1
|
Burlina A, Gasperini S, la Marca G, Pession A, Siri B, Spada M, Ruoppolo M, Tummolo A. Long-Term Management of Patients with Mild Urea Cycle Disorders Identified through the Newborn Screening: An Expert Opinion for Clinical Practice. Nutrients 2023; 16:13. [PMID: 38201843 PMCID: PMC10780676 DOI: 10.3390/nu16010013] [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: 10/26/2023] [Revised: 12/05/2023] [Accepted: 12/13/2023] [Indexed: 01/12/2024] Open
Abstract
Urea cycle disorders (UCDs) are a group of rare inborn errors of metabolism caused by a deficiency in one of the six enzymes or one of the two transporters involved in the urea cycle. Current guidelines suggest that early diagnosis and treatment of mild UCDs may improve survival and prevent decompensation and neurocognitive impairment. Nevertheless, clinical studies are very difficult to carry out in this setting due to the rarity of the diseases, and high-level evidence is scant and insufficient to draw conclusions and provide clinical guidelines. With the early introduction of newborn screening, the Italian healthcare organization fostered an advancement in expertise in metabolic disease management and screening programs, by allocating resources, and favoring the expansion of newborn screening. A group of experts operating in Italian centers decided to share their experience and provide advice for the management of mild UCDs in clinical practice. A consensus was reached by the Estimate-Talk-Estimate (ETE) method. Five items were identified, and statements for each item were agreed. Briefly, the panel advised completing the diagnosis by expanded newborn screening (ENS) with biochemical and genetic confirmation and by following up with the patient during the first year of life, with a routine laboratory and metabolic profile as well as with clinical observation. Early initiation of therapy is advised and should be followed by therapy adjustment once the diagnostic profile is completed. The therapy should be based on a low-protein diet and nitrogen scavengers. The long-term follow-up is based on growth and nutritional assessment, clinical and neurocognitive evaluation, and laboratory and instrumental parameter monitoring.
Collapse
Affiliation(s)
- Albero Burlina
- Division of Inherited Metabolic Diseases, Reference Centre for Expanded Newborn Screening, University Hospital of Padova, 35128 Padova, Italy
| | - Serena Gasperini
- Inherited Metabolic Unit Disorders, Pediatric Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy;
| | - Giancarlo la Marca
- Newborn Screening Lab, IRCCS Meyer Children’s Hospital, Department of Experimental and Clinical Biomedical Sciences, University of Florence, 50139 Firenze, Italy;
| | - Andrea Pession
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Barbara Siri
- Division of Metabolic Diseases and Hepatology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Marco Spada
- Department of Pediatrics, University of Turin, 10124 Turin, Italy;
| | - Margherita Ruoppolo
- Department of Molecular Medicine and Medical Biotechnology, University of Naples, Federico II, 80138 Naples, Italy;
- CEINGE–Biotecnologie Avanzate S.C.A.R.L., 80145 Naples, Italy
| | - Albina Tummolo
- Department of Metabolic Diseases and Clinical Genetics and Diabetology, Giovanni XXIII Children Hospital, Azienda Ospedaliero-Universitaria Consorziale, 70126 Bari, Italy;
| |
Collapse
|
3
|
Yeo M, Rehsi P, Dorman M, Grunewald S, Baruteau J, Chakrapani A, Footitt E, Prunty H, McSweeney M. Clinical experience with glycerol phenylbutyrate in 20 patients with urea cycle disorders at a UK paediatric centre. JIMD Rep 2023; 64:317-326. [PMID: 37701329 PMCID: PMC10494499 DOI: 10.1002/jmd2.12386] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/14/2023] [Accepted: 07/13/2023] [Indexed: 09/14/2023] Open
Abstract
In urea cycle disorders (UCDs) ammonia scavenger drugs, usually sodium-based, have been the mainstay of treatment. Increasingly, glycerol phenylbutyrate (GPB, Ravicti®) is being used but scant real-world data exist regarding clinical outcomes. A retrospective study of UCD patients initiated on or switched to GPB was performed at a UK centre. Data on population characteristics, treatment aspects, laboratory measurements, and clinical outcomes were collected before and after patients started GPB with a sub-group analysis undertaken for patients with ≥12 months of data before and after starting GPB. UCDs included arginosuccinate synthetase deficiency (n = 8), arginosuccinate lyase deficiency (n = 6), ornithine carbamoyltransferase deficiency (n = 3), and carbamoyl phosphate synthetase 1 deficiency (n = 3). In the sub-group analysis (n = 11), GPB resulted in lower plasma ammonia (31 vs. 41 μmol/L, p = 0.037), glutamine (670 vs. 838 μmol/L, p = 0.002), annualised hyperammonaemic episodes (0.2 vs. 1.9, p = 0.020), hospitalisations (0.5 vs. 2.2, p = 0.010), and hyperammonaemic episodes resulting in hospitalisation (0.2 vs. 1.6, p = 0.035) reflecting changes seen in the whole group. Overall, patients exposed to sodium and propylene glycol levels above UK daily limits reduced by 78% and 83% respectively. Mean levels of branched chain amino acids, haemoglobin, and white cell count were unchanged. Two adverse drug reactions (pancytopenia, fatigue/appetite loss) resolved without GPB discontinuation. Patients/families preferred GPB for its lower volume, greater palatability and easier administration. GPB appeared to improve biochemical measures and clinical outcomes. The causes are multi-factorial and are likely to include prolonged action of GPB and its good tolerability, even at higher doses, facilitating tighter control of ammonia.
