xml: <clinical_study>
    <!-- This xml conforms to an XML Schema at:
      https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
    <required_header>
      <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
      <link_text>Link to the current ClinicalTrials.gov record.</link_text>
      <url>https://clinicaltrials.gov/ct2/show/NCT06027385</url>
    </required_header>
    <id_info>
      <org_study_id>2017-GEN1</org_study_id>
      <nct_id>NCT06027385</nct_id>
    </id_info>
    <brief_title>Genetic Newborn Screening for Cystinosis and Spinal Muscular Atrophy</brief_title>
    <acronym>GENESIS1</acronym>
    <official_title>Scientific Basis for a Newborn Screening for Cystinosis and Spinal Muscular Atrophy</official_title>
    <sponsors>
      <lead_sponsor>
        <agency>Cystinose Stiftung</agency>
        <agency_class>Other</agency_class>
      </lead_sponsor>
      <collaborator>
        <agency>Labor Becker &amp; Kollegen, Munich, Germany</agency>
        <agency_class>Other</agency_class>
      </collaborator>
      <collaborator>
        <agency>Screening Labor Hannover</agency>
        <agency_class>Other</agency_class>
      </collaborator>
      <collaborator>
        <agency>Genetikum, Ulm, Germany</agency>
        <agency_class>Other</agency_class>
      </collaborator>
      <collaborator>
        <agency>Bavarian State Office of Health and Food Safety (LGL), Unterschleißheim, Germany</agency>
        <agency_class>Other</agency_class>
      </collaborator>
      <collaborator>
        <agency>Internal Medicine, Freiburg University Hospital, Freiburg, Germany</agency>
        <agency_class>Other</agency_class>
      </collaborator>
      <collaborator>
        <agency>Attorney DSZ Rechtsanwälte GmbH, Barkhovenallee 1, 45239 Essen</agency>
        <agency_class>Other</agency_class>
      </collaborator>
    </sponsors>
    <source>Cystinose Stiftung</source>
    <oversight_info>
      <has_dmc>No</has_dmc>
      <is_fda_regulated_drug>No</is_fda_regulated_drug>
      <is_fda_regulated_device>No</is_fda_regulated_device>
    </oversight_info>
    <brief_summary>
      <textblock>
        Newborn screening in Germany is a voluntary program. Cystinosis and spinal muscular atrophy&#xD;
        (SMA) are rare autosomal recessive diseases. They are inherited in an autosomal recessive&#xD;
        manner, i.e. both parents carry a defective gene. Neither disease can be detected early by&#xD;
        the methods established in routine newborn screening. However, common genetic mutations are&#xD;
        known for both diseases.&#xD;
  &#xD;
        The aim of the study presented here is to provide the scientific basis for molecular genetic&#xD;
        newborn screening for cystinosis and SMA. In particular, to investigate whether inclusion of&#xD;
        these diseases in general newborn screening should be recommended.&#xD;
  &#xD;
        The participating screening laboratories for this project are Labor Becker &amp; Kollegen,&#xD;
        Munich, Germany and Screening Laboratory Hannover, Germany. Hospitals that send their dry&#xD;
        blood spot cards for routine newborn screening to these laboratories will receive an offer to&#xD;
        participate in the pilot project. Participation is free of charge.&#xD;
  &#xD;
        Parents who wish to participate in this pilot project will receive an information sheet&#xD;
        explaining the screening process and objectives. A parent and the treating physician sign the&#xD;
        information sheet as documentation of informed consent. Their signature and informed consent&#xD;
        are required for the pilot.&#xD;
  &#xD;
        Routine NBS according to German pediatric guidelines involves the collection of dried blood&#xD;
        spot cards 36-72 hours after birth. Molecular genetic screening in the pilot project will be&#xD;
        performed with the same dried blood spot card used for routine newborn screening.&#xD;
  &#xD;
        In cystinosis, genetic testing for the 3 most common mutations in Germany will be performed.&#xD;
        In SMA, a homozygous deletion of exon 7 in the SMN gene is detected by a PCR test. The&#xD;
        molecular genetic test is performed on the same day as routine newborn screening.Normal&#xD;
        findings are not reported to parents. However, they can contact the laboratories to inquire&#xD;
        about them.&#xD;
  &#xD;
        Parents of newborns with two mutations in the cystinosis gene or with a homozygous deletion&#xD;
        of exon 7 in the SMN gene are immediately informed of the disease by a physician. Further&#xD;
        diagnostics to confirm the disease will be organized close to home.&#xD;
  &#xD;
        The study started on Jan. 15, 2018, and recruitment was completed on Sept. 30, 2022.&#xD;
      </textblock>
    </brief_summary>
    <detailed_description>
      <textblock>
        Population-based newborn screening (NBS) is an important public health program that has&#xD;
        vastly improved the course of several diseases through early detection. The selection of&#xD;
        screened disorders generally follows the 10 principles outlined by Wilson and Jungner. In&#xD;
        Germany, NBS has been a voluntary National Health Service program since 1969 which currently&#xD;
        covers 17 disorders. Current NBS methods, which employ tandem mass-spectrometric analysis of&#xD;
        newborn dried blood spots, cannot detect many potentially treatable genetic conditions. At&#xD;
        the same time, molecular-based NBS is increasingly feasible because DNA can be extracted from&#xD;
        a dried blood spot, next generation sequencing has become economical, and molecular&#xD;
        diagnostics have greater reliability and increased validity as genetic databases become more&#xD;
        refined and comprehensive. Nephropathic cystinosis and spinal muscular atrophy (SMA) are&#xD;
        eligible for molecular-based NBS because effective therapies are available.&#xD;
  &#xD;
        This study will provide a scientific basis for newborn screening for cystinosis and SMA and&#xD;
        investigate whether inclusion of these diseases in general newborn screening should be&#xD;
        recommended. By observing identified infants compared to symptomatically diagnosed patients&#xD;
