1
|
Chanvanichtrakool M, Schreiber JM, Chen WL, Barber J, Zhang A, Ah Mew N, Schulze A, Wilkening G, Nagamani SCS, Gropman A. Unraveling the Link: Seizure Characteristics and Ammonia Levels in Urea Cycle Disorder During Hyperammonemic Crises. Pediatr Neurol 2024; 159:48-55. [PMID: 39121557 DOI: 10.1016/j.pediatrneurol.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 06/02/2024] [Accepted: 06/25/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND This retrospective clinical study performed at a single clinical center aimed to identify the prevalence of seizures in individuals with urea cycle disorders (UCDs) with and without hyperammonemic (HA) crises. In addition, we sought to correlate the utility of biochemical markers and electroencephalography (EEG) in detecting subclinical seizures during HA. METHODS Medical records of individuals with UCDs enrolled in Urea Cycle Disorders Consortium Longitudinal Study (UCDC-LS) (NCT00237315) at Children's National Hospital between 2006 and 2022 were reviewed for evidence of clinical and subclinical seizuress during HA crises, and initial biochemical levels concurrently. RESULTS Eighty-five individuals with UCD were included in the analyses. Fifty-six of the 85 patients (66%) experienced HA crises, with a total of 163 HA events. Seizures are observed in 13% of HA events. Among all HA events with concomitant EEG, subclinical seizures were identified in 27% of crises of encephalopathy without clinical seizures and 53% of crises with clinical seizures. The odds of seizures increases 2.65 (95% confidence interval [CI], 1.51 to 4.66) times for every 100 μmol/L increase in ammonia and 1.14 (95% CI, 1.04 to 1.25) times for every 100 μmol/L increase in glutamine. CONCLUSIONS This study highlights the utility of EEG monitoring during crises for patients presenting with clinical seizures or encephalopathy with HA. During HA events, measurement of initial ammonia and glutamine can help determine risk for seizures and guide EEG monitoring decisions.
Collapse
Affiliation(s)
- Mongkol Chanvanichtrakool
- Faculty of Medicine Siriraj Hospital, Division of Neurology, Department of Pediatrics, Mahidol University, Bangkok, Thailand; Division of Neurogenetics & Developmental Pediatrics, Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, Washington, District of Columbia
| | - John M Schreiber
- Division of Neurogenetics & Developmental Pediatrics, Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, Washington, District of Columbia
| | - Wei-Liang Chen
- Division of Neurogenetics & Developmental Pediatrics, Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, Washington, District of Columbia
| | - John Barber
- Division of Biostatistics and Study Methodology, Children's National Medical Center, Washington, District of Columbia
| | - Anqing Zhang
- Division of Biostatistics and Study Methodology, Children's National Medical Center, Washington, District of Columbia
| | - Nicholas Ah Mew
- Division of Genetics & Metabolism, Children's National Hospital, Washington, District of Columbia
| | - Andreas Schulze
- Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada; Departments of Pediatrics and Biochemistry, University of Toronto, Toronto, Canada
| | - Greta Wilkening
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Andrea Gropman
- Division of Neurogenetics & Developmental Pediatrics, Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, Washington, District of Columbia.
| |
Collapse
|
2
|
You Y, Chen Z, Hu WW. The role of microglia heterogeneity in synaptic plasticity and brain disorders: Will sequencing shed light on the discovery of new therapeutic targets? Pharmacol Ther 2024; 255:108606. [PMID: 38346477 DOI: 10.1016/j.pharmthera.2024.108606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/05/2024] [Accepted: 02/02/2024] [Indexed: 02/18/2024]
Abstract
Microglia play a crucial role in interacting with neuronal synapses and modulating synaptic plasticity. This function is particularly significant during postnatal development, as microglia are responsible for removing excessive synapses to prevent neurodevelopmental deficits. Dysregulation of microglial synaptic function has been well-documented in various pathological conditions, notably Alzheimer's disease and multiple sclerosis. The recent application of RNA sequencing has provided a powerful and unbiased means to decipher spatial and temporal microglial heterogeneity. By identifying microglia with varying gene expression profiles, researchers have defined multiple subgroups of microglia associated with specific pathological states, including disease-associated microglia, interferon-responsive microglia, proliferating microglia, and inflamed microglia in multiple sclerosis, among others. However, the functional roles of these distinct subgroups remain inadequately characterized. This review aims to refine our current understanding of the potential roles of heterogeneous microglia in regulating synaptic plasticity and their implications for various brain disorders, drawing from recent sequencing research and functional studies. This knowledge may aid in the identification of pathogenetic biomarkers and potential factors contributing to pathogenesis, shedding new light on the discovery of novel drug targets. The field of sequencing-based data mining is evolving toward a multi-omics approach. With advances in viral tools for precise microglial regulation and the development of brain organoid models, we are poised to elucidate the functional roles of microglial subgroups detected through sequencing analysis, ultimately identifying valuable therapeutic targets.
Collapse
Affiliation(s)
- Yi You
- Department of Pharmacology and Department of Pharmacy of the Second Affiliated Hospital, Key Laboratory of Medical Neurobiology of the Ministry of Health of China, School of Basic Medical Sciences, Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Zhong Chen
- Department of Pharmacology and Department of Pharmacy of the Second Affiliated Hospital, Key Laboratory of Medical Neurobiology of the Ministry of Health of China, School of Basic Medical Sciences, Zhejiang University School of Medicine, Hangzhou 310058, China; Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Wei-Wei Hu
- Department of Pharmacology and Department of Pharmacy of the Second Affiliated Hospital, Key Laboratory of Medical Neurobiology of the Ministry of Health of China, School of Basic Medical Sciences, Zhejiang University School of Medicine, Hangzhou 310058, China.
| |
Collapse
|
3
|
Russo RS, Gasperini S, Bubb G, Neuman L, Sloan LS, Diaz GA, Enns GM. Efficacy and safety of pegzilarginase in arginase 1 deficiency (PEACE): a phase 3, randomized, double-blind, placebo-controlled, multi-centre trial. EClinicalMedicine 2024; 68:102405. [PMID: 38292042 PMCID: PMC10825663 DOI: 10.1016/j.eclinm.2023.102405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 02/01/2024] Open
Abstract
Background Arginase 1 Deficiency (ARG1-D) is a rare debilitating, progressive, inherited, metabolic disease characterized by marked increases in plasma arginine (pArg) and its metabolites, with increased morbidity, substantial reductions in quality of life, and premature mortality. Effective treatments that can lower arginine and improve clinical outcomes is currently lacking. Pegzilarginase is a novel human arginase 1 enzyme therapy. The present trial aimed to demonstrate efficacy of pegzilarginase on pArg and key mobility outcomes. Methods This Phase 3 randomized, double-blind, placebo-controlled, parallel-group clinical trial (clinicaltrials.govNCT03921541, EudraCT 2018-004837-34), randomized patients with ARG1-D 2:1 to intravenously/subcutaneously once-weekly pegzilarginase or placebo in conjunction with their individualized disease management. It was conducted in 7 countries; United States, United Kingdom, Canada, Austria, France, Germany, Italy. Primary endpoint was change from baseline in pArg after 24 weeks; key secondary endpoints were change from baseline at Week 24 in Gross Motor Function Measure part E (GMFM-E) and 2-min walk test (2MWT). Full Analysis Set was used for the analyses. Findings From 01 May 2019 to 29 March 2021, 32 patients were enrolled and randomized (pegzilarginase, n = 21; placebo, n = 11). Pegzilarginase lowered geometric mean pArg from 354.0 μmol/L to 86.4 μmol/L at Week 24 vs 464.7 to 426.6 μmol/L for placebo (95% CI: -67.1%, -83.5%; p < 0.0001) and normalized levels in 90.5% of patients (vs 0% with placebo). In addition, clinically relevant functional mobility improvements were demonstrated with pegzilarginase treatment. These effects were sustained long-term through additional 24 weeks of subsequent exposure. Pegzilarginase was well-tolerated, with adverse events being mostly transient and mild/moderate in severity. Interpretation These results support pegzilarginase as the first potential treatment to normalize pArg in ARG1-D and achieve clinically meaningful improvements in functional mobility. Funding Aeglea BioTherapeutics.
Collapse
Affiliation(s)
- Rossana Sanchez Russo
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, United States
| | - Serena Gasperini
- Paediatric Department, Fondazione IRCSS San Gerardo dei Tintori, Monza, Italy
| | - Gillian Bubb
- Aeglea BioTherapeutics, Inc., Austin, TX, United States
| | - Linda Neuman
- Aeglea BioTherapeutics, Inc., Austin, TX, United States
| | | | - George A. Diaz
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York City, NY, United States
| | - Gregory M. Enns
- Division of Medical Genetics, Department of Pediatrics, Stanford University School of Medicine and Lucille Packard Children's Hospital, Stanford, CA, United States
| | - PEACE Investigators
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, United States
- Paediatric Department, Fondazione IRCSS San Gerardo dei Tintori, Monza, Italy
- Aeglea BioTherapeutics, Inc., Austin, TX, United States
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York City, NY, United States
- Division of Medical Genetics, Department of Pediatrics, Stanford University School of Medicine and Lucille Packard Children's Hospital, Stanford, CA, United States
| |
Collapse
|
4
|
Pavuluri H, Jose M, Fasaludeen A, Sundaram S, Radhakrishnan A, Banerjee M, Menon RN. Arginase deficiency-An unheralded cause of developmental epileptic encephalopathy. Epileptic Disord 2023; 25:556-561. [PMID: 37243436 DOI: 10.1002/epd2.20081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/21/2023] [Accepted: 05/22/2023] [Indexed: 05/28/2023]
Abstract
Arginase deficiency, which leads to hyperargininaemia is a rare urea cycle disorder caused by a mutation in the ARG1 gene. It is an under-recognized cause of pediatric developmental epileptic encephalopathy, with the key coexistent clinical features being developmental delay or regression and spasticity. Detection of ARG1 gene mutation on genetic testing is the confirmatory diagnostic test. However, elevated levels of plasma arginine and low plasma arginase level can be considered as biochemical markers for diagnosis. We present two cases of arginase deficiency with genetically confirmed ARG1 mutation in one and biochemical confirmation in both. As the spectrum of epilepsy in arginase deficiency has been less explored, we attempted to elucidate the novel electroclinical features and syndromic presentations in these patients. Informed consent was obtained from families of patients. Electroclinical diagnosis was consistent with Lennox Gastaut syndrome (LGS) in the first patient while the second patient had refractory atonic seizures with electrophysiological features consistent with developmental and epileptic encephalopathy. Though primary hyperammonaemia is not a consistent feature, secondary hyperammonaemia in the setting of infectious triggers and drugs like valproate (valproate sensitivity) has been well described as also observed in our patient. In the absence of an overt antecedent in a child with spasticity and seizure disorder, with a progressive course consistent with a developmental epileptic encephalopathy, arginase deficiency merits consideration. Diagnosis often has important therapeutic implications with respect to dietary management and choice of the appropriate antiseizure medications.
Collapse
Affiliation(s)
- Harini Pavuluri
- R Madhavan Nayar Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram, India
| | - Manna Jose
- R Madhavan Nayar Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram, India
| | - Alfiya Fasaludeen
- R Madhavan Nayar Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram, India
| | - Soumya Sundaram
- R Madhavan Nayar Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram, India
| | - Ashalatha Radhakrishnan
- R Madhavan Nayar Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram, India
| | - Moinak Banerjee
- Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, India
| | - Ramshekhar N Menon
- R Madhavan Nayar Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram, India
| |
Collapse
|
5
|
The impact of amino acid metabolism on adult neurogenesis. Biochem Soc Trans 2023; 51:233-244. [PMID: 36606681 DOI: 10.1042/bst20220762] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/02/2022] [Accepted: 12/05/2022] [Indexed: 01/07/2023]
Abstract
Adult neurogenesis is a multistage process during which newborn neurons are generated through the activation and proliferation of neural stem cells (NSCs) and integrated into existing neural networks. Impaired adult neurogenesis has been observed in various neurological and psychiatric disorders, suggesting its critical role in cognitive function, brain homeostasis, and neural repair. Over the past decades, mounting evidence has identified a strong association between metabolic status and adult neurogenesis. Here, we aim to summarize how amino acids and their neuroactive metabolites affect adult neurogenesis. Furthermore, we discuss the causal link between amino acid metabolism, adult neurogenesis, and neurological diseases. Finally, we propose that systematic elucidation of how amino acid metabolism regulates adult neurogenesis has profound implications not only for understanding the biological underpinnings of brain development and neurological diseases, but also for providing potential therapeutic strategies to intervene in disease progression.
