Cystic Fibrosis

Introduction
• Cystic fibrosis (also known
as CF or mucoviscidosis) is a common recessive
genetic disease .
• The name cystic fibrosis refers to the
characteristic scarring (fibrosis) and cyst formation
within the pancreas . Difficulty breathing is the
most serious symptom and results from
frequent lung infections.

• CF is caused by a mutation in the gene for

the protein cystic fibrosis transmembrane
conductance regulator (CFTR). This gene is required
to regulate the components of sweat,digestive juices,
and mucus.
Introduction
• CF is most common among Caucasians;
one in 25 people of European
descent carry one allele for CF.

• Individuals with cystic fibrosis can be

diagnosed before birth by genetic testing
, or by a sweat test in early childhood.

• It is caused by more than 1000 known

mutation in CFTR gene , while 70% of
the cases arise from deletion of Phe508
(∆F508 ) which is located in cytoplasmic
domain of the CFTR protein .
HISTORY
• In 1938 Dorothy Hansine Andersen published an article, "Cystic
Fibrosis of the Pancreas and Its Relation to Celiac Disease: She
was the first to describe the characteristic cystic fibrosis of the
pancreas and to correlate it with the lung and intestinal disease
prominent in CF. She also first hypothesized that CF was a
recessive disease and first used pancreatic enzyme replacement to
treat affected children

• In 1988 the first mutation for CF, ΔF508 was discovered

by Francis Collins, Lap-Chee Tsui and John R. Riordan on the
seventh chromosome.

•In 1989 Lap-Chee Tsui led a team of researchers at the Hospital

for Sick Children in Toronto that discovered the gene responsible
for CF .
 Cystic Fibrosis ....
• Cystic fibrosis is a heterogeneous
recessive genetic disorder with
features that reflect mutations in the
cystic fibrosis transmembrane
conductance regulator (CFTR) gene.
A thick, sticky mucus clogs the lungs
and digestive system of people

• Individuals with defect in both copies

of CFTR genes develop cystic fibrosis
whereas single copy defect leads to be
carrier of CF .
CFTR
(Cystic fibrosis transmembrane conductance regulator)

• Cystic fibrosis transmembrane

conductance regulator (CFTR) is
a protein that in humans is
encoded by the CFTR gene.

• CFTR is a ABC transporter-

class ion channel that
transports chloride and thiocyanat
e ions across epithelial cell
membranes. Mutations of the
CFTR gene affect functioning of
the chloride ion channels in these Cystic fibrosis transmembrane
cell membranes, leading to cystic conductance regulator (ATP-
binding cassette sub-family C,
fibrosis and congenital absence of
member 7)
the vas deferens.
Cytogenetics of CFTR
• Park et al. (1987) concluded that CF is distal to and on the 5-prime side
of MET. They determined this by in situ hybridization on metaphase and
prometaphase chromosomes of normal lymphocytes as well as
lymphoblastoid cells containing a t(5;7)(q35;q22). Normal cells showed
clustering of MET grains to 7q31.

• In the course of studying a case of cystic fibrosis, Spence et al.

(1988) discovered what appeared to be a case of uniparental disomy: the
father did not contribute alleles to the propositus for markers near the
CF locus or for centromeric markers on chromosome 7.
Structure of CFTR
• The CFTR gene contains about 170,000 base pairs. This
gene encodes the instruction to build the CFTR protein.
CFTR is a glycoprotein with 1480 amino acids.
• The protein consists of five domains. There are two
transmembrane domains, each with six spans of alpha
helices .
• These are each connected to a nucleotide binding
domain (NBD) in the cytoplasm.
• The first NBD is connected to the second
transmembrane domain by a regulatory "R" domain
that is a unique feature of CFTR, not present in
other ABC transporters .
• The ion channel only opens when its R-domain has
been phosphorylated by PKA and ATP is bound at the
NBDs. The carboxyl terminal of the protein is anchored
to the cytoskeleton by a PDZ-interacting domain.
Structure of CFTR
CFTR
(Cystic fibrosis transmembrane conductance regulator)
CFTR
(Cystic fibrosis transmembrane conductance regulator)

Sequence:Chromosome: 7 ….CFTR in MapViewer

CFTR
(Cystic fibrosis transmembrane conductance regulator)

SNP linked to Gene CFTR:--

CFTR
(Cystic fibrosis transmembrane conductance regulator)
The similarity search of Human cystic fibrosis mRNA, encoding a
presumed transmembrane conductance regulator (CFTR) by Basic Local
Alignment Search Tool (89 BLAST)…..

