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Longo N, Diaz GA, Lichter-Konecki U, Schulze A, Inbar-Feigenberg M, Conway RL, Bannick AA, McCandless SE, Zori R, Hainline B, Ah Mew N, Canavan C, Vescio T, Kok T, Porter MH, Berry SA. Glycerol phenylbutyrate efficacy and safety from an open label study in pediatric patients under 2 months of age with urea cycle disorders. Mol Genet Metab 2021; 132:19-26. [PMID: 33388234 PMCID: PMC8655853 DOI: 10.1016/j.ymgme.2020.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND/AIMS Neonatal onset Urea cycle disorders (UCDs) can be life threatening with severe hyperammonemia and poor neurological outcomes. Glycerol phenylbutyrate (GPB) is safe and effective in reducing ammonia levels in patients with UCD above 2 months of age. This study assesses safety, ammonia control and pharmacokinetics (PK) of GPB in UCD patients below 2 months of age. METHODS This was an open-label study in UCD patients aged 0 - 2 months, consisting of an initiation/transition period (1 - 4 days) to GPB, followed by a safety extension period (6 months to 2 years). Patients presenting with a hyperammonemic crisis (HAC) did not initiate GPB until blood ammonia levels decreased to below 100 µmol/L while receiving sodium phenylacetate/sodium benzoate and/or hemodialysis. Ammonia levels, PK analytes and safety were evaluated during transition and monthly during the safety extension for 6 months and every 3 months thereafter. RESULTS All 16 patients with UCD (median age 0.48 months, range 0.1 to 2.0 months) successfully transitioned to GPB within 3 days. Average plasma ammonia level excluding HAC was 94.3 µmol/L at baseline and 50.4 µmol/L at the end of the transition period (p = 0.21). No patient had a HAC during the transition period. During the safety extension, the majority of patients had controlled ammonia levels, with mean plasma ammonia levels lower during GPB treatment than baseline. Mean glutamine levels remained within normal limits throughout the study. PK analyses indicate that UCD patients <2 months are able to hydrolyze GPB with subsequent absorption of phenylbutyric acid (PBA), metabolism to phenylacetic acid (PAA) and conjugation with glutamine. Plasma concentrations of PBA, PAA, and phenylacetylglutamine (PAGN) were stable during the safety extension phase and mean plasma phenylacetic acid: phenylacetylglutamine ratio remained below 2.5 suggesting no accumulation of GPB. All patients reported at least 1 treatment emergent adverse event with gastroesophageal reflux disease, vomiting, hyperammonemia, diaper dermatitis (37.5% each), diarrhea, upper respiratory tract infection and rash (31.3% each) being the most frequently reported. CONCLUSIONS This study supports safety and efficacy of GPB in UCD patients aged 0 -2 months who cannot be managed by dietary protein restriction and/or amino acid supplementation alone. GPB undergoes intestinal hydrolysis with no accumulation in this population.
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Affiliation(s)
| | - George A Diaz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Andreas Schulze
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Shawn E McCandless
- University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | | | - Bryan Hainline
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | | | - Teresa Kok
- Horizon Therapeutics plc, Deerfield, IL, USA.
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202
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Puri P, Dhiman RK, Taneja S, Tandon P, Merli M, Anand AC, Arora A, Acharya SK, Benjamin J, Chawla YK, Dadhich S, Duseja A, Eapan C, Goel A, Kalra N, Kapoor D, Kumar A, Madan K, Nagral A, Pandey G, Rao PN, Saigal S, Saraf N, Saraswat VA, Saraya A, Sarin SK, Sharma P, Shalimar, Shukla A, Sidhu SS, Singh N, Singh SP, Srivastava A, Wadhawan M. Nutrition in Chronic Liver Disease: Consensus Statement of the Indian National Association for Study of the Liver. J Clin Exp Hepatol 2021; 11:97-143. [PMID: 33679050 PMCID: PMC7897902 DOI: 10.1016/j.jceh.2020.09.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023] Open
Abstract
Malnutrition and sarcopenia are common in patients with chronic liver disease and are associated with increased risk of decompensation, infections, wait-list mortality and poorer outcomes after liver transplantation. Assessment of nutritional status and management of malnutrition are therefore essential to improve outcomes in patients with chronic liver disease. This consensus statement of the Indian National Association for Study of the Liver provides a comprehensive review of nutrition in chronic liver disease and gives recommendations for nutritional screening and treatment in specific clinical scenarios of malnutrition in cirrhosis in adults as well as children with chronic liver disease and metabolic disorders.
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Key Words
- ACLF, acute on chronic liver failure
- ASM, appendicular skeletal muscle mass
- BCAA, branched chain amino acids
- BIA, bioimpedance analysis
- BMD, bone mineral densitometry
- BMI, body mass index
- CLD, chronic liver disease
- CS, corn-starch
- CT, computed tomography
- CTP, Child–Turcotte–Pugh
- DEXA, dual-energy X-ray absorptiometry
- EASL, European Association for the Study of the Liver
- ESPEN, European society for Clinical Nutrition and Metabolism
- GSD, glycogen storage disease
- HGS, hand-grip strength
- IBW, ideal body weight
- IEM, inborn error of metabolism
- INASL, Indian National Association for Study of the Liver
- L3, third lumbar
- LFI, Liver Frailty Index
- MCT, medium-chain triglyceride
- MELD, model for end-stage liver disease
- MLD, metabolic liver disease
- MRI, magnetic resonance imaging
- RDA, recommended daily allowance
- REE, NASH
- RFH-NPT, Royal Free Hospital-Nutritional Prioritizing Tool
- SMI, skeletal muscle index
- Sarcopenia
- TEE, total energy expenditure
- chronic liver disease
- cirrhosis
- malnutrition
- non-alcoholic liver disease, resting energy expenditure
- nutrition
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Affiliation(s)
- Pankaj Puri
- Fortis Escorts Liver & Digestive Diseases Institute, New Delhi, 110025, India
| | - Radha K. Dhiman
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, 00185, Italy
| | - Anil C. Anand
- Kalinga Institute of Medical Sciences, Bhubhaneswar, 751024, Odisha, India
| | - Anil Arora
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences of Sir Ganga Ram Hospital, New Delhi, 110060, India
| | - Subrat K. Acharya
- Fortis Escorts Liver & Digestive Diseases Institute, New Delhi, 110025, India
| | - Jaya Benjamin
- Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, 110070, India
| | - Yogesh K. Chawla
- Kalinga Institute of Medical Sciences, Bhubhaneswar, 751024, Odisha, India
| | - Sunil Dadhich
- Department of Gastroenterology SN Medical College, Jodhpur, 342003, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - C.E. Eapan
- Department of Gastroenterology, Christian Medical College, Vellore, 632004, India
| | - Amit Goel
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Naveen Kalra
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Dharmesh Kapoor
- Department of Gastroenterology, Global Hospital, Hyderabad, 500004, India
| | - Ashish Kumar
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences of Sir Ganga Ram Hospital, New Delhi, 110060, India
| | - Kaushal Madan
- Max Smart Super Speciality Hospital, New Delhi, India
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital, Mumbai, 400026, India
| | - Gaurav Pandey
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Padaki N. Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, 500082, India
| | - Sanjiv Saigal
- Department of Hepatology, Medanta Hospital, Gurugram, 122001, India
| | - Neeraj Saraf
- Department of Hepatology, Medanta Hospital, Gurugram, 122001, India
| | - Vivek A. Saraswat
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110016, India
| | - Shiv K. Sarin
- Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, 110070, India
| | - Praveen Sharma
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences of Sir Ganga Ram Hospital, New Delhi, 110060, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110016, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GSMC & KEM Hospital, Mumbai, 400022, India
| | - Sandeep S. Sidhu
- Department of Gastroenterology, SPS Hospital, Ludhiana, 141001, India
| | - Namrata Singh
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110016, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, 753007, India
| | - Anshu Srivastava
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Manav Wadhawan
- Institute of Liver & Digestive Diseases, BL Kapur Memorial Hospital, New Delhi, 110005, India
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203
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Bernal AC, Tubio MC, Crespo C, Eiroa HD. Clinical and Genetic Characterization and Biochemical Correlation at Presentation in 48 Patients Diagnosed with Urea Cycle Disorders at the Hospital Juan P Garrahan, Argentina. JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2021. [DOI: 10.1590/2326-4594-jiems-2020-0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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204
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Coughlin CR, Tseng LA, Abdenur JE, Ashmore C, Boemer F, Bok LA, Boyer M, Buhas D, Clayton PT, Das A, Dekker H, Evangeliou A, Feillet F, Footitt EJ, Gospe SM, Hartmann H, Kara M, Kristensen E, Lee J, Lilje R, Longo N, Lunsing RJ, Mills P, Papadopoulou MT, Pearl PL, Piazzon F, Plecko B, Saini AG, Santra S, Sjarif DR, Stockler-Ipsiroglu S, Striano P, Van Hove JLK, Verhoeven-Duif NM, Wijburg FA, Zuberi SM, van Karnebeek CDM. Consensus guidelines for the diagnosis and management of pyridoxine-dependent epilepsy due to α-aminoadipic semialdehyde dehydrogenase deficiency. J Inherit Metab Dis 2021; 44:178-192. [PMID: 33200442 DOI: 10.1002/jimd.12332] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/21/2020] [Accepted: 11/13/2020] [Indexed: 12/19/2022]
Abstract
Pyridoxine-dependent epilepsy (PDE-ALDH7A1) is an autosomal recessive condition due to a deficiency of α-aminoadipic semialdehyde dehydrogenase, which is a key enzyme in lysine oxidation. PDE-ALDH7A1 is a developmental and epileptic encephalopathy that was historically and empirically treated with pharmacologic doses of pyridoxine. Despite adequate seizure control, most patients with PDE-ALDH7A1 were reported to have developmental delay and intellectual disability. To improve outcome, a lysine-restricted diet and competitive inhibition of lysine transport through the use of pharmacologic doses of arginine have been recommended as an adjunct therapy. These lysine-reduction therapies have resulted in improved biochemical parameters and cognitive development in many but not all patients. The goal of these consensus guidelines is to re-evaluate and update the two previously published recommendations for diagnosis, treatment, and follow-up of patients with PDE-ALDH7A1. Members of the International PDE Consortium initiated evidence and consensus-based process to review previous recommendations, new research findings, and relevant clinical aspects of PDE-ALDH7A1. The guideline development group included pediatric neurologists, biochemical geneticists, clinical geneticists, laboratory scientists, and metabolic dieticians representing 29 institutions from 16 countries. Consensus guidelines for the diagnosis and management of patients with PDE-ALDH7A1 are provided.
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Affiliation(s)
- Curtis R Coughlin
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laura A Tseng
- Department of Pediatrics Emma Children's Hospital, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Jose E Abdenur
- Division of Metabolic Disorders, CHOC Children's Hospital, Orange, California, USA
| | - Catherine Ashmore
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - François Boemer
- Department of Human Genetics, Centre Hospitalier Universitaire Sart-Tilman, Liège, Belgium
| | - Levinus A Bok
- Department of Pediatrics and Neonatology, Máxima Medical Center, Veldhoven, The Netherlands
| | - Monica Boyer
- Division of Metabolic Disorders, CHOC Children's Hospital, Orange, California, USA
| | - Daniela Buhas
- Division of Medical Genetics, Department of Specialized Medicine, Montreal Children's Hospital, McGill University Health Centre, Québec, Canada
| | - Peter T Clayton
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Anibh Das
- Clinic for Paediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Hanka Dekker
- VKS: Dutch Patient Organization for Metabolic Diseases, Zwolle, The Netherlands
| | - Athanasios Evangeliou
- Division of Child Neurology and Inherited Metabolic Disorders, 4th Department of Pediatrics, Aristotle University of Thessaloniki, General Hospital Papageorgiou, Thessaloniki, Greece
| | - François Feillet
- Reference Center for Inborn Errors of Metabolism, Pediatric Unit, University Hospital of Nancy, Nancy, France
- INSERM UMR S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, University of Lorraine, Nancy, France
| | - Emma J Footitt
- Department of Metabolic Paediatrics, Great Ormond Street Hospital, London, UK
| | - Sidney M Gospe
- Division of Pediatric Neurology, Departments of Neurology and Pediatrics, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Hans Hartmann
- Clinic for Paediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Majdi Kara
- Department of Pediatrics, University of Tripoli, Tripoli, Libya
| | - Erle Kristensen
- National Management of Newborn Screening and Advanced Laboratory Diagnostics in Inborn Errors of Metabolism, Department of Children and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Joy Lee
- Department of Metabolic Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Rina Lilje
- Department of Children and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Nicola Longo
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Roelineke J Lunsing
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Philippa Mills
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Maria T Papadopoulou
- Division of Child Neurology and Inherited Metabolic Disorders, 4th Department of Pediatrics, Aristotle University of Thessaloniki, General Hospital Papageorgiou, Thessaloniki, Greece
| | - Phillip L Pearl
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Flavia Piazzon
- Neurometabolic Clinic, Children's Institute, University of Sao Paulo, Brazil
| | - Barbara Plecko
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Arushi G Saini
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Saikat Santra
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Damayanti R Sjarif
- Department of Child Health, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Sylvia Stockler-Ipsiroglu
- Division of Biochemical Genetics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS "G. Gaslini" Institute, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genoa, Italy
| | - Johan L K Van Hove
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Frits A Wijburg
- Department of Pediatrics Emma Children's Hospital, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children & School of Medicine, University of Glasgow, Glasgow, UK
| | - Clara D M van Karnebeek
- Department of Pediatrics Emma Children's Hospital, Amsterdam University Medical Centre, Amsterdam, The Netherlands
- Department of Pediatrics, Amalia Children's Hospital, Radboud Centre for Mitochondrial Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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205
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Stockler‐Ipsiroglu S, Potter BK, Yuskiv N, Tingley K, Patterson M, van Karnebeek C. Developments in evidence creation for treatments of inborn errors of metabolism. J Inherit Metab Dis 2021; 44:88-98. [PMID: 32944978 PMCID: PMC7891579 DOI: 10.1002/jimd.12315] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 12/13/2022]
Abstract
Inborn errors of metabolism (IEM) represent the first group of genetic disorders, amenable to causal therapies. In addition to traditional medical diet and cofactor treatments, new treatment strategies such as enzyme replacement and small molecule therapies, solid organ transplantation, and cell-and gene-based therapies have become available. Inherent to the rare nature of the single conditions, generating high-quality evidence for these treatments in clinical trials and under real-world conditions has been challenging. Guidelines developed with standardized methodologies have contributed to improve the practice of care and long-term clinical outcomes. Adaptive trial designs allow for changes in sample size, group allocation and trial duration as the trial proceeds. n-of-1 studies may be used in small sample sized when participants are clinically heterogeneous. Multicenter observational and registry-based clinical trials are promoted via international research networks. Core outcome and standard data element sets will enhance comparative analysis of clinical trials and observational studies. Patient-centered outcome-research as well as patient-led research initiatives will further accelerate the development of therapies for IEM.
