Recent Advances in Wilson Disease

The primary objective of this study is to discuss the Recent Advances in Wilson Disease is one of
numerous rare autosomal recessive disorders that is present with varied phenotypes which can sometimes
make the diagnosis challenging caused by ATP7B gene deficiency that causes copper to accumulate in
your liver, brain, and other vital organs. According to Capone and Azzam (2018) in order to diagnose this
disease we need to involve several tests such as blood tests, urine tests, and a liver biopsy along with the
clinical evaluation. A ceruloplasmin level and Urinary copper levels with Kayser-Fleischer rings are usually
enough for diagnosis. Additional possibility of an alternate diagnosis is a liver biopsy for liver copper level
which is the most accurate and gold standard for Wilson disease. A positive result is a copper level greater
than 250 mcg/g of dry liver tissue. An MRI is helpful to check for brain involvement. Liver function tests are
deranged with elevated AST and ALT levels. However, genetic testing may be used to screen the family
members of those affected.

One of the recent advances stated here in our literature review is the identification and quantification
of Kayser Fleischer (KF) rings using an anterior segment optical coherence tomography (OCT) this allows
clinicians to identify diseases that aren't otherwise visible using conventional techniques by making it easier
to get an optical biopsy or in vivo imaging of different dystrophic, degenerative, and neoplastic ocular
surface and corneal pathologies (Mercado et al., 2022).

Authors: Members of the Group:

Maryam Moini Dela Cruz, Kim Kyrish Z.
Uyen To Dela Torre, Danica
Michael L. Schilsky Gualberto, Carla May Orange B.
Florendo, Raemel Nicole D.
Gabertan, Aira Mae C.
Gonzales, Vincent Guile
Jamora, Necca B.
Labus, Dlonra Arl C.
Llunado, Neyka Franchesca O.
Lata, Nathaniel John Edward
Introduction

Wilson Disease or also known as hepatolenticular degeneration which affects 1 in every 30,000
individuals with a carrier frequency of 1 in every. For a person to be affected, a copy of the gene from each
parent needs to be inherited. It is a rare, autosomal recessive disorder due to a mutation of the ATP7B
gene located in chromosome 13q which controls the protein transporter responsible for excreting excess
copper into bile and out of the body. (Ferenci, 1998)

The protein transporter is in the trans-Golgi network of the liver and brain. The major route of copper
excretion (95%) is through the liver. This excess copper first accumulates in the liver and then spills into
the blood and then to other organ systems. Causing an impaired hepatic copper excretion and copper
accumulation in various tissues particularly involving the brain, liver, and cornea.

According to Chaudhry, the symptoms usually are related to the brain and liver. Liver-related
symptoms include vomiting, weakness, ascites, swelling of the legs, yellowish skin, and itchiness. Brain or
neurological symptoms include tremors, muscle stiffness, trouble speaking, personality changes, anxiety,
and auditory or visual hallucinations. It is associated with the classic triad of cirrhosis, neurological
manifestations, and the ocular finding of Kayser-Fleischer rings.

According to Capone and Azzam (2018) the diagnosis involves blood tests, urine tests, and a liver
biopsy along with the clinical evaluation. A ceruloplasmin level which will be less than 20 mg/dL whereas a
normal value is 20 mg/dL to 40 mg/dL. Urinary copper levels will be raised more than 100 mcg/dL. These
two lab findings with Kayser-Fleischer rings are usually enough for diagnosis. Additional possibility of an
alternate diagnosis is a liver biopsy for liver copper level which is the most accurate and gold standard for
Wilson disease. A positive result is a copper level greater than 250 mcg/g of dry liver tissue. An MRI is
helpful to check for brain involvement. Liver function tests are deranged with elevated AST and ALT levels.
However, genetic testing may be used to screen the family members of those affected.

