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Sen K, Izem R, Long Y, Jiang J, Konczal LL, McCarter RJ, Gropman AL, Bedoyan JK. Are asymptomatic carriers of OTC deficiency always asymptomatic? A multicentric retrospective study of risk using the UCDC longitudinal study database. Mol Genet Genomic Med 2024; 12:e2443. [PMID: 38634223 PMCID: PMC11024633 DOI: 10.1002/mgg3.2443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 03/24/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Ornithine transcarbamylase deficiency (OTCD) due to an X-linked OTC mutation, is responsible for moderate to severe hyperammonemia (HA) with substantial morbidity and mortality. About 80% of females with OTCD remain apparently "asymptomatic" with limited studies of their clinical characteristics and long-term health vulnerabilities. Multimodal neuroimaging studies and executive function testing have shown that asymptomatic females exhibit limitations when stressed to perform at higher cognitive load and had reduced activation of the prefrontal cortex. This retrospective study aims to improve understanding of factors that might predict development of defined complications and serious illness in apparent asymptomatic females. A proband and her daughter are presented to highlight the utility of multimodal neuroimaging studies and to underscore that asymptomatic females with OTCD are not always asymptomatic. METHODS We review data from 302 heterozygote females with OTCD enrolled in the Urea Cycle Disorders Consortium (UCDC) longitudinal natural history database. We apply multiple neuroimaging modalities in the workup of a proband and her daughter. RESULTS Among the females in the database, 143 were noted as symptomatic at baseline (Sym). We focused on females who were asymptomatic (Asx, n = 111) and those who were asymptomatic initially upon enrollment in study but who later became symptomatic sometime during follow-up (Asx/Sym, n = 22). The majority of Asx (86%) and Asx/Sym (75%) subjects did not restrict protein at baseline, and ~38% of Asx and 33% of Asx/Sym subjects suffered from mild to severe neuropsychiatric conditions such as mood disorder and sleep problems. The risk of mild to severe HA sometime later in life for the Asx and Asx/Sym subjects as a combined group was ~4% (5/133), with ammonia ranging from 77 to 470 μM and at least half (2/4) of subjects requiring hospital admission and nitrogen scavenger therapy. For this combined group, the median age of first HA crisis was 50 years, whereas the median age of first symptom which included neuropsychiatric and/or behavioral symptoms was 17 years. The multimodal neuroimaging studies in female heterozygotes with OTCD also underscore that asymptomatic female heterozygotes with OTCD (e.g., proband) are not always asymptomatic. CONCLUSIONS Analysis of Asx and Asx/Sym females with OTCD in this study suggests that future evidence-based management guidelines and/or a clinical risk score calculator for this cohort could be useful management tools to reduce morbidity and improve long-term quality of life.
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Affiliation(s)
- Kuntal Sen
- Division of Neurogenetics and Neurodevelopmental PediatricsChildren's National Hospital, The George Washington School of MedicineWashingtonDCUSA
| | - Rima Izem
- Center for Translational Sciences, Children's National HospitalThe George Washington UniversityWashingtonDCUSA
- Children's National HospitalWashingtonDCUSA
| | - Yuelin Long
- Columbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Jiji Jiang
- Center for Translational Sciences, Children's National HospitalThe George Washington UniversityWashingtonDCUSA
- Children's National HospitalWashingtonDCUSA
| | - Laura L. Konczal
- Center for Human Genetics, University Hospitals Cleveland Medical Center, Department of Genetics and Genome SciencesCase Western Reserve University School of MedicineClevelandOhioUSA
| | - Robert J. McCarter
- Center for Translational Sciences, Children's National HospitalThe George Washington UniversityWashingtonDCUSA
- Children's National HospitalWashingtonDCUSA
| | - Andrea L. Gropman
- Division of Neurogenetics and Neurodevelopmental PediatricsChildren's National Hospital, The George Washington School of MedicineWashingtonDCUSA
- Center for Translational Sciences, Children's National HospitalThe George Washington UniversityWashingtonDCUSA
| | - Jirair K. Bedoyan
- Division of Genetic and Genomic Medicine, Department of PediatricsUPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
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2
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Lichter-Konecki U, Sanz JH, McCarter R. Relationship between longitudinal changes in neuropsychological outcome and disease biomarkers in urea cycle disorders. Pediatr Res 2023; 94:2005-2015. [PMID: 37454183 DOI: 10.1038/s41390-023-02722-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 05/29/2023] [Accepted: 06/15/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Urea cycle disorders (UCDs) cause impaired conversion of waste nitrogen to urea leading to rise in glutamine and ammonia. Elevated ammonia and glutamine have been implicated in brain injury. This study assessed relationships between biomarkers of metabolic control and long-term changes in neuropsychological test scores in participants of the longitudinal study of UCDs. The hypothesis was that elevated ammonia and glutamine are associated with neuropsychological impairment. METHODS Data from 146 participants who completed 2 neuropsychological assessments were analyzed. Neuropsychological tests that showed significant changes in scores over time were identified and associations between score change and interim metabolic biomarker levels were investigated. RESULTS Participants showed a significant decrease in performance on visual motor integration (VMI) and verbal learning immediate-recall. A decrease in scores was associated with experiencing interim hyperammonemic events (HAE) and frequency of HAE. Outside of HAE there was a significant association between median ammonia levels ≥50µmol/L and impaired VMI. CONCLUSION VMI and memory encoding are specifically affected in UCDs longitudinally, indicating that patients experience difficulties when required to integrate motor and visual functions and learn new information. Only ammonia biomarkers showed a significant association with impairment. Preventing HAE and controlling ammonia levels is key in UCD management. IMPACT The Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery VMI) and List A Trial 5 of the California Verbal Learning Test (CVLT) may be good longitudinal biomarkers of treatment outcome in urea cycle disorders (UCD). This is the first report of longitudinal biomarkers for treatment outcome in UCD. These two biomarkers of outcome may be useful for clinical trials assessing new treatments for UCD. These results will also inform educators how to design interventions directed at improving learning in individuals with UCDs.
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Affiliation(s)
- Uta Lichter-Konecki
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA.
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
| | - Jacqueline H Sanz
- Department of Pediatrics, George Washington University School of Medicine, Washington, DC, USA
- Department of Psychiatry and Behavioral Sciences, George Washington University School of Medicine, Washington, DC, USA
- Children's National Hospital, Washington, DC, USA
| | - Robert McCarter
- Department of Pediatrics, George Washington University School of Medicine, Washington, DC, USA
- Children's National Hospital, Washington, DC, USA
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Murali CN, Barber JR, McCarter R, Zhang A, Gallant N, Simpson K, Dorrani N, Wilkening GN, Hays RD, Lichter-Konecki U, Burrage LC, Nagamani SCS. Health-related quality of life in a systematically assessed cohort of children and adults with urea cycle disorders. Mol Genet Metab 2023; 140:107696. [PMID: 37690181 PMCID: PMC10866211 DOI: 10.1016/j.ymgme.2023.107696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/01/2023] [Accepted: 09/02/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE Individuals with urea cycle disorders (UCDs) may develop recurrent hyperammonemia, episodic encephalopathy, and neurological sequelae which can impact Health-related Quality of Life (HRQoL). To date, there have been no systematic studies of HRQoL in people with UCDs. METHODS We reviewed HRQoL and clinical data for 190 children and 203 adults enrolled in a multicenter UCD natural history study. Physical and psychosocial HRQoL in people with UCDs were compared to HRQoL in healthy people and people with phenylketonuria (PKU) and diabetes mellitus. We assessed relationships between HRQoL, UCD diagnosis, and disease severity. Finally, we calculated sample sizes required to detect changes in these HRQoL measures. RESULTS Individuals with UCDs demonstrated worse physical and psychosocial HRQoL than their healthy peers and peers with PKU and diabetes. In children, HRQoL scores did not differ by diagnosis or severity. In adults, individuals with decreased severity had worse psychosocial HRQoL. Finally, we show that a large number of individuals would be required in clinical trials to detect differences in HRQoL in UCDs. CONCLUSION Individuals with UCDs have worse HRQoL compared to healthy individuals and those with PKU and diabetes. Future work should focus on the impact of liver transplantation and other clinical variables on HRQoL in UCDs.
