Acute Intermittent Porphyria Carriers Research Articles

PF429 MOLECULAR GENETIC STUDY OF ACUTE INTERMITTENT PORPHYRIA IN RUSSIA

Background:Acute intermittent porphyria (AIP) is one of the most common and severe form of porphyrias. It is an autosomal dominant inherited disorder caused by mutation in hydroxymethylbilane synthase gene (HMBS) with low penetrance, which does not exceed 10–20%. AIP acute attacks have highly variable predominantly neurological symptoms and the disease is often misdiagnosed. Therefore, a correct diagnosis is possible only using molecular genetic analysis.Aims:Our aims were to describe mutational spectrum of HMBS gene in Russian AIP patients and to determine and discuss the possible genetic reasons, which could determine the nature of AIP penetrance.Methods:We used samples of genomic DNA collected from unrelated AIP probands (N = 157) and their relatives (N = 308). We isolated nuclear DNA from peripheral white blood cells. Mutational analysis was performed using Sanger sequencing of all functionally important regions of HMBS gene. Besides, we performed Whole Exome Sequencing (WES) on a small group of AIP patients (N = 6) using TrueSeq Exome Library Prep kit (Illumina) and Illumina HiSeq4000 system. For bioinformatic analysis we used hg19 version of human genome as a reference and detected variants differing from it separately in each patient's DNA sample by GATK software. We chose for further analysis those variants, which were nonsynonymous substitutions, splicing, non‐frameshift insertions or deletions or were located in 5’UTR, and had no accession number in SNP databases.Results:We found 91 different mutations in HMBS gene in 157 unrelated AIP patients, 49 of them were not previously described. The most common HMBS gene defects in Russian AIP patients are c.53delT (N = 16) and Arg173Trp (N = 13). During patients’ families genetic consulting we also revealed 118 asymptomatic AIP carriers out of 308 relatives tested. Also, as a preliminary study of additional factors that could affect specific AIP penetrance, we performed WES. After WES data filtration, we revealed about 103–136 variations in each exome (118 in average), which could be considered as mutations. Spectra of mutated genes in different patients virtually did not overlap. This fact supports our hypothesis that AIP penetrance has oligo‐ or polygenic nature. In 5 out of 6 patients we found heterozygous mutations in several genes causing different neurodegenerative disorders, which have partly similar symptoms with AIP, e.g. congenital myastenic syndrome (CMS): AGRN (Val1200Ile), DOK7 (Arg47Cys), SCN4A (Leu96Phe), UNC13A (Arg459Gly), ALG8 (Tyr67Asn) and FBXO38 (Arg754His).Summary/Conclusion:We described mutational spectrum of HMBS gene in Russian AIP patients and revealed two major mutations, which need to be looked for in newly counseled patients in the first place. As a result of WES data analysis we propose a hypothesis about the influence of mutations in genes associated with neurodegenerative diseases on AIP penetrance. This hypothesis we are planning to examine on the expanded sample of AIP patients which suffered acute attacks and their asymptomatic carrier relatives.

Medical and financial burden of acute intermittent porphyria

IntroductionA small proportion of patients with acute intermittent porphyria (AIP) suffer from recurrent porphyric attacks, with a severely diminished quality of life. In this retrospective case-control study, the burden of disease is quantified and compared among three AIP patient subgroups: cases with recurrent attacks, cases with one or occasional attacks and asymptomatic carriers.MethodsData from patient records and questionnaires were collected in patients between 1960 and 2016 at the Erasmus Medical Center, Rotterdam, the Netherlands. We collected symptoms related to porphyria, porphyria related complications, attack frequency, hospitalisation frequency, hospitalisation days related to acute porphyric attacks, frequency of heme infusions and medical healthcare costs based on hospitalisations and heme therapy.ResultsIn total 11 recurrent AIP cases, 24 symptomatic AIP cases and 53 AIP carriers as controls were included. All recurrent patients reported porphyria related symptoms, such as pain, neurological and/or psychiatric disorders, and nearly all developed complications, such as hypertension and chronic kidney disease. In the recurrent cases group, the median lifelong number of hospitalisation days related to porphyric attacks was 82 days per patient (range 10–374), and they spent a median of 346 days (range 34–945) at a day-care facility for prophylactic heme therapy; total follow-up time was 243 person-years (PYRS). In the symptomatic non-recurrent group the median lifelong number of hospitalisation days related to porphyric attacks was 7 days per patient (range 1–78), total follow-up time was 528 PYRS. The calculated total medical healthcare cost for recurrent cases group was €5.8 million versus €0.3 million for the symptomatic cases group.

