Biomarker Analysis of Morquio Syndrome
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Martell et al. Orphanet Journal of Rare Diseases 2011, 6:84 http://www.ojrd.com/content/6/1/84 RESEARCH Open Access Biomarker analysis of Morquio syndrome: identification of disease state and drug responsive markers Lisa Martell1, Kelly Lau1, Miranda Mei1, Vicki Burnett2, Celeste Decker1 and Erik D Foehr1* Abstract Background: This study was conducted to identify potential biomarkers that could be used to evaluate disease progression and monitor responses to enzyme replacement therapy (ERT) in patients with mucopolysaccharidosis (MPS) IVA. Methods: Levels of 88 candidate biomarkers were compared in plasma samples from 50 healthy controls and 78 MPSIVA patients not receiving ERT to test for significant correlations to the presence of MPSIVA. MPSIVA samples were also tested for correlations between candidate biomarkers and age, endurance, or urinary keratin sulfate (KS) levels. Then, levels of the same 88 analytes were followed over 36 weeks in 20 MPSIVA patients receiving ERT to test for significant correlations related to ERT, age, or endurance. Results: Nineteen candidate biomarkers were significantly different between MPSIVA and unaffected individuals. Of these, five also changed significantly in response to ERT: alpha-1-antitrypsin, eotaxin, lipoprotein(a), matrix metalloprotein (MMP)-2, and serum amyloid P. Three of these were significantly lower in MPSIVA individuals versus unaffected controls and were increased during ERT: alpha-1-antitrypsin, lipoprotein(a), and serum amyloid P. Conclusions: Candidate biomarkers alpha-1-antitrypsin, lipoprotein(a), and serum amyloid P may be suitable markers, in addition to urinary KS, to follow the response to ERT in MPSIVA patients. Background GALNS activity [1,2]. The International Morquio Regis- Mucopolysaccharidosis (MPS) IVA (OMIM #253000), try and the Morquio Clinical Assessment Program (Mor- also known as Morquio A syndrome, is an autosomal CAP, also known as MOR-001) found considerable recessive lysosomal storage disorder caused by deficient morbitity and mortality in MPSIVA individuals, including activity of N-acetylgalactosamine-6-sulfatase (GALNS) frequent surgical procedures, limited mobility, poor [1]. GALNS catalyzes the degradation of the glycosami- endurance and pulmonary function, and death in the sec- noglycans (GAGs), KS and chondroitin-6-sulfate (CS). In ond or third decade of life for patients with a severe phe- individuals affected with MPSIVA, KS and CS accumu- notype (about 68% of MPSIVA patients) [1,3]. Urinary late in the tissues, causing skeletal dysplasia, coarse facial GAG testing is used to screen for MPSIVA, with enzyme features, restricted growth and short stature, joint hyper- activity measurement in blood or fibroblasts to confirm mobility, valvular heart disease, pulmonary disease, diagnosis [1,2]. The incidence of MPSIVA ranges from 1 obstructive sleep apnea, hepatomegaly, corneal clouding, in 40,000 to 1 in 450,000 live births [1,2]. hearing loss, and poorly formed teeth [1]. Because more Currently there is no treatment for MPSIVA, only sup- than 150 mutations in the gene encoding GALNS have portive measures such as surgeries for skeletal dysplasia, been identified, there is considerable clinical heterogene- oxygen for poor lung function, and antibiotics for lung ity ranging from mild to severe based on the residual infections [1,2]. However, ERT with recombinant human (rh) GALNS (BMN110) is under clinical development, ERT provides a supply of the deficient enzyme and is * Correspondence: [email protected] available for MPS I, MPS II, and MPS VI [4]. 1BioMarin Pharmaceutical Inc. Novato, CA USA Full list of author information is available at the end of the article © 2011 Martell et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Martell et al. Orphanet Journal of Rare Diseases 2011, 6:84 Page 2 of 10 http://www.ojrd.com/content/6/1/84 In a mouse model of MPSIVA [5]. rhGALNS mark- this particular disease study. Analysis of samples was per- edly decreased storage in visceral organs, heart valves, formed using the Luminex platform. ligaments, connective tissues, and brain [6]. ERT (rhGALNS, BMN110) for MPSIVA is evaluated in a MOR-001 Phase I/II human trial. The clinical trial is a multicenter, The MOR-001 study is a multicenter, multinational, open-label, dose-escalation study to evaluate safety, tol- longitudinal clinical assessment of patients with MPS erability, and efficacy of BMN 110 in patients with MPS IVA not receiving ERT. This longitudinal study aims to IVA (clinical trial #NCT00884949) between 5 and 18 catalogue the spectrum of symptoms and biochemical years of age [7]. A global double blind, randomized, pla- abnormalities of subjects with MPS IVA. There have cebo-controlled Phase III study of BMN 110 in MPSIVA been 129 subjects enrolled through 2009 [3]. Analytes was initiated in 2011 [8]. were profiled and