USA.
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Affiliation(s)
- Paula C Zimbrean
- From the Departments of Psychiatry and Internal Medicine, Yale University School of Medicine, and the Wilson Disease Center for Excellence, Yale University Medical Center, New Haven, Conn
| | - Michael L Schilsky
- From the Departments of Psychiatry and Internal Medicine, Yale University School of Medicine, and the Wilson Disease Center for Excellence, Yale University Medical Center, New Haven, Conn
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Boga S, Jain D, Schilsky ML. Presentation of Progressive Familial Intrahepatic Cholestasis Type 3 Mimicking Wilson Disease: Molecular Genetic Diagnosis and Response to Treatment. Pediatr Gastroenterol Hepatol Nutr 2015; 18:202-8. [PMID: 26473142 PMCID: PMC4600706 DOI: 10.5223/pghn.2015.18.3.202] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 05/12/2015] [Accepted: 05/28/2015] [Indexed: 11/14/2022] Open
Abstract
Progressive familial intrahepatic cholestasis type 3 (PFIC3) is an autosomal recessive disorder of cholestasis of hepatocellular origin, typically seen in infancy or childhood caused by a defect in the ABCB4 located on chromosome 7. Here we report on an older patient, aged 15, who presented with biochemical testing that led to an initial consideration of a diagnosis of Wilson disease (WD) resulting in a delayed diagnosis of PFIC3. Diagnosis of PFIC3 was later confirmed by molecular studies that identified novel mutations in the ABCB4 gene. Cholestasis due to PFIC3 can cause elevated hepatic copper and increased urine copper excretion that overlap with current diagnostic criteria for WD. Molecular diagnostics are very useful for establishing the diagnosis of PFIC3. Ursodeoxycholic acid ameliorates cholestasis in PFIC3, and may help mediate a reduction in hepatic copper content in response to treatment.
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Affiliation(s)
- Salih Boga
- Division of Digestive Diseases and Section of Transplantation and Immunology, Department of Medicine and Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Dhanpat Jain
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Michael L Schilsky
- Division of Digestive Diseases and Section of Transplantation and Immunology, Department of Medicine and Surgery, Yale University School of Medicine, New Haven, CT, USA
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Karvellas CJ, Stravitz RT, Battenhouse H, Lee WM, Schilsky ML. Reply: To PMID 25308108. Liver Transpl 2015; 21:1009-10. [PMID: 25779618 PMCID: PMC4936905 DOI: 10.1002/lt.24109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 03/04/2015] [Indexed: 01/13/2023]
Affiliation(s)
| | - R. Todd Stravitz
- Division of Gastroenterology and Hepatology, Virginia Commonwealth
University, Richmond, VA
| | - Holly Battenhouse
- Faculty of Medicine, Medical University of South Carolina, Charleston,
SC
| | - William M. Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern
Medical Center, Dallas, TX
| | - Michael L. Schilsky
- Division of Digestive Diseases and Transplant and Immunology, Yale
University School of Medicine, New Haven, CT
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Moini M, Schilsky ML, Tichy EM. Review on immunosuppression in liver transplantation. World J Hepatol 2015; 7:1355-1368. [PMID: 26052381 PMCID: PMC4450199 DOI: 10.4254/wjh.v7.i10.1355] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 12/23/2014] [Accepted: 02/12/2015] [Indexed: 02/06/2023] Open
Abstract
The optimal level of immunosuppression in solid organ transplantation, in particular for the liver, is a delicate balance between the benefit of preventing rejection and the adverse side effects of immunosuppression. There is uncertainty about when this level is achieved in any individual recipient. Immunosuppression regimens vary between individual centers and changes with time as new agents and data are available. Presently concerns about the adverse side effects of calcineurin inhibitor, the main class of immunosuppressive agents used in liver transplantation (LT), has led to consideration of the use of antibody induction therapies for patients at higher risk of developing adverse side effects. The longevity of the transplanted organ is potentially improved by better management of rejection episodes and special consideration for tailoring of immunosuppression to the individual with viral hepatitis C, hepatocellular carcinoma or pregnancy. This review provides an overview of the current strategies for post LT immunosuppression and discusses modifications to consider for special patient populations.
