The Current Treatment of Rare Disease, Lysosomal Acid Lipase Deficiency (LAL-D) and Paroxysmal Nocturnal Haemoglobinuria (PNH)

Review Article

Austin J Clin Immunol. 2023; 9(2): 1059.

The Current Treatment of Rare Disease, Lysosomal Acid Lipase Deficiency (LAL-D) and Paroxysmal Nocturnal Haemoglobinuria (PNH)

O’Malley S*; Tian F

School of Food Science and Environmental Health, Technological University Dublin (TUD), Ireland

*Corresponding author: O’Malley S School of Food Science and Environmental Health, Technological University Dublin (TUD), Ireland. Tel: 0035312205673 Email: furong.tian@tudublin.ie

Received: June 27, 2023 Accepted: August 01, 2023 Published: August 08, 2023

Abstract

The Paroxysmal Nocturnal Hemoglobinuria (PNH) and Lysosomal acid Lipase Deficiency (LAL-D) are rare disorder disease. Ultomiris and Soliris for PNH and Kanuma for LAL-D are innovative treatments for PNH and LAL-D, respectively. These therapies can treat each ultra-rare condition by alleviating symptoms and lowering mortality rates for both diseases. The aim of this research is to investigate the rare diseases PNH and LAL-D, as well as the existing treatments for both. Each medicine should be safe and have a good therapeutic effect, with a wide range of benefits and few adverse effects. PRISMA (Preferred Reporting Items for Systematic Reviews) was used to evaluate three treatments: Ultomiris and Soliris for PNH and Kanuma for LAL-D. The search was limited to scientific research articles and clinical trials (Publication years between 2007 and 2022). In the analysis, 20 studies were chosen based on their treatment, concentration, population, year of publication, outcomes, and references. Extensive study on the present treatment of PNH and LAL-D was used to draw conclusions on the overall benefits, distribution, efficacy, and safety of the medicines. This study was also utilised to validate the overall improvement in the lives of people with PNH and LAL-D. Ultomiris has an average effect of 96.5% on PNH symptoms, including hemolysis events. Kanuma has a 90% typical impact against LAL-D by reducing symptoms such as LDL-C and normalising Aspartate Aminotransferase (AST) levels (LAL-D symptoms), whilst Soliris has an average 97% effect against PNH, by reducing the presence of lactate dehydrogenase, for example.

Keywords: Rare disease; Lysosomal acid lipase; Deficiency; Paroxysmal; Haemoglobinuria

Introduction

Paroxysmal Nocturnal Hemoglobinuria (PNH) and Lysosomal Acid Lipase Deficiency (LAL-D)

PNH (paroxysmal nocturnal hemoglobinuria) is a rare condition that causes a variety of vague symptoms. It mostly causes problems such as intravascular hemolysis, thrombosis, and bone marrow failure [1]. PNH is a rare blood illness in which blood cells are targeted by a component of the body's immune system. The process of destroying red blood cells is known as "haemolysis," and it is responsible for many of the disease's symptoms.

"Haemolytic PNH" affects approximately 5 persons out of every million in the general population, making it an ultra-rare disease [2]. PNH indications include red/brown/dark urine observed during late-night or early-morning bathroom visits. "Paroxysmal" means "sudden," and "nocturnal" means "at night,". Haemoglobinuria refers to the red blood cells breaking down in blood vessels which eventually appear in the urine [3].

Lysosomal Acid Lipase Deficiency (LAL-D) is an uncommon, chronic, and developing hereditary disease. It inhibits the body's ability to produce the Lysosomal Acid Lipase enzyme (LAL). LAL-D is an extremely rare genetic metabolic condition that causes multiorgan failure and premature infant death in newborns, children, and adults [4]. LAL-D is characterised by cholesteryl esters and triglyceride buildup, primarily in the liver and spleen, although it may occur in other organs [5].

