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Murphey K, Krishna I, Li H. Inborn errors of metabolism and pregnancy. Am J Obstet Gynecol MFM 2024; 6:101399. [PMID: 38871294 DOI: 10.1016/j.ajogmf.2024.101399] [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: 03/08/2024] [Revised: 05/07/2024] [Accepted: 05/28/2024] [Indexed: 06/15/2024]
Abstract
As the diagnosis and treatment of patients with inborn errors of metabolism has improved dramatically over the years, more people with these conditions are surviving into child-bearing years. Given the changes in metabolism throughout pregnancy, this time presents a unique challenge in their care. Overall metabolic shifts in pregnancy go from anabolism to catabolism driven by endocrinologic changes, along with changes in rates of gluconeogenesis, glucose consumption, amino acid transport, protein consumption, and lipid breakdown, result in a complicated metabolic picture. Additionally, maternal inborn errors of metabolism can affect a fetus, as in phenylketonuria, and fetal inborn errors of metabolism can affect the mother, as in certain fatty acid oxidation disorders. Data on these conditions is often very limited. A summary of the current literature, risks associated with pregnancy in inborn errors of metabolism, and suggestions for management of these conditions will be presented.
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Affiliation(s)
- Kristen Murphey
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA (Murphey and Li); Department of Pediatrics, Emory University School of Medicine & Children's Healthcare of Atlanta, Atlanta, GA (Li).
| | - Iris Krishna
- Department of Gynecology and Obstetrics, Division of Maternal-Fetal Medicine, Emory University School of Medicine, Atlanta, GA (Krishna)
| | - Hong Li
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA (Murphey and Li); Department of Pediatrics, Emory University School of Medicine & Children's Healthcare of Atlanta, Atlanta, GA (Li)
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2
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Feillet F, Ficicioglu C, Lagler FB, Longo N, Muntau AC, Burlina A, Trefz FK, van Spronsen FJ, Arnoux JB, Lindstrom K, Lilienstein J, Clague GE, Rowell R, Burton BK. Efficacy and safety of sapropterin before and during pregnancy: Final analysis of the Kuvan® Adult Maternal Paediatric European Registry (KAMPER) maternal and Phenylketonuria Developmental Outcomes and Safety (PKUDOS) PKU-MOMs sub-registries. J Inherit Metab Dis 2024; 47:636-650. [PMID: 38433424 DOI: 10.1002/jimd.12724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 01/24/2024] [Accepted: 02/19/2024] [Indexed: 03/05/2024]
Abstract
Infants born to mothers with phenylketonuria (PKU) may develop congenital abnormalities because of elevated phenylalanine (Phe) levels in the mother during pregnancy. Maintenance of blood Phe levels between 120 and 360 μmol/L reduces risks of birth defects. Sapropterin dihydrochloride helps maintain blood Phe control, but there is limited evidence on its risk-benefit ratio when used during pregnancy. Data from the maternal sub-registries-KAMPER (NCT01016392) and PKUDOS (NCT00778206; PKU-MOMs sub-registry)-were collected to assess the long-term safety and efficacy of sapropterin in pregnant women in a real-life setting. Pregnancy and infant outcomes, and the safety of sapropterin were assessed. Final data from 79 pregnancies in 57 women with PKU are reported. Sapropterin dose was fairly constant before and during pregnancy, with blood Phe levels maintained in the recommended target range during the majority (82%) of pregnancies. Most pregnancies were carried to term, and the majority of liveborn infants were reported as 'normal' at birth. Few adverse and serious adverse events were considered related to sapropterin, with these occurring in participants with high blood Phe levels. This report represents the largest population of pregnant women with PKU exposed to sapropterin. Results demonstrate that exposure to sapropterin during pregnancy was well-tolerated and facilitated maintenance of blood Phe levels within the target range, resulting in normal delivery. This critical real-world data may facilitate physicians and patients to make informed treatment decisions about using sapropterin in pregnant women with PKU and in women of childbearing age with PKU who are responsive to sapropterin.
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Affiliation(s)
- François Feillet
- Hôpital d'enfants Brabois, INSERM 1256 NGERE, Faculty of Medicine, Vandoeuvre les Nancy, France
| | - Can Ficicioglu
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Florian B Lagler
- Institute of Inherited Metabolic Diseases and Department of Pediatrics, Paracelsus Medical Private University, Salzburg, Austria
| | | | - Ania C Muntau
- University Children's Hospital, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Friedrich K Trefz
- Division of Inborn Metabolic Diseases, University Children's Hospital, Department of General Pediatrics, Heidelberg, Germany
| | - Francjan J van Spronsen
- Division of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center of Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | | | | | | | - Barbara K Burton
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Vos EN, Demirbas D, Mangel M, Gozalbo MER, Levy HL, Berry GT. The treatment of biochemical genetic diseases: From substrate reduction to nucleic acid therapies. Mol Genet Metab 2023; 140:107693. [PMID: 37716025 DOI: 10.1016/j.ymgme.2023.107693] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/29/2023] [Accepted: 08/29/2023] [Indexed: 09/18/2023]
Abstract
Newborn screening (NBS) began a revolution in the management of biochemical genetic diseases, greatly increasing the number of patients for whom dietary therapy would be beneficial in preventing complications in phenylketonuria as well as in a few similar disorders. The advent of next generation sequencing and expansion of NBS have markedly increased the number of biochemical genetic diseases as well as the number of patients identified each year. With the avalanche of new and proposed therapies, a second wave of options for the treatment of biochemical genetic disorders has emerged. These therapies range from simple substrate reduction to enzyme replacement, and now ex vivo gene therapy with autologous cell transplantation. In some instances, it may be optimal to introduce nucleic acid therapy during the prenatal period to avoid fetopathy. However, as with any new therapy, complications may occur. It is important for physicians and other caregivers, along with ethicists, to determine what new therapies might be beneficial to the patient, and which therapies have to be avoided for those individuals who have less severe problems and for which standard treatments are available. The purpose of this review is to discuss the "Standard" treatment plans that have been in place for many years and to identify the newest and upcoming therapies, to assist the physician and other healthcare workers in making the right decisions regarding the initiation of both the "Standard" and new therapies. We have utilized several diseases to illustrate the applications of these different modalities and discussed for which disorders they may be suitable. The future is bright, but optimal care of the patient, including and especially the newborn infant, requires a deep knowledge of the disease process and careful consideration of the necessary treatment plan, not just based on the different genetic defects but also with regards to different variants within a gene itself.
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Affiliation(s)
- E Naomi Vos
- Division of Genetics & Genomics, Boston Children's Hospital; and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States of America; Manton Center for Orphan Disease Research, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States of America.
| | - Didem Demirbas
- Division of Genetics & Genomics, Boston Children's Hospital; and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States of America; Manton Center for Orphan Disease Research, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States of America.
| | - Matthew Mangel
- Division of Genetics & Genomics, Boston Children's Hospital; and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States of America.
| | - M Estela Rubio Gozalbo
- Department of Pediatrics and Clinical Genetics, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands; GROW, Maastricht University, Minderbroedersberg 4-6, 6211 LK Maastricht, the Netherlands; MetabERN: European Reference Network for Hereditary Metabolic Disorders, Udine, Italy; UMD: United for Metabolic Diseases Member, Amsterdam, the Netherlands.
| | - Harvey L Levy
- Division of Genetics & Genomics, Boston Children's Hospital; and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States of America.
| | - Gerard T Berry
- Division of Genetics & Genomics, Boston Children's Hospital; and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States of America; Manton Center for Orphan Disease Research, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States of America.