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Abstract
BACKGROUND Wilson disease requires lifelong therapy, currently given daily in multiple divided dosages. AIM To prospectively evaluate once-daily trientine as therapy for Wilson disease. METHODS STUDY GROUP eight patients (seven males) aged 22-71 years with stable Wilson disease treated from 4 to 50 years. Patients were monitored for 3 months then for 12 months on a single daily dose of trientine (15 mg/kg). RESULTS All patients remained clinically well. ALT and AST fluctuated in some, but none required treatment stoppages or side effects. Liver synthetic function was unchanged. Mean 24-h urine copper and zinc excretions at end of treatment were 313.4 ± 191.7 and 2,214 ± 1,346 μg, respectively. CONCLUSIONS Once-daily trientine should be explored further for possible maintenance therapy for WD. Single daily dose may improve adherence to therapy. Larger trials and longer-term follow-up will establish the safety and treatment efficacy of this once-daily treatment regimen for WD (registration: NCT01472874).
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Affiliation(s)
- Aftab Ala
- Faculty of Health and Medical Sciences, Faculty of Health Management and Strategy, University of Surrey, Guildford, Surrey GU2 7JP UK
- Department of Gastroenterology and Hepatology, Frimley Health NHS Foundation Trust, Portsmouth Road, Camberley, Surrey GU16 7UJ UK
| | - Ermal Aliu
- Section of Immunology and Transplantation, Department of Surgery, Yale New Haven Transplantation Center, Yale University Medical Center, 333 Cedar Street LMP 1080, New Haven, CT 06520 USA
| | - Michael L. Schilsky
- Section of Immunology and Transplantation, Department of Surgery, Yale New Haven Transplantation Center, Yale University Medical Center, 333 Cedar Street LMP 1080, New Haven, CT 06520 USA
- Division of Digestive Diseases, Department of Medicine, Yale University Medical Center, New Haven, CT USA
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Schilsky ML, Roberts EA, Hahn S, Askari F. Costly choices for treating Wilson's disease. Hepatology 2015; 61:1106-8. [PMID: 25524500 DOI: 10.1002/hep.27663] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 10/31/2014] [Accepted: 12/11/2014] [Indexed: 01/28/2023]
Affiliation(s)
- Michael L Schilsky
- Yale-New Haven Transplantation Center, Yale School of Medicine, New Haven, CT
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46
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Karvellas CJ, Stravitz RT, Battenhouse H, Lee WM, Schilsky ML. Therapeutic hypothermia in acute liver failure: a multicenter retrospective cohort analysis. Liver Transpl 2015; 21:4-12. [PMID: 25308108 PMCID: PMC4939841 DOI: 10.1002/lt.24021] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [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] [Received: 05/19/2014] [Revised: 10/01/2014] [Accepted: 10/05/2014] [Indexed: 12/13/2022]
Abstract
The benefit of therapeutic hypothermia (TH) in acute liver failure (ALF) has not been previously demonstrated in a controlled fashion. This study sought to determine the impact of TH on 21-day survival and complications in ALF patients at high risk for cerebral edema. This was a retrospective cohort study of ALF patients in the US Acute Liver Failure Study Group with grade III or IV hepatic encephalopathy. TH (32°C-35°C) was used in 97 patients (8%); 1135 (92%) who were not cooled were controls. Intracranial pressure was monitored in 38 TH ALF patients (39.2% versus 22% of controls, P < 0.001). Rates of bleeding (12% for both) and bloodstream (17% versus 18%) and tracheal infections (21% versus 23%, P > 0.5 for all) were similar. Unadjusted 21-day overall (62% versus 60%) and transplant-free survival rates (45% versus 39%, P > 0.4 for both) were similar. Multivariate models were created for acetaminophen (APAP) patients (n = 582) and non-APAP patients (n = 613). For APAP patients, the Model for End-Stage Liver Disease [MELD; odds ratio (OR) = 0.91 per increment, 95% confidence interval (CI) = 0.89-0.94, P < 0.001] and vasopressors (OR = 0.16, 95% CI = 0.11-0.24, P < 0.001) were associated with decreased 21-day spontaneous survival. Survival was improved with TH in APAP patients who were <25 years old (age of 25 years: OR = 2.735, 95% CI = 1.001-7.467) but worsened for APAP patients who were 64 years old or older (age of 64 years: OR = 0.167, 95% CI = 0.028-0.999). For non-APAP patients, MELD (OR = 0.93 per increment, 95% CI = 0.91-0.95, P < 0.001) and vasopressors (OR = 0.60, 95% CI = 0.40-0.90, P = 0.01) were associated with worse outcomes, whereas TH had no impact (P = 0.93). In conclusion, TH in ALF was not associated with increased bleeding or infections. Although young APAP ALF patients may benefit, TH did not consistently affect 21-day survival. A prospective trial is required to clarify the utility of TH in ALF patients.
