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Bokayeva K, Jamka M, Walkowiak D, Duś-Żuchowska M, Herzig KH, Walkowiak J. Vitamin Status in Patients with Phenylketonuria: A Systematic Review and Meta-Analysis. Int J Mol Sci 2024; 25:5065. [PMID: 38791104 PMCID: PMC11120668 DOI: 10.3390/ijms25105065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/26/2024] Open
Abstract
The published data on the vitamin status of patients with phenylketonuria (PKU) is contradictory; therefore, this systematic review and meta-analysis evaluated the vitamin status of PKU patients. A comprehensive search of multiple databases (PubMed, Web of Sciences, Cochrane, and Scopus) was finished in March 2024. The included studies compared vitamin levels between individuals diagnosed with early-treated PKU and healthy controls while excluding pregnant and lactating women, untreated PKU or hyperphenylalaninemia cases, control groups receiving vitamin supplementation, PKU patients receiving tetrahydrobiopterin or pegvaliase, and conference abstracts. The risk of bias in the included studies was assessed by the Newcastle-Ottawa scale. The effect sizes were expressed as standardised mean differences. The calculation of effect sizes with 95% CI using fixed-effects models and random-effects models was performed. A p-value < 0.05 was considered statistically significant. The study protocol was registered in the PROSPERO database (CRD42024519589). Out of the initially identified 11,086 articles, 24 met the criteria. The total number of participants comprised 770 individuals with PKU and 2387 healthy controls. The meta-analyses of cross-sectional and case-control studies were conducted for vitamin B12, D, A, E, B6 and folate levels. PKU patients demonstrated significantly higher folate levels (random-effects model, SMD: 1.378, 95% CI: 0.436, 2.320, p = 0.004) and 1,25-dihydroxyvitamin D concentrations (random-effects model, SMD: 2.059, 95% CI: 0.250, 3.868, p = 0.026) compared to the controls. There were no significant differences in vitamin A, E, B6, B12 or 25-dihydroxyvitamin D levels. The main limitations of the evidence include a limited number of studies and their heterogeneity and variability in patients' compliance. Our findings suggest that individuals with PKU under nutritional guidance can achieve a vitamin status comparable to that of healthy subjects. Our study provides valuable insights into the nutritional status of PKU patients, but further research is required to confirm these findings and explore additional factors influencing vitamin status in PKU.
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Affiliation(s)
- Kamila Bokayeva
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Szpitalna Str. 27/33, 60-572 Poznań, Poland; (K.B.); (M.J.); (M.D.-Ż.); (K.-H.H.)
| | - Małgorzata Jamka
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Szpitalna Str. 27/33, 60-572 Poznań, Poland; (K.B.); (M.J.); (M.D.-Ż.); (K.-H.H.)
| | - Dariusz Walkowiak
- Department of Organization and Management in Health Care, Poznan University of Medical Sciences, Przybyszewskiego Str. 39, 60-356 Poznań, Poland;
| | - Monika Duś-Żuchowska
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Szpitalna Str. 27/33, 60-572 Poznań, Poland; (K.B.); (M.J.); (M.D.-Ż.); (K.-H.H.)
| | - Karl-Heinz Herzig
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Szpitalna Str. 27/33, 60-572 Poznań, Poland; (K.B.); (M.J.); (M.D.-Ż.); (K.-H.H.)
- Research Unit of Biomedicine and Internal Medicine, Biocenter of Oulu, Medical Research Center, Oulu University Hospital, University of Oulu, Aapistie Str. 5, 90220 Oulu, Finland
| | - Jarosław Walkowiak
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Szpitalna Str. 27/33, 60-572 Poznań, Poland; (K.B.); (M.J.); (M.D.-Ż.); (K.-H.H.)
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Hoss GRW, Sperb-Ludwig F, Tonon T, Poloni S, Behringer S, Blom HJ, Maillot F, Schwartz IVD. Homocysteine and methylmalonic acid in Phenylketonuria patients. Genet Mol Biol 2024; 46:e20230103. [PMID: 38591937 PMCID: PMC11000623 DOI: 10.1590/1678-4685-gmb-2023-0103] [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: 04/14/2023] [Accepted: 02/10/2024] [Indexed: 04/10/2024] Open
Abstract
Hyperhomocysteinemia and vitamin B12 deficiency have been reported in patients with phenylketonuria. In this study, total homocysteine (tHcy) and methylmalonic acid (MMA) levels were analyzed in samples from 25 phenylketonuria (PKU) patients. Comparisons were made between pre- and post-treatment values (n= 3); on treatment values, between periods with high and normal/low phenylalanine (Phe) levels (n= 20); and in women before, during and after pregnancy (n= 3). THcy levels decreased after treating PKU with metabolic formula (p=0.014). Except for a pregnant woman before pregnancy, none of the patients had tHcy values above the normal range. In fact, tHcy was < 5 μmol/L in 34% of the samples. We observed a decrease in Phe, tHcy, and tyrosine levels during pregnancy. MMA levels did not differ significantly, with values remaining in the normal range. These data indicate that there was no B12 deficiency in patients who adhere to the diet. In conclusion, in PKU patients treated with metabolic formula, tHcy is frequently not elevated, remaining even in the lower normal range in some patients. Thus, clinical follow-up and adherence to dietary treatment are crucial to prevent B12 deficiency.
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Affiliation(s)
- Giovana Regina Weber Hoss
- Hospital de Clínicas de Porto Alegre, Laboratório BRAIN, Porto
Alegre, RS, Brazil
- Universidade Federal do Rio Grande do Sul (UFRGS), Programa de
Pós-Graduação em Genética e Biologia Molecular, Porto Alegre, RS, Brazil
| | - Fernanda Sperb-Ludwig
- Hospital de Clínicas de Porto Alegre, Laboratório BRAIN, Porto
Alegre, RS, Brazil
- Universidade Federal do Rio Grande do Sul (UFRGS), Programa de
Pós-Graduação em Genética e Biologia Molecular, Porto Alegre, RS, Brazil
| | - Tássia Tonon
- Hospital de Clínicas de Porto Alegre, Laboratório BRAIN, Porto
Alegre, RS, Brazil
| | - Soraia Poloni
- Hospital de Clínicas de Porto Alegre, Laboratório BRAIN, Porto
Alegre, RS, Brazil
| | - Sidney Behringer
- University Medical Centre, Laboratory of Clinical Biochemistry and
Metabolism, Freiburg, Germany
| | - Henk J. Blom
- Erasmus Universiteit Rotterdam, Laboratory of Clinical Genetics, The
Netherlands
| | - François Maillot
- University Hospital of Tours, Department of Internal Medicine,
Tours, France
- UMR INSERM 1253, Tours, France
- Reference Center for Inherited Metabolic Diseases, Tours,
France
| | - Ida Vanessa Doederlein Schwartz
- Hospital de Clínicas de Porto Alegre, Laboratório BRAIN, Porto
Alegre, RS, Brazil
- Universidade Federal do Rio Grande do Sul (UFRGS), Programa de
Pós-Graduação em Genética e Biologia Molecular, Porto Alegre, RS, Brazil
- Hospital de Clínicas de Porto Alegre, Serviço de Genética Médica,
Porto Alegre, RS, Brazil
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3
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Mochel F. What can pediatricians learn from adult inherited metabolic diseases? J Inherit Metab Dis 2024. [PMID: 38520225 DOI: 10.1002/jimd.12729] [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: 02/03/2024] [Revised: 03/02/2024] [Accepted: 03/05/2024] [Indexed: 03/25/2024]
Abstract
The field of inherited metabolic diseases (IMD) has initially emerged and developed over decades in pediatric departments. Still, today, about 50% of patients with IMD are adults, and adult metabolic medicine (AMM) is getting more structured at national and international levels. There are several domains in which pediatricians can learn from AMM. First, long-term evolution of IMD patients, especially those treated since childhood, is critical to determine nutritional and neuropsychiatric outcomes in adults so that these outcomes can be better monitored, and patient care adjusted as much as possible from childhood. Conversely, the observation of attenuated phenotypes in adults of IMD known to present with severe phenotypes in children calls for caution in the development of newborn screening programs and, more largely, in the interpretation of next-generation sequencing data. Third, it is important for pediatricians to be familiar with adult-onset IMD as they expand our understanding of metabolism, including in children, such as oxysterols and glycogen metabolism. Last, the identification of common molecular and cellular mechanisms in neurodevelopment and neurodegeneration opens the way to synergistic therapeutic developments that will benefit both fields of pediatric and adult medicine. Overall, these observations underline the need of strong interdisciplinarity between pediatricians and adult specialists for the diagnosis and the treatment of IMD well beyond the issues of patient transition from pediatric to adult medicine.
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Affiliation(s)
- Fanny Mochel
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Medical Genetics, Reference Centers for Adult Neurometabolic Diseases and Adult Leukodystrophies, Paris, France
- INSERM U 1127, CNRS UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Paris Brain Institute, ICM, Paris, France
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4
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Tummolo A, Carella R, De Giovanni D, Paterno G, Simonetti S, Tolomeo M, Leone P, Barile M. Micronutrient Deficiency in Inherited Metabolic Disorders Requiring Diet Regimen: A Brief Critical Review. Int J Mol Sci 2023; 24:17024. [PMID: 38069347 PMCID: PMC10707160 DOI: 10.3390/ijms242317024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
Many inherited metabolic disorders (IMDs), including disorders of amino acid, fatty acid, and carbohydrate metabolism, are treated with a dietary reduction or exclusion of certain macronutrients, putting one at risk of a reduced intake of micronutrients. In this review, we aim to provide available evidence on the most common micronutrient deficits related to specific dietary approaches and on the management of their deficiency, in the meanwhile discussing the main critical points of each nutritional supplementation. The emerging concepts are that a great heterogeneity in clinical practice exists, as well as no univocal evidence on the most common micronutrient abnormalities. In phenylketonuria, for example, micronutrients are recommended to be supplemented through protein substitutes; however, not all formulas are equally supplemented and some of them are not added with micronutrients. Data on pyridoxine and riboflavin status in these patients are particularly scarce. In long-chain fatty acid oxidation disorders, no specific recommendations on micronutrient supplementation are available. Regarding carbohydrate metabolism disorders, the difficult-to-ascertain sugar content in supplementation formulas is still a matter of concern. A ketogenic diet may predispose one to both oligoelement deficits and their overload, and therefore deserves specific formulations. In conclusion, our overview points out the lack of unanimous approaches to micronutrient deficiencies, the need for specific formulations for IMDs, and the necessity of high-quality studies, particularly for some under-investigated deficits.
