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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fabry disease &#40;FD&#41; is an X-linked multisystem lysosomal storage disorder caused by mutations in the GLA gene&#46; These mutations result in a deficient or absent activity of the lysosomal enzyme alpha-galactosidase A &#40;&#945;Gal-A&#41;&#46; This leads to a systemic accumulation of globotriaosylceramide &#40;Gb3&#41; and related glycosphingolipids in the plasma and cellular lysosomes of a wide range of organs and tissues&#44; as podocytes and other cells in the kidneys&#44; cardiomyocytes&#44; vascular endothelial cells&#44; cells of the nervous system and others&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Gb3 deposition&#44; however&#44; may not be the only responsible for the organ manifestations&#44; since it might exist other unexplained factors that could cause some features of FD&#44; considering that disease manifestations may be present in the absence of severe deposits&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The FD diagnosis is usually difficult since there are numerous possible manifestations and several different pathogenic variants with variable organ involvement&#46; The mean delay to accurate diagnosis was estimated to be 13&#46;7 years for males and 16&#46;3 for females on the Fabry Outcome Survey&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the classic phenotype the first symptoms initiate during childhood such as neuropathic pain&#44; renal manifestations &#40;kidney injury and proteinuria&#41;&#44; cutaneous lesions &#40;angiokeratomas and telangiectasias&#41;&#44; cornea verticillata and other unspecific symptoms &#40;gastrointestinal disturbances&#44; hypohidrosis&#44; exercise intolerance&#41;&#46; These symptoms are followed by transient ischaemic attacks and strokes&#44; progressive renal insufficiency&#44; concentric left ventricular hypertrophy&#44; heart failure and typically premature death in the fourth or fifth decade of life&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Heterozygous female patients have a vast range of possible manifestations and severity which are dependent on the X chromosome inactivation and the type of variant&#46; Nevertheless&#44; a large proportion of patients present with later-onset phenotypes with a great variety of age of onset&#44; organ involvement and &#945;Gal-A levels&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">More than 900 variants in the GLA gene have been identified in the <span class="elsevierStyleItalic">Human Gene Mutation Database</span>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">There is still much debate about the pathogenicity of the D313Y variant&#44; although in recent years it has been considered to be a benign variant or a variant of unknown significance &#40;VUS&#41;&#44; especially after the concept of LysoGb3 levels as the biomarker of FD&#46; They are normally not increased in patients with D313Y variant&#46; Nonetheless&#44; there are several reports of patients with this variant that have important manifestations of FD with no other clinical or laboratory explanation&#46; This will be covered in more detail in the discussion&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In this article we present 2 cases within the same family &#40;mother and son&#41; that carry the D313Y variant&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Patient 1</span><p id="par0045" class="elsevierStylePara elsevierViewall">An 18-year-old male presented to the emergency department with fatigue&#44; hypertension&#44; anorexia and weight loss&#46; Laboratorial evaluation revealed severe anaemia &#40;haemoglobin&#58; 4&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41; and kidney injury &#40;creatinine&#58; 18&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; urea&#58; 373<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#46; Urinalysis was only positive for mild proteinuria &#40;365<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; Renal ultrasound showed small-sized kidneys with undifferentiated renal parenchyma&#46; On the extensive laboratory analysis only C3 was mildly reduced &#40;77<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#46; Protein electrophoresis&#44; immunoglobulins&#44; free light chains&#44; C4&#44; antinuclear antibodies&#44; ANCA&#44; anti-GBM were within the normal reference ranges or were negative&#46; Serologic profile of human immunodeficiency virus&#44; hepatitis B and C were innocent&#46; Echocardiogram displayed left ventricular hypertrophy &#40;LVH&#41;&#46; The cause of the kidney injury was not evident at the time of the clinical presentation&#46; Kidney biopsy was not performed because of advanced kidney disease and kidney size&#46; The patient was transplanted after six years on dialysis&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Patient 2</span><p id="par0050" class="elsevierStylePara elsevierViewall">A 43-year-old female was incidentally diagnosed with chronic