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ISSN : 1226-7155(Print)
ISSN : 2287-6618(Online)
International Journal of Oral Biology Vol.50 No.2 pp.74-82
DOI : https://doi.org/10.11620/IJOB.2025.50.2.74

Modeling fabry disease-associated cardiovascular phenotypes using isogenic α-Galactosidase A-knockout human induced pluripotent stem cells

Yun Ju Choi1, Young-Kyu Kim2, Sang-Hyun Min3,4*, Sang-Wook Park1,5*
1Department of Dental Bioscience, School of Dentistry, Chonnam National University, Gwangju 61186, Republic of Korea
2New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation (K-MEDI Hub), Daegu 41061, Republic of Korea
3BK21, Infectious Disease Helathcare, Kyungpook National University, Daegu 41566, Republic of Korea
4Department of Innovative Pharmaceutical Sciences, Kyungpook National University, Daegu 41566, Republic of Korea
5Department of Oral Biochemistry, Dental Science Research Institute, School of Dentistry, Chonnam National University, Gwangju
61186, Republic of Korea

†Yun Ju Choi and Young-Kyu Kim contributed equally to this work.


*Correspondence to:: Sang-Wook Park, E-mail: swpark@jnu.ac.krhttps://orcid.org/0000-0001-6076-5601
*Correspondence to:: Sang-Hyun Min, E-mail: shmin03@knu.ac.krhttps://orcid.org/0000-0002-9521-7848
April 29, 2025 May 30, 2025 May 30, 2025

Abstract


Fabry disease is an X-linked lysosomal storage disorder caused by GLA mutations, leading to a deficiency in α-Galactosidase A activity and subsequent accumulation of globotriaosylceramide (Gb3). This accumulation contributes to progressive multiorgan dysfunction, with cardiovascular complications, particularly endothelial dysfunction and left ventricular hypertrophy being major drivers of disease morbidity and mortality. Although enzyme replacement therapy is currently the standard treatment, its effectiveness is limited in addressing advanced cardiovascular pathology. To better understand Fabry-associated vascular and cardiac phenotypes, an isogenic human induced pluripotent stem cell (hiPSC) model in which GLA was knocked out was developed using CRISPR/ Cas9. GLA-knockout (GLA-KO) hiPSCs were differentiated into endothelial cells (ECs) and cardiomyocytes (CMs) to evaluate disease-relevant phenotypes in vitro . GLA-KO ECs exhibited normal morphology and differentiation capacity but showed markedly impaired tube formation, high expression of inflammatory genes ICAM1, VCAM1, and SELE, and increased mitochondrial and cytoplasmic reactive oxygen species levels. GLA-KO CMs demonstrated enlarged cell size and nuclear translocation of NFATC4, consistent with hypertrophic remodeling. Together, these findings recapitulate key features of Fabry vasculopathy and cardiomyopathy in a genetically defined, human-derived system. This platform enables direct investigation of Gb3-induced oxidative and inflammatory mechanisms and provides a valuable model for the preclinical evaluation of therapeutic strategies targeting the cardiovascular manifestations of Fabry disease.



초록


    © The Korean Academy of Oral Biology. All rights reserved.

