1
|
Trepp R, Muri R, Maissen-Abgottspon S, Haynes AG, Hochuli M, Everts R. Cognition after a 4-week high phenylalanine intake in adults with phenylketonuria - a randomized controlled trial. Am J Clin Nutr 2024; 119:908-916. [PMID: 38569786 DOI: 10.1016/j.ajcnut.2023.11.007] [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: 04/03/2023] [Revised: 10/30/2023] [Accepted: 11/15/2023] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Phenylketonuria (PKU) is an autosomal recessive metabolic disorder characterized by increased phenylalanine (Phe) concentrations in the blood and brain. Despite wide agreement on treatment during childhood, recommendations for adults are still controversial. OBJECTIVE To assess the impact of a 4-week increase in Phe intake (simulating normal dietary Phe consumption) on cognition, mood, and depression in early-treated adults with PKU in a double-blind, randomized controlled trial (RCT). METHODS In a single-site crossover trial, 30 adult patients with classical PKU diagnosed at birth were recruited. All patients underwent a 4-week period of oral Phe administration (1500-3000 mg Phe/d) and a 4-week placebo period in a randomly assigned order with age, sex, and place of usual medical care as stratification factors. Analyses were based on the intention-to-treat (ITT) and per protocol (PP) approach to claim noninferiority (noninferiority margin -4%), with working memory accuracy as the primary endpoint and additional cognitive domains, mood, and depression as secondary endpoints. RESULTS For the primary endpoint, a 4-week increase of Phe intake was noninferior to placebo with respect to working memory accuracy in both the ITT [point estimate 0.49; lower limit 95% confidence interval (CI): -1.99] and the PP analysis (point estimate -1.22; lower limit 95% CI: -2.60). Secondary outcomes (working memory reaction time, manual dexterity, mood, and depression) did not significantly differ between the Phe and placebo period, except for sustained attention (point estimate 31.0; lower limit 95% CI: 9.0). Adverse events were more frequent during the Phe than during the placebo period (95% CI: 1.03, 2.28, P = 0.037). CONCLUSIONS In early-treated adult patients with PKU, a 4-week high Phe intake was noninferior to continuing Phe restriction regarding working memory accuracy, and secondary outcomes did not differ except for sustained attention. Longer-term RCTs are required to determine whether low Phe levels need to be maintained throughout different periods of adulthood. This trial was registered at the clinicaltrials.gov as NCT03788343.
Collapse
Affiliation(s)
- Roman Trepp
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Raphaela Muri
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland; Support Center for Advanced Neuroimaging (SCAN), Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Stephanie Maissen-Abgottspon
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Alan G Haynes
- Institute of Social and Preventive Medicine and Clinical Trials Unit, University of Bern, Bern, Switzerland
| | - Michel Hochuli
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Regula Everts
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland; Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| |
Collapse
|
2
|
Lachmann R, Langeveld M. Phenylketonuria in adults: what do we know? Am J Clin Nutr 2024; 119:870-871. [PMID: 38296030 DOI: 10.1016/j.ajcnut.2024.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 01/23/2024] [Accepted: 01/23/2024] [Indexed: 02/17/2024] Open
Affiliation(s)
- Robin Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, United Kingdom.
| | - Mirjam Langeveld
- Department of Endocrinology and Metabolism, Amsterdam UMC, the Netherlands
| |
Collapse
|
3
|
Jahangiri Z, Rostampour N, Hovsepian S, Chegini R, Hashemipour M. Quality of Life in Patients with Phenylketonuria: A Systematic Review. Adv Biomed Res 2024; 13:15. [PMID: 38525399 PMCID: PMC10958725 DOI: 10.4103/abr.abr_238_23] [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: 07/05/2023] [Revised: 08/20/2023] [Accepted: 08/28/2023] [Indexed: 03/26/2024] Open
Abstract
The impact of phenylketonuria (PKU) on Quality of life (QoL) has been a topic of interest in recent research. This article reviews current researches on the impact of PKU on QoL. The review examines factors that may influence QoL, such as age, metabolic control, and treatment adherence. In this systematic review study, relevant articles were identified using a search strategy built with the keywords phenylketonuria, PKU, or hyperphenylalaninemia (or their synonyms) and QoL in Web of Science, Scopus, and PubMed databases. After identifying the articles, duplicates, reviews, scientific abstracts, articles published in languages other than English, and non relevant studies were excluded. The search strategy identified 951 records from databases, and after excluding duplicates, irrelevant studies, and those published in non English languages, 26 records were left that contained data on 1816 patients with PKU/hyperphenylalaninemia. The studies included both children/adolescents and adults. Overall, the studies found that the QoL of PKU patients was comparable to normative data, but some aspects such as emotional health and school functioning were lower. Metabolic control was found to significantly correlate with QoL. Younger patients and men had better QoL in several studies, while late treated patients and those with lower education had worse outcomes. It is concluded that QOL in patients with PKU is similar to the general population. However, given the chronic nature of the condition, it is important to pay special attention to their QoL. Poor QOL is associated with female gender, lower education, older age, and poor metabolic control.
Collapse
Affiliation(s)
- Zahra Jahangiri
- Metabolic Liver Disease Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Noushin Rostampour
- Metabolic Liver Disease Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Silva Hovsepian
- Metabolic Liver Disease Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rojin Chegini
- Metabolic Liver Disease Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahin Hashemipour
- Metabolic Liver Disease Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
4
|
Sundstrom R, Wetherill L, Sapp K, McPheron M, Lah M. Relationship satisfaction in adults with phenylketonuria is positively associated with following recommended treatment, having a partner involved in management, and maintaining good health. J Community Genet 2023; 14:627-638. [PMID: 37798460 PMCID: PMC10725410 DOI: 10.1007/s12687-023-00667-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/29/2023] [Indexed: 10/07/2023] Open
Abstract
RATIONALE Phenylketonuria (PKU) is a metabolic condition that requires treatment for life. There is increasing evidence that chronic illnesses put strain on relationships and marriages. However, no studies have examined the unique factors that metabolic conditions have on affected individuals and their relationship satisfaction. We surveyed a population of adult patients with PKU and assessed how management, treatment, and lifestyle factors impact their relationship satisfaction. PURPOSE The purpose of our study was to explore whether factors such as involvement of partner in PKU management, impact of challenges unique to PKU (e.g., diet, family planning, mood disturbances), and PKU treatment types were associated with the degree of relationship satisfaction. METHOD We surveyed adult patients with PKU (n = 82) who were either currently in or had previously been in a long-term relationship. We developed a 78-question survey that included unique questions regarding lifestyle, treatment, and management of their PKU in addition to a validated Relationship Assessment Score. Questions included single choice, multiple choice, and 3 open-ended questions. RESULTS We found that higher relationship satisfaction was associated with increased partner involvement, increased health, and adherence to recommended PKU treatments. Participants utilizing both diet and pharmaceutical treatment had the highest relationship satisfaction. Finally, participants who reported that their PKU did not contribute to the ending of a previous relationship reported higher relationship satisfaction scores. CONCLUSION This study suggests that involvement of partners in the management and treatment of a chronic illness and adherence to recommended treatments can significantly improve relationship satisfaction.
