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Burgess NM, Kelso W, Malpas CB, Winton-Brown T, Fazio T, Panetta J, De Jong G, Neath J, Atherton S, Velakoulis D, Walterfang M. The effect of improved dietary control on cognitive and psychiatric functioning in adults with phenylketonuria: the ReDAPT study. Orphanet J Rare Dis 2021; 16:35. [PMID: 33461585 PMCID: PMC7814424 DOI: 10.1186/s13023-020-01668-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/22/2020] [Indexed: 11/16/2022] Open
Abstract
Background Phenylketonuria (PKU) is an autosomal recessive inherited disorder characterised by a deficiency in phenylalanine hydroxylase. Untreated, PKU is associated with a wide range of cognitive and psychiatric sequelae. Contemporary management guidelines recommend lifetime dietary control of phenylalanine (Phe) levels, however many individuals who discontinue dietary control subsequently suffer symptoms of anxiety, depression and disturbances to cognition. We undertook a prospective cohort study of patients with early-treated phenylketonuria who had ceased dietary control to test the hypothesis that resumption of dietary control of PKU is associated with improvements in measures of psychiatric morbidity and cognitive functioning. Methods We re-initiated dietary control for early-treated patients with PKU and monitored cognitive and psychiatric outcomes over a twelve-month period. Assessments included objective cognitive function (measured by cognitive proficiency index (CPI)), anxiety and depression scales. General linear mixed model (GLMM) analyses were performed to assess change in psychometric variables from baseline over twelve months after resumption of dietary control. Results A total of nine patients were recruited. Mean age was 33 years (SD = 8.75), five were female. Mean time off dietary control was 19.1 years (SD = 11.3), and mean baseline phenylalanine (Phe) levels were 1108 µmol/L (SD = 293). GLMM analysis demonstrated a positive relationship between CPI and time on diet (b = 0.56 [95% CI = 0.17, 0.95]). Age, time off diet, Phe levels and depression scores were not associated with cognitive function. There was a negative relationship between time on diet and anxiety (b = − 0.88 95% CI = [− 1.26, − 0.50]) and depression ratings (b = − 0.61, 95% CI = [− 0.95, − 0.26]). Conclusions This study demonstrated improvements in cognitive function, anxiety, and depression ratings associated with resumption of dietary control of PKU. Raw Phe levels were not strongly associated with psychiatric or cognitive scores in this cohort. These findings support the importance of lifelong treatment for PKU in improving the cognitive and psychiatric sequelae of the disease.
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Affiliation(s)
- Nicholas M Burgess
- Neuropsychiatry Unit, Royal Melbourne Hospital, Level 2, John Cade Building, Melbourne,, 3050, Australia
| | - Wendy Kelso
- Neuropsychiatry Unit, Royal Melbourne Hospital, Level 2, John Cade Building, Melbourne,, 3050, Australia
| | - Charles B Malpas
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia.,Clinical Outcomes Research Unit (CORe), Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Toby Winton-Brown
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Timothy Fazio
- Department of Metabolic Medicine, Royal Melbourne Hospital, Melbourne, Australia.,Melbourne Medical School, Department of Medicine and Radiology, University of Melbourne, Parkville, Australia
| | - Julie Panetta
- Department of Metabolic Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Gerard De Jong
- Department of Metabolic Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Joanna Neath
- Neuropsychiatry Unit, Royal Melbourne Hospital, Level 2, John Cade Building, Melbourne,, 3050, Australia
| | | | - Dennis Velakoulis
- Neuropsychiatry Unit, Royal Melbourne Hospital, Level 2, John Cade Building, Melbourne,, 3050, Australia.,Melbourne Neuropsychiatry Centre, University of Melbourne and North-Western Mental Health, Melbourne, Australia
| | - Mark Walterfang
- Neuropsychiatry Unit, Royal Melbourne Hospital, Level 2, John Cade Building, Melbourne,, 3050, Australia. .,Melbourne Neuropsychiatry Centre, University of Melbourne and North-Western Mental Health, Melbourne, Australia. .,Florey Institute of Neuroscience and Mental Health, Melbourne, Australia.
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2
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Ashe K, Kelso W, Farrand S, Panetta J, Fazio T, De Jong G, Walterfang M. Psychiatric and Cognitive Aspects of Phenylketonuria: The Limitations of Diet and Promise of New Treatments. Front Psychiatry 2019; 10:561. [PMID: 31551819 PMCID: PMC6748028 DOI: 10.3389/fpsyt.2019.00561] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 07/17/2019] [Indexed: 12/30/2022] Open
Abstract
Phenylketonuria (PKU) is a recessive disorder of phenylalanine metabolism due to mutations in the gene for phenylalanine hydroxylase (PAH). Reduced PAH activity results in significant hyperphenylalaninemia, which leads to alterations in cerebral myelin and protein synthesis, as well as reduced levels of serotonin, dopamine, and noradrenaline in the brain. When untreated, brain development is grossly disrupted and significant intellectual impairment and behavioral disturbance occur. The advent of neonatal heel prick screening has allowed for diagnosis at birth, and the institution of a phenylalanine restricted diet. Dietary treatment, particularly when maintained across neurodevelopment and well into adulthood, has resulted in markedly improved outcomes at a cognitive and psychiatric level for individuals with PKU. However, few individuals can maintain full dietary control lifelong, and even with good control, an elevated risk remains of-in particular-mood, anxiety, and attentional disorders across the lifespan. Increasingly, dietary recommendations focus on maintaining continuous dietary treatment lifelong to optimize psychiatric and cognitive outcomes, although the effect of long-term protein restricted diets on brain function remains unknown. While psychiatric illness is very common in adult PKU populations, very little data exist to guide clinicians on optimal treatment. The advent of new treatments that do not require restrictive dietary management, such as the enzyme therapy Pegvaliase, holds the promise of allowing patients a relatively normal diet alongside optimized mental health and cognitive functioning.
