US 20060275279A1 (19) United States (12) Patent Application Publication (10) Pub. No.: US 2006/0275279 A1 ROZZell et al. (43) Pub. Date: Dec. 7, 2006 (54) METHODS FOR DISSOLVING CYSTINE (22) Filed: Jun. 6, 2005 STONES AND REDUCING CYSTINE IN URINE Publication Classification (76) Inventors: J. David Rozzell, Burbank, CA (US); (51) Int. Cl. Kavitha Vedha-Peters, Pasadena, CA A6II 38MSI (2006.01) (US) (52) U.S. Cl. ............................................................ 424/94.5 Correspondence Address: CHRISTIE, PARKER & HALE, LLP (57) ABSTRACT PO BOX 7O68 PASADENA, CA 91109–7068 (US) The present invention is directed to an improved method of treating cystinuria, utilizing the catalytic ability of cystinase (21) Appl. No.: 11/146,551 to increase the rate of cystine Stone dissolution. Patent Application Publication Dec. 7, 2006 Sheet 1 of 4 US 2006/0275279 A1 Hs1N1 Ncoh L-Homocysteine -- H2 O HOC n1ns 1-1N CO2H Cystathionine?3-lyase ls CO2H H2 Pyruvate L-Cystathionine H NH FIG. 1. Metabolic Reaction Catalyzed by Cystathionine-?s-Lyase Patent Application Publication Dec. 7, 2006 Sheet 2 of 4 US 2006/0275279 A1 NH2 Hs1 S Y1Ncoh L-Thiocysteine -- NH2 O Hozen-1- 1N1 no H Cystathionine e i 2 B-lyase CO2H NH2 P L-CystineA- y ruvate -- NH FIG. 2. "Un-Natural" Reaction Catalyzed by Cystathionine-?s-Lyase on L-Cystine Patent Application Publication Dec. 7, 2006 Sheet 3 of 4 US 2006/0275279 A1 Dissolution of Cystine Stones with Cystathionine beta-lyase (MetC) s -o-control (no MetC) al -H 1 mg/mL MetC g - 5 mg/mL MetC 3. -- 10 mg/mL MetC S. 1.5 Time (day) FIG. 3 Patent Application Publication Dec. 7, 2006 Sheet 4 of 4 US 2006/0275279 A1 10mg/mL Met C 5mg/mL Met C 1 mg/mL Met C 10mg/mL Met C 5mg/mL MetC" no enzyme O Stone no Stone control FIG. 4 US 2006/0275.279 A1 Dec. 7, 2006 METHODS FOR DISSOLVING CYSTINE STONES 0006. One of the most common methods for the removal AND REDUCING CYSTINE IN URINE of cystine Stones is percutaneous nephrolithotomy, in which a keyhole incision is made in the back and a nephroscope is BACKGROUND used to break up and remove the stones. Although this 0001. The cause of cystinuria, a genetic disease, is well procedure is less invasive than open Surgery, regular or understood. In healthy individuals, cystine is filtered from spinal anesthesia is normally required along with a hospital blood at the renal glomeruli and reabsorbed by the proximal stay of 2 to 3 days and a recovery time of a few weeks, in renal tubule cells via a transporter protein assembly that is which the patient may not be able to work (Ng and Streem, specialized for certain amino acids including cystine, argi 2001). nine, lysine, ornithine and citruline. In cystinurics this amino acid transporter assembly is defective, and cystine is 0007 An additional method for the treatment of cystine not reabsorbed normally. The cystine accumulates in the stones, which is a non-Surgical and minimally invasive urine in abnormally large amounts and, due to its insolubility route, involves the delivery of chemical solutions to the relative to other amino acids, crystallizes to produce stones. kidneys via a nephrostomy catheter for the chemical disso lution of the stones, also known as chemodissolution. A 0002 Cystinuria causes one of the most dangerous types variety of chemolytic agents have been used in this tech of kidney Stones, and cystinurics often experience a life of nique including Sodium bicarbonate and the organic buffer misery due to frequent Stone formation episodes. Cystine tris-hydroxymethylene-aminomethane (tromethamine-E) at stones are far more serious than the common calcium pH 10, both which act to provide a strongly alkaline envi oxalate stone because they can be over twenty-times larger ronment to dissolve the cystine Stones. Acetylcysteine is also than oxalate stones in weight and size. Cystine Stone formers frequently used in chemodissolution and dissolves the experience severe pain and frequently require emergency stones in a manner similar to D-penicillamine and Thiola by room visits, hospitalizations, and Surgeries. Current treat breaking the cystine disulfide and forming more soluble ment regimens for cystine Stones are often difficult and disulfides. However, this dissolution method has a limited unsuccessful. As a result, renal failure that results in a need role in the treatment of cystine Stones because these for dialysis or kidney transplantation is not uncommon. chemolytic agents perform extremely slowly and can typi Since no highly effective treatments for cystine stones exist, cally take weeks to months to dissolve stones (Ng and cystinurics face extremely difficult living circumstances, and the costs of cystinuria to the medical system are high, Streem, 2001). despite the low patient population (Beaudet, 1995). 