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Glass A, Goldberg O, Mozer-Glassberg Y, Waisbourd-Zinman O, Haskin O, Levi S, Landau D, Levi Erez D, Gurevich M, Alfandary H. An innocent bystander or a predisposing culprit? Kidney injury following pediatric liver transplantation. Pediatr Nephrol 2024:10.1007/s00467-024-06537-9. [PMID: 39320550 DOI: 10.1007/s00467-024-06537-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 09/04/2024] [Accepted: 09/04/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND Survival after pediatric liver transplantation has increased dramatically over the years, revealing extra-hepatic complications including impaired kidney function. We conducted a large single-center retrospective study to evaluate kidney outcomes after pediatric liver transplantation. METHODS From electronic charts of 121 children who underwent liver transplantation during 2007-2020, we collected pre- and post-transplant data. We investigated the presence of post-transplant permanent kidney injury, including proteinuria, hypertension, and decreased estimated glomerular filtration rate (eGFR). We excluded children who died, underwent liver-kidney transplantation, or had less than 1 year of follow-up. RESULTS During a median follow-up of 5.1 (interquartile range 2.9-7.3) years, eGFR decreased, mostly in the first year post-transplant. In addition, 41% of the children presented with acute kidney injury. At their last follow-up, 35% showed permanent kidney injury (hypertension 13%, proteinuria 36%, and eGFR < 90 mL/min per 1.73 m2 7%). Kidney ultrasounds were abnormal for 44% of the children at the last visit, compared to 11% before transplant (p < 0.001). In multivariate analysis, abnormal kidney ultrasound before transplant (odds ratio = 4.53, 95% CI 1.1-18.7) and liver disease with potential risk of primary kidney involvement (odds ratio = 4.77, 95% CI 1.58-14.4) were predictors for hypertension or decreased eGFR at the last follow-up. CONCLUSIONS The high prevalence of kidney injury after pediatric liver transplantation and the pretransplant predictors for kidney injury highlight the importance of a thorough kidney pretransplant evaluation and follow-up.
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Affiliation(s)
- Adi Glass
- Department of Pediatrics A, Schneider Children's Medical Center of Israel, Kaplan 14 St, Petach Tikva, Israel.
| | - Ori Goldberg
- Institute of Pulmonology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Mozer-Glassberg
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Orith Waisbourd-Zinman
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Orly Haskin
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Shelly Levi
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Daniel Landau
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Daniella Levi Erez
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Gurevich
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Liver Kidney Transplant Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Hadas Alfandary
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
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Judy RL, Reynolds JL, Jnah AJ. Identifying Metabolic Diseases That Precipitate Neonatal Seizures. Neonatal Netw 2024; 43:139-147. [PMID: 38816225 DOI: 10.1891/nn-2023-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Although a rare cause of neonatal seizures, inborn errors of metabolism (IEMs) remain an essential component of a comprehensive differential diagnosis for poorly controlled neonatal epilepsy. Diagnosing neonatal-onset metabolic conditions proves a difficult task for clinicians; however, routine state newborn screening panels now include many IEMs. Three in particular-pyridoxine-dependent epilepsy, maple syrup urine disease, and Zellweger spectrum disorders-are highly associated with neonatal epilepsy and neurocognitive injury yet are often misdiagnosed. As research surrounding biomarkers for these conditions is emerging and gene sequencing technologies are advancing, clinicians are beginning to better establish early identification strategies for these diseases. In this literature review, the authors aim to present clinicians with an innovative clinical guide highlighting IEMs associated with neonatal-onset seizures, with the goal of promoting quality care and safety.
