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Zielonka M, Kölker S, Garbade SF, Gleich F, Nagamani SCS, Gropman AL, Druck AC, Ramdhouni N, Göde L, Hoffmann GF, Posset R. Severity-adjusted evaluation of initial dialysis on short-term health outcomes in urea cycle disorders. Mol Genet Metab 2024; 143:108566. [PMID: 39299137 DOI: 10.1016/j.ymgme.2024.108566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 08/07/2024] [Accepted: 08/13/2024] [Indexed: 09/22/2024]
Abstract
OBJECTIVE In individuals with urea cycle disorders (UCDs) and neonatal disease onset, extracorporeal detoxification by continuous kidney replacement therapy is considered the therapeutic method of choice in addition to metabolic emergency treatment to resolve hyperammonemic decompensation. However, the indications for the initiation of dialysis are heterogeneously implemented transnationally, thereby hampering our understanding of (optimal) short-term health outcomes. METHODS We performed a retrospective comparative analysis evaluating the therapeutic effects of initial dialysis on survival as well as neurocognitive outcome parameters in individuals with UCDs in comparison to a severity-adjusted non-dialyzed control cohort. Overall, 108 individuals with a severe phenotype of male ornithine transcarbamylase deficiency (mOTC-D), citrullinemia type 1 (CTLN1) and argininosuccinic aciduria (ASA) were investigated by stratification based on a recently established and validated genotype-specific disease prediction model. RESULTS Mortality is associated with the height of initial peak plasma ammonium concentration, but appears to be independent from treatment with initial dialysis in mOTC-D. However, improved survival after initial dialysis was observed in CTLN1, while there was a trend towards improved survival in ASA. In survivors, annual frequency of (subsequent) metabolic decompensations did not differ between the dialyzed and non-dialyzed cohorts. Moreover, treatment with initial dialysis was not associated with improved neurocognitive outcomes. INTERPRETATION The present severity-adjusted comparative analysis reveals that general practice of initial dialysis is neither associated with improved survival in individuals with mOTC-D nor does it differ with regard to the neurocognitive outcome for the investigated UCD subtypes. However, initial dialysis might potentially prove beneficial for survival in CTLN1 and ASA. CLINICAL TRIAL REGISTRATION The UCDC database is recorded at the US National Library of Medicine (https://clinicaltrials.gov).
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Affiliation(s)
- Matthias Zielonka
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
| | - Stefan Kölker
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Sven F Garbade
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Florian Gleich
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Andrea L Gropman
- Children's National Health System and The George Washington School of Medicine, Washington, DC, USA
| | - Ann-Catrin Druck
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Nesrine Ramdhouni
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Laura Göde
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Georg F Hoffmann
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Roland Posset
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
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Posset R, Garbade SF, Gleich F, Scharre S, Okun JG, Gropman AL, Nagamani SCS, Druck AC, Epp F, Hoffmann GF, Kölker S, Zielonka M. Severity-adjusted evaluation of liver transplantation on health outcomes in urea cycle disorders. Genet Med 2024; 26:101039. [PMID: 38054409 DOI: 10.1016/j.gim.2023.101039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/07/2023] Open
Abstract
PURPOSE Liver transplantation (LTx) is performed in individuals with urea cycle disorders when medical management (MM) insufficiently prevents the occurrence of hyperammonemic events. However, there is a paucity of systematic analyses on the effects of LTx on health-related outcome parameters compared to individuals with comparable severity who are medically managed. METHODS We investigated the effects of LTx and MM on validated health-related outcome parameters, including the metabolic disease course, linear growth, and neurocognitive outcomes. Individuals were stratified into "severe" and "attenuated" categories based on the genotype-specific and validated in vitro enzyme activity. RESULTS LTx enabled metabolic stability by prevention of further hyperammonemic events after transplantation and was associated with a more favorable growth outcome compared with individuals remaining under MM. However, neurocognitive outcome in individuals with LTx did not differ from the medically managed counterparts as reflected by the frequency of motor abnormality and cognitive standard deviation score at last observation. CONCLUSION Whereas LTx enabled metabolic stability without further need of protein restriction or nitrogen-scavenging therapy and was associated with a more favorable growth outcome, LTx-as currently performed-was not associated with improved neurocognitive outcomes compared with long-term MM in the investigated urea cycle disorders.
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Affiliation(s)
- Roland Posset
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany.
| | - Sven F Garbade
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Florian Gleich
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Svenja Scharre
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen G Okun
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Andrea L Gropman
- Children's National Health System and The George Washington School of Medicine, Washington, DC
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Ann-Catrin Druck
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Friederike Epp
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Georg F Hoffmann
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Zielonka
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany.
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Posset R, Garbade SF, Gleich F, Nagamani SCS, Gropman AL, Epp F, Ramdhouni N, Druck AC, Hoffmann GF, Kölker S, Zielonka M. Impact of supplementation with L-citrulline/arginine after liver transplantation in individuals with Urea Cycle Disorders. Mol Genet Metab 2024; 141:108112. [PMID: 38301530 DOI: 10.1016/j.ymgme.2023.108112] [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: 10/25/2023] [Revised: 12/06/2023] [Accepted: 12/06/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVE Liver transplantation (LTx) is an intervention when medical management is not sufficiently preventing individuals with urea cycle disorders (UCDs) from the occurrence of hyperammonemic events. Supplementation with L-citrulline/arginine is regularly performed prior to LTx to support ureagenesis and is often continued after the intervention. However, systematic studies assessing the impact of long-term L-citrulline/arginine supplementation in individuals who have undergone LTx is lacking to date. METHODS Using longitudinal data collected systematically, a comparative analysis was carried out by studying the effects of long-term L-citrulline/arginine supplementation vs. no supplementation on health-related outcome parameters (i.e., anthropometric, neurological, and cognitive outcomes) in individuals with UCDs who have undergone LTx. Altogether, 52 individuals with male ornithine transcarbamylase deficiency, citrullinemia type 1 and argininosuccinic aciduria and a pre-transplant "severe" disease course who have undergone LTx were investigated by using recently established and validated genotype-specific in vitro enzyme activities. RESULTS Long-term supplementation of individuals with L-citrulline/arginine who have undergone LTx (n = 16) does neither appear to alter anthropometric nor neurocognitive endpoints when compared to their severity-adjusted counterparts that were not supplemented (n = 36) after LTx with mean observation periods between four to five years. Moreover, supplementation with L-citrulline/arginine was not associated with an increase of disease-specific plasma arithmetic mean values for the respective amino acids when compared to the non-supplemented control cohort. CONCLUSION Although supplementation with L-citrulline/arginine is often continued after LTx, this pilot study does neither identify altered long-term anthropometric or neurocognitive health-related outcomes nor does it find an adequate biochemical response as reflected by the unaltered plasma arithmetic mean values for L-citrulline or L-arginine. Further prospective analyses in larger samples and even longer observation periods will provide more insight into the usefulness of long-term supplementation with L-citrulline/arginine for individuals with UCDs who have undergone LTx.
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Affiliation(s)
- Roland Posset
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
| | - Sven F Garbade
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Florian Gleich
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Andrea L Gropman
- Children's National Health System and The George Washington School of Medicine, Washington, DC, USA
| | - Friederike Epp
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Nesrine Ramdhouni
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Ann-Catrin Druck
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Georg F Hoffmann
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Stefan Kölker
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Matthias Zielonka
- Heidelberg University, Medical Faculty Heidelberg, and Center for Pediatric and Adolescent Medicine, Department I, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
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张 钏, 惠 玲, 周 秉, 郑 雷, 王 玉, 郝 胜, 达 振, 马 莹, 郭 金, 曹 宗, 马 旭. [Disease spectrum and pathogenic genes of inherited metabolic disorder in Gansu Province of China]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2024; 26:67-71. [PMID: 38269462 PMCID: PMC10817745 DOI: 10.7499/j.issn.1008-8830.2308094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/04/2023] [Indexed: 01/26/2024]
Abstract
OBJECTIVES To investigate the disease spectrum and pathogenic genes of inherited metabolic disorder (IMD) among neonates in Gansu Province of China. METHODS A retrospective analysis was conducted on the tandem mass spectrometry data of 286 682 neonates who received IMD screening in Gansu Provincial Maternal and Child Health Hospital from January 2018 to December 2021. A genetic analysis was conducted on the neonates with positive results in tandem mass spectrometry during primary screening and reexamination. RESULTS A total of 23 types of IMD caused by 28 pathogenic genes were found in the 286 682 neonates, and the overall prevalence rate of IMD was 0.63 (1/1 593), among which phenylketonuria showed the highest prevalence rate of 0.32 (1/3 083), followed by methylmalonic acidemia (0.11, 1/8 959) and tetrahydrobiopterin deficiency (0.06, 1/15 927). In this study, 166 variants were identified in the 28 pathogenic genes, with 13 novel variants found in 9 genes. According to American College of Medical Genetics and Genomics guidelines, 5 novel variants were classified as pathogenic variants, 7 were classified as likely pathogenic variants, and 1 was classified as the variant of uncertain significance. CONCLUSIONS This study enriches the database of pathogenic gene variants for IMD and provides basic data for establishing an accurate screening and diagnosis system for IMD in this region.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - 宗富 曹
- 国家卫生健康委科学技术研究所/国家人类遗传资源中心北京100081
| | - 旭 马
- 国家卫生健康委科学技术研究所/国家人类遗传资源中心北京100081
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Seker Yilmaz B, Baruteau J, Chakrapani A, Champion M, Chronopoulou E, Claridge LC, Daly A, Davies C, Davison J, Dhawan A, Grunewald S, Gupte GL, Heaton N, Lemonde H, McKiernan P, Mills P, Morris AA, Mundy H, Pierre G, Rajwal S, Sivananthan S, Sreekantam S, Stepien KM, Vara R, Yeo M, Gissen P. Liver transplantation in ornithine transcarbamylase deficiency: A retrospective multicentre cohort study. Mol Genet Metab Rep 2023; 37:101020. [PMID: 38053940 PMCID: PMC10694733 DOI: 10.1016/j.ymgmr.2023.101020] [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: 11/01/2023] [Accepted: 11/01/2023] [Indexed: 12/07/2023] Open
Abstract
Ornithine transcarbamylase deficiency (OTCD) is an X-linked defect of ureagenesis and the most common urea cycle disorder. Patients present with hyperammonemia causing neurological symptoms, which can lead to coma and death. Liver transplantation (LT) is the only curative therapy, but has several limitations including organ shortage, significant morbidity and requirement of lifelong immunosuppression. This study aims to identify the characteristics and outcomes of patients who underwent LT for OTCD. We conducted a retrospective study for OTCD patients from 5 UK centres receiving LT in 3 transplantation centres between 2010 and 2022. Patients' demographics, family history, initial presentation, age at LT, graft type and pre- and post-LT clinical, metabolic, and neurocognitive profile were collected from medical records. A total of 20 OTCD patients (11 males, 9 females) were enrolled in this study. 6/20 had neonatal and 14/20 late-onset presentation. 2/20 patients had positive family history for OTCD and one of them was diagnosed antenatally and received prospective treatment. All patients were managed with standard of care based on protein-restricted diet, ammonia scavengers and supplementation with arginine and/or citrulline before LT. 15/20 patients had neurodevelopmental problems before LT. The indication for LT was presence (or family history) of recurrent metabolic decompensations occurring despite standard medical therapy leading to neurodisability and quality of life impairment. Median age at LT was 10.5 months (6-24) and 66 months (35-156) in neonatal and late onset patients, respectively. 15/20 patients had deceased donor LT (DDLT) and 5/20 had living related donor LT (LDLT). Overall survival was 95% with one patient dying 6 h after LT. 13/20 had complications after LT and 2/20 patients required re-transplantation. All patients discontinued dietary restriction and ammonia scavengers after LT and remained metabolically stable. Patients who had neurodevelopmental problems before LT persisted to have difficulties after LT. 1/5 patients who was reported to have normal neurodevelopment before LT developed behavioural problems after LT, while the remaining 4 maintained their abilities without any reported issues. LT was found to be effective in correcting the metabolic defect, eliminates the risk of hyperammonemia and prolongs patients' survival.
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Affiliation(s)
- Berna Seker Yilmaz
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Julien Baruteau
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Anupam Chakrapani
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Michael Champion
- Department of Inherited Metabolic Disease, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, SE1 7EH London, UK
| | - Efstathia Chronopoulou
- Department of Inherited Metabolic Disease, Division of Women's and Children's Services, University Hospitals Bristol NHS Foundation Trust, Bristol BS1 3NU, UK
| | | | - Anne Daly
- Birmingham Women's and Children's Hospital NHS Foundation Trust, B4 6NH, Birmingham, UK
| | - Catherine Davies
- Department of Inherited Metabolic Disease, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, SE1 7EH London, UK
| | - James Davison
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Anil Dhawan
- Paediatric Liver Gastroenterology and Nutrition Centre and Mowat Labs, King's College Hospital NHS Foundation Trust, WC2R 2LS, London, UK
| | - Stephanie Grunewald
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Girish L. Gupte
- Birmingham Women's and Children's Hospital NHS Foundation Trust, B4 6NH, Birmingham, UK
| | - Nigel Heaton
- Institute of Liver Studies, Kings College Hospital, Denmark Hill, WC2R 2LS London, UK
| | - Hugh Lemonde
- Department of Inherited Metabolic Disease, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, SE1 7EH London, UK
| | - Pat McKiernan
- Birmingham Women's and Children's Hospital NHS Foundation Trust, B4 6NH, Birmingham, UK
| | - Philippa Mills
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Andrew A.M. Morris
- Willink Unit, Genetic Medicine, Manchester Academic Health Sciences Centre, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
| | - Helen Mundy
- Department of Inherited Metabolic Disease, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, SE1 7EH London, UK
| | - Germaine Pierre
- Department of Inherited Metabolic Disease, Division of Women's and Children's Services, University Hospitals Bristol NHS Foundation Trust, Bristol BS1 3NU, UK
| | - Sanjay Rajwal
- Leeds Teaching Hospitals NHS Trust, LS9 7TF Leeds, UK
| | - Siyamini Sivananthan
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Srividya Sreekantam
- Birmingham Women's and Children's Hospital NHS Foundation Trust, B4 6NH, Birmingham, UK
| | - Karolina M. Stepien
- Adult Inherited Metabolic Diseases, Salford Royal NHS Foundation Trust, M6 8HD Salford, UK
| | - Roshni Vara
- Department of Inherited Metabolic Disease, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, SE1 7EH London, UK
| | - Mildrid Yeo
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Paul Gissen
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
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Posset R, Zielonka M, Gleich F, Garbade SF, Hoffmann GF, Kölker S. The challenge of understanding and predicting phenotypic diversity in urea cycle disorders. J Inherit Metab Dis 2023; 46:1007-1016. [PMID: 37702610 DOI: 10.1002/jimd.12678] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 09/14/2023]
Abstract
The Urea Cycle Disorders Consortium (UCDC) and the European registry and network for Intoxication type Metabolic Diseases (E-IMD) are the worldwide largest databases for individuals with urea cycle disorders (UCDs) comprising longitudinal data from more than 1100 individuals with an overall long-term follow-up of approximately 25 years. However, heterogeneity of the clinical phenotype as well as different diagnostic and therapeutic strategies hamper our understanding on the predictors of phenotypic diversity and the impact of disease-immanent and interventional variables (e.g., diagnostic and therapeutic interventions) on the long-term outcome. A new strategy using combined and comparative data analyses helped overcome this challenge. This review presents the mechanisms and relevant principles that are necessary for the identification of meaningful clinical associations by combining data from different data sources, and serves as a blueprint for future analyses of rare disease registries.
