markus m. lerch department of medicine a ernst-moritz-arndt universität greifswald medizinische...
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Markus M. Lerch Department of Medicine A
Ernst-Moritz-Arndt Universität Greifswald
Medizinische Klinik der königlichen Universität Greifswald
18591456
550 Jahre Universität Greifswald
Advances in the etiology of chronic pancreatitisEuropean Postgraduate School
in Gastroenterology Prague, April 2010
Chronic Pancreatitis - Etiology
Alcohol Idiopathic Metabolic Anatomical Hereditary Autoimmune
Reasons to discriminate between different etiologies:
Specific treatment options
Inherent co-morbidities
Different cancer surveillance strategies
0
10
20
30
40
50
60
70
80
90
100
0 5 10 15 20 25
Alcoholic-CP
Inci
denc
e of
cal
cific
atio
nsP
ropa
bilil
ty in
%
Time after onset of symptoms
Non-Alcoholic CP
Layer et al, Gastroenterology 1994;107:1481- 87
Chronic Pancreatitis – Alcohol Cessation
Chronic Pancreatitis - Alcohol Cessation
0 20 40 60 80 100
Strum et al, 1995
Miyaka et al, 1987
Bornman et al, 1980
Leger et al, 1974
Strum et al, 1971 Alcohol
Stop AlcoholGastard et al, 1973
Prinz et al, 1974
Marks et al, 1980
Hayakawa et al, 1989
Patients with pain [%]
Cu
mu
lativ
e In
cid
en
ce o
f ca
lcifi
catio
ns, %
years after diagnosis of chronic alcoholic pancreatitis
OR 2.0 [CI 1.1-3.8]
Chronic Pancreatitis – Cessation of Smoking Maisoneuve P, Gut 2005; 54: 510-514
Log rank p<0.0001
0 2 4 6 8 10 12 14 16
100
80
60
40
20
0
Smokers
Non-Smokers
Hereditary Pancreatitis
14 year old girl with chronic pancreatitis and R122H-mutation
48 year old women with chronic pancreatitisand R122H-mutation
Hereditary pancreatitis is clinically indistinguishable from other forms and varities of pancreatitis.
1952, first description ofhereditary pancreatitis (autosomal dominant trait).
1996 Discovery of the first mutation associated with hereditary pancreatitis in the cationic trypsinogen gene (PRSS1) by Whitcomb et al.
Hereditary pancreatitis in Germany
MünsterMünster
GreifswaldGreifswald
Weiss F.U. Am J Gastroenterol. 2008;103:2585-8.
Haplotype-Analysis of 10 unrelated families witha R122H mutation from an area of 100 km resulted in 7 different haplotypes. This precludes a Founder-Effect
Block A (17 kb) Block B (62 kb)
Chr. 7: 142,092-142,183 kbPRSS1 PRSS2
D22G
K23R
R116C
K92N
E79K
G83E
R122H/C
V123M
P36R
N29I/T
D100H
L104PC139F
Activation site
Cationic trypsin
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60
Cu
mu
lativ
e a
ge a
t ons
et,
%
R122H negativ
N29I A16V
Cu
mu
lativ
e in
cid
enc
e o
f dia
bete
s, %
age, years
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80
male female
age, years
Howes N, Lerch MM et al Clinical Gastroenterology and Hepatology 2004; 2: 252-261
Clinical course of Hereditary Pancreatitis
Alcoholic CP
50-70% increased riskfor pancreatic cancer in patients with hereditary pancreatitis. 40% cumulative risk until 70. years of age.
Elimination/Treatmentof causal factors:Smoking, AlcoholHyperlipidemia, Hypercalcemia,Gallstones, Duct stricture,Drugs and Medications age, years
0
10
20
30
40
50
60
0 20 40 60
cumulative pancreatic cancer risk, %
age
at d
iag
nosi
s of
pan
crea
tic c
an
cer 80
70
60
50
40
30
20Non-smokers smokers
p < 0.01
Pancreatic Cancer in Hereditary Pancreatitis
Howes N, Lerch MM et al Clinical Gastroenterology and Hepatology 2004; 2: 252-261;
Lowenfels AB, JAMA 2001; 286: 169-170.
