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Tanpaiboon P, Huang Y, Louie JZ, Sharma R, Cederbaum S, Salazar D. Plasma arginine levels in arginase deficiency in the "real world". Mol Genet Metab Rep 2024; 38:101042. [PMID: 38221915 PMCID: PMC10787283 DOI: 10.1016/j.ymgmr.2023.101042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/12/2023] [Accepted: 12/18/2023] [Indexed: 01/16/2024] Open
Abstract
Background Deficiency of arginase-1, the final enzyme in the urea cycle, causes a distinct clinical syndrome and is characterized biochemically by a high level of plasma arginine. While conventional therapy for urea cycle disorders can lower these levels to some extent, it does not normalize them. Until now, research on plasma arginine levels in this disorder has primarily relied on data from specialized tertiary centers, which limits the ability to assess the natural history and treatment efficacy of arginase-1 deficiency due to the small number of patients in each center and technical variations in plasma arginine measurements among different laboratories. Method In this study, we reported plasma arginine levels from 51 patients with arginase-1 deficiency in the database of Quest Diagnostics. The samples were collected from different US regions. Results The mean plasma arginine level in these treated patients was 373 μmol/L and the median level was 368.4 μmol/L. Our data set from 30 arginase deficiency patients with plasma amino acid data from five or more collections revealed significant correlations between the levels of arginine and five other amino acids (citrulline, alanine, ornithine, glutamine, and asparagine). Conclusion Despite treatment, the arginine levels remained persistently elevated and did not change significantly with age, suggesting the current treatment regimen is inadequate to control arginine levels and underscoring the need to seek more effective treatments for this disorder.
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Affiliation(s)
- Pranoot Tanpaiboon
- Biochemical Genetics, R&D Molecular Genetics & Oncology, Quest Diagnostics Nichols Institute, San Juan Capistrano, CA 92675, United States of America
| | - Yue Huang
- Division of Clinical Genetics, Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, United States of America
| | - Judy Z. Louie
- Biochemical Genetics, R&D Molecular Genetics & Oncology, Quest Diagnostics Nichols Institute, San Juan Capistrano, CA 92675, United States of America
| | - Rajesh Sharma
- Ex-employee Quest Diagnostics Nichols Institute, San Juan Capistrano, CA 92675, United States of America
| | - Stephen Cederbaum
- Division of Clinical Genetics, Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, United States of America
- Departments of Psychiatry, Pediatrics and Human Genetics and the Intellectual and Developmental Disabilities Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, United States of America
| | - Denise Salazar
- Biochemical Genetics, R&D Molecular Genetics & Oncology, Quest Diagnostics Nichols Institute, San Juan Capistrano, CA 92675, United States of America
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You Y, Chen Z, Hu WW. The role of microglia heterogeneity in synaptic plasticity and brain disorders: Will sequencing shed light on the discovery of new therapeutic targets? Pharmacol Ther 2024; 255:108606. [PMID: 38346477 DOI: 10.1016/j.pharmthera.2024.108606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/05/2024] [Accepted: 02/02/2024] [Indexed: 02/18/2024]
Abstract
Microglia play a crucial role in interacting with neuronal synapses and modulating synaptic plasticity. This function is particularly significant during postnatal development, as microglia are responsible for removing excessive synapses to prevent neurodevelopmental deficits. Dysregulation of microglial synaptic function has been well-documented in various pathological conditions, notably Alzheimer's disease and multiple sclerosis. The recent application of RNA sequencing has provided a powerful and unbiased means to decipher spatial and temporal microglial heterogeneity. By identifying microglia with varying gene expression profiles, researchers have defined multiple subgroups of microglia associated with specific pathological states, including disease-associated microglia, interferon-responsive microglia, proliferating microglia, and inflamed microglia in multiple sclerosis, among others. However, the functional roles of these distinct subgroups remain inadequately characterized. This review aims to refine our current understanding of the potential roles of heterogeneous microglia in regulating synaptic plasticity and their implications for various brain disorders, drawing from recent sequencing research and functional studies. This knowledge may aid in the identification of pathogenetic biomarkers and potential factors contributing to pathogenesis, shedding new light on the discovery of novel drug targets. The field of sequencing-based data mining is evolving toward a multi-omics approach. With advances in viral tools for precise microglial regulation and the development of brain organoid models, we are poised to elucidate the functional roles of microglial subgroups detected through sequencing analysis, ultimately identifying valuable therapeutic targets.
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Affiliation(s)
- Yi You
- Department of Pharmacology and Department of Pharmacy of the Second Affiliated Hospital, Key Laboratory of Medical Neurobiology of the Ministry of Health of China, School of Basic Medical Sciences, Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Zhong Chen
- Department of Pharmacology and Department of Pharmacy of the Second Affiliated Hospital, Key Laboratory of Medical Neurobiology of the Ministry of Health of China, School of Basic Medical Sciences, Zhejiang University School of Medicine, Hangzhou 310058, China; Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Wei-Wei Hu
- Department of Pharmacology and Department of Pharmacy of the Second Affiliated Hospital, Key Laboratory of Medical Neurobiology of the Ministry of Health of China, School of Basic Medical Sciences, Zhejiang University School of Medicine, Hangzhou 310058, China.