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Affiliation(s)
- Albina Tummolo
- Department of Metabolic Diseases, Clinical Genetics and Diabetology, Giovanni XXIII Children Hospital, Azienda Ospedaliero-Universitaria Consorziale, 70126 Bari, Italy; (R.C.); (D.D.G.); (G.P.)
| | - Rosa Carella
- Department of Metabolic Diseases, Clinical Genetics and Diabetology, Giovanni XXIII Children Hospital, Azienda Ospedaliero-Universitaria Consorziale, 70126 Bari, Italy; (R.C.); (D.D.G.); (G.P.)
| | - Donatella De Giovanni
- Department of Metabolic Diseases, Clinical Genetics and Diabetology, Giovanni XXIII Children Hospital, Azienda Ospedaliero-Universitaria Consorziale, 70126 Bari, Italy; (R.C.); (D.D.G.); (G.P.)
| | - Giulia Paterno
- Department of Metabolic Diseases, Clinical Genetics and Diabetology, Giovanni XXIII Children Hospital, Azienda Ospedaliero-Universitaria Consorziale, 70126 Bari, Italy; (R.C.); (D.D.G.); (G.P.)
| | - Simonetta Simonetti
- Regional Centre for Neonatal Screening, Department of Clinical Pathology and Neonatal Screening, Children’s Hospital “Giovanni XXIII”, Azienda Ospedaliero-Universitaria Consorziale, 70126 Bari, Italy;
| | - Maria Tolomeo
- Department of Biosciences, Biotechnology and Environment, University of Bari “A. Moro”, via Orabona 4, 70125 Bari, Italy; (M.T.); (P.L.)
- Department of DiBEST (Biologia, Ecologia e Scienze della Terra), University of Calabria, via P. Bucci 4C, 87036 Arcavacata di Rende, Italy
| | - Piero Leone
- Department of Biosciences, Biotechnology and Environment, University of Bari “A. Moro”, via Orabona 4, 70125 Bari, Italy; (M.T.); (P.L.)
| | - Maria Barile
- Department of Biosciences, Biotechnology and Environment, University of Bari “A. Moro”, via Orabona 4, 70125 Bari, Italy; (M.T.); (P.L.)
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Stolwijk NN, Bosch AM, Bouwhuis N, Häberle J, van Karnebeek C, van Spronsen FJ, Langeveld M, Hollak CEM. Food or medicine? A European regulatory perspective on nutritional therapy products to treat inborn errors of metabolism. J Inherit Metab Dis 2023; 46:1017-1028. [PMID: 37650776 DOI: 10.1002/jimd.12677] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/24/2023] [Accepted: 08/29/2023] [Indexed: 09/01/2023]
Abstract
Dietary or nutritional management strategies are the cornerstone of treatment for many inborn errors of metabolism (IEMs). Though a vital part of standard of care, the products prescribed for this are often not formally registered as medication. Instead, they are regulated as food or as food supplements, impacting the level of oversight as well as reimbursed policies. This scoping literature review explores the European regulatory framework relevant to these products and its implications for current clinical practice. Searches of electronic databases (PubMed, InfoCuria) were carried out, supplemented by articles identified by experts, from reference lists, relevant guidelines and case-law by the European Court of Justice. In the European Union (EU), nutritional therapy products are regulated as food supplements, food for special medical purposes (FSMPs) or medication. The requirements and level of oversight increase for each of these categories. Relying on lesser-regulated food products to treat IEMs raises concerns regarding product quality, safety, reimbursement and patient access. In order to ascertain whether a nutritional therapy product functions as medication and thus could be classified as such, we developed a flowchart to assess treatment characteristics (benefit, pharmacological attributes, and safety) with a case-based approach. Evaluating nutritional therapy products might reveal a justifiable need for a pharmaceutical product. A flowchart can facilitate systematically distinguishing products that function medication-like in the management of IEMs. Subsequently, finding and implementing appropriate solutions for these products might help improve the quality, safety and accessibility including reimbursement of treatment for IEMs.
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Affiliation(s)
- N N Stolwijk
- Medicine for Society, Platform at Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism. Amsterdam UMC, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM) Research Institute, Expertise center for inborn errors of Metabolism, MetabERN, University of Amsterdam, Amsterdam, The Netherlands
| | - A M Bosch
- Department of Pediatrics, Division of Metabolic Diseases, Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - N Bouwhuis
- Medicine for Society, Platform at Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Pharmacy, Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - J Häberle
- Department of Pediatrics, Division of Metabolism, University Children's Hospital Zürich, Zurich, Switzerland
| | - C van Karnebeek
- Department of Pediatrics and Human Genetics, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - F J van Spronsen
- Department of Metabolic Diseases, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - M Langeveld
- Department of Endocrinology and Metabolism. Amsterdam UMC, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM) Research Institute, Expertise center for inborn errors of Metabolism, MetabERN, University of Amsterdam, Amsterdam, The Netherlands
| | - C E M Hollak
- Medicine for Society, Platform at Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism. Amsterdam UMC, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM) Research Institute, Expertise center for inborn errors of Metabolism, MetabERN, University of Amsterdam, Amsterdam, The Netherlands
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6
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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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Udhani R, Kothari C, Sarvaiya J. A Comprehensive Study: Traditional and Cutting-Edge Analytical Techniques for the Biomarker Based Detection of the Micronutrients & POC Sensing Directions for Next-Generation Diagnostic. Crit Rev Anal Chem 2023:1-20. [PMID: 36720848 DOI: 10.1080/10408347.2023.2169823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Micronutrient deficiency is wide spread and highly affects morbidity, mortality, and well-being of human beings. Micronutrient deficiency gradually manifests into diseases, which effects pathophysiology directly or indirectly. There is an imprecision in the diagnosis of micronutrient deficiency because of two causes; the selection of the standard biomarker and the diagnostic technique used. In appropriate diagnosis could increase the severity of the disorder. Instead of a single a combination of biomarkers can give more stringent results for micronutrient testing. Several traditional analytical techniques are used for diagnosis but HPLC, ELISA & LCMS/MS are most sensitive and reliable methods used by CLSIA-certified labs. However, these techniques require well-equipped, centralized laboratory facilities. The diagnostic era moves toward the Point of Care Testing (POCT), a boon in emerging diagnostics, breaking all paradigms of traditional analytical techniques. POCT led us toward the development of biosensors, which encompasses many techniques like paper-based sensors, microfluidic chip, wearable devices, and smartphone-assisted diagnostics, which become more popular diagnostic tools. This outlook summarizes the micronutrients like vitamins A, B5, B6, B7, B9, B12 C, D, and E and Minerals like iron, calcium, zinc, magnesium, and sodium; along with its biomarkers, analytical techniques, and point of care innovation in micronutrients.
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Affiliation(s)
- Raveena Udhani
- Department of Pharmaceutical Analysis, Institute of Pharmacy, Nirma University, Ahmedabad, Gujarat, India
| | - Charmy Kothari
- Department of Pharmaceutical Analysis, Institute of Pharmacy, Nirma University, Ahmedabad, Gujarat, India
| | - Jayrajsinh Sarvaiya
- School of Engineering and Technology, National Forensic Science University, Gandhinagar, Gujarat, India
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8
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Huang HH, Cohen AA, Gaudreau P, Auray-Blais C, Allard D, Boutin M, Reid I, Turcot V, Presse N. Vitamin B-12 Intake from Dairy but Not Meat Is Associated with Decreased Risk of Low Vitamin B-12 Status and Deficiency in Older Adults from Quebec, Canada. J Nutr 2022; 152:2483-2492. [PMID: 36774114 PMCID: PMC9644171 DOI: 10.1093/jn/nxac143] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/26/2022] [Accepted: 06/19/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Vitamin B-12 deficiency can result in irreversible neurologic damages. It is most prevalent among older adults (∼5%-15%), mainly due to impaired absorption. Vitamin B-12 bioavailability varies between food sources, so their importance in preventing deficiency may also vary. OBJECTIVES Using the NuAge Database and Biobank, we examined the associations between vitamin B-12 intake (total and by specific food groups) and low vitamin B-12 status and deficiency in older adults. METHODS NuAge-the Quebec Longitudinal Study on Nutrition and Successful Aging-included 1753 adults aged 67-84 y who were followed 4 y. Analytic samples comprised 1230-1463 individuals. Dietary vitamin B-12 intake was assessed annually using three 24-h dietary recalls. Vitamin B-12 status was assessed annually as low serum vitamin B-12 (<221 pmol/L), elevated urinary methylmalonic acid (MMA)/creatinine ratio (>2 μmol/mmol), and a combination of both (deficiency). Vitamin B-12 supplement users were excluded. Multilevel logistic regressions, adjusted for relevant confounders, were used. RESULTS Across all study years, 21.8%-32.5% of participants had low serum vitamin B-12, 12.5%-17.0% had elevated urine MMA/creatinine, and 10.1%-12.7% had deficiency. Median (IQR) total vitamin B-12 intake was 3.19 μg/d (2.31-4.37). Main sources were "dairy" and "meat, poultry, and organ meats." The ORs (95% CIs) in the fifth quintile compared with the first of total vitamin B-12 intake were as follows: for low serum vitamin B-12, 0.52 (0.37, 0.75; P-trend < 0.0001); for elevated urine MMA/creatinine, 0.63 (0.37, 1.08; P-trend = 0.091); and for vitamin B-12 deficiency, 0.38 (0.18, 0.79; P-trend = 0.006). Similarly, ORs (95% CIs) in the fourth quartile compared with the first of dairy-derived vitamin B-12 intake were 0.46 (0.32, 0.66; P-trend < 0.0001), 0.51 (0.30, 0.87; P-trend = 0.006), and 0.35 (0.17, 0.73; P-trend = 0.003), respectively. No associations were observed with vitamin B-12 from "meat, poultry, and organ meats." CONCLUSIONS Higher dietary vitamin B-12 intake, especially from dairy, was associated with decreased risk of low vitamin B-12 status and deficiency in older adults. Food groups might contribute differently at reducing risk of deficiency in older populations.
