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Zhou W, Li H, Song J, Suo F, Gu M, Qi S. Healthy Plasma Exosomes Exert Potential Neuroprotective Effects against Methylmalonic Acid-Induced Hippocampal Neuron Injury. ACS Chem Neurosci 2024. [PMID: 39026168 DOI: 10.1021/acschemneuro.4c00224] [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: 07/20/2024] Open
Abstract
Exosomes have shown good potential for alleviating neurological deficits and delaying memory deterioration, but the neuroprotective effects of exosomes remain unknown. Methylmalonic acidemia is a metabolic disorder characterized by the accumulation of methylmalonic acid (MMA) in various tissues that inhibits neuronal survival and function, leading to accelerated neurological deterioration. Effective therapies to mitigate these symptoms are lacking. The purpose of this study was to explore the neuroprotective effects of plasma exosomes on cells and a mouse model of MMA-induced injury. We evaluated the ability of plasma exosomes to reduce the neuronal apoptosis, cross the blood-brain barrier, and affect various parameters related to neuronal function. MMA promoted cell apoptosis, disrupted the metabolic balance, and altered the expression of B-cell lymphoma-2 (Bcl-2), Bcl2-associated X (Bax), and synaptophysin-1 (Syp-1), and these changes may be involved in MMA-induced neuronal apoptosis. Additionally, plasma exosomes normalized learning and memory and protected against MMA-induced neuronal apoptosis. Our findings indicate that neurological deficits are linked to the pathogenesis of methylmalonic acidemia, and healthy plasma exosomes may exert neuroprotective and therapeutic effects by altering the expression of exosomal microRNAs, facilitating neuronal functional recovery in the context of this inherited metabolic disease. Intravenous plasma-derived exosome treatment may be a novel clinical therapeutic strategy for methylmalonic acidemia.
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Affiliation(s)
- Wei Zhou
- Research Center for Biochemistry and Molecular Biology and Jiangsu Key Laboratory of Brain Disease Bioinformation, Xuzhou Medical University, Xuzhou 221004, P.R China
- Newborn Screening Center, The Affiliated Xuzhou Maternity and Child Health Care Hospital of Xuzhou Medical University, Xuzhou 221009, P.R China
| | - Huizhong Li
- Newborn Screening Center, The Affiliated Xuzhou Maternity and Child Health Care Hospital of Xuzhou Medical University, Xuzhou 221009, P.R China
| | - Jinxiu Song
- Pharmacology College, Xuzhou Medical University, Xuzhou 221004, P.R China
| | - Feng Suo
- Newborn Screening Center, The Affiliated Xuzhou Maternity and Child Health Care Hospital of Xuzhou Medical University, Xuzhou 221009, P.R China
| | - Maosheng Gu
- Newborn Screening Center, The Affiliated Xuzhou Maternity and Child Health Care Hospital of Xuzhou Medical University, Xuzhou 221009, P.R China
| | - Suhua Qi
- Research Center for Biochemistry and Molecular Biology and Jiangsu Key Laboratory of Brain Disease Bioinformation, Xuzhou Medical University, Xuzhou 221004, P.R China
- Pharmacology College, Xuzhou Medical University, Xuzhou 221004, P.R China
- Medical and Technology School, Xuzhou Medical University, Xuzhou 221004, P.R China
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2
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Burlina AB, Burlina AP, Mignani R, Cazzorla C, Gueraldi D, Puma A, Loro C, Baumgartner MR, Gragnaniello V. Non-Hodgkin lymphoma in a kidney transplanted patient with methylmalonic acidemia: Metabolic susceptibility and the role of immunosuppression. JIMD Rep 2024; 65:56-62. [PMID: 38444575 PMCID: PMC10910225 DOI: 10.1002/jmd2.12411] [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: 10/30/2023] [Revised: 12/15/2023] [Accepted: 12/28/2023] [Indexed: 03/07/2024] Open
Abstract
Methylmalonic acidemia cblB type (MMA cblB) is an autosomal recessive inborn error of amino acid metabolism that results in impaired synthesis of adenosylcobalamin, a cofactor of methylmalonyl-CoA mutase. It presents with episodes of coma, vomiting, hypotonia, metabolic acidosis, and hyperammonemia. End-stage kidney disease is a long-term complication. Treatments include vitamin B12 supplementation, L-carnitine, and a low-protein diet. Liver, kidney, or combined liver-kidney transplantations are promising options, but they are not without complications. We report a patient suffering from MMA cblB who developed end-stage kidney disease at 18 years of age. Kidney transplantation allowed him to recover normal kidney function and good metabolic control. Unfortunately, after two decades, he developed non-Hodgkin lymphoma and severe chemotherapy toxicity which led to his death. The risk of lymphoproliferative diseases is known to increase after solid organ transplantation. However, in MMA, factors including mitochondrial dysfunction and oncometabolites, may further increase the risk of malignancy and drug toxicity. Our report highlights the importance of considering the increased risk of cancer in long-term follow-up of MMA cblB patients, especially after solid organ transplantation. Moreover, when chemotherapy is needed, the increased risk of toxicity and metabolic decompensation should be considered and monitored.