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3
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Russo RS, Gasperini S, Bubb G, Neuman L, Sloan LS, Diaz GA, Enns GM. Efficacy and safety of pegzilarginase in arginase 1 deficiency (PEACE): a phase 3, randomized, double-blind, placebo-controlled, multi-centre trial. EClinicalMedicine 2024; 68:102405. [PMID: 38292042 PMCID: PMC10825663 DOI: 10.1016/j.eclinm.2023.102405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 02/01/2024] Open
Abstract
Background Arginase 1 Deficiency (ARG1-D) is a rare debilitating, progressive, inherited, metabolic disease characterized by marked increases in plasma arginine (pArg) and its metabolites, with increased morbidity, substantial reductions in quality of life, and premature mortality. Effective treatments that can lower arginine and improve clinical outcomes is currently lacking. Pegzilarginase is a novel human arginase 1 enzyme therapy. The present trial aimed to demonstrate efficacy of pegzilarginase on pArg and key mobility outcomes. Methods This Phase 3 randomized, double-blind, placebo-controlled, parallel-group clinical trial (clinicaltrials.govNCT03921541, EudraCT 2018-004837-34), randomized patients with ARG1-D 2:1 to intravenously/subcutaneously once-weekly pegzilarginase or placebo in conjunction with their individualized disease management. It was conducted in 7 countries; United States, United Kingdom, Canada, Austria, France, Germany, Italy. Primary endpoint was change from baseline in pArg after 24 weeks; key secondary endpoints were change from baseline at Week 24 in Gross Motor Function Measure part E (GMFM-E) and 2-min walk test (2MWT). Full Analysis Set was used for the analyses. Findings From 01 May 2019 to 29 March 2021, 32 patients were enrolled and randomized (pegzilarginase, n = 21; placebo, n = 11). Pegzilarginase lowered geometric mean pArg from 354.0 μmol/L to 86.4 μmol/L at Week 24 vs 464.7 to 426.6 μmol/L for placebo (95% CI: -67.1%, -83.5%; p < 0.0001) and normalized levels in 90.5% of patients (vs 0% with placebo). In addition, clinically relevant functional mobility improvements were demonstrated with pegzilarginase treatment. These effects were sustained long-term through additional 24 weeks of subsequent exposure. Pegzilarginase was well-tolerated, with adverse events being mostly transient and mild/moderate in severity. Interpretation These results support pegzilarginase as the first potential treatment to normalize pArg in ARG1-D and achieve clinically meaningful improvements in functional mobility. Funding Aeglea BioTherapeutics.
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Affiliation(s)
- Rossana Sanchez Russo
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, United States
| | - Serena Gasperini
- Paediatric Department, Fondazione IRCSS San Gerardo dei Tintori, Monza, Italy
| | - Gillian Bubb
- Aeglea BioTherapeutics, Inc., Austin, TX, United States
| | - Linda Neuman
- Aeglea BioTherapeutics, Inc., Austin, TX, United States
| | | | - George A. Diaz
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York City, NY, United States
| | - Gregory M. Enns
- Division of Medical Genetics, Department of Pediatrics, Stanford University School of Medicine and Lucille Packard Children's Hospital, Stanford, CA, United States
| | - PEACE Investigators
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, United States
- Paediatric Department, Fondazione IRCSS San Gerardo dei Tintori, Monza, Italy
- Aeglea BioTherapeutics, Inc., Austin, TX, United States
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York City, NY, United States
- Division of Medical Genetics, Department of Pediatrics, Stanford University School of Medicine and Lucille Packard Children's Hospital, Stanford, CA, United States
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Mills SL, Roberts P, Ashfaq M, Leal K, Northrup H, Brown DL, Rodriguez‐Buritica D, Farach LS. Arginase deficiency masked by cerebral palsy and coagulopathy-Three varied presentations of Latin American origin. JIMD Rep 2023; 64:434-439. [PMID: 37927486 PMCID: PMC10623097 DOI: 10.1002/jmd2.12397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 11/07/2023] Open
Abstract
Arginase deficiency (ARG1-D) is an autosomal recessive inborn error of metabolism that is often misdiagnosed. Classic presentation of ARG1-D includes progressive symptoms of spasticity, delayed development, cognitive impairment, protein avoidance, and seizures. Patients who present atypically may evade diagnosis and require a thoughtful diagnostic workup. Here, we discuss three females of Latin American origin with differing clinical presentations, but who all have the same intronic pathogenic variant in ARG1. Importantly, we found that each case included elevated coagulopathy on laboratory testing and discussed one case in particular with manifestation of bleeding. When diagnosed early, treatment is favorable and can prevent progressive decline. While many states have added ARG1-D to their expanded newborn screening panels, still many states and countries do not screen for ARG1-D, and it can be missed in a healthy newborn. We aim to bring awareness to not only the classic presentation as a necessary consideration for otherwise unexplained spastic diplegia but also to the varied presentations of ARG1-D.
