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Porta F, Maiorana A, Gragnaniello V, Procopio E, Gasperini S, Taurisano R, Spada M, Dionisi-Vici C, Burlina A. Triheptanoin in patients with long-chain fatty acid oxidation disorders: clinical experience in Italy. Ital J Pediatr 2024; 50:204. [PMID: 39375714 DOI: 10.1186/s13052-024-01782-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 09/26/2024] [Indexed: 10/09/2024] Open
Abstract
BACKGROUND Long-chain fatty acid oxidation disorders (LC-FAOD) are rare and potentially life-threatening diseases that cause deficient energy production and accumulation of toxic metabolites. Despite dietary management, adherence to maximum fasting guidelines, restricted long-chain triglyceride intake and supplementation with medium-chain triglyceride (MCT) oil (current standard of care), most patients experience recurrent decompensation episodes that can require hospitalisation. Herein, we analysed the effectiveness and safety of triheptanoin (a highly purified, synthetic medium odd-chain triglyceride) treatment in a cohort of Italian patients with LC-FAOD. METHODS This retrospective, nationwide study included nine patients with LC-FAOD who switched from standard therapy with MCT oil to triheptanoin oral liquid. Data were collected between 2018 and 2022. Clinical outcome measures were the number and duration of intercurrent catabolic episodes and number and duration of metabolic decompensation episodes requiring hospitalisation. Creatine kinase (CK) levels and treatment-related adverse effects were also reported. RESULTS Patients were provided a mean ± standard deviation (SD) triheptanoin dose of 1.5 ± 0.9 g/kg/day in four divided administrations, which accounted for 23.9 ± 8.9% of patients' total daily caloric intake. Triheptanoin treatment was started between 2.7 and 16 years of age and was continued for 2.2 ± 0.9 years. The number of intercurrent catabolic episodes during triheptanoin treatment was significantly lower than during MCT therapy (4.3 ± 5.3 vs 22.0 ± 22.2; p = 0.034), as were the number of metabolic decompensations requiring hospitalisation (mean ± SD: 2.0 ± 2.5 vs 18.3 ± 17.7; p = 0.014), and annualised hospitalisation rates and duration. Mean CK levels (outside metabolic decompensation episodes) were lower with triheptanoin treatment versus MCT oil for seven patients. No intensive care unit admissions were required during triheptanoin treatment. Epigastric pain and diarrhoea were recorded as adverse effects during both MCT and triheptanoin treatment. CONCLUSIONS The significant improvement in clinical outcome measures after the administration of triheptanoin highlights that this treatment approach can be more effective than MCT supplementation in patients with LC-FAOD. Triheptanoin was well tolerated and decreased the number of intercurrent catabolic episodes, metabolic decompensation episodes requiring hospitalisation, and the annualised rate and duration of hospitalisations.
