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Pintus G, Vitturi N, Carraro G, Lenzini L, Gugelmo G, Fasan I, Madinelli A, Burlina A, Avogaro A, Calò LA. Renal Replacement Therapy in Methylmalonic Aciduria-Related Metabolic Failure: Case Report and Literature Review. J Clin Med 2024; 13:4304. [PMID: 39124570 PMCID: PMC11313451 DOI: 10.3390/jcm13154304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 07/17/2024] [Accepted: 07/18/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Methylmalonic Aciduria (MA) without homocystinuria (or isolated MA) is a group of rare inherited metabolic disorders which leads to the accumulation of methylmalonic acid (MMA), a toxic molecule that accumulates in blood, urine, and cerebrospinal fluid, causing acute and chronic complications including metabolic crises, acute kidney injury (AKI), and chronic kidney disease (CKD). Detailed Case Description: Herein, we report a case of a 39-year-old male with MA and stage IV CKD who experienced acute metabolic decompensation secondary to gastrointestinal infection. The patient underwent a single hemodialysis (HD) session to correct severe metabolic acidosis unresponsive to medical therapy and to rapidly remove MMA. The HD session resulted in prompt clinical improvement and shortening of hospitalization. DISCUSSION MMA accumulation in MA patients causes acute and life-threatening complications, such as metabolic decompensations, and long-term complications such as CKD, eventually leading to renal replacement therapy (RRT). Data reported in the literature show that, overall, all dialytic treatments (intermittent HD, continuous HD, peritoneal dialysis) are effective in MMA removal. HD, in particular, can be useful in the emergency setting to control metabolic crises, even with GFR > 15 mL/min. Kidney and/or liver transplantations are often needed in MA patients. While a solitary transplanted kidney can be rapidly affected by MMA exposure, with a decline in renal function even in the first year of follow-up, the combined liver-kidney transplantation showed better long-term results due to a combination of reduced MMA production along with increased urinary excretion. CONCLUSIONS Early diagnosis, multidisciplinary management and preventive measures are pivotal in MA patients to avoid recurrent AKI episodes and, consequently, to slow down CKD progression.
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Affiliation(s)
- Giovanni Pintus
- Hypertension Unit, Department of Medicine—DIMED, Padova University Hospital, University of Padova, 35128 Padua, Italy; (G.P.); (L.L.)
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Nicola Vitturi
- Division of Metabolic Diseases, Department of Medicine, Padova University Hospital, University of Padova, 35128 Padua, Italy; (N.V.); (G.G.); (A.M.); (A.A.)
| | - Gianni Carraro
- Nephrology, Dialysis and Transplant Unit, Department of Medicine, Padova University Hospital, University of Padova, 35128 Padua, Italy;
| | - Livia Lenzini
- Hypertension Unit, Department of Medicine—DIMED, Padova University Hospital, University of Padova, 35128 Padua, Italy; (G.P.); (L.L.)
| | - Giorgia Gugelmo
- Division of Metabolic Diseases, Department of Medicine, Padova University Hospital, University of Padova, 35128 Padua, Italy; (N.V.); (G.G.); (A.M.); (A.A.)
| | - Ilaria Fasan
- Division of Clinical Nutrition, Department of Medicine—DIMED, Padova University Hospital, University of Padova, 35128 Padua, Italy;
| | - Alberto Madinelli
- Division of Metabolic Diseases, Department of Medicine, Padova University Hospital, University of Padova, 35128 Padua, Italy; (N.V.); (G.G.); (A.M.); (A.A.)
| | - Alberto Burlina
- Division of Inherited Metabolic Diseases, Department of Women’s and Children’s Health, Padova University Hospital, University of Padova, 35128 Padua, Italy;
| | - Angelo Avogaro
- Division of Metabolic Diseases, Department of Medicine, Padova University Hospital, University of Padova, 35128 Padua, Italy; (N.V.); (G.G.); (A.M.); (A.A.)