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Affiliation(s)
- Shelby L. Mills
- Department of Pediatrics, Division of Medical GeneticsMcGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann HospitalHoustonTexasUSA
- College of Osteopathic Medicine of the Pacific‐NorthwestWestern University of Health SciencesLebanonOregonUSA
| | - Paige Roberts
- Department of Pediatrics, Division of Medical GeneticsMcGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann HospitalHoustonTexasUSA
| | - Myla Ashfaq
- Department of Pediatrics, Division of Medical GeneticsMcGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann HospitalHoustonTexasUSA
| | - Kathryn Leal
- Department of Pediatrics, Division of Medical GeneticsMcGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann HospitalHoustonTexasUSA
| | - Hope Northrup
- Department of Pediatrics, Division of Medical GeneticsMcGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann HospitalHoustonTexasUSA
| | - Deborah L. Brown
- Department of Pediatrics, Division of Hematology OncologyMcGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann HospitalHoustonTexasUSA
| | - David Rodriguez‐Buritica
- Department of Pediatrics, Division of Medical GeneticsMcGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann HospitalHoustonTexasUSA
| | - Laura S. Farach
- Department of Pediatrics, Division of Medical GeneticsMcGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth Houston) and Children's Memorial Hermann HospitalHoustonTexasUSA
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Huang X. Treatment and management for children with urea cycle disorder in chronic stage. Zhejiang Da Xue Xue Bao Yi Xue Ban 2023; 52:744-750. [PMID: 37807629 PMCID: PMC10764184 DOI: 10.3724/zdxbyxb-2023-0378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/27/2023] [Indexed: 10/10/2023]
Abstract
Urea cycle disorder (UCD) is a group of inherited metabolic diseases with high disability or fatality rate, which need long-term drug treatment and diet management. Except those with Citrin deficiency or liver transplantation, all pediatric patients require lifelong low protein diet with safe levels of protein intake and adequate energy and lipids supply for their corresponding age; supplementing essential amino acids and protein-free milk are also needed if necessary. The drugs for long-term use include nitrogen scavengers (sodium benzoate, sodium phenylbutyrate, glycerol phenylbutyrate), urea cycle activation/substrate supplementation agents (N-carbamylglutamate, arginine, citrulline), etc. Liver transplantation is recommended for pediatric patients not responding to standard diet and drug treatment, and those with severe progressive liver disease and/or recurrent metabolic decompensations. Gene therapy, stem cell therapy, enzyme therapy and other novel technologies may offer options for treatment in UCD patients. The regular biochemical assessments like blood ammonia, liver function and plasma amino acid profile are needed, and physical growth, intellectual development, nutritional intake should be also evaluated for adjusting treatment in time.
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Affiliation(s)
- Xinwen Huang
- Department of Genetics and Metabolism, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China.
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6
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Vockley J, Burton B, Jurecka A, Ganju J, Leiro B, Zori R, Longo N. Challenges and strategies for clinical trials in propionic and methylmalonic acidemias. Mol Genet Metab 2023; 139:107612. [PMID: 37245378 DOI: 10.1016/j.ymgme.2023.107612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/19/2023] [Accepted: 05/19/2023] [Indexed: 05/30/2023]
Abstract
Clinical trial development in rare diseases poses significant study design and methodology challenges, such as disease heterogeneity and appropriate patient selection, identification and selection of key endpoints, decisions on study duration, choice of control groups, selection of appropriate statistical analyses, and patient recruitment. Therapeutic development in organic acidemias (OAs) shares many challenges with other inborn errors of metabolism, such as incomplete understanding of natural history, heterogenous disease presentations, requirement for sensitive outcome measures and difficulties recruiting a small sample of participants. Here, we review strategies for the successful development of a clinical trial to evaluate treatment response in propionic and methylmalonic acidemias. Specifically, we discuss crucial decisions that may significantly impact success of the study, including patient selection, identification and selection of endpoints, determination of the study duration, consideration of control groups including natural history controls, and selection of appropriate statistical analyses. The significant challenges associated with designing a clinical trial in rare disease can sometimes be successfully met through strategic engagement with experts in the rare disease, seeking regulatory and biostatistical guidance, and early involvement of patients and families.
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Affiliation(s)
- Jerry Vockley
- Division Medical Genetics, Department of Pediatrics, University of Pittsburgh, School of Medicine, Center for Rare Disease Therapy, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Barbara Burton
- Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Agnieszka Jurecka
- CoA Therapeutics, Inc., a BridgeBio company, San Francisco, CA, USA.