Collapse
Affiliation(s)
- Mildrid Yeo
- Department of Paediatric Inherited Metabolic DiseaseGreat Ormond Street Hospital NHS Foundation Trust and Institute for Child HealthLondonUK
| | - Preeya Rehsi
- Department of Paediatric Inherited Metabolic DiseaseGreat Ormond Street Hospital NHS Foundation Trust and Institute for Child HealthLondonUK
| | - Megan Dorman
- Department of Paediatric Inherited Metabolic DiseaseGreat Ormond Street Hospital NHS Foundation Trust and Institute for Child HealthLondonUK
| | - Stephanie Grunewald
- Department of Paediatric Inherited Metabolic DiseaseGreat Ormond Street Hospital NHS Foundation Trust and Institute for Child HealthLondonUK
| | - Julien Baruteau
- Department of Paediatric Inherited Metabolic DiseaseGreat Ormond Street Hospital NHS Foundation Trust and Institute for Child HealthLondonUK
| | - Anupam Chakrapani
- Department of Paediatric Inherited Metabolic DiseaseGreat Ormond Street Hospital NHS Foundation Trust and Institute for Child HealthLondonUK
| | - Emma Footitt
- Department of Paediatric Inherited Metabolic DiseaseGreat Ormond Street Hospital NHS Foundation Trust and Institute for Child HealthLondonUK
| | - Helen Prunty
- Department of Paediatric Inherited Metabolic DiseaseGreat Ormond Street Hospital NHS Foundation Trust and Institute for Child HealthLondonUK
| | - Melanie McSweeney
- Department of Paediatric Inherited Metabolic DiseaseGreat Ormond Street Hospital NHS Foundation Trust and Institute for Child HealthLondonUK
| |
Collapse
|
4
|
Seker Yilmaz B, Baruteau J, Arslan N, Aydin HI, Barth M, Bozaci AE, Brassier A, Canda E, Cano A, Chronopoulou E, Connolly GM, Damaj L, Dawson C, Dobbelaere D, Douillard C, Eminoglu FT, Erdol S, Ersoy M, Fang S, Feillet F, Gokcay G, Goksoy E, Gorce M, Inci A, Kadioglu B, Kardas F, Kasapkara CS, Kilic Yildirim G, Kor D, Kose M, Marelli C, Mundy H, O’Sullivan S, Ozturk Hismi B, Ramachandran R, Roubertie A, Sanlilar M, Schiff M, Sreekantam S, Stepien KM, Uzun Unal O, Yildiz Y, Zubarioglu T, Gissen P. Three-Country Snapshot of Ornithine Transcarbamylase Deficiency. Life (Basel) 2022; 12:1721. [PMID: 36362876 PMCID: PMC9695856 DOI: 10.3390/life12111721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022] Open
Abstract
X-linked ornithine transcarbamylase deficiency (OTCD) is the most common urea cycle defect. The disease severity ranges from asymptomatic carrier state to severe neonatal presentation with hyperammonaemic encephalopathy. We audited the diagnosis and management of OTCD, using an online 12-question-survey that was sent to 75 metabolic centres in Turkey, France and the UK. Thirty-nine centres responded and 495 patients were reported in total. A total of 208 French patients were reported, including 71 (34%) males, 86 (41%) symptomatic and 51 (25%) asymptomatic females. Eighty-five Turkish patients included 32 (38%) males, 39 (46%) symptomatic and 14 (16%) asymptomatic females. Out of the 202 UK patients, 66 (33%) were male, 83 (41%) asymptomatic and 53 (26%) symptomatic females. A total of 19%, 12% and 7% of the patients presented with a neonatal-onset phenotype in France, Turkey and the UK, respectively. Vomiting, altered mental status and encephalopathy were the most common initial symptoms in all three countries. While 69% in France and 79% in Turkey were receiving protein restriction, 42% were on a protein-restricted diet in the UK. A total of 76%, 47% and 33% of patients were treated with ammonia scavengers in Turkey, France and the UK, respectively. The findings of our audit emphasize the differences and similarities in manifestations and management practices in three countries.