Remarkably another gene at

chromosome No. 20 showing
higher similarity with CFTR at
chromosome No. 7.
CFTR
(Cystic fibrosis transmembrane conductance regulator)

Some detail on the gene of chromosome no 20. showing higher similarity

with CFTR at chromosome No. 7 in BlAST .
Function of CFTR
•CFTR functions as a cAMP-activated ATP-gated anion channel,
increasing the conductance for certain anions (e.g. Cl-) to flow down
theirelectrochemical gradient.

•ATP-driven conformational changes, which in other ABC proteins fuel

uphill substrate transport across cellular membranes, in CFTR open and
close a gate to allow transmembrane flow of anions down
their electrochemical gradient. "Single CFTR channels open and
close stochastically in an ATP-dependent manner, the open state
catalyzing exclusively “downhill” Cl− movement at rates of millions of
ions per second, orders of magnitude too high for any enzymatic pump
cycle to support ".

•Essentially, CFTR is an ion channel that evolved as a 'broken' ABC

transporter that leaks when in open conformation.
Function of CFTR
• The CFTR is found in the epithelial cells of many organs including
the lung, liver, pancreas, digestive tract, reproductive tract, and skin.
Normally, the protein moves chloride and thiocyanate ions (with a
negative charge) out of an epithelial cell to the covering mucus . This
results in an electrical gradient being formed and in the movement of
(positively charged) sodium ions in the same direction as the chloride via a
paracellular pathway. Due to this movement, the water potential of the
mucus is reduced, resulting in the movement of water here by osmosis and
a more fluid mucus

•In sweat glands, CFTR defects result in reduced transport of sodium

chloride and sodium thiocyanate in the reabsorptive duct and saltier sweat.
This was the basis of a clinically important sweat test for cystic
fibrosis before genetic screening was available.
Protein Structure and Function
• CFTR transports chloride ions
(Cl-) ions across the membranes
of cells in the lungs, liver,
pancreas, digestive tract,
reproductive tract, and skin.
• CFTR is made up of five domains:
– two membrane-spanning
domains (MSD1 and MSD2)
that form the chloride ion
channel
– two nucleotide-binding
domains (NBD1 and NBD2)
that bind and hydrolyze ATP
(adenosine triphosphate)
– and a regulatory (R) domain. Side chain and backbone
• Delta F508, the most common contributions of Phe508 to
CF-causing mutation, occurs in CFTR folding.
the DNA sequence that codes for
the first nucleotide-binding
domain (NBD1).
Protein Structure and Function
Conserved domains of cystic fibrosis transmembrane conductance
regulator [Homo sapiens]
Types of mutations in CFTR
Changes in Protein structure
• CFTR functions principally as a cAMP-
induced chloride channel and appears
capable of regulating other ion channels.

• Besides the most common mutation,

ΔF508, accounting for about 70% of CF
chromosomes worldwide, more than 850
mutant alleles have been reported to the CF
Genetic Analysis Consortium.

• These mutations affect CFTR through a

variety of molecular mechanisms which can
produce little or no functional CFTR at the
apical membrane
 3D Image of Protein
• When a CFTR protein with the delta
F508 mutation reaches the ER, the
quality-control mechanism of this
cellular component recognizes that the
protein is folded incorrectly and marks
the defective protein for degradation. As
a result, delta F508 never reaches the cell
membrane.
• People who are homozygous for delta
F508 mutation tend to have the most
severe symptoms of cystic fibrosis due to
critical loss of chloride ion transport.
• This upsets the sodium and chloride ion
balance needed to maintain the normal,
thin mucus layer that is easily removed
by cilia lining the lungs and other organs.
The sodium and chloride ion imbalance
creates a thick, sticky mucus layer that
cannot be removed by cilia and traps
bacteria, resulting in chronic infections.
Characterization of cystic fibrosis
• Classic cystic fibrosis is
characterized by chronic
bacterial infection of the
airways and sinuses, fat
maldigestion due to
pancreatic exocrine
insufficiency, infertility in
males due to obstructive
azoospermia, and elevated
concentrations of chloride in
sweat.
• Patients with nonclassic
cystic fibrosis have at least
one copy of a mutant gene
that confers partial function
of the CFTR protein, and such
patients usually have no overt
signs of maldigestion because
some pancreatic exocrine
function is preserved
Signs and Symptoms
An individual born with the cystic fibrosis gene will usually
be diagnosed in the first year, although occasionally symptoms do not
become evident until adolescence, or even later. The symptoms and their
severity vary from person to person, but may include:

