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Hu Z, Hu L, Zhang C, Yin X, Zhang Y, Fang K, Wu B, Huang X. Simultaneous determination of total homocysteine, methionine, methylmalonic acid and 2-methylcitric acid in dried blood spots by ultra-performance liquid chromatography-tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2024; 1244:124253. [PMID: 39089063 DOI: 10.1016/j.jchromb.2024.124253] [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: 12/11/2023] [Revised: 07/10/2024] [Accepted: 07/20/2024] [Indexed: 08/03/2024]
Abstract
Homocysteine, methionine, methylmalonic acid and 2-methylcitric acid are clinically relevant markers in the methionine, propionate, and cobalamin metabolism. This study aimed to develop and validate an ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method for simultaneously determining total homocysteine, methionine, methylmalonic acid and 2-methylcitric acid in dried blood spots. Three 3.2 mm discs were punched from each calibrator, quality control, and sample dried blood spot into a 96-well U-plate. Each sample was spiked with internal standards and extracted. Then the supernatant was transferred to another 96-well U-plate. After nitrogen drying, the dried residues were reconstituted, centrifuged, and the resulting supernatant was transferred to another 96-well plate for analysis. The method was performed using UPLC-MS/MS within 3 min, validated according to guidance documents, and applied to 72 samples from confirmed patients with methionine, propionate, and cobalamin metabolism disorders. The UPLC-MS/MS method provided satisfactory separation of the four analytes. The R2 values were ≥ 0.9937 for all analytes. The recoveries ranged from 94.17 to 114.29 %, and the coefficients of variation for intraday and interday precision were 0.19 % to 5.23 % and 1.02 % to 6.89 %, respectively. No significant carry-over was detected for the four analytes, and most of confirmed samples exhibited biomarker patterns characteristic of the relevant disorders. A simple and fast UPLC-MS/MS method was successfully developed, validated, and applied to clinical samples for the simultaneous determination of total homocysteine, methionine, methylmalonic acid, and 2-methylcitric acid in dried blood spots.
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Affiliation(s)
- Zhenzhen Hu
- Department of Genetics and Metabolism, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Lingwei Hu
- Department of Genetics and Metabolism, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Chao Zhang
- Department of Genetics and Metabolism, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Xiaoshan Yin
- School of Health in Social Science, The University of Edinburg, United Kingdom
| | - Yu Zhang
- Zhejiang BiosanBiochemical Technologies Co., Ltd., Hangzhou, China
| | - Kexin Fang
- Department of Genetics and Metabolism, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Benqing Wu
- Department of Neonatology, Children's Medical Center, University of Chinese Academy of Science-Shenzhen Hospital, Shenzhen, Guangdong, China.
| | - Xinwen Huang
- Department of Genetics and Metabolism, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China.
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Liu Y, Ma X, Kang L, Jin Y, Li M, Song J, Li H, Cao Y, Yang Y. The utility of methylmalonic acid, methylcitrate acid, and homocysteine in dried blood spots for therapeutic monitoring of three inherited metabolic diseases. Front Nutr 2024; 11:1414681. [PMID: 38966413 PMCID: PMC11222987 DOI: 10.3389/fnut.2024.1414681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/11/2024] [Indexed: 07/06/2024] Open
Abstract
Backgroud Routine metabolic assessments for methylmalonic acidemia (MMA), propionic acidemia (PA), and homocysteinemia involve detecting metabolites in dried blood spots (DBS) and analyzing specific biomarkers in serum and urine. This study aimed to establish a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the simultaneous detection of three specific biomarkers (methylmalonic acid, methylcitric acid, and homocysteine) in DBS, as well as to appraise the applicability of these three DBS metabolites in monitoring patients with MMA, PA, and homocysteinemia during follow-up. Methods A total of 140 healthy controls and 228 participants were enrolled, including 205 patients with MMA, 17 patients with PA, and 6 patients with homocysteinemia. Clinical data and DBS samples were collected during follow-up visits. Results The reference ranges (25th-95th percentile) for DBS methylmalonic acid, methylcitric acid, and homocysteine were estimated as 0.04-1.02 μmol/L, 0.02-0.27 μmol/L and 1.05-8.22 μmol/L, respectively. Following treatment, some patients achieved normal metabolite concentrations, but the majority still exhibited characteristic biochemical patterns. The concentrations of methylmalonic acid, methylcitric acid, and homocysteine in DBS showed positive correlations with urine methylmalonic acid (r = 0.849, p < 0.001), urine methylcitric acid (r = 0.693, p < 0.001), and serum homocysteine (r = 0.721, p < 0.001) concentrations, respectively. Additionally, higher levels of DBS methylmalonic acid and methylcitric acid may be associated with increased cumulative complication scores. Conclusion The LC-MS/MS method established in this study reliably detects methylmalonic acid, methylcitric acid, and homocysteine in DBS. These three DBS metabolites can be valuable for monitoring patients with MMA, PA, and homocysteinemia during follow-up. Further investigation is required to determine the significance of these DBS biomarkers in assessing disease burden over time.
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Affiliation(s)
- Yi Liu
- Department of Clinical Laboratory, China-Japan Friendship Hospital, Beijing, China
| | - Xue Ma
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Lulu Kang
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying Jin
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Mengqiu Li
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Jinqing Song
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Haixia Li
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Yongtong Cao
- Department of Clinical Laboratory, China-Japan Friendship Hospital, Beijing, China
| | - Yanling Yang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
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Takeuchi I, Funayama R, Shoji H, Nambu R, Jimbo K, Hara T, Shimizu H, Nomura I, Iwama I, Kudo T, Shimizu T, Arai K. Evaluation of Deficient Nutrients in Infants and Toddlers Mainly Taking Amino Acid-Based Elemental Formulas: An Exploratory Study. ANNALS OF NUTRITION & METABOLISM 2024; 80:186-195. [PMID: 38754393 DOI: 10.1159/000539146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 04/29/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION This study evaluated nutrient deficiencies in infants and toddlers with inflammatory bowel disease (IBD) and eosinophilic gastrointestinal disorders (EGIDs), whose primary nutritional source is elemental formulas (EFs). METHODS The nutrient status of children with IBD and EGID aged 6 months to 6 years was evaluated. RESULTS Twenty-one children fed with EFs (EF group) and 25 controls (CL group) were enrolled. The selenium level in the EF group was lower than that in the CL group (2.2 μg/dL vs. 9.3 μg/dL; p < 0.01). Although fat-soluble vitamins were deficient in some EF group participants, no significant differences were observed in their concentration and insufficiency proportion. However, ascorbic acid deficiency was more frequent in the EF group, with significantly lower levels (8.6 μg/mL vs. 12.0 μg/mL; p < 0.01). The triene:tetraene ratio was significantly higher in the EF group (0.046 vs. 0.010; p < 0.01). Asparagine and taurine levels were significantly lower in the EF group (asparagine: p < 0.01; taurine: p < 0.01) and tyrosine and phenylalanine levels were higher in the EF group, resulting in a lower Fisher's ratio (p < 0.01). CONCLUSION Long-term feeding with EFs can cause deficiencies in essential fatty acids, selenium, and ascorbic acid and also carries a risk of amino acid imbalance in infants and toddlers.
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Affiliation(s)
- Ichiro Takeuchi
- Division of Gastroenterology, Center for Pediatric Inflammatory Bowel Disease, National Center for Child Health and Development, Tokyo, Japan
| | - Rie Funayama
- Division of Gastroenterology, Center for Pediatric Inflammatory Bowel Disease, National Center for Child Health and Development, Tokyo, Japan
| | - Hiromichi Shoji
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Ryusuke Nambu
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
| | - Keisuke Jimbo
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Tomoko Hara
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
| | - Hirotaka Shimizu
- Division of Gastroenterology, Center for Pediatric Inflammatory Bowel Disease, National Center for Child Health and Development, Tokyo, Japan
| | - Ichiro Nomura
- Division of Eosinophilic Gastrointestinal Disorders, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Itaru Iwama
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
| | - Takahiro Kudo
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Katsuhiro Arai
- Division of Gastroenterology, Center for Pediatric Inflammatory Bowel Disease, National Center for Child Health and Development, Tokyo, Japan
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Pajares-García S, González de Aledo-Castillo JM, Flores-Jiménez JE, Collado T, Pérez J, Paredes-Fuentes AJ, Argudo-Ramírez A, López-Galera RM, Prats B, García-Villoria J. Analysis of a second-tier test panel in dried blood spot samples using liquid chromatography-tandem mass spectrometry in Catalonia's newborn screening programme. Clin Chem Lab Med 2024; 62:493-505. [PMID: 37794778 DOI: 10.1515/cclm-2023-0216] [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: 02/28/2023] [Accepted: 09/21/2023] [Indexed: 10/06/2023]
Abstract
OBJECTIVES Acylcarnitine and amino acid analyses of dried blood spot (DBS) samples using tandem mass spectrometry in newborn screening (NBS) programmes can generate false positive (FP) results. Therefore, implementation of second-tier tests (2TTs) using DBS samples has become increasingly important to avoid FPs. The most widely used 2TT metabolites include methylmalonic acid, 3-hydroxypropionic acid, methylcitric acid, and homocysteine. METHODS We simultaneously measured 46 underivatised metabolites, including organic acids, acylglycine and acylcarnitine isomers, homocysteine, and orotic acid, in DBS samples using tandem mass spectrometry. To validate this method, we analysed samples from 147 healthy newborns, 160 patients with genetic disorders diagnosed via NBS, 20 patients with acquired vitamin B12 deficiency, 10 newborns receiving antibiotic treatment, and nine external quality control samples. RESULTS The validation study revealed that 31 metabolites showed good analytical performance. Furthermore, this method detected key metabolites for all diseases associated with increased levels of the following acylcarnitines: C3, C4, C5, C4DC/C5OH, and C5DC. The sensitivity of this method to detect all diseases was 100 %, and the specificity was 74-99 %, except for glutaric aciduria type 1. This method can also be used to diagnose mitochondrial fatty acid β-oxidation disorders (FAODs) and urea cycle defects (UCDs). CONCLUSIONS We have described a 2TT panel of 31 metabolites in DBS samples based on an easy and rapid method without derivatisation. Its implementation allowed us to distinguish between different organic acidurias, some FAODs, and UCDs. This new strategy has increased the efficiency of our NBS programme by reducing FP and false negative results, second sample requests, and the time required for diagnosis.