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Affiliation(s)
- Chaya N Murali
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA
| | - John R Barber
- Children's National Health System, Washington, DC, USA
| | | | - Anqing Zhang
- Children's National Health System, Washington, DC, USA
| | - Natalie Gallant
- Department of Pediatrics, University of California Irvine, Irvine, CA, USA
| | - Kara Simpson
- Children's National Health System, Washington, DC, USA
| | - Naghmeh Dorrani
- Department of Human Genetics, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Ron D Hays
- Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Uta Lichter-Konecki
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lindsay C Burrage
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA
| | - Sandesh C S Nagamani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA.
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4
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Ibrahim MS, Gold JI, Woodall A, Yilmaz BS, Gissen P, Stepien KM. Diagnostic and Management Issues in Patients with Late-Onset Ornithine Transcarbamylase Deficiency. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1368. [PMID: 37628367 PMCID: PMC10453542 DOI: 10.3390/children10081368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 07/24/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023]
Abstract
Ornithine transcarbamylase deficiency (OTCD) is the most common inherited disorder of the urea cycle and, in general, is transmitted as an X-linked recessive trait. Defects in the OTC gene cause an impairment in ureagenesis, resulting in hyperammonemia, which is a direct cause of brain damage and death. Patients with late-onset OTCD can develop symptoms from infancy to later childhood, adolescence or adulthood. Clinical manifestations of adults with OTCD vary in acuity. Clinical symptoms can be aggravated by metabolic stressors or the presence of a catabolic state, or due to increased demands upon the urea. A prompt diagnosis and relevant biochemical and genetic investigations allow the rapid introduction of the right treatment and prevent long-term complications and mortality. This narrative review outlines challenges in diagnosing and managing patients with late-onset OTCD.
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Affiliation(s)
- Majitha Seyed Ibrahim
- Department of Chemical Pathology, Teaching Hospital Batticaloa, Batticaloa 30000, Sri Lanka
| | - Jessica I. Gold
- Division of Human Genetics, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Alison Woodall
- Adult Inherited Metabolic Diseases, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
| | - Berna Seker Yilmaz
- Great Ormond Street Institute of Child Health, University College London, London WC1E 6BT, UK
| | - Paul Gissen
- Great Ormond Street Institute of Child Health, University College London, London WC1E 6BT, UK
- Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, UK
- National Institute of Health Research, Great Ormond Street Biomedical Research Centre, London WC1N 1EH, UK
| | - Karolina M. Stepien
- Adult Inherited Metabolic Diseases, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
- Division of Cardiovascular Sciences, University of Manchester, Manchester M13 9PL, UK
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Seker Yilmaz B, Baruteau J, Arslan N, Aydin HI, Barth M, Bozaci AE, Brassier A, Canda E, Cano A, Chronopoulou E, Connolly GM, Damaj L, Dawson C, Dobbelaere D, Douillard C, Eminoglu FT, Erdol S, Ersoy M, Fang S, Feillet F, Gokcay G, Goksoy E, Gorce M, Inci A, Kadioglu B, Kardas F, Kasapkara CS, Kilic Yildirim G, Kor D, Kose M, Marelli C, Mundy H, O’Sullivan S, Ozturk Hismi B, Ramachandran R, Roubertie A, Sanlilar M, Schiff M, Sreekantam S, Stepien KM, Uzun Unal O, Yildiz Y, Zubarioglu T, Gissen P. Three-Country Snapshot of Ornithine Transcarbamylase Deficiency. Life (Basel) 2022; 12:1721. [PMID: 36362876 PMCID: PMC9695856 DOI: 10.3390/life12111721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022] Open
Abstract
X-linked ornithine transcarbamylase deficiency (OTCD) is the most common urea cycle defect. The disease severity ranges from asymptomatic carrier state to severe neonatal presentation with hyperammonaemic encephalopathy. We audited the diagnosis and management of OTCD, using an online 12-question-survey that was sent to 75 metabolic centres in Turkey, France and the UK. Thirty-nine centres responded and 495 patients were reported in total. A total of 208 French patients were reported, including 71 (34%) males, 86 (41%) symptomatic and 51 (25%) asymptomatic females. Eighty-five Turkish patients included 32 (38%) males, 39 (46%) symptomatic and 14 (16%) asymptomatic females. Out of the 202 UK patients, 66 (33%) were male, 83 (41%) asymptomatic and 53 (26%) symptomatic females. A total of 19%, 12% and 7% of the patients presented with a neonatal-onset phenotype in France, Turkey and the UK, respectively. Vomiting, altered mental status and encephalopathy were the most common initial symptoms in all three countries. While 69% in France and 79% in Turkey were receiving protein restriction, 42% were on a protein-restricted diet in the UK. A total of 76%, 47% and 33% of patients were treated with ammonia scavengers in Turkey, France and the UK, respectively. The findings of our audit emphasize the differences and similarities in manifestations and management practices in three countries.