        outside the pilot project, we will determine whether and to what extent early diagnosis and&#xD;
        initiation of therapy leads to a more favorable prognosis.&#xD;
  &#xD;
        Cystinosis: Cystinosis is a rare autosomal recessive systemic disease with high morbidity and&#xD;
        mortality caused by pathogenic variants in the CTNS gene that encodes the lysosomal cystine&#xD;
        transporter cystinosin, leading to accumulation of cystine within the lysosome. Life-long&#xD;
        cystine-depleting therapy with oral cysteamine, the only specific therapy for cystinosis,&#xD;
        along with the availability of renal replacement therapy in childhood, has dramatically&#xD;
        improved patient outcomes. There is robust evidence that early initiation and sustained&#xD;
        therapy with cysteamine are both essential for delaying progression to chronic kidney disease&#xD;
        (CKD) and end-organ damage.&#xD;
  &#xD;
        Currently, the diagnosis of cystinosis is based on the presence of elevated cystine levels in&#xD;
        white blood cells. This method is unsuitable for NBS.&#xD;
  &#xD;
        Spinal Muscular Atrophy (SMA): Spinal muscular atrophy has a prevalence of approximately&#xD;
        1:10,000 live births in Germany. It is inherited in an autosomal recessive manner. Newborns&#xD;
        with spinal muscular atrophy are without clinical symptoms after birth.&#xD;
  &#xD;
        The cause of spinal muscular atrophy is a deletion of exon 7 in the SMN1 gene, the coding&#xD;
        gene for the &quot;survival motor neuron protein&quot;. Homozygous deletion lacks the functional SMN&#xD;
        protein on which the anterior horn cells in the spinal cord depend. Heterozygous carriers are&#xD;
        asymptomatic. Lack of the functional SMN protein results in damage to motor neurons at the&#xD;
        spinal cord level, leading to severe neurogenic remodeling and atrophy of skeletal muscles.&#xD;
  &#xD;
        In addition to the SMN1 gene, humans have an almost identical, adjacently located&#xD;
        &quot;pseudo-gene,&quot; the SMN2 gene. It differs from the SMN1 gene only by 5 single base pairs. The&#xD;
        SMN2 protein plays no role in healthy humans, since sufficient functional SMN1 protein is&#xD;
        present. The SMN2 gene contains a molecular switch that can completely shut down the&#xD;
        expression of the gene. The clinical variability of spinal muscular atrophy is explained by&#xD;
        differential expression of the SMN2 protein. Thus, the readout of the SMN2 gene including its&#xD;
        exon 7 by inhibition of the off switch represents a therapeutic target for the treatment of&#xD;
        SMA patients. The possibility of a therapy to positively influence the course of the disease&#xD;
        was demonstrated in the placebo-controlled multi-center study with an antisense&#xD;
        oligonucleotide nusinersen (Spinraza®) from Ionis/Biogen in 2015/2016.&#xD;
  &#xD;
        Diagnosis of the disease in cases of clinical suspicion has been made by targeted testing of&#xD;
        the SMN1 and SMN2 genes from EDTA blood and DNA isolated therefrom. The test is usually&#xD;
        performed in genetics laboratories using MLPA (multiplex ligation-dependent probe&#xD;
        amplification). Because a commercial kit is required for each sample, the test is too costly&#xD;
        for screening as part of newborn screening.&#xD;
  &#xD;
        Procedure:&#xD;
  &#xD;
        Study population Hospitals in Germany are free to choose which of the 11 certified&#xD;
        laboratories they send the dry blood spot cards to for newborn screening and whether they&#xD;
        want to participate in pilot projects.&#xD;
  &#xD;
        In this project, the Becker &amp; Kollegen laboratory in Munich and the Hannover screening&#xD;
        laboratory are informing their senders about the possibility of adding genetic screening for&#xD;
        cystinosis (Hannover) or cystinosis and SMA (Munich) to the routinely established newborn&#xD;
        screening.&#xD;
  &#xD;
        The study population includes newborns whose parents wish to participate in the pilot project&#xD;
        and have provided written informed consent. An additional information and consent sheet for&#xD;
        cystinosis and SMA screening is provided, which includes an explanation of the screening&#xD;
        process and objectives, expected benefits, possible adverse consequences of&#xD;
        non-participation, and the significance of the test results. Parents are informed that they&#xD;
        will be informed of normal, unremarkable results only upon request. Consent must be&#xD;
        documented with the signature of at least one parent and the signature of the informing&#xD;
        physician on the consent form. The consent form for the pilot project also includes consent&#xD;
        to share contact information and findings with a specialized center in the event of an&#xD;
        abnormal screening result.&#xD;
  &#xD;
        In the event of a positive result, the laboratory must first inform the sender and clarify&#xD;
        whether or not the child is still in hospital. If the child is still undergoing inpatient&#xD;
        treatment, the sender obtains the initial information from the parents and notifies an expert&#xD;
        for the corresponding diagnosis. If the child has already been discharged from the hospital,&#xD;
        the laboratory contacts the appropriate expert directly (Cystinosis: Priv.-Doz. Dr. med.&#xD;
        Katharina Hohenfellner, Rosenheim; SMA: Prof. Dr. med. Wolfgang Müller-Felber, Munich).&#xD;
  &#xD;
        Sampling Molecular genetic screening is performed using the same dry blood card (drops of&#xD;
        blood on a filter paper card) as routine NBS. No additional blood collection is required. If&#xD;
        little material is available, the regular NBS is performed first, followed by screening for&#xD;
        cystinosis and SMA. According to the pediatric guideline, the blood sample for the NBS should&#xD;
        be collected between 36 and 72 hours of life.&#xD;
  &#xD;
        In general, for all invalid results (i.e., if the control reaction fails) and for all&#xD;
        abnormal results the test is repeated internally for confirmation using the available blood&#xD;
