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Bugi MA, Jugănaru I, Simina IE, Nicoară DM, Cristun LI, Brad GF, Huțanu D, Isac R, Kozma K, Cîrnatu D, Mărginean O. Evaluating Therapy and Growth in Children with Phenylketonuria: A Retrospective Longitudinal Study from Two Romanian Centers. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1185. [PMID: 39064614 PMCID: PMC11279053 DOI: 10.3390/medicina60071185] [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: 06/26/2024] [Revised: 07/17/2024] [Accepted: 07/19/2024] [Indexed: 07/28/2024]
Abstract
Background and Objectives: Phenylketonuria (PKU) is a rare genetic disorder characterized by the inability to convert the essential amino acid phenylalanine into tyrosine. Early dietary treatment can successfully prevent complications, but controversies still exist regarding the attainment of normal growth in these patients. Materials and Methods: Eighteen patients with PKU from two Romanian reference centers were compared to eighteen non-PKU controls, matched for age and gender. The comparisons used weight-for-height, weight-for-age, height/length-for-age, and body mass index-for-age z-scores from birth to three years of age. Results: The PKU study group consisted of nine boys and nine girls, with a median follow-up period of thirty-six months (interquartile range = 9.75). While median values of all four growth metrics remained within the normal range across the entire study period, weight-for-age z-scores were significantly lower in PKU patients throughout most of the study (p < 0.001). Conclusions: The persistent lower weight-for-age z-scores of the PKU patients compared to controls indicate that ongoing monitoring and potential adjustments in dietary therapy may be necessary to further optimize growth outcomes.
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Affiliation(s)
- Meda-Ada Bugi
- Ph.D. School Department, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (M.-A.B.)
- Department of Pediatrics I, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania (G.-F.B.); (O.M.)
- Department of Pharmacy, University of Medicine and Pharmacy ‘Vasile Goldis’, 310025 Arad, Romania
| | - Iulius Jugănaru
- Department of Pediatrics I, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania (G.-F.B.); (O.M.)
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
- Department of Research Center for Disturbances of Growth and Development in Children–BELIVE, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300011 Timisoara, Romania
| | - Iulia-Elena Simina
- Department of Genetics, Center of Genomic Medicine, ‘Victor Babeş’ University of Medicine and Pharmacy, 300041 Timisoara, Romania;
| | - Delia-Maria Nicoară
- Ph.D. School Department, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (M.-A.B.)
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Lucian-Ioan Cristun
- Ph.D. School Department, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (M.-A.B.)
| | - Giorgiana-Flavia Brad
- Department of Pediatrics I, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania (G.-F.B.); (O.M.)
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Delia Huțanu
- Department of Biology-Chemistry, Biology-Chemistry-Geography Faculty, West University of Timisoara, 300115 Timisoara, Romania;
| | - Raluca Isac
- Department XI Pediatrics, Discipline III Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania;
| | - Kinga Kozma
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410000 Oradea, Romania;
- Regional Center of Medical Genetics Bihor, Emergency Clinical Hospital Bihor, 410000 Oradea, Romania
| | - Daniela Cîrnatu
- Department of Medicine, University of Medicine and Pharmacy ‘Vasile Goldis’, 310025 Arad, Romania
- Romanian National Institute of Public Health, Regional Centre, 300230 Timisoara, Romania
| | - Otilia Mărginean
- Department of Pediatrics I, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania (G.-F.B.); (O.M.)
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
- Department of Research Center for Disturbances of Growth and Development in Children–BELIVE, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300011 Timisoara, Romania
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Vos EN, Demirbas D, Mangel M, Gozalbo MER, Levy HL, Berry GT. The treatment of biochemical genetic diseases: From substrate reduction to nucleic acid therapies. Mol Genet Metab 2023; 140:107693. [PMID: 37716025 DOI: 10.1016/j.ymgme.2023.107693] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/29/2023] [Accepted: 08/29/2023] [Indexed: 09/18/2023]
Abstract
Newborn screening (NBS) began a revolution in the management of biochemical genetic diseases, greatly increasing the number of patients for whom dietary therapy would be beneficial in preventing complications in phenylketonuria as well as in a few similar disorders. The advent of next generation sequencing and expansion of NBS have markedly increased the number of biochemical genetic diseases as well as the number of patients identified each year. With the avalanche of new and proposed therapies, a second wave of options for the treatment of biochemical genetic disorders has emerged. These therapies range from simple substrate reduction to enzyme replacement, and now ex vivo gene therapy with autologous cell transplantation. In some instances, it may be optimal to introduce nucleic acid therapy during the prenatal period to avoid fetopathy. However, as with any new therapy, complications may occur. It is important for physicians and other caregivers, along with ethicists, to determine what new therapies might be beneficial to the patient, and which therapies have to be avoided for those individuals who have less severe problems and for which standard treatments are available. The purpose of this review is to discuss the "Standard" treatment plans that have been in place for many years and to identify the newest and upcoming therapies, to assist the physician and other healthcare workers in making the right decisions regarding the initiation of both the "Standard" and new therapies. We have utilized several diseases to illustrate the applications of these different modalities and discussed for which disorders they may be suitable. The future is bright, but optimal care of the patient, including and especially the newborn infant, requires a deep knowledge of the disease process and careful consideration of the necessary treatment plan, not just based on the different genetic defects but also with regards to different variants within a gene itself.