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Affiliation(s)
- He Helen Huang
- Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada,Research Centre on Aging, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada
| | - Alan A Cohen
- Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada,Research Centre on Aging, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada,Centre hospitalier universitaire de Sherbrooke Research Center, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada
| | - Pierrette Gaudreau
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada,Centre hospitalier de l'Université de Montréal Research Center, Montreal, Quebec, Canada
| | - Christiane Auray-Blais
- Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada,Centre hospitalier universitaire de Sherbrooke Research Center, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada
| | - David Allard
- Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Michel Boutin
- Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada,Centre hospitalier universitaire de Sherbrooke Research Center, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada
| | - Isabelle Reid
- Centre de recherche de l'Institut universitaire de gériatrie de Montréal, CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montréal, Quebec, Canada
| | - Valérie Turcot
- Research Centre on Aging, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada
| | - Nancy Presse
- Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada; Research Centre on Aging, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada; Centre de recherche de l'Institut universitaire de gériatrie de Montréal, CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montréal, Quebec, Canada.
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9
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Berger MM, Shenkin A, Schweinlin A, Amrein K, Augsburger M, Biesalski HK, Bischoff SC, Casaer MP, Gundogan K, Lepp HL, de Man AME, Muscogiuri G, Pietka M, Pironi L, Rezzi S, Cuerda C. ESPEN micronutrient guideline. Clin Nutr 2022; 41:1357-1424. [PMID: 35365361 DOI: 10.1016/j.clnu.2022.02.015] [Citation(s) in RCA: 175] [Impact Index Per Article: 87.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Trace elements and vitamins, named together micronutrients (MNs), are essential for human metabolism. Recent research has shown the importance of MNs in common pathologies, with significant deficiencies impacting the outcome. OBJECTIVE This guideline aims to provide information for daily clinical nutrition practice regarding assessment of MN status, monitoring, and prescription. It proposes a consensus terminology, since many words are used imprecisely, resulting in confusion. This is particularly true for the words "deficiency", "repletion", "complement", and "supplement". METHODS The expert group attempted to apply the 2015 standard operating procedures (SOP) for ESPEN which focuses on disease. However, this approach could not be applied due to the multiple diseases requiring clinical nutrition resulting in one text for each MN, rather than for diseases. An extensive search of the literature was conducted in the databases Medline, PubMed, Cochrane, Google Scholar, and CINAHL. The search focused on physiological data, historical evidence (published before PubMed release in 1996), and observational and/or randomized trials. For each MN, the main functions, optimal analytical methods, impact of inflammation, potential toxicity, and provision during enteral or parenteral nutrition were addressed. The SOP wording was applied for strength of recommendations. RESULTS There was a limited number of interventional trials, preventing meta-analysis and leading to a low level of evidence. The recommendations underwent a consensus process, which resulted in a percentage of agreement (%): strong consensus required of >90% of votes. Altogether the guideline proposes sets of recommendations for 26 MNs, resulting in 170 single recommendations. Critical MNs were identified with deficiencies being present in numerous acute and chronic diseases. Monitoring and management strategies are proposed. CONCLUSION This guideline should enable addressing suboptimal and deficient status of a bundle of MNs in at-risk diseases. In particular, it offers practical advice on MN provision and monitoring during nutritional support.
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Affiliation(s)
- Mette M Berger
- Department of Adult Intensive Care, Lausanne University Hospital (CHUV), Lausanne, Switzerland.
| | - Alan Shenkin
- Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, UK.
| | - Anna Schweinlin
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany.
| | - Karin Amrein
- Medical University of Graz, Department of Internal Medicine, Division of Endocrinology and Diabetology, Austria.
| | - Marc Augsburger
- University Centre of Legal Medicine Lausanne-Geneva, Lausanne University Hospital and University of Lausanne, Geneva University Hospital and University of Geneva, Lausanne-Geneva, Switzerland.
| | | | - Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany.
| | - Michael P Casaer
- KU Leuven, Department of Cellular and Molecular Medicine, Laboratory of Intensive Care Medicine, Leuven, Belgium.
| | - Kursat Gundogan
- Division of Intensive Care Medicine, Department of Internal Medicine, Erciyes University School of Medicine, Kayseri, Turkey.
| | | | - Angélique M E de Man
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam Medical Data Science (AMDS), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
| | - Giovanna Muscogiuri
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università di Napoli (Federico II), Naples, Italy; United Nations Educational, Scientific and Cultural Organization (UNESCO) Chair for Health Education and Sustainable Development, Federico II, University, Naples, Italy.
| | - Magdalena Pietka
- Pharmacy Department, Stanley Dudrick's Memorial Hospital, Skawina, Poland.
| | - Loris Pironi
- Alma Mater Studiorum - University of Bologna, Department of Medical and Surgical Sciences, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna, Centre for Chronic Intestinal Failure - Clinical Nutrition and Metabolism Unit, Italy.
| | - Serge Rezzi
- Swiss Nutrition and Health Foundation (SNHf), Epalinges, Switzerland.
| | - Cristina Cuerda
- Departamento de Medicina, Universidad Complutense de Madrid, Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
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10
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Methylmalonic acid analysis using urine filter paper samples to screen for metabolic vitamin B 12 deficiency in older adults. Bioanalysis 2022; 14:615-626. [PMID: 35546317 DOI: 10.4155/bio-2022-0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Aim: Methylmalonic acid (MMA) analysis in urine represents a noninvasive approach to screening for vitamin B12 deficiency in older adults. A method allowing the analysis of MMA/creatinine in fasting urine collected on filter paper was developed/validated. Method: Dry urine specimens were eluted using a solution containing internal standards, filtrated and analyzed by ultra-performance LC-MS/MS. Results: The method allowed the chromatographic separation of MMA from succinic acid. Dried urine samples were stable for 86 days at room temperature. The MMA/creatinine ratios measured in urine collected on filter paper were highly correlated with values derived from the corresponding liquid specimens. Conclusion: This robust filter paper method might greatly improve the accessibility and cost-effectiveness of vitamin B12 deficiency screening in older adults.
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11
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Gama MI, Pinto A, Daly A, Rocha JC, MacDonald A. The Impact of the Quality of Nutrition and Lifestyle in the Reproductive Years of Women with PKU on the Long-Term Health of Their Children. Nutrients 2022; 14:nu14051021. [PMID: 35267995 PMCID: PMC8912747 DOI: 10.3390/nu14051021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 02/24/2022] [Accepted: 02/24/2022] [Indexed: 11/29/2022] Open
Abstract
A woman’s nutritional status before and during pregnancy can affect the health of her progeny. Phenylketonuria (PKU), a rare disorder causing high blood and brain phenylalanine (Phe) concentrations, is associated with neurocognitive disability. Lifelong treatment is mainly dietetic with a Phe-restricted diet, supplemented with a low-Phe protein substitute. Treatment adherence commonly decreases in adolescence, with some adults ceasing dietary treatment. In maternal PKU, elevated blood Phe is harmful to the fetus so a strict Phe-restricted diet must be re-established preconception, and this is particularly difficult to achieve. A woman’s reproductive years introduces an opportunity to adopt healthier behaviours to prepare for successful pregnancies and positive health outcomes for both themselves and their children. Several factors can influence the health status of women with PKU. Political, socioeconomic, and individual food and lifestyle choices affect diet quality, metabolic control, and epigenetics, which then pre-condition the overall maternal health and long-term health of the child. Here, we reflect on a comprehensive approach to treatment and introduce practical recommendations to optimize the wellbeing of women with PKU and the resultant health of their children.
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Affiliation(s)
- Maria Inês Gama
- Nutrition & Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo dos Mártires da Pátria 130, 1169-056 Lisboa, Portugal; (M.I.G.); (J.C.R.)
| | - Alex Pinto
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.P.); (A.D.)
| | - Anne Daly
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.P.); (A.D.)
| | - Júlio César Rocha
- Nutrition & Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo dos Mártires da Pátria 130, 1169-056 Lisboa, Portugal; (M.I.G.); (J.C.R.)
- Reference Centre of Inherited Metabolic Diseases, Centro Hospitalar Universitário de Lisboa Central, 1169-045 Lisboa, Portugal
- CINTESIS—Center for Health Technology and Services Research, NOVA Medical School, Campo dos Mártires da Pátria 130, 1169-056 Lisboa, Portugal
| | - Anita MacDonald
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.P.); (A.D.)
- Correspondence:
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12
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Hinkel J, Schmitt J, Wurm M, Rosenbaum-Fabian S, Schwab KO, Jacobsen DW, Spiekerkoetter U, Fedosov SN, Hannibal L, Grünert SC. Elevated Plasma Vitamin B 12 in Patients with Hepatic Glycogen Storage Diseases. J Clin Med 2020; 9:jcm9082326. [PMID: 32707782 PMCID: PMC7463656 DOI: 10.3390/jcm9082326] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/13/2020] [Accepted: 07/17/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Hepatic glycogen storage diseases (GSDs) are inborn errors of metabolism affecting the synthesis or breakdown of glycogen in the liver. This study, for the first time, systematically assessed vitamin B12 status in a large cohort of hepatic GSD patients. Methods: Plasma vitamin B12, total plasma homocysteine (tHcy) and methylmalonic acid concentrations were measured in 44 patients with hepatic GSDs and compared to 42 healthy age- and gender-matched controls. Correlations of vitamin B12 status with different disease markers of GSDs (including liver transaminase activities and triglycerides) as well as the vitamin B12 intake were studied. Results: GSD patients had significantly higher plasma vitamin B12 concentrations than healthy controls (p = 0.0002). Plasma vitamin B12 concentration remained elevated in GSD patients irrespective of vitamin B12 intake. Plasma vitamin B12 concentrations correlated negatively with triglyceride levels, whereas no correlations were detected with liver transaminase activities (GOT and GPT) in GSD patients. Merging biomarker data of healthy controls and GSD patients showed a positive correlation between vitamin B12 status and liver function, which suggests complex biomarker associations. A combined analysis of biomarkers permitted a reliable clustering of healthy controls versus GSD patients. Conclusions: Elevated plasma concentration of vitamin B12 (irrespective of B12 intake) is a common finding in patients with hepatic GSD. The negative correlation of plasma vitamin B12 with triglyceride levels suggests an influence of metabolic control on the vitamin B12 status of GSD patients. Elevated vitamin B12 was not correlated with GOT and GPT in our cohort of GSD patients. Merging of data from healthy controls and GSD patients yielded positive correlations between these biomarkers. This apparent dichotomy highlights the intrinsic complexity of biomarker associations and argues against generalizations of liver disease and elevated vitamin B12 in blood. Further studies are needed to determine whether the identified associations are causal or coincidental, and the possible impact of chronically elevated vitamin B12 on GSD.