| | - Jitendra Ganju
- Independent Consultant to BridgeBio, San Francisco, CA, USA
| | - Beth Leiro
- Independent Consultant to BridgeBio, San Francisco, CA, USA
| | - Roberto Zori
- Department of Pediatrics, Division of Genetics and Metabolism, University of Florida, Gainesville, FL, USA
| | - Nicola Longo
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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7
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Diaz GA, Bechter M, Cederbaum SD. The role and control of arginine levels in arginase 1 deficiency. J Inherit Metab Dis 2023; 46:3-14. [PMID: 36175366 PMCID: PMC10091968 DOI: 10.1002/jimd.12564] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/22/2022] [Accepted: 09/27/2022] [Indexed: 01/19/2023]
Abstract
Arginase 1 Deficiency (ARG1-D) is a rare urea cycle disorder that results in persistent hyperargininemia and a distinct, progressive neurologic phenotype involving developmental delay, intellectual disability, and spasticity, predominantly affecting the lower limbs and leading to mobility impairment. Unlike the typical presentation of other urea cycle disorders, individuals with ARG1-D usually appear healthy at birth and hyperammonemia is comparatively less severe and less common. Clinical manifestations typically begin to develop in early childhood in association with high plasma arginine levels, with hyperargininemia (and not hyperammonemia) considered to be the primary driver of disease sequelae. Nearly five decades of clinical experience with ARG1-D and empirical studies in genetically manipulated models have generated a large body of evidence that, when considered in aggregate, implicates arginine directly in disease pathophysiology. Severe dietary protein restriction to minimize arginine intake and diversion of ammonia from the urea cycle are the mainstay of care. Although this approach does reduce plasma arginine and improve patients' cognitive and motor/mobility manifestations, it is inadequate to achieve and maintain sufficiently low arginine levels and prevent progression in the long term. This review presents a comprehensive discussion of the clinical and scientific literature, the effects and limitations of the current standard of care, and the authors' perspectives regarding the past, current, and future management of ARG1-D.
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Affiliation(s)
- George A Diaz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Stephen D Cederbaum
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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Gustafson KT, Mokhtari N, Manalo EC, Montoya Mira J, Gower A, Yeh YS, Vaidyanathan M, Esener SC, Fischer JM. Hybrid Silica-Coated PLGA Nanoparticles for Enhanced Enzyme-Based Therapeutics. Pharmaceutics 2022; 15:pharmaceutics15010143. [PMID: 36678770 PMCID: PMC9866096 DOI: 10.3390/pharmaceutics15010143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/22/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023] Open
Abstract
Some cancer cells rely heavily on non-essential biomolecules for survival, growth, and proliferation. Enzyme based therapeutics can eliminate these biomolecules, thus specifically targeting neoplastic cells; however, enzyme therapeutics are susceptible to immune clearance, exhibit short half-lives, and require frequent administration. Encapsulation of therapeutic cargo within biocompatible and biodegradable poly(lactic-co-glycolic acid) nanoparticles (PLGA NPs) is a strategy for controlled release. Unfortunately, PLGA NPs exhibit burst release of cargo shortly after delivery or upon introduction to aqueous environments where they decompose via hydrolysis. Here, we show the generation of hybrid silica-coated PLGA (SiLGA) NPs as viable drug delivery vehicles exhibiting sub-200 nm diameters, a metastable Zeta potential, and high loading efficiency and content. Compared to uncoated PLGA NPs, SiLGA NPs offer greater retention of enzymatic activity and slow the burst release of cargo. Thus, SiLGA encapsulation of therapeutic enzymes, such as asparaginase, could reduce frequency of administration, increase half-life, and improve efficacy for patients with a range of diseases.
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Affiliation(s)
- Kyle T. Gustafson
- Cancer Early Detection Advanced Research (CEDAR) Center, Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR 97239, USA
| | - Negin Mokhtari
- Cancer Early Detection Advanced Research (CEDAR) Center, Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
- Department of Electrical Engineering, Jacobs School of Engineering, University of California, San Diego, La Jolla, CA 92093, USA
| | - Elise C. Manalo
- Cancer Early Detection Advanced Research (CEDAR) Center, Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Jose Montoya Mira
- Cancer Early Detection Advanced Research (CEDAR) Center, Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR 97239, USA
| | - Austin Gower
- Cancer Early Detection Advanced Research (CEDAR) Center, Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Ya-San Yeh
- Cancer Early Detection Advanced Research (CEDAR) Center, Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
- Department of Bioengineering, Jacobs School of Engineering, University of California, San Diego, La Jolla, CA 92093, USA
| | - Mukanth Vaidyanathan
- Cancer Early Detection Advanced Research (CEDAR) Center, Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
- Department of Nano Engineering, Jacobs School of Engineering, University of California, San Diego, La Jolla, CA 92093, USA
| | - Sadik C. Esener
- Cancer Early Detection Advanced Research (CEDAR) Center, Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR 97239, USA
- Department of Electrical Engineering, Jacobs School of Engineering, University of California, San Diego, La Jolla, CA 92093, USA
- Department of Nano Engineering, Jacobs School of Engineering, University of California, San Diego, La Jolla, CA 92093, USA
| | - Jared M. Fischer
- Cancer Early Detection Advanced Research (CEDAR) Center, Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
- Department of Molecular and Medical Genetics, School of Medicine, Oregon Health & Science University, Portland, OR 97239, USA
- Correspondence:
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McNutt MC, Foreman N, Gotway G. Arginase 1 Deficiency in Patients Initially Diagnosed with Hereditary Spastic Paraplegia. Mov Disord Clin Pract 2022; 10:109-114. [PMID: 36698992 PMCID: PMC9847303 DOI: 10.1002/mdc3.13612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/12/2022] [Accepted: 10/23/2022] [Indexed: 11/09/2022] Open
Abstract
Background Arginase 1 Deficiency (ARG1-D) is a rare autosomal recessive urea cycle disorder (UCD) characterized by pathologic elevation of plasma arginine and debilitating manifestations. Based on clinical commonalities and low disease awareness, ARG1-D can be diagnosed as hereditary spastic paraplegia (HSP), leading to treatment delays. Cases A Hispanic woman with unremarkable medical history experienced progressive lower-limb spasticity in her 20s and received a diagnosis of HSP. She developed significant gait abnormalities and is unable to walk without assistance. More recently, two Hispanic brothers with childhood-onset manifestations including lower-limb spasticity, developmental delays, and seizures presented with suspected HSP. All three patients were ultimately diagnosed with ARG1-D based on plasma arginine several-fold above normal levels and loss-of-function ARG1 variants. Disease progression occurred before ARG1-D was correctly diagnosed. Literature Review Retrospective analyses demonstrate that diagnostic delays in ARG1-D are common and can be lengthy. Because of clinical similarities between ARG1-D and HSP, such as insidious onset and progressive spasticity, accurate diagnosis of ARG1-D is challenging. Timely ARG1-D diagnosis is critical because this UCD is a treatable genetic cause of progressive lower-limb spasticity. Conclusions Arginase 1 Deficiency should be considered in HSP differential diagnosis until biochemically/genetically excluded, and should be routinely included in HSP gene panels.