| | - Lorenzo Arcangelo Calò
- Nephrology, Dialysis and Transplant Unit, Department of Medicine, Padova University Hospital, University of Padova, 35128 Padua, Italy;
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Wiedemann A, Oussalah A, Lamireau N, Théron M, Julien M, Mergnac JP, Augay B, Deniaud P, Alix T, Frayssinoux M, Feillet F, Guéant JL. Clinical, phenotypic and genetic landscape of case reports with genetically proven inherited disorders of vitamin B 12 metabolism: A meta-analysis. Cell Rep Med 2022; 3:100670. [PMID: 35764087 PMCID: PMC9381384 DOI: 10.1016/j.xcrm.2022.100670] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/22/2021] [Accepted: 06/02/2022] [Indexed: 10/31/2022]
Abstract
Inherited disorders of B12 metabolism produce a broad spectrum of manifestations, with limited knowledge of the influence of age and the function of related genes. We report a meta-analysis on 824 patients with a genetically proven diagnosis of an inherited disorder of vitamin B12 metabolism. Gene clusters and age categories are associated with patients' manifestations. The "cytoplasmic transport" cluster is associated with neurological and ophthalmological manifestations, the "mitochondrion" cluster with hypotonia, acute metabolic decompensation, and death, and the "B12 availability" and "remethylation" clusters with anemia and cytopenia. Hypotonia, EEG abnormalities, nystagmus, and strabismus are predominant in the younger patients, while neurological manifestations, such as walking difficulties, peripheral neuropathy, pyramidal syndrome, cerebral atrophy, psychiatric disorders, and thromboembolic manifestations, are predominant in the older patients. These results should prompt systematic checking of markers of vitamin B12 status, including homocysteine and methylmalonic acid, when usual causes of these manifestations are discarded in adult patients.
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Affiliation(s)
- Arnaud Wiedemann
- Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, University of Lorraine, INSERM UMR_S 1256, 54000 Nancy, France; Department of Pediatrics, University Hospital of Nancy, 54000 Nancy, France; Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, 54000 Nancy, France
| | - Abderrahim Oussalah
- Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, University of Lorraine, INSERM UMR_S 1256, 54000 Nancy, France; Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, 54000 Nancy, France; Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, 54000 Nancy, France
| | - Nathalie Lamireau
- Department of Pediatrics, University Hospital of Nancy, 54000 Nancy, France
| | - Maurane Théron
- Department of Pediatrics, University Hospital of Nancy, 54000 Nancy, France
| | - Melissa Julien
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, 54000 Nancy, France
| | | | - Baptiste Augay
- Department of Pediatrics, University Hospital of Nancy, 54000 Nancy, France
| | - Pauline Deniaud
- Department of Pediatrics, University Hospital of Nancy, 54000 Nancy, France
| | - Tom Alix
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, 54000 Nancy, France
| | - Marine Frayssinoux
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, 54000 Nancy, France
| | - François Feillet
- Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, University of Lorraine, INSERM UMR_S 1256, 54000 Nancy, France; Department of Pediatrics, University Hospital of Nancy, 54000 Nancy, France; Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, 54000 Nancy, France
| | - Jean-Louis Guéant
- Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, University of Lorraine, INSERM UMR_S 1256, 54000 Nancy, France; Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, 54000 Nancy, France; Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, 54000 Nancy, France.
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Pang L, Chen J, Yu H, Huang H, Jin B, Wang X, Li H. Case Report: A Rare Case of Thrombotic Microangiopathy Induced by Remethylation Disorders. Front Med (Lausanne) 2022; 9:837253. [PMID: 35308551 PMCID: PMC8924285 DOI: 10.3389/fmed.2022.837253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/31/2022] [Indexed: 11/25/2022] Open
Abstract
In this research, we described a very rare case of thrombotic microangiopathy induced by remethylation disorders. A 16-year-old boy presented to the emergency department with 5 months of weakness and fatigue. He was diagnosed with thrombotic microangiopathy based on clinical manifestation and laboratory information, which showed microangiopathic hemolytic anemia, renal impairment, and thrombocytopenia. After a complex diagnostic workup, the metabolite screening parameters and sequencing results guided us toward the diagnosis of remethylation disorders. The patient was diagnosed with thrombotic microangiopathy induced by remethylation disorders (cblC).