kidney disease &#40;CKD&#41; on routine blood tests &#40;creatinine&#58; 2&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; urea&#58; 166<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#46; By that time&#44; the kidneys were small-sized and with undifferentiated renal parenchyma&#46; Urinalysis did not show proteinuria or haematuria&#46; The extensive laboratory analysis was inconclusive&#46; Kidney biopsy was not performed for the same reason of the previous case&#46; She started renal replacement therapy &#40;RRT&#41; after six years on follow-up&#46; The patient presented with neurologic symptoms &#40;neuropathic pain and decreased strength in the lower limbs&#44; with a predominance of paresis in the right lower limb&#41; one year before the CKD diagnosis&#46; An MRI of the brain was preformed and revealed multiple&#44; disseminated&#44; hyperintense white matter lesions &#40;WML&#41; on the periventricular and subcortical areas &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The patient 1&#44; as mentioned in the introduction&#44; is the son of the patient 2&#46; The worsening of the neurologic symptoms of the patient 2 along with the kidney failure history of both patients raised the hypothesis of FD&#46; Accordingly&#44; the patient 1 was firstly tested and the &#945;Gal-A activity in dried blood spot &#40;DBS&#41; assay was partially decreased &#40;2&#46;84<span class="elsevierStyleHsp" style=""></span>pmol per punch per h<span class="elsevierStyleSup">&#8722;1</span>&#41;&#46; Genetic testing revealed only the GLA variant D313Y &#40;Exon 6&#44; c&#46;937G&#62;T&#41;&#46; Afterwards the patient 2 was tested and revealed the same variant&#44; although with normal values of &#945;Gal-A activity&#46; Lyso-Gb3 plasma levels were within the normal range in both patients&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Both patients were evaluated for other symptoms of FD&#46; Cornea verticillata&#44; angiokeratomas&#44; gastrointestinal symptoms &#40;abdominal pain&#44; vomiting&#44; diarrhoea or constipation&#41;&#44; hypohidrosis&#47;hyperhidrosis were not detected&#46; The renal&#44; cardiac and neurological manifestations are represented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">There are contradicting findings about the clinical importance of the D313Y variant in the literature&#46; Yasuda et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> reported that in patients with this variant the expressed &#945;-Gal A transported to the lysosomes had about 60&#37; of the wild-type activity but resulted in a pseudodeficiency in plasma&#44; due to its instability at neutral pH&#46; This implies a lower D313Y mutant enzyme&#39;s activity in plasma than in leukocytes&#46; They also suggest that the presence of the D313Y variant should prompt further investigation to detect a second causative mutation&#44; since this can further impair the &#945;-Gal A activity and&#47;or stability and explain the disease manifestation in those patients&#46; Oder et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> also corroborate that D313Y variant by itself does not lead to severe organ manifestations&#46; They assessed 6 patients with that variant at baseline and during a 4-year follow-up&#46; No significant manifestations were identified&#46; Only one patient showed white matter lesions in the MRI but without neurological manifestations&#46; Niemann et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> present 2 patients of the same family &#40;father and daughter&#41; with D313Y variant with reduced levels of &#945;-Gal A activity&#44; without relevant clinical manifestations of FD &#40;the daughter had only unspecific pain in her arms&#41; and LysoGb3 was found below the average in the daughter and undetectable in the father&#46; This strengthens their assumption that this variant is not associated with FD with the current concept of lyso-Gb3 accumulation as a hallmark of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> Since there is significant activity of &#945;-Gal A with the D313Y variant it only leads to a small amount of lyso-Gb3&#46; Nevertheless&#44; the pathogenic role of lyso-Gb3 is not well established since the mechanisms apart from lyso-Gb3 accumulation&#44; that lead to organ manifestations&#44; are still unknown&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">On the other hand&#44; there is some clinical evidence in the literature that this variant may present with clinical features of FD&#46; In some studies&#44; it was identified a leading feature&#44; more frequently cerebrovascular involvement followed by renal manifestations&#46; Some cases presented with a later-onset phenotype&#46; Yenicerioglu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> tried to estimate the prevalence of FD in CKD patients not on dialysis and without a known cause &#40;1453 CKD patients&#44; with disclosure of 3 variants in mutation analysis&#41; and found 2 D313Y carriers with moderate renal insufficiency &#40;CKD stage G3b&#41; and