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Affiliation(s)
- Sonia Pajares-García
- Department of Biochemistry and Molecular Genetics, Section of Inborn Errors of Metabolism-IBC, Hospital Clinic, Barcelona, Spain
- Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain
| | | | - José Eduardo Flores-Jiménez
- Department of Biochemistry and Molecular Genetics, Section of Inborn Errors of Metabolism-IBC, Hospital Clinic, Barcelona, Spain
| | - Tatiana Collado
- Department of Biochemistry and Molecular Genetics, Section of Inborn Errors of Metabolism-IBC, Hospital Clinic, Barcelona, Spain
| | - Judit Pérez
- Department of Biochemistry and Molecular Genetics, Section of Inborn Errors of Metabolism-IBC, Hospital Clinic, Barcelona, Spain
| | - Abraham José Paredes-Fuentes
- Department of Biochemistry and Molecular Genetics, Section of Inborn Errors of Metabolism-IBC, Hospital Clinic, Barcelona, Spain
| | - Ana Argudo-Ramírez
- Department of Biochemistry and Molecular Genetics, Section of Inborn Errors of Metabolism-IBC, Hospital Clinic, Barcelona, Spain
| | - Rosa María López-Galera
- Department of Biochemistry and Molecular Genetics, Section of Inborn Errors of Metabolism-IBC, Hospital Clinic, Barcelona, Spain
- Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain
- Biomedical Research Institute, August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Blanca Prats
- Health Department, Maternal and Child Health Service, Public Health Agency of Catalonia, The Government of Catalonia, Barcelona, Spain
| | - Judit García-Villoria
- Department of Biochemistry and Molecular Genetics, Section of Inborn Errors of Metabolism-IBC, Hospital Clinic, Barcelona, Spain
- Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain
- Biomedical Research Institute, August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Chien YH, Hwu WL. The modern face of newborn screening. Pediatr Neonatol 2023; 64 Suppl 1:S22-S29. [PMID: 36481189 DOI: 10.1016/j.pedneo.2022.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
Newborn screening (NBS) has been developed for years to identify newborns with severe but treatable conditions. Taiwan's NBS system, after the initial setup for a total coverage of newborns in 1990s, was later optimized to ensure the timely return of results in infants with abnormal results. Advancements in techniques such as Tandem mass spectrometry enable the screening into a multiplex format and increase the conditions to be screened. Furthermore, advances in therapies, such as enzyme replacement therapy, stem cell transplantation, and gene therapy, significantly expand the needs for newborn screening. Advances in genomics and biomarkers discovery improve the test accuracy with the assistance of second-tier tests, and have the potential to be the first-tier test in the future. Therefore, challenge of NBS now is the knowledge gap, including the evidence of the long-term clinical benefits in large cohorts especially in conditions with new therapies, phenotypic variations and the corresponding management of some screened diseases, and cost-effectiveness of extended NBS programs. A short-term and a long-term follow-up program should be implemented to gather those outcomes better especially in the genomic era. Ethical and psychosocial issues are also potentially encountered frequently. Essential education and better informed consent should be considered fundamental to parallel those new tests into future NBS.
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Affiliation(s)
- Yin-Hsiu Chien
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan; Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Pediatrics, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Wuh-Liang Hwu
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan; Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Pediatrics, National Taiwan University College of Medicine, Taipei, Taiwan
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Identification of potential interferents of methylmalonic acid: A previously unrecognized pitfall in clinical diagnostics and newborn screening. Clin Biochem 2023; 111:72-80. [PMID: 36202155 DOI: 10.1016/j.clinbiochem.2022.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Determination of methylmalonic acid (MMA) from dried blood spots (DBS) is commonly performed in clinical diagnostics and newborn screening for propionic acidemia (PA) and methylmalonic acidemia. Isobaric compounds of MMA having the same mass can affect diagnostic reliability and quantitative results, which represents a previously unrecognized pitfall in clinical assays for MMA. We set out to identify interfering substances of MMA in DBS, serum and urine samples from confirmed patients with PA and methylmalonic acidemia. METHODS Techniques included quadrupole time-of-flight high-resolution mass spectrometry (QTOF HR-MS), nuclear magnetic resonance (NMR) spectroscopy, liquid chromatography (LC) and tandem mass spectrometry (MS/MS). RESULTS The five isobaric metabolites detected in DBS, serum and urine from PA and methylmalonic acidemia patients were confirmed as 2-methyl-3-hydroxybutyrate, 3-hydroxyisovalerate, 2-hydroxyisovalerate, 3-hydroxyvalerate and succinate using a series of experiments. An additional unknown substance with low abundance remained unidentified. CONCLUSIONS The presented results facilitate the diagnostic and quantitative reliability of the MMA determination in clinical assays. Isobaric species should be investigated in assays for MMA to eliminate possible interference in a wide range of conditions including PA, methylmalonic acidemia, a vitamin B12 deficiency, ketosis and lactic acidosis.
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Briso-Montiano Á, Vilas A, Richard E, Ruiz-Sala P, Morato E, Desviat LR, Ugarte M, Rodríguez-Pombo P, Pérez B. Hepatocyte-like cells differentiated from methylmalonic aciduria cblB type induced pluripotent stem cells: A platform for the evaluation of pharmacochaperoning. Biochim Biophys Acta Mol Basis Dis 2022; 1868:166433. [PMID: 35569737 DOI: 10.1016/j.bbadis.2022.166433] [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: 10/19/2021] [Revised: 04/22/2022] [Accepted: 05/04/2022] [Indexed: 11/24/2022]
Abstract
Methylmalonic aciduria cblB type (MMA cblB type, MMAB OMIM #251110), caused by a deficiency in the enzyme ATP:cob(I)alamin adenosyltransferase (ATR, E.C_2. 5.1.17), is a severe metabolic disorder with a poor prognosis despite treatment. We recently described the potential therapeutic use of pharmacological chaperones (PCs) after increasing the residual activity of ATR in patient-derived fibroblasts. The present work reports the successful generation of hepatocyte-like cells (HLCs) differentiated from two healthy and two MMAB induced pluripotent stem cell (iPSC) lines, and the use of this platform for testing the effects of PCs. The MMAB cells produced little ATR, showed reduced residual ATR activity, and had higher concentrations of methylmalonic acid compared to healthy HLCs. Differential proteome analysis revealed the two MMAB HCLs to show reproducible differentiation, but this was not so for the healthy HLCs. Interestingly, PC treatment in combination with vitamin B12 increased the amount of ATR available, and subsequently ATR activity, in both MMAB HLCs. More importantly, the treatment significantly reduced the methylmalonic acid content of both. In summary, the HLC model would appear to be an excellent candidate for the pharmacological testing of the described PCs, for analyzing the effects of new drugs, and investigating the repurposing of older drugs, before testing in animal models.
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Affiliation(s)
- Á Briso-Montiano
- Centro de Diagnóstico de Enfermedades Moleculares (CEDEM), Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Centro de Biología Molecular "Severo Ochoa" UAM-CSIC, Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Madrid, Spain; Instituto de Investigación Sanitaria Hospital La Paz (IdiPAZ), ISCIII, Madrid, Spain.
| | - A Vilas
- Centro de Diagnóstico de Enfermedades Moleculares (CEDEM), Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Centro de Biología Molecular "Severo Ochoa" UAM-CSIC, Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Madrid, Spain; Instituto de Investigación Sanitaria Hospital La Paz (IdiPAZ), ISCIII, Madrid, Spain.
| | - E Richard
- Centro de Diagnóstico de Enfermedades Moleculares (CEDEM), Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Centro de Biología Molecular "Severo Ochoa" UAM-CSIC, Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Madrid, Spain; Instituto de Investigación Sanitaria Hospital La Paz (IdiPAZ), ISCIII, Madrid, Spain.
| | - P Ruiz-Sala
- Centro de Diagnóstico de Enfermedades Moleculares (CEDEM), Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Centro de Biología Molecular "Severo Ochoa" UAM-CSIC, Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Madrid, Spain; Instituto de Investigación Sanitaria Hospital La Paz (IdiPAZ), ISCIII, Madrid, Spain.
| | - E Morato
- Centro de Biología Molecular "Severo Ochoa" UAM-CSIC, Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain.
| | - L R Desviat
- Centro de Diagnóstico de Enfermedades Moleculares (CEDEM), Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Centro de Biología Molecular "Severo Ochoa" UAM-CSIC, Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Madrid, Spain; Instituto de Investigación Sanitaria Hospital La Paz (IdiPAZ), ISCIII, Madrid, Spain.
| | - M Ugarte
- Centro de Diagnóstico de Enfermedades Moleculares (CEDEM), Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Centro de Biología Molecular "Severo Ochoa" UAM-CSIC, Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Madrid, Spain; Instituto de Investigación Sanitaria Hospital La Paz (IdiPAZ), ISCIII, Madrid, Spain.
| | - P Rodríguez-Pombo
- Centro de Diagnóstico de Enfermedades Moleculares (CEDEM), Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Centro de Biología Molecular "Severo Ochoa" UAM-CSIC, Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Madrid, Spain; Instituto de Investigación Sanitaria Hospital La Paz (IdiPAZ), ISCIII, Madrid, Spain.
| | - B Pérez
- Centro de Diagnóstico de Enfermedades Moleculares (CEDEM), Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Centro de Biología Molecular "Severo Ochoa" UAM-CSIC, Universidad Autónoma de Madrid, Cantoblanco, 28049 Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Madrid, Spain; Instituto de Investigación Sanitaria Hospital La Paz (IdiPAZ), ISCIII, Madrid, Spain.