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Affiliation(s)
- E Naomi Vos
- Division of Genetics & Genomics, Boston Children's Hospital; and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States of America; Manton Center for Orphan Disease Research, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States of America.
| | - Didem Demirbas
- Division of Genetics & Genomics, Boston Children's Hospital; and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States of America; Manton Center for Orphan Disease Research, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States of America.
| | - Matthew Mangel
- Division of Genetics & Genomics, Boston Children's Hospital; and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States of America.
| | - M Estela Rubio Gozalbo
- Department of Pediatrics and Clinical Genetics, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands; GROW, Maastricht University, Minderbroedersberg 4-6, 6211 LK Maastricht, the Netherlands; MetabERN: European Reference Network for Hereditary Metabolic Disorders, Udine, Italy; UMD: United for Metabolic Diseases Member, Amsterdam, the Netherlands.
| | - Harvey L Levy
- Division of Genetics & Genomics, Boston Children's Hospital; and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States of America.
| | - Gerard T Berry
- Division of Genetics & Genomics, Boston Children's Hospital; and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States of America; Manton Center for Orphan Disease Research, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States of America.
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Pinto A, Ilgaz F, Evans S, van Dam E, Rocha JC, Karabulut E, Hickson M, Daly A, MacDonald A. Phenylalanine Tolerance over Time in Phenylketonuria: A Systematic Review and Meta-Analysis. Nutrients 2023; 15:3506. [PMID: 37630696 PMCID: PMC10458574 DOI: 10.3390/nu15163506] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 07/29/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
In phenylketonuria (PKU), natural protein tolerance is defined as the maximum natural protein intake maintaining a blood phenylalanine (Phe) concentration within a target therapeutic range. Tolerance is affected by several factors, and it may differ throughout a person's lifespan. Data on lifelong Phe/natural protein tolerance are limited and mostly reported in studies with low subject numbers. This systematic review aimed to investigate how Phe/natural protein tolerance changes from birth to adulthood in well-controlled patients with PKU on a Phe-restricted diet. Five electronic databases were searched for articles published until July 2020. From a total of 1334 results, 37 articles met the eligibility criteria (n = 2464 patients), and 18 were included in the meta-analysis. The mean Phe (mg/day) and natural protein (g/day) intake gradually increased from birth until 6 y (at the age of 6 months, the mean Phe intake was 267 mg/day, and natural protein intake was 5.4 g/day; at the age of 5 y, the mean Phe intake was 377 mg/day, and the natural protein intake was 8.9 g/day). However, an increase in Phe/natural protein tolerance was more apparent at the beginning of late childhood and was >1.5-fold that of the Phe tolerance in early childhood. During the pubertal growth spurt, the mean natural protein/Phe tolerance was approximately three times higher than in the first year of life, reaching a mean Phe intake of 709 mg/day and a mean natural protein intake of 18 g/day. Post adolescence, a pooled analysis could only be performed for natural protein intake. The mean natural protein tolerance reached its highest (32.4 g/day) point at the age of 17 y and remained consistent (31.6 g/day) in adulthood, but limited data were available. The results of the meta-analysis showed that Phe/natural protein tolerance (expressed as mg or g per day) increases with age, particularly at the beginning of puberty, and reaches its highest level at the end of adolescence. This needs to be interpreted with caution as limited data were available in adult patients. There was also a high degree of heterogeneity between studies due to differences in sample size, the severity of PKU, and target therapeutic levels for blood Phe control.
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Affiliation(s)
- Alex Pinto
- Department of Dietetics, Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (S.E.); (A.D.); (A.M.)