mild proteinuria&#46; Data from another study<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> that included 14 patients carrying the D313Y variant provided more evidence that this mutation might lead to organ manifestations compatible with FD&#58; 4 patients had cerebrovascular involvement &#40;stroke at a young age&#41;&#59; 7 with acroparaesthesias&#47;polyneuropathy&#59; 2 presented cardiac hypertrophy but suffered from arterial hypertension&#59; 1 had impaired renal function of unknown aetiology but without proteinuria&#59; 1 with cornea verticillata&#46; Another example of central nervous system involvement is in Lenders et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> also reported neurological involvement&#46; They presented a family of 8 carriers of GLA D313Y and demonstrated the existence of multifocal WML in 7 carriers&#44; without any other possible cause in the extensive investigation&#46; None of those patients had other symptoms of FD&#46; In another study&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> where they include 62 subjects demonstrating phenotypic traits suggestive of FD or belonging to families with a FD diagnosis&#44; the authors identified 17 individuals with the D313Y variant&#46; LysoGb3 was found normal in all patients&#46; In the male subjects&#44; except for one&#44; had &#945;-galA activity decreased in a range 56&#46;2&#8211;87&#46;5&#37; compared to normal&#46; In the group of D313Y variant&#44; 4 were healthy but the rest presented characteristic manifestations of FD&#46; Notably&#44; 4 had end-stage renal disease &#40;ESRD&#41; on dialysis&#44; 6 had WML&#44; and also with other typical traits &#40;acroparesthesias &#8211; 5&#44; CKD not on dialysis &#8211; 2&#44; LVH &#8211; 1&#44; strokes of unknow origin &#8211; 1&#44; cornea venticillata &#8211; 1&#44; hearing loss &#8211; 1&#44; GI symptoms &#8211; 1&#41;&#46; Like in our case&#44; one patient reported&#44; in this article&#44; initiated dialysis at a young age &#40;25&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The manifestations of FD are nonspecific&#46; Both our patients had unexplained renal insufficiency with mild or absent proteinuria&#44; which is very atypical for the usual progression of the renal manifestations of FD&#46; Normally&#44; proteinuria is one of the initial kidney manifestations and it may initiate in the early teen years and more frequently during early adulthood&#46; CKD progressively develops over time&#46; The time of the presentation of end-stage renal failure in patient 1 is also highly unusual&#46; Although&#44; in an English cohort study of 98 hemizygous males&#44; the mean age of ESRF was 37 years&#44; the youngest ESFR patient presented at 18 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> One important limitation in our article was the unavailability of kidney biopsy&#44; which we abdicated due to unacceptable risks without significant benefit&#46; Patient 1 had only another trait of FD&#44; LVH&#44; but it may have other explanations like hypertension&#46; As for patient 2&#44; she has cerebral involvement with WML patent in the MRI and neurologic symptoms &#40;paresis in the right lower limb and neuropathic pain in both lower limbs&#41;&#46; Although these manifestations have some factors that do not fully fit in FD&#44; no other explanation for them was identified despite thorough investigation&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Even if D313Y variant is currently not considered to be pathogenic for presenting normal lyso-Gb3 values and for the majority of cases having a benign course&#44; there is a considerable number of patients that presented with signs&#47;symptoms consistent with FD without any other explanation&#46; Although&#44; at the same time&#44; it is difficult to attribute them to FD as it has a great range of different presentations and there are important FD traits missing&#46; Based in our findings in these particular patients&#44; we cannot claim that their definite diagnosis is FD but this VUS should not be undervalued&#44; and identified D313Y carriers may benefit of a consistent follow-up&#47;assessment&#44; expecting and monitoring possible manifestations of FD&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Funding</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors received no financial support for the research&#44; authorship&#44; and&#47;or publication of this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflict of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">All the authors declared no competing interests&#46;</p></span></span>"
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    "fechaRecibido" => "2021-06-11"
    "fechaAceptado" => "2022-01-02"
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            2 => "Renal insufficiency"
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          "clase" => "keyword"
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            0 => "Enfermedad de Fabry"
            1 => "Variante D313Y"
