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We read the publication written by Lin et al1 with great interest. The authors suggest that the majority of functionally defective carboxypeptidase A1 (CPA1) mutations can elicit reduced expression due to nonsense-mediated decay (NMD) and therefore, only a small subset of the earlier reported CPA1 variants2 will predispose to chronic pancreatitis (CP) via the misfolding-dependent pathway.3 This paper seemingly offered an explanation for the earlier finding of Wu et al4 where the authors reported no association with CP of rare functionally defective CPA1 variants in a large Chinese cohort.
However, it was earlier reported that functionally impaired variants of the CPA1 gene were strongly associated with sporadic cases of non-alcoholic, early-onset CP in European, Indian and Japanese populations.5 In addition, members of two Polish families carrying the p.S282P variant of the CPA1 gene developed hereditary CP.6 Protein misfolding and consequent endoplasmic reticulum (ER) stress were described as a potential disease mechanism of hereditary pancreatitis caused by loss-of-function variants of CPA1 and PRSS1 genes.3 6 7 Recently, the finding that a knock-in mouse model carrying the misfolding-causing p.N256K CPA1 variant developed CP confirmed the significance of the misfolding-dependent pathway in the disease mechanism8 and revealed a novel opportunity for in vivo …
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