        sample. If the quality of the blood sample is poor (e.g., too little blood), the laboratory&#xD;
        will request a new blood sample. If there is too little material to perform the required next&#xD;
        generation sequencing, the laboratory will also request another dried blood sample.&#xD;
  &#xD;
        Measurements and Methods Cystinosis: For cystinosis screening, multiplex PCR was performed at&#xD;
        the first stage to detect the three most common CTNS mutations in Germany, i.e. a 57kb&#xD;
        deletion (responsible for about half of cystinosis in Europe and North America)&#xD;
        c.18_21delGACT, p.T7Ffs*7 and c.926dupG, p.S310Qfs*55 . Heterozygous samples will be&#xD;
        subjected to amplicon-based next-generation sequencing for 101 pathogenic mutations. This&#xD;
        approach predicts a detection rate of 96.5%.&#xD;
  &#xD;
        SMA The triplex PCR for the CTNS mutations described above is complemented by another PCR&#xD;
        that detects exon 7 in the SMN1 gene. With this quadruplex PCR, a specific signal is obtained&#xD;
        for normal samples (those without or with heterozygous exon 7 deletion in both alleles of the&#xD;
        SMN1 gene). SMA screening is considered positive if a homozygous exon 7 deletion is detected&#xD;
        in the SMN1 gene. The absence of PCR amplification indicates the absence of a functional SMN1&#xD;
        copy, i.e., an affected newborn. Heterozygous individuals cannot be detected by this method&#xD;
        Detection rate, false positive and false negative results An overall detection rate of more&#xD;
        than 95% is assumed for both diseases. False negative screening results are unlikely. In&#xD;
        cystinosis, false negative results are possible due to previously unknown rare mutations or&#xD;
        patients not carrying any of the three most common mutations. In SMA, patients in whom a&#xD;
        heterozygous deletion is combined with a point mutation are not considered. In patients with&#xD;
        symptoms of cystinosis or SMA, further diagnostic tests are performed independently of&#xD;
        screening.&#xD;
  &#xD;
        False positive screening results are also very unlikely. In cystinosis, a heterozygous sample&#xD;
        may falsely appear as homozygous due to &quot;allelic dropout&quot; (PCR failure of an allele due to&#xD;
        mutations in the primer binding region).&#xD;
  &#xD;
        Confirmation of diagnosis Cystinosis: In patients found to have either a homozygous or&#xD;
        compound heterozygous mutation in a CTNS gene, the diagnosis is confirmed by determining the&#xD;
        intraleukocytic cystine level from EDTA blood. This sample is sent to the metabolic&#xD;
        laboratory in Münster within the first 14 days of life.&#xD;
  &#xD;
        SMA: If exon 7 in the SMN1 gene is homozygous, SMA must be assumed (&gt; 50% type I with most&#xD;
        severe course). In order to classify the severity of SMA, further diagnostics are required by&#xD;
        recording the number of SMN-2 copies. Another blood sample will be sent by the responsible&#xD;
        care center to the reference laboratory in Ulm. The verification test results are forwarded&#xD;
        to the screening laboratory for quality control.&#xD;
  &#xD;
        Care of the affected child Cystinosis: Children with positive cystinosis screening results&#xD;
        are referred to the nearest metabolic disease center. Therapy with cysteamine will be started&#xD;
        immediately after the diagnosis is confirmed..&#xD;
  &#xD;
        SMA: Children with positive SMA screening results are referred either to the Center for&#xD;
        Neuromuscular Diseases in the Social Pediatric Center of the Dr. von Hauner Children's&#xD;
        Hospital (Bavaria) or to the University Hospitals of Essen and Münster.&#xD;
  &#xD;
        Project scope The project was initially limited to 200,000 samples, with the possibility of&#xD;
        expansion.&#xD;
      </textblock>
    </detailed_description>
    <overall_status>Completed</overall_status>
    <start_date type="Actual">January 15, 2018</start_date>
    <completion_date type="Actual">September 30, 2022</completion_date>
    <primary_completion_date type="Actual">September 30, 2022</primary_completion_date>
    <phase>N/A</phase>
    <study_type>Interventional</study_type>
    <has_expanded_access>No</has_expanded_access>
    <study_design_info>
      <allocation>N/A</allocation>
      <intervention_model>Single Group Assignment</intervention_model>
      <intervention_model_description>All newborns whose parents have agreed to participate in the pilot project will be tested for three mutations in the CTNS gene and a homozygous deletion of exon 7 in the SMN1-gene.</intervention_model_description>
      <primary_purpose>Screening</primary_purpose>
      <masking>None (Open Label)</masking>
    </study_design_info>
    <primary_outcome>
      <measure>Number of participants with confirmed diagnosis of Cystinosis</measure>
      <time_frame>up to 60 months</time_frame>
      <description>Newborns identified with 57-kb CTNS mutation homozygous, compound heterozygous , with c.18_21delGACT p.T7Ffs*7 homozygous or compound heterozygous or c.926_927insG, p.S310Qfs * 55 homozygous or compound heterozygous and elevated white blood cell cystine level.</description>
    </primary_outcome>
    <primary_outcome>
      <measure>Number of participants with heterozygous mutations</measure>
      <time_frame>up to 4 weeks</time_frame>
      <description>Newborns identified with heterozygous CTNS mutations of 57-kb CTNS and heterozygous c.18_21delGACT p.T7Ffs*7 mutations and heterozygous c.926_927insG, p.S310Qfs * 55 mutations</description>
    </primary_outcome>
    <primary_outcome>
      <measure>Number of participants with confirmed diagnosis of SMA</measure>
      <time_frame>up to 48 months</time_frame>
      <description>Newborns identified with homozygous deletion of exon 7 in the SMN1-gene</description>
    </primary_outcome>
    <primary_outcome>
      <measure>time interval until start of treatment for both diseases</measure>
      <time_frame>up to 4 weeks</time_frame>
      <description>For both diseases the time interval will be evaluated from the time of identification in screening to the introduction of therapy.</description>