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A Simple Flow Injection Analysis-Tandem Mass Spectrometry Method to Reduce False Positives of C5-Acylcarnitines Due to Pivaloylcarnitine Using Reference Ions. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9050694. [PMID: 35626871 PMCID: PMC9139860 DOI: 10.3390/children9050694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/12/2022] [Accepted: 05/06/2022] [Indexed: 11/21/2022]
Abstract
Flow injection analysis−tandem mass spectrometry (FIA-TMS) has been applied in a first-tier test of newborn screening (NBS). Although isovalerylcarnitine (i-C5), which is a diagnostic indicator of isovaleric acidemia (IVA), is isobaric with pivaloylcarnitine (p-C5), 2-methylbutyrylcarnitine, and n-valerylcarnitine, these isomers cannot be distinguished by the FIA-TMS. There are many reports of false positives derived from p-C5 due to the use of pivalate-conjugated antibiotics. In this study, we developed a new FIA-TMS method to distinguish i-C5 and p-C5. We found that the intensity ratio of product ions for i-C5 and p-C5 was different in a certain range even under the same analytical conditions. The product ions with the most distinct differences in ionic intensity between the isomers and the collision energies that produce them were determined to be m/z 246.2 > 187.1 and −15 V, respectively. In addition to the quantification ion, a reference ion was defined, and the similarity of the i-C5 and p-C5 reference ion ratios (i-C5 score and p-C5 score, respectively) were used to estimate which isomer (i-C5 and p-C5) was responsible for elevated C5 acylcarnitine in dried blood spots (DBSs). As a result of analyses of 11 DBS samples derived from pivalate-conjugated antibiotics and four DBS samples from IVA patients using our method, it was found that our method was able to correctly determine the type of C5-acylcarnitine (i-C5 or p-C5) in the DBS samples. Implementation of this new FIA-TMS method into the current NBS protocol will allow for a reduction in false positives in IVA.
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Kagawa R, Tajima G, Maeda T, Sakura F, Nakamura-Utsunomiya A, Hara K, Nishimura Y, Yuasa M, Shigematsu Y, Tanaka H, Fujihara S, Yoshii C, Okada S. Pilot Study on Neonatal Screening for Methylmalonic Acidemia Caused by Defects in the Adenosylcobalamin Synthesis Pathway and Homocystinuria Caused by Defects in Homocysteine Remethylation. Int J Neonatal Screen 2021; 7:ijns7030039. [PMID: 34287232 PMCID: PMC8293178 DOI: 10.3390/ijns7030039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/26/2021] [Accepted: 07/05/2021] [Indexed: 11/16/2022] Open
Abstract
Neonatal screening (NS) for methylmalonic acidemia uses propionylcarnitine (C3) as a primary index, which is insufficiently sensitive at detecting methylmalonic acidemia caused by defects in the adenosylcobalamin synthesis pathway. Moreover, homocystinuria from cystathionine β-synthase deficiency is screened by detecting hypermethioninemia, but methionine levels decrease in homocystinuria caused by defects in homocysteine remethylation. To establish NS detection of methylmalonic acidemia and homocystinuria of these subtypes, we evaluated the utility of indices (1) C3 ≥ 3.6 μmol/L and C3/acetylcarnitine (C2) ≥ 0.23, (2) C3/methionine ≥ 0.25, and (3) methionine < 10 μmol/L, by retrospectively applying them to NS data of 59,207 newborns. We found positive results in 116 subjects for index (1), 37 for (2), and 15 for (3). Second-tier tests revealed that for index 1, methylmalonate (MMA) was elevated in two cases, and MMA and total homocysteine (tHcy) were elevated in two cases; for index 2 that MMA was elevated in one case; and for index 3 that tHcy was elevated in one case. Though data were anonymized, two cases identified by index 1 had been diagnosed with maternal vitamin B12 deficiency during NS. Methylene tetrahydrofolate reductase deficiency was confirmed for the case identified by index 3, which was examined because an elder sibling was affected by the same disease. Based on these data, a prospective NS study is underway.
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Affiliation(s)
- Reiko Kagawa
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Minami-ku, Hiroshima 734-8551, Japan; (R.K.); (F.S.); (S.O.)
| | - Go Tajima
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Minami-ku, Hiroshima 734-8551, Japan; (R.K.); (F.S.); (S.O.)
- Division of Neonatal Screening, Research Institute, National Center for Child Health and Development, Setagaya-ku, Tokyo 157-8535, Japan;
- Correspondence: ; Tel.: +81-3-5494-7133
| | - Takako Maeda
- Division of Neonatal Screening, Research Institute, National Center for Child Health and Development, Setagaya-ku, Tokyo 157-8535, Japan;
| | - Fumiaki Sakura
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Minami-ku, Hiroshima 734-8551, Japan; (R.K.); (F.S.); (S.O.)
| | | | - Keiichi Hara
- Department of Pediatrics, National Hospital Organization Kure Medical Center and Chugoku Cancete Center, Kure 737-0023, Japan;
| | - Yutaka Nishimura
- Department of General Perinatology, Hiroshima City Hiroshima Citizens Hospital, Naka-Ku, Hiroshima 730-8518, Japan;
| | - Miori Yuasa
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Eiheiji-cho, Fukui 910-1193, Japan; (M.Y.); (Y.S.)
| | - Yosuke Shigematsu
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Eiheiji-cho, Fukui 910-1193, Japan; (M.Y.); (Y.S.)
| | - Hiromi Tanaka
- Hiroshima City Medical Association Clinical Laboratory, Naka-ku, Hiroshima 730-8611, Japan; (H.T.); (S.F.); (C.Y.)
| | - Saki Fujihara
- Hiroshima City Medical Association Clinical Laboratory, Naka-ku, Hiroshima 730-8611, Japan; (H.T.); (S.F.); (C.Y.)
| | - Chiyoko Yoshii
- Hiroshima City Medical Association Clinical Laboratory, Naka-ku, Hiroshima 730-8611, Japan; (H.T.); (S.F.); (C.Y.)
| | - Satoshi Okada
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Minami-ku, Hiroshima 734-8551, Japan; (R.K.); (F.S.); (S.O.)
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10
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Mikami-Saito Y, Maekawa M, Wada Y, Kanno T, Kurihara A, Sato Y, Yamamoto T, Arai-Ichinoi N, Kure S. Essential oils can cause false-positive results of medium-chain acyl-CoA dehydrogenase deficiency. Mol Genet Metab Rep 2020; 25:100674. [PMID: 33204637 PMCID: PMC7653163 DOI: 10.1016/j.ymgmr.2020.100674] [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: 10/24/2020] [Accepted: 10/25/2020] [Indexed: 11/30/2022] Open
Abstract
Newborn screening is a public health care program worldwide to prevent patients from critical illness or conditions. Tandem mass spectrometry allows multiplex, inexpensive, and rapid newborn screening. However, mass spectrometry used for newborn screening to date is not able to separate peaks of compounds with similar m/z, which could lead to false-positive results without additional second-tier tests, such as fragmentation. We experienced three neonatal cases with high levels of markers, octanoylcarnitine and octanoylcarnitine/decanoylcarnitine ratio used to pick up possible cases of medium-chain acyl-CoA dehydrogenase (MCAD) deficiency. The babies were born consecutively in a maternity hospital. Their second acylcarnitine profiles were normal, and the genetic tests for ACADM were negative. Analysis of samples extracted from their first Guthrie cards where blood was not stained also showed peaks equivalent to octanoylcarnitine and decanoylcarnitine, indicating contamination. Environmental surveillance in the maternity ward suggested that essential oils used there might contain the contaminated compound. LC-HRMS/MS and in silico analysis revealed that false-positive results might be due to contamination with the essential oils in Guthrie cards, and causal agents were sphinganine (d17:0) and 2-[2-hydroxyethyl(pentadecyl)amino]ethanol. Thus, health care providers should be cautioned about use of essential oils when collecting blood samples on Guthrie cards. False-positive results can waste costly social resources and cause a physical and psychological burden for children and parents.
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Key Words
- C10, decanoylcarnitine,
- C8, octanoylcarnitine,
- Decanoylcarnitine
- Essential oils
- FAOD, fatty acid oxidation disorder,
- False-positive
- LC-HRMS/MS, liquid chromatography-high resolution-tandem mass spectrometry
- LC-MS/MS, liquid chromatography-tandem mass spectrometry,
- MCAD deficiency
- MCAD, medium-chain acyl-CoA dehydrogenase,
- NBS, newborn screening
- Newborn screening
- Octanoylcarnitine
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Affiliation(s)
- Yasuko Mikami-Saito
- Department of Pediatrics, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
| | - Masamitsu Maekawa
- Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
| | - Yoichi Wada
- Department of Pediatrics, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
- Corresponding author.