Collapse
Affiliation(s)
- Rachel Sundstrom
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, 975 W. Walnut, IB 130, Indianapolis, IN, 46202, USA
- Froedtert & The Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI, 53226, USA
| | - Leah Wetherill
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, 975 W. Walnut, IB 130, Indianapolis, IN, 46202, USA
| | - Katie Sapp
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, 975 W. Walnut, IB 130, Indianapolis, IN, 46202, USA
| | - Molly McPheron
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, 975 W. Walnut, IB 130, Indianapolis, IN, 46202, USA
| | - Melissa Lah
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, 975 W. Walnut, IB 130, Indianapolis, IN, 46202, USA.
| |
Collapse
|
5
|
De Giorgi A, Nardecchia F, Romani C, Leuzzi V. Metabolic control and clinical outcome in adolescents with phenylketonuria. Mol Genet Metab 2023; 140:107684. [PMID: 37672857 DOI: 10.1016/j.ymgme.2023.107684] [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: 06/30/2023] [Revised: 08/11/2023] [Accepted: 08/11/2023] [Indexed: 09/08/2023]
Abstract
The main neurological, cognitive, and behavioural consequences of phenylketonuria have been eradicated thanks to new-born screening and Phe-restricted diet therapy. However, the effects of high phenylalanine levels during adolescence and adulthood on neurocognitive functions remain a concern. This systematic review aimed at collecting clinical data suggesting the safest metabolic target for early treated PKU during the second decade of life. Twenty studies met the inclusion criteria for full-text review. Relevant studies included papers that (a) examined the relationship between metabolic control and neurocognitive functions during adolescence or (b) investigated the impact of metabolic control in adolescence on adult outcomes. Most studies showed a positive correlation between metabolic control during adolescence and neurocognitive outcomes across ages. This was true both for IQ and executive functions, although data on executive functions were less clear, and it remains to be established whether they are more vulnerable to Phe than IQ. Taken together present evidence confirm brain vulnerability to Phe during adolescence and suggests that low average Phe levels and low Phe fluctuations should be maintained throughout life. While results are fully compatible with current European recommendations, clinical and methodological limitations coupled with remarkable interindividual variability prevented a clear identification of a safe threshold for Phe blood levels during adolescence.
Collapse
Affiliation(s)
- Agnese De Giorgi
- Unit of Child Neurology and Psychiatry, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Francesca Nardecchia
- Unit of Child Neurology and Psychiatry, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Cristina Romani
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Vincenzo Leuzzi
- Unit of Child Neurology and Psychiatry, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy.
| |
Collapse
|
6
|
Manti F, Nardecchia F, De Leo S, Carducci C, Romani C, Palermo L, Angeloni A, Leuzzi V. Towards precision medicine for phenylketonuria: The effect of restoring a strict metabolic control in adult patients with early-treated phenylketonuria. Mol Genet Metab 2023; 140:107666. [PMID: 37549444 DOI: 10.1016/j.ymgme.2023.107666] [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: 06/11/2023] [Revised: 07/23/2023] [Accepted: 07/24/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND AND OBJECTIVE Neonatal screening and early treatment have changed the natural history of PKU, preventing severe neurological and intellectual disability. Nevertheless, the outcome of the disease in early-treated adult patients (ETPKU) is less than optimal, the predictive value of metabolic biomarkers is feeble, and the recommended levels of blood phenylalanine (Phe) for adulthood are controversial. A crucial question whose answer will improve our understanding and treatment of PKU is whether cognitive outcomes can be modulated by levels of Phe even in early-treated adults. To address this question, we carried out an interventional study in seven ETPKU women planning a pregnancy. METHODS They underwent an extensive neurocognitive assessment at baseline, and 3 and 6 months after having attained the blood Phe concentration recommended to prevent PKU fetopathy, but before pregnancy. RESULTS After 3 and 6 months with a stable blood Phe level of about 240 μmol/L, all participants experienced significant improvements in almost all neurocognitive domains and tasks. IQ also increased of 11 to 21 points from the last assessment before enrolment. This pattern remained strong and consistent after correction for multiple comparisons. CONCLUSION Our results indicate that a) strong cognitive improvement is possible even in adulthood and may be demonstrated by lowering Phe near normal levels; b) testing cognition under different metabolic conditions may unveil an individual vulnerability to Phe. These results pave the way for personalised treatment of the disease in adults with ETPKU.
Collapse
Affiliation(s)
- Filippo Manti
- Department of Human Neuroscience - Unit of Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Francesca Nardecchia
- Department of Human Neuroscience - Unit of Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Sabrina De Leo
- Department of Clinical Medicine, Azienda Ospedaliero Universitaria Policlinico Umberto I, Rome, Italy
| | - Claudia Carducci
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Cristina Romani
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Liana Palermo
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Antonio Angeloni
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Vincenzo Leuzzi
- Department of Human Neuroscience - Unit of Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy.
| |
Collapse
|
7
|
Ilgaz F, Ford S, O’Driscoll MF, MacDonald A. Adult PKU Clinics in the UK-Users' Experiences and Perspectives. Nutrients 2023; 15:4352. [PMID: 37892429 PMCID: PMC10610305 DOI: 10.3390/nu15204352] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/01/2023] [Accepted: 10/05/2023] [Indexed: 10/29/2023] Open
Abstract
Adults with PKU require life-long management, and ideally, their care should be in a specialised adult metabolic clinic. Their outcomes and co-morbidities have received much attention, but data are lacking on their experience, satisfaction and expectations about the care they receive. This survey reports the experiences and care adults with PKU receive from specialist metabolic clinics in the UK. The online survey developed by the UK NSPKU (National Society for Phenylketonuria), was placed on the NSPKU website from February 2021 to December 2022, and was completed by adults with PKU (≥18 years) or their carers/family members. Sixty-five adult PKU patients and 9 caregivers of adult patients completed the questionnaire (63% female in total). Only 32% of respondents were following a Phe-restricted diet with protein substitute intake as prescribed; the rest were partially adherent or not on dietary restrictions. Nineteen per cent (n = 14/74) had not been reviewed in clinic for two years. Half of the respondents (50%) described their experience in adult clinics as "good". Half of the patients were unable to contact their dietitians with questions or concerns, and only 24% considered that they received adequate support. Clinic reviews usually included anthropometric (82%) and dietary assessments (64%), discussion on management of PKU in daily life (78%) and a blood test (71%). Eighty-eight per cent reported they had at least one neurocognitive, mental health or behavioural co-morbidity but less than half of the patients reported an assessment on their neurocognitive functioning or mental health issues. Adult male patients appeared to have less detailed clinic review than females. Less than half (44%) of the respondents reported that they performed a blood spot for blood Phe at least monthly, but only 32% considered they had been informed about the risk of high Phe levels in adulthood. Although time, cost and stress related to travelling were barriers to a face-to-face review, more than 40% of patients had concerns about remote appointments. The frequency and extent of monitoring of adults with PKU, attending specialist adult services, were less than those specified by the PKU European guidelines. The care of women of reproductive age is prioritised over men. Adult metabolic health services require further attention, development and resources to provide a high standard and equitable service to patients with PKU.