    </primary_outcome>
    <number_of_arms>1</number_of_arms>
    <enrollment type="Actual">300000</enrollment>
    <condition>Cystinosis</condition>
    <condition>Cystinosis, Nephropathic</condition>
    <condition>Spinal Muscular Atrophy</condition>
    <arm_group>
      <arm_group_label>Tested Newborns</arm_group_label>
      <arm_group_type>Experimental</arm_group_type>
      <description>Tested for three mutations in the CTNS gene and one mutation in the SMN1 gene.</description>
    </arm_group>
    <intervention>
      <intervention_type>Diagnostic Test</intervention_type>
      <intervention_name>molecular-based screening</intervention_name>
      <description>Test for three mutations in the CTNS gene and one mutation in the SMA1 gene.</description>
      <arm_group_label>Tested Newborns</arm_group_label>
    </intervention>
    <eligibility>
      <criteria>
        <textblock>
          Inclusion Criteria:&#xD;
  &#xD;
            -  Newborns whose dry bloodspot card was sent to screening labs involved in the project&#xD;
  &#xD;
            -  Consent of guardians&#xD;
  &#xD;
          Exclusion Criteria:&#xD;
  &#xD;
            -  no consent of guardians&#xD;
        </textblock>
      </criteria>
      <gender>All</gender>
      <minimum_age>36 Hours</minimum_age>
      <maximum_age>72 Hours</maximum_age>
      <healthy_volunteers>No</healthy_volunteers>
    </eligibility>
    <overall_official>
      <last_name>Katharina Hohenfellner, PD Dr.</last_name>
      <role>Study Chair</role>
      <affiliation>RoMed Hospital</affiliation>
    </overall_official>
    <location>
      <facility>
        <name>RoMed Hospital</name>
        <address>
          <city>Rosenheim</city>
          <state>Bavaria</state>
          <zip>83022</zip>
          <country>Germany</country>
        </address>
      </facility>
    </location>
    <location>
      <facility>
        <name>University Hospital Essen, Center for Pediatrics and Adolescent Medicine</name>
        <address>
          <city>Essen</city>
          <zip>45122</zip>
          <country>Germany</country>
        </address>
      </facility>
    </location>
    <location>
      <facility>
        <name>Dr. von Haunersches Kinderspital</name>
        <address>
          <city>München</city>
          <zip>80337</zip>
          <country>Germany</country>
        </address>
      </facility>
    </location>
    <location>
      <facility>
        <name>University Hospital Münster, Clinic and Polyclinic for Pediatrics and Adolescent Medicine</name>
        <address>
          <city>Münster</city>
          <zip>48149</zip>
          <country>Germany</country>
        </address>
      </facility>
    </location>
    <location_countries>
      <country>Germany</country>
    </location_countries>
    <reference>
      <citation>Hohenfellner K, Elenberg E, Ariceta G, Nesterova G, Soliman NA, Topaloglu R. Newborn Screening: Review of its Impact for Cystinosis. Cells. 2022 Mar 25;11(7):1109. doi: 10.3390/cells11071109.</citation>
      <PMID>35406673</PMID>
    </reference>
    <reference>
      <citation>Vill K, Blaschek A, Schara U, Kolbel H, Hohenfellner K, Harms E, Olgemoller B, Walter MC, Muller-Felber W. [Spinal muscular atrophy : Time for newborn screening?]. Nervenarzt. 2017 Dec;88(12):1358-1366. doi: 10.1007/s00115-017-0447-3. German.</citation>
      <PMID>29101527</PMID>
    </reference>
    <reference>
      <citation>Hohenfellner K, Bergmann C, Fleige T, Janzen N, Burggraf S, Olgemoller B, Gahl WA, Czibere L, Froschauer S, Roschinger W, Vill K, Harms E, Nennstiel U. Molecular based newborn screening in Germany: Follow-up for cystinosis. Mol Genet Metab Rep. 2019 Sep 18;21:100514. doi: 10.1016/j.ymgmr.2019.100514. eCollection 2019 Dec.</citation>
      <PMID>31641587</PMID>
    </reference>
    <reference>
      <citation>Fleige T, Burggraf S, Czibere L, Haring J, Gluck B, Keitel LM, Landt O, Harms E, Hohenfellner K, Durner J, Roschinger W, Becker M. Next generation sequencing as second-tier test in high-throughput newborn screening for nephropathic cystinosis. Eur J Hum Genet. 2020 Feb;28(2):193-201. doi: 10.1038/s41431-019-0521-3. Epub 2019 Sep 30.</citation>
      <PMID>31570786</PMID>
    </reference>
    <reference>
      <citation>Vill K, Kolbel H, Schwartz O, Blaschek A, Olgemoller B, Harms E, Burggraf S, Roschinger W, Durner J, Glaser D, Nennstiel U, Wirth B, Schara U, Jensen B, Becker M, Hohenfellner K, Muller-Felber W. One Year of Newborn Screening for SMA - Results of a German Pilot Project. J Neuromuscul Dis. 2019;6(4):503-515. doi: 10.3233/JND-190428.</citation>
      <PMID>31594245</PMID>
    </reference>
    <reference>
      <citation>Czibere L, Burggraf S, Fleige T, Gluck B, Keitel LM, Landt O, Durner J, Roschinger W, Hohenfellner K, Wirth B, Muller-Felber W, Vill K, Becker M. High-throughput genetic newborn screening for spinal muscular atrophy by rapid nucleic acid extraction from dried blood spots and 384-well qPCR. Eur J Hum Genet. 2020 Jan;28(1):23-30. doi: 10.1038/s41431-019-0476-4. Epub 2019 Jul 30.</citation>
      <PMID>31363188</PMID>
    </reference>
    <verification_date>August 2023</verification_date>
    <study_first_submitted>August 17, 2023</study_first_submitted>
    <study_first_submitted_qc>August 30, 2023</study_first_submitted_qc>
    <study_first_posted type="Actual">September 7, 2023</study_first_posted>
    <last_update_submitted>August 30, 2023</last_update_submitted>
    <last_update_submitted_qc>August 30, 2023</last_update_submitted_qc>
    <last_update_posted type="Actual">September 7, 2023</last_update_posted>
    <responsible_party>
      <responsible_party_type>Sponsor</responsible_party_type>
    </responsible_party>
    <keyword>Newborn Screening</keyword>
    <keyword>Screening</keyword>
    <keyword>Molecular-based Screening</keyword>
    <condition_browse>
      <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
      <mesh_term>Muscular Atrophy</mesh_term>
      <mesh_term>Muscular Atrophy, Spinal</mesh_term>
      <mesh_term>Cystinosis</mesh_term>
      <mesh_term>Atrophy</mesh_term>
    </condition_browse>
    <patient_data>
      <sharing_ipd>No</sharing_ipd>
    </patient_data>
    <!-- Results have not yet been posted for this study                                          -->
  </clinical_study>
  