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Affiliation(s)
- Julia Hinkel
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center—University of Freiburg, 79106 Freiburg, Germany; (J.H.); (J.S.); (S.R.-F.); (K.O.S.); (U.S.)
| | - Johannes Schmitt
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center—University of Freiburg, 79106 Freiburg, Germany; (J.H.); (J.S.); (S.R.-F.); (K.O.S.); (U.S.)
| | - Michael Wurm
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center—University of Freiburg, 79106 Freiburg, Germany; (J.H.); (J.S.); (S.R.-F.); (K.O.S.); (U.S.)
- Department of Pediatrics, St. Hedwigs Campus, University Children’s Hospital Regensburg, 93049 Regensburg, Germany;
| | - Stefanie Rosenbaum-Fabian
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center—University of Freiburg, 79106 Freiburg, Germany; (J.H.); (J.S.); (S.R.-F.); (K.O.S.); (U.S.)
| | - Karl Otfried Schwab
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center—University of Freiburg, 79106 Freiburg, Germany; (J.H.); (J.S.); (S.R.-F.); (K.O.S.); (U.S.)
| | - Donald W. Jacobsen
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA;
| | - Ute Spiekerkoetter
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center—University of Freiburg, 79106 Freiburg, Germany; (J.H.); (J.S.); (S.R.-F.); (K.O.S.); (U.S.)
| | - Sergey N. Fedosov
- Department of Molecular Biology and Genetics, Aarhus University, DK-8000 Aarhus C, Denmark;
| | - Luciana Hannibal
- Laboratory of Clinical Biochemistry and Metabolism, Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center - University of Freiburg, Faculty of Medicine, 79106 Freiburg, Germany
- Correspondence: (L.H.); (S.C.G.)
| | - Sarah C. Grünert
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center—University of Freiburg, 79106 Freiburg, Germany; (J.H.); (J.S.); (S.R.-F.); (K.O.S.); (U.S.)
- Correspondence: (L.H.); (S.C.G.)
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13
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Akış M, Kant M, Işık İ, Kısa PT, Köse E, Arslan N, İşlekel H. Functional vitamin B12 deficiency in phenylketonuria patients and healthy controls: An evaluation with combined indicator of vitamin B12 status as a biochemical index. Ann Clin Biochem 2020; 57:291-299. [PMID: 32482081 DOI: 10.1177/0004563220935140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Vitamin B12 deficiency frequently appears in phenylketonuria patients having a diet poor in natural protein. The aims of this study were to evaluate vitamin B12 status in phenylketonuria patients by using combined indicator of vitamin B12 status (cB12) as well as methylmalonic acid and homocysteine, more specific and sensitive markers, in comparison with healthy controls. METHODS Fifty-three children and adolescents with phenylketonuria under dietary treatment and 30 healthy controls were assessed cross-sectionally. Serum vitamin B12 and folate concentrations were analysed by chemiluminescence immunoassay. Plasma methylmalonic acid and total homocysteine concentrations were measured by liquid chromatography-tandem mass spectrometry and liquid chromatography, respectively. cB12 was calculated by using a formula involving blood parameters. RESULTS Methylmalonic acid and folate concentrations in phenylketonuria group were higher compared with controls. Methylmalonic acid concentrations were high in 56.5% of the patients and 26.7% of the controls with normal vitamin B12 concentrations. Based on cB12, a significant difference within the normal values was detected between the groups. However, although 24.5% of phenylketonuria patients and 13.3% of controls had decreased vitamin B12 status according to cB12, there was no significant difference. CONCLUSION Children and adolescents with phenylketonuria having a strict diet can be at risk of functional vitamin B12 deficiency. This deficiency can be accurately determined by measuring methylmalonic acid concentrations. Calculation of cB12 as a biochemical index did not provide additional information compared with the measurement of methylmalonic acid alone, but may be helpful for classification of some patients with increased methylmalonic acid as having adequate vitamin B12 status.
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Affiliation(s)
- Merve Akış
- Department of Medical Biochemistry, School of Medicine, Balikesir University, Balikesir, Turkey
| | - Melis Kant
- Department of Medical Biochemistry, Institute of Health Sciences, School of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - İshak Işık
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Health Sciences University Antalya Training and Research Hospital, Antalya, Turkey
| | - Pelin Teke Kısa
- Division of Pediatric Metabolism and Nutrition, Dokuz Eylul University, Izmir, Turkey
| | - Engin Köse
- Division of Pediatric Metabolism and Nutrition, Dokuz Eylul University, Izmir, Turkey
| | - Nur Arslan
- Division of Pediatric Metabolism and Nutrition, Dokuz Eylul University, Izmir, Turkey
| | - Hüray İşlekel
- Department of Medical Biochemistry, School of Medicine, Dokuz Eylul University, Izmir, Turkey.,Department of Molecular Medicine, Institute of Health Sciences, Dokuz Eylul University, Izmir, Turkey
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14
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Manta-Vogli PD, Schulpis KH, Dotsikas Y, Loukas YL. Nutrition and medical support during pregnancy and lactation in women with inborn errors of intermediary metabolism disorders (IEMDs). J Pediatr Endocrinol Metab 2020; 33:5-20. [PMID: 31804959 DOI: 10.1515/jpem-2019-0048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 09/20/2019] [Indexed: 12/25/2022]
Abstract
The establishment of expanded newborn screening (NBS) not only results in the early diagnosis and treatment of neonates with inborn errors of intermediary metabolism disorders (IEMDs) but also helps the affected females to reach the reproductive age under medical and dietetic support, as well as to give birth to normal infants. In this review, we aimed to focus on laboratory investigation tests, dietetic management and medical support for most known IEMD pregnant and lactating women, such as those suffering from aminoacidopathies, carbohydrate metabolic diseases and fatty acid (FAO) oxidation disorders.
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Affiliation(s)
- Penelope D Manta-Vogli
- Department of Clinical Nutrition and Dietetics, Agia Sofia Children's Hospital, Athens, Greece
| | | | - Yannis Dotsikas
- Laboratory of Pharm. Analysis, Department of Pharmacy, National and Kapodestrian University of Athens, Panepistimiopolis Zographou, GR-157 71, Athens, Greece, Phone: +30 210 7274696, Fax: +30 210 7274039
| | - Yannis L Loukas
- Laboratory of Pharm. Analysis, Department of Pharmacy, National and Kapodestrian University of Athens, Panepistimiopolis Zographou, GR-157 71, Athens, Greece, Phone: +30 210 7274224, Fax: +30 211 1826131
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15
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van Vliet K, Rodenburg IL, van Ginkel WG, Lubout CMA, Wolffenbuttel BHR, van der Klauw MM, Heiner-Fokkema MR, van Spronsen FJ. Biomarkers of Micronutrients in Regular Follow-Up for Tyrosinemia Type 1 and Phenylketonuria Patients. Nutrients 2019; 11:E2011. [PMID: 31461828 PMCID: PMC6769775 DOI: 10.3390/nu11092011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/16/2019] [Accepted: 08/21/2019] [Indexed: 12/26/2022] Open
Abstract
Phenylketonuria (PKU) is treated with dietary restrictions and sometimes tetrahydrobiopterin (BH4). PKU patients are at risk for developing micronutrient deficiencies, such as vitamin B12 and folic acid, likely due to their diet. Tyrosinemia type 1 (TT1) is similar to PKU in both pathogenesis and treatment. TT1 patients follow a similar diet, but nutritional deficiencies have not been investigated yet. In this retrospective study, biomarkers of micronutrients in TT1 and PKU patients were investigated and outcomes were correlated to dietary intake and anthropometric measurements from regular follow-up measurements from patients attending the outpatient clinic. Data was analyzed using Kruskal-Wallis, Fisher's exact and Spearman correlation tests. Furthermore, descriptive data were used. Overall, similar results for TT1 and PKU patients (with and without BH4) were observed. In all groups high vitamin B12 concentrations were seen rather than B12 deficiencies. Furthermore, all groups showed biochemical evidence of vitamin D deficiency. This study shows that micronutrients in TT1 and PKU patients are similar and often within the normal ranges and that vitamin D concentrations could be optimized.
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Affiliation(s)
- Kimber van Vliet
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Iris L Rodenburg
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Willem G van Ginkel
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Charlotte M A Lubout
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Bruce H R Wolffenbuttel
- Department of Endocrinology, Groningen, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Melanie M van der Klauw
- Department of Endocrinology, Groningen, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - M Rebecca Heiner-Fokkema
- Laboratory of Metabolic Diseases, Groningen, Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Francjan J van Spronsen
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
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16
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Wolffenbuttel BH, Wouters HJ, Heiner-Fokkema MR, van der Klauw MM. The Many Faces of Cobalamin (Vitamin B 12) Deficiency. Mayo Clin Proc Innov Qual Outcomes 2019; 3:200-214. [PMID: 31193945 PMCID: PMC6543499 DOI: 10.1016/j.mayocpiqo.2019.03.002] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Although cobalamin (vitamin B12) deficiency was described over a century ago, it is still difficult to establish the correct diagnosis and prescribe the right treatment. Symptoms related to vitamin B12 deficiency may be diverse and vary from neurologic to psychiatric. A number of individuals with vitamin B12 deficiency may present with the classic megaloblastic anemia. In clinical practice, many cases of vitamin B12 deficiency are overlooked or sometimes even misdiagnosed. In this review, we describe the heterogeneous disease spectrum of patients with vitamin B12 deficiency in whom the diagnosis was either based on low serum B12 levels, elevated biomarkers like methylmalonic acid and/or homocysteine, or the improvement of clinical symptoms after the institution of parenteral vitamin B12 therapy. We discuss the possible clinical signs and symptoms of patients with B12 deficiency and the various pitfalls of diagnosis and treatment.
