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Metabolic disorders

1. Organic acidemias
2. Amino acid metabolism disorders
3. Urea cycle metabolism disorders
4. Fatty acid metabolism disordres
5. Carbohydrate metabolism disorders
6. Peroxisomal disorders
7. Purine metabolism disorders
8. Mineral metabolism disorders
9. Mucopolysaccharidoses
10. Lipid storage disorders
11. Hemochromatosis
12. Cystic fibrosis

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Organic acidemias MSUD

1. Major phenotypic expression:


Overwhelming illness in the first days of life with lethargy progressive to
coma, opisthotonus, and convulsions;
recurrent episodes leading to developmental delay;
characteristic maple syrup odor, branched-chain amino acidemia and
aminoaciduria;
branched-chain oxoaciduria; deficiency of branched-chain oxoacid
dehydrogenase.

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MSUD - introduction

accumulation in body fluids elevated quantities of leucine, isoleucine, and


valine and their corresponding oxoacids
unusual odor quite like that of maple syrup

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Metabolic pathways in the catabolism of leucine, isoleucine and valine. The


site of the defect is shown at the oxo-acid step in each of the three pathways.

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MSUD clinical features

Infants with classic MSUD - normal at birth, but remain well for only a few
days
Vomiting or difficulty to feed - early symptoms
By the end of the first week - lethargic, progressive neurologic
deterioration
periods of flaccidity alternating with hypertonicity
abnormal eye movements, convulsions occur regularly
Finally apnea, coma, and death

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MSUD genetics and pathogenesis

an autosomal recessive trait


all ethnic groups
The fundamental defect is in the activity of the branchedchain oxoacid
dehydrogenase multienzyme complex: E1- a decarboxylase; E2 - an acyl
transferase; E3 - a flavoprotein lipoamide dehydrogenase
enzyme activity can be measured in human liver, kidney and leukocytes,
cultured fibroblasts or lymphoblasts and amniotic fluid cells
mutations scanning with allele-specific oligonucleotide probes

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MSUD - genetics

The E1 gene chromosome 19q13.1-13.2


E1Beta - 6p21-22
E2 - 1p31
E3 - 7q31-32
Mutations occur in each gene, but a majority in the E1 and E2 genes.
The mutation in the Mennonite population (MSUD is common) is a T to A
transition - yields a single missense tyrosine to asparagine change at
position 393 (Y393N)

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MSUD - screening

Rapid screening for MSUD - tandem MS - forms the basis for all of the
neonatal screening programs for this disease.

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Amino acid metabolism disorders - Phenylketonuria

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What is it?

autosomal recessive disorder (commonly known as PKU)


increases the levels of an aminoacid called phenylalanine in the blood
phenylalanine is an indispensable amino acid obtained through diet
If not treated, phenylalanine builds up to harmful levels in the body, causing
intellectual disability and other serious health problems.

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What are the symptoms?


the signs and symptoms vary from mild to severe.
classic PKU - most severe form
without treatment development of permanent intellectual disability after few
months
common: seizures, delayed development, behavioral problems, and psychiatric
disorders
musty or mouse-like odor - side effect of excess phenylalanine in the body.
lighter skin and hair than unaffected family members
skin disorders - eczema.
less severe forms - variant PKU and non-PKU hyperphenylalaninemia
smaller risk of brain damage.
treatment not required

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Pregnancy
Babies born to mothers with PKU and uncontrolled phenylalanine levels significant risk of intellectual disability due to exposure to very high levels of
phenylalanine before birth
low birth weight
grow slowly
heart defects or other heart problems
small head size (microcephaly)
behavioral problems
risk of pregnancy loss.

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How common is it?

The occurrence of PKU varies among ethnic groups and geographic regions
worldwide
In the United States, PKU occurs in 1 in 10,000 to 15,000 newborns.
In Poland 1 in 8000 newborns
Most cases of PKU are detected shortly after birth by newborn screening, and
treatment is started promptly result: the severe signs and symptoms of classic
PKU are rarely seen.

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Testing

Plasma phenylalanine concentration:


The main route for phenylalanine metabolism - hydroxylation of phenylalanine to
tyrosine by phenylalanine hydroxylase (PAH).
The diagnosis of primary phenylalanine hydroxylase deficiency (PAH deficiency) detection of an elevated plasma phenylalanine (Phe) concentration and evidence of
normal BH4 cofactor metabolism.
Individuals with PAH deficiency - plasma phenylalanine (Phe) concentrations
persistently higher than 120 mol/L (2 mg/dL) in the untreated state

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Testing

Newborn screening:
PAH deficiency is most commonly diagnosed upon routine screening of newborns.
PAH deficiency can be detected in virtually 100% of cases by newborn screening
utilizing the Guthrie card bloodspot obtained from a heel prick.