  
text: download date: ClinicalTrials.gov processed this data on September 20, 2023
  link text: Link to the current ClinicalTrials.gov record.
  url: https://clinicaltrials.gov/ct2/show/NCT06027385
  org study id: 2017-GEN1
  nct id: NCT06027385
  lead sponsor: 
  collaborator: 
  collaborator: 
  collaborator: 
  collaborator: 
  collaborator: 
  collaborator: 
  has dmc: No
  is fda regulated drug: No
  is fda regulated device: No
  Newborn screening in Germany is a voluntary program. Cystinosis and spinal muscular atrophy
        (SMA) are rare autosomal recessive diseases. They are inherited in an autosomal recessive
        manner, i.e. both parents carry a defective gene. Neither disease can be detected early by
        the methods established in routine newborn screening. However, common genetic mutations are
        known for both diseases.
  
        The aim of the study presented here is to provide the scientific basis for molecular genetic
        newborn screening for cystinosis and SMA. In particular, to investigate whether inclusion of
        these diseases in general newborn screening should be recommended.
  
        The participating screening laboratories for this project are Labor Becker & Kollegen,
        Munich, Germany and Screening Laboratory Hannover, Germany. Hospitals that send their dry
        blood spot cards for routine newborn screening to these laboratories will receive an offer to
        participate in the pilot project. Participation is free of charge.
  