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Adams AD, Fiesco-Roa MÓ, Wong L, Jenkins GP, Malinowski J, Demarest OM, Rothberg PG, Hobert JA. Phenylalanine hydroxylase deficiency treatment and management: A systematic evidence review of the American College of Medical Genetics and Genomics (ACMG). Genet Med 2023; 25:100358. [PMID: 37470789 DOI: 10.1016/j.gim.2022.12.005] [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: 12/05/2022] [Revised: 12/08/2022] [Accepted: 12/08/2022] [Indexed: 07/21/2023] Open
Abstract
PURPOSE Elevated serum phenylalanine (Phe) levels due to biallelic pathogenic variants in phenylalanine hydroxylase (PAH) may cause neurodevelopmental disorders or birth defects from maternal phenylketonuria. New Phe reduction treatments have been approved in the last decade, but uncertainty on the optimal lifespan goal Phe levels for patients with PAH deficiency remains. METHODS We searched Medline and Embase for evidence of treatment concerning PAH deficiency up to September 28, 2021. Risk of bias was evaluated based on study design. Random-effects meta-analyses were performed to compare IQ, gestational outcomes, and offspring outcomes based on Phe ≤ 360 μmol/L vs > 360 μmol/L and reported as odds ratio and 95% CI. Remaining results were narratively synthesized. RESULTS A total of 350 studies were included. Risk of bias was moderate. Lower Phe was consistently associated with better outcomes. Achieving Phe ≤ 360 μmol/L before conception substantially lowered the risk of negative effect to offspring in pregnant individuals (odds ratio = 0.07, 95% CI = 0.04-0.14; P < .0001). Adverse events due to pharmacologic treatment were common, but medication reduced Phe levels, enabling dietary liberalization. CONCLUSIONS Reduction of Phe levels to ≤360 μmol/L through diet or medication represents effective interventions to treat PAH deficiency.
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Affiliation(s)
- April D Adams
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX; Division of Maternal-Fetal Medicine, Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Moisés Ó Fiesco-Roa
- Programa de Maestría y Doctorado en Ciencias Médicas, Universidad Nacional Autónoma de México (UNAM), Mexico City, Mexico; Laboratorio de Citogenética, Instituto Nacional de Pediatría, Mexico City, Mexico
| | | | | | | | | | - Paul G Rothberg
- Department of Pathology & Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Judith A Hobert
- University of Utah School of Medicine, Salt Lake City, UT; ARUP Laboratories, Salt Lake City, UT
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Elhawary NA, AlJahdali IA, Abumansour IS, Elhawary EN, Gaboon N, Dandini M, Madkhali A, Alosaimi W, Alzahrani A, Aljohani F, Melibary EM, Kensara OA. Genetic etiology and clinical challenges of phenylketonuria. Hum Genomics 2022; 16:22. [PMID: 35854334 PMCID: PMC9295449 DOI: 10.1186/s40246-022-00398-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/08/2022] [Indexed: 02/08/2023] Open
Abstract
This review discusses the epidemiology, pathophysiology, genetic etiology, and management of phenylketonuria (PKU). PKU, an autosomal recessive disease, is an inborn error of phenylalanine (Phe) metabolism caused by pathogenic variants in the phenylalanine hydroxylase (PAH) gene. The prevalence of PKU varies widely among ethnicities and geographic regions, affecting approximately 1 in 24,000 individuals worldwide. Deficiency in the PAH enzyme or, in rare cases, the cofactor tetrahydrobiopterin results in high blood Phe concentrations, causing brain dysfunction. Untreated PKU, also known as PAH deficiency, results in severe and irreversible intellectual disability, epilepsy, behavioral disorders, and clinical features such as acquired microcephaly, seizures, psychological signs, and generalized hypopigmentation of skin (including hair and eyes). Severe phenotypes are classic PKU, and less severe forms of PAH deficiency are moderate PKU, mild PKU, mild hyperphenylalaninaemia (HPA), or benign HPA. Early diagnosis and intervention must start shortly after birth to prevent major cognitive and neurological effects. Dietary treatment, including natural protein restriction and Phe-free supplements, must be used to maintain blood Phe concentrations of 120-360 μmol/L throughout the life span. Additional treatments include the casein glycomacropeptide (GMP), which contains very limited aromatic amino acids and may improve immunological function, and large neutral amino acid (LNAA) supplementation to prevent plasma Phe transport into the brain. The synthetic BH4 analog, sapropterin hydrochloride (i.e., Kuvan®, BioMarin), is another potential treatment that activates residual PAH, thus decreasing Phe concentrations in the blood of PKU patients. Moreover, daily subcutaneous injection of pegylated Phe ammonia-lyase (i.e., pegvaliase; PALYNZIQ®, BioMarin) has promised gene therapy in recent clinical trials, and mRNA approaches are also being studied.
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Affiliation(s)
- Nasser A. Elhawary
- Department of Medical Genetics, College of Medicine, Umm Al-Qura University, P.O. Box 57543, Mecca, 21955 Saudi Arabia
| | - Imad A. AlJahdali
- Department of Community Medicine, College of Medicine, Umm Al-Qura University, P.O. Box 57543, Mecca, 21955 Saudi Arabia
| | - Iman S. Abumansour
- Department of Medical Genetics, College of Medicine, Umm Al-Qura University, P.O. Box 57543, Mecca, 21955 Saudi Arabia
| | - Ezzeldin N. Elhawary
- Faculty of Medicine, MS Genomic Medicine Program, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Nagwa Gaboon
- Department of Clinical Genetics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohammed Dandini
- Department of Laboratory and Blood Bank, Maternity and Children Hospital, Mecca, Saudi Arabia
| | - Abdulelah Madkhali
- Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Wafaa Alosaimi
- Department of Hematology, Maternity and Children Hospital, Mecca, Saudi Arabia
| | - Abdulmajeed Alzahrani
- Department of Laboratory and Blood Bank at Maternity and Children Hospital, Mecca, Saudi Arabia
| | - Fawzia Aljohani
- Department of Pediatric Clinics, Maternity and Children Hospital, King Salman Medical City, Madinah, Saudi Arabia
| | - Ehab M. Melibary
- Department of Medical Genetics, College of Medicine, Umm Al-Qura University, P.O. Box 57543, Mecca, 21955 Saudi Arabia
| | - Osama A. Kensara
- Department of Clinical Nutrition, Faculty of Applied Medical Sciences, Umm Al-Qura University, Jeddah, Saudi Arabia
- Department of Biochemistry, Batterjee Medical College, Jeddah, Saudi Arabia
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Altman G, Hussain K, Green D, Strauss BJG, Wilcox G. Mental health diagnoses in adults with phenylketonuria: a retrospective systematic audit in a large UK single centre. Orphanet J Rare Dis 2021; 16:520. [PMID: 34930395 PMCID: PMC8691050 DOI: 10.1186/s13023-021-02138-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recently published European Society for Phenylketonuria (ESPKU) guidelines have recommended a lifelong diet with phenylalanine (Phe) control ≤ 600 μmol/L for phenylketonuria (PKU) patients. This study aimed to identify whether PKU adult patients are at a higher risk of mental health diagnoses if their 2-year average Phe level is higher than the ESPKU European guidelines. Published studies identified by a literature review showed that related studies have been published in American and European PKU study populations but not in the United Kingdom (UK) study populations. Previous studies also involved a smaller number of participants due to this being a rare disease. RESULTS We undertook a retrospective audit at a single large PKU centre in the UK. 244 adult PKU patients at the centre were included, 220 of which had a recorded Phe level. Approximately 75% of the patients in this study did not meet the ESPKU European guidelines for Phe control. A systematic search of the electronic patient record was undertaken looking for mental health diagnoses. Compared to two-year average Phe levels ≤ 600 μmol/L, PKU adult patients with two-year average Phe levels > 600 μmol/L were more likely to have diagnoses of low mood, depression, anxiety, or mood swings, but only low mood reached statistical significance (p < 0.05). CONCLUSIONS PKU patients with two-year average Phenylalanine levels greater than ESPKU guidelines may be at greater risk of mental health diagnoses and symptoms. Many of these adult PKU patients will be lost to follow-up, and therefore may be receiving treatment for mental health conditions in the community. Multicentre UK studies and international collaborations are required to overcome low participant numbers in the study of this rare disease.
