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Mohammadzadeh Z, Sharifi L, Fatholahpour A, Bazshahi E. The investigation of serum phenylalanine levels based on infant feeding method: a cross-sectional study of children less than two years old with phenylketonuria (PKU). Int Breastfeed J 2024; 19:12. [PMID: 38351011 PMCID: PMC10865657 DOI: 10.1186/s13006-024-00617-0] [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: 08/01/2023] [Accepted: 01/28/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Clinical advice may suggest discontinuing breastfeeding after the diagnosis of phenylketonuria in infants as the only effective way to monitor the newborn's intake and accurate measurement of phenylalanine (Phe). This study aims to investigate the prevalence and duration of breastfeeding, as well as its effect on serum Phe levels in infants with phenylketonuria at Education and Therapy Medical Center, Be'sat Hospital, Iran. METHODS We conducted a cross-sectional study of 34 children under two years old diagnosed with phenylketonuria between September 2018 and December 2022. Infants were categorized as breastfed and non-breastfed (bottle-fed) based on their feeding method after diagnosis. Data on age at diagnosis, medical records, demographic information, and anthropometric indices were collected, and infants with incomplete data or mixed feeding (formula + breast milk) were excluded from the study. RESULTS Of 94 infants managed in our hospital, 34 had complete medical records. Among the all patients 13 (38%) continued to be breastfed combined with phenylalanine-free amino acid-based protein substitute, while 21 (62%) were did not receive breast milk. The mean duration of breastfeeding was 2.57 ± 0.59 (1-3) months. The mean age at diagnosis was 22.6 ± 18.4 days. Phenylalanine concentrations at diagnosis were mean 10, SD 5.44; range 4-24 mg/dL [0.22-1.33 μmol/L] in the breastfed group and mean 14.3, SD 10.2; range 5-37 mg/dL [0.27-2.05 μmol/L] in the non-breastfed group.Non-breastfed infants had lower serum Phe levels than breastfed infants: mean 3.76, SD 2.10; range 1-7 mg/dL [0.05-0.38 μmol/L] and mean 4.89, SD 3.68; range 2-19 mg/dL [0.11-1.05 μmol/L], respectively, although not statistically significant [(t (34) = 118.0, P = 0.51]. Also we found no significant associations in body measurements for weight, height, and head circumference at birth and final assessment. CONCLUSIONS In conclusion, during treatment, there were no statistically significant associations between breastfeeding and serum Phe levels with growth in children with phenylketonuria.
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Affiliation(s)
- Zaniar Mohammadzadeh
- Department of Community Nutrition, Besat Hospital, Kurdistan University of Medical Sciences, Pasdaran St., Head On Hotel Shadi, Sanandaj, 66177-13446, Iran
| | - Loghman Sharifi
- Non-Communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Asadolah Fatholahpour
- Department of Pediatrics, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Elham Bazshahi
- Department of Community Nutrition, Besat Hospital, Kurdistan University of Medical Sciences, Pasdaran St., Head On Hotel Shadi, Sanandaj, 66177-13446, Iran.
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2
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Quarenghi M, Giana A, Turri Quarenghi R, Volonté F. Sleeve gastrectomy is feasible in obese patients with phenylketonuria: A case report and literature review. Int J Surg Case Rep 2023; 109:108458. [PMID: 37437324 PMCID: PMC10362251 DOI: 10.1016/j.ijscr.2023.108458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/15/2023] [Accepted: 06/27/2023] [Indexed: 07/14/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Patients with phenylketonuria (PKU) exhibit a high incidence of obesity. Currently, bariatric surgery remains the most effective long-term treatment for obese patients. However, limited data regarding the applicability of bariatric surgery to obese patients with PKU have been reported in the literature. CASE PRESENTATION A case involving a young woman, in whom sleeve gastrectomy was performed to manage obesity that was resistant to conservative therapy, is presented herein. CLINICAL DISCUSSION The present report is the first to describe sleeve gastrectomy in an obese patient with PKU. The surgery proceeded without complications. Furthermore, the patient's phenylalanine levels remained under control for the first 3 months after surgery, with no major neurological complications. The diet prescribed in the first few months after surgery is complex; nevertheless, it is feasible to follow if supervised by a dietary team specialised in rare metabolic diseases. CONCLUSION Bariatric surgery in this patient with PKU did not result in any major complications. Surgery is feasible but it is important for the dietetic team involved to have expertise in PKU management.
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Affiliation(s)
- Massimo Quarenghi
- Clinical Nutrition and Dietetics, Department of Internal Medicine, Ospedale Regionale La Carità, Ente Ospedaliero Cantonale, Locarno, Switzerland.
| | - Arianna Giana
- Clinical Nutrition and Dietetics, Department of Internal Medicine, Ospedale Regionale San Giovanni, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | | | - Francesco Volonté
- Department of Surgery, Lugano Regional Hospital, Ente Ospedaliero Cantonale, Lugano, Switzerland; Department of Surgery, Sant'Anna Clinic, Via Sant'Anna 1, 6924 Lugano, Switzerland
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3
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Schwartz IVD, Quesada AA, Ribeiro EM, Martins AM, Vilela DRF, Pessoa A. Neuropsychological and quality of life outcomes in PKU patients: expert recommendations of assessment tools in Brazil. ARQUIVOS DE NEURO-PSIQUIATRIA 2023. [PMID: 37336507 PMCID: PMC10371414 DOI: 10.1055/s-0043-1768677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Phenylketonuria (PKU) is an inborn error of metabolism caused by deficient activity of phenylalanine hydroxylase. In Brazil, the National Neonatal Screening Program enables early treatment of patients with PKU, which prevents them from developing severe neurological damage and mental disabilities. However, between 20 and 30% of early-treated patients with PKU present focal cognitive deficits, including deficits in working memory, processing speed, and psychiatric symptoms such as anxiety, depression, and attention deficit hyperactivity disorder (ADHD). Therefore, age-specific neuropsychiatric and cognitive tests are important components of PKU patient care. To date, there are no officially approved guidelines or recommendations of tools in Portuguese validated for use in Brazil that could be applied to assess these parameters in patients with PKU. OBJECTIVE To recommend tools validated for use in Brazil that can be used in daily clinical practice to assess quality of life and neuropsychological outcomes in patients with PKU. METHODS Six Brazilian experts discussed about eligible tools based on their clinical experience, the feasibility of their use in clinical routines, and their availability in public health services. Before the meeting, an independent review of the literature was conducted to identify the currently validated tools in Brazil, using the MEDLINE and SciELO databases. RESULTS The experts recommended nine tools to assess quality of life (Peds-QL, SF-36 or WHOQOL-bref), executive function (BRIEF or Bayley-III), IQ (SONR 2½-7[a] or WASI) and ADHD (MTA-SNAP-IV and ASRS). CONCLUSION These instruments may be easily incorporated into clinical practice and improve the quality of multidisciplinary care of patients with PKU.
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Affiliation(s)
- Ida Vanessa Doederlein Schwartz
- Universidade Federal do Rio Grande do Sul, Porto Alegre RS, Brazil
- Hospital de Clínicas de Porto Alegre, Porto Alegre RS, Brazil
| | | | | | | | | | - André Pessoa
- Hospital Albert Sabin, Fortaleza CE, Brazil
- Universidade Estadual do Ceará, Fortaleza CE, Brazil
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4
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Christ SE, Clocksin HE, Zalik M, Goodlett BD, Sacharow SJ, Abbene EE. Neuropsychological assessment of adults with phenylketonuria using the NIH toolbox. Mol Genet Metab 2023; 139:107579. [PMID: 37099821 DOI: 10.1016/j.ymgme.2023.107579] [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: 01/31/2023] [Revised: 04/06/2023] [Accepted: 04/07/2023] [Indexed: 04/28/2023]
Abstract
Among researchers and clinicians, there is a call for the development and validation of new measures to better assess and characterize neurocognitive difficulties associated with early-treated phenylketonuria (ETPKU) and other metabolic disorders. The NIH Toolbox represents a relatively new computer-administered assessment tool and provides a sampling of performance across multiple cognitive domains, several of which (e.g., executive function, processing speed) are at risk for disruption in ETPKU. The goal of the present study was to provide an initial evaluation of the value and sensitivity of the NIH Toolbox for use with individuals with ETPKU. To this end, a sample of adults with ETPKU and a demographically-matched comparison group without PKU completed the cognitive and motor batteries of the Toolbox. Results indicate that overall performance (as reflected by the Fluid Cognition Composite) was sensitive to both group differences (ETPKU vs non-PKU) as well as blood Phe levels (a marker of metabolic control). The present findings offer preliminary support for the utility of the NIH Toolbox as a measure of neurocognitive functioning in individuals with ETPKU. Future research including a larger sample size and broader age range is needed to fully validate the Toolbox for clinical and research use with individuals with ETPKU.
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Affiliation(s)
- Shawn E Christ
- Department of Psychological Sciences, University of Missouri, Columbia, MO 65211, USA.
| | - Hayley E Clocksin
- Department of Psychological Sciences, University of Missouri, Columbia, MO 65211, USA
| | - Maia Zalik
- Department of Psychological Sciences, University of Missouri, Columbia, MO 65211, USA
| | | | - Stephanie J Sacharow
- Boston Children's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA 02115, USA
| | - Emily E Abbene
- Department of Psychological Sciences, University of Missouri, Columbia, MO 65211, USA
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5
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Moritz L, Klotz K, Grünert SC, Hannibal L, Spiekerkoetter U. Metabolic phenotyping in phenylketonuria reveals disease clustering independently of metabolic control. Mol Genet Metab 2023; 138:107509. [PMID: 36791482 DOI: 10.1016/j.ymgme.2023.107509] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/17/2023]
Abstract
Phenylketonuria (PKU, MIM #261600) is one of the most common inborn errors of metabolism (IEM) with an incidence of 1:10000 in the European population. PKU is caused by autosomal recessive mutations in phenylalanine hydroxylase (PAH) and manifests with elevation of phenylalanine (Phe) in plasma and urine. Untreated PKU manifests with intellectual disability including seizures, microcephaly and behavioral abnormalities. Early treatment and good compliance result in a normal intellectual outcome in many but not in all patients. This study examined plasma metabolites in patients with PKU (n = 27), hyperphenylalaninemia (HPA, n = 1) and healthy controls (n = 32) by LC- MS/MS. We hypothesized that PKU patients would exhibit a distinct "submetabolome" compared to that of healthy controls. We further hypothesized that the submetabolome of PKU patients with good metabolic control would resemble that of healthy controls. Results from this study show: (i) Distinct clustering of healthy controls and PKU patients based on polar metabolite profiling, (ii) Increased and decreased concentrations of metabolites within and afar from the Phe pathway in treated patients, and (iii) A specific PKU-submetabolome independently of metabolic control assessed by Phe in plasma. We examined the relationship between PKU metabolic control and extended metabolite profiles in plasma. The PKU submetabolome characterized in this study represents the combined effects of dietary adherence, adjustments in metabolic pathways to compensate for defective Phe processing, as well as metabolic derangements that could not be corrected with dietary management even in patients classified as having good metabolic control. New therapeutic targets may be uncovered to approximate the PKU submetabolome to that of healthy controls and prevent long-term organ damage.
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Affiliation(s)
- Lennart Moritz
- Laboratory of Clinical Biochemistry and Metabolism, Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center, University of Freiburg, 79106 Freiburg, Germany; Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Katharina Klotz
- Laboratory of Clinical Biochemistry and Metabolism, Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Sarah Catharina Grünert
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Luciana Hannibal
- Laboratory of Clinical Biochemistry and Metabolism, Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center, University of Freiburg, 79106 Freiburg, Germany.
| | - Ute Spiekerkoetter
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center, University of Freiburg, 79106 Freiburg, Germany.
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6
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Thomas L, Olson A, Romani C. The impact of metabolic control on cognition, neurophysiology, and well-being in PKU: A systematic review and meta-analysis of the within-participant literature. Mol Genet Metab 2023; 138:106969. [PMID: 36599257 DOI: 10.1016/j.ymgme.2022.106969] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022]
Abstract
Phenylketonuria (PKU) is a metabolic disease where Phenylalanine (Phe) rises much above normal levels. Cross-sectional and correlational studies provide valuable information on the importance of maintaining low blood-Phe to achieve good outcomes, but they may be confounded, at least partially, by differences in participant demographics. Moreover, the effect of Phe at older ages is difficult to ascertain because of strong associations between Phe levels across ages. Within-participant studies avoid confounding issues. We have reviewed these studies. We followed PRISMA guidelines to search the literature for studies reporting the impact of Phe changes within participants. Phe was either increased or decreased through diet relaxation/resumption or through pharmacological interventions. Forty-six separate articles reported, singly or in combination, results on cognition (N = 37), well-being (N = 22) and neurophysiological health (N = 14). For all studies, we established, in a binary way, whether a benefit of lower Phe was or was not demonstrated and compared numbers showing benefit versus a null or negative outcome. We then analyzed whether critical parameters (e.g., length of the study/condition for the change, size of Phe change achieved) influenced presence or absence of benefit. For a subset of studies that reported quantitative cognitive outcomes, we carried out a meta-analysis to estimate the size of change in cognitive performance associated with a change in Phe and its significance. There were significantly more studies with benefits than no benefits, both for cognitive and well-being outcomes, and a trend in this direction for neurophysiological outcomes. The meta-analysis showed a highly significant effect size both overall (0.55) and when studies with adults/adolescents were considered separately (0.57). There was some indication that benefits were easier to demonstrate when differences in Phe were larger and achieved across a longer period, but these effects were not always consistent. These results reinforce results from the literature by demonstrating the importance of lower Phe in children as well as in adolescents and adults, even when confounding factors in group composition are eliminated. The field would benefit from further studies where Phe levels are contrasted within-participants to ascertain how much Phe needs to be changed and for how long to see a difference and which measures demonstrate a difference (e.g., which cognitive tasks).
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7
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Romani C, Olson A, Aitkenhead L, Baker L, Patel D, Spronsen FV, MacDonald A, Wegberg AV, Huijbregts S. Meta-analyses of cognitive functions in early-treated adults with phenylketonuria. Neurosci Biobehav Rev 2022; 143:104925. [PMID: 36283539 DOI: 10.1016/j.neubiorev.2022.104925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/07/2022] [Accepted: 10/21/2022] [Indexed: 11/05/2022]
Abstract
Our study estimated size of impairment for different cognitive functions in early-treated adults with PKU (AwPKU) by combining literature results in a meta-analytic way. We analysed a large set of functions (N = 19), each probed by different measures (average = 12). Data were extracted from 26 PKU groups and matched controls, with 757 AwPKU contributing 220 measures. Effect sizes (ESs) were computed using Glass' ∆ where differences in performance between clinical/PKU and control groups are standardized using the mean and standard deviation of the control groups. Significance was assessed using measures nested within independent PKU groups as a random factor. The weighted Glass' ∆ was - 0.44 for all functions taken together, and - 0.60 for IQ, both highly significant. Separate, significant impairments were found for most functions, but with great variability (ESs from -1.02 to -0.18). The most severe impairments were in reasoning, visual-spatial attention speed, sustained attention, visuo-motor control, and flexibility. Effect sizes were larger with speed than accuracy measures, and with visuo-spatial than verbal stimuli. Results show a specific PKU profile that needs consideration when monitoring the disease.