        Parents who wish to participate in this pilot project will receive an information sheet
        explaining the screening process and objectives. A parent and the treating physician sign the
        information sheet as documentation of informed consent. Their signature and informed consent
        are required for the pilot.
  
        Routine NBS according to German pediatric guidelines involves the collection of dried blood
        spot cards 36-72 hours after birth. Molecular genetic screening in the pilot project will be
        performed with the same dried blood spot card used for routine newborn screening.
  
        In cystinosis, genetic testing for the 3 most common mutations in Germany will be performed.
        In SMA, a homozygous deletion of exon 7 in the SMN gene is detected by a PCR test. The
        molecular genetic test is performed on the same day as routine newborn screening.Normal
        findings are not reported to parents. However, they can contact the laboratories to inquire
        about them.
  
        Parents of newborns with two mutations in the cystinosis gene or with a homozygous deletion
        of exon 7 in the SMN gene are immediately informed of the disease by a physician. Further
        diagnostics to confirm the disease will be organized close to home.
  
        The study started on Jan. 15, 2018, and recruitment was completed on Sept. 30, 2022.
  Population-based newborn screening (NBS) is an important public health program that has
        vastly improved the course of several diseases through early detection. The selection of
        screened disorders generally follows the 10 principles outlined by Wilson and Jungner. In
        Germany, NBS has been a voluntary National Health Service program since 1969 which currently
        covers 17 disorders. Current NBS methods, which employ tandem mass-spectrometric analysis of
        newborn dried blood spots, cannot detect many potentially treatable genetic conditions. At
        the same time, molecular-based NBS is increasingly feasible because DNA can be extracted from
        a dried blood spot, next generation sequencing has become economical, and molecular
        diagnostics have greater reliability and increased validity as genetic databases become more
        refined and comprehensive. Nephropathic cystinosis and spinal muscular atrophy (SMA) are
        eligible for molecular-based NBS because effective therapies are available.
  
        This study will provide a scientific basis for newborn screening for cystinosis and SMA and
        investigate whether inclusion of these diseases in general newborn screening should be
        recommended. By observing identified infants compared to symptomatically diagnosed patients
        outside the pilot project, we will determine whether and to what extent early diagnosis and
        initiation of therapy leads to a more favorable prognosis.
  
        Cystinosis: Cystinosis is a rare autosomal recessive systemic disease with high morbidity and
        mortality caused by pathogenic variants in the CTNS gene that encodes the lysosomal cystine
        transporter cystinosin, leading to accumulation of cystine within the lysosome. Life-long
        cystine-depleting therapy with oral cysteamine, the only specific therapy for cystinosis,
        along with the availability of renal replacement therapy in childhood, has dramatically
        improved patient outcomes. There is robust evidence that early initiation and sustained
        therapy with cysteamine are both essential for delaying progression to chronic kidney disease
        (CKD) and end-organ damage.
  
        Currently, the diagnosis of cystinosis is based on the presence of elevated cystine levels in
        white blood cells. This method is unsuitable for NBS.
  
        Spinal Muscular Atrophy (SMA): Spinal muscular atrophy has a prevalence of approximately
        1:10,000 live births in Germany. It is inherited in an autosomal recessive manner. Newborns
        with spinal muscular atrophy are without clinical symptoms after birth.
  
        The cause of spinal muscular atrophy is a deletion of exon 7 in the SMN1 gene, the coding
        gene for the "survival motor neuron protein". Homozygous deletion lacks the functional SMN
        protein on which the anterior horn cells in the spinal cord depend. Heterozygous carriers are
        asymptomatic. Lack of the functional SMN protein results in damage to motor neurons at the
        spinal cord level, leading to severe neurogenic remodeling and atrophy of skeletal muscles.
  
        In addition to the SMN1 gene, humans have an almost identical, adjacently located
        "pseudo-gene," the SMN2 gene. It differs from the SMN1 gene only by 5 single base pairs. The
        SMN2 protein plays no role in healthy humans, since sufficient functional SMN1 protein is
        present. The SMN2 gene contains a molecular switch that can completely shut down the
        expression of the gene. The clinical variability of spinal muscular atrophy is explained by
        differential expression of the SMN2 protein. Thus, the readout of the SMN2 gene including its
        exon 7 by inhibition of the off switch represents a therapeutic target for the treatment of
        SMA patients. The possibility of a therapy to positively influence the course of the disease
        was demonstrated in the placebo-controlled multi-center study with an antisense
        oligonucleotide nusinersen (Spinraza®) from Ionis/Biogen in 2015/2016.
  