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Affiliation(s)
- Roland Posset
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Zielonka
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
- Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany
| | - Florian Gleich
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Sven F Garbade
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Georg F Hoffmann
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Division of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Kho J, Polak U, Jiang MM, Odom JD, Hunter JV, Ali SM, Burrage LC, Nagamani SC, Pautler RG, Thompson HP, Urayama A, Jin Z, Lee B. Argininosuccinate lyase deficiency causes blood-brain barrier disruption via nitric oxide-mediated dysregulation of claudin expression. JCI Insight 2023; 8:e168475. [PMID: 37490345 PMCID: PMC10544197 DOI: 10.1172/jci.insight.168475] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 07/19/2023] [Indexed: 07/27/2023] Open
Abstract
Nitric oxide (NO) is a critical signaling molecule that has been implicated in the pathogenesis of neurocognitive diseases. Both excessive and insufficient NO production have been linked to pathology. Previously, we have shown that argininosuccinate lyase deficiency (ASLD) is a novel model system to investigate cell-autonomous, nitric oxide synthase-dependent NO deficiency. Humans with ASLD are at increased risk for developing hyperammonemia due to a block in ureagenesis. However, natural history studies have shown that individuals with ASLD have multisystem disease including neurocognitive deficits that can be independent of ammonia. Here, using ASLD as a model of NO deficiency, we investigated the effects of NO on brain endothelial cells in vitro and the blood-brain barrier (BBB) in vivo. Knockdown of ASL in human brain microvascular endothelial cells (HBMECs) led to decreased transendothelial electrical resistance, indicative of increased cell permeability. Mechanistically, treatment with an NO donor or inhibition of Claudin-1 improved barrier integrity in ASL-deficient HBMECs. Furthermore, in vivo assessment of a hypomorphic mouse model of ASLD showed increased BBB leakage, which was partially rescued by NO supplementation. Our results suggest that ASL-mediated NO synthesis is required for proper maintenance of brain microvascular endothelial cell functions as well as BBB integrity.
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Affiliation(s)
- Jordan Kho
- Department of Molecular and Human Genetics and
| | | | | | | | - Jill V. Hunter
- Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children’s Hospital, Houston, Texas, USA
| | | | - Lindsay C. Burrage
- Department of Molecular and Human Genetics and
- Texas Children’s Hospital, Houston, Texas, USA
| | - Sandesh C.S. Nagamani
- Department of Molecular and Human Genetics and
- Texas Children’s Hospital, Houston, Texas, USA
| | - Robia G. Pautler
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, Texas, USA
| | - Hannah P. Thompson
- Department of Neurology, University of Texas Health Science Center, Houston, Texas, USA
| | - Akihiko Urayama
- Department of Neurology, University of Texas Health Science Center, Houston, Texas, USA
| | - Zixue Jin
- Department of Molecular and Human Genetics and
| | - Brendan Lee
- Department of Molecular and Human Genetics and
- Texas Children’s Hospital, Houston, Texas, USA
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8
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Czarnecka AM, Obara-Michlewska M, Wesół-Kucharska D, Greczan M, Kaczor M, Książyk J, Rokicki D, Zielińska M. S100B Protein but Not 3-Nitrotyrosine Positively Correlates with Plasma Ammonia in Patients with Inherited Hyperammonemias: A New Promising Diagnostic Tool? J Clin Med 2023; 12:jcm12062411. [PMID: 36983411 PMCID: PMC10056255 DOI: 10.3390/jcm12062411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/15/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
Individuals with inherited hyperammonemias often present developmental and intellectual deficiencies which are likely to be exaggerated by hyperammonemia episodes in long-term outcomes. In order to find a new, systemic marker common to the course of congenital hyperammonemias, we decided to measure the plasma level of S100 calcium-binding protein B (S100B), which is associated with cerebral impairment. Further, we analyzed three mechanistically diverged but linked with oxidative-nitrosative stress biochemical parameters: 3-nitrotyrosine (3-NT), a measure of plasma proteins' nitration; advanced oxidation protein products (AOPP), a measure of protein oxidation; and glutathione peroxidase (GPx) activity, a measure of anti-oxidative enzymatic capacity. The plasma biomarkers listed above were determined for the first time in congenital hyperammonemia. Also, the level of pro- and anti-inflammatory mediators (i.e., IL-12, IL-6, IL-8, TNF-α, IL-1β, and IL-10) and chemokines (IP-10, MCP-1, MIG, and RANTES) were quantified. S100B was positively correlated with plasma ammonia level, while noticeable levels of circulating 3-NT in some of the patients' plasma did not correlate with ammonia concentration. Overall, the linear correlation between ammonia and S100B but not standard oxidative stress-related markers offers a unique perspective for the future identification and monitoring of neurological deficits risk-linked with hyperammonemia episodes in patients with inherited hyperammonemias. The S100B measure may support the development of therapeutic targets and clinical monitoring in these disorders.
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Affiliation(s)
- Anna Maria Czarnecka
- Department of Neurotoxicology, Mossakowski Medical Research Institute Polish Academy of Sciences, Pawińskiego 5, 02-106 Warsaw, Poland
| | - Marta Obara-Michlewska
- Department of Neurotoxicology, Mossakowski Medical Research Institute Polish Academy of Sciences, Pawińskiego 5, 02-106 Warsaw, Poland
| | - Dorota Wesół-Kucharska
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Milena Greczan
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Magdalena Kaczor
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Janusz Książyk
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Dariusz Rokicki
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Magdalena Zielińska
- Department of Neurotoxicology, Mossakowski Medical Research Institute Polish Academy of Sciences, Pawińskiego 5, 02-106 Warsaw, Poland
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9
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Mütze U, Gleich F, Barić I, Baumgartner M, Burlina A, Chapman KA, Chien Y, Cortès‐Saladelafont E, De Laet C, Dobbelaere D, Eysken F, Gautschi M, Santer R, Häberle J, Joaquín C, Karall D, Lindner M, Lund AM, Mühlhausen C, Murphy E, Roland D, Ruiz Gomez A, Skouma A, Grünert SC, Wagenmakers M, Garbade SF, Kölker S, Boy N. Impact of the SARS-CoV-2 pandemic on the health of individuals with intoxication-type metabolic diseases-Data from the E-IMD consortium. J Inherit Metab Dis 2023; 46:220-231. [PMID: 36266255 PMCID: PMC9874390 DOI: 10.1002/jimd.12572] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/20/2022] [Accepted: 10/19/2022] [Indexed: 01/27/2023]
Abstract
The SARS-CoV-2 pandemic challenges healthcare systems worldwide. Within inherited metabolic disorders (IMDs) the vulnerable subgroup of intoxication-type IMDs such as organic acidurias (OA) and urea cycle disorders (UCD) show risk for infection-induced morbidity and mortality. This study (observation period February 2020 to December 2021) evaluates impact on medical health care as well as disease course and outcome of SARS-CoV-2 infections in patients with intoxication-type IMDs managed by participants of the European Registry and Network for intoxication type metabolic diseases Consortium (E-IMD). Survey's respondents managing 792 patients (n = 479 pediatric; n = 313 adult) with intoxication-type IMDs (n = 454 OA; n = 338 UCD) in 14 countries reported on 59 (OA: n = 36; UCD: n = 23), SARS-CoV-2 infections (7.4%). Medical services were increasingly requested (95%), mostly alleviated by remote technologies (86%). Problems with medical supply were scarce (5%). Regular follow-up visits were reduced in 41% (range 10%-50%). Most infected individuals (49/59; 83%) showed mild clinical symptoms, while 10 patients (17%; n = 6 OA including four transplanted MMA patients; n = 4 UCD) were hospitalized (metabolic decompensation in 30%). ICU treatment was not reported. Hospitalization rate did not differ for diagnosis or age group (p = 0.778). Survival rate was 100%. Full recovery was reported for 100% in outpatient care and 90% of hospitalized individuals. SARS-CoV-2 impacts health care of individuals with intoxication-type IMDs worldwide. Most infected individuals, however, showed mild symptoms and did not require hospitalization. SARS-CoV-2-induced metabolic decompensations were usually mild without increased risk for ICU treatment. Overall prognosis of infected individuals is very promising and IMD-specific or COVID-19-related complications have not been observed.
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Affiliation(s)
- Ulrike Mütze
- Centre for Child and Adolescent Medicine, Division of Neuropaediatrics and Metabolic Medicine, Department of General PaediatricsUniversity Hospital HeidelbergHeidelbergGermany
| | - Florian Gleich
- Centre for Child and Adolescent Medicine, Division of Neuropaediatrics and Metabolic Medicine, Department of General PaediatricsUniversity Hospital HeidelbergHeidelbergGermany
| | - Ivo Barić
- University of Zagreb, School of Medicine and Department of PediatricsUniversity Hospital Center ZagrebZagrebCroatia
| | - Mathias Baumgartner
- University Children's Hospital and Children's Research Center, University of ZurichZurichSwitzerland
| | - Alberto Burlina
- Division of Inherited Metabolic DiseaseUniversity Hospital PadovaPadovaItaly
| | | | - Yin‐Hsiu Chien
- Department of Medical Genetics and PediatricsNational Taiwan University HospitalTaipeiTaiwan
| | - Elisenda Cortès‐Saladelafont
- University Hospital Germans Trias i Pujol, Department of Paediatrics, Unit of Inherited Metabolic Diseases and NeuropediatricsUniversitat Autònoma de BarcelonaBadalonaSpain
| | - Corinne De Laet
- Hôpital Universitaire des Enfants Reine Fabiola‐Université Libre de BruxellesBrusselsBelgium
| | - Dries Dobbelaere
- Medical Reference Center for Inherited Metabolic DiseasesJeanne de Flandre University Hospital and RADEME Research Team for Rare Metabolic and Developmental Diseases, CHRU LilleLilleFrance
| | - Francois Eysken
- Department of Pediatric Inherited Metabolic DiseasesUniversity Hospital of Antwerp UZAAntwerpBelgium
| | - Matthias Gautschi
- Department of Paediatrics, Division of Paediatric Endocrinology, Diabetology and Metabolism, InselspitalUniversity Hospital BernBernSwitzerland
| | - Rene Santer
- University Children's Hospital, University Medical Centre Hamburg‐EppendorfHamburgGermany
| | - Johannes Häberle
- University Children's Hospital and Children's Research Center, University of ZurichZurichSwitzerland
| | - Clara Joaquín
- Endocrinology and Nutrition DepartmentHospital Universitari Germans Trias i PujolBadalonaSpain
| | - Daniela Karall
- Clinic for PediatricsMedical University of InnsbruckInnsbruckAustria
| | - Martin Lindner
- Goethe University Frankfurt/Main, Uni.‐Children's HospitalFrankfurt/MainGermany
| | - Allan M. Lund
- Centre Inherited Metabolic Diseases, Departments of Paediatrics and Clinical GeneticsCopenhagen University HospitalCopenhagenDenmark
| | - Chris Mühlhausen
- Universitätsmedizin Göttingen, Georg‐August‐UniversitätGöttingenGermany
| | - Elaine Murphy
- National Hospital for Neurology and Neurosurgery, Charles Dent Metabolic UnitLondonUK
| | - Dominique Roland
- Institute of Pathology and Human Genetics (IPG)CharleroisBelgium
| | | | - Anastasia Skouma
- Institouto Ygeias Tou Paidiou, Institute of Child HealthAthensGreece
| | - Sarah C. Grünert
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical CentreUniversity of Freiburg, Faculty of MedicineFreiburgGermany
| | | | - Sven F. Garbade
- Centre for Child and Adolescent Medicine, Division of Neuropaediatrics and Metabolic Medicine, Department of General PaediatricsUniversity Hospital HeidelbergHeidelbergGermany
| | - Stefan Kölker
- Centre for Child and Adolescent Medicine, Division of Neuropaediatrics and Metabolic Medicine, Department of General PaediatricsUniversity Hospital HeidelbergHeidelbergGermany
| | - Nikolas Boy
- Centre for Child and Adolescent Medicine, Division of Neuropaediatrics and Metabolic Medicine, Department of General PaediatricsUniversity Hospital HeidelbergHeidelbergGermany
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10
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Scharre S, Posset R, Garbade SF, Gleich F, Seidl MJ, Druck A, Okun JG, Gropman AL, Nagamani SCS, Hoffmann GF, Kölker S, Zielonka M. Predicting the disease severity in male individuals with ornithine transcarbamylase deficiency. Ann Clin Transl Neurol 2022; 9:1715-1726. [PMID: 36217298 PMCID: PMC9639638 DOI: 10.1002/acn3.51668] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Ornithine transcarbamylase deficiency (OTC-D) is an X-linked metabolic disease and the most common urea cycle disorder. Due to high phenotypic heterogeneity, ranging from lethal neonatal hyperammonemic events to moderate symptoms and even asymptomatic individuals, the prediction of the disease course at an early disease stage is very important to individually adjust therapies such as medical treatment or liver transplantation. In this translational study, we developed a severity-adjusted classification system based on in vitro residual enzymatic OTC activity. METHODS Applying a cell-based expression system, residual enzymatic OTC activities of 71 pathogenic OTC variants were spectrophotometrically determined and subsequently correlated with clinical and biochemical outcome parameters of 119 male individuals with OTC-D (mOTC-D) as reported in the UCDC and E-IMD registries. RESULTS Integration of multiple data sources enabled the establishment of a robust disease prediction model for mOTC-D. Residual enzymatic OTC activity not only correlates with age at first symptoms, initial peak plasma ammonium concentration and frequency of metabolic decompensations but also predicts mortality. The critical threshold of 4.3% residual enzymatic activity distinguishes a severe from an attenuated phenotype. INTERPRETATION Residual enzymatic OTC activity reliably predicts the disease severity in mOTC-D and could thus serve as a tool for severity-adjusted evaluation of therapeutic strategies and counselling patients and parents.