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Testing

Three methods of newborn screening currently in use:


Guthrie card bacterial inhibition assay (BIA), a time-tested, inexpensive,
simple, and reliable test
Fluorometric analysis, a reliable quantitative and automated test which produces
fewer false positive test results than the BIA
Tandem mass spectrometry (MS), the same benefits as fluorometric analysis,
can also measure tyrosine concentration, and be useful in interpreting Phe
concentration. Can be used to identify numerous other metabolic disorders on the
same sample

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Clinical testing

Targeted mutation analysis.


A panel of four to 15 common point mutations and very small deletions -detection
rate of approximately 30%-50%.
Mutation scanning.
detects virtually all point mutations in the PAH gene. Mutation scanning by DHPLC a fast and very efficient method to detect locus-specific point mutations
Sequence analysis.
Sequencing of all 13 exons - mutation detection rate of about 99%.
Duplication/deletion analysis.
Comparative multiplex dosage analysis - useful in detecting large duplications or
deletions when no mutations have been identified by mutation scanning or sequence
analysis.

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Prevalence

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Treatment of Manifestations
Restriction of dietary phenylalanine.
normalization of the concentrations of Phe and Tyr in the blood
Phe concentrations of 120-360 mol/L (2-6 mg/dL) or 40-240 mol/L (1-4 mg/dL) regarded as safe.
A diet restricted in Phe - initiated as soon as possible after birth and continued at
least into adolescence
The diet must be carefully monitored so that growth and nutritional status are
unaffected
Supplementation with BH4.
many individuals with PAH deficiency - responsive to the 6R-BH4 stereoisomer in
pharmacologic doses (20 mg/kg daily in divided oral doses)
the 6R-BH4 enhances in vivo phenylalanine hydroxylation and lowers plasma
phenylalanine concentration with improved tolerance of dietary phenylalanine

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Treatment of Manifestations
Treatment in infancy.
A Phe-restricted diet
Breastfeeding with Phe-free formula
Intake of tyrosine and total amino acids
Avoid long periods of low blood Phe concentration - harmful to brain development.
Treatment in childhood.
Total amino acid consumption of 2 g/kg/day, 25 mg tyrosine/kg/day.
Treatment in adolescence and adulthood.
Various

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Surveillance
Plasma Phe and Tyr concentrations - monitored regularly
No recommendations for surveillance

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What to avoid?

Aspartame - an artificial sweetener in widespread use - contains phenylalanine

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Molecular Genetics
Gene symbol: PAH
Chromosomal locus: 12q23.2
Protein name: phenylalanine-4-hydroxylase

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Normal allelic variants

13 exons
90 kilobases
2.4-kb mature messenger RNA
31 different polymorphisms neutral effect

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Pathologic allelic variants


500 different disease-causing mutations
Mutations: missense, splice-site, and nonsense mutations, small deletions, and
insertions

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Alkaptonuria
deficiency of homogentisate 1,2-dioxygenase - an enzyme that converts
homogentisic acid (HGA) to maleylacetoacetic acid in the tyrosine degradation
pathway.
major features: HGA in urine, ochronosis (bluish-black pigmentation in connective
tissue), arthritis of the spine and joints.
oxidation of the HGA - melanin-like product dark urine upon standing
ochronosis: after age 30 years;
arthritis: third decade.
other manifestations: pigment deposition, aortic or mitral valve calcification or
regurgitation and occasionally aortic dilatation, renal stones, and prostate stones.