Collapse
|
6
|
Diaz GA, Bechter M, Cederbaum SD. The role and control of arginine levels in arginase 1 deficiency. J Inherit Metab Dis 2023; 46:3-14. [PMID: 36175366 PMCID: PMC10091968 DOI: 10.1002/jimd.12564] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/22/2022] [Accepted: 09/27/2022] [Indexed: 01/19/2023]
Abstract
Arginase 1 Deficiency (ARG1-D) is a rare urea cycle disorder that results in persistent hyperargininemia and a distinct, progressive neurologic phenotype involving developmental delay, intellectual disability, and spasticity, predominantly affecting the lower limbs and leading to mobility impairment. Unlike the typical presentation of other urea cycle disorders, individuals with ARG1-D usually appear healthy at birth and hyperammonemia is comparatively less severe and less common. Clinical manifestations typically begin to develop in early childhood in association with high plasma arginine levels, with hyperargininemia (and not hyperammonemia) considered to be the primary driver of disease sequelae. Nearly five decades of clinical experience with ARG1-D and empirical studies in genetically manipulated models have generated a large body of evidence that, when considered in aggregate, implicates arginine directly in disease pathophysiology. Severe dietary protein restriction to minimize arginine intake and diversion of ammonia from the urea cycle are the mainstay of care. Although this approach does reduce plasma arginine and improve patients' cognitive and motor/mobility manifestations, it is inadequate to achieve and maintain sufficiently low arginine levels and prevent progression in the long term. This review presents a comprehensive discussion of the clinical and scientific literature, the effects and limitations of the current standard of care, and the authors' perspectives regarding the past, current, and future management of ARG1-D.
Collapse
Affiliation(s)
- George A Diaz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Stephen D Cederbaum
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
7
|
McNutt MC, Foreman N, Gotway G. Arginase 1 Deficiency in Patients Initially Diagnosed with Hereditary Spastic Paraplegia. Mov Disord Clin Pract 2022; 10:109-114. [PMID: 36698992 PMCID: PMC9847303 DOI: 10.1002/mdc3.13612] [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: 07/18/2022] [Revised: 10/12/2022] [Accepted: 10/23/2022] [Indexed: 11/09/2022] Open
Abstract
Background Arginase 1 Deficiency (ARG1-D) is a rare autosomal recessive urea cycle disorder (UCD) characterized by pathologic elevation of plasma arginine and debilitating manifestations. Based on clinical commonalities and low disease awareness, ARG1-D can be diagnosed as hereditary spastic paraplegia (HSP), leading to treatment delays. Cases A Hispanic woman with unremarkable medical history experienced progressive lower-limb spasticity in her 20s and received a diagnosis of HSP. She developed significant gait abnormalities and is unable to walk without assistance. More recently, two Hispanic brothers with childhood-onset manifestations including lower-limb spasticity, developmental delays, and seizures presented with suspected HSP. All three patients were ultimately diagnosed with ARG1-D based on plasma arginine several-fold above normal levels and loss-of-function ARG1 variants. Disease progression occurred before ARG1-D was correctly diagnosed. Literature Review Retrospective analyses demonstrate that diagnostic delays in ARG1-D are common and can be lengthy. Because of clinical similarities between ARG1-D and HSP, such as insidious onset and progressive spasticity, accurate diagnosis of ARG1-D is challenging. Timely ARG1-D diagnosis is critical because this UCD is a treatable genetic cause of progressive lower-limb spasticity. Conclusions Arginase 1 Deficiency should be considered in HSP differential diagnosis until biochemically/genetically excluded, and should be routinely included in HSP gene panels.
Collapse
|
8
|
Bin Sawad A, Jackimiec J, Bechter M, Trucillo A, Lindsley K, Bhagat A, Uyei J, Diaz GA. Epidemiology, methods of diagnosis, and clinical management of patients with arginase 1 deficiency (ARG1-D): A systematic review. Mol Genet Metab 2022; 137:153-163. [PMID: 36049366 DOI: 10.1016/j.ymgme.2022.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/18/2022] [Accepted: 08/20/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Arginase 1 Deficiency (ARG1-D) is a rare, progressive, metabolic disorder that is characterized by devastating manifestations driven by elevated plasma arginine levels. It typically presents in early childhood with spasticity (predominately affecting the lower limbs), mobility impairment, seizures, developmental delay, and intellectual disability. This systematic review aims to identify and describe the published evidence outlining the epidemiology, diagnosis methods, measures of disease progression, clinical management, and outcomes for ARG1-D patients. METHODS A comprehensive literature search across multiple databases such as MEDLINE, Embase, and a review of clinical studies in ClinicalTrials.gov (with results reported) was carried out per PRISMA guidelines on 20 April 2020 with no date restriction. Pre-defined eligibility criteria were used to identify studies with data specific to patients with ARG1-D. Two independent reviewers screened records and extracted data from included studies. Quality was assessed using the modified Newcastle-Ottawa Scale for non-comparative studies. RESULTS Overall, 55 records reporting 40 completed studies and 3 ongoing studies were included. Ten studies reported the prevalence of ARG1-D in the general population, with a median of 1 in 1,000,000. Frequently reported diagnostic methods included genetic testing, plasma arginine levels, and red blood cell arginase activity. However, routine newborn screening is not universally available, and lack of disease awareness may prevent early diagnosis or lead to misdiagnosis, as the disease has overlapping symptomology with other diseases, such as cerebral palsy. Common manifestations reported at time of diagnosis and assessed for disease progression included spasticity (predominately affecting the lower limbs), mobility impairment, developmental delay, intellectual disability, and seizures. Severe dietary protein restriction, essential amino acid supplementation, and nitrogen scavenger administration were the most commonly reported treatments among patients with ARG1-D. Only a few studies reported meaningful clinical outcomes of these interventions on intellectual disability, motor function and adaptive behavior assessment, hospitalization, or death. The overall quality of included studies was assessed as good according to the Newcastle-Ottawa Scale. CONCLUSIONS Although ARG1-D is a rare disease, published evidence demonstrates a high burden of disease for patients. The current standard of care is ineffective at preventing disease progression. There remains a clear need for new treatment options as well as improved access to diagnostics and disease awareness to detect and initiate treatment before the onset of clinical manifestations to potentially enable more normal development, improve symptomatology, or prevent disease progression.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - George A Diaz
- Division of Medical Genetics and Genomics in the Department of Genetics and Genomic Sciences at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
9
|
Bin Sawad A, Pothukuchy A, Badeaux M, Hodson V, Bubb G, Lindsley K, Uyei J, Diaz GA. Natural history of arginase 1 deficiency and the unmet needs of patients: A systematic review of case reports. JIMD Rep 2022; 63:330-340. [PMID: 35822089 PMCID: PMC9259395 DOI: 10.1002/jmd2.12283] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 03/10/2022] [Accepted: 03/15/2022] [Indexed: 12/20/2022] Open
Abstract
Background Arginase 1 deficiency (ARG1‐D) is a rare, progressive and debilitating urea cycle disorder characterized by clinical manifestations including spasticity, seizures, developmental delay, and intellectual disability. The aim of this systematic review was to identify and summarize the natural history of ARG1‐D and the unmet needs of patients. Methods A comprehensive search of published case reports was undertaken to identify patients with ARG1‐D regardless of interventions, comparisons, or outcomes. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and other evidence‐based medicine literature databases were searched on 20 April 2020. Quality was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist. (PROSPERO registration: CRD42020212142.) Results One hundred and fifty seven ARG1‐D patients were included from 111 publications (good overall quality based on JBI's Checklist); 84 (53.5%) were males. Motor deficits (including spasticity), intellectual disability, and seizures were reported in >50% of the cases. Mean age (SD) at diagnosis was 6.4 years and the laboratory findings most commonly reported to support diagnosis included elevated plasma arginine (81.5%), mutation in ARG1 gene through genetic testing (60%), and absence/reduction of red blood cell arginase activity (51%). Reported management approaches mainly included dietary protein restriction (68%), nitrogen scavengers (45%), and essential amino acid supplements (21%). Author‐reported clinical improvement was documented for 26% of patients, 15% deteriorated, and 19% had limited or no change; notably, no indication of clinical outcome was reported for 40% cases. Conclusion This review illustrates a significant burden of disease and highlights a considerable unmet need for clinically effective treatment options for patients with ARG1‐D.
Collapse
Affiliation(s)
| | | | | | | | | | - Kristina Lindsley
- Health Economics and Outcomes Research ‐ Evidence Synthesis IQVIA, Inc. San Francisco California USA
| | - Jennifer Uyei
- Health Economics and Outcomes Research ‐ Evidence Synthesis IQVIA, Inc. San Francisco California USA
| | - George A. Diaz
- Division of Medical Genetics and Genomics, Department of Genetics and Genomic Sciences Icahn School of Medicine at Mount Sinai New York New York USA
| |
Collapse
|
10
|
Surrer DB, Fromm MF, Maas R, König J. L-Arginine and Cardioactive Arginine Derivatives as Substrates and Inhibitors of Human and Mouse NaCT/Nact. Metabolites 2022; 12:metabo12040273. [PMID: 35448460 PMCID: PMC9026504 DOI: 10.3390/metabo12040273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/17/2022] [Accepted: 03/19/2022] [Indexed: 01/25/2023] Open
Abstract
The uptake transporter NaCT (gene symbol SLC13A5) is expressed in liver and brain and important for energy metabolism and brain development. Substrates include tricarboxylic acid cycle intermediates, e.g., citrate and succinate. To gain insights into the substrate spectrum of NaCT, we tested whether arginine and the cardioactive L-arginine metabolites asymmetric dimethylarginine (ADMA) and L-homoarginine are also transported by human and mouse NaCT/Nact. Using HEK293 cells overexpressing human or mouse NaCT/Nact we characterized these substances as substrates. Furthermore, inhibition studies were performed using the arginine derivative symmetric dimethylarginine (SDMA), the NaCT transport inhibitor BI01383298, and the prototypic substrate citrate. Arginine and the derivatives ADMA and L-homoarginine were identified as substrates of human and mouse NaCT. Transport of arginine and derivatives mediated by human and mouse NaCT were dose-dependently inhibited by SDMA. Whereas BI01383298 inhibited only human NaCT-mediated citrate uptake, it inhibits the uptake of arginine and derivatives mediated by both human NaCT and mouse Nact. In contrast, the prototypic substrate citrate inhibited the transport of arginine and derivatives mediated only by human NaCT. These results demonstrate a so far unknown link between NaCT/Nact and L-arginine and its cardiovascular important derivatives.
Collapse
Affiliation(s)
| | | | | | - Jörg König
- Correspondence: ; Tel.: +49-9131-8522077
| |
Collapse
|
11
|
Nakajima H, Fukuhara S. Two Japanese siblings with arginase-1 deficiency identified using a novel frameshift mutation of ARG1 (p.Lys41Thrfs ∗2). J Pediatr Endocrinol Metab 2022; 35:125-129. [PMID: 34653322 DOI: 10.1515/jpem-2021-0436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 09/27/2021] [Indexed: 11/15/2022]
Abstract
We described two Japanese siblings with arginase-1 (ARG1) deficiency. A 10-year-old girl (the proband and elder sister) was referred to our hospital complaining about her short stature. We diagnosed her with ARG1 deficiency, possibly with elevated levels of blood ammonia and plasma arginine. Her younger sister was found to have spastic paraparesis in her lower extremities and short stature at the age of 4 years. The younger sister also had high levels of plasma arginine, instead of normal levels of blood ammonia. Interestingly, they also prefer to avoid protein-rich foods such as meat, soybeans, cow milk, and dairy products. Genetic testing identified compound heterozygous mutations (c.121_122insCTT [p.Lys41Thrfs∗2] and c.298G>A [p.Asp100Asn]) in the ARG1 gene. The ARG1 mutation of p.Lys41Thrfs∗2 is a novel pathogenic mutation according to open databases and literature.
