Safety and efficacy of idursulfase in the treatment of mucopolysaccharidosis II (Hunter syndrome): a post-marketing study in Japan.

OBJECTIVES: Enzyme replacement therapy with idursulfase has been shown to improve somatic signs and symptoms of mucopolysaccharidosis type II (MPS II). Idursulfase is available in Japan (since 2007), based on the outcome of clinical trials conducted in the United States, but data from Japanese patients are limited. METHODS: This was a postmarketing study of Japanese MPS II patients treated with 0.5 mg/kg intravenous idursulfase weekly, conducted over a period of 8 years after initial administration. Assessments included the safety profile, survival rate, degree of clinical improvement, change in urinary uronic acid (UA) concentration, and 6-minute walk test (6MWT). RESULTS: The safety and efficacy analysis populations included 145 and 143 patients, respectively. The incidence of serious adverse events was 42.8% and the incidence of adverse drug reactions was 48.3%. The 7-year survival rate was 82.7%. Improvements in the clinical features of hepatosplenomegaly, skin, joint, and respiratory disorders were reported (per investigator's assessment). The mean change in urinary UA concentration was -128.39 mg/g creatinine, and that of 6MWT walking distance was +31.8 m. CONCLUSION: Long-term idursulfase treatment was well tolerated, and effective in improving clinical features, reducing urinary UA, and slowing disease progression in Japanese MPS II patients.

Total and single species of uronic acid-bearing glycosaminoglycans in urine of newborns of 2-3days of age for early diagnosis application.

BACKGROUND: Urine are easily accessible and relatively simple to process and uronic acid-bearing glycosaminoglycans (UA-GAGs) may serve as biomarkers for several diseases, like for mucopolysaccharidosis. METHODS: We report a study from a large cohort of healthy newborns of 2-3days to have a basic profile of total content of urinary UA-GAGs, their composition and structural signatures utilizing a rapid extractive method and sensitive separation of enzymatic released disaccharides by capillary electrophoresis-light induced fluorescence. Results were also compared with those obtained from normal adult subjects. RESULTS: A total of UA-GAGs content of ~35µg/mg creatinine was observed in 331 newborns versus 1.5µg/mg creatinine of adult urine composed of ~90% chondroitin sulfate (CS), ~7% heparan sulfate (HS) and ~3% hyaluronic acid (HA). No significant differences were observed with adults. Specific ratios between the main CS disaccharides were informative of a significant greater 4-sulfation and charge density for newborn compared to adults. The HS from newborn urine was mainly composed by the non-sulfated (~64%) and mono-sulfated (~28%) disaccharides. No significant differences were observed versus adult urine. CONCLUSIONS: The present method is able to measure changes in UA-GAG composition and their structure independently of the age of subjects and rapidly applicable to the newborn diagnosis without necessity to have creatinine levels. Moreover, modifications in charge density values as well as the presence of sulfate groups in specific positions may be indicative of altered conditions.

[Prognostication and prophylaxis of the adhesions recurrence postoperatively in patients suffering acute adhesive peritoneal disease complicated by ileus].

The results of treatment of 92 patients, suffering an acute ileus, were analyzed. After urgent operative interventions for an acute ileus the recurrence have occurred in 19.6% patients. To reduce the operative intervention traumaticity the preference was given to local viscerolysis conduction. For the adhesions occurrence prophylaxis a barrier medicines were used, what have promoted the reduction of contents of a connective tissue metabolites, excluding oxyprolin, concentration of which have exceeded such in a control, what have guaranteed the risk lowering for postoperative adhesions occurrence.

Enzyme replacement therapy attenuates disease progression in two Japanese siblings with mucopolysaccharidosis type VI.