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Affiliation(s)
- Killian Ashe
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Wendy Kelso
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Sarah Farrand
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Julie Panetta
- Statewide Adult Metabolic Service, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Tim Fazio
- Statewide Adult Metabolic Service, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Gerard De Jong
- Statewide Adult Metabolic Service, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Mark Walterfang
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Melbourne Neuropsychiatry Centre, University of Melbourne and North-Western Mental Health, Melbourne, VIC, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
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3
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Rocha JC, MacDonald A. Treatment options and dietary supplements for patients with phenylketonuria. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1536541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Júlio César Rocha
- Centro de Genética Médica, Centro Hospitalar do Porto - CHP, Porto, Portugal
- Faculdade de Ciências da Saúde, Universidade Fernando Pessoa, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
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4
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Zhao H, Xu Y, Lin S, Spain JC, Zhou NY. The molecular basis for the intramolecular migration (NIH shift) of the carboxyl group duringpara-hydroxybenzoate catabolism. Mol Microbiol 2018; 110:411-424. [PMID: 30070064 DOI: 10.1111/mmi.14094] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Huan Zhao
- State Key Laboratory of Microbial Metabolism; and School of Life Sciences & Biotechnology; Shanghai Jiao Tong University; Shanghai 200240 China
| | - Ying Xu
- State Key Laboratory of Microbial Metabolism; and School of Life Sciences & Biotechnology; Shanghai Jiao Tong University; Shanghai 200240 China
| | - Shuangjun Lin
- State Key Laboratory of Microbial Metabolism; and School of Life Sciences & Biotechnology; Shanghai Jiao Tong University; Shanghai 200240 China
| | - Jim C. Spain
- Center for Environmental Diagnostics & Bioremediation; University of West Florida; 11000 University Parkway Pensacola FL 32514-5751 USA
| | - Ning-Yi Zhou
- State Key Laboratory of Microbial Metabolism; and School of Life Sciences & Biotechnology; Shanghai Jiao Tong University; Shanghai 200240 China
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5
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Thomas J, Nguyen-Driver M, Bausell H, Breck J, Zambrano J, Birardi V. Strategies for Successful Long-Term Engagement of Adults With Phenylalanine Hydroxylase Deficiency Returning to the Clinic. JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2017. [DOI: 10.1177/2326409817733015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Janet Thomas
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Heather Bausell
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Jane Breck
- Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
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Maternal Phenylketonuria: Long-term Outcomes in Offspring and Post-pregnancy Maternal Characteristics. JIMD Rep 2015; 21:23-33. [PMID: 25712380 DOI: 10.1007/8904_2014_365] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 08/25/2014] [Accepted: 09/15/2014] [Indexed: 12/12/2022] Open
Abstract
Maternal phenylketonuria (MPKU) is a well-recognized complication of PKU and one of the most potent teratogenic syndromes of pregnancy. Virtually all offspring from untreated pregnancies in women with classic PKU have intellectual disabilities and microcephaly. Congenital heart disease and intrauterine growth retardation occur many times more often than expected in the general population. Control of maternal blood phenylalanine during pregnancy prevents most if not all of these complications. Previous studies demonstrated the benefits of treatment in terms of birth parameters and early development. In this study, physical examinations, a medical history, and neuropsychological evaluation were obtained in 47 children from 24 mothers with PKU who received treatment during pregnancy. Mothers were interviewed and administered an abbreviated IQ test. Associations between maternal factors and offspring outcomes were also analyzed.The 21 male and 26 female offspring ranged in age from 1 month to 26 years with 21 (62%) over 6 years. Results indicated mean intercanthal distances above the 70th percentile. Microcephaly was present in 19% of offspring, with head circumference below the third percentile. None of the offspring had cardiac anomalies. Mean offspring IQ was 94 ± 19, with 12% performing in the range of intellectual disability (IQ < 70). Among children >5 years of age, 25% had learning disabilities, 31% had attention deficit hyperactivity disorder (ADHD), 22% were on ADHD medication, and 34% had a diagnosis of anxiety and/or depression. Among the 24 mothers, 12 reported following the diet for PKU. Only one woman on diet had a blood phenylalanine concentration <360 μmol/L (recommended range) and the majority had indications of poor nutritional status. Mean maternal Full Scale IQ was 94 ± 16 (range = 61-117), with 25% performing in the borderline intellectual range (IQ < 85). Verbal IQ was significantly lower than Performance IQ (p = 0.01, CI 2.7, 16.1). On the self-report Beck Depression Inventory, Second Edition, 25% received scores indicating mild to moderate depression, and on the Beck Anxiety Inventory, 46% reported mild to moderate anxiety. Offspring IQ correlated with maternal metabolic control during pregnancy (r = 0.51), maternal IQ (r = -0.62), and socioeconomic position (r = -0.48). Offspring with ADHD, learning disabilities, or emotional disturbances were more likely to have mothers with anxiety and/or depression. To ensure optimal offspring outcomes, healthcare providers need to assess maternal nutrition, blood phenylalanine concentrations, cognitive abilities, and socioeconomic position. Interventions can then be initiated that reduce psychosocial stressors and enhance adherence to diet and positive parenting, which in turn can lead to better cognitive functioning, behavior, and emotional well-being in their children.
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7
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Setoodeh A, Yarali B, Rabbani A, Khatami S, Shams S. Tetrahydrobiopterin responsiveness in a series of 53 cases of phenylketonuria and hyperphenylalaninemia in Iran. Mol Genet Metab Rep 2015. [PMID: 28649530 PMCID: PMC5471163 DOI: 10.1016/j.ymgmr.2015.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
To determine the prevalence of 6R-Tetrahydrobiopterin (BH4) responsive phenylketonuria (PKU) in 53 cases of patients with various classification of hyperphenylalaninemia and PKU Excluding the BH4 deficient type referring to children's medical center in Iran (phenylalanine 360–2420 μmol/L), the single dose of 20 mg/kg (Kuvan®) and duration of 24 h was used. Results Among the 4 different categories of mild hyperphenylalaninemia requiring treatment, mild, moderate and classic PKU, the BH4 responders were 90%, 35.7%, 5.6% and 0% respectively after 24 h. Conclusion BH4 responsiveness is more prevalent in mild hyperphenylalaninemia and mild PKU patients in Iran.
