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Jimenez-Blasco D, Agulla J, Lapresa R, Garcia-Macia M, Bobo-Jimenez V, Garcia-Rodriguez D, Manjarres-Raza I, Fernandez E, Jeanson Y, Khoury S, Portais JC, Padro D, Ramos-Cabrer P, Carmeliet P, Almeida A, Bolaños JP. Weak neuronal glycolysis sustains cognition and organismal fitness. Nat Metab 2024:10.1038/s42255-024-01049-0. [PMID: 38789798 DOI: 10.1038/s42255-024-01049-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 04/15/2024] [Indexed: 05/26/2024]
Abstract
The energy cost of neuronal activity is mainly sustained by glucose1,2. However, in an apparent paradox, neurons modestly metabolize glucose through glycolysis3-6, a circumstance that can be accounted for by the constant degradation of 6-phosphofructo-2-kinase-fructose-2,6-bisphosphatase-3 (PFKFB3)3,7,8, a key glycolysis-promoting enzyme. To evaluate the in vivo physiological importance of this hypoglycolytic metabolism, here we genetically engineered mice with their neurons transformed into active glycolytic cells through Pfkfb3 expression. In vivo molecular, biochemical and metabolic flux analyses of these neurons revealed an accumulation of anomalous mitochondria, complex I disassembly, bioenergetic deficiency and mitochondrial redox stress. Notably, glycolysis-mediated nicotinamide adenine dinucleotide (NAD+) reduction impaired sirtuin-dependent autophagy. Furthermore, these mice displayed cognitive decline and a metabolic syndrome that was mimicked by confining Pfkfb3 expression to hypothalamic neurons. Neuron-specific genetic ablation of mitochondrial redox stress or brain NAD+ restoration corrected these behavioural alterations. Thus, the weak glycolytic nature of neurons is required to sustain higher-order organismal functions.
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Affiliation(s)
- Daniel Jimenez-Blasco
- Institute of Functional Biology and Genomics, Universidad de Salamanca, CSIC, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Hospital Universitario de Salamanca, Universidad de Salamanca, CSIC, Salamanca, Spain
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Madrid, Spain
| | - Jesús Agulla
- Institute of Functional Biology and Genomics, Universidad de Salamanca, CSIC, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Hospital Universitario de Salamanca, Universidad de Salamanca, CSIC, Salamanca, Spain
| | - Rebeca Lapresa
- Institute of Functional Biology and Genomics, Universidad de Salamanca, CSIC, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Hospital Universitario de Salamanca, Universidad de Salamanca, CSIC, Salamanca, Spain
| | - Marina Garcia-Macia
- Institute of Functional Biology and Genomics, Universidad de Salamanca, CSIC, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Hospital Universitario de Salamanca, Universidad de Salamanca, CSIC, Salamanca, Spain
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Madrid, Spain
| | - Veronica Bobo-Jimenez
- Institute of Functional Biology and Genomics, Universidad de Salamanca, CSIC, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Hospital Universitario de Salamanca, Universidad de Salamanca, CSIC, Salamanca, Spain
| | - Dario Garcia-Rodriguez
- Institute of Functional Biology and Genomics, Universidad de Salamanca, CSIC, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Hospital Universitario de Salamanca, Universidad de Salamanca, CSIC, Salamanca, Spain
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Madrid, Spain
| | - Israel Manjarres-Raza
- Institute of Functional Biology and Genomics, Universidad de Salamanca, CSIC, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Hospital Universitario de Salamanca, Universidad de Salamanca, CSIC, Salamanca, Spain
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Madrid, Spain
| | - Emilio Fernandez
- Institute of Functional Biology and Genomics, Universidad de Salamanca, CSIC, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Hospital Universitario de Salamanca, Universidad de Salamanca, CSIC, Salamanca, Spain
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Madrid, Spain
| | - Yannick Jeanson
- RESTORE, University of Toulouse, Inserm U1031, CNRS 5070, UPS, EFS, Toulouse, France
| | - Spiro Khoury
- RESTORE, University of Toulouse, Inserm U1031, CNRS 5070, UPS, EFS, Toulouse, France
- MetaboHUB-MetaToul, National Infrastructure of Metabolomics and Fluxomics, Toulouse, France
| | - Jean-Charles Portais
- RESTORE, University of Toulouse, Inserm U1031, CNRS 5070, UPS, EFS, Toulouse, France
- MetaboHUB-MetaToul, National Infrastructure of Metabolomics and Fluxomics, Toulouse, France
- Toulouse Biotechnology Institute, INSA de Toulouse INSA/CNRS 5504, UMR INSA/INRA 792, Toulouse, France
| | - Daniel Padro
- CIC biomaGUNE, Basque Research and Technology Alliance, Donostia-San Sebastián, Spain
| | - Pedro Ramos-Cabrer
- CIC biomaGUNE, Basque Research and Technology Alliance, Donostia-San Sebastián, Spain
- Ikerbasque, Basque Foundation for Science, Bilbao, Spain
| | - Peter Carmeliet
- Laboratory of Angiogenesis and Vascular Metabolism, Department of Oncology and Leuven Cancer Institute (LKI), KU Leuven, VIB Center for Cancer Biology, VIB, Leuven, Belgium
- Center for Biotechnology, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Angeles Almeida
- Institute of Functional Biology and Genomics, Universidad de Salamanca, CSIC, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Hospital Universitario de Salamanca, Universidad de Salamanca, CSIC, Salamanca, Spain
| | - Juan P Bolaños
- Institute of Functional Biology and Genomics, Universidad de Salamanca, CSIC, Salamanca, Spain.