Recurrent (2 or more) episodes of acute Pancreatitis without identifyable cause or etiology or
Idiopathic chronic Pancreatitis - especially in children and young adults under the age of 25 years or
Pancreatitis in a patients with a positive family history of Pancreatitis (one or more first or second degree relatives)
Indications for Genetic Hereditary Pancreatitis testing
I. Ellis, M.M. Lerch, D.C. Whitcomb: Pancreatology 2001:1:405-415
0 5 10 15 20 25 30
0
20
40
60
80
Try
psi
n a
ctiv
ity (
%)
Time (min)
G191R
PRSS2
0 0.5 1 1.5 2
0
20
40
60
80
100
R122C
Wild-Type
pH 8.0, 5 mM Ca2+
Try
psi
n a
ctiv
ity (
%)
Time (h)
Simon et al. J. Biol. Chem. 2002; 277: 5404-5410 Witt et al Nature Genetics 2006; 38: 668-73.
Wild-Type
PRSS1
Pathophysiological role of two mutant trypsinogens:Decreased autoactivation
wt R122C
reducing non-reducing
60
42
30
22
17
kDa
wt R122C
Simon P. et al. J. Biol. Chem. 2002; 277: 5404-5410
SHI
CH2
ICIH
=COO-H3N+-
PRSS1
Cystein
Trypsinogen
Wild type G191R
0 2 5 10 0 2 5 10 min
Trypsin
insertion of a new cleavage site EGGKD / ERGKD
PRSS2
Witt et al Nature Genetics 2006; 38: 668-73.
The phenotype of two novel trypsinogen mutations
II:1 II:4II:262y
II:354y
III:612y
III:517y
III:424y
III:325y
III:230y
III:131y
II:552y
II:6 II:745y
I:187y
I:169y diab.
Symbole
o. A.
Pancreatitis
test for R122C
carrier
PRSS1
Simon P. et al. J. Biol. Chem. 2002; 277: 5404-5410
Screening of Exon 4
for G191R mutations:
ICP/HP 17/1414 (1.2%)
ACP 4/405 (1.0%)
CONTROL 157/4581 (3.5%)
PRSS2
Witt et al Nature Genetics 2006; 38: 668-73.
0 0.5 1 1.5 2
0
20
40
60
80
100
Wild type
pH 8.0, 5 mM Ca2+
Try
ps
in A
ctiv
ity
(%)
time (h)
Kereszturi et al. Hum Mutation 2009; 30: 575-82
R116C Trypsin – Retention and ER Stress
R116C
I
II
III
IV
63y 62y
48y 44y 40y 38y 36y
17y 15y
35
25
Homogenate Pellet SupernatantkDa
wtwt wtwt wtwt R116CR116CR116CR116CR116CR116C
Expression in 293T cells
100
70BiP (78 kDa)
wt R116A R116C
PRSS-Mutations: „gain or loss of function“ ?
Autoactivation Autolysis Cathepsin B-ind. activation
A16V ? ? ?
D19A ▲
D22G ▲
K23R ▲
N29I ▲ ◄► ◄►
E79K ▼ ◄►
R122C ▼ ▼ ▼
R122H ▲ ▼ ◄►
XXX ◄► ◄► ◄►
R116C ◄► ◄► ◄►
G191R ▼ ▲ ?
▼ intracellular processing
▼ intracellular processing
Sporadic point mutations in the PRSS1- Gen in idiopathic chronic Pancreatitis
In 5 of 50 Patients with idiopathic Pancreatitis (10%) mutations inthe cationic Trypsinogen gene were found.
10%
90%
35%
65%
Affected Patients represented 35%of all patients under 25 years. Simon P, Weiss F.U. et al JAMA. 2002;288:2122
Sporadic point mutations in the PRSS1- The French CohortRebours V Am J Gastroenterol 2008; 103: 111-119, Rebours AJG 2009; 104: 2312Masson E et al Clin Gastroenterol Hepatol 2008; 6: 82-88
In 78 families with hereditary pancreatitis and 200 individuals (6673 patients years) PRSS1 mutations were detected in 68%. R122H: 78%, N29I: 12% and others 10%.
Cumulative risk of pancreatic cancer was 11% at the age of 50 and 49% at the age of 75.
Smoking and diabetes mellitus are the main risk factors.
Trypsinogen copy number variations are present in 6% of idiopathic chronic pancreatitis cases but are unrelated to familial chronic or tropical calcifying pancreatitis.