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Affiliation(s)
- Aria Setoodeh
- Division of Pediatric Endocrinology, Children's Medical Center, Tehran, Iran
| | - Bahram Yarali
- Division of Pediatric Neurology, Children's Medical Center, Tehran, Iran
| | - Ali Rabbani
- Growth and Development Center, Children's Medical Center, Tehran, Iran
| | | | - Sedigheh Shams
- Division of Pathology, Children's Medical Center, Tehran, Iran
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8
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Vockley J, Andersson HC, Antshel KM, Braverman NE, Burton BK, Frazier DM, Mitchell J, Smith WE, Thompson BH, Berry SA. Phenylalanine hydroxylase deficiency: diagnosis and management guideline. Genet Med 2014; 16:188-200. [PMID: 24385074 DOI: 10.1038/gim.2013.157] [Citation(s) in RCA: 400] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 08/29/2013] [Indexed: 11/08/2022] Open
Abstract
Phenylalanine hydroxylase deficiency, traditionally known as phenylketonuria, results in the accumulation of phenylalanine in the blood of affected individuals and was the first inborn error of metabolism to be identified through population screening. Early identification and treatment prevent the most dramatic clinical sequelae of the disorder, but new neurodevelopmental and psychological problems have emerged in individuals treated from birth. The additional unanticipated recognition of a toxic effect of elevated maternal phenylalanine on fetal development has added to a general call in the field for treatment for life. Two major conferences sponsored by the National Institutes of Health held >10 years apart reviewed the state of knowledge in the field of phenylalanine hydroxylase deficiency, but there are no generally accepted recommendations for therapy. The purpose of this guideline is to review the strength of the medical literature relative to the treatment of phenylalanine hydroxylase deficiency and to develop recommendations for diagnosis and therapy of this disorder. Evidence review from the original National Institutes of Health consensus conference and a recent update by the Agency for Healthcare Research and Quality was used to address key questions in the diagnosis and treatment of phenylalanine hydroxylase deficiency by a working group established by the American College of Medical Genetics and Genomics. The group met by phone and in person over the course of a year to review these reports, develop recommendations, and identify key gaps in our knowledge of this disorder. Above all, treatment of phenylalanine hydroxylase deficiency must be life long, with a goal of maintaining blood phenylalanine in the range of 120-360 µmol/l. Treatment has predominantly been dietary manipulation, and use of low protein and phenylalanine medical foods is likely to remain a major component of therapy for the immediate future. Pharmacotherapy for phenylalanine hydroxylase deficiency is in early stages with one approved medication (sapropterin, a derivative of the natural cofactor of phenylalanine hydroxylase) and others under development. Eventually, treatment of phenylalanine hydroxylase deficiency will be individualized with multiple medications and alternative medical foods available to tailor therapy. The primary goal of therapy should be to lower blood phenylalanine, and any interventions, including medications, or combination of therapies that help to achieve that goal in an individual, without other negative consequences, should be considered appropriate therapy. Significant evidence gaps remain in our understanding of the optimum therapies for phenylalanine hydroxylase deficiency, nonphenylalanine effects of these therapies, and long-term sequelae of even well-treated disease in children and adults.
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Affiliation(s)
- Jerry Vockley
- 1] Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA [2] Department of Human Genetics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Hans C Andersson
- Hayward Genetics Center, Tulane University Medical School, New Orleans, Louisiana, USA
| | - Kevin M Antshel
- Department of Psychology, Syracuse University, Syracuse, New York, USA
| | - Nancy E Braverman
- Department of Human Genetics and Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Barbara K Burton
- Department of Pediatrics, Northwestern University Medical School, Chicago, Illinois, USA
| | - Dianne M Frazier
- Department of Pediatrics, University of North Carolina, at Chapel Hill, Chapel Hill, North Carolina, USA
| | - John Mitchell
- Department of Human Genetics and Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Wendy E Smith
- Department of Pediatrics, Maine Medical Center, Portland, Maine, USA1
| | - Barry H Thompson
- The American College of Medical Genetics and Genomics, Bethesda, Maryland, USA
| | - Susan A Berry
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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9
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Bilder DA, Burton BK, Coon H, Leviton L, Ashworth J, Lundy BD, Vespa H, Bakian AV, Longo N. Psychiatric symptoms in adults with phenylketonuria. Mol Genet Metab 2013; 108:155-60. [PMID: 23339767 DOI: 10.1016/j.ymgme.2012.12.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 12/21/2012] [Accepted: 12/21/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The objective of this study was to identify psychiatric symptom patterns reported by individuals with phenylketonuria (PKU) in the outpatient clinic setting. METHODS Brief Symptom Inventory (BSI) results, phenylalanine (phe) levels, and demographic information were collected through a retrospective chart review on 64 participants in the study, "A Diversified Approach for PKU Treatment" (ADAPT). RESULTS The number of BSI scores meeting clinical threshold was significantly elevated for all global indexes and 6 out of 7 symptom subscales in patients with PKU. Recent and mean phe levels were correlated with age at the time of screening (R(2)=0.10, R(2)=0.10, respectively; p<0.05). Psychoticism and the Positive Symptom Distress Index (PSDI) scores were associated with metabolic control. CONCLUSIONS The results of this study demonstrate a positive correlation between phe levels and psychiatric symptom severity in individuals with PKU.
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Affiliation(s)
- Deborah A Bilder
- Department of Psychiatry, Division of Child and Adolescent Psychiatry, University of Utah School of Medicine, Salt Lake City, UT, USA.
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Bone A, Kuehl AK, Angelino AF. A Neuropsychiatric Perspective of Phenylketonuria I: Overview of Phenylketonuria and Its Neuropsychiatric Sequelae. PSYCHOSOMATICS 2012; 53:517-23. [DOI: 10.1016/j.psym.2012.04.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 04/20/2012] [Accepted: 04/23/2012] [Indexed: 11/30/2022]
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Weber SL, Segal S, Packman W. Inborn errors of metabolism: psychosocial challenges and proposed family systems model of intervention. Mol Genet Metab 2012; 105:537-41. [PMID: 22532988 DOI: 10.1016/j.ymgme.2012.01.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Inborn errors of metabolism result in psychosocial crises that challenge individual and familial modes of functioning across the life cycle. Increased stress, mood disorders, interpersonal challenges, decreased quality of life, and grief reactions are all common for patients and their families. To effectively care for these patients, a holistic approach to their care, which incorporates their social context, is essential. Patients and their families need support as they focus on immediate practical demands, grieve over illness-related losses, and reorient future expectations. A family systems based model provides a flexible and individualized approach to care that allows for optimal psychosocial adjustment throughout the disease process.
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Affiliation(s)
- Stacy L Weber
- Palo Alto University, Department of Psychology, Palo Alto, CA 94304, USA.
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12
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Yi S, Kable J, Evatt M, Singh R. A randomized, placebo-controlled, double-blind trial of supplemental docosahexaenoic acid on cognitive processing speed and executive function in females of reproductive age with phenylketonuria: A pilot study. Prostaglandins Leukot Essent Fatty Acids 2011; 85:317-27. [PMID: 22000478 PMCID: PMC4324569 DOI: 10.1016/j.plefa.2011.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2011] [Revised: 09/07/2011] [Accepted: 09/11/2011] [Indexed: 10/16/2022]
Abstract
Low blood docosahexaenoic acid (DHA) is reported in patients with phenylketonuria (PKU); however, the functional implications in adolescents and adults are unknown. This pilot study investigated the effect of supplemental DHA on cognitive performance in 33 females with PKU ages 12-47 years. Participants were randomly assigned to receive DHA (10mg/kg/day) or placebo for 4.5 months. Performance on cognitive processing speed and executive functioning tasks was evaluated at baseline and follow up. Intention-to-treat and per protocol analyses were performed. At follow up, biomarkers of DHA status were significantly higher in the DHA-supplemented group. Performance on the cognitive tasks and reported treatment-related adverse events did not differ. While no evidence of cognitive effect was seen, a larger sample size is needed to be conclusive, which may not be feasible in this population. Supplementation was a safe and effective way to increase biomarkers of DHA status (www.clinicaltrials.gov; Identifier: NCT00892554).