        Diagnosis of the disease in cases of clinical suspicion has been made by targeted testing of
        the SMN1 and SMN2 genes from EDTA blood and DNA isolated therefrom. The test is usually
        performed in genetics laboratories using MLPA (multiplex ligation-dependent probe
        amplification). Because a commercial kit is required for each sample, the test is too costly
        for screening as part of newborn screening.
  
        Procedure:
  
        Study population Hospitals in Germany are free to choose which of the 11 certified
        laboratories they send the dry blood spot cards to for newborn screening and whether they
        want to participate in pilot projects.
  
        In this project, the Becker & Kollegen laboratory in Munich and the Hannover screening
        laboratory are informing their senders about the possibility of adding genetic screening for
        cystinosis (Hannover) or cystinosis and SMA (Munich) to the routinely established newborn
        screening.
  
        The study population includes newborns whose parents wish to participate in the pilot project
        and have provided written informed consent. An additional information and consent sheet for
        cystinosis and SMA screening is provided, which includes an explanation of the screening
        process and objectives, expected benefits, possible adverse consequences of
        non-participation, and the significance of the test results. Parents are informed that they
        will be informed of normal, unremarkable results only upon request. Consent must be
        documented with the signature of at least one parent and the signature of the informing
        physician on the consent form. The consent form for the pilot project also includes consent
        to share contact information and findings with a specialized center in the event of an
        abnormal screening result.
  
        In the event of a positive result, the laboratory must first inform the sender and clarify
        whether or not the child is still in hospital. If the child is still undergoing inpatient
        treatment, the sender obtains the initial information from the parents and notifies an expert
        for the corresponding diagnosis. If the child has already been discharged from the hospital,
        the laboratory contacts the appropriate expert directly (Cystinosis: Priv.-Doz. Dr. med.
        Katharina Hohenfellner, Rosenheim; SMA: Prof. Dr. med. Wolfgang Müller-Felber, Munich).
  
        Sampling Molecular genetic screening is performed using the same dry blood card (drops of
        blood on a filter paper card) as routine NBS. No additional blood collection is required. If
        little material is available, the regular NBS is performed first, followed by screening for
        cystinosis and SMA. According to the pediatric guideline, the blood sample for the NBS should
        be collected between 36 and 72 hours of life.
  
        In general, for all invalid results (i.e., if the control reaction fails) and for all
        abnormal results the test is repeated internally for confirmation using the available blood
        sample. If the quality of the blood sample is poor (e.g., too little blood), the laboratory
        will request a new blood sample. If there is too little material to perform the required next
        generation sequencing, the laboratory will also request another dried blood sample.
  
        Measurements and Methods Cystinosis: For cystinosis screening, multiplex PCR was performed at
        the first stage to detect the three most common CTNS mutations in Germany, i.e. a 57kb
        deletion (responsible for about half of cystinosis in Europe and North America)
        c.18_21delGACT, p.T7Ffs*7 and c.926dupG, p.S310Qfs*55 . Heterozygous samples will be
        subjected to amplicon-based next-generation sequencing for 101 pathogenic mutations. This
        approach predicts a detection rate of 96.5%.
  
        SMA The triplex PCR for the CTNS mutations described above is complemented by another PCR
        that detects exon 7 in the SMN1 gene. With this quadruplex PCR, a specific signal is obtained
        for normal samples (those without or with heterozygous exon 7 deletion in both alleles of the
        SMN1 gene). SMA screening is considered positive if a homozygous exon 7 deletion is detected
        in the SMN1 gene. The absence of PCR amplification indicates the absence of a functional SMN1
        copy, i.e., an affected newborn. Heterozygous individuals cannot be detected by this method
        Detection rate, false positive and false negative results An overall detection rate of more
        than 95% is assumed for both diseases. False negative screening results are unlikely. In
        cystinosis, false negative results are possible due to previously unknown rare mutations or
        patients not carrying any of the three most common mutations. In SMA, patients in whom a
        heterozygous deletion is combined with a point mutation are not considered. In patients with
        symptoms of cystinosis or SMA, further diagnostic tests are performed independently of
        screening.
  
        False positive screening results are also very unlikely. In cystinosis, a heterozygous sample
        may falsely appear as homozygous due to "allelic dropout" (PCR failure of an allele due to
        mutations in the primer binding region).
  
        Confirmation of diagnosis Cystinosis: In patients found to have either a homozygous or
        compound heterozygous mutation in a CTNS gene, the diagnosis is confirmed by determining the
        intraleukocytic cystine level from EDTA blood. This sample is sent to the metabolic
        laboratory in Münster within the first 14 days of life.
  
        SMA: If exon 7 in the SMN1 gene is homozygous, SMA must be assumed (> 50% type I with most
        severe course). In order to classify the severity of SMA, further diagnostics are required by
        recording the number of SMN-2 copies. Another blood sample will be sent by the responsible
        care center to the reference laboratory in Ulm. The verification test results are forwarded
        to the screening laboratory for quality control.
  
        Care of the affected child Cystinosis: Children with positive cystinosis screening results
        are referred to the nearest metabolic disease center. Therapy with cysteamine will be started
        immediately after the diagnosis is confirmed..
  