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Affiliation(s)
- George Altman
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK. .,The Mark Holland Adult Inherited Metabolic Disorders Unit, Ladywell Building, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK.
| | - Kamran Hussain
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Diane Green
- The Mark Holland Adult Inherited Metabolic Disorders Unit, Ladywell Building, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | - Boyd J G Strauss
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Department of Medicine, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Gisela Wilcox
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,The Mark Holland Adult Inherited Metabolic Disorders Unit, Ladywell Building, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
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Abstract
Phenylketonuria (PKU; also known as phenylalanine hydroxylase (PAH) deficiency) is an autosomal recessive disorder of phenylalanine metabolism, in which especially high phenylalanine concentrations cause brain dysfunction. If untreated, this brain dysfunction results in severe intellectual disability, epilepsy and behavioural problems. The prevalence varies worldwide, with an average of about 1:10,000 newborns. Early diagnosis is based on newborn screening, and if treatment is started early and continued, intelligence is within normal limits with, on average, some suboptimal neurocognitive function. Dietary restriction of phenylalanine has been the mainstay of treatment for over 60 years and has been highly successful, although outcomes are still suboptimal and patients can find the treatment difficult to adhere to. Pharmacological treatments are available, such as tetrahydrobiopterin, which is effective in only a minority of patients (usually those with milder PKU), and pegylated phenylalanine ammonia lyase, which requires daily subcutaneous injections and causes adverse immune responses. Given the drawbacks of these approaches, other treatments are in development, such as mRNA and gene therapy. Even though PAH deficiency is the most common defect of amino acid metabolism in humans, brain dysfunction in individuals with PKU is still not well understood and further research is needed to facilitate development of pathophysiology-driven treatments.
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Affiliation(s)
- Francjan J van Spronsen
- Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands.
| | - Nenad Blau
- University Children's Hospital in Zurich, Zurich, Switzerland
| | - Cary Harding
- Department of Molecular and Medical Genetics and Department of Pediatrics, Oregon Health & Science University, Oregon, USA
| | | | - Nicola Longo
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Annet M Bosch
- University of Amsterdam, Department of Pediatrics, Division of Metabolic Disorders, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Wiedemann A, Oussalah A, Jeannesson É, Guéant JL, Feillet F. [Phenylketonuria, from diet to gene therapy]. Med Sci (Paris) 2020; 36:725-734. [PMID: 32821049 DOI: 10.1051/medsci/2020127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The prognosis for phenylketonuria (PKU) has been improved by neonatal screening and dietary management via a low-phenylalanine diet. This treatment must be followed throughout life, which induces severe compliance problems. Drug treatment with sapropterin (or BH4) has come to help a reduced percentage of patients who respond to this drug. A subcutaneous enzyme therapy is available in the USA and has obtained European marketing authorization, but generates significant side effects, which limits its effectiveness. New therapeutic options for PKU are currently being developed, in particular gene therapy. The purpose of this article is to take stock of the pathophysiology and the various new therapeutic modalities currently in development.
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Affiliation(s)
- Arnaud Wiedemann
- Centre de référence des maladies métaboliques, Service de pédiatrie, CHRU de Nancy, 54000 Nancy, France - Inserm UMR_S 1256 (NGERE, Nutrition Génétique et Exposition aux Risques Environnementaux), Faculté de médecine de Nancy, Université de Lorraine, 54000 Nancy, France
| | - Abderrahim Oussalah
- Inserm UMR_S 1256 (NGERE, Nutrition Génétique et Exposition aux Risques Environnementaux), Faculté de médecine de Nancy, Université de Lorraine, 54000 Nancy, France - Département de médecine moléculaire, Laboratoire de biochimie et de biologie moléculaire nutrition, CHRU de Nancy, 54000 France
| | - Élise Jeannesson
- Inserm UMR_S 1256 (NGERE, Nutrition Génétique et Exposition aux Risques Environnementaux), Faculté de médecine de Nancy, Université de Lorraine, 54000 Nancy, France - Département de médecine moléculaire, Laboratoire de biochimie et de biologie moléculaire nutrition, CHRU de Nancy, 54000 France
| | - Jean-Louis Guéant
- Inserm UMR_S 1256 (NGERE, Nutrition Génétique et Exposition aux Risques Environnementaux), Faculté de médecine de Nancy, Université de Lorraine, 54000 Nancy, France - Département de médecine moléculaire, Laboratoire de biochimie et de biologie moléculaire nutrition, CHRU de Nancy, 54000 France
| | - François Feillet
- Centre de référence des maladies métaboliques, Service de pédiatrie, CHRU de Nancy, 54000 Nancy, France - Inserm UMR_S 1256 (NGERE, Nutrition Génétique et Exposition aux Risques Environnementaux), Faculté de médecine de Nancy, Université de Lorraine, 54000 Nancy, France
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Manta-Vogli PD, Dotsikas Y, Loukas YL, Schulpis KH. The phenylketonuria patient: A recent dietetic therapeutic approach. Nutr Neurosci 2020; 23:628-639. [PMID: 30359206 DOI: 10.1080/1028415x.2018.1538196] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Phenylalanine hydroxylase (PAH) deficiency, commonly named phenylketonuria (PKU) is a disorder of phenylalanine (Phe) metabolism inherited with an autosomal recessive trait. It is characterized by high blood and cerebral Phe levels, resulting in intellectual disabilities, seizures, etc. Early diagnosis and treatment of the patients prevent major neuro-cognitive deficits. Treatment consists of a lifelong restriction of Phe intake, combined with the supplementation of special medical foods, such as Amino Acid medical food (AA-mf), enriched in tyrosine (Tyr) and other amino acids and nutrients to avoid nutritional deficits. Developmental and neurocognitive outcomes for patients, however, remain suboptimal, especially when adherence to the demanding diet is poor. Additions to treatment include new, more palatable foods, based on Glycomacropeptide that contains limited amounts of Phe, the administration of large neutral amino acids to prevent phenylalanine entry into the brain and tetrahydrobiopterin cofactor capable of increasing residual PAH activity. Moreover, further efforts are underway to develop an oral therapy containing phenylalanine ammonia-lyase. Nutritional support of PKU future mothers (maternal PKU) is also discussed. This review aims to summarize the current literature on new PKU treatment strategies.