- Institute of Biomedical Research of Salamanca (IBSAL), Hospital Universitario de Salamanca, Universidad de Salamanca, CSIC, Salamanca, Spain.
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Madrid, Spain.
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Lai LM, Gropman AL, Whitehead MT. MR Neuroimaging in Pediatric Inborn Errors of Metabolism. Diagnostics (Basel) 2022; 12:diagnostics12040861. [PMID: 35453911 PMCID: PMC9027484 DOI: 10.3390/diagnostics12040861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 02/04/2023] Open
Abstract
Inborn errors of metabolism (IEM) are a group of disorders due to functional defects in one or more metabolic pathways that can cause considerable morbidity and death if not diagnosed early. While individually rare, the estimated global prevalence of IEMs comprises a substantial number of neonatal and infantile disorders affecting the central nervous system. Clinical manifestations of IEMs may be nonspecific. Newborn metabolic screens do not capture all IEMs, and likewise, genetic testing may not always detect pathogenic variants. Neuroimaging is a critical component of the work-up, given that imaging sometimes occurs before prenatal screen results are available, which may allow for recognition of imaging patterns that lead to early diagnosis and treatment of IEMs. This review will demonstrate the role of magnetic resonance imaging (MRI) and proton magnetic resonance spectroscopy (1H MRS) in the evaluation of IEMs. The focus will be on scenarios where MRI and 1H MRS are suggestive of or diagnostic for IEMs, or alternatively, refute the diagnosis.
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Affiliation(s)
- Lillian M. Lai
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
- Department of Radiology, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - Andrea L. Gropman
- Department of Neurology, Children’s National, Washington, DC 20010, USA;
| | - Matthew T. Whitehead
- Department of Radiology, Children’s National, Washington, DC 20010, USA
- Correspondence: ; Tel.: +1-202-476-5000
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3
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Whitehead MT, Lai LM, Blüml S. Clinical 1H MRS in childhood neurometabolic diseases — part 2: MRS signatures. Neuroradiology 2022; 64:1111-1126. [DOI: 10.1007/s00234-022-02918-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/10/2022] [Indexed: 12/23/2022]
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Whitehead MT, Bluml S. Proton and Multinuclear Spectroscopy of the Pediatric Brain. Magn Reson Imaging Clin N Am 2021; 29:543-555. [PMID: 34717844 DOI: 10.1016/j.mric.2021.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Magnetic resonance spectroscopy (MRS) is a valuable adjunct to structural brain imaging. State-of-the-art MRS has benefited greatly from recent technical advancements. Neurometabolic alterations in pediatric brain diseases have implications for diagnosis, prognosis, and therapy. Herein, the authors discuss MRS technical considerations and applications in the setting of various pediatric disease processes including tumors, metabolic diseases, hypoxic/ischemic encephalopathy/stroke, epilepsy, demyelinating disease, and infection.