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Affiliation(s)
- S.H.L. Yi
- Emory University, Nutrition & Health Sciences Program of the Graduate Division of Biological & Biomedical Sciences, Atlanta, GA, United States
| | - J.A. Kable
- Emory University, School of Medicine, Department of Pediatrics, United States
| | - M.L. Evatt
- Department of Veterans Affairs Medical Center, Atlanta, GA, United States
- Emory University School of Medicine, Department of Neurology, United States
| | - R.H. Singh
- Emory University, Nutrition & Health Sciences Program of the Graduate Division of Biological & Biomedical Sciences, Atlanta, GA, United States
- Emory University School of Medicine, Department of Human Genetics, 2165 N. Decatur Road, Decatur, GA 30033, United States
- Corresponding author at: Emory University School of Medicine, Department of Human Genetics, 2165 N. Decatur Road, Decatur, GA 30033, United States. Tel.: +1 404 778 8519; fax: +1 404 778 8562. (R.H. Singh)
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13
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Abstract
Currently, there is no international consensus on how patients with phenylketonuria (PKU) (or milder forms of hyperphenylalaninaemia) should be followed in clinical practice. Guidelines concerning the frequency and type of assessments that should be made according to age usually focus on blood phenylalanine concentrations. A need exists for improved guidelines on how to do the follow-up of individuals with PKU/milder forms of hyperphenylalaninaemia. An interdisciplinary approach for monitoring patients is required, involving relevant clinical investigations and regular contact with a clinician and dietician/nutritionist as well as contact with social health worker, psychologist and neurologist, at least at request. This chapter presents a scheme for follow-up. However, by no means this scheme aims to present the one for all time follow-up programme. The scheme for follow-up may rather serve as a start for further discussion in larger groups of professionals in collaboration with patients and their parents. A number of questions remain unanswered, and further research is still needed to fine-tune the management of PKU at different ages.
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van Spronsen FJ. Mild hyperphenylalaninemia: to treat or not to treat. J Inherit Metab Dis 2011; 34:651-6. [PMID: 21347590 PMCID: PMC3183992 DOI: 10.1007/s10545-011-9283-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 12/20/2010] [Accepted: 01/14/2011] [Indexed: 11/21/2022]
Abstract
One of the issues to be resolved in phenylketonuria is whether patients with mild hyperphenylalaninemia need treatment, or in other words, in what patients treatment needs to be started. Do patients need treatment when phenylalanine concentrations in blood are >360 μmol/L or >600 μmol/L? This paper reviews the literature on the outcome of untreated patients with mild hyperphenylalaninemia to try to determine whether outcome is normal. The paper concludes that there is, in fact, only one paper that can be used to answer this question. Therefore, the question is whether we may rely on one paper to draw conclusions or whether more research is necessary to determine whether all patients with phenylalanine concentrations >360 μmol/L or all patients with phenylalanine concentrations >600 μmol/L require treatment.
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15
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Yi SHL, Kable JA, Evatt ML, Singh RH. A cross-sectional study of docosahexaenoic acid status and cognitive outcomes in females of reproductive age with phenylketonuria. J Inherit Metab Dis 2011; 34:455-63. [PMID: 21305356 PMCID: PMC4227302 DOI: 10.1007/s10545-011-9277-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Revised: 01/03/2011] [Accepted: 01/11/2011] [Indexed: 11/29/2022]
Abstract
Diet therapy for phenylketonuria (PKU) requires restricted phenylalanine (Phe) intake, with the majority of protein and other nutrients coming from synthetic medical food. The fatty acid docosahexaenoic acid (DHA) is important in brain development and function; however, there are reports of low blood DHA concentrations in people treated for PKU. Although the implications of this low blood DHA are unclear, subtle cognitive deficits have been reported in those treated early and continuously for PKU. For this study, we investigated the relationship between DHA status and cognitive performance in 41 females 12 years and older with PKU. Participants were attending the baseline visit of a research-based camp or a supplementation trial. We assessed the domains of verbal ability, processing speed, and executive function using standardized tests, and the proportions of DHA in plasma and red blood cell (RBC) total lipids using gas chromatography/mass spectrometry. Percent plasma and RBC total lipid DHA were significantly lower in the participants compared with laboratory controls (P < .001), and participants consumed no appreciable DHA according to diet records. Plasma and RBC DHA both negatively correlated with plasma Phe (P < .02), and performance on the verbal ability task positively correlated with RBC DHA controlling for plasma Phe (R = .32, P = .03). The relationship between DHA and domains related to verbal ability, such as learning and memory, should be confirmed in a controlled trial. Domains of processing speed and executive function may require a larger sample size to clarify any association with DHA.
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Affiliation(s)
- Sarah H. L. Yi
- Nutrition & Health Sciences Program of the Graduate Division of Biological & Biomedical Sciences, Emory University, Atlanta, GA, USA
| | - Julie A. Kable
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Marian L. Evatt
- Department of Veterans Affairs Medical Center, Atlanta, GA, USA
| | - Rani H. Singh
- Nutrition & Health Sciences Program of the Graduate Division of Biological & Biomedical Sciences, Emory University, Atlanta, GA, USA
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, USA
- 2165 N. Decatur Road, Decatur, GA 30033, USA
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16
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Abstract
Phenylketonuria is the most prevalent disorder caused by an inborn error in aminoacid metabolism. It results from mutations in the phenylalanine hydroxylase gene. Phenotypes can vary from a very mild increase in blood phenylalanine concentrations to a severe classic phenotype with pronounced hyperphenylalaninaemia, which, if untreated, results in profound and irreversible mental disability. Neonatal screening programmes identify individuals with phenylketonuria. The initiation of a phenylalanine-restricted diet very soon after birth prevents most of the neuropsychological complications. However, the diet is difficult to maintain and compliance is often poor, especially in adolescents, young adults, and pregnant women. Tetrahydrobiopterin stimulates phenylalanine hydroxylase activity in about 20% of patients, and in those patients serves as a useful adjunct to the phenylalanine-restricted diet because it increases phenylalanine tolerance and allows some dietary freedom. Possible future treatments include enzyme substitution with phenylalanine ammonia lyase, which degrades phenylalanine, and gene therapy to restore phenylalanine hydroxylase activity.