    This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

    Introduction

    Fabry disease (OMIM: 301500) is a common X-linked lysosomal storage disorders, which is caused by a deficiency of α-Galactosidase A (GLA) [1]. The defect in GLA activity is caused by genetic mutations in the GLA gene on Xq22.1. Loss of GLA activity caused by a GLA gene mutation leads to progressive accumulation of globotriaosylceramide (Gb3) and its derivatives throughout the body, which leads to various complications, such as angiokeratomas, kidney diseases, cardiovascular diseases, and neuropathy [2]. Until now, several therapies for treating Fabry disease have been applied to the Fabry disease patients. Among the multiple therapeutic strategies developed for the management of Fabry disease, enzyme replacement therapy (ERT) with recombinant human GLA, such as agalsidase alfa (Replagal®) and agalsidase beta (Fabrazyme®), has been the most extensively implemented approach, demonstrating efficacy in reducing Gb3 accumulation and alleviating clinical symptoms [3,4]. However, ERT has notable limitations, such as the requirement for lifelong intravenous infusions, high treatment costs, immune responses against the exogenous enzyme, and insufficient enzyme delivery to critical organs like the heart and kidneys [5]. Additionally, ERT does not completely prevent disease progression, particularly in patients with advanced organ involvement. To overcome these challenges and to gain a deeper understanding of Fabry disease pathophysiology, patient-derived human induced pluripotent stem cells (hiPSCs) have emerged as a valuable model system. hiPSC-derived models recapitulate patientspecific genetic backgrounds and provide a renewable source of disease-relevant cell types, facilitating studies on disease mechanisms and therapeutic development. Furthermore, advances in genome editing technologies, such as CRISPR/Cas9, have enabled not only the correction of pathogenic mutations but also the introduction of disease-causing genetic alterations, allowing for the generation of disease models without direct reliance on patient-derived samples [6]. In a previous report, we have demonstrated that vascular endothelial cells (ECs) differentiated from Fabry disease patient-specific hiPSCs exhibit functional impairments, in part due to enhanced thrombospondin-1 expression [7]. Furthermore, CRISPR/ Cas9-mediated generation of GLA-knockout (GLA-KO) hiPSCs has provided a genetically defined platform for studying Fabry disease without the variability of patient-derived lines [8]. Based on these findings, in the present study, we generated GLA-KO hiPSCs and differentiated them into cardiovascular lineage cells, including vascular ECs and cardiomyocytes (CMs). We then analyzed whether these GLA-KO hiPSC-derived cells could faithfully recapitulate key pathological features of Fabry disease. This isogenic, patient-independent in vitro model provides a new tool to dissect the cellular mechanisms underlying Fabry disease and to explore potential therapeutic interventions targeting cardiovascular complications.

    Materials and Methods

    1. hiPSC culture and genome editing

    The hiPSC line (hFSiPS1) was obtained from the National Stem Cell Bank of Korea and maintained in mTeSR1 medium (STEMCELL Technologies) on Matrigel-coated plates under standard conditions (37℃, 5% CO2) [9]. Cells were passaged every 5–6 days using ReLeSR (STEMCELL Technologies). GLA-KO hiPSCs were generated by transfecting 5 μg of Cas9/ sgRNA plasmid as described previously [8]. Clones harboring a 10-base pair (bp) deletion in the GLA gene were validated by Deep-sequencing and then Sanger sequencing. Deep sequencing-based analysis of genome edited clones was conducted with support from the Center for Genome Engineering at the Institute for Basic Science (IBS) in Daejeon, Republic of Korea.

    2. Endothelial differentiation and purification

    hiPSCs were differentiated into ECs using a 10-day protocol. Cells were treated with Activin A (120-14P; PeproTech), BMP4 (120-05ET; PeproTech), and CP21R7 (S7954; Selleckchem) (#72112; STEMCELL Technologies) (days 0–3), followed by VEGF-A (100-20; PeproTech), bFGF (100-18B; PeproTech), and forskolin (#72112; STEMCELL Technologies) (days 3–5), and maintained in EGM-2 (C-22111; PromoCell) supplemented with VEGF-A and bFGF (days 5–10). On day 10, CD31 and CD144 expression were assessed by flow cytometry using PE-anti-CD31 (555446; BD Biosciences) and Alexa 647-anti- CD144 (561567; BD Biosciences). CD144+ cells were enriched by CD144 (VE-cadherin) MicroBeads (130-097-857; Miltenyi Biotec) for functional assays, including tube formation on Matrigel (354277; Corning).

    3. Cardiomyocyte differentiation

    hiPSCs were plated on Matrigel in mTeSR1 with Y-27632 (72308; STEMCELL Technologies), and cardiac differentiation was induced using 12 μM CHIR99021 (SML1046; Sigma- Aldrich) (day 0), followed by 1% B27 minus insulin (A1895601; Gibco) (days 1–2), 5 μM IWP-2 (I0536; Merk) (days 3–4), and full B27 (day 7 onward). Beating CMs were observed by days 8–10 and used after day 14 for analyses.

    4. Flow cytometry

    Single-cell suspensions were stained with PE-anti-CD31 and Alexa 647-anti-CD144 and analyzed on a BD Aria III cytometer. Data was processed using FlowJo software.

    5. α-Galactosidase A enzymatic activity

    GLA activity in ECs was measured using an α-Galactosidase Activity Assay Kit (K407-100; BioVision) according to the manufacturer’s instructions.