Collapse
Affiliation(s)
- Fatma Ilgaz
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Hacettepe University, 06100 Ankara, Turkey
| | - Suzanne Ford
- Southmead Hospital North Bristol Trust, Bristol BS10 5NB, UK;
- National Society for Phenylketonuria (NSPKU), Sheffield S12 9ET, UK
| | - Michael F. O’Driscoll
- Department of Adult Child & Midwifery, School of Health Social Care & Education, Middlesex University, London NW4 4BT, UK;
| | - Anita MacDonald
- Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK;
| |
Collapse
|
8
|
Rocha JC, Ahring KK, Bausell H, Bilder DA, Harding CO, Inwood A, Longo N, Muntau AC, Pessoa ALS, Rohr F, Sivri S, Hermida Á. Expert Consensus on the Long-Term Effectiveness of Medical Nutrition Therapy and Its Impact on the Outcomes of Adults with Phenylketonuria. Nutrients 2023; 15:3940. [PMID: 37764724 PMCID: PMC10536918 DOI: 10.3390/nu15183940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/28/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
Many adults with phenylketonuria (PKU) rely on medical nutrition therapy (MNT; low phenylalanine (Phe) diet with protein substitutes/medical foods) to maintain blood Phe concentrations within recommended ranges and prevent PKU-associated comorbidities. Despite disease detection through newborn screening and introduction of MNT as early as birth, adherence to MNT often deteriorates from childhood onwards, complicating the assessment of its effectiveness in the long term. Via a modified Delphi process, consensus (≥70% agreement) was sought on 19 statements among an international, multidisciplinary 13-member expert panel. After three iterative voting rounds, the panel achieved consensus on 17 statements related to the limitations of the long-term effectiveness of MNT (7), the burden of long-term reliance on MNT (4), and its potential long-term detrimental health effects (6). According to the expert panel, the effectiveness of MNT is limited in the long term, is associated with a high treatment burden, and demonstrates that adults with PKU are often unable to achieve metabolic control through dietary management alone, creating an unmet need in the adult PKU population.
Collapse
Affiliation(s)
- Júlio César Rocha
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Campo Mártires da Pátria 130, 1169-056 Lisboa, Portugal
- Reference Centre of Inherited Metabolic Diseases, Centro Hospitalar Universitário de Lisboa Central, Rua Jacinta Marto, 1169-045 Lisboa, Portugal
- CINTESIS@RISE, Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade NOVA de Lisboa, Campo Mártires da Pátria 130, 1169-056 Lisboa, Portugal
| | - Kirsten K. Ahring
- Departments of Paediatrics and Clinical Genetics, PKU Clinic, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Heather Bausell
- Division of Genetics, Genomics, and Metabolism, Ann & Robert H Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL 60611, USA
| | - Deborah A. Bilder
- Department of Psychiatry, Division of Child & Adolescent Psychiatry, University of Utah Huntsman Mental Health Institute, 501 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Cary O. Harding
- Department of Molecular and Medical Genetics, Oregon Health & Science University, 3222 SW Research Drive, Portland, OR 97239, USA
| | - Anita Inwood
- Queensland Lifespan Metabolic Medicine Service, Queensland Children’s Hospital, 501 Stanley St., South Brisbane, QLD 4101, Australia
- School of Nursing and Social Work, The University of Queensland, Chamberlain Building, St. Lucia, QLD 4072, Australia
| | - Nicola Longo
- Department of Pediatrics, Division of Medical Genetics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Ania C. Muntau
- Department of Pediatrics, University Children’s Hospital, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - André L. Santos Pessoa
- Albert Sabin Children’s Hospital, R. Tertuliano Sales, 544—Vila União, Fortaleza 60410-794, CE, Brazil
- Av. Dr. Silas Munguba, 1700—Itaperi, State University of Ceará (UECE), Fortaleza 60714-903, CE, Brazil
| | | | - Serap Sivri
- Division of Pediatric Metabolism, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Gevher Nesibe Cd., 06230 Ankara, Turkey
| | - Álvaro Hermida
- Diagnosis and Treatment of Congenital Metabolic Diseases Unit (UDyTEMC), Department of Pediatrics, Faculty of Medicine, Clinical University Hospital of Santiago de Compostela, University of Santiago de Compostela, CIBERER, MetabERN, Institute of Clinical Research of Santiago de Compostela (IDIS), Rúa de San Francisco s/n, 15706 Santiago de Compostela, Spain
| |
Collapse
|
9
|
Schoen MS, Boland KM, Christ SE, Cui X, Ramakrishnan U, Ziegler TR, Alvarez JA, Singh RH. Total choline intake and working memory performance in adults with phenylketonuria. Orphanet J Rare Dis 2023; 18:222. [PMID: 37516884 PMCID: PMC10386684 DOI: 10.1186/s13023-023-02842-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/21/2023] [Indexed: 07/31/2023] Open
Abstract
BACKGROUND Despite early diagnosis and compliance with phenylalanine (Phe)-restricted diets, many individuals with phenylketonuria (PKU) still exhibit neurological changes and experience deficits in working memory and other executive functions. Suboptimal choline intake may contribute to these impairments, but this relationship has not been previously investigated in PKU. The objective of this study was to determine if choline intake is correlated with working memory performance, and if this relationship is modified by diagnosis and metabolic control. METHODS This was a cross-sectional study that included 40 adults with PKU and 40 demographically matched healthy adults. Web-based neurocognitive tests were used to assess working memory performance and 3-day dietary records were collected to evaluate nutrient intake. Recent and historical blood Phe concentrations were collected as measures of metabolic control. RESULTS Working memory performance was 0.32 z-scores (95% CI 0.06, 0.58) lower, on average, in participants with PKU compared to participants without PKU, and this difference was not modified by total choline intake (F[1,75] = 0.85, p = 0.36). However, in a subgroup with complete historical blood Phe data, increased total choline intake was related to improved working memory outcomes among participants with well controlled PKU (Phe = 360 µmol/L) after adjusting for intellectual ability and mid-childhood Phe concentrations (average change in working memory per 100 mg change in choline = 0.11; 95% CI 0.02, 0.20; p = 0.02). There also was a trend, albeit nonsignificant (p = 0.10), for this association to be attenuated with increased Phe concentrations. CONCLUSIONS Clinical monitoring of choline intake is essential for all individuals with PKU but may have important implications for working memory functioning among patients with good metabolic control. Results from this study should be confirmed in a larger controlled trial in people living with PKU.