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Affiliation(s)
- Svenja Scharre
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Roland Posset
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Sven F. Garbade
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Florian Gleich
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Marie J. Seidl
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Ann‐Catrin Druck
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Jürgen G. Okun
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Andrea L. Gropman
- Division of Neurodevelopmental Pediatrics and Neurogenetics, Children's National Health System and The George Washington School of MedicineWashingtonDistrict of ColumbiaUSA
| | - Sandesh C. S. Nagamani
- Department of Molecular and Human GeneticsBaylor College of Medicine and Texas Children's HospitalHoustonTexasUSA
| | - Georg F. Hoffmann
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Stefan Kölker
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Matthias Zielonka
- Division of Pediatric Neurology and Metabolic Medicine, Center for Child and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
- Heidelberg Research Center for Molecular Medicine (HRCMM)HeidelbergGermany
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11
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Bin Sawad A, Jackimiec J, Bechter M, Trucillo A, Lindsley K, Bhagat A, Uyei J, Diaz GA. Epidemiology, methods of diagnosis, and clinical management of patients with arginase 1 deficiency (ARG1-D): A systematic review. Mol Genet Metab 2022; 137:153-163. [PMID: 36049366 DOI: 10.1016/j.ymgme.2022.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/18/2022] [Accepted: 08/20/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Arginase 1 Deficiency (ARG1-D) is a rare, progressive, metabolic disorder that is characterized by devastating manifestations driven by elevated plasma arginine levels. It typically presents in early childhood with spasticity (predominately affecting the lower limbs), mobility impairment, seizures, developmental delay, and intellectual disability. This systematic review aims to identify and describe the published evidence outlining the epidemiology, diagnosis methods, measures of disease progression, clinical management, and outcomes for ARG1-D patients. METHODS A comprehensive literature search across multiple databases such as MEDLINE, Embase, and a review of clinical studies in ClinicalTrials.gov (with results reported) was carried out per PRISMA guidelines on 20 April 2020 with no date restriction. Pre-defined eligibility criteria were used to identify studies with data specific to patients with ARG1-D. Two independent reviewers screened records and extracted data from included studies. Quality was assessed using the modified Newcastle-Ottawa Scale for non-comparative studies. RESULTS Overall, 55 records reporting 40 completed studies and 3 ongoing studies were included. Ten studies reported the prevalence of ARG1-D in the general population, with a median of 1 in 1,000,000. Frequently reported diagnostic methods included genetic testing, plasma arginine levels, and red blood cell arginase activity. However, routine newborn screening is not universally available, and lack of disease awareness may prevent early diagnosis or lead to misdiagnosis, as the disease has overlapping symptomology with other diseases, such as cerebral palsy. Common manifestations reported at time of diagnosis and assessed for disease progression included spasticity (predominately affecting the lower limbs), mobility impairment, developmental delay, intellectual disability, and seizures. Severe dietary protein restriction, essential amino acid supplementation, and nitrogen scavenger administration were the most commonly reported treatments among patients with ARG1-D. Only a few studies reported meaningful clinical outcomes of these interventions on intellectual disability, motor function and adaptive behavior assessment, hospitalization, or death. The overall quality of included studies was assessed as good according to the Newcastle-Ottawa Scale. CONCLUSIONS Although ARG1-D is a rare disease, published evidence demonstrates a high burden of disease for patients. The current standard of care is ineffective at preventing disease progression. There remains a clear need for new treatment options as well as improved access to diagnostics and disease awareness to detect and initiate treatment before the onset of clinical manifestations to potentially enable more normal development, improve symptomatology, or prevent disease progression.
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Affiliation(s)
| | | | | | | | | | | | | | - George A Diaz
- Division of Medical Genetics and Genomics in the Department of Genetics and Genomic Sciences at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
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12
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Scharping M, Brennenstuhl H, Garbade SF, Wild B, Posset R, Zielonka M, Kölker S, Haun MW, Opladen T. Unmet Needs of Parents of Children with Urea Cycle Disorders. CHILDREN 2022; 9:children9050712. [PMID: 35626889 PMCID: PMC9140128 DOI: 10.3390/children9050712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/03/2022] [Accepted: 05/09/2022] [Indexed: 12/26/2022]
Abstract
(1) Background: Phenotypic diversity and long-term health outcomes of individuals with urea cycle disorders (UCDs) have been described in detail. However, there is limited information on the burden on affected families. (2) Methods: To evaluate the family burden in parents with children suffering from UCDs, we used validated questionnaires. Socio-demographic characteristics were evaluated, and an adapted version of the Parental Need Scale for Rare Diseases questionnaire was used. The survey was conducted in families of UCD patients cared for at the University Children’s Hospital Heidelberg. (3) Results: From April to November 2021, 59 participants were interviewed (mothers n = 34, fathers n = 25). The affected patients most frequently suffered from ornithine transcarbamylase deficiency (OTC-D) (female n = 12, male n = 12), followed by argininosuccinate synthetase deficiency (ASS-D, n = 13) and argininosuccinate lyase deficiency (ASL-D, n = 8). About one-third of the participants were “dissatisfied” or “extremely dissatisfied” with health professionals’ disease knowledge. In addition, 30% of the participants reported a medium or high need for “additional information on the development of their children”, and 44% reported a medium or high need “for information on available services”. A majority of 68% reported a need for additional support regarding services such as support groups (42%) or psychological counseling (29%). (4) Conclusions: Our study indicates that there is an unmet need for sufficient information about the development of children with UCDs, as well as for information about available support services for families with UCD patients. Furthermore, the results highlight the importance of establishing or improving family-centered care approaches. This pilot study may serve as a template for the assessment of the family burden associated with other inherited metabolic diseases.
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Affiliation(s)
- Mara Scharping
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.S.); (H.B.); (S.F.G.); (R.P.); (M.Z.); (S.K.)
| | - Heiko Brennenstuhl
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.S.); (H.B.); (S.F.G.); (R.P.); (M.Z.); (S.K.)
| | - Sven F. Garbade
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.S.); (H.B.); (S.F.G.); (R.P.); (M.Z.); (S.K.)
| | - Beate Wild
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, 69120 Heidelberg, Germany; (B.W.); (M.W.H.)
| | - Roland Posset
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.S.); (H.B.); (S.F.G.); (R.P.); (M.Z.); (S.K.)
| | - Matthias Zielonka
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.S.); (H.B.); (S.F.G.); (R.P.); (M.Z.); (S.K.)
| | - Stefan Kölker
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.S.); (H.B.); (S.F.G.); (R.P.); (M.Z.); (S.K.)
| | - Markus W. Haun
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, 69120 Heidelberg, Germany; (B.W.); (M.W.H.)
| | - Thomas Opladen
- Division of Child Neurology and Metabolic Medicine, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (M.S.); (H.B.); (S.F.G.); (R.P.); (M.Z.); (S.K.)
- Correspondence:
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13
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Kölker S, Gleich F, Mütze U, Opladen T. Rare Disease Registries Are Key to Evidence-Based Personalized Medicine: Highlighting the European Experience. Front Endocrinol (Lausanne) 2022; 13:832063. [PMID: 35317224 PMCID: PMC8934440 DOI: 10.3389/fendo.2022.832063] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/31/2022] [Indexed: 12/24/2022] Open
Abstract
Rare diseases, such as inherited metabolic diseases, have been identified as a health priority within the European Union more than 20 years ago and have become an integral part of EU health programs and European Reference Networks. Having the potential to pool data, to achieve sufficient sample size, to overcome the knowledge gap on rare diseases and to foster epidemiological and clinical research, patient registries are recognized as key instruments to evidence-based medicine for individuals with rare diseases. Patient registries can be used for multiple purposes, such as (1) describing the natural history and phenotypic diversity of rare diseases, (2) improving case definition and indication to treat, (3) identifying strategies for risk stratification and early prediction of disease severity (4), evaluating the impact of preventive, diagnostic, and therapeutic strategies on individual health, health economics, and the society, and (5) informing guideline development and policy makers. In contrast to clinical trials, patient registries aim to gather real-world evidence and to achieve generalizable results based on patient cohorts with a broad phenotypic spectrum. In order to develop a consistent and sustained framework for rare disease registries, uniform core principles have been formulated and have been formalized through the European Rare Disease Registration Infrastructure. Adherence to these core principles and compliance with the European general data protection regulations ensures that data collected and stored in patient registries can be exchanged and pooled in a protected environment. To illustrate the benefits and limitations of patient registries on rare disease research this review focuses on inherited metabolic diseases.
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14
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Kido J, Matsumoto S, Häberle J, Inomata Y, Kasahara M, Sakamoto S, Horikawa R, Tanemura A, Okajima H, Suzuki T, Nakamura K. Role of liver transplantation in urea cycle disorders: Report from a nationwide study in Japan. J Inherit Metab Dis 2021; 44:1311-1322. [PMID: 34232532 DOI: 10.1002/jimd.12415] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 07/05/2021] [Accepted: 07/05/2021] [Indexed: 12/12/2022]
Abstract
Urea cycle disorders (UCDs) are inherited metabolic diseases causing hyperammonemia by defects in urea cycle enzymes or transporters. Liver transplantation (LT) currently is the only curative treatment option until novel therapies become available. We performed a nationwide questionnaire-based study between January 2000 and March 2018 to investigate the effect of LT in patients with UCDs in Japan. A total of 231 patients with UCDs were enrolled in this study. Of them, a total of 78 patients with UCDs (30 male and 16 female ornithine transcarbamylase deficiency (OTCD), 21 carbamoyl phosphate synthetase 1 deficiency (CPSD), 10 argininosuccinate synthetase deficiency (ASSD) and 1 arginase 1 deficiency (ARGD)) had undergone LT. Concerning the maximum blood ammonia levels at the onset time in the transplanted male OTCD (N = 28), female OTCD (N = 15), CPSD (N = 21) and ASSD (N = 10), those were median 634 (IQR: 277-1172), 268 (211-352), 806 (535-1382), and 628 (425-957) μmol/L, respectively. The maximum blood ammonia levels in female OTCD were thus significantly lower than in the other UCDs (all P < .01). LT was effective for long-term survival, prevented recurrent hyperammonemia attack, and lowered baseline blood ammonia levels in patients with UCDs. LT had limited effect for ameliorating neurodevelopmental outcome in patients with severe disease because hyperammonemia at the onset time already had a significant impact on the brain. Patients with ASSD may be more likely to survive without cognitive impairment by receiving early LT despite severe neonatal hyperammonemia ≥ 360 μmol/L. In patients with neonatal onset OTCD or CPSD, there may be additional factors with adverse effects on the brain that are not improved by LT.
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Affiliation(s)
- Jun Kido
- Department of Pediatrics, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Shirou Matsumoto
- Department of Pediatrics, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Johannes Häberle
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
| | - Yukihiro Inomata
- Department of Transplantation and Pediatric Surgery, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
- Labor Welfare Corporation, Kumamoto Rosai Hospital, Yatsushiro, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Reiko Horikawa
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hideaki Okajima
- Department of Pediatric Surgery, Kanazawa Medical University, Kanazawa, Japan
| | - Tatsuya Suzuki
- Department of Pediatric Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kimitoshi Nakamura
- Department of Pediatrics, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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15
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Toquet S, Spodenkiewicz M, Douillard C, Maillot F, Arnoux JB, Damaj L, Odent S, Moreau C, Redonnet-Vernhet I, Mesli S, Servais A, Noel E, Charriere S, Rigalleau V, Lavigne C, Kaphan E, Roubertie A, Besson G, Bigot A, Servettaz A, Mochel F, Garnotel R. Adult-onset diagnosis of urea cycle disorders: Results of a French cohort of 71 patients. J Inherit Metab Dis 2021; 44:1199-1214. [PMID: 34014557 DOI: 10.1002/jimd.12403] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/19/2022]
Abstract
Urea cycle disorders (UCD) are rare diseases that usually affect neonates or young children. During decompensations, hyperammonemia is neurotoxic, leading to severe symptoms and even coma and death if not treated rapidly. The aim was to describe a cohort of patients with adult onset of UCDs in a multicentric, retrospective and descriptive study of French adult patients with a diagnosis after 16 years of age of UCDs due to a deficiency in one of the 6 enzymes (arginase, ASL, ASS, CPS1, NAGS, OTC) or the two transporters (ORNT1 or citrin). Seventy-one patients were included (68% female, 32% male). The diagnosis was made in the context of (a) a metabolic decompensation (42%), (b) family history (55%), or (c) chronic symptoms (3%). The median age at diagnosis was 33 years (range 16-86). Eighty-nine percent of patients were diagnosed with OTC deficiency, 7% CPS1 deficiency, 3% HHH syndrome and 1% argininosuccinic aciduria. For those diagnosed during decompensations (including 23 OTC cases, mostly female), 89% required an admission in intensive care units. Seven deaths were attributed to UCD-6 decompensations and 1 epilepsy secondary to inaugural decompensation. This is the largest cohort of UCDs diagnosed in adulthood, which confirms the triad of neurological, gastrointestinal and psychiatric symptoms during hyperammonemic decompensations. We stress that females with OTC deficiency can be symptomatic. With 10% of deaths in this cohort, UCDs in adults remain a life-threatening condition. Physicians working in adult care must be aware of late-onset presentations given the implications for patients and their families.
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Affiliation(s)
- Ségolène Toquet
- Service de Médecine Interne, Hôpital Robert Debré, CHU Reims, France
| | | | - Claire Douillard
- Service d'Endocrinologie et Métabolismes, Hôpital Claude Huriez, Centre de Référence des Maladies Héréditaires du métabolisme, CHU Lille, France
| | - François Maillot
- Service de Médecine Interne, Hôpital Bretonneau, CHRU de Tours, France
| | - Jean-Baptiste Arnoux
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Necker-Enfants Malades, CHU Paris, France
| | - Lena Damaj
- Service de Pédiatrie, CHU Hôpital Sud, Rennes, France
| | - Sylvie Odent
- Service de Génétique Clinique, CHU Hôpital Sud, Rennes, France
| | - Caroline Moreau
- Service de Biochimie et Toxicologie, CHU Pontchaillou, Rennes, France
| | | | - Samir Mesli
- Laboratoire de Biochimie, Hôpital Pellegrin, CHU Bordeaux, France
| | - Aude Servais
- Service de Néphrologie adulte, Hôpital Necker-Enfants Malades, CHU Paris, France
| | - Esther Noel
- Service de Médecine Interne, Hôpital Universitaire de Strasbourg, CHRU Strasbourg, France
| | - Sybill Charriere
- Fédération d'endocrinologie, maladies métaboliques, diabète et nutrition, Hôpital Louis Pradel, Centre de Référence des Maladies Héréditaires du Métabolisme, Bron, France
| | | | | | - Elsa Kaphan
- Pôle de Neurosciences Cliniques, CHU Timone, AP-HM, Marseille, France
| | - Agathe Roubertie
- Département de neuropédiatrie, Hôpital Gui de Chauliac, CHU Montpellier, France
| | | | - Adrien Bigot
- Service de Médecine Interne, Hôpital Bretonneau, CHRU de Tours, France
| | - Amélie Servettaz
- Service de Médecine Interne, Hôpital Robert Debré, CHU Reims, France
| | - Fanny Mochel
- Département de génétique, Hôpital Pitié-Salpêtrière, CHU Paris, France
| | - Roselyne Garnotel
- Laboratoire de Biochimie-Pharmacologie-Toxicologie, CHU Reims, France
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16
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Gobin-Limballe S, Ottolenghi C, Reyal F, Arnoux JB, Magen M, Simon M, Brassier A, Jabot-Hanin F, Lonlay PD, Pontoizeau C, Guirat M, Rio M, Gesny R, Gigarel N, Royer G, Steffann J, Munnich A, Bonnefont JP. OTC deficiency in females: Phenotype-genotype correlation based on a 130-family cohort. J Inherit Metab Dis 2021; 44:1235-1247. [PMID: 34014569 DOI: 10.1002/jimd.12404] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/30/2022]
Abstract
OTC deficiency, an inherited urea cycle disorder, is caused by mutations in the X-linked OTC gene. Phenotype-genotype correlations are well understood in males but still poorly known in females. Taking advantage of a cohort of 130 families (289 females), we assessed the relative contribution of OTC enzyme activity, X chromosome inactivation, and OTC gene sequencing to genetic counseling in heterozygous females. Twenty two percent of the heterozygous females were clinically affected, with episodic (11%), chronic (7.5%), or neonatal forms of the disease (3.5%). Overall mortality rate was 4%. OTC activity, ranging from 0% to 60%, did not correlate with phenotype at the individual level. Analysis of multiple samples from 4 mutant livers showed intra-hepatic variability of OTC activity and X inactivation profile (range of variability: 30% and 20%, respectively) without correlation between both parameters for 3 of the 4 livers. Ninety disease-causing variants were found, 27 of which were novel. Mutations were classified as "mild" or "severe," based on male phenotypes and/or in silico prediction. In our cohort, a serious disease occurred in 32% of females with a severe mutation, compared to 4% in females with a mild mutation (odds ratio = 1.365; P = 1.6e-06). These data should help prenatal diagnosis for heterozygous females and genetic counseling after fortuitous findings of OTC variants in pangenomic sequencing.
