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Altered Energetics of Exercise Explain Risk of Rhabdomyolysis in Very Long-Chain Acyl-CoA Dehydrogenase Deficiency. PLoS One 2016; 11:e0147818. [PMID: 26881790 PMCID: PMC4755596 DOI: 10.1371/journal.pone.0147818] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 01/09/2016] [Indexed: 12/31/2022] Open
Abstract
Rhabdomyolysis is common in very long-chain acyl-CoA dehydrogenase deficiency (VLCADD) and other metabolic myopathies, but its pathogenic basis is poorly understood. Here, we show that prolonged bicycling exercise against a standardized moderate workload in VLCADD patients is associated with threefold bigger changes in phosphocreatine (PCr) and inorganic phosphate (Pi) concentrations in quadriceps muscle and twofold lower changes in plasma acetyl-carnitine levels than in healthy subjects. This result is consistent with the hypothesis that muscle ATP homeostasis during exercise is compromised in VLCADD. However, the measured rates of PCr and Pi recovery post-exercise showed that the mitochondrial capacity for ATP synthesis in VLCADD muscle was normal. Mathematical modeling of oxidative ATP metabolism in muscle composed of three different fiber types indicated that the observed altered energy balance during submaximal exercise in VLCADD patients may be explained by a slow-to-fast shift in quadriceps fiber-type composition corresponding to 30% of the slow-twitch fiber-type pool in healthy quadriceps muscle. This study demonstrates for the first time that quadriceps energy balance during exercise in VLCADD patients is altered but not because of failing mitochondrial function. Our findings provide new clues to understanding the risk of rhabdomyolysis following exercise in human VLCADD.
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Immonen T, Ahola E, Toppila J, Lapatto R, Tyni T, Lauronen L. Peripheral neuropathy in patients with long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency - A follow-up EMG study of 12 patients. Eur J Paediatr Neurol 2016; 20:38-44. [PMID: 26653362 DOI: 10.1016/j.ejpn.2015.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 10/14/2015] [Accepted: 10/21/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND The neonatal screening and early start of the dietary therapy have improved the outcome of long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD). The acute symptoms of LCHADD are hypoketotic hypoglycemia, failure to thrive, hepatopathy and rhabdomyolysis. Long term complications are retinopathy and neuropathy. Speculated etiology of these long term complications are the accumulation and toxicity of hydroxylacylcarnitines and long-chain fatty acid metabolites or deficiency of essential fatty acids. AIMS To study the possible development of polyneuropathy in LCHADD patients with current dietary regimen. METHODS Development of polyneuropathy in 12 LCHADD patients with the homozygous common mutation c.G1528C was evaluated with electroneurography (ENG) studies. The ENG was done 1-12 times to each patient, between the ages of 3 and 40 years. Clinical data of the patients were collected from the patient records. RESULTS The first sign of polyneuropathy was detected between the ages of 6-12 years, the first abnormality being reduction of the sensory amplitudes of the sural nerves. With time, progression was detected by abnormalities in sensory responses extending to upper limbs, as well as abnormalities in motor responses in lower limbs. Altogether, eight of the patients had polyneuropathy, despite good compliancy of the diet. CONCLUSIONS This study is the first to report the evolution of polyneuropathy with clinical neurophysiological methods in a relative large LCHADD patient group. Despite early start, and good compliance of the therapy, 6/10 of the younger patients developed neuropathy. However, in most patients the polyneuropathy was less severe than previously described.
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Affiliation(s)
- Tuuli Immonen
- Children's Hospital, University of Helsinki, Helsinki University Hospital, Finland.
| | - Emilia Ahola
- Children's Hospital, University of Helsinki, Helsinki University Hospital, Finland
| | - Jussi Toppila
- Department of Clinical Neurophysiology, Children's Hospital, University of Helsinki, HUS Medical Imaging Center, Finland
| | - Risto Lapatto
- Children's Hospital, University of Helsinki, Helsinki University Hospital, Finland
| | - Tiina Tyni
- Children's Hospital, University of Helsinki, Helsinki University Hospital, Finland
| | - Leena Lauronen
- Department of Clinical Neurophysiology, Children's Hospital, University of Helsinki, HUS Medical Imaging Center, Finland
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Strandqvist A, Haglind CB, Zetterström RH, Nemeth A, von Döbeln U, Stenlid MH, Nordenström A. Neuropsychological Development in Patients with Long-Chain 3-Hydroxyacyl-CoA Dehydrogenase (LCHAD) Deficiency. JIMD Rep 2015; 28:75-84. [PMID: 26545880 DOI: 10.1007/8904_2015_505] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/24/2015] [Accepted: 09/28/2015] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Reports on cognitive outcomes in long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD) are scarce. We present results from neuropsychological assessments of eight patients diagnosed with LCHADD prior to newborn screening with regard to clinical disease severity. METHODS Intellectual ability and adaptive and executive functions were assessed using age-appropriate Wechsler Scales, Adaptive Behavior Assessment Scales (ABAS), and Behavior Rating Inventory of Executive Function (BRIEF). RESULTS Five patients performed in the normal range on IQ tests but with lower scores on verbal working memory. In addition, they had lower parent-rated adaptive and executive functions.Three patients had intellectual disabilities with IQs below normal and/or autism spectrum disorders. In addition, they had low results on parent-rated adaptive functions. (Two of these patients had epilepsy.) Conclusions: Patients with LCHADD seem to have a specific cognitive pattern, with presentation as intellectual disability and specific autistic deficiencies or a normal IQ with weaknesses in auditive verbal memory and adaptive and executive functions. Future studies are warranted to investigate whether newborn screening programs and early treatment may promote improved neuropsychological development and outcomes.
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Affiliation(s)
- A Strandqvist
- Department of Women and Children's Health, Karolinska Institutet, 171 76, Stockholm, Sweden.,Department of Psychology, Karolinska University Hospital, Stockholm, Sweden
| | - C Bieneck Haglind
- Department of Women and Children's Health, Karolinska Institutet, 171 76, Stockholm, Sweden. .,Department of Pediatrics, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.
| | - R H Zetterström
- Departments of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Center for Inherited Metabolic Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - A Nemeth
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatric Gastroenterology, Hepatology and Nutrition, Karolinska University Hospital, Stockholm, Sweden
| | - U von Döbeln
- Center for Inherited Metabolic Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Laboratory Medicine, Division for Metabolic Diseases, Karolinska Institutet, Stockholm, Sweden
| | - M Halldin Stenlid
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - A Nordenström
- Department of Women and Children's Health, Karolinska Institutet, 171 76, Stockholm, Sweden.,Department of Pediatric Endocrinology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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Houten SM, Violante S, Ventura FV, Wanders RJA. The Biochemistry and Physiology of Mitochondrial Fatty Acid β-Oxidation and Its Genetic Disorders. Annu Rev Physiol 2015; 78:23-44. [PMID: 26474213 DOI: 10.1146/annurev-physiol-021115-105045] [Citation(s) in RCA: 477] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Mitochondrial fatty acid β-oxidation (FAO) is the major pathway for the degradation of fatty acids and is essential for maintaining energy homeostasis in the human body. Fatty acids are a crucial energy source in the postabsorptive and fasted states when glucose supply is limiting. But even when glucose is abundantly available, FAO is a main energy source for the heart, skeletal muscle, and kidney. A series of enzymes, transporters, and other facilitating proteins are involved in FAO. Recessively inherited defects are known for most of the genes encoding these proteins. The clinical presentation of these disorders may include hypoketotic hypoglycemia, (cardio)myopathy, arrhythmia, and rhabdomyolysis and illustrates the importance of FAO during fasting and in hepatic and (cardio)muscular function. In this review, we present the current state of knowledge on the biochemistry and physiological functions of FAO and discuss the pathophysiological processes associated with FAO disorders.
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Affiliation(s)
- Sander M Houten
- Department of Genetics and Genomic Sciences and Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, NY 10029; ,
| | - Sara Violante
- Department of Genetics and Genomic Sciences and Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, NY 10029; ,
| | - Fatima V Ventura
- Metabolism and Genetics Group, Research Institute for Medicines and Pharmaceutical Sciences, iMed.ULisboa, 1649-003 Lisboa, Portugal; .,Department of Biochemistry and Human Biology, Faculty of Pharmacy, University of Lisbon, 1649-003 Lisboa, Portugal
| | - Ronald J A Wanders
- Laboratory Genetic Metabolic Diseases, Department of Clinical Chemistry, University of Amsterdam, 1100 DE Amsterdam, The Netherlands; .,Department of Pediatrics, Emma Children's Hospital, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Haack TB, Jackson CB, Murayama K, Kremer LS, Schaller A, Kotzaeridou U, de Vries MC, Schottmann G, Santra S, Büchner B, Wieland T, Graf E, Freisinger P, Eggimann S, Ohtake A, Okazaki Y, Kohda M, Kishita Y, Tokuzawa Y, Sauer S, Memari Y, Kolb-Kokocinski A, Durbin R, Hasselmann O, Cremer K, Albrecht B, Wieczorek D, Engels H, Hahn D, Zink AM, Alston CL, Taylor RW, Rodenburg RJ, Trollmann R, Sperl W, Strom TM, Hoffmann GF, Mayr JA, Meitinger T, Bolognini R, Schuelke M, Nuoffer JM, Kölker S, Prokisch H, Klopstock T. Deficiency of ECHS1 causes mitochondrial encephalopathy with cardiac involvement. Ann Clin Transl Neurol 2015; 2:492-509. [PMID: 26000322 PMCID: PMC4435704 DOI: 10.1002/acn3.189] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 02/03/2015] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Short-chain enoyl-CoA hydratase (ECHS1) is a multifunctional mitochondrial matrix enzyme that is involved in the oxidation of fatty acids and essential amino acids such as valine. Here, we describe the broad phenotypic spectrum and pathobiochemistry of individuals with autosomal-recessive ECHS1 deficiency. METHODS Using exome sequencing, we identified ten unrelated individuals carrying compound heterozygous or homozygous mutations in ECHS1. Functional investigations in patient-derived fibroblast cell lines included immunoblotting, enzyme activity measurement, and a palmitate loading assay. RESULTS Patients showed a heterogeneous phenotype with disease onset in the first year of life and course ranging from neonatal death to survival into adulthood. The most prominent clinical features were encephalopathy (10/10), deafness (9/9), epilepsy (6/9), optic atrophy (6/10), and cardiomyopathy (4/10). Serum lactate was elevated and brain magnetic resonance imaging showed white matter changes or a Leigh-like pattern resembling disorders of mitochondrial energy metabolism. Analysis of patients' fibroblast cell lines (6/10) provided further evidence for the pathogenicity of the respective mutations by showing reduced ECHS1 protein levels and reduced 2-enoyl-CoA hydratase activity. While serum acylcarnitine profiles were largely normal, in vitro palmitate loading of patient fibroblasts revealed increased butyrylcarnitine, unmasking the functional defect in mitochondrial β-oxidation of short-chain fatty acids. Urinary excretion of 2-methyl-2,3-dihydroxybutyrate - a potential derivative of acryloyl-CoA in the valine catabolic pathway - was significantly increased, indicating impaired valine oxidation. INTERPRETATION In conclusion, we define the phenotypic spectrum of a new syndrome caused by ECHS1 deficiency. We speculate that both the β-oxidation defect and the block in l-valine metabolism, with accumulation of toxic methacrylyl-CoA and acryloyl-CoA, contribute to the disorder that may be amenable to metabolic treatment approaches.