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Affiliation(s)
- Berna Seker Yilmaz
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Julien Baruteau
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
- National Institute of Health Research Great Ormond Street Biomedical Research Centre, London WC1N 1EH, UK
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Nur Arslan
- Paediatric Metabolic Medicine Department, Dokuz Eylul University Faculty of Medicine, Izmir 35340, Turkey
| | - Halil Ibrahim Aydin
- Paediatric Metabolic Medicine Department, Baskent University Faculty of Medicine, Ankara 06490, Turkey
| | - Magalie Barth
- Centre de Référence des Maladies Héréditaires du Métabolisme, CHU Angers, 4 rue Larrey, CEDEX 9, 49933 Angers, France
| | - Ayse Ergul Bozaci
- Paediatric Metabolic Medicine Department, Diyarbakir Children’s Hospital, Diyarbakir 21100, Turkey
| | - Anais Brassier
- Reference Center for Inborn Errors of Metabolism, Necker University Hospital, APHP and University of Paris Cité, 75015 Paris, France
| | - Ebru Canda
- Paediatric Metabolic Medicine Department, Ege University Faculty of Medicine, Izmir 35100, Turkey
| | - Aline Cano
- Reference Center of Inherited Metabolic Disorders, Timone Enfants Hospital, 264 rue Saint-Pierre, 13005 Marseille, France
| | - Efstathia Chronopoulou
- Department of Inherited Metabolic Disease, Division of Women’s and Children’s Services, University Hospitals Bristol NHS Foundation Trust, Bristol BS1 3NU, UK
| | | | - Lena Damaj
- Centre de Compétence Maladies Héréditaires du Métabolisme, CHU Hôpital Sud, CEDEX 2, 35203 Rennes, France
| | - Charlotte Dawson
- Metabolic Medicine Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
| | - Dries Dobbelaere
- Medical Reference Center for Inherited Metabolic Diseases, Jeanne de Flandre University Hospital and RADEME Research Team for Rare Metabolic and Developmental Diseases, EA 7364 CHRU Lille, 59000 Lille, France
| | - Claire Douillard
- Medical Reference Center for Inherited Metabolic Diseases, Jeanne de Flandre University Hospital and RADEME Research Team for Rare Metabolic and Developmental Diseases, EA 7364 CHRU Lille, 59000 Lille, France
| | - Fatma Tuba Eminoglu
- Paediatric Metabolic Medicine Department, Ankara University Faculty of Medicine, Ankara 06080, Turkey
| | - Sahin Erdol
- Paediatric Metabolic Medicine Department, Uludag University Faculty of Medicine, Bursa 16059, Turkey
| | - Melike Ersoy
- Paediatric Metabolic Medicine Department, Dr Sadi Konuk Reseach & Training Hospital, Istanbul 34450, Turkey
| | - Sherry Fang
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - François Feillet
- Centre de Référence des Maladies Métaboliques de Nancy, CHU Brabois Enfants, 5 Rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - Gulden Gokcay
- Paediatric Metabolic Medicine Department, Istanbul University Istanbul Faculty of Medicine, Istanbul 34093, Turkey
| | - Emine Goksoy
- Paediatric Metabolic Medicine Department, Cengiz Gokcek Children’s Hospital, Gaziantep 27010, Turkey
| | - Magali Gorce
- Centre de Référence des Maladies Rares du Métabolisme, Hôpital des Enfants—CHU Toulouse, 330 Avenue de Grande-Bretagne, CEDEX 9, 31059 Toulouse, France
| | - Asli Inci
- Paediatric Metabolic Medicine Department, Gazi University Faculty of Medicine, Ankara 06500, Turkey
| | - Banu Kadioglu
- Paediatric Metabolic Medicine Department, Konya City Hospital, Konya 42020, Turkey
| | - Fatih Kardas
- Paediatric Metabolic Medicine Department, Erciyes University Faculty of Medicine, Kayseri 38030, Turkey
| | - Cigdem Seher Kasapkara
- Paediatric Metabolic Medicine Department, Ankara Yildirim Beyazit University Faculty of Medicine, Ankara 06800, Turkey
| | - Gonca Kilic Yildirim
- Paediatric Metabolic Medicine Department, Osmangazi University Faculty of Medicine, Eskisehir 26480, Turkey
| | - Deniz Kor
- Paediatric Metabolic Medicine Department, Cukurova University Faculty of Medicine, Adana 01250, Turkey
| | - Melis Kose
- Paediatric Metabolic Medicine Department, Faculty of Medicine, Izmir Katip Celebi University, Izmir 35620, Turkey
| | - Cecilia Marelli
- MMDN, University Montpellier, EPHE, INSERM, 34090 Montpellier, France
- Expert Center for Metabolic and Neurogenetic Diseases, Centre Hospitalier Universitaire (CHU), 34090 Montpellier, France
| | - Helen Mundy
- Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | | | - Burcu Ozturk Hismi
- Paediatric Metabolic Medicine Department, Marmara University Faculty of Medicine, Istanbul 34854, Turkey
| | | | - Agathe Roubertie
- MMDN, University Montpellier, EPHE, INSERM, 34090 Montpellier, France
- Expert Center for Metabolic and Neurogenetic Diseases, Centre Hospitalier Universitaire (CHU), 34090 Montpellier, France
| | - Mehtap Sanlilar
- Paediatric Metabolic Medicine Department, Antalya Training and Research Hospital, Antalya 07100, Turkey
| | - Manuel Schiff
- Reference Center for Inborn Errors of Metabolism, Necker University Hospital, APHP and University of Paris Cité, 75015 Paris, France
| | - Srividya Sreekantam
- Birmingham Women’s and Children’s Hospital NHS Foundation Trust, Birmingham B4 6NH, UK
| | - Karolina M. Stepien
- Adult Inherited Metabolic Diseases, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Ozlem Uzun Unal
- Paediatric Metabolic Medicine Department, Kocaeli University Faculty of Medicine, Kocaeli 41380, Turkey
| | - Yilmaz Yildiz
- Paediatric Metabolic Medicine Department, Hacettepe University Faculty of Medicine, Ankara 06230, Turkey
| | - Tanyel Zubarioglu
- Paediatric Metabolic Medicine Department, Istanbul University-Cerrahpasa Faculty of Medicine, Istanbul 34096, Turkey
| | - Paul Gissen
- Genetics and Genomic Medicine Department, Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
- National Institute of Health Research Great Ormond Street Biomedical Research Centre, London WC1N 1EH, UK
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
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Fernández-Elías VE, Tornero-Aguilera JF, Parraca JA, Clemente-Suárez VJ. Psychological Stress Triggers a Hyperammonemia Episode in Patient with Ornithine Transcarbamylase Deficiency. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11516. [PMID: 36141788 PMCID: PMC9517620 DOI: 10.3390/ijerph191811516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/01/2022] [Accepted: 09/08/2022] [Indexed: 06/16/2023]
Abstract
An 18-year-old male motorcycle racer, who was a participant in the FIM Road Racing World Championship and had a history of Ornithine Transcarbamylase deficiency, developed nausea and dizziness while driving his motorcycle and became unconscious right after he stopped at the box. He was rapidly attended to by the medical personnel of the circuit, and once he recovered consciousness, he was taken to the local hospital where the blood analysis showed hyperammonemia (307 μg/dL) and excess alkalosis. The patient was properly following the prescribed treatment, and there were no environmental stressors. Hence, psychological stress and its somatization due to the risky task that the patient was performing could have triggered the episode. Stress must be considered as a potential cause, triggering strenuous metabolic stress that leads to hyperammonemia.
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Affiliation(s)
| | | | - Jose Alberto Parraca
- Departamento de Desporto e Saúde, Escola de Saúde e Desenvolvimento Humano, Universidade de Évora, Largo dos Colegiais, 7000 Évora, Portugal
- Comprehensive Health Research Centre (CHRC), Universidade de Évora, 7000 Évora, Portugal
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7
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Benefits of tailored disease management in improving tremor, white matter hyperintensities, and liver enzymes in a child with heterozygous X-linked ornithine transcarbamylase deficiency. Mol Genet Metab Rep 2022; 33:100891. [PMID: 36620387 PMCID: PMC9817482 DOI: 10.1016/j.ymgmr.2022.100891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 01/11/2023] Open
Abstract
We report the case of a 19-month-old girl with late-onset ornithine transcarbamylase (OTC) deficiency initially referred to gastroenterology for intermittent vomiting lasting a year and abnormal liver enzymes (AST 730 U/L [reference range 26-55 U/L]; ALT 1213 U/L [reference range 11-30 U/L]) without hepatomegaly. While the patient was hospitalized for liver biopsy, intermittent tremors of the upper extremities with varying severity were noted. The patient was presumed to have hyperammonemia secondary to acute liver failure and was discharged after 5 days; follow-up monitoring led to readmission 7 days later. A brain MRI showed nonspecific bilateral pericallosal and bifrontal white matter FLAIR hyperintensities. These findings raised suspicion for a metabolic disease and prompted a genetics consultation. After inconclusive biochemical testing and worsening clinical status, rapid whole genome sequencing results were obtained identifying a novel, de novo, likely pathogenic, variant c.608C > T (p.Ser203Phe) in the OTC gene. The patient was promptly started on an oral nitrogen scavenger, citrulline supplementation, and protein restriction. Ammonia and glutamine levels normalized within 1 month of treatment and have stayed within the goal ranges with continued tailoring of treatment. Her parents noted resolution of vomiting and improved mood stability. Liver enzymes normalized after 2 months of treatment. The tremor, identified as asterixis, improved and a repeat brain MRI 3 months after the initial imaging showed near-complete resolution of previous white matter hyperintensities.