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Affiliation(s)
| | - Chris Ottolenghi
- Metabolomic and Proteomic Biochemistry Department, Necker Hospital, APHP Centre- Paris University, Paris, France
- INSERM UMR1163, Institut Imagine, Paris University, Paris, France
| | - Fabien Reyal
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
- Breast Gynecologic Cancer Reconstructive Team, Institut Curie, Paris University, Paris, France
| | - Jean-Baptiste Arnoux
- Inherited Metabolic Disease Department and National Reference Centre for Inherited Metabolic diseases, Necker Hospital, APHP Centre-Paris University, Paris, France
- INSERM U1151, INEM, Paris University, Paris, France
| | - Maryse Magen
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
| | - Marie Simon
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
| | - Anaïs Brassier
- Inherited Metabolic Disease Department and National Reference Centre for Inherited Metabolic diseases, Necker Hospital, APHP Centre-Paris University, Paris, France
- INSERM U1151, INEM, Paris University, Paris, France
| | - Fabienne Jabot-Hanin
- Bioinformatics Platform, Paris University, INSERM UMR1163, Institut Imagine, Paris, France
- Structure Federative de Recherche Necker, INSERM US24/CNRS UMS3633, Paris, France
| | - Pascale De Lonlay
- Inherited Metabolic Disease Department and National Reference Centre for Inherited Metabolic diseases, Necker Hospital, APHP Centre-Paris University, Paris, France
- INSERM U1151, INEM, Paris University, Paris, France
| | - Clement Pontoizeau
- Metabolomic and Proteomic Biochemistry Department, Necker Hospital, APHP Centre- Paris University, Paris, France
- INSERM UMR1163, Institut Imagine, Paris University, Paris, France
| | - Manel Guirat
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
| | - Marlene Rio
- Clinical Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
| | - Roselyne Gesny
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
| | - Nadine Gigarel
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
| | - Ghislaine Royer
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
| | - Julie Steffann
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
- INSERM UMR1163, Institut Imagine, Paris University, Paris, France
| | - Arnold Munnich
- INSERM UMR1163, Institut Imagine, Paris University, Paris, France
- Clinical Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
| | - Jean-Paul Bonnefont
- Molecular Genetics Department, Necker Hospital, APHP Centre-Paris University, Paris, France
- INSERM UMR1163, Institut Imagine, Paris University, Paris, France
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17
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Vernon HJ, Manoli I. Milestones in treatments for inborn errors of metabolism: Reflections on Where chemistry and medicine meet. Am J Med Genet A 2021; 185:3350-3358. [PMID: 34165242 DOI: 10.1002/ajmg.a.62385] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 05/23/2021] [Accepted: 05/25/2021] [Indexed: 12/16/2022]
Abstract
From Sir Archibald Garrod's initial description of the tetrad of albinism, alkaptonuria, cystinuria, and pentosuria to today, the field of medicine dedicated to inborn errors of metabolism has evolved from disease identification and mechanistic discovery to the development of therapies designed to subvert biochemical defects. In this review, we highlight major milestones in the treatment and diagnosis of inborn errors of metabolism, starting with dietary therapy for phenylketonuria in the 1950s and 1960s, and ending with current approaches in genetic manipulation.
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Affiliation(s)
- Hilary J Vernon
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Irini Manoli
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, Maryland, USA
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18
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Ruxmohan S, Quinonez J, Choudhari J, Poudel S, Pandav K. Hyperammonemic Encephalopathy in an Adolescent Patient of Citrullinemia Type 1 With an Atypical Presentation. Cureus 2021; 13:e15109. [PMID: 34159013 PMCID: PMC8212435 DOI: 10.7759/cureus.15109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Citrullinemia refers to a family of autosomal recessive disorders involving the urea cycle. Three forms exist, which have different implications. Type I citrullinemia exists in both mild and severe forms. It arises due to mutations with argininosuccinate synthase leading to accumulation of ammonia and producing symptoms of lethargy, poor feeding, and seizures. Type II citrullinemia occurs due to citrin mutations involved in the urea cycle transport or during neonatal cholestasis. Management of both conditions requires low-protein diets along with arginine, sodium benzoate, and sodium phenylacetate. While traditional treatment shows improved outcomes, modifications may be necessary depending on a patient’s presentation. We present a unique case of a 19-year-old wheelchair-bound female with a past medical history of heterozygous type I citrullinemia, seizures, and chronic encephalopathy presented to a local children’s hospital for evaluation of altered mental status with a lethargic mental state. She was initially found to have an ammonia level of 329 µmol/L and choledocholithiasis on admission. Dietary modification with intravenous dextrose and intralipids with oral lactulose saw improvement in her labs. However, her ammonia level increased to 381 µmol/L despite such interventions. Intensive care was required to normalize her serum ammonia level and clear her for a magnetic resonance cholangiopancreatography (MRCP). We present a unique case of heterozygous type I citrullinemia with some overlap with type II citrullinemia features. Further studies are needed to understand better the observed unique presentation and long-term clinical implications associated with the disease.
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Affiliation(s)
- Samir Ruxmohan
- Department of Neurology, Larkin Community Hospital, South Miami, USA
| | - Jonathan Quinonez
- Department of Neurology, Larkin Community Hospital, South Miami, USA
| | - Jinal Choudhari
- Orthopedics, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Division of Research & Academic Affairs, Larkin Community Hospital, South Miami, USA
| | - Sujan Poudel
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Division of Research & Academic Affairs, Larkin Community Hospital, South Miami, USA
| | - Krunal Pandav
- Division of Research & Academic Affairs, Larkin Community Hospital, South Miami, USA
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19
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Juchniewicz P, Piotrowska E, Kloska A, Podlacha M, Mantej J, Węgrzyn G, Tukaj S, Jakóbkiewicz-Banecka J. Dosage Compensation in Females with X-Linked Metabolic Disorders. Int J Mol Sci 2021; 22:ijms22094514. [PMID: 33925963 PMCID: PMC8123450 DOI: 10.3390/ijms22094514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 01/19/2023] Open
Abstract
Through the use of new genomic and metabolomic technologies, our comprehension of the molecular and biochemical etiologies of genetic disorders is rapidly expanding, and so are insights into their varying phenotypes. Dosage compensation (lyonization) is an epigenetic mechanism that balances the expression of genes on heteromorphic sex chromosomes. Many studies in the literature have suggested a profound influence of this phenomenon on the manifestation of X-linked disorders in females. In this review, we summarize the clinical and genetic findings in female heterozygotic carriers of a pathogenic variant in one of ten selected X-linked genes whose defects result in metabolic disorders.
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Affiliation(s)
- Patrycja Juchniewicz
- Department of Medical Biology and Genetics, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308 Gdańsk, Poland; (P.J.); (A.K.); (J.J.-B.)
| | - Ewa Piotrowska
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308 Gdańsk, Poland; (M.P.); (J.M.); (G.W.); (S.T.)
- Correspondence: ; Tel.: +48-58-523-6040
| | - Anna Kloska
- Department of Medical Biology and Genetics, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308 Gdańsk, Poland; (P.J.); (A.K.); (J.J.-B.)
| | - Magdalena Podlacha
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308 Gdańsk, Poland; (M.P.); (J.M.); (G.W.); (S.T.)
| | - Jagoda Mantej
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308 Gdańsk, Poland; (M.P.); (J.M.); (G.W.); (S.T.)
| | - Grzegorz Węgrzyn
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308 Gdańsk, Poland; (M.P.); (J.M.); (G.W.); (S.T.)
| | - Stefan Tukaj
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308 Gdańsk, Poland; (M.P.); (J.M.); (G.W.); (S.T.)
| | - Joanna Jakóbkiewicz-Banecka
- Department of Medical Biology and Genetics, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308 Gdańsk, Poland; (P.J.); (A.K.); (J.J.-B.)
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20
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Liu Y, Luo Y, Xia L, Qiu B, Zhou T, Feng M, Wang C, Xue F, Chen X, Han L, Zhang J, Xia Q. Outcome of Liver Transplantation for Neonatal-onset Citrullinemia Type I. Transplantation 2021; 105:569-576. [PMID: 33617202 DOI: 10.1097/tp.0000000000003261] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND We evaluated the outcome of liver transplantation (LT) in neonatal-onset citrullinemia type I patients, especially its impact on neurological deficits and developmental retardation. METHODS From October 2006 to October 2019, 5 of the 2003 children who received LT at Ren Ji Hospital had been diagnosed with citrullinemia type I. The primary indication for transplantation was repeated metabolic compensation and developmental retardation in 4 patients and prophylactic transplantation in the other. Among them, 3 patients received living donor LT and 2 received orthotopic LT. RESULTS All recipients had successfully recovered within the median follow-up period of 32 months (range, 6-54 mo). Transplantation restored citrulline metabolism and liver function. Plasma ammonia and citrulline concentration decreased to normal levels with no further hyperammonemic episodes being reported, even after normal diet intake began. Meanwhile, uracil-2 and orotic acid were not detected in urinary excretion. Strikingly, patients suffered developmental retardation before LT showed improved psychomotor ability and significant catch-up growth during the follow-up period. Cognitive ability, including language skills and academic performance, also greatly improved. Three patients had sustained brain injuries and exhibited severe neurological deficits before transplantation, especially repeated generalized tonic-clonic seizures. LT halted neurological deterioration and controlled seizure episodes, which further facilitated the intellectual development and improvement of life quality. CONCLUSIONS LT is an effective treatment for neonatal-onset citrullinemia type I patients, which reverses metabolism decompensation and improves quality of life. For patients who have suffered severe hyperammonemic insults, LT should be conducted at an early age to avoid further neurological or developmental deficits.
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Affiliation(s)
- Yuan Liu
- Department of Liver Surgery, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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21
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Posset R, Kölker S, Gleich F, Okun JG, Gropman AL, Nagamani SCS, Scharre S, Probst J, Walter ME, Hoffmann GF, Garbade SF, Zielonka M. Severity-adjusted evaluation of newborn screening on the metabolic disease course in individuals with cytosolic urea cycle disorders. Mol Genet Metab 2020; 131:390-397. [PMID: 33288448 PMCID: PMC8315358 DOI: 10.1016/j.ymgme.2020.10.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/29/2020] [Accepted: 10/31/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The implementation of newborn screening (NBS) programs for citrullinemia type 1 (CTLN1) and argininosuccinic aciduria (ASA) is subject to controversial debate. The aim of this study was to assess the impact of NBS on the metabolic disease course and clinical outcome of affected individuals. METHODS In 115 individuals with CTLN1 and ASA, we compared the severity of the initial hyperammonemic episode (HAE) and the frequency of (subsequent) HAEs with the mode of diagnosis. Based on a recently established functional disease prediction model, individuals were stratified according to their predicted severe or attenuated phenotype. RESULTS Individuals with predicted attenuated forms of CTLN1 and ASA were overrepresented in the NBS group, while those with a predicted severe phenotype were underrepresented compared to individuals identified after the manifestation of symptoms (SX). Identification by NBS was associated with reduced severity of the initial HAE both in individuals with predicted severe and attenuated phenotypes, while it was not associated with lower frequency of (subsequent) HAEs. Similar results were obtained when including some patients diagnosed presymptomatically (i.e. prenatal testing, and high-risk family screening) in this analysis. CONCLUSION Since one of the major challenges of NBS outcome studies is the potential overrepresentation of individuals with predicted attenuated phenotypes in NBS cohorts, severity-adjusted evaluation of screened and unscreened individuals is important to avoid overestimation of the NBS effect. NBS enables the attenuation of the initial HAE but does not affect the frequency of subsequent metabolic decompensations in individuals with CTLN1 and ASA. Future long-term studies will need to evaluate the clinical impact of this finding, especially with regard to mortality, as well as cognitive outcome and quality of life of survivors.
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Affiliation(s)
- Roland Posset
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Stefan Kölker
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Florian Gleich
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Jürgen G Okun
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Andrea L Gropman
- Children's National Health System and The George Washington School of Medicine, Washington, DC, USA
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Svenja Scharre
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Joris Probst
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Magdalena E Walter
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Georg F Hoffmann
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Sven F Garbade
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Matthias Zielonka
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany; Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany.
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22
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Mütze U, Garbade SF, Gramer G, Lindner M, Freisinger P, Grünert SC, Hennermann J, Ensenauer R, Thimm E, Zirnbauer J, Leichsenring M, Gleich F, Hörster F, Grohmann-Held K, Boy N, Fang-Hoffmann J, Burgard P, Walter M, Hoffmann GF, Kölker S. Long-term Outcomes of Individuals With Metabolic Diseases Identified Through Newborn Screening. Pediatrics 2020; 146:peds.2020-0444. [PMID: 33051224 DOI: 10.1542/peds.2020-0444] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Although extended newborn screening (NBS) programs have been introduced more than 20 years ago, their impact on the long-term clinical outcome of individuals with inherited metabolic diseases (IMDs) is still rarely investigated. METHODS We studied the clinical outcomes of individuals with IMDs identified by NBS between 1999 and 2016 in a prospective multicenter observational study. RESULTS In total, 306 screened individuals with IMDs (115 with phenylketonuria and 191 with other IMDs with a lifelong risk for metabolic decompensation) were followed for a median time of 6.2 years. Although the risk for metabolic decompensation was disease-specific and NBS could not prevent decompensations in every individual at risk (n = 49), the majority did not develop permanent disease-specific signs (75.9%), showed normal development (95.6%) and normal cognitive outcome (87.7%; mean IQ: 100.4), and mostly attended regular kindergarten (95.2%) and primary school (95.2%). This demonstrates that not only individuals with phenylketonuria, serving as a benchmark, but also those with lifelong risk for metabolic decompensation had a favorable long-term outcome. High NBS process quality is the prerequisite of this favorable outcome. This is supported by 28 individuals presenting with first symptoms at a median age of 3.5 days before NBS results were available, by the absence of neonatal decompensations after the report of NBS results, and by the challenge of keeping relevant process parameters at a constantly high level. CONCLUSIONS NBS for IMDs, although not completely preventing clinical presentations in all individuals, can be considered a highly successful program of secondary prevention.