Collapse
Affiliation(s)
- Hisakazu Nakajima
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Pediatrics, University Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Pediatrics, Midorigaoka Hospital, Takatsuki, Osaka 5611121, Japan
| | - Shota Fukuhara
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Pediatrics, University Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
| |
Collapse
|
12
|
Bin Sawad A, Jackimiec J, Bechter M, Hull M, Yeaw J, Wang Y, Diaz GA. Health care resource utilization in the management of patients with Arginase 1 Deficiency in the US: a retrospective, observational, claims database study. J Med Econ 2022; 25:848-856. [PMID: 35695271 DOI: 10.1080/13696998.2022.2089517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Arginase 1 Deficiency (ARG1-D) is an inherited metabolic disease that leads to significant morbidity. AIMS Despite the recognized burden of disease, information on health care resource utilization (HCRU) among patients with ARG1-D is lacking. We, therefore, sought to evaluate HCRU in ARG1-D relative to non-ARG1-D cohort. MATERIALS AND METHODS Patients with ≥2 ICD-10-CM diagnosis codes for ARG1-D were identified (first diagnosis code = index date) using professional fee claims linked with prescription claims. Patients with ARG1-D were matched 1:1 to a comparator cohort of patients with other medical conditions. Matching variables included age, sex, index year, payer type (Medicare, Medicaid, third party) and geographic region. RESULTS A total of 77 patients met the inclusion criteria for the ARG1-D cohort, with a median age of 15 years, 52% <18 years, and 52% male. Several concurrent diagnoses were recorded at a higher frequency in the ARG1-D cohort versus the matched comparator (spasticity 7 times higher; developmental delay ∼2 times higher; intellectual disability 5 times higher; and seizures 8 times higher). Emergency room visits occurred twice as often, laboratory tests were performed 1.5 times more often, hospitalization was required 3 times more often, and mean length of stay was longer for patients with ARG1-D than the comparator cohort (2.4 days vs. 0.3 days). LIMITATIONS A relatively short study period while the burden of ARG1-D increases over a lifetime due to disease progression. CONCLUSIONS Patients with ARG1-D had significantly greater HCRU compared with those without the disease; they presented with a more extensive comorbidity profile, accessed the health care system more frequently, required more intense monitoring and management, and had more frequent and longer hospitalizations relative to the comparator group. These findings demonstrate a high health burden in ARG1-D that is not mitigated by standard-of-care measures and emphasize the need for improved treatment options.
Collapse
Affiliation(s)
| | | | | | | | | | - Yi Wang
- IQVIA, Inc, Falls Church, VA, USA
| | - George A Diaz
- Division of Medical Genetics and Genomics in the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
13
|
Dorum S, Havalı C. Case series of arginase 1 deficiency: Expanding the spectrum in hyperargininemia. Pediatr Int 2022; 64:e14945. [PMID: 34343381 DOI: 10.1111/ped.14945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/27/2021] [Accepted: 07/26/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Arginase-1 deficiency is a rare, autosomal recessively inherited disorder of the urea cycle. In this study, we describe the clinical and molecular details of six patients who were diagnosed with argininemia, and we describe two of the patients with hyperargininemia who carried two novel variations of the Arginase-1 gene. METHODS The clinical and demographic characteristics of the patients were retrospectively evaluated. RESULTS The ages of the six patients ranged from 1 day to 20 years, and each patient had consanguineous parents. Neuromotor retardation and spastic paraparesis were found in all patients except one, who was diagnosed prenatally. Hyperargininemia was present in all patients. Urinary orotic acid excretion was increased in four of the six patients. The diagnosis was confirmed by genetic analysis in all the patients. Elevated liver enzymes were detected in three patients and blood urea nitrogen levels were normal in each of the six patients. CONCLUSIONS In this study, we describe the two patients with hyperargininemia who carried two novel variations of the ARG1 gene. Also, we present a patient with normal neurodevelopment who was diagnosed prenatally and treated at an early stage of the disease.
Collapse
Affiliation(s)
- Sevil Dorum
- Division of Metabolism, Department of Pediatrics, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - Cengiz Havalı
- Division of Pediatric Neurology, Department of Pediatrics, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| |
Collapse
|
14
|
Squires JE, Alonso EM, Ibrahim SH, Kasper V, Kehar M, Martinez M, Squires RH. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr 2022; 74:138-158. [PMID: 34347674 DOI: 10.1097/mpg.0000000000003268] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ABSTRACT Pediatric acute liver failure (PALF) is a rare, rapidly progressive clinical syndrome with significant morbidity and mortality. The phenotype of PALF manifests as abrupt onset liver dysfunction, which can be brought via disparate etiology. Management is reliant upon intensive clinical care and support, often provided by the collaborative efforts of hepatologists, critical care specialists, and liver transplant surgeons. The construction of an age-based diagnostic approach, the identification of a potential underlying cause, and the prompt implementation of appropriate therapy can be lifesaving; however, the dynamic and rapidly progressive nature of PALF also demands that diagnostic inquiries be paired with monitoring strategies for the recognition and treatment of common complications of PALF. Although liver transplantation can provide a potential life-saving therapeutic option, the ability to confidently determine the certainness that liver transplant is needed for an individual child has been hampered by a lack of adequately tested clinical decision support tools and accurate predictive models. Given the accelerated progress in understanding PALF, we will provide clinical guidance to pediatric gastroenterologists and other pediatric providers caring for children with PALF by presenting the most recent advances in diagnosis, management, pathophysiology, and associated outcomes.
Collapse
Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Estella M Alonso
- Department Pediatric Hepatology, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois, USA
| | - Samar H Ibrahim
- Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vania Kasper
- Division of Pediatric Gastroenterology, Nutrition and Liver Diseases, Hasbro Children's Hospital, Providence, RI
| | - Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Mercedes Martinez
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY
| | - Robert H Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
15
|
Keshavan N, Wood M, Alderson LM, Cortina‐Borja M, Skeath R, McSweeney M, Dixon M, Cleary MA, Footitt E, Batzios S. Clinical status, biochemical profile and management of a single cohort of patients with arginase deficiency. JIMD Rep 2021; 63:123-130. [PMID: 35281666 PMCID: PMC8898719 DOI: 10.1002/jmd2.12266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/22/2021] [Accepted: 12/06/2021] [Indexed: 11/18/2022] Open
Abstract
Arginase deficiency is a rare autosomal recessive urea cycle disorder (UCD) caused by mutations in the ARG1 gene encoding arginase that catalyses the hydrolysis of arginine to ornithine and urea. Patients have hyperargininaemia and progressive neurological impairment but generally suffer fewer metabolic decompensations compared to other UCDs. The objective is to describe the clinical features, biochemical profile, neuroradiological findings and experience of managing children with arginase deficiency. Twenty‐year retrospective review of patient medical records at a single metabolic centre was performed. Six patients from three unrelated families were identified. Mean age at first symptom was 3.3 (1.5–9.0) years, while mean age at diagnosis was 8.8 (0.16–15.92) years. Four patients developed spastic diplegia and two of six with spastic quadriplegia with classical features including hyperreflexia, clonus and toe walking. This resulted in gait abnormalities that have been monitored using the GAITRite system and required Achilles tendon release in five children. Generalised tonic‐clonic seizures and/or absences were present in three of six children and were controlled with anticonvulsants. All patients had moderate learning difficulties. Neuroimaging showed cerebral/cerebellar atrophy in four patients and basal ganglia abnormalities in two. Arginine levels were universally elevated throughout follow‐up despite protein restriction, essential amino acid supplementation and ammonia scavengers, and neurological outcome was generally poor. Two patients died following severe metabolic decompensation in adolescence. Children with arginase deficiency continue to present a management challenge of what appears to be an inexorable course of neurocognitive impairment. Further insight into disease mechanisms may provide insight into novel treatment strategies.
Collapse
Affiliation(s)
- Nandaki Keshavan
- Department of Paediatric Metabolic Medicine Great Ormond Street Hospital NHS Trust London UK
- UCL Great Ormond Street Hospital Institute of Child Health London UK
| | - Michelle Wood
- Department of Physiotherapy Great Ormond Street Hospital NHS Trust London UK
| | - Lucy M. Alderson
- UCL Great Ormond Street Hospital Institute of Child Health London UK
- Department of Physiotherapy Great Ormond Street Hospital NHS Trust London UK
| | - Mario Cortina‐Borja
- Population, Policy and Practice Research and Teaching Department UCL Great Ormond Street Hospital Institute of Child Health London UK
| | - Rachel Skeath
- Department of Dietetics Great Ormond Street Hospital NHS Trust London UK
| | - Mel McSweeney
- Department of Paediatric Metabolic Medicine Great Ormond Street Hospital NHS Trust London UK
| | - Marjorie Dixon
- Department of Dietetics Great Ormond Street Hospital NHS Trust London UK
| | - Maureen A. Cleary
- Department of Paediatric Metabolic Medicine Great Ormond Street Hospital NHS Trust London UK
| | - Emma Footitt
- Department of Paediatric Metabolic Medicine Great Ormond Street Hospital NHS Trust London UK
| | - Spyros Batzios
- Department of Paediatric Metabolic Medicine Great Ormond Street Hospital NHS Trust London UK
| |
Collapse
|
16
|
Kido J, Matsumoto S, Takeshita E, Hayasaka C, Yamada K, Kagawa J, Nakajima Y, Ito T, Iijima H, Endo F, Nakamura K. Current status of surviving patients with arginase 1 deficiency in Japan. Mol Genet Metab Rep 2021; 29:100805. [PMID: 34646736 PMCID: PMC8495172 DOI: 10.1016/j.ymgmr.2021.100805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 12/14/2022] Open
Abstract
Arginase 1 (ARG1) deficiency is a rare urea cycle disorder (UCD), with an estimated frequency of 1 per 2,200,000 births in Japan. Patients with ARG1 deficiency develop symptoms in late infancy or pre-school age with progressive neurological manifestations and sometimes present with severe hepatic disease. We previously investigated the status of UCDs in Japan; however, only one patient was identified as having ARG1 deficiency. Therefore, we aimed to investigate the current status of patients with ARG1 deficiency in 2018–2021 because almost 10 years have passed since the previous study. We present the disease history, clinical outcome, and treatment of five surviving patients with ARG1 deficiency and discuss the features of ARG1 deficiency in Japan. We found that clinicians often face difficulty in diagnosing ARG1 deficiency at the early stage of onset because of interpatient variability in onset time and clinical manifestations. Blood L-arginine and guanidino compounds were considered to be the major factors causing adverse neurodevelopmental outcomes. Therefore, early detection and intervention of ARG1 deficiency is essential for improved neurodevelopmental outcomes. Liver transplantation has been considered an effective treatment option that can dramatically improve the quality of life of patients, prior to the neurological manifestation of symptoms caused by ARG1 deficiency.
Collapse
Affiliation(s)
- Jun Kido
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto City, Kumamoto, Japan
| | - Shirou Matsumoto
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto City, Kumamoto, Japan
| | - Eiko Takeshita
- Department of Pediatrics, Yanagawa Institute for Developmental Disabilities, International University of Health and Welfare, Yanagawa City, Fukuoka, Japan
| | | | - Keitaro Yamada
- Department of Pediatric Neurology, Aichi Developmental Disability Center Central Hospital, Kasugai City, Aichi, Japan
| | - Jiro Kagawa
- Department of Pediatrics, Fujieda Municipal General Hospital, Fujieda City, Shizuoka, Japan
| | - Yoko Nakajima
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake City, Aichi, Japan
| | - Tetsuya Ito
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake City, Aichi, Japan
| | - Hiroyuki Iijima
- Department of General Pediatrics & Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Fumio Endo
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto City, Kumamoto, Japan
| | - Kimitoshi Nakamura
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto City, Kumamoto, Japan
| |
Collapse
|
17
|
Li M, Qin J, Xiong K, Jiang B, Zhang T. Review of arginase as a promising biocatalyst: characteristics, preparation, applications and future challenges. Crit Rev Biotechnol 2021; 42:651-667. [PMID: 34612104 DOI: 10.1080/07388551.2021.1947962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
As a committed step in the urea cycle, arginase cleaves l-arginine to form l-ornithine and urea. l-Ornithine is essential to: cell proliferation, collagen formation and other physiological functions, while the urea cycle itself converts highly toxic ammonia to urea for excretion. Recently, arginase was exploited as an efficient catalyst for the environmentally friendly synthesis of l-ornithine, an abundant nonprotein amino acid that is widely employed as a food supplement and nutrition product. It was also proposed as an arginine-reducing agent in order to treat arginase deficiency and to be a means of depleting arginine to treat arginine auxotrophic tumors. Targeting arginase inhibitors of the arginase/ornithine pathway offers great promise as a therapy for: cardiovascular, central nervous system diseases and cancers with high arginase expression. In this review, recent advances in the characteristics, structure, catalytic mechanism and preparation of arginase were summarized, with a focus being placed on the biotechnical and medical applications of arginase. In particular, perspectives have been presented on the challenges and opportunities for the environmentally friendly utilization of arginase during l-ornithine production and in therapies.