Collapse
Affiliation(s)
- Meriah S Schoen
- Department of Human Genetics, Emory University School of Medicine, 101 Woodruff Circle, Suite 7130, Atlanta, GA, 30322, USA.
| | - Kelly M Boland
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Shawn E Christ
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Xiangqin Cui
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Usha Ramakrishnan
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Thomas R Ziegler
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jessica A Alvarez
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Rani H Singh
- Department of Human Genetics, Emory University School of Medicine, 101 Woodruff Circle, Suite 7130, Atlanta, GA, 30322, USA
| |
Collapse
|
10
|
Muri R, Maissen-Abgottspon S, Reed MB, Kreis R, Hoefemann M, Radojewski P, Pospieszny K, Hochuli M, Wiest R, Lanzenberger R, Trepp R, Everts R. Compromised white matter is related to lower cognitive performance in adults with phenylketonuria. Brain Commun 2023; 5:fcad155. [PMID: 37265600 PMCID: PMC10231812 DOI: 10.1093/braincomms/fcad155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/19/2023] [Accepted: 05/12/2023] [Indexed: 06/03/2023] Open
Abstract
Despite increasing knowledge about the effects of phenylketonuria on brain structure and function, it is uncertain whether white matter microstructure is affected and if it is linked to patients' metabolic control or cognitive performance. Thus, we quantitatively assessed white matter characteristics in adults with phenylketonuria and assessed their relationship to concurrent brain and blood phenylalanine levels, historical metabolic control and cognitive performance. Diffusion tensor imaging and 1H spectroscopy were performed in 30 adults with early-treated classical phenylketonuria (median age 35.5 years) and 54 healthy controls (median age 29.3 years). Fractional anisotropy and mean, axial and radial diffusivity were investigated using tract-based spatial statistics, and white matter lesion load was evaluated. Brain phenylalanine levels were measured with 1H spectroscopy whereas concurrent plasma phenylalanine levels were assessed after an overnight fast. Retrospective phenylalanine levels were collected to estimate historical metabolic control, and a neuropsychological evaluation assessed the performance in executive functions, attention and processing speed. Widespread reductions in mean diffusivity, axial diffusivity and fractional anisotropy occurred in patients compared to controls. Mean diffusivity and axial diffusivity were decreased in several white matter tracts and were most restricted in the optic radiation (effect size rrb = 0.66 to 0.78, P < 0.001) and posterior corona radiata (rrb = 0.83 to 0.90, P < 0.001). Lower fractional anisotropy was found in the optic radiation and posterior corona radiata (rrb = 0.43 to 0.49, P < 0.001). White matter microstructure in patients was significantly associated with cognition. Specifically, inhibition was related to axial diffusivity in the external capsule (rs = -0.69, P < 0.001) and the superior (rs = -0.58, P < 0.001) and inferior longitudinal fasciculi (rs = -0.60, P < 0.001). Cognitive flexibility was associated with mean diffusivity of the posterior limb of the internal capsule (rs = -0.62, P < 0.001), and divided attention correlated with fractional anisotropy of the external capsule (rs = -0.61, P < 0.001). Neither concurrent nor historical metabolic control was significantly associated with white matter microstructure. White matter lesions were present in 29 out of 30 patients (96.7%), most often in the parietal and occipital lobes. However, total white matter lesion load scores were unrelated to patients' cognitive performance and metabolic control. In conclusion, our findings demonstrate that white matter alterations in early-treated phenylketonuria persist into adulthood, are most prominent in the posterior white matter and are likely to be driven by axonal damage. Furthermore, diffusion tensor imaging metrics in adults with phenylketonuria were related to performance in attention and executive functions.
Collapse
Affiliation(s)
- Raphaela Muri
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, 3010 Bern, Switzerland
- Support Center for Advanced Neuroimaging (SCAN), University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, 3010 Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, 3012 Bern, Switzerland
- Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, 3010 Bern, Switzerland
| | - Stephanie Maissen-Abgottspon
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, 3010 Bern, Switzerland
- Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, 3010 Bern, Switzerland
| | - Murray Bruce Reed
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, 1090 Vienna, Austria
| | - Roland Kreis
- Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, 3010 Bern, Switzerland
- Magnetic Resonance Methodology, Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, 3010 Bern, Switzerland
| | - Maike Hoefemann
- Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, 3010 Bern, Switzerland
- Magnetic Resonance Methodology, Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, 3010 Bern, Switzerland
| | - Piotr Radojewski
- Support Center for Advanced Neuroimaging (SCAN), University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, 3010 Bern, Switzerland
- Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, 3010 Bern, Switzerland
| | - Katarzyna Pospieszny
- Support Center for Advanced Neuroimaging (SCAN), University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, 3010 Bern, Switzerland
| | - Michel Hochuli
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, 3010 Bern, Switzerland
| | - Roland Wiest
- Support Center for Advanced Neuroimaging (SCAN), University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, 3010 Bern, Switzerland
- Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, 3010 Bern, Switzerland
| | - Rupert Lanzenberger
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, 1090 Vienna, Austria
| | | | - Regula Everts
- Correspondence to: Regula Everts Department of Diabetes, Endocrinology Nutritional Medicine and Metabolism, Inselspital Bern University Hospital and University of Bern Freiburgstrasse, Bern 3010, Switzerland E-mail:
| |
Collapse
|
11
|
Cognitive Functioning in Adults with Phenylketonuria in a Cohort of Spanish Patients. Behav Neurol 2023; 2023:9681740. [PMID: 36815863 PMCID: PMC9931468 DOI: 10.1155/2023/9681740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 02/10/2023] Open
Abstract
The early introduction of a low phenylalanine (Phe) diet has been demonstrated to be the most successful treatment in subjects with phenylketonuria (PKU), especially for preventing severe cognitive and neurological damages. However, it still concerns that even if treated in the first months of life with supplements and following a diet, they can show slight scores below people without PKU in neuropsychological assignments. We investigated 20 adults with classical PKU aged 19-48 years (mean age 29 years) and 20 heathy controls matched by age, gender, and years of education. Patients and controls were assessed with an extended neuropsychological battery, as well as psychological aspects and quality of life, also the last Phe level result was obtained. Results showed that the most affected cognitive domains are processing speed, executive functioning, memory, and also theory of mind, but very well-preserved verbal fluency, language, and visuospatial functioning. In quality of life, some significant results were seen specially in anxiety of Phe levels, anxiety of Phe levels during pregnancy, guilt if poor adherence to supplements, and if dietary protein restriction not followed. No significant results were obtained for the psychological variables. In conclusion, it has been shown that a combination of a low Phe diet, supplement intake, and keeping Phe levels in a low range seems appropriate to have the most normal and alike cognitive performance to persons without PKU.
Collapse
|
12
|
Costa-Lathan C, Vazquez-Agra N, Marques-Afonso AT, Cruces-Sande A, Martinez-Olmos MA, Araujo-Vilar D, Hermida-Ameijeiras A. The role of phenylalanine levels in the neuropsychological and neuroanatomical status of adult patients with phenylketonuria: The impact of fluctuations. J Investig Med 2023; 71:149-158. [PMID: 36647337 DOI: 10.1177/10815589221143485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
We aimed to evaluate the role of plasma phenylalanine (Phe) levels and its fluctuations in some neurocognitive domains and brain magnetic resonance imaging (MRI) findings in adult patients with phenylketonuria (PKU). It was an observational study that included patients older than 18 years with early-treated classical PKU. Plasma Phe levels were measured every other month throughout 2 years and predictor variables were the mean, maximum (max), minimum (min), range (min-max), and plasma Phe levels at the time of cognitive testing. Patients were evaluated for executive function, processing speed, visual attention, and fluid cognitive abilities using the Trail Making Test (TMT) and for the presence of brain MRI abnormalities. In all, 22 patients with a mean age of 34 years were included, of which 18 (81%) were women. Patients with higher range and maximum Phe levels had a poorer time-based performance on TMT form A and form B. Patients with brain MRI abnormalities had higher range, maximum, and mean Phe levels. Range of Phe levels showed a good performance for MRI abnormalities (area under the curve (AUC): 0.881, standard error (SE): 0.095, 95% CI: 0.695-0.999, p = 0.044) and for the poorest time-based performances on TMT form A (AUC: 0.822, SE: 0.092, 95% CI: 0.641-0.999, p = 0.024) and B (AUC: 0.816, SE: 0.094, 95% CI: 0.632-0.999, p = 0.021). Greater Phe variability may have a negative impact on some neurocognitive domains and could be related to the severity of brain structural damage in adult patients with PKU.