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Affiliation(s)
| | - Andrew Olson
- Psychology Department, University of Birmingham, UK.
| | | | - Lucy Baker
- Psychology Department, Aston University, UK.
| | | | | | - Anita MacDonald
- Birmingham Women' s and Children's NHS Foundation Trust, UK.
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van Vliet K, van Ginkel WG, Jahja R, Daly A, MacDonald A, Santra S, De Laet C, Goyens PJ, Vara R, Rahman Y, Cassiman D, Eyskens F, Timmer C, Mumford N, Gissen P, Bierau J, van Hasselt PM, Wilcox G, Morris AAM, Jameson EA, de la Parra A, Arias C, Garcia MI, Cornejo V, Bosch AM, Hollak CEM, Rubio‐Gozalbo ME, Brouwers MCGJ, Hofstede FC, de Vries MC, Janssen MCH, van der Ploeg AT, Langendonk JG, Huijbregts SCJ, van Spronsen FJ. Neurocognitive outcome and mental health in children with tyrosinemia type 1 and phenylketonuria: A comparison between two genetic disorders affecting the same metabolic pathway. J Inherit Metab Dis 2022; 45:952-962. [PMID: 35722880 PMCID: PMC9540223 DOI: 10.1002/jimd.12528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/23/2022] [Accepted: 06/15/2022] [Indexed: 12/04/2022]
Abstract
Tyrosinemia type 1 (TT1) and phenylketonuria (PKU) are both inborn errors of phenylalanine-tyrosine metabolism. Neurocognitive and behavioral outcomes have always featured in PKU research but received less attention in TT1 research. This study aimed to investigate and compare neurocognitive, behavioral, and social outcomes of treated TT1 and PKU patients. We included 33 TT1 patients (mean age 11.24 years; 16 male), 31 PKU patients (mean age 10.84; 14 male), and 58 age- and gender-matched healthy controls (mean age 10.82 years; 29 male). IQ (Wechsler-subtests), executive functioning (the Behavioral Rating Inventory of Executive Functioning), mental health (the Achenbach-scales), and social functioning (the Social Skills Rating System) were assessed. Results of TT1 patients, PKU patients, and healthy controls were compared using Kruskal-Wallis tests with post-hoc Mann-Whitney U tests. TT1 patients showed a lower IQ and poorer executive functioning, mental health, and social functioning compared to healthy controls and PKU patients. PKU patients did not differ from healthy controls regarding these outcome measures. Relatively poor outcomes for TT1 patients were particularly evident for verbal IQ, BRIEF dimensions "working memory", "plan and organize" and "monitor", ASEBA dimensions "social problems" and "attention problems", and for the SSRS "assertiveness" scale (all p values <0.001). To conclude, TT1 patients showed cognitive impairments on all domains studied, and appeared to be significantly more affected than PKU patients. More attention should be paid to investigating and monitoring neurocognitive outcome in TT1 and research should focus on explaining the underlying pathophysiological mechanism.
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Affiliation(s)
- Kimber van Vliet
- Division of Metabolic DiseasesUniversity of Groningen, University Medical Center Groningen, Beatrix Children's HospitalGroningenThe Netherlands
| | - Willem G. van Ginkel
- Division of Metabolic DiseasesUniversity of Groningen, University Medical Center Groningen, Beatrix Children's HospitalGroningenThe Netherlands
| | - Rianne Jahja
- Division of Metabolic DiseasesUniversity of Groningen, University Medical Center Groningen, Beatrix Children's HospitalGroningenThe Netherlands
| | - Anne Daly
- Birmingham Children's HospitalBirminghamUK
| | | | | | - Corinne De Laet
- Hôpital Universitaire des Enfants Reine FabiolaUniversité Libre de BruxellesBrusselsBelgium
| | - Philippe J. Goyens
- Hôpital Universitaire des Enfants Reine FabiolaUniversité Libre de BruxellesBrusselsBelgium
| | | | | | - David Cassiman
- University Hospital Gasthuisberg, University of LeuvenLeuvenBelgium
| | - Francois Eyskens
- Kon. Mathilde Moeder‐ en KindcentrumUniversity Hospital of AntwerpAntwerpBelgium
| | | | - Nicky Mumford
- NIHR Great Ormond Street Hospital Biomedical Research CentreUniversity College LondonLondonUK
| | - Paul Gissen
- NIHR Great Ormond Street Hospital Biomedical Research CentreUniversity College LondonLondonUK
| | - Jörgen Bierau
- Maastricht University Medical CenterMaastrichtThe Netherlands
| | - Peter M. van Hasselt
- Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Gisela Wilcox
- School of Medical Sciences, Faculty of Biology Medicine & HealthUniversity of ManchesterManchesterUK
- The Mark Holland Metabolic Unit, Salford Royal Foundation NHS TrustSalfordUK
| | - Andrew A. M. Morris
- Willink Metabolic Unit, Manchester Centre for Genomic MedicineManchester University Hospitals NHS Foundation Trust, St Mary's HospitalManchesterUK
| | - Elisabeth A. Jameson
- Willink Metabolic Unit, Manchester Centre for Genomic MedicineManchester University Hospitals NHS Foundation Trust, St Mary's HospitalManchesterUK
| | - Alicia de la Parra
- Laboratory of Genetics and Metabolic Disease (LABGEM), Institute of Nutrition and Food Technology (INTA)University of ChileSantiagoChile
| | - Carolina Arias
- Laboratory of Genetics and Metabolic Disease (LABGEM), Institute of Nutrition and Food Technology (INTA)University of ChileSantiagoChile
| | - Maria I. Garcia
- Laboratory of Genetics and Metabolic Disease (LABGEM), Institute of Nutrition and Food Technology (INTA)University of ChileSantiagoChile
| | - Veronica Cornejo
- Laboratory of Genetics and Metabolic Disease (LABGEM), Institute of Nutrition and Food Technology (INTA)University of ChileSantiagoChile
| | - Annet M. Bosch
- Department of Pediatrics, Division of Metabolic Disorders, Emma Children's Hospital, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Carla E. M. Hollak
- Department of Internal MedicineDivision of Endocrinology and Metabolism, Amsterdam UMC ‐ Location AMCAmsterdamThe Netherlands
| | - M. Estela Rubio‐Gozalbo
- Departments of Pediatrics and Laboratory Genetic Metabolic DiseasesMaastricht University Medical HospitalMaastrichtThe Netherlands
| | - Martijn C. G. J. Brouwers
- Department of Internal Medicine, Division of Endocrinology and Metabolic DiseaseMaastricht University Medical CentreMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
| | - Floris C. Hofstede
- Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | | | | | - Ans T. van der Ploeg
- Departments of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Janneke G. Langendonk
- Department of Internal medicine, Center for Lysosomal and Metabolic Diseases, Erasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Stephan C. J. Huijbregts
- University of Leiden, Clinical Child and Adolescent Studies: Neurodevelopmental DisordersLeidenThe Netherlands
| | - Francjan J. van Spronsen
- Division of Metabolic DiseasesUniversity of Groningen, University Medical Center Groningen, Beatrix Children's HospitalGroningenThe Netherlands
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9
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Liemburg GB, Huijbregts SCJ, Rutsch F, Feldmann R, Jahja R, Weglage J, Och U, Burgerhof JGM, van Spronsen FJ. Metabolic control during the neonatal period in phenylketonuria: associations with childhood IQ. Pediatr Res 2022; 91:874-878. [PMID: 34497359 DOI: 10.1038/s41390-021-01728-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/13/2021] [Accepted: 07/09/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND In phenylketonuria, treatment and subsequent lowering of phenylalanine levels usually occur within the first month of life. This study investigated whether different indicators of metabolic control during the neonatal period were associated with IQ during late childhood/early adolescence. METHODS Overall phenylalanine concentration during the first month of life (total "area under the curve"), proportion of phenylalanine concentrations above upper target level (360 μmol/L) and proportion below lower target level (120 μmol/L) during this period, diagnostic phenylalanine levels, number of days until phenylalanine levels were <360 μmol/L, and lifetime and concurrent phenylalanine levels were correlated with IQ scores of 64 PKU patients (mean age 10.8 years, SD 2.9). RESULTS Overall phenylalanine concentration and proportion of phenylalanine concentrations >360 μmol/L during the first month of life negatively correlated with IQ in late childhood/early adolescence. Separately, phenylalanine concentrations during different periods within the first month of life (0-10 days, 11-20 days, 21-30 days) were negatively correlated with later IQ as well, but correlation strengths did not differ significantly. No further significant associations were found. CONCLUSIONS In phenylketonuria, achievement of target-range phenylalanine levels during the neonatal period is important for cognition later in life, also when compared to other indicators of metabolic control. IMPACT In phenylketonuria, it remains unclear during which age periods or developmental stages metabolic control is most important for later cognitive outcomes. Phenylalanine levels during the neonatal period were clearly and negatively related to later IQ, whereas no significant associations were observed for other indices of metabolic control. This emphasizes the relative importance of this period for cognitive development in phenylketonuria. No further distinctions were observed in strength of associations with later IQ between different indicators of metabolic control during the neonatal period. Thus, achievement of good metabolic control within 1 month after birth appears "safe" with respect to later cognitive outcomes.
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Affiliation(s)
- Geertje B Liemburg
- Division of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Stephan C J Huijbregts
- Department of Clinical Child and Adolescent Studies/Leiden Institute for Brain and Cognition, Leiden University, Leiden, The Netherlands.
| | - Frank Rutsch
- Department of Pediatrics, Münster University, University Children's Hospital, Münster, Germany
| | - Reinhold Feldmann
- Department of Pediatrics, Münster University, University Children's Hospital, Münster, Germany
| | - Rianne Jahja
- Division of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Josef Weglage
- Department of Pediatrics, Münster University, University Children's Hospital, Münster, Germany
| | - Ulrike Och
- Department of Pediatrics, Münster University, University Children's Hospital, Münster, Germany
| | - Johannes G M Burgerhof
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Francjan J van Spronsen
- Division of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Santos BBD, Oliveira BMD, Monteiro VCL, Poloni S, Tonon T, Schwartz IVD. Brazilian Food Reference Guide for Phenylalanine Content: A Study Based on the Perception of PKU Patients and Health Providers. JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2022. [DOI: 10.1590/2326-4594-jiems-2022-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
| | | | | | | | | | - Ida V. D. Schwartz
- Universidade Federal do Rio Grande do Sul, Brazil; Hospital de Clínicas de Porto Alegre, Brazil; Universidade Federal do Rio Grande do Sul, Brazil; Hospital de Clínicas de Porto Alegre, Brazil
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11
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Bilder DA, Arnold GL, Dimmock D, Grant ML, Janzen D, Longo N, Nguyen-Driver M, Jurecki E, Merilainen M, Amato G, Waisbren S. Improved attention linked to sustained phenylalanine reduction in adults with early-treated phenylketonuria. Am J Med Genet A 2021; 188:768-778. [PMID: 34826353 PMCID: PMC9299696 DOI: 10.1002/ajmg.a.62574] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/22/2021] [Accepted: 10/29/2021] [Indexed: 12/03/2022]
Abstract
Pegvaliase is approved to reduce phenylalanine (Phe) levels for people with phenylketonuria (PKU). PRISM‐1 (NCT01819727) and PRISM‐2 (NCT01889862) data were analyzed to evaluate the relationship between Phe and inattention in adult participants with PKU. In the modified‐intent‐to‐treat population (N = 156), baseline mean (SE) plasma Phe was 1263 (29) μmol/L and the Attention Deficit Hyperactivity Disorder Rating Scale‐IV Inattentive (IA) symptoms score was 9.8 (0.5). Mean (SE) IA scores fell 9.0 (1.1) in Quartile 1 (Phe reduction between 1166 and 2229 μmol/L) versus 4.3 (0.7) in Quartile 4 (Phe reduction of 139 μmol/L to increase of 934 μmol/L), p = 0.004. Least squares mean (SE) change from baseline IA score was −7.9 (0.7) for participants with final Phe ≤ 360 μmol/L and −4.5 (0.7) for final Phe > 360 μmol/L, p < 0.001. In the inattention subgroup, IA scores fell 13.3 (1.5) in Quartile 1 (Phe reduction between 1288 and 2229 μmol/L) versus 6.2 (1.3) in Quartile 4 (Phe reduction of 247 to increase of 934 μmol/L), p = 0.009. Inattention symptoms improved among those whose Phe levels decreased, particularly those with high baseline IA scores. IA improvements were larger among participants with the greatest plasma Phe reductions, supporting this value as a therapeutic goal.
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Affiliation(s)
- Deborah A Bilder
- Department of Psychiatry, Division of Child & Adolescent Psychiatry, University of Utah Huntsman Mental Health Institute, Salt Lake City, Utah, USA
| | - Georgianne L Arnold
- Department of Genetics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David Dimmock
- Rady Children's Institute for Genomic Medicine, San Diego, California, USA
| | - Mitzie L Grant
- Department of Academic Psychiatry, Drexel University College of Medicine and St. Christopher's Hospital for Children, Philadelphia, Pennsylvania, USA
| | - Darren Janzen
- Department of Pediatrics, Division of Pediatric Psychology, Oregon Health & Science University, Portland, Oregon, USA
| | - Nicola Longo
- Department of Pediatrics, Division of Medical Genetics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Mina Nguyen-Driver
- Department of Pediatrics, Division of Pediatric Psychology, Oregon Health & Science University, Portland, Oregon, USA
| | | | | | - Gianni Amato
- BioMarin Pharmaceutical Inc., Novato, California, USA.,Biostats LLC, San Francisco, California, USA
| | - Susan Waisbren
- Department of Medicine, Division of Genetics and Genomics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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12
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Zaguri D, Zimmermann MR, Meisl G, Levin A, Rencus-Lazar S, Knowles TPJ, Gazit E. Kinetic and Thermodynamic Driving Factors in the Assembly of Phenylalanine-Based Modules. ACS NANO 2021; 15:18305-18311. [PMID: 34694771 DOI: 10.1021/acsnano.1c07537] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The formation of ordered protein and peptide assemblies is a phenomenon related to a wide range of human diseases. However, the mechanism of assembly at the molecular level remains largely unknown. Minimal models enable the exploration of the underlying interactions that are at the core of such self-assembly processes. In particular, the ability of phenylalanine, a single aromatic amino acid, to form an amyloid-like structure has challenged the previous dogma viewing a peptide backbone as a prerequisite for assembly. The driving forces controlling the nucleation and assembly in the absence of a peptide backbone remain to be identified. Here, aiming to unravel these forces, we explored the kinetics and thermodynamics of three phenylalanine-containing molecules during their assembly process: the amino acid phenylalanine, which accumulates in phenylketonuria patients, the diphenylalanine core-motif of the amyloid β peptide related to Alzheimer's disease, and the extended triphenylalanine peptide which forms a range of distinct nanostructures in vitro. We found that the aggregation propensity, regarding the critical monomer concentration, strongly increases with size, with triphenylalanine being the most aggregation-prone species under our experimental conditions. In the context of classical nucleation theory, this increase in aggregation propensity can be attributed to the larger free energy decrease upon aggregation of larger peptides and is not due to the presence/absence of a peptide bond per se. Taken together, this work provides insights into the aggregation processes of chemically simple systems and suggests that both backbone-containing peptides and backbone-lacking amino acids assemble through a similar mechanism, thus supporting the classification of amino acids in the continuum of amyloid-forming building blocks.