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Affiliation(s)
- Penelope D Manta-Vogli
- Department of Clinical Nutrition & Dietetics Agia Sofia Children's Hospital, Athens, Greece
| | - Yannis Dotsikas
- Department of Pharmacy, Laboratory of Pharm. Analysis, National and Kapodestrian University of Athens, Panepistimiopolis Zographou, GR 157 71, Athens, Greece
| | - Yannis L Loukas
- Department of Pharmacy, Laboratory of Pharm. Analysis, National and Kapodestrian University of Athens, Panepistimiopolis Zographou, GR 157 71, Athens, Greece
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Manta-Vogli PD, Schulpis KH, Dotsikas Y, Loukas YL. Nutrition and medical support during pregnancy and lactation in women with inborn errors of intermediary metabolism disorders (IEMDs). J Pediatr Endocrinol Metab 2020; 33:5-20. [PMID: 31804959 DOI: 10.1515/jpem-2019-0048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 09/20/2019] [Indexed: 12/25/2022]
Abstract
The establishment of expanded newborn screening (NBS) not only results in the early diagnosis and treatment of neonates with inborn errors of intermediary metabolism disorders (IEMDs) but also helps the affected females to reach the reproductive age under medical and dietetic support, as well as to give birth to normal infants. In this review, we aimed to focus on laboratory investigation tests, dietetic management and medical support for most known IEMD pregnant and lactating women, such as those suffering from aminoacidopathies, carbohydrate metabolic diseases and fatty acid (FAO) oxidation disorders.
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Affiliation(s)
- Penelope D Manta-Vogli
- Department of Clinical Nutrition and Dietetics, Agia Sofia Children's Hospital, Athens, Greece
| | | | - Yannis Dotsikas
- Laboratory of Pharm. Analysis, Department of Pharmacy, National and Kapodestrian University of Athens, Panepistimiopolis Zographou, GR-157 71, Athens, Greece, Phone: +30 210 7274696, Fax: +30 210 7274039
| | - Yannis L Loukas
- Laboratory of Pharm. Analysis, Department of Pharmacy, National and Kapodestrian University of Athens, Panepistimiopolis Zographou, GR-157 71, Athens, Greece, Phone: +30 210 7274224, Fax: +30 211 1826131
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Nyuzuki H, Yamazaki T, Saito M, Ohtake A. First Japanese case of maternal phenylketonuria treated with sapropterin dihydrochloride and the normal growth and development of the child. Mol Genet Metab Rep 2019; 21:100526. [PMID: 31720228 PMCID: PMC6839020 DOI: 10.1016/j.ymgmr.2019.100526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/19/2019] [Accepted: 09/19/2019] [Indexed: 01/21/2023] Open
Abstract
Sapropterin dihydrochloride (SD) may be a new treatment option for women with phenylketonuria (PKU) who plan to become pregnant. We report the first Japanese case of maternal PKU treated with SD. The patient was administered SD at 10-20 mg/kg/day, which increased phenylalanine tolerance during the pregnancy and lactation. No adverse events occurred, and she delivered a healthy neonate. Normal growth and development of the child confirms the efficacy and safety of SD.
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Affiliation(s)
- Hiromi Nyuzuki
- Department of Pediatrics, Niigata University, Niigata, Japan
- Division of Functional Genomics & Systems Medicine, Research Center for Genomic Medicine, Saitama Medical University, Saitama, Japan
- Department of Pediatrics, Saitama Medical University, Saitama, Japan
| | - Taro Yamazaki
- Department of Pediatrics, Saitama Medical University, Saitama, Japan
| | - Megumi Saito
- Department of Clinical Genomics, Saitama Medical University, Saitama, Japan
| | - Akira Ohtake
- Department of Pediatrics, Saitama Medical University, Saitama, Japan
- Department of Clinical Genomics, Saitama Medical University, Saitama, Japan
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Romanowicz J, Leonetti C, Dhari Z, Korotcova L, Ramachandra SD, Saric N, Morton PD, Bansal S, Cheema A, Gallo V, Jonas RA, Ishibashi N. Treatment With Tetrahydrobiopterin Improves White Matter Maturation in a Mouse Model for Prenatal Hypoxia in Congenital Heart Disease. J Am Heart Assoc 2019; 8:e012711. [PMID: 31331224 PMCID: PMC6761654 DOI: 10.1161/jaha.119.012711] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/24/2019] [Indexed: 01/05/2023]
Abstract
Background Reduced oxygen delivery in congenital heart disease causes delayed brain maturation and white matter abnormalities in utero. No treatment currently exists. Tetrahydrobiopterin (BH4) is a cofactor for neuronal nitric oxide synthase. BH4 availability is reduced upon NOS activation, such as during hypoxic conditions, and leads to toxin production. We hypothesize that BH4 levels are depleted in the hypoxic brain and that BH4 replacement therapy mitigates the toxic effects of hypoxia on white matter. Methods and Results Transgenic mice were used to visualize oligodendrocytes. Hypoxia was introduced during a period of white matter development equivalent to the human third trimester. BH4 was administered during hypoxia. BH4 levels were depleted in the hypoxic brain by direct quantification (n=7-12). The proliferation (n=3-6), apoptosis (n=3-6), and developmental stage (n=5-8) of oligodendrocytes were determined immunohistologically. Total oligodendrocytes increased after hypoxia, consistent with hypoxia-induced proliferation seen previously; however, mature oligodendrocytes were less prevalent in hypoxia, and there was accumulation of immature oligodendrocytes. BH4 treatment improved the mature oligodendrocyte number such that it did not differ from normoxia, and accumulation of immature oligodendrocytes was not observed. These results persisted beyond the initial period of hypoxia (n=3-4). Apoptosis increased with hypoxia but decreased with BH4 treatment to normoxic levels. White matter myelin levels decreased following hypoxia by western blot. BH4 treatment normalized myelination (n=6-10). Hypoxia worsened sensory-motor coordination on balance beam tasks, and BH4 therapy normalized performance (n=5-9). Conclusions Suboptimal BH4 levels influence hypoxic white matter abnormalities. Repurposing BH4 for use during fetal brain development may limit white matter dysmaturation in congenital heart disease.
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Affiliation(s)
- Jennifer Romanowicz
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
| | - Camille Leonetti
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Zaenab Dhari
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Ludmila Korotcova
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Shruti D. Ramachandra
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Nemanja Saric
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Paul D. Morton
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Shivani Bansal
- Lombardi Comprehensive Cancer CenterGeorgetown University Medical CenterWashingtonDC
| | - Amrita Cheema
- Lombardi Comprehensive Cancer CenterGeorgetown University Medical CenterWashingtonDC
| | - Vittorio Gallo
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Richard A. Jonas
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
| | - Nobuyuki Ishibashi
- Children's National Heart InstituteChildren's National Health SystemWashingtonDC
- Center for Neuroscience ResearchChildren's National Health SystemWashingtonDC
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Muntau AC, Adams DJ, Bélanger-Quintana A, Bushueva TV, Cerone R, Chien YH, Chiesa A, Coşkun T, de Las Heras J, Feillet F, Katz R, Lagler F, Piazzon F, Rohr F, van Spronsen FJ, Vargas P, Wilcox G, Bhattacharya K. International best practice for the evaluation of responsiveness to sapropterin dihydrochloride in patients with phenylketonuria. Mol Genet Metab 2019; 127:1-11. [PMID: 31103398 DOI: 10.1016/j.ymgme.2019.04.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/14/2019] [Accepted: 04/13/2019] [Indexed: 12/26/2022]
Abstract
Phenylketonuria (PKU) is an inherited metabolic disease caused by phenylalanine hydroxylase (PAH) deficiency. As the resulting high blood phenylalanine (Phe) concentration can have detrimental effects on brain development and function, international guidelines recommend lifelong control of blood Phe concentration with dietary and/or medical therapy. Sapropterin dihydrochloride is a synthetic preparation of tetrahydrobiopterin (6R-BH4), the naturally occurring cofactor of PAH. It acts as a pharmacological chaperone, reducing blood Phe concentration and increasing dietary Phe tolerance in BH4-responsive patients with PAH deficiency. Protocols to establish responsiveness to sapropterin dihydrochloride vary widely. Two meetings were held with an international panel of clinical experts in PKU management to develop recommendations for sapropterin dihydrochloride response testing. At the first meeting, regional differences and similarities in testing practices were discussed based on guidelines, a literature review, outcomes of a global physician survey, and case reports. Statements developed based on the discussions were sent to all participants for consensus (>70% of participants) evaluation using a 7-level rating system, and further discussed during the second meeting. The experts recommend sapropterin dihydrochloride response testing in patients with untreated blood Phe concentrations of 360-2000 μmol/L, except in those with two null mutations. For neonates, a 24-h sapropterin dihydrochloride loading test is recommended; responsiveness is defined as a decrease in blood Phe ≥30%. For older infants, children, adolescents, and adults, a test duration of ≥48 h or a 4-week trial is recommended. The main endpoint for a 48-h to 7-day trial is a decrease in blood Phe, while improved Phe tolerance is the endpoint to be assessed during a longer trial. Longer trials may not be feasible in some locations due to lack of reimbursement for hospitalization, while a 4-week trial may not be possible due to limited access to sapropterin dihydrochloride or public health regulation. A 48-h response test should be considered in pregnant patients who cannot achieve blood Phe ≤360 μmol/L with a Phe-restricted diet. Durability of response and clinical benefits of sapropterin dihydrochloride should be assessed over the long term. Harmonization of protocols is expected to improve identification of responders and comparability of test results worldwide.