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Affiliation(s)
- Tobias B Haack
- Institute of Human Genetics, Technische Universität München81675, Munich, Germany
- Institute of Human Genetics, Helmholtz Zentrum München, German Research Center for Environmental Health85764, Neuherberg, Germany
| | - Christopher B Jackson
- Institute of Clinical Chemistry and University Children's Hospital, University of Bern3010, Bern, Switzerland
| | - Kei Murayama
- Department of Metabolism, Chiba Children's HospitalChiba, 266-0007, Japan
| | - Laura S Kremer
- Institute of Human Genetics, Technische Universität München81675, Munich, Germany
- Institute of Human Genetics, Helmholtz Zentrum München, German Research Center for Environmental Health85764, Neuherberg, Germany
| | - André Schaller
- Division of Human Genetics, Department of Pediatrics, University of Bern3010, Bern, Switzerland
| | - Urania Kotzaeridou
- Divisions of Inherited Metabolic Disease and Neuropediatrics, Department of General Pediatrics, University Hospital HeidelbergD-69120, Heidelberg, Germany
| | - Maaike C de Vries
- Department of Pediatrics, Nijmegen Center for Mitochondrial Disorders, Radboud University Center6525 GA, Nijmegen, The Netherlands
| | - Gudrun Schottmann
- Department of Neuropediatrics and NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin13353, Berlin, Germany
| | - Saikat Santra
- Department of Pediatrics, Birmingham Children's HospitalBirmingham, B4 6NH, United Kingdom
| | - Boriana Büchner
- Department of Neurology, Friedrich-Baur-Institute, Ludwig-Maximilians-University80336, Munich, Germany
| | - Thomas Wieland
- Institute of Human Genetics, Technische Universität München81675, Munich, Germany
- Institute of Human Genetics, Helmholtz Zentrum München, German Research Center for Environmental Health85764, Neuherberg, Germany
| | - Elisabeth Graf
- Institute of Human Genetics, Technische Universität München81675, Munich, Germany
- Institute of Human Genetics, Helmholtz Zentrum München, German Research Center for Environmental Health85764, Neuherberg, Germany
| | - Peter Freisinger
- Department of Pediatrics, Klinikum Reutlingen72764, Reutlingen, Germany
| | - Sandra Eggimann
- Institute of Clinical Chemistry and University Children's Hospital, University of Bern3010, Bern, Switzerland
| | - Akira Ohtake
- Department of Pediatrics, Faculty of Medicine, Saitama Medical UniversitySaitama, 350-0495, Japan
| | - Yasushi Okazaki
- Division of Translational Research, Research Center for Genomic Medicine, Saitama Medical UniversitySaitama, 350-1241, Japan
- Division of Functional Genomics & Systems Medicine, Research Center for Genomic Medicine, Saitama Medical UniversitySaitama, 350-1241, Japan
| | - Masakazu Kohda
- Division of Translational Research, Research Center for Genomic Medicine, Saitama Medical UniversitySaitama, 350-1241, Japan
| | - Yoshihito Kishita
- Division of Functional Genomics & Systems Medicine, Research Center for Genomic Medicine, Saitama Medical UniversitySaitama, 350-1241, Japan
| | - Yoshimi Tokuzawa
- Division of Functional Genomics & Systems Medicine, Research Center for Genomic Medicine, Saitama Medical UniversitySaitama, 350-1241, Japan
| | - Sascha Sauer
- Max-Planck-Institute for Molecular Genetics, Otto-Warburg Laboratory14195, Berlin, Germany
| | - Yasin Memari
- Wellcome Trust Sanger InstituteHinxton, Cambridge, CB10 1SA, United Kingdom
| | | | - Richard Durbin
- Wellcome Trust Sanger InstituteHinxton, Cambridge, CB10 1SA, United Kingdom
| | - Oswald Hasselmann
- Department of Neuropediatrics, Children's Hospital of Eastern Switzerland St.Gallen9006, St. Gallen, Switzerland
| | - Kirsten Cremer
- Institute of Human Genetics, University of Bonn53127, Bonn, Germany
| | - Beate Albrecht
- Institut für Humangenetik, Universitätsklinikum Essen, Universität Duisburg-Essen45122, Essen, Germany
| | - Dagmar Wieczorek
- Institut für Humangenetik, Universitätsklinikum Essen, Universität Duisburg-Essen45122, Essen, Germany
| | - Hartmut Engels
- Institute of Human Genetics, University of Bonn53127, Bonn, Germany
| | - Dagmar Hahn
- Institute of Clinical Chemistry and University Children's Hospital, University of Bern3010, Bern, Switzerland
| | - Alexander M Zink
- Institute of Human Genetics, University of Bonn53127, Bonn, Germany
| | - Charlotte L Alston
- Wellcome Trust Centre for Mitochondrial Research, Institute of Neuroscience, The Medical School, Newcastle UniversityNewcastle upon Tyne, NE2 4HH, United Kingdom
| | - Robert W Taylor
- Wellcome Trust Centre for Mitochondrial Research, Institute of Neuroscience, The Medical School, Newcastle UniversityNewcastle upon Tyne, NE2 4HH, United Kingdom
| | - Richard J Rodenburg
- Department of Pediatrics, Nijmegen Center for Mitochondrial Disorders, Radboud University Center6525 GA, Nijmegen, The Netherlands
| | - Regina Trollmann
- Department of Pediatrics, Friedrich-Alexander-University of Erlangen-Nürnberg91054, Erlangen, Germany
| | - Wolfgang Sperl
- Department of Pediatrics, Paracelsus Medical University Salzburg5020, Salzburg, Austria
| | - Tim M Strom
- Institute of Human Genetics, Technische Universität München81675, Munich, Germany
- Institute of Human Genetics, Helmholtz Zentrum München, German Research Center for Environmental Health85764, Neuherberg, Germany
| | - Georg F Hoffmann
- Divisions of Inherited Metabolic Disease and Neuropediatrics, Department of General Pediatrics, University Hospital HeidelbergD-69120, Heidelberg, Germany
| | - Johannes A Mayr
- Department of Pediatrics, Paracelsus Medical University Salzburg5020, Salzburg, Austria
| | - Thomas Meitinger
- Institute of Human Genetics, Technische Universität München81675, Munich, Germany
- Institute of Human Genetics, Helmholtz Zentrum München, German Research Center for Environmental Health85764, Neuherberg, Germany
- Munich Cluster for Systems Neurology (SyNergy)80336, Munich, Germany
- DZNE – German Center for Neurodegenerative Diseases80336, Munich, Germany
| | - Ramona Bolognini
- Division of Human Genetics, Department of Pediatrics, University of Bern3010, Bern, Switzerland
| | - Markus Schuelke
- Department of Neuropediatrics and NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin13353, Berlin, Germany
| | - Jean-Marc Nuoffer
- Institute of Clinical Chemistry and University Children's Hospital, University of Bern3010, Bern, Switzerland
| | - Stefan Kölker
- Divisions of Inherited Metabolic Disease and Neuropediatrics, Department of General Pediatrics, University Hospital HeidelbergD-69120, Heidelberg, Germany
| | - Holger Prokisch
- Institute of Human Genetics, Technische Universität München81675, Munich, Germany
- Institute of Human Genetics, Helmholtz Zentrum München, German Research Center for Environmental Health85764, Neuherberg, Germany
| | - Thomas Klopstock
- Department of Neurology, Friedrich-Baur-Institute, Ludwig-Maximilians-University80336, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy)80336, Munich, Germany
- DZNE – German Center for Neurodegenerative Diseases80336, Munich, Germany
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Haglind CB, Nordenström A, Ask S, von Döbeln U, Gustafsson J, Stenlid MH. Increased and early lipolysis in children with long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency during fast. J Inherit Metab Dis 2015; 38:315-22. [PMID: 25141826 DOI: 10.1007/s10545-014-9750-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 07/03/2014] [Accepted: 07/16/2014] [Indexed: 12/31/2022]
Abstract
Children with long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHAD) have a defect in the degradation of long-chain fatty acids and are at risk of hypoketotic hypoglycemia and insufficient energy production as well as accumulation of toxic fatty acid intermediates. Knowledge on substrate metabolism in children with LCHAD deficiency during fasting is limited. Treatment guidelines differ between centers, both as far as length of fasting periods and need for night feeds are concerned. To increase the understanding of fasting intolerance and improve treatment recommendations, children with LCHAD deficiency were investigated with stable isotope technique, microdialysis, and indirect calometry, in order to assess lipolysis and glucose production during 6 h of fasting. We found an early and increased lipolysis and accumulation of long chain acylcarnitines after 4 h of fasting, albeit no patients developed hypoglycemia. The rate of glycerol production, reflecting lipolysis, averaged 7.7 ± 1.6 µmol/kg/min, which is higher compared to that of peers. The rate of glucose production was normal for age; 19.6 ± 3.4 µmol/kg/min (3.5 ± 0.6 mg/kg/min). Resting energy expenditure was also normal, even though the respiratory quotient was increased indicating mainly glucose oxidation. The results show that lipolysis and accumulation of long chain acylcarnitines occurs before hypoglycemia in fasting children with LCHAD, which may indicate more limited fasting tolerance than previously suggested.