Collapse
Affiliation(s)
- Mengli Li
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, China
| | - Jiufu Qin
- Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, Lyngby, Denmark
| | - Kai Xiong
- Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, Lyngby, Denmark
| | - Bo Jiang
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, China.,International Joint Laboratory on Food Safety, Jiangnan University, Wuxi, Jiangsu, China
| | - Tao Zhang
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, China
| |
Collapse
|
18
|
Bakirtzis C, Smyrni N, Afrantou T, Boziki MK, Grigoriadis N. Spastic gait, intellectual disability and seizures due to a rare mutation causing hyperargininemia. Clin Neurol Neurosurg 2021; 208:106895. [PMID: 34419780 DOI: 10.1016/j.clineuro.2021.106895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 11/28/2022]
Abstract
Hyperargininemia is an autosomal recessive disorder caused by a defect in the arginase I enzyme. We present a case of a 20-year-old male with severe spastic gait, intellectual disability and seizures. Metabolic tests revealed high levels of arginine in blood serum. Hyperargininemia was attributed to a likely pathogenic rare mutation of ARG1 gene [Chr6: g131905002_131905002 G>A (p.Arg308Gln) homozygous] detected in Whole Exome Sequencing resulting in deficiency in arginase I enzyme. Following the diagnosis, the patient has been treated with low protein diet, aminoacid and vitamin supplements. The accumulation of arginine, may contribute to the pathogenesis of severe neurological manifestations, however, low protein intake diet may lead to a favorable outcome. Therefore, clinicians should screen for hyperargininemia in early childhood in case of strong clinical suspicion.
Collapse
Affiliation(s)
- Christos Bakirtzis
- Second Department of Neurology, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Nikoletta Smyrni
- Second Department of Neurology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodora Afrantou
- Second Department of Neurology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Nikolaos Grigoriadis
- Second Department of Neurology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
19
|
Diaz GA, Schulze A, McNutt MC, Leão‐Teles E, Merritt JL, Enns GM, Batzios S, Bannick A, Zori RT, Sloan LS, Potts SL, Bubb G, Quinn AG. Clinical effect and safety profile of pegzilarginase in patients with arginase 1 deficiency. J Inherit Metab Dis 2021; 44:847-856. [PMID: 33325055 PMCID: PMC8359196 DOI: 10.1002/jimd.12343] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 11/30/2020] [Accepted: 12/14/2020] [Indexed: 12/29/2022]
Abstract
Hyperargininemia in patients with arginase 1 deficiency (ARG1-D) is considered a key driver of disease manifestations, including spasticity, developmental delay, and seizures. Pegzilarginase (AEB1102) is an investigational enzyme therapy which is being developed as a novel arginine lowering approach. We report the safety and efficacy of intravenously (IV) administered pegzilarginase in pediatric and adult ARG1-D patients (n = 16) from a Phase 1/2 study (101A) and the first 12 weeks of an open-label extension study (102A). Substantial disease burden at baseline included lower-limb spasticity, developmental delay, and previous hyperammonemic episodes in 75%, 56%, and 44% of patients, respectively. Baseline plasma arginine (pArg) was elevated (median 389 μM, range 238-566) on standard disease management. Once weekly repeat dosing resulted in a median decrease of pArg of 277 μM after 20 cumulative doses (n = 14) with pArg in the normal range (40 to 115 μM) in 50% of patients at 168 hours post dose (mean pegzilarginase dose 0.10 mg/kg). Lowering pArg was accompanied by improvements in one or more key mobility assessments (6MWT, GMFM-D & E) in 79% of patients. In 101A, seven hypersensitivity reactions occurred in four patients (out of 162 infusions administered). Other common treatment-related adverse events (AEs) included vomiting, hyperammonemia, pruritus, and abdominal pain. Treatment-related serious AEs that occurred in five patients were all observed in 101A. Pegzilarginase was effective in lowering pArg levels with an accompanying clinical response in patients with ARG1-D. The improvements with pegzilarginase occurred in patients receiving standard treatment approaches, which suggests that pegzilarginase could offer benefit over existing disease management.
Collapse
Affiliation(s)
- George A. Diaz
- Icahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Andreas Schulze
- University of Toronto and The Hospital for Sick ChildrenTorontoOntarioCanada
| | | | | | | | | | | | - Allison Bannick
- Children's Hospital of MichiganWayne State UniversityDetroitMichiganUSA
| | | | | | | | | | | |
Collapse
|
20
|
Nagamani SCS, Ali S, Izem R, Schady D, Masand P, Shneider BL, Leung DH, Burrage LC. Biomarkers for liver disease in urea cycle disorders. Mol Genet Metab 2021; 133:148-156. [PMID: 33846069 PMCID: PMC8195846 DOI: 10.1016/j.ymgme.2021.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/03/2021] [Accepted: 04/04/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Urea cycle disorders (UCDs) are among the most common inborn errors of liver metabolism. As therapies for hyperammonemia associated with urea cycle dysfunction have improved, chronic complications, such as liver disease, have become increasingly apparent in individuals with UCDs. Liver disease in UCDs may be associated with hepatic inflammation, hepatic fibrosis, portal hypertension, liver cancer and even liver failure. However, except for monitoring serum aminotransferases, there are no clear guidelines for screening and/or monitoring individuals with UCDs for liver disease. Thus, we systematically evaluated the potential utility of several non-invasive biomarkers for liver fibrosis in UCDs. METHODS We evaluated grey-scale ultrasonography, liver stiffness obtained from shear wave elastography (SWE), and various serum biomarkers for hepatic fibrosis and necroinflammation, in a cohort of 28 children and adults with various UCDs. RESULTS Overall, we demonstrate a high burden of liver disease in our participants with 46% of participants having abnormal grey-scale ultrasound pattern of the liver parenchyma, and 52% of individuals having increased liver stiffness. The analysis of serum biomarkers revealed that 32% of participants had elevated FibroTest™ score, a marker for hepatic fibrosis, and 25% of participants had increased ActiTest™ score, a marker for necroinflammation. Interestingly, liver stiffness did not correlate with ultrasound appearance or FibroTest™. CONCLUSION Overall, our results demonstrate the high overall burden of liver disease in UCDs and highlights the need for further studies exploring new tools for identifying and monitoring individuals with UCDs who are at risk for this complication. TRIAL REGISTRATION This study has been registered in ClinicalTrials.gov (NCT03721367).
Collapse
MESH Headings
- Adolescent
- Adult
- Argininosuccinate Lyase/blood
- Biomarkers/blood
- Child
- Child, Preschool
- Elasticity Imaging Techniques
- Female
- Genetic Diseases, Inborn/blood
- Genetic Diseases, Inborn/diagnostic imaging
- Genetic Diseases, Inborn/genetics
- Genetic Diseases, Inborn/pathology
- Humans
- Hyperammonemia/blood
- Hyperammonemia/genetics
- Hyperammonemia/metabolism
- Hyperammonemia/pathology
- Liver/diagnostic imaging
- Liver/pathology
- Liver Cirrhosis/blood
- Liver Cirrhosis/diagnostic imaging
- Liver Cirrhosis/genetics
- Liver Cirrhosis/pathology
- Liver Diseases/blood
- Liver Diseases/genetics
- Liver Diseases/metabolism
- Liver Diseases/pathology
- Male
- Metabolism, Inborn Errors/genetics
- Middle Aged
- Ultrasonography
- Urea Cycle Disorders, Inborn/blood
- Urea Cycle Disorders, Inborn/genetics
- Urea Cycle Disorders, Inborn/metabolism
- Urea Cycle Disorders, Inborn/pathology
- Young Adult
Collapse
Affiliation(s)
- Sandesh C S Nagamani
- Department of Molecular & Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA
| | - Saima Ali
- Department of Molecular & Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Rima Izem
- Division of Biostatistics and Study Methodology, Children's National Research Institute, Silver Spring, MD, USA; Department of Pediatrics, George Washington University, Washington, DC, USA; Department of Epidemiology, George Washington University, Washington, DC, USA
| | - Deborah Schady
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Prakash Masand
- Texas Children's Hospital, Houston, TX, USA; Edward B. Singleton Department of Radiology, Texas Children's Hospital, Houston, TX 77030, USA
| | - Benjamin L Shneider
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX, USA
| | - Daniel H Leung
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX, USA
| | - Lindsay C Burrage
- Department of Molecular & Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA.
| |
Collapse
|
21
|
Kennedy AD, Ford L, Wittmann B, Conner J, Wulff J, Mitchell M, Evans AM, Toal DR. Global biochemical analysis of plasma, serum and whole blood collected using various anticoagulant additives. PLoS One 2021; 16:e0249797. [PMID: 33831088 PMCID: PMC8031419 DOI: 10.1371/journal.pone.0249797] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/25/2021] [Indexed: 01/23/2023] Open
Abstract
Introduction Analysis of blood for the evaluation of clinically relevant biomarkers requires precise collection and sample handling by phlebotomists and laboratory staff. An important consideration for the clinical application of metabolomics are the different anticoagulants utilized for sample collection. Most studies that have characterized differences in metabolite levels in various blood collection tubes have focused on single analytes. We define analyte levels on a global metabolomics platform following blood sampling using five different, but commonly used, clinical laboratory blood collection tubes (i.e., plasma anticoagulated with either EDTA, lithium heparin or sodium citrate, along with no additive (serum), and EDTA anticoagulated whole blood). Methods Using an untargeted metabolomics platform we analyzed five sample types after all had been collected and stored at -80°C. The biochemical composition was determined and differences between the samples established using matched-pair t-tests. Results We identified 1,117 biochemicals across all samples and detected a mean of 1,036 in the sample groups. Compared to the levels of metabolites in EDTA plasma, the number of biochemicals present at statistically significant different levels (p<0.05) ranged from 452 (serum) to 917 (whole blood). Several metabolites linked to screening assays for rare diseases including acylcarnitines, bilirubin and heme metabolites, nucleosides, and redox balance metabolites varied significantly across the sample collection types. Conclusions Our study highlights the widespread effects and importance of using consistent additives for assessing small molecule levels in clinical metabolomics. The biochemistry that occurs during the blood collection process creates a reproducible signal that can identify specimens collected with different anticoagulants in metabolomic studies. Impact statement In this manuscript, normal/healthy donors had peripheral blood collected using multiple anticoagulants as well as serum during a fasted blood draw. Global metabolomics is a new technology being utilized to draw clinical conclusions and we interrogated the effects of different anticoagulants on the levels of biochemicals from each of the donors. Characterizing the effects of the anticoagulants on biochemical levels will help researchers leverage the information using global metabolomics in order to make conclusions regarding important disease biomarkers.