            2 => "Enfermedad renal"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Fabry disease is a multisystem lysosomal storage disorder caused by mutations in the GLA gene that result in a deficient or absent activity of alpha-galactosidase A&#46; There is a wide spectrum of GLA gene variants&#44; some of which are described as non-pathogenic&#46; The clinical importance of the D313Y variant is still under debate&#44; although in recent years it has been considered as a variant of unknown significance or a benign variant&#46; Despite this prevailing notion&#44; there are multiple case reports of patients with D313Y variant that presented signs and symptoms consistent with FD without any other etiological explanation&#46; In this article&#44; we present two family members with an important renal phenotype and other typical manifestations of FD &#40;white matter lesions and left ventricular hypertrophy&#41; that only had the D313Y variant&#46; These cases suggest that this variant of unknown significance may contribute to the development of common features of FD and should not be undervalued&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La enfermedad de Fabry &#40;EF&#41; es un trastorno de almacenamiento lisos&#243;mico multisist&#233;mico causado por mutaciones en el gen GLA que tienen como resultado una actividad deficiente o ausente de alfa-galactosidasa A&#46; Existe un amplio espectro de variantes del gen GLA&#44; algunas de las cuales se describen como no pat&#243;genas&#46; La importancia cl&#237;nica de la variante D313Y a&#250;n est&#225; en debate&#44; aunque en los &#250;ltimos a&#241;os se ha considerado una variante de significado incierto o una variante benigna&#46; A pesar de esta noci&#243;n predominante&#44; existen m&#250;ltiples reportes de casos de pacientes con variante D313Y que presentaron signos y s&#237;ntomas consistentes con EF sin ninguna otra explicaci&#243;n etiol&#243;gica&#46; En este art&#237;culo presentamos 2 familiares con un importante fenotipo renal y otras manifestaciones t&#237;picas de la EF &#40;lesiones de la sustancia blanca e hipertrofia ventricular izquierda&#41; que solo presentaban la variante D313Y&#46; Estos casos indican que esta variante de significado incierto puede contribuir al desarrollo de caracter&#237;sticas comunes de la EF y no debe subestimarse&#46;</p></span>"
      ]
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Axial T2 &#40;A&#41;&#44; Axial T2 FLAIR &#40;B&#41;&#44; Coronal T2 &#40;C&#41; &#8211; demonstrating disseminated punctuated and confluent WML on the periventricular and subcortical areas &#40;patient 2&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col">Sex&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col">Age<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Laboratory findings</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Manifestations</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mutation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Enzyme activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Lyso-Gb3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Renal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cardiac&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Neurologic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">D313Y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Partially decreased&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">CKD-RRT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">LVH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">D313Y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CKD-RRT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">WML&nbsp;\t\t\t\t\t\t\n
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                  "referenciaCompleta" => "Disease TOMaMBoI&#46; 150&#58; &#945;-galactosidase a deficiency&#58; fabry disease&#46; <a target="_blank" href="https://ommbid.mhmedical.com/content.aspx?bookid=971%26sectionid=62644837%26jumpsectionID=62644922">https&#58;&#47;&#47;ommbid&#46;mhmedical&#46;com&#47;content&#46;aspx&#63;bookid&#61;971&#167;ionid&#61;62644837&#38;jumpsectionID&#61;62644922&#35;1102896682</a>&#46;"
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                    0 => array:2 [
                      "titulo" => "The relationship of vascular glycolipid storage to clinical manifestations of Fabry disease&#58; a cross-sectional study of a large cohort of clinically affected heterozygous women"
                      "autores" => array:1 [
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                          "etal" => false
                          "autores" => array:4 [
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Case report
D313Y variant in two related end-stage renal disease patients – Pathogenic or not yet?
Dos pacientes con enfermedad renal terminal con la variante de significado incierto D313Y: ¿patógena o aún no?
Rita Vicente
Corresponding author
rita.r.vicente@hotmail.com

Corresponding author.