Mucopolysaccharidosis type VI (MPS VI) is a progressive, multisystem autosomal recessive lysosomal disorder resulting from deficient N-acetylgalactosamine-4-sulphatase (ASB) and the consequent accumulation of glycosaminoglycan (GAG). Preclinical and clinical studies had demonstrated clinical benefits of early initiation of systemic therapies in patients with MPS. In this case report, two siblings with MPS VI started enzyme replacement therapy (ERT) with weekly infusions of recombinant human ASB (Galsulfase) at 1mg/kg. Sibling 1 started ERT 5.6 years of age and Sibling 2 was 6 weeks old. The disease status in these two siblings prior to and for no less than 36 months of ERT was followed up and compared. The treatment was well tolerated by both siblings. During 36 months of ERT, symptoms typical of MPS VI including short stature, progressive dysmorphic facial features, hepatosplenomegaly, hearing impairment, corneal clouding, and dysostosis multiplex were largely absent in the younger sibling. Her cardiac functions and joint mobility were well preserved. On the other hand, her affected brother had typical MPS VI phenotypic features described above before commencing ERT at the equivalent age, of 3 years. There was significant improvement in the shoulder range of motion and hearing loss after 36 months of treatment and cardiac function was largely preserved. His skeletal deformity and short stature remained unchanged. The results showed that early ERT initiated at newborn is safe and effective in preventing or slowing down disease progression of MPS VI including bone deformities. These observations indicate that early diagnosis and treatment of MPS VI before development of an irreversible disease is critical for optimal clinical outcome.

The significance of potassium chloride sensitivity test and urinary uronic acid level in the diagnosis of chronic pelvic pain syndrome.

OBJECTIVES: Noninvasive tests are needed for the diagnosis of chronic pelvic pain syndrome. We evaluated the significance of potassium chloride sensitivity test and urinary CTAB-precipitable uronate level in patients with chronic pelvic pain syndrome (CPPS). METHODS: We included 25 patients with interstitial cystitis (IC), and 30 patients with chronic prostatitis (CP) who applied to our outpatient clinic with the complaints of frequency, dysuria and pain on urination between the years 2003 and 2005. Thirty-five subjects were studied as healthy controls. All patients underwent cystoscopy, cystometry, voiding diary, sodium chloride, and potassium chloride filling tests. Visual analog scale (VAS) was used to determine pain scores. Patients with CP also underwent NaCl and KCl voiding tests. Urinary CTAB-precipitable uronate levels were obtained in all subjects. RESULTS: KCl test had a good sensitivity for IC. As for the patients with CP, KCl voiding test was useful, but KCl filling test was not. Urinary CTAB-precipitable uronate level was found to be significantly higher in patients with IC and CP than controls, and in patients with IC than in patients with CP. CONCLUSIONS: The results of our study suggest that KCl voiding test is a good candidate to be used in the diagnostic workup of patients with category III CP, and urinary CTAB-precipitable uronate level measurement may be a noninvasive diagnostic aid for IC and CP.

A defect in exodegradative pathways provides insight into endodegradation of heparan and dermatan sulfates.

Within cells, dermatan sulfate (DS) and heparan sulfate (HS) are degraded in two steps. The initial endohydrolysis of these polysaccharides is followed by the sequential action of lysosomal exoenzymes to reduce the resulting oligosaccharides to monosaccharides and inorganic sulfate. Mucopolysaccharidosis (MPS) type II is a lysosomal storage disorder caused by a deficiency of the exoenzyme iduronate-2-sulfatase (I2S). Consequently, partially degraded fragments of DS and HS have been shown to accumulate in the lysosomes of affected cells and are excreted in the urine. Di- to hexadecasaccharides, isolated from the urine of a MPS II patient using anion exchange and gel filtration chromatography, were identified using electrospray ionization-tandem mass spectrometry (ESI-MS/MS). These oligosaccharides were shown to have non-reducing terminal iduronate-2-sulfate residues by digestion with recombinant I2S. A pattern of growing oligosaccharide chains composed of alternating uronic acid and N-acetylhexosamine residues was identified and suggested to originate from DS. A series of oligosaccharides consisting of hexosamine/N-acetylhexosamine alternating with uronic acid residues was also identified and on the basis of the presence of unacetylated hexosamine; these oligosaccharides are proposed to derive from HS. The presence of both odd and even-length oligosaccharides suggests both endo-beta-glucuronidase and endo-N-acetylhexosaminidase activities toward both glycosaminoglycans. Furthermore, the putative HS oligosaccharide structures identified indicate that heparanase activities are directed toward regions of both low and high sulfation, while the N-acetylhexosaminidase activity acted only in regions of low sulfation in this polysaccharide.

Dietary fibres ameliorate decreased synthesis of heparan sulphate in streptozotocin induced diabetic rats.

