Biomarkers for diagnosis of Wilson's disease

Abstract

Background: Wilson's disease, first described by Samuel Wilson in 1912, is an autosomal recessive metabolic disorder resulting from mutations in the ATP7B gene. The disease develops as a consequence of copper accumulating in affected tissues. There is no gold standard for the diagnosis of Wilson's disease, which is often delayed due to the non-specific clinical features and the need for a combination of clinical and laboratory tests for diagnosis. This delay may in turn affect clinical outcome and has implications for other family members in terms of diagnosis. The Leipzig criteria were established to help standardise diagnosis and management. However, it should be emphasised that these criteria date from 2003, and many of these have not been formally evaluated; this review examines the evidence behind biochemical testing for Wilson's disease.

Objectives: To determine the diagnostic accuracy of three biochemical tests at specified cut-off levels for Wilson's disease. The index tests covered by this Cochrane Review are caeruloplasmin, 24-hour urinary copper and hepatic copper content. These tests were evaluated in those with suspected Wilson's disease and appropriate controls (either healthy or those with chronic liver disease other than Wilson's). In the absence of a gold standard for diagnosing Wilson's disease, we have used the Leipzig criteria as a clinical reference standard. To investigate whether index tests should be performed in all individuals who have been recommended for testing for Wilson's disease, or whether these tests should be limited to subgroups of individuals.

Search methods: We identified studies by extensive searching of, e.g. the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, the Web of Science and clinical trial registries (29 May 2019). Date of the most recent search of the Cochrane Cystic Fibrosis and Genetic Disorders Inborn Errors of Metabolism Register: 29 May 2019.

Selection criteria: We included prospective and retrospective cohort studies that assessed the diagnostic accuracy of an index test using the Leipzig criteria as a clinical reference standard for the diagnosis of Wilson's disease.

Data collection and analysis: Two review authors independently reviewed and extracted data and assessed the methodological quality of each included study using the QUADAS-2 tool. We had planned to undertake meta-analyses of the sensitivity, specificity at relevant cut-offs for each of the biochemical tests for Wilson's, however, due to differences in the methods used for each biochemical index test, it was not possible to combine the results in meta-analyses and hence these are described narratively.

Main results: Eight studies, involving 5699 participants (which included 1009 diagnosed with Wilson's disease) were eligible for inclusion in the review. Three studies involved children only, one adults only and the four remaining studies involved both children and adults. Two evaluated participants with hepatic signs and six with a combination of hepatic and neurological signs and symptoms of Wilson's disease, as well as pre-symptomatic individuals. The studies were of variable methodological quality; with high risk if bias for participant selection and the reference standard used being of greatest methodological concern. Key differences between studies include differences in assay methodology, different cut-off values for diagnostic thresholds, different age and ethnicity groups. Concerns around study design imply that diagnostic accuracy figures may not transfer to populations outside of the relevant study.

Index test: caeruloplasmin Five studies evaluated various thresholds of caeruloplasmin (4281 participants, of which 541 had WD). For caeruloplasmin a cut-off of 0.2 g/L as in the Leipzig criteria achieved a sensitivity of 77.1% to 99%, with variable specificity of 55.9% to 82.8%. Using the cut-off of 0.1 g/L of the Leipzig criteria seemed to lower the sensitivity overall, 65% to 78.9%, while increasing the specificity to 96.6% to 100%.

Index test: hepatic copper Four studies evaluated various thresholds of hepatic copper (1150 participants, of which 367 had WD). The hepatic copper cut-off of 4 μmol/g used in the Leipzig criteria achieved a sensitivity of 65.7% to 94.4%, with a variable specificity of 52.2% to 98.6%.

Index test: 24-hour urinary copper Three studies evaluated various thresholds of 24-hour urinary copper (268 participants, of which 101 had WD). For 24-hour urinary copper, a cut-off of 0.64 to 1.6 μmol/24 hours used in the Leipzig criteria achieved a variable sensitivity of 50.0% to 80.0%, with a specificity of 75.6% to 98.3%.

Authors' conclusions: The cut-offs used for caeruloplasmin, 24-hour urinary copper and hepatic copper for diagnosing Wilson's disease are method-dependent and require validation in the population in which such index tests are going to be used. Binary cut-offs and use of single-test strategies to rule Wilson's disease in or out is not supported by the evidence in this review. There is insufficient evidence to inform testing in specific subgroups, defined by age, ethnicity or clinical subgroups.

1

Study flow diagram.

2

Risk of bias and applicability concerns graph: review authors' judgements about each domain presented as percentages across included studies

3

Forest plot of tests: 1 Caeruloplasmin (Leipzig criteria threshold 0.1g/L), 2 Caeruloplasmin (Leipzig criteria threshold 0.2g/L), 3 Caeruloplasmin (other threshold 0.14g/L), 4 Caeruloplasmin (other threshold 0.15g/L), 5 Caeruloplasmin (other threshold 0.18g/L), 6 Caeruloplasmin (other threshold 0.19g/L).

4

Forest plot of tests: 7 Hepatic copper (Leipzig criteria threshold >4 μmol/g), 8 Hepatic copper (other threshold 1.2 μmol/g), 9 Hepatic copper (other threshold 1.5 μmol/g), 10 Hepatic copper (other threshold 3.3 μmol/g).

5

Forest plot of tests: 11 24‐hour urinary copper (Leipzig criteria threshold 0.64 μmol/24 hours), 12 24‐hour urinary copper (Leipzig criteria threshold 1.6 μmol/24 hours), 13 24‐hour urinary copper (threshold 0.8 μmol/24 hours), 14 24‐hour urinary copper (threshold 1.06 μmol/24 hours).

1. Test

Caeruloplasmin (Leipzig criteria threshold 0.1 g/L).

2. Test

Caeruloplasmin (Leipzig criteria threshold 0.2 g/L).

3. Test

Caeruloplasmin (other threshold 0.14 g/L).

4. Test

Caeruloplasmin (other threshold 0.15 g/L).

5. Test

Caeruloplasmin (other threshold 0.18 g/L).

6. Test

Caeruloplasmin (other threshold 0.19 g/L).

7. Test

Hepatic copper (Leipzig criteria threshold > 4 μmol/g).

8. Test

Hepatic copper (other threshold 1.2 μmol/g).

9. Test

Hepatic copper (other threshold 1.5 μmol/g).

10. Test

Hepatic copper (other threshold 3.3 μmol/g).

11. Test

24‐hour urinary copper (Leipzig criteria threshold 0.64 μmol/24 hours).

12. Test

24‐hour urinary copper (Leipzig criteria threshold 1.6 μmol/24 hours).

13. Test

24‐hour urinary copper (threshold 0.8 μmol/24 hours).

14. Test

24‐hour urinary copper (threshold 1.06 μmol/24 hours).