    6. Immunocytochemistry and cell size measurement

    Day 30 CMs were fixed in 4% paraformaldehyde, permeabilized, and stained with rabbit anti-cardiac troponin T (cTnT) (ab45932; Abcam) and mouse anti-nuclear factor of activated T cells, cytoplasmic 4 (NFATC4) (sc-271597; Santa Cruz Biotechnology), followed by Alexa Fluor-conjugated secondary antibodies and DAPI. Fluorescence images were acquired using a Nikon Eclipse Ti confocal microscope. Cell size was measured from cTnT-labeled cells using ImageJ.

    7. Quantitative reverse transcription polymerase chain reaction

    Total RNA was extracted using TRIzol, and cDNA was synthesized using GoScript RT System (A6101; Promega). Quantitative reverse transcription polymerase chain reaction (qRT-PCR) was performed with KAPA SYBR® FAST qPCR Kit (KK4602; Kapa Biosystems) on a StepOnePlus system (Applied Biosystems). Data were normalized to GAPDH and analyzed using the 2–ΔΔCt method. Primer sequences used for qRT-PCR are listed in Table 1.

    8. Reactive oxygen species measurement

    Mitochondrial and cytoplasmic reactive oxygen species (ROS) were detected using 5 μM MitoSOX Red (M36008; Thermo Fisher Scientific) and CellROX Green (C10444; Thermo Fisher Scientific), respectively. Cells were imaged in real time using the Incucyte® Zoom system (Sartorius), and fluorescence intensity was quantified using Incucyte software.

    9. Statistical analysis

    All quantitative data are expressed as mean ± standard deviation. Statistical significance between two groups was evaluated using an unpaired two-tailed Student’s t-test. A minimum of three independent biological replicates (n ≥ 3) was included for each condition. All analyses were performed using GraphPad Prism (version 9.0), and p -values less than 0.05 were considered statistically significant.

    Results

    1. GLA-KO hiPSC-derived endothelial cells retain differentiation potential but lack GLA enzymatic activity

    To investigate the impact of GLA deficiency on vascular EC function, we utilized a previously established hiPSC line (hFSiPS1) harboring a 10-bp deletion in exon 3 of the GLA gene, introduced via CRISPR/Cas9-mediated genome editing (Fig. 1A and 1B). Sanger sequencing subsequently confirmed the presence of a hemizygous 10-bp deletion, resulting in a frameshift mutation and disruption of the GLA coding sequence (Fig. 1C). Following genome editing, GLA-KO hiPSCs were differentiated into vascular ECs using a defined stepwise protocol (Fig. 1D). Flow cytometry analysis of the endothelial markers CD31 and CD144 revealed that approximately 45% of differentiated cells in both wild-type (WT) and GLA-KO hiPSCderived populations were CD31/CD144 double-positive (Fig. 1E), indicating that GLA deficiency does not impair endothelial differentiation efficiency. However, enzymatic assays revealed a complete loss of GLA activity in GLA-KO hiPSC-derived ECs, whereas WT hiPSC-derived ECs retained robust enzyme activity (Fig. 1F). Together, these results demonstrate that while GLA deficiency does not affect the endothelial differentiation potential of hiPSCs, it fully abrogates GLA enzymatic function. This system thus provides a genetically defined and functionally validated in vitro model to study Fabry disease-associated vascular pathology.

    2. Hypertrophic phenotype in cardiomyocytes derived from GLA-KO hiPSCs

    Given that left ventricular hypertrophy is a hallmark clinical feature of Fabry disease, we next differentiated WT and GLA-KO hiPSCs into CMs using a chemically defined monolayer protocol (Fig. 2A). To assess hypertrophic changes, we measured the cell size of day 30 CMs. Immunofluorescence staining for cTnT showed that GLA-KO hiPSC-derived CMs exhibited significantly increased cell size compared to WT counterparts (Fig. 2B and 2C). To further investigate hypertrophic signaling, we examined the localization of NFATC4 ―a transcription factor that translocates into the nucleus in response to hypertrophic stimuli. In GLA-KO hiPSC-derived CMs, NFATC4 was predominantly nuclear, whereas in WT hiPSC-derived CMs, it remained cytoplasmic (Fig. 2D, yellow arrow). These findings indicate that GLA deficiency induces a hypertrophic phenotype in hiPSC-derived CMs, recapitulating features of Fabry cardiomyopathy.