The role of dietary fibers in diabetes has been studied by several workers. Long term dietary treatment with increased amounts of fiber-rich low-glycaemic index natural foods improves blood glucose and reduces the number of hypoglycemic events in type I diabetic patients. On the other hand Rohrbach and Martin and Cohen and Surma described changes in the general and biochemical structure of renal tissues such as the glomerular basement membranes. One of these changes was the reduction and undersulfation of the glycoconjugate and glycosaminoglycan heparan sulfate, which plays an important role in renal structure and function. The purpose of the present study was to determine specific effects of two types of dietary fiber on the composition of kidney glycoconjugates in an animal model of diabetes type I. Streptozotocin-treated diabetic rats were fed either a control diet or diets containing 10% wheat bran (insoluble dietary fiber) or 5% guar gum (soluble dietary fiber). Effects of these fibers on glycaemic control and nephropathy were assessed using previously described methodologies. The effect of dietary fiber in the glycoconjugate composition of kidneys of control and diabetic animals was studied by estimating their total hexose content, sulfated glycosaminoglycans, hexosamines and uronic acids. The activities of enzymes that participate in the synthesis of saccharides and glycoconjugates (L-glutamine-fructose-6-phosphate aminotransferase) and their degradation (N-acetyl-beta-glucosaminidase and beta-glucuronidase) were also evaluated. Results indicated that both soluble and insoluble dietary fibers ameliorated a significant increase in the activity of GFAT. Heparan sulfate was also isolated and quantified. Results indicated that the renal content of heparan sulfate decreased in diabetic animals and that this decrement was ameliorated by the ingestion of both soluble and insoluble fiber in the diet.

[Biopolymers in urine of patients with syringomyelia]. / Biopolimery mochi bol'nykh siringomieliei.

Urine of patients with syringomyelia was analysed by gel filtration, ion-exchange chromatography and analytical chemistry methods. Increased level of acidic glycoproteins and decreased level glycosaminoglycans levels were found. Patients with syringomyelia had smaller glycosaminoglycans components of proteoglycans than normal subjects.

Increased urinary uronic acid excretion in experimentally-induced renal papillary necrosis in rats.

We have evaluated the potential of urinary uronic acid measurement as an early indicator in the development of renal papillary necrosis (RPN). Urinary uronic acid was quantified with a range of other urinary biochemical parameters in rats given multiple doses of N-phenylanthranilic acid (NPAA) or mefenamic acid (MFA), each of which induces a dose-related papillary necrosis. In addition, histological examination was also carried out to confirm the development and presence of RPN. NPAA was administered to male wistar rats at p.o. doses of 100, 250, and 500 mg/kg and MFA at p.o. doses of 75, 150, and 300 mg/kg on days 1-4 and 8-11, and urine samples were collected for 16 hours each day. NPAA increased uronic acid excretion two-fold for both medium and high doses from day four. MFA increased uronic acid excretion to two and a half-fold by day 10 in the highest dose administered. Urinary creatinine was equally elevated in a dose-related manner following treatment with either NPAA or MFA. None of the other routine markers (urinary or serum) of nephrotoxicity showed any statistical changes. NPAA produced a dose- and time-related increase in excretion of uronic acid. Evidence of widespread papillary necrosis was seen histologically at the high doses of NPAA or MFA. The significant elevation of uronic acid in urine following treatment with either NPAA or MFA was well ahead of the development of RPN detectable by routine histology, suggesting that uronic acid measurement could serve as an early indicator of RPN. The assessment of urinary uronic acid may therefore provide a novel sensitive and selective marker of identifying the lesion earlier than is currently possible. An increase in urinary uronic acid following NPAA and MFA treatment supports the biochemical basis of these changes as a representative of acid mucopolysaccharides accumulation.

Urinary glycosaminoglycans excretion in Graves' disease.

Urinary excretion of glycosaminoglycans was measured in 10 patients with pretibial myxoedema, 7 of whom also had thyroid-associated ophthalmopathy, and in 3 additional patients with ophthalmopathy but no skin changes. Total uronic acid excretion was raised above control levels in only 2 patients, who had both eye and skin disease of recent onset. In these patients excretion was initially three times the control level but declined sharply in subsequent months. This decline was in the absence of effective treatment or spontaneous improvement and would appear to reflect the natural history of the disease. These data show that although glycosaminoglycans excretion may be disturbed in Graves' disease, it provides an unreliable reflection of clinical status and of the effectiveness of treatment.