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Key Words
- ALT, alanine transaminase
- AST, aspartate aminotransferase
- Asterixis
- BASC-3, Behavior Assessment System for Children
- BCAA, branched-chain amino acid
- FLAIR, fluid-attenuated inversion recovery
- GGT, gamma-glutamyl transferase
- Late onset
- MRI, magnetic resonance imaging
- MRS, magnetic resonance spectroscopy
- Manifesting heterozygote
- OTC, ornithine transcarbamylase
- Ornithine transcarbamylase deficiency
- PT, prothrombin time
- Partial onset
- TID, 3 times a day
- UCD, urea cycle disorder
- Urea cycle disorder
- WPPSI-IV, Wechsler Preschool and Primary Scale of Intelligence
- X linked
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8
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Sen K, Whitehead M, Castillo Pinto C, Caldovic L, Gropman A. Fifteen years of urea cycle disorders brain research: Looking back, looking forward. Anal Biochem 2022; 636:114343. [PMID: 34637785 PMCID: PMC8671367 DOI: 10.1016/j.ab.2021.114343] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/13/2021] [Accepted: 08/17/2021] [Indexed: 01/03/2023]
Abstract
Urea cycle disorders (UCD) are inherited diseases resulting from deficiency in one of six enzymes or two carriers that are required to remove ammonia from the body. UCD may be associated with neurological damage encompassing a spectrum from asymptomatic/mild to severe encephalopathy, which results in most cases from Hyperammonemia (HA) and elevation of other neurotoxic intermediates of metabolism. Electroencephalography (EEG), Magnetic resonance imaging (MRI) and Proton Magnetic resonance spectroscopy (MRS) are noninvasive measures of brain function and structure that can be used during HA to guide management and provide prognostic information, in addition to being research tools to understand the pathophysiology of UCD associated brain injury. The Urea Cycle Rare disorders Consortium (UCDC) has been invested in research to understand the immediate and downstream effects of hyperammonemia (HA) on brain using electroencephalogram (EEG) and multimodal brain MRI to establish early patterns of brain injury and to track recovery and prognosis. This review highlights the evolving knowledge about the impact of UCD and HA in particular on neurological injury and recovery and use of EEG and MRI to study and evaluate prognostic factors for risk and recovery. It recognizes the work of others and discusses the UCDC's prior work and future research priorities.
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Affiliation(s)
- Kuntal Sen
- Division of Neurogenetics and Neurodevelopmental Pediatrics, Children's National Hospital, Washington D.C., United States
| | - Matthew Whitehead
- Division of Radiology, Children's National Hospital, Washington D.C., United States
| | | | - Ljubica Caldovic
- Childrens' Research Institute, Children's National Hospital, Washington D.C., United States
| | - Andrea Gropman
- Division of Neurogenetics and Neurodevelopmental Pediatrics, Children's National Hospital, Washington D.C., United States.
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9
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Sen K, Anderson AA, Whitehead MT, Gropman AL. Review of Multi-Modal Imaging in Urea Cycle Disorders: The Old, the New, the Borrowed, and the Blue. Front Neurol 2021; 12:632307. [PMID: 33995244 PMCID: PMC8113618 DOI: 10.3389/fneur.2021.632307] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/26/2021] [Indexed: 12/16/2022] Open
Abstract
The urea cycle disorders (UCD) are rare genetic disorder due to a deficiency of one of six enzymes or two transport proteins that act to remove waste nitrogen in form of ammonia from the body. In this review, we focus on neuroimaging studies in OTCD and Arginase deficiency, two of the UCD we have extensively studied. Ornithine transcarbamylase deficiency (OTCD) is the most common of these, and X-linked. Hyperammonemia (HA) in OTCD is due to deficient protein handling. Cognitive impairments and neurobehavioral disorders have emerged as the major sequelae in Arginase deficiency and OTCD, especially in relation to executive function and working memory, impacting pre-frontal cortex (PFC). Clinical management focuses on neuroprotection from HA, as well as neurotoxicity from other known and yet unclassified metabolites. Prevention and mitigation of neurological injury is a major challenge and research focus. Given the impact of HA on neurocognitive function of UCD, neuroimaging modalities, especially multi-modality imaging platforms, can bring a wealth of information to understand the neurocognitive function and biomarkers. Such information can further improve clinical decision making, and result in better therapeutic interventions. In vivo investigations of the affected brain using multimodal neuroimaging combined with clinical and behavioral phenotyping hold promise. MR Spectroscopy has already proven as a tool to study biochemical aberrations such as elevated glutamine surrounding HA as well as to diagnose partial UCD. Functional Near Infrared Spectroscopy (fNIRS), which assesses local changes in cerebral hemodynamic levels of cortical regions, is emerging as a non-invasive technique and will serve as a surrogate to fMRI with better portability. Here we review two decades of our research using non-invasive imaging and how it has contributed to an understanding of the cognitive effects of this group of genetic conditions.
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Affiliation(s)
- Kuntal Sen
- Division of Neurogenetics and Neurodevelopmental Pediatrics, Department of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, United States
| | - Afrouz A Anderson
- Department of Research, Focus Foundation, Crofton, MD, United States
| | - Matthew T Whitehead
- Department of Radiology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, United States
| | - Andrea L Gropman
- Division of Neurogenetics and Neurodevelopmental Pediatrics, Department of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, United States
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Anderson AA, Gropman A, Le Mons C, Stratakis CA, Gandjbakhche AH. Hemodynamics of Prefrontal Cortex in Ornithine Transcarbamylase Deficiency: A Twin Case Study. Front Neurol 2020; 11:809. [PMID: 32922350 PMCID: PMC7456944 DOI: 10.3389/fneur.2020.00809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 06/29/2020] [Indexed: 11/30/2022] Open
Abstract
Ornithine transcarbamylase deficiency (OTCD) is the most common form of urea cycle disorder characterized by the presence of hyperammonemia (HA). In patients with OTCD, HA is known to cause impairments in domains of executive function and working memory. Monitoring OTCD progression and investigating neurocognitive biomarkers can, therefore, become critical in understanding the underlying brain function in a population with OTCD. We used functional near infrared spectroscopy (fNIRS) to examine the hemodynamics of prefrontal cortex (PFC) in a fraternal twin with and without OTCD. fNIRS is a non-invasive and wearable optical technology that can be used to assess cortical hemodynamics in a realistic clinical setting. We quantified the hemodynamic variations in total-hemoglobin as assessed by fNIRS while subjects performed the N-back working memory (WM) task. Our preliminary results showed that the sibling with OTCD had higher variation in a very low frequency band (<0.03 Hz, related to mechanism of cerebral autoregulation) compared to the control sibling. The difference between these variations was not as prominent in the higher frequency band, indicating the possible role of impaired autoregulation and cognitive function due to presence of HA. We further examined the functional connectivity in PFC, where the OTCD sibling showed lower interhemispheric functional connectivity as the task load increased. Our pilot results are the first to show the utility of fNIRS in monitoring OTCD cortical hemodynamics, indicating the possibility of inefficient neurocognitive function. This study provides a novel insight into the monitoring of OTCD focusing on the contribution of physiological process and neurocognitive function in this population.