Collapse
Affiliation(s)
- Adam D. Kennedy
- Metabolon, Morrisville, North Carolina, United States of America
- * E-mail:
| | - Lisa Ford
- Metabolon, Morrisville, North Carolina, United States of America
| | - Bryan Wittmann
- Metabolon, Morrisville, North Carolina, United States of America
| | - Jesse Conner
- Metabolon, Morrisville, North Carolina, United States of America
| | - Jacob Wulff
- Metabolon, Morrisville, North Carolina, United States of America
| | - Matthew Mitchell
- Metabolon, Morrisville, North Carolina, United States of America
| | - Anne M. Evans
- Metabolon, Morrisville, North Carolina, United States of America
| | - Douglas R. Toal
- Metabolon, Morrisville, North Carolina, United States of America
| |
Collapse
|
22
|
Huang Y, Sharma R, Feigenbaum A, Lee C, Sahai I, Sanchez Russo R, Neira J, Brooks SS, Jackson KE, Wong D, Cederbaum S, Lacbawan FL, Rowland CM, Tanpaiboon P, Salazar D. Arginine to ornithine ratio as a diagnostic marker in patients with positive newborn screening for hyperargininemia. Mol Genet Metab Rep 2021; 27:100735. [PMID: 33732618 PMCID: PMC7937551 DOI: 10.1016/j.ymgmr.2021.100735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 02/20/2021] [Indexed: 11/27/2022] Open
Abstract
Arginase deficiency is a rare inborn error of metabolism that interrupts the final step of the urea cycle. Untreated individuals often present with episodic hyperammonemia, developmental delay, cognitive impairment, and spasticity in early childhood. The newborn screening (NBS) algorithms for arginase deficiency vary between individual states in the US but often include hyperargininemia and elevated arginine to ornithine (Arg/Orn) ratio. Here, we report 14 arginase deficiency cases, including two patients with positive NBS for hyperargininemia in whom the diagnosis of arginase deficiency was delayed owing to normal or near normal plasma arginine levels on follow-up testing. To improve the detection capability for arginase deficiency, we evaluated plasma Arg/Orn ratio as a secondary diagnostic marker in positive NBS cases for hyperargininemia. We found that plasma Arg/Orn ratio combined with plasma arginine was a better marker than plasma arginine alone to differentiate patients with arginase deficiency from unaffected newborns. In fact, elevated plasma arginine in combination with an Arg/Orn ratio of ≥1.4 identified all 14 arginase deficiency cases. In addition, we examined the impact of age on plasma arginine and ornithine levels. Plasma arginine increased 0.94 μmol/L/day while ornithine was essentially unchanged in the first 31 days of life, which resulted in a similar increasing trend for the Arg/Orn ratio (0.01/day). This study demonstrated that plasma Arg/Orn ratio as a secondary diagnostic marker improved the detection capability for arginase deficiency in newborns with hyperargininemia, which will allow timely detection of arginase deficiency and hence initiation of treatment before developing symptoms.
Collapse
Affiliation(s)
- Yue Huang
- Division of Medical Genetics, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, United States of America
| | - Rajesh Sharma
- Biochemical Genetics, Advanced Diagnostics-Genetics, Genomics and R&D, Quest Diagnostics Nichols Institute, San Juan Capistrano, CA 92675, United States of America
| | - Annette Feigenbaum
- Department of Pediatrics, University of California San Diego and Rady Children's Hospital, San Diego, CA 92161, United States of America
| | - Chung Lee
- Division of Medical Genetics, Lucile Packard Children's Hospital, Stanford School of Medicine, Stanford, CA 94305, United States of America
| | - Inderneel Sahai
- New England Newborn Screening Program, University of Massachusetts, Worcester, MA 01605, United States of America
| | - Rossana Sanchez Russo
- Department of Human Genetics, Emory University, Atlanta, GA 30322, United States of America
| | - Juanita Neira
- Department of Human Genetics, Emory University, Atlanta, GA 30322, United States of America
| | - Susan Sklower Brooks
- Division of Medical Genetics, Department of Pediatrics, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States of America
| | - Kelly E Jackson
- Norton Children's Hospital and University of Louisville School of Medicine, Louisville, KY 40202, United States of America
| | - Derek Wong
- Division of Medical Genetics, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, United States of America
| | - Stephen Cederbaum
- Division of Medical Genetics, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, United States of America.,Departments of Psychiatry and Human Genetics and the Intellectual and Developmental Disabilities Research Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, United States of America
| | - Felicitas L Lacbawan
- Biochemical Genetics, Advanced Diagnostics-Genetics, Genomics and R&D, Quest Diagnostics Nichols Institute, San Juan Capistrano, CA 92675, United States of America
| | - Charles M Rowland
- Biochemical Genetics, Advanced Diagnostics-Genetics, Genomics and R&D, Quest Diagnostics Nichols Institute, San Juan Capistrano, CA 92675, United States of America
| | - Pranoot Tanpaiboon
- Biochemical Genetics, Advanced Diagnostics-Genetics, Genomics and R&D, Quest Diagnostics Nichols Institute, San Juan Capistrano, CA 92675, United States of America
| | - Denise Salazar
- Biochemical Genetics, Advanced Diagnostics-Genetics, Genomics and R&D, Quest Diagnostics Nichols Institute, San Juan Capistrano, CA 92675, United States of America
| |
Collapse
|
23
|
Novel ARG1 variants identified in a patient with arginase 1 deficiency. Hum Genome Var 2021; 8:8. [PMID: 33542202 PMCID: PMC7862390 DOI: 10.1038/s41439-021-00139-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/15/2020] [Accepted: 12/23/2020] [Indexed: 12/31/2022] Open
Abstract
We report a case of a 13-year-old boy with arginase 1 deficiency carrying a new variant in ARG1. Sanger sequencing identified the compound heterozygous variants: NM_000045.4: c.365G>A (p.Trp122*)/c.820G>A (p.Asp274Asn). Although not previously reported, the p.Asp274Asn variant is predicted to have strong pathogenicity because it is located in a highly conserved domain in the protein core and arginase activity in the patient was below measurement sensitivity.
Collapse
|
24
|
Elsayed LEO, Mohammed IN, Hamed AAA, Elseed MA, Salih MAM, Yahia A, Abubaker R, Koko M, Abd Allah ASI, Elbashir MI, Ibrahim ME, Brice A, Ahmed AE, Stevanin G. Novel Homozygous Missense Mutation in the ARG1 Gene in a Large Sudanese Family. Front Neurol 2020; 11:569996. [PMID: 33193012 PMCID: PMC7658625 DOI: 10.3389/fneur.2020.569996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/25/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Arginases catalyze the last step in the urea cycle. Hyperargininemia, a rare autosomal-recessive disorder of the urea cycle, presents after the first year of age with regression of milestones and evolves gradually into progressive spastic quadriplegia and cognitive dysfunction. Genetic studies reported various mutations in the ARG1 gene that resulted in hyperargininemia due to a complete or partial loss of arginase activity. Case Presentation: Five patients from an extended highly consanguineous Sudanese family presented with regression of the acquired milestones, spastic quadriplegia, and mental retardation. The disease onset ranged from 1 to 3 years of age. Two patients had epileptic seizures and one patient had stereotypic clapping. Genetic testing using whole-exome sequencing, done for the patients and a healthy parent, confirmed the presence of a homozygous novel missense variant in the ARG1 gene [GRCh37 (NM_001244438.1): exon 4: g.131902487T>A, c.458T>A, p.(Val153Glu)]. The variant was predicted pathogenic by five algorithms and affected a highly conserved amino acid located in the protein domain ureohydrolase, arginase subgroup. Sanger sequencing of 13 sampled family members revealed complete co-segregation between the variant and the disease distribution in the family in line with an autosomal-recessive mode of inheritance. Biochemical analysis confirmed hyperargininemia in five patients. Conclusion: This study reports the first Sudanese family with ARG1 mutation. The reported variant is a loss-of-function missense mutation. Its pathogenicity is strongly supported by the clinical phenotype, the computational functional impact prediction, the complete co-segregation with the disease, and the biochemical assessment.
Collapse
Affiliation(s)
- Liena E O Elsayed
- Faculty of Medicine, University of Khartoum, Khartoum, Sudan.,College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia.,Institut du Cerveau, INSERM, CNRS, Sorbonne Université, Paris, France
| | | | - Ahlam A A Hamed
- Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | - Maha A Elseed
- Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | - Mustafa A M Salih
- Division of Pediatric Neurology, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ashraf Yahia
- Faculty of Medicine, University of Khartoum, Khartoum, Sudan.,Institut du Cerveau, INSERM, CNRS, Sorbonne Université, Paris, France.,Department of Biochemistry, Faculty of Medicine, National University, Khartoum, Sudan.,Ecole Pratique des Hautes Etudes, EPHE, PSL Research University, Paris, France
| | - Rayan Abubaker
- Department of Molecular Biology, Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Mahmoud Koko
- Department of Neurology and Epileptology, Hertie Institute for Clinical Brain Research, Tuebingen, Germany
| | | | | | - Muntaser E Ibrahim
- Department of Molecular Biology, Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Alexis Brice
- Institut du Cerveau, INSERM, CNRS, Sorbonne Université, Paris, France.,APHP, Pitié-Salpêtrière Hospital, Department of genetics, Paris, France
| | - Ammar E Ahmed
- Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | - Giovanni Stevanin
- Institut du Cerveau, INSERM, CNRS, Sorbonne Université, Paris, France.,Ecole Pratique des Hautes Etudes, EPHE, PSL Research University, Paris, France.,APHP, Pitié-Salpêtrière Hospital, Department of genetics, Paris, France
| |
Collapse
|
25
|
Cui D, Liu Y, Jin L, Hu L, Cao L. A novel compound heterozygous mutation in the arginase-1 gene identified in a Chinese patient with argininemia: A case report. Medicine (Baltimore) 2020; 99:e21634. [PMID: 32769929 PMCID: PMC7593080 DOI: 10.1097/md.0000000000021634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Arginineemia, also known as arginase deficiency, is a rare autosomal recessive metabolic disease. The diagnosis sometimes may be delayed due to atypical clinical manifestations. Confirmation of arginineemia depends on genetic testing. PATIENT CONCERNS We reported a Chinese male child presenting with hyperargininemia and progressive spastic diplegia, who has a novel compound heterozygous mutation in the arginase-1 (ARG1) gene (c.263-266delAGAA, p.K88Rfs45;c.674T>C,p.L216P), respectively, coming from his mother and father. DIAGNOSIS The patient was diagnosed with argininemia with a novel compound homozygous mutation of the ARG1 gene at the age of 12 years. INTERVENTIONS The patient had a low-protein diet (0.8 g/kg/day). Baclofen, eperisone hydrochloride, botulinum toxin, and rehabilitation training were used to improve his spastic diplegia symptoms for 3 months. OUTCOMES The patient's blood arginine was still high after 3 months' low-protein diet. His spastic diplegia symptoms had not aggravated after 3 months' treatment. CONCLUSIONS Argininemia should be considered in a patient with slowly progressive neurologic manifestations, especially spastic diplegia. This case also suggests that tandem mass spectrometry should be used as an effective tool in the validity of neonatal screening for early diagnosis.
Collapse
|
26
|
Häberle J, Burlina A, Chakrapani A, Dixon M, Karall D, Lindner M, Mandel H, Martinelli D, Pintos-Morell G, Santer R, Skouma A, Servais A, Tal G, Rubio V, Huemer M, Dionisi-Vici C. Suggested guidelines for the diagnosis and management of urea cycle disorders: First revision. J Inherit Metab Dis 2019; 42:1192-1230. [PMID: 30982989 DOI: 10.1002/jimd.12100] [Citation(s) in RCA: 249] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/04/2019] [Accepted: 04/08/2019] [Indexed: 02/06/2023]
Abstract
In 2012, we published guidelines summarizing and evaluating late 2011 evidence for diagnosis and therapy of urea cycle disorders (UCDs). With 1:35 000 estimated incidence, UCDs cause hyperammonemia of neonatal (~50%) or late onset that can lead to intellectual disability or death, even while effective therapies do exist. In the 7 years that have elapsed since the first guideline was published, abundant novel information has accumulated, experience on newborn screening for some UCDs has widened, a novel hyperammonemia-causing genetic disorder has been reported, glycerol phenylbutyrate has been introduced as a treatment, and novel promising therapeutic avenues (including gene therapy) have been opened. Several factors including the impact of the first edition of these guidelines (frequently read and quoted) may have increased awareness among health professionals and patient families. However, under-recognition and delayed diagnosis of UCDs still appear widespread. It was therefore necessary to revise the original guidelines to ensure an up-to-date frame of reference for professionals and patients as well as for awareness campaigns. This was accomplished by keeping the original spirit of providing a trans-European consensus based on robust evidence (scored with GRADE methodology), involving professionals on UCDs from nine countries in preparing this consensus. We believe this revised guideline, which has been reviewed by several societies that are involved in the management of UCDs, will have a positive impact on the outcomes of patients by establishing common standards, and spreading and harmonizing good practices. It may also promote the identification of knowledge voids to be filled by future research.