0008 Given the drawbacks of the current methods for the treatment of cystine Stones, a minimally invasive, non 0003) Given the severity of the symptoms of cystinuria, Surgical route for treatment in which the cystinuric is treated treatment is essential. The first course of treatment usually under general anesthesia and in outpatient care would be involves management of urinary cystine levels to reduce the highly desirable. Chemodissolution possess these desirable risk of stone formation. These management methods include characteristics, however the slow rate of dissolution using Substantially increasing the intake of water (thereby increas the current chemical Solutions makes this an unfeasible ing the urine Volume and the amount of cystine that can be treatment. solubilized), dietary restrictions of methionine, which is a metabolic precursor of cystine, and Sodium, and oral admin 0009. The present invention overcomes this major draw istration of potassium citrate to increase the pH of the urine, back of chemodissolution by utilizing the catalytic ability of thereby increasing the solubility of cystine. When these an enzyme to increase the rate of cystine Stone dissolution to methods are ineffective, drug therapy is often used. provide an improved method of treatment. 0004 Drug therapy involves the use of thiol-containing SUMMARY OF THE INVENTION drugs, such as D-penicillamine, C.-mercaptopropionylgly 0010. One embodiment of the present invention is cine (Thiola), and captopril, to break the cystine disulfide directed to a method for dissolving cystine Stones, compris bond and form more soluble mixed disulfides. However, these drugs frequently give the patient various unpleasant ing the step of administering to a patient in need thereof a side effects such as gastrointestinal intolerance, rash and therapeutically effective amount of a cystinase. pain in the joints (Sakhaee and Sutton, 1996). These man 0011) Another embodiment of the present invention is agement techniques for cystinuric patients are often not directed to a method for the treatment of cystinuria, com Successful; one study saw 14 of 16 patients, who were using prising administering to a patient in need thereof a thera these management methods, nevertheless develop cystine peutically effective amount of a cystinase. stones (Chow and Streem, 1996). 0012 Another embodiment of the present invention is 0005. When cystine stone formation cannot be prevented directed to a method for lowering the concentration of using hydration, dietary restrictions and drug therapy, Sur cystine in a patient’s urine, comprising the step of admin gical management is necessary. Cystinuric patients often istering a therapeutically effective amount of a cystinase to have recurrent episodes of Stone formation and Surgeries in the patient. their lifetime. Shock wave lithotripsy, the use of high-energy 0013 In one embodiment of the present invention, the shock waves for Stone fragmentation, can be used for cystinase is cyStathionine B-lyase. treatment of cystine stones that are Smaller than 1.5 cm. Cystine Stones are the most Sturdy of all urinary stones and 0014. In another embodiment of the present invention, lithotripsy is generally ineffective in breaking them up. the cystinase is selected from the group consisting of cys However, Smaller cystine Stones may be fragmented with tothionine-gamma-lyase, cystine transaminase, cystine tran lithotripsy because more frequent shocks at higher energy shydrogenase, cystine reductase, cyStathionine B-lyase, and can be used. mixtures thereof. US 2006/0275.279 A1 Dec. 7, 2006 0015. In another embodiment of the present invention, tathionine to L-homocysteine in the biosynthesis of L-me the cystinase is covalently attached to a polymer. In one thionine (FIG. 1). This same enzyme has also been reported embodiment, that polymer is polyethylene glycol. to catalyze at a comparable rate an "un-natural reaction: the 0016. In still another embodiment of the present inven conversion of L-cystine into pyruvate, ammonia and thio tion, the cystinase is entrapped in a polymeric material. In cysteine, as shown in FIG. 2 (Dwivedi et al., 1982). Other one embodiment, that polymeric material comprises at least cystinases include cystothionine-gamma-lyase, cystine tran about 50% of a polylalkanoic acid, optionally polylactic saminase, cystine transhydrogenase, and cystine reductase. acid. Others will be apparent to those of skill in the art. 0027. Because of the high activity of cystinases toward 0017. In another embodiment of the present invention, cystine and the production of Soluble compounds upon its the cystinase is administered via a catheter into the kidney breakdown, these enzymes can be utilized for the dissolution of the patient. of cystine Stones in the kidneys through the use of a nephrostomy catheter in a manner similar to the chemodis BRIEF DESCRIPTION OF THE DRAWINGS solution method currently used. Thus, one embodiment of 0018. The patent or application file contains at least one the present invention is directed to the use of a cystinase for drawing executed in color. Copies of this patent or patent dissolution of cystine Stones in the kidneys. application publication with color drawings will be provided 0028 General Materials and Methods.