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Affiliation(s)
- Alberto B. Burlina
- Division of Inherited Metabolic Diseases, Department of Women's and Children's HealthUniversity Hospital of PaduaPaduaItaly
- Division of Inherited Metabolic Diseases, Department of Women's and Children's HealthUniversity of PaduaPaduaItaly
| | | | - Renzo Mignani
- Nephrology and Dialysis DepartmentInfermi HospitalRiminiItaly
| | - Chiara Cazzorla
- Division of Inherited Metabolic Diseases, Department of Women's and Children's HealthUniversity Hospital of PaduaPaduaItaly
| | - Daniela Gueraldi
- Division of Inherited Metabolic Diseases, Department of Women's and Children's HealthUniversity Hospital of PaduaPaduaItaly
| | - Andrea Puma
- Division of Inherited Metabolic Diseases, Department of Women's and Children's HealthUniversity Hospital of PaduaPaduaItaly
| | - Christian Loro
- Division of Inherited Metabolic Diseases, Department of Women's and Children's HealthUniversity Hospital of PaduaPaduaItaly
| | - Matthias R. Baumgartner
- Division of Metabolism and Children's Research CenterUniversity Children's Hospital Zurich, University of ZurichZurichSwitzerland
| | - Vincenza Gragnaniello
- Division of Inherited Metabolic Diseases, Department of Women's and Children's HealthUniversity Hospital of PaduaPaduaItaly
- Division of Inherited Metabolic Diseases, Department of Women's and Children's HealthUniversity of PaduaPaduaItaly
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Martinelli D, Catesini G, Greco B, Guarnera A, Parrillo C, Maines E, Longo D, Napolitano A, De Nictolis F, Cairoli S, Liccardo D, Caviglia S, Sidorina A, Olivieri G, Siri B, Bianchi R, Spagnoletti G, Dello Strologo L, Spada M, Dionisi-Vici C. Neurologic outcome following liver transplantation for methylmalonic aciduria. J Inherit Metab Dis 2023; 46:450-465. [PMID: 36861405 DOI: 10.1002/jimd.12599] [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: 11/28/2022] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023]
Abstract
Liver and liver/kidney transplantation are increasingly used in methylmalonic aciduria, but little is known on their impact on CNS. The effect of transplantation on neurological outcome was prospectively assessed in six patients pre- and post-transplant by clinical evaluation and by measuring disease biomarkers in plasma and CSF, in combination with psychometric tests and brain MRI studies. Primary (methylmalonic- and methylcitric acid) and secondary biomarkers (glycine and glutamine) significantly improved in plasma, while they remained unchanged in CSF. Differently, biomarkers of mitochondrial dysfunction (lactate, alanine, and related ratios) significantly decreased in CSF. Neurocognitive evaluation documented significant higher post-transplant developmental/cognitive scores and maturation of executive functions corresponding to improvement of brain atrophy, cortical thickness, and white matter maturation indexes at MRI. Three patients presented post-transplantation reversible neurological events, which were differentiated, by means of biochemical and neuroradiological evaluations, into calcineurin inhibitor-induced neurotoxicity and metabolic stroke-like episode. Our study shows that transplantation has a beneficial impact on neurological outcome in methylmalonic aciduria. Early transplantation is recommended due to the high risk of long-term complications, high disease burden, and low quality of life.