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Affiliation(s)
- Nenad Blau
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital, Zurich, Switzerland.
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Feillet F, van Spronsen FJ, MacDonald A, Trefz FK, Demirkol M, Giovannini M, Bélanger-Quintana A, Blau N. Challenges and pitfalls in the management of phenylketonuria. Pediatrics 2010; 126:333-41. [PMID: 20624808 DOI: 10.1542/peds.2009-3584] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Despite recent advances in the management of phenylketonuria and hyperphenylalaninemia, important questions on the management of this disorder remain unanswered. Consensus exists on the need for neonatal screening and early treatment, yet disagreement persists over threshold levels of blood phenylalanine for starting treatment, target blood phenylalanine levels, and the management of older patient groups. The mainstay of treatment is a phenylalanine-restricted diet, but its application varies between and within countries. Beyond diet treatment, there is a lack of consensus on the use of newer treatments such as tetrahydrobiopterin. Although neonatal screening and early treatment has meant that most well-treated children grow up with near-normal IQ scores, the effect of relaxing metabolic control on cognitive and executive function later in life is still not fully understood. Although it is clear from the available literature that the active control of blood phenylalanine levels is of vital importance, there are other treatment-related factors that affect outcome. A uniform and firmly evidence-based approach to the management of phenylketonuria is required.
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Affiliation(s)
- François Feillet
- Service de Médecine Infantile 1, Centre de Référence des Maladies Héréditaires du Métabolisme, INSERM U 954, CHU Brabois Enfants, Vandoeuvre les Nancy, France
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18
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Rebuffat A, Harding CO, Ding Z, Thöny B. Comparison of adeno-associated virus pseudotype 1, 2, and 8 vectors administered by intramuscular injection in the treatment of murine phenylketonuria. Hum Gene Ther 2010; 21:463-77. [PMID: 19916803 PMCID: PMC2865356 DOI: 10.1089/hum.2009.127] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Accepted: 11/15/2009] [Indexed: 12/20/2022] Open
Abstract
Phenylketonuria (PKU) is caused by hepatic phenylalanine hydroxylase (PAH) deficiency and is associated with systemic accumulation of phenylalanine (Phe). Previously we demonstrated correction of murine PKU after intravenous injection of a recombinant type 2 adeno-associated viral vector pseudotyped with type 8 capsid (rAAV2/8), which successfully directed hepatic transduction and Pah gene expression. Here, we report that liver PAH activity and phenylalanine clearance were also restored in PAH-deficient mice after simple intramuscular injection of either AAV2 pseudotype 1 (rAAV2/1) or rAAV2/8 vectors. Serotype 2 AAV vector (rAAV2/2) was also investigated, but long-term phenylalanine clearance has been observed only for pseudotypes 1 and 8. Therapeutic correction was shown in both male and female mice, albeit more effectively in males, in which correction lasted for the entire period of the experiment (>1 year). Although phenylalanine levels began to rise in female mice at about 8-10 months after rAAV2/8 injection they remained only mildly hyperphenylalaninemic thereafter and subsequent supplementation with synthetic tetrahydrobiopterin resulted in a transient decrease in blood phenylalanine. Alternatively, subsequent administration of a second vector with a different AAV pseudotype to avoid immunity against the previously administrated vector was also successful for long-term treatment of female PKU mice. Overall, this relatively less invasive gene transfer approach completes our previous studies and allows comparison of complementary strategies in the development of efficient PKU gene therapy protocols.
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Affiliation(s)
- Alexandre Rebuffat
- Division of Clinical Chemistry and Biochemistry, Department of Pediatrics, University of Zürich, CH-8032 Zürich, Switzerland
| | - Cary O. Harding
- Department of Molecular and Medical Genetics, Oregon Health and Science University, Portland, OR 97201, USA
| | - Zhaobing Ding
- Division of Clinical Chemistry and Biochemistry, Department of Pediatrics, University of Zürich, CH-8032 Zürich, Switzerland
- Present address: Institute of Bioengineering and Nanotechnology, The Nanos, 138669, Singapore
| | - Beat Thöny
- Division of Clinical Chemistry and Biochemistry, Department of Pediatrics, University of Zürich, CH-8032 Zürich, Switzerland
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van Spronsen FJ, Burgard P. The truth of treating patients with phenylketonuria after childhood: the need for a new guideline. J Inherit Metab Dis 2008; 31:673-9. [PMID: 18690552 DOI: 10.1007/s10545-008-0918-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2008] [Revised: 06/23/2008] [Accepted: 06/25/2008] [Indexed: 11/30/2022]
Abstract
In recent years, an increasing number of national guidelines on the treatment of phenylketonuria (PKU) have emerged. Most of these guidelines are dedicated to the care of children, while less attention is paid to the care of adults, although all guidelines underline the importance of diet for life. This review aims to summarize issues that need to be addressed within a guideline on the treatment of PKU, especially when care for patients beyond childhood is concerned. In this respect, it is of importance that adult patients, both willing and unwilling to be treated, need a guideline for care and follow-up. In PKU there is certainly a need for an improved unified guideline, especially after childhood, although many of the considerations in this article also apply to recommendations for treatment of children. Such a guideline will be a tool to improve treatment in PKU patients but should also include recommendations for collecting data for clinical and research purposes. Guideline development should also focus on nutritional, neuropsychological and psychosocial issues and not only on target plasma phenylalanine concentrations. In addition, guidelines must address not only what has to be done but also how it can be done, thereby improving concordance with the recommendations for treatment and management.
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Affiliation(s)
- F J van Spronsen
- Section of Metabolic Diseases, Beatrix Children's Hospital, University Medical Centre of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.
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20
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Recommendations for Personalized Dietary Adjustments Based on Patient Response to Tetrahydrobiopterin (BH4) in Phenylketonuria. TOP CLIN NUTR 2008. [DOI: 10.1097/01.tin.0000318911.54358.a1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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21
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Abstract
Phenylketonuria (PKU) is an inborn error of metabolism affecting approximately one in every 10,000 infants born in Europe and the USA. Unless treated with a phenylalanine-restricted diet beginning in infancy, PKU can be associated with mental retardation, seizures, eczema and other symptoms. Treatment prevents the most severe consequences of PKU, but compliance with the strict dietary regimen is poor, especially in adolescents and adults. Despite the decline in IQ and increased emotional problems associated with poor adherence to the diet, few novel advances in treatments for PKU have occurred since 1963, when it became the first condition for which newborn screening was available. Sparked in part by acceptance of the policy of lifelong dietary treatment, alternative therapies are being investigated. These include innovations in production of low-protein foods, psychosocial interventions, new medications, enzyme therapy and perhaps even gene therapy in the future.