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Affiliation(s)
- C Bieneck Haglind
- Women's and Children's Health, Karolinska Institute, Stockholm, Sweden,
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Karall D, Brunner-Krainz M, Kogelnig K, Konstantopoulou V, Maier EM, Möslinger D, Plecko B, Sperl W, Volkmar B, Scholl-Bürgi S. Clinical outcome, biochemical and therapeutic follow-up in 14 Austrian patients with Long-Chain 3-Hydroxy Acyl CoA Dehydrogenase Deficiency (LCHADD). Orphanet J Rare Dis 2015; 10:21. [PMID: 25888220 PMCID: PMC4407779 DOI: 10.1186/s13023-015-0236-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 01/29/2015] [Indexed: 12/31/2022] Open
Abstract
Background LCHADD is a long-fatty acid oxidation disorder with immediate symptoms and long-term complications. We evaluated data on clinical status, biochemical parameters, therapeutic regimens and outcome of Austrian LCHADD patients. Study design Clinical and outcome data including history, diagnosis, short- and long-term manifestations, growth, psychomotor development, hospitalizations, therapy of 14 Austrian patients with LCHADD were evaluated. Biochemically, we evaluated creatine kinase (CK) and acyl carnitine profiles. Results All LCHADD patients are homozygous for the common mutation. Three are siblings. Diagnosis was first established biochemically. Nine/14 (64%) were prematures, with IRDS occurring in six. In nine (64%), diagnosis was established through newborn screening, the remaining five (36%) were diagnosed clinically. Four pregnancies were complicated by HELLP syndrome, one by preeclampsia. In two, intrauterine growth retardation and placental insufficiency were reported. Five were diagnosed with hepatopathy at some point, seven with cardiomyopathy and eight with retinopathy, clinically relevant only in one patient. Polyneuropathy is only present in one. Three patients have a PEG, one is regularly fed via NG-tube. Growth is normal in all, as well as psychomotor development, except for two extremely premature girls. In 11 patients, 165 episodes with elevated creatine kinase concentrations were observed with 6-31 (median 14) per patient; three have shown no elevated CK concentrations. Median total carnitine on therapy was 19 μmol/l (range 11-61). For 14 patients, there have been 181 hospitalizations (median 9 per patient), comprising 1337 in-patient-days. All centres adhere to treatment with a fat-defined diet; patients have between 15% and 40% of their energy intake from fat (median 29%), out of which between 20% and 80% are medium-chain triglycerides (MCT) (median 62%). Four patients have been treated with heptanoate (C7). Conclusion Our data show LCHADD outcome can be favourable. Growth and psychomotor development is normal, except in two prematures. Frequency of CK measurements decreases with age, correlating with a decreasing number of hospitalizations. About 50% develop complications affecting different organ systems. There is no relevant difference between the patients treated in the respective centers. Concluding from single case reports, anaplerotic therapy with heptanoate should be further evaluated.
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Affiliation(s)
- Daniela Karall
- Medical University of Innsbruck, Clinic for Pediatrics, Inherited Metabolic Disorders, Anichstrasse 35, 6020, Innsbruck, Austria.
| | | | - Katharina Kogelnig
- Medical University of Innsbruck, Clinic for Pediatrics, Inherited Metabolic Disorders, Anichstrasse 35, 6020, Innsbruck, Austria.
| | | | - Esther M Maier
- Dr. von Hauner Children's Hospital, University of Munich, Munich, Germany.
| | | | | | | | | | - Sabine Scholl-Bürgi
- Medical University of Innsbruck, Clinic for Pediatrics, Inherited Metabolic Disorders, Anichstrasse 35, 6020, Innsbruck, Austria.
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Martin JM, Gillingham MB, Harding CO. Use of propofol for short duration procedures in children with long chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) or trifunctional protein (TFP) deficiencies. Mol Genet Metab 2014; 112:139-42. [PMID: 24780638 PMCID: PMC4121654 DOI: 10.1016/j.ymgme.2014.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/26/2014] [Accepted: 03/26/2014] [Indexed: 11/28/2022]
Abstract
The medication propofol, commonly used for anesthesia, has been avoided in patients with mitochondrial fatty acid oxidation disorders (FAODs) due to concerns that it contains long-chain fatty acids (LCFAs), and because of reports of severe side effects in some critically ill patients receiving high-dose propofol infusions that mimic some of the symptoms regularly found in FAOD patients. In this secondary analysis, we examined the outcomes of 8 children with long-chain 3-hydroxyacyl CoA dehydrogenase (LCHAD) deficiency or trifunctional protein (TFP) deficiency who were repeatedly sedated for an electroretinogram (ERG) as part of a longitudinal study of the progression of chorioretinopathy commonly found in this population. A total of 39 sedated ERG procedures were completed using propofol for sedation. The propofol dosing, estimated total energy needs of the subject, and inpatient dietary intake recording were completed in 32 of these procedures. The LCFAs in the propofol provided approximately 1.0% of the average total daily energy needs. The sedation with propofol resulted in no adverse side effects and was safely used in this short duration procedure.
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Affiliation(s)
- Julie M Martin
- Department of Molecular & Medical Genetics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Melanie B Gillingham
- Department of Molecular & Medical Genetics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA; Graduate Programs in Human Nutrition, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Cary O Harding
- Department of Molecular & Medical Genetics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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60
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Anderson S, Brooks SS. When the usual symptoms become an unusual diagnosis: a case report of trifunctional protein complex. Neonatal Netw 2013; 32:262-273. [PMID: 23835545 DOI: 10.1891/0730-0832.32.4.262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Disorders of mitochondrial fatty acid b-oxidation should be considered in any infant who presents with unexplained hypoglycemia and/or myopathy. Although disorders of trifunctional protein (TFP) complex including long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) and mitochondrial TFP deficiencies are extremely rare, the combined incidence of mitochondrial fatty acid disorders is quite frequent. With the expansion of newborn screening, what were once considered uncommon disorders are being identified with increasing frequency in asymptomatic infants. The following case scenario presents an infant who developed symptoms prior to the completion of newborn screening. This fairly routine course for a late-preterm infant reveals an extremely rare inborn error of metabolism, LCHAD deficiency. An overview of TFP complex, the differential diagnoses as the case unfolds, diagnostic test results, acute care management, and short-term patient follow-up is presented. With experience, health care providers often become accustomed to and expect to see common things regularly. This case presents a scenario which, as it unfolds, appears to be quite common. It turns out, however, to be very uncommon.
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Affiliation(s)
- Sharon Anderson
- University of Medicine and Dentistry of New Jersey-School of Nursing, Newark, NJ 07101, USA.
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Olpin SE. Pathophysiology of fatty acid oxidation disorders and resultant phenotypic variability. J Inherit Metab Dis 2013; 36:645-58. [PMID: 23674167 PMCID: PMC7101856 DOI: 10.1007/s10545-013-9611-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 03/27/2013] [Accepted: 04/10/2013] [Indexed: 12/16/2022]
Abstract
Fatty acids are a major fuel for the body and fatty acid oxidation is particularly important during fasting, sustained aerobic exercise and stress. The myocardium and resting skeletal muscle utilise long-chain fatty acids as a major source of energy. Inherited disorders affecting fatty acid oxidation seriously compromise the function of muscle and other highly energy-dependent tissues such as brain, nerve, heart, kidney and liver. Such defects encompass a wide spectrum of clinical disease, presenting in the neonatal period or infancy with recurrent hypoketotic hypoglycaemic encephalopathy, liver dysfunction, hyperammonaemia and often cardiac dysfunction. In older children, adolescence or adults there is often exercise intolerance with episodic myalgia or rhabdomyolysis in association with prolonged aerobic exercise or other exacerbating factors. Some disorders are particularly associated with toxic metabolites that may contribute to encephalopathy, polyneuropathy, axonopathy and pigmentary retinopathy. The phenotypic diversity encountered in defects of fat oxidation is partly explained by genotype/phenotype correlation and certain identifiable environmental factors but there remain many unresolved questions regarding the complex interaction of genetic, epigenetic and environmental influences that dictate phenotypic expression. It is becoming increasingly clear that the view that most inherited disorders are purely monogenic diseases is a naive concept. In the future our approach to understanding the phenotypic diversity and management of patients will be more realistically achieved from a polygenic perspective.
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Affiliation(s)
- Simon E Olpin
- Department of Clinical Chemistry, Sheffield Children's Hospital, Sheffield S10 2TH, UK.
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Shi T, Moravec CS, Perez DM. Novel proteins associated with human dilated cardiomyopathy: selective reduction in α(1A)-adrenergic receptors and increased desensitization proteins. J Recept Signal Transduct Res 2013; 33:96-106. [PMID: 23384050 DOI: 10.3109/10799893.2013.764897] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract Therapeutics to treat human heart failure (HF) and the identification of proteins associated with HF are still limited. We analyzed α(1)-adrenergic receptor (AR) subtypes in human HF and performed proteomic analysis on more uniform samples to identify novel proteins associated with human HF. Six failing hearts with end-stage dilated cardiomyopathy (DCM) and four non-failing heart controls were subjected to proteomic analysis. Out of 48 identified proteins, 26 proteins were redundant between samples. Ten of these 26 proteins were previously reported to be associated with HF. Of the newly identified proteins, we found several muscle proteins and mitochondrial/electron transport proteins, while novel were functionally similar to previous reports. However, we also found novel proteins involved in functional classes such as β-oxidation and G-protein coupled receptor signaling and desensitization not previously associated with HF. We also performed radioligand-binding studies on the heart samples and not only confirmed a large loss of β(1)-ARs in end-stage DCM, but also found a selective decrease in the α(1A)-AR subtype not previously reported. We have identified new proteins and functional categories associated with end-stage DCM. We also report that similar to the previously characterized loss of β(1)-AR in HF, there is also a concomitant loss of α(1A)-ARs, which are considered cardioprotective proteins.