| | - Tomoe Kanno
- Public Health Society of Miyagi Prefecture, 7-1 Tsutsumishita, Matsumori, Izumi-ku, Sendai, Miyagi 981-3111, Japan
| | - Ai Kurihara
- Public Health Society of Miyagi Prefecture, 7-1 Tsutsumishita, Matsumori, Izumi-ku, Sendai, Miyagi 981-3111, Japan
| | - Yuko Sato
- Public Health Society of Miyagi Prefecture, 7-1 Tsutsumishita, Matsumori, Izumi-ku, Sendai, Miyagi 981-3111, Japan
| | - Toshio Yamamoto
- Public Health Society of Miyagi Prefecture, 7-1 Tsutsumishita, Matsumori, Izumi-ku, Sendai, Miyagi 981-3111, Japan
| | - Natsuko Arai-Ichinoi
- Department of Pediatrics, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
| | - Shigeo Kure
- Department of Pediatrics, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
- Tohoku Medical Megabank Organization, Tohoku University, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8573, Japan
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11
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Lin Y, Chen D, Peng W, Wang K, Lin W, Zhuang J, Zheng Z, Li M, Fu Q. Newborn screening for isovaleric acidemia in Quanzhou, China. Clin Chim Acta 2020; 509:25-29. [PMID: 32505769 DOI: 10.1016/j.cca.2020.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/05/2020] [Accepted: 06/03/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Isovaleric acidemia (IVA) is a rare autosomal recessive disorder of leucine metabolism caused by a defective isovaleryl-CoA dehydrogenase (IVD) gene. Reports of IVA diagnoses following newborn screening (NBS) in the Chinese population are few. METHODS We investigated the biochemical, clinical, and molecular profiles of 5 patients with IVA in China. The estimated incidence of IVA in Quanzhou, China is 1 in 1:84,469. RESULTS Initial NBS revealed mild to markedly increased isovalerylcarnitine (C5) concentrations in all 5 patients, and differential diagnosis revealed increased urinary isovaleryglycine concentrations in 2 patients. One patient presented with acute neonatal symptoms, whereas the other 4 remained asymptomatic. Eight distinct IVD gene variants were identified. The most common variant was c.1208A > G (p.Y403C), with an allele frequency of 30%. Five variants were previously unreported, namely, c.499A > G (p.M167V), c.640A > G (p.T214A), c.740G > A (p.G247E), c.832G > C (p.V278L), and c.1195G > C (p.D399H). Different in silico prediction analyses suggested that these previously unreported missense variants are pathogenic. Protein modelling analyses also showed that these missense variants may cause structural damage and dysfunction in IVD. CONCLUSIONS Patients with IVA may have C5 concentrations approaching the cut-off values, highlighting the need for stringent recall criteria and second-tier tests to improve screening performance.
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Affiliation(s)
- Yiming Lin
- Neonatal Disease Screening Center, Quanzhou Maternity and Children's Hospital, 700 Fengze Street, Quanzhou, Fujian Province 362000, China
| | - Dongmei Chen
- Department of Neonatal Intensive Care Unit, Quanzhou Maternity and Children's Hospital, 700 Fengze Street, Quanzhou, Fujian Province 362000, China
| | - Weilin Peng
- Neonatal Disease Screening Center, Quanzhou Maternity and Children's Hospital, 700 Fengze Street, Quanzhou, Fujian Province 362000, China
| | - Kunyi Wang
- Integrated Technical Service Center, Quanzhou Customs, Quanzhou, Fujian Province 362000, China
| | - Weihua Lin
- Neonatal Disease Screening Center, Quanzhou Maternity and Children's Hospital, 700 Fengze Street, Quanzhou, Fujian Province 362000, China
| | - Jianlong Zhuang
- Prenatal Diagnosis Center, Quanzhou Maternity and Children's Hospital, 700 Fengze Street, Quanzhou, Fujian Province 362000, China
| | - Zhenzhu Zheng
- Neonatal Disease Screening Center, Quanzhou Maternity and Children's Hospital, 700 Fengze Street, Quanzhou, Fujian Province 362000, China
| | - Min Li
- Hangzhou Genuine Clinical Laboratory Co. Ltd, Hangzhou, Zhejiang Province 310007, China.
| | - Qingliu Fu
- Neonatal Disease Screening Center, Quanzhou Maternity and Children's Hospital, 700 Fengze Street, Quanzhou, Fujian Province 362000, China.
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12
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Gavrilov DK, Piazza AL, Pino G, Turgeon C, Matern D, Oglesbee D, Raymond K, Tortorelli S, Rinaldo P. The Combined Impact of CLIR Post-Analytical Tools and Second Tier Testing on the Performance of Newborn Screening for Disorders of Propionate, Methionine, and Cobalamin Metabolism. Int J Neonatal Screen 2020; 6:33. [PMID: 33073028 PMCID: PMC7423003 DOI: 10.3390/ijns6020033] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/07/2020] [Indexed: 12/13/2022] Open
Abstract
The expansion of the recommend uniform screening panel to include more than 50 primary and secondary target conditions has resulted in a substantial increase of false positive results. As an alternative to subjective manipulation of cutoff values and overutilization of molecular testing, here we describe the performance outcome of an algorithm for disorders of methionine, cobalamin, and propionate metabolism that includes: (1) first tier screening inclusive of the broadest available spectrum of markers measured by tandem mass spectrometry; (2) integration of all results into a score of likelihood of disease for each target condition calculated by post-analytical interpretive tools created byCollaborative Laboratory Integrated Reports (CLIR), a multivariate pattern recognition software; and (3) further evaluation of abnormal scores by a second tier test measuring homocysteine, methylmalonic acid, and methylcitric acid. This approach can consistently reduce false positive rates to a <0.01% level, which is the threshold of precision newborn screening. We postulate that broader adoption of this algorithm could lead to substantial savings in health care expenditures. More importantly, it could prevent the stress and anxiety experienced by many families when faced with an abnormal newborn screening result that is later resolved as a false positive outcome.
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Affiliation(s)
- Dimitar K Gavrilov
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
| | - Amy L Piazza
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
| | - Gisele Pino
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
| | - Coleman Turgeon
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
| | - Dietrich Matern
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
| | - Devin Oglesbee
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
| | - Kimiyo Raymond
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
| | - Silvia Tortorelli
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
| | - Piero Rinaldo
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
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13
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Bo R, Musha I, Yamada K, Kobayashi H, Hasegawa Y, Awano H, Arao M, Kikuchi T, Taketani T, Ohtake A, Yamaguchi S, Iijima K. Need for strict clinical management of patients with carnitine palmitoyltransferase II deficiency: Experience with two cases detected by expanded newborn screening. Mol Genet Metab Rep 2020; 24:100611. [PMID: 32489884 PMCID: PMC7260588 DOI: 10.1016/j.ymgmr.2020.100611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 12/31/2022] Open
Abstract
In Japan, carnitine palmitoyltransferase II (CPTII) deficiency has been included as one of the primary target diseases in the expanded newborn mass screening program since 2018. However, many cases of the severe infantile hepatocardiomuscular form of CPTII deficiency showed severe neurodevelopmental delay or sudden death, which indicated that management of CPTII deficiency in the acute phase remains to be studied in detail. Herein, we discuss two cases diagnosed by newborn mass screening. Patient 1 was under strict clinical management from the neonatal period, with >20 admissions in 14 months, while Patient 2 was managed using a relatively relaxed approach, with only 2 admissions in the same period. Patient 1 showed normal development; however, Patient 2 expired at the age of 1 year 2 months. To develop strategies for preventing sudden deaths in patients with CPTII deficiency, this retrospective study focused on detailed clinical management practices and biochemical findings during the acute phase. We also investigated the correlation between conventional biomarkers (such as creatine kinase) and long-chain acylcarnitines. We propose that strict monitoring and immediate medical attention, even in case of slight fever or minor abdominal symptoms, can help prevent sudden death in patients with CPTII deficiency. Considering the higher morbidity rate of such patients, strict and acute management of CPTII deficiency cannot be overemphasized.
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Affiliation(s)
- Ryosuke Bo
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.,Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan
| | - Ikuma Musha
- Department of Pediatrics, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Saitama 350-0495, Japan
| | - Kenji Yamada
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan
| | - Hironori Kobayashi
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan
| | - Yuki Hasegawa
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan
| | - Hiroyuki Awano
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Masato Arao
- Department of Pediatrics, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Saitama 350-0495, Japan
| | - Toru Kikuchi
- Department of Pediatrics, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Saitama 350-0495, Japan
| | - Takeshi Taketani
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan
| | - Akira Ohtake
- Department of Pediatrics, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Saitama 350-0495, Japan
| | - Seiji Yamaguchi
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
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14
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Almási T, Guey LT, Lukacs C, Csetneki K, Vokó Z, Zelei T. Systematic literature review and meta-analysis on the epidemiology of methylmalonic acidemia (MMA) with a focus on MMA caused by methylmalonyl-CoA mutase (mut) deficiency. Orphanet J Rare Dis 2019; 14:84. [PMID: 31023387 PMCID: PMC6485056 DOI: 10.1186/s13023-019-1063-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/08/2019] [Indexed: 12/13/2022] Open
Abstract
Methylmalonic acidemia/aciduria (MMA) is a genetically heterogeneous group of inherited metabolic disorders biochemically characterized by the accumulation of methylmalonic acid. Isolated MMA is primarily caused by the deficiency of methylmalonyl-CoA mutase (MMA mut; EC 5.4.99.2). A systematic literature review and a meta-analysis were undertaken to assess and compile published epidemiological data on MMA with a focus on the MMA mut subtype (OMIM #251000). Of the 1114 identified records, 227 papers were assessed for eligibility in full text, 48 articles reported on disease epidemiology, and 39 articles were included into the quantitative synthesis. Implementation of newborn screening in various countries has allowed for the estimation of birth prevalence of MMA and its isolated form. Meta-analysis pooled point estimates of MMA (all types) detection rates were 0.79, 1.12, 1.22 and 6.04 per 100,000 newborns in Asia-Pacific, Europe, North America and the Middle East and North Africa (MENA) regions, respectively. The detection rate of isolated MMA was < 1 per 100,000 newborns in all regions with the exception of MENA where it approached 6 per 100,000 newborns. Few studies published data on the epidemiology of MMA mut, therefore no meta-analysis could have been performed on this subtype. Most of the identified papers reported birth prevalence estimates below 1 per 100,000 newborns for MMA mut. The systematic literature review clearly demonstrates that MMA and its subtypes are ultra-rare disorders.