Collapse
Affiliation(s)
- Johannes Häberle
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
| | - Alberto Burlina
- Division of Inborn Metabolic Disease, Department of Pediatrics, University Hospital Padua, Padova, Italy
| | - Anupam Chakrapani
- Department of Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marjorie Dixon
- Dietetics, Great Ormond Street Hospital for Children, NHS Trust, London, UK
| | - Daniela Karall
- Clinic for Pediatrics, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Lindner
- University Children's Hospital, Frankfurt am Main, Germany
| | - Hanna Mandel
- Institute of Human Genetics and metabolic disorders, Western Galilee Medical Center, Nahariya, Israel
| | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children's Hospital, Rome, Italy
| | - Guillem Pintos-Morell
- Centre for Rare Diseases, University Hospital Vall d'Hebron, Barcelona, Spain
- CIBERER_GCV08, Research Institute IGTP, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - René Santer
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anastasia Skouma
- Institute of Child Health, Agia Sofia Children's Hospital, Athens, Greece
| | - Aude Servais
- Service de Néphrologie et maladies métaboliques adulte Hôpital Necker 149, Paris, France
| | - Galit Tal
- The Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Vicente Rubio
- Instituto de Biomedicina de Valencia (IBV-CSIC), Centro de Investigación Biomédica en Red para Enfermedades Raras (CIBERER), Valencia, Spain
| | - Martina Huemer
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
- Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria
| | | |
Collapse
|
27
|
Cornelius LP, Raju V, Julin A. Arginase Deficiency Presenting as Acute Encephalopathy. J Pediatr Neurosci 2019; 14:133-136. [PMID: 31649772 PMCID: PMC6798281 DOI: 10.4103/jpn.jpn_36_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/19/2019] [Accepted: 06/03/2019] [Indexed: 11/20/2022] Open
Abstract
Urea cycle disorders are rare metabolic disorders that present as encephalopathy with hyperammonemia. Arginase deficiency causing hyperargininemia is one among the urea cycle disorders, which usually presents as spastic diplegia. Hyperammonemic encephalopathy is rare in arginase deficiency. We present a rare case of arginase deficiency presenting as acute encephalopathy in a child.
Collapse
Affiliation(s)
- Leema Pauline Cornelius
- Department of Paediatric Neurology, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
| | - Vivekasaravanan Raju
- Department of Paediatric Neurology, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
| | - Asir Julin
- Department of Paediatric Neurology, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
| |
Collapse
|
28
|
Appleton RE, Gupta R. Cerebral palsy: not always what it seems. Arch Dis Child 2019; 104:809-814. [PMID: 30413492 DOI: 10.1136/archdischild-2018-315633] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 10/10/2018] [Accepted: 10/10/2018] [Indexed: 12/17/2022]
Abstract
Cerebral palsy (CP) is not a disease, but a neurological syndrome, a combination of signs and symptoms, some of which may occur in neurodegenerative or metabolic disorders, particularly those with an onset in the first 2 years of life. There are many different causes of the syndrome. All children with CP should undergo brain MRI, even with an identified antenatal or perinatal insult. Children with CP should be referred to a paediatric neurologist or a clinical geneticist, or both, if appropriate and particularly in the absence of a known perinatal cerebral insult, with brain MRI that is reported to be normal, a progression in, or new, signs or where there is a reported 'family history of CP'. Finally, a few of the CP syndromes may be readily treatable and potentially prevent irreversible neurological and cognitive impairment.
Collapse
Affiliation(s)
- Richard E Appleton
- The Roald Dahl EEG Unit, Neurophysiology Department, Alder Hey Children's Health Park, Liverpool, UK
| | - Rajat Gupta
- Department of Neurology, Birmingham Children's Hospital, Birmingham, UK
| |
Collapse
|
29
|
Yahyaoui R, Blasco-Alonso J, Benito C, Rodríguez-García E, Andrade F, Aldámiz-Echevarría L, Muñoz-Hernández MC, Vega AI, Pérez-Cerdá C, García-Martín ML, Pérez B. A new metabolic disorder in human cationic amino acid transporter-2 that mimics arginase 1 deficiency in newborn screening. J Inherit Metab Dis 2019; 42:407-413. [PMID: 30671984 DOI: 10.1002/jimd.12063] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/30/2018] [Indexed: 11/06/2022]
Abstract
PURPOSE We report a patient with a human cationic amino acid transporter 2 (CAT-2) defect discovered due to a suspected arginase 1 deficiency observed in newborn screening (NBS). METHODS A NBS sample was analyzed using tandem mass spectrometry. Screen results were confirmed by plasma and urine amino acid quantification. Molecular diagnosis was done using clinical exome sequencing. Dimethylated arginines were determined by HPLC and nitrate/nitrite levels by a colorimetric assay. The metabolomic profile was analyzed using 1D nuclear magnetic resonance spectroscopy. RESULTS A Spanish boy of nonconsanguineous parents had high arginine levels in a NBS blood sample. Plasma and urinary cationic amino acids were high. Arginase enzyme activity in erythrocytes was normal and no pathogenic mutations were identified in the ARG1 gene. Massive parallel sequencing detected two loss-of-function mutations in the SLC7A2 gene. Currently, the child receives a protein-controlled diet of 1.2 g/kg/day with protein-and amino-acid free infant formula, 30 g/day, and is asymptomatic. CONCLUSION We identified a novel defect in human CAT-2 due to biallelic pathogenic variants in the SLC7A2 gene. The characteristic biochemical profile includes high plasma and urine arginine, ornithine, and lysine levels. NBS centers should know of this disorder since it can be detected in arginase 1 deficiency screening.
Collapse
Affiliation(s)
- Raquel Yahyaoui
- Laboratory of Metabolic Disorders and Newborn Screening Center of Eastern Andalusia, Málaga Regional University Hospital, Málaga, Spain
- Grupo Endocrinología y Nutrición, Diabetes y Obesidad, Instituto de Investigación Biomédica de Málaga-IBIMA
| | | | - Carmen Benito
- Department of Genetics, Málaga Regional University Hospital, Málaga, Spain
| | - Enrique Rodríguez-García
- Grupo Endocrinología y Nutrición, Diabetes y Obesidad, Instituto de Investigación Biomédica de Málaga-IBIMA
- Laboratorios Vircell, SL, Granada, Spain
| | - Fernando Andrade
- Metabolomics Platform, Metabolism Group, BioCruces Health Research Institute, CIBERER, Barakaldo, Spain
| | - Luis Aldámiz-Echevarría
- Metabolomics Platform, Metabolism Group, BioCruces Health Research Institute, CIBERER, Barakaldo, Spain
| | - María C Muñoz-Hernández
- BIONAND, Andalusian Center for Nanomedicine and Biotechnology, Junta de Andalucía, Universidad de Málaga, Málaga, Spain
| | - Ana I Vega
- Centro Diagnóstico de Enfermedades Moleculares (CEDEM), Centro de Biología Molecular, Universidad Autónoma de Madrid, CIBERER, idiPAZ, Madrid, Spain
| | - Celia Pérez-Cerdá
- Centro Diagnóstico de Enfermedades Moleculares (CEDEM), Centro de Biología Molecular, Universidad Autónoma de Madrid, CIBERER, idiPAZ, Madrid, Spain
| | - María L García-Martín
- BIONAND, Andalusian Center for Nanomedicine and Biotechnology, Junta de Andalucía, Universidad de Málaga, Málaga, Spain
| | - Belén Pérez
- Centro Diagnóstico de Enfermedades Moleculares (CEDEM), Centro de Biología Molecular, Universidad Autónoma de Madrid, CIBERER, idiPAZ, Madrid, Spain
| |
Collapse
|
30
|
Krystofova J, Pathipati P, Russ J, Sheldon A, Ferriero D. The Arginase Pathway in Neonatal Brain Hypoxia-Ischemia. Dev Neurosci 2019; 40:437-450. [PMID: 30995639 PMCID: PMC6784534 DOI: 10.1159/000496467] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/20/2018] [Indexed: 12/11/2022] Open
Abstract
Brain damage after hypoxia-ischemia (HI) occurs in an age-dependent manner. Neuroprotective strategies assumed to be effective in adults might have deleterious effects in the immature brain. In order to create effective therapies, the complex pathophysiology of HI in the developing brain requires exploring new mechanisms. Critical determinants of neuronal survival after HI are the extent of vascular dysfunction, inflammation, and oxidative stress, followed later by tissue repair. The key enzyme of these processes in the human body is arginase (ARG) that acts via the bioavailability of nitric oxide, and the synthesis of polyamines and proline. ARG is expressed throughout the brain in different cells. However, little is known about the effect of ARG in pathophysiological states of the brain, especially hypoxia-ischemia. Here, we summarize the role of ARG during neurodevelopment as well as in various brain pathologies.
Collapse
Affiliation(s)
- Jana Krystofova
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA,
| | - Praneeti Pathipati
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Jeffrey Russ
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Ann Sheldon
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Donna Ferriero
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
31
|
Yucel H, Kasapkara ÇS, Akcaboy M, Aksoy E, Sahin GE, Derinkuyu BE, Senel S, Ceylaner S. Recurrent hepatic failure and status epilepticus: an uncommon presentation of hyperargininemia. Metab Brain Dis 2018; 33:1775-1778. [PMID: 29961243 DOI: 10.1007/s11011-018-0281-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 06/26/2018] [Indexed: 10/28/2022]
Abstract
Argininemia is a rare hereditary disease due to a deficiency of hepatic arginase, which is the last enzyme of the urea cycle and hydrolyzes arginine to ornithine and urea. Herein we report a patient with arginase I (ARG1) deficiency who presented with recurrent nonconvulsive status epilepticus and liver failure. A novel homozygous frameshift mutation c.703_707delGGACTinsAGACTGGACC (p.G235Rfs*20) was detected.
Collapse
Affiliation(s)
- Husniye Yucel
- Department of Pediatrics, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Babur Caddesi No. 44, 06080, Altındag, Ankara, Turkey
| | - Çiğdem Seher Kasapkara
- Department of Pediatric Metabolism and Nutrition, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Meltem Akcaboy
- Department of Pediatrics, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Babur Caddesi No. 44, 06080, Altındag, Ankara, Turkey.
| | - Erhan Aksoy
- Department of Pediatric Neurology, Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Gülseren Evirgen Sahin
- Department of Pediatric Gastroenterology, Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Betul Emine Derinkuyu
- Department of Pediatric Radiology, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Saliha Senel
- Department of Pediatrics, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Babur Caddesi No. 44, 06080, Altındag, Ankara, Turkey
| | | |
Collapse
|
32
|
A serum metabolomics signature of hypothermia fatalities involving arginase activity, tryptophan content, and phosphatidylcholine saturation. Int J Legal Med 2018; 133:889-898. [PMID: 30229331 DOI: 10.1007/s00414-018-1937-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 09/11/2018] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Hypothermia is a potentially lethal condition whose postmortem diagnosis is often complex to perform due to the absence of pathognomonic lesions and biomarkers. Our first study of human serum and urinary metabolome in hypothermia fatalities sought novel biomarkers with better diagnostic performances than those already existing. MATERIAL AND METHOD Thirty-two cases of hypothermia deaths and 16 cases excluding known antemortem exposure to cold or postmortem elements suggesting hypothermia were selected. A targeted metabolomic study allowing the detection and quantitation of 188 metabolites was performed on collected serum and urine using direct flow injection (FIA) and liquid chromatography (LC) separation, both coupled to tandem mass spectrometry (MS/MS). Amino acid quantification was also carried on using an in-house LC-MS/MS method in order to replicate the results obtained with the metabolomic study. RESULTS A discriminant metabolic signature allowing a clear separation between hypothermia and control groups was obtained in the serum. This signature was characterized by increased arginase activity and fatty acid unsaturation along with decreased levels of tryptophan in hypothermia fatalities compared to controls. By contrast, no discriminant metabolic signature separating hypothermia from control fatalities was found in urines. DISCUSSION The serum metabolic signature of hypothermia fatalities herein observed pointed toward metabolic adaptations that likely aimed at heat production enhancement, endothelial function, and cell membrane fluidity preservation. Novel biomarkers potentially useful in a hypothermia diagnosis were also identified.