Neither specific ATP7B mutations nor elevated hepatic Cu levels by themselves can answer for the
various pathological changes of WD. Recent times have seen the emergence of novel molecular
information regarding WD development and metabolic fingerprints of WD abnormalities. Studies on WD
patients and animal models have shown that extrahepatic tissues and non-parenchymal liver cells
contribute to the liver phenotype and have identified nuclear receptor (NR) dysregulation, epigenetic
modifications, and mitochondrial dysfunction as key features of the disease's pathogenesis. (Dev et.al.,
2022)

The evaluation of WD patients can be complicated, and it is dependent on a complex combination of

clinical data that are gleaned through patient history, physical examination, laboratory tests, and imaging
studies. No single test can conclusively confirm or rule out the condition. Using innovative biomarkers and
contemporary diagnostic technologies to quickly identify symptoms and signs may help to shorten treatment
times and enhance patient prognosis (Szczerbinska et.al., 2021). In the case of typical neurological
symptoms with Kayser-Fleischer rings, the assessment may be simple, but it is frequently overlooked for a
number of years. No one test is sensitive or specific enough to diagnose or rule out WD on its own. Usually,
an array of studies, including molecular genetic testing and measurements of copper metabolism, are
required. ( Ott et.al., 2019)
Methods

This study is based on research regarding Advancement in Rare Liver disease—Wilson Disease. A
thorough collection of supporting article is done to present the innovation in diagnosing Wilson disease

The study provides the advances in diagnosis and treatment of Wilson Disease, the different changes
in methods for earlier detection and the advances on treatment to control the disease. The researchers used
Qualitative research to explain further the concept of advancement in the field of science specifically in
Wilson Disease.

The research paradigm that follows depicted the possible input, process, and output of the study.
The input of the study was the main article regarding the Recent Advancement in Wilson Disease by Schilsky
et al. The collection of supporting articles for an in-depth understanding is the process done by the
researchers. The output of the study was the collected advancement in the disease.
Results

1. Diagnosis

All in all, despite the difficulty of diagnosing Wilson’s Disease, there are still various ways to diagnose
individuals with WD. The combination of Kayser Fleischer rings, cirrhosis, and neurological complications
can be useful clinical findings to link with Wilson’s Disease, although some of the patients present only with
one or two of these findings, making it challenging to identify as early as possible. Genetic testing, imaging
and biochemical evaluation of copper, ceruloplasmin and liver enzymes have also been helpful in
establishing the diagnosis.

One of the recent advances is the identification and quantification of Kayser Fleischer (KF) rings
using an anterior segment optical coherence tomography (OCT), it allows clinicians to identify diseases that
aren't otherwise visible using conventional techniques by making it easier to get an optical biopsy or in vivo
imaging of different dystrophic, degenerative, and neoplastic ocular surface and corneal pathologies
(Mercado et al., 2022). The KF rings can be seen as a yellow orange band in OCT.
By enhancing the understanding of copper metabolism and perhaps allowing for the early detection
of neurological disorders, imaging advancements like positron emission tomography (PET) imaging and
magnetic resonance spectroscopy have also aided in diagnosis. In earlier days, radio copper was used to
identify variations in copper metabolism between WD patients and healthy people by assessing the
radioactivity in their serum and stool. Recently, PET in mice for 24 hours, following injection of 64CuCl2
orally or intravenously revealed that ATP7B knockout enhanced tracer. According to the clinical signs of WD,
the liver increased its uptake by many fold and decreased its biliary excretion (Bartnicka & Blower, 2018).
PET imaging can detect the accumulation and reduced clearance of copper from the body.

The use of magnetic resonance spectroscopy (MRS) is another imaging advance that can be useful
in the diagnosis of Wilson’s disease, especially in the pediatric population. The application of brain proton
(H1; hydrogen) MRS (H1MRS) in pediatric neuroradiology has some advantages over adult acquisitions
(lack of motion due to children's sedation and lack of brain iron deposition allow for optimal results), it also
necessitates a thorough understanding of pediatric pathologies and familiarity with the developmental
changes in spectral patterns (Liserre, Pinelli, and Gasparotti, 2021). MR spectroscopy results show the
concentrations of N-acetyl aspartate (NAA), choline (Cho), and creatine (Cr), as well as the metabolite ratios
of NAA/Cho, NAA/Cr, and Cho/Cr in brain tissue, were significantly lower in WD patients compared to healthy
individuals. In contrast to WD patients with liver-only involvement, those with mixed neurologic and hepatic
involvement showed a more pronounced drop in NAA, NAA/Cr, and NAA/Cho. This might be used as a way
to identify early neurological involvement in pediatric WD patients.