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Affiliation(s)
- Diego Martinelli
- Division of Metabolism, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital, Rome, Italy
| | - Giulio Catesini
- Division of Metabolism, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital, Rome, Italy
| | - Benedetta Greco
- Division of Metabolism, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital, Rome, Italy
- Clinical Psychology Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessia Guarnera
- Neuroradiology Unit, Imaging Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Chiara Parrillo
- Medical Physics Unit, Risk Management Enterprise, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Evelina Maines
- Division of Metabolism, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital, Rome, Italy
- Pediatric Department, S.Chiara Hospital of Trento, Trento, Italy
| | - Daniela Longo
- Neuroradiology Unit, Imaging Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Antonio Napolitano
- Medical Physics Unit, Risk Management Enterprise, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesca De Nictolis
- Division of Metabolism, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital, Rome, Italy
| | - Sara Cairoli
- Division of Metabolism, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital, Rome, Italy
| | - Daniela Liccardo
- Division of Hepatology, Gastroenterology and Nutrition, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Stefania Caviglia
- Clinical Psychology Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Anna Sidorina
- Division of Metabolism, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital, Rome, Italy
| | - Giorgia Olivieri
- Division of Metabolism, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital, Rome, Italy
| | - Barbara Siri
- Division of Metabolism, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital, Rome, Italy
| | - Roberto Bianchi
- Department of Anesthesiology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Gionata Spagnoletti
- Unit of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Luca Dello Strologo
- Renal Transplant Unit, Bambino Gesù, Children's Hospital, IRCCS, Rome, Italy
| | - Marco Spada
- Unit of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolism, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital, Rome, Italy
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Sen K, Burrage LC, Chapman KA, Ginevic I, Mazariegos GV, Graham BH. Solid organ transplantation in methylmalonic acidemia and propionic acidemia: A points to consider statement of the American College of Medical Genetics and Genomics (ACMG). Genet Med 2023; 25:100337. [PMID: 36534118 DOI: 10.1016/j.gim.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Kuntal Sen
- Division of Neurogenetics and Neurodevelopmental Pediatrics, Center for Neuroscience and Behavioral Medicine, Children's National Hospital, Washington, DC
| | - Lindsay C Burrage
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX; Texas Children's Hospital, Houston, TX
| | - Kimberly A Chapman
- Rare Disease Institute, Children's National Hospital, Washington, DC; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Ilona Ginevic
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Brett H Graham
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
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- American College of Medical Genetics and Genomics, Bethesda, MD
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Waisbren SE. Review of neuropsychological outcomes in isolated methylmalonic acidemia: recommendations for assessing impact of treatments. Metab Brain Dis 2022; 37:1317-1335. [PMID: 35348993 DOI: 10.1007/s11011-022-00954-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 03/09/2022] [Indexed: 11/29/2022]
Abstract
Methylmalonic acidemia (MMA) due to methylmalonyl-CoA mutase deficiency (OMIM #251,000) is an autosomal recessive disorder of organic acid metabolism associated with life-threatening acute metabolic decompensations and significant neuropsychological deficits. "Isolated" MMA refers to the presence of excess methylmalonic acid without homocysteine elevation. Belonging to this class of disorders are those that involve complete deficiency (mut0) and partial deficiency (mut-) of the methylmalonyl-CoA mutase enzyme and other disorders causing excess methylmalonic acid excretion. These other disorders include enzymatic subtypes related to cobalamin A defect (cblA) (OMIM #25,110), cobalamin B defect (cblB) (OMIM #251,110) and related conditions. Neuropsychological attributes associated with isolated MMA have become more relevant as survival rates increased following improved diagnostic and treatment strategies. Children with this disorder still are at risk for developmental delay, cognitive difficulties and progressive declines in functioning. Mean IQ for all types apart from cblA defect enzymatic subtype is rarely above 85 and much lower for mut0 enzymatic subtype. Identifying psychological domains responsive to improvements in biochemical status is important. This review suggests that processing speed, working memory, language, attention, and quality of life may be sensitive to fluctuations in metabolite levels while IQ and motor skills may be less amenable to change. Due to slower developmental trajectories, Growth Scale Values, Projected Retained Ability Scores and other indices of change need to be incorporated into clinical trial study protocols. Neuropsychologists are uniquely qualified to provide a differentiated picture of cognitive, behavioral and emotional consequences of MMA and analyze benefits or shortcomings of novel treatments.