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Affiliation(s)
- Afrouz A. Anderson
- National Institutes of Health (NIH), National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Andrea Gropman
- Children's National Medical Center, Division of Neurogenetics and Neurodevelopmental Pediatrics, Washington, DC, United States
| | - Cynthia Le Mons
- National Urea Cycle Disorders Foundation, Pasadena, CA, United States
| | - Constantine A. Stratakis
- National Institutes of Health (NIH), National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Amir H. Gandjbakhche
- National Institutes of Health (NIH), National Institute of Child Health and Human Development, Bethesda, MD, United States
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Anderson A, Gropman A, Le Mons C, Stratakis C, Gandjbakhche A. Evaluation of neurocognitive function of prefrontal cortex in ornithine transcarbamylase deficiency. Mol Genet Metab 2020; 129:207-212. [PMID: 31952925 PMCID: PMC7416502 DOI: 10.1016/j.ymgme.2019.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/30/2019] [Accepted: 12/30/2019] [Indexed: 02/02/2023]
Abstract
Hyperammonia due to ornithine transcarbamylase deficiency (OTCD) can cause a range of deficiencies in domains of executive function and working memory. Only a few fMRI studies have focused on neuroimaging data in a population with OTCD. Yet, there is a need for monitoring the disease progression and neurocognitive function in this population. In this study, we used a non-invasive neuroimaging technique, functional Near Infrared Spectroscopy (fNIRS), to examine the hemodynamics of prefrontal cortex (PFC) based on neural activation in an OTCD population. Using fNIRS, we measured the activation in PFC of the participants while performing the Stroop task. Behavioral assessment such as reaction time and correct response were recorded. We investigated the difference in behavioral measures as well as brain activation in left and right PFC in patients with OTCD and controls. Results revealed a distinction in left PFC activation between controls and patients with OTCD, where control subjects showed higher task related activation increase. Subjects with OTCD also exhibited bilateral increase in PFC activation. There was no significant difference in response time or correct response between the two groups. Our findings suggest the alterations in neurocognitive function of PFC in OTCD compared to the controls despite the behavioral profiles exhibiting no such differences. This is a first study using fNIRS to examine a neurocognitive function in OTCD population and can provide a novel insight into the screening of OTCD progression and examining neurocognitive changes.
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Affiliation(s)
- Afrouz Anderson
- NIH, National Institute of Child Health and Human Development, Bethesda, MD 20892, United States of America
| | - Andrea Gropman
- Children's National Medical Center, Division of Neurogenetics and Neurodevelopmental Pediatrics, Washington, DC 20010, United States of America
| | - Cynthia Le Mons
- National Urea Cycle Disorders Foundation, Pasadena, California 91105
| | - Constantine Stratakis
- NIH, National Institute of Child Health and Human Development, Bethesda, MD 20892, United States of America
| | - Amir Gandjbakhche
- NIH, National Institute of Child Health and Human Development, Bethesda, MD 20892, United States of America.
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Waisbren SE, Stefanatos AK, Kok TMY, Ozturk‐Hismi B. Neuropsychological attributes of urea cycle disorders: A systematic review of the literature. J Inherit Metab Dis 2019; 42:1176-1191. [PMID: 31268178 PMCID: PMC7250134 DOI: 10.1002/jimd.12146] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 06/25/2019] [Accepted: 07/01/2019] [Indexed: 12/30/2022]
Abstract
Urea cycle disorders (UCDs) are rare inherited metabolic conditions that impair the effectiveness of the urea cycle responsible for removing excess ammonia from the body. The estimated incidence of UCDs is 1:35 000 births, or approximately 113 new patients with UCD per year. This review summarizes neuropsychological outcomes among patients with the eight UCDs in reports published since 1980. Rates of intellectual disabilities published before (and including) 2000 and after 2000 were pooled and compared for each UCD. Since diagnoses for UCDs tended to occur earlier and better treatments became more readily available after the turn of the century, this assessment will characterize the extent that current management strategies have improved neuropsychological outcomes. The pooled sample included data on cognitive abilities of 1649 individuals reported in 58 citations. A total of 556 patients (34%) functioned in the range of intellectual disabilities. The decline in the proportion of intellectual disabilities in six disorders, ranged from 7% to 41%. Results from various studies differed and the cohorts varied with respect to age at symptom onset, age at diagnosis and treatment initiation, current age, severity of the metabolic deficiency, management strategies, and ethnic origins. The proportion of cases with intellectual disabilities ranged from 9% to 65% after 2000 in the seven UCDs associated with cognitive deficits. Positive outcomes from some studies suggest that it is possible to prevent or reverse the adverse impact of UCDs on neuropsychological functioning. It is time to "raise the bar" in terms of expectations for treatment effectiveness.
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Affiliation(s)
- Susan E. Waisbren
- Division of Genetics and Genomics, Department of Pediatrics, Boston Children's HospitalBostonMassachusetts
- Department of Medicine, Harvard Medical SchoolBostonMassachusetts
| | - Arianna K. Stefanatos
- Department of Child & Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of PhiladelphiaPhiladelphiaPennsylvania
| | | | - Burcu Ozturk‐Hismi
- Division of Genetics and Genomics, Department of Pediatrics, Boston Children's HospitalBostonMassachusetts
- Tepecik Education and Research HospitalIzmirTurkey
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Thangarajh M, Hendriksen J, McDermott MP, Martens W, Hart KA, Griggs RC. Relationships between DMD mutations and neurodevelopment in dystrophinopathy. Neurology 2019; 93:e1597-e1604. [PMID: 31594858 DOI: 10.1212/wnl.0000000000008363] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 05/22/2019] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE We performed a prospective, cross-sectional analysis of neurodevelopmental concerns and psychosocial adjustment in relation to DMD mutations in young steroid-naive boys with dystrophinopathy. METHODS We evaluated 196 steroid-naive boys with dystrophinopathy who were enrolled in the Finding the Optimal Regimen for Duchenne Muscular Dystrophy trial. The neurodevelopmental concerns and psychosocial adjustment challenges were analyzed in relation to DMD mutation. A parent or legal guardian reported neurodevelopmental concerns in 4 domains (speech, learning and attentional difficulties, and autism spectrum disorder [ASD]) and completed the Personal Adjustment and Role Skills Scale to assess psychosocial adjustment. We also assessed whether boys of DMD carrier mothers were more vulnerable to speech delay and learning difficulties. RESULTS We found that 39% of boys were reported to have speech delay with a mean age of speaking at 28 months (range 7-66 months). Learning difficulties were reported in 28% of participants. Inattentive-overactive and oppositional-defiant behavior was reported in 8% and 5% of participants, respectively. Psychosocial adjustment challenges were reported in 4% of participants. An ASD diagnosis was reported in 3 participants. Speech delay and learning difficulties were more common in boys with mutations downstream of DMD exon 45. Neurodevelopmental concerns were not associated with DMD deletion, duplication, or point mutation subtype. Boys of DMD carrier mothers did not have longer speech delay or more learning difficulties. CONCLUSION Our data support evidence for a relationship between neurodevelopmental concerns and DMD mutation. A longitudinal assessment of developmental trajectory is necessary to evaluate how specific DMD mutations affect brain function.