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Affiliation(s)
- Tímea Almási
- Syreon Research Institute, Mexikói str. 65/A, Budapest, H-1142, Hungary.
| | | | | | - Kata Csetneki
- Syreon Research Institute, Mexikói str. 65/A, Budapest, H-1142, Hungary
| | - Zoltán Vokó
- Syreon Research Institute, Mexikói str. 65/A, Budapest, H-1142, Hungary.,Department of Health Policy & Health Economics, Eötvös Loránd University, Budapest, Hungary
| | - Tamás Zelei
- Syreon Research Institute, Mexikói str. 65/A, Budapest, H-1142, Hungary
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15
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Development of a screening and confirmatory method for the analysis of polar endogenous compounds in saliva based on a liquid chromatographic-tandem mass spectrometric system. J Chromatogr A 2019; 1590:88-95. [DOI: 10.1016/j.chroma.2019.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 12/10/2018] [Accepted: 01/01/2019] [Indexed: 02/06/2023]
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16
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Messina M, Meli C, Raudino F, Pittalá A, Arena A, Barone R, Giuffrida F, Iacobacci R, Muccilli V, Sorge G, Fiumara A. Expanded Newborn Screening Using Tandem Mass Spectrometry: Seven Years of Experience in Eastern Sicily. Int J Neonatal Screen 2018; 4:12. [PMID: 33072938 PMCID: PMC7510204 DOI: 10.3390/ijns4020012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 04/04/2018] [Indexed: 01/05/2023] Open
Abstract
The expanded newborn screening for selected inborn errors of metabolism (IEM) in Sicily was introduced in 2007 by a Regional project entitled "Early detection of congenital metabolic diseases: expanded neonatal screening". It established two newborn screening laboratories, for Western and Eastern Sicily, which started their activity in 2011. Here we present the results of expanded screening (excluding phenylketonuria (PKU)) of the Eastern laboratory from January 2011 to December 2017. Our data highlight the importance of the expanded newborn screening as a basic health program to avoid the underestimation of rare diseases and the need of further investigations even when there are no textbook alterations of the metabolic profiles. We performed our analysis on dried blood spot by tandem mass spectrometry, according to Italian guidelines. A total of 196 samples from 60,408 newborns gave positive screening results (recall rate 0.32%) while 12 babies were true positive, including 2 newborns whose mothers resulted in being affected by a metabolic disease. The overall frequency of IEM found in the screening panel was 1:6041 (mothers excluded) or 1:5034 (mothers included). The introduction of MS/MS technology in Sicily has significantly increased the detection of inherited metabolic disorders, including those not previously covered, with a predictable improved outcome for several disorders.
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Affiliation(s)
- MariaAnna Messina
- Referral Center for Inherited Metabolic Diseases, Pediatric Clinical, AOU Policlinico-VE, Via Santa Sofia 78, 95123 Catania, Italy
- Correspondence: ; Tel.: +39-095-3781-493
| | - Concetta Meli
- Referral Center for Inherited Metabolic Diseases, Pediatric Clinical, AOU Policlinico-VE, Via Santa Sofia 78, 95123 Catania, Italy
| | - Federica Raudino
- Referral Center for Inherited Metabolic Diseases, Pediatric Clinical, AOU Policlinico-VE, Via Santa Sofia 78, 95123 Catania, Italy
| | - Annarita Pittalá
- Referral Center for Inherited Metabolic Diseases, Pediatric Clinical, AOU Policlinico-VE, Via Santa Sofia 78, 95123 Catania, Italy
| | - Alessia Arena
- Referral Center for Inherited Metabolic Diseases, Pediatric Clinical, AOU Policlinico-VE, Via Santa Sofia 78, 95123 Catania, Italy
| | - Rita Barone
- Child Neurology and Psichiatry, AOU Policlinico-VE, Via Santa Sofia 78, 95123 Catania, Italy
| | - Fortunata Giuffrida
- Referral Center for Inherited Metabolic Diseases, Pediatric Clinical, AOU Policlinico-VE, Via Santa Sofia 78, 95123 Catania, Italy
| | - Riccardo Iacobacci
- Referral Center for Inherited Metabolic Diseases, Pediatric Clinical, AOU Policlinico-VE, Via Santa Sofia 78, 95123 Catania, Italy
| | - Vera Muccilli
- Chemistry Department, Uiversity of Catania, Viale Andrea Doria 5, 95123 Catania, Italy
| | - Giovanni Sorge
- Referral Center for Inherited Metabolic Diseases, Pediatric Clinical, AOU Policlinico-VE, Via Santa Sofia 78, 95123 Catania, Italy
| | - Agata Fiumara
- Referral Center for Inherited Metabolic Diseases, Pediatric Clinical, AOU Policlinico-VE, Via Santa Sofia 78, 95123 Catania, Italy
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17
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Schlune A, Riederer A, Mayatepek E, Ensenauer R. Aspects of Newborn Screening in Isovaleric Acidemia. Int J Neonatal Screen 2018; 4:7. [PMID: 33072933 PMCID: PMC7548899 DOI: 10.3390/ijns4010007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 01/22/2018] [Indexed: 12/19/2022] Open
Abstract
Isovaleric acidemia (IVA), an inborn error of leucine catabolism, is caused by mutations in the isovaleryl-CoA dehydrogenase (IVD) gene, resulting in the accumulation of derivatives of isovaleryl-CoA including isovaleryl (C5)-carnitine, the marker metabolite used for newborn screening (NBS). The inclusion of IVA in NBS programs in many countries has broadened knowledge of the variability of the condition, whereas prior to NBS, two distinct clinical phenotypes were known, an "acute neonatal" and a "chronic intermittent" form. An additional biochemically mild and potentially asymptomatic form of IVA and its association with a common missense mutation, c.932C>T (p.A282V), was discovered in subjects identified through NBS. Deficiency of short/branched chain specific acyl-CoA dehydrogenase (2-methylbutyryl-CoA dehydrogenase), a defect of isoleucine degradation whose clinical significance remains unclear, also results in elevated C5-carnitine, and may therefore be detected by NBS for IVA. Treatment strategies for the long-term management of symptomatic IVA comprise the prevention of catabolism, dietary restriction of natural protein or leucine intake, and supplementation with l-carnitine and/or l-glycine. Recommendations on how to counsel and manage individuals with the mild phenotype detected by NBS are required.
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Affiliation(s)
- Andrea Schlune
- Experimental Pediatrics and Metabolism, Department of General Pediatrics, Neonatology and Pediatric Cardiology, Heinrich Heine University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany
| | - Anselma Riederer
- Department of Obstetrics and Gynecology, Hospital Altötting-Burghausen, Teaching Hospital of the Ludwig-Maximilians-Universität München, Vinzenz-von-Paul-Strasse 10, 84503 Altötting, Germany
| | - Ertan Mayatepek
- Experimental Pediatrics and Metabolism, Department of General Pediatrics, Neonatology and Pediatric Cardiology, Heinrich Heine University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany
| | - Regina Ensenauer
- Experimental Pediatrics and Metabolism, Department of General Pediatrics, Neonatology and Pediatric Cardiology, Heinrich Heine University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany
- Correspondence: ; Tel.: +49-211-81-17687
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18
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Monostori P, Klinke G, Richter S, Baráth Á, Fingerhut R, Baumgartner MR, Kölker S, Hoffmann GF, Gramer G, Okun JG. Simultaneous determination of 3-hydroxypropionic acid, methylmalonic acid and methylcitric acid in dried blood spots: Second-tier LC-MS/MS assay for newborn screening of propionic acidemia, methylmalonic acidemias and combined remethylation disorders. PLoS One 2017; 12:e0184897. [PMID: 28915261 PMCID: PMC5600371 DOI: 10.1371/journal.pone.0184897] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 09/01/2017] [Indexed: 12/20/2022] Open
Abstract
Background and aims Increased propionylcarnitine levels in newborn screening are indicative for a group of potentially severe disorders including propionic acidemia (PA), methylmalonic acidemias and combined remethylation disorders (MMACBL). This alteration is relatively non-specific, resulting in the necessity of confirmation and differential diagnosis in subsequent tests. Thus, we aimed to develop a multiplex approach for concurrent determination of 3-hydroxypropionic acid, methylmalonic acid and methylcitric acid from the same dried blood spot (DBS) as in primary screening (second-tier test). We also set out to validate the method using newborn and follow-up samples of patients with confirmed PA or MMACBL. Methods The assay was developed using liquid chromatography–tandem mass spectrometry and clinically validated with retrospective analysis of DBS samples from PA or MMACBL patients. Results Reliable determination of all three analytes in DBSs was achieved following simple and fast (<20 min) sample preparation without laborious derivatization or any additional pipetting steps. The method clearly distinguished the pathological and normal samples and differentiated between PA and MMACBL in all stored newborn specimens. Methylcitric acid was elevated in all PA samples; 3-hydroxypropionic acid was also high in most cases. Methylmalonic acid was increased in all MMACBL specimens; mostly together with methylcitric acid. Conclusions A liquid chromatography–tandem mass spectrometry assay allowing simultaneous determination of the biomarkers 3-hydroxypropionic acid, methylmalonic acid and methylcitric acid in DBSs has been developed. The assay can use the same specimen as in primary screening (second-tier test) which may reduce the need for repeated blood sampling. The presented preliminary findings suggest that this method can reliably differentiate patients with PA and MMACBL in newborn screening. The validated assay is being evaluated prospectively in a pilot project for extension of the German newborn screening panel (‟Newborn screening 2020”; Newborn Screening Center, University Hospital Heidelberg).