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Affiliation(s)
- Matthew T Whitehead
- Department of Radiology, Children's National Hospital, 111 Michigan Avenue NW, Washington, DC 20010, USA; Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA; The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
| | - Stefan Bluml
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, 450 Sunset Boulevard, Los Angeles, CA 90027, USA; Rudi Schulte Research Institute, Santa Barbara, CA, USA
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Abstract
Inborn errors of metabolism, also known as inherited metabolic diseases, constitute an important group of conditions presenting with neurologic signs in newborns. They are individually rare but collectively common. Many are treatable through restoration of homeostasis of a disrupted metabolic pathway. Given their frequency and potential for treatment, the clinician should be aware of this group of conditions and learn to identify the typical manifestations of the different inborn errors of metabolism. In this review, we summarize the clinical, laboratory, electrophysiologic, and neuroimaging findings of the different inborn errors of metabolism that can present with florid neurologic signs and symptoms in the neonatal period.
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MESH Headings
- Adult
- Female
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/diagnostic imaging
- Infant, Newborn, Diseases/physiopathology
- Infant, Newborn, Diseases/therapy
- Metabolism, Inborn Errors/diagnosis
- Metabolism, Inborn Errors/diagnostic imaging
- Metabolism, Inborn Errors/physiopathology
- Metabolism, Inborn Errors/therapy
- Neuroimaging
- Pregnancy
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Affiliation(s)
- Carlos R Ferreira
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, United States; Rare Disease Institute, Children's National Health System, Washington, DC, United States
| | - Clara D M van Karnebeek
- Departments of Pediatrics and Clinical Genetics, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Department of Pediatrics, Centre for Molecular Medicine and Therapeutics, University of British Columbia, Vancouver, BC, Canada.
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6
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van Karnebeek CDM, Sayson B, Lee JJY, Tseng LA, Blau N, Horvath GA, Ferreira CR. Metabolic Evaluation of Epilepsy: A Diagnostic Algorithm With Focus on Treatable Conditions. Front Neurol 2018; 9:1016. [PMID: 30559706 PMCID: PMC6286965 DOI: 10.3389/fneur.2018.01016] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 11/12/2018] [Indexed: 01/04/2023] Open
Abstract
Although inborn errors of metabolism do not represent the most common cause of seizures, their early identification is of utmost importance, since many will require therapeutic measures beyond that of common anti-epileptic drugs, either in order to control seizures, or to decrease the risk of neurodegeneration. We translate the currently-known literature on metabolic etiologies of epilepsy (268 inborn errors of metabolism belonging to 21 categories, with 74 treatable errors), into a 2-tiered diagnostic algorithm, with the first-tier comprising accessible, affordable, and less invasive screening tests in urine and blood, with the potential to identify the majority of treatable conditions, while the second-tier tests are ordered based on individual clinical signs and symptoms. This resource aims to support the pediatrician, neurologist, biochemical, and clinical geneticists in early identification of treatable inborn errors of metabolism in a child with seizures, allowing for timely initiation of targeted therapy with the potential to improve outcomes.
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Affiliation(s)
- Clara D M van Karnebeek
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,Centre for Molecular Medicine and Therapeutics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada.,Departments of Pediatrics and Clinical Genetics, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Bryan Sayson
- Division of Biochemical Diseases, Department of Pediatrics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Jessica J Y Lee
- Centre for Molecular Medicine and Therapeutics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Laura A Tseng
- Departments of Pediatrics and Clinical Genetics, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Nenad Blau
- Dietmar-Hopp Metabolic Center, University Children's Hospital, Heidelberg, Germany.,Division of Metabolism, University Children's Hospital, Zurich, Switzerland
| | - Gabriella A Horvath
- Division of Biochemical Diseases, Department of Pediatrics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Carlos R Ferreira
- Division of Genetics and Metabolism, Children's National Health System, Washington, DC, United States.,National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, United States
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Jung YH, Kim H, Jeon SY, Kwon JM, Lee D, Choi SH, Kang DH. Aberrant interactions of peripheral measures and neurometabolites with lipids in complex regional pain syndrome using magnetic resonance spectroscopy: A pilot study. Mol Pain 2018; 14:1744806917751323. [PMID: 29336203 PMCID: PMC5774727 DOI: 10.1177/1744806917751323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background The aim of this study was to assess peripheral measures and central metabolites associated with lipids using magnetic resonance spectroscopy. Results Twelve patients with complex regional pain syndrome (CRPS) and 11 healthy controls participated. Using magnetic resonance spectroscopy, we measured the levels of lipid 13a (Lip13a) and lipid 09 (Lip09) relative to total creatine (tCr) levels in the right and left thalamus. We found negative correlations of Lip13a/tCr in the right thalamus with red blood cells or neutrophils, but a positive correlation between Lip13a/tCr and lymphocytes in the controls. We found negative correlations between Lip09/tCr and peripheral pH or platelets in the controls. There were positive correlations between Lip09a/tCr and myo-inositol/tCr, between Lip13a/tCr and N-acetylaspartate (NAA)/tCr, and between Lip09/tCr and NAA/tCr in healthy controls. On the other hand, there were positive correlations between Lip13a/tCr and Lip09/tCr and urine pH in CRPS patients. There were significant correlations between Lip13a/tCr or Lip09/tCr and different peripheral measures depending on the side of the thalamus (right or left) in CRPS patients. Conclusion This is the first report indicating that abnormal interactions of Lip13a and Lip09 in the thalamus with peripheral measures and central metabolites may mediate the complex pathophysiological mechanisms underlying CRPS.