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Diagnosis/testing
detection of a significant amount of HGA in the urine by GCMS
the amount of HGA excreted per day - between 1-8 g
a normal 24-hour urine sample - 20-30 mg of HGA

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Management
Treatment of manifestations:
management of joint pain tailored to the individual;
physical and occupational therapy - maintain muscle strength and flexibility;
knee, hip, and shoulder replacements when needed;
surgical intervention for prostate stones and renal stones as needed.
Surveillance:
in individuals over age 40 years - echocardiography to detect aortic dilation, aortic or
mitral valve calcification, and regurgitation; CT to detect coronary artery calcification.
Agents/circumstances to avoid: physical stress to the spine and large joints,
heavy manual labor or high-impact sports - reduce progression of severe arthritis

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Genetic counseling
autosomal recessive disease
at conception - sib of an affected individual:
25% chance of being affected
50% chance of being an asymptomatic carrier
25% chance of being unaffected and not a carrier

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Molecular Genetic Testing


HGD - the gene encoding homogentisate 1,2-dioxygenase

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Normal allelic variants


The normal HGD gene
3q21-q23
54.3 kb
14 exons
1715-bp transcript

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Pathologic allelic variants


67 mutations in HGD have been reported
The mutations are distributed throughout the HGD gene sequence.
The majority of mutations: missense, but nonsense, frame shift, and splice-site
mutations do occur

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Normal gene product


homogentisate 1,2-dioxygenase - an enzyme in the phenylalanine/tyrosine
degradation pathway
445 amino acids
expressed in the liver and kidney, small intestine, colon and prostate
Homogentisate 1,2-dioxygenase functions in the metabolism of HGA by catalyzing an
oxidative cleavage of the benzene ring to yield maleylacetoacetic acid. It requires
oxygen, ferrous iron, and sulfhydryl groups

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Disorders of fatty acid oxidation - Medium chain acyl CoA


dehydrogenase (MCAD)

MAJOR PHENOTYPIC EXPRESSION


Hypoketotic hypoglycemia, myopathy, cardiomyopathy, sudden infant
death syndrome, hyperammonemia, hyperuricemia, elevated creatine
kinase, dicarboxylic aciduria
elevated levels of octanoyl and hexanoylcarnitine
deficient activity of medium chain acyl CoA dehydrogenase
mutation in the gene, especially A G 985

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MCAD
most common disorder of fatty acid oxidation
1 in 6000 to 10 000 caucasian births

2 general types of presentation:


The first - hypoketotic hypoglycemia is the clinical picture of Reye
syndrome
The second - chronic disruption of muscle function with symptoms relevant
to myopathy or cardiomyopathy, including weakness, hypotonia,
congestive heart failure, or arrhythmia
Another presentation is with the sudden infant death syndrome (SIDS)

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MCAD - genetics

MCAD deficiency is autosomal recessive


The gene is on chromosome 1 - ACADM
A single mutation from A to G (985), leading to a lysine (K) to glutamic acid
(E) change in residue 329 of the protein, accounts for virtually all of the
patients studied.

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MCAD - Prevalence

MCAD deficiency is prevalent in individuals of European (especially


northern) descent.
The overall frequency of the disorder is between 1:4,900 and 1:17,000;
Based on newborn screening programs worldwide, the incidence of MCAD
deficiency has been defined in:
Northern Germany (1:4,900 newborns)
Southern Germany (1:8,500 newborns)
New South Wales, Australia (1:25,000 newborns)
USA (1:15,700 newborns)
Taiwan (~1:700,000 live births)
Japan (1:51,000 live births)

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Treatment of Manifestations

reversal of catabolism and sustained anabolism by provision of simple


carbohydrates by mouth (for example, glucose tablets, or sweetened, nondiet beverages)
Hypoglycemia must be avoided by frequent feedings to avoid catabolism, if
necessary by intravenous administration of glucose

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Carbohydrate metabolism - galactosemia

MAJOR PHENOTYPIC EXPRESSION


hepatomegaly
jaundice
vomiting
failure to thrive
cataracts
mental retardation
deficiency of galactose-1-phosphate uridyl transferase

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Galactose-1-phosphate uridyl
transferase, the site of the enzyme
defect in patients with galactosemia.
The brackets indicate the uridyl and
glucose-1-phosphate moieties of
UDPG which have split at the arrow in
the uridyl transferase reaction,
transferring the uridyl group from G-1-P
of UDPG to galactose-1-phosphate
(Gal-1-P) to form
uridinediphosphogalactose
(UDPGal).