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Anakha J, Kawathe PS, Datta S, Jawalekar SS, Banerjee UC, Pande AH. Human arginase 1, a Jack of all trades? 3 Biotech 2022; 12:264. [PMID: 36082360 PMCID: PMC9450830 DOI: 10.1007/s13205-022-03326-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/22/2022] [Indexed: 11/24/2022] Open
Abstract
Arginine, a conditionally essential amino acid, plays a crucial role in several metabolic and signalling pathways. Arginine metabolism in the body can be significantly increased under stress or during certain pathological conditions. Depletion of circulating arginine by administering arginine-hydrolysing enzyme has been shown to mitigate varied pathophysiological conditions ranging from cancer, inflammatory conditions, and microbial infection. This review provides an overview of such intriguing expanse of potential applications of recombinant human arginase 1 for different pathological conditions and its status of development.
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Affiliation(s)
- J. Anakha
- Department of Biotechnology, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S.A.S. Nagar, Mohali, Punjab 160062 India
| | - Priyanka S. Kawathe
- Department of Biotechnology, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S.A.S. Nagar, Mohali, Punjab 160062 India
| | - Sayantap Datta
- Department of Pharmacological and Pharmaceutical Sciences, University of Houston, 4800 Calhoun Rd, Houston, TX 77004 USA
| | - Snehal Sainath Jawalekar
- Department of Biotechnology, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S.A.S. Nagar, Mohali, Punjab 160062 India
| | - Uttam Chand Banerjee
- Department of Biotechnology, Amity University Punjab, 82A, IT City, International Airport Road, Mohali, 140306 India
| | - Abhay H. Pande
- Department of Biotechnology, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S.A.S. Nagar, Mohali, Punjab 160062 India
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Bin Sawad A, Jackimiec J, Bechter M, Trucillo A, Lindsley K, Bhagat A, Uyei J, Diaz GA. Epidemiology, methods of diagnosis, and clinical management of patients with arginase 1 deficiency (ARG1-D): A systematic review. Mol Genet Metab 2022; 137:153-163. [PMID: 36049366 DOI: 10.1016/j.ymgme.2022.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/18/2022] [Accepted: 08/20/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Arginase 1 Deficiency (ARG1-D) is a rare, progressive, metabolic disorder that is characterized by devastating manifestations driven by elevated plasma arginine levels. It typically presents in early childhood with spasticity (predominately affecting the lower limbs), mobility impairment, seizures, developmental delay, and intellectual disability. This systematic review aims to identify and describe the published evidence outlining the epidemiology, diagnosis methods, measures of disease progression, clinical management, and outcomes for ARG1-D patients. METHODS A comprehensive literature search across multiple databases such as MEDLINE, Embase, and a review of clinical studies in ClinicalTrials.gov (with results reported) was carried out per PRISMA guidelines on 20 April 2020 with no date restriction. Pre-defined eligibility criteria were used to identify studies with data specific to patients with ARG1-D. Two independent reviewers screened records and extracted data from included studies. Quality was assessed using the modified Newcastle-Ottawa Scale for non-comparative studies. RESULTS Overall, 55 records reporting 40 completed studies and 3 ongoing studies were included. Ten studies reported the prevalence of ARG1-D in the general population, with a median of 1 in 1,000,000. Frequently reported diagnostic methods included genetic testing, plasma arginine levels, and red blood cell arginase activity. However, routine newborn screening is not universally available, and lack of disease awareness may prevent early diagnosis or lead to misdiagnosis, as the disease has overlapping symptomology with other diseases, such as cerebral palsy. Common manifestations reported at time of diagnosis and assessed for disease progression included spasticity (predominately affecting the lower limbs), mobility impairment, developmental delay, intellectual disability, and seizures. Severe dietary protein restriction, essential amino acid supplementation, and nitrogen scavenger administration were the most commonly reported treatments among patients with ARG1-D. Only a few studies reported meaningful clinical outcomes of these interventions on intellectual disability, motor function and adaptive behavior assessment, hospitalization, or death. The overall quality of included studies was assessed as good according to the Newcastle-Ottawa Scale. CONCLUSIONS Although ARG1-D is a rare disease, published evidence demonstrates a high burden of disease for patients. The current standard of care is ineffective at preventing disease progression. There remains a clear need for new treatment options as well as improved access to diagnostics and disease awareness to detect and initiate treatment before the onset of clinical manifestations to potentially enable more normal development, improve symptomatology, or prevent disease progression.