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Affiliation(s)
- Ania C Muntau
- University Children's Hospital, University Medical Center Hamburg Eppendorf, Hamburg, Germany.
| | - Darius J Adams
- Atlantic Health System, Morristown Medical Center, Morristown, NJ, USA.
| | | | - Tatiana V Bushueva
- National Medical Research Center of Children's Health of the Ministry of Health of the Russian Federation, Moscow, Russia.
| | - Roberto Cerone
- G. Gaslini Institute, University of Genova, Genova, Italy.
| | | | - Ana Chiesa
- Centro de Investigaciones Endocrinologicas "Dr Cesar Bergadá" CEDIE, CONICET, Hospital de Niños Ricardo Gutierrez, Fundacion de Endocrinologia Infantil, Buenos Aires, Argentina.
| | - Turgay Coşkun
- Hacettepe University Faculty of Medicine, Ankara, Turkey.
| | - Javier de Las Heras
- Hospital Universitario de Cruces, Biocruces Health Research Institute and University of the Basque Country UPV/EHU, Vizcaya, Spain.
| | - François Feillet
- Children's University Hospital, CHU Brabois, Vandoeuvre les Nancy, France.
| | - Rachel Katz
- Ann and Robert Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | | | - Flavia Piazzon
- Associação de Pais e Amigos dos Excepcionais de São Paulo (APAE DE SÃO PAULO), São Paulo, SP, Brazil.
| | - Fran Rohr
- Boston Children's Hospital, Boston, MA, USA.
| | - Francjan J van Spronsen
- Beatrix Children's Hospital, University Medical Center of Groningen, University of Groningen, Groningen, the Netherlands.
| | - Paula Vargas
- Hospital Materno Infantil Presidente Vargas, Porto Alegre, RS, Brazil.
| | - Gisela Wilcox
- University of Manchester & Salford Royal NHS Foundation Trust, Salford, UK.
| | - Kaustuv Bhattacharya
- Genetic Metabolic Disorders Service, University of Sydney, Children's Hospital Westmead Clinical School, Sydney, NSW, Australia.
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14
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Kure S, Shintaku H. Tetrahydrobipterin-responsive phenylalanine hydroxylase deficiency. J Hum Genet 2019; 64:67-71. [PMID: 30504912 DOI: 10.1038/s10038-018-0529-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/16/2018] [Accepted: 10/19/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Shigeo Kure
- Department of Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Haruo Shintaku
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
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15
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Ford S, O'Driscoll M, MacDonald A. Reproductive experience of women living with phenylketonuria. Mol Genet Metab Rep 2018; 17:64-68. [PMID: 30416967 PMCID: PMC6218656 DOI: 10.1016/j.ymgmr.2018.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/28/2018] [Accepted: 09/29/2018] [Indexed: 12/30/2022] Open
Abstract
Introduction Many women with PKU are well-informed about the risks of maternal PKU but there are several barriers to achieving satisfactory metabolic control before and during pregnancy. Many studies have documented the outcome of maternal PKU infants, but very little has been reported about the experiences of women of reproductive age with PKU, particularly about their psychosexual development, pre-conception, pregnancy and postnatal experience. Methods In the UK, in a subsection of an online questionnaire conducted by the National Society for PKU (NSPKU) about living with PKU, women aged 18 years and over completed 9 closed questions about their pre-conception, pregnancy and post-natal experiences and an open-ended question on their reproductive health. Results 300 women aged 18 years and over with PKU completed this questionnaire with 37% (n = 111/300) of women already having children. 56% (n = 71/128) of pregnancies were planned and a further 18% (n = 23/128) of women had both planned and unplanned pregnancies. Most women (73%, n = 200/273) expressed concerns, fears and distress about pregnancy and two thirds of women who had at least one pregnancy stated that having PKU made pregnancy more stressful and difficult. 60% (n = 164/273) were concerned that they may cause harm to a baby, 58% (n = 159/273) worried about their ability to manage a strict diet during pregnancy, 54% (n = 147/273) had anxiety about their ability to maintain blood Phe within target range, and 48% (n = 132/273) feared having an unplanned pregnancy. Postnatally, 48% (n = 45/93) had low mood or sadness, 41% (n = 38/93) were depressed, 34% (n = 32/93) felt unable to cope, 33% (n = 31/93) said they could not manage their PKU and care for their baby, 14% (n = 13/93) struggled with child care needs and 4% (n = 4/94) worried they might hurt themselves or their baby through being unable to manage their diet. Conclusions Many women with PKU have unmet sexual and reproductive health needs. Pregnancy fears are prominent from adolescence onwards and for some women overarching concerns about their ability to cope with pregnancy led to a decision not to have children. Interventions are needed to reduce the psychological impact of the risk of maternal PKU syndrome and assist with safe pregnancies. Post-natal experiences of women with PKU give rise to concern.
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Affiliation(s)
- Suzanne Ford
- National Society for Phenylketonuria, Preston, United Kingdom
| | | | - Anita MacDonald
- Birmingham Women's & Children's NHS Trust, Birmingham, United Kingdom
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16
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Sakamoto O, Arai-Ichinoi N, Murayama K, Kure S. Successful control of maternal phenylketonuria by tetrahydrobiopterin. Pediatr Int 2018; 60:985-986. [PMID: 30345699 DOI: 10.1111/ped.13678] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/02/2018] [Accepted: 08/10/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Osamu Sakamoto
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | | | - Kei Murayama
- Center for Medical Genetics and Department of Metabolism, Chiba Children's Hospital, Chiba, Japan
| | - Shigeo Kure
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
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17
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Kuseyri O, Weissbach A, Bruggemann N, Klein C, Giżewska M, Karall D, Scholl-Bürgi S, Romanowska H, Krzywińska-Zdeb E, Monavari AA, Knerr I, Yapıcı Z, Leuzzi V, Opladen T. Pregnancy management and outcome in patients with four different tetrahydrobiopterin disorders. J Inherit Metab Dis 2018; 41:849-863. [PMID: 29594647 DOI: 10.1007/s10545-018-0169-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 02/27/2018] [Accepted: 03/05/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Inborn errors of tetrahydrobiopterin (BH4) biosynthesis or recycling are a group of very rare neurometabolic diseases. Following growing awareness and improved availability of drug treatment the number of patients with BH4 disorders reaching adulthood is constantly increasing. Pregnancy care of patients with these disorders is therefore a new challenge for clinicians. METHODS This retrospective study summarises for the first time clinical and biochemical monitoring data of 16 pregnancies in seven women with different disorders of BH4 metabolism and evaluates treatment regimens before and during pregnancy in relation to the obstetrical outcome and paediatric follow-up. RESULTS Worsening of pre-existing neurological symptoms or occurrence of new symptoms during pregnancy was not observed in most of the cases. Treatment regimens remained mostly unchanged. Pregnancies were not complicated by disease-specific features. Organ abnormalities, miscarriage, prematurity, IUGR and chromosomal changes were occasionally reported, without showing any association with the standard drug treatment for BH4 deficiencies. CONCLUSION Although our data on 16 pregnancies in seven patients did not present any association of standard drug treatment with an increased rate of pregnancy complications, abnormal obstetrical or paediatric outcome, an intensive clinical and biochemical supervision by a multidisciplinary team before, during and after the pregnancy in any BH4 deficiency is essential since available data on pregnancies in patients with BH4 deficiencies is limited.