2. Management

Chelating agents, such as, British anti-Lewisite (BAL) or 2,3-dimercaptopropanol, D-penicillamine

and trientine (diethylene tetramine), are a group of medications that work by enhancing the elimination of
extra copper from the body through the urine or, in the case of tetrathiomolybdate (TTM), into the bile. These
drugs bind with plasma copper to facilitate the excretion from the body D-penicillamine has side effects that
can be very serious. According to MedlinePlus (2018), the side effects include rash, itching, hives, shedding
skin, fever, joint pain, or swollen lymph nodes, painful or itchy blisters and sores on the skin, mouth, and
genitals, fever, sore throat, chills, unusual bleeding or bruising, shortness of breath, unexplained cough or
wheezing, foamy or pink, red, brown, or bloody urine, muscle weakness, drooping eyelids, or double vision.
Trientine may have fewer side effects compared to D-penicillamine.
 Those WD patients who experienced serious side effects with chelating agents are treated using zinc
salts, which decreases the absorption of dietary copper from the intestine. When copper is absorbed by
enterocytes, copper replaces zinc on the metallothionein peptide. When high levels of metallothionein are
induced in intestinal cells by zinc, copper absorption is inhibited. Metallothionein is a primarily cytosolic
protein with a higher binding affinity for copper than zinc (Camarata, Ala, and Schilsky, 2019). This leads to
the negative copper balance necessary for detoxification of the excess injurious copper within the liver and
other tissues.

3. New therapeutic agents and new treatment strategies

3.1 Trientine

Penicillamine, a chelating agent that chelates heavy metal such as copper to form soluble complex
and renally excreted in urine that is been used to treat adults with Wilson Disease (Mejias & Ramphul, 2020).
However Penicillamine (d-penicillamine) has multiple side effects leading to Trientine to become the
preferred first line treatment for WD. Trientine is a drug medication given through oral route that is also easily
excreted in urine with lesser side effects for the patient. 20 mg/kg initially and becomes ~15 mg/kg given as
it was divided into 2-4 times of doses daily. Maintenance of medication is significant to not lessen the
optimization management of WD. Studies were made suggesting a possible efficacy for once daily dose of
trientine as a maintenance therapy of WD including a limited pilot studies.

According to the study of Ala et al. (2015), patients remained clinically well with ALT and AST
fluctuation but no requirements to have the treatment to stop. Liver synthetic function was also unchanged.
The possibility of once- daily trientine should be explored further as it may improve the adherence of therapy.
Larger trials and longer-term follow-up may establish the safety treatment of this single dose medication
regimen for WD patients.

3.2 TTM

As a result of this genetic disorder, accumulation of high amounts of copper in the liver and brain
happens and when left untreated it can result in hepatitis, neurological complication, or death.
Tetrathiomolybdate(TTM), a copper chelating agent that has been studied as an initial treatment for WD
patients. It is a drug that is potent de-coppering agent that has multiple actions; It binds coppers in plasma
in a tripartite complex with albumin, and interferes in the absorption of copper from food to the gut. It also
had a role in removal of copper from metallothionein in tissues, including hepatocytes that rest in increasing
biliary excretion of copper; it appears that it can enter cells and pass the blood-brain barrier (BBB) to the
neuronal cells.

A study was also made suggesting the role of TTM as an anti-angiogenesis, anti-inflammatory and
anti-fibrosis through cytokines inhibition and de-coppering. TTM has an ammonium salt that has been used
to initially treat WD however it is unstable and has a difficulty in usage clinically and storing. Trials are made
using a much more stable compound of TTM, Bis-choline TTM(ALXN1840) as a treatment for WD. A study
was made of I, II, III phases and only the III phase is still ongoing. Phase II of the study shows a commencing
safety profile overall. Although 1/3 had an increase in transaminase early on after the TTM initiation, this is
resolved by discontinuation or dose reduction and were not associated with satellite increase of bilirubin.
During the extension of treatment marking the initial 6 months, a stable liver function was maintained even
in those patients who have cirrhosis. A reduction of non-ceruloplasmin bound serum copper to within the
normal ranges between 8-12 weeks after initiation of treatment was seen in patients and most had
improvements of neurological symptoms. Phase III is still ongoing and recruiting WD patients that are naïve
to this kind of treatment and those that are in maintenance therapy.