    3. GLA-deficient endothelial cells exhibit impaired angiogenic function and elevated oxidative stress

    To assess the functional impairment caused by GLA deficiency in ECs, we compared the morphology of WT and GLAKO hiPSC-derived ECs under phase-contrast microscope. Both cell types exhibited a typical cobblestone-like appearance, with no overt morphological differences (Fig. 3A, upper panel). However, when subjected to a Matrigel-based tube formation assay, GLA-KO ECs displayed a markedly impaired ability to form tube-like vascular structures compared to WT ECs, indicating compromised angiogenic function (Fig. 3A, lower panel). To elucidate potential mechanisms underlying this dysfunction, we assessed the expression of inflammatory markers via qRTPCR. GLA-KO ECs exhibited significantly elevated expressions of ICAM1, VCAM1, and SELE (Fig. 3B), suggesting the activation of a pro-inflammatory phenotype. Since inflammation is closely linked to oxidative stress, we evaluated intracellular ROS levels using MitoSOXTM Red and CellROXTM staining. Both mitochondrial and cytoplasmic ROS levels were substantially elevated in GLA-KO ECs relative to WT ECs (Fig. 4A and 4B). Taken together, these findings support a model in which GLA deficiency leads to the lysosomal accumulation of Gb3, triggering excessive production of mitochondrial and cytoplasmic ROS. The resulting oxidative stress amplifies pro-inflammatory signaling cascades, thereby contributing to vascular endothelial dysfunction (Fig. 5).

    Discussion

    Although clinical manifestations of Fabry disease span various organ systems, including the kidneys, heart, and nervous system, cardiovascular complications are particularly critical and contribute significantly to disease morbidity [10]. In this study, we established a GLA-KO hiPSC model via CRISPR/ Cas9 genome editing tool, and differentiated it into two major cardiovascular lineages to investigate the cellular phenotypes associated with Fabry disease. Our findings demonstrate that GLA-KO hiPSC-derived cardiovascular cells recapitulate key pathological features of the disease, including endothelial dysfunction and CM hypertrophy. Importantly, our data suggest a mechanistic cascade in which Gb3 accumulation promotes ROS production, which in turn amplifies inflammatory signaling and disrupts endothelial homeostasis. These phenotypes are consistent with previous clinical and preclinical findings implicating vascular inflammation and redox imbalance in Fabry pathogenesis [11,12]. Recent literature further supports this link, demonstrating that lysosomal Gb3 accumulation can trigger oxidative stress through NOX2 activation and mitochondrial dysfunction, ultimately impairing autophagy and intracellular trafficking. These interconnected pathways are increasingly recognized as contributors to cardiovascular remodeling and inflammation in Fabry disease [13]. This cellular stress response, including mitochondrial ROS production and autophagic impairment, may in turn contribute to downstream functional consequences such as vascular stiffness, leukocyte adhesion, and eventual microvascular dysfunction―features commonly observed in Fabry patients [14]. This pathophysiological sequence is summarized in our proposed model (Fig. 5) and aligns with accumulating evidence that Fabry disease is not solely a storage disorder, but also a disease of secondary cellular stress responses. In parallel, GLA-KO hiPSC-derived CMs exhibited increased cell size and nuclear translocation of NFATC4, a transcription factor activated during pathological hypertrophy. These results mirror clinical observations of left ventricular hypertrophy in Fabry patients and support the use of patient-independent isogenic models for dissecting Fabryassociated cardiomyopathy mechanisms [15,16]. Given the limitations of current therapies in reversing cardiac pathology, this model offers a valuable translational platform for mechanistic investigation and preclinical drug screening. Nevertheless, this study has several limitations. The 2D in vitro system does not fully recapitulate the complex multicellular and biomechanical environment of human tissues. Moreover, the analysis was limited to two cardiovascular cell types, whereas Fabry disease affects multiple organ systems. Finally, physiological factors such as shear stress and chronic metabolic cues were not included but will be important for future model refinement. Despite these limitations, our isogenic GLA-KO hiPSC-based system provides a robust and versatile platform for modeling Fabry disease. It enables mechanistic dissection of disease-driving processes such as oxidative stress, inflammation, and hypertrophy, and represents a valuable tool for developing and testing new therapeutic strategies, particularly those aimed at targeting the cardiovascular complications of Fabry disease.