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Affiliation(s)
- Mathula Thangarajh
- From the Department of Neurology (M.T.), Children's National Health System, Washington, DC; Kempenhaeghe Center for Neurological Learning Disabilities (J.H.), Heeze, the Netherlands; and School of Medicine and Dentistry (M.P.M., W.M., K.A.H., R.C.G.), University of Rochester Medical Center, NY. M.T. is currently affiliated with the Department of Neurology, Virginia Commonwealth University, Richmond.
| | - Jos Hendriksen
- From the Department of Neurology (M.T.), Children's National Health System, Washington, DC; Kempenhaeghe Center for Neurological Learning Disabilities (J.H.), Heeze, the Netherlands; and School of Medicine and Dentistry (M.P.M., W.M., K.A.H., R.C.G.), University of Rochester Medical Center, NY. M.T. is currently affiliated with the Department of Neurology, Virginia Commonwealth University, Richmond
| | - Michael P McDermott
- From the Department of Neurology (M.T.), Children's National Health System, Washington, DC; Kempenhaeghe Center for Neurological Learning Disabilities (J.H.), Heeze, the Netherlands; and School of Medicine and Dentistry (M.P.M., W.M., K.A.H., R.C.G.), University of Rochester Medical Center, NY. M.T. is currently affiliated with the Department of Neurology, Virginia Commonwealth University, Richmond
| | - William Martens
- From the Department of Neurology (M.T.), Children's National Health System, Washington, DC; Kempenhaeghe Center for Neurological Learning Disabilities (J.H.), Heeze, the Netherlands; and School of Medicine and Dentistry (M.P.M., W.M., K.A.H., R.C.G.), University of Rochester Medical Center, NY. M.T. is currently affiliated with the Department of Neurology, Virginia Commonwealth University, Richmond
| | - Kimberly A Hart
- From the Department of Neurology (M.T.), Children's National Health System, Washington, DC; Kempenhaeghe Center for Neurological Learning Disabilities (J.H.), Heeze, the Netherlands; and School of Medicine and Dentistry (M.P.M., W.M., K.A.H., R.C.G.), University of Rochester Medical Center, NY. M.T. is currently affiliated with the Department of Neurology, Virginia Commonwealth University, Richmond
| | - Robert C Griggs
- From the Department of Neurology (M.T.), Children's National Health System, Washington, DC; Kempenhaeghe Center for Neurological Learning Disabilities (J.H.), Heeze, the Netherlands; and School of Medicine and Dentistry (M.P.M., W.M., K.A.H., R.C.G.), University of Rochester Medical Center, NY. M.T. is currently affiliated with the Department of Neurology, Virginia Commonwealth University, Richmond
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Thangarajh M, Kaat AJ, Bibat G, Mansour J, Summerton K, Gioia A, Berger C, Hardy KK, Wagner KR. The NIH Toolbox for cognitive surveillance in Duchenne muscular dystrophy. Ann Clin Transl Neurol 2019; 6:1696-1706. [PMID: 31472009 PMCID: PMC6764624 DOI: 10.1002/acn3.50867] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE We performed a prospective, cross-sectional cognitive assessment in subjects with Duchenne Muscular Dystrophy (DMD) and their biological mothers. METHODS Thirty subjects with out-of-frame mutations in the dystrophin (DMD) gene, and 25 biological mothers were evaluated using the National Institutes of Health Toolbox Cognition Battery (NIHTB-CB). A parent completed the Behavior Rating Inventory of Executive Functioning (BRIEF), a standardized rating scale of executive functioning, for their child. Mothers completed self-reports of BRIEF and Neuro Quality-of-Life (NeuroQoL) Cognitive Function. RESULTS Overall, the subjects with DMD scored approximately one standard deviation (SD) below age-corrected norms on the NIHTB-CB Total Cognition score. They scored 1.5 SD below age-corrected norms in Fluid Cognition, which evaluates the cognitive domains of executive function, working memory, episodic memory, attention, and processing speed. Their performance was consistent with age expectations (i.e., within 1 SD below age-corrected norms) in Crystalized Cognition, which evaluates vocabulary and reading. Subjects with DMD had higher T-scores in several domains of BRIEF, demonstrating greater difficulty in executive functioning. The biological mothers had overall average or above average T-scores on NIHTB-CB. Mothers who were carriers of DMD mutation performed lower overall compared to mothers who were not carriers of DMD mutation (Cohen's d = -1.1). Carrier mothers performed lower than average (1.5 SD) in Executive Function, measured by Flanker Inhibitory Control and Attention. Biological mothers scored within expected score ranges for adults in BRIEF and NeuroQoL. INTERPRETATION The NIHTB-CB, combined with standardized self-reported measures, can be a sensitive screening tool for cognitive surveillance in DMD.
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Affiliation(s)
- Mathula Thangarajh
- Department of NeurologyChildren’s National Health SystemDistrict of ColumbiaWashington
| | - Aaron J. Kaat
- Department of Medical Social SciencesNorthwestern UniversityChicagoIllinois
| | - Genila Bibat
- Center for Genetic Muscle DisordersKennedy Krieger Institute, Johns Hopkins School of MedicineBaltimoreMaryland
| | - Jennifer Mansour
- Center for Genetic Muscle DisordersKennedy Krieger Institute, Johns Hopkins School of MedicineBaltimoreMaryland
| | - Katherine Summerton
- Center for Genetic Muscle DisordersKennedy Krieger Institute, Johns Hopkins School of MedicineBaltimoreMaryland
| | - Anthony Gioia
- Departments of Psychiatry & Behavioral Science and PediatricsGeorge Washington University School of MedicineDistrict of ColumbiaWashington
| | - Carly Berger
- Departments of Psychiatry & Behavioral Science and PediatricsGeorge Washington University School of MedicineDistrict of ColumbiaWashington
| | - Kristina K. Hardy
- Departments of Psychiatry & Behavioral Science and PediatricsGeorge Washington University School of MedicineDistrict of ColumbiaWashington
| | - Kathryn R. Wagner
- Center for Genetic Muscle DisordersKennedy Krieger Institute, Johns Hopkins School of MedicineBaltimoreMaryland
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Enns GM, Porter MH, Francis-Sedlak M, Burdett A, Vockley J. Perspectives on urea cycle disorder management: Results of a clinician survey. Mol Genet Metab 2019; 128:102-108. [PMID: 31377149 DOI: 10.1016/j.ymgme.2019.07.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/12/2019] [Accepted: 07/16/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND/AIMS Urea cycle disorders (UCDs) are rare inborn errors of urea synthesis. US and European consensus statements on the diagnosis and treatment of UCDs were last published in 2001 and 2019, respectively. Recommendations are based primarily on case reports and expert opinion and there is limited agreement or consistency related to long-term management approaches. A clinician survey was conducted to assess current real-world practices and perspectives on challenges and unmet needs. METHODS A 14-item multiple-choice survey was administered to physicians in 2017. Clinicians who reported actively managing at least 1 patient with UCD were eligible to participate. Descriptive statistics were calculated for each survey item (frequencies for categorical variables; means, standard deviations, medians, and ranges for continuous variables). RESULTS Sixty-six US clinicians completed the survey (65 geneticists; 1 pediatric neurologist). Over 90% of responders agreed or strongly agreed that even modest elevations in ammonia could cause physiological and functional brain damage; >80% of respondents agreed that asymptomatic UCD patients are at risk of brain damage over time due to mild/subclinical elevations in ammonia. Eighty-six percent of clinicians agreed or strongly agreed with recommending genetic testing for female relatives when a patient is diagnosed with ornithine transcarbamylase deficiency. Ninety-four percent of respondents agreed that patients have better disease control when they are more adherent to their UCD therapy. Nearly 90% indicated that clinicians and patients would benefit from updated UCD management guidance. More than half (53%) of respondents rated the symptoms of UCDs as extremely or very burdensome to the everyday lives of patients and their families; only 8% rated UCD symptoms as slightly or not at all burdensome. The majority of clinicians agreed (48%) or strongly agreed (32%) that caring for a child or family member with a UCD has a negative impact on the quality of life and/or health of family members/guardians (e.g. stress, relationships, ability to work). CONCLUSIONS This self-reported survey suggests a need for updated and expanded clinical guidance on the long-term treatment and management of UCD patients.