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Affiliation(s)
| | | | | | | | | | | | | | - George A Diaz
- Division of Medical Genetics and Genomics in the Department of Genetics and Genomic Sciences at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
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12
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Bin Sawad A, Pothukuchy A, Badeaux M, Hodson V, Bubb G, Lindsley K, Uyei J, Diaz GA. Natural history of arginase 1 deficiency and the unmet needs of patients: A systematic review of case reports. JIMD Rep 2022; 63:330-340. [PMID: 35822089 PMCID: PMC9259395 DOI: 10.1002/jmd2.12283] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 03/10/2022] [Accepted: 03/15/2022] [Indexed: 12/20/2022] Open
Abstract
Background Arginase 1 deficiency (ARG1‐D) is a rare, progressive and debilitating urea cycle disorder characterized by clinical manifestations including spasticity, seizures, developmental delay, and intellectual disability. The aim of this systematic review was to identify and summarize the natural history of ARG1‐D and the unmet needs of patients. Methods A comprehensive search of published case reports was undertaken to identify patients with ARG1‐D regardless of interventions, comparisons, or outcomes. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and other evidence‐based medicine literature databases were searched on 20 April 2020. Quality was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist. (PROSPERO registration: CRD42020212142.) Results One hundred and fifty seven ARG1‐D patients were included from 111 publications (good overall quality based on JBI's Checklist); 84 (53.5%) were males. Motor deficits (including spasticity), intellectual disability, and seizures were reported in >50% of the cases. Mean age (SD) at diagnosis was 6.4 years and the laboratory findings most commonly reported to support diagnosis included elevated plasma arginine (81.5%), mutation in ARG1 gene through genetic testing (60%), and absence/reduction of red blood cell arginase activity (51%). Reported management approaches mainly included dietary protein restriction (68%), nitrogen scavengers (45%), and essential amino acid supplements (21%). Author‐reported clinical improvement was documented for 26% of patients, 15% deteriorated, and 19% had limited or no change; notably, no indication of clinical outcome was reported for 40% cases. Conclusion This review illustrates a significant burden of disease and highlights a considerable unmet need for clinically effective treatment options for patients with ARG1‐D.
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Affiliation(s)
| | | | | | | | | | - Kristina Lindsley
- Health Economics and Outcomes Research ‐ Evidence Synthesis IQVIA, Inc. San Francisco California USA
| | - Jennifer Uyei
- Health Economics and Outcomes Research ‐ Evidence Synthesis IQVIA, Inc. San Francisco California USA
| | - George A. Diaz
- Division of Medical Genetics and Genomics, Department of Genetics and Genomic Sciences Icahn School of Medicine at Mount Sinai New York New York USA
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13
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Li J, DeNicola GM, Ruffell B. Metabolism in tumor-associated macrophages. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2022; 367:65-100. [PMID: 35461660 PMCID: PMC9094395 DOI: 10.1016/bs.ircmb.2022.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Macrophages functionally adapt to a diverse set of signals, a process that is critical for their role in maintaining or restoring tissue homeostasis. This process extends to cancer, where macrophages respond to a series of inflammatory and metabolic cues that direct a maladaptive healing response. Tumor-associated macrophages (TAMs) have altered glucose, amino acid, and lipid metabolic profiles, and interfering with this metabolic shift can blunt the ability of macrophages to promote tumor growth, metastasis, and the creation of an immunosuppressive microenvironment. Here we will review changes in metabolites and metabolic pathways in TAMs and link these with the phenotypic and functional properties of the cells. We will also discuss current strategies targeting TAM metabolism as a therapeutic intervention in cancer.
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Affiliation(s)
- Jie Li
- Department of Immunology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA,Cancer Biology PhD Program, University of South Florida, Tampa, FL 33620
| | - Gina M. DeNicola
- Department of Cancer Physiology, Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Brian Ruffell
- Department of Immunology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, United States; Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, United States.