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Affiliation(s)
- Ulrike Mütze
- Division of Child Neurology and Metabolic Medicine and Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany;
| | - Sven F Garbade
- Division of Child Neurology and Metabolic Medicine and Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Gwendolyn Gramer
- Division of Child Neurology and Metabolic Medicine and Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Lindner
- Division of Pediatric Neurology, University Children's Hospital Frankfurt, Frankfurt, Germany
| | - Peter Freisinger
- Children's Hospital Reutlingen, Klinikum am Steinenberg Reutlingen, Reutlingen, Germany
| | - Sarah Catharina Grünert
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Julia Hennermann
- Villa Metabolica, Center for Pediatric and Adolescent Medicine, University Medical Center Mainz, Mainz, Germany
| | - Regina Ensenauer
- Department of General Pediatrics, Neonatology, and Pediatric Cardiology, University Children's Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute of Child Nutrition, Max Rubner-Institut, Karlsruhe, Germany
| | - Eva Thimm
- Department of General Pediatrics, Neonatology, and Pediatric Cardiology, University Children's Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Judith Zirnbauer
- Department of Pediatric and Adolescent Medicine, Medical School, Ulm University, Ulm, Germany; and
| | - Michael Leichsenring
- Department of Pediatric and Adolescent Medicine, Medical School, Ulm University, Ulm, Germany; and
| | - Florian Gleich
- Division of Child Neurology and Metabolic Medicine and Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Friederike Hörster
- Division of Child Neurology and Metabolic Medicine and Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Karina Grohmann-Held
- Division of Child Neurology and Metabolic Medicine and Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany.,Center for Child and Adolescent Medicine, University Hospital Greifswald, Greifswald, Germany
| | - Nikolas Boy
- Division of Child Neurology and Metabolic Medicine and Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Junmin Fang-Hoffmann
- Division of Child Neurology and Metabolic Medicine and Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Burgard
- Division of Child Neurology and Metabolic Medicine and Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Magdalena Walter
- Division of Child Neurology and Metabolic Medicine and Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Georg F Hoffmann
- Division of Child Neurology and Metabolic Medicine and Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Division of Child Neurology and Metabolic Medicine and Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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23
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Considering Proximal Urea Cycle Disorders in Expanded Newborn Screening. Int J Neonatal Screen 2020; 6:ijns6040077. [PMID: 33124615 PMCID: PMC7712149 DOI: 10.3390/ijns6040077] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/20/2020] [Accepted: 09/29/2020] [Indexed: 02/06/2023] Open
Abstract
Proximal urea cycle disorders (PUCDs) have adverse outcomes such as intellectual disability and death, which may benefit from newborn screening (NBS) through early detection and prevention with early treatment. Ornithine transcarbamylase deficiency (OTCD) and carbamoyl phosphate synthetase 1 deficiency (CPS1D) are screened in six and eight states in the United States. We analyzed current evidence to see if it supports inclusion of PUCDs in the NBS panels based upon prevention potential, medical, diagnostic, treatment, and public health rationales. A literature review was performed in PubMed using MESH terms for OTCD, CPS1D, and NAGSD. A systematic review was performed in the hallmark of NBS inclusion criteria. We reviewed 31 articles. Molecular and biochemical diagnosis is available to provide diagnostic evidence. Untreated PUCDs have a significant burden with considerable developmental delay and mortality that may improve with early treatment. Tandem mass spectrometry can be used for NBS for PUCDs; however, citrulline and glutamine alone are not specific. Medical treatments currently available for PUCDs meet existing medical, diagnostic, treatment, and public health rationales. Improvement in NBS algorithms to increase sensitivity and specificity will allow earlier diagnosis and treatment to potentially improve disability and mortality rates.
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24
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Ozturk K, McKinney AM, Nascene D. Urea Cycle Disorders: A Neuroimaging Pattern Approach Using Diffusion and FLAIR MRI. J Neuroimaging 2020; 31:144-150. [PMID: 32920938 DOI: 10.1111/jon.12787] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/29/2020] [Accepted: 08/31/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND PURPOSE This study aimed to assess characteristic regions of MRI involvement utilizing diffusion weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) at urea cycle disorder (UCD) diagnosis to determine the possible association between initial MRI patterns within 10 days of the first hyperammonemia episode, serum ammonia levels, and severity of neurological outcome based on clinical follow-up of >30 days. METHODS Ten patients with UCDs (4 females; median age: 5.4 years, age range: 6 days-54 years) were included who underwent MRI during a first episode of hyperammonemia. The topographical distribution of the DWI and FLAIR abnormalities in the cerebral cortex, deep gray matter, white matter, posterior limb of internal capsule, cerebral peduncle, and cerebellum was evaluated. Possible correlations between the brain injury patterns on DWI/FLAIR images, serum ammonia levels, and severity of neurological outcome were investigated by a trend correlation. RESULTS The UCD cohort (n = 10) involved four ornithine transcarbamoylase deficiencies, four argininosuccinic aciduria, one carbomoylphosphate synthetase deficiency, and one citrullinemia type-1. The observed trend in the distribution of DWI abnormalities as the severity of neurological sequela outcome increased was with diffuse cerebral cortex or corpus striatum involvement. Patients with initial peak serum ammonia ≥450 µmol/L had a grade 2 to 4 outcome, and those with peak ammonia <450 µmol/L had a grade 0 or 1 outcome. CONCLUSIONS The presence of more severe neurological outcome could be associated with diffuse cerebral cortex or corpus striatum involvement on DWI and high serum ammonia levels in patients with UCD.
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Affiliation(s)
- Kerem Ozturk
- Department of Radiology, University of Minnesota, Minneapolis, MN
| | - Alexander M McKinney
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL
| | - David Nascene
- Department of Radiology, University of Minnesota, Minneapolis, MN
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Posset R, Garbade SF, Gleich F, Gropman AL, de Lonlay P, Hoffmann GF, Garcia-Cazorla A, Nagamani SCS, Baumgartner MR, Schulze A, Dobbelaere D, Yudkoff M, Kölker S, Zielonka M. Long-term effects of medical management on growth and weight in individuals with urea cycle disorders. Sci Rep 2020; 10:11948. [PMID: 32686765 PMCID: PMC7371674 DOI: 10.1038/s41598-020-67496-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 06/08/2020] [Indexed: 12/18/2022] Open
Abstract
Low protein diet and sodium or glycerol phenylbutyrate, two pillars of recommended long-term therapy of individuals with urea cycle disorders (UCDs), involve the risk of iatrogenic growth failure. Limited evidence-based studies hamper our knowledge on the long-term effects of the proposed medical management in individuals with UCDs. We studied the impact of medical management on growth and weight development in 307 individuals longitudinally followed by the Urea Cycle Disorders Consortium (UCDC) and the European registry and network for Intoxication type Metabolic Diseases (E-IMD). Intrauterine growth of all investigated UCDs and postnatal linear growth of asymptomatic individuals remained unaffected. Symptomatic individuals were at risk of progressive growth retardation independent from the underlying disease and the degree of natural protein restriction. Growth impairment was determined by disease severity and associated with reduced or borderline plasma branched-chain amino acid (BCAA) concentrations. Liver transplantation appeared to have a beneficial effect on growth. Weight development remained unaffected both in asymptomatic and symptomatic individuals. Progressive growth impairment depends on disease severity and plasma BCAA concentrations, but cannot be predicted by the amount of natural protein intake alone. Future clinical trials are necessary to evaluate whether supplementation with BCAAs might improve growth in UCDs.
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Affiliation(s)
- Roland Posset
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Sven F Garbade
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Florian Gleich
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | | | - Pascale de Lonlay
- Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Service de Maladies Metaboliques (MaMEA), filière G2M, Université Paris-Descartes, Paris, France
| | - Georg F Hoffmann
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Angeles Garcia-Cazorla
- Hospital San Joan de Deu, Institut Pediàtric de Recerca. Servicio de Neurologia and CIBERER, ISCIII, Barcelona, Spain
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Matthias R Baumgartner
- University Children's Hospital Zurich and Children's Research Center, Zurich, Switzerland
| | - Andreas Schulze
- University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada
| | - Dries Dobbelaere
- Centre de Référence Maladies Héréditaires du Métabolisme de L'Enfant Et de L'Adulte, Jeanne de Flandre Hospital, CHRU Lille, and Faculty of Medicine, University Lille 2, Lille, France
| | - Marc Yudkoff
- School of Medicine and Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Stefan Kölker
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Matthias Zielonka
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
- Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany.
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26
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Pontoizeau C, Roda C, Arnoux JB, Vignolo-Diard P, Brassier A, Habarou F, Barbier V, Grisel C, Abi-Warde MT, Boddaert N, Kuster A, Servais A, Kaminska A, Hennequin C, Dupic L, Lesage F, Touati G, Valayannopoulos V, Chadefaux-Vekemans B, Oualha M, Eisermann M, Ottolenghi C, de Lonlay P. Neonatal factors related to survival and intellectual and developmental outcome of patients with early-onset urea cycle disorders. Mol Genet Metab 2020; 130:110-117. [PMID: 32273051 DOI: 10.1016/j.ymgme.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/14/2020] [Accepted: 03/14/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE We aimed to identify prognostic factors for survival and long-term intellectual and developmental outcome in neonatal patients with early-onset urea cycle disorders (UCD) experiencing hyperammonaemic coma. METHODS We retrospectively analysed ammonia (NH3) and glutamine levels, electroencephalogram and brain images obtained during neonatal coma of UCD patients born between 1995 and 2011 and managed at a single centre and correlated them to survival and intellectual and developmental outcome. RESULTS We included 38 neonates suffering from deficiencies of argininosuccinate synthetase (ASSD, N = 12), ornithine transcarbamylase (OTCD, N = 10), carbamoylphosphate synthetase 1 (CPSD, N = 7), argininosuccinate lyase (ASLD, N = 7), N-acetylglutamate synthase (NAGS, N = 1) or arginase (ARGD, N = 1). Symptoms occurred earlier in mitochondrial than in cytosolic UCD. Sixty-eight percent of patients survived, with a mean (standard deviation-SD) follow-up of 10.4 (5.3) years. Mortality was mostly observed in OTCD (N = 7/10) and CPSD (N = 4/7) patients. Plasma NH3 level during the neonatal period, expressed as area under the curve, but not glutamine level was associated with mortality (p = .044 and p = .610). 62.1% of the patients had normal intellectual and developmental outcome. Intellectual and developmental outcome tended to correlate with UCD subtype (p = .052). No difference in plasma NH3 or glutamine level during the neonatal period among developmental outcomes was identified. EEG severity was linked to UCD subtypes (p = .004), ammonia levels (p = .037), duration of coma (p = .043), and mortality during the neonatal period (p = .020). Status epilepticus was recorded in 6 patients, 3 of whom died neonatally, 1 developed a severe intellectual disability while the 2 last patients had a normal development. CONCLUSION UCD subtypes differed by survival rate, intellectual and developmental outcome and EEG features in the neonatal period. Hyperammonaemia expressed as area under the curve was associated with survival but not with intellectual and developmental outcome whereas glutamine was not associated with one of these outcomes. Prognostic value of video-EEG monitoring and the association between status epilepticus and mortality should be assessed in neonatal hyperammonaemic coma in further studies.
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Affiliation(s)
- Clément Pontoizeau
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France.
| | - Célina Roda
- Université de Paris, CRESS, INSERM, INRA, HERA team (Health Environmental Risk Assessment), F-75004 Paris, France
| | - Jean-Baptiste Arnoux
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | | | - Anais Brassier
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Florence Habarou
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Valérie Barbier
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Coraline Grisel
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Marie-Thérèse Abi-Warde
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Nathalie Boddaert
- Department of Pediatric Radiology, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, PRES Sorbonne Paris Cité, INSERM U1000, Institut Imagine, Paris, France
| | - Alice Kuster
- Pediatric Critical Care Unit, Femme-Enfants-Adolescents Hospital, Nantes University, Nantes, France
| | - Aude Servais
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Department of Nephrology, Transplantation, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Anna Kaminska
- Neurophysiology Unit, AP-HP, Necker Enfants Malades Hospital, Paris, France
| | - Carole Hennequin
- Biochemistry, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Laurent Dupic
- Pediatric Critical Care Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Fabrice Lesage
- Pediatric Critical Care Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Guy Touati
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Vassili Valayannopoulos
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
| | - Bernadette Chadefaux-Vekemans
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Mehdi Oualha
- Pediatric Critical Care Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Monika Eisermann
- Neurophysiology Unit, AP-HP, Necker Enfants Malades Hospital, Paris, France
| | - Chris Ottolenghi
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France; Metabolomics Unit, Necker Enfants Malades Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Pascale de Lonlay
- Reference Center of Inherited Metabolic Diseases, Necker Enfants Malades Hospital, APHP, Imagine Institute, Paris Descartes University, Paris, France
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27
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Gerstein MT, Markus AR, Gianattasio KZ, Le Mons C, Bartos J, Stevens DM, Mew NA. Choosing between medical management and liver transplant in urea cycle disorders: A conceptual framework for parental treatment decision-making in rare disease. J Inherit Metab Dis 2020; 43:438-458. [PMID: 31883128 PMCID: PMC7318329 DOI: 10.1002/jimd.12209] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/27/2019] [Accepted: 12/20/2019] [Indexed: 02/06/2023]
Abstract
Urea cycle disorders (UCD) are rare inherited metabolic disorders caused by deficiencies of enzymes and transporters required to convert neurotoxic ammonia into urea. These deficiencies cause elevated blood ammonia, which if untreated may result in death, but even with optimal medical management, often results in recurrent brain damage. There are two major treatments for UCD: medical management or liver transplantation. Both are associated with mortality and morbidity but the evidence comparing outcomes is sparse. Thus, families face a dilemma: should their child be managed medically, or should they undergo a liver transplant? To (a) describe the factors that contribute to treatment choice among parents of children diagnosed with UCD and to (b) organise these factors into a conceptual framework that reflects how these issues interrelate to shape the decision-making experience of this population. Utilising grounded theory, qualitative data were collected through semi-structured interviews with parents (N = 35) and providers (N = 26) of children diagnosed with UCD and parent focus groups (N = 19). Thematic content analysis and selective and axial coding were applied. The framework highlights the life-cycle catalysts that frame families' personal perceptions of risks and benefits and describes the clinical, personal, social, and system factors that drive treatment choice including disease severity, stability, and burden, independence, peer experiences, and cost, coverage and access to quality care. Findings equip providers with evidence upon which to prepare for productive patient interactions about treatment options. They also provide a foundation for the development of patient-centred outcome measures to better evaluate effectiveness of treatments in this population.
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Affiliation(s)
- Maya T. Gerstein
- Department of Health Policy and Management, Milken Institute School of Public HealthThe George Washington UniversityWashingtonDistrict of Columbia
| | - Anne R. Markus
- Department of Health Policy and Management, Milken Institute School of Public HealthThe George Washington UniversityWashingtonDistrict of Columbia
| | - Kan Z. Gianattasio
- Department of Health Policy and Management, Milken Institute School of Public HealthThe George Washington UniversityWashingtonDistrict of Columbia
| | | | - Janice Bartos
- National Urea Cycle Disorders FoundationPasadenaCalifornia
| | - David M. Stevens
- Department of Health Policy and Management, Milken Institute School of Public HealthThe George Washington UniversityWashingtonDistrict of Columbia
| | - Nicholas Ah Mew
- Rare Disease Institute, Children's National Health SystemWashingtonDistrict of Columbia
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28
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Martinelli D, Fiermonte G, Häberle J, Boenzi S, Goffredo BM, Travaglini L, Agolini E, Porcelli V, Dionisi-Vici C. CUGC for hyperornithinemia-hyperammonemia-homocitrullinuria (HHH) syndrome. Eur J Hum Genet 2020; 28:982-987. [PMID: 32242103 DOI: 10.1038/s41431-020-0616-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 03/03/2020] [Accepted: 03/10/2020] [Indexed: 12/30/2022] Open
Affiliation(s)
- Diego Martinelli
- Division of Metabolism and Research Unit of Metabolic Biochemistry, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Giuseppe Fiermonte
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari, Bari, Italy
| | - Johannes Häberle
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Sara Boenzi
- Division of Metabolism and Research Unit of Metabolic Biochemistry, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Bianca Maria Goffredo
- Division of Metabolism and Research Unit of Metabolic Biochemistry, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Lorena Travaglini
- Unit of Neuromuscular and Neurodegenerative Disorders, Laboratory of Molecular Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Emanuele Agolini
- Molecular Genetics Laboratory, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Vito Porcelli
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari, Bari, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolism and Research Unit of Metabolic Biochemistry, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
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29
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Matoori S, Bao Y, Schmidt A, Fischer EJ, Ochoa-Sanchez R, Tremblay M, Oliveira MM, Rose CF, Leroux JC. An Investigation of PS-b-PEO Polymersomes for the Oral Treatment and Diagnosis of Hyperammonemia. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2019; 15:e1902347. [PMID: 31721441 DOI: 10.1002/smll.201902347] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 10/02/2019] [Indexed: 05/17/2023]
Abstract
Ammonia-scavenging transmembrane pH-gradient poly(styrene)-b-poly(ethylene oxide) polymersomes are investigated for the oral treatment and diagnosis of hyperammonemia, a condition associated with serious neurologic complications in patients with liver disease as well as in infants with urea cycle disorders. While these polymersomes are highly stable in simulated intestinal fluids at extreme bile salt and osmolality conditions, they unexpectedly do not reduce plasmatic ammonia levels in cirrhotic rats after oral dosing. Incubation in dietary fiber hydrogels mimicking the colonic environment suggests that the vesicles are probably destabilized during the dehydration of the intestinal chyme. The findings question the relevance of commonly used simulated intestinal fluids for studying vesicular stability. With the encapsulation of a pH-sensitive dye in the polymersome core, the local pH increase upon ammonia influx could be exploited to assess the ammonia concentration in the plasma of healthy and cirrhotic rats as well as in other fluids. Due to its high sensitivity and selectivity, this polymersome-based assay could prove useful in the monitoring of hyperammonemic patients and in other applications such as drug screening tests.