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Affiliation(s)
- Francesco Porta
- Department of Paediatrics, University of Turin, Turin, Italy
| | - Arianna Maiorana
- Division of Metabolic Diseases and Hepatology, Bambino Gesù Children‛s Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Vincenza Gragnaniello
- Division of Inherited Metabolic Diseases, Department of Women and Children‛s Health, Reference Centre for Expanded Newborn Screening, University Hospital, Padua, Italy
| | - Elena Procopio
- Metabolic and Neuromuscular Unit, Meyer Children‛s Hospital IRCCS, Florence, Italy
| | - Serena Gasperini
- Department of Paediatrics, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Roberta Taurisano
- Division of Metabolic Diseases and Hepatology, Bambino Gesù Children‛s Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Marco Spada
- Department of Paediatrics, University of Turin, Turin, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolic Diseases and Hepatology, Bambino Gesù Children‛s Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Alberto Burlina
- Division of Inherited Metabolic Diseases, Department of Women and Children‛s Health, Reference Centre for Expanded Newborn Screening, University Hospital, Padua, Italy
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Yang EC, Fang Z, Tan R, Guo Y, He S, Kruger E, Nedzesky J, Marsden D. Clinical manifestations, healthcare resource utilization, and costs among patients with long-chain fatty acid oxidation disorders: a retrospective claims database analysis. Curr Med Res Opin 2024:1-14. [PMID: 39291999 DOI: 10.1080/03007995.2024.2405124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 09/12/2024] [Indexed: 09/19/2024]
Abstract
OBJECTIVE Long-chain fatty acid oxidation disorders (LC-FAOD) are a group of rare genetic inborn errors of metabolism. Clinical manifestations may result in frequent healthcare visits, hospitalizations, and early death. This retrospective cohort study assessed manifestations, healthcare resource use (HRU), direct medical costs, and the impact of COVID-19 on HRU among patients with LC-FAOD. METHODS The IQVIA PharMetrics Plus database was searched for pediatric (0-17 years) and adult (≥18 years) patients with confirmed LC-FAOD (ICD-10-CM Diagnosis Code E71.310) and ≥12 months continuous enrollment (CE) between January 2016-February 2020. A non-LC-FAOD general population cohort was randomly selected and matched using 1:20 exact matching on age, gender, payer type, and CE start year. Manifestations were identified via ICD-10 diagnosis codes (any billing position). Overall HRU and attributable costs were stratified by care setting. Pre-COVID-19 (March 2019-February 2020) and during COVID-19 (March 2020-February 2021) HRU was assessed among a subgroup of patients and the general population. Outcomes were evaluated among children and adults, respectively. RESULTS 423 patients with LC-FAOD (47% female; 79.7% children) were included. The mean enrollment duration was 2.6 ± 1.2 years. 22.6% of children with LC-FAOD had at least one major clinical event (MCE), consisting of rhabdomyolysis (10.1%), hypoglycemia (9.8%), or cardiomyopathy (8.6%) versus 1.5% overall occurrence in the general population. Adults with LC-FAOD had a higher incidence of MCEs (37.2%) than children with LC-FAOD. Annualized all-cause HRU in all care settings and mean total annualized medical costs (children: $17,082 vs $4144; adults: $43,602 vs $3949) were higher in patients with LC-FAOD versus the general population. Patients with LC-FAOD had substantially fewer healthcare visits during COVID-19 across care settings than during the pre-COVID-19 period. CONCLUSIONS LC-FAOD impart a high burden on patients. Extended hospital stays and increased outpatient management were especially pronounced for adults and for patients with ≥1 MCE, resulting in substantially higher medical costs than the general population.
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Affiliation(s)
| | - Zhenzhen Fang
- Tianjin Happy Life Technology Co., Ltd, Beijing, China
| | - Ruixin Tan
- Tianjin Happy Life Technology Co., Ltd, Beijing, China
| | - Yun Guo
- Tianjin Happy Life Technology Co., Ltd, Beijing, China
| | - Siyi He
- Tianjin Happy Life Technology Co., Ltd, Beijing, China
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Elizondo G, Saini A, Gonzalez de Alba C, Gregor A, Harding CO, Gillingham MB, Vinocur JM. Cardiac phenotype in adolescents and young adults with long-chain 3-hydroxyacyl CoA dehydrogenase (LCHAD) deficiency. Genet Med 2024; 26:101123. [PMID: 38501492 DOI: 10.1016/j.gim.2024.101123] [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: 08/28/2023] [Revised: 03/14/2024] [Accepted: 03/14/2024] [Indexed: 03/20/2024] Open
Abstract
PURPOSE Long-chain 3-hydroxyacyl-coenzyme A dehydrogenase deficiency (LCHADD) is a rare fatty acid oxidation disorder characterized by recurrent episodes of metabolic decompensation and rhabdomyolysis, as well as retinopathy, peripheral neuropathy, and cardiac involvement, such as infantile dilated cardiomyopathy. Because LCHADD patients are surviving longer, we sought to characterize LCHADD-associated major cardiac involvement in adolescence and young adulthood. METHODS A retrospective cohort of 16 adolescent and young adult participants with LCHADD was reviewed for cardiac phenotype. RESULTS Major cardiac involvement occurred in 9 of 16 participants, including sudden death, out-of-hospital cardiac arrest, acute cardiac decompensations with heart failure and/or in-hospital cardiac arrest, end-stage dilated cardiomyopathy, and moderate restrictive cardiomyopathy. Sudden cardiac arrest was more common in males and those with a history of infant cardiomyopathy. CONCLUSION The cardiac manifestations of LCHADD in adolescence and early adulthood are complex and distinct from the phenotype seen in infancy. Life-threatening arrhythmia occurs at substantial rates in LCHADD, often in the absence of metabolic decompensation or rhabdomyolysis. The potential risk factors identified here-male sex and history of infant cardiomyopathy-may hint at strategies for risk stratification and possibly the prevention of these events.
