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FAP ‐ Genetics

Familial  autosomic dominant.

Familial  autosomic dominant.

No modifier genes identified so far, but familial 

No modifier genes identified so far, but familial aggregation of  subphenotypes.

aggregation of  subphenotypes.

Parent of  origin effects: Anticipation of  age at onset, increased penetrance, particularly on mother to child transmission. Still unexplained 

enetic im rintin ? .

Parent of  origin effects: Anticipation of  age at onset, increased penetrance, particularly on mother to child transmission. Still unexplained 

enetic im rintin ? .

?I

II

III

IV

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II – Molecular Biology

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 –  

The fundamental constituent of amyloid in PAF is identical

immunochemically to a small serum

The fundamental constituent of amyloid in PAF is identical

immunochemically to a small serumprotein, transthyretin (TTR).

[Costa et al., PNAS, 1978]

protein, transthyretin (TTR).

[Costa et al., PNAS, 1978]

oc em ca c arac er za on o sfundamental constituent of amyloid

reveals the presence of a TTR mutation, 

oc em ca c arac er za on o sfundamental constituent of amyloid

reveals the presence of a TTR mutation, w a me on ne or va nesubstitution at position 30.w a me on ne or va nesubstitution at position 30.

[Saraiva et al., Trans  Assoc  Am Physicians, 1983][Saraiva et al., Trans  Assoc  Am Physicians, 1983]

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-20 -10

ACAGAAGTCCACTCATTCTTGGCAGGATGGCTTCTCATCGTCTGCTCCTCCTCTGCCTTGCTGGA

FAP..........................-M--A--S--H--R--L--L--L--L--C--L--A--G-

-1 1 10

CTGGTATTTGTGTCTGAGGCTGGCCCTACGGGCACCGGTGAATCCAAGTGTCCTCTGATGGTCAAA 

-L--V--F--V--S--E--A--G--P--T--G--T--G--E--S--K--C--P--L--M--V--K-

20 30

ATTR V30MGTTCTAGATGCTGTCCGAGGCAGTCCTGCCATCAATGTGGCCATGCATGTGTTCAGAAAGGCTGCT 

-V--L--D--A--V--R--G--S--P--A--I--N--V--A--M--H--V--F--R--K--A--A-

40 50

GATGACACCTGGGAGCCATTTGCCTCTGGGAAAACCAGTGAGTCTGGAGAGCTGCATGGGCTCACA-D--D--T--W--E--P--F--A--S--G--K--T--S--E--S--G--E--L--H--G--L--T-

60 70 80

ACTGAGGAGGAATTTGTAGAAGGGATATACAAAGTGGAAATAGACACCAAATCTTACTGGAAGGCA

-T--E--E--E--F--V--E--G--I--Y--K--V--E--I--D--T--K--S--Y--W--K--A-

90 100

CTTGGCATCTCCCCATTCCATGAGCATGCAGAGGTGGTATTCACAGCCAACGACTCCGGCCCCCGC 

-L--G--I--S--P--F--H--E--H--A--E--V--V--F--T--A--N--D--S--G--P--R-

110 120CGCTACACCATTGCCGCCCTGCTGAGCCCCTACTCCTATTCCACCACGGCTGTCGTCACCAATCCC  

-R--Y--T--I--A--A--L--L--S--P--Y--S--Y--S--T--T--A--V--V--T--N--P-

127

AAGGAATGAGGGACTTCTCCTCCAGTGGACCTGAAGGACGAGGGATGGGATTTCATGTAACCAAGA

-K--E--*-.........................................................

GTATTCCATTTTTACTAAAGCAGTGTTTTCACCTCATATGCTATGTTAGAAGTCCAGGCAGAGACA  

..................................................................

ATAAAACATTCCTGTGAAAGGCACTTTTCATTCC 

...................................

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Amyloid Type Precursor Disease

apo econ ary  reac ve  amy o os sFMF

AL Ig light chains (κ,λ)

ATTR Transthyretin

TTR V30M

TTR L111M

Senile systemic amyloidosis

Polyneuropathy

Cardiomiopathy

AapoAI apoA‐I Arg 26

apoA‐I Arg 60

Polyneuropathy, Nephropathy

Nephropathy

A Lys Lysozime Thr 56, His 67 Nephropathy

AFibA Fibrinogen Aα E526V, R554L Nephropathy

AGel Gelsolin Asn 187 FFA

ACys Cystatin C Gln 68 HCHWA, Icelandic type

Aβ2M β2‐microglobulin Hemodialisis amyloidosis

’

βPP Gln 618

HCHWA, Dutch type

AScr PrPC, PrPSc, PrPCJD Kuru, Scrapie, CJD, GSS

m n a etes me tus, type 

ACal procalcitonin Thyroid medulary carcinoma

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  u a ons

Arg 47 Ile 50

Glu 18

Neuropathy

Vitreous/other

Lys 61

Val 107Leu 30

Leu 33

Val 33

Tyr 77

Gly 42

Ala 30 Ile 33

Arg 58

Cys 114

ro 

Gly 18

Asn 35Ser 24

Thr 34

ro 

Ala 47Val 47

Gln 89 Ala 60

Arg 10

Ala 49

Pro 55

Gly 30Met 30

Arg 50

Leu 64

Gly 97

Ile 112

Ile 122

Leu 68

Lys 59

Asp 45

Ser 84

Ala 71

His 60

Ile 20 Met 111Ile 50

Ser 125 Ser 6 

Cardiomiopathy

Met 119

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III – Epidemiology

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PAF ‐ distribuição

‐Cávado

(733)

e porta ores  nut3

100 ou mais (4)

60 a  99 (3)

40 a  59 (3)

30 a  39 (3)

3525 TTR V30M carriers registeredat Centro de Estudos de 

Paramiloidose, Porto (June 2008), 

3525 TTR V30M carriers registeredat Centro de Estudos de 

Paramiloidose, Porto (June 2008), 78

Serra da Estrela

(1206)Gran e Porto

(102)

Baixo Vouga

10 a  19 (2)

0 a  9 (11)

Junho de 2008 

covering most patients an eat ycarriers above 20 years of age (data from genetic counceling).

covering most patients an eat ycarriers above 20 years of age (data from genetic counceling).