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Affiliation(s)
- Dor Zaguri
- The Shmunis School of Biomedicine and Cancer Research, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Manuela R Zimmermann
- Yusuf Hamied Department of Chemistry, University of Cambridge, Cambridge CB2 1EW, United Kingdom
| | - Georg Meisl
- Yusuf Hamied Department of Chemistry, University of Cambridge, Cambridge CB2 1EW, United Kingdom
| | - Aviad Levin
- Yusuf Hamied Department of Chemistry, University of Cambridge, Cambridge CB2 1EW, United Kingdom
| | - Sigal Rencus-Lazar
- The Shmunis School of Biomedicine and Cancer Research, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Tuomas P J Knowles
- Yusuf Hamied Department of Chemistry, University of Cambridge, Cambridge CB2 1EW, United Kingdom
- Cavendish Laboratory, University of Cambridge, Cambridge CB3 0HE, United Kingdom
| | - Ehud Gazit
- The Shmunis School of Biomedicine and Cancer Research, Tel Aviv University, Tel Aviv 6997801, Israel
- BLAVATNIK CENTER for Drug Discovery for Drug Discovery, Tel Aviv University, Tel Aviv 6997801, Israel
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13
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Aitkenhead L, Krishna G, Ellerton C, Moinuddin M, Matcham J, Shiel L, Hossain S, Kiffin M, Foley J, Skeath R, Cleary M, Lachmann R, Murphy E. Long-term cognitive and psychosocial outcomes in adults with phenylketonuria. J Inherit Metab Dis 2021; 44:1353-1368. [PMID: 34145605 DOI: 10.1002/jimd.12413] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 05/31/2021] [Accepted: 06/16/2021] [Indexed: 12/22/2022]
Abstract
Previous studies have suggested that cognitive and psychosocial underfunctioning in early-treated adults with phenylketonuria (PKU) may be explained by suboptimal adherence to dietary treatments, however, these studies often employ small samples, with different outcome measures, definitions and cut-offs. Samples have also tended to comprise participants with a limited range of blood phenylalanine concentrations, and often individuals who may not have been treated early enough to avoid neurological damage. In this study, we explore the impact of lifetime dietary control, as indicated by blood phenylalanine concentrations in childhood, adolescence and adulthood, on long-term cognitive and psychosocial outcomes in a large sample of adults with PKU who were diagnosed by neonatal screening and commenced on dietary treatment within the first month of life. One hundred and fifty-four participants underwent cognitive testing, assessing attention, learning, working memory, language, executive functioning and processing speed. One hundred and forty-nine completed measures of psychosocial functioning, documenting educational, occupational, quality of life, emotional and social outcomes which were compared with a group of healthy controls. Many adults with PKU demonstrated cognitive impairments, most frequently affecting processing speed (23%), executive function (20%) and learning (12%). Cognitive outcomes were related to measures of historic metabolic control, but only processing speed was significantly related to phenylalanine concentration at the time of testing after controlling for historic levels. Adults with PKU did not, however, differ from controls in educational, occupational, quality of life or emotional outcomes, or on a measure of family functioning, and showed only minor differences in relationship style. These findings have implications for patient counselling and decisions regarding the management of PKU in adulthood.
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Affiliation(s)
- Lynne Aitkenhead
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
- UCL Institute of Neurology, London, UK
| | - Gauri Krishna
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Charlotte Ellerton
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Md Moinuddin
- UCL Institute of Child Health, London, UK
- Faculty of Health, Social Care & Medicine, Edge Hill University, Ormskirk, UK
| | - Jessica Matcham
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Lisha Shiel
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Shasoty Hossain
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Marianne Kiffin
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Jennifer Foley
- UCL Institute of Neurology, London, UK
- Department of Neuropsychology, National Hospital of Neurology & Neurosurgery, London, UK
| | - Rachel Skeath
- Department of Metabolic Medicine, Great Ormond Street Hospital, London, UK
| | - Maureen Cleary
- Department of Metabolic Medicine, Great Ormond Street Hospital, London, UK
- Great Ormond Street Hospital NIHR Biomedical Research Centre, London, UK
| | - Robin Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
- UCL Institute of Neurology, London, UK
| | - Elaine Murphy
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
- UCL Institute of Neurology, London, UK
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14
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Cognitive Outcomes and Relationships with Phenylalanine in Phenylketonuria: A Comparison between Italian and English Adult Samples. Nutrients 2020; 12:nu12103033. [PMID: 33022955 PMCID: PMC7599948 DOI: 10.3390/nu12103033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/23/2020] [Accepted: 09/24/2020] [Indexed: 02/06/2023] Open
Abstract
We aimed to assess if the same cognitive batteries can be used cross-nationally to monitor the effect of Phenylketonuria (PKU). We assessed whether a battery, previously used with English adults with PKU (AwPKU), was also sensitive to impairments in Italian AwPKU. From our original battery, we selected a number of tasks that comprehensively assessed visual attention, visuo-motor coordination, executive functions (particularly, reasoning, planning, and monitoring), sustained attention, and verbal and visual memory and learning. When verbal stimuli/or responses were involved, stimuli were closely matched between the two languages for psycholinguistic variables. We administered the tasks to 19 Italian AwPKU and 19 Italian matched controls and compared results from with 19 English AwPKU and 19 English matched controls selected from a previously tested cohort. Participant election was blind to cognitive performance and metabolic control, but participants were closely matched for age and education. The Italian AwPKU group had slightly worse metabolic control but showed levels of performance and patterns of impairment similar to the English AwPKU group. The Italian results also showed extensive correlations between adult cognitive measures and metabolic measures across the life span, both in terms of Phenylalanine (Phe) levels and Phe fluctuations, replicating previous results in English. These results suggest that batteries with the same and/or matched tasks can be used to assess cognitive outcomes across countries allowing results to be compared and accrued. Future studies should explore potential differences in metabolic control across countries to understand what variables make metabolic control easier to achieve.
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15
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Martins AM, Pessoa ALS, Quesada AA, Ribeiro EM. Unmet needs in PKU and the disease impact on the day-to-day lives in Brazil: Results from a survey with 228 patients and their caregivers. Mol Genet Metab Rep 2020; 24:100624. [PMID: 32742934 PMCID: PMC7387838 DOI: 10.1016/j.ymgmr.2020.100624] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/26/2020] [Accepted: 06/27/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Accumulation of phenylalanine (Phe) due to deficiency in the enzyme phenylalanine hydroxylase (PAH), responsible for the conversion of Phe into tyrosine leads to Phenylketonuria (PKU), a rare autosomal recessive inborn error of metabolism with a mean prevalence of approximately 1:10,000 to 1:15,000 newborns. Physical, neurocognitive and psychiatric symptoms include neurodevelopmental disorder as intellectual disability and autism spectrum disorder. The most common treatments such as low-Phe diet and supplements may decrease blood Phe concentrations, but neuropsychological, behavioral and social issues still occur in some patients. This study aimed to better understand (i) the Brazilian population's knowledge about newborn screening (NBS), the main diagnostic method for PKU, as well as (ii) the impacts of phenylketonuria in the daily lives of patients and parents. METHODS Two surveys in Real World Data format gathering of Brazilian residents by online questionnaires with (i) 1000 parents of children up to 5 years old between March and April 2019; (ii) 228 PKU patients and caregivers in March 2019. The survey was conducted in partnership with Abril Publisher and two Brazilian patient associations: Metabolic Mothers and SAFE Brasil, for families with rare diseases and PKU patients, respectively. RESULTS The first questionnaire shows that 93% of parents recognize the importance of NBS and 92% report that their children have undergone the test. Still, two out of ten participants did not know what the exam is or what it is for. From the second questionnaire nine out of ten patients had their PKU diagnosis by NBS. Although strict dietary controls for PKU were claimed by 44% of respondents from second questionnaire, 55% assume not following all nutritionist recommendations and 52% did not maintain routinely Phe control levels. In addition, 53% said they had high spending on medical appointments, therapies and purchase of special foods. CONCLUSIONS Despite the lack of understanding, the awareness of NBS importance is present in the studied population. The early diagnosis of most PKU patients in the study corroborates with neonatal screening central role of PKU early detection. The difficulty in adhering to dietary adjustments and the possibility that current and new therapeutic strategies other than diet could be determinant to achieve the recommended Phe levels.
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Affiliation(s)
- Ana Maria Martins
- Reference Center in Inborn Errors of Metabolism, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Andre Luiz Santos Pessoa
- Albert Sabin Children's Hospital, Fortaleza, Ceará, Brazil
- State University of Ceará (UECE), Fortaleza, Ceará, Brazil
| | | | - Erlane Marques Ribeiro
- Albert Sabin Children's Hospital, Fortaleza, Ceará, Brazil
- Christus University Center Medical School, Fortaleza, Brazil
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16
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Hopf S, Nowak C, Hennermann JB, Schmidtmann I, Pfeiffer N, Pitz S. Saccadic reaction time and ocular findings in phenylketonuria. Orphanet J Rare Dis 2020; 15:124. [PMID: 32450880 PMCID: PMC7249436 DOI: 10.1186/s13023-020-01407-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 05/11/2020] [Indexed: 01/12/2023] Open
Abstract
Background Phenylketonuria (PKU) is an inherited metabolic disorder characterized by reduced activity of phenylalanine hydroxylase resulting in elevated blood phenylalanine (Phe) concentration. Despite some obvious ocular changes, the disorder has been poorly recognized by ophthalmologists. Neurophysiologic tests imply prolonged reaction time correlating with increased phenylalanine blood concentrations. We aimed to test saccadic reaction time in PKU patients in dependency of blood phenylalanine concentrations. Methods Nineteen biochemically diagnosed PKU patients and 100 controls completed comprehensive ophthalmologic and orthoptic examinations including saccadometry by infrared based video-oculography. Peak velocity, gain, and particularly latency of reflexive saccades were compared to controls, and regression analysis was performed. Results Latency of reflexive saccades was not associated with the current phenylalanine concentration. Although in 10 out of 19 patients phenylalanine concentrations were outside the age-related therapeutic range, latency differed little between PKU patients and the controls, as well as peak velocity and gain. Ocular findings occurred as partial hypopigmentation of the iris in one late diagnosed patient aged 36 years, and as bilateral cataracts (possibly due to steroid intake) with refractive amblyopia, strabismus, high myopia, and glaucoma in another late diagnosed patient aged 46 years. Visual acuity was reduced in eight PKU patients. Conclusions Saccadometry, particularly saccadic reaction time, is not useful in the monitoring of phenylketonuria. Ophthalmic examination is recommended in PKU patients, as the occurrence of ocular pathologies was relatively high.
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Affiliation(s)
- Susanne Hopf
- Department of Ophthalmology, University Medical Center Mainz, Langenbeckstr 1, 55131, Mainz, Germany.
| | | | - Julia B Hennermann
- Villa Metabolica, Department of Pediatric and Adolescent Medicine, University Medical Center Mainz, Mainz, Germany
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center Mainz, Mainz, Germany
| | - Norbert Pfeiffer
- Department of Ophthalmology, University Medical Center Mainz, Langenbeckstr 1, 55131, Mainz, Germany
| | - Susanne Pitz
- Department of Ophthalmology, University Medical Center Mainz, Langenbeckstr 1, 55131, Mainz, Germany.,Orbital Center, Ophthalmic Clinic, Bürgerhospital Frankfurt, Frankfurt, Germany
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17
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Ferreira BK, Rodrigues MT, Streck EL, Ferreira GC, Schuck PF. White matter disturbances in phenylketonuria: Possible underlying mechanisms. J Neurosci Res 2020; 99:349-360. [PMID: 32141105 DOI: 10.1002/jnr.24598] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/09/2020] [Accepted: 02/04/2020] [Indexed: 12/24/2022]
Abstract
White matter pathologies, as well as intellectual disability, microcephaly, and other central nervous system injuries, are clinical traits commonly ascribed to classic phenylketonuria (PKU). PKU is an inherited metabolic disease elicited by the deficiency of phenylalanine hydroxylase. Accumulation of l-phenylalanine (Phe) and its metabolites is found in tissues and body fluids in phenylketonuric patients. In order to mitigate the clinical findings, rigorous dietary Phe restriction constitutes the core of therapeutic management in PKU. Myelination is the process whereby the oligodendrocytes wrap myelin sheaths around the axons, supporting the conduction of action potentials. White matter injuries are implicated in the brain damage related to PKU, especially in untreated or poorly treated patients. The present review summarizes evidence toward putative mechanisms driving the white matter pathology in PKU patients.