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Skvorak K, Liu J, Kruse N, Mehmood R, Das S, Jenne S, Chng C, Lao UL, Duan D, Asfaha J, Du F, Teadt L, Sero A, Ching C, Riggins J, Pope L, Yan P, Mashiana H, Ismaili MHA, McCluskie K, Huisman G, Silverman AP. Oral enzyme therapy for maple syrup urine disease (MSUD) suppresses plasma leucine levels in intermediate MSUD mice and healthy nonhuman primates. J Inherit Metab Dis 2023; 46:1089-1103. [PMID: 37494004 DOI: 10.1002/jimd.12662] [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: 05/20/2023] [Revised: 07/06/2023] [Accepted: 07/25/2023] [Indexed: 07/27/2023]
Abstract
Maple syrup urine disease (MSUD) is an inborn error of branched-chain amino acid metabolism affecting several thousand individuals worldwide. MSUD patients have elevated levels of plasma leucine and its metabolic product α-ketoisocaproate (KIC), which can lead to severe neurotoxicity, coma, and death. Patients must maintain a strict diet of protein restriction and medical formula, and periods of noncompliance or illness can lead to acute metabolic decompensation or cumulative neurological impairment. Given the lack of therapeutic options for MSUD patients, we sought to develop an oral enzyme therapy that can degrade leucine within the gastrointestinal tract prior to its systemic absorption and thus enable patients to maintain acceptable plasma leucine levels while broadening their access to natural protein. We identified a highly active leucine decarboxylase enzyme from Planctomycetaceae bacterium and used directed evolution to engineer the enzyme for stability to gastric and intestinal conditions. Following high-throughput screening of over 12 000 enzyme variants over 9 iterative rounds of evolution, we identified a lead variant, LDCv10, which retains activity following simulated gastric or intestinal conditions in vitro. In intermediate MSUD mice or healthy nonhuman primates given a whey protein meal, oral treatment with LDCv10 suppressed the spike in plasma leucine and KIC and reduced the leucine area under the curve in a dose-dependent manner. Reduction in plasma leucine correlated with decreased brain leucine levels following oral LDCv10 treatment. Collectively, these data support further development of LDCv10 as a potential new therapy for MSUD patients.
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Affiliation(s)
| | - Joyce Liu
- Codexis, Inc., Redwood City, California, USA
| | - Nikki Kruse
- Codexis, Inc., Redwood City, California, USA
| | | | | | | | | | - U Loi Lao
- Codexis, Inc., Redwood City, California, USA
| | - Da Duan
- Codexis, Inc., Redwood City, California, USA
| | | | - Faye Du
- Codexis, Inc., Redwood City, California, USA
| | - Leann Teadt
- Codexis, Inc., Redwood City, California, USA
| | | | | | | | - Lianne Pope
- Codexis, Inc., Redwood City, California, USA
| | - Ping Yan
- Codexis, Inc., Redwood City, California, USA
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Deon M, Guerreiro G, Girardi J, Ribas G, Vargas CR. Treatment of maple syrup urine disease: Benefits, risks, and challenges of liver transplantation. Int J Dev Neurosci 2023; 83:489-504. [PMID: 37340513 DOI: 10.1002/jdn.10283] [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: 10/17/2022] [Revised: 02/06/2023] [Accepted: 05/21/2023] [Indexed: 06/22/2023] Open
Abstract
Maple syrup urine disease (MSUD) is caused by a deficiency in the activity of the branched-chain α-ketoacid dehydrogenase (BCKD) complex, promoting the accumulation of the branched-chain amino acids (BCAA) leucine, isoleucine, and valine, as well as their respective α-keto acids. MSUD is an autosomal recessive hereditary metabolic disorder characterized by ketoacidosis, ataxia, coma, and mental and psychomotor retardation. The mechanisms involved in the brain damage caused by MSUD are not fully understood. Early diagnosis and treatment, as well as proper control of metabolic decompensation crises, are crucial for patients' survival and for a better prognosis. The recommended treatment consists of a high-calorie diet with restricted protein intake and specific formulas containing essential amino acids, except those accumulated in MSUD. This treatment will be maintained throughout life, being adjusted according to the patients' nutritional needs and BCAA concentration. Because dietary treatment may not be sufficient to prevent neurological damage in MSUD patients, other therapeutic strategies have been studied, including liver transplantation. With transplantation, it is possible to obtain an increase of about 10% of the normal BCKD in the body, an amount sufficient to maintain amino acid homeostasis and reduce metabolic decompensation crises. However, the experience related to this practice is very limited when considering the shortage of liver for transplantation and the risks related to the surgical procedure and immunosuppression. Thus, the purpose of this review is to survey the benefits, risks, and challenges of liver transplantation in the treatment of MSUD.