- School of Health Professions, Faculty of Health, University of Plymouth, Plymouth PL4 6AB, UK;
| | - Fatma Ilgaz
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Hacettepe University, 06100 Ankara, Turkey;
| | - Sharon Evans
- Department of Dietetics, Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (S.E.); (A.D.); (A.M.)
| | - Esther van Dam
- Beatrix Children’s Hospital, University of Groningen, University Medical Center, 9700 RB Groningen, The Netherlands;
| | - Júlio César Rocha
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciencias Medicas, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal;
- CINTESIS@RISE, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal
- Reference Centre of Inherited Metabolic Diseases, Centro Hospitalar Universitario de Lisboa Central, 1169-045 Lisboa, Portugal
| | - Erdem Karabulut
- Department of Biostatistics, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey;
| | - Mary Hickson
- School of Health Professions, Faculty of Health, University of Plymouth, Plymouth PL4 6AB, UK;
| | - Anne Daly
- Department of Dietetics, Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (S.E.); (A.D.); (A.M.)
| | - Anita MacDonald
- Department of Dietetics, Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (S.E.); (A.D.); (A.M.)
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The financial and time burden associated with phenylketonuria treatment in the United States. Mol Genet Metab Rep 2019; 21:100523. [PMID: 31660292 PMCID: PMC6807265 DOI: 10.1016/j.ymgmr.2019.100523] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/13/2019] [Indexed: 01/08/2023] Open
Abstract
Background Phenylketonuria (PKU) imposes a substantial burden on people living with the condition and their families. However, little is known about the time cost and financial burden of having PKU or caring for a child with the condition. Methods and findings Primary data were collected with a detailed cost and utilization survey. Primary outcomes included utilization and out-of-pocket costs of medical services, medical formula, and prescribed low-protein food consumption, as well as the time and perceived effort involved in following the PKU diet. Respondents were people living with PKU or parents of children with PKU identified through a state newborn screening program database. Secondary administrative claims data were also used to calculate mean total, insurer, and out-of-pocket payments in inpatient, outpatient (office visits, emergency room, and laboratory tests), and pharmacy settings for privately insured persons with PKU. Payments were calculated for sapropterin and for PKU formula.In primary data analysis (children n = 32, adults n = 52), annual out-of-pocket costs were highest for low-protein foods (child = $1651; adult = $967) compared with other categories of care. The time burden of PKU care was high; families reported spending more than 300 h per year shopping for and preparing special diet foods.In secondary data analysis, children 12-17 years old had the highest average medical expenditures ($54,147; n = 140) compared to children 0-11 years old ($19,057; n = 396) and adults 18 years and older ($40,705; n = 454). Medication costs were the largest contributor to medical costs, accounting for 61-81% of total costs across age groups. Sapropterin was the largest driver of medication costs, accounting for 85% of child medication costs and 92% of adult medication costs. Conclusion Treatment for PKU incurs a substantial time and cost burden on persons with PKU and their families. Estimated medical expenditures using claims data varied by age group, but sapropterin represented the largest cost for PKU treatment from a payer perspective across age groups.
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Vockley J, Dobrowolski SF, Arnold GL, Guerrero RB, Derks TGJ, Weinstein DA. Complex patterns of inheritance, including synergistic heterozygosity, in inborn errors of metabolism: Implications for precision medicine driven diagnosis and treatment. Mol Genet Metab 2019; 128:1-9. [PMID: 31358473 PMCID: PMC8931500 DOI: 10.1016/j.ymgme.2019.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/18/2019] [Accepted: 07/18/2019] [Indexed: 01/03/2023]
Abstract
Inborn errors of metabolism have traditionally been viewed as the quintessential single gene disorders; defects in one gene leads to loss of activity of one enzyme causing a metabolic imbalance and clinical disease. However, reality has never been quite that simple, and the classic "one gene-one enzyme" paradigm has been upended in many ways. Multiple gene defects can lead to the same biochemical phenotype, often with different clinical symptoms. Additionally, different mutations in the same gene can cause variable phenotypes, often most dramatic when a disease can be identified by pre-symptomatic screening. Moreover, response to therapy is not homogeneous across diseases and specific mutations. Perhaps the biggest deviation from traditional monogenic inheritance is in the setting of synergistic heterozygosity, a multigenic inheritance pattern in which mutations in multiple genes in a metabolic pathway lead to sufficient disruption of flux through the pathway, mimicking a monogenic disorder caused by homozygous defects in one gene in that pathway. In addition, widespread adoption of whole exome and whole genome sequencing in medical genetics has led to the realization that individual patients with apparently hybrid phenotypes can have mutations in more than one gene, leading to a mixed genetic disorder. Each of these situations point to a need for as much precision as possible in diagnosing metabolic disease, and it is likely to become increasingly critical to drive therapy. This article examines examples in traditional monogenic disorders that illustrates these points and define inborn errors of metabolism as complex genetic traits on the leading edge of precision medicine.