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Affiliation(s)
- Bruce H.R. Wolffenbuttel
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, NL-9700 RB, The Netherlands
- Correspondence: Address to Bruce H. R. Wolffenbuttel, MD, PhD, Department of Endocrinology, University of Groningen, University Medical Center Groningen, HPC AA31 9700 RB Groningen, The Netherlands
| | - Hanneke J.C.M. Wouters
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, NL-9700 RB, The Netherlands
- Department of Haematology, University of Groningen, University Medical Center Groningen, Groningen, NL-9700 RB, The Netherlands
| | - M. Rebecca Heiner-Fokkema
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, NL-9700 RB, The Netherlands
| | - Melanie M. van der Klauw
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, NL-9700 RB, The Netherlands
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17
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Evers RAF, van Wegberg AMJ, van Dam E, de Vries MC, Janssen MCH, van Spronsen FJ. Anthropomorphic measurements and nutritional biomarkers after 5 years of BH 4 treatment in phenylketonuria patients. Mol Genet Metab 2018; 124:238-242. [PMID: 30078395 DOI: 10.1016/j.ymgme.2018.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/17/2018] [Accepted: 06/17/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Roeland A F Evers
- University of Groningen, University Medical Center Groningen, Division of Metabolic Diseases, PO box 30.001, 9700 RB Groningen, The Netherlands
| | - Annemiek M J van Wegberg
- University of Groningen, University Medical Center Groningen, Division of Metabolic Diseases, PO box 30.001, 9700 RB Groningen, The Netherlands; Radboud University Medical Center Nijmegen, Department of Gastroenterology and Hepatology-Dietetics, PO box 9101, 6500 HB Nijmegen, The Netherlands
| | - Esther van Dam
- University of Groningen, University Medical Center Groningen, Division of Metabolic Diseases, PO box 30.001, 9700 RB Groningen, The Netherlands
| | - Maaike C de Vries
- Radboud University Medical Center Nijmegen, Department of Pediatrics, PO box 9101, 6500 HB Nijmegen, The Netherlands
| | - Mirian C H Janssen
- Radboud University Medical Center, Department of Internal Medicine, PO box 9101, 6500 HB Nijmegen, The Netherlands
| | - Francjan J van Spronsen
- University of Groningen, University Medical Center Groningen, Division of Metabolic Diseases, PO box 30.001, 9700 RB Groningen, The Netherlands.
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18
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Stroup BM, Ney DM, Murali SG, Rohr F, Gleason ST, van Calcar SC, Levy HL. Metabolomic Insights into the Nutritional Status of Adults and Adolescents with Phenylketonuria Consuming a Low-Phenylalanine Diet in Combination with Amino Acid and Glycomacropeptide Medical Foods. J Nutr Metab 2017; 2017:6859820. [PMID: 29464117 PMCID: PMC5804357 DOI: 10.1155/2017/6859820] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 10/23/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Nutrient status in phenylketonuria (PKU) requires surveillance due to the restrictive low-Phe diet in combination with amino acid medical foods (AA-MF) or glycomacropeptide medical foods (GMP-MF). Micronutrient profiles of medical foods are diverse, and optimal micronutrient supplementation in PKU has not been established. METHODS In a crossover design, 30 participants with PKU were randomized to consume AA-MF and Glytactin™ GMP-MF in combination with a low-Phe diet for 3 weeks each. Fasting venipunctures, medical food logs, and 3-day food records were obtained. Metabolomic analyses were completed in plasma and urine by Metabolon, Inc. RESULTS The low-Phe diets in combination with AA-MF and GMP-MF were generally adequate based on Dietary Reference Intakes, clinical measures, and metabolomics. Without micronutrient supplementation of medical foods, >70% of participants would have inadequate intakes for 11 micronutrients. Despite micronutrient supplementation of medical foods, inadequate intakes of potassium in 93% of participants and choline in >40% and excessive intakes of sodium in >63% of participants and folic acid in >27% were observed. Sugar intake was excessive and provided 27% of energy. CONCLUSIONS Nutrient status was similar with AA-MF and Glytactin GMP-MF. More research related to micronutrient supplementation of medical foods for the management of PKU is needed.
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Affiliation(s)
- Bridget M. Stroup
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Denise M. Ney
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Sangita G. Murali
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Frances Rohr
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sally T. Gleason
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Sandra C. van Calcar
- Department of Molecular and Medical Genetics, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Harvey L. Levy
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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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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Singh RH, Cunningham AC, Mofidi S, Douglas TD, Frazier DM, Hook DG, Jeffers L, McCune H, Moseley KD, Ogata B, Pendyal S, Skrabal J, Splett PL, Stembridge A, Wessel A, Rohr F. Updated, web-based nutrition management guideline for PKU: An evidence and consensus based approach. Mol Genet Metab 2016; 118:72-83. [PMID: 27211276 DOI: 10.1016/j.ymgme.2016.04.008] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/15/2016] [Accepted: 04/15/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND In 2014, recommendations for the nutrition management of phenylalanine hydroxylase deficiency were published as a companion to the concurrently published American College of Medical Genetics and Genomics guideline for the medical treatment of phenylketonuria (PKU). These were developed primarily from a summary of findings from the PKU scientific review conference sponsored by the National Institutes of Health and Agency for Healthcare Research & Quality along with additional systematic literature review. Since that time, the Genetic Metabolic Dietitians International and the Southeast Regional Newborn Screening and Genetics Collaborative have partnered to create a web-based technology platform for the update and development of nutrition management guidelines for inherited metabolic disorders. OBJECTIVE The purpose of this PKU guideline is to establish harmonization in treatment and monitoring, to guide the integration of nutrition therapy in the medical management of PKU, and to improve outcomes (nutritional, cognitive, and developmental) for individuals with PKU in all life stages while reducing associated medical, educational, and social costs. METHODS Six research questions critical to PKU nutrition management were formulated to support guideline development: Review, critical appraisal, and abstraction of peer-reviewed studies and unpublished practice literature, along with expert Delphi survey feedback, nominal group process, and external review from metabolic physicians and dietitians were utilized for development of recommendations relevant to each question. Recommendations address nutrient intake, including updated protein requirements, optimal blood phenylalanine concentrations, nutrition interventions, monitoring parameters specific to life stages, adjunct therapies, and pregnancy and lactation. Recommendations were graded using a rigorous system derived from the Academy of Nutrition and Dietetics. RESULTS AND CONCLUSION These guidelines, updated utilizing a thorough and systematic approach to literature analysis and national consensus process, are now easily accessible to the global community via the newly developed digital platform. For additional details on specific topics, readers are encouraged to review materials on the online portal: https://GMDI.org/.
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Affiliation(s)
- Rani H Singh
- Department of Human Genetics, Emory University School of Medicine, 2165 North Decatur Road, Decatur, Atlanta, GA 30033, USA; Nutrition Health Sciences Program, Graduate Division of Biological and Biomedical Sciences, Emory University School of Arts and Sciences, Atlanta, GA, USA.
| | - Amy C Cunningham
- Hayward Genetics Center, Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA 70112, USA.
| | - Shideh Mofidi
- Inherited Metabolic Disease Center, Maria Fareri Childrens Hospital, Westchester Medical Center, New York Medical College, Valhalla, New York, USA.
| | - Teresa D Douglas
- Department of Human Genetics, Emory University School of Medicine, 2165 North Decatur Road, Decatur, Atlanta, GA 30033, USA.
| | - Dianne M Frazier
- Division of Genetics and Metabolism, University of North Carolina School of Medicine, 1100 Manning Drive, Chapel Hill, NC 27599, USA.
| | | | - Laura Jeffers
- Cleveland Clinic, Center for Human Nutrition, 9500 Euclid Ave, Cleveland, OH 44195, USA.
| | - Helen McCune
- Pediatric Genetics and Metabolism, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32607, USA.
| | - Kathryn D Moseley
- Genetics Division, USC/Keck School of Medicine, 1801 Marengo St. Rm. 1G-24, Los Angeles, CA 90033, USA.
| | - Beth Ogata
- University of Washington, Department of Pediatrics, UW-CHDD, Box 357920, Seattle, WA 98195, USA.
| | - Surekha Pendyal
- Division of Genetics and Metabolism, University of North Carolina School of Medicine, 1100 Manning Drive, Chapel Hill, NC 27599, USA.
| | - Jill Skrabal
- Department of Medical Genetics, University of Nebraska Medical Center/Children's Hospital and Medical Center, 981200 Nebraska Medical Center, Omaha, NE. 68198-1200, USA.
| | - Patricia L Splett
- Evaluation Consultant Splett & Associates, LLC, 399 Badger Blvd W., Stanchfield, MN 55080, USA.
| | - Adrya Stembridge
- Department of Human Genetics, Emory University School of Medicine, 2165 North Decatur Road, Decatur, Atlanta, GA 30033, USA.
| | - Ann Wessel
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA.
| | - Frances Rohr
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA.
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Comparison of atherogenic risk factors among poorly controlled and well-controlled adolescent phenylketonuria patients. Cardiol Young 2016; 26:901-8. [PMID: 26278115 DOI: 10.1017/s104795111500150x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Previous studies investigating the known risk factors of atherosclerosis in phenylketonuria patients have shown conflicting results. The primary aim of our study was to investigate the serum atherogenic markers in adolescent classical phenylketonuria patients and compare these parameters with healthy peers. The secondary aim was to compare these atherogenic markers in well-controlled and poorly controlled patients. METHODS A total of 59 patients (median age: 12.6 years, range: 11-17 years) and 44 healthy controls (median age: 12.0 years, range: 11-15 years) were enrolled in our study. Phenylketonuria patients were divided into two groups: well-controlled (serum phenylalanine levels below 360 µmol/L; 24 patients) and poorly controlled patients (serum phenylalanine levels higher than 360 µmol/L). RESULTS The mean high-density lipoprotein cholesterol levels of well-controlled patients (1.0±0.2 mmol/L) were significantly lower compared with poorly controlled patients and controls (1.1±0.2 mmol/L, p=0.011 and 1.4±0.2 mmol/L, p<0.001, respectively). Poorly controlled patients had lower high-density lipoprotein cholesterol levels than healthy controls (p=0.003). Homocysteine levels of both well-controlled (9.8±6.4 µmol/L) and poorly controlled (9.2±5.6 µmol/L) patients were higher compared with controls (5.8±1.8 µmol/L, p<0.01). The mean platelet volume of well-controlled patients (9.5±1.1 fL) was higher than that of poorly controlled patients and controls (8.9±0.8 fL, p=0.024 and 7.7±0.6 fL, p<0.001, respectively). CONCLUSION Lower high-density lipoprotein cholesterol and higher homocysteine and mean platelet volume levels were detected in phenylketonuria patients. In particular, these changes were more prominent in well-controlled patients. We conclude that phenylketonuria patients might be at risk for atherosclerosis, and therefore screening for atherosclerotic risk factors should be included in the phenylketonuria therapy and follow-up in addition to other parameters.