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Affiliation(s)
- Sylvia Stockler‐Ipsiroglu
- Division of Biochemical Genetics, Department of Pediatrics, and BC Children's Hospital Research InstituteUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Beth K. Potter
- School of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada
| | - Nataliya Yuskiv
- Division of Biochemical Genetics, Department of Pediatrics, and BC Children's Hospital Research InstituteUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Kylie Tingley
- School of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada
| | - Marc Patterson
- Division of Child and Adolescent Neurology, Departments of Neurology Pediatrics and Medical GeneticsMayo Clinic Children's CenterRochesterMinnesotaUSA
| | - Clara van Karnebeek
- Departments of Pediatrics and Clinical GeneticsAmsterdam University Medical CentresAmsterdamThe Netherlands
- Department of PediatricsRadboud University Medical CentreNijmegenThe Netherlands
- Department of PediatricsBC Children's Hospital Research Institute, Centre for Molecular Medicine and TherapeuticsVancouverBritish ColumbiaCanada
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206
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Rossi L, Pierigè F, Bregalda A, Magnani M. Preclinical developments of enzyme-loaded red blood cells. Expert Opin Drug Deliv 2020; 18:43-54. [PMID: 32924643 DOI: 10.1080/17425247.2020.1822320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Therapeutic enzymes are currently used in the treatment of several diseases. In most cases, the benefits are limited due to poor in vivo stability, immunogenicity, and drug-induced inactivating antibodies. A partial solution to the problem is obtained by masking the therapeutic protein by chemical modifications. Unfortunately, this is not a satisfactory solution because frequent adverse events, including anaphylaxis, can arise. AREA COVERED Among the delivery systems, we focused on red blood cells for the delivery of therapeutic enzymes. Erythrocytes possess a long circulation time, a reduced immunogenicity, there is no need of chemical modifications and the encapsulated enzyme remains active because it is protected by the cell membrane. Here we discuss some representative applications of the preclinical developments of the field. Some of these are currently in clinic, others are approaching the clinic and others are illustrative of the development process. The selected examples are not always the most recent, but they are the most useful for a comparative approach. EXPERT OPINION The results discussed confirm the central role that red blood cells can play in the treatment of several conditions and suggest the benefit in using a natural cellular carrier in terms of pharmacokinetic, biodistribution, safety, and efficacy.
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Affiliation(s)
- Luigia Rossi
- Department of Biomolecular Sciences, University of Urbino , Urbino, Italy.,EryDel SpA , Bresso, Italy
| | - Francesca Pierigè
- Department of Biomolecular Sciences, University of Urbino , Urbino, Italy
| | | | - Mauro Magnani
- Department of Biomolecular Sciences, University of Urbino , Urbino, Italy.,EryDel SpA , Bresso, Italy
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207
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Meijer R, Vivekananda U, Balestrini S, Walker M, Lachmann R, Haeberle J, Murphy E. Ammonia: what adult neurologists need to know. Pract Neurol 2020:practneurol-2020-002654. [PMID: 33310884 DOI: 10.1136/practneurol-2020-002654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 12/31/2022]
Abstract
Hyperammonaemia is often encountered in acute neurology and can be the cause of acute or chronic neurological symptoms. Patients with hyperammonaemia may present with seizures or encephalopathy, or may be entirely asymptomatic. The underlying causes are diverse but often straightforward to diagnose, although sometimes require specialist investigations. Haemodialysis or haemo(dia)filtration is the first-line treatment for acute severe hyperammonaemia (of any cause) in an adult. Here we discuss our approach to adult patients with hyperammonaemia identified by a neurologist.
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Affiliation(s)
- Rick Meijer
- Department of Internal Medicine, Amsterdam University Medical Centers, Location VU University Medical Center, Amsterdam, The Netherlands
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Umesh Vivekananda
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Simona Balestrini
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
- Chalfont Centre for Epilepsy, Buckinghamshire, UK
| | - Matthew Walker
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Robin Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Johannes Haeberle
- Department of Pediatrics, University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
| | - Elaine Murphy
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
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208
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Makris G, Lauber M, Rüfenacht V, Gemperle C, Diez-Fernandez C, Caldovic L, Froese DS, Häberle J. Clinical and structural insights into potential dominant negative triggers of proximal urea cycle disorders. Biochimie 2020; 183:89-99. [PMID: 33309754 DOI: 10.1016/j.biochi.2020.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 12/31/2022]
Abstract
Despite biochemical and genetic testing being the golden standards for identification of proximal urea cycle disorders (UCDs), genotype-phenotype correlations are often unclear. Co-occurring partial defects affecting more than one gene have not been demonstrated so far in proximal UCDs. Here, we analyzed the mutational spectrum of 557 suspected proximal UCD individuals. We probed oligomerizing forms of NAGS, CPS1 and OTC, and evaluated the surface exposure of residues mutated in heterozygously affected individuals. BN-PAGE and gel-filtration chromatography were employed to discover protein-protein interactions within recombinant enzymes. From a total of 281 confirmed patients, only 15 were identified as "heterozygous-only" candidates (i.e. single defective allele). Within these cases, the only missense variants to potentially qualify as dominant negative triggers were CPS1 p.Gly401Arg and NAGS p.Thr181Ala and p.Tyr512Cys, as assessed by residue oligomerization capacity and surface exposure. However, all three candidates seem to participate in critical intramolecular functions, thus, unlikely to facilitate protein-protein interactions. This interpretation is further supported by BN-PAGE and gel-filtration analyses revealing no multiprotein proximal urea cycle complex formation. Collectively, genetic analysis, structural considerations and in vitro experiments point against a prominent role of dominant negative effects in human proximal UCDs.
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Affiliation(s)
- Georgios Makris
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Matthias Lauber
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Véronique Rüfenacht
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Corinne Gemperle
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Carmen Diez-Fernandez
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland; Nextech Invest, Bahnhofstrasse 18, 8001, Zurich, Switzerland
| | - Ljubica Caldovic
- Center for Genetic Medicine Research, Children's National Hospital, Washington, DC, USA
| | - D Sean Froese
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Johannes Häberle
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.
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209
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Posset R, Kölker S, Gleich F, Okun JG, Gropman AL, Nagamani SCS, Scharre S, Probst J, Walter ME, Hoffmann GF, Garbade SF, Zielonka M. Severity-adjusted evaluation of newborn screening on the metabolic disease course in individuals with cytosolic urea cycle disorders. Mol Genet Metab 2020; 131:390-397. [PMID: 33288448 PMCID: PMC8315358 DOI: 10.1016/j.ymgme.2020.10.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/29/2020] [Accepted: 10/31/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The implementation of newborn screening (NBS) programs for citrullinemia type 1 (CTLN1) and argininosuccinic aciduria (ASA) is subject to controversial debate. The aim of this study was to assess the impact of NBS on the metabolic disease course and clinical outcome of affected individuals. METHODS In 115 individuals with CTLN1 and ASA, we compared the severity of the initial hyperammonemic episode (HAE) and the frequency of (subsequent) HAEs with the mode of diagnosis. Based on a recently established functional disease prediction model, individuals were stratified according to their predicted severe or attenuated phenotype. RESULTS Individuals with predicted attenuated forms of CTLN1 and ASA were overrepresented in the NBS group, while those with a predicted severe phenotype were underrepresented compared to individuals identified after the manifestation of symptoms (SX). Identification by NBS was associated with reduced severity of the initial HAE both in individuals with predicted severe and attenuated phenotypes, while it was not associated with lower frequency of (subsequent) HAEs. Similar results were obtained when including some patients diagnosed presymptomatically (i.e. prenatal testing, and high-risk family screening) in this analysis. CONCLUSION Since one of the major challenges of NBS outcome studies is the potential overrepresentation of individuals with predicted attenuated phenotypes in NBS cohorts, severity-adjusted evaluation of screened and unscreened individuals is important to avoid overestimation of the NBS effect. NBS enables the attenuation of the initial HAE but does not affect the frequency of subsequent metabolic decompensations in individuals with CTLN1 and ASA. Future long-term studies will need to evaluate the clinical impact of this finding, especially with regard to mortality, as well as cognitive outcome and quality of life of survivors.
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Affiliation(s)
- Roland Posset
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Stefan Kölker
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Florian Gleich
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Jürgen G Okun
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Andrea L Gropman
- Children's National Health System and The George Washington School of Medicine, Washington, DC, USA
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Svenja Scharre
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Joris Probst
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Magdalena E Walter
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Georg F Hoffmann
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Sven F Garbade
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Matthias Zielonka
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany; Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany.
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Raucci U, Borrelli O, Di Nardo G, Tambucci R, Pavone P, Salvatore S, Baldassarre ME, Cordelli DM, Falsaperla R, Felici E, Ferilli MAN, Grosso S, Mallardo S, Martinelli D, Quitadamo P, Pensabene L, Romano C, Savasta S, Spalice A, Strisciuglio C, Suppiej A, Valeriani M, Zenzeri L, Verrotti A, Staiano A, Villa MP, Ruggieri M, Striano P, Parisi P. Cyclic Vomiting Syndrome in Children. Front Neurol 2020; 11:583425. [PMID: 33224097 PMCID: PMC7667239 DOI: 10.3389/fneur.2020.583425] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/14/2020] [Indexed: 12/13/2022] Open
Abstract
Cyclic Vomiting Syndrome (CVS) is an underdiagnosed episodic syndrome characterized by frequent hospitalizations, multiple comorbidities, and poor quality of life. It is often misdiagnosed due to the unappreciated pattern of recurrence and lack of confirmatory testing. CVS mainly occurs in pre-school or early school-age, but infants and elderly onset have been also described. The etiopathogenesis is largely unknown, but it is likely to be multifactorial. Recent evidence suggests that aberrant brain-gut pathways, mitochondrial enzymopathies, gastrointestinal motility disorders, calcium channel abnormalities, and hyperactivity of the hypothalamic-pituitary-adrenal axis in response to a triggering environmental stimulus are involved. CVS is characterized by acute, stereotyped and recurrent episodes of intense nausea and incoercible vomiting with predictable periodicity and return to baseline health between episodes. A distinction with other differential diagnoses is a challenge for clinicians. Although extensive and invasive investigations should be avoided, baseline testing toward identifying organic causes is recommended in all children with CVS. The management of CVS requires an individually tailored therapy. Management of acute phase is mainly based on supportive and symptomatic care. Early intervention with abortive agents during the brief prodromal phase can be used to attempt to terminate the attack. During the interictal period, non-pharmacologic measures as lifestyle changes and the use of reassurance and anticipatory guidance seem to be effective as a preventive treatment. The indication for prophylactic pharmacotherapy depends on attack intensity and severity, the impairment of the QoL and if attack treatments are ineffective or cause side effects. When children remain refractory to acute or prophylactic treatment, or the episode differs from previous ones, the clinician should consider the possibility of an underlying disease and further mono- or combination therapy and psychotherapy can be guided by accompanying comorbidities and specific sub-phenotype. This review was developed by a joint task force of the Italian Society of Pediatric Gastroenterology Hepatology and Nutrition (SIGENP) and Italian Society of Pediatric Neurology (SINP) to identify relevant current issues and to propose future research directions on pediatric CVS.