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Affiliation(s)
- Lu Pang
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Jian Chen
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Haiyan Yu
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Haiming Huang
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Bo Jin
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Xin Wang
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haixia Li
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
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Boussetta A, Jellouli M, Maamouri R, Talbi A, Skhiri H, Gargah T. Acute renal failure in a 7-year-old boy: do not miss rare and treatable cause. J Nephrol 2021; 35:1731-1735. [PMID: 34773602 DOI: 10.1007/s40620-021-01190-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/22/2021] [Indexed: 11/28/2022]
Affiliation(s)
- A Boussetta
- Pediatric Nephrology Department, Charles Nicolle Hospital, Tunis, Tunisia. .,Department of Ophthalmology, Habib Thameur Hospital, Tunis, Tunisia. .,Department of Biochemistry, La Rabta Hospital, Tunis, Tunisia. .,Department of Nephrology, Fattouma Bourguiba Hospital, Monastir, Tunisia. .,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - M Jellouli
- Pediatric Nephrology Department, Charles Nicolle Hospital, Tunis, Tunisia.,Department of Ophthalmology, Habib Thameur Hospital, Tunis, Tunisia.,Department of Biochemistry, La Rabta Hospital, Tunis, Tunisia.,Department of Nephrology, Fattouma Bourguiba Hospital, Monastir, Tunisia.,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - R Maamouri
- Department of Ophthalmology, Habib Thameur Hospital, Tunis, Tunisia.,Department of Biochemistry, La Rabta Hospital, Tunis, Tunisia.,Department of Nephrology, Fattouma Bourguiba Hospital, Monastir, Tunisia.,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - A Talbi
- Department of Biochemistry, La Rabta Hospital, Tunis, Tunisia.,Department of Nephrology, Fattouma Bourguiba Hospital, Monastir, Tunisia.,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - H Skhiri
- Department of Nephrology, Fattouma Bourguiba Hospital, Monastir, Tunisia.,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.,Faculty of Medicine of Monastir, University of Monastir, Monastir, Tunisia
| | - T Gargah
- Pediatric Nephrology Department, Charles Nicolle Hospital, Tunis, Tunisia.,Department of Ophthalmology, Habib Thameur Hospital, Tunis, Tunisia.,Department of Biochemistry, La Rabta Hospital, Tunis, Tunisia.,Department of Nephrology, Fattouma Bourguiba Hospital, Monastir, Tunisia.,Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Hemolytic Uremic Syndrome Due to Methylmalonic Acidemia and Homocystinuria in an Infant: A Case Report and Literature Review. CHILDREN-BASEL 2021; 8:children8020112. [PMID: 33562640 PMCID: PMC7915400 DOI: 10.3390/children8020112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/29/2021] [Accepted: 02/02/2021] [Indexed: 12/20/2022]
Abstract
Methylmalonic acidemia and homocystinuria cobalamin C (cblC) type is the most common inborn error of the intracellular cobalamin metabolism, associated with multisystem involvement and high mortality rates, especially in the early-onset form of the disease. Hemolytic uremic syndrome (HUS) is a rare manifestation and needs to be distinguished from other causes of renal thrombotic microangiopathy. We describe a case of a 3-month-old infant, with failure to thrive, hypotonia and pallor, who developed HUS in the setting of cblC deficit, along with dilated cardiomyopathy, and presented delayed response to optic stimulation in visual evoked potentials, as well as enlarged bilateral subarachnoid spaces and delayed myelination in brain magnetic resonance imaging. Renal damage was reversed, while neurodevelopmental profile and eye contact improved after supplementation with parenteral hydroxycobalamin, oral folic acid, betaine and levocarnitine. Homozygous mutation of c.271dupA in the MMACHC gene was ultimately detected. In this report, we highlight the diagnostic challenges as well as the significance of early recognition and multidisciplinary management of this unusual condition. A brief review of published case reports of early-onset cblC deficit and related HUS is depicted, pointing out the initial clinical presentation, signs of renal damage and outcome, MMACHC gene type of mutations and accompanying extra-renal manifestations.