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Vashi P, Edwin P, Popiel B, Lammersfeld C, Gupta D. Methylmalonic Acid and Homocysteine as Indicators of Vitamin B-12 Deficiency in Cancer. PLoS One 2016; 11:e0147843. [PMID: 26807790 PMCID: PMC4725715 DOI: 10.1371/journal.pone.0147843] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 01/08/2016] [Indexed: 12/15/2022] Open
Abstract
Background/Aims Normal or high serum vitamin B-12 levels can sometimes be seen in a B-12 deficient state, and can therefore be misleading. High levels of Methymalonic Acid (MMA) and Homocysteine (HC) have been identified as better indicators of B-12 deficiency than the actual serum B-12 level itself. We evaluated the prevalence of vitamin B-12 deficiency using appropriate cut-off levels of vitamin B-12, MMA and HC, and determined the relationship between serum levels of vitamin B-12, MMA and HC in cancer. Methods This is a cross-sectional study using a consecutive case series of 316 cancer patients first seen at Cancer Treatment Centers of America® (CTCA) at Midwestern Regional Medical Center between April 2014 and June 2014. All patients were evaluated at baseline for vitamin B-12 (pg/mL), MMA (nmol/L) and HC (μmol/L) levels. In accordance with previously published research, the following cut-offs were used to define vitamin B-12 deficiency: <300 pg/mL for vitamin B-12, >260 nmol/L for MMA and >12 μmol/L for HC. The relationship between B-12, MMA and HC was evaluated using Spearman's rho correlation coefficient and cross-tabulation analysis. Receiver Operating Characteristic (ROC) curves were estimated using the non-parametric method to further evaluate the diagnostic accuracy of vitamin B-12 using Fedosov quotient as the "gold standard". Results Mean age at presentation was 52.5 years. 134 (42.4%) patients were males while 182 (57.6%) were females. Median vitamin B-12, MMA and HC levels were 582.5 pg/mL, 146.5 nmol/L and 8.4 μmol/L respectively. Of 316 patients, 28 (8.9%) were vitamin B-12 deficient based on vitamin B-12 (<300pg/mL), 34 (10.8%) were deficient based on MMA (>260 nmol/L) while 55 (17.4%) were deficient based on HC (>12 μmol/L). Correlation analysis revealed a significant weak negative correlation between vitamin B-12 and MMA (rho = -0.22) as well as B-12 and HC (rho = -0.35). ROC curves suggested MMA to have the best discriminatory power in predicting B-12 deficiency. Conclusion Vitamin B-12 is poorly correlated with MMA and HC in cancer. Using serum vitamin B-12 alone to evaluate B-12 status in cancer may fail to identify those with functional deficiency. A thorough clinical assessment is important to identify patients that may have risk factors and/or symptoms suggestive of deficiency. These patients should have additional testing of MMA and HC regardless of their B-12 levels.
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Affiliation(s)
- Pankaj Vashi
- Cancer Treatment Centers of America (CTCA) at Midwestern Regional Medical Center, 2520 Elisha Ave, Zion, Illinois, 60099, United States of America
| | - Persis Edwin
- Cancer Treatment Centers of America (CTCA) at Midwestern Regional Medical Center, 2520 Elisha Ave, Zion, Illinois, 60099, United States of America
| | - Brenten Popiel
- Cancer Treatment Centers of America (CTCA) at Midwestern Regional Medical Center, 2520 Elisha Ave, Zion, Illinois, 60099, United States of America
| | - Carolyn Lammersfeld
- Cancer Treatment Centers of America (CTCA) at Midwestern Regional Medical Center, 2520 Elisha Ave, Zion, Illinois, 60099, United States of America
| | - Digant Gupta
- Cancer Treatment Centers of America (CTCA) at Midwestern Regional Medical Center, 2520 Elisha Ave, Zion, Illinois, 60099, United States of America
- * E-mail:
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Crujeiras V, Aldámiz-Echevarría L, Dalmau J, Vitoria I, Andrade F, Roca I, Leis R, Fernandez-Marmiesse A, Couce ML. Vitamin and mineral status in patients with hyperphenylalaninemia. Mol Genet Metab 2015; 115:145-50. [PMID: 26123187 DOI: 10.1016/j.ymgme.2015.06.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 06/22/2015] [Accepted: 06/22/2015] [Indexed: 10/23/2022]
Abstract
Natural sources of protein and some vitamins and minerals are limited in phenylketonuria (PKU) treated patients, who should receive optimal supplementation although this is not yet fully established. We conducted a cross-sectional observational multicenter study including 156 patients with hyperphenylalaninemia. Patients were stratified by age, phenotype, disease detection and type of treatment. Annual median blood phenylalanine (Phe) levels, Phe tolerance, anthropometric measurements, and biochemical parameters (total protein, prealbumin, electrolytes, selenium, zinc, B12, folic acid, ferritin, 25-OH vitamin D) were collected in all patients. 81.4% of patients had biochemical markers out of recommended range but no clinical symptoms. Total protein, calcium, phosphorus, B12, ferritin, and zinc levels were normal in most patients. Prealbumin was reduced in 34.6% of patients (74% with PKU phenotype and 94% below 18 years old), showing almost all (96.3%) an adequate adherence to diet. Selenium was diminished in 25% of patients (95% with PKU phenotype) and also 25-OHD in 14%. Surprisingly, folic acid levels were increased in 39% of patients, 66% with classic PKU. Phosphorus and B12 levels were found diminished in patients with low adherence to diet. Patients under BH4 therapy only showed significant lower levels of B12. This study shows a high percentage of prealbumin and selenium deficiencies as well as an increased level of folic acid in PKU treated patients, which should lead us to assess an adjustment for standards supplements formulated milks.
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Affiliation(s)
- Vanesa Crujeiras
- Unit of Gastroenterology and Nutrition, Department of Pediatrics, Hospital Clinico Universitario de Santiago, Travesía da Choupana s/n, 15706 Santiago de Compostela, A Coruña, Spain
| | - Luis Aldámiz-Echevarría
- Unit of Metabolism, Department of Pediatrics, Hospital de Cruces, Group of Metabolism, Biocruces Health Research Institute, CIBERER, Plaza de Cruces s/n, 48903 Barakaldo, Vizcaya, Spain.
| | - Jaime Dalmau
- Unit of Metabolopathies, Hospital Universitario la Fe, Bulevarsur s/n, 46021 Valencia, Spain.
| | - Isidro Vitoria
- Unit of Metabolopathies, Hospital Universitario la Fe, Bulevarsur s/n, 46021 Valencia, Spain.
| | - Fernando Andrade
- Unit of Metabolism, Department of Pediatrics, Hospital de Cruces, Group of Metabolism, Biocruces Health Research Institute, CIBERER, Plaza de Cruces s/n, 48903 Barakaldo, Vizcaya, Spain.
| | - Iria Roca
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, S. Neonatology, Department of Pediatrics, Hospital Clinico Universitario de Santiago, Travesía da Choupana s/n, 15706 Santiago de Compostela, A Coruña, Spain.
| | - Rosaura Leis
- Unit of Gastroenterology and Nutrition, Department of Pediatrics, Hospital Clinico Universitario de Santiago, IDIS, Travesía da Choupana s/n, 15706 Santiago de Compostela, A Coruña, Spain.
| | - Ana Fernandez-Marmiesse
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, S. Neonatology, Department of Pediatrics, Hospital Clinico Universitario de Santiago, CIBERER, Health Research Institute of Santiago de Compostela (IDIS), Travesía da Choupana s/n, 15706 Santiago de Compostela, A Coruña, Spain.
| | - María L Couce
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, S. Neonatology, Department of Pediatrics, Hospital Clínico Universitario de Santiago de Compostela, CIBERER, Health Research Institute of Santiago de Compostela (IDIS), A Choupana, s/n, 15706 Santiago de Compostela, A Coruña, Spain.
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Functional cobalamin (vitamin B12) deficiency: role of advanced age and disorders associated with increased oxidative stress. Eur J Clin Nutr 2015; 69:687-92. [PMID: 25563739 DOI: 10.1038/ejcn.2014.272] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 11/07/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND/OBJECTIVE Functional cobalamin (Cbl; vitamin B12) deficiency (that is, high levels of the Cbl-dependent metabolites, methylmalonic acid (MMA) and homocysteine (HCys), despite normal serum Cbl values) is common in the elderly and is associated with neurocognitive abnormalities, but its cause is unknown. As only reduced Cbls are metabolically active, the possibility that functional Cbl deficiency is associated with disorders having biomarkers indicative of increased oxidative stress (oxidant risks) was considered. SUBJECTS/METHODS A retrospective record review of community-dwelling adults evaluated over a 12-year period for Cbl deficiency in a primary care setting who had serum Cbl values ⩾400 pg/ml (n=170). RESULTS When no oxidant risks were present, older subjects (⩾70 years) had higher metabolite values than younger individuals (<70 years). MMA values were even higher in the elderly when one oxidant risk was present and in younger subjects when two or more oxidant risks were present. Even at Cbl levels ⩾800 pg/ml, MMA values were increased in 73% of elderly subjects with at least one oxidant risk. HCys values were also higher in both age groups when at least two oxidant risks were present. Cyanocobalamin therapy decreased MMA and HCys values in 86 and 76% of subjects, respectively, with nonresponders more likely to have two or more oxidant risks. CONCLUSION Functional Cbl deficiency is associated with disorders marked by increased oxidative stress particularly in the elderly; it occurs even when Cbl levels are high and is not consistently corrected with high-dose cyanocobalamin therapy. Thus, current approaches to recognizing and managing this disorder may be inadequate.