Collapse
Affiliation(s)
| | - Nestor Vazquez-Agra
- Department of Internal Medicine, University Hospital of Santiago de Compostela, A Coruña, Spain
| | | | - Anton Cruces-Sande
- Laboratory of Neurochemistry, Department of Biochemistry and Molecular Biology, Faculty of Medicine, University of Santiago de Compostela, A Coruña, Spain
| | - Miguel-Angel Martinez-Olmos
- Division of Endocrinology and Nutrition, University Hospital of Santiago de Compostela, A Coruña, Spain.,CIBER Pathophysiology of Obesity and Nutrition (CIBERobn), Carlos III Health Institute, Madrid, Spain
| | - David Araujo-Vilar
- Division of Endocrinology and Nutrition, University Hospital of Santiago de Compostela, A Coruña, Spain.,UETeM-Molecular Pathology Group, Department of Medicine, IDIS-CIMUS, University of Santiago de Compostela, A Coruña, Spain
| | - Alvaro Hermida-Ameijeiras
- Department of Internal Medicine, University Hospital of Santiago de Compostela, A Coruña, Spain.,UETeM-Molecular Pathology Group, Department of Medicine, IDIS-CIMUS, University of Santiago de Compostela, A Coruña, Spain
| |
Collapse
|
13
|
Thomas L, Olson A, Romani C. The impact of metabolic control on cognition, neurophysiology, and well-being in PKU: A systematic review and meta-analysis of the within-participant literature. Mol Genet Metab 2023; 138:106969. [PMID: 36599257 DOI: 10.1016/j.ymgme.2022.106969] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022]
Abstract
Phenylketonuria (PKU) is a metabolic disease where Phenylalanine (Phe) rises much above normal levels. Cross-sectional and correlational studies provide valuable information on the importance of maintaining low blood-Phe to achieve good outcomes, but they may be confounded, at least partially, by differences in participant demographics. Moreover, the effect of Phe at older ages is difficult to ascertain because of strong associations between Phe levels across ages. Within-participant studies avoid confounding issues. We have reviewed these studies. We followed PRISMA guidelines to search the literature for studies reporting the impact of Phe changes within participants. Phe was either increased or decreased through diet relaxation/resumption or through pharmacological interventions. Forty-six separate articles reported, singly or in combination, results on cognition (N = 37), well-being (N = 22) and neurophysiological health (N = 14). For all studies, we established, in a binary way, whether a benefit of lower Phe was or was not demonstrated and compared numbers showing benefit versus a null or negative outcome. We then analyzed whether critical parameters (e.g., length of the study/condition for the change, size of Phe change achieved) influenced presence or absence of benefit. For a subset of studies that reported quantitative cognitive outcomes, we carried out a meta-analysis to estimate the size of change in cognitive performance associated with a change in Phe and its significance. There were significantly more studies with benefits than no benefits, both for cognitive and well-being outcomes, and a trend in this direction for neurophysiological outcomes. The meta-analysis showed a highly significant effect size both overall (0.55) and when studies with adults/adolescents were considered separately (0.57). There was some indication that benefits were easier to demonstrate when differences in Phe were larger and achieved across a longer period, but these effects were not always consistent. These results reinforce results from the literature by demonstrating the importance of lower Phe in children as well as in adolescents and adults, even when confounding factors in group composition are eliminated. The field would benefit from further studies where Phe levels are contrasted within-participants to ascertain how much Phe needs to be changed and for how long to see a difference and which measures demonstrate a difference (e.g., which cognitive tasks).
Collapse
|
14
|
Manti F, Caviglia S, Cazzorla C, Dicintio A, Pilotto A, Burlina AP. Expert opinion of an Italian working group on the assessment of cognitive, psychological, and neurological outcomes in pediatric, adolescent, and adult patients with phenylketonuria. Orphanet J Rare Dis 2022; 17:443. [PMID: 36544165 PMCID: PMC9769037 DOI: 10.1186/s13023-022-02488-2] [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: 04/28/2022] [Accepted: 08/15/2022] [Indexed: 12/24/2022] Open
Abstract
Phenylketonuria (PKU) is an inherited metabolic disease characterized by a defective conversion of phenylalanine (Phe) to tyrosine, potentially leading to Phe accumulation in the brain. Dietary restriction since birth has led to normal cognitive development. However, PKU patients can still develop cognitive or behavioral abnormalities and subtle neurological deficits. Despite the increasing evidence in the field, the assessment of neurocognitive, psychopathological, and neurological follow-up of PKU patients at different ages is still debated. The high interindividual variability in the cognitive outcome of PKU patients makes the specificity of the neurocognitive and behavioral assessment extremely challenging. In the present paper, a multidisciplinary panel of Italian PKU experts discussed different tools available for cognitive, psychopathological, and neurological assessment at different ages based on the existing literature and daily clinical practice. This study aims to provide evidence and a real-life-based framework for a specific clinical assessment of pediatric, adolescent, and adult patients affected by PKU.
Collapse
Affiliation(s)
- Filippo Manti
- grid.7841.aUnit of Child Neurology and Psychiatry, Department of Human Neuroscience, University of Rome La Sapienza, Rome, Italy
| | - Stefania Caviglia
- grid.414125.70000 0001 0727 6809Unit of Clinical Psychology, Department of Neurosciences, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Chiara Cazzorla
- grid.411474.30000 0004 1760 2630Division of Inborn Metabolic Diseases, Department of Pediatrics, University Hospital, Padua, Italy
| | - Annamaria Dicintio
- grid.488556.2Department of Metabolic Diseases and Clinical Genetics, Giovanni XXIII Children Hospital, Azienda Ospedaliero-Universitaria Consorziale Policlinico, 70126 Bari, Italy
| | - Andrea Pilotto
- grid.7637.50000000417571846Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | |
Collapse
|
15
|
Romani C, Olson A, Aitkenhead L, Baker L, Patel D, Spronsen FV, MacDonald A, Wegberg AV, Huijbregts S. Meta-analyses of cognitive functions in early-treated adults with phenylketonuria. Neurosci Biobehav Rev 2022; 143:104925. [PMID: 36283539 DOI: 10.1016/j.neubiorev.2022.104925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/07/2022] [Accepted: 10/21/2022] [Indexed: 11/05/2022]
Abstract
Our study estimated size of impairment for different cognitive functions in early-treated adults with PKU (AwPKU) by combining literature results in a meta-analytic way. We analysed a large set of functions (N = 19), each probed by different measures (average = 12). Data were extracted from 26 PKU groups and matched controls, with 757 AwPKU contributing 220 measures. Effect sizes (ESs) were computed using Glass' ∆ where differences in performance between clinical/PKU and control groups are standardized using the mean and standard deviation of the control groups. Significance was assessed using measures nested within independent PKU groups as a random factor. The weighted Glass' ∆ was - 0.44 for all functions taken together, and - 0.60 for IQ, both highly significant. Separate, significant impairments were found for most functions, but with great variability (ESs from -1.02 to -0.18). The most severe impairments were in reasoning, visual-spatial attention speed, sustained attention, visuo-motor control, and flexibility. Effect sizes were larger with speed than accuracy measures, and with visuo-spatial than verbal stimuli. Results show a specific PKU profile that needs consideration when monitoring the disease.