, Iolanda Santos, Miguel Coimbra, Joana Santos, Ricardo Santos, Manuel Amoedo, Carlos Pires
Nephrology Department, Hospital Espírito Santo de Évora, E.P.E., Évora, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fabry disease &#40;FD&#41; is an X-linked multisystem lysosomal storage disorder caused by mutations in the GLA gene&#46; These mutations result in a deficient or absent activity of the lysosomal enzyme alpha-galactosidase A &#40;&#945;Gal-A&#41;&#46; This leads to a systemic accumulation of globotriaosylceramide &#40;Gb3&#41; and related glycosphingolipids in the plasma and cellular lysosomes of a wide range of organs and tissues&#44; as podocytes and other cells in the kidneys&#44; cardiomyocytes&#44; vascular endothelial cells&#44; cells of the nervous system and others&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Gb3 deposition&#44; however&#44; may not be the only responsible for the organ manifestations&#44; since it might exist other unexplained factors that could cause some features of FD&#44; considering that disease manifestations may be present in the absence of severe deposits&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The FD diagnosis is usually difficult since there are numerous possible manifestations and several different pathogenic variants with variable organ involvement&#46; The mean delay to accurate diagnosis was estimated to be 13&#46;7 years for males and 16&#46;3 for females on the Fabry Outcome Survey&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the classic phenotype the first symptoms initiate during childhood such as neuropathic pain&#44; renal manifestations &#40;kidney injury and proteinuria&#41;&#44; cutaneous lesions &#40;angiokeratomas and telangiectasias&#41;&#44; cornea verticillata and other unspecific symptoms &#40;gastrointestinal disturbances&#44; hypohidrosis&#44; exercise intolerance&#41;&#46; These symptoms are followed by transient ischaemic attacks and strokes&#44; progressive renal insufficiency&#44; concentric left ventricular hypertrophy&#44; heart failure and typically premature death in the fourth or fifth decade of life&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Heterozygous female patients have a vast range of possible manifestations and severity which are dependent on the X chromosome inactivation and the type of variant&#46; Nevertheless&#44; a large proportion of patients present with later-onset phenotypes with a great variety of age of onset&#44; organ involvement and &#945;Gal-A levels&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">More than 900 variants in the GLA gene have been identified in the <span class="elsevierStyleItalic">Human Gene Mutation Database</span>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">There is still much debate about the pathogenicity of the D313Y variant&#44; although in recent years it has been considered to be a benign variant or a variant of unknown significance &#40;VUS&#41;&#44; especially after the concept of LysoGb3 levels as the biomarker of FD&#46; They are normally not increased in patients with D313Y variant&#46; Nonetheless&#44; there are several reports of patients with this variant that have important manifestations of FD with no other clinical or laboratory explanation&#46; This will be covered in more detail in the discussion&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In this article we present 2 cases within the same family &#40;mother and son&#41; that carry the D313Y variant&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Patient 1</span><p id="par0045" class="elsevierStylePara elsevierViewall">An 18-year-old male presented to the emergency department with fatigue&#44; hypertension&#44; anorexia and weight loss&#46; Laboratorial evaluation revealed severe anaemia &#40;haemoglobin&#58; 4&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41; and kidney injury &#40;creatinine&#58; 18&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; urea&#58; 373<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#46; Urinalysis was only positive for mild proteinuria &#40;365<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; Renal ultrasound showed small-sized kidneys with undifferentiated renal parenchyma&#46; On the extensive laboratory analysis only C3 was mildly reduced &#40;77<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#46; Protein electrophoresis&#44; immunoglobulins&#44; free light chains&#44; C4&#44; antinuclear antibodies&#44; ANCA&#44; anti-GBM were within the normal reference ranges or were negative&#46; Serologic profile of human immunodeficiency virus&#44; hepatitis B and C were innocent&#46; Echocardiogram displayed left ventricular hypertrophy &#40;LVH&#41;&#46; The cause of the kidney injury was not evident at the time of the clinical presentation&#46; Kidney biopsy was not performed because of advanced kidney disease and kidney size&#46; The patient was transplanted after six years on dialysis&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Patient 2</span><p id="par0050" class="elsevierStylePara elsevierViewall">A 43-year-old female was incidentally diagnosed with chronic kidney disease &#40;CKD&#41; on routine blood tests &#40;creatinine&#58; 2&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; urea&#58; 166<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#46; By that time&#44; the kidneys were small-sized and with undifferentiated renal parenchyma&#46; Urinalysis did not show proteinuria or haematuria&#46; The extensive laboratory analysis was inconclusive&#46; Kidney biopsy was not performed for the same reason of the previous case&#46; She started renal replacement therapy &#40;RRT&#41; after six years on follow-up&#46; The patient presented with neurologic symptoms &#40;neuropathic pain and decreased strength in the lower limbs&#44; with a predominance of paresis in the right lower limb&#41; one year before the CKD diagnosis&#46; An