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Affiliation(s)
- Gabriela Elizondo
- Department of Molecular and Medical Genetics, Oregon Health and Science University, Portland, OR
| | - Ajesh Saini
- Department of Molecular and Medical Genetics, Oregon Health and Science University, Portland, OR; Portland State University, Urban Honors College, Portland, OR
| | | | - Ashley Gregor
- Department of Molecular and Medical Genetics, Oregon Health and Science University, Portland, OR
| | - Cary O Harding
- Department of Molecular and Medical Genetics, Oregon Health and Science University, Portland, OR
| | - Melanie B Gillingham
- Department of Molecular and Medical Genetics, Oregon Health and Science University, Portland, OR.
| | - Jeffrey M Vinocur
- Division of Pediatric Cardiology, Yale University School of Medicine, New Haven, CT
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Yang E, Kruger E, Yin D, Mace K, Tierney M, Liao N, Cibelli E, Drozd D, Ross N, Deering KL, Herout P, Harshaw Q, Shillington A, Thomas N, Marsden D, Kritzer A, Vockley J. Major clinical events and healthcare resource use among patients with long-chain fatty acid oxidation disorders in the United States: Results from LC-FAOD Odyssey program. Mol Genet Metab 2024; 142:108350. [PMID: 38458123 DOI: 10.1016/j.ymgme.2024.108350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/16/2024] [Accepted: 02/18/2024] [Indexed: 03/10/2024]
Abstract
Major clinical events (MCEs) related to long-chain fatty acid oxidation disorders (LC-FAOD) in triheptanoin clinical trials include inpatient or emergency room (ER) visits for three major clinical manifestations: rhabdomyolysis, hypoglycemia, and cardiomyopathy. However, outcomes data outside of LC-FAOD clinical trials are limited. The non-interventional cohort LC-FAOD Odyssey study examines data derived from US medical records and patient reported outcomes to quantify LC-FAOD burden according to management strategy including MCE frequency and healthcare resource utilization (HRU). Thirty-four patients were analyzed of which 21 and 29 patients had received triheptanoin and/or medium chain triglycerides (MCT), respectively. 36% experienced MCEs while receiving triheptanoin versus 54% on MCT. Total mean annualized MCE rates on triheptanoin and MCT were 0.1 and 0.7, respectively. Annualized disease-related inpatient and ER events were lower on triheptanoin (0.2, 0.3, respectively) than MCT (1.2, 1.0, respectively). Patients were managed more in an outpatient setting on triheptanoin (8.9 annualized outpatient visits) vs MCT (7.9). Overall, this shows that those with LC-FAOD in the Odyssey program experienced fewer MCEs and less HRU in inpatient and ER settings during triheptanoin-treated periods compared with the MCT-treated periods. The MCE rate was lower after initiation of triheptanoin, consistent with clinical trials.