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Abstract
Phenylketonuria (PKU) is an inborn error of metabolism of the amino acid phenylalanine. It is an autosomal recessive disorder with a rate of incidence of 1 in 10,000 in Caucasian populations. Mutations in the phenylalanine hydroxylase (PAH) gene are the major cause of PKU, due to the loss of the catalytic activity of the enzyme product PAH. Newborn screening for PKU allows early intervention, avoiding irreparable neurological damage and intellectual disability that would arise from untreated PKU. The current primary treatment of PKU is the limitation of dietary protein intake, which in the long term may be associated with poor compliance in some cases and other health problems due to malnutrition. The only alternative therapy currently approved is the supplementation of BH4, the requisite co-factor of PAH, in the orally-available form of sapropterin dihydrochloride. This treatment is not universally available, and is only effective for a proportion (estimated 30%) of PKU patients. Research into novel therapies for PKU has taken many different approaches to address the lack of PAH activity at the core of this disorder: enzyme replacement via virus-mediated gene transfer, transplantation of donor liver and recombinant PAH protein, enzyme substitution using phenylalanine ammonia lyase (PAL) to provide an alternative pathway for the metabolism of phenylalanine, and restoration of native PAH activity using chemical chaperones and nonsense read-through agents. It is hoped that continuing efforts into these studies will translate into a significant improvement in the physical outcome, as well as quality of life, for patients with PKU.
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Affiliation(s)
- Gladys Ho
- 1 Genetic Metabolic Disorders Research Unit; 2 Disciplines of Paediatrics and Child Health and 3 Genetic Medicine, University of Sydney, Sydney, NSW, Australia ; 4 Genetic Metabolic Disorders Service, Western Sydney Genetics Program, Children's Hospital at Westmead, Sydney, NSW, Australia
| | - John Christodoulou
- 1 Genetic Metabolic Disorders Research Unit; 2 Disciplines of Paediatrics and Child Health and 3 Genetic Medicine, University of Sydney, Sydney, NSW, Australia ; 4 Genetic Metabolic Disorders Service, Western Sydney Genetics Program, Children's Hospital at Westmead, Sydney, NSW, Australia
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Abstract
BACKGROUND PKU patients on a strict low protein diet get most of their folic acid intake from protein substitute. Several protein substitutes contain high amounts of this vitamin. Concern has been raised about the safety of high levels of folic acid, especially in relation to cancer risk. METHODS This cross-sectional study included 34 children and 22 adults with PKU. A dietary interview was performed and intake of folic acid and vitamin B12 from protein substitute was calculated for patients compliant with their protein substitute. Intakes of folic acid and vitamin B12 were compared with plasma levels of folate, vitamin B12, and homocysteine. RESULTS Children aged 2-9 years had the highest intake of folic acid according to RDI (449 %), and children aged 7-10 years had the highest intake of folic acid according to UL (155 %). Median plasma folate level in PKU children was two times the upper reference level and in PKU adults well above. Children between 10 and 13 years had the highest level of plasma folate. Young children had both a high intake and high plasma levels of vitamin B12. Homocysteine levels were low or in the lower part of the normal reference range in most patients. CONCLUSION Children with PKU are at a particular risk of receiving folic acid high above RDI and many children with PKU receive doses above the UL. Many PKU patients have a very high level of plasma folate related to a very high content of folic acid in many of their protein substitutes.
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Procházková D, Jarkovský J, Vinohradská H, Konečná P, Machačová L, Doležel Z. Controlled diet in phenylketonuria and hyperphenylalaninemia may cause serum selenium deficiency in adult patients: the Czech experience. Biol Trace Elem Res 2013; 154:178-84. [PMID: 23771645 DOI: 10.1007/s12011-013-9724-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 06/03/2013] [Indexed: 10/26/2022]
Abstract
Phenylketonuria is an inherited disorder of metabolism of the amino acid phenylalanine caused by a deficit of the enzyme phenylalanine hydroxylase. It is treated with a low-protein diet containing a low content of phenylalanine to prevent mental affection of the patient. Because of the restricted intake of high-biologic-value protein, patients with phenylketonuria may have lower than normal serum concentrations of pre-albumin, selenium, zinc and iron. The objective of the present study was to assess the compliance of our phenylketonuric (PKU) and hyperphenylalaninemic (HPA) patients; to determine the concentration of serum pre-albumin, selenium, zinc and iron to discover the potential correlation between the amount of proteins in food and their metabolic control. We studied 174 patients of which 113 were children (age 1-18), 60 with PKU and 53 with HPA and 61 were adults (age 18-42), 51 with PKU and 10 with HPA. We did not prove a statistically significant difference in the concentration of serum pre-albumin, zinc and iron among the respective groups. We proved statistically significant difference in serum selenium concentrations of adult PKU and HPA patients (p = 0.006; Mann-Whitney U test). These results suggest that controlled low-protein diet in phenylketonuria and hyperphenylalaninemia may cause serum selenium deficiency in adult patients.
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Affiliation(s)
- Dagmar Procházková
- Department of Pediatrics, University Hospital Brno, Medical Faculty of Masaryk University Brno, Cernopolni 9, Brno 62500, Czech Republic.
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Robert M, Rocha JC, van Rijn M, Ahring K, Bélanger-Quintana A, MacDonald A, Dokoupil K, Gokmen Ozel H, Lammardo AM, Goyens P, Feillet F. Micronutrient status in phenylketonuria. Mol Genet Metab 2013; 110 Suppl:S6-17. [PMID: 24113686 DOI: 10.1016/j.ymgme.2013.09.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Revised: 09/15/2013] [Accepted: 09/15/2013] [Indexed: 12/12/2022]
Abstract
Patients with phenylketonuria (PKU) encompass an 'at risk' group for micronutrient imbalances. Optimal nutrient status is challenging particularly when a substantial proportion of nutrient intake is from non-natural sources. In PKU patients following dietary treatment, supplementation with micronutrients is a necessity and vitamins and minerals should either be added to supplement phenylalanine-free l-amino acids or given separately. In this literature review of papers published since 1990, the prevalence of vitamin and mineral deficiency is described, with reference to age of treatment commencement, type of treatment, dietary compliance, and dietary practices. Biological micronutrient inadequacies have been mainly reported for zinc, selenium, iron, vitamin B12 and folate. The aetiology of these results and possible clinical and biological implications are discussed. In PKU there is not a simple relationship between the dietary intake and nutritional status, and there are many independent and interrelated complex factors that should be considered other than quantitative nutritional intake.
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Affiliation(s)
- M Robert
- Nutrition and Metabolism Unit, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium
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Wiig I, Motzfeldt K, Løken EB, Kase BF. Nutritional Consequences of Adhering to a Low Phenylalanine Diet for Late-Treated Adults with PKU : Low Phe Diet for Adults with PKU. JIMD Rep 2012; 7:109-16. [PMID: 23430504 PMCID: PMC3575047 DOI: 10.1007/8904_2012_157] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 05/14/2012] [Accepted: 05/21/2012] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND The main treatment for phenylketonuria (PKU) is a low phenylalanine (Phe) diet, phenylalanine-free protein substitute and low-protein special foods. This study describes dietary composition and nutritional status in late-diagnosed adult patients adhering to a PKU diet. METHODS Nineteen patients, followed at Oslo University Hospital in Norway, participated; median age was 48 years (range 26-66). Subjects were mild to severely mentally retarded. Food intake, clinical data and blood analyses relevant for nutritional status were assessed. RESULTS Median energy intake was 2,091 kcal/day (range 1,537-3,277 kcal/day). Carbohydrates constituted 59% (range 53-70%) of the total energy, including 15% from added sugar; 26% was from fat. The total protein intake was 1.02 g/kg/day (range 0.32-1.36 g/kg/day), including 0.74 g/kg/day (range 0.13-1.07 g/kg/day) from protein substitutes. Median dietary Phe intake was 746 mg/day (range 370-1,370 mg/day). Median serum Phe was 542 μmol/L (range 146-1,310 mg/day). Fortified protein substitutes supplied the main source of micronutrients. Iron intake was 39.5 mg/day (range 24.6-57 mg/day), exceeding the upper safe intake level. Intake of folate and folic acid, calculated as dietary folate equivalents, was 1,370 μg/day (range 347-1744 μg/day), and resulted in high blood folate concentrations. Median intake of vitamin B(12) was 7.0 μg/day (range 0.9-15.1 μg/day). CONCLUSIONS The diet supplied adequate protein and energy. Fortification of the protein substitutes resulted in excess intake of micronutrients. The protein substitutes may require adjustment to meet nutritional recommendations for adults with PKU.
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Affiliation(s)
- Ingrid Wiig
- Centre for Rare Disorders, Oslo University Hospital, 4950, Nydalen, N-0424 Oslo, Norway
| | - Kristina Motzfeldt
- Department of Pediatrics, Oslo University Hospital, Ole Vigs gate 25, N-0366 Oslo, Norway
| | - Elin Bjørge Løken
- Department of Nutrition, Institute of Basic Medical Sciences, University in Oslo, 1046, Blindern, N-0317 Oslo, Norway
| | - Bengt Frode Kase
- Centre for Rare Disorders, Oslo University Hospital, 4950, Nydalen, N-0424 Oslo, Norway
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de Groot MJ, Hoeksma M, van Rijn M, Slart RHJA, van Spronsen FJ. Relationships between lumbar bone mineral density and biochemical parameters in phenylketonuria patients. Mol Genet Metab 2012; 105:566-70. [PMID: 22300845 DOI: 10.1016/j.ymgme.2012.01.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Accepted: 01/08/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND The etiology of reduced bone mineral density (BMD) in phenylketonuria (PKU) is unknown. Reduced BMD may be inherent to PKU and/or secondary to its dietary treatment. MATERIALS AND METHODS Lumbar BMD was measured by dual-energy X-ray absorptiometry in 53 early and continuously treated PKU patients (median age 16, range 2-35 years). First, Z-scores of BMD were correlated to age group, clinical severity of PKU, mean phenylalanine (Phe) concentration and Phe variation in the year prior to DXA scanning, as well as to blood vitamin, mineral, and alkaline phosphatase concentrations. Second, parameters were compared between subjects with reduced BMD (Z-score<-2 SD) and subjects with normal BMD. RESULTS BMD was significantly reduced in our cohort (p=0.000). Z-scores of BMD were neither significantly correlated to age group, nor clinical severity of PKU. Both mean Phe concentration and Phe variation in the year prior to DXA scanning did not significantly correlate with Z-scores of BMD. Higher blood calcium concentrations were significantly associated with lower BMD (r(2)=-0.485, p=0.004). Other biochemical parameters, including vitamin B12 availability markers, did not show significant correlations with Z-score of BMD. Subjects with reduced BMD had significantly higher blood phosphorus concentrations than subjects with normal BMD (p=0.009). No other significant differences were found between both BMD groups. CONCLUSION Reduced BMD in PKU is present from early age onward and does not progress with age. Therefore, BMD deserves attention from early age onward in PKU patients. Our findings are consistent with increased bone turnover in PKU. It remains unclear whether reduced BMD is inherent to PKU and/or secondary to its dietary treatment.