Screening for hepatocellular carcinoma in acute intermittent porphyria: a 15-year follow-up in northern Sweden

To evaluate the benefit of screening for hepatocellular carcinoma (HCC) in gene carriers of acute intermittent porphyria (AIP) and estimate the annual incidence of HCC in this group. All AIP gene carriers aged ≥55 years from the northernmost county in Sweden, Norrbotten, were invited for screening in this prospective study every 1-1.5 years during the period 1994-2009. We registered all HCC cases amongst AIP gene carriers in the northern region of Sweden (four counties). We compared gene carriers with repeated screening intervals of <2 years (Group A) with controls (Group B; i.e. gene carriers who had never been screened, those screened for the first time or screened at intervals of >2 years, or dropouts). The screening included radiological examination of the liver and relevant laboratory tests. A total of 62 AIP subjects participated in the study, comprising 33% of the total AIP population aged >55 years in the northern region of Sweden. HCC was diagnosed in 22 AIP subjects (12 men and 10 women), mean age 69 (59-82) years. Amongst these subjects, 73% had experienced prior AIP attacks. The incidence rate ratio for HCC was 64 (52 in men and 93 in women). There were no cases of hepatitis B/C or alcohol abuse. Liver cirrhosis was rare. Liver resection could be performed in most subjects in Group A. Fourteen patients died of HCC, one in Group A and 13 in Group B. Compared with those who were not screened regularly, screening was associated with improved 3-year and 5-year survival (P = 0.005 and 0.038). Screening for HCC in carriers of AIP enables early diagnosis and a choice of potentially curative treatments with improved prognosis. We recommend annual screening using liver imaging for AIP gene carriers >50 years of age.

Clinical aspects of acute intermittent porphyria in northern Sweden: A population-based study

The objective of this study was to update the clinical issues of acute intermittent porphyria (AIP), as they have not been in focus for years, and to be aware of potentially associated disorders and social consequences. A total of 356 gene carriers of AIP from northern Sweden participated in this retrospective population-based study. Eight mutations were found with a predominance of W198X (89%). Clinical manifestations of AIP (manifest AIP) were identified in 42%, 65% were women. Women were more severely stricken by AIP attacks concerning number and duration, hospital admission and early onset. Men reporting most attacks were > 40 years of age. In addition to traditional symptoms during attacks, fatigue was commonly described. Chronic AIP symptoms and disability pension due to AIP were reported in about 20% of subjects. Precipitating factors were reported with evident sex differences. Half of the gene carriers who were on medications used drugs considered not safe (in 1999), mainly antihypertensive drugs. Smoking was associated with high AIP attack frequency. Elevated levels of ALT, bile acids, creatinine, U-ALA and U-PBG and decreased levels of creatinine clearance were associated with manifest AIP. The same was true for hypertension and myalgia in the legs. Hepatoma was strikingly overrepresented. The high prevalence of manifest AIP in this study could be explained by a mutation-dependent penetrance. Our results emphasize the importance of early diagnosis, counselling and treatment of attacks, screening and treatment of associated disorders.

Oxidative Stress in Porphyria and Carriers

We sought to establish a causal relationship between oxidative stress and porphyria in patients and carriers. We reported changes in urinary porphyrin concentrations related to 8-hydroxy-2'-deoxyguanosine. We measured urinary 8-hydroxy-2'-deoxyguanosine concentration in porphyria patients and carriers with multifactorial inheritance as a possible marker of attack. The porphyria types included 10 patients with porphyria cutanea tarda, 5 with variegate porphyria, 8 with hereditary coproporphyria, 7 with congenital erythropoietic porphyria, 5 with erythropoietic protoporphyria, 5 with acute intermittent porphyria, 7 erythropoietic protoporphyria carriers, and 7 acute intermittent porphyria carriers. Urinary porphyrin concentrations in these patients were significantly higher than those in healthy subjects (p<0.001). Urinary 8-hydroxy-2'-deoxyguanosine concentrations were significantly high in dermatopathy porphyria types namely porphyria cutanea tarda (p<0.001), variegate porphyria (p<0.05), hereditary coproporphyria (p<0.05), congenital erythropoietic phyria (p<0.05), and erythropoietic protoporphyria (p<0.001). These results reveal that urinary 8-hydroxy-2'-deoxyguanosine concentration in cutis porphyria types is a good predictor of attack and abatement.