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Affiliation(s)
- Simon Matoori
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, 8093, Switzerland
| | - Yinyin Bao
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, 8093, Switzerland
| | - Aaron Schmidt
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, 8093, Switzerland
| | - Eric J Fischer
- Institute for Chemical and Bioengineering, Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, 8093, Switzerland
| | | | - Mélanie Tremblay
- Hepato-Neuro Laboratory, CRCHUM, Montréal, H2X 0A9, Québec, Canada
| | | | | | - Jean-Christophe Leroux
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, 8093, Switzerland
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Häberle J, Burlina A, Chakrapani A, Dixon M, Karall D, Lindner M, Mandel H, Martinelli D, Pintos-Morell G, Santer R, Skouma A, Servais A, Tal G, Rubio V, Huemer M, Dionisi-Vici C. Suggested guidelines for the diagnosis and management of urea cycle disorders: First revision. J Inherit Metab Dis 2019; 42:1192-1230. [PMID: 30982989 DOI: 10.1002/jimd.12100] [Citation(s) in RCA: 249] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/04/2019] [Accepted: 04/08/2019] [Indexed: 02/06/2023]
Abstract
In 2012, we published guidelines summarizing and evaluating late 2011 evidence for diagnosis and therapy of urea cycle disorders (UCDs). With 1:35 000 estimated incidence, UCDs cause hyperammonemia of neonatal (~50%) or late onset that can lead to intellectual disability or death, even while effective therapies do exist. In the 7 years that have elapsed since the first guideline was published, abundant novel information has accumulated, experience on newborn screening for some UCDs has widened, a novel hyperammonemia-causing genetic disorder has been reported, glycerol phenylbutyrate has been introduced as a treatment, and novel promising therapeutic avenues (including gene therapy) have been opened. Several factors including the impact of the first edition of these guidelines (frequently read and quoted) may have increased awareness among health professionals and patient families. However, under-recognition and delayed diagnosis of UCDs still appear widespread. It was therefore necessary to revise the original guidelines to ensure an up-to-date frame of reference for professionals and patients as well as for awareness campaigns. This was accomplished by keeping the original spirit of providing a trans-European consensus based on robust evidence (scored with GRADE methodology), involving professionals on UCDs from nine countries in preparing this consensus. We believe this revised guideline, which has been reviewed by several societies that are involved in the management of UCDs, will have a positive impact on the outcomes of patients by establishing common standards, and spreading and harmonizing good practices. It may also promote the identification of knowledge voids to be filled by future research.
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Affiliation(s)
- Johannes Häberle
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
| | - Alberto Burlina
- Division of Inborn Metabolic Disease, Department of Pediatrics, University Hospital Padua, Padova, Italy
| | - Anupam Chakrapani
- Department of Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marjorie Dixon
- Dietetics, Great Ormond Street Hospital for Children, NHS Trust, London, UK
| | - Daniela Karall
- Clinic for Pediatrics, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Lindner
- University Children's Hospital, Frankfurt am Main, Germany
| | - Hanna Mandel
- Institute of Human Genetics and metabolic disorders, Western Galilee Medical Center, Nahariya, Israel
| | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children's Hospital, Rome, Italy
| | - Guillem Pintos-Morell
- Centre for Rare Diseases, University Hospital Vall d'Hebron, Barcelona, Spain
- CIBERER_GCV08, Research Institute IGTP, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - René Santer
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anastasia Skouma
- Institute of Child Health, Agia Sofia Children's Hospital, Athens, Greece
| | - Aude Servais
- Service de Néphrologie et maladies métaboliques adulte Hôpital Necker 149, Paris, France
| | - Galit Tal
- The Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Vicente Rubio
- Instituto de Biomedicina de Valencia (IBV-CSIC), Centro de Investigación Biomédica en Red para Enfermedades Raras (CIBERER), Valencia, Spain
| | - Martina Huemer
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
- Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria
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31
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Zielonka M, Kölker S, Gleich F, Stützenberger N, Nagamani SCS, Gropman AL, Hoffmann GF, Garbade SF, Posset R. Early prediction of phenotypic severity in Citrullinemia Type 1. Ann Clin Transl Neurol 2019; 6:1858-1871. [PMID: 31469252 PMCID: PMC6764635 DOI: 10.1002/acn3.50886] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 08/14/2019] [Indexed: 12/31/2022] Open
Abstract
Objective Citrullinemia type 1 (CTLN1) is an inherited metabolic disease affecting the brain which is detectable by newborn screening. The clinical spectrum is highly variable including individuals with lethal hyperammonemic encephalopathy in the newborn period and individuals with a mild‐to‐moderate or asymptomatic disease course. Since the phenotypic severity has not been predictable early during the disease course so far, we aimed to design a reliable disease prediction model. Methods We used a newly established mammalian biallelic expression system to determine residual enzymatic activity of argininosuccinate synthetase 1 (ASS1; OMIM #215700) in 71 individuals with CTLN1, representing 48 ASS1 gene variants and 50 different, mostly compound heterozygous combinations in total. Residual enzymatic ASS1 activity was correlated to standardized biochemical and clinical endpoints available from the UCDC and E‐IMD databases. Results Residual enzymatic ASS1 activity correlates with peak plasma ammonium and L‐citrulline concentrations at initial presentation. Individuals with 8% of residual enzymatic ASS1 activity or less had more frequent and more severe hyperammonemic events and lower cognitive function than those above 8%, highlighting that residual enzymatic ASS1 activity allows reliable severity prediction. Noteworthy, empiric clinical practice of affected individuals is in line with the predicted disease severity supporting the notion of a risk stratification‐based guidance of therapeutic decision‐making based on residual enzymatic ASS1 activity in the future. Interpretation Residual enzymatic ASS1 activity reliably predicts the phenotypic severity in CTLN1. We propose a new severity‐adjusted classification system for individuals with CTLN1 based on the activity results of the newly established biallelic expression system.
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Affiliation(s)
- Matthias Zielonka
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.,Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany
| | - Stefan Kölker
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Florian Gleich
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Nicolas Stützenberger
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Andrea L Gropman
- Children's National Health System, The George Washington School of Medicine, District of Columbia, Washington
| | - Georg F Hoffmann
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Sven F Garbade
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Roland Posset
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
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32
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Silvera-Ruiz SM, Arranz JA, Häberle J, Angaroni CJ, Bezard M, Guelbert N, Becerra A, Peralta F, de Kremer RD, Laróvere LE. Urea cycle disorders in Argentine patients: clinical presentation, biochemical and genetic findings. Orphanet J Rare Dis 2019; 14:203. [PMID: 31426867 PMCID: PMC6700778 DOI: 10.1186/s13023-019-1177-3] [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: 03/27/2019] [Accepted: 08/13/2019] [Indexed: 12/30/2022] Open
Abstract
Background The incidence, prevalence, and molecular epidemiology of urea cycle disorders (UCDs) in Argentina remain underexplored. The present study is the first to thoroughly assess the clinical and molecular profiles of UCD patients examined at a single reference center in Argentina. Results Forty-nine UCD cases were collected. About half (26/49, 53%) manifested neonatally with classical presentation and had a high mortality (25/26, 96%). Ornithine transcarbamylase deficiency (OTCD) was the most common UCD (26 patients). Argininosuccinate synthetase deficiency (ASSD) was detected in 19 cases, while argininosuccinate lyase deficiency (ASLD) was diagnosed in 4 cases. Molecular genetic analysis revealed 8 private OTC mutations and two large deletion/duplication events in the OTC gene. Most mutations in the ASS1 and ASL genes were recurrent missense changes, and four alterations were novel. The clinical outcome of our UCD cohort was poor, with an overall mortality of 57% (28/49 cases), and a 28% (6/21) disability rate among the survivors. Conclusions Most patients in our case series showed severe neonatal onset, with high morbidity/mortality. We detected in total 19 mutations, most of them recurrent and of high frequency worldwide. Noteworthy, we highlight the presence of a geographic cluster with high prevalence of a point mutation in the ASS1 gene. This study suggests that these disorders may be more frequent than commonly assumed, and stresses the need for increased awareness amongst health professionals and greater availability of diagnostic tools for accurate identification, early diagnosis, and timely treatment. Electronic supplementary material The online version of this article (10.1186/s13023-019-1177-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Silene M Silvera-Ruiz
- Centro de Estudio de las Metabolopatías Congénitas, Hospital de Niños de la Santísima Trinidad, Cátedra de Clínica Pediátrica, Fac. Cs. Médicas, UNC, Ferroviarios 1250, CP 5014, Córdoba, Argentina.
| | - José A Arranz
- Unitat Metab, Hospital Vall d'Hebron, Barcelona, Spain
| | - Johannes Häberle
- University Children's Hospital and Children's Research Center, Zurich, Switzerland
| | - Celia J Angaroni
- Centro de Estudio de las Metabolopatías Congénitas, Hospital de Niños de la Santísima Trinidad, Cátedra de Clínica Pediátrica, Fac. Cs. Médicas, UNC, Ferroviarios 1250, CP 5014, Córdoba, Argentina
| | - Miriam Bezard
- Centro de Estudio de las Metabolopatías Congénitas, Hospital de Niños de la Santísima Trinidad, Cátedra de Clínica Pediátrica, Fac. Cs. Médicas, UNC, Ferroviarios 1250, CP 5014, Córdoba, Argentina
| | - Norberto Guelbert
- Sección Enfermedades Metabólicas, Hospital de Niños de la Santísima Trinidad, Córdoba, Argentina
| | - Adriana Becerra
- Sección Enfermedades Metabólicas, Hospital de Niños de la Santísima Trinidad, Córdoba, Argentina
| | - Fernanda Peralta
- Centro de Estudio de las Metabolopatías Congénitas, Hospital de Niños de la Santísima Trinidad, Cátedra de Clínica Pediátrica, Fac. Cs. Médicas, UNC, Ferroviarios 1250, CP 5014, Córdoba, Argentina
| | - Raquel Dodelson de Kremer
- Centro de Estudio de las Metabolopatías Congénitas, Hospital de Niños de la Santísima Trinidad, Cátedra de Clínica Pediátrica, Fac. Cs. Médicas, UNC, Ferroviarios 1250, CP 5014, Córdoba, Argentina
| | - Laura E Laróvere
- Centro de Estudio de las Metabolopatías Congénitas, Hospital de Niños de la Santísima Trinidad, Cátedra de Clínica Pediátrica, Fac. Cs. Médicas, UNC, Ferroviarios 1250, CP 5014, Córdoba, Argentina
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Posset R, Gropman AL, Nagamani SCS, Burrage LC, Bedoyan JK, Wong D, Berry GT, Baumgartner MR, Yudkoff M, Zielonka M, Hoffmann GF, Burgard P, Schulze A, McCandless SE, Garcia-Cazorla A, Seminara J, Garbade SF, Kölker S. Impact of Diagnosis and Therapy on Cognitive Function in Urea Cycle Disorders. Ann Neurol 2019; 86:116-128. [PMID: 31018246 DOI: 10.1002/ana.25492] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/02/2019] [Accepted: 04/21/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Individuals with urea cycle disorders (UCDs) often present with intellectual and developmental disabilities. The major aim of this study was to evaluate the impact of diagnostic and therapeutic interventions on cognitive outcomes in UCDs. METHODS This prospective, observational, multicenter study includes data from 503 individuals with UCDs who had comprehensive neurocognitive testing with a cumulative follow-up of 702 patient-years. RESULTS The mean cognitive standard deviation score (cSDS) was lower in symptomatic than in asymptomatic (p < 0.001, t test) individuals with UCDs. Intellectual disability (intellectual quotient < 70, cSDS < -2.0) was associated with the respective subtype of UCD and early disease onset, whereas height of the initial peak plasma ammonium concentration was inversely associated with neurocognitive outcomes in mitochondrial (proximal) rather than cytosolic (distal) UCDs. In ornithine transcarbamylase and argininosuccinate synthetase 1 deficiencies, we did not find evidence that monoscavenger therapy with sodium or glycerol phenylbutyrate was superior to sodium benzoate in providing cognitive protection. Early liver transplantation appears to be beneficial for UCDs. It is noteworthy that individuals with argininosuccinate synthetase 1 and argininosuccinate lyase deficiencies identified by newborn screening had better neurocognitive outcomes than those diagnosed after the manifestation of first symptoms. INTERPRETATION Cognitive function is related to interventional and non-interventional variables. Early detection by newborn screening and early liver transplantation appear to offer greater cognitive protection, but none of the currently used nitrogen scavengers was superior with regard to long-term neurocognitive outcome. Further confirmation could determine these variables as important clinical indicators of neuroprotection for individuals with UCDs. ANN NEUROL 2019.
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Affiliation(s)
- Roland Posset
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Andrea L Gropman
- Children's National Health System and George Washington School of Medicine, Washington, DC
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Lindsay C Burrage
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Jirair K Bedoyan
- Center for Human Genetics and Department of Genetics and Genome Sciences, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Derek Wong
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | - Gerard T Berry
- Harvard Medical School and Boston Children's Hospital, Boston, MA
| | - Matthias R Baumgartner
- University Children's Hospital Zurich and Children's Research Center, Zurich, Switzerland
| | - Marc Yudkoff
- University of Pennsylvania School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA
| | - Matthias Zielonka
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Research Center for Molecular Medicine, Heidelberg, Germany
| | - Georg F Hoffmann
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Burgard
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas Schulze
- Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Shawn E McCandless
- Children's Hospital Colorado and University of Colorado, School of Medicine, Aurora, CO
| | - Angeles Garcia-Cazorla
- Hospital San Joan de Deu, Institut Pediàtric de Recerca. Servicio de Neurologia and CIBERER, ISCIII, Barcelona, Spain
| | - Jennifer Seminara
- Children's National Health System and George Washington School of Medicine, Washington, DC
| | - Sven F Garbade
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Teufel U, Burgard P, Meyburg J, Lindner M, Poeschl J, Ruef P, Hoffmann GF, Kölker S. High blood pressure, a red flag for the neonatal manifestation of urea cycle disorders. Orphanet J Rare Dis 2019; 14:80. [PMID: 30961665 PMCID: PMC6454767 DOI: 10.1186/s13023-019-1055-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 04/01/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Neonatal manifestation of life-threatening hyperammonemic encephalopathy in urea cycle disorders (UCD) is often misdiagnosed as neonatal sepsis, resulting in significantly delayed start of specific treatment and poor outcome. The major aim of this study was to identify specific initial symptoms or signs to clinically distinguish hyperammonemic encephalopathy in neonates from neonatal sepsis in order to identify affected individuals with UCD and to start metabolic therapy without delay. Furthermore, we evaluated the impact of diagnostic delay, peak plasma ammonium (NH4+) concentration, mode of emergency treatment and transfer to a tertiary referral center on the outcome. METHODS Detailed information of 17 patients (born between 1994 and 2012) with confirmed diagnosis of UCD and neonatal hyperammonemic encephalopathy were collected from the original medical records. RESULTS The initially suspected diagnosis was neonatal sepsis in all patients, but was not confirmed in any of them. Unlike neonatal sepsis and not previously reported blood pressure increased above the 95th percentile in 13 (81%) of UCD patients before emergency treatment was started. Respiratory alkalosis was found in 11 (65%) of UCD patients, and in 14 (81%) plasma NH4+concentrations further increased despite initiation of metabolic therapy. CONCLUSION Detection of high blood pressure could be a valuable parameter for distinguishing neonatal sepsis from neonatal manifestation of UCD. Since high blood pressure is not typical for neonatal sepsis, other reasons such as encephalopathy and especially hyperammonemic encephalopathy (caused by e.g. UCD) should be searched for immediately. However, our result that the majority of newborns with UCD initially present with high blood pressure has to be evaluated in larger patient cohorts.