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Affiliation(s)
- Susan E Waisbren
- Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
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Vimalesvaran S, Dhawan A. Liver transplantation for pediatric inherited metabolic liver diseases. World J Hepatol 2021; 13:1351-1366. [PMID: 34786171 PMCID: PMC8568579 DOI: 10.4254/wjh.v13.i10.1351] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/23/2021] [Accepted: 08/20/2021] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) remains the gold standard treatment for end stage liver disease in the pediatric population. For liver based metabolic disorders (LBMDs), the decision for LT is predicated on a different set of paradigms. With improved outcomes post-transplantation, LT is no longer merely life saving, but has the potential to also significantly improve quality of life. This review summarizes the clinical presentation, medical treatment and indications for LT for some of the common LBMDs. We also provide a practical update on the dilemmas and controversies surrounding the indications for transplantation, surgical considerations and prognosis and long terms outcomes for pediatric LT in LBMDs. Important progress has been made in understanding these diseases in recent years and with that we outline some of the new therapies that have emerged.
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Affiliation(s)
- Sunitha Vimalesvaran
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London SE5 9RS, United Kingdom
| | - Anil Dhawan
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London SE5 9RS, United Kingdom
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7
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Forny P, Hörster F, Ballhausen D, Chakrapani A, Chapman KA, Dionisi‐Vici C, Dixon M, Grünert SC, Grunewald S, Haliloglu G, Hochuli M, Honzik T, Karall D, Martinelli D, Molema F, Sass JO, Scholl‐Bürgi S, Tal G, Williams M, Huemer M, Baumgartner MR. Guidelines for the diagnosis and management of methylmalonic acidaemia and propionic acidaemia: First revision. J Inherit Metab Dis 2021; 44:566-592. [PMID: 33595124 PMCID: PMC8252715 DOI: 10.1002/jimd.12370] [Citation(s) in RCA: 109] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 02/03/2021] [Accepted: 02/15/2021] [Indexed: 12/13/2022]
Abstract
Isolated methylmalonic acidaemia (MMA) and propionic acidaemia (PA) are rare inherited metabolic diseases. Six years ago, a detailed evaluation of the available evidence on diagnosis and management of these disorders has been published for the first time. The article received considerable attention, illustrating the importance of an expert panel to evaluate and compile recommendations to guide rare disease patient care. Since that time, a growing body of evidence on transplant outcomes in MMA and PA patients and use of precursor free amino acid mixtures allows for updates of the guidelines. In this article, we aim to incorporate this newly published knowledge and provide a revised version of the guidelines. The analysis was performed by a panel of multidisciplinary health care experts, who followed an updated guideline development methodology (GRADE). Hence, the full body of evidence up until autumn 2019 was re-evaluated, analysed and graded. As a result, 21 updated recommendations were compiled in a more concise paper with a focus on the existing evidence to enable well-informed decisions in the context of MMA and PA patient care.
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Affiliation(s)
- Patrick Forny
- Division of Metabolism and Children's Research CenterUniversity Children's Hospital Zurich, University of ZurichZurichSwitzerland
| | - Friederike Hörster
- Division of Neuropediatrics and Metabolic MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Diana Ballhausen
- Paediatric Unit for Metabolic Diseases, Department of Woman‐Mother‐ChildUniversity Hospital LausanneLausanneSwitzerland
| | - Anupam Chakrapani
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust and Institute for Child HealthNIHR Biomedical Research Center (BRC), University College LondonLondonUK
| | - Kimberly A. Chapman
- Rare Disease Institute, Children's National Health SystemWashingtonDistrict of ColumbiaUSA
| | - Carlo Dionisi‐Vici
- Division of Metabolism, Department of Pediatric SpecialtiesBambino Gesù Children's HospitalRomeItaly
| | - Marjorie Dixon
- Dietetics, Great Ormond Street Hospital for Children NHS Foundation TrustLondonUK