    Funding

    This study was financially supported by Chonnam National University (grant number: 2021-2282, 2022-2566). This research was also supported by the Bio & Medical Technology Development Program of the National Research Foundation (NRF) funded by the Korean government (MSIT) (No. RS- 2023-00261905, 2022M3A9E4017151).

    Conflicts of Interest

    No potential conflict of interest relevant to this article was reported.

    Figure

    IJOB-50-2-74_F1.gif

    Generation and characterization of GLA-KO hiPSC-derived vascular ECs. (A) A schematic figure illustrating the generation of GLA-KO hiPSCs using CRISPR/Cas9-mediated genome editing and clonal selection. This figure was created in BioRender. Jeong, J. (2025) https://BioRender.com/6ypa1kq. (B) Targeted DNA sequence analysis showing a 10-base pair (bp) deletion in exon 3 of the GLA gene in GLA-KO hiPSCs compared to the wild-type (WT) sequence. (C) Representative Sanger sequencing chromatogram confirming the 10-bp deletion at the GLA target locus. (D) A schematic figure of the differentiation protocol used to derive vascular ECs from hiPSCs. (E) Flow cytometry analysis of differentiated ECs stained for CD31-PE and CD144-Alexa647. (F) GLA activity assay in ECs derived from WT and GLA-KO hiPSCs. Data are presented as the mean ± standard deviation of four independent experiments.

    GLA, α-Galactosidase A; GLA-KO, GLA-knockout; hiPSC, human induced pluripotent stem cell; EC, endothelial cell.

    ****p < 0.0001 vs. DMSO control.

    IJOB-50-2-74_F2.gif

    Characterization of CMs derived from GLA-KO hiPSCs. (A) A schematic representation of the differentiation protocol used to generate CMs from hiPSCs. Differentiation was induced by sequential modulation of Wnt signaling using CHIR99021 and IWR2. (B) Representative immunofluorescence images of day 30 CMs derived from wild-type (WT) and GLA-KO hiPSCs. Cells were stained with cTnT (green) and DAPI (blue). Scale bar, 20 μm. (C) Quantification of cell size in WT and GLA-KO hiPSC-derived CMs at day 30 (n = 100). (D) Immunofluorescence staining for NFATC4 (red) and DAPI (blue) in D30 CMs. In GLA-KO hiPSC-derived CMs, NFATC4 showed predominant nuclear localization (yellow arrows), indicative of hypertrophic signaling activation. Scale bar is 20 μm.

    GLA, α-Galactosidase A; GLA-KO, GLA-knockout; hiPSC, human induced pluripotent stem cell; CM, cardiomyocyte; cTnT, cardiac troponin T; NFATC4, nuclear factor of activated T cells, cytoplasmic 4.

    ****p < 0.0001.

    IJOB-50-2-74_F3.gif

    GLA-KO ECs exhibit impaired tube formation and elevated pro-inflammatory genes. (A) Representative phase-contrast and tube formation images of hiPSC-derived ECs on Matrigel acquired on day 20 of differentiation using an inverted microscope. Scale bars indicate 100 μm. (B) Quantitative RT-PCR analysis of inflammatory gene expression (ICAM1, VCAM1, SELE) in WT and GLA-KO ECs. Data represent mean ± standard deviation from three biological replicates.

    GLA, α-Galactosidase A; GLA-KO, GLAknockout; hiPSC, human induced pluripotent stem cell; RT-PCR, reverse transcription polymerase chain reaction; WT, wild-type; EC, endothelial cell.

    *p < 0.05, **p < 0.01.

    IJOB-50-2-74_F4.gif

    Elevated oxidative stress in GLA deficienct ECs. (A) MitoSOX Red staining for mitochondrial ROS and CellROX staining for general cytoplasmic ROS in WT and GLA-KO ECs. Scale bars indicate 100 μm. (B) Quantification of MitoSOX and CellROX fluorescence intensity. Data represent mean ± standard deviation from nine biological replicates.

    GLA, α-Galactosidase A; GLA-KO, GLAknockout; ROS, reactive oxygen species; WT, wild-type; EC, endothelial cell.

    *p < 0.05, **p < 0.01.

    IJOB-50-2-74_F5.gif

    Proposed model of Fabry diseaseassociated endothelial dysfunction in GLAdeficient hiPSC-derived endothelial cells.