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Affiliation(s)
- Umberto Raucci
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, Institute for Research, Hospitalization and Health Care (IRCCS), Rome, Italy
| | - Osvaldo Borrelli
- Division of Neurogastroenterology and Motility, Department of Pediatric Gastroenterology, University College London (UCL) Institute of Child Health and Great Ormond Street Hospital, London, United Kingdom
| | - Giovanni Di Nardo
- Chair of Pediatrics, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Faculty of Medicine & Psychology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, Institute for Research, Hospitalization and Health Care (IRCCS), Rome, Italy
| | - Piero Pavone
- Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Silvia Salvatore
- Pediatric Department, Ospedale “F. Del Ponte,” University of Insubria, Varese, Italy
| | | | | | - Raffaele Falsaperla
- Neonatal Intensive Care and Pediatric Units, S. Marco Hospital, Vittorio Emanuele Hospital, Catania, Italy
| | - Enrico Felici
- Unit of Pediatrics, The Children Hospital, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Michela Ada Noris Ferilli
- Division of Neurology, Bambino Gesù Children's Hospital, Institute for Research, Hospitalization and Health Care (IRCCS), Rome, Italy
| | - Salvatore Grosso
- Clinical Pediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Saverio Mallardo
- Pediatric Department, Santa Maria Goretti Hospital, Sapienza University of Rome, Latina, Italy
| | - Diego Martinelli
- Division of Metabolism, Department of Pediatric Specialties, Bambino Gesù Children's Hospital, Institute for Research, Hospitalization and Health Care (IRCCS), Rome, Italy
| | - Paolo Quitadamo
- Department of Pediatrics, A.O.R.N. Santobono-Pausilipon, Naples, Italy
| | - Licia Pensabene
- Pediatric Unit, Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Claudio Romano
- Pediatric Gastroenterology Unit, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University of Messina, Messina, Italy
| | | | - Alberto Spalice
- Child Neurology Division, Department of Pediatrics, “Sapienza,” University of Rome, Rome, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child, General and Specialistic Surgery, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | - Agnese Suppiej
- Pediatric Section, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Massimiliano Valeriani
- Division of Neurology, Bambino Gesù Children's Hospital, Institute for Research, Hospitalization and Health Care (IRCCS), Rome, Italy
| | - Letizia Zenzeri
- Emergency Pediatric Department, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
| | - Annamaria Staiano
- Section of Pediatrics, Department of Translational Medical Science, “Federico II” University of Naples, Naples, Italy
| | - Maria Pia Villa
- Chair of Pediatrics, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Faculty of Medicine & Psychology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Martino Ruggieri
- Unit of Rare Diseases of the Nervous System in Childhood, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genova, Italy
- Institute for Research, Hospitalization and Health Care (IRCCS) “G. Gaslini” Institute, Genova, Italy
| | - Pasquale Parisi
- Chair of Pediatrics, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Faculty of Medicine & Psychology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Maines E, Catesini G, Boenzi S, Mosca A, Candusso M, Dello Strologo L, Martinelli D, Maiorana A, Liguori A, Olivieri G, Taurisano R, Piemonte F, Rizzo C, Spada M, Dionisi-Vici C. Plasma methylcitric acid and its correlations with other disease biomarkers: The impact in the follow up of patients with propionic and methylmalonic acidemia. J Inherit Metab Dis 2020; 43:1173-1185. [PMID: 32681732 DOI: 10.1002/jimd.12287] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 12/14/2022]
Abstract
Methylcitric acid (MCA) analysis has been mainly utilized for the diagnosis of propionate disorders or as a second-tier test in newborn screening, but its utility for patients monitoring still needs to be established. We explored the potential contribution of MCA in the long-term management of organic acidurias. We prospectively evaluated plasma MCA and its relationship with disease biomarkers, clinical status, and disease burden in 22 patients, 13 with propionic acidemia (PA) and nine with methylmalonic acidemia (MMA) on standard treatment and/or after transplantation. Samples were collected at scheduled routine controls or during episodes of metabolic decompensation (MD), 10 patients were evaluated after transplantation (six liver, two combined liver and kidney, 2 kidney). MCA levels were higher in PA compared to MMA and its levels were not influenced by the clinical status (MD vs well state). In MMA, MCA was higher in elder patients and, along with fibroblast growth factor 21 (FGF21) and plasma methylmalonic acid, negatively correlated with GFR. In both diseases, MCA correlated with ammonia, glycine, lysine, C3, and the C3/C2, C3/C16 ratios. The disease burden showed a direct correlation with MCA and FGF21, for both diseases. All transplanted patients showed a significant reduction of MCA in comparison to baseline values, with some differences dependent on the type of transplantation. Our study provided new insights in understanding the disease pathophysiology, showing similarities between MCA and FGF21 in predicting disease burden, long-term complications and in evaluating the impact of organ transplantation.
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Affiliation(s)
- Evelina Maines
- Division of Metabolism, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Giulio Catesini
- Division of Metabolism, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Sara Boenzi
- Division of Metabolism, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Antonella Mosca
- Division of Hepatology, Gastroenterology and Nutrition, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Manila Candusso
- Division of Hepatology, Gastroenterology and Nutrition, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Arianna Maiorana
- Division of Metabolism, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Alessandra Liguori
- Division of Metabolism, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Giorgia Olivieri
- Division of Metabolism, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Roberta Taurisano
- Division of Metabolism, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Fiorella Piemonte
- Unit of Muscular and Neurodegenerative Diseases, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Cristiano Rizzo
- Division of Metabolism, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Marco Spada
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolism, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
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212
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Lee T, Yoshii K, Yoshida S, Suga T, Nakamura K, Sasai H, Murayama K, Kobayashi H, Hasegawa Y, Takeshima Y. Retrospective evaluations revealed pre-symptomatic citrulline concentrations measured by newborn screening were significantly low in late-onset ornithine transcarbamylase deficiency patients. Clin Chim Acta 2020; 510:633-637. [PMID: 32828733 DOI: 10.1016/j.cca.2020.08.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/17/2020] [Accepted: 08/18/2020] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Ornithine transcarbamylase deficiency (OTCD) is the most common urea cycle disorder. Late-onset OTCD manifests after the neonatal period; therefore, if pre-symptomatic diagnosis and treatment are performed, it can improve the prognosis by preventing hyperammonemia. However, pre-symptomatic diagnosis is unreliable as the specific screening marker of OTCD has not been established yet. This retrospective study aimed to evaluate the pre-symptomatic blood citrulline levels in patients with late-onset OTCD. METHODS Patients with late-onset OTCD who were born after the newborn screening based on tandem mass spectrometry (MS/MS-NBS) was started and were referred to Hyogo College of Medicine Hospital between 2014 and 2018 were included. Pre-symptomatic blood citrulline levels measured by MS/MS-NBS were retrospectively evaluated. RESULTS Four patients were included in this study. The pre-symptomatic blood citrulline levels were 2.02, 4.50, 4.97, and 3.75 µmol/l, respectively. Compared with the citrulline levels in all newborns in Hyogo prefecture, these values were significantly low. CONCLUSIONS These results suggest the possibility that hypocitrullinemia detected by the MS/MS-NBS can be used as a screening marker for some patients with late-onset OTCD. Further retrospective evaluation of pre-symptomatic citrulline levels in patients with late-onset OTCD, as well as prospective monitoring of hypocitrullinemia on the MS/MS-NBS should be conducted.
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Affiliation(s)
- Tomoko Lee
- Department of Pediatrics, Hyogo College of Medicine, Nishinomiya, Japan.
| | - Katsuhiko Yoshii
- Department of Pediatrics, Chibune General Hospital, Osaka, Japan
| | - Satoru Yoshida
- Department of Pediatrics, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Takenori Suga
- Pediatric Intensive Care Unit, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Kimitoshi Nakamura
- Department of Pediatrics, Kumamoto University Graduate School of Medicine, Kumamoto, Japan
| | - Hideo Sasai
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Kei Murayama
- Department of Metabolism, Chiba Children's Hospital, Chiba, Japan
| | - Hironori Kobayashi
- Department of Pediatrics, Shimane University Faculty of Medicine, Shimane, Japan
| | - Yuki Hasegawa
- Department of Pediatrics, Shimane University Faculty of Medicine, Shimane, Japan
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Verduci E, Carbone MT, Borghi E, Ottaviano E, Burlina A, Biasucci G. Nutrition, Microbiota and Role of Gut-Brain Axis in Subjects with Phenylketonuria (PKU): A Review. Nutrients 2020; 12:E3319. [PMID: 33138040 PMCID: PMC7692600 DOI: 10.3390/nu12113319] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/27/2020] [Indexed: 12/12/2022] Open
Abstract
The composition and functioning of the gut microbiota, the complex population of microorganisms residing in the intestine, is strongly affected by endogenous and exogenous factors, among which diet is key. Important perturbations of the microbiota have been observed to contribute to disease risk, as in the case of neurological disorders, inflammatory bowel disease, obesity, diabetes, cardiovascular disease, among others. Although mechanisms are not fully clarified, nutrients interacting with the microbiota are thought to affect host metabolism, immune response or disrupt the protective functions of the intestinal barrier. Similarly, key intermediaries, whose presence may be strongly influenced by dietary habits, sustain the communication along the gut-brain-axis, influencing brain functions in the same way as the brain influences gut activity. Due to the role of diet in the modulation of the microbiota, its composition is of high interest in inherited errors of metabolism (IEMs) and may reveal an appealing therapeutic target. In IEMs, for example in phenylketonuria (PKU), since part of the therapeutic intervention is based on chronic or life-long tailored dietetic regimens, important variations of the microbial diversity or relative abundance have been observed. A holistic approach, including a healthy composition of the microbiota, is recommended to modulate host metabolism and affected neurological functions.
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Affiliation(s)
- Elvira Verduci
- Department of Paediatrics, Vittore Buzzi Children’s Hospital-University of Milan, Via Lodovico Castelvetro, 32, 20154 Milan, Italy
- Department of Health Science, University of Milan, via di Rudinì 8, 20142 Milan, Italy; (E.B.); (E.O.)
| | - Maria Teresa Carbone
- UOS Metabolic and Rare Diseases, AORN Santobono, Via Mario Fiore 6, 80122 Naples, Italy;
| | - Elisa Borghi
- Department of Health Science, University of Milan, via di Rudinì 8, 20142 Milan, Italy; (E.B.); (E.O.)
| | - Emerenziana Ottaviano
- Department of Health Science, University of Milan, via di Rudinì 8, 20142 Milan, Italy; (E.B.); (E.O.)
| | - Alberto Burlina
- Division of Inborn Metabolic Diseases, Department of Diagnostic Services, University Hospital of Padua, Via Orus 2B, 35129 Padua, Italy;
| | - Giacomo Biasucci
- Department of Paediatrics & Neonatology, Guglielmo da Saliceto Hospital, Via Taverna Giuseppe, 49, 29121 Piacenza, Italy;
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Francini-Pesenti F, Gugelmo G, Lenzini L, Vitturi N. Nutrient Intake and Nutritional Status in Adult Patients with Inherited Metabolic Diseases Treated with Low-Protein Diets: A Review on Urea Cycle Disorders and Branched Chain Organic Acidemias. Nutrients 2020; 12:E3331. [PMID: 33138136 PMCID: PMC7693747 DOI: 10.3390/nu12113331] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 12/31/2022] Open
Abstract
Low-protein diets (LPDs) are the main treatment for urea cycle disorders (UCDs) and organic acidemias (OAs). In most cases, LPDs start in childhood and must be continued into adulthood. The improved life expectancy of patients with UCDs and OAs raises the question of their consequences on nutritional status in adult subjects. As this topic has so far received little attention, we conducted a review of scientific studies that investigated the nutrient intake and nutritional status in adult patients with UCDs and branched chain organic acidemias (BCOAs) on LPD. METHODS The literature search was conducted in PubMed/MEDLINE, Scopus, EMBASE and Google Scholar from 1 January 2000 to 31 May 2020, focusing on nutrient intake and nutritional status in UCD and OA adult patients. RESULTS Despite protein restriction is recommended as the main treatment for UCDs and OAs, in these patients, protein intake ranges widely, with many patients who do not reach safety levels. When evaluated, micronutrient intake resulted below recommended values in some patients. Lean body mass resulted in most cases lower than normal range while fat body mass (FM) was often found normal or higher than the controls or reference values. Protein intake correlated inversely with FM both in adult and pediatric UCD patients. CONCLUSIONS The clinical management of adult patients with UCDs and BCOAs should include an accurate assessment of the nutritional status and body composition. However, as little data is still available on this topic, further studies are needed to better clarify the effects of LPDs on nutritional status in adult UCD and BCOA patients.
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Affiliation(s)
- Francesco Francini-Pesenti
- Department of Medicine-DIMED, University of Padova, Division of Clinical Nutrition, University Hospital, 35128 Padova, Italy; (F.F.-P.); (G.G.)
| | - Giorgia Gugelmo
- Department of Medicine-DIMED, University of Padova, Division of Clinical Nutrition, University Hospital, 35128 Padova, Italy; (F.F.-P.); (G.G.)
| | - Livia Lenzini
- Department of Medicine-DIMED, University of Padova, Hypertension Unit, University Hospital, 35128 Padova, Italy;
| | - Nicola Vitturi
- Department of Medicine-DIMED, Division of Metabolic Diseases, University Hospital, 35128 Padova, Italy
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Del Re S, Empain A, Vicinanza A, Balasel O, Johansson AB, Stalens JP, De Laet C. Irritability, Poor Feeding and Respiratory Alkalosis in Newborns: Think about Metabolic Emergencies. A Brief Summary of Hyperammonemia Management. Pediatr Rep 2020; 12:77-85. [PMID: 33113778 PMCID: PMC7717652 DOI: 10.3390/pediatric12030019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 07/27/2020] [Indexed: 12/19/2022] Open
Abstract
The urea cycle is a series of metabolic reactions that convert ammonia into urea in order to eliminate it from the body. Urea cycle disorders are characterized by hyperammonemia, which can cause irreversible damages in central nervous system. We report a series of three newborns presenting irritability, poor feeding and tachypnea. Their first gas analysis revealed respiratory alkalosis. Hyperammonemia was confirmed, and three different enzymatic blocks in the urea cycle were diagnosed. Immediate treatment consisted in the removal of ammonia by reduction of the catabolic state, dietary adjustments, use of nitrogen scavenging agents and ultimately hemodiafiltration. Hyperammonemia is a medical emergency whose treatment should not be delayed. This report aims to highlight the importance of suspecting urea cycle disorders in newborns with aspecific signs of hyperammonemia and respiratory alkalosis, and to sum up the broad lines of hyperammonemia management.
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Affiliation(s)
- Stefano Del Re
- Neonatal Intensive Care Unit, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, 1020 Brussels, Belgium; (O.B.); (A.-B.J.)