| | - Sarah C. Grünert
- Department of General Paediatrics, Adolescent Medicine and Neonatology, Medical Centre‐University of FreiburgFaculty of MedicineFreiburgGermany
| | - Stephanie Grunewald
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust and Institute for Child HealthNIHR Biomedical Research Center (BRC), University College LondonLondonUK
| | - Goknur Haliloglu
- Department of Pediatrics, Division of Pediatric NeurologyHacettepe University Children's HospitalAnkaraTurkey
| | - Michel Hochuli
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, InselspitalBern University Hospital and University of BernBernSwitzerland
| | - Tomas Honzik
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of MedicineCharles University and General University Hospital in PraguePragueCzech Republic
| | - Daniela Karall
- Department of Paediatrics I, Inherited Metabolic DisordersMedical University of InnsbruckInnsbruckAustria
| | - Diego Martinelli
- Division of Metabolism, Department of Pediatric SpecialtiesBambino Gesù Children's HospitalRomeItaly
| | - Femke Molema
- Department of Pediatrics, Center for Lysosomal and Metabolic DiseasesErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Jörn Oliver Sass
- Department of Natural Sciences & Institute for Functional Gene Analytics (IFGA)Bonn‐Rhein Sieg University of Applied SciencesRheinbachGermany
| | - Sabine Scholl‐Bürgi
- Department of Paediatrics I, Inherited Metabolic DisordersMedical University of InnsbruckInnsbruckAustria
| | - Galit Tal
- Metabolic Unit, Ruth Rappaport Children's HospitalRambam Health Care CampusHaifaIsrael
| | - Monique Williams
- Department of Pediatrics, Center for Lysosomal and Metabolic DiseasesErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Martina Huemer
- Division of Metabolism and Children's Research CenterUniversity Children's Hospital Zurich, University of ZurichZurichSwitzerland
- Department of PaediatricsLandeskrankenhaus BregenzBregenzAustria
| | - Matthias R. Baumgartner
- Division of Metabolism and Children's Research CenterUniversity Children's Hospital Zurich, University of ZurichZurichSwitzerland
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Molema F, Martinelli D, Hörster F, Kölker S, Tangeraas T, de Koning B, Dionisi‐Vici C, Williams M. Liver and/or kidney transplantation in amino and organic acid-related inborn errors of metabolism: An overview on European data. J Inherit Metab Dis 2021; 44:593-605. [PMID: 32996606 PMCID: PMC8247334 DOI: 10.1002/jimd.12318] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/29/2020] [Accepted: 09/25/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND This study provides a general overview on liver and/or kidney transplantation in patients with an amino and organic acid-related disorder (AOA) with the aim to investigate patient characteristics and global outcome in Europe. This study was an initiative of the E-IMD and the AOA subnetwork of MetabERN. METHODS A questionnaire was sent to all clinically active European Society for the Study of Inborn Errors of Metabolism (SSIEM) members. The questionnaire focused on transplanted individuals with methylmalonic acidemia (MMA), propionic acidemia (PA), maple syrup urine disease (MSUD), and urea-cycle disorders (UCDs). RESULTS We identified 280 transplanted AOA patients (liver transplantation in 20 MMA, 37 PA, 47 MSUD, and 111 UCD patients, kidney or combined liver and kidney transplantation in 57 MMA patients and undefined transplantation type in 8 MMA patients), followed by 51 metabolic centers. At a median follow-up of 3.5 years, posttransplant survival ranged between 78% and 100%, being the lowest in PA patients. Overall, the risk of mortality was highest within 14 days posttransplantation. Neurological complications were mainly reported in Mut0 type MMA (n = 8). Nonneurological complications occurred in MMA (n = 28), PA (n = 7), and UCD (n = 14) patients, while it was virtually absent in MSUD patients. Only 116/280 patients were psychologically tested. In all, except MSUD patients, the intelligence quotient (IQ) remained unchanged in the majority (76/94, 81%). Forty-one percentage (9/22) of MSUD patient showed improved IQ. CONCLUSION The survival in AOA individuals receiving liver and/or kidney transplantation seems satisfactory. Evidence-based guidelines, systematic data collection, and improved cooperation between transplantation centers and European Reference Networks are indispensable to improve patient care and outcomes.