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Affiliation(s)
- Ting Shi
- Department of Molecular Cardiology, Lerner Research Institute, Cleveland, OH, USA
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63
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Yiu EM, Ryan MM. Genetic axonal neuropathies and neuronopathies of pre-natal and infantile onset. J Peripher Nerv Syst 2012; 17:285-300. [DOI: 10.1111/j.1529-8027.2012.00412.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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64
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Haglind CB, Stenlid MH, Ask S, Alm J, Nemeth A, Döbeln U, Nordenström A. Growth in Long-Chain 3-Hydroxyacyl-CoA Dehydrogenase Deficiency. JIMD Rep 2012; 8:81-90. [PMID: 23430524 DOI: 10.1007/8904_2012_164] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Revised: 05/16/2012] [Accepted: 06/11/2012] [Indexed: 12/14/2022] Open
Abstract
UNLABELLED Long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency is an inborn error of fatty acid metabolism that affects the degradation of long chain fatty acids and causes insufficient energy production and accumulation of toxic intermediates. The treatment consists of a diet low in fat, with supplementation of medium-chain triglycerides that bypass the metabolic block. In addition, frequent feeds and extra carbohydrates are given during febrile illnesses to reduce lipolysis. Hence, this diet differs from the general dietary recommendations for growing children. Furthermore, the Swedish dietary instructions for fat intake in LCHAD deficiency are given in grams, which differ from most guidelines that recommend fat intake as percentage shares of total caloric intake. AIMS To assess growth in patients with LCHAD deficiency, in relation to dietary treatment and to evaluate if overweight/obesity is more common than in the normal population. RESULTS The growth velocity showed acceleration after diagnosis and the start of treatment, followed by a period of stable or decelerated growth. The majority of the patients developed overweight to a greater extent than children without LCHAD deficiency. Several patients also went through a phase of obesity. Data on final height (FH) showed that three out of five patients had grown according to their genetic potential. CONCLUSIONS Regular and frequent follow-up and careful monitoring of weight are essential to avoid the development of overweight and obesity. The Swedish dietary instructions defining fat intake in total grams per day may be an alternative approach to achieve a moderate total caloric intake.
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Affiliation(s)
- C Bieneck Haglind
- Karolinska Institute Department of Clinical Science, Intervention and Technology, Division of Pediatrics B57, Karolinska University Hospital Huddinge, SE-141 86, Stockholm, Sweden,
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Fletcher AL, Pennesi ME, Harding CO, Weleber RG, Gillingham MB. Observations regarding retinopathy in mitochondrial trifunctional protein deficiencies. Mol Genet Metab 2012; 106:18-24. [PMID: 22459206 PMCID: PMC3506186 DOI: 10.1016/j.ymgme.2012.02.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 02/23/2012] [Accepted: 02/23/2012] [Indexed: 12/31/2022]
Abstract
Although the retina is thought to primarily rely on glucose for fuel, inherited deficiency of one or more activities of mitochondrial trifunctional protein results in a pigmentary retinopathy leading to vision loss. Many other enzymatic deficiencies in fatty acid oxidation pathways have been described, none of which results in retinal complications. The etiology of retinopathy among patients with defects in trifunctional protein is unknown. Trifunctional protein is a heteroctomer; two genes encode the alpha and beta subunits of TFP respectively, HADHA and HADHB. A common mutation in HADHA, c.1528G>C, leads to a single amino acid substitution, p. Glu474Gln, and impairs primarily long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) activity leading to LCHAD deficiency (LCHADD). Other mutations in HADHA or HADHB often lead to significant reduction in all three enzymatic activities and result in trifunctional protein deficiency (TFPD). Despite many similarities in clinical presentation and phenotype, there is growing evidence that they can result in different chronic complications. This review will outline the clinical similarities and differences between LCHADD and TFPD, describe the course of the associated retinopathy, propose a genotype/phenotype correlation with the severity of retinopathy, and discuss the current theories about the etiology of the retinopathy.
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Affiliation(s)
- Autumn L Fletcher
- Department of Molecular & Medical Genetics, School of Medicine, Oregon Health & Science University, Mail Code L-103, 3181 SW Sam Jackson Park Rd Portland, OR 97239, USA.
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Okuläre Zeichen eines mitochondrialen trifunktionalen Proteindefekts. Ophthalmologe 2012; 109:277-82. [DOI: 10.1007/s00347-011-2480-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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67
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Lamireau D, Feghali H, Redonnet-Vernhet I, Mesli S, Carles D, Brissaud O. [Acute fatty liver in pregnancy: revealing fetal fatty acid oxidation disorders]. Arch Pediatr 2012; 19:277-81. [PMID: 22325456 DOI: 10.1016/j.arcped.2011.12.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Revised: 08/20/2011] [Accepted: 12/23/2011] [Indexed: 12/20/2022]
Abstract
Acute fatty liver of pregnancy (AFLP) and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome are serious maternal illnesses occurring in the third trimester of pregnancy with significant perinatal and maternal mortality. AFLP may result from mitochondrial defects in the beta-oxidation of fatty acids, in particular a deficiency of the long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) in the fetus. Clinical findings in AFLP vary and its diagnosis is complicated by a significant overlap in clinical and biochemical features with HELLP syndrome. We report the case of 2 siblings who died, the first one in the neonatal period of asphyxia with multivisceral presentation and the second one from sudden death at 7 months. Autopsy of the latter infant revealed hepatic steatosis associated with cardiomyopathy, which led to suspicion of a fatty acid oxidation deficiency. Mutation analysis demonstrated that both children were homozygous for the common mutation c.1528G>C and the parents were heterozygous for this same mutation. This case demonstrates the importance of screening mothers with acute fatty liver disease of pregnancy and their children at birth for a metabolic disease. This article proposes several metabolic tests for mother and child suspected of having beta-oxidation of a fatty acid disorder.
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Affiliation(s)
- D Lamireau
- Unité de réanimation pédiatrique, hôpital Pellegrin-Enfants, CHU Pellegrin, place Amélie-Raba-Léon, 33076 Bordeaux-cedex, France.
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68
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Behrend AM, Harding CO, Shoemaker JD, Matern D, Sahn DJ, Elliot DL, Gillingham MB. Substrate oxidation and cardiac performance during exercise in disorders of long chain fatty acid oxidation. Mol Genet Metab 2012; 105:110-5. [PMID: 22030098 PMCID: PMC3253922 DOI: 10.1016/j.ymgme.2011.09.030] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 09/23/2011] [Accepted: 09/24/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND The use of long-chain fatty acids (LCFAs) for energy is inhibited in inherited disorders of long-chain fatty acid oxidation (FAO). Increased energy demands during exercise can lead to cardiomyopathy and rhabdomyolysis. Medium-chain triglycerides (MCTs) bypass the block in long-chain FAO and may provide an alternative energy substrate to exercising muscle. OBJECTIVES To determine the influence of isocaloric MCT versus carbohydrate (CHO) supplementation prior to exercise on substrate oxidation and cardiac workload in participants with carnitine palmitoyltransferase 2 (CPT2), very long-chain acyl-CoA dehydrogenase (VLCAD) and long-chain 3-hydroxyacyl CoA dehydrogenase (LCHAD) deficiencies. DESIGN Eleven subjects completed two 45-minute, moderate intensity, treadmill exercise studies in a randomized crossover design. An isocaloric oral dose of CHO or MCT-oil was administered prior to exercise; hemodynamic and metabolic indices were assessed during exertion. RESULTS When exercise was pretreated with MCT, respiratory exchange ratio (RER), steady state heart rate and generation of glycolytic intermediates significantly decreased while circulating ketone bodies significantly increased. CONCLUSIONS MCT supplementation prior to exercise increases the oxidation of medium chain fats, decreases the oxidation of glucose and acutely lowers cardiac workload during exercise for the same amount of work performed when compared with CHO pre-supplementation. We propose that MCT may expand the usable energy supply, particularly in the form of ketone bodies, and improve the oxidative capacity of the heart in this population.
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69
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Joost K, Ounap K, Zordania R, Uudelepp ML, Olsen RK, Kall K, Kilk K, Soomets U, Kahre T. Prevalence of Long-Chain 3-Hydroxyacyl-CoA Dehydrogenase Deficiency in Estonia. JIMD Rep 2011; 2:79-85. [PMID: 23430857 DOI: 10.1007/8904_2011_51] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 03/12/2011] [Accepted: 03/17/2011] [Indexed: 12/13/2022] Open
Abstract
The aim of our study was to evaluate the prevalence of long chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD) in the general Estonian population and among patients with symptoms suggestive of fatty acid oxidation (FAO) defects. We collected DNA from a cohort of 1,040 anonymous newborn blood spot samples. We screened these samples for the presence of the common c.1528G>C mutation in the HADHA gene. Based on the clinical suspicion of FAO defects, we screened suspected individuals since 2004 for the common c.1528G>C mutation in the HADHA gene and since 2008 in addition by tandem mass spectrometric analysis of plasma acylcarnitines. Our results showed that the carrier frequency of the c.1528G>C mutation in the Estonian population is high - 1:173. During the screening of symptomatic patients, we identified five LCHADD patients in four families. Three patients were retrospectively identified by molecular screening of the HADHA gene. One patient was homozygous for the c.1528G>C mutation in the HADHA gene, and two siblings were compound heterozygotes with HADHA genotype c.[1528G>C]+[1690-2A>G]. Among patients tested using acylcarnitine profiling, we identified two cases with an abnormal acylcarnitine profile typical to LCHADD. Molecular analysis showed homozygosity for c.1528G>C mutation. Based on a carrier frequency of 1:173 (95% Confidence Interval 1:76-1:454) and taking into account that the c.1528G>C mutation makes up 87.5% of disease alleles in Estonian LCHADD patients, the estimated prevalence of LCHADD in Estonia would be 1: 91,700.