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Affiliation(s)
- Jennifer Gentile
- Harvard Medical School, Division of Genetics, Children’s Hospital, 1 Autumn Street, Room 526, Boston, MA 02115, USA
| | - Matthew R Fickie
- Harvard-Partners Center for Genetics & Genomics, 77 Avenue Louis Pasteur, NRB Room 250, Boston, MA 02115, USA
| | - Susan Waisbren
- Harvard Medical School, Division of Genetics, Children’s Hospital, 1 Autumn Street, Room 526, Boston, MA 02115, USA
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22
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Levy HL, Milanowski A, Chakrapani A, Cleary M, Lee P, Trefz FK, Whitley CB, Feillet F, Feigenbaum AS, Bebchuk JD, Christ-Schmidt H, Dorenbaum A. Efficacy of sapropterin dihydrochloride (tetrahydrobiopterin, 6R-BH4) for reduction of phenylalanine concentration in patients with phenylketonuria: a phase III randomised placebo-controlled study. Lancet 2007; 370:504-10. [PMID: 17693179 DOI: 10.1016/s0140-6736(07)61234-3] [Citation(s) in RCA: 224] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Early and strict dietary management of phenylketonuria is the only option to prevent mental retardation. We aimed to test the efficacy of sapropterin, a synthetic form of tetrahydrobiopterin (BH4), for reduction of blood phenylalanine concentration. METHODS We enrolled 89 patients with phenylketonuria in a Phase III, multicentre, randomised, double-blind, placebo-controlled trial. We randomly assigned 42 patients to receive oral doses of sapropterin (10 mg/kg) and 47 patients to receive placebo, once daily for 6 weeks. The primary endpoint was mean change from baseline in concentration of phenylalanine in blood after 6 weeks. Analysis was on an intention-to-treat basis. The study is registered with ClinicalTrials.gov, number NCT00104247. FINDINGS 88 of 89 enrolled patients received at least one dose of study drug, and 87 attended the week 6 visit. Mean age was 20 (SD 9.7) years. At baseline, mean concentration of phenylalanine in blood was 843 (300) micromol/L in patients assigned to receive sapropterin, and 888 (323) micromol/L in controls. After 6 weeks of treatment, patients given sapropterin had a decrease in mean blood phenylalanine of 236 (257) micromol/L, compared with a 3 (240) micromol/L increase in the placebo group (p<0.0001). After 6 weeks, 18/41 (44%) patients (95% CI 28-60) in the sapropterin group and 4/47 (9%) controls (95% CI 2-20) had a reduction in blood phenylalanine concentration of 30% or greater from baseline. Blood phenylalanine concentrations fell by about 200 micromol/L after 1 week in the sapropterin group and this reduction persisted for the remaining 5 weeks of the study (p<0.0001). 11/47 (23%) patients in the sapropterin group and 8/41 (20%) in the placebo group experienced adverse events that might have been drug-related (p=0.80). Upper respiratory tract infections were the most common disorder. INTERPRETATION In some patients with phenylketonuria who are responsive to BH4, sapropterin treatment to reduce blood phenylalanine could be used as an adjunct to a restrictive low-phenylalanine diet, and might even replace the diet in some instances.
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Affiliation(s)
- Harvey L Levy
- Children's Hospital Boston and Harvard Medical School, Boston, MA, USA.
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23
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Abstract
Well-established dietary protocols have prevented mental retardation for infants born with phenylketonuria (PKU). Dietary protocols for managing females with PKU in their reproductive years exist but are not followed by most of them. Infants who are born to mothers with PKU who are not on dietary treatment usually have serious medical problems, such as mental retardation, heart defects, and other serious congenital anomalies (e.g., orofacial clefting and bladder exstrophy)--a condition known as maternal PKU syndrome. The focus of this article is to review the pathophysiology, associated developmental issues, and existing management protocols used to manage these two separate but highly connected disorders.
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24
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Abstract
Newborn screening for phenylketonuria began 35 to 40 years ago in most industrialized countries. Because of this initiative, which resulted in early institution of phenylalanine-restricted diets, there are now many young adults with this disease who have normal or near-normal intellectual function. In North America alone, 200 patients with phenylketonuria enter adulthood every year. Most expert panels recommend following a phenylalanine-restricted "diet for life." However, there are few adult physicians dedicated to continuing care of this group, with the possible exception of maternal phenylketonuria. Up to 10% of adults with classic phenylketonuria, and possibly 50% of those with milder variants, may not need treatment; after adolescence, intelligence does not appear to deteriorate, at least into early adulthood, even if diet therapy is discontinued or not in good control. However, neuropsychological and psychosocial problems develop frequently, needing focused and intensive support by health care providers. New investigative methods and treatment options are on the horizon. There is an urgent need for physicians who will orchestrate the care of adults with phenylketonuria.
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Affiliation(s)
- W B Hanley
- Phenylketonuria Programme, Division of Clinical and Biochemical Genetics, Department of Pediatrics and the Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada.
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25
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Bailey NM, Andrews TM. Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD) and the diagnosis of anxiety disorders: a review. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2003; 47 Suppl 1:50-61. [PMID: 14516374 DOI: 10.1046/j.1365-2788.47.s1.25.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND/METHODS During the development of Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities[DC-LD] a literature review of diagnostic issues in anxiety disorders in adults with intellectual disability (ID) was undertaken using electronic and hand searching of journals. RESULTS Relevant general concepts in the general population are reviewed briefly before those related specifically to adults with ID. The literature relating to the diagnosis of specific anxiety disorders is reviewed, although with the exception of obsessive compulsive disorder this consists mainly of case reports. Difficulties in the use of diagnostic systems developed for the general population for the diagnosis of anxiety disorders in adults with ID are frequently commented upon. CONCLUSIONS It is concluded that anxiety disorders are well recognized in adults with ID, although their prevalence is uncertain, and that the use of modified diagnostic criteria may aid further research in this area.
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Affiliation(s)
- N M Bailey
- Somerset Partnership NHS and Social Care Trust, South Somerset Community Team for Adults with Learning Disabilities, Yeovil, Somerset, UK.