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14
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Keshavan N, Wood M, Alderson LM, Cortina‐Borja M, Skeath R, McSweeney M, Dixon M, Cleary MA, Footitt E, Batzios S. Clinical status, biochemical profile and management of a single cohort of patients with arginase deficiency. JIMD Rep 2021; 63:123-130. [PMID: 35281666 PMCID: PMC8898719 DOI: 10.1002/jmd2.12266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/22/2021] [Accepted: 12/06/2021] [Indexed: 11/18/2022] Open
Abstract
Arginase deficiency is a rare autosomal recessive urea cycle disorder (UCD) caused by mutations in the ARG1 gene encoding arginase that catalyses the hydrolysis of arginine to ornithine and urea. Patients have hyperargininaemia and progressive neurological impairment but generally suffer fewer metabolic decompensations compared to other UCDs. The objective is to describe the clinical features, biochemical profile, neuroradiological findings and experience of managing children with arginase deficiency. Twenty‐year retrospective review of patient medical records at a single metabolic centre was performed. Six patients from three unrelated families were identified. Mean age at first symptom was 3.3 (1.5–9.0) years, while mean age at diagnosis was 8.8 (0.16–15.92) years. Four patients developed spastic diplegia and two of six with spastic quadriplegia with classical features including hyperreflexia, clonus and toe walking. This resulted in gait abnormalities that have been monitored using the GAITRite system and required Achilles tendon release in five children. Generalised tonic‐clonic seizures and/or absences were present in three of six children and were controlled with anticonvulsants. All patients had moderate learning difficulties. Neuroimaging showed cerebral/cerebellar atrophy in four patients and basal ganglia abnormalities in two. Arginine levels were universally elevated throughout follow‐up despite protein restriction, essential amino acid supplementation and ammonia scavengers, and neurological outcome was generally poor. Two patients died following severe metabolic decompensation in adolescence. Children with arginase deficiency continue to present a management challenge of what appears to be an inexorable course of neurocognitive impairment. Further insight into disease mechanisms may provide insight into novel treatment strategies.
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Affiliation(s)
- Nandaki Keshavan
- Department of Paediatric Metabolic Medicine Great Ormond Street Hospital NHS Trust London UK
- UCL Great Ormond Street Hospital Institute of Child Health London UK
| | - Michelle Wood
- Department of Physiotherapy Great Ormond Street Hospital NHS Trust London UK
| | - Lucy M. Alderson
- UCL Great Ormond Street Hospital Institute of Child Health London UK
- Department of Physiotherapy Great Ormond Street Hospital NHS Trust London UK
| | - Mario Cortina‐Borja
- Population, Policy and Practice Research and Teaching Department UCL Great Ormond Street Hospital Institute of Child Health London UK
| | - Rachel Skeath
- Department of Dietetics Great Ormond Street Hospital NHS Trust London UK
| | - Mel McSweeney
- Department of Paediatric Metabolic Medicine Great Ormond Street Hospital NHS Trust London UK
| | - Marjorie Dixon
- Department of Dietetics Great Ormond Street Hospital NHS Trust London UK
| | - Maureen A. Cleary
- Department of Paediatric Metabolic Medicine Great Ormond Street Hospital NHS Trust London UK
| | - Emma Footitt
- Department of Paediatric Metabolic Medicine Great Ormond Street Hospital NHS Trust London UK
| | - Spyros Batzios
- Department of Paediatric Metabolic Medicine Great Ormond Street Hospital NHS Trust London UK
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15
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Kido J, Matsumoto S, Takeshita E, Hayasaka C, Yamada K, Kagawa J, Nakajima Y, Ito T, Iijima H, Endo F, Nakamura K. Current status of surviving patients with arginase 1 deficiency in Japan. Mol Genet Metab Rep 2021; 29:100805. [PMID: 34646736 PMCID: PMC8495172 DOI: 10.1016/j.ymgmr.2021.100805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 12/14/2022] Open
Abstract
Arginase 1 (ARG1) deficiency is a rare urea cycle disorder (UCD), with an estimated frequency of 1 per 2,200,000 births in Japan. Patients with ARG1 deficiency develop symptoms in late infancy or pre-school age with progressive neurological manifestations and sometimes present with severe hepatic disease. We previously investigated the status of UCDs in Japan; however, only one patient was identified as having ARG1 deficiency. Therefore, we aimed to investigate the current status of patients with ARG1 deficiency in 2018–2021 because almost 10 years have passed since the previous study. We present the disease history, clinical outcome, and treatment of five surviving patients with ARG1 deficiency and discuss the features of ARG1 deficiency in Japan. We found that clinicians often face difficulty in diagnosing ARG1 deficiency at the early stage of onset because of interpatient variability in onset time and clinical manifestations. Blood L-arginine and guanidino compounds were considered to be the major factors causing adverse neurodevelopmental outcomes. Therefore, early detection and intervention of ARG1 deficiency is essential for improved neurodevelopmental outcomes. Liver transplantation has been considered an effective treatment option that can dramatically improve the quality of life of patients, prior to the neurological manifestation of symptoms caused by ARG1 deficiency.