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Affiliation(s)
- O Kuseyri
- Division of Child Neurology and Metabolic Diseases, University Children's Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany.
| | - A Weissbach
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | - N Bruggemann
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | - C Klein
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | - M Giżewska
- Department of Paediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - D Karall
- Department of Paediatrics I, Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - S Scholl-Bürgi
- Department of Paediatrics I, Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - H Romanowska
- Department of Paediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - E Krzywińska-Zdeb
- Department of Paediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - A A Monavari
- National Centre for Inherited Metabolic Disorders, Temple Street Children's University Hospital, Dublin, Ireland
| | - I Knerr
- National Centre for Inherited Metabolic Disorders, Temple Street Children's University Hospital, Dublin, Ireland
| | - Z Yapıcı
- Department of Child Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - V Leuzzi
- Department of Paediatrics and Child Neurology and Psychiatry, Sapienza Università di Roma, Roma, Italy
| | - T Opladen
- Division of Child Neurology and Metabolic Diseases, University Children's Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
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Abstract
Once based mainly in paediatrics, inborn errors of metabolism (IEM), or inherited metabolic disorders (IMD) represent a growing adult medicine specialty. Individually rare these conditions have currently, a collective estimated prevalence of >1:800. Diagnosis has improved through expanded newborn screening programs, identification of potentially affected family members and greater awareness of symptomatic presentations in adolescence and in adulthood. Better survival and reduced mortality from previously lethal and debilitating conditions means greater numbers transition to adulthood. Pregnancy, once contraindicated for many, may represent a challenging but successful outcome. Successful pregnancies are now reported in a wide range of IEM. Significant challenges remain, given the biological stresses of pregnancy, parturition and the puerperium. Known diagnoses allow preventive and pre-emptive management. Unrecognized metabolic disorders especially, remain a preventable cause of maternal and neonatal mortality and morbidity. Increased awareness of these conditions amongst all clinicians is essential to expedite diagnosis and manage appropriately. This review aims to describe normal adaptations to pregnancy and discuss how various types of IEM may be affected. Relevant translational research and clinical experience will be reviewed with practical management aspects cited. Based on current literature, the impact of maternal IEM on mother and/or foetus, as well as how foetal IEM may affect the mother, will be considered. Insights gained from these rare disorders to more common conditions will be explored. Gaps in the literature, unanswered questions and steps to enhance further knowledge and systematically capture experience, such as establishment of an IEM-pregnancy registry, will be summarized.
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Affiliation(s)
- Gisela Wilcox
- School of Medical Sciences, Faculty of Biology Medicine & Health, University of Manchester, Manchester, UK.
- The Mark Holland Metabolic Unit, Salford Royal Foundation NHS Trust, Salford, Greater Manchester, M6 8HD, UK.
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19
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van Wegberg AMJ, MacDonald A, Ahring K, Bélanger-Quintana A, Blau N, Bosch AM, Burlina A, Campistol J, Feillet F, Giżewska M, Huijbregts SC, Kearney S, Leuzzi V, Maillot F, Muntau AC, van Rijn M, Trefz F, Walter JH, van Spronsen FJ. The complete European guidelines on phenylketonuria: diagnosis and treatment. Orphanet J Rare Dis 2017; 12:162. [PMID: 29025426 PMCID: PMC5639803 DOI: 10.1186/s13023-017-0685-2] [Citation(s) in RCA: 421] [Impact Index Per Article: 60.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 07/11/2017] [Indexed: 12/22/2022] Open
Abstract
Phenylketonuria (PKU) is an autosomal recessive inborn error of phenylalanine metabolism caused by deficiency in the enzyme phenylalanine hydroxylase that converts phenylalanine into tyrosine. If left untreated, PKU results in increased phenylalanine concentrations in blood and brain, which cause severe intellectual disability, epilepsy and behavioural problems. PKU management differs widely across Europe and therefore these guidelines have been developed aiming to optimize and standardize PKU care. Professionals from 10 different European countries developed the guidelines according to the AGREE (Appraisal of Guidelines for Research and Evaluation) method. Literature search, critical appraisal and evidence grading were conducted according to the SIGN (Scottish Intercollegiate Guidelines Network) method. The Delphi-method was used when there was no or little evidence available. External consultants reviewed the guidelines. Using these methods 70 statements were formulated based on the highest quality evidence available. The level of evidence of most recommendations is C or D. Although study designs and patient numbers are sub-optimal, many statements are convincing, important and relevant. In addition, knowledge gaps are identified which require further research in order to direct better care for the future.
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Affiliation(s)
- A. M. J. van Wegberg
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, PO BOX 30.001, 9700 RB Groningen, The Netherlands
| | - A. MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Birmingham, UK
| | - K. Ahring
- Department of PKU, Kennedy Centre, Glostrup, Denmark
| | - A. Bélanger-Quintana
- Metabolic Diseases Unit, Department of Paediatrics, Hospital Ramon y Cajal Madrid, Madrid, Spain
| | - N. Blau
- University Children’s Hospital, Dietmar-Hoppe Metabolic Centre, Heidelberg, Germany
- University Children’s Hospital Zürich, Zürich, Switzerland
| | - A. M. Bosch
- Department of Paediatrics, Division of Metabolic Disorders, Academic Medical Centre, University Hospital of Amsterdam, Amsterdam, The Netherlands
| | - A. Burlina
- Division of Inherited Metabolic Diseases, Department of Paediatrics, University Hospital of Padova, Padova, Italy
| | - J. Campistol
- Neuropaediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - F. Feillet
- Department of Paediatrics, Hôpital d’Enfants Brabois, CHU Nancy, Vandoeuvre les Nancy, France
| | - M. Giżewska
- Department of Paediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, Szczecin, Poland
| | - S. C. Huijbregts
- Department of Clinical Child and Adolescent Studies-Neurodevelopmental Disorders, Faculty of Social Sciences, Leiden University, Leiden, The Netherlands
| | - S. Kearney
- Clinical Psychology Department, Birmingham Children’s Hospital, Birmingham, UK
| | - V. Leuzzi
- Department of Paediatrics, Child Neurology and Psychiatry, Sapienza University of Rome, Via dei Sabelli 108, 00185 Rome, Italy
| | - F. Maillot
- CHRU de Tours, Université François Rabelais, INSERM U1069, Tours, France
| | - A. C. Muntau
- University Children’s Hospital, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - M. van Rijn
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, PO BOX 30.001, 9700 RB Groningen, The Netherlands
| | - F. Trefz
- Department of Paediatrics, University of Heidelberg, Heidelberg, Germany
| | - J. H. Walter
- Medicine, Manchester Academic Health Sciences Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - F. J. van Spronsen
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, PO BOX 30.001, 9700 RB Groningen, The Netherlands
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Yildiz Y, Dursun A, Tokatli A, Coskun T, Sivri S. Partial hydatidiform mole in a phenylketonuria patient treated with sapropterin dihydrochloride. Gynecol Endocrinol 2017; 33:19-20. [PMID: 27898272 DOI: 10.1080/09513590.2016.1247796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Strict control of hyperphenylalaninemia is necessary in pregnant women with phenylketonuria (PKU) in order to prevent phenylalanine embryopathy in the fetus, characterized by intrauterine growth restriction, dysmorphic facies, congenital heart disease, microcephaly and intellectual disability, collectively known as maternal PKU syndrome. Sapropterin dihydrochloride (SD), an alternative or adjunct to dietary therapy in patients with tetrahydrobiopterin (BH4)-responsive PKU, has recently been used in several cases to treat PKU during pregnancy with satisfactory results. Here, we report two pregnancies treated with SD and unrestricted diet in a patient with BH4-responsive mild PKU. The first pregnancy resulted in a partial hydatidiform mole and was terminated, whereas a healthy infant was born from the second pregnancy. Phenylalanine control was optimal in both pregnancies. To the best of our knowledge, this is the first report on the development of partial hydatidiform mole associated with SD treatment and the second report on molar pregnancy in PKU. While the relation between SD and molar pregnancy is unknown, further studies may be needed to investigate the possible effects of SD on fertilization.