MRI of the brain was preformed and revealed multiple&#44; disseminated&#44; hyperintense white matter lesions &#40;WML&#41; on the periventricular and subcortical areas &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The patient 1&#44; as mentioned in the introduction&#44; is the son of the patient 2&#46; The worsening of the neurologic symptoms of the patient 2 along with the kidney failure history of both patients raised the hypothesis of FD&#46; Accordingly&#44; the patient 1 was firstly tested and the &#945;Gal-A activity in dried blood spot &#40;DBS&#41; assay was partially decreased &#40;2&#46;84<span class="elsevierStyleHsp" style=""></span>pmol per punch per h<span class="elsevierStyleSup">&#8722;1</span>&#41;&#46; Genetic testing revealed only the GLA variant D313Y &#40;Exon 6&#44; c&#46;937G&#62;T&#41;&#46; Afterwards the patient 2 was tested and revealed the same variant&#44; although with normal values of &#945;Gal-A activity&#46; Lyso-Gb3 plasma levels were within the normal range in both patients&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Both patients were evaluated for other symptoms of FD&#46; Cornea verticillata&#44; angiokeratomas&#44; gastrointestinal symptoms &#40;abdominal pain&#44; vomiting&#44; diarrhoea or constipation&#41;&#44; hypohidrosis&#47;hyperhidrosis were not detected&#46; The renal&#44; cardiac and neurological manifestations are represented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">There are contradicting findings about the clinical importance of the D313Y variant in the literature&#46; Yasuda et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> reported that in patients with this variant the expressed &#945;-Gal A transported to the lysosomes had about 60&#37; of the wild-type activity but resulted in a pseudodeficiency in plasma&#44; due to its instability at neutral pH&#46; This implies a lower D313Y mutant enzyme&#39;s activity in plasma than in leukocytes&#46; They also suggest that the presence of the D313Y variant should prompt further investigation to detect a second causative mutation&#44; since this can further impair the &#945;-Gal A activity and&#47;or stability and explain the disease manifestation in those patients&#46; Oder et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> also corroborate that D313Y variant by itself does not lead to severe organ manifestations&#46; They assessed 6 patients with that variant at baseline and during a 4-year follow-up&#46; No significant manifestations were identified&#46; Only one patient showed white matter lesions in the MRI but without neurological manifestations&#46; Niemann et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> present 2 patients of the same family &#40;father and daughter&#41; with D313Y variant with reduced levels of &#945;-Gal A activity&#44; without relevant clinical manifestations of FD &#40;the daughter had only unspecific pain in her arms&#41; and LysoGb3 was found below the average in the daughter and undetectable in the father&#46; This strengthens their assumption that this variant is not associated with FD with the current concept of lyso-Gb3 accumulation as a hallmark of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> Since there is significant activity of &#945;-Gal A with the D313Y variant it only leads to a small amount of lyso-Gb3&#46; Nevertheless&#44; the pathogenic role of lyso-Gb3 is not well established since the mechanisms apart from lyso-Gb3 accumulation&#44; that lead to organ manifestations&#44; are still unknown&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">On the other hand&#44; there is some clinical evidence in the literature that this variant may present with clinical features of FD&#46; In some studies&#44; it was identified a leading feature&#44; more frequently cerebrovascular involvement followed by renal manifestations&#46; Some cases presented with a later-onset phenotype&#46; Yenicerioglu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> tried to estimate the prevalence of FD in CKD patients not on dialysis and without a known cause &#40;1453 CKD patients&#44; with disclosure of 3 variants in mutation analysis&#41; and found 2 D313Y carriers with moderate renal insufficiency &#40;CKD stage G3b&#41; and mild proteinuria&#46; Data from another study<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> that included 14 patients carrying the D313Y variant provided more evidence that this mutation might lead to organ manifestations compatible with FD&#58; 4 patients had cerebrovascular involvement &#40;stroke at a young age&#41;&#59; 7 with acroparaesthesias&#47;polyneuropathy&#59; 2 presented cardiac hypertrophy but suffered from arterial hypertension&#59; 1 had impaired renal function of unknown aetiology but without proteinuria&#59; 1 with cornea verticillata&#46; Another example of central nervous system involvement is in Lenders et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> also reported neurological involvement&#46; They presented a family of 8 carriers of GLA D313Y and demonstrated the existence of multifocal WML in 7 carriers&#44; without any other possible cause in the extensive investigation&#46; None of those patients had other symptoms of FD&#46; In another study&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> where they include 62 subjects demonstrating phenotypic traits suggestive of FD or belonging to families with a FD diagnosis&#44; the authors identified 17 individuals with the D313Y variant&#46; LysoGb3 was found normal in all patients&#46; In the male subjects&#44; except for one&#44; had &#945;-galA activity decreased in a range 56&#46;2&#8211;87&#46;5&#37; compared to normal&#46; In the group of D313Y variant&#44; 4 were healthy but the rest presented characteristic manifestations of FD&#46; Notably&#44; 4 had end-stage renal disease &#40;ESRD&#41; on dialysis&#44; 6 had WML&#44; and also with other typical