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Affiliation(s)
- Péter Monostori
- Department of General Pediatrics, Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
- * E-mail:
| | - Glynis Klinke
- Department of General Pediatrics, Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Sylvia Richter
- Department of General Pediatrics, Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Ákos Baráth
- Department of Pediatrics, University of Szeged, Szeged, Hungary
| | - Ralph Fingerhut
- Children’s Research Center, Division of Metabolism, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Matthias R. Baumgartner
- Children’s Research Center, Division of Metabolism, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Stefan Kölker
- Department of General Pediatrics, Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Georg F. Hoffmann
- Department of General Pediatrics, Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Gwendolyn Gramer
- Department of General Pediatrics, Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen G. Okun
- Department of General Pediatrics, Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Hagiwara SI, Kubota M, Nambu R, Kagimoto S. Screening of carnitine and biotin deficiencies on tandem mass spectrometry. Pediatr Int 2017; 59:458-461. [PMID: 27634667 DOI: 10.1111/ped.13167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 08/09/2016] [Accepted: 09/08/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND It is important to assess pediatric patients for nutritional deficiency when they are receiving specific interventions, such as enteral feeding. We focused on measurement of C0 and 3-hydroxyisovalerylcarnitine (C5-OH) with tandem mass spectrometry (MS/MS), which is performed as part of the newborn mass screening. The purpose of this study was to investigate the usefulness of MS/MS for screening carnitine and biotin deficiencies. METHODS Forty-two children (24 boys, 18 girls) were enrolled between December 2013 and December 2015. Blood tests, including measurement of serum free carnitine via the enzyme cycling method, and acylcarnitine analysis on MS/MS of dried blood spot (DBS), were performed for the evaluation of nutrition status. RESULTS Median patient age was 2 years (range, 2 months-14 years). Mean serum free carnitine was 41.8 ± 19.2 μmol/L. In six of the 42 patients, serum free carnitine was <20 μmol/L (range, 4.0-18.7 μmol/L). C0 and C5-OH measured on MS/MS of DBS were 33.8 ± 20.2 nmol/mL and 0.48 ± 0.22 nmol/mL, respectively. There was a strong positive correlation (r = 0.89, P < 0.001) between serum free carnitine and C0 measured on the same day. In one patient on hydrolyzed formula, C5-OH was >1.00 nmol/L. Therapy-resistant eczema was improved by treatment with additional biotin and a non-hydrolyzed formula. CONCLUSION C0 and C5-OH, measured on MS/MS of DBS, were useful for screening carnitine and biotin deficiencies.
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Affiliation(s)
- Shin-Ichiro Hagiwara
- Division of General Pediatrics, Saitama Children's Medical Center, Saitama, Japan
| | - Mitsuru Kubota
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Ryusuke Nambu
- Division of General Pediatrics, Saitama Children's Medical Center, Saitama, Japan
| | - Seiichi Kagimoto
- Division of General Pediatrics, Saitama Children's Medical Center, Saitama, Japan
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Reference interval of methylmalonic acid concentrations in dried blood spots of healthy, term newborns to facilitate neonatal screening of vitamin B12 deficiency. Clin Biochem 2016; 49:973-8. [DOI: 10.1016/j.clinbiochem.2016.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 03/04/2016] [Accepted: 03/23/2016] [Indexed: 11/18/2022]
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Wagner M, Tonoli D, Varesio E, Hopfgartner G. The use of mass spectrometry to analyze dried blood spots. MASS SPECTROMETRY REVIEWS 2016; 35:361-438. [PMID: 25252132 DOI: 10.1002/mas.21441] [Citation(s) in RCA: 162] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Dried blood spots (DBS) typically consist in the deposition of small volumes of capillary blood onto dedicated paper cards. Comparatively to whole blood or plasma samples, their benefits rely in the fact that sample collection is easier and that logistic aspects related to sample storage and shipment can be relatively limited, respectively, without the need of a refrigerator or dry ice. Originally, this approach has been developed in the sixties to support the analysis of phenylalanine for the detection of phenylketonuria in newborns using bacterial inhibition test. In the nineties tandem mass spectrometry was established as the detection technique for phenylalanine and tyrosine. DBS became rapidly recognized for their clinical value: they were widely implemented in pediatric settings with mass spectrometric detection, and were closely associated to the debut of newborn screening (NBS) programs, as a part of public health policies. Since then, sample collection on paper cards has been explored with various analytical techniques in other areas more or less successfully regarding large-scale applications. Moreover, in the last 5 years a regain of interest for DBS was observed and originated from the bioanalytical community to support drug development (e.g., PK studies) or therapeutic drug monitoring mainly. Those recent applications were essentially driven by improved sensitivity of triple quadrupole mass spectrometers. This review presents an overall view of all instrumental and methodological developments for DBS analysis with mass spectrometric detection, with and without separation techniques. A general introduction to DBS will describe their advantages and historical aspects of their emergence. A second section will focus on blood collection, with a strong emphasis on specific parameters that can impact quantitative analysis, including chromatographic effects, hematocrit effects, blood effects, and analyte stability. A third part of the review is dedicated to sample preparation and will consider off-line and on-line extractions; in particular, instrumental designs that have been developed so far for DBS extraction will be detailed. Flow injection analysis and applications will be discussed in section IV. The application of surface analysis mass spectrometry (DESI, paper spray, DART, APTDCI, MALDI, LDTD-APCI, and ICP) to DBS is described in section V, while applications based on separation techniques (e.g., liquid or gas chromatography) are presented in section VI. To conclude this review, the current status of DBS analysis is summarized, and future perspectives are provided.
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Affiliation(s)
- Michel Wagner
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Life Sciences Mass Spectrometry, Quai Ernest-Ansermet 30, 1211, Geneva, Switzerland
| | - David Tonoli
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Life Sciences Mass Spectrometry, Quai Ernest-Ansermet 30, 1211, Geneva, Switzerland
| | - Emmanuel Varesio
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Life Sciences Mass Spectrometry, Quai Ernest-Ansermet 30, 1211, Geneva, Switzerland
| | - Gérard Hopfgartner
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Life Sciences Mass Spectrometry, Quai Ernest-Ansermet 30, 1211, Geneva, Switzerland
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Ktena YP, Paul SM, Hauser NS, Sloan JL, Gropman A, Manoli I, Venditti CP. Delineating the spectrum of impairments, disabilities, and rehabilitation needs in methylmalonic acidemia (MMA). Am J Med Genet A 2015; 167A:2075-84. [PMID: 25959030 DOI: 10.1002/ajmg.a.37127] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 04/02/2015] [Indexed: 11/08/2022]
Abstract
Methylmalonic acidemia patients have complex rehabilitation needs that can be targeted to optimize societal independence and quality of life. Thirty-seven individuals with isolated MMA (28 mut, 5 cblA, 4 cblB), aged 2-33 years, were enrolled in a natural history study, and underwent age-appropriate clinical assessments to characterize impairments and disabilities. Neurological examination and brain imaging studies were used to document movement disorders and the presence of basal ganglia injury. A range of impairments and disabilities were identified by a team of physical medicine experts. Movement disorders, such as chorea and tremor, were common (n = 31, 83%), even among patients without evidence of basal ganglia injury. Joint hypermobility (n = 24, 69%) and pes planus (n = 22, 60%) were frequent and, in many cases, under-recognized. 23 (62%) patients required gastrostomy feedings. 18/31 patients >4 years old (58%) had difficulties with bathing and dressing. 16 of 23 school-aged patients received various forms of educational support. Five of the 10 adult patients were employed or in college; three lived independently. Unmet needs were identified in access to rehabilitation services, such as physical therapy (unavailable to 14/31), and orthotics (unavailable to 15/22). We conclude that patients with MMA are challenged by a number of functional limitations in essential activities of mobility, self-care, and learning, in great part caused by movement disorders and ligamentous laxity. Early assessment, referral, and implementation of age-appropriate rehabilitation services should significantly improve independence and quality of life.
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Affiliation(s)
- Yiouli P Ktena
- Organic Acid Research Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Scott M Paul
- Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Natalie S Hauser
- Organic Acid Research Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Jennifer L Sloan
- Organic Acid Research Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Andrea Gropman
- Center for Neuroscience Research (CNR), Children's National Medical Center, Washington, District of Columbia
| | - Irini Manoli
- Organic Acid Research Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Charles P Venditti
- Organic Acid Research Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
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23
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Suitability of methylmalonic acid and total homocysteine analysis in dried bloodspots. Anal Chim Acta 2015; 853:435-441. [DOI: 10.1016/j.aca.2014.10.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 10/27/2014] [Accepted: 10/28/2014] [Indexed: 11/23/2022]
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Schroder TH, Quay TAW, Lamers Y. Methylmalonic acid quantified in dried blood spots provides a precise, valid, and stable measure of functional vitamin B-12 status in healthy women. J Nutr 2014; 144:1658-63. [PMID: 25143369 DOI: 10.3945/jn.114.194829] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Methylmalonic acid (MMA) is a sensitive and specific functional biomarker of vitamin B-12 status, commonly assessed in plasma or serum. Dried blood spots (DBSs) allow simpler and more cost-efficient blood sampling than plasma. To facilitate convenient testing for vitamin B-12 deficiency in large-scale surveys and in population groups from remote areas, we developed a method for MMA quantification in DBSs and tested its applicability as well as the long-term stability of MMA in DBSs at various temperatures. MMA was extracted from an 8-mm DBS punch with water:methanol (95:5, v:v) and methyl-d3-malonic acid as the internal standard. After sample cleanup by ultrafiltration and hexane extraction, MMA was quantified by using reversed-phase LC-tandem mass spectrometry. Extraction conditions were optimized to maximize the detection signal and achieve DBS extract concentrations above the lowest limit of quantification (signal-to-noise ratio ≥ 10) of 10 nmol/L. Recovery was between 93% and 96%. Intra- and interassay variation (CV%) for DBS MMA was 0.49% and 2.3%, respectively. Calibrators showed linearity (R(2) = 0.998) between 10 and 10,000 nmol/L. In 94 healthy women, MMA concentrations in DBS extract (min-max: 10.2-80.5 nmol/L) and plasma (min-max: 68-950 nmol/L) were correlated (ρ = 0.90) (P < 0.001). MMA concentrations in DBSs were stable at room temperature for 1 wk, in the refrigerator for 8 wk, and at -80°C for at least 1 y. This simple and robust method allows quantification of MMA in DBSs of healthy individuals. The linear relation between plasma and DBS MMA suggests that DBS MMA could predict plasma MMA, the current reference indicator for functional vitamin B-12 deficiency. With the advantages of minimally invasive specimen collection and no need for laborious blood processing steps, this method has the potential to be a reliable, convenient, and field-applicable alternative for assessment of vitamin B-12 status.