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Affiliation(s)
- Ye-Ha Jung
- 1 Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Korea
| | - Hyeonjin Kim
- 2 Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - So Yeon Jeon
- 1 Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Korea
| | - Jeong Min Kwon
- 3 Department of Experimental Animal Research, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Dasom Lee
- 1 Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Korea
| | - Soo-Hee Choi
- 1 Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Korea
| | - Do-Hyung Kang
- 1 Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Korea
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Jung YH, Kim H, Jeon SY, Kwon JM, Lee WJ, Kim YC, Jang JH, Choi SH, Lee JY, Kang DH. Brain Metabolites and Peripheral Biomarkers Associated with Neuroinflammation in Complex Regional Pain Syndrome Using [11C]-(R)-PK11195 Positron Emission Tomography and Magnetic Resonance Spectroscopy: A Pilot Study. PAIN MEDICINE 2018; 20:504-514. [DOI: 10.1093/pm/pny111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Ye-Ha Jung
- Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Korea
| | - Hyeonjin Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - So Yeon Jeon
- Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Korea
| | - Jeong Min Kwon
- Department of Experimental Animal Research, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Won Joon Lee
- Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Korea
| | - Yong Chul Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Joon Hwan Jang
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Korea
| | - Soo-Hee Choi
- Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Korea
- Department of Psychiatry and Institute of Human Behavioral Sciences, Seoul National University College of Medicine, Seoul, Korea
| | - Jun-Young Lee
- Department of Psychiatry and Behavioral Science, Seoul National University College of Medicine & SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Do-Hyung Kang
- Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Korea
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Korea
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Tajima G, Hara K, Tsumura M, Kagawa R, Okada S, Sakura N, Maruyama S, Noguchi A, Awaya T, Ishige M, Ishige N, Musha I, Ajihara S, Ohtake A, Naito E, Hamada Y, Kono T, Asada T, Sasai H, Fukao T, Fujiki R, Ohara O, Bo R, Yamada K, Kobayashi H, Hasegawa Y, Yamaguchi S, Takayanagi M, Hata I, Shigematsu Y, Kobayashi M. Newborn screening for carnitine palmitoyltransferase II deficiency using (C16+C18:1)/C2: Evaluation of additional indices for adequate sensitivity and lower false-positivity. Mol Genet Metab 2017; 122:67-75. [PMID: 28801073 DOI: 10.1016/j.ymgme.2017.07.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Carnitine palmitoyltransferase (CPT) II deficiency is one of the most common forms of mitochondrial fatty acid oxidation disorder (FAOD). However, newborn screening (NBS) for this potentially fatal disease has not been established partly because reliable indices are not available. METHODS We diagnosed CPT II deficiency in a 7-month-old boy presenting with hypoglycemic encephalopathy, which apparently had been missed in the NBS using C16 and C18:1 concentrations as indices. By referring to his acylcarnitine profile from the NBS, we adopted the (C16+C18:1)/C2 ratio (cutoff 0.62) and C16 concentration (cutoff 3.0nmol/mL) as alternative indices for CPT II deficiency such that an analysis of a dried blood specimen collected at postnatal day five retroactively yielded the correct diagnosis. Thereafter, positive cases were assessed by measuring (1) the fatty acid oxidation ability of intact lymphocytes and/or (2) CPT II activity in the lysates of lymphocytes. The diagnoses were then further confirmed by genetic analysis. RESULTS The disease was diagnosed in seven of 21 newborns suspected of having CPT II deficiency based on NBS. We also analyzed the false-negative patient and five symptomatic patients for comparison. Values for the NBS indices of the false-negative, symptomatic patient were lower than those of the seven affected newborns. Although it was difficult to differentiate the false-negative patient from heterozygous carriers and false-positive subjects, the fatty acid oxidation ability of the lymphocytes and CPT II activity clearly confirmed the diagnosis. Among several other indices proposed previously, C14/C3 completely differentiated the seven NBS-positive patients and the false-negative patient from the heterozygous carriers and the false-positive subjects. Genetic analysis revealed 16 kinds of variant alleles. The most prevalent, detected in ten alleles in nine patients from eight families, was c.1148T>A (p.F383Y), a finding in line with those of several previous reports on Japanese patients. CONCLUSIONS These findings suggested that CPT II deficiency can be screened by using (C16+C18:1)/C2 and C16 as indices. An appropriate cutoff level is required to achieve adequate sensitivity albeit at the cost of a considerable increase in the false-positive rate, which might be reduced by using additional indices such as C14/C3.