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Affiliation(s)
- Gregory M Enns
- Stanford University, School of Medicine, Stanford, CA, USA.
| | | | | | | | - Jerry Vockley
- University of Pittsburgh, School of Medicine, Graduate School of Public Health, Pittsburgh, PA, USA
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Buerger C, Garbade SF, Alber FD, Waisbren SE, McCarter R, Kölker S, Burgard P. Impairment of cognitive function in ornithine transcarbamylase deficiency is global rather than domain-specific and is associated with disease onset, sex, maximum ammonium, and number of hyperammonemic events. J Inherit Metab Dis 2019; 42:243-253. [PMID: 30671983 PMCID: PMC7439789 DOI: 10.1002/jimd.12013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 10/18/2018] [Accepted: 11/12/2018] [Indexed: 12/15/2022]
Abstract
Beginning in 2006, the Urea Cycle Disorders Consortium (UCDC) has conducted a longitudinal study of eight inherited deficiencies of enzymes and transporters of the urea cycle, including 444 individuals with ornithine transcarbamylase deficiency (OTCD), of whom 300 (67 males, 233 females) received psychological evaluation. In a cross-sectional study (age range, 3-71 years), analysis of covariance (ANCOVA) determined the association between outcomes in five cognitive domains (global intelligence, executive functions, memory, visuomotor integration, visual perception) and sex, age at testing and timing of disease onset defined as early onset (≤28 days; EO), late onset (LO), or asymptomatic (AS). The dataset of 183 subjects with complete datasets (31 males, 152 females) revealed underrepresentation of EO subjects (2 males, 4 females), who were excluded from the ANCOVA. Although mean scores of LO and AS individuals were within 1 SD of the population norm, AS subjects attained significantly higher scores than LO subjects and males higher scores than females. Correlations between cognitive domains were high, particularly intelligence proved to be a distinguished indicator for cognitive functioning. Maximum plasma ammonium concentration and intelligence correlated significantly higher in EO (r = -0.47) than in LO subjects (r = 0.04). Correlation between the number of hyperammonemic events and intelligence scores were similar for EO (r = -0.30) and LO (r = -0.26) individuals. The number of clinical symptoms was significantly associated with intelligence (r = -0.28) but not with scores in other domains. Results suggest that OTCD has a global impact on cognitive functioning rather than a specific effect on distinct cognitive domains.
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Affiliation(s)
- Corinna Buerger
- Division of Neuropaediatrics and Inherited Metabolic Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Sven F. Garbade
- Division of Neuropaediatrics and Inherited Metabolic Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Fabienne Dietrich Alber
- Division of Metabolism and Children’s Research Centre, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Susan E. Waisbren
- Division of Genetics and Genomics, Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Robert McCarter
- Center for Translational Sciences, Children’s National Health System, The George Washington University, Washington, District of Columbia
| | - Stefan Kölker
- Division of Neuropaediatrics and Inherited Metabolic Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Burgard
- Division of Neuropaediatrics and Inherited Metabolic Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Abstract
BACKGROUND Genetic data have the potential to impact patient care significantly. In primary care and in the ICU, patients are undergoing genetic testing. Genetics is also transforming cancer care and undiagnosed diseases. Optimal personalized medicine relies on the understanding of disease penetrance. In this article, I examine the complexity of penetrance. METHODS In this article, I assess how variable penetrance can be seen with many diseases, including those of different modes of inheritance, and how genomic testing is being applied effectively for many diseases. In this article, I also identify challenges in the field, including the interpretation of gene variants. RESULTS Using advancing bioinformatics and detailed phenotypic assessment, we can increase the yield of genomic testing, particularly for highly penetrant conditions. The technologies are useful and applicable to different medical situations. CONCLUSIONS There are now effective genome diagnostics for many diseases. However, the best personalized application of these data still requires skilled interpretation.
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Affiliation(s)
- Joseph T.C. Shieh
- Division of Medical Genetics, Department of Pediatrics, Institute for Human Genetics, University of California, San Francisco, San Francisco, California
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18
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Barkovich E, Robinson C, Gropman A. Brain biomarkers and neuroimaging to diagnose urea cycle disorders and assess prognosis. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1242407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Waisbren SE, Gropman AL, Batshaw ML. Improving long term outcomes in urea cycle disorders-report from the Urea Cycle Disorders Consortium. J Inherit Metab Dis 2016; 39:573-84. [PMID: 27215558 PMCID: PMC4921309 DOI: 10.1007/s10545-016-9942-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 04/26/2016] [Accepted: 04/27/2016] [Indexed: 12/31/2022]
Abstract
The Urea Cycle Disorders Consortium (UCDC) has conducted, beginning in 2006, a longitudinal study (LS) of eight enzyme deficiencies/transporter defects associated with the urea cycle. These include N-acetylglutamate synthase deficiency (NAGSD); Carbamyl phosphate synthetase 1 deficiency (CPS1D); Ornithine transcarbamylase deficiency (OTCD); Argininosuccinate synthetase deficiency (ASSD) (Citrullinemia); Argininosuccinate lyase deficiency (ASLD) (Argininosuccinic aciduria); Arginase deficiency (ARGD, Argininemia); Hyperornithinemia, hyperammonemia, homocitrullinuria (HHH) syndrome (or mitochondrial ornithine transporter 1 deficiency [ORNT1D]); and Citrullinemia type II (mitochondrial aspartate/glutamate carrier deficiency [CITRIN]). There were 678 UCD patients enrolled in 14 sites in the U.S., Canada, and Europe at the writing of this paper. This review summarizes findings of the consortium related to outcome, focusing primarily on neuroimaging findings and neurocognitive function. Neuroimaging studies in late onset OTCD offered evidence that brain injury caused by biochemical dysregulation may impact functional neuroanatomy serving working memory processes, an important component of executive function and regulation. Additionally, there were alteration in white mater microstructure and functional connectivity at rest. Intellectual deficits in OTCD and other urea cycle disorders (UCD) vary. However, when neuropsychological deficits occur, they tend to be more prominent in motor/performance areas on both intelligence tests and other measures. In some disorders, adults performed significantly less well than younger patients. Further longitudinal follow-up will reveal whether this is due to declines throughout life or to improvements in diagnostics (especially newborn screening) and treatments in the younger generation of patients.