Genetic and biochemical characterization of 16 acute intermittent porphyria cases with a high prevalence of the R173W mutation

Acute intermittent porphyria (AIP) is a metabolic disease with a variable prevalence among different countries. In some areas of southern Europe it remains to be fully evaluated. We undertook a genetic and biochemical study of 16 unrelated Spanish AIP patients and relatives. The genetic analyses showed they harboured the following mutations in the porphobilinogen deaminase gene: R173W, G111R, L278P, L238P, R116W, R26C, 340insT, 730delCT, 691del30bp, and IVS14+1g>a. The mutation R173W was found in 6 patients (37.5%), including the only patients of our series with >3 recurrent porphyria attacks. While in clinical remission, all AIP patients exhibited sustained increased excretion of porphyrins and precursors. PBG excretion showed a high between-subject variation and was not related to erythrocyte PBG deaminase activity. The study of family members allowed the identification of 22 asymptomatic AIP carriers. These included 8 persons harbouring the R173W mutation belonging to four different families. Six of these latent AIP subjects showed increased PBG elimination, and in two the urinary levels were >10-fold the normal limit. These results reinforce the hypothesis that the R173W mutation may have a high biochemical and clinical penetrance among AIP patients.

Variations in Porphobilinogen and 5-Aminolevulinic Acid Concentrations in Plasma and Urine from Asymptomatic Carriers of the Acute Intermittent Porphyria Gene with Increased Porphyrin Precursor Excretion

The heme precursors porphobilinogen (PBG) and 5-aminolevulinic acid (ALA) accumulate during overt crises of acute intermittent porphyria (AIP), and high excretion of these metabolites often continues in the asymptomatic phase. We measured concentrations of PBG and ALA and investigated the correlation between these metabolites in plasma and urine in 10 asymptomatic AIP carriers with high excretion and in 5 healthy individuals. We quantified plasma concentrations with an HPLC-mass spectrometric method and urine concentrations with ion-exchange chromatography. The mean (SD) plasma concentrations of PBG and ALA in the AIP carriers were 3.1 (1.0) and 1.7 (0.7) micromol/L, respectively. The mean 8-h urinary excretion amounts of PBG and ALA in the AIP carriers were 102 (25) and 56 (18) micromol, respectively, whereas the corresponding values for healthy individuals were 2.9 (0.7) and 9.3 (1.2) micromol. The correlations between PBG and ALA values in plasma and urine of the AIP carriers were 0.678 and 0.856, respectively. The mean PBG/ALA ratio was approximately 2.0 in both plasma and urine for the AIP carriers and 0.3 in urine for the healthy individuals. The renal clearance rates for PBG and ALA were 71 (15) and 70 (13) mL/min, respectively. The described HPLC-mass spectrometric method enabled characterization of variations in plasma PBG and ALA in AIP carriers during an 8-h period. The renal clearances were similar for both metabolites. This method could be used to monitor AIP patients during treatment.

Biochemical compared to molecular diagnosis in acute intermittent porphyria

The biochemical and the molecular diagnoses of an inherited porphyria require experience. False positive or negative screening tests and the low penetrance of the disease make a correct diagnosis difficult.The biochemical and the molecular procedures for the diagnosis of acute intermittent porphyria were applied to five unrelated patients suffering from acute intermittent porphyria. All patients were shown to be gene carriers of acute intermittent porphyria by both methods. The two different possibilities of the diagnosis corresponded well. In a family definitively identified by molecular diagnosis of one of the patients and his relatives, the patient's two children were asymptomatic. His son was shown to be a gene carrier of the father's deficiency by biochemical as well as molecular analysis, whereas his daughter was not affected by acute intermittent porphyria.

Pro-oxidant and antioxidant factors in acute intermittent porphyria: family studies.