Galactosemia - clinical manifestations

appear within days of birth or of the initiation of milk feedings - increase in


severity in the first months of life
vomiting and jaundice - develop a few days after milk feedings are begun
anorexia, failure to gain weight or to increase in length, or even weight loss
hepatomegaly - constant finding on examination
edema, ascites
hypoprothrombinemia and bleeding.
splenomegaly
fatal - if milk feedings are continued

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Galactosemia - sepsis

sepsis neonatorum - most commonly E. coli


complications of sepsis - osteomyelitis and meningitis
gangrene
impaired granulocyte function

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Galactosemia - genetics

autosomal recessive trait


the enzyme defect - uridyl transferase - can be detected in the erythrocyte
or in cultured fibroblasts and amniotic cells, leukocytes and liver
in patients with classic galactosemia, the activity of the enzyme is virtually
completely absent
Incidence rates 1:55000 (Duarte variant 1 in 3000-4000 but no clinical
manifestations)
9p13 transferase gene (GALT)
cDNA 3.9kb
neonatal screening in the US

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Galactosemia most common mutations

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Protocol for galactosemia

Galactose

Galactose structure is identical to that of glucose except for the position of


the hydroxyl on carbon 4
Lactose - the principal sugar of mammalian milks - predominant dietary
source of galactose; it is a disaccharide in which glucose and galactose are
linked in an -1,4-glucosidic bond in which an oxygen bridge connects
carbon 1 of galactose and carbon 4 of glucose
The pathogenesis of most of the clinical manifestations of galactosemia is
the accumulation of Gal-1-P in tissues
Treatment exclusion of galactose from the diet

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Purine metabolism Lesch Nyhan disease


MAJOR PHENOTYPIC EXPRESSION
retardation of motor development
spasticity
involuntary movements
self-injurious behavior
hyperuricemia
uricosuria
urinary tract calculi
nephropathy
tophi
gouty arthritis
deficient activity of hypoxanthine guanine phosphoribosyl transferase
(HPRT)
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Hypoxanthine-guanine phosphoribosyl transferase

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Lesch-Nyhan disease

male infants - normal at birth, develop normally for the first 6 to 8 months
first sign - orange crystals or orange sand in the diapers (crystalluria)
defective motor development - evident in the second six months of life
failure to reach developmental milestones
patients do not learn to walk, and must have some support even to sit
unaided
but do learn to sit in a chair if fastened securely
involuntary movements - 100 percent of patients
self-injurious behaviour

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Tay-Sachs disease
Disease characteristics:
Hexosaminidase A deficiency
neurodegenerative disorder caused by intralysosomal storage of the specific
glycosphingolipid -GM2 ganglioside.
Tay-Sachs disease (acute infantile):
progressive weakness
loss of motor skills
decreased attentiveness
neurodegeneration
seizures
blindness
spasticity
death, usually before age 5

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Tay-Sachs disease
The juvenile (subacute) and adult-onset variants
later onsets
slower progression
more variable neurologic findings: progressive dystonia, spinocerebellar
degeneration, motor neuron disease, bipolar form of psychosis.

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Diagnosis/testing
demonstration of absent to near-absent beta-hexosaminidase A (HEX A) enzymatic
activity in the serum or white blood cells of a symptomatic individual in the presence
of normal or elevated activity of the beta-hexosaminidase B (HEX B) isoenzyme
Mutation analysis of the HEXA gene: for genetic counseling purposes to
1) to distinguish pseudodeficiency alleles from disease-causing alleles in individuals
with apparent deficiency of HEX A enzymatic activity
2) to identify specific disease-causing alleles in affected individuals

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Management
Treatment:
supportive
provide adequate nutrition and hydration
manage infectious disease
protect the airway
control seizures
Seizure control:
conventional anticonvulsant drugs: benzodiazepines, phenytoins, barbiturates
progressive
change in type and severity

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Management
adult-onset hexosaminidase A deficiency with psychiatric manifestations:
conventional antipsychotic or antidepressant therapy
treatment with lithium salts
electroconvulsive therapy - beneficial in ameliorating psychotic depression.

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Genetic counseling
autosomal recessive manner
At conception, each sib of an affected individual:
25% chance of being affected
50% chance of being an asymptomatic carrier
25% chance of being unaffected and not a carrier

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Prevention of Tay-Sachs disease (19711992, showing 90%


reduction in the disease in Jewish population (19701993)

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Prevalence
previously one in 3600 Ashkenazi Jewish births
carrier rate for TSD: one in 30 among Jewish Americans of Ashkenazi extraction
(Central and Eastern Europe).
now the incidence of TSD in the Ashkenazi Jewish population - reduced by greater
than 90% - result of extensive genetic counseling of carriers identified through
carrier screening programs and monitoring of at-risk pregnancies
Among Sephardic Jews and all non-Jews - 100 times less common - carrier
frequency (between 1/250 and 1/300)
all ethnic, racial, and religious groups.
Certain populations isolated genetically: French Canadians of Quebec, Cajuns from
Louisiana and the Old Order Amish in Pennsylvania - carry HEXA mutations with
frequencies comparable to or even greater than Ashkenazi Jews.