Chymotrypsin C (CTRC) variants that diminish activity or secretion are associated with chronic pancreatitis Rosendahl et al Nature Genetics 2008; 40: 78-82
Chymotrypsin C is a trypsin-degrading enzyme. Alterations in the CTRC Gene at position p.R254W and p.K247_R254del are present in 30 out of 901 (3.3%) pancreatitis individuals but only in 21 of 2804 controls (0.7%).
Functional analysis showed impaired activity or reduced secretion indicating that loss of function alterations in CTRC predispose to pancreatitis.
Pancreatic secretory Trypsin Inhibitor (PSTI, SPINK-1)
Model by A. Brunskil & W. F. Furey Model by A. Brunskil & W. F. Furey
Witt et al, (Nat. Genet., 2000) Mutations in 23% of children with idiopathic chronic Pancreatitis autosomal-recessive disorder
Pfützer et al, (Gastroenterology, 2000)Mutations in idiopathic chronic Pancreatitis (25%), hereditary Pancreatitis and inthe healthy population (2%). Modifier - Gene, risk of pancreatitis < 1%
Bhatia et al, Schneider et al, (Gastroenterology, 2002)Mutations in tropical calcifying pancreatitis (up to 44%) and in ‘Fibrocalculous Pancreatic Diabetes mellitus‘ (55%). Risk factor for tropical Pancreatitis and Diabetes mellitus
SPINK1-Mutations in Patients with Hereditary PancreatitisSymbols
Empty symbol
chronic Pancreatitis
positiv for PRSS1 Mutation
positiv for N34S Mutation
Asymptomatic carrier
wt
IV:1 8
IV:25
I:154
I:2 81
II:164
II:3 61
II:5 60
III:2 36
II:2 II:4 69
II:7 50
III:516
II:6 68
III:613
II:8 46
III:3 35
III:1 III:4
I:1 I:287
II:259
II:359
II:462
III:432
II:150
III:128
III:226
III:330
I:245
II:1
I:145
SPINK1 Mutations (N34S) are found among Pancreatitis patients as well as among healthy carriers of Trypsinogen mutations. Weiss F.U. et al. J. Med. Gen. 2003;40:e40,1-5
I.
II.
III.
SPINK1 Mutations in Hereditary PancreatitisP
hen
oty
pe,
% o
f to
tal
Cumulative Incidence of Pancreatitis
Age at disease onset, years0 10 20 30 40 50 60
0
20
40
60
80
100
PRSS1, SPINK wt
PRSS1, SPINK N34S
0 10 20 30 40 50 60
20
40
60
80
100
mild Pancreatitis
severe Pancreatitis
0 10 20 30 40 50 600
20
40
60
80
100
No Diabetes
Diabetes
SPINK1 Mutations have no influence on the severity of clinical disease courseof hereditary pancreatitis Weiss F.U. et al. J. Med. Gen. 2003;40:e40,1-5
Hyderabad Calicut Total
Patients/Controls Patients/Controls Patients/Controls(n=140) (n=155) (n=166) (n=175) (n=306) (n=330)
Leu26Val 0.48 0.30 0.45 0.28 0.46* 0.29* * p= 0.013
Ser53Gly 0.10 0.06 0.09 0.04 0.09* 0.04** p= 0.152
Association of CTSB Polymorphisms with Tropical Calcific Pancreatitis
Mahurkar et al. Gut. 2006 55:1270-5.
ethnic origin: Dravidian
N34S positive N34S negative Controls(n=134) (n=172) (n=330)
Leu26Val 0.45 0.46 0.29
His110His111
E64d
n C/C C/G G/G pGpG
(Mahurkar)
Patients 64 23 31 10 0,398 (51/128) 0,46
Controls 100 30 44 26 0,480 (96/200) 0,29
X2 p-Value 0,428 0,578 0,117 0,147 0,013
OR 0,764 0,836 1,897 0,718 2,09
95% CI0,372 -
1,5690,424 -
1,6480,792 -
4,621 0,45 - 1,15 1,55 - 2,81
CTSB Val26 mutation in German ICP Patients
Weiss et al. Gut. 2007 56(9):1322-3.