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Affiliation(s)
- Susan E Waisbren
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrea L Gropman
- Children's Research Institute, Children's National Health System, Washington, DC, USA
| | - Mark L Batshaw
- Departments of Pediatrics and Neurology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
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In Vivo NMR Studies of the Brain with Hereditary or Acquired Metabolic Disorders. Neurochem Res 2015; 40:2647-85. [PMID: 26610379 DOI: 10.1007/s11064-015-1772-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 11/10/2015] [Accepted: 11/12/2015] [Indexed: 01/09/2023]
Abstract
Metabolic disorders, whether hereditary or acquired, affect the brain, and abnormalities of the brain are related to cellular integrity; particularly in regard to neurons and astrocytes as well as interactions between them. Metabolic disturbances lead to alterations in cellular function as well as microscopic and macroscopic structural changes in the brain with diabetes, the most typical example of metabolic disorders, and a number of hereditary metabolic disorders. Alternatively, cellular dysfunction and degeneration of the brain lead to metabolic disturbances in hereditary neurological disorders with neurodegeneration. Nuclear magnetic resonance (NMR) techniques allow us to assess a range of pathophysiological changes of the brain in vivo. For example, magnetic resonance spectroscopy detects alterations in brain metabolism and energetics. Physiological magnetic resonance imaging (MRI) detects accompanying changes in cerebral blood flow related to neurovascular coupling. Diffusion and T1/T2-weighted MRI detect microscopic and macroscopic changes of the brain structure. This review summarizes current NMR findings of functional, physiological and biochemical alterations within a number of hereditary and acquired metabolic disorders in both animal models and humans. The global view of the impact of these metabolic disorders on the brain may be useful in identifying the unique and/or general patterns of abnormalities in the living brain related to the pathophysiology of the diseases, and identifying future fields of inquiry.
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Pacheco-Colón I, Washington SD, Sprouse C, Helman G, Gropman AL, VanMeter JW. Reduced Functional Connectivity of Default Mode and Set-Maintenance Networks in Ornithine Transcarbamylase Deficiency. PLoS One 2015; 10:e0129595. [PMID: 26067829 PMCID: PMC4466251 DOI: 10.1371/journal.pone.0129595] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 05/11/2015] [Indexed: 12/21/2022] Open
Abstract
Background and Purpose Ornithine transcarbamylase deficiency (OTCD) is an X-chromosome linked urea cycle disorder (UCD) that causes hyperammonemic episodes leading to white matter injury and impairments in executive functioning, working memory, and motor planning. This study aims to investigate differences in functional connectivity of two resting-state networks—default mode and set-maintenance—between OTCD patients and healthy controls. Methods Sixteen patients with partial OTCD and twenty-two control participants underwent a resting-state scan using 3T fMRI. Combining independent component analysis (ICA) and region-of-interest (ROI) analyses, we identified the nodes that comprised each network in each group, and assessed internodal connectivity. Results Group comparisons revealed reduced functional connectivity in the default mode network (DMN) of OTCD patients, particularly between the anterior cingulate cortex/medial prefrontal cortex (ACC/mPFC) node and bilateral inferior parietal lobule (IPL), as well as between the ACC/mPFC node and the posterior cingulate cortex (PCC) node. Patients also showed reduced connectivity in the set-maintenance network, especially between right anterior insula/frontal operculum (aI/fO) node and bilateral superior frontal gyrus (SFG), as well as between the right aI/fO and ACC and between the ACC and right SFG. Conclusion Internodal functional connectivity in the DMN and set-maintenance network is reduced in patients with partial OTCD compared to controls, most likely due to hyperammonemia-related white matter damage. Because several of the affected areas are involved in executive functioning, it is postulated that this reduced connectivity is an underlying cause of the deficits OTCD patients display in this cognitive domain.
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Affiliation(s)
- Ileana Pacheco-Colón
- Center for Functional and Molecular Imaging, Georgetown University, Washington, DC, United States of America
- Department of Neurology, Georgetown University Medical Center, Washington, DC, United States of America
- * E-mail:
| | - Stuart D. Washington
- Center for Functional and Molecular Imaging, Georgetown University, Washington, DC, United States of America
- Department of Neurology, Georgetown University Medical Center, Washington, DC, United States of America
| | - Courtney Sprouse
- Department of Neurogenetics, Children’s National Health System, Washington, DC, United States of America
- George Washington University of the Health Sciences, Washington, DC, United States of America
| | - Guy Helman
- Department of Neurogenetics, Children’s National Health System, Washington, DC, United States of America
| | - Andrea L. Gropman
- Center for Functional and Molecular Imaging, Georgetown University, Washington, DC, United States of America
- Department of Neurogenetics, Children’s National Health System, Washington, DC, United States of America
- George Washington University of the Health Sciences, Washington, DC, United States of America
- Medical Genetics Branch, NHGRI, National Institutes of Health, Bethesda, Maryland, United States of America
| | - John W. VanMeter
- Center for Functional and Molecular Imaging, Georgetown University, Washington, DC, United States of America
- Department of Neurology, Georgetown University Medical Center, Washington, DC, United States of America
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Tarasenko TN, Rosas OR, Singh LN, Kristaponis K, Vernon H, McGuire PJ. A new mouse model of mild ornithine transcarbamylase deficiency (spf-j) displays cerebral amino acid perturbations at baseline and upon systemic immune activation. PLoS One 2015; 10:e0116594. [PMID: 25647322 PMCID: PMC4315515 DOI: 10.1371/journal.pone.0116594] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 12/12/2014] [Indexed: 01/09/2023] Open
Abstract
Ornithine transcarbamylase deficiency (OTCD, OMIM# 311250) is an inherited X-linked urea cycle disorder that is characterized by hyperammonemia and orotic aciduria. In this report, we describe a new animal model of OTCD caused by a spontaneous mutation in the mouse Otc gene (c.240T>A, p.K80N). This transversion in exon 3 of ornithine transcarbamylase leads to normal levels of mRNA with low levels of mature protein and is homologous to a mutation that has also been described in a single patient affected with late-onset OTCD. With higher residual enzyme activity, spf-J were found to have normal plasma ammonia and orotate. Baseline plasma amino acid profiles were consistent with mild OTCD: elevated glutamine, and lower citrulline and arginine. In contrast to WT, spf-J displayed baseline elevations in cerebral amino acids with depletion following immune challenge with polyinosinic:polycytidylic acid. Our results indicate that the mild spf-J mutation constitutes a new mouse model that is suitable for mechanistic studies of mild OTCD and the exploration of cerebral pathophysiology during acute decompensation that characterizes proximal urea cycle dysfunction in humans.
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Affiliation(s)
- Tatyana N Tarasenko
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Odrick R Rosas
- Universidad Central de Caribe, Bayamon, Puerto Rico, United States of America
| | - Larry N Singh
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Kara Kristaponis
- Department of Neurogenetics, Kennedy Krieger Institute, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Hilary Vernon
- Kennedy Krieger Institute, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Peter J McGuire
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, United States of America
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