Collapse
Affiliation(s)
- Berna Seker Yilmaz
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Julien Baruteau
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
- National Institute of Health Research Great Ormond Street Biomedical Research Centre, London WC1N 1EH, UK
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Nur Arslan
- Paediatric Metabolic Medicine Department, Dokuz Eylul University Faculty of Medicine, Izmir 35340, Turkey
| | - Halil Ibrahim Aydin
- Paediatric Metabolic Medicine Department, Baskent University Faculty of Medicine, Ankara 06490, Turkey
| | - Magalie Barth
- Centre de Référence des Maladies Héréditaires du Métabolisme, CHU Angers, 4 rue Larrey, CEDEX 9, 49933 Angers, France
| | - Ayse Ergul Bozaci
- Paediatric Metabolic Medicine Department, Diyarbakir Children’s Hospital, Diyarbakir 21100, Turkey
| | - Anais Brassier
- Reference Center for Inborn Errors of Metabolism, Necker University Hospital, APHP and University of Paris Cité, 75015 Paris, France
| | - Ebru Canda
- Paediatric Metabolic Medicine Department, Ege University Faculty of Medicine, Izmir 35100, Turkey
| | - Aline Cano
- Reference Center of Inherited Metabolic Disorders, Timone Enfants Hospital, 264 rue Saint-Pierre, 13005 Marseille, France
| | - Efstathia Chronopoulou
- Department of Inherited Metabolic Disease, Division of Women’s and Children’s Services, University Hospitals Bristol NHS Foundation Trust, Bristol BS1 3NU, UK
| | | | - Lena Damaj
- Centre de Compétence Maladies Héréditaires du Métabolisme, CHU Hôpital Sud, CEDEX 2, 35203 Rennes, France
| | - Charlotte Dawson
- Metabolic Medicine Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
| | - Dries Dobbelaere
- Medical Reference Center for Inherited Metabolic Diseases, Jeanne de Flandre University Hospital and RADEME Research Team for Rare Metabolic and Developmental Diseases, EA 7364 CHRU Lille, 59000 Lille, France
| | - Claire Douillard
- Medical Reference Center for Inherited Metabolic Diseases, Jeanne de Flandre University Hospital and RADEME Research Team for Rare Metabolic and Developmental Diseases, EA 7364 CHRU Lille, 59000 Lille, France
| | - Fatma Tuba Eminoglu
- Paediatric Metabolic Medicine Department, Ankara University Faculty of Medicine, Ankara 06080, Turkey
| | - Sahin Erdol
- Paediatric Metabolic Medicine Department, Uludag University Faculty of Medicine, Bursa 16059, Turkey
| | - Melike Ersoy
- Paediatric Metabolic Medicine Department, Dr Sadi Konuk Reseach & Training Hospital, Istanbul 34450, Turkey
| | - Sherry Fang
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - François Feillet
- Centre de Référence des Maladies Métaboliques de Nancy, CHU Brabois Enfants, 5 Rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - Gulden Gokcay
- Paediatric Metabolic Medicine Department, Istanbul University Istanbul Faculty of Medicine, Istanbul 34093, Turkey
| | - Emine Goksoy
- Paediatric Metabolic Medicine Department, Cengiz Gokcek Children’s Hospital, Gaziantep 27010, Turkey
| | - Magali Gorce
- Centre de Référence des Maladies Rares du Métabolisme, Hôpital des Enfants—CHU Toulouse, 330 Avenue de Grande-Bretagne, CEDEX 9, 31059 Toulouse, France
| | - Asli Inci
- Paediatric Metabolic Medicine Department, Gazi University Faculty of Medicine, Ankara 06500, Turkey
| | - Banu Kadioglu
- Paediatric Metabolic Medicine Department, Konya City Hospital, Konya 42020, Turkey
| | - Fatih Kardas
- Paediatric Metabolic Medicine Department, Erciyes University Faculty of Medicine, Kayseri 38030, Turkey
| | - Cigdem Seher Kasapkara
- Paediatric Metabolic Medicine Department, Ankara Yildirim Beyazit University Faculty of Medicine, Ankara 06800, Turkey
| | - Gonca Kilic Yildirim
- Paediatric Metabolic Medicine Department, Osmangazi University Faculty of Medicine, Eskisehir 26480, Turkey
| | - Deniz Kor
- Paediatric Metabolic Medicine Department, Cukurova University Faculty of Medicine, Adana 01250, Turkey
| | - Melis Kose
- Paediatric Metabolic Medicine Department, Faculty of Medicine, Izmir Katip Celebi University, Izmir 35620, Turkey
| | - Cecilia Marelli
- MMDN, University Montpellier, EPHE, INSERM, 34090 Montpellier, France