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Affiliation(s)
- Femke Molema
- Department of Pediatrics, Center for Lysosomal and Metabolic DiseasesErasmus MC University Medical Center, AOA subgroup MetabERNRotterdamThe Netherlands
- Subnetwork for Amino and Organic Acid‐Related Disorders (AOA)European Reference Network for Hereditary Metabolic Disorders (MetabERN)UdineItaly
| | - Diego Martinelli
- Subnetwork for Amino and Organic Acid‐Related Disorders (AOA)European Reference Network for Hereditary Metabolic Disorders (MetabERN)UdineItaly
- U.O.C. Patologia MetabolicaOspedale Pediatrico Bambino Gesù, AOA Subgroup MetabERNRomeItaly
| | - Friederike Hörster
- Subnetwork for Amino and Organic Acid‐Related Disorders (AOA)European Reference Network for Hereditary Metabolic Disorders (MetabERN)UdineItaly
- Centre for Child and Adolescent Medicine, Division of Neuropaediatrics and Metabolic MedicineUniversity Hospital Heidelberg, AOA Subgroup MetabERNHeidelbergGermany
| | - Stefan Kölker
- Subnetwork for Amino and Organic Acid‐Related Disorders (AOA)European Reference Network for Hereditary Metabolic Disorders (MetabERN)UdineItaly
- Centre for Child and Adolescent Medicine, Division of Neuropaediatrics and Metabolic MedicineUniversity Hospital Heidelberg, AOA Subgroup MetabERNHeidelbergGermany
| | - Trine Tangeraas
- Subnetwork for Amino and Organic Acid‐Related Disorders (AOA)European Reference Network for Hereditary Metabolic Disorders (MetabERN)UdineItaly
- Department of Paediatric and Adolescent Medicine, AOA subgroup MetabERNOslo University Hospital RikshospitaletOsloNorway
| | - Barbara de Koning
- Department of Paediatric Gastro‐EnterologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Carlo Dionisi‐Vici
- Subnetwork for Amino and Organic Acid‐Related Disorders (AOA)European Reference Network for Hereditary Metabolic Disorders (MetabERN)UdineItaly
- U.O.C. Patologia MetabolicaOspedale Pediatrico Bambino Gesù, AOA Subgroup MetabERNRomeItaly
| | - Monique Williams
- Department of Pediatrics, Center for Lysosomal and Metabolic DiseasesErasmus MC University Medical Center, AOA subgroup MetabERNRotterdamThe Netherlands
- Subnetwork for Amino and Organic Acid‐Related Disorders (AOA)European Reference Network for Hereditary Metabolic Disorders (MetabERN)UdineItaly
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1- 13C-propionate breath testing as a surrogate endpoint to assess efficacy of liver-directed therapies in methylmalonic acidemia (MMA). Genet Med 2021; 23:1522-1533. [PMID: 33820958 PMCID: PMC8354855 DOI: 10.1038/s41436-021-01143-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To develop a safe and noninvasive in vivo assay of hepatic propionate oxidative capacity. METHODS A modified 1-13C-propionate breath test was administered to 57 methylmalonic acidemia (MMA) subjects, including 19 transplant recipients, and 16 healthy volunteers. Isotopomer enrichment (13CO2/12CO2) was measured in exhaled breath after an enteral bolus of sodium-1-13C-propionate, and normalized for CO2 production. 1-13C-propionate oxidation was then correlated with clinical, laboratory, and imaging parameters collected via a dedicated natural history protocol. RESULTS Lower propionate oxidation was observed in patients with the severe mut0 and cblB subtypes of MMA, but was near normal in those with the cblA and mut- forms of the disorder. Liver transplant recipients demonstrated complete restoration of 1-13C-propionate oxidation to control levels. 1-13C-propionate oxidation correlated with cognitive test result, growth indices, bone mineral density, renal function, and serum biomarkers. Test repeatability was robust in controls and in MMA subjects (mean coefficient of variation 6.9% and 12.8%, respectively), despite widely variable serum methylmalonic acid concentrations in the patients. CONCLUSION Propionate oxidative capacity, as measured with 1-13C-propionate breath testing, predicts disease severity and clinical outcomes, and could be used to assess the therapeutic effects of liver-targeted genomic therapies for MMA and related disorders of propionate metabolism. TRIAL REGISTRATION This clinical study is registered in www.clinicaltrials.gov with the ID: NCT00078078. Study URL: http://clinicaltrials.gov/ct2/show/NCT00078078.