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Molecular genetics

Gene name: HEXA


Gene locus: 15q23-q24
Protein name: beta-hexosaminidase subunit alpha

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Normal allelic variants

35,000 bp
contains 14 exons

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Pathologic allelic variants


more than 100 HEXA mutations identified to date
>90 - acute infantile phenotype (Tay-Sachs disease)
small insertions, deletions producing frameshifts, nucleotide substitutions producing
stop codons
Among Ashkenazi Jewish people - two mutations associated with the acute infantile
form account for 90-95% of all alleles
In the non-Jewish general population - two other mutations account for 35% alleles
associated with the acute infantile phenotype
The mutations in Ashkenazi Jew:
null alleles - no protein product
gene is transcriptionally active
The most frequent allele: 4-bp insertion in exon 11 - frameshift and downstream
stop codon in the coding sequence normal transcription - undetectable mRNA
The second major allele - donor splice-junction mutation in intron 12 - production of
several aberrantly spliced mRNAs.
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Normal gene product


HEXA - Beta-hexosaminidase alpha chain
heterodimeric protein
GM2 gangliosidase

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Abnormal gene product


variety of effects:
defective processing
defective subunit assembly
defective catalytic activity

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Cystic fibrosis

recognised 1936
accumulation of thick mucous secretions
blockage of the airways
secondary infection
significant cause of chronic ill health and mortality in childhood and early adult life.
Icidence rate - 1 in 2000 to 1 in 3000
African-Americans (1 in 15000)
Asian-Americans (1 in 31 000).

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Clinical features

lungs and the pancreas - organs most commonly affected


chronic lung disease caused by recurrent infections
fibrotic changes in the lungs with secondary cardiac failure - heart-lung transplant
85% of persons with CF pancreatic function impaired: reduced enzyme secretion due
to blockage of the pancreatic ducts
increase in the fat content of the stools
nasal polyps
rectal prolapse
cirrhosis (disruption of normal liver structure)
diabetes mellitus
male infertility - CBAVD
chronic pancreatitis

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Diagnosis/testing
diagnosis of cystic fibrosis - established in individuals with one or more characteristic
phenotypic features of CF
abnormality in CFTR function:
presence of two disease-causing mutations in the CFTR gene
abnormal sweat chloride values (>60 mEq/L)
transepithelial nasal potential difference (NPD) measurements characteristic of CF

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Management
Treatment of manifestations:
treatment/prevention of pulmonary complications using oral or inhaled antibiotics
bronchodilators
anti-inflammatory agents
mucolytic agents
chest physiotherapy
lung or heart/lung transplantation in selected patients
topical steroids
surgical intervention for nasal/sinus symptoms
special infant formulas to enhance weight gain
oral pancreatic enzyme replacement
additional fat-soluble vitamins and zinc
management of CF-related diabetes mellitus (CFRD) by an endocrinologist
assisted reproductive technologies (ART) for male infertility

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Prevention of secondary complications

airway clearance using chest physiotherapy (CPT)


variety of airway clearance techniques (ACTs)
antibiotics to eradicate initial airway infection and prevent chronic airway infection
immunizations

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Surveillance

regularly scheduled visits to CF care providers


pulmonary function studies
chest radiographs
specific blood and urine tests
cultures of respiratory tract secretions - P. aeruginosa

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Agents/circumstances to avoid
respiratory irritants (smoke, dust)
respiratory infectious agents (especially viruses)
dehydration

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GENETICS
autosomal recessive inheritance
most serious autosomal recessive disorder European origin
possible explanations: multiple CF loci and high mutation rate

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Cystic fibrosis gene

chromosome 7q31
CF transmembrane conductance regulator (CFTR)
250 kb
27 exons
1900 mutations and polymorphisms to date

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Carrier frequency for mutant CFTR alleles

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Pathologic allelic variants

more than 1900 mutations are known


mostly point mutations
small (1-84 bp) deletions
The most common mutation - delF508 (Phe508del) - 30%-80% (depending on the
ethnic group) of mutant alleles

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DelF508

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Core mutation panel

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10 most common mutations in Caucasian pop.

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delF508

Dele2,3(21kb)