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Affiliation(s)
- Bruna Klippel Ferreira
- Laboratório de Neuroenergética e Erros Inatos do Metabolismo, Programa de Bioquímica e Biofísica Celular, Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Porto Alegre, Brazil
| | - Melissa Torres Rodrigues
- Laboratório de Erros Inatos do Metabolismo, Escola de Ciências da Saúde e da Vida, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil.,Programa de Pós-graduação em Biologia Celular e Molecular, Escola de Ciências da Saúde e da Vida, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Emilio Luiz Streck
- Laboratório de Neurologia Experimental, Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, Brazil
| | - Gustavo Costa Ferreira
- Laboratório de Neuroenergética e Erros Inatos do Metabolismo, Programa de Bioquímica e Biofísica Celular, Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Porto Alegre, Brazil
| | - Patricia Fernanda Schuck
- Laboratório de Erros Inatos do Metabolismo, Escola de Ciências da Saúde e da Vida, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil.,Programa de Pós-graduação em Biologia Celular e Molecular, Escola de Ciências da Saúde e da Vida, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
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18
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Palermo L, MacDonald A, Limback E, Robertson L, Howe S, Geberhiwot T, Romani C. Emotional health in early-treated adults with phenylketonuria (PKU): Relationship with cognitive abilities and blood phenylalanine. J Clin Exp Neuropsychol 2019; 42:142-159. [DOI: 10.1080/13803395.2019.1696753] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Liana Palermo
- School of Life and Health Sciences, Aston University, Birmingham, UK
- Inherited Metabolic Disorders Service, Queen Elizabeth Hospital, Birmingham, UK
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Anita MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Birmingham, UK
| | - Ellie Limback
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Louise Robertson
- Inherited Metabolic Disorders Service, Queen Elizabeth Hospital, Birmingham, UK
| | - Sarah Howe
- Inherited Metabolic Disorders Service, Queen Elizabeth Hospital, Birmingham, UK
| | - Tarekegn Geberhiwot
- Inherited Metabolic Disorders Service, Queen Elizabeth Hospital, Birmingham, UK
| | - Cristina Romani
- School of Life and Health Sciences, Aston University, Birmingham, UK
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19
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Romani C, Manti F, Nardecchia F, Valentini F, Fallarino N, Carducci C, De Leo S, MacDonald A, Palermo L, Leuzzi V. Adult cognitive outcomes in phenylketonuria: explaining causes of variability beyond average Phe levels. Orphanet J Rare Dis 2019; 14:273. [PMID: 31779649 PMCID: PMC6883518 DOI: 10.1186/s13023-019-1225-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022] Open
Abstract
Objective The objective was to deepen the understanding of the causes of individual variability in phenylketonuria (PKU) by investigating which metabolic variables are most important for predicting cognitive outcomes (Phe average vs Phe variation) and by assessing the risk of cognitive impairment associated with adopting a more relaxed approach to the diet than is currently recommended. Method We analysed associations between metabolic and cognitive measures in a mixed sample of English and Italian early-treated adults with PKU (N = 56). Metabolic measures were collected through childhood, adolescence and adulthood; cognitive measures were collected in adulthood. Metabolic measures included average Phe levels (average of median values for each year in a given period) and average Phe variations (average yearly standard deviations). Cognition was measured with IQ and a battery of cognitive tasks. Results Phe variation was as important, if not more important, than Phe average in predicting adult outcomes and contributed independently. Phe variation was particularly detrimental in childhood. Together, childhood Phe variation and adult Phe average predicted around 40% of the variation in cognitive scores. Poor cognitive scores (> 1 SD from controls) occurred almost exclusively in individuals with poor metabolic control and the risk of poor scores was about 30% higher in individuals with Phe values exceeding recommended thresholds. Conclusions Our results provide support for current European guidelines (average Phe value = < 360 μmol/l in childhood; = < 600 μmo/l from 12 years onwards), but they suggest an additional recommendation to maintain stable levels (possibly Phe SD = < 180 μmol/l throughout life). Public significance statements We investigated the relationship between how well people with phenylketonuria control blood Phe throughout their life and their ability to carry out cognitive tasks in adulthood. We found that avoiding blood Phe peaks was as important if not more important that maintaining average low Phe levels. This was particularly essential in childhood. We also found that blood Phe levels above recommended European guidelines was associated with around 30% increase in the risk of poor cognitive outcomes.
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Affiliation(s)
- Cristina Romani
- School of Life and Health Sciences, Aston University, Aston Triangle, Birmingham, England, B4 7ET, UK.
| | - Filippo Manti
- Department of Human Neuroscience - Unit of Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Francesca Nardecchia
- Department of Human Neuroscience - Unit of Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | | | | | - Claudia Carducci
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Sabrina De Leo
- Department of Clinical Medicine, Policlinico Umberto I, Rome, Italy
| | - Anita MacDonald
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Liana Palermo
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Vincenzo Leuzzi
- Department of Human Neuroscience - Unit of Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
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20
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Askarizadeh A, Khatami S, Rouhi Dehnabeh S. The Comparison of Iodine-Type and MnO2-Type Oxidation for Measuring the Levels of Urine Neopterin and Biopterin in Patients with Hyperphenylalaninemia: A Descriptive-Analytic Study in Iran. Indian J Clin Biochem 2019; 34:436-443. [DOI: 10.1007/s12291-018-0777-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 07/05/2018] [Indexed: 10/28/2022]
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21
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Leuzzi V, Chiarotti F, Nardecchia F, van Vliet D, van Spronsen FJ. Predictability and inconsistencies of cognitive outcome in patients with phenylketonuria and personalised therapy: the challenge for the future guidelines. J Med Genet 2019; 57:145-150. [DOI: 10.1136/jmedgenet-2019-106278] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/06/2019] [Accepted: 08/11/2019] [Indexed: 11/04/2022]
Abstract
Phenylketonuria (PKU) is a prototypical model of a neurodevelopmental metabolic disease that follows a cascade of pathological events affecting brain maturation and functioning. Neonatal screening and early treatment have eradicated the classical PKU phenotype in patients with early and continuously treated phenylketonuria (ECTPKU). However, effort is required to optimise the treatment of the disease to minimise the risk of lifelong neurological, cognitive and behavioural impairment, and to solve issues on the variability in clinical outcome that are rather not understood and has yet hampered a more personalised approach to its treatment. The aim of the present review is to focus on the inconsistencies in the clinical outcome of adult patients with ECTPKU unexplained by the biochemical markers adopted for the monitoring of the disease to date. The interindividual variability of clinical outcome in late as well as in early treated patients under similar biochemical control suggests the existence of disease-independent determinants influencing the individual vulnerability to the neurotoxic effect of phenylalanine. This is further supported by the low predictive power of blood phenylalanine on the clinical outcome from the second decade of life onwards. In conclusion, individual vulnerability to the metabolic alterations of PKU contributes to the prognosis of PKU, also in patients with ECTPKU. The biological factors constitutive of this vulnerability are unknown (but have not been the object of many studies so far) and should be the target of further research as prerequisite for a personalised treatment aimed at avoiding burden and costs of overtreatment and clinical consequences and risks of undertreatment in patients with PKU.
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22
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Abstract
This is an introduction to the special issue on cognitive impairments in inherited metabolic diseases (IMD). It provides an overview of the studies included, focusing on the possibility of selective impairments which could provide unique evidence on the specificity of neural circuitries mediating cognitive functions. It will suggest that these circuitries have different metabolic properties which make them especially apt to carry out certain functions, but also particularly susceptible to certain forms of metabolic disruption. Knowledge of selective impairments is also crucial to properly evaluate the difficulties engendered by individual diseases and track treatment outcomes. IMR research holds the promise of a more complete understanding of cognition, from cellular functioning to behaviour and of further improvements in treatment. Advances, however, will require detailed assessments, comparisons across diseases, and the integration of different levels of explanation. This will be possible only through close collaborations between centres and types of professionals.
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Affiliation(s)
- Cristina Romani
- a School of Life and Health Sciences, Aston University , Birmingham , UK
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23
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Bartus A, Palasti F, Juhasz E, Kiss E, Simonova E, Sumanszki C, Reismann P. The influence of blood phenylalanine levels on neurocognitive function in adult PKU patients. Metab Brain Dis 2018; 33:1609-1615. [PMID: 29948654 DOI: 10.1007/s11011-018-0267-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 06/06/2018] [Indexed: 10/14/2022]
Abstract
It is well known that hyperphenylalaninemia caused by phenylketonuria (PKU) negatively influences cognitive performance. Several tests have been used to study these functions. Until now, no universal, optimal tool has been developed for detecting PKU-caused brain dysfunctions. Using computerized neuropsychological tests during daily routine would be helpful for screening subclinical brain deficits in adult PKU patients. In a monocentric, cross-sectional study, adult patients with PKU (n = 46; median age = 29.5 years; female/male ratio = 21/25) were tested with the computerized Cambridge Cognition (CANTAB) test measuring neurocognitive functions. Patients were divided into two groups: The "on diet" group included patients whose blood Phe-level was under 600 μmol/l (n = 20), and the "loose diet" group included patients whose blood Phe-level was above 600 μmol/l (n = 26) at the examination time. The results of the PKU-affected individuals were compared with a healthy control group (n = 31; median age = 25 years; female/male ratio = 11/20). Compared with the control group, PKU patients had significantly worse test results in memory, problem-solving skills, and strategy. However, there were no significant differences in response speed or initial thinking time. There was no correlation between the blood Phe-level, tyrosine (Tyr)-level or Phe/Tyr ratio and the different cognitive test results. There were no significant differences in test results between the two PKU subgroups. Several cognitive functions measured by CANTAB are negatively influenced by hyperphenylalaninemia in adult PKU patients. However, response speed and initial thinking time were not impaired as seriously as other functions. Patients with lower Phe-levels failed to achieve better test results than patients whose Phe-levels were notably elevated.
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Affiliation(s)
- A Bartus
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi Street 46, Budapest, H-1088, Hungary
| | - F Palasti
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi Street 46, Budapest, H-1088, Hungary
| | - E Juhasz
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi Street 46, Budapest, H-1088, Hungary
| | - E Kiss
- 1st Department of Pediatrics, Semmelweis University, Bókay János u. 53-54, Budapest, H-1083, Hungary
| | - E Simonova
- 1st Department of Pediatrics, Semmelweis University, Bókay János u. 53-54, Budapest, H-1083, Hungary
| | - Cs Sumanszki
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi Street 46, Budapest, H-1088, Hungary
| | - P Reismann
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi Street 46, Budapest, H-1088, Hungary.
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Hofman DL, Champ CL, Lawton CL, Henderson M, Dye L. A systematic review of cognitive functioning in early treated adults with phenylketonuria. Orphanet J Rare Dis 2018; 13:150. [PMID: 30165883 PMCID: PMC6117942 DOI: 10.1186/s13023-018-0893-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 08/16/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Even though early dietary management of phenylketonuria (PKU) successfully prevents severe neurological impairments, deficits in cognitive functioning are still observed. These deficits are believed to be the result of elevated levels of phenylalanine throughout life. Research on cognitive functioning in adults with PKU (AwPKU) often focuses on domains shown to be compromised in children with PKU, such as attention and executive functions, whereas other cognitive domains have received less attention. This systematic review aimed to provide an overview of cognitive functioning across domains examined in early treated (ET) AwPKU. METHODS A systematic search was performed in Ovid MEDLINE(R), PsycINFO, Web of Science, Cochrane, Scopus, Embase, ScienceDirect, and PubMed for observational studies on cognitive performance in ET AwPKU. RESULTS Twenty-two peer-reviewed publications, reporting on outcomes from 16 studies were reviewed. Collectively, the results most consistently showed deficits in vigilance, working memory and motor skills. Deficits in other cognitive domains were less consistently observed or were understudied. Furthermore, despite reports of several associations between cognitive performance and phenylalanine (Phe) levels throughout life the relationship remains unclear. Inconsistencies in findings across studies could be explained by the highly heterogeneous nature of study samples, resulting in large inter- and intra-variability in Phe levels, as well as the use of a variety of tests across cognitive domains, which differ in sensitivity. The long-term cognitive outcomes of early and continuous management of PKU remain unclear. CONCLUSIONS To better understand the development of cognitive deficits in ET AwPKU, future research would benefit from 1) (inter)national multicentre-studies; 2) more homogeneous study samples; 3) the inclusion of other nutritional measures that might influence cognitive functioning (e.g. Phe fluctuations, Phe:Tyrosine ratio and micronutrients such as vitamin B12); and 4) careful selection of appropriate cognitive tests.
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Affiliation(s)
| | | | | | - Mick Henderson
- Biochemical Genetics, Specialist Laboratory Medicine, St James’s University Hospital, Block 46, Leeds, LS9 7TF UK
| | - Louise Dye
- School of Psychology, University of Leeds, Leeds, LS2 9JT UK
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25
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Montoya Parra GA, Singh RH, Cetinyurek-Yavuz A, Kuhn M, MacDonald A. Status of nutrients important in brain function in phenylketonuria: a systematic review and meta-analysis. Orphanet J Rare Dis 2018; 13:101. [PMID: 29941009 PMCID: PMC6020171 DOI: 10.1186/s13023-018-0839-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 06/05/2018] [Indexed: 01/08/2023] Open
Abstract
Background Despite early and ongoing dietary management with a phe-restricted diet, suboptimal neuropsychological function has been observed in PKU. The restrictive nature of the PKU diet may expose patients to sub-optimal nutritional intake and deficiencies which may impact normal brain function. A systematic review of the published literature was carried out, where possible with meta-analysis, to compare the status of nutrients (Nutrients: DHA, EPA phospholipids, selenium, vitamins B6, B12, E, C, A, D, folic acid, choline, uridine, calcium, magnesium, zinc, iron, iodine and cholesterol) known to be important for brain development and functioning between individuals with PKU and healthy controls. Results Of 1534 publications identified, 65 studies met the entry criteria. Significantly lower levels of DHA, EPA and cholesterol were found for PKU patients compared to healthy controls. No significant differences in zinc, vitamins B12, E and D, calcium, iron and magnesium were found between PKU patients and controls. Because of considerable heterogeneity, the meta-analyses findings for folate and selenium were not reported. Due to an insufficient number of publications (< 4) no meta-analysis was undertaken for vitamins A, C and B6, choline, uridine, iodine and phospholipids. Conclusions The current data show that PKU patients have lower availability of DHA, EPA and cholesterol. Compliance with the phe-restricted diet including the micronutrient fortified protein substitute (PS) is essential to ensure adequate micronutrient status. Given the complexity of the diet, patients’ micronutrient and fatty acid status should be continuously monitored, with a particular focus on patients who are non-compliant or poorly compliant with their PS. Given their key role in brain function, assessment of the status of nutrients where limited data was found (e.g. choline, iodine) should be undertaken. Standardised reporting of studies in PKU would strengthen the output of meta-analysis and so better inform best practice for this rare condition. Electronic supplementary material The online version of this article (10.1186/s13023-018-0839-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gina A Montoya Parra
- Danone Nutricia Research, Nutricia Advanced Medical Nutrition, Utrecht, The Netherlands.
| | - Rani H Singh
- Metabolic Genetics and Nutrition Program, Emory University, Atlanta, GA, USA
| | | | - Mirjam Kuhn
- Danone Nutricia Research, Nutricia Advanced Medical Nutrition, Utrecht, The Netherlands
| | - Anita MacDonald
- Department of Metabolic Diseases, Birmingham Children's Hospital, Birmingham, UK
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26
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De Felice S, Romani C, Geberhiwot T, MacDonald A, Palermo L. Language processing and executive functions in early treated adults with phenylketonuria (PKU). Cogn Neuropsychol 2018; 35:148-170. [DOI: 10.1080/02643294.2017.1422709] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Sara De Felice
- School of Life and Health Sciences, Aston University, Birmingham, UK
- IMD Department, Queen Elizabeth Hospital, Birmingham, UK
| | - Cristina Romani
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | | | - Anita MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Birmingham, UK
| | - Liana Palermo
- School of Life and Health Sciences, Aston University, Birmingham, UK
- IMD Department, Queen Elizabeth Hospital, Birmingham, UK
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
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27
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van Wegberg AMJ, MacDonald A, Ahring K, Bélanger-Quintana A, Blau N, Bosch AM, Burlina A, Campistol J, Feillet F, Giżewska M, Huijbregts SC, Kearney S, Leuzzi V, Maillot F, Muntau AC, van Rijn M, Trefz F, Walter JH, van Spronsen FJ. The complete European guidelines on phenylketonuria: diagnosis and treatment. Orphanet J Rare Dis 2017; 12:162. [PMID: 29025426 PMCID: PMC5639803 DOI: 10.1186/s13023-017-0685-2] [Citation(s) in RCA: 407] [Impact Index Per Article: 58.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 07/11/2017] [Indexed: 12/22/2022] Open
Abstract
Phenylketonuria (PKU) is an autosomal recessive inborn error of phenylalanine metabolism caused by deficiency in the enzyme phenylalanine hydroxylase that converts phenylalanine into tyrosine. If left untreated, PKU results in increased phenylalanine concentrations in blood and brain, which cause severe intellectual disability, epilepsy and behavioural problems. PKU management differs widely across Europe and therefore these guidelines have been developed aiming to optimize and standardize PKU care. Professionals from 10 different European countries developed the guidelines according to the AGREE (Appraisal of Guidelines for Research and Evaluation) method. Literature search, critical appraisal and evidence grading were conducted according to the SIGN (Scottish Intercollegiate Guidelines Network) method. The Delphi-method was used when there was no or little evidence available. External consultants reviewed the guidelines. Using these methods 70 statements were formulated based on the highest quality evidence available. The level of evidence of most recommendations is C or D. Although study designs and patient numbers are sub-optimal, many statements are convincing, important and relevant. In addition, knowledge gaps are identified which require further research in order to direct better care for the future.