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Dimitrov B, Molema F, Williams M, Schmiesing J, Mühlhausen C, Baumgartner MR, Schumann A, Kölker S. Organic acidurias: Major gaps, new challenges, and a yet unfulfilled promise. J Inherit Metab Dis 2021; 44:9-21. [PMID: 32412122 DOI: 10.1002/jimd.12254] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/29/2020] [Accepted: 05/12/2020] [Indexed: 12/12/2022]
Abstract
Organic acidurias (OADs) comprise a biochemically defined group of inherited metabolic diseases. Increasing awareness, reliable diagnostic work-up, newborn screening programs for some OADs, optimized neonatal and intensive care, and the development of evidence-based recommendations have improved neonatal survival and short-term outcome of affected individuals. However, chronic progression of organ dysfunction in an aging patient population cannot be reliably prevented with traditional therapeutic measures. Evidence is increasing that disease progression might be best explained by mitochondrial dysfunction. Previous studies have demonstrated that some toxic metabolites target mitochondrial proteins inducing synergistic bioenergetic impairment. Although these potentially reversible mechanisms help to understand the development of acute metabolic decompensations during catabolic state, they currently cannot completely explain disease progression with age. Recent studies identified unbalanced autophagy as a novel mechanism in the renal pathology of methylmalonic aciduria, resulting in impaired quality control of organelles, mitochondrial aging and, subsequently, progressive organ dysfunction. In addition, the discovery of post-translational short-chain lysine acylation of histones and mitochondrial enzymes helps to understand how intracellular key metabolites modulate gene expression and enzyme function. While acylation is considered an important mechanism for metabolic adaptation, the chronic accumulation of potential substrates of short-chain lysine acylation in inherited metabolic diseases might exert the opposite effect, in the long run. Recently, changed glutarylation patterns of mitochondrial proteins have been demonstrated in glutaric aciduria type 1. These new insights might bridge the gap between natural history and pathophysiology in OADs, and their exploitation for the development of targeted therapies seems promising.
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Affiliation(s)
- Bianca Dimitrov
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Femke Molema
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Monique Williams
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jessica Schmiesing
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Chris Mühlhausen
- Department of Pediatrics and Adolescent Medicine, University Medical Centre Göttingen, Göttingen, Germany
| | - Matthias R Baumgartner
- Division of Metabolism and Children's Research Center, University Children's Hospital, Zurich, Switzerland
| | - Anke Schumann
- Department of General Pediatrics, Center for Pediatrics and Adolescent Medicine, University Hospital of Freiburg, Freiburg, Germany
| | - Stefan Kölker
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Knotek M, Novak R, Jaklin-Kekez A, Mrzljak A. Combined liver-kidney transplantation for rare diseases. World J Hepatol 2020; 12:722-737. [PMID: 33200012 PMCID: PMC7643210 DOI: 10.4254/wjh.v12.i10.722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/30/2020] [Accepted: 09/18/2020] [Indexed: 02/06/2023] Open
Abstract
Combined liver and kidney transplantation (CLKT) is indicated in patients with failure of both organs, or for the treatment of end-stage chronic kidney disease (ESKD) caused by a genetic defect in the liver. The aim of the present review is to provide the most up-to-date overview of the rare conditions as indications for CLKT. They are major indications for CLKT in children. However, in some of them (e.g., atypical hemolytic uremic syndrome or primary hyperoxaluria), CLKT may be required in adults as well. Primary hyperoxaluria is divided into three types, of which type 1 and 2 lead to ESKD. CLKT has been proven effective in renal function replacement, at the same time preventing recurrence of the disease. Nephronophthisis is associated with liver fibrosis in 5% of cases and these patients are candidates for CLKT. In alpha 1-antitrypsin deficiency, hereditary C3 deficiency, lecithin cholesterol acyltransferase deficiency and glycogen storage diseases, glomerular or tubulointerstitial disease can lead to chronic kidney disease. Liver transplantation as a part of CLKT corrects underlying genetic and consequent metabolic abnormality. In atypical hemolytic uremic syndrome caused by mutations in the genes for factor H, successful CLKT has been reported in a small number of patients. However, for this indication, CLKT has been largely replaced by eculizumab, an anti-C5 antibody. CLKT has been well established to provide immune protection of the transplanted kidney against donor-specific antibodies against class I HLA, facilitating transplantation in a highly sensitized recipient.
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Affiliation(s)
- Mladen Knotek
- Department of Medicine, Tree Top Hospital, Hulhumale 23000, Maldives
- Department of Medicine, Merkur University Hospital, Zagreb 10000, Croatia
- School of Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Rafaela Novak
- School of Medicine, University of Zagreb, Zagreb 10000, Croatia
| | | | - Anna Mrzljak
- Department of Medicine, Merkur University Hospital, Zagreb 10000, Croatia
- School of Medicine, University of Zagreb, Zagreb 10000, Croatia.