Population Ethnic origin (n) pG (Val26)
CEPH Mixed Caucasian 92 0,320
Pooled_CEPH Caucasian 94 0,323
HapMap-CEU European 55 0,355
SC_95_C Caucasian 45 0,367
HapMap-YRISub-Saharan African 52 0,394
TSC_42_C Caucasian 41 0,430
JBIC-allele Japanese 732 0,493
HapMap-JPT Asian 44 0,523
HapMap-HCB Asian 43 0,547
1198 0,452 ± 0,042
Cathepsin B mutation Leu26Val in pancreatitis
see refSNP ID: rs12338 at http://www.ncbi.nlm.nih.gov /SNP/snp_ref.cgi?rs=12338
Mahurkar et al. Gut 2006 55:1270-5
N34S positive N34S negative Controls(n=134) (n=172) (n=330)
Leu26Val 0.45 0.46 0.29
Weiss et al. Gut 2007 56:1322-3
Chronic Pancreatitis and CFTR Mutations
F 508 Mutation
Kerem et al. Science
1989; 245: 1073-80
Kerem et al. Science
1989; 245: 1073-80
One third of patients (n=27) with idiopathic pancreatitis carry CFTR-Mutations (Risk x 80). J. Cohn et al. New Engl J Med 1998;339:653-58
CFTR Mutations represent a risk factor for chronic pancreatitis in patients without a history of alcohol abuse (19% of n = 60), but not for those with alcoholic pancreatitis (8.5% of n = 72).N. Sharer et al. New Engl J Med 1998;339:645-52
Weiss FU Gut 2005; 54: 1456-1460
CFTR allele frequency
12/66 Patients with CFTR Mutations, 8/66 Patients with T5 Allels
Prevalence of gene mutations in chronic pancreatitis
Idiopathic pancreatitis
45.5%
Trypsinogen mutations
10%
SPINK-1 mutations
15.2%
T5 Allels
12.1%
CFTR mutations
18.2%
Chymotrypsin C mutations
10%
Metabolic Chronic Pancreatitis – Causal treatment
Hyperparathyroidism: Hyperthyreoidims leads to increased serum calcium levels, what is associated with an increased risk of pancreatitis.
The incidence of chronic pancreatitis is between 1.5 - 7%.
Early parathyreoidectomy leads to resolution of symptoms.
Bess MA JAMA 1980; 243: 246-247; Russel CF Br. J. Surg. 1982; 69: 244-247;
Hyperlipidemia (apoCII deficiency, lipoprotein lipase deficiency)
Serum triglyercide levels > 1000 mg/dlIncidence extremely lowTreatment which maintains TG below 500 mg/dl leads to resolution of symptoms.
Toskes PP, Gastroenterol Clin North Am 1990; 19: 783-791.
Summary and ConclusionSummary and Conclusion
Hereditary chronic and idiopathic chronic pancreatitis are associated with mutations in the trypsinogen gene, the SPINK-1 Gene, the chymotrypsin C gene and the CFTR gene.
More genes will surely be identified.
The pathophysiological impact of these gene mutations are not
completety understood and further experiments are warranted.
Etiologies of pancreatitis already treatable (such as autoimmune pancreatitis etc. ) need to be distinguished from pancreatitis varieties that are not yet treatable – but may become so.
In hereditary pancreatitis (trypsin mutations) smoking cessation may reduce the risk of pancreatic cancer. Other surveillance strategies are, however, urgently needed.
Julia MayerleUli WeissPeter SimonAli AghdassiGabriele Sauter
www.pancreas.de
Julia MayerleUli WeissPeter SimonAli AghdassiGabriele Sauter
www.pancreas.de
Chronic Pancreatitis - Alcohol Cessation
0
20
40
60
80
100
Bicarbonate Lipase Chymotrypsin
Stop Alcohol
Alcohol
Gullo et al, Gastroenterology 1988;95:1063-68
Out
put i
n %
of
initi
al
n= 18 vs. 14 pt∆ 4-11 yearsp<0.01
P. Simon, F.U. Weiss et al. J Biol Chem. 2002;277:5404-10
Diagnosis and Screening for Hereditary Pancreatitis
A C G C C N G C G T G T
C T
Sequence in Exon 3 ArgRSS1 wt AAC-GCC-CGC-GTG-T CysR-122-C AAC-GCC-TGC-GTG-T
Afl III BstU I
Wild
type
Wild
type
R122H
R122H
R122C
R122C
Contro
l
Contro
l
Today, restriction enzyme digest with BstU I represents the most extensive initial screening test for hereditary pancreatitis.
Natural Course of Alcoholic Chronic Pancreatitis -
Modified according to R Ammann, Schweiz Rundsch Med Prax. 1970; 59: 792-5.
Pain
Serum Enzyme Elevation
Exocrine Pancreatic Function
Stage 1 (early) Stage 2 Stage 3
5 10 15 years
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