traits &#40;acroparesthesias &#8211; 5&#44; CKD not on dialysis &#8211; 2&#44; LVH &#8211; 1&#44; strokes of unknow origin &#8211; 1&#44; cornea venticillata &#8211; 1&#44; hearing loss &#8211; 1&#44; GI symptoms &#8211; 1&#41;&#46; Like in our case&#44; one patient reported&#44; in this article&#44; initiated dialysis at a young age &#40;25&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The manifestations of FD are nonspecific&#46; Both our patients had unexplained renal insufficiency with mild or absent proteinuria&#44; which is very atypical for the usual progression of the renal manifestations of FD&#46; Normally&#44; proteinuria is one of the initial kidney manifestations and it may initiate in the early teen years and more frequently during early adulthood&#46; CKD progressively develops over time&#46; The time of the presentation of end-stage renal failure in patient 1 is also highly unusual&#46; Although&#44; in an English cohort study of 98 hemizygous males&#44; the mean age of ESRF was 37 years&#44; the youngest ESFR patient presented at 18 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> One important limitation in our article was the unavailability of kidney biopsy&#44; which we abdicated due to unacceptable risks without significant benefit&#46; Patient 1 had only another trait of FD&#44; LVH&#44; but it may have other explanations like hypertension&#46; As for patient 2&#44; she has cerebral involvement with WML patent in the MRI and neurologic symptoms &#40;paresis in the right lower limb and neuropathic pain in both lower limbs&#41;&#46; Although these manifestations have some factors that do not fully fit in FD&#44; no other explanation for them was identified despite thorough investigation&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Even if D313Y variant is currently not considered to be pathogenic for presenting normal lyso-Gb3 values and for the majority of cases having a benign course&#44; there is a considerable number of patients that presented with signs&#47;symptoms consistent with FD without any other explanation&#46; Although&#44; at the same time&#44; it is difficult to attribute them to FD as it has a great range of different presentations and there are important FD traits missing&#46; Based in our findings in these particular patients&#44; we cannot claim that their definite diagnosis is FD but this VUS should not be undervalued&#44; and identified D313Y carriers may benefit of a consistent follow-up&#47;assessment&#44; expecting and monitoring possible manifestations of FD&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Funding</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors received no financial support for the research&#44; authorship&#44; and&#47;or publication of this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflict of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">All the authors declared no competing interests&#46;</p></span></span>"
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    "fechaRecibido" => "2021-06-11"
    "fechaAceptado" => "2022-01-02"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1744679"
          "palabras" => array:3 [
            0 => "Fabry disease"
            1 => "D313Y variant"
            2 => "Renal insufficiency"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1744680"
          "palabras" => array:3 [
            0 => "Enfermedad de Fabry"
            1 => "Variante D313Y"
            2 => "Enfermedad renal"
          ]
        ]
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Fabry disease is a multisystem lysosomal storage disorder caused by mutations in the GLA gene that result in a deficient or absent activity of alpha-galactosidase A&#46; There is a wide spectrum of GLA gene variants&#44; some of which are described as non-pathogenic&#46; The clinical importance of the D313Y variant is still under debate&#44; although in recent years it has been considered as a variant of unknown significance or a benign variant&#46; Despite this prevailing notion&#44; there are multiple case reports of patients with D313Y variant that presented signs and symptoms consistent with FD without any other etiological explanation&#46; In this article&#44; we present two family members with an important renal phenotype and other typical manifestations of FD &#40;white matter lesions and left ventricular hypertrophy&#41; that only had the D313Y variant&#46; These cases suggest that this variant of unknown significance may contribute to the development of common features of FD and should not be undervalued&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La enfermedad de Fabry &#40;EF&#41; es un trastorno de almacenamiento lisos&#243;mico multisist&#233;mico causado por mutaciones en el gen GLA que tienen como resultado una actividad deficiente o ausente de alfa-galactosidasa A&#46; Existe un amplio espectro de variantes del gen GLA&#44; algunas de las cuales se describen como no pat&#243;genas&#46; La importancia cl&#237;nica de la variante D313Y a&#250;n est&#225; en debate&#44; aunque en los &#250;ltimos a&#241;os se ha considerado una variante de significado incierto o una variante benigna&#46; A pesar de esta noci&#243;n predominante&#44; existen m&#250;ltiples reportes de casos de pacientes con variante D313Y que presentaron signos y s&#237;ntomas consistentes con EF sin ninguna otra explicaci&#243;n etiol&#243;gica&#46; En este art&#237;culo presentamos 2 familiares con un importante fenotipo renal y otras manifestaciones t&#237;picas de la EF &#40;lesiones de la sustancia blanca e hipertrofia ventricular izquierda&#41; que solo presentaban la variante D313Y&#46; Estos casos indican que esta variante de significado incierto puede contribuir al desarrollo de caracter&#237;sticas comunes de la EF y no debe subestimarse&#46;</p></span>"
      ]
    ]