- Correspondence: ; Tel.: +32-496-616024
| | - Aurélie Empain
- Department of Nutrition and Metabolism, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, 1020 Brussels, Belgium; (A.E.); (C.D.L.)
| | - Alfredo Vicinanza
- Pediatric Intensive Care Unit, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, 1020 Brussels, Belgium;
| | - Ovidiu Balasel
- Neonatal Intensive Care Unit, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, 1020 Brussels, Belgium; (O.B.); (A.-B.J.)
| | - Anne-Britt Johansson
- Neonatal Intensive Care Unit, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, 1020 Brussels, Belgium; (O.B.); (A.-B.J.)
| | - Jean-Philippe Stalens
- Neonatal Non-Intensive Care Unit, Centre Hospitalier de Wallonie Picarde (Site Union), 7500 Tournai, Belgium;
| | - Corinne De Laet
- Department of Nutrition and Metabolism, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, 1020 Brussels, Belgium; (A.E.); (C.D.L.)
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216
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Kenneson A, Singh RH. Presentation and management of N-acetylglutamate synthase deficiency: a review of the literature. Orphanet J Rare Dis 2020; 15:279. [PMID: 33036647 PMCID: PMC7545900 DOI: 10.1186/s13023-020-01560-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/24/2020] [Indexed: 12/19/2022] Open
Abstract
Background N-Acetylglutamate synthase (NAGS) deficiency is an extremely rare autosomal recessive metabolic disorder affecting the urea cycle, leading to episodes of hyperammonemia which can cause significant morbidity and mortality. Since its recognition in 1981, NAGS deficiency has been treated with carbamylglutamate with or without other measures (nutritional, ammonia scavengers, dialytic, etc.). We conducted a systematic literature review of NAGS deficiency to summarize current knowledge around presentation and management. Methods Case reports and case series were identified using the Medline database, as well as references from other articles and a general internet search. Clinical data related to presentation and management were abstracted by two reviewers. Results In total, 98 cases of NAGS deficiency from 79 families, in 48 articles or abstracts were identified. Of these, 1 was diagnosed prenatally, 57 were neonatal cases, 34 were post-neonatal, and 6 did not specify age at presentation or were asymptomatic at diagnosis. Twenty-one cases had relevant family history. We summarize triggers of hyperammonemic episodes, diagnosis, clinical signs and symptoms, and management strategies. DNA testing is the preferred method of diagnosis, although therapeutic trials to assess response of ammonia levels to carbamylglutamate may also be helpful. Management usually consists of treatment with carbamylglutamate, although the reported maintenance dose varied across case reports. Protein restriction was sometimes used in conjunction with carbamylglutamate. Supplementation with citrulline, arginine, and sodium benzoate also were reported. Conclusions Presentation of NAGS deficiency varies by age and symptoms. In addition, both diagnosis and management have evolved over time and vary across clinics. Prompt recognition and appropriate treatment of NAGS deficiency with carbamylglutamate may improve outcomes of affected individuals. Further research is needed to assess the roles of protein restriction and supplements in the treatment of NAGS deficiency, especially during times of illness or lack of access to carbamylglutamate.
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Affiliation(s)
- Aileen Kenneson
- Department of Human Genetics, Emory University, Atlanta, GA, USA.
| | - Rani H Singh
- Department of Human Genetics, Emory University, Atlanta, GA, USA. .,Department of Pediatrics, Emory University, Atlanta, GA, USA.
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Considering Proximal Urea Cycle Disorders in Expanded Newborn Screening. Int J Neonatal Screen 2020; 6:ijns6040077. [PMID: 33124615 PMCID: PMC7712149 DOI: 10.3390/ijns6040077] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/20/2020] [Accepted: 09/29/2020] [Indexed: 02/06/2023] Open
Abstract
Proximal urea cycle disorders (PUCDs) have adverse outcomes such as intellectual disability and death, which may benefit from newborn screening (NBS) through early detection and prevention with early treatment. Ornithine transcarbamylase deficiency (OTCD) and carbamoyl phosphate synthetase 1 deficiency (CPS1D) are screened in six and eight states in the United States. We analyzed current evidence to see if it supports inclusion of PUCDs in the NBS panels based upon prevention potential, medical, diagnostic, treatment, and public health rationales. A literature review was performed in PubMed using MESH terms for OTCD, CPS1D, and NAGSD. A systematic review was performed in the hallmark of NBS inclusion criteria. We reviewed 31 articles. Molecular and biochemical diagnosis is available to provide diagnostic evidence. Untreated PUCDs have a significant burden with considerable developmental delay and mortality that may improve with early treatment. Tandem mass spectrometry can be used for NBS for PUCDs; however, citrulline and glutamine alone are not specific. Medical treatments currently available for PUCDs meet existing medical, diagnostic, treatment, and public health rationales. Improvement in NBS algorithms to increase sensitivity and specificity will allow earlier diagnosis and treatment to potentially improve disability and mortality rates.
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218
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Solé C, Arriaga M, Cañedo E. High Blood Pressure in a Urea Cycle Disorder: Case Report. AJP Rep 2020; 10:e347-e351. [PMID: 33133764 PMCID: PMC7591362 DOI: 10.1055/s-0040-1716733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 11/14/2022] Open
Abstract
Introduction Urea cycle disorders (UCDs) form a group of metabolic pathological conditions that might develop serious neurological consequences. Early diagnosis, before irreversible damage is established, is the most important prognostic and morbidity factor. Case Report We present the case of a 5-day newborn with high blood pressure and respiratory distress. Diagnosis was type I citrullinemia. With appropriate citrullinemia guided-treatment blood pressure returned to normal. Conclusion High blood pressure has been rarely described as a lead symptom for the debut of a UCD. We must take this into consideration as an early recognition and treatment of these disorders are of the utmost importance.
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Affiliation(s)
- Carolina Solé
- Department of Neonatology, Gregorio Marañon Hospital, Madrid, Spain
| | - María Arriaga
- Department of Neonatology, Gregorio Marañon Hospital, Madrid, Spain
| | - Elvira Cañedo
- Department of Metabolism Diseases and Nutrition, Niño Jesús Hospital, Madrid, Spain
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219
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Abstract
Metabolic disorders in a neonate can present with involvement of any organ system and can be challenging to diagnose. A newborn can present with an acute metabolic crisis such as hyperammonemia or seizures needing immediate management, with a more chronic clinical picture such as cholestatic liver disease, or with structural abnormalities such as skeletal manifestations. Early detection of treatable metabolic conditions is important to improve outcomes. Newborn screening has facilitated early detection and initiation of therapy for many metabolic disorders. However, normal testing does not rule out a metabolic disorder and a high index of suspicion should remain when caring for any critically ill neonate without a diagnosis. Whole exome sequencing (WES) or whole genome sequencing (WGS) can be powerful tools in rapid diagnosis of a potentially treatable metabolic condition in a critically ill neonate. This review presents classic clinical presentations of neonatal metabolic disorders and also highlights some uncommon neonatal manifestations of metabolic disorders to improve the recognition and diagnosis of these conditions.
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Affiliation(s)
- Anna-Kaisa Niemi Md
- Division of Neonatology, Rady Children's Hospital San Diego, University of California San Diego, San Diego, CA
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220
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Hidaka M, Higashi E, Uwatoko T, Uwatoko K, Urashima M, Takashima H, Watanabe Y, Kitazono T, Sugimori H. Late-onset ornithine transcarbamylase deficiency: a rare cause of recurrent abnormal behavior in adults. Acute Med Surg 2020; 7:e565. [PMID: 32995020 PMCID: PMC7507316 DOI: 10.1002/ams2.565] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/16/2020] [Accepted: 07/31/2020] [Indexed: 11/12/2022] Open
Abstract
Background Ornithine transcarbamylase is an enzyme of the urea cycle, which produces urea from ammonia. Although ornithine transcarbamylase deficiency mainly occurs as a severe neonatal-onset disease, a late-onset form that could become symptomatic from infancy to adulthood is also known. Case presentation A 34-year-old man presented with sudden onset of abnormal behavior, lethargy, and hyperammonemia (108 µmol/L). He had recently increased daily protein intake, which suggested urea cycle disorder. After initiation of protein-restricted diet and treatment with arginine and sodium phenylbutyrate, his symptoms resolved, along with a decrease in the ammonia level. An R40H(c.119G > A) mutation in the OTC gene was identified. Conclusion Awareness of adult onset ornithine transcarbamylase deficiency in a patient with acute psychiatric symptoms due to hyperammonemia is important.
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Affiliation(s)
- Masaoki Hidaka
- Department of Cerebrovascular Medicine Stroke Center Saga Prefecture Medical Centre Koseikan Saga Japan
| | - Eiji Higashi
- Department of Cerebrovascular Medicine Stroke Center Saga Prefecture Medical Centre Koseikan Saga Japan
| | - Takeshi Uwatoko
- Department of Cerebrovascular Medicine Stroke Center Saga Prefecture Medical Centre Koseikan Saga Japan
| | - Kiku Uwatoko
- Department of Neurology Stroke Center Saga Prefecture Medical Centre Koseikan Saga Japan
| | - Mayumi Urashima
- Department of Pediatrics Saga Prefecture Medical Centre Koseikan Saga Japan
| | - Hiroshi Takashima
- Department of Neurology Stroke Center Saga Prefecture Medical Centre Koseikan Saga Japan
| | - Yoriko Watanabe
- Research Institute of Medical Mass Spectrometry Kurume University School of Medicine Kurume Japan.,Department of Pediatrics and Child Health Kurume University School of Medicine Kurume Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Hiroshi Sugimori
- Department of Cerebrovascular Medicine Stroke Center Saga Prefecture Medical Centre Koseikan Saga Japan
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221
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Häberle J. Therapeutische Optionen bei angeborenen Stoffwechselstörungen. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-00936-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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222
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Huemer M. Beitrag von Leitlinien zur Standardisierung in der Medizin. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-00933-9] [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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223
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Mattke AC, Shikata F, McGill J, Justo R, Venugopal P. Successful management of a neonate with OTC deficiency presenting with hyperammonemia and severe cardiac dysfunction with extracorporeal membrane oxygenation support and continuous renal replacement therapy. JIMD Rep 2020; 55:12-14. [PMID: 32905004 PMCID: PMC7463050 DOI: 10.1002/jmd2.12135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/22/2020] [Accepted: 02/24/2020] [Indexed: 11/24/2022] Open
Abstract
Ornithine transcarbamylase (OTC) deficiency is an X-linked urea cycle disorder which-in severe form-results in rapid accumulation of ammonia and glutamine with subsequent irreversible brain injury. We present a case of severe left ventricular dysfunction with hyperammonemic crisis caused by OTC deficiency which was managed with veno-arterial extracorporeal membrane oxygenation support combined with continuous renal replacement therapy. Aggressive treatment led to normalization of ammonia and full left ventricular recovery.
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Affiliation(s)
- Adrian C. Mattke
- Paediatric Intensive Care Unit, Queensland Children's HospitalSouth BrisbaneQueenslandAustralia
- Queensland Pediatric Cardiac Service, Queensland Children's HospitalSouth BrisbaneQueenslandAustralia
- University of Queensland, Brisbane, School of MedicineSt LuciaQueenslandAustralia
- Paediatric Critical Care Research Group, CCHRUniversity of QueenslandSt LuciaQueenslandAustralia
| | - Fumiaki Shikata
- Queensland Pediatric Cardiac Service, Queensland Children's HospitalSouth BrisbaneQueenslandAustralia
| | - James McGill
- Metabolic Medicine, Queensland Children's HospitalSouth BrisbaneQueenslandAustralia
| | - Rob Justo
- Queensland Pediatric Cardiac Service, Queensland Children's HospitalSouth BrisbaneQueenslandAustralia
- University of Queensland, Brisbane, School of MedicineSt LuciaQueenslandAustralia
| | - Prem Venugopal
- Queensland Pediatric Cardiac Service, Queensland Children's HospitalSouth BrisbaneQueenslandAustralia
- University of Queensland, Brisbane, School of MedicineSt LuciaQueenslandAustralia
- Paediatric Critical Care Research Group, CCHRUniversity of QueenslandSt LuciaQueenslandAustralia
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224
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Ames EG, Luckritz KE, Ahmad A. A retrospective review of outcomes in the treatment of hyperammonemia with renal replacement therapy due to inborn errors of metabolism. Pediatr Nephrol 2020; 35:1761-1769. [PMID: 32232638 DOI: 10.1007/s00467-020-04533-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 02/08/2020] [Accepted: 03/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Outcomes for severe hyperammonemia treated with renal replacement therapy (RRT) reported in the literature vary widely. This has created differing recommendations regarding when RRT is beneficial for hyperammonemic patients. METHODS To evaluate our institution's experience with RRT in pediatric patients with inborn errors of metabolism (IEMs) and potential prognostic indicators of a better or worse outcome, we performed a retrospective chart review of patients who received RRT for hyperammonemia. Our cohort included 19 patients with confirmed IEMs who received RRT between 2000 and 2017. Descriptive statistics are presented as medians with interquartile ranges with appropriate statistical testing assuming unequal variance. RESULTS There were 16 males (84%) and 3 females (16%) identified for inclusion in this study. There were 9 survivors (47%) and 10 non-survivors (53%). The average age of survivors was 67 months (age range from 3 days to 15.6 years). The average age of non-survivors was 1.8 months (age range from 2 days to 18.7 months). Peak ammonia, ammonia on admission, and at RRT initiation were higher in non-survivors compared with survivors. Higher ammonia levels and no change in ammonia between admission and RRT initiation were associated with an increased risk of mortality. CONCLUSIONS Hyperammonemia affects two distinct patient populations; neonates with markedly elevated ammonia levels on presentation and older children who often have established IEM diagnoses and require RRT after failing nitrogen-scavenging therapy. Our experience demonstrates no significant change in mortality associated with neonatal hyperammonemia, which remains high despite improvements in RRT and intensive care.