Collapse
|
33
|
Liu XW, Tang CL, Zheng H, Wu JX, Wu F, Mo YY, Liu X, Zhu HJ, Yin CL, Cheng B, Ruan JX, Song FM, Chen ZN, Song H, Guo HW, Liang YH, Su ZH. Investigation of the hepatoprotective effect of Corydalis saxicola Bunting on carbon tetrachloride-induced liver fibrosis in rats by 1H-NMR-based metabonomics and network pharmacology approaches. J Pharm Biomed Anal 2018; 159:252-261. [DOI: 10.1016/j.jpba.2018.06.065] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/30/2018] [Accepted: 06/30/2018] [Indexed: 12/30/2022]
|
34
|
Jichlinski A, Clarke L, Whitehead MT, Gropman A. "Cerebral Palsy" in a Patient With Arginase Deficiency. Semin Pediatr Neurol 2018; 26:110-114. [PMID: 29961498 DOI: 10.1016/j.spen.2017.03.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Inborn errors of metabolism (IEMs) are thought to present in infancy with acute decompensation including feeding intolerance and vomiting, lethargy, and coma. Most practitioners assume that children will be diagnosed in their first months of life. However, certain IEMs present more insidiously, and occasionally children fail to receive newborn screening resulting in delayed diagnoses, as metabolic and genetic disorders are overlooked causes of cognitive and neurologic deficits. Although signs and symptoms may be present but subtle, careful and detailed history taking, particularly of a child's diet and neurologic medical history, in addition to certain physical examination findings may suggest a diagnosis that is later supported by laboratory and radiographic testing. We present the case of an 11-year-old girl who presented with a diagnosis of cerebral palsy, seizure disorder, and concerns of fatigue and increasing seizure frequency. During hospitalization, she was found to have hyperammonemia, and a diagnosis of arginase deficiency was made. More thorough review of her previous records may have raised suspicion for IEM earlier.
Collapse
Affiliation(s)
- Amanda Jichlinski
- From the Department of Pediatrics, Children's National Health System, Washington, DC.
| | - Lindsay Clarke
- Department of Neurology, Children's National Health System, Washington, DC
| | | | - Andrea Gropman
- Department of Neurology, Children's National Health System, Washington, DC
| |
Collapse
|
35
|
Abstract
Once based mainly in paediatrics, inborn errors of metabolism (IEM), or inherited metabolic disorders (IMD) represent a growing adult medicine specialty. Individually rare these conditions have currently, a collective estimated prevalence of >1:800. Diagnosis has improved through expanded newborn screening programs, identification of potentially affected family members and greater awareness of symptomatic presentations in adolescence and in adulthood. Better survival and reduced mortality from previously lethal and debilitating conditions means greater numbers transition to adulthood. Pregnancy, once contraindicated for many, may represent a challenging but successful outcome. Successful pregnancies are now reported in a wide range of IEM. Significant challenges remain, given the biological stresses of pregnancy, parturition and the puerperium. Known diagnoses allow preventive and pre-emptive management. Unrecognized metabolic disorders especially, remain a preventable cause of maternal and neonatal mortality and morbidity. Increased awareness of these conditions amongst all clinicians is essential to expedite diagnosis and manage appropriately. This review aims to describe normal adaptations to pregnancy and discuss how various types of IEM may be affected. Relevant translational research and clinical experience will be reviewed with practical management aspects cited. Based on current literature, the impact of maternal IEM on mother and/or foetus, as well as how foetal IEM may affect the mother, will be considered. Insights gained from these rare disorders to more common conditions will be explored. Gaps in the literature, unanswered questions and steps to enhance further knowledge and systematically capture experience, such as establishment of an IEM-pregnancy registry, will be summarized.
Collapse
Affiliation(s)
- Gisela Wilcox
- School of Medical Sciences, Faculty of Biology Medicine & Health, University of Manchester, Manchester, UK.
- The Mark Holland Metabolic Unit, Salford Royal Foundation NHS Trust, Salford, Greater Manchester, M6 8HD, UK.
| |
Collapse
|
36
|
Cai X, Yu D, Xie Y, Zhou H. Argininemia as a cause of severe chronic stunting and partial growth hormone deficiency (PGHD): A case report. Medicine (Baltimore) 2018; 97:e9880. [PMID: 29443755 PMCID: PMC5839826 DOI: 10.1097/md.0000000000009880] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/21/2018] [Accepted: 01/24/2018] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Argininemia is an autosomal recessive inherited disorder of the urea cycle. Because of its atypical symptoms in early age, diagnosis can be delayed until the typical chronic manifestations - including spastic diplegia, deterioration in cognitive function, and epilepsy - appear in later childhood. PATIENT CONCERNS A Chinese boy initially presented with severe stunting and partial growth hormone deficiency (PGHD) at 3 years old and was initially treated with growth hormone replacement therapy. Seven years later (at 10 years old), he presented with spastic diplegia, cognitive function lesions, epilepsy, and peripheral neuropathy. DIAGNOSES Ultimately, the patient was diagnosed with argininemia with homozygous mutation (c.32T>C) of the ARG1 gene at 10 years old. Blood tests showed mildly elevated blood ammonia and creatine kinase, and persistently elevated bilirubin. INTERVENTIONS Protein intake was limited to 0.8 g/kg/day, citrulline (150-200 mg [kg d]) was prescribed. OUTCOMES The patient's mental state and vomiting had improved after 3 months treatment. At 10 years and 9 month old, his height and weight had reached 121cm and 22kg, respectively, but his spastic diplegia symptoms had not improved. LESSONS This case demonstrates that stunting and PGHD that does not respond to growth hormone replacement therapy might hint at inborn errors of metabolism (IEM). IEM should also be considered in patients with persistently elevated bilirubin with or without abnormal liver transaminase, as well as elevated blood ammonia and creatine kinase, in the absence of hepatic disease.
Collapse
Affiliation(s)
- Xiaotang Cai
- Department of Pediatrics, West China Second University Hospital
- Key Laboratory of Obstetric and Gynaecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, Sichuan, China
| | - Dan Yu
- Department of Pediatrics, West China Second University Hospital
- Key Laboratory of Obstetric and Gynaecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, Sichuan, China
| | - Yongmei Xie
- Department of Pediatrics, West China Second University Hospital
- Key Laboratory of Obstetric and Gynaecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, Sichuan, China
| | - Hui Zhou
- Department of Pediatrics, West China Second University Hospital
- Key Laboratory of Obstetric and Gynaecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
37
|
Koo M, Lipshutz GS, Cederbaum SD, Lassman C. Biopsy-proven Hepatocellular Carcinoma in a 53-year-old Woman With Arginase Deficiency. Pediatr Dev Pathol 2017; 20:517-521. [PMID: 29187023 DOI: 10.1177/1093526617697058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Arginase 1 deficiency, the least common urea cycle disorder, commonly presents with childhood-onset spastic paraplegia, progressive neurologic impairment, epilepsy, and developmental delay or regression. Biopsy-proven cirrhosis and hepatocellular carcinoma diagnosed via clinical and imaging studies (but without biopsy confirmation) have been previously reported. We report, herein, a case of a 53-year-old woman with arginase 1 deficiency who developed symptoms of "abdominal bloating." Imaging studies (ultrasound and magnetic resonance imaging) demonstrated 2 dominant hepatic masses, measuring 5.9 cm and 5.7 cm in greatest dimensions and located in hepatic segments 5 and 6, respectively. Core biopsies of the lesions demonstrated well-differentiated hepatocellular carcinoma. Immunohistochemistry performed on the segment 5 lesion was negative for arginase 1. This report represents, to the best of our knowledge, the first case of biopsy-proven hepatocellular carcinoma in an individual with arginase 1 deficiency.
Collapse
Affiliation(s)
- Matthew Koo
- 1 Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, California
| | - Gerald S Lipshutz
- 2 Department of Surgery, David Geffen School of Medicine at UCLA, California.,3 Intellectual and Developmental Disabilities Research Center at UCLA, California
| | - Stephen D Cederbaum
- 3 Intellectual and Developmental Disabilities Research Center at UCLA, California
| | - Charles Lassman
- 1 Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, California
| |
Collapse
|
38
|
Bigot A, Tchan MC, Thoreau B, Blasco H, Maillot F. Liver involvement in urea cycle disorders: a review of the literature. J Inherit Metab Dis 2017; 40:757-769. [PMID: 28900784 DOI: 10.1007/s10545-017-0088-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 08/13/2017] [Accepted: 08/29/2017] [Indexed: 12/20/2022]
Abstract
Urea cycle disorders (UCDs) are inborn errors of metabolism of the nitrogen detoxification pathway and encompass six principal enzymatic deficiencies. The aging of UCD patients leads to a better knowledge of the long-term natural history of the condition and to the reporting of previously unnoticed manifestations. Despite historical evidence of liver involvement in UCDs, little attention has been paid to this organ until recently. Hence, we reviewed the available scientific evidence on acute and chronic liver dysfunction and liver carcinogenesis in UCDs and discuss their pathophysiology. Overall, liver involvement, such as acute liver failure or steatotic-like disease, which may evolve toward cirrhosis, has been reported in all six main UCDs. Excessive glycogen storage is also a prominent histologic feature, and hypoglycemia has been reported in citrin deficiency. Hepatocarcinomas seem frequent in some UCDs, such as in citrin deficiency, and can sometimes occur in non-cirrhotic patients. UCDs may differ in liver involvement according to the enzymatic deficiency. Ornithine transcarbamylase deficiency may be associated more with acute liver failure and argininosuccinic aciduria with chronic liver failure and cirrhosis. Direct toxicity of metabolites, downstream metabolic deficiencies, impaired tricarboxylic acid cycle, oxidative stress, mitochondrial dysfunction, energy deficit, and putative toxicity of therapies combine in various ways to cause the different liver diseases reported.
Collapse
Affiliation(s)
- Adrien Bigot
- CHRU de Tours, service médecine interne, Tours, France.
- CHRU de Tours, centre de référence des maladies héréditaires du métabolisme, Tours, France.
- Department of Genetic Medicine, Westmead Hospital, Sydney, Australia.
- Service de Médecine Interne, Hôpital Bretonneau, 2, boulevard Tonnelle, 37044, Tours, France.
| | - Michel C Tchan
- Department of Genetic Medicine, Westmead Hospital, Sydney, Australia
| | - Benjamin Thoreau
- CHRU de Tours, service médecine interne, Tours, France
- CHRU de Tours, centre de référence des maladies héréditaires du métabolisme, Tours, France
- Université François Rabelais, Tours, France
- UMR INSERM U 1069, Tours, France
| | - Hélène Blasco
- CHRU de Tours, centre de référence des maladies héréditaires du métabolisme, Tours, France
- Université François Rabelais, Tours, France
- CHRU de Tours, service de biochimie-biologie moléculaire, Tours, France
- UMR INSERM U930, 37000, Tours, France
| | - François Maillot
- CHRU de Tours, service médecine interne, Tours, France
- CHRU de Tours, centre de référence des maladies héréditaires du métabolisme, Tours, France
- Université François Rabelais, Tours, France
- UMR INSERM U 1069, Tours, France
| |
Collapse
|
39
|
Therrell BL, Currier R, Lapidus D, Grimm M, Cederbaum SD. Newborn screening for hyperargininemia due to arginase 1 deficiency. Mol Genet Metab 2017; 121:308-313. [PMID: 28659245 DOI: 10.1016/j.ymgme.2017.06.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 06/11/2017] [Accepted: 06/11/2017] [Indexed: 12/31/2022]
Abstract
Hyperargininemia caused by Arginase 1 deficiency is a rare disorder of the urea cycle that can be diagnosed by elevation of arginine in newborn screening blood spots when analyzed by tandem mass spectrometry. Hyperargininemia is currently included as a secondary target on the U.S. Recommended Uniform Screening Panel, which directly influences state-based newborn screening. Because of the apparent low disease frequency and lack of case detection and treatment data, detailed attention has not been given to a model newborn screening algorithm including appropriate analytical cutoff values for disease indicators. In this paper we assess the frequency of hyperargininemia in the U.S. identified by newborn screening to date and document the current status and variability of hyperargininemia newborn screening across U.S. newborn screening programs. We also review other data that support improved screening efficacy by utilizing the arginine/ornithine ratio and other amino acid ratios as discriminators in the screening algorithm. Analysis of archived California screening data showed that an arginine cutoff of 50μM combined with an arginine/ornithine ratio of 1.4 would have resulted in a recall rate of 0.01%. Using an arginine cutoff of 60μM and an arginine/(phenylalanine x leucine) ratio of 1.4, reportedly used in one screening program, or the R4S Tool Runner, would have resulted in a recall rate of <0.005%. All 9 diagnosed patients would have been found for either protocol. Thus, use of appropriate ratios as part of the screening algorithm has the potential to increase both screening sensitivity and specificity. Improved newborn screening effectiveness should lead to better case detection and more rapid treatment to lower plasma arginine levels hence improving long term outcome of individuals with hyperargininemia.