    GLA, α-Galactosidase A; hiPSC, human induced pluripotent stem cell; Gb3, globotriaosylceramide; ROS, reactive oxygen species.

    Table

    Primers used in this paper

    Reference

    1. Mehta A, Hughes DA. Fabry disease: synonyms: alphagalactosidase a deficiency, anderson-fabry disease [Internet]. Seattle: University of Washington; 2024 [cited 2025 Mar 20]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1292/
    2. Amodio F, Caiazza M, Monda E, Rubino M, Capodicasa L, Chiosi F, Simonelli V, Dongiglio F, Fimiani F, Pepe N, Chimenti C, Calabrò P, Limongelli G. An overview of molecular mechanisms in Fabry disease. Biomolecules 2022;12.
    3. Schiffmann R, Kopp JB, Austin HA 3rd, Sabnis S, Moore DF, Weibel T, Balow JE, Brady RO. Enzyme replacement therapy in Fabry disease: a randomized controlled trial. JAMA 2001;285:2743-9.
    4. Germain DP. Fabry disease. Orphanet J Rare Dis 2010;5:30.
    5. Azevedo O, Gago MF, Miltenberger-Miltenyi G, Sousa N, Cunha D. Fabry disease therapy: state-of-the-art and current challenges. Int J Mol Sci 2020;22:206.
    6. Choi DK, Kim YK, HoonYu J, Min SH, Park SW. Genome editing of hPSCs: recent progress in hPSC-based disease modeling for understanding disease mechanisms. Prog Mol Biol Transl Sci 2021;181:271-87.
    7. Do HS, Park SW, Im I, Seo D, Yoo HW, Go H, Kim YH, Koh GY, Lee BH, Han YM. Enhanced thrombospondin-1 causes dysfunction of vascular endothelial cells derived from Fabry disease-induced pluripotent stem cells. EBioMedicine 2020;52:102633.
    8. Kim YK, Yu JH, Min SH, Park SW. Generation of a GLA knockout human-induced pluripotent stem cell line, KSBCi002- A-1, using CRISPR/Cas9. Stem Cell Res 2020;42:101676.
    9. Uhm KO, Kim SJ, Jo EH, Go GY, Choi HY, Im YS, Ha HY, Kim JH, Koo SK. Generation of human induced pluripotent stem cell lines from human dermal fibroblasts using a non-integration system. Stem Cell Res 2017;21:13-5.
    10. Monda E, Falco L, Palmiero G, Rubino M, Perna A, Diana G, Verrillo F, Dongiglio F, Cirillo A, Fusco A, Caiazza M, Limongelli G. Cardiovascular involvement in Fabry’s disease: new advances in diagnostic strategies, outcome prediction and management. Card Fail Rev 2023;9:e12.
    11. Faro DC, Di Pino FL, Monte IP. Inflammation, oxidative stress, and endothelial dysfunction in the pathogenesis of vascular damage: unraveling novel cardiovascular risk factors in Fabry disease. Int J Mol Sci 2024;25:8273.
    12. Ravarotto V, Carraro G, Pagnin E, Bertoldi G, Simioni F, Maiolino G, Martinato M, Landini L, Davis PA, Calò LA. Oxidative stress and the altered reaction to it in Fabry disease: a possible target for cardiovascular-renal remodeling? PLoS One 2018;13:e0204618.
    13. Bertoldi G, Caputo I, Driussi G, Stefanelli LF, Di Vico V, Carraro G, Nalesso F, Calò LA. Biochemical mechanisms beyond glycosphingolipid accumulation in Fabry disease: might they provide additional therapeutic treatments? J Clin Med 2023;12:2063.
    14. Del Pinto R, Ferri C. The role of immunity in Fabry disease and hypertension: a review of a novel common pathway. High Blood Press Cardiovasc Prev 2020;27:539-46.
    15. Yousef Z, Elliott PM, Cecchi F, Escoubet B, Linhart A, Monserrat L, Namdar M, Weidemann F. Left ventricular hypertrophy in Fabry disease: a practical approach to diagnosis. Eur Heart J 2013;34:802-8.
    16. Li Q, Lin X, Yang X, Chang J. NFATc4 is negatively regulated in miR-133a-mediated cardiomyocyte hypertrophic repression. Am J Physiol Heart Circ Physiol 2010;298:H1340-7.