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Affiliation(s)
- Elizabeth G Ames
- Division of Pediatric Genetics, Metabolism, and Genomic Medicine, Department of Pediatrics, University of Michigan, D5240 Medical Professional Building, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - Kera E Luckritz
- Division of Pediatric Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ayesha Ahmad
- Division of Pediatric Genetics, Metabolism, and Genomic Medicine, Department of Pediatrics, University of Michigan, D5240 Medical Professional Building, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
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225
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The Application of Next-Generation Sequencing (NGS) in Neonatal-Onset Urea Cycle Disorders (UCDs): Clinical Course, Metabolomic Profiling, and Genetic Findings in Nine Chinese Hyperammonemia Patients. BIOMED RESEARCH INTERNATIONAL 2020; 2020:5690915. [PMID: 32934962 PMCID: PMC7479453 DOI: 10.1155/2020/5690915] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/10/2020] [Accepted: 08/17/2020] [Indexed: 12/19/2022]
Abstract
During Jan. 2016–Dec. 2019, nine Chinese patients from eight unrelated families were diagnosed with neonatal-onset UCDs by targeted panel sequencing or whole-exome sequencing (WES). Their clinical manifestations, biochemical features, 180-day-age outcomes, and molecular genetic characteristics were reviewed retrospectively. NGS-based tests revealed 7 patients diagnosed with ornithine transcarbamylase deficiency (OTCD) and 2 with carbamoylphosphate synthetase I deficiency (CPS1D). The spectrum of the clinical presentation of nine affected individuals progressed from unspecific symptoms like poor feeding to somnolence, coma, and death. All patients presented with an acute hyperammonemia. The most robust metabolic pattern in OTCD was hyperglutaminemic hyperammonemia with high concentration of urine orotic acid, and it was reported in six patients. Of ten variants found on the OTC gene and CPS1 gene, 3 were novel: (c.176T>C (p.L59P)) in the OTC gene, c.2938G>A (p.G980S) and c.3734T>A (p.L1245H) in the CPS1 gene. There was a high mortality rate of 77.78% (7/9) for all the defects combined. An OTC-deficient male and a CPS1-deficient female survived from episodes of hyperammonemia. Although prompt recognition of UCD and the use of alternative pathway therapy in addition to provision of appropriate nutrition and dialysis improved survival, the overall outcomes for the neonatal-onset type are poor in China.
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226
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Matoori S, Forster V, Agostoni V, Bettschart-Wolfensberger R, Bektas RN, Thöny B, Häberle J, Leroux JC, Kabbaj M. Preclinical evaluation of liposome-supported peritoneal dialysis for the treatment of hyperammonemic crises. J Control Release 2020; 328:503-513. [PMID: 32860926 DOI: 10.1016/j.jconrel.2020.08.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/07/2020] [Accepted: 08/20/2020] [Indexed: 12/19/2022]
Abstract
Liposome-supported peritoneal dialysis (LSPD) with transmembrane pH-gradient liposomes was previously shown to enhance ammonia removal in cirrhotic rats and holds promise for the treatment of hyperammonemic crises-associated disorders. The main objective of this work was to conduct the preclinical evaluation of LSPD in terms of pharmacokinetics, ammonia uptake, and toxicology to seek regulatory approval for a first-in-human study. The formulation containing citric acid-loaded liposomes was administered intraperitoneally at two different doses once daily for ten days to healthy minipigs. It was also tested in a domestic pig model of hyperammonemia. The pharmacokinetics of citric acid and 1,2-dipalmitoyl-sn-glycero-3-phosphocholine was linear following intraperitoneal administration of medium and high dose. There was no systemic accumulation following daily doses over ten days. The systemic exposure to phospholipids remained low. Furthermore, the liposome-containing peritoneal fluid contained significantly higher ammonia levels than the liposome-free control, demonstrating efficient ammonia sequestration in the peritoneal space. This was indeed confirmed by the ability of LSPD to decrease plasmatic ammonia levels in artificially induced hyperammonemic pigs. LSPD was well tolerated, and no complement activation-related pseudoallergy reactions were observed. The safety profile, the linear pharmacokinetics of citric acid following repeated administrations of LSPD as well as the linear dose-dependent ammonia sequestration in the peritoneal space provide a strong basis for the clinical investigation of LSPD.
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Affiliation(s)
- Simon Matoori
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland; John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | | | - Valentina Agostoni
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
| | - Regula Bettschart-Wolfensberger
- Department of Clinical Diagnostics and Services, Section of Anaesthesiology, Vetsuisse Faculty University of Zurich, Zurich, Switzerland
| | - Rima Nadine Bektas
- Department of Clinical Diagnostics and Services, Section of Anaesthesiology, Vetsuisse Faculty University of Zurich, Zurich, Switzerland
| | - Beat Thöny
- Division of Metabolism, University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
| | - Johannes Häberle
- Division of Metabolism, University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
| | - Jean-Christophe Leroux
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland.
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227
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Olgac A, Kasapkara CS, Kilic M, Keskin EY, Sandal G, Cram DS, Haberle J, Torun D. Carbonic anhydrase VA deficiency: a very rare case of hyperammonemic encephalopathy. J Pediatr Endocrinol Metab 2020; 33:1349-1352. [PMID: 32809955 DOI: 10.1515/jpem-2020-0117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/22/2020] [Indexed: 12/19/2022]
Abstract
Objectives Carbonic anhydrase VA (CAVA) deficiency is a rare autosomal recessive inborn error of metabolism that leads to acute metabolic crises, especially in the neonatal or infantile period. It is caused by a deficiency of the enzyme CAVA, which is encoded by the CA5A gene. Case presentation Fifteen patients with homozygous pathogenic CA5A mutations involving 10 different lesions have been reported in the literature up to date. Main clinical and biochemical features of CAVA deficiency include lethargy, hyperammonemic encephalopathy, metabolic acidosis, elevated lactate and hypoglycemia. In most patients reported so far, a single metabolic decompensation attack has been reported, and they have remained stable thereafter with no further crisis. Conclusions We report the 16th case of CAVA deficiency, who was diagnosed by whole-exome sequencing and showed a typical course of the disease with normal development at 18 months.
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Affiliation(s)
- Asburce Olgac
- Department of Pediatric Metabolism, Dr. Sami Ulus Maternity and Child Health Training and Research Hospital, Ankara, Turkey
| | - Cigdem Seher Kasapkara
- Department of Pediatric Metabolism, Dr. Sami Ulus Maternity and Child Health Training and Research Hospital, Ankara, Turkey
| | - Mustafa Kilic
- Department of Pediatric Metabolism, Dr. Sami Ulus Maternity and Child Health Training and Research Hospital, Ankara, Turkey
| | - Ebru Yılmaz Keskin
- Department of Pediatric Hematology and Oncology, Süleyman Demirel University Medical Faculty, Isparta, Turkey
| | - Gonca Sandal
- Department of Neonatology, Süleyman Demirel University Medical Faculty, Isparta, Turkey
| | | | - Johannes Haberle
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Deniz Torun
- Department of Medical Genetics, Gulhane Faculty of Medicine, University of Health Sciences, Ankara, Turkey
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228
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Mitochondrial carbonic anhydrase VA deficiency in three Indian infants manifesting early metabolic crisis. Brain Dev 2020; 42:534-538. [PMID: 32381389 DOI: 10.1016/j.braindev.2020.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 04/04/2020] [Accepted: 04/19/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hyperammonemia and hyperlactatemia in neonates and young children with non-specific biochemical markers poses a diagnostic challenge. An accurate diagnosis is essential for effective management. CASE REPORTS We present three infants from unrelated families, one with infantile and two with neonatal hyperammonemic encephalopathy, hypoglycaemia, and hyperlactatemia. The underlying cause was confirmed following whole exome sequencing as biochemical markers were not conclusive of a definite diagnosis. CONCLUSION The combination of hyperammonemic encephalopathy, hyperlactatemia and hypoglycemia in neonates and infants should prompt physicians to suspect Carbonic anhydrase VA deficiency. Majority of these children can have a favourable long-term outcome with symptomatic treatment.
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229
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Rapid Phenotype-Driven Gene Sequencing with the NeoSeq Panel: A Diagnostic Tool for Critically Ill Newborns with Suspected Genetic Disease. J Clin Med 2020; 9:jcm9082362. [PMID: 32718099 PMCID: PMC7464859 DOI: 10.3390/jcm9082362] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 12/17/2022] Open
Abstract
New genomic sequencing techniques have shown considerable promise in the field of neonatology, increasing the diagnostic rate and reducing time to diagnosis. However, several obstacles have hindered the incorporation of this technology into routine clinical practice. We prospectively evaluated the diagnostic rate and diagnostic turnaround time achieved in newborns with suspected genetic diseases using a rapid phenotype-driven gene panel (NeoSeq) containing 1870 genes implicated in congenital malformations and neurological and metabolic disorders of early onset (<2 months of age). Of the 33 newborns recruited, a genomic diagnosis was established for 13 (39.4%) patients (median diagnostic turnaround time, 7.5 days), resulting in clinical management changes in 10 (76.9%) patients. An analysis of 12 previous prospective massive sequencing studies (whole genome (WGS), whole exome (WES), and clinical exome (CES) sequencing) in newborns admitted to neonatal intensive care units (NICUs) with suspected genetic disorders revealed a comparable median diagnostic rate (37.2%), but a higher median diagnostic turnaround time (22.3 days) than that obtained with NeoSeq. Our phenotype-driven gene panel, which is specific for genetic diseases in critically ill newborns is an affordable alternative to WGS and WES that offers comparable diagnostic efficacy, supporting its implementation as a first-tier genetic test in NICUs.
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230
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Posset R, Garbade SF, Gleich F, Gropman AL, de Lonlay P, Hoffmann GF, Garcia-Cazorla A, Nagamani SCS, Baumgartner MR, Schulze A, Dobbelaere D, Yudkoff M, Kölker S, Zielonka M. Long-term effects of medical management on growth and weight in individuals with urea cycle disorders. Sci Rep 2020; 10:11948. [PMID: 32686765 PMCID: PMC7371674 DOI: 10.1038/s41598-020-67496-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 06/08/2020] [Indexed: 12/18/2022] Open
Abstract
Low protein diet and sodium or glycerol phenylbutyrate, two pillars of recommended long-term therapy of individuals with urea cycle disorders (UCDs), involve the risk of iatrogenic growth failure. Limited evidence-based studies hamper our knowledge on the long-term effects of the proposed medical management in individuals with UCDs. We studied the impact of medical management on growth and weight development in 307 individuals longitudinally followed by the Urea Cycle Disorders Consortium (UCDC) and the European registry and network for Intoxication type Metabolic Diseases (E-IMD). Intrauterine growth of all investigated UCDs and postnatal linear growth of asymptomatic individuals remained unaffected. Symptomatic individuals were at risk of progressive growth retardation independent from the underlying disease and the degree of natural protein restriction. Growth impairment was determined by disease severity and associated with reduced or borderline plasma branched-chain amino acid (BCAA) concentrations. Liver transplantation appeared to have a beneficial effect on growth. Weight development remained unaffected both in asymptomatic and symptomatic individuals. Progressive growth impairment depends on disease severity and plasma BCAA concentrations, but cannot be predicted by the amount of natural protein intake alone. Future clinical trials are necessary to evaluate whether supplementation with BCAAs might improve growth in UCDs.
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Affiliation(s)
- Roland Posset
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Sven F Garbade
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Florian Gleich
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | | | - Pascale de Lonlay
- Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Service de Maladies Metaboliques (MaMEA), filière G2M, Université Paris-Descartes, Paris, France
| | - Georg F Hoffmann
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Angeles Garcia-Cazorla
- Hospital San Joan de Deu, Institut Pediàtric de Recerca. Servicio de Neurologia and CIBERER, ISCIII, Barcelona, Spain
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Matthias R Baumgartner
- University Children's Hospital Zurich and Children's Research Center, Zurich, Switzerland
| | - Andreas Schulze
- University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada
| | - Dries Dobbelaere
- Centre de Référence Maladies Héréditaires du Métabolisme de L'Enfant Et de L'Adulte, Jeanne de Flandre Hospital, CHRU Lille, and Faculty of Medicine, University Lille 2, Lille, France
| | - Marc Yudkoff
- School of Medicine and Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Stefan Kölker
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Matthias Zielonka
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
- Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany.
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231
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Schiergens KA, Weiß KJ, Dokoupil K, Fleissner S, Maier EM. [Dietary treatment of inborn errors of metabolism-a balancing act between indulgence and therapy]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:864-871. [PMID: 32542434 DOI: 10.1007/s00103-020-03168-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
For many inborn metabolic diseases, a lifelong diet is a crucial part of the therapy since pharmacological therapy is available for only a few conditions and patients. The implementation of a low natural protein diet with a reduced intake of natural protein and the complementary use of synthetic amino acid mixtures is described using the examples of phenylketonuria and urea cycle disorders focusing on children and adolescents. For phenylketonuria, the amino acid supplement is free of phenylalanine whereas for urea cycle disorders, it exclusively consists of essential amino acids. The dietary treatment aims to maintain metabolic stability and to prevent accumulation of toxic metabolites. At the same time, the nutritional requirements to ensure growth and development must be met. Therefore, patients need to follow strict rules regarding the choice of food products. This restrictive therapy interferes with the desire for autonomy and the joy of eating and often results in a reduced quality of life.Following the diet is crucial for a favorable outcome. To meet its requirements, patients and their families are provided with training. It is a great challenge not only to support the patients and their families in all practical aspects of dietary management, but also to motivate them to lifelong adherence in order to ensure the best possible outcome.