A liver transplant or fibrosis, or both, arise in about 50% of adolescents and adults with LAL-D within three years after the onset of clinical symptoms. The median age of onset for both children and adults with LAL-D is 5.8 years. The LAL-D condition can be identified with a quick blood test [4].

Kanuma (Sebelipase alfa) is an ERT (enzyme replacement therapy). Kanuma's major ingredient, sebelipase alfa, is a synthetic version of the enzyme LAL. Sebelipase alfa substitutes LAL by helping in fat breakdown and avoiding fat accumulation in the body's cells, hence preventing LAL-D symptoms such as liver damage and mortality [6].

Registry and Diagnosis

PNH can be challenging to identify and make a diagnosis because it is an extremely rare condition. Less than 40% of PNH patients have a diagnosis within a year of their first symptoms, and 24% of PNH diagnoses can take five years or more [7].

PNH should be suspected in those who have symptoms of intravascular hemolysis, such as hemoglobinuria or an extremely high serum LDH concentration. A diagnosis may be made using a comprehensive clinical assessment, a complete patient history, and a range of specialty testing [8].

Previously, PNH was diagnosed using tests that sensitised the complement lysis activity on RBCs. In most countries, a Flow Cytometric (FCM) assessment of glycosyl phosphatidylinositol-anchored proteins has essentially replaced the once-common acidified serum lysis test (Ham test). (GPI-AP) [9].

To fully characterise PNH, both bone marrow analysis and flow cytometric detection of GPI expression on peripheral blood cells are required [8].

The Global PNH Patient Registry is a flexible online platform for safely gathering and storing data for medical research. Users of the database can fill out surveys about their own experiences with disease and additionally gain insight about other patients' experiences by viewing compiled survey data [10].

The differential diagnosis of metabolic liver disorders, for instance Lysosomal Acid Lipase Deficiency (LAL-D), can be problematic in clinical settings [11]. Given the disease's unpredictable development and the possibility of liver failure and/or accelerated atherosclerosis being factors in early mortality, there is evidence that LAL-D may be severely underdiagnosed or misdiagnosed [12].

Fortunately, given the availability of a simple diagnostic test and recently approved treatment, LAL-D should be considered in the differential diagnosis in relevant clinical circumstances. An LAL enzyme-based biochemical test can detect LAL-D, allowing for active patient monitoring to identify potential illness outcomes [11].

LAL-D is diagnosed by measurements of activity in the blood or other tissues, as well as assessments of lipid buildup on various organs using radiological techniques such as MRI [13]. The LIPA gene's mutations can also be found using genetic testing. Due to the low level of suspicion for the diagnosis and the commonality of the major clinical and biochemical abnormalities, biopsy findings and radiographic findings are not considered diagnostic, although they do aid increase the suspicion of LAL-D [12].

There are a number of registries for people with LAL-D that gather information, analyse it, and raise awareness of the condition. These registries serve as a catalyst for research that aims to better the lives of PNH patients. These include the Global LAL-D Registry, the LAL-D Alliance Patient Registry, and the LAL-D Registry [14].

Symptoms of PNH and LAL-D

When the immune system targets red blood cells and platelets, PNH occurs. If neglected, PNH can lead to thrombosis, chronic renal failure, or hemolytic anaemia [3]. Hemolysis causes PNH signs and symptoms such as fatigue, dysphagia, dyspnea, stomach pain, erectile dysfunction, haemoglobinuria, and anaemia [15].

Two antibodies, Ultomiris and Soliris, bind to and inactivate the complement protein C5 to prevent blood clotting. Both Soliris and Ultomiris improve PNH patients' quality of life while lowering hemolysis to terminate the symptoms and signs of PNH [16].

Lysosomal Acid Lipase Deficiency (LAL-D) is an uncommon, chronic, and progressive hereditary disease. It inhibits the body's ability to produce the Lysosomal Acid Lipase enzyme (LAL). LAL-D is an extremely rare genetic metabolic condition that causes multiorgan failure and premature infant death in newborns, children, and adults [4]. Sebelipase alfa acts as an LAL substitute by assisting in fat breakdown and limiting fat accumulation in the body's cells, hence preventing LAL-D symptoms such as liver damage and death [6].