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Affiliation(s)
- Yilmaz Yildiz
- a Division of Pediatric Metabolism , Department of Pediatrics, Faculty of Medicine, Hacettepe University , Ankara , Turkey
| | - Ali Dursun
- a Division of Pediatric Metabolism , Department of Pediatrics, Faculty of Medicine, Hacettepe University , Ankara , Turkey
| | - Aysegul Tokatli
- a Division of Pediatric Metabolism , Department of Pediatrics, Faculty of Medicine, Hacettepe University , Ankara , Turkey
| | - Turgay Coskun
- a Division of Pediatric Metabolism , Department of Pediatrics, Faculty of Medicine, Hacettepe University , Ankara , Turkey
| | - Serap Sivri
- a Division of Pediatric Metabolism , Department of Pediatrics, Faculty of Medicine, Hacettepe University , Ankara , Turkey
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21
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MacDonald A, Ahring K, Almeida MF, Belanger-Quintana A, Blau N, Burlina A, Cleary M, Coskum T, Dokoupil K, Evans S, Feillet F, Giżewska M, Gokmen Ozel H, Lotz-Havla AS, Kamieńska E, Maillot F, Lammardo AM, Muntau AC, Puchwein-Schwepcke A, Robert M, Rocha JC, Santra S, Skeath R, Strączek K, Trefz FK, van Dam E, van Rijn M, van Spronsen F, Vijay S. The challenges of managing coexistent disorders with phenylketonuria: 30 cases. Mol Genet Metab 2015; 116:242-51. [PMID: 26498184 DOI: 10.1016/j.ymgme.2015.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 10/06/2015] [Accepted: 10/07/2015] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The few published case reports of co-existent disease with phenylketonuria (PKU) are mainly genetic and familial conditions from consanguineous marriages. The clinical and demographic features of 30 subjects with PKU and co-existent conditions were described in this multi-centre, retrospective cohort study. METHODS Diagnostic age of PKU and co-existent condition, treatment regimen, and impact of co-existent condition on blood phenylalanine (Phe) control and PKU management were reported. RESULTS 30 patients (11 males and 19 females), with PKU and a co-existent condition, current median age of 14 years (range 0.4 to 40 years) from 13 treatment centres from Europe and Turkey were described. There were 21 co-existent conditions with PKU; 9 were autoimmune; 6 gastrointestinal, 3 chromosomal abnormalities, and 3 inherited conditions. There were only 5 cases of parental consanguinity. Some patients required conflicting diet therapy (n=5), nutritional support (n=7) and 5 children had feeding problems. There was delayed diagnosis of co-existent conditions (n=3); delayed treatment of PKU (n=1) and amenorrhea associated with Grave's disease that masked a PKU pregnancy for 12 weeks. Co-existent conditions adversely affected blood Phe control in 47% (n=14) of patients. Some co-existent conditions increased the complexity of disease management and increased management burden for patients and caregivers. CONCLUSIONS Occurrence of co-existent disease is not uncommon in patients with PKU and so investigation for co-existent disorders when the clinical history is not completely consistent with PKU is essential. Integrating care of a second condition with PKU management is challenging.
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Affiliation(s)
| | - K Ahring
- Center for PKU, The Kennedy Centre, University Hospital, Glostrup, Copenhagen, Denmark
| | - M F Almeida
- Centro de Genética Médica Doutor Jacinto de Magalhães, CHP EPE, Porto, Portugal; Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, Porto, Portugal
| | | | - N Blau
- Dietmar-Hopp Metabolic Center, University Children's Hospital, Heidelberg, Germany
| | - A Burlina
- Division of Inherited Metabolic Diseases, University Hospital, Padua, Italy
| | - M Cleary
- Hospital for Sick Children, Great Ormond Street, London, UK
| | - T Coskum
- Department of Inherited Metabolic Disorders, Hacettepe University, Ankara, Turkey
| | - K Dokoupil
- Department of Metabolism and Nutrition, Dr. von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - S Evans
- The Children's Hospital, Birmingham, UK
| | - F Feillet
- Hôpital d'enfants Brabois, Vandoeuvre les Nancy, France
| | - M Giżewska
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology, Pomeranian Medical University, Szczecin, Poland
| | - H Gokmen Ozel
- Department of Nutrition and Dietetics, Hacettepe University, Ankara, Turkey
| | - A S Lotz-Havla
- Dr. von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - E Kamieńska
- Department of Paediatrics and Haematology, Pomeranian Medical University, Szczecin, Poland
| | - F Maillot
- CHRU de Tours, service de medicine interne, Université François Rabelais, Tours, France
| | - A M Lammardo
- Depart Ped, San Paolo Hosp Univ Milan, Milan, Italy
| | - A C Muntau
- University Children's Hospital, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | | | - M Robert
- Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium
| | - J C Rocha
- Centro de Genética Médica Doutor Jacinto de Magalhães, CHP EPE, Porto, Portugal; Faculdade de Ciências da Saúde, Universidade Fernando Pessoa, Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Portugal
| | - S Santra
- The Children's Hospital, Birmingham, UK
| | - R Skeath
- Hospital for Sick Children, Great Ormond Street, London, UK
| | - K Strączek
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology, Pomeranian Medical University, Szczecin, Poland
| | - F K Trefz
- Division of Inborn Metabolic Diseases, University Children's Hospital, Heidelberg, Germany
| | - E van Dam
- Section of Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - M van Rijn
- Section of Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - F van Spronsen
- Section of Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - S Vijay
- The Children's Hospital, Birmingham, UK
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The Kuvan(®) Adult Maternal Paediatric European Registry (KAMPER) Multinational Observational Study: Baseline and 1-Year Data in Phenylketonuria Patients Responsive to Sapropterin. JIMD Rep 2015. [PMID: 25822821 DOI: 10.1007/8904_2015_425] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/18/2023] Open
Abstract
INTRODUCTION Sapropterin dihydrochloride (Kuvan(®)), a synthetic 6R-diastereoisomer of tetrahydrobiopterin (BH4), is approved in Europe for the treatment of patients aged ≥4 years with hyperphenylalaninaemia (HPA) due to BH4-responsive phenylalanine hydroxylase (PAH) deficiency, in conjunction with a phenylalanine-restricted diet, and also for the treatment of patients with BH4 deficiency. AIMS/METHODS KAMPER is an ongoing, observational, multicentre registry with the primary objective of providing information over 15 years on long-term safety of sapropterin dihydrochloride treatment in patients with HPA. Here we report initial data on characteristics from patients recruited by the time of the third interim analysis and results at 1 year. RESULTS Overall, 325 patients from 55 sites in seven European countries were included in the analysis: 296 (91.1%) patients with PAH deficiency (median [Q1, Q3] age, 10.3 [7.2, 15.0] years) and 29 (8.9%) with BH4 deficiency (12.8 [6.6, 18.9] years). Fifty-nine patients (18.2%) were aged ≥18 years; 4 patients were pregnant. No elderly patients (aged ≥65 years) or patients with renal or hepatic insufficiency were enroled in the study. Twelve-month data were available for 164 patients with PAH deficiency and 16 with BH4 deficiency. No new safety concerns were identified as of May 2013. CONCLUSIONS Initial data from KAMPER show that sapropterin dihydrochloride has a favourable safety profile. Registry data collected over time will provide insight into the management and outcomes of patients with PAH deficiency and BH4 deficiency, including long-term safety, impact on growth and neurocognitive outcomes and the effect of sapropterin dihydrochloride treatment on populations of special interest.