Collapse
Affiliation(s)
| | - Andrew Olson
- Psychology Department, University of Birmingham, UK.
| | | | - Lucy Baker
- Psychology Department, Aston University, UK.
| | | | | | - Anita MacDonald
- Birmingham Women' s and Children's NHS Foundation Trust, UK.
| | | | | |
Collapse
|
16
|
Muri R, Maissen‐Abgottspon S, Rummel C, Rebsamen M, Wiest R, Hochuli M, Jansma BM, Trepp R, Everts R. Cortical thickness and its relationship to cognitive performance and metabolic control in adults with phenylketonuria. J Inherit Metab Dis 2022; 45:1082-1093. [PMID: 36117142 PMCID: PMC9827942 DOI: 10.1002/jimd.12561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/14/2022] [Accepted: 09/16/2022] [Indexed: 01/12/2023]
Abstract
Despite good control of phenylalanine (Phe) levels during childhood and adolescence, adults with phenylketonuria (PKU) often show abnormalities in the white matter of the brain, which have been associated with poorer cognitive performance. However, whether such a relationship exists with cortical gray matter is still unknown. Therefore, we investigated cortical thickness and surface area in adults with early-treated PKU and their relationship to cognitive functions and metabolic control. We included 30 adult patients with early-treated and metabolically well-controlled PKU (median age: 35.5 years) and 54 healthy controls (median age: 29.3 years). Surface-based morphometry was derived from T1-weighted magnetic resonance images using FreeSurfer, and general intelligence, executive functions, and attention were assessed. Concurrent plasma Phe, tyrosine, and tryptophan levels were measured in patients. In addition, Phe levels were collected retrospectively to calculate the index of dietary control. Patients showed a thinner cortex than controls in regions of the bilateral temporal, parietal, and occipital lobes (effect size r = -0.34 to -0.42, p < 0.05). No group differences in surface area were found. In patients, accuracy in the working memory task was positively correlated with thickness in the left insula (r = 0.45, p = 0.013), left fusiform gyrus (r = 0.39, p = 0.032), and right superior temporal gyrus (r = 0.41, p = 0.024), but did not survive false discovery rate correction. Neither concurrent nor historical metabolic parameters were related to cortical thickness. Taken together, adults with PKU showed widespread reductions in cortical thickness despite good metabolic control in childhood and adolescence. However, alterations in cortical thickness were unrelated to metabolic parameters and cognitive performance.
Collapse
Affiliation(s)
- Raphaela Muri
- Department of Diabetes, Endocrinology, Nutritional Medicine and MetabolismInselspital, Bern University Hospital and University of BernBernSwitzerland
- Support Center for Advanced Neuroimaging (SCAN)University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalBernSwitzerland
- Graduate School for Health SciencesUniversity of BernBernSwitzerland
- Translational Imaging Center (TIC)Swiss Institute for Translational and Entrepreneurial MedicineBernSwitzerland
| | - Stephanie Maissen‐Abgottspon
- Department of Diabetes, Endocrinology, Nutritional Medicine and MetabolismInselspital, Bern University Hospital and University of BernBernSwitzerland
- Translational Imaging Center (TIC)Swiss Institute for Translational and Entrepreneurial MedicineBernSwitzerland
| | - Christian Rummel
- Support Center for Advanced Neuroimaging (SCAN)University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalBernSwitzerland
| | - Michael Rebsamen
- Support Center for Advanced Neuroimaging (SCAN)University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalBernSwitzerland
| | - Roland Wiest
- Support Center for Advanced Neuroimaging (SCAN)University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalBernSwitzerland
- Translational Imaging Center (TIC)Swiss Institute for Translational and Entrepreneurial MedicineBernSwitzerland
| | - Michel Hochuli
- Department of Diabetes, Endocrinology, Nutritional Medicine and MetabolismInselspital, Bern University Hospital and University of BernBernSwitzerland
| | - Bernadette M. Jansma
- Department of Cognitive NeuroscienceMaastricht UniversityMaastrichtThe Netherlands
- Maastricht Brain Imaging Center (M‐BIC)MaastrichtThe Netherlands
| | - Roman Trepp
- Department of Diabetes, Endocrinology, Nutritional Medicine and MetabolismInselspital, Bern University Hospital and University of BernBernSwitzerland
| | - Regula Everts
- Department of Diabetes, Endocrinology, Nutritional Medicine and MetabolismInselspital, Bern University Hospital and University of BernBernSwitzerland
- Translational Imaging Center (TIC)Swiss Institute for Translational and Entrepreneurial MedicineBernSwitzerland
- Neuropediatrics, Development and Rehabilitation, Department of Pediatrics, InselspitalBern University Hospital, University of BernBernSwitzerland
| |
Collapse
|
17
|
A comprehensive assessment of neurocognitive and psychological functioning in adults with early-treated phenylketonuria. J Int Neuropsychol Soc 2022:1-10. [PMID: 36134437 DOI: 10.1017/s1355617722000686] [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] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Relative to youth with early-treated phenylketonuria (ETPKU), much less is known regarding the cognitive profile of adults with ETPKU. The present study aimed to address this gap by providing a comprehensive assessment of neuropsychological functioning among adults with ETPKU. METHOD A sample of 40 adults with ETPKU (ages 18 - 36) and a demographically matched group of 32 healthy individuals without PKU participated. Participants completed a comprehensive neuropsychological battery including the NIH Toolbox, Wechsler Abbreviated Scale of Intelligence - Second Edition (WASI-II), Conners' Continuous Performance Test (CPT-3), select subtests from the Weschler Adult Intelligence Scale - Fourth Edition (WAIS-IV) as well as several self-report measures of cognitive and psychoemotional functioning. Scores from these tests were combined to create cognitive composites reflecting overall task performance in the areas of verbal ability, visuospatial skills, executive functioning, motor skills, and processing speed. RESULTS No group differences were observed for full scale IQ or verbal ability. However, individuals with ETPKU demonstrated poorer performance on measures of executive functioning, processing speed, motor skills, and visuospatial skills as compared to the non-PKU group. Within the ETPKU group, recent blood phenylalanine levels (an indicator of metabolic control) were significantly correlated with performance across most cognitive domains and aspects of psychological functioning. CONCLUSIONS Present findings suggest that the neuropsychological profile of adult ETPKU is characterized by circumscribed impairments in select cognitive domains. In addition, the results underscore the importance of maintaining metabolic control across the lifespan in individuals with ETPKU.