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Affiliation(s)
- Theresa H Schroder
- Food, Nutrition, and Health, Faculty of Land and Food Systems, University of British Columbia, Vancouver, BC, Canada
| | - Teo A W Quay
- Food, Nutrition, and Health, Faculty of Land and Food Systems, University of British Columbia, Vancouver, BC, Canada
| | - Yvonne Lamers
- Food, Nutrition, and Health, Faculty of Land and Food Systems, University of British Columbia, Vancouver, BC, Canada
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Mak CM, Lee HCH, Chan AYW, Lam CW. Inborn errors of metabolism and expanded newborn screening: review and update. Crit Rev Clin Lab Sci 2014; 50:142-62. [PMID: 24295058 DOI: 10.3109/10408363.2013.847896] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Inborn errors of metabolism (IEM) are a phenotypically and genetically heterogeneous group of disorders caused by a defect in a metabolic pathway, leading to malfunctioning metabolism and/or the accumulation of toxic intermediate metabolites. To date, more than 1000 different IEM have been identified. While individually rare, the cumulative incidence has been shown to be upwards of 1 in 800. Clinical presentations are protean, complicating diagnostic pathways. IEM are present in all ethnic groups and across every age. Some IEM are amenable to treatment, with promising outcomes. However, high clinical suspicion alone is not sufficient to reduce morbidities and mortalities. In the last decade, due to the advent of tandem mass spectrometry, expanded newborn screening (NBS) has become a mandatory public health strategy in most developed and developing countries. The technology allows inexpensive simultaneous detection of more than 30 different metabolic disorders in one single blood spot specimen at a cost of about USD 10 per baby, with commendable analytical accuracy and precision. The sensitivity and specificity of this method can be up to 99% and 99.995%, respectively, for most amino acid disorders, organic acidemias, and fatty acid oxidation defects. Cost-effectiveness studies have confirmed that the savings achieved through the use of expanded NBS programs are significantly greater than the costs of implementation. The adverse effects of false positive results are negligible in view of the economic health benefits generated by expanded NBS and these could be minimized through increased education, better communication, and improved technologies. Local screening agencies should be given the autonomy to develop their screening programs in order to keep pace with international advancements. The development of biochemical genetics is closely linked with expanded NBS. With ongoing advancements in nanotechnology and molecular genomics, the field of biochemical genetics is still expanding rapidly. The potential of tandem mass spectrometry is extending to cover more disorders. Indeed, the use of genetic markers in T-cell receptor excision circles for severe combined immunodeficiency is one promising example. NBS represents the highest volume of genetic testing. It is more than a test and it warrants systematic healthcare service delivery across the pre-analytical, analytical, and post-analytical phases. There should be a comprehensive reporting system entailing genetic counselling as well as short-term and long-term follow-up. It is essential to integrate existing clinical IEM services with the expanded NBS program to enable close communication between the laboratory, clinicians, and allied health parties. In this review, we will discuss the history of IEM, its clinical presentations in children and adult patients, and its incidence among different ethnicities; the history and recent expansion of NBS, its cost-effectiveness, associated pros and cons, and the ethical issues that can arise; the analytical aspects of tandem mass spectrometry and post-analytical perspectives regarding result interpretation.
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Affiliation(s)
- Chloe Miu Mak
- Chemical Pathology Laboratory, Department of Pathology, Princess Margaret Hospital , Hong Kong, SAR , China and
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Hayashi H, Tokuriki S, Okuno T, Shigematsu Y, Yasushi A, Matsuyama G, Sawada K, Ohshima Y. Biotin and carnitine deficiency due to hypoallergenic formula nutrition in infants with milk allergy. Pediatr Int 2014; 56:286-8. [PMID: 24730636 DOI: 10.1111/ped.12319] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 01/07/2014] [Accepted: 02/06/2014] [Indexed: 12/01/2022]
Abstract
Amino acid formulas and hydrolyzed formulas given to infants in Japan with milk allergies theoretically contain little, if any, biotin and carnitine. We assessed biotin and carnitine insufficiency in six infants with milk allergy who were fed amino acid formulas and/or hydrolyzed formulas, by measuring urine 3-hydroxyisovaleric acid (3-HIA) and serum free carnitine (C0), respectively. All patients presented with elevated urine 3-HIA and lowered serum C0 compared with post-menstrual age-matched infants who were fed breast milk or standard infant formulas. Supplementation with biotin and L-carnitine immediately improved the insufficiency. Care should be taken to avoid biotin and carnitine deficiency in allergic infants fed amino acid or hydrolyzed formulas.
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Affiliation(s)
- Hisako Hayashi
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Yoshida-gun, Japan
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27
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Tokuriki S, Hayashi H, Okuno T, Yoshioka K, Okazaki S, Kawakita A, Ohta G, Hata I, Shigematsu Y, Ohshima Y. Biotin and carnitine profiles in preterm infants in Japan. Pediatr Int 2013; 55:342-5. [PMID: 23316835 DOI: 10.1111/ped.12053] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 12/16/2012] [Accepted: 12/27/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Biotin plays an important role as a covalently bound coenzyme for carboxylases. Carnitine is essential in β-oxidation to transport long-chain fatty acids across the inner mitochondrial membrane. The present study was conducted to assess the risk of biotin and carnitine deficiencies in preterm infants who received enteral feeding with maternal milk and/or standard infant formula made in Japan. METHODS Forty-six infants were enrolled in the study. Urine and serum samples and dried blood spots were collected at 1 week and 1 month of age. Additionally, samples were collected at 40 and 44 weeks post-menstrual age (PMA) in preterm infants. Free carnitine and C5-OH acylcarnitine, which consist of 3-hydroxyisovalerylcarnitine as a major isomer, were measured in serum samples and dried blood spots using tandem mass spectrometry. Urine 3-hydroxyisovaleric acid (3-HIVA) was measured using gas chromatography/mass spectrometry. RESULTS The free carnitine levels in preterm infants were significantly lower than those in term infants, but increased with PMA in serum samples and dried blood spots. C5-OH acylcarnitine and urinary 3-HIVA levels, which were very low in term infants, were increased with PMA in preterm infants. CONCLUSION The present results may indicate chronic biotin deficiency in preterm infants fed maternal milk and/or standard infant formula. Analyses of carnitine profiles of dried blood spots and urine 3-HIVA are relatively non-invasive and useful for the early detection of biotin deficiency in preterm infants.
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Affiliation(s)
- Shuko Tokuriki
- Department of Pediatrics, University of Fukui, Fukui, Japan.
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Chen WH, Hsieh SL, Hsu KP, Chen HP, Su XY, Tseng YJ, Chien YH, Hwu WL, Lai F. Web-based newborn screening system for metabolic diseases: machine learning versus clinicians. J Med Internet Res 2013; 15:e98. [PMID: 23702487 PMCID: PMC3668606 DOI: 10.2196/jmir.2495] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Revised: 03/04/2013] [Accepted: 04/07/2013] [Indexed: 01/06/2023] Open
Abstract
Background A hospital information system (HIS) that integrates screening data and interpretation of the data is routinely requested by hospitals and parents. However, the accuracy of disease classification may be low because of the disease characteristics and the analytes used for classification. Objective The objective of this study is to describe a system that enhanced the neonatal screening system of the Newborn Screening Center at the National Taiwan University Hospital. The system was designed and deployed according to a service-oriented architecture (SOA) framework under the Web services .NET environment. The system consists of sample collection, testing, diagnosis, evaluation, treatment, and follow-up services among collaborating hospitals. To improve the accuracy of newborn screening, machine learning and optimal feature selection mechanisms were investigated for screening newborns for inborn errors of metabolism. Methods The framework of the Newborn Screening Hospital Information System (NSHIS) used the embedded Health Level Seven (HL7) standards for data exchanges among heterogeneous platforms integrated by Web services in the C# language. In this study, machine learning classification was used to predict phenylketonuria (PKU), hypermethioninemia, and 3-methylcrotonyl-CoA-carboxylase (3-MCC) deficiency. The classification methods used 347,312 newborn dried blood samples collected at the Center between 2006 and 2011. Of these, 220 newborns had values over the diagnostic cutoffs (positive cases) and 1557 had values that were over the screening cutoffs but did not meet the diagnostic cutoffs (suspected cases). The original 35 analytes and the manifested features were ranked based on F score, then combinations of the top 20 ranked features were selected as input features to support vector machine (SVM) classifiers to obtain optimal feature sets. These feature sets were tested using 5-fold cross-validation and optimal models were generated. The datasets collected in year 2011 were used as predicting cases. Results The feature selection strategies were implemented and the optimal markers for PKU, hypermethioninemia, and 3-MCC deficiency were obtained. The results of the machine learning approach were compared with the cutoff scheme. The number of the false positive cases were reduced from 21 to 2 for PKU, from 30 to 10 for hypermethioninemia, and 209 to 46 for 3-MCC deficiency. Conclusions This SOA Web service–based newborn screening system can accelerate screening procedures effectively and efficiently. An SVM learning methodology for PKU, hypermethioninemia, and 3-MCC deficiency metabolic diseases classification, including optimal feature selection strategies, is presented. By adopting the results of this study, the number of suspected cases could be reduced dramatically.