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Patient&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mutation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Enzyme activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Lyso-Gb3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Renal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cardiac&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">D313Y&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Partially decreased&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">LVH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">D313Y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">CKD-RRT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">WML&nbsp;\t\t\t\t\t\t\n
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      "titulo" => "References"
      "seccion" => array:1 [
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          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:16 [
            0 => array:3 [
              "identificador" => "bib0085"
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                0 => array:1 [
                  "referenciaCompleta" => "Disease TOMaMBoI&#46; 150&#58; &#945;-galactosidase a deficiency&#58; fabry disease&#46; <a target="_blank" href="https://ommbid.mhmedical.com/content.aspx?bookid=971%26sectionid=62644837%26jumpsectionID=62644922">https&#58;&#47;&#47;ommbid&#46;mhmedical&#46;com&#47;content&#46;aspx&#63;bookid&#61;971&#167;ionid&#61;62644837&#38;jumpsectionID&#61;62644922&#35;1102896682</a>&#46;"
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            1 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The relationship of vascular glycolipid storage to clinical manifestations of Fabry disease&#58; a cross-sectional study of a large cohort of clinically affected heterozygous women"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "S&#46; Gupta"
                            1 => "M&#46; Ries"
                            2 => "S&#46; Kotsopoulos"
                            3 => "R&#46; Schiffmann"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.md.0000178976.62537.6b"
                      "Revista" => array:6 [
                        "tituloSerie" => "Medicine"
                        "fecha" => "2005"
                        "volumen" => "84"
                        "paginaInicial" => "261"
                        "paginaFinal" => "268"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16148726"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
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              "identificador" => "bib0095"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fabry disease defined&#58; baseline clinical manifestations of 366 patients in the Fabry Outcome Survey"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Mehta"
                            1 => "R&#46; Ricci"
                            2 => "U&#46; Widmer"
                            3 => "F&#46; Dehout"
                            4 => "A&#46; Garcia de Lorenzo"
                            5 => "C&#46; Kampmann"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2362.2004.01309.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Clin Invest"
                        "fecha" => "2004"
                        "volumen" => "34"
                        "paginaInicial" => "236"
                        "paginaFinal" => "242"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15025684"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The metabolic and molecular bases of inherited disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "C&#46; Scriver"
                          ]
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                    ]
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                    0 => array:1 [
                      "Libro" => array:4 [
                        "edicion" => "8th ed&#46;"
                        "fecha" => "2001"
                        "editorial" => "McGraw-Hill"
                        "editorialLocalizacion" => "New York"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fabry disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "D&#46;P&#46; Germain"
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1750-1172-5-30"
                      "Revista" => array:5 [
                        "tituloSerie" => "Orphanet J Rare Dis"
                        "fecha" => "2010"
                        "volumen" => "5"
                        "paginaInicial" => "30"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21092187"
                            "web" => "Medline"
                          ]
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            5 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "6"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fabry disease&#58; characterization of alpha-galactosidase A double mutations and the D313Y plasma enzyme pseudodeficiency allele"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46; Yasuda"
                            1 => "J&#46; Shabbeer"
                            2 => "S&#46;D&#46; Benson"
                            3 => "I&#46; Maire"
                            4 => "R&#46;M&#46; Burnett"
                            5 => "R&#46;J&#46; Desnick"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/humu.10275"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hum Mutat"
                        "fecha" => "2003"
                        "volumen" => "22"
                        "paginaInicial" => "486"
                        "paginaFinal" => "492"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14635108"
                            "web" => "Medline"
                          ]
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                      ]
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Article information
ISSN: 20132514
Original language: English
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