Excessive salt in sweat, dehydration ,Chronic cough, possibly

with blood streaking,Wheezing,Frequent Bronchitis and other airway
infections,Thick mucus secretions in the lungs,Chronic
sinusitis,Asthma,Nasal polyps (growths inside the nose),Failure to put on
weight,abdominal swelling, pain and flatulence,Frequent, foul-smelling
stools,Failure of newborn to pass stoo,Fatigue

Late onset of puberty, inflammation of the pancreas,

cirrhosis (a liver condition), and infertility may also be associated with
cystic fibrosis.
Signs and Symptoms
LUNG
• Lung disease results from clogging of the airways
due to mucus build-up, decreased mucociliary
clearance and resulting
inflammation. Inflammation and infection will
cause injury and structural changes to the lungs,
leading to a variety of symptoms.

• In the early stages, incessant coughing,

copious phlegm production, and decreased ability
to exercise are common.
LUNG
• Other symptoms include coughing up
blood (hemoptysis), high blood pressure in
the lung (pulmonary hypertension), heart
failure, difficulties getting enough oxygen to
the body (hypoxia), and respiratory failure
requiring support with breathing masks such
as bilevel positive airway pressure machines
or ventilators.

• In later stages, changes in the architecture

of the lung such as pathology in the major
airways (bronchiectasis) further exacerbate
difficulties in breathing.
Lung Infection
• Staphylococcus aureus, Haemophilus
influenzae, and Pseudomonas aeruginosa are
the three most common organisms causing
lung infections in CF patients .

• In addition to typical bacterial infections,

people with CF more commonly develop
other types of lung disease. Among these
is allergic broncho pulmonary aspergillosis ,
in which the body's response to the
common fungus Aspergillus fumigatus causes
worsening of breathing problems .
G I tract
• Intestinal abnormality
– Meconium ileus
– Distal intestinal obstruction
syndrome (DIOS)
– Rectal prolapse

• Hepatobiliary disease
– Focal biliary cirrhosis
– Multilobular cirrhosis

• Pancreatic endocrine dysfunction colonoscopy for distal

– Cystic fibrosis related diabetes intestinal obstruction
syndrome in cystic fibrosis
patients
ENDOCRINE
• The pancreas contains the islets of
Langerhans , which are responsible for
making insulin, a hormone that helps
regulate blood glucose .
• Damage of the pancreas can lead to loss of
the islet cells , leading to a type of diabetes
that is unique to those with the disease.
• This cystic fibrosis related diabetes (CFRD)
shares characteristics that can be found
in Type 1 and Type 2 diabetics, and is one of
the principal non-pulmonary complications
of CF.
• Vitamin D is involved in calcium and phosphate regulation. Poor uptake of
vitamin D from the diet because of malabsorption can lead to the bone
disease osteoporosis in which weakened bones are more susceptible to fractures .
• In addition, people with CF often develop clubbing of their fingers and toes due
to the effects of chronic illness and low oxygen in their tissues.
 INFERTILITY
• Affects both men and women. At least 97% of men
with cystic fibrosis are infertile, but not sterile and
can have children with assisted reproductive
techniques. These men make normal sperm but are
missing the tube (vas deferens), which connects
the testes to the ejaculatory ducts of the penis
.Many men found to have congenital absence of the
vas deferens during evaluation for infertility have a
mild, previously undiagnosed form of CF.