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Affiliation(s)
- Marion Deon
- Faculdade de Farmácia, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
- Serviço de Genética Médica, HCPA, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
| | - Gilian Guerreiro
- Faculdade de Farmácia, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
- Serviço de Genética Médica, HCPA, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
| | - Julia Girardi
- Residência em Análises Clínicas do Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Graziela Ribas
- Serviço de Genética Médica, HCPA, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
| | - Carmen Regla Vargas
- Faculdade de Farmácia, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
- Serviço de Genética Médica, HCPA, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
- Programa de Pós-Graduação em Ciências Farmacêuticas, Porto Alegre, Rio Grande do Sul, Brazil
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Chen T, Lu D, Xu F, Ji W, Zhan X, Gao X, Qiu W, Zhang H, Liang L, Gu X, Han L. Newborn screening of maple syrup urine disease and the effect of early diagnosis. Clin Chim Acta 2023; 548:117483. [PMID: 37421976 DOI: 10.1016/j.cca.2023.117483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Maple syrup urine disease (MSUD) is a rare disease for which newborn screening (NBS) is feasible but not universally applied in China. We shared our experiences with MSUD NBS. METHODS Tandem mass spectrometry-based NBS for MSUD was implemented in January 2003, and diagnostic methods included urine organic acid analysis via gas chromatography-mass spectrometry and genetic analysis. RESULTS Six MSUD patients were identified from 1.3 million newborns, yielding an incidence of 1:219,472, in Shanghai, China. The areas under the curve (AUCs) of total leucine (Xle), Xle/phenylalanine ratio, and Xle/alanine ratio were all 1.000. Some amino acid and acylcarnitine concentrations were markedly low in MSUD patients. 47 MSUD patients identified here and in other centers were investigated, which included 14 patients identified by NBS and 33 patients diagnosed clinically. Forty-four patients were subclassified into classic (n = 29), intermediate (n = 11) and intermittent (n = 4) subtypes. Due to earlier diagnosis and treatment, screened classic patients showed a higher survival rate (62.5%, 5/8) than clinically diagnosed classic patients (5.2%, 1/19). Overall, 56.8% (25/44) of MSUD patients and 77.8% (21/27) of classic patients carried variants in the BCKDHB gene. Among 61 identified genetic variants, 16 novel variants were identified. CONCLUSION MSUD NBS in Shanghai, China, enabled earlier detection and increased survivorship in the screened population.
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Affiliation(s)
- Ting Chen
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Deyun Lu
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Feng Xu
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Wenjun Ji
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Xia Zhan
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Xiaolan Gao
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Wenjuan Qiu
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Huiwen Zhang
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Lili Liang
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Xuefan Gu
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Lianshu Han
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China.
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Liu Q, Li F, Zhou J, Liu X, Peng J, Gong L. Neonatal maple syrup urine disease case report and literature review. Medicine (Baltimore) 2022; 101:e32174. [PMID: 36550798 PMCID: PMC9771221 DOI: 10.1097/md.0000000000032174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE The main clinical symptoms of maple syrup urine disease (MSUD) are dehydration, acidosis, nervous system symptoms and intellectual disability. The brain imaging findings were mainly caused by cytotoxic edema. The lesions usually occur at the site consistent with the myelination process of normal neonates. The distribution is mostly symmetric, and the diffusion is obviously limited. PATIENT CONCERNS Herein, we report a rare case of an 8-day-old female patient who presented with abnormal symptoms, such as difficulty eating, convulsions, slow reaction, difficulty in correcting hypoglycemia and severe metabolic disorders. Brain magnetic resonance imaging (MRI) revealed abnormal signal intensity mainly involving the brainstem, cervical spinal cord, bilateral cerebellar hemispheres, basal ganglia, thalamus, precentral gyrus, and postcentral gyrus with characteristic hyperintensity on diffusion-weighted imaging (DWI) sequence. MSUD is rarely reported, while cervical spinal cord involvement is extremely rare. DIAGNOSES Blood tandem mass spectrometry, urine organic acid detection, and genetic disease overall genetic tests were performed to further confirm the diagnosis of MSUD. INTERVENTIONS Under general anesthesia, she underwent open surgical procedures for liver transplantation. OUTCOMES The child was in a stable condition after liver transplantation, and the diet was not restricted. LESSONS MSUD in neonates is rare. Our case report and literature review was aim to describe the clinic and imaging characteristics of it, and highlight physicians must be aware of this entity in newborns so as to reduce misdiagnosis due to unfamiliarity.
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Affiliation(s)
- Qiao Liu
- Department of Medical Imaging Center, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Fang Li
- Department of Medical Imaging Center, Ganzhou People’s Hospital, Ganzhou, China
| | - Jingjing Zhou
- Department of Medical Imaging Center, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaoyu Liu
- Department of Medical Imaging Center, Ganzhou People’s Hospital, Ganzhou, China
| | - Jidong Peng
- Department of Medical Imaging Center, Ganzhou People’s Hospital, Ganzhou, China
| | - Lianggeng Gong
- Department of Medical Imaging Center, Second Affiliated Hospital of Nanchang University, Nanchang, China
- * Correspondence: Lianggeng Gong, Department of Medical Imaging Center, Second Affiliated Hospital of Nanchang University, Nanchang, China (e-mail: )
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7
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Squires JE, Horslen SP. CAQ Corner: Genetic liver disease. Liver Transpl 2022; 28:1231-1244. [PMID: 35377526 DOI: 10.1002/lt.26467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/25/2022] [Accepted: 03/01/2022] [Indexed: 01/13/2023]
Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Simon P Horslen
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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