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Affiliation(s)
- A. M. J. van Wegberg
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, PO BOX 30.001, 9700 RB Groningen, The Netherlands
| | - A. MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Birmingham, UK
| | - K. Ahring
- Department of PKU, Kennedy Centre, Glostrup, Denmark
| | - A. Bélanger-Quintana
- Metabolic Diseases Unit, Department of Paediatrics, Hospital Ramon y Cajal Madrid, Madrid, Spain
| | - N. Blau
- University Children’s Hospital, Dietmar-Hoppe Metabolic Centre, Heidelberg, Germany
- University Children’s Hospital Zürich, Zürich, Switzerland
| | - A. M. Bosch
- Department of Paediatrics, Division of Metabolic Disorders, Academic Medical Centre, University Hospital of Amsterdam, Amsterdam, The Netherlands
| | - A. Burlina
- Division of Inherited Metabolic Diseases, Department of Paediatrics, University Hospital of Padova, Padova, Italy
| | - J. Campistol
- Neuropaediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - F. Feillet
- Department of Paediatrics, Hôpital d’Enfants Brabois, CHU Nancy, Vandoeuvre les Nancy, France
| | - M. Giżewska
- Department of Paediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, Szczecin, Poland
| | - S. C. Huijbregts
- Department of Clinical Child and Adolescent Studies-Neurodevelopmental Disorders, Faculty of Social Sciences, Leiden University, Leiden, The Netherlands
| | - S. Kearney
- Clinical Psychology Department, Birmingham Children’s Hospital, Birmingham, UK
| | - V. Leuzzi
- Department of Paediatrics, Child Neurology and Psychiatry, Sapienza University of Rome, Via dei Sabelli 108, 00185 Rome, Italy
| | - F. Maillot
- CHRU de Tours, Université François Rabelais, INSERM U1069, Tours, France
| | - A. C. Muntau
- University Children’s Hospital, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - M. van Rijn
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, PO BOX 30.001, 9700 RB Groningen, The Netherlands
| | - F. Trefz
- Department of Paediatrics, University of Heidelberg, Heidelberg, Germany
| | - J. H. Walter
- Medicine, Manchester Academic Health Sciences Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - F. J. van Spronsen
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, PO BOX 30.001, 9700 RB Groningen, The Netherlands
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28
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van Spronsen FJ, van Wegberg AMJ, Ahring K, Bélanger-Quintana A, Blau N, Bosch AM, Burlina A, Campistol J, Feillet F, Giżewska M, Huijbregts SC, Kearney S, Leuzzi V, Maillot F, Muntau AC, Trefz FK, van Rijn M, MacDonald A. Issues with European guidelines for phenylketonuria - Authors' reply. Lancet Diabetes Endocrinol 2017; 5:683-684. [PMID: 28842159 DOI: 10.1016/s2213-8587(17)30202-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Francjan J van Spronsen
- Division of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB, Groningen, Netherlands.
| | - Annemiek M J van Wegberg
- Division of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB, Groningen, Netherlands
| | - Kirsten Ahring
- Department of PKU, Kennedy Centre, Copenhagen University Hospital, Glostrup, Denmark
| | | | - Nenad Blau
- University Children's Hospital, Dietmar-Hoppe Metabolic Centre, Heidelberg, Germany; University Children's Hospital Zurich, Zurich, Switzerland
| | - Annet M Bosch
- Department of Paediatrics, Division of Metabolic Disorders, Academic Medical Centre, University Hospital of Amsterdam, Amsterdam, Netherlands
| | - Alberto Burlina
- Division of Inherited Metabolic Diseases, Department of Paediatrics, University Hospital of Padova, Padova, Italy
| | - Jaime Campistol
- Neuropaediatrics Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Francois Feillet
- Department of Pediatrics, Hôpital d'Enfants Brabois, CHU Nancy, Vandoeuvre les Nancy, France
| | - Maria Giżewska
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, Szczecin, Poland
| | - Stephan C Huijbregts
- Department of Clinical Child and Adolescent Studies-Neurodevelopmental Disorders, Faculty of Social Sciences, Leiden University, Leiden, Netherlands
| | - Shauna Kearney
- Clinical Psychology Department, Birmingham Children's Hospital, Birmingham, UK
| | - Vincenzo Leuzzi
- Department of Pediatrics, Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Francois Maillot
- Internal Medicine Service, CHRU de Tours, François Rabelais University, Tours, France
| | - Ania C Muntau
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fritz K Trefz
- University Children's Hospital, Dietmar-Hoppe Metabolic Centre, Heidelberg, Germany
| | - Margreet van Rijn
- Department of Dietetics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Anita MacDonald
- Dietetic Department, Birmingham Children's Hospital, Birmingham, UK
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29
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van Spronsen FJ, van Wegberg AM, Ahring K, Bélanger-Quintana A, Blau N, Bosch AM, Burlina A, Campistol J, Feillet F, Giżewska M, Huijbregts SC, Kearney S, Leuzzi V, Maillot F, Muntau AC, Trefz FK, van Rijn M, Walter JH, MacDonald A. Key European guidelines for the diagnosis and management of patients with phenylketonuria. Lancet Diabetes Endocrinol 2017; 5:743-756. [PMID: 28082082 DOI: 10.1016/s2213-8587(16)30320-5] [Citation(s) in RCA: 239] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 09/11/2016] [Accepted: 09/28/2016] [Indexed: 12/14/2022]
Abstract
We developed European guidelines to optimise phenylketonuria (PKU) care. To develop the guidelines, we did a literature search, critical appraisal, and evidence grading according to the Scottish Intercollegiate Guidelines Network method. We used the Delphi method when little or no evidence was available. From the 70 recommendations formulated, in this Review we describe ten that we deem as having the highest priority. Diet is the cornerstone of treatment, although some patients can benefit from tetrahydrobiopterin (BH4). Untreated blood phenylalanine concentrations determine management of people with PKU. No intervention is required if the blood phenylalanine concentration is less than 360 μmol/L. Treatment is recommended up to the age of 12 years if the phenylalanine blood concentration is between 360 μmol/L and 600 μmol/L, and lifelong treatment is recommended if the concentration is more than 600 μmol/L. For women trying to conceive and during pregnancy (maternal PKU), untreated phenylalanine blood concentrations of more than 360 μmol/L need to be reduced. Treatment target concentrations are as follows: 120-360 μmol/L for individuals aged 0-12 years and for maternal PKU, and 120-600 μmol/L for non-pregnant individuals older than 12 years. Minimum requirements for the management and follow-up of patients with PKU are scheduled according to age, adherence to treatment, and clinical status. Nutritional, clinical, and biochemical follow-up is necessary for all patients, regardless of therapy.
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Affiliation(s)
- Francjan J van Spronsen
- Division of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
| | - Annemiek Mj van Wegberg
- Division of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Kirsten Ahring
- Department of PKU, Kennedy Centre, Copenhagen University Hospital, Glostrup, Denmark
| | | | - Nenad Blau
- University Children's Hospital, Dietmar-Hoppe Metabolic Centre, Heidelberg, Germany; University Children's Hospital Zurich, Zurich, Switzerland
| | - Annet M Bosch
- Department of Paediatrics, Division of Metabolic Disorders, Academic Medical Centre, University Hospital of Amsterdam, Amsterdam, Netherlands
| | - Alberto Burlina
- Division of Inherited Metabolic Diseases, Department of Paediatrics, University Hospital of Padova, Padova, Italy
| | - Jaime Campistol
- Neuropaediatrics Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Francois Feillet
- Department of Pediatrics, Hôpital d'Enfants Brabois, CHU Nancy, Vandoeuvre les Nancy, France
| | - Maria Giżewska
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, Szczecin, Poland
| | - Stephan C Huijbregts
- Department of Clinical Child and Adolescent Studies-Neurodevelopmental Disorders, Faculty of Social Sciences, Leiden University, Leiden, Netherlands
| | - Shauna Kearney
- Clinical Psychology Department, Birmingham Children's Hospital, Birmingham, UK
| | - Vincenzo Leuzzi
- Department of Pediatrics, Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Francois Maillot
- Internal Medicine Service, CHRU de Tours, François Rabelais University, Tours, France
| | - Ania C Muntau
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fritz K Trefz
- University Children's Hospital, Dietmar-Hoppe Metabolic Centre, Heidelberg, Germany
| | - Margreet van Rijn
- Department of Dietetics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - John H Walter
- Manchester Academic Health Sciences Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Anita MacDonald
- Dietetic Department, Birmingham Children's Hospital, Birmingham, UK
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30
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Burgard P, Ullrich K, Ballhausen D, Hennermann JB, Hollak CEM, Langeveld M, Karall D, Konstantopoulou V, Maier EM, Lang F, Lachmann R, Murphy E, Garbade S, Hoffmann GF, Kölker S, Lindner M, Zschocke J. Issues with European guidelines for phenylketonuria. Lancet Diabetes Endocrinol 2017; 5:681-683. [PMID: 28842158 DOI: 10.1016/s2213-8587(17)30201-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Peter Burgard
- Centre for Paediatric and Adolescent Medicine, Division for Neuropaediatrics and Metabolic Medicine, Heidelberg University Hospital, D-69120 Heidelberg, Germany.
| | - Kurt Ullrich
- University Center for Rare Diseases, International Center for Lysosomal Disorders, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Diana Ballhausen
- Centre des Maladies Moléculaires, Service de Médecine Génétique, CHUV BT-02-252, Lausanne, Switzerland
| | - Julia B Hennermann
- Centre for Paediatric and Adolescent Medicine, Johannes Gutenberg-Universität Mainz, Villa, Metabolica, Mainz, Germany
| | - Carla E M Hollak
- Division of Clinical Endocrinology & Metabolism, Academic Medical Center, Amsterdam, Netherlands
| | - Mirjam Langeveld
- Division of Clinical Endocrinology & Metabolism, Academic Medical Center, Amsterdam, Netherlands
| | - Daniela Karall
- Clinic for Pediatrics I, Medical University Innsbruck, Inherited Metabolic Disorders, Innsbruck, Austria
| | | | - Esther M Maier
- Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Frauke Lang
- Centre for Paediatric and Adolescent Medicine, Johannes Gutenberg-Universität Mainz, Villa, Metabolica, Mainz, Germany
| | - Robin Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Elaine Murphy
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Sven Garbade
- Centre for Paediatric and Adolescent Medicine, Division for Neuropaediatrics and Metabolic Medicine, Heidelberg University Hospital, D-69120 Heidelberg, Germany
| | - Georg F Hoffmann
- Centre for Paediatric and Adolescent Medicine, Division for Neuropaediatrics and Metabolic Medicine, Heidelberg University Hospital, D-69120 Heidelberg, Germany
| | - Stefan Kölker
- Centre for Paediatric and Adolescent Medicine, Division for Neuropaediatrics and Metabolic Medicine, Heidelberg University Hospital, D-69120 Heidelberg, Germany
| | - Martin Lindner
- University Children's Hospital Frankfurt, Frankfurt am Main, Germany
| | - Johannes Zschocke
- Division of Human Genetics, Medical University Innsbruck, Innsbruck, Austria
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31
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Romani C, Palermo L, MacDonald A, Limback E, Hall SK, Geberhiwot T. The impact of phenylalanine levels on cognitive outcomes in adults with phenylketonuria: Effects across tasks and developmental stages. Neuropsychology 2017; 31:242-254. [PMID: 28240926 PMCID: PMC5331922 DOI: 10.1037/neu0000336] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Objective: Phenylketonuria (PKU) is due to an inability to metabolize the amino acid phenylalanine (Phe), leading to its accumulation in the brain. Phe levels can be controlled following a protein-free diet, but cognitive impairments are still present. A number of questions remain to be answered related to which type of metabolic control is important, the age when it is important, the cognitive functions which are most affected and, the best tests to use to monitor cognitive health. Method: We investigated the impact of metabolic control at different ages on cognitive performance in 37 early treated adults with PKU. Results: (a) Phe variation was as associated to performance as average Phe showing that stable dietary control is as important as strict control; (b) For some tasks, current and adult Phe were stronger predictors of performance than childhood or adolescent Phe, showing the importance of a strict diet even in adulthood; and (c) The relationship between performance and Phe levels varied depending on time and cognitive domain. For some functions (sustained attention, visuomotor coordination), Phe at the time of testing was the best predictor. While for other functions (visual attention, executive functions) there was a diminishing or stable relationship across time. Conclusion: Results show the importance of selecting the right tasks to monitor outcomes across ages, but also that the impact of bio-chemical disruptions is different for different functions, at different ages. We show how inherited metabolic diseases offer us a unique vantage point to inform our understanding of brain development and functioning.
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Affiliation(s)
| | - Liana Palermo
- School of Life and Health Sciences, Aston University
| | | | - Ellie Limback
- School of Life and Health Sciences, Aston University
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32
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Jahja R, van Spronsen FJ, de Sonneville LMJ, van der Meere JJ, Bosch AM, Hollak CEM, Rubio-Gozalbo ME, Brouwers MCGJ, Hofstede FC, de Vries MC, Janssen MCH, van der Ploeg AT, Langendonk JG, Huijbregts SCJ. Long-Term Follow-Up of Cognition and Mental Health in Adult Phenylketonuria: A PKU-COBESO Study. Behav Genet 2017; 47:486-497. [PMID: 28776207 PMCID: PMC5574956 DOI: 10.1007/s10519-017-9863-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 07/07/2017] [Indexed: 11/25/2022]
Abstract
Cognitive and mental health problems in individuals with the inherited metabolic disorder phenylketonuria (PKU) have often been associated with metabolic control and its history. For the present study executive functioning (EF) was assessed in 21 PKU patients during childhood (T1, mean age 10.4 years, SD = 2.0) and again in adulthood (T2, mean age 25.8 years, SD = 2.3). At T2 additional assessments of EF in daily life and mental health were performed. Childhood (i.e. 0–12 years) blood phenylalanine was significantly related to cognitive flexibility, executive motor control, EF in daily life and mental health in adulthood (i.e. at T2). Patients with a greater increase in phenylalanine levels after the age of 12 performed more poorly on EF-tasks at T2. Group-based analyses showed that patients with phenylalanine <360 µmol/L in childhood and phenylalanine ≥360 µmol/L from age 13 onwards (n = 11) had better cognitive flexibility and executive motor control than those who had phenylalanine ≥360 µmol/L throughout life (n = 7), supporting the notion that phenylalanine should be below the recommended upper treatment target of 360 µmol/L during childhood for better outcome in adulthood. Despite some results indicating additional influence of phenylalanine levels between 13 and 17 years of age, evidence for a continued influence of phenylalanine levels after childhood on adult outcomes was largely lacking. This may be explained by the fact that the patients in the present study had relatively low phenylalanine levels during childhood (mean: 330 µmol/L, range: 219–581 µmol/L) and thereafter (mean Index of Dietary Control at T2: 464 µmol/L, range: 276–743 µmol/L), which may have buffered against transitory periods of poor metabolic control during adolescence and early adulthood.