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26
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Abstract
Inborn errors of metabolism often present with a variety of psychiatric symptoms. With improved diagnosis and treatment options, many patients have increased lifespans; consequently, issues of long-term quality of life are coming to the forefront. Mental health concerns are among these issues. To demonstrate the connection between the course of metabolic disease and its psychiatric manifestations, four different inborn errors of metabolism are reviewed: phenylketonuria, Wilson disease, acute intermittent porphyria, and metachromatic leukodystrophy.
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Affiliation(s)
- Y Estrov
- Department of Psychiatry, University of California, San Diego, USA
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27
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Williams K. Benefits of normalizing plasma phenylalanine: impact on behaviour and health. A case report. J Inherit Metab Dis 1998; 21:785-90. [PMID: 9870203 DOI: 10.1023/a:1005482732411] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
An elderly man with mental retardation who had never received dietary treatment for his phenylketonuria was placed on a phenylalanine-restricted diet. Social skills and walking gait improved and a new interest in the objects in his environment developed spontaneously. A 2-year analysis of diet, blood plasma phenylalanine levels and behavioural state indicated that small differences in phenylalanine intake impacted his well-being. Of significant note, leg tremor and spasm that precipitated severe self-injury were only reversible when plasma blood phenylalanine concentrations were titrated to near normal ranges and daily phenylalanine intake was strictly controlled. This case may offer a potential explanation for some of the late treatment failures that have been reported and suggest new avenues to explore in the late treatment of PKU.
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Affiliation(s)
- K Williams
- Monson Developmental Center, Springfield, MA 01119, USA
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28
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Ris MD, Weber AM, Hunt MM, Berry HK, Williams SE, Leslie N. Adult psychosocial outcome in early-treated phenylketonuria. J Inherit Metab Dis 1997; 20:499-508. [PMID: 9266385 DOI: 10.1023/a:1005389110739] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Concerns about the psychosocial risk of adults with early-treated phenylketonuria (ETPKU) are predicated on four sources of scientific data: (1) consistent documentation of increased behavioural risk in children with ETPKU; (2) recent evidence of neurocognitive impairment in adults with ETPKU; (3) reports of neuroimaging abnormalities in adults with ETPKU; and (4) preliminary evidence of increased rates of psychiatric disturbance in this population. We studied the psychosocial adjustment of 25 patients, aged 18 years and older, with ETPKU. On most psychosocial outcome measures, patients were indistinguishable from 15 sibling controls. However, on a self-report inventory of psychiatric symptoms, 20% of the patients demonstrated significant morbidity. Psychosocial outcome of these patients was unrelated to concurrent or historical biological dietary disease factors, unlike neurocognitive outcome. A strong relationship was demonstrated, however, between neurocognitive measures and psychosocial morbidity. These findings indicate that a significant minority of patients with ETPKU develop psychosocial difficulties with multiple clinical elevations on a psychiatric inventory. However, most adults with ETPKU cope with the challenges of young adulthood with the same degree of success as their unaffected siblings. Neuropsychological surveillance during childhood and adolescence is important in identifying patients at risk for both neurocognitive and psychosocial morbidity.
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Affiliation(s)
- M D Ris
- Department of Pediatrics, University of Cincinnati College of Medicine, Ohio, USA
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29
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La Malfa G, Notarelli A, Hardoy MC, Bertelli M, Cabras PL. Psychopathology and mental retardation: an Italian epidemiological study using the PIMRA. RESEARCH IN DEVELOPMENTAL DISABILITIES 1997; 18:179-184. [PMID: 9220543 DOI: 10.1016/s0891-4222(97)00002-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The incidence of psychopathology was studied in 176 adult patients with mental retardation through administration of the Psychopathology Instrument for Mentally Retarded Adults (PIMRA). Prevalence of answers relating to anxiety, tendency to live apart and body complaints in the group with mild mental retardation was documented. For people with severe intellectual impairments, mood disturbances with inconsistent behaviours was most prevalent. Implications of the findings are discussed.
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Affiliation(s)
- G La Malfa
- Neurological and Psychiatric Sciences Department, University of Florence, Italy
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30
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Pietz J, Fätkenheuer B, Burgard P, Armbruster M, Esser G, Schmidt H. Psychiatric disorders in adult patients with early-treated phenylketonuria. Pediatrics 1997; 99:345-50. [PMID: 9041285 DOI: 10.1542/peds.99.3.345] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To determine psychiatric disorders in patients with phenylketonuria (PKU) and to test whether biochemical control, intellectual functioning, white matter abnormalities visible on magnetic resonance imaging (MRI), and/or style of parenting influence psychopathology. DESIGN AND SUBJECTS This cross-sectional study consisted of 35 PKU patients 17 to 33 years of age (mean: 22.2). From a total of 67 patients, 3 patients were selected because of other causes of possible brain damage. Then 35 patients were randomly drawn with comparison with a control sample (n = 181) from an epidemiologic study. METHODS We used a standardized, highly structured, face-to-face interview; intelligence quotient (IQ) test; cranial MRI (n = 26); and monitoring of plasma phenylalanine. RESULTS The overall rate of psychiatric disorders was 25.7% in PKU patients and 16.1% in controls. This difference was not statistically significant. The pattern of psychiatric disturbances was different for PKU patients and controls (Fisher's exact test): in PKU patients, externalizing disorders were reduced (PKU: not present, controls: 7.8%), whereas internalizing disorders (PKU: 25.7%, controls: 8.3%) were increased. International Classification of Diseases, version 10, diagnoses were predominantly those of the depressive category and more frequent in women (8 of 18 females and 1 of 17 males). A correlation between IQ and both biochemical control up to 12 years of age and school education of parents was confirmed. No correlation was found between the severity or pattern of psychiatric disturbances and school education of parents, biochemical control, IQ, or the extension of MRI-visible, white matter abnormalities. It was found that a restrictive controlling style of parenting is a risk factor for the development of psychiatric symptoms. CONCLUSIONS Our results support a psychological perspective for the development of psychiatric symptoms in PKU. Thus, optimizing medical treatment necessary to prevent brain damage should be accompanied by psychiatric monitoring and psychological support for the families.