3.3 Zinc Salts

An alternative treatment was given to patient’s intolerant of chelation agents that are zinc salts. This
is also used for initial and maintenance therapy of patients who are stable or asymptomatic. An initial study
made in US tested zinc acetate as the preferred zinc salt. A perception was there that alternative zinc agents
might not be as effective or well absorbed. With Consideration of past studies a review of a single center
experience of a patient who undergoes zinc therapy for WD with zinc acetate and also patients who undergo
zinc therapy with alternative zinc salts (Camarata et al., 2019). Absorption of zinc was found to be better
with zinc acetate, zinc salts, zinc gluconate and zinc picolinate. For different salts, there is a similar adequacy
with respect to achieve a urine copper excretion of <100 mcg per day and a normal ALT. Disease progression
of WD was absolutely prevented with patient with normal ALT and<100 mcg per day urine copper excretion
on zinc treatment, for the long term it is still need to be observed however majority of this patients that
achieved both of this parameters were clinically stable and doing well

3.4 Methanobactin

Methylosinus trichosporium, a bacteria with a potent affinity for copper that produces a peptide called
methanobactin. Methanobactin can be found inside hepatocytes and has a role in removing toxic copper
from cells and prevents mitochondrial injury. The treatment using methanobactin reversed liver injury and
mitochondrial dysfunction in animal models of WD in the acute phase of toxicity. A treatment that is given to
a WD disease rat model that has a short duration has an effect that was sustained for several weeks after
stopping treatment.

According to White (2016), mitochondria benefit in dropping copper levels that were able to resume
to their full function. Methanobactin interferes with the death of liver cells and prevents liver failure.
Researchers have compared methanobactin to chelators, Methanobactin can eliminate copper overload in
the liver cells within a few days, even in the stages that a possibility of severe damage can prevent organ
failure.

A second study was made with the same animal model. They are animals that are fed a high fat diet
that compounded the injury of copper to the liver Methanobactin is used as a treatment that helps to prevent
mitochondrial injury and improve liver cells. Intriguingly, this study centered the convergence of pathways
for liver injury for steatohepatitis and for WD with a potential synchronous oxidative injury to hepatocytes.
This might have relevance for patients with WD that have progression of their liver disease even after or
during treatment that is directed against the copper toxicity alone and patients who may have exacerbation
of their injury if they have concomitant NASH.

3.5 Gene Therapy

Theoretically this therapy can provide a potential cure for genetic disorder. Wilson's Disease is a
monogenic inherited disorder with impaired ATP7B function. This Therapy aims to be given once only that
delivers working ATP7B gene into the cells to produce working transporter proteins. Its goal is to remove
excess copper and restore liver function. By clearing copper from bloodstream, the toxic effect on organs
should be reduced (Disease Treatments | ASGCT - American Society of Gene & Cell Therapy |, 2021).
Lentiviral gene, a gene that transfers that integrates the ATP7B gene into the genome has shown to be
effective for alteration on disease progression in animal models of WD. However, concerns are raised that
this kind of technique can cause oncogenesis.

An alternative vector for gene therapy, Adeno-associated virus ability for direct extra-chromosomal
gene transfer to hepatocytes. AAV encoding human ATP7B complementary DNA (cDNA) in WD mouse,
enough expression of ATP7B was reached to reduce hepatic copper and prevent liver injury. However,
having a large size of ATP7B cDNA can affect the cloning capacity of the vector. Overcoming this limitation,
a shorter vector coding for a miniATP7Bprotein was made that is effective in reaching the long-term copper
homeostasis in WD mouse. Based on these studies, AAV gene transfer for genetic corrections in humans is
possible and being planned and has an issue to overcome, patients being administered with AAV has a
potential for using neutralizing antibodies that have pre-existent antibodies and those patients who've
developed antibodies after. Re-introducing the gene as hepatocytes in the same AAV vector would help to
maintain the therapy by allowing safe gene transfer.

