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Lung Disease Caused by ABCA3 Mutations

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Lung Disease Caused by ABCA3 Mutations Thorax Online First, published on August 11, 2016 as 10.1136/thoraxjnl-2016-208649 Interstitial lung disease ORIGINAL ARTICLE Thorax: first published as 10.1136/thoraxjnl-2016-208649 on 11 August 2016. Downloaded from Lung disease caused by ABCA3 mutations Carolin Kröner,1 Thomas Wittmann,1 Simone Reu,2 Veronika Teusch,3 Mathias Klemme,4 Daniela Rauch,1 Meike Hengst,1 Matthias Kappler,1 Nazan Cobanoglu,5 Tugba Sismanlar,6 Ayse T Aslan,6 Ilaria Campo,7 Marijke Proesmans,8 Thomas Schaible,9 Susanne Terheggen-Lagro,10 Nicolas Regamey,11 Ernst Eber,12 Jürgen Seidenberg,13 Nicolaus Schwerk,14 Charalampos Aslanidis,15 Peter Lohse,16 Frank Brasch,17 Ralf Zarbock,1 Matthias Griese1 ▸ Additional material is ABSTRACT published online only. To view Background Knowledge about the clinical spectrum of Key messages please visit the journal online (http://dx.doi.org/10.1136/ lung disease caused by variations in the ATP binding thoraxjnl-2016-208649). cassette subfamily A member 3 (ABCA3) gene is limited. Here we describe genotype-phenotype correlations in a For numbered affiliations see What is the key question? end of article. European cohort. ▸ What is the phenotype of patients with two Methods We retrospectively analysed baseline and disease-causing mutations in the ATP-binding Correspondence to outcome characteristics of 40 patients with two disease- cassette subfamily A member 3 (ABCA3) Professor Dr Matthias Griese, causing ABCA3 mutations collected between 2001 and surfactant lipid transporter gene and how does Department of Pediatric Pneumology, Dr. von Hauner 2015. it correlate to genotype? Children’s Hospital, LMU, Results Of 22 homozygous (15 male) and 18 German Center for Lung compound heterozygous patients (3 male), 37 presented What is the bottom line? research (DZL), Lindwurmstraße with neonatal respiratory distress syndrome as term ▸ In a cohort of 40 subjects three phenotypes 4, Munich 80337, Germany; babies. At follow-up, two major phenotypes are were differentiated, patients with null/null [email protected] mutations died before the age of 6 months, muenchen.de documented: patients with (1) early lethal mutations subdivided into (1a) dying within the first 6 months or long-term (>5 years) survival in this cohort was Received 29 March 2016 (1b) before the age of 5 years, and (2) patients with <20% and response to treatment was uncertain. Revised 7 June 2016 prolonged survival into childhood, adolescence or Accepted 12 July 2016 Why read on? adulthood. Patients with null/null mutations predicting ▸ Explore in-depth clinical, biochemical, complete ABCA3 deficiency died within the 1st weeks to radiological and histological characteristics of http://thorax.bmj.com/ months of life, while those with null/other or other/other patients with pulmonary disease caused by mutations had a more variable presentation and ABCA3 mutations for a better understanding of outcome. Treatment with exogenous surfactant, systemic this orphan disease. steroids, hydroxychloroquine and whole lung lavages had apparent but many times transient effects in individual subjects. Conclusions Overall long-term (>5 years) survival of patients.7 With respect to clinical details, several subjects with two disease-causing ABCA3 mutations was – case reports61520 and one case series with nine on October 1, 2021 by guest. Protected copyright. <20%. Response to therapies needs to be ascertained in patients are available,21 larger studies reporting randomised controlled trials. clinical phenotype details with association to geno- type are lacking. In this study, we broaden the clinical knowledge about this patient group by presenting genetic, bio- INTRODUCTION chemical, clinical, radiological and histological find- The ATP-binding cassette subfamily A member 3 ings in a cohort of 40 patients from Europe. (ABCA3) protein is a 1704 amino acid protein, belonging to the ABC transporter family,1 encoded by a single gene with 33 exons located on chromo- METHODS some 16.23ABCA3 is predominantly expressed in Patients lung tissue,4 localised to the membranes of the All children and adults identified in the programme lamellar bodies of alveolar type II cells, where it is for rare lung diseases of the Kids Lung Register critical for pulmonary surfactant synthesis and pro- (KLR) between 1 January 2001 and 30 June 2015 cessing.5 ABCA3 mutations have been associated with homozygous or compound heterozygous – To cite: Kröner C, with lethal neonatal respiratory distress,6 8 paediat- mutations in the ABCA3 gene were included in this Wittmann T, Reu S, et al. 8–12 fi Thorax Published Online ric and adult interstitial lung disease, and sur- study ( gure 1). Previously published patients were