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Affiliation(s)
- J Pietz
- Department of Pediatric Neurology, University of Heidelberg, Germany
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31
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Affiliation(s)
- T. Joseph Kappock
- Department of Chemistry, Yale University, P.O. Box 208107 New Haven, Connecticut 06520-8107
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32
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Affiliation(s)
- P B Acosta
- Ross Products Division, Abbott Laboratories, Columbus, OH 43215, USA
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33
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Güttler F, Guldberg P. Mutations in the phenylalanine hydroxylase gene: genetic determinants for the phenotypic variability of hyperphenylalaninemia. ACTA PAEDIATRICA (OSLO, NORWAY : 1992). SUPPLEMENT 1994; 407:49-56. [PMID: 7766959 DOI: 10.1111/j.1651-2227.1994.tb13451.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Phenylalanine hydroxylase (PAH) deficiency is a heterogeneous disease at the phenotype level. The spectrum of clinical and metabolic phenotypes spans from the potential pathogenic disease classical phenylketonuria (PKU) to the benign condition non-PKU hyperphenylalaninemia (non-PKU HPA). This review provides an introduction to the clinical variants of PAH deficiency, and summarizes our attempts to define the disease at the molecular level and to relate mutation genotype to clinical outcome. Complete genotype determination in a large number of patients with PAH-deficient hyperphenylalaninemia demonstrates that clinical heterogeneity can be explained by a multiplicity of mutations in the PAH gene. Some combinations of mutations are associated with phenylalanine levels fluctuating around the border between PKU and non-PKU HPA. However, certain mutations seem always to cause non-PKU HPA irrespective of the mutation on the second allele and can, therefore, unambiguously be designated as being associated with the non-PKU HPA phenotype. Our results suggest that mutation analysis in newborns presenting with hyperphenylalaninemia can be used for rapid and highly efficient differential diagnosis of PAH deficiency, and for predicting the severity of the disease. These possibilities may facilitate and optimize the management of hyperphenylalaninemia and thereby improve prognosis.
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Affiliation(s)
- F Güttler
- Danish Center for Human Genome Research, John F Kennedy Institute, Glostrup
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34
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Burgard P, Armbruster M, Schmidt E, Rupp A. Psychopathology of patients treated early for phenylketonuria: results of the German collaborative study of phenylketonuria. ACTA PAEDIATRICA (OSLO, NORWAY : 1992). SUPPLEMENT 1994; 407:108-10. [PMID: 7766943 DOI: 10.1111/j.1651-2227.1994.tb13467.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
At the age of 13 years, 60 adolescents, suffering from phenylalaninemia due to hydroxylase deficiency, and their mothers were simultaneously investigated with a standardized psychiatric interview in order to determine the adolescents' psychiatric status. Forty symptoms related to emotional disorders, antisocial and conduct disorders, hyperkinetic syndromes, and specific symptoms like psychophysiological pains, enuresis, encopresis, tics, stereotypies, and eating disorders were examined. Severity level was rated as undisturbed, mild, moderate, and severe disturbance. Comparison with a representative sample of 191 age mates revealed a double rate of moderate disturbances for the PKU sample. There was no association between severity level and sex as well as mean phenylalanine level during the first 13 years of the patients' lives. No PKU specific diagnosis could be determined. WISC-R-IQ below 90 was associated with a threefold risk of more severe disturbance and patients with more than three adverse familial circumstances had a 50% chance of getting a psychiatric diagnosis. It is concluded that the observed disturbances result from stress associated more with the chronic condition than with the increased phenylalanine level.
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Affiliation(s)
- P Burgard
- German Collaborative Study of Children, Department of Pediatrics, University of Berlin
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35
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Levy HL, Waisbren SE. PKU in adolescents: rationale and psychosocial factors in diet continuation. ACTA PAEDIATRICA (OSLO, NORWAY : 1992). SUPPLEMENT 1994; 407:92-7. [PMID: 7766970 DOI: 10.1111/j.1651-2227.1994.tb13463.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Follow-up of early-treated children with PKU has shown that diet discontinuation in childhood presents risks of cognitive and emotional dysfunction in a substantial number of adolescents and young adults. This dysfunction includes IQ loss, mental processing abnormalities, learning difficulties, anxiety and personality disorders. In addition, neurologic deterioration has been reported in several such individuals. As a consequence of this current understanding of PKU, diet continuation, at least through adolescence and in the young adult years, is now recommended. Many centers are extending this to a policy of "diet for life". This represents a major challenge to adolescents and their families. Metabolic control using the criteria applied during childhood is virtually impossible to achieve past 12 years of age. Time constraints, social pressures, financial limitations and growing independence from the family combine to interfere with dietary control. Added to these difficulties are the biological changes during teenage years which reduce phenylalanine tolerance. To meet these challenges, we have identified a number of psychosocial factors that interfere with adherence to medical recommendations. The factors most highly related to metabolic control were social support for the diet and positive perceptions of treatment. This information has led to the development of support programs for adolescents and young adults with PKU.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- H L Levy
- Biochemical Genetics Unit of the Division of Genetics, Children's Hospital, Boston, MA 02115, USA
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36
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Abstract
Twenty-eight young women with phenylketonuria (PKU) attending a Maternal PKU Summer Camp were interviewed and administered a personality inventory, the Minnesota Multiphasic Personality Inventory (MMPI). The 12 young women who were either late-treated (treatment initiated after 90 days) or who had terminated the diet for a period of at least 5 years (the extended exposure group) were compared to the 16 women who were early-treated and had remained continuously on diet (the continuously treated group). Although the mean blood phenylalanine and tyrosine concentrations at the camp for the two groups were comparable (973 +/- 344 and 1033 +/- 284 mumol/L for phenylalanine and 43 +/- 16 and 40 +/- 25 mumol/L for tyrosine), the women in the extended exposure group evidenced significantly greater psychopathology as measured by the MMPI and self-report; thought disorder and mood disturbances were associated with diet termination in PKU.
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Affiliation(s)
- S E Waisbren
- Department of Psychiatry, Harvard Medical School, Boston, MA 02115
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37
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Tuinier S, Verhoeven WM. Psychiatry and mental retardation: towards a behavioural pharmacological concept. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 1993; 37 Suppl 1:16-25. [PMID: 7903880 DOI: 10.1111/j.1365-2788.1993.tb00889.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The rediscovery of psychiatric disorders in mentally retarded subjects has revealed the inadequacy of existing diagnostic and classification systems. The major reason for the limitations of the latter is that such systems have not been developed for application in subjects with substantial intellectual handicaps or other brain dysfunctions. Furthermore, the impact of the different aetiological brain factors is more or less neglected, and so are the specific interrelations between brain dysfunctions and psychiatric symptoms. For a better understanding of the behavioural disorders in mentally retarded subjects, the data from primate studies should be taken into consideration, especially where these suggest a relationship between developmental factors and brain dysfunction. Finally, a functional approach is advocated, linking biological and psychological dysfunctions, that could eventually lead to a so-called functional psychopharmacology.
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Affiliation(s)
- S Tuinier
- Vincent van Gogh Institute for Psychiatry, Venray, The Netherlands
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