- Expert Center for Metabolic and Neurogenetic Diseases, Centre Hospitalier Universitaire (CHU), 34090 Montpellier, France
| | - Helen Mundy
- Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | | | - Burcu Ozturk Hismi
- Paediatric Metabolic Medicine Department, Marmara University Faculty of Medicine, Istanbul 34854, Turkey
| | | | - Agathe Roubertie
- MMDN, University Montpellier, EPHE, INSERM, 34090 Montpellier, France
- Expert Center for Metabolic and Neurogenetic Diseases, Centre Hospitalier Universitaire (CHU), 34090 Montpellier, France
| | - Mehtap Sanlilar
- Paediatric Metabolic Medicine Department, Antalya Training and Research Hospital, Antalya 07100, Turkey
| | - Manuel Schiff
- Reference Center for Inborn Errors of Metabolism, Necker University Hospital, APHP and University of Paris Cité, 75015 Paris, France
| | - Srividya Sreekantam
- Birmingham Women’s and Children’s Hospital NHS Foundation Trust, Birmingham B4 6NH, UK
| | - Karolina M. Stepien
- Adult Inherited Metabolic Diseases, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Ozlem Uzun Unal
- Paediatric Metabolic Medicine Department, Kocaeli University Faculty of Medicine, Kocaeli 41380, Turkey
| | - Yilmaz Yildiz
- Paediatric Metabolic Medicine Department, Hacettepe University Faculty of Medicine, Ankara 06230, Turkey
| | - Tanyel Zubarioglu
- Paediatric Metabolic Medicine Department, Istanbul University-Cerrahpasa Faculty of Medicine, Istanbul 34096, Turkey
| | - Paul Gissen
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
- National Institute of Health Research Great Ormond Street Biomedical Research Centre, London WC1N 1EH, UK
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| |
Collapse
|
5
|
Martín-Hernández E, Quijada-Fraile P, Correcher P, Meavilla S, Sánchez-Pintos P, de las Heras Montero J, Blasco-Alonso J, Dougherty L, Marquez A, Peña-Quintana L, Cañedo E, García-Jimenez MC, Moreno Lozano PJ, Murray Hurtado M, Camprodon Gómez M, Barrio-Carreras D, de los Santos M, del Toro M, Couce ML, Vitoria Miñana I, Morales Conejo M, Bellusci M. Switching to Glycerol Phenylbutyrate in 48 Patients with Urea Cycle Disorders: Clinical Experience in Spain. J Clin Med 2022; 11:jcm11175045. [PMID: 36078975 PMCID: PMC9457033 DOI: 10.3390/jcm11175045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 11/30/2022] Open
Abstract
Background and objectives: Glycerol phenylbutyrate (GPB) has demonstrated safety and efficacy in patients with urea cycle disorders (UCDs) by means of its clinical trial program, but there are limited data in clinical practice. In order to analyze the efficacy and safety of GPB in clinical practice, here we present a national Spanish experience after direct switching from another nitrogen scavenger to GPB. Methods: This observational, retrospective, multicenter study was performed in 48 UCD patients (age 11.7 ± 8.2 years) switching to GPB in 13 centers from nine Spanish regions. Clinical, biochemical, and nutritional data were collected at three different times: prior to GPB introduction, at first follow-up assessment, and after one year of GPB treatment. Number of related adverse effects and hyperammonemic crisis 12 months before and after GPB introduction were recorded. Results: GPB was administered at a 247.8 ± 102.1 mg/kg/day dose, compared to 262.6 ± 126.1 mg/kg/day of previous scavenger (46/48 Na-phenylbutyrate). At first follow-up (79 ± 59 days), a statistically significant reduction in ammonia (from 40.2 ± 17.3 to 32.6 ± 13.9 μmol/L, p < 0.001) and glutamine levels (from 791.4 ± 289.8 to 648.6 ± 247.41 μmol/L, p < 0.001) was observed. After one year of GPB treatment (411 ± 92 days), we observed an improved metabolic control (maintenance of ammonia and glutamine reduction, with improved branched chain amino acids profile), and a reduction in hyperammonemic crisis rate (from 0.3 ± 0.7 to less than 0.1 ± 0.3 crisis/patients/year, p = 0.02) and related adverse effects (RAE, from 0.5 to less than 0.1 RAEs/patients/year p < 0.001). Conclusions: This study demonstrates the safety of direct switching from other nitrogen scavengers to GPB in clinical practice, which improves efficacy, metabolic control, and RAE compared to previous treatments.