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Affiliation(s)
- K Joost
- The Centre of Excellence for Translational Medicine, University of Tartu, Tartu, Estonia,
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70
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Abstract
BACKGROUND An increasing array of rare inherited conditions can be detected as part of the universal newborn screening programme. The introduction and evaluation of these service developments require consideration of the ethical issues involved and appropriate mechanisms for informing parents and gaining consent if required. Exploration of parental views is needed to inform the debate and specifically consider whether more flexible protocols are needed to fit with the public perception of new developments in this context. OBJECTIVE This study has been undertaken to explore perceptions and attitudes of parents and future parents to an expanded newborn screening programme in the United Kingdom and the necessary information provision and consent processes. DESIGN AND PARTICIPANTS A mixed methods study involving focus groups (n = 29) and a web-survey (n = 142) undertaken with parents and future parents. RESULTS AND CONCLUSIONS Parents want guaranteed information provision with clear decision-making powers and an awareness of the choices available to them. The difference between existing screening provision and expanded screening was not considered to be significant enough by participants to warrant formal written, informed consent for expanded screening. It is argued that the ethical review processes need to be more flexible towards the provision of information and consent processes for service developments in newborn screening.
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Affiliation(s)
- Louise Moody
- Department of Industrial Design, Coventry University, UK.
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71
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Sykut-Cegielska J, Gradowska W, Piekutowska-Abramczuk D, Andresen BS, Olsen RKJ, Ołtarzewski M, Pronicki M, Pajdowska M, Bogdańska A, Jabłońska E, Radomyska B, Kuśmierska K, Krajewska-Walasek M, Gregersen N, Pronicka E. Urgent metabolic service improves survival in long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency detected by symptomatic identification and pilot newborn screening. J Inherit Metab Dis 2011; 34:185-95. [PMID: 21103935 DOI: 10.1007/s10545-010-9244-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Revised: 08/04/2010] [Accepted: 10/29/2010] [Indexed: 10/18/2022]
Abstract
UNLABELLED Long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD) is a fatty acid oxidation disorder with especially high mortality and uncertain long-term outcome. The aim of the study was to analyze the influence of diagnostic approach on survival in 59 affected children. Referral to a metabolic center was replaced over time by urine/blood testing in centralized metabolic laboratory (selective screening) and by pilot tandem mass spectrometry newborn screening (NBS). Molecular analysis revealed the prevalent mutation in the HADHA gene in all 58 examined cases. Twenty patients died. The number of detections and number of deaths were respectively 9 and 4 (44%) in the patients recognized by differential diagnosis, 28 and 9 (32%) - by selective screening, and 11 and 1 (9%) - by NBS. In 80% of cases the death occurred before or within 3 weeks from the identification. Urgent and active metabolic service remarkably influenced the surviving. The current age of 39 survivors is 0.5 to 23 yrs (mean 7.2 yrs). The disease frequency estimated on the patients number was 1: 115 450, whereas in the pilot NBS - 1: 109 750 (658 492 neonates tested). Interestingly, the phenylalanine level in asymptomatic neonates frequently exceeded the cut-off values. CONCLUSIONS 1) Urgent metabolic intervention decreases mortality of LCHAD-deficient patients, but the prognosis is still uncertain. 2) Emergent metabolic reporting and service are crucial also for the survival of neonates detected by NBS. 3) The nationwide selective screening appeared efficient in LCHADD detection in the country. 4) Transient mild hyperphenylalaninaemia may occur in LCHAD-deficient newborns.
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Affiliation(s)
- Jolanta Sykut-Cegielska
- Department of Metabolic Diseases, Endocrinology and Diabetology, Children's Memorial Health Institute, Warsaw, Poland
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72
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Desbrée A, Houdon L, Touati G, Djemili S, Choker G, Flodrops H. Infection à EBV révélatrice à l’âge de 3 ans d’un déficit en 3-hydroxyacyl-CoA déshydrogénase des acides gras à chaîne longue (LCHAD). Arch Pediatr 2011; 18:18-22. [DOI: 10.1016/j.arcped.2010.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2009] [Revised: 02/14/2010] [Accepted: 09/06/2010] [Indexed: 11/24/2022]
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73
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Piekutowska-Abramczuk D, Olsen RKJ, Wierzba J, Popowska E, Jurkiewicz D, Ciara E, Ołtarzewski M, Gradowska W, Sykut-Cegielska J, Krajewska-Walasek M, Andresen BS, Gregersen N, Pronicka E. A comprehensive HADHA c.1528G>C frequency study reveals high prevalence of long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency in Poland. J Inherit Metab Dis 2010; 33 Suppl 3:S373-7. [PMID: 20814823 DOI: 10.1007/s10545-010-9190-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 08/03/2010] [Accepted: 08/09/2010] [Indexed: 11/29/2022]
Abstract
Isolated long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD) is associated with c.1528G>C substitution in the HADHA gene, since most patients have the prevalent mutation on at least one allele. As it is known that the disease is relatively frequent in Europe, especially around the Baltic Sea, and that the majority of Polish LCHADD patients originate from the coastal Pomeranian province, partly inhabited by an ancient ethnic group, the Kashubians, we aimed to determine the carrier frequency of the prevalent HADHA mutation in various districts of Poland with special focus on the Kashubian district. A total of 6,854 neonatal dried blood samples from the entire country, including 2,976 Pomeranian neonates of Kashubian origin, were c.1528G>C genotyped. Fifty-nine heterozygous carriers for the prevalent c.1528G>C substitution (41 Pomeranian children) were detected in the studied group. Our data reveal a geographically skewed distribution of the c.1528C allele in the Polish population; in the northern Pomeranian province the carrier frequency is 1:73, which is the highest frequency ever reported, whereas in the remaining regions it is 1:217. Hence, the incidence of LCHADD in Poland is predicted to be 1:118,336 versus 1:16,900 in the Pomeranian district. Despite the relative rarity of the disease, screening for LCHADD in neonates born in the northern part of Poland, especially those of Kashubian origin, is justified. Our data allow us to suggest a probable Kashubian origin of the prevalent c.1528G>C mutation.
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Affiliation(s)
- Dorota Piekutowska-Abramczuk
- Department of Medical Genetics, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland.
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74
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Sperk A, Mueller M, Spiekerkoetter U. Outcome in six patients with mitochondrial trifunctional protein disorders identified by newborn screening. Mol Genet Metab 2010; 101:205-7. [PMID: 20659813 DOI: 10.1016/j.ymgme.2010.07.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2010] [Accepted: 07/04/2010] [Indexed: 12/31/2022]
Abstract
Before the newborn screening era, disorders of the mitochondrial trifunctional protein (TFP) complex including long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD) presented with high morbidity and mortality. Data on outcome and prognosis of TFP deficiency disorders since implementation of screening are scarce. We here characterize 6 screened patients with a disorder of the TFP complex (3 of those with LCHADD) with respect to clinical presentation and molecular features. Three of 6 patients were symptomatic prior availability of screening results on days 4-5 of life. Of the three asymptomatic patients recognised by screening, one acutely died at 3months at home during an infection. Two patients remained asymptomatic with preventive measures during follow-up until the age of 3years. One of them had an older sibling with identical genotype born before the screening era, who became symptomatic with 15months. We conclude that newborn screening for disorders of the TFP complex allows identification of asymptomatic cases; however, the acute presentation in 3/6 babies before screening is noteworthy and troublesome. TFP and LCHAD deficiencies remain life-threatening disorders. This is in clear contrast to other defects of long-chain fatty acid oxidation after identification by newborn screening.
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Affiliation(s)
- Astrid Sperk
- University Children's Hospital, Department of General Pediatrics, Moorenstr. 5, 40225 Duesseldorf, Germany
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75
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Wilcken B. Fatty acid oxidation disorders: outcome and long-term prognosis. J Inherit Metab Dis 2010; 33:501-6. [PMID: 20049534 DOI: 10.1007/s10545-009-9001-1] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 09/27/2009] [Accepted: 10/05/2009] [Indexed: 12/30/2022]
Abstract
Assessing the outcome of fatty acid oxidation disorders is difficult, as most are rare. For diagnosis by newborn screening, the situation is compounded: far more cases are diagnosed by screening than by clinical presentation, representing a somewhat different cohort. The literature on outcome was reviewed. For disorders other than medium-chain acyl-coenzyme A (CoA) dehydrogenase (MCAD) deficiency there was insufficient evidence to make many firm statements. In MCAD deficiency, risk of death in the first 72 h is around 4%, with a further approximately 5-7% fatality rate in the first 6 years but very low subsequent risk in previously undiagnosed patients. The risk of death after diagnosis is very low at any age, with good management. The long-term outcome is good nowadays. Very-long-chain acyl-CoA dehydrogenase deficiency poses a risk of death in early infancy, but the condition is generally treatable, with a good outcome after diagnosis. Approximately 10-20% of patients diagnosed by newborn screening and treated nevertheless suffer episodic rhabdomyolysis. Some patients never become symptomatic. Isolated long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency is treatable, but most patients suffer episodic hypoketotic hypoglycaemia and rhabdomyolysis. Generalised mitochondrial tri-functional protein deficiency has high early mortality rate. A more insidious presentation also occurs, with symptoms sometimes confined to progressive axonal neuropathy. Among carnitine cycle disorders, carnitine transporter deficiency, potentially lethal, is uniformly successfully treated orally with carnitine. Carnitine-acylcarnitine translocase and early-onset carnitine palmitoyl transferase type II (CPT II) deficiencies have an extremely high neonatal mortality rate. Late-onset CPT II is characterised only by episodic rhabdomyolysis on severe exercise. CPT type IA deficiency may often be benign, although early presentation with hypoketotic hypoglycaemia certainly occurs.