Given the crucial role of iron and porphyrins in oxidative cellular damage in the chronic porphyrias, we undertook an extensive study in families with acute porphyrias to evaluate the possible role of similar oxidative damage in these diseases, whose natural history is often also complicated by neoplastic evolution. Four unrelated patients with acute intermittent porphyria (AIP) were studied together with 37 members of four different families. Aminolevulinic acid and porphobilinogen were measured in urine, and porphyrins in urine, plasma and stools. The activity of the congenitally deficient enzyme, porphobilinogen deaminase, and the concentrations of plasma iron, transferrin, ferritin, and various antioxidants (ascorbic acid, retinol, tocopherol, alpha- and beta-carotene, by a personal HPLC method) and the urinary and plasma metabolites of nitrous oxide were also assayed. The results showed no relationship between the observed increase of porphyrin metabolites and the presence of markers of oxidative damage or the decrease of circulating antioxidants: however, when such a decrease was registered, it depended on spontaneous or iatrogenic iron accumulation. We conclude that family screening, recommended for the identification of AIP carriers, must also include evaluation of iron stores with a view to preventing the oxidative damage and in order to forestall the neoplastic evolution of the disease.

Novel Mutation and Polymorphisms of the HMBS Gene Detected by Denaturing HPLC

Acute intermittent porphyria (AIP) is an autosomal dominant, inborn error of the metabolism of heme biosynthesis caused by partial deficiency of hydroxymethylbilane synthase (HMBS). This enzyme catalyzes the condensation of four molecules of porphobilinogen to a tetrapyrrole, hydroxymethylbilane. AIP is characterized by acute attacks of a neurological disorder manifesting as abdominal pain, hypertension, tachycardia, peripheral neuropathy, and mental dysfunction. Biochemical diagnosis of AIP relies on increased urinary porphobilinogen and normal fecal porphyrin excretion (1). Identification of presymptomatic AIP carriers in families with affected individuals is of clinical importance because avoidance of precipitating agents (e.g., drugs and alcohol) can prevent the occurrence of the first porphyric attack, which may be life-threatening. However, there is a significant overlap between the enzyme activities of healthy individuals and patients with AIP (2). In addition, there is a variant of AIP, in which the red blood cell (RBC) HMBS activity is normal (3). DNA-based diagnosis of presymptomatic AIP has been more reliable than diagnosis by RBC HMBS activity, and, thus, direct detection of mutations in presymptomatic AIP is now the definitive approach. The human HMBS gene spans ∼10 kb of DNA on chromosome 11q24.1-24.2 and contains 15 exons (4). Extensive allelic heterogeneity has been demonstrated in this gene, and 159 mutations have been identified in the HMBS gene (5). Most of these mutations are found only in individual families, except those found in Dutch (R116W) (6) and Swedish (W198X) (7) AIP families. Although DNA sequencing can identify all the mutations, this approach is both labor-intensive and time-consuming (8). Several methods that accelerate mutational screening before sequencing have been developed, such as single-strand conformation polymorphism analysis (9), heteroduplex gel analysis (10), and denaturing gradient gel electrophoresis (11)(12). Recently, denaturing HPLC (DHPLC) appears to be more sensitive than other methods in mutation detection, as exemplified …

Family study of acute intermittent porphyria and hereditary coproporphyria in Niigata and Akita prefectures, Japan

Simple screening tests, urinary porphobilinogen (PBG) for acute intermittent porphyria (AIP) and fecal coproporphyrin for hereditary Coproporphyria (HCP), were performed in a family study of AIP and HCP. Urinary PBG was positive in 93 of 211 members of 10 AIP families, but was negative in 568 of 572 controls. Fecal coproporphyrin was positive in 54 of 108 members of 10 HCP families, but was negative in 188 controls. A dominant inheritance was assumed by a chi-square test and Weinberg segregation ratio. Worsening factors around puberty were suggested by the onset age and cumulative percentage of genetically loaded cases. Sex-related expression of symptoms was also inferred by a higher incidence of both porphyrias in females than in males. Fitness and penetrance of both porphyrias were good. An l-triiodothyronine loading test was the most useful for the detection of masked carriers of AIP. In conclusion, AIP and HCP in Japan show a dominant inheritance with sex-related metabolic and clinical manifestations.

Heterogeneity of acute intermittent porphyria: a subtype with normal erythrocyte porphobilinogen deaminase activity in Germany.