3.6 Cell Therapy

Phenotypic way of correction of WD is possible through liver transplantation. Transplanting an

enough number of healthy hepatocytes may restore the ATP7B gene related ATPase activity to normalize
copper metabolism. It is also associated with prevention of fulminant hepatitis, decreased inflammation, and
increased short term survival. Achieving adequate clinical improvement needs a repeated cycle of cell
transplantation. There is also limitation that can occur with this approach including a needed large number
of cells that is a requirement for a long-term immunosuppression and the difference of each patient in
success implantation of their is a present disease in the liver that can alters the livers' microcirculation

According to Gupta (2014), recently a noninvasive imaging was developed to have a demonstration
on copper removal from the liver, including after cell therapy. These developments will help advance the
gene/ cell therapy approaches, particularly as it lays down a new path for clinical trials with Wilson's disease.

The researchers presented the recent advances in Wilson's disease, specifically in the diagnosis,
management, treatment, and monitoring of the disease. It is commendable that the researchers mentioned
the principles of the instrumentation used in the diagnosis of WD and gave emphasis to the benefits of those
machines. However, there's no further elaboration regarding the previous diagnostic tools for WD, so it can
be compared to the recent one.

The journal provided information on how drugs used in the management of Wilson's Disease worked
inside the human body: decreasing intake, blocking absorption, and increasing excretion of copper, as well
as the administration of each drug. The various side effects of those drugs were not mentioned in the journal,
which can be a helpful tool to medical professionals when it comes to the formulation of new drugs, knowing
the lesser risk to the general population.

This journal provided other study materials that can be used by future researcher as reference and
recent advances in therapeutic agents however some of the resources are not updated. All the suggested
therapy and therapeutic agents are still mostly on trial stage where WD doesn’t have a direct treatment.
Many of this therapeutic agents can produce permanent damage to the patient that is not mentioned in this
journal, however the journal has compiled a lot of studies that contributes in further research on this particular
disease it also mention how the therapeutic agents and the therapy works in the body backing with
supporting studies.
Discussion

Wilson's Disease is a relatively uncommon genetic disorder. A rare autosomal recessive hereditary
condition passed down through families. It is related to extra copper released in the human body. The Human
body needs 0.75 mg copper per day and the excess copper is excreted through feces and urine. But in
Wilson's disease the excess copper in a human body is kept. The excess copper deposits on various organs
such as liver and brain and other important tissues.

In addition, one notable pattern to mention is the mutation of the ATP7B gene that is essential for
copper transport and excretion, is being subjected to several tests including Exchangeable Copper (CuEXC),
Relative Exchangeable Copper (REC), and Adeno-Associated Vector (AAV) gene therapy.

Furthermore, the results conclude that clinical findings such as Kayser Fleischer rings, cirrhosis, and
neurological complications are helpful in the diagnosis of WD as well as ceruloplasmin, which is a significant
marker. However, it is difficult to identify WD in patients that only displayed one or two out of all the findings.

To validate the results, Kayser Fleischer rings can be identified with the help of optical coherence
tomography (OCT) that can identify diseases which cannot be found in other techniques. Furthermore, liver
enzymes can be detected using imaging and biochemical evaluation. Neurological disorders can be detected
by positron emission tomography (PET) imaging and magnetic resonance spectroscopy.

This review covers recent progress in WD pathophysiology characterization and provides emerging
strategies for enhancing WD diagnosis and treatment. These recent findings imply that unique biomarkers
and better therapies for WD with various disease presentations may be developed in the future.

While past studies suggested that 1 in 30,000 people globally have it, recent investigations of
individuals's genomes indicate that it may be more widespread, with one research in the United Kingdom
finding that as many as 1 in 7,000 people have the gene mutation associated with Wilson disease (Yale
Medicine). Because of its rarity, WD is frequently missed or delayed in diagnosis. The emergence of the
numerous diagnostic, therapeutic, and monitoring options for people with WD, the technical breakthroughs
in genetic testing, imaging, and treatment mentioned here provide hope for more precise detection and
management of WD in the coming years although additional research is much needed.

For people suffering with WD, there are numerous diagnostic, therapeutic, and monitoring techniques
available. While many patients are diagnosed and adequately assessed using current accessible methods,
diagnosis and monitoring have revealed to be more difficult in some patients who have borderline
ceruloplasmin levels, ambiguous genetic findings, and unexplained clinical characteristics (Ripolles et al.,
2021). Early diagnosis and adequate long-term therapy determine patient prognosis. Delays in diagnosis,
and hence in initiating de-coppering treatment, can have disastrous implications. Technological
developments in genetic diagnostics, neuroimaging, biomarker characterization, and sophisticated
therapeutics may bring hope for more precise detection and management of WD in the future year.