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Affiliation(s)
- Bridget Wilcken
- Biochemical Genetics and Newborn Screening, The Children's Hospital at Westmead, Westmead, NSW, Australia.
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76
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Bennett MJ. Pathophysiology of fatty acid oxidation disorders. J Inherit Metab Dis 2010; 33:533-7. [PMID: 20824345 DOI: 10.1007/s10545-010-9170-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Revised: 08/13/2009] [Accepted: 08/24/2009] [Indexed: 10/19/2022]
Abstract
Mitochondrial fatty acid oxidation represents an important pathway for energy generation during periods of increased energy demand such as fasting, febrile illness and muscular exertion. In liver, the primary end products of the pathway are ketone bodies, which are released into the circulation and provide energy to tissues that are not able to oxidize fatty acids such as brain. Other tissues, such as cardiac and skeletal muscle are capable of direct utilization of the fatty acids as sources of energy. This article provides an overview of the pathogenesis of fatty acid oxidation disorders. It describes the different tissue involvement with the disease processes and correlates disease phenotype with the nature of the genetic defect for the known disorders of the pathway.
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Affiliation(s)
- M J Bennett
- Department of Pathology & Laboratory Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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77
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Spiekerkoetter U. Mitochondrial fatty acid oxidation disorders: clinical presentation of long-chain fatty acid oxidation defects before and after newborn screening. J Inherit Metab Dis 2010; 33:527-32. [PMID: 20449660 DOI: 10.1007/s10545-010-9090-x] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2009] [Revised: 01/29/2010] [Accepted: 03/24/2010] [Indexed: 12/27/2022]
Abstract
The different long-chain fatty acid oxidation defects present with similar heterogeneous clinical phenotypes of different severity. Organs mainly affected comprise the heart, liver, and skeletal muscles. All symptoms are reversible with sufficient energy supply. In some long-chain fatty acid oxidation defects, disease-specific symptoms occur. Only in disorders of the mitochondrial trifunctional protein (TFP) complex, including long-chain 3-hydroxyacyl-coenzyme A (CoA) dehydrogenase (LCHAD) deficiency, neuropathy and retinopathy develop that are progressive and irreversible despite current treatment measures. In most long-chain fatty acid oxidation defects, no clear genotype-phenotype correlation exists due to molecular heterogeneity. However, some isolated mutations have been identified to be associated with only mild phenotypes, e.g., the V243A mutation in very-long-chain acyl-CoA dehydrogenase (VLCAD) deficiency. LCHAD deficiency is due to the prevalent homozygous 1528G>C mutation and presents with heterogeneous clinical phenotypes, suggesting the importance of other environmental and genetic factors. For some disorders, it was shown that residual enzyme activity measured in fibroblasts or lymphocytes correlated with severity of clinical phenotype. Implementation of newborn screening has significantly reduced morbidity and mortality of long-chain fatty acid oxidation defects. However, the severest forms of TFP deficiency are still highly associated with neonatal death. Newborn screening also identifies a great number of mildly affected patients who may never develop clinical symptoms throughout life. However, later-onset exercise-induced myopathic symptoms remain characteristic clinical features of long-chain fatty acid oxidation defects. Disease prevalence has increased with newborn screening.
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Affiliation(s)
- Ute Spiekerkoetter
- Department of General Pediatrics, University Children's Hospital, Duesseldorf, Germany.
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78
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Illsinger S, Das AM. Impact of selected inborn errors of metabolism on prenatal and neonatal development. IUBMB Life 2010; 62:403-13. [PMID: 20503433 DOI: 10.1002/iub.336] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
In general, data regarding maturational processes of different metabolic pathways in the very vulnerable fetal and neonatal period are rare. This review is to substantiate the impact of selected inborn errors of metabolism on this critical period of life and their clinical manifestation. Significant adaptation of mitochondrial/energy-, carbohydrate-, lysosomal-, and amino acid-metabolism occurs during early prenatal and neonatal development. In utero, metabolic environment has an impact on the development of the fetus as well as fetal organ maturation. Defects of distinct metabolic pathways could therefore already be of significant relevance in utero and for clinical manifestations in the early fetal and neonatal period. Disturbances of these pathways may influence intrauterine growth and health. Production of a toxic intrauterine milieu, energy-deficiency, modification of membrane function, or disturbance of the normal intrauterine expression of genes may be responsible for fetal compromise and developmental disorders. Three categories of metabolic disorders will be discussed: the "intoxication type" (classical galactosemia, ornithine transcarbamylase deficiency, and "maternal phenylketonuria"), the "storage type" (Morbus Niemann Pick type C), and the "energy deficient type" (including long-chain fatty acid oxidation disorders, pyruvate dehydrogenase deficiency, and respiratory chain defects). For these disorders, the pathophysiology of early manifestation, special aspects regarding the prenatal and neonatal period, and diagnostic as well as therapeutic options are presented.
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Affiliation(s)
- Sabine Illsinger
- Clinic for Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Germany.
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79
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A case of severe preeclampsia leading to the diagnosis of de novo abnormal fatty acid metabolism and ACE gene deletion. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2010; 32:695-7. [PMID: 20707960 DOI: 10.1016/s1701-2163(16)34575-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Enzymes involved in the metabolism of free fatty acids are essential for the proper use of caloric intake. Abnormal enzymes unable to degrade fatty acids will result in an accumulation of fatty acids in organs like the liver, impairing its function. CASE A 28-year-old primigravid woman underwent induction of labour because of severe preeclampsia. She was subsequently found to be a carrier for mutations in several fatty acid enzymes as well as the angiotensin converting enzyme. CONCLUSION During pregnancy, the increased need for fatty acid degradation will expose women who are carriers of mutations in these enzymes. The clinical manifestations in such women include acute fatty liver of pregnancy that may mimic severe preeclampsia. Strict metabolic control to avoid excess fatty acid degradation may allow for better pregnancy outcomes and newborn assessment.
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80
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Drake E, Gibson ME. Issues for consideration. Nurs Womens Health 2010; 14:198-211. [PMID: 20579296 DOI: 10.1111/j.1751-486x.2010.01541.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Emily Drake
- University of Virginia School of Nursing, Charlottesville, VA, USA
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81
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Tonin AM, Ferreira GC, Grings M, Viegas CM, Busanello EN, Amaral AU, Zanatta A, Schuck PF, Wajner M. Disturbance of mitochondrial energy homeostasis caused by the metabolites accumulating in LCHAD and MTP deficiencies in rat brain. Life Sci 2010; 86:825-31. [PMID: 20399795 DOI: 10.1016/j.lfs.2010.04.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Revised: 03/31/2010] [Accepted: 04/02/2010] [Indexed: 12/31/2022]
Abstract
AIMS We investigated the in vitro effects of 3-hydroxydodecanoic (3HDA), 3-hydroxytetradecanoic (3HTA) and 3-hydroxypalmitic (3HPA) acids, which accumulate in tissues of patients affected by mitochondrial trifunctional protein (MTP) and isolated long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiencies, on various parameters of energy homeostasis in mitochondrial preparations from brain of young rats. MAIN METHODS We measured the respiratory parameters state 4, state 3, respiratory control ratio (RCR) and ADP/O ratio by the rate of oxygen consumption, as well as the mitochondrial membrane potential and the matrix NAD(P)H levels in the presence of the fatty acids. KEY FINDINGS We found that 3HDA, 3HTA and 3HPA markedly increased state 4 respiration and diminished the RCR using glutamate plus malate or succinate as substrates. 3HTA and 3HPA also diminished the mitochondrial membrane potential and the matrix NAD(P)H levels. In addition, 3HTA decreased state 3 respiration using glutamate/malate, but not pyruvate/malate or succinate as substrates. Our data indicate that the long-chain 3-hydroxy fatty acids that accumulate in LCHAD/MTP deficiencies act as uncouplers of oxidative phosphorylation, while 3HTA also behaves as a metabolic inhibitor. SIGNIFICANCE It is presumed that impairment of brain energy homeostasis caused by these endogenous accumulating compounds may contribute at least in part to the neuropathology of LCHAD/MTP deficiencies.
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Affiliation(s)
- Anelise M Tonin
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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82
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Tonin AM, Grings M, Busanello ENB, Moura AP, Ferreira GC, Viegas CM, Fernandes CG, Schuck PF, Wajner M. Long-chain 3-hydroxy fatty acids accumulating in LCHAD and MTP deficiencies induce oxidative stress in rat brain. Neurochem Int 2010; 56:930-6. [PMID: 20381565 DOI: 10.1016/j.neuint.2010.03.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Revised: 03/23/2010] [Accepted: 03/29/2010] [Indexed: 01/07/2023]
Abstract
Accumulation of long-chain 3-hydroxy fatty acids is the biochemical hallmark of long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) and mitochondrial trifunctional protein (MTP) deficiencies. These disorders are clinically characterized by neurological symptoms, such as convulsions and lethargy, as well as by cardiomyopathy and muscle weakness. In the present work we investigated the in vitro effect of 3-hydroxydodecanoic (3HDA), 3-hydroxytetradecanoic (3HTA) and 3-hydroxypalmitic (3HPA) acids, which accumulate in these disorders, on important oxidative stress parameters in cerebral cortex of young rats in the hope to clarify the mechanisms leading to the brain damage found in patients affected by these disorders. It was first verified that these compounds significantly induced lipid peroxidation, as determined by increased thiobarbituric acid-reactive substances levels. In addition, carbonyl formation was significantly increased and sulfhydryl content decreased by 3HTA and 3HPA, which indicates that these fatty acids elicit protein oxidative damage. 3HTA and 3HPA also diminished the reduced glutathione (GSH) levels, without affecting nitrate and nitrite production. Finally, we observed that the addition of the antioxidants and free radical scavengers trolox and deferoxamine (DFO) was able to partially prevent lipid oxidative damage, whereas DFO fully prevented the reduction on GSH levels induced by 3HTA. Our present data showing that 3HDA, 3HTA and 3HPA elicit oxidative stress in rat brain indicate that oxidative damage may represent an important pathomechanism involved in the neurologic symptoms manifested by patients affected by LCHAD and MTP deficiencies.