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Philipponnet C, Desenclos J, Brailova M, Aniort J, Kemeny JL, Deville C, Fremeaux-Bacchi V, Souweine B, Heng AE. Cobalamin c deficiency associated with antifactor h antibody-associated hemolytic uremic syndrome in a young adult. BMC Nephrol 2020; 21:96. [PMID: 32164588 PMCID: PMC7066776 DOI: 10.1186/s12882-020-01748-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/27/2020] [Indexed: 02/06/2023] Open
Abstract
Background Thrombotic microangiopathy (TMA) syndromes are characterized by the association of hemolytic anemia, thrombocytopenia and organ injury due to arteriolar and capillary thrombosis. Case presentation We report the first case of adult onset cobalamin C (Cbl C) disease associated with anti-factor H antibody-associated hemolytic uremic syndrome (HUS). A 19-year-old woman was admitted to the nephrology department owing to acute kidney failure, proteinuria, and hemolytic anemia with schizocytes. TMA was diagnosed and plasma exchanges were started in emergency. Exhaustive analyses showed 1) circulating anti factor H antibody and 2) hyperhomocysteinemia, hypomethioninemia and high levels of methylmalonic aciduria pointing towards Clb C disease. Cbl C disease has been confirmed by methylmalonic aciduria and homocystinuria type C protein gene sequencing revealing two heterozygous pathogenic variants. The kidney biopsy showed 1) intraglomerular and intravascular thrombi 2) noticeable thickening of the capillary wall with a duplication aspect of the glomerular basement membrane and a glomerular capillary wall IgM associated with Cbl C disease related TMA. We initiated treatment including hydroxycobalamin, folinic acid, betaine and levocarnitine and Eculizumab. Rituximab infusions were performed allowing a high decrease in anti-factor H antibody rate. Six month after the disease onset, Eculizumab was weaning and vitaminotherapy continued. Outcome was favorable with a dramatic improvement in kidney function. Conclusion TMA with renal involvement can have a complex combination of risk factors including anti-FH autoantibody in the presence of cblC deficiency.
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Affiliation(s)
- C Philipponnet
- Nephrology, Dialysis and Transplantation Department, CHU Clermont Ferrand, University Clermont Auvergne, Clermont Ferrand, France.
| | - J Desenclos
- Nephrology, Dialysis and Transplantation Department, CHU Clermont Ferrand, University Clermont Auvergne, Clermont Ferrand, France
| | - M Brailova
- Biochemistry Department, CHU Clermont Ferrand, University Clermont Auvergne, Clermont Ferrand, France
| | - J Aniort
- Nephrology, Dialysis and Transplantation Department, CHU Clermont Ferrand, University Clermont Auvergne, Clermont Ferrand, France
| | - J L Kemeny
- Anatomy and Pathology Department, CHU Clermont Ferrand, University Clermont Auvergne, Clermont Ferrand, France
| | - C Deville
- Nephrology, Dialysis and Transplantation Department, CHU Clermont Ferrand, University Clermont Auvergne, Clermont Ferrand, France
| | - V Fremeaux-Bacchi
- Assistance Publique-Hopitaux de Paris; Laboratory of Immunology, Georges Pompidou Hospital, Paris, France
| | - B Souweine
- Médecine intensive et réanimation, CHU Clermont Ferrand, University Clermont Auvergne, Clermont Ferrand, France
| | - A E Heng
- Nephrology, Dialysis and Transplantation Department, CHU Clermont Ferrand, University Clermont Auvergne, Clermont Ferrand, France
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Favorable course of previously undiagnosed Methylmalonic Aciduria with Homocystinuria (cblC type) presenting with pulmonary hypertension and aHUS in a young child: a case report. Ital J Pediatr 2018; 44:90. [PMID: 30103768 PMCID: PMC6205155 DOI: 10.1186/s13052-018-0530-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 08/01/2018] [Indexed: 02/08/2023] Open
Abstract
Background Cobalamin C (cblC) defect is the most common inborn error of Vitamin B12 metabolism often causing severe neurological, renal, gastrointestinal and hematological symptoms. Onset with pulmonary hypertension (PAH) and atypical hemolytic-uremic syndrome (aHUS) is rare. Case presentation We describe the case of a 2-years old child, previously in good health, admitted to the hospital with severe respiratory symptoms, rapid worsening of clinical conditions, O2 desaturation and palmo-plantar edema. The patient showed PAH and laboratory findings compatible with aHUS. cblC defect, an inborn error of metabolism, was identified as the cause of all the symptoms described (cardiac, respiratory and renal involvement). Results of neonatal screening for inborn errors of metabolism had been negative. Administration of IM OHCbl (intramuscular hydroxocobalamin), oral betaine and symptomatic treatment with diuretics and anti-hypertensive systemic and pulmonary drugs induced dramatic improvement of both cardiac and systemic symptoms. Conclusions In this case of cblC defect the metabolic treatment completely reverted symptoms of aHUS and PAH. The course was favorable, and the prognosis is what we foresee for the future.
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