Since the illness was first described, much has been learned and undoubtedly developments in the
pharmaceutical and transplantation sectors have enabled for better care of WD patients. However, the
pharmacological arsenal is still primitive, with side effects, a non-specific mechanism of action, and patients
being forced to take medication multiple times per day for the rest of their lives. Distinction aids in the
selection of therapy and the amounts of pharmaceuticals used, although no research has rigorously
investigated this field. Gene therapy and hepatocyte cell transplantation are potential treatments for WD, but
there is still a long way to go before they can be utilized safely and easily in humans. Awareness among
health professionals about varied presenting features of WD and high index of suspicion may have
prognostic implications. The condition is best addressed by a multidisciplinary team that comprises a
gastroenterologist, geneticist, mental health nurse, neurologist, dietitian, nurse practitioner, pathologist,
radiologist, and an internist. Indeed, while substantial advancements have been made in this period, many
physiological factors of this disorder remain unclear, necessitating more study to uncover solutions.

Gaps and Contraindications

Early detection is vital for avoiding long-term problems. WD is currently an undiagnosed condition.
The most common cause of serious complications and fatality is delayed diagnosis of the disease. Prompt
detection and treatment of asymptomatic patients may indeed prevent clinical manifestations.

Modalities for Diagnosis

Calculated non-ceruloplasmin-bound copper (NCC) has been posited as a diagnostic marker of WD,
due to its elevation in serum concentration in patients with the disease. However, when ceruloplasmin is
determined by immunoassay, some studies show a 25% increase in FNs in patients with WD. False positives
(FPs) in patients with cholestasis, acute liver failure or copper poisoning were also reported.

For such grounds, the European Association for the Study of the Liver (EASL) does not advocate
using ceruloplasmin-bound copper concentration to diagnose WD. (EASL, 2017). A scoring system based
on AST, ALT, ALP, AST/ALT ratio, urate, and hemoglobin values has been shown to have an 88% sensitivity
and an 87% specificity for diagnosing fulminant WD. However, in the pediatric population, these tests have
much lower diagnostic performance (Palumbo et al., 2019).

Various recent investigations have evaluated the diagnostic performance of direct detection of
exchangeable copper (CuEXC) in WD serum, with promising sensitivity and specificity results. The relative
exchangeable copper (REC) marker has the most significant diagnostic power for WD .CuEXC and REC
may give valuable information on the severity and spread of WD, demonstrating good diagnostic
performanceTo present, these positive results justify the use of this test in selected situations to identify
individuals who may benefit from screening for ATP7B mutations. Several scientific organizations have
issued clinical recommendations outlining various diagnostic criteri such as the American Association for the
Study of Liver Diseases (AASLD), EASL and the European Society for Paediatric Gastroenterology
Hepatology and Nutrition (ESPGHAN) recommend using the Leipzig scoring system. (Martinez-morillo &
Bauca, 2022).

The biochemical assays available for the diagnosis of WD have limitations that result in low
diagnostic performance. Promising findings for CuEXC and REC have been reported, encouraging
laboratory professionals to add and assess these criteria. Prospective studies to establish the reliability of
this biochemical measure are required. Despite the availability of genetic testing for the diagnosis of WD,
the lack of a genotype-phenotype link necessitates the use of additional markers to measure copper
(Martinez-morillo & Bauca, 2022).

Gene Therapy

The adeno-associated vector gene therapy may have its use on the disease however certain
limitations should be considered. The size of the ATP7B complementary DNA is too large that it affects the
 cloning capacity of the vector (Moini et al, 2021). Due to its small size, the Adeno-associated vector may
not be able to comply with the required delivery of genes that are larger than 4.8 kilobyte, therefore a
limitation of its capacity for DNA transgene insertion (Suparna Sanyal, 2022). Secondly, is the presence of
neutralizing antibodies for Adeno-associated vectors that have the ability to neutralize the effectivity of the
cure of the AAV-mediated gene therapy, thus minimizing the size of suitable candidates for the said
treatment (Suparna Sanyal, 2022). Since Adeno-associated vectors are viruses, the human immune
system will create antibodies that will neutralize them immediately upon exposure. Every so often these
neutralizing antibodies are already present in the patient’s blood before the gene therapy due to the fact
that they are exposed to Adeno-associated vectors in the environment (Emma Yasinski, 2020). Another
thing to mention is the large number of serotypes and capsids for Adeno-associated vectors that have
varied function and efficacy as well as production and purification requirements (Suparna Sanyal, 2022).
One example is the AAV2, which (Emma Yasinski, 2020) said to have neutralizing antibodies to other
commonly used Adeno-associated vectors such as AAV5 and AAV8. Lastly, Adeno-associated vector drug
products have empty and partially filled capsids of varying degree which compromise safety and efficacy
(Suparna Sanyal, 2022).