First: [please include Day factant metabolism dysfunction.13 14 In a recent included with additional information and/or for Month Year] doi:10.1136/ study, genotype-phenotype correlation with respect completion of the cohort (see online thoraxjnl-2016-208649 to outcome was analysed in a cohort of 185 supplementary tables S1 and S2). The patients’ Kröner C, et al. Thorax 2016;0:1–8. doi:10.1136/thoraxjnl-2016-208649 1 Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd (& BTS) under licence. Interstitial lung disease Thorax: first published as 10.1136/thoraxjnl-2016-208649 on 11 August 2016. Downloaded from Figure 1 Flow chart of patients included in the study. DPLD, diffuse parenchymal lung disease. status at last follow-up was compared with the initial presenta- available, we used histopathological categorisation and result of tion and was categorised as dead, sick-worse (the patient had electron microscopy in the records. more severe symptoms), sick-same (the symptoms were of Immunohistochemical staining for ABCA3 was performed in all similar severity) or sick-better (the patient had milder symptoms 12 available slides. After pretreatment with Target Unmasking and/or less therapy). The patients’ response to therapies was Fluid (Panpath, Amsterdam, the Netherlands) at 90°C, primary analysed from the records and classified in comparison to antibody against ABCA3 protein (Seven Hills Bioreagents, before the therapy was started: no improvement (therapy did Cincinnati, USA) was used for 60 min at room temperature, not yield any positive effect), moderate improvement (therapy diluted 1:8000. Primary antibody was detected by Vectastain yielded some positive effect, eg, milder mechanical ventilation, ABC-Kit Elite Universal (Vector Laboratories, Burlingame, USA) less oxygen needed and/or effect was only transient) and good and AEC+ chromogen (Dako, Santa Clara, USA), counterstained ’ improvement (therapy yielded a clear positive effect, eg, with haematoxylin Gill s formula (Vector Laboratories). http://thorax.bmj.com/ weaning from mechanical ventilation possible). Microscopic pictures were taken with a Leica DM4000 (Leica, Wetzlar, Germany). Slides were blinded and scored semiquantita- Genetic analysis tively with respect to ABCA3 staining pattern (0=no staining, ABCA3 was analysed using Sanger sequencing (primers are indi- 1=diffuse staining, 2=ring-like structures stained), ABCA3 aggre- cated in online supplementary table S3). Variations were gates (0=no aggregates, 1=small aggregates, 2=big aggregates) grouped according to Wambach et al:7 missense mutations, and intensity of ABCA3 staining (0=no staining, 1=weak staining, insertions and deletions were classified as ‘other’ mutations, 2=moderate staining, 3=strong staining). Scoring was analysed whereas frameshift mutations, nonsense mutations or deletion using Fisher’s exact test. As controls we used tumour-free lung on October 1, 2021 by guest. Protected copyright. of an entire exon were classified as ‘null’ mutations. tissue from children (n=10, median age 9.3 years (2.3–17.5)), who received biopsy for diagnosis of pulmonary nodules associated Structure-function analysis of previously undescribed ABCA3 with oncological diseases (nephroblastoma (n=6), hepatoblastoma mutations (n=1), osteosarcoma (n=2), nerve sheath tumour (n=1)). The predicted effect of ABCA3 mutations on protein function was calculated using PROVEAN,22 SIFT23 and PolyPhen2.24 Radiological studies Total protein and surfactant protein B and C concentration Radiological studies were scored by a paediatric radiologist (VT) in bronchoalveolar lavage fluid according to the criteria of Fleischner Society.28 CT scans and Surfactant protein B (SP-B) and surfactant protein C (SP-C) chest X-rays (CXR) were rated in three sections on the left were determined in bronchoalveolar lavage fluid (BALF), and right sides: apex to carina, carina to lower pulmonary vein obtained prior to exogenous surfactant application, using quan- and lower pulmonary vein to diaphragm. The incidence of hilar titative western blotting.25 26 lymphadenopathy, ground glass opacity, cysts, bronchial wall thick- ening, bronchiectasis/peripheral bronchial dilatation, reticular Lung biopsy, histopathology, electron microscopy and pattern, nodular pattern, lobe retraction and consolidation was immunohistochemistry evaluated for each lung section on both, CXR and CT scans. CT All available lung biopsies were collected as paraffin blocks or scans were in addition assessed for honeycombing, crazy paving slides and evaluated by a pathologist specialised in pulmonary and paraseptal emphysema, CXRs for hyperinflation. Each item diseases (SR). Histology was scored by severity (0=none, 1=dis- was scored as 0=none, 1=discrete, 2=diffuse or 3=very strong. crete, 2=moderate, 3=strong).27 When material
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