Patients with acute intermittent porphyria can be subdivided into three groups, according to the porphobilinogen deaminase activity in their erythrocytes. The first group has lowered, the second overlapping and the third normal porphobilinogen deaminase activity. Of 385 acute intermittent porphyria patients 5% had normal porphobilinogen deaminase activity. Gene carriers of acute intermittent porphyria, which have normal porphobilinogen deaminase activity but display slight, moderate or high aberrations of excretion, are recognized by analysis of urinary haem precursors and faecal porphyrins. Six individuals suffering from acute intermittent porphyria were detected in three families with normal porphobilinogen deaminase. There were no differences in the latent and clinical phases of acute intermittent porphyria between patients with lowered and those with normal porphobilinogen deaminase. One female with normal activity in erythrocytes, in which the porphyria disease process is triggered by barbiturates and carbamazepine, is presented. After therapy with high doses of glucose and omission of inducing agents, this woman was free of symptoms, and the excretion of different urinary porphyrin precursors and porphyrins decreased by between 65 and 93%.

Diagnosis of acute intermittent porphyria in northern Sweden: an evaluation of mutation analysis and biochemical methods.

To validate the use of a recently observed guanine to adenine mutation in exon 10 in the porphobilinogen deaminase (PBGD) gene as a diagnostic marker of acute intermittent porphyria (AIP). To evaluate the efficiency of the traditional biochemical diagnostic methods. Matched and blinded case-control study (1:4). A primary health care centre in Arjeplog, the National Porphyria Research Unit and a department of clinical genetics in Stockholm. A total of 48/49 (98%) patients over the age of 15 years living in Arjeplog with AIP, diagnosed according to standard clinical and biochemical criteria. For each AIP patient, four controls were matched for age, sex and geographical area and 164/196 (86%) participated. In the validity study, 35 patients were selected as indisputable AIP gene carriers, according to strict biochemical criteria, and 92 matched controls were selected with strict exclusion criteria. Validity, specificity and sensitivity of DNA diagnosis for this AIP mutation. Specificity and sensitivity of traditional biochemical methods. Validity study: the mutation was found in all 35 individuals classified as carriers of AIP. None of the 92 controls had the mutation. Evaluation study: all 48 AIP gene carriers, diagnosed by traditional methods, had the mutation, as had one of the control persons. In an inconclusive group of five persons with heredity for AIP, two had a positive DNA test. The PBGD mutation analysis was found to have full specificity and sensitivity and can be used as the sole diagnostic method in the family complex studied, representing the major AIP mutation in Sweden. The traditional diagnostic methods, used in optimal combinations, work in most cases, but they do not show high precision. However, they must be used when the specific mutation in the PBGD gene is not known.

Catabolism of 5-Aminolevulinic Acid to CO2 by Rat Liver Mitochondria

5-Aminolevulinic acid (ALA), the heme precursor accumulated in plasma and several organs of carriers of acute intermittent porphyria, hereditary tyrosinemia, and saturnism, was previously shown to yield reactive oxygen species upon metal-catalyzed aerobic oxidation and to cause the in vivo and in vitro impairment of rat liver mitochondrial functions. We have studied the uptake and catabolism of [5-14C]ALA to CO2 by isolated rat liver mitochondria (RLM) with the aim of determining whether possible ALA-driven oxidative injury to mitochondria can also occur into the matrix. Using silicone oil centrifugation of [5-14C]ALA-treated RLM, ALA was found to partition evenly into the intra- and extramatrix space of the mitochondrial preparations. The yield of evolved 14CO2 is very low (0.2%), responds to the concentration of added ADP, and is inhibited by malonate (75% at 2 mM), iproniazid (45% at 2 mM), β-chloroalanine (36% at 1 mM), and aminooxyacetate (55% at 0.1 mM). With both iproniazid and aminooxyacetate, the percentage of inhibition is the same as that observed with the latter inhibitor alone. These data indicate that ALA decarboxylation by the Krebs cycle is a minor process and that it is initiated enzymically (transaminase) and not by metal-catalyzed ALA autoxidation.

Genetic carrier detection in Norwegian families with acute intermittent porphyria.

Early detection of carriers of acute intermittent porphyria (AIP) is of great value as an assistance for correct diagnosis and prevention of attacks. In order to complement traditional biochemical methods, restriction fragment length polymorphism (RFLP) studies as well as analysis for a previously identified point mutation were included in a study of three Norwegian AIP families. Several asymptomatic carriers could be identified, and the study thus demonstrates the usefulness of the combination of biochemical and genetic analysis.