Cell Therapy

Possible restrictions with the cell transplantation approach are the large number of cells needed, the
longer span of immunosuppression and the variation of the implantation’s success if a disease inside the
liver is already present (Moini et al, 2021). Other possible contraindications in liver transplantation include
severe pulmonary hypertension, sepsis and advanced or metastatic hepatocellular carcinoma (Hertl, 2022).

The methods written is direct and it mentioned the approach that was done to be able to make the
article as well as the input and output of the study and other references provided by the group. As for the
results, it is well written, and it didn't fail to mention the techniques done to be able to diagnose the disease.
The clinical findings are also pointed out as well as the tests they utilized. The results covered an alternative
to those who suffered from side effects. New strategies for the treatment of Wilson’s disease are also
provided in great detail and mentioned all of their effectivity and use. Lastly, the discussion provided an
insight on the disease's background and pattern from the study. Although lengthy, the limitations are also
mentioned as well as the validity of the results.

III. Reference

Main Article
Moyni, M., To, U., & Schilsky, M. (2021, April 5). Recent advances in Wilson disease. National Center for
Biotechnology Information. Retrieved December 21, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7838529/

Supporting
Wilson’s disease - Symptoms and causes. (2022, October 25). Mayo Clinic. Retrieved December 21, 2022, from
https://www.mayoclinic.org/diseases-conditions/wilsons-disease/symptoms-causes/syc-20353251
Ryan, A., Nevitt, S., Tuohy, O., & Cook, P. (2019, November 19). Biomarkers for diagnosis of Wilson’s disease.
Cochrane Library. Retrieved December 21, 2022, from
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012267.pub2/full
Schilsky, M. (2022, August). Wilson disease: Diagnostic tests. UpToDate. Retrieved December 21, 2022, from
https://www.uptodate.com/contents/wilson-disease-diagnostic-tests
Sanyal, S. (2022, October 7). The Pros and Cons of Lentiviral and Adeno-Associated Viral Vectors. Retrieved from:
https://themedicinemaker.com/manufacture/the-pros-and-cons-of-lentiviral-and-adeno-associated-viral-vectors

Yasinski, E. (2020, September 25). Thwarting AAV-Neutralizing Antibodies Could Improve Gene Therapy. Retrieved
from:

https://www.the-scientist.com/news-opinion/thwarting-aav-neutralizing-antibodies-could-improve-gene-therapy-
67981#:~:text=Because%20AAVs%20are%20viruses%2C%20the,to%20AAVs%20in%20the%20environment

Moini, et al. (2021, April 5). Recent advances in Wilson disease. Retrieved from: retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7838529/

Hertl, M. (2022, September). Liver Transplantation. Retreived from:

https://www.msdmanuals.com/professional/immunology-allergic-disorders/transplantation/liver-transplantation

Martínez-Morillo, E. & Bauça, J. (2022, April 26). Biochemical diagnosis of Wilson’s disease: an update. Advances in
Laboratory Medicine / Avances en Medicina de Laboratorio, 3(2), 103-113. Retrieved from:
https://doi.org/10.1515/almed-2022-0020

European Association For The Study Of The Liver. (2020). EASL clinical practice guidelines: Wilson’s disease.
Journal of hepatology, 56(3), 671-685

Palumbo, C. S., & Schilsky, M. L. (2019, April 7). Clinical practice guidelines in Wilson disease. Annals of
translational medicine, 7(Suppl 2).