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Affiliation(s)
- Jun Kido
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto City, Kumamoto, Japan
| | - Shirou Matsumoto
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto City, Kumamoto, Japan
| | - Eiko Takeshita
- Department of Pediatrics, Yanagawa Institute for Developmental Disabilities, International University of Health and Welfare, Yanagawa City, Fukuoka, Japan
| | | | - Keitaro Yamada
- Department of Pediatric Neurology, Aichi Developmental Disability Center Central Hospital, Kasugai City, Aichi, Japan
| | - Jiro Kagawa
- Department of Pediatrics, Fujieda Municipal General Hospital, Fujieda City, Shizuoka, Japan
| | - Yoko Nakajima
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake City, Aichi, Japan
| | - Tetsuya Ito
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake City, Aichi, Japan
| | - Hiroyuki Iijima
- Department of General Pediatrics & Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Fumio Endo
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto City, Kumamoto, Japan
| | - Kimitoshi Nakamura
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto City, Kumamoto, Japan
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Cheng PNM, Liu AM, Bessudo A, Mussai F. Safety, PK/PD and preliminary anti-tumor activities of pegylated recombinant human arginase 1 (BCT-100) in patients with advanced arginine auxotrophic tumors. Invest New Drugs 2021; 39:1633-1640. [PMID: 34287772 DOI: 10.1007/s10637-021-01149-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
Background The study determined the safety, pharmacokinetics/pharmacodynamics (PK/PD), and recommended Phase II dose of BCT-100 for arginine auxotrophic tumours in a non-Chinese population. Methods This is a Phase I, 3 + 3 dose-escalation, open-label, multi-centre study in two arginine auxotrophic cancers-Malignant Melanoma (MM) and Castration Resistant Prostate Cancer (CRPC). Patients were enrolled to receive weekly intravenous BCT-100. The dose cohorts were respectively 0.5 mg/kg, 1.0 mg/kg, 1.7 mg/kg and 2.7 mg/kg. Results There were 14 MM and 9 CRPC patients, 16 males and 7 females with a median age of 71. No dose-limiting toxicities were reported. Among all the AEs, 18 were drug-related (mostly were Grade 1). Although there were individual variations in PKs amongst the patients in each cohort, the median arginine level was maintained at 2.5 µM (lower limit of quantification) in all 4 cohorts of patients after the second BCT-100 injection. Therapeutic Arginine Depletion was found in the 1.7 and 2.7 mg/kg/week cohorts when anti-tumor activities were observed. The two cohorts had a similar AUC (20,947 and 19,614 h*µg/ml respectively). Since the 2.7 mg/kg/week cohort had a more sustained arginine depletion for 2 weeks, the 2.7 mg/kg/week dose is chosen as the future phase II dose. There were two complete remissions (1 MM & 1 CRPC), 1PR (MM) and 2 stable diseases with a disease control rate (CR + PR + SD) of 5/23 (22%). Conclusions BCT-100 is safe in a non-Chinese population and has anti-tumor activities in both MM and CRPC. Weekly BCT-100 at 2.7 mg/kg is defined as the optimal biological dose for future clinical phase II studies.
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Affiliation(s)
- Paul N M Cheng
- Bio-Cancer Treatment International Ltd, Hong Kong, China.
| | - Angela M Liu
- Bio-Cancer Treatment International Ltd, Hong Kong, China
| | - Alberto Bessudo
- California Cancer Associates for Research and Excellence, Fresno, CA, US
| | - Francis Mussai
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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17
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Diaz GA, Schulze A, McNutt MC, Leão‐Teles E, Merritt JL, Enns GM, Batzios S, Bannick A, Zori RT, Sloan LS, Potts SL, Bubb G, Quinn AG. Clinical effect and safety profile of pegzilarginase in patients with arginase 1 deficiency. J Inherit Metab Dis 2021; 44:847-856. [PMID: 33325055 PMCID: PMC8359196 DOI: 10.1002/jimd.12343] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 11/30/2020] [Accepted: 12/14/2020] [Indexed: 12/29/2022]
Abstract
Hyperargininemia in patients with arginase 1 deficiency (ARG1-D) is considered a key driver of disease manifestations, including spasticity, developmental delay, and seizures. Pegzilarginase (AEB1102) is an investigational enzyme therapy which is being developed as a novel arginine lowering approach. We report the safety and efficacy of intravenously (IV) administered pegzilarginase in pediatric and adult ARG1-D patients (n = 16) from a Phase 1/2 study (101A) and the first 12 weeks of an open-label extension study (102A). Substantial disease burden at baseline included lower-limb spasticity, developmental delay, and previous hyperammonemic episodes in 75%, 56%, and 44% of patients, respectively. Baseline plasma arginine (pArg) was elevated (median 389 μM, range 238-566) on standard disease management. Once weekly repeat dosing resulted in a median decrease of pArg of 277 μM after 20 cumulative doses (n = 14) with pArg in the normal range (40 to 115 μM) in 50% of patients at 168 hours post dose (mean pegzilarginase dose 0.10 mg/kg). Lowering pArg was accompanied by improvements in one or more key mobility assessments (6MWT, GMFM-D & E) in 79% of patients. In 101A, seven hypersensitivity reactions occurred in four patients (out of 162 infusions administered). Other common treatment-related adverse events (AEs) included vomiting, hyperammonemia, pruritus, and abdominal pain. Treatment-related serious AEs that occurred in five patients were all observed in 101A. Pegzilarginase was effective in lowering pArg levels with an accompanying clinical response in patients with ARG1-D. The improvements with pegzilarginase occurred in patients receiving standard treatment approaches, which suggests that pegzilarginase could offer benefit over existing disease management.
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Affiliation(s)
- George A. Diaz
- Icahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Andreas Schulze
- University of Toronto and The Hospital for Sick ChildrenTorontoOntarioCanada
| | | | | | | | | | | | - Allison Bannick
- Children's Hospital of MichiganWayne State UniversityDetroitMichiganUSA
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