Starch and dietary fiber components are excreted and degraded to variable extents in ileostomy subjects consuming mixed diets with wheat- or oat-bran bread.

The study was conducted to determine if the excretion of starch and dietary fiber components varies in ileostomy subjects consuming diets high or low in dietary fiber. Excretion of starch, enzyme-resistant starch and dietary fiber components was studied in nine human subjects with ileostomies, who consumed (in a crossover design) a wheat bread-based diet (daily intake 274 g starch, 2.4 g enzyme-resistant starch and 14.4 g total dietary fiber) and a high fiber diet based on oat-bran bread (daily intake 243 g starch, 2.7 g enzyme-resistant starch and 40.2 g total dietary fiber). Food and excreta were collected on d 3 and 17. No significant differences in excretion of starch, enzyme-resistant starch or dietary fiber components were found on these 2 d in each dietary period. When subjects consumed the wheat bread-based diet they excreted (mean +/- SD) 3.3 +/- 1.7 g starch and 2.4 +/- 0.4 g enzyme-resistant starch daily, whereas when consuming the oat bran-based diet they excreted 4.5 +/- 3.1 g starch and 2.5 +/- 0.4 g enzyme-resistant starch. During both dietary periods subjects excreted significantly greater amounts of certain dietary fiber polysaccharide residues (fucose, galactose and uronic acid) than they ingested. This indicates a contribution of endogenous and/or microbial material to the dietary fiber value in ileostomy effluents. However, significantly less excretion of some dietary fiber polysaccharide residues, especially glucose residues, during the oat-bran bread-based dietary period was also noted. This was presumably caused by a degradation of mixed-linked (1,3),(1,4)-beta-D-glucans.

Reduced inhibitory activity of uronic-acid-rich protein in urine of stone formers.

We recently reported that human urine contains a newly identified urinary glycoprotein acting as a potent inhibitor against calcium oxalate crystallization. This inhibitor is a uronic-acid-rich protein (UAP) with a molecular weight of approximately 35 kDa. In the present study, UAP was isolated from urine of stone formers and of subjects without a stone history, and its inhibitory activity was tested in a calcium oxalate crystallization system in vitro. Our results show a weaker inhibitory activity of UAP extracted from the urine of stone formers than that extracted from the urine of healthy subjects. Preliminary analyses of amino acid and carbohydrate content showed some differences between the two groups. The main difference was the reduction in sialic acid in UAP isolated from the urine of stone formers. We suggest that UAP contributes significantly to total urinary inhibitory activity of calcium oxalate crystallization and that the decrease in this activity in the urine of recurrent stone formers is due, in part, to the weak inhibitory activity of UAP. A structural abnormality of UAP could explain the diminution of its inhibitory activity in the urine of stone formers.

Urinary glycosaminoglycan excretion as a laboratory marker in the diagnosis of interstitial cystitis.

Urinary macromolecular uronate and glycosaminoglycan uronate concentrations were determined in 209 urine specimens obtained from 192 interstitial cystitis patients, 47 asymptomatic normal individuals and 32 spinal cord injury patients. As a group the concentration of macromolecular uronate or glycosaminoglycan uronate was significantly less in the interstitial cystitis patients than in the normal controls. Some interstitial cystitis patients showed low values of macromolecular uronate and glycosaminoglycan uronate. Analysis of the population distributions suggested that macromolecular uronate may have significant value in diagnosis of interstitial cystitis.

Normal MPS excretion, but dermatan sulphaturia, combined with a mild Maroteaux-Lamy phenotype.

A mildly affected Maroteaux-Lamy patient is described. Electrophoretic separation of acid mucopolysaccharides (MPS) in the urine showed an increased excretion of dermatan sulphate in spite of a normal total excretion of MPS.

A rapid method for ovulation detection.

Uronic acid (UA) content in whole urine showed a characteristic pattern of fluctuations during menstrual cycle (24 cycles) with a distinct peak on the day of ovulation (midcycle peak 1043 + 68 micrograms/ml urine. This peak of maximal UA concentration was validated by ultrasonography (abdominal and/or vaginal scanner and basal body temperature. In hormonal induced menstrual cycle (5 cycles) a significant decrease in Ua concentrations were observed during the follicular phase (20%) and in the midcycle peak (11%) when they were compared with the same values in the normal cycle. Nevertheless, two days after the ovulation peak occurs a second peak can be observed (1344 + 799 micrograms UA/ml urine). On the other hand in the anovulatory cycles (5 cycles) the same diminishing behavior in the UA concentrations were observed in both phases of the cycle (50-60%) with the expected lack of the midcycle peak. Results that clearly show that UA excretion in urine reflect a excellent correlation with the menstrual cycle allowing us to propose this technique as an accurate and reliable method to detect ovulation.