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Scala I, Concolino D, Della Casa R, Nastasi A, Ungaro C, Paladino S, Capaldo B, Ruoppolo M, Daniele A, Bonapace G, Strisciuglio P, Parenti G, Andria G. Long-term follow-up of patients with phenylketonuria treated with tetrahydrobiopterin: a seven years experience. Orphanet J Rare Dis 2015; 10:14. [PMID: 25757997 PMCID: PMC4351928 DOI: 10.1186/s13023-015-0227-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 01/15/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Phenylketonuria (PKU) is an autosomal recessive disorder caused by the deficiency of phenylalanine hydroxylase that catalyzes the conversion of phenylalanine to tyrosine, using tetrahydrobiopterin (BH4) as coenzyme. Besides dietary phenylalanine restriction, new therapeutic options are emerging, such as the treatment with BH4 in subgroups of PKU patients responding to a loading test with BH4. METHODS A no-profit open-label interventional trial with long-term oral BH4 therapy, sponsored by the Italian Medicines Agency (AIFA), was performed in a group of 17 PKU patients resulted as BH4 responders among 46 subjects analyzed for BH4-responsiveness (prot. FARM5MATC7). We report on efficacy and safety data of BH4 therapy and analyze factors predicting BH4-responsiveness and long-term response to BH4. A BH4-withdrawal test was used as a proof of the efficacy of long-term therapy with BH4. RESULTS Forty-four percent of the patients responded to the 48 h-long loading test with BH4. All the phenotypic classes were represented. Genotype was the best predictor of responsiveness, along with lower phenylalanine levels at diagnosis, higher tolerance and lower phenylalanine/tyrosine ratio before the test. In BH4 responder patients, long-term BH4 therapy resulted safe and effective in increasing tolerance while maintaining a good metabolic control. The BH4 withdrawal test, performed in a subset of patients, showed that improved tolerance was directly dependent on BH4 assumption. Tolerance to phenylalanine was re-evaluated in 43.5% of patients and was longitudinally analyzed in 5 patients. CONCLUSIONS Long-term treatment with BH4 is safe and effective in increasing tolerance to phenylalanine. There is real need to assess the actual tolerance to phenylalanine in PKU patients to ameliorate quality of life, improve nutritional status, avoiding unnecessarily restricted diets, and interpret the effects of new therapies for PKU.
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Affiliation(s)
- Iris Scala
- Department of Translational Medicine-Section of Pediatrics, Federico II University, Via S. Pansini 5, 80131, Naples, Italy.
| | - Daniela Concolino
- Department of Pediatrics, Magna Graecia University, Catanzaro, Italy.
| | - Roberto Della Casa
- Department of Translational Medicine-Section of Pediatrics, Federico II University, Via S. Pansini 5, 80131, Naples, Italy.
| | - Anna Nastasi
- Department of Clinical Medicine and Surgery, Physiology Nutrition Unit, Federico II University, Naples, Italy.
| | - Carla Ungaro
- Department of Translational Medicine-Section of Pediatrics, Federico II University, Via S. Pansini 5, 80131, Naples, Italy.
| | - Serena Paladino
- Department of Translational Medicine-Section of Pediatrics, Federico II University, Via S. Pansini 5, 80131, Naples, Italy.
| | - Brunella Capaldo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy.
| | - Margherita Ruoppolo
- Department of Molecular Medicine and Medical Biotechnology, Federico II University, Naples, Italy.
- CEINGE-Biotecnologie Avanzate s.c.ar.l., Naples, Italy.
| | - Aurora Daniele
- CEINGE-Biotecnologie Avanzate s.c.ar.l., Naples, Italy.
- Dipartimento di Scienze e Tecnologie Ambientali Biologiche Farmaceutiche, Seconda Università degli Studi di Napoli, Caserta, Italy.
| | - Giuseppe Bonapace
- Department of Pediatrics, Magna Graecia University, Catanzaro, Italy.
| | - Pietro Strisciuglio
- Department of Translational Medicine-Section of Pediatrics, Federico II University, Via S. Pansini 5, 80131, Naples, Italy.
| | - Giancarlo Parenti
- Department of Translational Medicine-Section of Pediatrics, Federico II University, Via S. Pansini 5, 80131, Naples, Italy.
| | - Generoso Andria
- Department of Translational Medicine-Section of Pediatrics, Federico II University, Via S. Pansini 5, 80131, Naples, Italy.
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Setoodeh A, Yarali B, Rabbani A, Khatami S, Shams S. Tetrahydrobiopterin responsiveness in a series of 53 cases of phenylketonuria and hyperphenylalaninemia in Iran. Mol Genet Metab Rep 2015. [PMID: 28649530 PMCID: PMC5471163 DOI: 10.1016/j.ymgmr.2015.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
To determine the prevalence of 6R-Tetrahydrobiopterin (BH4) responsive phenylketonuria (PKU) in 53 cases of patients with various classification of hyperphenylalaninemia and PKU Excluding the BH4 deficient type referring to children's medical center in Iran (phenylalanine 360–2420 μmol/L), the single dose of 20 mg/kg (Kuvan®) and duration of 24 h was used. Results Among the 4 different categories of mild hyperphenylalaninemia requiring treatment, mild, moderate and classic PKU, the BH4 responders were 90%, 35.7%, 5.6% and 0% respectively after 24 h. Conclusion BH4 responsiveness is more prevalent in mild hyperphenylalaninemia and mild PKU patients in Iran.
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Affiliation(s)
- Aria Setoodeh
- Division of Pediatric Endocrinology, Children's Medical Center, Tehran, Iran
| | - Bahram Yarali
- Division of Pediatric Neurology, Children's Medical Center, Tehran, Iran
| | - Ali Rabbani
- Growth and Development Center, Children's Medical Center, Tehran, Iran
| | | | - Sedigheh Shams
- Division of Pathology, Children's Medical Center, Tehran, Iran
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