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Affiliation(s)
- Katharina A Schiergens
- Abteilung für angeborene Stoffwechselerkrankungen, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital der LMU München, Lindwurmstr. 4, 80337, München, Deutschland
| | - Katharina J Weiß
- Abteilung für angeborene Stoffwechselerkrankungen, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital der LMU München, Lindwurmstr. 4, 80337, München, Deutschland
| | - Katharina Dokoupil
- Abteilung für angeborene Stoffwechselerkrankungen, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital der LMU München, Lindwurmstr. 4, 80337, München, Deutschland
| | - Sandra Fleissner
- Abteilung für angeborene Stoffwechselerkrankungen, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital der LMU München, Lindwurmstr. 4, 80337, München, Deutschland
| | - Esther M Maier
- Abteilung für angeborene Stoffwechselerkrankungen, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital der LMU München, Lindwurmstr. 4, 80337, München, Deutschland.
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Seltene Erkrankungen in der Pädiatrie – von der Diagnostik und Behandlung einzelner Erkrankungen zum Aufbau von Netzwerkstrukturen. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-00978-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ZusammenfassungDie Versorgung von Menschen mit seltenen Erkrankungen (SE) stellt das Gesundheitssystem vor große Aufgaben. Dieses betrifft in besonderem Maße die Kinder- und Jugendmedizin, denn mehr als 80 % aller SE werden im Verlauf des Kindesalters symptomatisch. Oft fehlten und fehlen trotz rascher diagnostischer und therapeutischer Fortschritte belastbare Behandlungs- und Betreuungskonzepte mit ausreichender personeller Kontinuität und Expertise im ambulanten wie auch stationären Bereich.Derzeit leben in Deutschland ca. 4 Mio. Patienten mit einer SE, und jeder Kinder- und Jugendmediziner, ob in der Praxis oder in der Spezialambulanz im Universitätsklinikum, wird immer wieder mit diesen Patienten beschäftigt sein. In den letzten Jahren konnten die diagnostischen und jetzt zunehmend auch ursächlich therapeutischen Möglichkeiten entscheidend verbessert werden. Dieser Prozess ist äußerst dynamisch, wie die aktuellen Entwicklungen und Diskussionen um die ursächlichen genetischen Therapien der spinalen Muskelatrophie zeigen. Zur erfolgreichen Umsetzung der medizinischen Fortschritte in unser Gesundheitssystem wurde unter entscheidender Einbeziehung der Selbsthilfe, die für die Betroffenen von SE und ihre Angehörigen essenzielle Arbeiten leistet, 2013 ein Nationaler Aktionsplan für Menschen mit Seltenen Erkrankungen erarbeitet und verabschiedet. Dieser sieht sektorenübergreifende Versorgungsstrukturen und die Strukturierung von Zentren für seltene Erkrankungen vor. Innovationsfondprojekte haben inzwischen konkrete Verbesserungen der Versorgung von Patienten mit SE erfolgreich erprobt, und die Deutsche Gesellschaft für Kinder- und Jugendmedizin (DGKJ) hat eine neue Kommission für SE unter Einbeziehung der Patientenvertretung Allianz Chronischer Seltener Erkrankungen (ACHSE) e. V. und der Deutschen Gesellschaft für Humangenetik eingerichtet. Diese soll sich dieser speziellen Thematik widmen sowie diese positiven Entwicklungen beratend unterstützen. Mit diesem Artikel nehmen wir eine aktuelle Standortbestimmung vor und geben Anregungen für Diskussionen.
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Del Río C, Martín-Hernández E, Ruiz A, Quijada-Fraile P, Rubio P. Perioperative management of children with urea cycle disorders. Paediatr Anaesth 2020; 30:780-791. [PMID: 32375202 DOI: 10.1111/pan.13905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Urea cycle disorders are congenital metabolism errors that affect ammonia elimination. Clinical signs and prognosis are strongly influenced by peak ammonia levels. Numerous triggers associated with metabolic decompensation have been described with many of them, including fasting or stress, being related to the perioperative period. AIMS We aimed to assess perioperative complications in pediatric patients with urea cycle disorders requiring general anesthesia in our center. METHODS We reviewed the clinical history of all the pediatric patients with a confirmed urea cycle disorders diagnosis requiring surgery or a diagnostic procedure with anesthesia between January 2002 and June 2018. RESULTS We included 33 operations (major surgery, minor surgery, and diagnostic procedures) carried out on 10 patients via different anesthetic techniques. We observed the following complications: intraoperative hyperglycemia in one case, postoperative vomiting in eight cases, and slightly increased postoperative ammonia levels (54, 59, and 69 µmol/L) with normal preoperative levels in three cases without associated metabolic decompensation. There were two cases of perioperative hyperammonemia (72 and 69 µmol/L) secondary to preoperative metabolic decompensation (137 and 92 µmol/L) with the levels progressively dropping and normalizing in the first 24-48 hours, respectively. CONCLUSIONS Procedures under anesthesia on pediatric patients with urea cycle diseases should be performed by experienced multidisciplinary teams at specialized centers. Perioperative management focused on avoiding catabolism (especially during fasting) and monitoring signs associated with metabolic decompensation to allow for its early treatment should be included in routine anesthetic techniques for children with urea cycle disorders.
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Affiliation(s)
- Cristina Del Río
- Department of Pediatric Anesthesiology, University Hospital 12 de Octubre, Madrid, Spain
| | - Elena Martín-Hernández
- Unit of Mitochondrial and Inherited Metabolic Diseases, Pediatric Department, University Hospital 12 de Octubre, Madrid, Spain.,National Reference Center, European Reference Network for Hereditary Metabolic Disorders (MetabERN), Madrid, Spain
| | - Alicia Ruiz
- Department of Pediatric Anesthesiology, University Hospital 12 de Octubre, Madrid, Spain
| | - Pilar Quijada-Fraile
- Unit of Mitochondrial and Inherited Metabolic Diseases, Pediatric Department, University Hospital 12 de Octubre, Madrid, Spain.,National Reference Center, European Reference Network for Hereditary Metabolic Disorders (MetabERN), Madrid, Spain
| | - Paloma Rubio
- Department of Pediatric Anesthesiology, University Hospital 12 de Octubre, Madrid, Spain
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234
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Clinical and biochemical characteristics of patients with ornithine transcarbamylase deficiency. Clin Biochem 2020; 84:63-72. [PMID: 32569589 DOI: 10.1016/j.clinbiochem.2020.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/31/2020] [Accepted: 06/16/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Ornithine transcarbamylase deficiency (OTCD) is pleomorphic congenital hyperammonemia, in which the prognosis of the patient is determined both by genotype and environmental factors. This study investigated the clinical and biochemical characteristics of OTCD patients with different prognosis. METHOD Of 35 OTCD patients, six males deceased at the first disease-onset, 17 males survived and had controllable ammonia levels after treatment, and 12 females survived through the first disease-onset but had intractable hyperammonemia and high mortality. Fasting blood samples from patients collected at three disease stages were used for the analysis of amino acid (AA) profile, acylcarnitine profile, and micronutrients. Differences in profiles between patients and healthy controls and within patient groups were studied. RESULTS All OTCD patients had accumulation of glutamine, homocitrulline, lysine, glutamate, cystathionine, and pipecolic acid, as well as deficiency of citrulline, tryptophan, threonine, and carnitine. For male non-survivors, most other AAs and long-chain acylcarnitines were elevated at disease onset, of which the levels of creatine, N-acetylaspartic acid, and homoarginine were remarkably high. Male survivors and female patients had most other AAs at low to normal levels. Compared with male survivors, female patients had much lower protein-intolerance, as indicated by significantly lower levels of protein consumption indicators, including essential AAs, 1-methylhistidine, acylcarnitines et al., but high levels of ammonia. Female patients still had significantly higher levels of citrulline, homocitrulline, and citrulline/arginine compared to male survivors. CONCLUSION Unique profiles were observed in each group of OTCD patients, indicating specific physiological changes that happened to them.
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Pontoizeau C, Roda C, Arnoux JB, Vignolo-Diard P, Brassier A, Habarou F, Barbier V, Grisel C, Abi-Warde MT, Boddaert N, Kuster A, Servais A, Kaminska A, Hennequin C, Dupic L, Lesage F, Touati G, Valayannopoulos V, Chadefaux-Vekemans B, Oualha M, Eisermann M, Ottolenghi C, de Lonlay P. Neonatal factors related to survival and intellectual and developmental outcome of patients with early-onset urea cycle disorders. Mol Genet Metab 2020; 130:110-117. [PMID: 32273051 DOI: 10.1016/j.ymgme.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/14/2020] [Accepted: 03/14/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE We aimed to identify prognostic factors for survival and long-term intellectual and developmental outcome in neonatal patients with early-onset urea cycle disorders (UCD) experiencing hyperammonaemic coma. METHODS We retrospectively analysed ammonia (NH3) and glutamine levels, electroencephalogram and brain images obtained during neonatal coma of UCD patients born between 1995 and 2011 and managed at a single centre and correlated them to survival and intellectual and developmental outcome. RESULTS We included 38 neonates suffering from deficiencies of argininosuccinate synthetase (ASSD, N = 12), ornithine transcarbamylase (OTCD, N = 10), carbamoylphosphate synthetase 1 (CPSD, N = 7), argininosuccinate lyase (ASLD, N = 7), N-acetylglutamate synthase (NAGS, N = 1) or arginase (ARGD, N = 1). Symptoms occurred earlier in mitochondrial than in cytosolic UCD. Sixty-eight percent of patients survived, with a mean (standard deviation-SD) follow-up of 10.4 (5.3) years. Mortality was mostly observed in OTCD (N = 7/10) and CPSD (N = 4/7) patients. Plasma NH3 level during the neonatal period, expressed as area under the curve, but not glutamine level was associated with mortality (p = .044 and p = .610). 62.1% of the patients had normal intellectual and developmental outcome. Intellectual and developmental outcome tended to correlate with UCD subtype (p = .052). No difference in plasma NH3 or glutamine level during the neonatal period among developmental outcomes was identified. EEG severity was linked to UCD subtypes (p = .004), ammonia levels (p = .037), duration of coma (p = .043), and mortality during the neonatal period (p = .020). Status epilepticus was recorded in 6 patients, 3 of whom died neonatally, 1 developed a severe intellectual disability while the 2 last patients had a normal development. CONCLUSION UCD subtypes differed by survival rate, intellectual and developmental outcome and EEG features in the neonatal period. Hyperammonaemia expressed as area under the curve was associated with survival but not with intellectual and developmental outcome whereas glutamine was not associated with one of these outcomes. Prognostic value of video-EEG monitoring and the association between status epilepticus and mortality should be assessed in neonatal hyperammonaemic coma in further studies.
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Affiliation(s)
- Clément Pontoizeau
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France.
| | - Célina Roda
- Université de Paris, CRESS, INSERM, INRA, HERA team (Health Environmental Risk Assessment), F-75004 Paris, France
| | - Jean-Baptiste Arnoux
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | | | - Anais Brassier
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Florence Habarou
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Valérie Barbier
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Coraline Grisel
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Marie-Thérèse Abi-Warde
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Nathalie Boddaert
- Department of Pediatric Radiology, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, PRES Sorbonne Paris Cité, INSERM U1000, Institut Imagine, Paris, France
| | - Alice Kuster
- Pediatric Critical Care Unit, Femme-Enfants-Adolescents Hospital, Nantes University, Nantes, France
| | - Aude Servais
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Department of Nephrology, Transplantation, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Anna Kaminska
- Neurophysiology Unit, AP-HP, Necker Enfants Malades Hospital, Paris, France
| | - Carole Hennequin
- Biochemistry, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Laurent Dupic
- Pediatric Critical Care Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Fabrice Lesage
- Pediatric Critical Care Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Guy Touati
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Vassili Valayannopoulos
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Bernadette Chadefaux-Vekemans
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Mehdi Oualha
- Pediatric Critical Care Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Monika Eisermann
- Neurophysiology Unit, AP-HP, Necker Enfants Malades Hospital, Paris, France
| | - Chris Ottolenghi
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Pascale de Lonlay
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
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Palka-Kotlowska M, Cabezón-Gutiérrez L, Custodio-Cabello S, Quijada-Fraile PI, Chumillas-Calzada S. Chemotherapy in a Breast Cancer Patient Heterozygous Carrier of Ornithine Transcarbamylase Deficiency. Cureus 2020; 12:e8301. [PMID: 32601573 PMCID: PMC7317123 DOI: 10.7759/cureus.8301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/24/2020] [Indexed: 11/17/2022] Open
Abstract
Urea cycle disorders (UCDs) are an unusual genetic condition that may lead to hyperammonemia in catabolic situations such as surgery, infections or chemotherapy administration. Without specific treatment, it causes life-threatening encephalopathy. We present the case of a young woman, heterozygous carrier of ornithine transcarbamylase deficiency (OTCD) with breast cancer, who was treated with surgery, chemotherapy, radiotherapy and hormone therapy while following a protocol to minimize the risk of metabolic decompensation due to her condition.