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Affiliation(s)
- Martijn J de Groot
- Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Abstract
Phenylalanine hydroxylase deficiency is an autosomal recessive disorder that results in intolerance to the dietary intake of the essential amino acid phenylalanine. It occurs in approximately 1:15,000 individuals. Deficiency of this enzyme produces a spectrum of disorders including classic phenylketonuria, mild phenylketonuria, and mild hyperphenylalaninemia. Classic phenylketonuria is caused by a complete or near-complete deficiency of phenylalanine hydroxylase activity and without dietary restriction of phenylalanine most children will develop profound and irreversible intellectual disability. Mild phenylketonuria and mild hyperphenylalaninemia are associated with lower risk of impaired cognitive development in the absence of treatment. Phenylalanine hydroxylase deficiency can be diagnosed by newborn screening based on detection of the presence of hyperphenylalaninemia using the Guthrie microbial inhibition assay or other assays on a blood spot obtained from a heel prick. Since the introduction of newborn screening, the major neurologic consequences of hyperphenylalaninemia have been largely eradicated. Affected individuals can lead normal lives. However, recent data suggest that homeostasis is not fully restored with current therapy. Treated individuals have a higher incidence of neuropsychological problems. The mainstay of treatment for hyperphenylalaninemia involves a low-protein diet and use of a phenylalanine-free medical formula. This treatment must commence as soon as possible after birth and should continue for life. Regular monitoring of plasma phenylalanine and tyrosine concentrations is necessary. Targets of plasma phenylalanine of 120-360 μmol/L (2-6 mg/dL) in the first decade of life are essential for optimal outcome. Phenylalanine targets in adolescence and adulthood are less clear. A significant proportion of patients with phenylketonuria may benefit from adjuvant therapy with 6R-tetrahydrobiopterin stereoisomer. Special consideration must be given to adult women with hyperphenylalaninemia because of the teratogenic effects of phenylalanine. Women with phenylalanine hydroxylase deficiency considering pregnancy should follow special guidelines and assure adequate energy intake with the proper proportion of protein, fat, and carbohydrates to minimize risks to the developing fetus. Molecular genetic testing of the phenylalanine hydroxylase gene is available for genetic counseling purposes to determine carrier status of at-risk relatives and for prenatal testing.
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Abstract
Currently, there is no international consensus on how patients with phenylketonuria (PKU) (or milder forms of hyperphenylalaninaemia) should be followed in clinical practice. Guidelines concerning the frequency and type of assessments that should be made according to age usually focus on blood phenylalanine concentrations. A need exists for improved guidelines on how to do the follow-up of individuals with PKU/milder forms of hyperphenylalaninaemia. An interdisciplinary approach for monitoring patients is required, involving relevant clinical investigations and regular contact with a clinician and dietician/nutritionist as well as contact with social health worker, psychologist and neurologist, at least at request. This chapter presents a scheme for follow-up. However, by no means this scheme aims to present the one for all time follow-up programme. The scheme for follow-up may rather serve as a start for further discussion in larger groups of professionals in collaboration with patients and their parents. A number of questions remain unanswered, and further research is still needed to fine-tune the management of PKU at different ages.
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Demirkol M, Giżewska M, Giovannini M, Walter J. Follow up of phenylketonuria patients. Mol Genet Metab 2011; 104 Suppl:S31-9. [PMID: 22018725 DOI: 10.1016/j.ymgme.2011.08.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 07/31/2011] [Accepted: 08/07/2011] [Indexed: 11/26/2022]
Abstract
In recent years our understanding of the follow up policies for PKU has increased substantially. In particular, we now understand the importance of maintaining control of blood phenylalanine (phe) concentrations life-long to achieve the best long-term neuropsychological outcomes. The concordance with the follow up strategy remains a key challenge for the future, especially with respect to adolescents and young adults. The recent therapies could ease the burden of the dietary phe restriction for PKU patients and their families. The time may be right for revisiting the guidelines for follow up of PKU in order to address a number of important issues related to PKU management: promotion of breastfeeding to complementary feeding up to 2 years of age for prevention of early growth retardation and later overweight development, treatment advancements for metabolic control, blood phe and tyr variability, routine screening measures for nutritional biomarkers, neurocognitive and psychological assessments, bone pathology, understanding the challenges of compliance and transitioning into adulthood as an individual with PKU and addressing unmet needs in this population.
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Affiliation(s)
- M Demirkol
- Div Nutrition and Metabolism, Children's Hospital, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey.
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Trefz F, Maillot F, Motzfeldt K, Schwarz M. Adult phenylketonuria outcome and management. Mol Genet Metab 2011; 104 Suppl:S26-30. [PMID: 21944883 DOI: 10.1016/j.ymgme.2011.08.025] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 08/23/2011] [Accepted: 08/23/2011] [Indexed: 11/16/2022]
Abstract
The problem to evaluate treatment outcome in adult PKU (phenylketonuric) patients lies in the heterogeneity of the adult PKU population. This heterogeneity is not only based on the different treatment history of every individual patient but also on the different severity of the underlying defect of the enzyme phenylalanine hydroxylase. Recent, partly double blind studies in adult PKU patients further support recommendation for lifelong treatment. However, it has become evident that dietary treatment is suboptimal and continuation to adulthood often not accepted. Late detected PKU patients (up to 4-6 years of age) benefit from strict dietary treatment and are able to catch up in intellectual performance. Untreated, severely retarded patients with behavioral changes may benefit from introduction of dietary treatment. However, individual decision is necessary and based on the personal situation of the patient. In early and well treated patients a number of studies have demonstrated that cognitive and neurosychologic tests are different from controls. In addition there is evidence that patients with higher blood phenylalanine (phe) levels demonstrate more often psychiatric symptoms like depression and anxiety. Medical problems are more often observed: there are certain risks as impaired growth, decreased bone mineral density and nutrional deficits probably caused by dietary treatment with an artificial protein substitute and/or missing compliance with an unpleasant diet. The long term risk of a strict dietary treatment must be balanced with the risk of higher blood phe (mean blood phenylalanine >600-900 μmol/L) on cognitive and neuropsychological functions and psychiatric symptoms. Further studies should consider the role of blood phe exposure for brain development in childhood and for brain function in all ages. Besides mean blood phe, fluctuation of blood phe over time is important. Fluctuation of blood phe is decreased by sapropterin treatment in responsive patients which would on the long term may have positive effects on cognitive outcome. Further studies also should include adult PKU patients.
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Affiliation(s)
- F Trefz
- Kreiskliniken Reutlingen GmbH, Reutlingen, Germany.
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MacDonald A, Rocha JC, van Rijn M, Feillet F. Nutrition in phenylketonuria. Mol Genet Metab 2011; 104 Suppl:S10-8. [PMID: 21944460 DOI: 10.1016/j.ymgme.2011.08.023] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 08/24/2011] [Accepted: 08/24/2011] [Indexed: 12/31/2022]
Abstract
The same basic principles are used to deliver dietary treatment in PKU that was developed sixty years ago. Dietary treatment is undoubtedly very successful, but it has gradually evolved and been guided commonly by individual experience and expert opinion only. There is little international consensus about dietary practice with improvements in specialist dietary products concentrating on taste and presentation rather than nutritional composition. Many areas of dietary treatment have not been rigorously examined. In particular, the amino acid and micronutrient profile of Phenylalanine-free (phe-free) amino acids requires further study. In different formulations of phe-free amino acids, there are variations in the amino acid patterns as well the amount of essential and non essential amino acids per 100g/amino acids. The amount of added tyrosine and branch chain amino varies substantially, and in PKU specifically, there is little data about their relative absorption rates and bioavailability. In phe-free amino acids, there is evidence suggesting that some of the added micronutrients may be excessive and so the source and amount of each micronutrient should be scrutinized, with a need for the development of international nutritional composition standards exclusively for these products. There is a dearth of data about the life-long phenylalanine tolerance of patients or the nutritional state of adult patients treated with diet. There is a growing need to measure body composition routinely in children with PKU and with the rise in childhood obesity, it is important to measure body fatness and identify those who are at greatest risk of 'co-morbidities' of obesity. There is necessity for international collaboration to ensure robust data is collected on many basic aspects of nutritional care to guarantee that diet therapy is delivered to the highest standard.
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Walter JH. Vitamin B12 deficiency and phenylketonuria. Mol Genet Metab 2011; 104 Suppl:S52-4. [PMID: 21824796 DOI: 10.1016/j.ymgme.2011.07.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Revised: 07/17/2011] [Accepted: 07/18/2011] [Indexed: 10/18/2022]
Abstract
The literature regarding the vitamin B(12) status of patients with phenylketonuria was reviewed. Adequate amounts of B(12) are provided in products used in dietary treatment; however, a number of case reports and cohort studies document deficiency in those who have discontinued taking amino acid, mineral and vitamin supplements but who continue to eat only very limited amounts of natural protein. Symptoms and signs of B(12) deficiency are variable but severe deficiency may cause serious neurological disease. Nitrous oxide anaesthesia is a particular risk. It is recommended that plasma total homocysteine and plasma or urinary methylmalonate should be routinely measured, as they are more sensitive markers of deficiency than serum B(12) concentrations. Functional B(12) deficiency can occur in the presence of a normal B(12) concentration.
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Affiliation(s)
- John H Walter
- Medicine, Manchester Academic Health Sciences Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom.
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