        SMA: Children with positive SMA screening results are referred either to the Center for
        Neuromuscular Diseases in the Social Pediatric Center of the Dr. von Hauner Children's
        Hospital (Bavaria) or to the University Hospitals of Essen and Münster.
  
        Project scope The project was initially limited to 200,000 samples, with the possibility of
        expansion.
  allocation: N/A
  intervention model: Single Group Assignment
  intervention model description: All newborns whose parents have agreed to participate in the pilot project will be tested for three mutations in the CTNS gene and a homozygous deletion of exon 7 in the SMN1-gene.
  primary purpose: Screening
  masking: None (Open Label)
  measure: Number of participants with confirmed diagnosis of Cystinosis
  time frame: up to 60 months
  description: Newborns identified with 57-kb CTNS mutation homozygous, compound heterozygous , with c.18_21delGACT p.T7Ffs*7 homozygous or compound heterozygous or c.926_927insG, p.S310Qfs * 55 homozygous or compound heterozygous and elevated white blood cell cystine level.
  measure: Number of participants with heterozygous mutations
  time frame: up to 4 weeks
  description: Newborns identified with heterozygous CTNS mutations of 57-kb CTNS and heterozygous c.18_21delGACT p.T7Ffs*7 mutations and heterozygous c.926_927insG, p.S310Qfs * 55 mutations
  measure: Number of participants with confirmed diagnosis of SMA
  time frame: up to 48 months
  description: Newborns identified with homozygous deletion of exon 7 in the SMN1-gene
  measure: time interval until start of treatment for both diseases
  time frame: up to 4 weeks
  description: For both diseases the time interval will be evaluated from the time of identification in screening to the introduction of therapy.
  arm group label: Tested Newborns
  arm group type: Experimental
  description: Tested for three mutations in the CTNS gene and one mutation in the SMN1 gene.
  intervention type: Diagnostic Test
  intervention name: molecular-based screening
  description: Test for three mutations in the CTNS gene and one mutation in the SMA1 gene.
  arm group label: Tested Newborns
  criteria: 
  gender: All
  minimum age: 36 Hours
  maximum age: 72 Hours
  healthy volunteers: No
  last name: Katharina Hohenfellner, PD Dr.
  role: Study Chair
  affiliation: RoMed Hospital
  facility: 
  facility: 
  facility: 
  facility: 
  country: Germany
  citation: Hohenfellner K, Elenberg E, Ariceta G, Nesterova G, Soliman NA, Topaloglu R. Newborn Screening: Review of its Impact for Cystinosis. Cells. 2022 Mar 25;11(7):1109. doi: 10.3390/cells11071109.
  PMID: 35406673
  citation: Vill K, Blaschek A, Schara U, Kolbel H, Hohenfellner K, Harms E, Olgemoller B, Walter MC, Muller-Felber W. [Spinal muscular atrophy : Time for newborn screening?]. Nervenarzt. 2017 Dec;88(12):1358-1366. doi: 10.1007/s00115-017-0447-3. German.
  PMID: 29101527
  citation: Hohenfellner K, Bergmann C, Fleige T, Janzen N, Burggraf S, Olgemoller B, Gahl WA, Czibere L, Froschauer S, Roschinger W, Vill K, Harms E, Nennstiel U. Molecular based newborn screening in Germany: Follow-up for cystinosis. Mol Genet Metab Rep. 2019 Sep 18;21:100514. doi: 10.1016/j.ymgmr.2019.100514. eCollection 2019 Dec.
  PMID: 31641587
  citation: Fleige T, Burggraf S, Czibere L, Haring J, Gluck B, Keitel LM, Landt O, Harms E, Hohenfellner K, Durner J, Roschinger W, Becker M. Next generation sequencing as second-tier test in high-throughput newborn screening for nephropathic cystinosis. Eur J Hum Genet. 2020 Feb;28(2):193-201. doi: 10.1038/s41431-019-0521-3. Epub 2019 Sep 30.
  PMID: 31570786
  citation: Vill K, Kolbel H, Schwartz O, Blaschek A, Olgemoller B, Harms E, Burggraf S, Roschinger W, Durner J, Glaser D, Nennstiel U, Wirth B, Schara U, Jensen B, Becker M, Hohenfellner K, Muller-Felber W. One Year of Newborn Screening for SMA - Results of a German Pilot Project. J Neuromuscul Dis. 2019;6(4):503-515. doi: 10.3233/JND-190428.
  PMID: 31594245
  citation: Czibere L, Burggraf S, Fleige T, Gluck B, Keitel LM, Landt O, Durner J, Roschinger W, Hohenfellner K, Wirth B, Muller-Felber W, Vill K, Becker M. High-throughput genetic newborn screening for spinal muscular atrophy by rapid nucleic acid extraction from dried blood spots and 384-well qPCR. Eur J Hum Genet. 2020 Jan;28(1):23-30. doi: 10.1038/s41431-019-0476-4. Epub 2019 Jul 30.
  PMID: 31363188
  responsible party type: Sponsor
  mesh term: Muscular Atrophy
  mesh term: Muscular Atrophy, Spinal
  mesh term: Cystinosis
  mesh term: Atrophy
  sharing ipd: No