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Affiliation(s)
| | | | | | - PIlar Quijada-Fraile
- Unidad Pediátrica De Enfermedades Raras, Metabólicas-Hereditarias Y Mitocondriales, Hospital Universitario 12 de Octubre, Madrid, ESP
| | - Silvia Chumillas-Calzada
- Unidad Pediátrica De Enfermedades Raras, Metabólicas-Hereditarias Y Mitocondriales, Hospital Universitario 12 de Octubre, Madrid, ESP
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237
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Saritaş Nakip Ö, Yıldız Y, Tokatlı A. Retrospective evaluation of 85 patients with urea cycle disorders: one center experience, three new mutations. J Pediatr Endocrinol Metab 2020; 33:721-728. [PMID: 32447331 DOI: 10.1515/jpem-2019-0413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 03/07/2020] [Indexed: 12/30/2022]
Abstract
Objectives Urea cycle disorders (UCDs) are rare hereditary diseases. This study was conducted to help identify the characteristics of UCDs in Turkey. Methods The primary outcome was to determine patient characteristics. Investigating the relationships between the patient outcomes and ammonia levels were the secondary outcomes. Eighty five patients from 79 families, diagnosed with UCD at a single metabolic referral center between 1979 and 2017, were included. Clinical and laboratory data were retrieved retrospectively from hospital records. Results Classical citrullinemia was the most common type of UCD; citrin deficiency and carbamoyl phosphate synthase 1 deficiency (CPS1D) were the rarest. One thirty one hyperammonemic episodes were recorded. The peak ammonia levels were found to be significantly associated with polycythemia and hypocalcemia at presentation. The median peak ammonia values of the patients who died were higher than those of the survivors. The highest mortality rate was in the classical citrullinemia group. The mortality rate of the first hyperammonemic crisis was 28.6%, while it was 6.7% in subsequent episodes with an odds ratio of 4.28 (95% CI: 1.67-11.0) (p=0.001). Forty-four patients underwent genetic analysis and genetic variants were detected in 42 patients (95%). Three of the detected variants have not been previously reported. Conclusions This is the largest UCD series in Turkey and may serve as a guide to clinical, biochemical and genetic features of UCDs in our country. Prevention of hyperammonemia may be the most influential measure to improve long term survival.
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Affiliation(s)
- Özlem Saritaş Nakip
- Pediatric Intensive Care Unit, Department of Pediatrics, Hacettepe University İhsan Doğramacı Children's Hospital, 06230, Ankara, Turkey
| | - Yılmaz Yıldız
- Hacettepe University İhsan Doğramacı Children's Hospital, Ankara, Turkey
| | - Ayşegül Tokatlı
- Hacettepe University İhsan Doğramacı Children's Hospital, Ankara, Turkey
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Management of 35 critically ill hyperammonemic neonates: Role of early administration of metabolite scavengers and continuous hemodialysis. Arch Pediatr 2020; 27:250-256. [PMID: 32418642 DOI: 10.1016/j.arcped.2020.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 02/24/2020] [Accepted: 05/02/2020] [Indexed: 12/30/2022]
Abstract
Neurological involvement is frequent in inherited metabolic disease of the intoxication type. Hyperammonemic coma related to these diseases may cause severe neurological sequelae. Early optimal treatment is mandatory combining metabolite scavengers (MS) and sometimes continuous veno-venous hemodialysis (CVVHD). We aimed to describe the therapeutic management of hyperammonemia in neonates upon diagnosis of their metabolic disease and to compare neonates managed with MS alone or with both MS and CVVHD. We conducted a retrospective study including all neonates admitted for initial hyperammonemia to the pediatric intensive care unit of a Reference Center of Inherited Metabolic Diseases, between 2001 and 2012. The study included 35 neonates. Before admission, MS were initiated for 11 neonates. At admission, the median ammonia levels were 391 μmol/L and were significantly lower in neonates who received MS before admission. At admission, ammonia levels were 644 μmol/L in dialyzed and 283 μmol/L in non-dialyzed neonates. The median time to reach a 50% decrease of the initial ammonia levels was significantly shorter in dialyzed neonates; however, the normalization of ammonia levels was similar between dialyzed and non-dialyzed neonates. Hemodynamic disorders were more frequent in dialyzed neonates. CONCLUSION: MS represent an effective treatment for hyperammonemia and should be available in all pediatric units to avoid the need for CVVHD. Although CVVHD enhances the kinetics of toxic metabolite decrease, it is associated with adverse hemodynamic effects.
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239
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Xu J, Zhang A, Huang F. Biallelic mutations in carbamoyl phosphate synthetase 1 induced hyperammonemia in a neonate: A case report. Exp Ther Med 2020; 20:623-629. [PMID: 32537019 DOI: 10.3892/etm.2020.8717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 09/20/2019] [Indexed: 12/13/2022] Open
Abstract
The aim of the present report was to describe the clinical presentation, diagnosis, and treatment of a case of carbamoyl phosphate synthetase 1 (CPS1) deficiency in a neonate, specifically, a 3 day-old female who visited Hunan Provincial People's Hospital due to anorexia and lethargy for 1 day. Physical and laboratory examination, and MRI were undertaken. Whole exome sequencing (WES) was applied for molecular etiology identification. Sanger sequencing was utilized to validate the variants detected by WES. Structural modeling was conducted for pathogenic analysis. Clinical examination revealed increased intracranial pressure, hyperammonemia, reduced citrulline, and increased glutamic acid levels. WES identified compound heterozygosity of c.713G>C, p.Arg238Pro and c.2339G>A, p.Arg780His in CPS1 (NCBI reference sequence, NM_001875.4) as candidate pathogenic variants. Sanger sequencing validated these variants. Structural modeling further confirmed the pathogenesis of these mutations. In conclusion, CPS1 deficiency in neonates is a serious condition that may be misdiagnosed due to severe infection. WES can be a helpful tool in facilitating the diagnosis of this disease.
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Affiliation(s)
- Jun Xu
- Department of Neonatology, Children's Medical Center, Hunan Provincial People's Hospital and The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, P.R. China
| | - Aimin Zhang
- Department of Neonatology, Children's Medical Center, Hunan Provincial People's Hospital and The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, P.R. China
| | - Furong Huang
- Department of Neonatology, Children's Medical Center, Hunan Provincial People's Hospital and The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, P.R. China
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Gerstein MT, Markus AR, Gianattasio KZ, Le Mons C, Bartos J, Stevens DM, Mew NA. Choosing between medical management and liver transplant in urea cycle disorders: A conceptual framework for parental treatment decision-making in rare disease. J Inherit Metab Dis 2020; 43:438-458. [PMID: 31883128 PMCID: PMC7318329 DOI: 10.1002/jimd.12209] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/27/2019] [Accepted: 12/20/2019] [Indexed: 02/06/2023]
Abstract
Urea cycle disorders (UCD) are rare inherited metabolic disorders caused by deficiencies of enzymes and transporters required to convert neurotoxic ammonia into urea. These deficiencies cause elevated blood ammonia, which if untreated may result in death, but even with optimal medical management, often results in recurrent brain damage. There are two major treatments for UCD: medical management or liver transplantation. Both are associated with mortality and morbidity but the evidence comparing outcomes is sparse. Thus, families face a dilemma: should their child be managed medically, or should they undergo a liver transplant? To (a) describe the factors that contribute to treatment choice among parents of children diagnosed with UCD and to (b) organise these factors into a conceptual framework that reflects how these issues interrelate to shape the decision-making experience of this population. Utilising grounded theory, qualitative data were collected through semi-structured interviews with parents (N = 35) and providers (N = 26) of children diagnosed with UCD and parent focus groups (N = 19). Thematic content analysis and selective and axial coding were applied. The framework highlights the life-cycle catalysts that frame families' personal perceptions of risks and benefits and describes the clinical, personal, social, and system factors that drive treatment choice including disease severity, stability, and burden, independence, peer experiences, and cost, coverage and access to quality care. Findings equip providers with evidence upon which to prepare for productive patient interactions about treatment options. They also provide a foundation for the development of patient-centred outcome measures to better evaluate effectiveness of treatments in this population.
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Affiliation(s)
- Maya T. Gerstein
- Department of Health Policy and Management, Milken Institute School of Public HealthThe George Washington UniversityWashingtonDistrict of Columbia
| | - Anne R. Markus
- Department of Health Policy and Management, Milken Institute School of Public HealthThe George Washington UniversityWashingtonDistrict of Columbia
| | - Kan Z. Gianattasio
- Department of Health Policy and Management, Milken Institute School of Public HealthThe George Washington UniversityWashingtonDistrict of Columbia
| | | | - Janice Bartos
- National Urea Cycle Disorders FoundationPasadenaCalifornia
| | - David M. Stevens
- Department of Health Policy and Management, Milken Institute School of Public HealthThe George Washington UniversityWashingtonDistrict of Columbia
| | - Nicholas Ah Mew
- Rare Disease Institute, Children's National Health SystemWashingtonDistrict of Columbia
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Probst J, Kölker S, Okun JG, Kumar A, Gursky E, Posset R, Hoffmann GF, Peravali R, Zielonka M. Chronic hyperammonemia causes a hypoglutamatergic and hyperGABAergic metabolic state associated with neurobehavioral abnormalities in zebrafish larvae. Exp Neurol 2020; 331:113330. [PMID: 32339612 DOI: 10.1016/j.expneurol.2020.113330] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/29/2020] [Accepted: 04/23/2020] [Indexed: 12/13/2022]
Abstract
Chronic hyperammonemia is a common condition affecting individuals with inherited urea cycle disorders resulting in progressive cognitive impairment and behavioral abnormalities. Altered neurotransmission has been proposed as major source of neuronal dysfunction during chronic hyperammonemia, but the molecular pathomechanism has remained incompletely understood. Here we show that chronic exposure to ammonium acetate induces locomotor dysfunction and abnormal feeding behavior in zebrafish larvae, indicative for an impairment of higher brain functions. Biochemically, chronically elevated ammonium concentrations cause enhanced activity of glutamate decarboxylase isoforms GAD1 and GAD2 with increased formation of GABA and concomitant depletion of glutamate, ultimately leading to a dysfunctional hypoglutamatergic and hyperGABAergic metabolic state. Moreover, elevated GABA concentrations are accompanied by increased expression of GABAA receptor subunits alpha-1, gamma-2 and delta, supporting the notion of an increased GABA tone in chronic hyperammonemia. Propionate oxidation as major anaplerotic reaction sufficiently compensates for the transamination-dependent withdrawal of 2-oxoglutarate, thereby preventing bioenergetic dysfunction under chronic hyperammonemic conditions. Thus, our study extends the hypothesis of alterations in the glutamatergic and GABAergic system being an important pathophysiological factor causing neurobehavioral impairment in chronic hyperammonemia. Given that zebrafish larvae have already been successfully used for high-throughput identification of novel compounds to treat inherited neurological diseases, the reported zebrafish model should be considered an important tool for systematic drug screening targeting altered glutamatergic and GABAergic metabolism under chronic hyperammonemic conditions in the future.
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Affiliation(s)
- Joris Probst
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen G Okun
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Amrish Kumar
- Institute of Toxicology and Genetics (ITG), Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Eduard Gursky
- Institute of Toxicology and Genetics (ITG), Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Roland Posset
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Georg F Hoffmann
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Ravindra Peravali
- Institute of Toxicology and Genetics (ITG), Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Matthias Zielonka
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany.
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Isler J, Rüfenacht V, Gemperle C, Allegri G, Häberle J. Improvement of diagnostic yield in carbamoylphosphate synthetase 1 ( CPS1) molecular genetic investigation by RNA sequencing. JIMD Rep 2020; 52:28-34. [PMID: 32154057 PMCID: PMC7052687 DOI: 10.1002/jmd2.12091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 11/06/2019] [Accepted: 12/02/2019] [Indexed: 12/29/2022] Open
Abstract
Carbamoylphosphate synthetase 1 (CPS1) deficiency is a rare inborn error of metabolism leading often to neonatal onset hyperammonemia with coma and high mortality. The biochemical features of the disease are nonspecific and cannot distinguish this condition from other defects of the urea cycle, namely N‐acetylglutamate synthase deficiency. Therefore, molecular genetic investigation is required for confirmation of the disease, and nowadays this is done with increasing frequency applying next‐generation sequencing (NGS) techniques. Our laboratory has a long‐standing interest in CPS1 molecular genetic investigation and receives samples from centers in Europe and many other countries. We perform RNA‐based CPS1 molecular genetic investigation as first line investigation and wanted in this study to evaluate our experience with this approach as compared to NGS. In the past 15 years, 297 samples were analyzed, which were referred from 37 countries. CPS1 deficiency could be confirmed in 155 patients carrying 136 different genotypes with only a single mutation recurring more than two times. About 10% of the total 172 variants comprised complex changes (eg, intronic changes possibly affecting splicing, deletions, insertions, or deletions_insertions), which would have been partly missed if only NGS was done. Likewise, RNA analysis was crucial for correct interpretation of at least half of the complex mutations. This study gives highest sensitivity to RNA‐based CPS1 molecular genetic investigation and underlines that NGS should be done together with copy number variation analysis. We propose that unclear cases should be investigated by RNA sequencing in addition, if this method is not used as the initial diagnostic procedure.