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Affiliation(s)
- Go Tajima
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan; Division of Neonatal Screening, Research Institute, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo 157-8535, Japan.
| | - Keiichi Hara
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan; Department of Pediatrics, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, 3-1 Aoyama-cho, Kure 737-0023, Japan.
| | - Miyuki Tsumura
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Reiko Kagawa
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Satoshi Okada
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Nobuo Sakura
- Nursing House for Severe Motor and Intellectual Severities Suzugamine, 104-27 Minaga, Itsukaichi-cho, Saeki-ku, Hiroshima 731-5122, Japan.
| | - Shinsuke Maruyama
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan.
| | - Atsuko Noguchi
- Department of Pediatrics, Akita University Graduate School of Medicine, 44-2 Hasunuma, Hiroomote, Akita 010-8543, Japan.
| | - Tomonari Awaya
- Department of Pediatrics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Mika Ishige
- Department of Pediatrics and Child Health, Nihon University School of Medicine, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo 101-8309, Japan.
| | - Nobuyuki Ishige
- Division of Newborn Screening, Tokyo Health Service Association, 1-2-59 Ichiga-Sadohara, Shinjuku-ku, Tokyo 162-8460, Japan.
| | - Ikuma Musha
- Department of Pediatrics, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Saitama 350-0495, Japan.
| | - Sayaka Ajihara
- Department of Pediatrics, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Saitama 350-0495, Japan.
| | - Akira Ohtake
- Department of Pediatrics, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Saitama 350-0495, Japan.
| | - Etsuo Naito
- Department of Pediatrics, Japanese Red Cross Tokushima Hinomine Rehabilitation Center, 4-1 Shinbiraki, Chuden-cho, Komatsushima, Tokushima 773-0015, Japan.
| | - Yusuke Hamada
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka 565-0871, Japan.
| | - Tomotaka Kono
- Division of Endocrinology and Metabolism, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama 330-8777, Japan.
| | - Tomoko Asada
- Department of Pediatrics, Faculty of Medicine, University of Miyazaki Hospital, 5200 Kihara, Kiyotake-cho, Miyazaki 889-1692, Japan.
| | - Hideo Sasai
- Department of Pediatrics, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu 501-1193, Japan.
| | - Toshiyuki Fukao
- Department of Pediatrics, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu 501-1193, Japan.
| | - Ryoji Fujiki
- Department of Technology Development, Kazusa DNA Research Institute, Kisarazu, Chiba 292-0818, Japan.
| | - Osamu Ohara
- Department of Technology Development, Kazusa DNA Research Institute, Kisarazu, Chiba 292-0818, Japan.
| | - Ryosuke Bo
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan; Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.
| | - Kenji Yamada
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan.
| | - Hironori Kobayashi
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan.
| | - Yuki Hasegawa
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan.
| | - Seiji Yamaguchi
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan.
| | - Masaki Takayanagi
- Department of Nursing, Faculty of Health Care and Medical Sport, Teikyo Heisei University, 6-19 Chiharadai-Nishi, Ichihara 290-0192, Japan.
| | - Ikue Hata
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka-Shimoaizuki, Eiheiji-cho, Fukui 910-1193, Japan.
| | - Yosuke Shigematsu
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka-Shimoaizuki, Eiheiji-cho, Fukui 910-1193, Japan.
| | - Masao Kobayashi
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
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