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Affiliation(s)
- Wei-Hsin Chen
- National Taiwan University, Graduate Institute of Biomedical Electronics and Bioinformatics, Taipei, Taiwan
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Kobayashi Y, Ishikawa N, Tsumura M, Fujii Y, Okada S, Shigematsu Y, Kobayashi M. Acute severe encephalopathy related to human herpesvirus-6 infection in a patient with carnitine palmitoyltransferase 2 deficiency carrying thermolabile variants. Brain Dev 2013; 35:449-53. [PMID: 22854105 DOI: 10.1016/j.braindev.2012.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Revised: 05/28/2012] [Accepted: 06/29/2012] [Indexed: 11/27/2022]
Abstract
We describe a male infant with carnitine palmitoyltransferase 2 (CPT2) deficiency who presented with acute encephalopathy related to human herpesvirus-6 (HHV-6) infection. He was hospitalized for pylexia and status epilepticus, diagnosed with acute encephalopathy, and treated with intensive supportive care including mechanical ventilation, support for hypothermia, and control of the intracranial pressure, that caused severe neurological sequelae. HHV-6 was detected in his cerebrospinal fluid, indicating HHV-6 related encephalopathy. In the acute phase, acylcarnitine analysis of blood suggested a defect of long chain fatty acid β-oxidation, and CPT2 deficiency was genetically confirmed. In addition, other gene alterations that have been previously reported as "thermolabile variants" were found. Some patients with the infantile form of CPT2 deficiency present with acute encephalopathy, but others do not develop encephalopathy. The correlation between phenotype and genotype has not been clarified. Our case may contribute to the elucidation of the genetic factor involved in acute encephalopathy in CPT2 deficiency.
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Affiliation(s)
- Yoshiyuki Kobayashi
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan.
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Janzen N, Steuerwald U, Sander S, Terhardt M, Peter M, Sander J. UPLC-MS/MS analysis of C5-acylcarnitines in dried blood spots. Clin Chim Acta 2013; 421:41-5. [PMID: 23499962 DOI: 10.1016/j.cca.2013.03.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Revised: 02/28/2013] [Accepted: 03/01/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Metabolic screening including newborn screening requires further differentiation of C5-acylcarnitines in order to separate different metabolic disorders and to detect interferents like pivalic acid originating from antibiotics. METHODS For individual quantification of C5-acylcarnitine isoforms in dried blood spots we combined UPLC using a C18 column and gradient elution with tandem mass spectrometry in ESI+mode. RESULTS Results were linear, coefficients of determination (R(2))>0.9977, intra- and inter-assay coefficients of variations <5.2%, recovery 96.8-105.2%, limits of detection and quantitation <0.2 μmol/L. Out of 29.309 blood samples of the isolated population of the Faroe Islands 56 exceeded the cut-off of 0.5 μmol/L for C5-acylcarnitine; 45 of which could be retested using the method described. Pivaloylcarnitine was identified in 43 samples, isovalerylcarnitine was found in two samples. CONCLUSIONS The method was developed to allow direct re-analysis of samples showing elevated concentrations of C5-acylcarnitines in a metabolic screening program based on quantification of acylcarnitines after butylation. The technique should be especially useful in newborn screening for exclusion of false positives and for differentiation between isovaleric acidemia and 2-methylbutyryl-CoA dehydrogenase deficiency.
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Affiliation(s)
- Nils Janzen
- Screening-Labor Hannover, Hannover, Germany.
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Dénes J, Szabó E, Robinette SL, Szatmári I, Szőnyi L, Kreuder JG, Rauterberg EW, Takáts Z. Metabonomics of Newborn Screening Dried Blood Spot Samples: A Novel Approach in the Screening and Diagnostics of Inborn Errors of Metabolism. Anal Chem 2012; 84:10113-20. [DOI: 10.1021/ac302527m] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Júlia Dénes
- Biomolecular Medicine, Department
of Surgery and Cancer, Imperial College London, United Kingdom
| | | | - Steven L. Robinette
- Biomolecular Medicine, Department
of Surgery and Cancer, Imperial College London, United Kingdom
| | - Ildikó Szatmári
- Metabolic Diagnostic Laboratory,
1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - László Szőnyi
- Metabolic Diagnostic Laboratory,
1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Joachim G. Kreuder
- Hesse
Child Health Centre, Johann Wolfgang Goethe University Hospital, Giessen,
Germany
| | - Ernst W. Rauterberg
- Hesse
Child Health Centre, Johann Wolfgang Goethe University Hospital, Giessen,
Germany
| | - Zoltán Takáts
- Biomolecular Medicine, Department
of Surgery and Cancer, Imperial College London, United Kingdom
- Metabolic Diagnostic Laboratory,
1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
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Lund AM, Hougaard DM, Simonsen H, Andresen BS, Christensen M, Dunø M, Skogstrand K, Olsen RKJ, Jensen UG, Cohen A, Larsen N, Saugmann-Jensen P, Gregersen N, Brandt NJ, Christensen E, Skovby F, Nørgaard-Pedersen B. Biochemical screening of 504,049 newborns in Denmark, the Faroe Islands and Greenland--experience and development of a routine program for expanded newborn screening. Mol Genet Metab 2012; 107:281-93. [PMID: 22795865 DOI: 10.1016/j.ymgme.2012.06.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 06/08/2012] [Accepted: 06/08/2012] [Indexed: 10/28/2022]
Abstract
Expanded newborn screening for selected inborn errors of metabolism (IEM) in Denmark, the Faroe Islands and Greenland was introduced in 2002. We now present clinical, biochemical, and statistical results of expanded screening (excluding PKU) of 504,049 newborns during nine years as well as diagnoses and clinical findings in 82,930 unscreened newborns born in the same period. The frequencies of diagnoses made within the panel of disorders screened for are compared with the frequencies of the disorders in the decade preceding expanded newborn screening. The expanded screening was performed as a pilot study during the first seven years, and the experience obtained during these years was used in the development of the routine neonatal screening program introduced in 2009. Methods for screening included tandem mass spectrometry and an assay for determination of biotinidase activity. A total of 310 samples from 504,049 newborns gave positive screening results. Of the 310 results, 114 were true positive, including results from 12 newborns in which the disease in question was subsequently diagnosed in their mothers. Thus, the overall frequency of an IEM in the screening panel was 1:4942 (mothers excluded) or 1:4421 (mothers included). The false positive rate was 0.038% and positive predictive value 37%. Overall specificity was 99.99%. All patients with true positive results were followed in The Center for Inherited Metabolic Disorders in Copenhagen, and the mean follow-up period was 45 months (range 2109 months). There were no deaths among the 102 children, and 94% had no clinically significant sequelae at last follow-up. Our study confirms the higher frequency of selected IEM after implementation of expanded newborn screening and suggests an improved outcome for several disorders. We argue that newborn screening for these disorders should be standard of care, though unresolved issues remain, e.g. about newborns with a potential for remaining asymptomatic throughout life. Well organized logistics of the screening program from screening laboratory to centralized, clinical management is important.
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Affiliation(s)
- Allan Meldgaard Lund
- Center for Inherited Metabolic Disorders, Department of Clinical Genetics, Copenhagen University Hospital, Copenhagen, Denmark.
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Clinical validation of cutoff target ranges in newborn screening of metabolic disorders by tandem mass spectrometry: a worldwide collaborative project. Genet Med 2011; 13:230-54. [PMID: 21325949 DOI: 10.1097/gim.0b013e31820d5e67] [Citation(s) in RCA: 262] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To achieve clinical validation of cutoff values for newborn screening by tandem mass spectrometry through a worldwide collaborative effort. METHODS Cumulative percentiles of amino acids and acylcarnitines in dried blood spots of approximately 25–30 million normal newborns and 10,742 deidentified true positive cases are compared to assign clinical significance, which is achieved when the median of a disorder range is, and usually markedly outside, either the 99th or the 1st percentile of the normal population. The cutoff target ranges of analytes and ratios are then defined as the interval between selected percentiles of the two populations. When overlaps occur, adjustments are made to maximize sensitivity and specificity taking all available factors into consideration. RESULTS As of December 1, 2010, 130 sites in 45 countries have uploaded a total of 25,114 percentile data points, 565,232 analyte results of true positive cases with 64 conditions, and 5,341 cutoff values. The average rate of submission of true positive cases between December 1, 2008, and December 1, 2010, was 5.1 cases/day. This cumulative evidence generated 91 high and 23 low cutoff target ranges. The overall proportion of cutoff values within the respective target range was 42% (2,269/5,341). CONCLUSION An unprecedented level of cooperation and collaboration has allowed the objective definition of cutoff target ranges for 114 markers to be applied to newborn screening of rare metabolic disorders.
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Kasapkara CS, Ezgu FS, Okur I, Tumer L, Biberoglu G, Hasanoglu A. N-carbamylglutamate treatment for acute neonatal hyperammonemia in isovaleric acidemia. Eur J Pediatr 2011; 170:799-801. [PMID: 21207059 DOI: 10.1007/s00431-010-1362-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2010] [Accepted: 11/22/2010] [Indexed: 01/20/2023]
Abstract
Hyperammonemia occurs mainly in patients with branched-chain organic acidemias such as propionic, methylmalonic, and isovaleric acidemias. Its pathophysiological process is mainly via the competitive inhibition of N-acetylglutamate synthetase. Oral carglumic acid (N-carbamylglutamate) administration can correct hyperammonemia in neonates with propionic and methylmalonic acidemias, thus avoiding dialysis therapy. Isovaleric acidemia is an autosomal recessive disease of leucine metabolism due to deficiency of isovaleryl-CoA dehydrogenase. For the first time, we report a neonate with isovaleric acidemia, whose plasma ammonia concentration dropped dramatically after one oral load of carglumic acid. This experience suggests that carglumic acid could be considered for acute hyperammonemia resulting from isovaleric acidemia. However, trials with more patients are needed.
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Affiliation(s)
- Cigdem Seher Kasapkara
- Department of Pediatric Nutrition and Metabolism, Gazi University Medical School, Besevler, Ankara, 06500, Turkey.
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