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Affiliation(s)
- Jerry Vockley
- University of Pittsburgh School of Medicine, Department of Pediatrics, Pittsburgh, PA, United States of America; UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, United States of America.
| | - Steven F Dobrowolski
- University of Pittsburgh School of Medicine, Department of Pathology, Pittsburgh, PA. UPMC Children's Hospital of Pittsburgh. 4401 Penn Avenue, Pittsburgh, PA 15224, United States of America
| | - Georgianne L Arnold
- University of Pittsburgh School of Medicine, Department of Pediatrics, Pittsburgh, PA, United States of America; UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, United States of America
| | | | - Terry G J Derks
- Section of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, PO box 30 001, 9700, RB, Groningen, the Netherlands
| | - David A Weinstein
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT 06030, United States of America; GSD Program, Connecticut Children's Medical Center, Hartford, CT 06106, United States of America
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Turki A, Ueda K, Cheng B, Giezen A, Salvarinova R, Stockler-Ipsiroglu S, Elango R. The Indicator Amino Acid Oxidation Method with the Use of l-[1-13C]Leucine Suggests a Higher than Currently Recommended Protein Requirement in Children with Phenylketonuria. J Nutr 2017; 147:211-217. [PMID: 28053173 DOI: 10.3945/jn.116.240218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/01/2016] [Accepted: 12/01/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Phenylketonuria is characterized by mutations in the Phe hydroxylase gene that leads to the accumulation of Phe in plasma and the brain. The standard of care for phenylketonuria is nutritional management with dietary restriction of Phe and the provision of sufficient protein and energy for growth and health maintenance. The protein requirement in children with phenylketonuria is empirically determined based upon phenylketonuria nutritional guidelines that are adjusted individually in response to biochemical markers and growth. OBJECTIVE We determined dietary protein requirements in children with phenylketonuria with the use of the indicator amino acid oxidation (IAAO) technique, with l-[1-13C]Leu as the indicator amino acid. METHODS Four children (2 males; 2 females) aged 9-18 y with phenylketonuria [mild hyperphenylalanemia (mHPA); 6-10 mg/dL (360-600 μmol/L)] were recruited to participate in ≥7 separate test protein intakes (range: 0.2-3.2 g ⋅ kg-1 ⋅ d-1) with the IAAO protocol with the use of l-[1-13C]Leu followed by the collection of breath and urine samples over 8 h. The diets were isocaloric and provided energy at 1.7 times the resting energy expenditure. Protein was provided as a crystalline amino acid mixture based on an egg protein pattern, except Phe and Leu, which were maintained at a constant across intakes. Protein requirement was determined with the use of a 2-phase linear-regression crossover analysis of the rate of l-[1-13C]Leu tracer oxidation. RESULTS The mean protein requirement was determined to be 1.85 g ⋅ kg-1 ⋅ d-1 (R2 = 0.66; 95% CI: 1.37, 2.33). This result is substantially higher than the 2014 phenylketonuria recommendations (1.14-1.33 g ⋅ kg-1 ⋅ d-1; based on 120-140% above the current RDA for age). CONCLUSIONS To our knowledge, this is the first study to directly define a quantitative requirement for protein intake in children with mHPA and indicates that current protein recommendations in children with phenylketonuria may be insufficient. This trial was registered at clinicaltrials.gov as NCT01965691.
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Affiliation(s)
- Abrar Turki
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada.,Department of Pediatrics and
| | - Keiko Ueda
- Department of Pediatrics and.,Division of Biochemical Diseases, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Barbara Cheng
- Department of Pediatrics and.,Division of Biochemical Diseases, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Alette Giezen
- Department of Pediatrics and.,Division of Biochemical Diseases, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Ramona Salvarinova
- Department of Pediatrics and.,Division of Biochemical Diseases, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Sylvia Stockler-Ipsiroglu
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada.,Department of Pediatrics and.,Division of Biochemical Diseases, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Rajavel Elango
- Department of Pediatrics and .,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada; and.,Division of Biochemical Diseases, BC Children's Hospital, Vancouver, British Columbia, Canada
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