Decreased urinary uronic acid levels in individuals with interstitial cystitis.

The pathogenesis of interstitial cystitis currently is unknown. A possible etiology is that the transitional epithelium is defective, leading to molecular leaks that initiate the disease complex. An important surface defense mechanism is the glycosaminoglycans or polysaccharides that line the bladder epithelium and act as a nonspecific antiadherence factor blocking access of bacteria, microcrystals, proteins and ions to the underlying transitional cells. We examined the excretion of urinary macromolecular uronic acid and glycosaminoglycans in normal individuals and those with interstitial cystitis. A total of 37 controls had a mean macromolecular uronic acid level of 56 nmol. per mg. creatinine, compared to 40.2 nmol. per mg. creatinine in 43 patients with active disease (differences were significant, p equals 0.03). The median excretions of glycosaminoglycan uronate for controls and patients were 15.1 and 11.1 nmol. per mg. creatinine, respectively. (There was an over-all tendency to decrease excretion in patients with a p value of 0.06.) Specimens obtained at cystoscopy from patients with active interstitial cystitis had ureteral macromolecular uronic acid levels of 40.5 nmol. uronate per mg. creatinine compared to 43.6 nmol. uronate per mg. creatinine from the bladder. Interstitial cystitis patients had 16.0 nmol. glycosaminoglycan uronate per mg. creatinine compared to 14.6 nmol. per mg. creatinine in normal controls. Neither of these differences was statistically significant. It would appear that there is a tendency to lower macromolecular uronic acid and polysaccharide excretion in individuals afflicted with this syndrome.

Serum and urine glycosaminoglycans in myeloid leukemia and myelodysplasia.

Urinary glycosaminoglycan excretion is increased in a variety of human diseases, including malignancy. We have measured serum and urine glycosaminoglycan levels by the carbazole method of uronic acid determination in patients with myeloid leukemia or myelodysplasia. Eleven patients were studied during active disease as well as eight in complete remission. Serum levels in patients with active disease did not differ significantly from 11 healthy volunteers with no hematological disease. In contrast, the median urine level for the patients with active disease was 7.6 mg uronate/g Creatinine (Creat) compared to 2.6 for controls (p less than 0.002). Interestingly, the eight patients in complete remission also had a significant increase in uronate excretion with a median of 7.3 (p less than 0.002). These results suggest that elevated urinary glycosaminoglycan levels in leukemia are not due to impaired ability of the liver to clear circulating glycosaminoglycans or overproduction by leukemic cells. The observed increase in glycosaminoglycan excretion may be due to altered bone marrow matrix metabolism that is often not reversed by the achievement of hematologic remission.

Studies on carbohydrate moieties of glycoproteins in established adjuvant induced arthritis.

The investigation presents the metabolic changes in the carbohydrate components of glycoproteins in several tissues of adjuvant arthritic rats. The experimental arthritis induces a significant modification of total carbohydrate moieties of glycoproteins in arthritic tissues. In both acute and chronic phases of the disease, the adjuvant arthritis caused a significant increase in the levels of carbohydrate moieties of tissue glycoproteins viz. total hexose, hexosamine, fucose, sialic acid, total neutral sugar content and neutral sugar monosaccharides. In addition, the urinary excretions of hexosamine and uronic acid in arthritic rats were found to be elevated significantly. The data from the investigation clearly indicate that the experimental arthritis induces an increased glycoprotein synthesis in most of the tissues examined.

Urinary proteoglycan degradation product excretion in patients with rheumatoid arthritis and osteoarthritis.

The excretion of sugar components of glycosaminoglycans in the urine was investigated in 19 healthy controls, 27 patients with rheumatoid arthritis, and 24 with osteoarthritis. Both groups of patients excreted significantly more glucosamine, galactosamine, and mannose than the controls. The total uronic acid excretion, also, was higher in the two groups than in the healthy subjects. The possibility of using this method for the long term follow up of rheumatoid arthritis and osteoarthritis and the response to treatment is discussed.