Collapse
|
18
|
Burton BK, Hermida Á, Bélanger-Quintana A, Bell H, Bjoraker KJ, Christ SE, Grant ML, Harding CO, Huijbregts SCJ, Longo N, McNutt MC, Nguyen-Driver MD, Santos Pessoa AL, Rocha JC, Sacharow S, Sanchez-Valle A, Sivri HS, Vockley J, Walterfang M, Whittle S, Muntau AC. Management of early treated adolescents and young adults with phenylketonuria: Development of international consensus recommendations using a modified Delphi approach. Mol Genet Metab 2022; 137:114-126. [PMID: 36027720 DOI: 10.1016/j.ymgme.2022.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/16/2022] [Accepted: 07/23/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Early treated patients with phenylketonuria (PKU) often become lost to follow-up from adolescence onwards due to the historical focus of PKU care on the pediatric population and lack of programs facilitating the transition to adulthood. As a result, evidence on the management of adolescents and young adults with PKU is limited. METHODS Two meetings were held with a multidisciplinary international panel of 25 experts in PKU and comorbidities frequently experienced by patients with PKU. Based on the outcomes of the first meeting, a set of statements were developed. During the second meeting, these statements were voted on for consensus generation (≥70% agreement), using a modified Delphi approach. RESULTS A total of 37 consensus recommendations were developed across five areas that were deemed important in the management of adolescents and young adults with PKU: (1) general physical health, (2) mental health and neurocognitive functioning, (3) blood Phe target range, (4) PKU-specific challenges, and (5) transition to adult care. The consensus recommendations reflect the personal opinions and experiences from the participating experts supported with evidence when available. Overall, clinicians managing adolescents and young adults with PKU should be aware of the wide variety of PKU-associated comorbidities, initiating screening at an early age. In addition, management of adolescents/young adults should be a joint effort between the patient, clinical center, and parents/caregivers supporting adolescents with gradually gaining independent control of their disease during the transition to adulthood. CONCLUSIONS A multidisciplinary international group of experts used a modified Delphi approach to develop a set of consensus recommendations with the aim of providing guidance and offering tools to clinics to aid with supporting adolescents and young adults with PKU.
Collapse
Affiliation(s)
- Barbara K Burton
- Ann and Robert H. Lurie Children's Hospital and Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Álvaro Hermida
- Clinical University Hospital of Santiago de Compostela, University of Santiago de Compostela, CIBERER, MetabERN, Institute of Clinical Research of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | | | - Heather Bell
- Fred A. Litwin Family Centre in Genetic Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | | | - Shawn E Christ
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Mitzie L Grant
- Department of Psychiatry, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Cary O Harding
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, OR, USA
| | | | - Nicola Longo
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Markey C McNutt
- McDermott Center for Human Growth and Development, UT Southwestern Medical Center, Dallas, TX, USA
| | - Mina D Nguyen-Driver
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, OR, USA
| | - André L Santos Pessoa
- Pediatric Neurology Service, Albert Sabin Children's Hospital, University of Ceará State, Fortaleza, Ceará, Brazil
| | - Júlio César Rocha
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Portugal; Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia; Melbourne Neuropsychiatry Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Stephanie Sacharow
- CINTESIS-Center for Health Technology and Services Research, NOVA Medical School, Lisboa, Portugal; Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
| | - Amarilis Sanchez-Valle
- Reference Centre of Inherited Metabolic Diseases, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - H Serap Sivri
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA
| | - Jerry Vockley
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Mark Walterfang
- Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL, USA; Melbourne Neuropsychiatry Centre, Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia; University Children's Hospital, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Sarah Whittle
- Hacettepe University, Faculty of Medicine, Department of Pediatrics, Section of Pediatric Metabolism, Ankara, Turkey
| | - Ania C Muntau
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
19
|
Biasucci G, Brodosi L, Bettocchi I, Noto D, Pochiero F, Urban ML, Burlina A. The management of transitional care of patients affected by phenylketonuria in Italy: Review and expert opinion. Mol Genet Metab 2022; 136:94-100. [PMID: 35589496 DOI: 10.1016/j.ymgme.2022.04.004] [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: 02/15/2022] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 12/24/2022]
Abstract
Phenylketonuria (PKU) is a metabolic inherited disorder in which transition from infancy to adult care is particularly difficult and not sufficiently regulated. According to the scientific literature, only few medical centers offer healthcare assistance for adult patients with PKU that are therefore still treated in pediatric settings. This generates psychological, emotional, and organizational discomfort among patients, leading them to discontinue the follow-up. European guidelines and national consensus documents underline this unmet need and the lack of practical recommendations for a structured transitional pathway in PKU. The aim of this review and expert opinion is to propose good practices for managing the transition period of PKU patients, based on the literature and the experience of a panel of Italian experts in PKU. The consensus of the experts was obtained through the administration of three rounds of surveys and one structured interview. The result is the first proposal of a pathway for an efficient transition of PKU patients. Key steps of the proposed pathway are the "a priori" planning involving the pediatric and adult teams, the acceptance of the patient and his/her family to the process, the preliminary definition of appropriate spaces in the structure, the organization of meetings with the joint team, and the appointment of a transition coordinator. For the first time, the involvement of decision makers and patient associations is proposed.
Collapse
Affiliation(s)
- Giacomo Biasucci
- Department of Paediatrics & Neonatology, Guglielmo da Saliceto Hospital, Via Taverna Giuseppe, 49, 29121 Piacenza, Italy
| | - Lucia Brodosi
- Department of Medical and Surgical Sciences, "Alma Mater" University, Sant'Orsola-Malpighi Hospital, Bologna, Italy.
| | - Ilaria Bettocchi
- Pediatric Unit, Department of Medical and Surgical Sciences, Regional Centre for Expanded Newborn Screening, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Davide Noto
- Unit of Internal Medicine and Genetic Dyslipidemia, Azienda Ospedaliera Universitaria Policlinico "Paolo Giaccone" (University Hospital), Palermo, Italy
| | - Francesca Pochiero
- Metabolic and Muscular Unit, Neuroscience Department, Meyer Children's Hospital, Florence, Italy
| | - Maria Letizia Urban
- Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Alberto Burlina
- Division of Inborn Metabolic Diseases, Department of Diagnostic Services, University Hospital of Padua, Via Orus 2B, 35129 Padua, Italy
| |
Collapse
|
20
|
Abgottspon S, Muri R, Christ SE, Hochuli M, Radojewski P, Trepp R, Everts R. Neural correlates of working memory and its association with metabolic parameters in early-treated adults with phenylketonuria. Neuroimage Clin 2022; 34:102974. [PMID: 35248901 PMCID: PMC8897706 DOI: 10.1016/j.nicl.2022.102974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/22/2022] [Accepted: 02/25/2022] [Indexed: 11/18/2022]
Abstract
Working memory (WM) accuracy was significantly reduced in the PKU group. Reaction time did not differ between individuals with PKU and controls. No group differences were found with regard to neural activation. Neural activation was related to concurrent metabolic parameters. Results suggest interrelations between neural, cognitive, and metabolic parameters.