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Affiliation(s)
- Ulrike Teufel
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany. .,Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Peter Burgard
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jochen Meyburg
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Lindner
- University Children's Hospital Frankfurt, Frankfurt, Germany
| | - Johannes Poeschl
- Department of Pediatrics, Clinic of Neonatology, University of Heidelberg, Heidelberg, Germany
| | - Peter Ruef
- Department of Pediatrics, SLK-Kliniken Heilbronn GmbH, Heilbronn, Germany
| | - Georg F Hoffmann
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Center for Child and Adolescent Medicine, Division of Pediatric Neurology and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Posset R, Garbade SF, Boy N, Burlina AB, Dionisi-Vici C, Dobbelaere D, Garcia-Cazorla A, de Lonlay P, Teles EL, Vara R, Mew NA, Batshaw ML, Baumgartner MR, McCandless S, Seminara J, Summar M, Hoffmann GF, Kölker S, Burgard P. Transatlantic combined and comparative data analysis of 1095 patients with urea cycle disorders-A successful strategy for clinical research of rare diseases. J Inherit Metab Dis 2019; 42:93-106. [PMID: 30740724 PMCID: PMC7329920 DOI: 10.1002/jimd.12031] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND To improve our understanding of urea cycle disorders (UCDs) prospectively followed by two North American (NA) and European (EU) patient cohorts. AIMS Description of the NA and EU patient samples and investigation of the prospects of combined and comparative analyses for individuals with UCDs. METHODS Retrieval and comparison of the data from 1095 individuals (NA: 620, EU: 475) from two electronic databases. RESULTS The proportion of females with ornithine transcarbamylase deficiency (fOTC-D), particularly those being asymptomatic (asfOTC-D), was higher in the NA than in the EU sample. Exclusion of asfOTC-D resulted in similar distributions in both samples. The mean age at first symptoms was higher in NA than in EU patients with late onset (LO), but similar for those with early (≤ 28 days) onset (EO) of symptoms. Also, the mean age at diagnosis and diagnostic delay for EO and LO patients were similar in the NA and EU cohorts. In most patients (including fOTC-D), diagnosis was made after the onset of symptoms (59.9%) or by high-risk family screening (24.7%), and less often by newborn screening (8.9%) and prenatal testing (3.7%). Analysis of clinical phenotypes revealed that EO patients presented with more symptoms than LO individuals, but that numbers of symptoms correlated with plasma ammonium concentrations in EO patients only. Liver transplantation was reported for 90 NA and 25 EU patients. CONCLUSIONS Combined analysis of databases drawn from distinct populations opens the possibility to increase sample sizes for natural history questions, while comparative analysis utilizing differences in approach to treatment can evaluate therapeutic options and enhance long-term outcome studies.
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Affiliation(s)
- Roland Posset
- Centre for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Inherited Metabolic Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Sven F. Garbade
- Centre for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Inherited Metabolic Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Nikolas Boy
- Centre for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Inherited Metabolic Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Alberto B. Burlina
- Azienda Ospedaliera di Padova, U.O.C. Malattie Metaboliche Ereditarie, Padova, Italy
| | - Carlo Dionisi-Vici
- Ospedale Pediatrico Bambino Gésu, U.O.C. Patologia Metabolica, Rome, Italy
| | - Dries Dobbelaere
- Centre de Référence Maladies Héréditaires du Métabolisme de l’Enfant et de l’Adulte, Jeanne de Flandre Hospital, CHRU Lille, and RADEME EA 7364, Faculty of Medicine, University Lille 2, Lille 59037, France
| | - Angeles Garcia-Cazorla
- Hospital San Joan de Deu, Institut Pediàtric de Recerca. Servicio de Neurologia and CIBERER, ISCIII, Barcelona, Spain
| | - Pascale de Lonlay
- Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Service de Maladies Métaboliques, Paris, France
| | - Elisa Leão Teles
- Unidade de Doenças Metabólicas, Serviço de Pediatria, Hospital de S. João, EPE, Porto, Portugal
| | - Roshni Vara
- Evelina Children’s Hospital, St Thomas’ Hospital, London, UK
| | - Nicholas Ah Mew
- Children’s National Health System and The George Washington School of Medicine, Washington, District of Columbia, USA
| | - Mark L. Batshaw
- Children’s National Health System and The George Washington School of Medicine, Washington, District of Columbia, USA
| | | | - Shawn McCandless
- Case Western Reserve University and University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Jennifer Seminara
- Children’s National Health System and The George Washington School of Medicine, Washington, District of Columbia, USA
| | - Marshall Summar
- Rare Disease Institute, Children’s National Health System, 111 Michigan Ave., NW, Washington, DC, 20010, USA
| | - Georg F. Hoffmann
- Centre for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Inherited Metabolic Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Stefan Kölker
- Centre for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Inherited Metabolic Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Peter Burgard
- Centre for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Inherited Metabolic Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
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Kido J, Matsumoto S, Mitsubuchi H, Endo F, Nakamura K. Early liver transplantation in neonatal-onset and moderate urea cycle disorders may lead to normal neurodevelopment. Metab Brain Dis 2018; 33:1517-1523. [PMID: 29948653 DOI: 10.1007/s11011-018-0259-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 05/28/2018] [Indexed: 12/11/2022]
Abstract
Urea cycle disorders (UCDs) are inherited metabolic diseases that lead to hyperammonemia. Neurodevelopmental outcomes of patients with UCDs depend on the maximum ammonia concentration (MAC) in the blood during onset. MAC ≥360 μM is a marker of poor neurodevelopmental outcomes. We investigated the neurodevelopmental outcomes and MAC at onset for 177 patients with UCDs in Japan (median age, 8 years and 2 months; range, 10 days-72 years), including 57 patients with male ornithine transcarbamylase (OTCD), 59 patients with female OTCD, 23 patients with carbamoyl-phosphate synthetase 1 deficiency (CPSD), 28 patients with arginosuccinate synthetase deficiency, 9 patients with arginosuccinate lyase deficiency (ALD), and 1 patient with arginase 1 deficiency. Neurodevelopmental outcomes of patients with CPSD and ALD were poor because most had neonatal onset with blood MAC ≥300 μM at onset. Although OTCD, particularly female late-onset OTCD, has good neurodevelopmental outcomes among those with UCDs, it is not necessarily a mild disease with good long-term outcomes. Patients with severe UCDs and MAC ≥300 μM at onset should undergo liver transplantation (LT). Moreover, this study suggested that if the onset of UCD began during the neonatal period, then even UCD patients with MAC <300 μM at onset should undergo LT to protect the brain.
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Affiliation(s)
- Jun Kido
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto City, Kumamoto Prefecture, 860-8556, Japan.
| | - Shirou Matsumoto
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto City, Kumamoto Prefecture, 860-8556, Japan
| | - Hiroshi Mitsubuchi
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto City, Kumamoto Prefecture, 860-8556, Japan
| | - Fumio Endo
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto City, Kumamoto Prefecture, 860-8556, Japan
| | - Kimitoshi Nakamura
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto City, Kumamoto Prefecture, 860-8556, Japan
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Porta F, Peruzzi L, Bonaudo R, Pieretti S, Busso M, Cocchi E, Conio A, Pagliardini V, Spada M. Differential response to renal replacement therapy in neonatal‐onset inborn errors of metabolism. Nephrology (Carlton) 2018; 23:957-961. [DOI: 10.1111/nep.13409] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Francesco Porta
- Departments of PediatricsDialysis and Transplantation Unit, Città della Salute e della Scienza, Regina Margherita Children's Hospital Torino Italy
| | - Licia Peruzzi
- Departments of NephrologyDialysis and Transplantation Unit, Città della Salute e della Scienza, Regina Margherita Children's Hospital Torino Italy
| | - Roberto Bonaudo
- Departments of NephrologyDialysis and Transplantation Unit, Città della Salute e della Scienza, Regina Margherita Children's Hospital Torino Italy
| | - Silvia Pieretti
- Departments of PediatricsDialysis and Transplantation Unit, Città della Salute e della Scienza, Regina Margherita Children's Hospital Torino Italy
| | - Marta Busso
- Departments of PediatricsDialysis and Transplantation Unit, Città della Salute e della Scienza, Regina Margherita Children's Hospital Torino Italy
| | - Enrico Cocchi
- Departments of PediatricsDialysis and Transplantation Unit, Città della Salute e della Scienza, Regina Margherita Children's Hospital Torino Italy
| | - Alessandra Conio
- Departments of Anesthesia and Intensive CareDialysis and Transplantation Unit, Città della Salute e della Scienza, Regina Margherita Children's Hospital Torino Italy
| | - Veronica Pagliardini
- Departments of PediatricsDialysis and Transplantation Unit, Città della Salute e della Scienza, Regina Margherita Children's Hospital Torino Italy
| | - Marco Spada
- Departments of PediatricsDialysis and Transplantation Unit, Città della Salute e della Scienza, Regina Margherita Children's Hospital Torino Italy
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Zielonka M, Breuer M, Okun JG, Carl M, Hoffmann GF, Kölker S. Pharmacologic rescue of hyperammonemia-induced toxicity in zebrafish by inhibition of ornithine aminotransferase. PLoS One 2018; 13:e0203707. [PMID: 30199544 PMCID: PMC6130883 DOI: 10.1371/journal.pone.0203707] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 08/24/2018] [Indexed: 12/30/2022] Open
Abstract
Hyperammonemia is the common biochemical hallmark of urea cycle disorders, activating neurotoxic pathways. If untreated, affected individuals have a high risk of irreversible brain damage and mortality. Here we show that acute hyperammonemia strongly enhances transamination-dependent formation of osmolytic glutamine and excitatory glutamate, thereby inducing neurotoxicity and death in ammoniotelic zebrafish larvae via synergistically acting overactivation of NMDA receptors and bioenergetic impairment induced by depletion of 2-oxoglutarate. Intriguingly, specific and irreversible inhibition of ornithine aminotransferase (OAT) by 5-fluoromethylornithine rescues zebrafish from lethal concentrations of ammonium acetate and corrects hyperammonemia-induced biochemical alterations. Thus, OAT inhibition is a promising and effective therapeutic approach for preventing neurotoxicity and mortality in acute hyperammonemia.
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Affiliation(s)
- Matthias Zielonka
- University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division for Pediatric Neurology and Metabolic Medicine, Heidelberg, Germany
- Heidelberg Research Center for Molecular Medicine (HRCMM), Heidelberg, Germany
- * E-mail:
| | - Maximilian Breuer
- University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division for Pediatric Neurology and Metabolic Medicine, Heidelberg, Germany
| | - Jürgen Günther Okun
- University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division for Pediatric Neurology and Metabolic Medicine, Heidelberg, Germany
| | - Matthias Carl
- Heidelberg University, Medical Faculty Mannheim, Department of Cell and Molecular Biology, Mannheim, Germany
- University of Trento, Center for Integrative Biology (CIBIO), Laboratory of Translational Neurogenetics, Trento, Italy
| | - Georg Friedrich Hoffmann
- University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division for Pediatric Neurology and Metabolic Medicine, Heidelberg, Germany
| | - Stefan Kölker
- University Hospital Heidelberg, Center for Child and Adolescent Medicine, Division for Pediatric Neurology and Metabolic Medicine, Heidelberg, Germany
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Waisbren SE, Cuthbertson D, Burgard P, Holbert A, McCarter R, Cederbaum S. Biochemical markers and neuropsychological functioning in distal urea cycle disorders. J Inherit Metab Dis 2018; 41:657-667. [PMID: 29423830 PMCID: PMC6041144 DOI: 10.1007/s10545-017-0132-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 11/29/2017] [Accepted: 12/28/2017] [Indexed: 10/18/2022]
Abstract
Urea cycle disorders often present as devastating metabolic conditions, resulting in high mortality and significant neuropsychological damage, despite treatment. The Urea Cycle Disorders Longitudinal Study is a natural history study that collects data from regular clinical follow-up and neuropsychological testing. This report examines links between biochemical markers (ammonia, glutamine, arginine, citrulline) and primary neuropsychological endpoints in three distal disorders, argininosuccinic acid synthetase deficiency (ASD or citrullinemia type I), argininosuccinic acid lyase deficiency (ASA or ALD), and arginase deficiency (ARGD). Laboratory results and test scores from neuropsychological evaluations were assessed in 145 study participants, ages 3 years and older, with ASD (n = 64), ASA (n = 65) and ARGD (n = 16). Mean full scale IQ was below the population mean of 100 ± 15 for all groups: (ASD = 79 ± 24; ASA = 71 ± 21; ARGD = 65 ± 19). The greatest deficits were noted in visual performance and motor skills for all groups. While ammonia levels remain prominent as prognostic biomarkers, other biomarkers may be equally valuable as correlates of neuropsychological functioning. Cumulative exposure to the biomarkers included in the study proved to be highly sensitive indicators of neuropsychological outcomes, even when below the cut-off levels generally considered toxic. Blood levels of biomarkers obtained on the day of neuropsychological evaluations were not correlated with measures of functioning for any disorder in any domain. The importance of cumulative exposure supports early identification and confirms the need for well-controlled management of all biochemical abnormalities (and not just ammonia) that occur in urea cycle disorders.
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Affiliation(s)
- Susan E Waisbren
- Division of Genetics and Genomics, Boston Children's Hospital and Department of Medicine, Harvard Medical School, 1 Autumn Street #525, Boston, MA, 02115, USA.
| | - David Cuthbertson
- Health Informatics Institute, University of South Florida, Tampa, FL, USA
| | - Peter Burgard
- Centre for Child and Adolescent Medicine, Division of Neuropediatrics and Inherited Metabolic Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | - Amy Holbert
- Health Informatics Institute, University of South Florida, Tampa, FL, USA
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Abstract
Newborn screening programs aim to achieve presymptomatic diagnosis of treatable disorders allowing for early initiation of medical care to prevent or reduce significant morbidity and mortality. Many of the conditions included in the newborn screening panels are inborn errors of metabolism; however, screening for endocrine, hematologic, immunologic, and cardiovascular diseases, and hearing loss is also included in many panels. Newborn screening tests are not diagnostic and therefore diagnostic testing is needed to confirm or exclude the suspected diagnosis. Further advancement in technology is expected to allow continuous expansion of newborn screening.