(261)Baixo Mondego

(72)Cova da Beira

The residence of 97% of theseThe residence of 97% of thesecarriers is known. Northern coastalareas most heavily affected.carriers is known. Northern coastalareas most heavily affected. Península de Setubal

(90)

(291)ran e  s oa

Number of live patients > 1000. National re istr   im lementationNumber of live patients > 1000. National re istr   im lementationunder way.under way.

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‐

Northern Portugal, one study only (HIEF)

Alves IL et al. Human Mutation 1997  9 3   226‐33

Northern Portugal, one study only (HIEF)

Alves IL et al. Human Mutation 1997  9 3   226‐33

In 5000 individuals:In 5000 individuals:

• Met 30 8

• Met 119 35

• Met 30/Met 119 1

• Asn 90 12

• Unknown 3

• Thr 190 1

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‐

Northern Sweden – endemic counties (ELISA)

Holmgren et al.  J Med  Genet 1994, 31, 351‐4

Northern Sweden – endemic counties (ELISA)

Holmgren et al.  J Med  Genet 1994, 31, 351‐4

In 1276 individuals:In 1276 individuals:

• Met 30 16

• Met 30/Met 30 3

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 –

© 2001 National Geographic Society

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The Travels of a Gene?

© 2001 National Geographic Society

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-

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• Nerve and skin

• Fat as irate

• Other

The basis of diagnosis in old times (before genetic testing)The basis of diagnosis in old times (before genetic testing)

It is rarely positive in asymptomatic carriersIt is rarely positive in asymptomatic carriers

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ATTR V30M  – Molecular Testin 

30

·· AGTCCTGCCATCAATGTGGCCGTGCATGTG ·· 

·· -S--P--A--I--N--V--A-- V --H--V- ··

↓ ·· AGTCCTGCCATCAATGTGGCC A TGCATGTG ·· 

·· -S--P--A--I--N--V--A-- M --H--V- ··

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 – 

AlternativesAlternatives

• SSCP

• DHPLC

TTR V28M• e c.

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-

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FAP - Tr tm nt

Before the advent of liver transplantation, FAP was anincurable disease.Before the advent of liver transplantation, FAP was anincurable disease.

  , 

and is effective because > 90% of human TTR is producedin the liver.

  , 

and is effective because > 90% of human TTR is producedin the liver.

Only current alternative:Only current alternative:, , 

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 –  

Aconselhamento genético

• Diagnóstico pré‐natal

• Dia nóstico  ré‐im lanta ão

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DESENVOLVIMENTO

EMBRIONÁRIO PRÉ- IMPLANTAÇÃO

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1º Dia Dia 1-2 Dia 2

Dia 3

• 1º e 2º glóbulos polares

  Dia 4

BIÓPSIA

• a ast meros, ao ia

• Células da trofoectoderme de blastocistos, ao 5º dia

Dia 4

Dia 5

Dia 6ia 6-7

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PROCESSO DE FIV

• Exames preliminares ♀ ♂

≥  • ≥  

• ICSI - não contaminaçãoez

 c u as a granu osa

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ABERTURA DA ZONA PELÚCIDA

• Solução ácida de Tyrode (pH 2.2)• aser• Dissecção parcial

*Meio sem Ca2+/Mg2+

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TRANSFERÊNCIA DE EMBRIÕES

4º ou 5º dia após punção folicular

TAXA DE GRAVIDEZ CLÍNICA EM DGPI22,4%

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• Inibição da formação de amilóide

• Estabilizadores do tetrâmero de TTR • Remoção da proteína circulante

• Remoção dos depósitos

• Antagonistas dos glicosaminoglicanos

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r og nese ‐.

Estes estudos mostraramue é relativamente fácil

obter fibras com ascaracterísticas genéricas dasfibras de amilóide a partir deum grande número deproteínas ou fragmentos

proteicos.

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r og nese ‐A fibrilogénese passa quase sempre pela formaçãode um intermediário, que pode formar fibras deimediato, ou a partir de agregados de tipo amorfo.

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-pH 5.3 pH <3pH 3

Rearranjedtetramer

Nativetetramer A-state

Amyloid

fibrils

Early model, based onacidic denaturationEarly model, based onacidic denaturation

SAP GAGs

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Serag et al. Nature Struct Biol 9: 734-9, 2002

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‐

Hou, X. et al. FEBS Journal 2007, 274 (7), 1637-50.

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Kadowaki et al., J Chem Neuroanatomy 28 (2004) 93–100

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FAP – lini l Tri l

DMSO CEP II/III (?) 1984

Apheresis CEP I/II 2001

CPHPC (Ro 63‐8695) CAAPP / Roche II/III 2002

Fx‐1006A FoldRx II/III 2009

un sa

Doxycyclin IBMC ? ?