Current Treatment

Ultomiris and Soliris as the current treatment for PNH: Eculizumab has been found to improve survival in people with paroxysmal nocturnal hemoglobinuria by decreasing intravascular hemolysis and thrombosis. The goal of raulizumab, a long-acting, second-generation complement component 5 (C5) inhibitor, is to reduce the burden of the eculizumab treatment regimen and the likelihood of breakthrough hemolysis [17]. Ravulizumab binds aggressively and preferentially to the complement protein C5, similarly to the first-generation C5 inhibitor eculizumab, preventing the formation of the terminal complement complex C5b-9, which causes cell lysis [18].

In PNH patients who had previously had eculizumab therapy and were clinically stable, investigations have shown that ravulizumab is noninferior to eculizumab. Nevertheless, Ultomiris may be preferred by patients since it only requires intravenous injections every 8 weeks as opposed to every 2 weeks with Soliris IV injections [19].

The function of ravulizumab and eculizumab in the modulation of complement. The C3 activation stage is the culmination of the complement alternative, lectin, and classical pathways. At this stage, CD55 often suppresses the production of the C3 convertase, preventing the formation of C3b [20]. The membrane assault complex is produced when C5b combines with C3b and other complement proteins after being split into C5a and C5b by the C5 convertase (MAC) [21].

Eculizumab and Ravulizumab both suppress the complement C5 activation [21]. The body's own red blood cells are typically not attacked by the Membrane Attack Complex (MAC), the terminal complement system's by-product, because CD59 inhibits this. Patients suffering PNH however, lack the CD59, allowing MAC to target red blood cells. [22].

The terminal complement system, which includes the synthesis of the MAC, is effectively shut down by both C5 inhibitors' interactions with complement C5 [22]. As a result, PNH patients experience much less hemolysis and a decrease in Neisseria clearance [23].

Kanuma as the Current Treatment for LAL-D

Alexion Pharmaceuticals, Inc developed Sebelipase alfa (Kanuma), a recombinant human Lysosomal Acid Lipase (LAL) for long-term enzyme replacement therapy in patients with LAL deficiency [24]. Kanuma was authorised as an ERT for LAL insufficiency in the European Union and the United States in 2015, respectively [25].

Preclinical research has demonstrated how the creation of an LAL Enzyme Replacement Treatment (ERT) permits the rectification of metabolic flaws cause by LAL-D [26]. In vivo studies in a mouse model, demonstrated how LAL replacement directs the enzyme to the intended compartment by LAL replacement, which decreases the damaging effects of LAL-D. The LAL-deficient invivo model revealed that treated mice outlived untreated animals and that hepatic lipid storage was dramatically enhanced [27].

Ultomiris and Soliris for PNH and Kanuma for LAL-D are innovative treatments for PNH and LAL-D, respectively. These therapies can treat each ultra-rare condition by alleviating symptoms and lowering mortality rates for both diseases. Each medicine should be safe and have a good therapeutic effect, with a wide range of benefits and few adverse effects.

This review is to demonstrate the effects of current PNH and LAL-D treatment by presenting correct data from scientific articles, studies, and clinical trials.

The object will be focus on PNH and LAL-D impact the patient, the efficacy and safety of the current therapeutics for PNH and LAL-D. The global approval of the treatments, and the benefits and drawbacks of the novel medicine will be discussed.

Method

Systematic Reviews and Meta-Analyses

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist was completed, and a flowchart was created in accordance with the PRISMA rules and registration information. The screening process was used to determine articles for inclusion and exclusion. Reasons for articles being excluded varied from; Studies that are not a Randomize Clinical Trial (RCT), Not relevant to the current treatment of PNH and LAL-D, and Language limitation. During the screening process, the eliminated articles, were recorded using the principles outlined in the PRISMA statement 2020 (Figure 2).