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12
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Molema F, Williams M, Langendonk J, Darwish-Murad S, van de Wetering J, Jacobs E, Onkenhout W, Brusse E, van der Eerden A, Wagenmakers M. Neurotoxicity including posterior reversible encephalopathy syndrome after initiation of calcineurin inhibitors in transplanted methylmalonic acidemia patients: Two case reports and review of the literature. JIMD Rep 2020; 51:89-104. [PMID: 32071844 PMCID: PMC7012740 DOI: 10.1002/jmd2.12088] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 10/15/2019] [Accepted: 11/15/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction New neurological symptoms in methylmalonic acidemia (MMA) patients after liver and/or kidney transplantation (LKT) are often described as metabolic stroke‐like‐events. Since calcineurin inhibitors (CNIs) are a well‐known cause of new neurological symptoms in non‐MMA transplanted patients, we investigated the incidence of CNI‐induced neurotoxicity including posterior reversible encephalopathy syndrome (PRES) in post‐transplanted MMA patients. Methods We report the two MMA patients treated with LKT in our center. Additionally, we performed a systematic review of case reports/series of post‐transplanted MMA patients and determined if CNI‐induced neurotoxicity/PRES was a likely cause of new neurological symptoms. Definite CNI‐induced neurotoxicity was defined as new neurological symptoms during CNI treatment with symptom improvement after CNI dose reduction/discontinuation. PRES was defined as CNI‐induced neurotoxicity with signs of vasogenic edema on brain magnetic resonance imaging (MRI)‐scan post‐transplantation. Results Our two MMA patients both developed CNI‐induced neurotoxicity, one had PRES. In literature, 230 transplanted MMA patients were identified. Neurological follow‐up was reported in 54 of them, of which 24 were excluded from analysis since no anti‐rejection medication was reported. Thirty patients, all using CNI, were included. Sixteen patients (53%) had no new neurological symptoms post‐transplantation and five patients (17%) had definite CNI neurotoxicity of whom two had PRES. Including our cases this results in a pooled incidence of 22% (7/32) definite CNI neurotoxicity and 9% PRES (3/32) in post‐transplanted MMA patients on CNI. Conclusion In MMA post‐transplanted patients with new neurological symptoms CNI‐induced neurotoxicity/PRES should be considered. Early recognition of CNI‐induced neurotoxicity is essential to initiate dose reduction/discontinuation of CNI to minimize persistent neurologic damage and improve outcome. Concise one sentence take home message In all post‐transplanted MMA patients with new neurological symptoms CNI‐induced neurotoxicity/PRES should be considered, and directly reducing the dose/discontinuation of CNI is essential.
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Affiliation(s)
- Femke Molema
- Department of Pediatrics, Center for Lysosomal and Metabolic Disease Erasmus - Sophia Children's Hospital, University Medical Center Rotterdam The Netherlands
| | - Monique Williams
- Department of Pediatrics, Center for Lysosomal and Metabolic Disease Erasmus - Sophia Children's Hospital, University Medical Center Rotterdam The Netherlands
| | - Janneke Langendonk
- Department of Internal Medicine, Erasmus University Medical Center Center for Lysosomal and Metabolic Disease Rotterdam The Netherlands
| | - Sarwa Darwish-Murad
- Department of Gastroenterology and Hepatology Erasmus University Medical Center Rotterdam The Netherlands
| | - Jacqueline van de Wetering
- Department of Internal Medicine Erasmus University Medical Center, Nephrology and Transplantation, Rotterdam Transplant Group Rotterdam The Netherlands
| | - Ed Jacobs
- Department of Pediatrics, Center for Lysosomal and Metabolic Disease Erasmus - Sophia Children's Hospital, University Medical Center Rotterdam The Netherlands.,Department of Clinical Genetics Erasmus University Medical Center Rotterdam The Netherlands
| | - Willem Onkenhout
- Department of Pediatrics, Center for Lysosomal and Metabolic Disease Erasmus - Sophia Children's Hospital, University Medical Center Rotterdam The Netherlands.,Department of Clinical Genetics Erasmus University Medical Center Rotterdam The Netherlands
| | - Esther Brusse
- Department of Neurology Erasmus University Medical Center Rotterdam The Netherlands
| | - Anke van der Eerden
- Department of Radiology Erasmus University Medical Center Rotterdam The Netherlands
| | - Margreet Wagenmakers
- Department of Internal Medicine, Erasmus University Medical Center Center for Lysosomal and Metabolic Disease Rotterdam The Netherlands
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