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Maines E, Piccoli G, Pascarella A, Colucci F, Burlina AB. Inherited hyperammonemias: a Contemporary view on pathogenesis and diagnosis. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2018.1409108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Evelina Maines
- Pediatric Unit, Provincial Centre for Rare Diseases, Department of Women’s and Children’s Health, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Giovanni Piccoli
- CIBIO - Centre for integrative biology, Università degli Studi di Trento, Italy & Dulbecco Telethon Institute, Trento, Italy
| | - Antonia Pascarella
- Division of Inherited Metabolic Diseases, Reference Centre Expanded Newborn Screening, Department of Women’s and Children’s Health, University Hospital, Padova, Italy
| | - Francesca Colucci
- Division of Inherited Metabolic Diseases, Reference Centre Expanded Newborn Screening, Department of Women’s and Children’s Health, University Hospital, Padova, Italy
| | - Alberto B. Burlina
- Division of Inherited Metabolic Diseases, Reference Centre Expanded Newborn Screening, Department of Women’s and Children’s Health, University Hospital, Padova, Italy
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Longo N, Holt RJ. Glycerol phenylbutyrate for the maintenance treatment of patients with deficiencies in enzymes of the urea cycle. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1405807] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Nicola Longo
- Division of Medical Genetics, University of Utah, Salt Lake City, UT, USA
| | - Robert J. Holt
- Medical Affairs, Horizon Pharma, Lake Forest, IL, USA
- Department of Pharmacy Practice, University of Illinois, Chicago, IL, USA
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Evans M, Truby H, Boneh A. The Relationship between Dietary Intake, Growth, and Body Composition in Inborn Errors of Intermediary Protein Metabolism. J Pediatr 2017. [PMID: 28629683 DOI: 10.1016/j.jpeds.2017.05.048] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To examine relationships between dietary intake, growth and body composition patterns in patients with inborn errors of intermediary protein metabolism and to determine a safe protein:energy ratio (P:E ratio) associated with optimal growth outcomes. STUDY DESIGN Retrospective longitudinal data of growth and dietary intake in patients (n = 75) with isovaleric acidemia (IVA; n = 7), methylmalonic acidemia/propionic acidemia (MMA/PA; n = 14), urea cycle defects (UCD; n = 44), classical maple syrup urine disease (MSUD; n = 10) were collected. Prospective longitudinal data of growth, dietary intake, and body composition from 21 patients: IVA (n = 5), MMA/PA (n = 6), UCD (n = 7), and MSUD (n = 3) were collected at clinic visits. RESULTS Fifty-two of 75 (66%), 49 of 74 (68%), and 44 of 65 (68%) patients had a z-score of 0 (±1) for lifetime weight, height, and body mass index, respectively. Patients with MMA/PA had the lowest median height and weight z-scores, and MSUD patients had highest median body mass index z-score at all ages. In IVA, MMA/PA, and UCD, total natural protein intake met or exceeded the Food and Agriculture Organization of the United Nations (FAO)/World Health Organization (WHO)/United Nations University (UNU) recommended safe levels. Median percentage fat mass was 17.6% in IVA, 20.7% in MMA/PA, 19.4% in UCD, and 17.8% in MSUD. There was a significant negative correlation between percentage fat mass and total protein intake in IVA, MMA/PA, and UCD (r = -0.737; P = .010). The correlation between the P:E ratio and growth variables in IVA, MMA/PA, and UCD suggest a safe P:E ratio (>1.5 to < 2.9) g protein:100 kcal/day. CONCLUSION Growth outcomes in inborn errors of intermediary protein metabolism are not always ideal. Most patients with IVA, MMA/PA, and UCD consume sufficient natural protein to meet FAO/WHO/UNU recommendations. A P:E ratio range of (>1.5 to < 2.9)g protein/100 kcal/day correlates with optimal growth outcomes.
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Affiliation(s)
- Maureen Evans
- Department of Metabolic Medicine, Royal Children's Hospital and Murdoch Children's Research Institute, Melbourne, Australia; Department of Nutrition and Food Services, Royal Children's Hospital, Melbourne, Australia; Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Australia.
| | - Helen Truby
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Australia
| | - Avihu Boneh
- Department of Metabolic Medicine, Royal Children's Hospital and Murdoch Children's Research Institute, Melbourne, Australia; Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Australia; Department of Pediatrics, University of Melbourne, Melbourne, Australia
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Nettesheim S, Kölker S, Karall D, Häberle J, Posset R, Hoffmann GF, Heinrich B, Gleich F, Garbade SF. Incidence, disease onset and short-term outcome in urea cycle disorders -cross-border surveillance in Germany, Austria and Switzerland. Orphanet J Rare Dis 2017; 12:111. [PMID: 28619060 PMCID: PMC5472961 DOI: 10.1186/s13023-017-0661-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/30/2017] [Indexed: 12/30/2022] Open
Abstract
Background Urea cycle disorders (UCDs) are a group of rare inherited metabolic disorders. Affected individuals often present with hyperammonemic encephalopathy (HE) and have an increased risk of severe neurologic disease and early death. The study aims to provide epidemiologic data and to describe the disease manifestation and short-term outcome. Method Cross-border surveillance of newly diagnosed patients with UCDs - below 16 years of age - was performed from July 2012 to June 2015 in Germany and Austria and from January 2012 to December 2015 in Switzerland. Inquiries were sent monthly to all Pediatric Departments in Germany and Switzerland, and quarterly to the Austrian Metabolic Group. In addition, data were collected via a second source (metabolic laboratories) in all three countries. Results Between July 2012 and June 2015, fifty patients (Germany: 39, Austria: 7, Switzerland: 4) with newly diagnosed UCDs were reported and later confirmed resulting in an estimated cumulative incidence of 1 in 51,946 live births. At diagnosis, thirty-nine patients were symptomatic and 11 asymptomatic [10 identified by newborn screening (NBS), 1 by high-risk-family screening (HRF)]. The majority of symptomatic patients (30 of 39 patients) developed HE with (n = 25) or without coma (n = 5), 28 of them with neonatal onset. Despite emergency treatment 15 of 30 patients with HE already died during the newborn period. Noteworthy, 10 of 11 patients diagnosed by NBS or HRF remained asymptomatic. Comparison with the European registry and network for intoxication type metabolic diseases (E-IMD) demonstrated that cross-national surveillance identified a higher number of clinically severe UCD patients characterized by earlier onset of symptoms, higher peak ammonium concentrations in plasma and higher mortality. Conclusion Cross-border surveillance is a powerful tool to identify patients with UCDs demonstrating that (1) the cumulative incidence of UCDs is lower than originally suggested, (2) the mortality rate is still high in patients with neonatal onset of symptoms, and (3) onset type and peak plasma ammonium concentration predict mortality.
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Affiliation(s)
- Susanne Nettesheim
- Division of Neuropediatrics and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Stefan Kölker
- Division of Neuropediatrics and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Daniela Karall
- Medical University of Innsbruck, Clinic for Pediatrics I, Inherited Metabolic Disorders, Innsbruck, Austria
| | - Johannes Häberle
- University Children's Hospital Zurich, Division of Metabolism and Children's Research Center, Zurich, Switzerland
| | - Roland Posset
- Division of Neuropediatrics and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Georg F Hoffmann
- Division of Neuropediatrics and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Beate Heinrich
- Erhebungseinheit für Seltene Pädiatrische Erkrankungen in Deutschland, Coordination Center for Clinical Studies, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Florian Gleich
- Division of Neuropediatrics and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Sven F Garbade
- Division of Neuropediatrics and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
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Diez-Fernandez C, Rüfenacht V, Häberle J. Mutations in the Human Argininosuccinate Synthetase (ASS1) Gene, Impact on Patients, Common Changes, and Structural Considerations. Hum Mutat 2017; 38:471-484. [DOI: 10.1002/humu.23184] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 01/14/2017] [Indexed: 12/30/2022]
Affiliation(s)
- Carmen Diez-Fernandez
- Division of Metabolism; University Children´s Hospital and Children's Research Center; Zurich Switzerland
| | - Véronique Rüfenacht
- Division of Metabolism; University Children´s Hospital and Children's Research Center; Zurich Switzerland
| | - Johannes Häberle
- Division of Metabolism; University Children´s Hospital and Children's Research Center; Zurich Switzerland
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Newborn screening: a review of history, recent advancements, and future perspectives in the era of next generation sequencing. Curr Opin Pediatr 2016; 28:694-699. [PMID: 27552071 DOI: 10.1097/mop.0000000000000414] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the development and recent advancements of newborn screening. RECENT FINDINGS Early initiation of medical care has modified the outcome for many disorders that were previously associated with high morbidity (such as cystic fibrosis, primary immune deficiencies, and inborn errors of metabolism) or with significant neurodevelopmental disabilities (such as phenylketonuria and congenital hypothyroidism). The new era of mass spectrometry and next generation sequencing enables the expansion of the newborn screen panel, and will help to address technical issues such as turnaround time, and decreasing false-positive and false-negative rates for the testing. SUMMARY The newborn screening program is a successful public health initiative that facilitates early diagnosis of treatable disorders to reduce long-term morbidity and mortality.
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Husson MC, Schiff M, Fouilhoux A, Cano A, Dobbelaere D, Brassier A, Mention K, Arnoux JB, Feillet F, Chabrol B, Guffon N, Elie C, de Lonlay P. Efficacy and safety of i.v. sodium benzoate in urea cycle disorders: a multicentre retrospective study. Orphanet J Rare Dis 2016; 11:127. [PMID: 27663197 PMCID: PMC5034629 DOI: 10.1186/s13023-016-0513-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 09/06/2016] [Indexed: 12/30/2022] Open
Abstract
Background The efficacy and safety of intra-venous (i.v.) sodium benzoate for treating acute episodes of hyperammonemia in urea cycle enzyme disorders (UCD) is well known. However, published data do not provide a clear picture of the benefits and risks of this drug. We report a retrospective multicentre study on the use of i.v. sodium benzoate in patients treated for UCD between 2000 and 2010 in the 6 French reference centres for metabolic diseases. Results Sixty-one patients with UCDs - 22 ornithine transcarbamylase (20 confirmed, 2 suspected), 18 arginino-succinate synthetase, 15 carbamoyl phosphate synthetase, 3 arginosuccinate lyase, 1 arginase deficiency, 1 N-acetylglutamate synthetase, 1 HHH syndrome - required i.v. sodium benzoate over the course of 95 acute episodes (NH3 > 100 μmol/L or high-risk situations, i.e., gastroenteritis, surgery). Forty out of 61 patients experienced only one episode of decompensation (neonatal coma, 68.6 %). The most frequent cause of late decompensation was infection (55.5 %). A loading dose of i.v. sodium benzoate (median 250 mg/kg over 2 h) was administered for 41/95 acute episodes. The median maintenance dose was 246.1 mg/kg/day, administered via peripheral venous infusion in all cases except one via a central line. The total median duration of i.v. sodium benzoate treatment per episode was 2 days (0–13 days). The median durations of hospitalization in intensive care and metabolic units were 4 days (0–17 days) and 10 days (0–70 days), respectively. Eight patients died during the neonatal coma (n = 6) or surgery (n = 2). The median plasma ammonium level before treatment was 245.5 μmol/L (20.0–2274.0 μmol/L); it decreased to 40.0 μmol/L in patients who were alive (13.0–181.0 μmol/L) at the end of treatment with i.v. sodium benzoate. A decrease in ammonium level to ≤ 100 μmol/L was obtained in 92.8 % of episodes (64/69 of the episodes recorded for the 53 surviving patients). Five patients required another treatment for hyperammonemia (sodium phenylacetate + sodium benzoate, haemofiltration). Eighteen side effects were reported related to the i.v. infusion (local diffusion, oedema). Conclusion This 10-year retrospective study shows that i.v. sodium benzoate associated with an emergency regimen is an effective and safe treatment for acute episodes of UCD.
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Affiliation(s)
- Marie-Caroline Husson
- Etablissement Pharmaceutique des Hôpitaux de Paris, AGEPS, 7 rue du Fer à Moulin, Paris, 75005, France.
| | - Manuel Schiff
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Robert-Debré, AP-HP, Paris, France
| | - Alain Fouilhoux
- Reference Centre for Inherited Metabolic Disorders, Hôpital Femme Mère-Enfant, Lyon, France
| | - Aline Cano
- Centre de Référence des Maladies Héréditaires du Métabolisme, CHU Timone Enfants, Marseille, France
| | - Dries Dobbelaere
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Jeanne-de-Flandre, CHRU Lille, Lille, France
| | - Anais Brassier
- Reference Centre for Inherited Metabolic Disorders (MaMEA), Hôpital Necker-Enfants Malades, Institut Imagine, Université Paris Descartes, 149 rue de Sèvres, 75743, Paris, Cedex 15, France
| | - Karine Mention
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Jeanne-de-Flandre, CHRU Lille, Lille, France
| | - Jean-Baptiste Arnoux
- Reference Centre for Inherited Metabolic Disorders (MaMEA), Hôpital Necker-Enfants Malades, Institut Imagine, Université Paris Descartes, 149 rue de Sèvres, 75743, Paris, Cedex 15, France
| | - François Feillet
- Centre de Référence des Maladies Héréditaires du Métabolisme, CHU de Nancy, Hôpital Brabois Enfants, Vandoeuvre-les-Nancy, France
| | - Brigitte Chabrol
- Centre de Référence des Maladies Héréditaires du Métabolisme, CHU Timone Enfants, Marseille, France
| | - Nathalie Guffon
- Reference Centre for Inherited Metabolic Disorders, Hôpital Femme Mère-Enfant, Lyon, France
| | - Caroline Elie
- URC/CIC Paris Centre, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, 75015, Paris, France
| | - Pascale de Lonlay
- Reference Centre for Inherited Metabolic Disorders (MaMEA), Hôpital Necker-Enfants Malades, Institut Imagine, Université Paris Descartes, 149 rue de Sèvres, 75743, Paris, Cedex 15, France
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Clinical course of 63 patients with neonatal onset urea cycle disorders in the years 2001-2013. Orphanet J Rare Dis 2016; 11:116. [PMID: 27538463 PMCID: PMC4991093 DOI: 10.1186/s13023-016-0493-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 07/27/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Urea cycle disorders (UCDs) are rare inherited metabolic defects of ammonia detoxification. In about half of patients presenting with a UCD, the first symptoms appear within a few days after birth. These neonatal onset patients generally have a severe defect of urea cycle function and their survival and outcome prognoses are often limited. To understand better the current situation of neonatal onset in UCDs, we have performed a multicentre, retrospective, non-interventional case series study focussing on the most severe UCDs, namely defects of carbamoyl phosphate synthetase 1 (CPS1), ornithine transcarbamylase (OTC), and argininosuccinate synthetase (ASS). METHODS AND RESULTS Data of 63 patients were collected (27 patients with ASS deficiency, 23 patients with OTC deficiency, and 12 patients with CPS1 deficiency, one patient definite diagnosis not documented). The majority of patients (43/63, 68 %) had an initial ammonia concentration exceeding 500 μmol/L (normal < 100), of which most (26/43, 60.5 %) were also encephalopathic and were treated with hemodialysis. In patients surviving the initial crisis, recurrence of hyperammonemic events within the first 1.5 years of life occurred frequently (mean 3.6 events, range 0-20). Of all patients, 16 (25.4 %) died during or immediately after the neonatal period. CONCLUSION We observed in this cohort of neonatal onset UCD patients a high rate of initial life-threatening hyperammonemia and a high risk of recurrence of severe hyperammonemic crises. These corresponded to a high mortality rate during the entire study period (30.2 %) despite the fact that patients were treated in leading European metabolic centers. This underlines the need to critically re-evaluate the current treatment strategies in these patients.
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