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Affiliation(s)
- Jasmine Isler
- Division of Metabolism and Children's Research Center University Children's Hospital Zurich Zurich Switzerland
| | - Véronique Rüfenacht
- Division of Metabolism and Children's Research Center University Children's Hospital Zurich Zurich Switzerland
| | - Corinne Gemperle
- Division of Metabolism and Children's Research Center University Children's Hospital Zurich Zurich Switzerland
| | - Gabriella Allegri
- Division of Metabolism and Children's Research Center University Children's Hospital Zurich Zurich Switzerland
| | - Johannes Häberle
- Division of Metabolism and Children's Research Center University Children's Hospital Zurich Zurich Switzerland
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Maines E, Urru SAM, Burri E, Piccoli G, Pedrolli A, Pasqualini A, Burlina AL, Temporin G. Formulation and Clinical Evaluation of Sodium Benzoate Oral Solution for the Treatment of Urea Cycle Disorders in Pediatric Patients. AAPS PharmSciTech 2020; 21:100. [PMID: 32152836 DOI: 10.1208/s12249-020-01642-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/17/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Sodium benzoate, a common food preservative, is used in the treatment of patients with urea cycle disorders (UCDs) as it stimulates ammonia removal by a non-urea cycle-based pathway. Despite its use in the clinical routine, no commercially available oral formulations currently exist. Liquid formulation is normally well accepted in pediatric age and allows precise dosage according to the children's needs. AIMS (1) To prepare an oral sodium benzoate solution in different tastes and determine its stability, palatability, and tolerability and (2) to describe the long-term follow-up of two pediatric patients with UCDs treated with our formulation. METHODS We prepared five oral solutions of sodium benzoate (200 mg/ml) by adding different flavoring agents. We measured drug concentration in the samples by high-performance liquid chromatography (HPLC). We evaluated palatability and tolerability with adult volunteers. Long-term drug compliance and metabolic control were appraised in two pediatric patients. RESULTS All the oral solutions remained stable at room temperature along the 96-day test period, and they were well tolerated. The mint-flavored solution resulted the most palatable and preferred by adult volunteers. We report good drug compliance and good metabolic outcomes for both pediatric patients during the entire follow-up. CONCLUSIONS Our study highlighted the stability and tolerability of flavored sodium benzoate oral solutions. These solutions were well accepted during a long-term follow-up and guaranteed a good metabolic control. Since taste attributes are critical to ensure acceptable medication adherence in the pediatric age, flavored liquid formulations of sodium benzoate may be an efficient strategy to achieve therapeutic outcomes in UCD pediatric patients.
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Understanding acute metabolic decompensation in propionic and methylmalonic acidemias: a deep metabolic phenotyping approach. Orphanet J Rare Dis 2020; 15:68. [PMID: 32143654 PMCID: PMC7060614 DOI: 10.1186/s13023-020-1347-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 03/03/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Pathophysiology of life-threatening acute metabolic decompensations (AMD) in propionic acidemia (PA) and isolated methylmalonic acidemia (MMA) is insufficiently understood. Here, we study the metabolomes of PA and MMA patients over time, to improve insight in which biochemical processes are at play during AMD. METHODS Longitudinal data from clinical chemistry analyses and metabolic assays over the life-course of 11 PA and 13 MMA patients were studied retrospectively. Direct-infusion high-resolution mass spectrometry was performed on 234 and 154 remnant dried blood spot and plasma samples of PA and MMA patients, respectively. In addition, a systematic literature search was performed on reported biomarkers. All results were integrated in an assessment of biochemical processes at play during AMD. RESULTS We confirmed many of the metabolite alterations reported in literature, including increases of plasma valine and isoleucine during AMD in PA patients. We revealed that plasma leucine and phenylalanine, and urinary pyruvic acid were increased during AMD in PA patients. 3-hydroxyisovaleric acid correlated positively with plasma ammonia. We found that known diagnostic biomarkers were not significantly further increased, while intermediates of the branched-chain amino acid (BCAA) degradation pathway were significantly increased during AMD. CONCLUSIONS We revealed that during AMD in PA and MMA, BCAA and BCAA intermediates accumulate, while known diagnostic biomarkers remain essentially unaltered. This implies that these acidic BCAA intermediates are responsible for metabolic acidosis. Based on this, we suggest to measure plasma 3-hydroxyisovaleric acid and urinary ketones or 3-hydroxybutyric acid for the biochemical follow-up of a patient's metabolic stability.
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Baruteau J, Khalil Y, Grunewald S, Zancolli M, Chakrapani A, Cleary M, Davison J, Footitt E, Waddington SN, Gissen P, Mills P. Urea Cycle Related Amino Acids Measured in Dried Bloodspots Enable Long-Term In Vivo Monitoring and Therapeutic Adjustment. Metabolites 2019; 9:E275. [PMID: 31718089 PMCID: PMC6918381 DOI: 10.3390/metabo9110275] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 10/19/2019] [Accepted: 11/05/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Dried bloodspots are easy to collect and to transport to assess various metabolites, such as amino acids. Dried bloodspots are routinely used for diagnosis and monitoring of some inherited metabolic diseases. METHODS Measurement of amino acids from dried blood spots by liquid chromatography-tandem mass spectrometry. RESULTS We describe a novel rapid method to measure underivatised urea cycle related amino acids. Application of this method enabled accurate monitoring of these amino acids to assess the efficacy of therapies in argininosuccinate lyase deficient mice and monitoring of these metabolites in patients with urea cycle defects. CONCLUSION Measuring urea cycle related amino acids in urea cycle defects from dried blood spots is a reliable tool in animal research and will be of benefit in the clinic, facilitating optimisation of protein-restricted diet and preventing amino acid deprivation.
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Affiliation(s)
- Julien Baruteau
- Genetics and Genomic Medicine, Great Ormond Street Institute of Child Health, University College London, London WC1E 6BT, UK; (Y.K.); (P.G.); (P.M.)
- Gene Transfer Technology Group, Institute for Women’s Health, University College London, London WC1E 6BT, UK;
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; (S.G.); (A.C.); (M.C.); (J.D.); (E.F.)
- National Institute of Health Research Great Ormond Street Hospital Biomedical Research Centre, London W1T 7HA, UK;
| | - Youssef Khalil
- Genetics and Genomic Medicine, Great Ormond Street Institute of Child Health, University College London, London WC1E 6BT, UK; (Y.K.); (P.G.); (P.M.)
| | - Stephanie Grunewald
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; (S.G.); (A.C.); (M.C.); (J.D.); (E.F.)
| | - Marta Zancolli
- National Institute of Health Research Great Ormond Street Hospital Biomedical Research Centre, London W1T 7HA, UK;
| | - Anupam Chakrapani
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; (S.G.); (A.C.); (M.C.); (J.D.); (E.F.)
| | - Maureen Cleary
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; (S.G.); (A.C.); (M.C.); (J.D.); (E.F.)
| | - James Davison
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; (S.G.); (A.C.); (M.C.); (J.D.); (E.F.)
| | - Emma Footitt
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; (S.G.); (A.C.); (M.C.); (J.D.); (E.F.)
| | - Simon N. Waddington
- Gene Transfer Technology Group, Institute for Women’s Health, University College London, London WC1E 6BT, UK;
- Wits/SAMRC Antiviral Gene Therapy Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
| | - Paul Gissen
- Genetics and Genomic Medicine, Great Ormond Street Institute of Child Health, University College London, London WC1E 6BT, UK; (Y.K.); (P.G.); (P.M.)
- Gene Transfer Technology Group, Institute for Women’s Health, University College London, London WC1E 6BT, UK;
- MRC Laboratory for Molecular Cell Biology, University College London, London WC1E 6BT, UK
| | - Philippa Mills
- Genetics and Genomic Medicine, Great Ormond Street Institute of Child Health, University College London, London WC1E 6BT, UK; (Y.K.); (P.G.); (P.M.)
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Free Radical Scavengers Prevent Argininosuccinic Acid-Induced Oxidative Stress in the Brain of Developing Rats: a New Adjuvant Therapy for Argininosuccinate Lyase Deficiency? Mol Neurobiol 2019; 57:1233-1244. [PMID: 31707633 DOI: 10.1007/s12035-019-01825-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/24/2019] [Indexed: 12/31/2022]
Abstract
Tissue accumulation and high urinary excretion of argininosuccinate (ASA) is the biochemical hallmark of argininosuccinate lyase deficiency (ASLD), a urea cycle disorder mainly characterized by neurologic abnormalities, whose pathogenesis is still unknown. Thus, in the present work, we evaluated the in vitro and in vivo effects of ASA on a large spectrum of oxidative stress parameters in brain of adolescent rats in order to test whether disruption of redox homeostasis could be involved in neurodegeneration of this disorder. ASA provoked in vitro lipid and protein oxidation, decreased reduced glutathione (GSH) concentrations, and increased reactive oxygen species generation in cerebral cortex and striatum. Furthermore, these effects were totally prevented or attenuated by the antioxidants melatonin and GSH. Similar results were obtained by intrastriatal administration of ASA, in addition to increased reactive nitrogen species generation and decreased activities of superoxide dismutase, glutathione peroxidase, and glutathione S-transferase. It was also observed that melatonin and N-acetylcysteine prevented most of ASA-induced in vivo pro-oxidant effects in striatum. Taken together, these data indicate that disturbance of redox homeostasis induced at least in part by high brain ASA concentrations per se may potentially represent an important pathomechanism of neurodegeneration in patients with ASLD and that therapeutic trials with appropriate antioxidants may be an adjuvant treatment for these patients.
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Ranucci G, Rigoldi M, Cotugno G, Bernabei SM, Liguori A, Gasperini S, Goffredo BM, Martinelli D, Monti L, Francalanci P, Candusso M, Parini R, Dionisi-Vici C. Chronic liver involvement in urea cycle disorders. J Inherit Metab Dis 2019; 42:1118-1127. [PMID: 31260111 DOI: 10.1002/jimd.12144] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 06/21/2019] [Accepted: 06/28/2019] [Indexed: 12/15/2022]
Abstract
The increased survival of urea cycle disorders (UCDs) patients has led the attention to clinical manifestations that characterize the long-term disease course. Acute and chronic liver disease have been anecdotally reported since the very first description of UCDs. However, a detailed analysis of long-term liver involvement in large patient cohorts is still needed. Chronic liver damage in UCDs has probably a multifactorial origin, but the specific underlying mechanisms of liver disease have not yet been well elucidated. In this study, we report on chronic liver involvement and on associated metabolic abnormalities in a large cohort of 102 UCD patients, followed by two reference centers in Italy. Chronic liver involvement was observed in over 60% of UCDs patients, and comparison between individual diseases showed a significant higher frequency in argininosuccinate lyase deficiency (ASLD) and in hyperornithinemia-hyperammonemia-homocitrullinemia (HHH) syndrome with elevation of transaminases and of gamma-GT in ASLD, and of alpha-fetoprotein in HHH syndrome. Also, consistent with a chronic hepatic dysfunction, ultrasound examination revealed more pronounced abnormalities in ASLD and in HHH syndrome, when compared to other UCDs. Our study highlights in a large UCDs patients' cohort that chronic liver disease is a common finding in UCDs, often with a distinct phenotype between different diseases. Furthers studies are needed to elucidate the specific involvement of different metabolic pathways in the pathogenesis of liver dysfunction in UCDs.
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Affiliation(s)
- Giusy Ranucci
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Miriam Rigoldi
- Medical Genetics Unit, Rare Diseases Center, ASST San Gerardo Hospital, Monza, Italy
| | - Giovanna Cotugno
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Silvia Maria Bernabei
- Division of Artificial Nutrition, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandra Liguori
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Serena Gasperini
- Pediatric Rare Diseases Unit, Department of Pediatrics, MBBM Foundation, ATS Monza e Brianza, Monza, Italy
| | | | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Lidia Monti
- Department of Radiology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paola Francalanci
- Department of Pathology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Manila Candusso
- Division of Hepatology and Gastroenterology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rossella Parini
- Pediatric Rare Diseases Unit, Department of Pediatrics, MBBM Foundation, ATS Monza e Brianza, Monza, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Enns GM, Porter MH, Francis-Sedlak M, Burdett A, Vockley J. Perspectives on urea cycle disorder management: Results of a clinician survey. Mol Genet Metab 2019; 128:102-108. [PMID: 31377149 DOI: 10.1016/j.ymgme.2019.07.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/12/2019] [Accepted: 07/16/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND/AIMS Urea cycle disorders (UCDs) are rare inborn errors of urea synthesis. US and European consensus statements on the diagnosis and treatment of UCDs were last published in 2001 and 2019, respectively. Recommendations are based primarily on case reports and expert opinion and there is limited agreement or consistency related to long-term management approaches. A clinician survey was conducted to assess current real-world practices and perspectives on challenges and unmet needs. METHODS A 14-item multiple-choice survey was administered to physicians in 2017. Clinicians who reported actively managing at least 1 patient with UCD were eligible to participate. Descriptive statistics were calculated for each survey item (frequencies for categorical variables; means, standard deviations, medians, and ranges for continuous variables). RESULTS Sixty-six US clinicians completed the survey (65 geneticists; 1 pediatric neurologist). Over 90% of responders agreed or strongly agreed that even modest elevations in ammonia could cause physiological and functional brain damage; >80% of respondents agreed that asymptomatic UCD patients are at risk of brain damage over time due to mild/subclinical elevations in ammonia. Eighty-six percent of clinicians agreed or strongly agreed with recommending genetic testing for female relatives when a patient is diagnosed with ornithine transcarbamylase deficiency. Ninety-four percent of respondents agreed that patients have better disease control when they are more adherent to their UCD therapy. Nearly 90% indicated that clinicians and patients would benefit from updated UCD management guidance. More than half (53%) of respondents rated the symptoms of UCDs as extremely or very burdensome to the everyday lives of patients and their families; only 8% rated UCD symptoms as slightly or not at all burdensome. The majority of clinicians agreed (48%) or strongly agreed (32%) that caring for a child or family member with a UCD has a negative impact on the quality of life and/or health of family members/guardians (e.g. stress, relationships, ability to work). CONCLUSIONS This self-reported survey suggests a need for updated and expanded clinical guidance on the long-term treatment and management of UCD patients.
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Affiliation(s)
- Gregory M Enns
- Stanford University, School of Medicine, Stanford, CA, USA.
| | | | | | | | - Jerry Vockley
- University of Pittsburgh, School of Medicine, Graduate School of Public Health, Pittsburgh, PA, USA
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