A modified spectrophotometric assay for porphobilinogen deaminase: its application in the detection of both carriers and patients with acute intermittent porphyria.

A spectrophotometric method for porphobilinogen deaminase assay in erythrocytes is described. This test is determinant for the definite diagnosis of acute intermittent porphyria. In the method described, delta-aminolevulinic acid is used as substrate. Mercaptoethanol and zinc ions are introduced to maintain delta-aminolevulinic acid dehydratase in optimal conditions and to guarantee the in vitro production of porphobilinogen. An incubation temperature of 45 degrees C leads to the production of uroporphyrins, which are measured spectrophotometrically at 405 nm, giving reproducible results. The assay can be performed easily in any clinical laboratory and is valuable for detecting both patients and carriers of acute intermittent porphyria.

Are free radicals involved in lead poisoning?

1. The enolamine form of 5-aminolaevulinic acid (ALA), a haem precursor that accumulates in lead poisoning and in acute intermittent porphyria (AIP), undergoes fast autoxidation at slightly alkaline pH with concomitant generation of reactive oxygen species. 2. The transmembrane potential, Ca2+ ion fluxes and state-4 respiratory rate, of isolated rat liver mitochondria are severely affected by mM addition of ALA; the toxic role of ALA-produced oxygen radicals was demonstrated by use of appropriate scavengers. 3. Induction of superoxide dismutase biosynthesis in lead-exposed workers, in AIP carriers and in ALA-treated rats, is viewed as a protective response against oxygen radical toxicity. 4. 5-Aminolaevulinic acid-generated oxygen radicals, together with Pb-stimulated Fe-dependent lipid peroxidation, might be involved in the aetiology of the neuropsychiatric manifestations of both plumbism and acute intermittent porphyria.

Quantitative Determination of Porphobilinogen in Urine: Reuse of Disposable Ion-Exchange Columns

It was emphasized in a recent review 1 that 1) the determination of urine porphobilinogen (PBG) is the most important analysis in the diagnosis of an attack of acute porphyria, and 2) quantitative ion-exchange analysis for PBG is indispensable in the detection of asymptomatic carriers of acute intermittent porphyria (AIP). Existing methods for quantitative ion-exchange analysis of urine PBG are laborious, timeconsuming and expensive. The simple Bio-Rad PBG test, based on use of disposable resin columns and designed for qualitative assay of PBG, was therefore developed into a quantitative method and modified so that the disposable columns could be reused. This modified test, a feasible and economical technique within the reach of smaller hospital laboratories, is described in detail.

Acute porphyrias: Differential diagnosis and family studies

1. 1. Studies on the differential diagnosis of the acute porphyrias are presented. 2. 2. Five families carrying Acute Intermittent Porphyria (AIP) are summarized. 3. 3. Early detection of asymptomatic carriers of AIP has been achieved with the uroporphyrinogen-I-synthase (URO-S) assay. 4. 4. A family with Variegate Porphyria (VP) is presented. 5. 5. A family with Coproporphyria (CP) is described. 6. 6. In the two tatter families, asymptomatic carriers have been detected by analysis of fecal porphyrins.

Erythrocyte uroporphyrinogen I synthase activity in diagnosis of acute intermittent porphyria.

Measurement of the activity of uroporphyrinogen I synthase provides an excellent laboratory aid in the diagnosis of acute intermittent porphyria, particularly in those patients who are asymptomatic or in whom the disease is not biochemically manifested by porphyrin precursor excretion. We describe here a simplified fluorometric method for measuring the activity of this enzyme in whole blood. The assay is based upon a coupled-enzyme procedure in which added delta-aminolevulinic acid and the dehydratase that is present in erythrocytes are used to generate porphobilinogen as substrate for uroporphyrinogen synthase. After appropriate incubation the protein is removed we sensitivity, specificity, and precision of the assay compare well with previously described procedures. Activity in nonporphyric male subjects was 31 (SD, 6.0) nmol of porphyrin formed per milliliter of erythrocytes per hour at 37 degrees C. Application of the method for identifying gene carriers of acute intermittent porphyria is demonstrated in three generations of an affected family.