Mercado, C. et al. (2022, December 23). Anterior Segment Optical Coherence Tomography for Various Ocular Surface
Lesions and Corneal Pathologies. American Academy of Ophthalmology. Retrieved from
https://eyewiki.aao.org/Anterior_Segment_Optical_Coherence_Tomography_for_Various_Ocular_Surface_Lesions_
and_Corneal_Pathologies

Bartnicka, J. J., & Blower, P. J. (2018). Insights into Trace Metal Metabolism in Health and Disease from PET: "PET
Metallomics". Journal of nuclear medicine : official publication, Society of Nuclear Medicine, 59(9), 1355–1359.
https://doi.org/10.2967/jnumed.118.212803

Liserre, R., Pinelli, L., and Gasparotti, R. (2021). MR Spectroscopy In Pediatric Neuroradiology. Translational
Pediatrics, 10(4), 1169-1200. doi: 10.21037/tp-20-445

MedlinePlus. (2018, April 15). Retrieved from https://medlineplus.gov/druginfo/meds/a618021.html

Camarata, M.A., Ala, A., and Schilsky, M.L. (2019). Zinc Maintenance Therapy for Wilson Disease: A Comparison
Between Zinc Acetate and Alternative Zinc Preparations. Hepatology Communications, 3(8), 1151-1158. doi:
10.1002/hep4.1384

Ala, A., Aliu, E., & Schilsky, M. L. (2015). Prospective Pilot Study of a Single Daily Dosage of Trientine for the
Treatment of Wilson Disease. Digestive Diseases and Sciences, 60(5), 1433–1439. https://doi.org/10.1007/s10620-
014-3495-6

Mejias, S. G., & Ramphul, K. (2020). Penicillamine. PubMed; StatPearls Publishing.

https://www.ncbi.nlm.nih.gov/books/NBK513316/
Sánchez-Monteagudo, A., Ripollés, E., Berenguer, M., & Espinós, C. (2021). Wilson's Disease: Facing the Challenge
of Diagnosing a Rare Disease. Biomedicines, 9(9), 1100. https://doi.org/10.3390/biomedicines9091100

Dev, S., Kruse RL., Hamilton, JP., and Lutsenko, S. (2022, March 30). Wilson Disease: Update on Pathophysiology
and treatment. Frontiers in Cell and Developmental Biology. Retrieved May 02, 2022, from
https://www.frontiersin.org/articles/10.3389/fcell.2022.871877/full

Szczerbinska, BK., and Lach, HC. (2021, October 27). Wilson’s Disease: An Update on the Diagnostic Workup and
Management. Journal of Clinical Medicine. Retrieved October 30, 2021, from
https://www.mdpi.com/2077-0383/10/21/5097/htm

Ferenci, P., and Ott, P. (2019, February 6). Wilson’s disease: Fatal when overlooked, curable when diagnosed. Journal
of Hepatology. Retrieved May 21, 2019, from
https://www.journal-of-hepatology.eu/article/S0168-8278(19)30114-X/fulltext
Chaudhry, H., and Anilkumar, A. (2022). Wilson's Disease. National Library of Medicine. Retrieved August 8, 2022,
from
https://www.ncbi.nlm.nih.gov/books/NBK441990/
Ferenci, P. (1998, February). Wilson's Disease. Clinics in Liver Disease. Retrieved June 22, 2005, from
https://www.sciencedirect.com/science/article/abs/pii/S1089326105703627
Capone, K., and Azzam, RK. (2018). Wilson's Disease: A review for the general pediatrician. Pediatric Annals,
Retrieved October 31, 2018, from
https://journals.healio.com/doi/full/10.3928/19382359-20181031-01
White, V. (2016, July 21). Methanobactin - an agent against Wilson’s disease. Drug Target
Review.https://www.drugtargetreview.com/news/12495/methanobactin-wilsons-
disease/#:~:text=Methanobactin%20reversed%20acute%20stages%20of%20Wilson

Disease Treatments | ASGCT - American Society of Gene & Cell Therapy |. (2021, July 21).
Patienteducation.asgct.org.https://patienteducation.asgct.org/disease-treatments/wilson-
disease#:~:text=Gene%20therapy%20aims%20to%20b

Gupta, S. (2014). Cell therapy to remove excess copper in Wilson’s disease. Annals of the New York Academy of
Sciences, 1315(1), 70–80. https://doi.org/10.1111/nyas.12450