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Affiliation(s)
- Rianne Jahja
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - Francjan J van Spronsen
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands.
| | - Leo M J de Sonneville
- Department of Clinical Child and Adolescent Studies & Leiden Institute for Brain and Cognition, Leiden University, Leiden, The Netherlands
| | - Jaap J van der Meere
- University of Groningen, Department of Developmental and Clinical Neuropsychology, Groningen, The Netherlands
| | | | | | - M Estela Rubio-Gozalbo
- University Hospital Maastricht and Laboratory Genetic Metabolic Diseases, Maastricht, The Netherlands
| | - Martijn C G J Brouwers
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, University Hospital Maastricht, Maastricht, The Netherlands
| | - Floris C Hofstede
- Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maaike C de Vries
- University Medical Center St Radboud Nijmegen, Nijmegen, The Netherlands
| | - Mirian C H Janssen
- University Medical Center St Radboud Nijmegen, Nijmegen, The Netherlands
| | - Ans T van der Ploeg
- Center for Lysosomal and Metabolic Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Janneke G Langendonk
- Center for Lysosomal and Metabolic Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Stephan C J Huijbregts
- Department of Clinical Child and Adolescent Studies & Leiden Institute for Brain and Cognition, Leiden University, Leiden, The Netherlands.,Department of Clinical Child and Adolescent Studies, Leiden University, Wassenaarseweg 52, P.O. Box 9555, 2300 RB, Leiden, The Netherlands
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Dietary patterns, cost and compliance with low-protein diet of phenylketonuria and other inherited metabolic diseases. Eur J Clin Nutr 2017; 72:87-92. [PMID: 28656971 DOI: 10.1038/ejcn.2017.102] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 04/20/2017] [Accepted: 05/03/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND/OBJECTIVES Phenylketonuria (PKU) and several other inherited metabolic diseases (IMD) require a lifelong low-protein diet (LPD), otherwise they lead to many health complications. LPDs, however, carry a significant economic burden for patients and their families. The objective of this study was to explore the costs of low-protein foods (LPFs) necessary for LPD as well as dietary patterns and compliance towards an LPD. SUBJECTS/METHODS A detailed questionnaire was created in cooperation with National Association of PKU and other IMD (NSPKU), and consequently sent to all NSPKU members treated with an LPD (n=303). A total of 184 respondents from the Czech Republic were included in the study (174 had PKU, 10 had other IMD). RESULTS The average daily consumption of LPF was equal to 411.7 g (PKU) and 345.6 g (other IMD), which corresponds to energy value of 5558 kJ and 4438 kJ, respectively, per patient per day. Patients mostly consumed low-protein flour (≈30% of energy intake), pasta (≈18%), basic pastry (≈15%) and sweets (≈10%). The average monthly costs of LPDs were equal to [euro ]130 (PKU) and [euro ]129 (other IMD) per patient per month. The compliance with LPD was decreasing with increasing age (P<0.0001). CONCLUSIONS This is the largest study examining costs and dietary patterns of LPDs in patients with PKU and the first study of this kind in other IMD patients requiring an LPD. The study clearly showed that an LPD carries a very high economic burden for families, which may lead to less LPD compliance and potential severe health consequences.
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Romani C, MacDonald A, De Felice S, Palermo L. Speed of processing and executive functions in adults with phenylketonuria: Quick in finding the word, but not the ladybird. Cogn Neuropsychol 2017. [PMID: 28632427 DOI: 10.1080/02643294.2017.1320278] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A reduction in processing speed is widely reported in phenylketonuria (PKU), possibly due to white matter pathology. We investigated possible deficits and their relationships with executive functions in a sample of 37 early-treated adults with PKU (AwPKUs). AwPKUs were not characterized by a generalized speed deficit, but instead their performance could be explained by two more specific impairments: (a) a deficit in the allocation of visuo-spatial attention that reduced speed in visual search tasks, in some reading conditions and visuo-motor coordination tasks; and (b) a more conservative decision mechanism that slowed down returning an answer across domains. These results suggest that the impairments in executive functions seen in AwPKUs are not the consequence of a generalized speed deficit. They also suggest that processing speed is linked to the efficiency of a particular cognitive component and cannot be considered a general function spanning domains. Similarities with patterns in ageing are discussed.
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Affiliation(s)
- Cristina Romani
- a School of Life and Health Sciences , Aston University , Birmingham , UK
| | | | - Sara De Felice
- a School of Life and Health Sciences , Aston University , Birmingham , UK
| | - Liana Palermo
- a School of Life and Health Sciences , Aston University , Birmingham , UK.,c Queen Elizabeth Hospital , Birmingham , UK.,d Department of Medical and Surgical Sciences , Magna Graecia University of Catanzaro , Catanzaro , Italy
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Caprile C, Campistol J, Puigcerver L, Gutiérrez-Mata AP, Alonso-Colmenero I, Colomé R, Navarra J. Subtle visuomotor deficits and reduced benefit from practice in early treated phenylketonuria. J Clin Exp Neuropsychol 2017; 39:931-940. [PMID: 28165881 DOI: 10.1080/13803395.2017.1281381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Phenylketonuria (PKU) is a rare metabolic disease that causes slight-to-severe neurological symptoms. Slow performance has been observed in PKU but the influence of high-order (i.e., not purely motor) deficits and of temporary variations of the phenylalanine (Phe) level on this slowness has not been fully corroborated as yet. Response speed and the effect of motor practice during the performance of a visuomotor coordination task were measured, in a group of patients with early-treated phenylketonuria (ET PKU). METHOD We compared the performance of a group of early-treated PKU patients with ages ranging from 11 to 25 years and a control group of healthy volunteers on a computerized visuomotor task. Participants performed rapid movements towards one of five response buttons, as indicated by a visual stimulus that could appear in five different positions on a computer screen. The results of our visuomotor task were correlated with neurobiological data (Phe levels) and with neuropsychological measures of motor (finger tapping) and executive functions (Stroop task). RESULTS The ET PKU group showed slower responses than the control group. Furthermore, an absence of a practice effect (i.e., faster response times at the end of the study) was found in the PKU group but not in the control group. Our results also revealed that this absence of practice effect correlated with higher Phe levels on the testing day with respect to the average Phe level of the previous 12 months and, although weakly, with performance on the Stroop task. CONCLUSIONS This pattern of results indicates slower visuomotor performance and a less beneficial effect of practice in ET PKU. The correlations found among our visuomotor measures, the same-day Phe level, and the Stroop test may reflect the negative effects of dopamine reduction in brain areas involved in motor control, selective attention, and learning.
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Affiliation(s)
- Claudia Caprile
- a Experimental Psychology & Brain Disorders Laboratory , Fundació Sant Joan de Déu, Hospital Sant Joan de Déu , Esplugues de Llobregat, Barcelona , Spain
| | - Jaume Campistol
- b Servei de Neurologia Pediàtrica , Hospital Sant Joan de Déu , Esplugues de Llobregat, Barcelona , Spain
| | - Laura Puigcerver
- a Experimental Psychology & Brain Disorders Laboratory , Fundació Sant Joan de Déu, Hospital Sant Joan de Déu , Esplugues de Llobregat, Barcelona , Spain.,c Department of Cognition, Development and Educational Psychology , University of Barcelona , Barcelona , Spain
| | | | - Itziar Alonso-Colmenero
- b Servei de Neurologia Pediàtrica , Hospital Sant Joan de Déu , Esplugues de Llobregat, Barcelona , Spain
| | - Roser Colomé
- e UTAE Learning Disorders Unit , Hospital Sant Joan de Déu , Barcelona , Spain
| | - Jordi Navarra
- a Experimental Psychology & Brain Disorders Laboratory , Fundació Sant Joan de Déu, Hospital Sant Joan de Déu , Esplugues de Llobregat, Barcelona , Spain.,c Department of Cognition, Development and Educational Psychology , University of Barcelona , Barcelona , Spain
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Palermo L, Geberhiwot T, MacDonald A, Limback E, Hall SK, Romani C. Cognitive outcomes in early-treated adults with phenylketonuria (PKU): A comprehensive picture across domains. Neuropsychology 2017; 31:255-267. [PMID: 28080075 PMCID: PMC5328133 DOI: 10.1037/neu0000337] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Phenylketonuria (PKU) is an inherited metabolic disease which affects cognitive functions due to an inability to metabolize phenylalanine which leads to the accumulation of toxic by-products (Phe) in the brain. PKU can be effectively treated with a low phenylalanine diet, but some cognitive deficits remain. Studies have reported impairments, especially for processing speed and executive functions, but there is a lack of comprehensive assessment across cognitive domains. Moreover, it is important to establish outcomes in early treated adults with PKU (AwPKU) who have better metabolic control than groups previously reported in the literature. METHOD We tested 37 AwPKU with an unprecedented number of tasks (N = 28) and measures (N = 44) and compared results with 30 controls matched for age and education. RESULTS We found (a) group impairments, particularly in tasks tapping speed of processing and complex executive functions; (b) high variability across participants, with a sizable number of AwPKU with completely normal performance (about 38%); (c) but also a sizable number of participants who were clearly impaired (about 24%); and (d) good performance in tasks tapping verbal learning, verbal memory and orthographic processing, indicating no generalized learning impairment. CONCLUSION Our results indicate good outcomes, but also that deficits are still present with current treatment policies. (PsycINFO Database Record
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Affiliation(s)
- Liana Palermo
- School of Life and Health Sciences, Aston University
| | | | | | - Ellie Limback
- School of Life and Health Sciences, Aston University
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Neurological and Neuropsychological Problems in Tyrosinemia Type I Patients. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 959:111-122. [PMID: 28755189 DOI: 10.1007/978-3-319-55780-9_10] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Clinically, Hereditary Tyrosinemia type I (HTI) is especially characterized by severe liver dysfunction in early life. However, recurrent neurological crises are another main finding in these patients when they are treated with a tyrosine and phenylalanine restricted diet only. This is caused by the accumulation of δ-aminolevulinic acid due to the inhibitory effect of succinylacetone on the enzyme that metabolizes δ-aminolevulinic acid. Due to the biochemical and clinical resemblance of these neurological crises and acute intermittent porphyria, this group of symptoms in HTI patients is mostly called porphyria-like-syndrome. The neurological crises in HTI patients disappeared after the introduction of treatment with 2-(2 nitro-4-3 trifluoro-methylbenzoyl)-1, 3-cyclohexanedione (NTBC). However, if NTBC treatment is stopped for a while, severe neurological dysfunction will reappear.If NTBC treatment is started early and given continuously, all clinical problems seem to be solved. However, recent research findings indicate that HTI patients have a non-optimal neurocognitive outcome, showing (among others) a lower IQ and impaired executive functioning and social cognition. Unfortunately the exact neuropsychological profile of these HTI patients is not known yet, neither are the exact pathophysiological mechanisms underlying these impairments. It may be hypothesized that the biochemical changes such as high blood tyrosine or low blood phenylalanine concentrations are important in this respect, but an direct toxic effect of NTBC or production of toxic metabolites (that previously characterized the disease before introduction of NTBC) cannot be excluded either. This chapter discusses the neurological and neuropsychological symptoms associated with HTI in detail. An extended section on possible underlying pathophysiological mechanisms of such symptoms is also included.
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Messina MA, Meli C, Conoci S, Petralia S. A facile method for urinary phenylalanine measurement on paper-based lab-on-chip for PKU therapy monitoring. Analyst 2017; 142:4629-4632. [DOI: 10.1039/c7an01115f] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A miniaturized paper-based lab-on-chip (LoC) was developed for the facile measurement of urinary Phe (phenylalanine) level on PKU (Phenylketonuria) treated patient.
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Affiliation(s)
- M. A. Messina
- Azienda Ospedaliero Universitaria Policlinico Vittorio Emanuele
- Catania
- Italy
| | - C. Meli
- Azienda Ospedaliero Universitaria Policlinico Vittorio Emanuele
- Catania
- Italy
| | - S. Conoci
- STMicroelectronics
- Stradale Primosole
- 50-95121 Catania
- Italy
| | - S. Petralia
- STMicroelectronics
- Stradale Primosole
- 50-95121 Catania
- Italy
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Boy N, Heringer J, Haege G, Glahn EM, Hoffmann GF, Garbade SF, Kölker S, Burgard P. A cross-sectional controlled developmental study of neuropsychological functions in patients with glutaric aciduria type I. Orphanet J Rare Dis 2015; 10:163. [PMID: 26693825 PMCID: PMC4689061 DOI: 10.1186/s13023-015-0379-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 12/14/2015] [Indexed: 01/26/2023] Open
Abstract
Background Glutaric aciduria type I (GA-I) is an inherited metabolic disease due to deficiency of glutaryl-CoA dehydrogenase (GCDH). Cognitive functions are generally thought to be spared, but have not yet been studied in detail. Methods Thirty patients detected by newborn screening (n = 13), high-risk screening (n = 3) or targeted metabolic testing (n = 14) were studied for simple reaction time (SRT), continuous performance (CP), visual working memory (VWM), visual-motor coordination (Tracking) and visual search (VS). Dystonia (n = 13 patients) was categorized using the Barry-Albright-Dystonia Scale (BADS). Patients were compared with 196 healthy controls. Developmental functions of cognitive performances were analysed using a negative exponential function model. Results BADS scores correlated with speed tests but not with tests measuring stability or higher cognitive functions without time constraints. Developmental functions of GA-I patients significantly differed from controls for SRT and VS but not for VWM and showed obvious trends for CP and Tracking. Dystonic patients were slower in SRT and CP but reached their asymptote of performance similar to asymptomatic patients and controls in all tests. Asymptomatic patients did not differ from controls, except showing significantly better results in Tracking and a trend for slower reactions in visual search. Data across all age groups of patients and controls fitted well to a model of negative exponential development. Conclusions Dystonic patients predominantly showed motor speed impairment, whereas performance improved with higher cognitive load. Patients without motor symptoms did not differ from controls. Developmental functions of cognitive performances were similar in patients and controls. Performance in tests with higher cognitive demand might be preserved in GA-I, even in patients with striatal degeneration. Electronic supplementary material The online version of this article (doi:10.1186/s13023-015-0379-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nikolas Boy
- Department of General Paediatrics, Division of Child Neurology and Inherited Metabolic Diseases, Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany.
| | - Jana Heringer
- Department of General Paediatrics, Division of Child Neurology and Inherited Metabolic Diseases, Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany.
| | - Gisela Haege
- Department of General Paediatrics, Division of Child Neurology and Inherited Metabolic Diseases, Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany.
| | - Esther M Glahn
- Department of General Paediatrics, Division of Child Neurology and Inherited Metabolic Diseases, Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany.
| | - Georg F Hoffmann
- Department of General Paediatrics, Division of Child Neurology and Inherited Metabolic Diseases, Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany.
| | - Sven F Garbade
- Faculty of Applied Psychology, SRH University of Applied Sciences, D-69123, Heidelberg, Germany.
| | - Stefan Kölker
- Department of General Paediatrics, Division of Child Neurology and Inherited Metabolic Diseases, Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany.
| | - Peter Burgard
- Department of General Paediatrics, Division of Child Neurology and Inherited Metabolic Diseases, Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany.