Collapse
Affiliation(s)
- Bradford L Therrell
- National Newborn Screening and Global Resource Center, Austin, TX, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States.
| | - Robert Currier
- Genetic Disease Screening Program, California Department of Public Heath, Richmond, CA, United States
| | | | | | - Stephen D Cederbaum
- Departments of Psychiatry, Pediatrics and Human Genetics, The Intellectual Development and Disabilities Research Center, University of California, Los Angeles, CA, United States
| |
Collapse
|
40
|
Analytes related to erythrocyte metabolism are reliable biomarkers for preanalytical error due to delayed plasma processing in metabolomics studies. Clin Chim Acta 2017; 466:105-111. [PMID: 28069401 DOI: 10.1016/j.cca.2017.01.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 12/14/2016] [Accepted: 01/05/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Delaying plasma separation after phlebotomy (processing delay) can cause perturbations of numerous small molecule analytes. This poses a major challenge to the clinical application of metabolomics analyses. In this study, we further define the analyte changes that occur during processing delays and generate a model for the post hoc detection of this preanalytical error. METHODS Using an untargeted metabolomics platform we analyzed EDTA-preserved plasma specimens harvested after processing delays lasting from minutes to days. Identified biomarkers were tested on (i) a test-set of samples exposed to either minimal (n=28) or long delays (n=40) and (ii) samples collected in a clinical setting for metabolomics analysis (n=141). RESULTS A total of 149 of 803 plasma analytes changed significantly during processing delays lasting 0-20h. Biomarkers related to erythrocyte metabolism, e.g., 5-oxoproline, lactate, and an ornithine/arginine ratio, were the strongest predictors of plasma separation delays, providing 100% diagnostic accuracy in the test set. Together these biomarkers could accurately predict processing delays >2h in a pilot study and we found evidence of sample mishandling in 4 of 141 clinically derived specimens. CONCLUSIONS Our study highlights the widespread effects of processing delays and proposes that erythrocyte metabolism creates a reproducible signal that can identify mishandled specimens in metabolomics studies.
Collapse
|
41
|
Stasyuk N, Gayda G, Yepremyan H, Stepien A, Gonchar M. Fluorometric enzymatic assay of l-arginine. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2017; 170:184-190. [PMID: 27450117 DOI: 10.1016/j.saa.2016.07.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 07/07/2016] [Accepted: 07/09/2016] [Indexed: 06/06/2023]
Abstract
The enzymes of l-arginine (further - Arg) metabolism are promising tools for elaboration of selective methods for quantitative Arg analysis. In our study we propose an enzymatic method for Arg assay based on fluorometric monitoring of ammonia, a final product of Arg splitting by human liver arginase I (further - arginase), isolated from the recombinant yeast strain, and commercial urease. The selective analysis of ammonia (at 415nm under excitation at 360nm) is based on reaction with o-phthalaldehyde (OPA) in the presence of sulfite in alkali medium: these conditions permit to avoid the reaction of OPA with any amino acid. A linearity range of the fluorometric arginase-urease-OPA method is from 100nM to 6μМ with a limit of detection of 34nM Arg. The method was used for the quantitative determination of Arg in the pooled sample of blood serum. The obtained results proved to be in a good correlation with the reference enzymatic method and literature data. The proposed arginase-urease-OPA method being sensitive, economical, selective and suitable for both routine and micro-volume formats, can be used in clinical diagnostics for the simultaneous determination of Arg as well as urea and ammonia in serum samples.
Collapse
Affiliation(s)
- Nataliya Stasyuk
- Institute of Cell Biology, National Academy of Science of Ukraine, Drahomanov Str. 14/16, 79005 Lviv, Ukraine
| | - Galina Gayda
- Institute of Cell Biology, National Academy of Science of Ukraine, Drahomanov Str. 14/16, 79005 Lviv, Ukraine.
| | - Hasmik Yepremyan
- Scientific and Production Center "Armbiotechnology", National Academy of Sciences of Armenia, Armenia
| | - Agnieszka Stepien
- Department of Dietetics, Institute of Nursing and Health Sciences, Medical Faculty, University of Rzeszow, Al. mjr.W.Kopisto 2 a, 35-310 Rzeszów, Poland; Centre for Innovative Research in Medical and Natural Sciences, Medical Faculty of the University of Rzeszow, Warzywna 1A, 35-310 Rzeszów, Poland
| | - Mykhailo Gonchar
- Institute of Cell Biology, National Academy of Science of Ukraine, Drahomanov Str. 14/16, 79005 Lviv, Ukraine
| |
Collapse
|
42
|
Huemer M, Carvalho DR, Brum JM, Ünal Ö, Coskun T, Weisfeld-Adams JD, Schrager NL, Scholl-Bürgi S, Schlune A, Donner MG, Hersberger M, Gemperle C, Riesner B, Ulmer H, Häberle J, Karall D. Clinical phenotype, biochemical profile, and treatment in 19 patients with arginase 1 deficiency. J Inherit Metab Dis 2016; 39:331-340. [PMID: 27038030 DOI: 10.1007/s10545-016-9928-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 03/10/2016] [Accepted: 03/15/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Arginase 1 (ARG1) deficiency is a rare urea cycle disorder (UCD). This hypothesis-generating study explored clinical phenotypes, metabolic profiles, molecular genetics, and treatment approaches in a cohort of children and adults with ARG1 deficiency to add to our understanding of the underlying pathophysiology. METHODS Clinical data were retrieved retrospectively from physicians using a questionnaire survey. Plasma aminoacids, guanidinoacetate (GAA), parameters indicating oxidative stress and nitric oxide (NO) synthesis as well as asymmetric dimethylarginine (ADMA) were measured at a single study site. RESULTS Nineteen individuals with ARG1 deficiency and 19 matched controls were included in the study. In patients, paraparesis, cognitive impairment, and seizures were significantly associated suggesting a shared underlying pathophysiology. In patients plasma GAA exceeded normal ranges and plasma ADMA was significantly elevated. Compared to controls, nitrate was significantly higher, and the nitrite:nitrate ratio significantly lower in subjects with ARG1 deficiency suggesting an advantage for NO synthesis by inducible NO synthase (iNOS) over endothelial NOS (eNOS). Logistic regression revealed no significant impact of any of the biochemical parameters (including arginine, nitrates, ADMA, GAA, oxidative stress) or protein restriction on long-term outcome. CONCLUSION Three main hypotheses which must be evaluated in a hypothesis driven confirmatory study are delineated from this study: 1) clinical manifestations in ARG1 deficiency are not correlated with arginine, protein intake, ADMA, nitrates or oxidative stress. 2) GAA is elevated and may be a marker or an active part of the pathophysiology of ARG1 deficiency. 3) Perturbations of NO metabolism merit future attention in ARG1 deficiency.
Collapse
Affiliation(s)
- Martina Huemer
- Division of Metabolic Diseases and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.
- Radiz - Rare Disease Initiative Zurich, University Zurich, Zurich, Switzerland.
- Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria.
| | - Daniel R Carvalho
- Genetic Unit, SARAH Network of Rehabilitation Hospital, Brasilia, Brazil
| | - Jaime M Brum
- Molecular Pathology Department, Rede Sarah de Hospitais de Reabilitação, Brasilia, Brazil
| | - Özlem Ünal
- Department of Paediatrics, Division of Paediatric Nutrition and Metabolism, Hacettepe University Faculty of Medicine, Ankara, Turkey
- Ankara Children's Hospital, Haematology-Oncology Research and Education Hospital, Ankara, Turkey
| | - Turgay Coskun
- Department of Paediatrics, Division of Paediatric Nutrition and Metabolism, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - James D Weisfeld-Adams
- Program for Inherited Metabolic Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nina L Schrager
- Program for Inherited Metabolic Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sabine Scholl-Bürgi
- Clinic for Pediatrics I, Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Andrea Schlune
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Markus G Donner
- Department of Gastroenterology, Hepatology and Infectious diseases, Heinrich Heine University, Düsseldorf, Germany
| | - Martin Hersberger
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital Zurich, Zurich, Switzerland
| | - Claudio Gemperle
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital Zurich, Zurich, Switzerland
| | - Brunhilde Riesner
- Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria
| | - Hanno Ulmer
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Häberle
- Division of Metabolic Diseases and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- Radiz - Rare Disease Initiative Zurich, University Zurich, Zurich, Switzerland
| | - Daniela Karall
- Clinic for Pediatrics I, Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| |
Collapse
|
43
|
Hou Y, Hu S, Jia S, Nawaratna G, Che D, Wang F, Bazer FW, Wu G. Whole-body synthesis of L-homoarginine in pigs and rats supplemented with L-arginine. Amino Acids 2016; 48:993-1001. [PMID: 26676627 DOI: 10.1007/s00726-015-2145-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 11/24/2015] [Indexed: 12/15/2022]
Abstract
Recent studies suggest an important role for L-homoarginine in cardiovascular, hepatic and neurological functions, as well as the regulation of glucose metabolism. However, little is known about whole-body L-homoarginine synthesis or its response to dietary L-arginine intake in animals. Four series of experiments were conducted to determine L-homoarginine synthesis and catabolism in pigs and rats. In Experiment 1, male and female pigs were fed a corn- and soybean meal-based diet supplemented with 0.0-2.42 % L-arginine-HCl. In Experiment 2, male and female rats were fed a casein-based diet, while receiving drinking water containing supplemental L-arginine-HCl to provide 0.0-3.6 g L-arginine/kg body-weight/day. In both experiments, urine collected from the animals for 24 h was analyzed for L-homoarginine and related metabolites. In Experiment 3, pigs and rats received a single oral dose of 1 or 10 mg L-homoarginine/kg body-weight, respectively, and their urine was collected for 24 h for analyses of L-homoarginine and related substances. In Experiment 4, slices of pig and rat tissues (including liver, brain, kidney, heart, and skeletal-muscle) were incubated for 1 h in Krebs-bicarbonate buffer containing 5 or 50 µM L-homoarginine. Our results indicated that: (a) animal tissues did not degrade L-homoarginine in the presence of physiological concentrations of other amino-acids; (b) 95-96 % of orally administered L-homoarginine was recovered in urine; (c) L-homoarginine was quantitatively a minor product of L-arginineg catabolism in the body; and (d) dietary L-arginine supplementation dose-dependently increased whole-body L-homoarginine synthesis. These novel findings provide a new framework for future studies of L-homoarginine metabolism and physiology in animals and humans.
Collapse
Affiliation(s)
- Yongqing Hou
- Hubei Key Laboratory of Animal Nutrition and Feed Science, Hubei Collaborative Innovation Center for Animal Nutrition and Feed Safety,, Wuhan Polytechnic University, Wuhan, 430023, China
- Department of Animal Science, Texas A&M University, College Station, TX, 77843, USA
| | - Shengdi Hu
- Department of Animal Science, Texas A&M University, College Station, TX, 77843, USA
| | - Sichao Jia
- Department of Animal Science, Texas A&M University, College Station, TX, 77843, USA
| | - Gayan Nawaratna
- Department of Animal Science, Texas A&M University, College Station, TX, 77843, USA
| | - Dongsheng Che
- Department of Animal Science, Texas A&M University, College Station, TX, 77843, USA
| | - Fenglai Wang
- Department of Animal Science, Texas A&M University, College Station, TX, 77843, USA
| | - Fuller W Bazer
- Department of Animal Science, Texas A&M University, College Station, TX, 77843, USA
| | - Guoyao Wu
- Hubei Key Laboratory of Animal Nutrition and Feed Science, Hubei Collaborative Innovation Center for Animal Nutrition and Feed Safety,, Wuhan Polytechnic University, Wuhan, 430023, China.
- Department of Animal Science, Texas A&M University, College Station, TX, 77843, USA.
| |
Collapse
|