quantified from plasma samples With ERT in development for MPS IVA, identification obtained from the initial visit of the first 78 of MPS of biomarkers to evaluate disease progression and IVA subjects and compared with the samples from 50 response to treatment becomes more important. To date, controls subjects (61% female, female age range 21-70, KS has been identified as an important biomarker for mean female age 45; 39% male, male age range 24-71, MPS IVA [9] as it accumulates in the tissues, particularly mean male age 47). Analyte profiles obtained in the the cartilage, cornea, and heart valves, in MPS IVA MPSIVA group were then sub-analyzed to determine if patients [10]. KS storage in the cartilage causes cartilage any significant correlations existed to subject age, per- disruption, which contributes to increased circulating formance in an endurance test (6 minute walk test; 6 levels of KS in MPS IVA patients relative to healthy indivi- MWT), or levels of urinary KS (uKS). duals. KS can be quantified in urine and plasma and may be helpful for screening and for following the clinical MOR-002 course and efficacy of treatment [9,11]. KS levels in urine The MOR-002 study is a multicenter, open-label, dose- and plasma have been shown to vary with age (with escalation study to evaluate the safety, tolerability, and plasma levels generally peaking between 5 to 10 years of efficacy of BMN 110 in patients with MPS IVA between age and urine levels peaking between 1 and 5 years of age) 5 and 18 years of age. Twenty subjects enrolled in the and increase with clinical severity of MPS IVA [12]. study, and 18 subjects completed 36 weeks of therapy While KS is an important and treatment-related biomar- with weekly 4 to 5 hours intravenous infusions of BMN ker to track MPSIVA disease progression and response to 110. The study used 3 consecutive 12-week dosing inter- ERT, it is not known whether there are additional biomar- vals (the dose escalation phase), using the following kers associated with MPS IVA and their relationship to KS regimen: levels, disease severity, disease progression and response to Weeks 1012: 0.1 mg/kg/week ERT. The goal of the current study is to identify additional Weeks 13-24: 1.0 mg/kg/week candidate biomarkers that support evaluations of disease Weeks 25-36: 2.0 mg/kg/week progression and monitoring response to ERT and examine Subjects completing the 36-week dose-escalation per- their relationships with levels of KS. iod had the option to continue drug treatment for an additional 36 weeks. Subjects continuing treatment after Methods the dose-escalation period received weekly 4 to 5 hour Analytes intravenous (IV) infusions of BMN 110 at a dose of 1.0 To identify and evaluate potential biomarkers for MPS mg/kg/week. Clinical outcomes included measures of IVA, this study examined 88 different analytes from endurance (6 MWT), 3 minute stair climb test (3 plasma samples obtained from 50 healthy adult control MSCT) and pulmonary function (forced vital capacity subjects, 78 MPS IVA subjects not receiving ERT from [FVC]), examined at baseline and weeks 6, 12, 18, 24, the MOR-001 study, and 20 subjects receiving ERT with 30, 36, 48, 60, and 72 [7]. BMN 110 from the MOR-002 study. The analytes for this The same 88 analytes studied in MOR-001 patients study were from the Human Multi-Analyte Profile were profiled longitudinally in 20 MOR-002 study sub- (MAP)v1.6fromRulesBasedMedicine(AustinTX). jects at baseline, 12, 24, and 36 weeks post-ERT during This is an 88-biomarker MAP providing quantitative the dose escalating phase. Analyte profiles were then multiplexed assays covering different biological pathways. sub-analyzed to determine if any significant correlations Biomarkers included in this MAP were selected to pro- existed to subject age or performance in the 6 MWT. vide a comprehensive understanding of complex drug Both MOR-001 and MOR-002 were approved by an and disease effects. The analytes on the Human MAP Institutional Review Board and informed consent was v1.6 are a pre-set panel and were not custom selected for obtained from all human subjects. Martell et al. Orphanet Journal of Rare Diseases 2011, 6:84 Page 3 of 10 http://www.ojrd.com/content/6/1/84 Statistical analysis significantly higher in MPS IVA subjects versus unaf- T-tests were performed to check for significant differ- fected controls, and the other 16 were significantly ences in analytes between MPS IVA patients and unaf- lower in MPS IVA subjects compared to controls. fected control subjects (for MOR-001), between older (over 9.5 years) and younger (9.5 years or less) MPS Analyte correlations in MPS IVA subjects not receiving IVA subjects, between MPS IVA subjects with high ERT (> 24.6 μg/mg creatinine) and low (≤ 24.6 μg/mg creati- Correlation with age nine) uKS, and between MPS IVA subjects with high Table 3 lists the 11 analytes that were significantly differ- (> 235 meters) and low (≤ 235 meters) 6 MWT scores.