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Saad K, Elserogy Y, Abdel Rahman AA, Al-Atram AA, Mohamad IL, ElMelegy TTH, Bjørklund G, El-Houfy AA. ADHD, autism and neuroradiological complications among phenylketonuric children in Upper Egypt. Acta Neurol Belg 2015; 115:657-63. [PMID: 25576444 DOI: 10.1007/s13760-014-0422-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 12/29/2014] [Indexed: 02/05/2023]
Abstract
The aim of this study is to evaluate the neuropsychological status in a cohort of children with early and continuously treated phenylketonuria in Assiut, Upper Egypt. The study was implemented in seventy-eight phenylketonuria (PKU) children. Only 34 patients met the inclusion criteria. Investigated patients were evaluated according to detailed history, neurological examination, Childhood Autism Rating Scale, full scale Intelligence Quotient, attention deficit hyperactivity disorder, electroencephalography and magnetic resonance imaging (MRI). This study concluded that the prognosis for early diagnosed children with PKU treated from the first weeks of life is generally good. However, they are at increased risk for neurological complications and behavioral problems. So, neonatal screening for PKU is highly recommended in Egypt, for early detection and management. In addition, neuropsychological and MRI assessments in PKU children should be done.
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Affiliation(s)
- Khaled Saad
- Department of Pediatrics, Assiut University, Asyût, 71516, Egypt.
| | - Yasser Elserogy
- Department of Neuropsychiatry, Assiut University, Asyût, 71516, Egypt
| | | | | | - Ismail L Mohamad
- Department of Pediatrics, Assiut University, Asyût, 71516, Egypt
| | - Tarek T H ElMelegy
- Department of Clinical Pathology, Assiut University, Asyût, 71516, Egypt
| | - Geir Bjørklund
- Council for Nutritional and Environmental Medicine, Mo i Rana, Norway
| | - Amira A El-Houfy
- Department of Community Health Nursing, Assiut University, Asyût, 71516, Egypt
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Bosch AM, Burlina A, Cunningham A, Bettiol E, Moreau-Stucker F, Koledova E, Benmedjahed K, Regnault A. Assessment of the impact of phenylketonuria and its treatment on quality of life of patients and parents from seven European countries. Orphanet J Rare Dis 2015; 10:80. [PMID: 26084935 PMCID: PMC4542123 DOI: 10.1186/s13023-015-0294-x] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 06/09/2015] [Indexed: 01/26/2023] Open
Abstract
Background The strict and demanding dietary treatment and mild cognitive abnormalities seen in PKU treated from a young age can be expected to affect the health-related quality of life (HRQoL) of patients and their families. Our aim was to describe the HRQoL of patients with PKU from a large international study, using generic HRQoL measures and an innovative PKU-specific HRQoL questionnaire (PKU-QOL). Analyses were exploratory, performed post-hoc on data collected primarily to validate the PKU-QOL. Methods A multicentre, prospective, non-interventional, observational study conducted in France, Germany, Italy, The Netherlands, Spain, Turkey and the UK. Patients diagnosed with PKU aged ≥9 years old and treated with a Phe-restricted diet and/or Phe-free amino acid protein supplements and/or pharmacological therapy were included in the study; parents of at least one patient with PKU aged <18 years were also included. HRQoL was assessed by generic measures (Pediatric Quality-of-Life Inventory; Medical Outcome Survey 36 item Short Form; Child Health Questionnaire 28 item Parent Form) and the newly developed PKU-QOL. Mean generic domain scores were interpreted using published reference values from the general population. PKU-QOL domain scores were described overall and in different subgroups of patients defined according to severity of PKU, overall assessment of patient’s health status by the investigator and treatment with tetrahydrobiopterin (BH4). Results Data from 559 subjects were analysed: 306 patients (92 children, 110 adolescents, 104 adults) and 253 parents. Mean domain scores of generic measures in the study were comparable to the general population. The highest PKU-QOL impact scores (indicating greater impact) were for emotional impact of PKU, anxiety about blood Phe levels, guilt regarding poor adherence to dietary restrictions or Phe-free amino acid supplement intake and anxiety regarding blood Phe levels during pregnancy. Patients with mild/moderate PKU and those receiving BH4 reported lower practical and emotional impacts of the diet and Phe-free amino acid supplement intake. Conclusion Patients with PKU showed good HRQoL in the study, both with the generic and PKU-specific measures. Negative impacts of PKU on a patient’s life, including the emotional impact of PKU and its management, was delineated by the PKU-QOLs across all age groups. Electronic supplementary material The online version of this article (doi:10.1186/s13023-015-0294-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annet M Bosch
- Department of Paediatrics, Division of Metabolic Disorders, Academic Medical Centre, University Hospital of Amsterdam, Amsterdam, The Netherlands.
| | - Alberto Burlina
- Division of Metabolic Disorders, Department of Paediatrics, University Hospital of Padova, Padova, Italy.
| | - Amy Cunningham
- Hayward Genetics Center, Tulane University School of Medicine, New Orleans, LA, USA.
| | - Esther Bettiol
- Infection Control Program, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | | | - Ekaterina Koledova
- Mapi, Health Economics & Outcomes Research and Strategic Market Access, Lyon, France
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Nardecchia F, Manti F, Chiarotti F, Carducci C, Carducci C, Leuzzi V. Neurocognitive and neuroimaging outcome of early treated young adult PKU patients: A longitudinal study. Mol Genet Metab 2015; 115:84-90. [PMID: 25952249 DOI: 10.1016/j.ymgme.2015.04.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 04/22/2015] [Accepted: 04/25/2015] [Indexed: 10/23/2022]
Abstract
The aim of the study was to explore the outcome of neurocognitive deficits and neuroimaging correlates in young adult early treated phenylketonuric (PKU) patients. We conducted a longitudinal study of 14 PKU patients that were assessed for IQ and neuropsychological functioning including executive functions (EF) over 14 years of follow-up (age range at 1st and 2nd assessments were 7.8-13.5 and 22.2-27.7 years, respectively). The IQ of all 14 PKU patients was within the normal range. With respect to the 1st assessment, mean IQ at follow-up did not decrease significantly. Compared to control subjects (n = 14), mean IQ of patients was significantly lower (p = .0005). Throughout adolescence and early adulthood there was an improvement of neuropsychological functioning of PKU patients in spite of the relaxation of diet, however some deficits were still detectable when compared to controls. All patients that underwent a second MRI scan showed white matter alterations ranging from mild to severe which was correlated neither with IQ nor with EF scoring. Cognitive, neuropsychological and neuroimaging outcome was influenced from life-long and/or second decade of life metabolic control. Nevertheless patients' developmental trajectories were in some cases independent from metabolic control. Our results support the hypothesis of an individual vulnerability to phenylalanine. However, as long as individual factors that account for the vulnerability to Phe are not recognized, strict dietary control is recommended for all the patients also in the second decade of life.
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Affiliation(s)
- Francesca Nardecchia
- Department of Pediatrics and Child and Adolescent Neuropsychiatry, SAPIENZA University of Rome, Via dei Sabelli 108, 00185 Rome, Italy; Department of Physiology and Pharmacology, SAPIENZA University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy.
| | - Filippo Manti
- Department of Pediatrics and Child and Adolescent Neuropsychiatry, SAPIENZA University of Rome, Via dei Sabelli 108, 00185 Rome, Italy.
| | - Flavia Chiarotti
- Istituto Superiore di Sanità, Department of Cell Biology and Neuroscience, Viale Regina Elena 299, 00161 Rome, Italy.
| | - Claudia Carducci
- Department of Experimental Medicine, SAPIENZA University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Carla Carducci
- Department of Experimental Medicine, SAPIENZA University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Vincenzo Leuzzi
- Department of Pediatrics and Child and Adolescent Neuropsychiatry, SAPIENZA University of Rome, Via dei Sabelli 108, 00185 Rome, Italy.
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Abstract
Detection of individuals with phenylketonuria (PKU), an autosomal recessively inherited disorder in phenylalanine degradation, is straightforward and efficient due to newborn screening programs. A recent introduction of the pharmacological treatment option emerged rapid development of molecular testing. However, variants responsible for PKU do not all suppress enzyme activity to the same extent. A spectrum of over 850 variants, gives rise to a continuum of hyperphenylalaninemia from very mild, requiring no intervention, to severe classical PKU, requiring urgent intervention. Locus-specific and genotypes database are today an invaluable resource of information for more efficient classification and management of patients. The high-tech molecular methods allow patients' genotype to be obtained in a few days, especially if each laboratory develops a panel for the most frequent variants in the corresponding population.
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Affiliation(s)
- Nenad Blau
- Division of Inborn Metabolic Diseases, University Children's Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
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44
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Camp KM, Parisi MA, Acosta PB, Berry GT, Bilder DA, Blau N, Bodamer OA, Brosco JP, Brown CS, Burlina AB, Burton BK, Chang CS, Coates PM, Cunningham AC, Dobrowolski SF, Ferguson JH, Franklin TD, Frazier DM, Grange DK, Greene CL, Groft SC, Harding CO, Howell RR, Huntington KL, Hyatt-Knorr HD, Jevaji IP, Levy HL, Lichter-Konecki U, Lindegren ML, Lloyd-Puryear MA, Matalon K, MacDonald A, McPheeters ML, Mitchell JJ, Mofidi S, Moseley KD, Mueller CM, Mulberg AE, Nerurkar LS, Ogata BN, Pariser AR, Prasad S, Pridjian G, Rasmussen SA, Reddy UM, Rohr FJ, Singh RH, Sirrs SM, Stremer SE, Tagle DA, Thompson SM, Urv TK, Utz JR, van Spronsen F, Vockley J, Waisbren SE, Weglicki LS, White DA, Whitley CB, Wilfond BS, Yannicelli S, Young JM. Phenylketonuria Scientific Review Conference: state of the science and future research needs. Mol Genet Metab 2014; 112:87-122. [PMID: 24667081 DOI: 10.1016/j.ymgme.2014.02.013] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 02/25/2014] [Accepted: 02/26/2014] [Indexed: 01/17/2023]
Abstract
New developments in the treatment and management of phenylketonuria (PKU) as well as advances in molecular testing have emerged since the National Institutes of Health 2000 PKU Consensus Statement was released. An NIH State-of-the-Science Conference was convened in 2012 to address new findings, particularly the use of the medication sapropterin to treat some individuals with PKU, and to develop a research agenda. Prior to the 2012 conference, five working groups of experts and public members met over a 1-year period. The working groups addressed the following: long-term outcomes and management across the lifespan; PKU and pregnancy; diet control and management; pharmacologic interventions; and molecular testing, new technologies, and epidemiologic considerations. In a parallel and independent activity, an Evidence-based Practice Center supported by the Agency for Healthcare Research and Quality conducted a systematic review of adjuvant treatments for PKU; its conclusions were presented at the conference. The conference included the findings of the working groups, panel discussions from industry and international perspectives, and presentations on topics such as emerging treatments for PKU, transitioning to adult care, and the U.S. Food and Drug Administration regulatory perspective. Over 85 experts participated in the conference through information gathering and/or as presenters during the conference, and they reached several important conclusions. The most serious neurological impairments in PKU are preventable with current dietary treatment approaches. However, a variety of more subtle physical, cognitive, and behavioral consequences of even well-controlled PKU are now recognized. The best outcomes in maternal PKU occur when blood phenylalanine (Phe) concentrations are maintained between 120 and 360 μmol/L before and during pregnancy. The dietary management treatment goal for individuals with PKU is a blood Phe concentration between 120 and 360 μmol/L. The use of genotype information in the newborn period may yield valuable insights about the severity of the condition for infants diagnosed before maximal Phe levels are achieved. While emerging and established genotype-phenotype correlations may transform our understanding of PKU, establishing correlations with intellectual outcomes is more challenging. Regarding the use of sapropterin in PKU, there are significant gaps in predicting response to treatment; at least half of those with PKU will have either minimal or no response. A coordinated approach to PKU treatment improves long-term outcomes for those with PKU and facilitates the conduct of research to improve diagnosis and treatment. New drugs that are safe, efficacious, and impact a larger proportion of individuals with PKU are needed. However, it is imperative that treatment guidelines and the decision processes for determining access to treatments be tied to a solid evidence base with rigorous standards for robust and consistent data collection. The process that preceded the PKU State-of-the-Science Conference, the conference itself, and the identification of a research agenda have facilitated the development of clinical practice guidelines by professional organizations and serve as a model for other inborn errors of metabolism.
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Affiliation(s)
- Kathryn M Camp
- Office of Dietary Supplements, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Melissa A Parisi
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | | | - Gerard T Berry
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Deborah A Bilder
- Department of Psychiatry, University of Utah, Salt Lake City, UT 84108, USA.
| | - Nenad Blau
- University Children's Hospital, Heidelberg, Germany; University Children's Hospital, Zürich, Switzerland.
| | - Olaf A Bodamer
- University of Miami Miller School of Medicine, Miami, FL 33136, USA.
| | - Jeffrey P Brosco
- University of Miami Mailman Center for Child Development, Miami, FL 33101, USA.
| | | | | | - Barbara K Burton
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA.
| | - Christine S Chang
- Agency for Healthcare Research and Quality, Rockville, MD 20850, USA.
| | - Paul M Coates
- Office of Dietary Supplements, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Amy C Cunningham
- Tulane University Medical School, Hayward Genetics Center, New Orleans, LA 70112, USA.
| | | | - John H Ferguson
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | | | | | - Dorothy K Grange
- Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA.
| | - Carol L Greene
- University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Stephen C Groft
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Cary O Harding
- Oregon Health & Science University, Portland, OR 97239, USA.
| | - R Rodney Howell
- University of Miami Miller School of Medicine, Miami, FL 33136, USA.
| | | | - Henrietta D Hyatt-Knorr
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Indira P Jevaji
- Office of Research on Women's Health, National Institutes of Health, Bethesda, MD 20817, USA.
| | - Harvey L Levy
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Uta Lichter-Konecki
- George Washington University, Children's National Medical Center, Washington, DC 20010, USA.
| | | | | | | | | | - Melissa L McPheeters
- Vanderbilt Evidence-based Practice Center, Institute for Medicine and Public Health, Nashville, TN 37203, USA.
| | - John J Mitchell
- McGill University Health Center, Montreal, Quebec H3H 1P3, Canada.
| | - Shideh Mofidi
- Maria Fareri Children's Hospital of Westchester Medical Center, Valhalla, NY 10595, USA.
| | - Kathryn D Moseley
- University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA.
| | - Christine M Mueller
- Office of Orphan Products Development, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA.
| | - Andrew E Mulberg
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA.
| | - Lata S Nerurkar
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Beth N Ogata
- University of Washington, Seattle, WA 98195, USA.
| | - Anne R Pariser
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA.
| | - Suyash Prasad
- BioMarin Pharmaceutical Inc., San Rafael, CA 94901, USA.
| | - Gabriella Pridjian
- Tulane University Medical School, Hayward Genetics Center, New Orleans, LA 70112, USA.
| | | | - Uma M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | | | | | - Sandra M Sirrs
- Vancouver General Hospital, University of British Columbia, Vancouver V5Z 1M9, Canada.
| | | | - Danilo A Tagle
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Susan M Thompson
- The Children's Hospital at Westmead, Sydney, NSW 2145, Australia.
| | - Tiina K Urv
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Jeanine R Utz
- University of Minnesota, Minneapolis, MN 55455, USA.
| | - Francjan van Spronsen
- University of Groningen, University Medical Center of Groningen, Beatrix Children's Hospital, Netherlands.
| | - Jerry Vockley
- University of Pittsburgh, Pittsburgh, PA 15224, USA.
| | - Susan E Waisbren
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Linda S Weglicki
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Desirée A White
- Department of Psychology, Washington University, St. Louis, MO 63130, USA.
| | | | - Benjamin S Wilfond
- Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA 98101, USA.
| | | | - Justin M Young
- The Young Face, Facial Plastic and Reconstructive Surgery, Cumming, GA 30041, USA.