Background Phenylketonuria (PKU) is an inborn error of metabolism affecting the conversion of phenylalanine (Phe) into tyrosine. Previous research has found cognitive and functional brain alterations in individuals with PKU even if treated early. However, little is known about working memory processing and its association with task performance and metabolic parameters. The aim of the present study was to examine neural correlates of working memory and its association with metabolic parameters in early-treated adults with PKU. Methods This cross-sectional study included 20 early-treated adults with PKU (mean age: 31.4 years ± 9.0) and 40 healthy controls with comparable age, sex, and education (mean age: 29.8 years ± 8.2). All participants underwent functional magnetic resonance imaging (fMRI) of working memory to evaluate the fronto-parietal working memory network. Fasting blood samples were collected from the individuals with PKU to acquire a concurrent plasma amino acid profile, and retrospective Phe concentrations were obtained to estimate an index of dietary control. Results On a cognitive level, early-treated adults with PKU displayed significantly lower accuracy but comparable reaction time in the working memory task compared to the control group. Whole-brain analyses did not reveal differences in working memory-related neural activation between the groups. Exploratory region-of-interest (ROI) analyses indicated reduced neural activation in the left and right middle frontal gyri and the right superior frontal gyrus in the PKU group compared to the control group. However, none of the ROI analyses survived correction for multiple comparisons. Neural activation was related to concurrent Phe, tyrosine, and tryptophan concentrations but not to retrospective Phe concentrations. Conclusion In early-treated adults with PKU, cognitive performance and neural activation are slightly altered, a result that is partly related to metabolic parameters. This study offers a rare insight into the complex interplay between metabolic parameters, neural activation, and cognitive performance in a sample of individuals with PKU.
Collapse
Affiliation(s)
- Stephanie Abgottspon
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Switzerland; Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, Bern, Switzerland
| | - Raphaela Muri
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Switzerland; Support Center for Advanced Neuroimaging (SCAN), Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Switzerland; Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, Bern, Switzerland
| | - Shawn E Christ
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Michel Hochuli
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Switzerland
| | - Piotr Radojewski
- Support Center for Advanced Neuroimaging (SCAN), Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Switzerland; Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, Bern, Switzerland
| | - Roman Trepp
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Switzerland; Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, Bern, Switzerland
| | - Regula Everts
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Switzerland; Division of Neuropaediatrics, Development and Rehabilitation, Inselspital Bern, Children's University Hospital, Bern, Switzerland; Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, Bern, Switzerland.
| |
Collapse
|
21
|
Leuzzi V, Nardecchia F. Looking back at the neonatal period in early-treated phenylketonuric patients. Pediatr Res 2022; 91:730-732. [PMID: 35058603 DOI: 10.1038/s41390-022-01937-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 10/16/2021] [Accepted: 12/20/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Vincenzo Leuzzi
- Unit of Child Neurology and Psychiatry, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy.
| | - Francesca Nardecchia
- Unit of Child Neurology and Psychiatry, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
22
|
Robertson L, Adam S, Ellerton C, Ford S, Hill M, Randles G, Woodall A, Young C, MacDonald A. Dietetic Management of Adults with Phenylketonuria (PKU) in the UK: A Care Consensus Document. Nutrients 2022; 14:nu14030576. [PMID: 35276935 PMCID: PMC8838652 DOI: 10.3390/nu14030576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/14/2022] [Accepted: 01/21/2022] [Indexed: 02/05/2023] Open
Abstract
There is an increasing number of adults and elderly patients with phenylketonuria (PKU) who are either early, late treated, or untreated. The principal treatment is a phenylalanine-restricted diet. There is no established UK training for dietitians who work with adults within the specialty of Inherited Metabolic Disorders (IMDs), including PKU. To address this, a group of experienced dietitians specializing in IMDs created a standard operating procedure (SOP) on the dietetic management of adults with PKU to promote equity of care in IMD dietetic services and to support service provision across the UK. The group met virtually over a period of 12 months until they reached 100% consensus on the SOP content. Areas of limited evidence included optimal blood phenylalanine reporting times to patients, protein requirements in older adults, management of weight and obesity, and management of disordered eating and eating disorders. The SOP does not include guidance on maternal PKU management. The SOP can be used as a tool for training dietitians new to the specialty and to raise the standard of education and care for patients with PKU in the UK.
Collapse
Affiliation(s)
- Louise Robertson
- Department of Inherited Metabolic Disorders, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2TH, UK
- Correspondence: ; Tel.: +44-121-3716989
| | - Sarah Adam
- NHS Greater Glasgow and Clyde, Royal Hospital for Children, Glasgow G51 4TF, UK; (S.A.); (C.Y.)
| | - Charlotte Ellerton
- Charles Dent Metabolic Unit, University College London Hospitals NHS Foundation Trust, National Hospital for Neurology & Neurosurgery, Queen Square, London WC1N 3BG, UK;
| | - Suzanne Ford
- North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, UK;
- National Society for Phenylketonuria, Richard House, Winckley Square, Preston PR1 3HP, UK
| | - Melanie Hill
- Adult Inherited Metabolic Disorders Service at Sheffield Teaching Hospitals NHS Foundation Trust, Herries Road, Sheffield S5 7AU, UK;
| | - Gemma Randles
- Guys and St Thomas NHS Foundation Trust, London SE1 7EU, UK;
| | - Alison Woodall
- Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford M6 8HD, UK;
| | - Carla Young
- NHS Greater Glasgow and Clyde, Royal Hospital for Children, Glasgow G51 4TF, UK; (S.A.); (C.Y.)
| | - Anita MacDonald
- Birmingham Women’s and Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK;
| |
Collapse
|
23
|
Cannon Homaei S, Barone H, Kleppe R, Betari N, Reif A, Haavik J. ADHD symptoms in neurometabolic diseases: Underlying mechanisms and clinical implications. Neurosci Biobehav Rev 2021; 132:838-856. [PMID: 34774900 DOI: 10.1016/j.neubiorev.2021.11.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/09/2021] [Accepted: 11/09/2021] [Indexed: 12/16/2022]
Abstract
Neurometabolic diseases (NMDs) are typically caused by genetic abnormalities affecting enzyme functions, which in turn interfere with normal development and activity of the nervous system. Although the individual disorders are rare, NMDs are collectively relatively common and often lead to lifelong difficulties and high societal costs. Neuropsychiatric manifestations, including ADHD symptoms, are prominent in many NMDs, also when the primary biochemical defect originates in cells and tissues outside the nervous system. ADHD symptoms have been described in phenylketonuria, tyrosinemias, alkaptonuria, succinic semialdehyde dehydrogenase deficiency, X-linked ichthyosis, maple syrup urine disease, and several mitochondrial disorders, but are probably present in many other NMDs and may pose diagnostic and therapeutic challenges. Here we review current literature linking NMDs with ADHD symptoms. We cite emerging evidence that many NMDs converge on common neurochemical mechanisms that interfere with monoamine neurotransmitter synthesis, transport, metabolism, or receptor functions, mechanisms that are also considered central in ADHD pathophysiology and treatment. Finally, we discuss the therapeutic implications of these findings and propose a path forward to increase our understanding of these relationships.
Collapse
Affiliation(s)
- Selina Cannon Homaei
- Division of Psychiatry, Haukeland University Hospital, Norway; Department of Biomedicine, University of Bergen, Norway.
| | - Helene Barone
- Regional Resource Center for Autism, ADHD, Tourette Syndrome and Narcolepsy, Western Norway, Division of Psychiatry, Haukeland University Hospital, Norway.
| | - Rune Kleppe
- Division of Psychiatry, Haukeland University Hospital, Norway; Norwegian Centre for Maritime and Diving Medicine, Department of Occupational Medicine, Haukeland University Hospital, Norway.
| | - Nibal Betari
- Department of Biomedicine, University of Bergen, Norway.
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Frankfurt am Main, Germany.
| | - Jan Haavik
- Division of Psychiatry, Haukeland University Hospital, Norway; Department of Biomedicine, University of Bergen, Norway.
| |
Collapse
|