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Affiliation(s)
| | - R. Todd Stravitz
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University, Richmond, USA
| | - Holly Battenhouse
- Faculty of Medicine, Medical University of South Carolina, Charleston, USA
| | - William M. Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Michael L. Schilsky
- Division of Digestive Diseases and Transplant and Immunology, Yale University School of Medicine, New Haven, USA
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Abstract
The diagnosis of Wilson disease has evolved from the original description of a neurological syndrome by Wilson and other contemporaries at the turn of the 20th century to where we recognize that there is a spectrum of clinical liver and neuropsychiatric disease diagnosed by a combination of clinical and biochemical tests and more recently by molecular genetic analysis. The history of the evolution of the findings that help us establish a diagnosis of Wilson disease are presented in the following brief summary of a century of progress toward this end.
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Affiliation(s)
- Michael L Schilsky
- Yale University School of Medicine, 333 Cedar Street, LMP 1080, New Haven, CT 06520, United States.
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48
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Karkhanis J, Verna EC, Chang MS, Stravitz RT, Schilsky ML, Lee WM, Brown RS. Reply: To PMID 23929808. Hepatology 2014; 60:1448. [PMID: 24596256 PMCID: PMC5571826 DOI: 10.1002/hep.27110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 02/28/2014] [Indexed: 12/07/2022]
Affiliation(s)
- Jamuna Karkhanis
- Department of Medicine, Columbia University College of Physicians
& Surgeons, New York, NY
| | - Elizabeth C. Verna
- Department of Medicine, Columbia University College of Physicians
& Surgeons, New York, NY
| | - Matthew S. Chang
- Department of Medicine, Columbia University College of Physicians
& Surgeons, New York, NY
| | - R. Todd Stravitz
- Section of Hepatology, Virginia Commonwealth University, Richmond,
VA
| | - Michael L. Schilsky
- Division of Digestive Diseases and Section of Immunology and
Transplantation, Department of Medicine and Surgery, Yale University School of
Medicine, New Haven, CT
| | - William M. Lee
- Division of Digestive and Liver Diseases, Department of Internal
Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Robert S. Brown
- Department of Medicine, Columbia University College of Physicians
& Surgeons, New York, NY
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49
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Abstract
Although Wilsons's disease (WD) may be treated with copper chelation (to remove copper) or zinc salts (to prevent absorption) to alleviate or prevent symptom development in most patients, there are WD patients for whom medical therapy is inadequate and survival would be unlikely without liver transplantation. Liver transplantation is indicated for the ∼5% of WD patients with acute liver failure as the first presentation of disease, most commonly in the second decade of life, or those who present with end-stage liver disease and severe hepatic insufficiency, most commonly in the third and fourth decades. Liver transplantation restores normal biliary copper excretion (thereby preventing disease recurrence) and promotes removal of copper from extrahepatic sites. Outcomes of liver transplantation for WD are excellent, including both cadaveric and living donors.
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Affiliation(s)
- Michael L Schilsky
- Sections of Digestive Disease and Immunology and Transplantation, Yale New Haven Transplant Center, Yale University School of Medicine, New Haven, Connecticut
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50
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