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Affiliation(s)
- Anelise M Tonin
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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83
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Steinmann D, Knab J, Priebe HJ. Perioperative management of a child with long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency. Paediatr Anaesth 2010; 20:371-3. [PMID: 20470346 DOI: 10.1111/j.1460-9592.2010.03274.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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84
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Purevsuren J, Fukao T, Hasegawa Y, Kobayashi H, Li H, Mushimoto Y, Fukuda S, Yamaguchi S. Clinical and molecular aspects of Japanese patients with mitochondrial trifunctional protein deficiency. Mol Genet Metab 2009; 98:372-7. [PMID: 19699128 DOI: 10.1016/j.ymgme.2009.07.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Revised: 07/17/2009] [Accepted: 07/17/2009] [Indexed: 10/20/2022]
Abstract
Mitochondrial trifunctional protein (MTP) deficiency is a rare inherited metabolic disorder of mitochondrial fatty acid oxidation. We newly characterized three novel mutations in 2 Japanese patients with MTP deficiency, and investigated the clinical and molecular aspects of 5 Japanese patients including 3 previously reported cases. Herein, we describe the characterization of four missense mutations, R214C, H346R, R411K, and V422G, in the HADHB gene, which have been identified in Japanese patients, employing a newly developed, sensitive transient expression analysis. Co-transfection of wild-type HADHA and HADHB cDNAs in SV40-transfected fibroblasts from a MTP-deficient patient yielded sufficient enzyme activity to evaluate low-level residual enzyme activity, using two incubation temperatures of 30 degrees C and 37 degrees C. At 30 degrees C, residual enzyme activity was higher than that at 37 degrees C in V422G, R214C, and R411K. However, H346R, which was seen in the most severe case, showed no enzyme activity at both temperatures. Our results demonstrate that a defect of HADHB in MTP deficiency is rather common in Japanese patients, and the mutational spectrum is heterogeneous. The present findings showed that all missense mutations in this study were disease-causing. Although the number of patients is still limited, it is suggested that the phenotype is correlated with the genotype and a combination of two mutant alleles of the HADHB gene in MTP deficiency.
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Affiliation(s)
- Jamiyan Purevsuren
- Department of Pediatrics, Shimane University, Faculty of Medicine, Izumo, Japan
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85
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Spiekerkoetter U, Lindner M, Santer R, Grotzke M, Baumgartner MR, Boehles H, Das A, Haase C, Hennermann JB, Karall D, de Klerk H, Knerr I, Koch HG, Plecko B, Röschinger W, Schwab KO, Scheible D, Wijburg FA, Zschocke J, Mayatepek E, Wendel U. Management and outcome in 75 individuals with long-chain fatty acid oxidation defects: results from a workshop. J Inherit Metab Dis 2009; 32:488-97. [PMID: 19399638 DOI: 10.1007/s10545-009-1125-9] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 03/24/2009] [Accepted: 03/25/2009] [Indexed: 10/20/2022]
Abstract
At present, long-chain fatty acid oxidation (FAO) defects are diagnosed in a number of countries by newborn screening using tandem mass spectrometry. In the majority of cases, affected newborns are asymptomatic at time of diagnosis and acute clinical presentations can be avoided by early preventive measures. Because evidence-based studies on management of long-chain FAO defects are lacking, we carried out a retrospective analysis of 75 patients from 18 metabolic centres in Germany, Switzerland, Austria and the Netherlands with special regard to treatment and disease outcome. Dietary treatment is effective in many patients and can prevent acute metabolic derangements and prevent or reverse severe long-term complications such as cardiomyopathy. However, 38% of patients with very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency had intermittent muscle weakness and pain despite adhering to therapy. Seventy-six per cent of patients with disorders of the mitochondrial trifunctional protein (TFP)-complex including long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency, had long-term myopathic symptoms. Of these, 21% had irreversible peripheral neuropathy and 43% had retinopathy. The main principle of treatment was a fat-reduced and fat-modified diet. Fat restriction differed among patients with different enzyme defects and was strictest in disorders of the TFP-complex. Patients with a medium-chain fat-based diet received supplementation of essential long-chain fatty acids. l-Carnitine was supplemented in about half of the patients, but in none of the patients with VLCAD deficiency identified by newborn screening. In summary, in this cohort the treatment regimen was adapted to the severity of the underlying enzyme defect and thus differed among the group of long-chain FAO defects.
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Affiliation(s)
- U Spiekerkoetter
- Department of General Pediatrics, University Children's Hospital, Düsseldorf, Germany.
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86
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Long-chain 3-hydroxyacyl-coenzyme A dehydrogenase deficiency and cardiogenic shock. Int J Cardiol 2009; 136:e1-2. [PMID: 18662835 DOI: 10.1016/j.ijcard.2008.04.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Accepted: 04/26/2008] [Indexed: 11/22/2022]
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87
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Chegary M, Brinke HT, Ruiter JPN, Wijburg FA, Stoll MSK, Minkler PE, van Weeghel M, Schulz H, Hoppel CL, Wanders RJA, Houten SM. Mitochondrial long chain fatty acid beta-oxidation in man and mouse. Biochim Biophys Acta Mol Cell Biol Lipids 2009; 1791:806-15. [PMID: 19465148 DOI: 10.1016/j.bbalip.2009.05.006] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Revised: 04/28/2009] [Accepted: 05/18/2009] [Indexed: 10/20/2022]
Abstract
Several mouse models for mitochondrial fatty acid beta-oxidation (FAO) defects have been developed. So far, these models have contributed little to our current understanding of the pathophysiology. The objective of this study was to explore differences between murine and human FAO. Using a combination of analytical, biochemical and molecular methods, we compared fibroblasts of long chain acyl-CoA dehydrogenase knockout (LCAD(-/-)), very long chain acyl-CoA dehydrogenase knockout (VLCAD(-/-)) and wild type mice with fibroblasts of VLCAD-deficient patients and human controls. We show that in mice, LCAD and VLCAD have overlapping and distinct roles in FAO. The absence of VLCAD is apparently fully compensated, whereas LCAD deficiency is not. LCAD plays an essential role in the oxidation of unsaturated fatty acids such as oleic acid, but seems redundant in the oxidation of saturated fatty acids. In strong contrast, LCAD is neither detectable at the mRNA level nor at the protein level in men, making VLCAD indispensable in FAO. Our findings open new avenues to employ the existing mouse models to study the pathophysiology of human FAO defects.
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Affiliation(s)
- Malika Chegary
- Department of Clinical Chemistry, Emma Children's Hospital, Academic Medical Center, University of Amsterdam, The Netherlands
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88
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Dyke PC, Konczal L, Bartholomew D, McBride KL, Hoffman TM. Acute dilated cardiomyopathy in a patient with deficiency of long-chain 3-hydroxyacyl-CoA dehydrogenase. Pediatr Cardiol 2009; 30:523-6. [PMID: 19083141 DOI: 10.1007/s00246-008-9351-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Revised: 11/11/2008] [Accepted: 11/14/2008] [Indexed: 11/30/2022]
Abstract
Deficiency of long-chain 3-hydroxyacyl-coenzyme A (CoA) dehydrogenase (LCHADD) is a rare inborn error of metabolism. It is associated with hypertrophic cardiomyopathy and less frequently with dilated cardiomyopathy. The incidence and pathophysiology of cardiac involvement in LCHADD is poorly understood. This report describes the acute decompensation of a 3-year-old girl who had LCHADD with rapidly developing dilated cardiomyopathy. A review of the literature and possible causes of cardiomyopathy in LCHADD are explored.
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Affiliation(s)
- Peter C Dyke
- Department of Pediatrics, Nationwide Children's Hospital Heart Center, Columbus, OH 43205-2696, USA
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89
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Fingerhut R, Olgemöller B. Newborn screening for inborn errors of metabolism and endocrinopathies: an update. Anal Bioanal Chem 2008; 393:1481-97. [DOI: 10.1007/s00216-008-2505-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Revised: 09/16/2008] [Accepted: 10/16/2008] [Indexed: 11/29/2022]
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90
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Badertscher A, Bauersfeld U, Arbenz U, Baumgartner MR, Schinzel A, Balmer C. Cardiomyopathy in newborns and infants: a broad spectrum of aetiologies and poor prognosis. Acta Paediatr 2008; 97:1523-8. [PMID: 18652581 DOI: 10.1111/j.1651-2227.2008.00957.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
AIM This study set out to describe the initial clinical findings, morbidity, mortality and aetiology of infant cardiomyopathy focusing on potential risk factors for an adverse outcome. METHODS We retrospectively analysed clinical and laboratory findings of all patients diagnosed at our institution from 1995 to 2004 with cardiomyopathy within their first year of life. RESULTS Of the 35 patients, cardiomyopathy was classified as dilated in 18, hypertrophic in 14 and unclassified in 3. The aetiologies were genetic syndromes (8), metabolic diseases (5), familial isolated cardiomyopathy (3) and myopathy (1). During a median follow-up of 1.5 years (range 0-9 years), 13 patients died from progressive heart failure and two underwent heart transplants. Estimated survival and freedom from transplant was 69, 66, 58 and 50% after 0.5, 1, 2 and 6 years, respectively. Patients with severe heart failure symptoms within the first month of life had significantly worse outcomes than patients without heart failure symptoms. CONCLUSION High morbidity and poor prognosis result through progressive heart failure. Aetiology and clinical course are especially heterogeneous in infants. The most commonly identified aetiologies are genetic syndromes and metabolic diseases. A multidisciplinary approach is recommended for defining the aetiology and developing individual treatment strategies.