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Hood A, Grange DK, Christ SE, Steiner R, White DA. Variability in phenylalanine control predicts IQ and executive abilities in children with phenylketonuria. Mol Genet Metab 2014; 111:445-51. [PMID: 24568837 PMCID: PMC4144445 DOI: 10.1016/j.ymgme.2014.01.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 01/24/2014] [Accepted: 01/24/2014] [Indexed: 10/25/2022]
Abstract
A number of studies have revealed significant relationships between cognitive performance and average phenylalanine (Phe) levels in children with phenylketonuria (PKU), but only a few studies have been conducted to examine the relationships between cognitive performance and variability (fluctuations) in Phe levels. In the current study, we examined a variety of indices of Phe control to determine which index best predicted IQ and executive abilities in 47 school-age children with early- and continuously-treated PKU. Indices of Phe control were mean Phe, the index of dietary control, change in Phe with age, and several indices of variability in Phe (standard deviation, standard error of estimate, and percentage of spikes). These indices were computed over the lifetime and during 3 developmental epochs (<5, 5.0-9.9, and ≥10 years of age). Results indicated that variability in Phe was generally a stronger predictor of cognitive performance than other indices of Phe control. In addition, executive performance was better predicted by variability in Phe during older than younger developmental epochs. These results indicate that variability in Phe should be carefully controlled to maximize cognitive outcomes and that Phe control should not be liberalized as children with PKU age.
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Affiliation(s)
- Anna Hood
- Department of Psychology, Campus Box 1125, Washington University, St. Louis, MO 63130, USA
| | - Dorothy K Grange
- Department of Pediatrics, Campus Box 8116, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Shawn E Christ
- Department of Psychological Sciences, 210 McAlester Hall, University of Missouri, Columbia, MO 65211, USA
| | - Robert Steiner
- Department of Pediatrics, Institute on Development and Disability, 3181 SW Sam Jackson Park Rd., Oregon Health & Science University, Portland, OR 97239, USA; Department of Molecular & Medical Genetics, Institute on Development and Disability, 3181 SW Sam Jackson Park Rd., Oregon Health & Science University, Portland, OR 97239, USA
| | - Desirée A White
- Department of Psychology, Campus Box 1125, Washington University, St. Louis, MO 63130, USA.
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Neurocognitive evidence for revision of treatment targets and guidelines for phenylketonuria. J Pediatr 2014; 164:895-899.e2. [PMID: 24485821 DOI: 10.1016/j.jpeds.2013.12.015] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 11/14/2013] [Accepted: 12/11/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To compare the neurocognitive outcomes of patients with phenylketonuria (PKU) to determine whether decreasing phenylalanine (Phe) levels to <240 is preferable to the use of 360 μmol/L as an upper-target Phe level. An additional aim was to establish the influence of biochemical indices other than Phe on neurocognitive outcomes. STUDY DESIGN Patients with PKU (n = 63; mean age 10.8 ± 2.3 years) and healthy controls (n = 73; mean age 10.9 ± 2.2 years) performed computerized tasks measuring neurocognitive functions (inhibitory control, cognitive flexibility, and motor control). Lifetime and concurrent blood Phe levels, Phe-to-tyrosine ratio (Phe:Tyr), and Phe variations were examined in relation to neurocognitive outcomes using nonparametric tests and regression analyses. RESULTS Patients with PKU with Phe levels ≤240 μmol/L and healthy controls performed equally well. Patients with Phe levels between 240 and 360 μmol/L and ≥360 μmol/L performed more poorly than did controls across tasks. Patients with Phe levels ≤240 μmol/L performed significantly better than patients with levels between 240 and 360 μmol/L on tasks measuring inhibitory control and cognitive flexibility. Absolute Phe levels and Phe variation were the best predictors of motor control, whereas Phe:Tyr were the best predictors of inhibitory control. CONCLUSIONS The results of this study suggest that upper Phe targets should be lowered to optimize neurocognitive outcomes. Moreover, Phe variation and Phe:Tyr appear to be of additional value in treatment monitoring.
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Leuzzi V, Mannarelli D, Manti F, Pauletti C, Locuratolo N, Carducci C, Carducci C, Vanacore N, Fattapposta F. Age-related psychophysiological vulnerability to phenylalanine in phenylketonuria. Front Pediatr 2014; 2:57. [PMID: 25003100 PMCID: PMC4066367 DOI: 10.3389/fped.2014.00057] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 05/23/2014] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Phenylketonuria (PKU) is caused by the inherited defect of the phenylalanine hydroxylase enzyme, which converts phenylalanine (Phe) into tyrosine (Tyr). Neonatal screening programs and early treatment have radically changed the natural history of PKU. Nevertheless, an increased risk of neurocognitive and psychiatric problems in adulthood remains a challenging aspect of the disease. In order to assess the vulnerability of complex skills to Phe, we explored: (a) the effect of a rapid increase in blood Phe levels on event-related potentials (ERP) in PKU subjects during their second decade of life; (b) the association (if existing) between psychophysiological and neurocognitive features. METHODS Seventeen early-treated PKU subjects, aged 10-20, underwent ERP [mismatch negativity, auditory P300, contingent negative variation (CNV), and Intensity Dependence of Auditory Evoked Potentials] recording before and 2 h after an oral loading of Phe. Neurocognitive functioning, historical and concurrent biochemical values of blood Phe, Tyr, and Phe/Tyr ratio, were all included in the statistical analysis. RESULTS Event-related potential components were normally detected in all the subjects. In subjects younger than 13 CNV amplitude, W2-CNV area, P3b latency, and reaction times in motor responses were negatively influenced by Phe-loading. Independently from the psychophysiological vulnerability, some neurocognitive skills were more impaired in younger patients. No correlation was found between biochemical alterations and neurocognitive and psychophysiological findings. CONCLUSION The vulnerability of the emerging neurocognitive functions to Phe suggests a strict metabolic control in adolescents affected by PKU and a neurodevelopmental approach in the study of neurocognitive outcome in PKU.
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Affiliation(s)
- Vincenzo Leuzzi
- Department of Paediatrics, Child Neurology and Psychiatry, Sapienza Università di Roma , Rome , Italy
| | - Daniela Mannarelli
- Department of Neurology and Psychiatry, Sapienza Università di Roma , Rome , Italy
| | - Filippo Manti
- Department of Paediatrics, Child Neurology and Psychiatry, Sapienza Università di Roma , Rome , Italy
| | - Caterina Pauletti
- Department of Neurology and Psychiatry, Sapienza Università di Roma , Rome , Italy
| | - Nicoletta Locuratolo
- Department of Neurology and Psychiatry, Sapienza Università di Roma , Rome , Italy
| | - Carla Carducci
- Department of Experimental Medicine, Sapienza Università di Roma , Rome , Italy
| | - Claudia Carducci
- Department of Molecular Medicine, Sapienza Università di Roma , Rome , Italy
| | - Nicola Vanacore
- Centre for Epidemiology, Surveillance and Health Promotion (CNESPS), Istituto Superiore di Sanità , Rome , Italy
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A comparison of phenylketonuria with attention deficit hyperactivity disorder: do markedly different aetiologies deliver common phenotypes? Brain Res Bull 2013; 99:63-83. [PMID: 24140048 DOI: 10.1016/j.brainresbull.2013.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 09/04/2013] [Accepted: 10/07/2013] [Indexed: 01/21/2023]
Abstract
Phenylketonuria (PKU) is a well-defined metabolic disorder arising from a mutation that disrupts phenylalanine metabolism and so produces a variety of neural changes indirectly. Severe cognitive impairment can be prevented by dietary treatment; however, residual symptoms may be reported. These residual symptoms appear to overlap a more prevalent childhood disorder: Attention Deficit/Hyperactivity Disorder (ADHD). However, the aetiology of ADHD is a vast contrast to PKU: it seems to arise from a complex combination of genes; and it has a substantial environmental component. We ask whether these two disorders result from two vastly different genotypes that converge on a specific core phenotype that includes similar dysfunctions of Gray's (Gray, 1982) Behavioural Inhibition System (BIS), coupled with other disorder-specific dysfunctions. If so, we believe comparison of the commonalities will allow greater understanding of the neuropsychology of both disorders. We review in detail the aetiology, treatment, neural pathology, cognitive deficits and electrophysiological abnormalities of PKU; and compare this with selected directly matching aspects of ADHD. The biochemical and neural pathologies of PKU and ADHD are quite distinct in their causes and detail; but they result in the disorder in the brain of large amino acid levels, dopamine and white matter that are very similar and could explain the overlap of symptoms within and between the PKU and ADHD spectra. The common deficits affect visual function, motor function, attention, working memory, planning, and inhibition. For each of PKU and ADHD separately, a subset of deficits has been attributed to a primary dysfunction of behavioural inhibition. In the case of ADHD (excluding the inattentive subtype) this has been proposed to involve a specific failure of the BIS; and we suggest that this is also true of PKU. This accounts for a substantial proportion of the parallels in the superficial symptoms of both disorders and we see this as linked to prefrontal, rather than more general, dysfunction of the BIS.
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Fonnesbeck CJ, McPheeters ML, Krishnaswami S, Lindegren ML, Reimschisel T. Estimating the probability of IQ impairment from blood phenylalanine for phenylketonuria patients: a hierarchical meta-analysis. J Inherit Metab Dis 2013. [PMID: 23197105 DOI: 10.1007/s10545-012-9564-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Though the control of blood phenylalanine (Phe) levels is essential for minimizing impairment in individuals with phenylketonuria (PKU), the empirical basis for the selection of specific blood Phe levels as targets has not been evaluated. We evaluated the current evidence that particular Phe levels are optimal for minimizing or avoiding cognitive impairment in individuals with PKU. This work uses meta-estimates of blood Phe-IQ correlation to predict the probability of low IQ for a range of Phe levels. We believe this metric is easily interpretable by clinicians, and hence useful in making recommendations for Phe intake. The median baseline association of Phe with IQ was estimated to be negative, both in the context of historical (median = -0.026, 95 % BCI = [-0.040, -0.013]) and concurrent (-0.007, [-0.014, 0.000]) measurement of Phe relative to IQ. The estimated additive fixed effect of critical period Phe measurement was also nominally negative for historical measurement (-0.010, [-0.022, 0.003]) and positive for concurrent measurement (0.007, [-0.018, 0.035]). Probabilities corresponding to historical measures of blood Phe demonstrated an increasing chance of low IQ with increasing Phe, with a stronger association seen between blood Phe measured during the critical period than later. In contrast, concurrently-measured Phe was more weakly correlated with the probability of low IQ, though the correlation is still positive, irrespective of whether Phe was measured during the critical or non-critical period. This meta-analysis illustrates the utility of a Bayesian hierarchical approach for not only combining information from a set of candidate studies, but also for combining different types of data to estimate parameters of interest.
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Affiliation(s)
- Christopher J Fonnesbeck
- Department of Biostatistics, Vanderbilt University Medical Center, 1161 21st Ave South, S-2323 Medical Center North, Nashville, TN 37232-2158, USA.
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Berry SA, Brown C, Grant M, Greene CL, Jurecki E, Koch J, Moseley K, Suter R, van Calcar SC, Wiles J, Cederbaum S. Newborn screening 50 years later: access issues faced by adults with PKU. Genet Med 2013; 15:591-9. [PMID: 23470838 PMCID: PMC3938172 DOI: 10.1038/gim.2013.10] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 01/15/2013] [Indexed: 11/09/2022] Open
Abstract
Fifty years after the implementation of universal newborn screening programs for phenylketonuria, the first disease identified through newborn screening and considered a success story of newborn screening, a cohort of adults with phenylketonuria treated from birth provides valuable information about effects of long-term treatment for inborn errors of metabolism in general, and phenylketonuria specifically. For phenylketonuria, newborn screening allows early implementation of the phenylalanine-restricted diet, eliminating the severe neurocognitive and neuromotor impairment associated with untreated phenylketonuria. However, executive function impairments and psychiatric problems are frequently reported even for those treated early and continuously with the phenylalanine-restricted diet alone. Moreover, a large percentage of adults with phenylketonuria are reported as lost to follow-up by metabolic clinics. While a group of experts identified by the National Institutes of Health convenes to update treatment guidelines for phenylketonuria, we explore individual patient, social, and economic factors preventing >70% of adult phenylketonuria patients in the United States from accessing treatment. As more conditions are identified through newborn screening, factors affecting access to treatment grow in importance, and we must continue to be vigilant in assessing and addressing factors that affect patient treatment outcomes and not just celebrate amelioration of the most severe manifestations of disease.
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Affiliation(s)
- Susan A. Berry
- Department of Pediatrics, Division of
Genetics and Metabolism, University of Minnesota, Minneapolis,
Minnesota, USA
| | | | - Mitzie Grant
- Departments of Psychiatry and Pediatrics,
Drexel University College of Medicine, Philadelphia,
Pennsylvania, USA
| | - Carol L. Greene
- Department of Pediatrics, Division of
Genetics, University of Maryland, Baltimore, Maryland,
USA
| | | | | | - Kathryn Moseley
- Department of Pediatrics, Genetics Division,
University of Southern California Keck School of Medicine, Los
Angeles, California, USA
| | - Ruth Suter
- BioMarin Pharmaceutical Inc.,
Novato, California, USA
| | - Sandra C. van Calcar
- Department of Pediatrics and Waisman Center,
University of Wisconsin-Madison, Madison, Wisconsin,
USA
| | - Judy Wiles
- Facet Communications Inc.,
Toronto, Ontario, Canada
| | - Stephen Cederbaum
- Departments of Psychiatry, Pediatrics and
Human Genetics, University of California, Los Angeles, Los Angeles,
California, USA
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