Collapse
Affiliation(s)
- Elena Martín-Hernández
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Hospital Universitario 12 de Octubre, Instituto de Investigación i+12, CIBERER, 28041 Madrid, Spain
- Correspondence:
| | - Pilar Quijada-Fraile
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Hospital Universitario 12 de Octubre, Instituto de Investigación i+12, CIBERER, 28041 Madrid, Spain
| | - Patricia Correcher
- Centro de Referencia Nacional de Enfermedades Metabólicas (CSUR), Hospital La Fé de Valencia, 46026 Valencia, Spain
| | - Silvia Meavilla
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital San Joan de Deu Barcelona, 08950 Esplugues de Llobregat, Spain
| | - Paula Sánchez-Pintos
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital Clínico Universitario de Santiago de Compostela, IDIS, CIBERER, 15706 Santiago de Compostela, Spain
| | - Javier de las Heras Montero
- Division of Pediatric Metabolism, CIBERER, MetabERN, Cruces University Hospital, University of the Basque Country (UPV/EHU) and Biocruces-Bizkaia Health Research Institute, 48903 Barakaldo, Spain
| | - Javier Blasco-Alonso
- Sección de Gastroenterología y Nutrición Infantil, Unidad de Enfermedades Metabólicas Hereditarias, Grupo IBIMA Multidisciplinar Pediátrico, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain
| | - Lucy Dougherty
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital Vall D’Hebrón, 08035 Barcelona, Spain
| | - Ana Marquez
- Unidad de Gastroenterología y Enfermedades Metabólicas, Hospital de Badajoz, 06002 Badajoz, Spain
| | - Luis Peña-Quintana
- Unidad de Gastroenterología y Nutrición Pediátrica, Complejo Hospitalario Universitario Insular Materno-Infantil de Las Palmas, CIBEROBN, ISCIII, ACIP, Universidad de Las Palmas de Gran Canaria, 35016 Las Palmas de Gran Canaria, Spain
| | - Elvira Cañedo
- Unidad de Gastroenterología y Nutrición, Hospital del Niño Jesús, 28009 Madrid, Spain
| | | | - Pedro Juan Moreno Lozano
- Unidad de Enfermedades Musculares y Metabólicas Hereditarias, Departamento de Medicina Interna, Hospital Clinic, 08036 Barcelona, Spain
| | - Mercedes Murray Hurtado
- Pediatría, Sección de Nutrición y Errores Innatos del Metabolismo, Complejo Hospitalario Universitario de Canarias, 38320 San Cristóbal de La Laguna, Spain
| | - María Camprodon Gómez
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital Vall D’Hebrón, 08035 Barcelona, Spain
| | - Delia Barrio-Carreras
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Hospital Universitario 12 de Octubre, Instituto de Investigación i+12, CIBERER, 28041 Madrid, Spain
| | - Mariela de los Santos
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital San Joan de Deu Barcelona, 08950 Esplugues de Llobregat, Spain
| | - Mireia del Toro
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital Vall D’Hebrón, 08035 Barcelona, Spain
| | - María L. Couce
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) de Enfermedades Metabólicas, Hospital Clínico Universitario de Santiago de Compostela, IDIS, CIBERER, 15706 Santiago de Compostela, Spain
| | - Isidro Vitoria Miñana
- Centro de Referencia Nacional de Enfermedades Metabólicas (CSUR), Hospital La Fé de Valencia, 46026 Valencia, Spain
| | - Montserrat Morales Conejo
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Hospital Universitario 12 de Octubre, Instituto de Investigación i+12, CIBERER, 28041 Madrid, Spain
| | - Marcello Bellusci
- Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Hospital Universitario 12 de Octubre, Instituto de Investigación i+12, CIBERER, 28041 Madrid, Spain
| |
Collapse
|