• Some women have fertility difficulties due to Intracytoplasmic sperm

thickened cervical mucus or malnutrition. In severe injection can be used to
cases, malnutrition disrupts ovulation and provide fertility for men
causes amenorrhea. with cystic fibrosis
Treatment of other aspects
• Newborns with CF typically require surgery,
whereas adults with distal intestinal
obstruction syndrome typically do not.
• Treatment of pancreatic insufficiency by
replacement of missing digestive enzymes
allows the duodenum to properly absorb
nutrients and vitamins that would otherwise
be lost in the feces.
• So far, no large-scale research involving the
incidence ofatherosclerosis and coronary
heart disease in adults with cystic fibrosis has
been conducted. This is likely due to the fact
that the vast majority of people with cystic
fibrosis do not live long enough to develop
clinically significant atherosclerosis or
coronary heart disease.
Treatment of other aspects
• Diabetes is the most common
non-pulmonary complication of CF. It
mixes features of type 1 and type
2 diabetes, and is recognized as a distinct
entity, cystic fibrosis-related
diabetes(CFRD). While oral anti-diabetic
drugs are sometimes used, the only
recommended treatment is the use
of insulin injections or an insulin
pump, and, unlike in type 1 and 2 diabetes,
dietary restrictions are not recommended.
Treatment of other aspects
• Development of osteoporosis can be prevented
by increased intake of vitamin D and calcium , and can be
treated by bisphosphonates , although adverse effects can
be an issue. Poor growth may be avoided by insertion of
a feeding tube for increasing calories through
supplemental feeds or by administration of
injected growth hormone.

• Sinus infections are treated by prolonged

courses of antibiotics. The development of nasal polyps or
other chronic changes within the nasal passages may
severely limit airflow through the nose, and over time
reduce the patient's sense of smell. Sinus surgery is often
used to alleviate nasal obstruction and to limit further
infections. Nasal steroids such as fluticasone are used to
decrease nasal inflammation.
Treatment of other aspects
• Gene Therapy has made massive advances in the way that cystic fibrosis has been
treated throughout the world. With the help of the Cystic Fibrosis Trust , which
has a league of highly professional gene therapists, both somatic and Adeno-
associated viral vector have made advances. The Adenoviridae , or more commonly
known as the cold virus, is genetically altered, allowing the 'thin mucus gene' to
enter lung cells. They are currently stage 3 /Clinical_trial , and following the
success of these trials, the treatment can become readily available and valid in the
eyes of the medical world.

• Male infertility caused by absence of the vas deferens may be overcome

with testicular sperm extraction (TEST), collecting sperm cells directly from the
testicles. If the collected sample contains too few sperm cells to likely have a
spontaneous fertilization, intracytoplasmic sperm injection can be performed.

•Female infertility may be overcome by assisted reproduction technology,

particularly embryo transfer techniques.
Gene Therapy and cystic fibrosis
Recombinant adeno-associated viral
vectors (rAAV)-mediating gene-targeting approaches
used to generate new cystic fibrosis ferret and pig
models.
(a) Schematic representation of the mechanism of
gene targeting using rAAV. Target sequence
homology (blue) and a selectable marker (red)
are packaged between two AAV inverted terminal
repeats (ITRs). Following infection, homologous
recombination between the rAAV vector and the
target genomic locus mediates insertion of the
selectable marker.
(b) (b) Design of rAAV vectors used to disrupt the
coding sequence of the CFTR gene through
targeted insertion of a neomycin expression
cassette in exon 10.
(c) (c) Design of rAAV vectors used to delete the
F508 codon in exon 10 of the CFTR gene. In this
approach, the neomycin expression cassette is
inserted into intron 11 of theCFTR gene.
 Treatment of cystic fibrosis in
Herbal Medicine
Herbs beneficial to cystic fibrosis patients
include:

To help break down mucus:

Thyme (thymus vulgaris), Indian tobacco (lobelia

inflata), anise (pimpinella anisum), hyssop
(hyssopus officinalis), licorice root (glycyrrhiza
glabra), rosemary (rosemarinus officinalis)

For acute infection:

Coneflower (echinacea purpurea), goldenseal

(hydrastis canadensis), thyme (thymus vulgaris),
wild indigo (baptisia tinctoria)
 Treatment of cystic fibrosis in
Homeopathic medicine
Remedies which may be prescribed for cystic
fibrosis patients include:

Antimonium tart - for rattling, unproductive

cough

Carbo vegetabilis - for difficulty breathing

Laurocerasus - for collapsed lung

 REFERENCES
http://www.emedicine.com/

(http://www.genet.sickkids.on.ca/cftr/)

http://www.nhlbi.nih.gov/health/health-topics/topics/cf

http://www.medicinenet.com/cystic_fibrosis/article.htm

www.nlm.nih.gov/medlineplus/cysticfibrosis.html

http://en.wikipedia.org/wiki/Cystic_fibrosis
THANK YOU