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Affiliation(s)
- Andrea Badertscher
- Division of Cardiology, University Children's Hospital, Zurich, Switzerland
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91
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Abstract
Inherited defects in mitochondrial fatty-acid beta-oxidation comprise a group of at least 12 diseases characterized by distinct enzyme or transporter deficiencies. Most of these diseases have a variable age of onset and clinical severity. Symptoms are often episodic and associated with mild viral illness, physiologic stress, or prolonged exercise that overwhelms the ability of mitochondria to oxidize fatty acids. Depending on the specific genetic defect, patients develop fasting hypoketotic hypoglycemia, cardiomyopathy, rhabdomyolysis, liver dysfunction, or sudden death. Neuropathy and pigmentary retinopathy are seen in some of the diseases. The diagnosis is based on finding an accumulation of specific biochemical markers such as acylcarnitine metabolites in blood and urinary dicarboxylic acids and acylglycines. Confirmatory testing requires enzymatic studies and DNA analysis. Therapeutic approaches are generally effective in preventing severe symptomatic episodes, including sudden death. Newborn screening for fatty-acid oxidation disorders promises to identify many affected patients before the onset of symptoms.
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Affiliation(s)
- Michelle Kompare
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE 68198, USA
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92
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Purevsuren J, Fukao T, Hasegawa Y, Fukuda S, Kobayashi H, Yamaguchi S. Study of deep intronic sequence exonization in a Japanese neonate with a mitochondrial trifunctional protein deficiency. Mol Genet Metab 2008; 95:46-51. [PMID: 18693053 DOI: 10.1016/j.ymgme.2008.06.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Revised: 06/25/2008] [Accepted: 06/25/2008] [Indexed: 10/21/2022]
Abstract
Mitochondrial trifunctional protein (MTP) comprises heterooctamer alpha4beta4 and a deficiency in this protein causes a mitochondrial long-chain beta-oxidation defect. Here, we describe the molecular basis of an MTPbeta-subunit deficiency in a Japanese neonate. Mutation screening at the genomic level including all exons and exon-intron boundaries identified a novel c.1136A>G (H346R) mutation in exon 13 of the maternal allele, but none in the paternal allele. Analysis by RT-PCR identified paternal-specific 106- and 56-bp intronic insertions between exons 7 and 8, which introduced premature terminations. This intronic exonization was caused by a deep intronic mutation in intron 7 on the paternal allele that generates a cryptic splice donor site. This is the first report of a deep intronic mutation in MTP deficiency.
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Affiliation(s)
- Jamiyan Purevsuren
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 Enya, Izumo, Shimane 693-8501, Japan.
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93
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Fahnehjelm KT, Holmström G, Ying L, Haglind CB, Nordenström A, Halldin M, Alm J, Nemeth A, von Döbeln U. Ocular characteristics in 10 children with long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency: a cross-sectional study with long-term follow-up. Acta Ophthalmol 2008; 86:329-37. [PMID: 18162058 DOI: 10.1111/j.1600-0420.2007.01121.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To present long-term ocular complications and electroretinographic (ERG) findings in children with long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency - a life-threatening metabolic disease - and the relation to age at diagnosis, treatment and other clinical parameters. METHODS Ten children with LCHAD deficiency underwent repeated ophthalmological evaluations including ERG. RESULTS All 10 children developed chorioretinal pathology. Regardless of age at diagnosis, initiation of treatment and age at examination, inter-individual differences were present. Profound chorioretinal atrophy, severe visual impairment and progressive myopia had developed in two teenagers. Milder chorioretinopathy with or without subnormal visual acuity was present in all other children. ERG was pathological in seven children. The chorioretinopathy often started in the peripapillary or perimacular areas. In one patient, unilateral visual impairment was associated with fibrosis. CONCLUSION Early diagnosis and adequate therapy might delay but not prevent the progression of retinal complications. Late diagnosis with severe symptoms at diagnosis, neonatal hypoglycaemia and frequent decompensations may increase the progression rate of the chorioretinopathy. LCHAD deficiency, a potentially lethal disease, is sometimes difficult to diagnose. Unusual chorioretinal findings should alert the ophthalmologist to the long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency, especially if there is a history of neonatal hypoglycaemia or failure to thrive.
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94
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Lee M, Cook CR, Wilkins I. A new association of second-trimester echogenic bowel and metabolic disease of the neonate. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2007; 26:1119-22. [PMID: 17646378 DOI: 10.7863/jum.2007.26.8.1119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Maureen Lee
- University of Illinois at Chicago, Chicago, IL 60612, USA.
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95
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Hayes B, Lynch B, O'Keefe M, Monavari AA, Treacy EP. Long chain fatty acid oxidation defects in children: importance of detection and treatment options. Ir J Med Sci 2007; 176:189-92. [PMID: 17431731 DOI: 10.1007/s11845-007-0025-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2006] [Accepted: 03/12/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Mitochondrial beta oxidation plays a major role in energy production. Long chain fatty acid oxidation defects include deficiency of the trifunctional protein (rare) or more commonly defects of the long chain 3-hydroxy acyl-CoA dehydrogenase enzyme (LCHAD). These long chain defects have variable presentations, they may present in the neonate or infant with sudden death, hepatopathy (Reyes disease), hypoketotic hypoglycaemia, rhabdomyolysis, myopathy, cardiomyopathy and with late complications such as peripheral neuropathy, pigmentary retinopathy, retinal degeneration and progressive visual loss. The correct diagnosis at presentation is not only life saving but also allows for the appropriate dietary and other intervention, which may have major effects on outcome. AIM Three case reports of patients with long chain fatty acid oxidation defects who have shown significant benefits from treatment are reported. CONCLUSIONS These paediatric presentations illustrate the clinical heterogeneity of long chain fatty acid oxidation defects and opportunities for effective management if correctly diagnosed.
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Affiliation(s)
- B Hayes
- National Centre for Inherited Metabolic Disorders, Children's University Hospital, Temple St, Dublin 1, Ireland
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96
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Abstract
Frequently, placentas sent for pathologic examination include a clinical diagnosis that does not suggest a specific placental lesion. Pathologists who do not have great experience in this field may need some assistance with selecting the pertinent placental lesions to look for. This brief outline is included to define these conditions and present a list of the specific placental lesions that deserve consideration. The placental examination should be directed with the goal of identifying or noting and recording specifically the presence or absence of the relevant pathologic lesions. The syndromes or conditions considered in this context include neonatal encephalopathy, preterm birth, fetal growth restriction, maternal diabetes mellitus, thrombophilias, HELLP syndrome, and fetal hydrops.
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Affiliation(s)
- Frederick T Kraus
- Washington University Medical School, Department of OB-GYN, Campus Box 8064, St. Louis, MO 63110, USA.
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97
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Blake F, Blessmann M, Werle H, Li L, Gbara A. Long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency with inadvertent caries in infants. Int J Paediatr Dent 2007; 17:72-4. [PMID: 17181583 DOI: 10.1111/j.1365-263x.2006.00763.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD) is a rare systemic disease that is associated with early tooth decay. CASE REPORT This report describes the case of a 3-year-old boy suffering from LCHADD. At the time of referral, extensive carious lesions of the subject's maxillary dentition necessitated the surgical removal of eight teeth. Preventive treatment for LCHADD involves a regular oral intake of glucose that is vital for the survival of the affected individual. In young infants, the glucose solution needs to be administered as often as every 3 h in order to prevent hypoglycaemia, leading to a local environment similar to that experienced in nursing bottle syndrome. While nursing bottle syndrome can be resolved by eliminating the sugar substrate and curtailing the feeding sessions, these alternatives are not available in cases of LCHADD. CONCLUSION This report highlights this rare disease and emphasizes its dire consequences for the dentition. Prophylactic recommendations for high-risk children are reviewed. Familiarity with LCHADD allows this high-risk group of patients to be identified, and thus, ensures diligent prophylactic action.
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Affiliation(s)
- Felix Blake
- Department of Oral and Maxillofacial Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
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98
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Gillingham MB, Purnell JQ, Jordan J, Stadler D, Haqq AM, Harding CO. Effects of higher dietary protein intake on energy balance and metabolic control in children with long-chain 3-hydroxy acyl-CoA dehydrogenase (LCHAD) or trifunctional protein (TFP) deficiency. Mol Genet Metab 2007; 90:64-9. [PMID: 16996288 PMCID: PMC2813195 DOI: 10.1016/j.ymgme.2006.08.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2006] [Revised: 08/07/2006] [Accepted: 08/07/2006] [Indexed: 11/19/2022]
Abstract
The incidence of overweight and obesity is increasing among children with long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) or mitochondrial trifunctional (TFP) deficiency. Traditional treatment includes fasting avoidance and consumption of a low-fat, high-carbohydrate diet. A diet higher in protein and lower in carbohydrate may help to lower total energy intake while maintaining good metabolic control. To determine the short-term safety and efficacy of a high protein diet, subjects were admitted to the General Clinical Research Center and fed an ad-libitum high-protein diet and a high-carbohydrate diet for 6 days each using a randomized, crossover design. Nine subjects with LCHAD or TFP deficiency, age 7-14 were enrolled. Body composition was determined by DEXA. Total energy intake was evaluated daily. Resting energy expenditure and substrate utilization were determined by indirect calorimetry. Post-prandial metabolic responses of plasma glucose, insulin, leptin, ghrelin, acylcarnitines, and triglyceride were determined in response to a liquid meal. Subjects had a higher fat mass, lower lean mass and higher plasma leptin levels compared to reference values. While on the high protein diet energy consumption was an average of 50 kcals/day lower (p = 0.02) and resting energy expenditure was an average of 170 kcals/day higher (p = 0.05) compared to the high carbohydrate diet. Short-term higher protein diets were safe, well tolerated, and resulted in lowered energy intake and increased energy expenditure than the standard high-carbohydrate diet. Long-term studies are needed to determine whether higher protein diets will reduce the risk of overweight and obesity in children with LCHAD or TFP deficiency.
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Affiliation(s)
- Melanie B Gillingham
- The Department of Pediatrics, Oregon Health and Science University, Portland, OR 97239, USA.
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Das AM, Hartmann H. Metabolische Myopathien. Monatsschr Kinderheilkd 2006. [DOI: 10.1007/s00112-006-1307-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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