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Affiliation(s)
- Erru Yang
- Ultragenyx Pharmaceutical Inc., Novato, CA, USA.
| | | | - David Yin
- PicnicHealth, San Francisco, CA, USA
| | | | | | | | | | - Dan Drozd
- PicnicHealth, San Francisco, CA, USA
| | | | | | | | | | | | - Nina Thomas
- Ultragenyx Pharmaceutical Inc., Novato, CA, USA
| | | | - Amy Kritzer
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA
| | - Jerry Vockley
- Division of Medical Genetics and Center for Rare Disease Therapy, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
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Mütze U, Ottenberger A, Gleich F, Maier EM, Lindner M, Husain RA, Palm K, Beblo S, Freisinger P, Santer R, Thimm E, vom Dahl S, Weinhold N, Grohmann‐Held K, Haase C, Hennermann JB, Hörbe‐Blindt A, Kamrath C, Marquardt I, Marquardt T, Behne R, Haas D, Spiekerkoetter U, Hoffmann GF, Garbade SF, Grünert SC, Kölker S. Neurological outcome in long-chain hydroxy fatty acid oxidation disorders. Ann Clin Transl Neurol 2024; 11:883-898. [PMID: 38263760 PMCID: PMC11021608 DOI: 10.1002/acn3.52002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/04/2024] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVE This study aims to elucidate the long-term benefit of newborn screening (NBS) for individuals with long-chain 3-hydroxy-acyl-CoA dehydrogenase (LCHAD) and mitochondrial trifunctional protein (MTP) deficiency, inherited metabolic diseases included in NBS programs worldwide. METHODS German national multicenter study of individuals with confirmed LCHAD/MTP deficiency identified by NBS between 1999 and 2020 or selective metabolic screening. Analyses focused on NBS results, confirmatory diagnostics, and long-term clinical outcomes. RESULTS Sixty-seven individuals with LCHAD/MTP deficiency were included in the study, thereof 54 identified by NBS. All screened individuals with LCHAD deficiency survived, but four with MTP deficiency (14.8%) died during the study period. Despite NBS and early treatment neonatal decompensations (28%), symptomatic disease course (94%), later metabolic decompensations (80%), cardiomyopathy (28%), myopathy (82%), hepatopathy (32%), retinopathy (17%), and/or neuropathy (22%) occurred. Hospitalization rates were high (up to a mean of 2.4 times/year). Disease courses in screened individuals with LCHAD and MTP deficiency were similar except for neuropathy, occurring earlier in individuals with MTP deficiency (median 3.9 vs. 11.4 years; p = 0.0447). Achievement of dietary goals decreased with age, from 75% in the first year of life to 12% at age 10, and consensus group recommendations on dietary management were often not achieved. INTERPRETATION While NBS and early treatment result in improved (neonatal) survival, they cannot reliably prevent long-term morbidity in screened individuals with LCHAD/MTP deficiency, highlighting the urgent need of better therapeutic strategies and the development of disease course-altering treatment.
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Affiliation(s)
- Ulrike Mütze
- Medical Faculty of Heidelberg, Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic MedicineHeidelberg UniversityHeidelbergGermany
| | - Alina Ottenberger
- Medical Faculty of Heidelberg, Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic MedicineHeidelberg UniversityHeidelbergGermany
| | - Florian Gleich
- Medical Faculty of Heidelberg, Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic MedicineHeidelberg UniversityHeidelbergGermany
| | - Esther M. Maier
- Dr. von Hauner Children's Hospital, Ludwig‐Maximilians‐UniversityMunichGermany
| | - Martin Lindner
- Division of Pediatric NeurologyUniversity Children's Hospital FrankfurtFrankfurtGermany
| | - Ralf A. Husain
- Center for Inborn Metabolic Disorders, Department of NeuropediatricsJena University HospitalJenaGermany
| | - Katja Palm
- Division of Endocrinology, Diabetology and Metabolic MedicineUniversity Children's HospitalMagdeburgGermany
| | - Skadi Beblo
- Department of Women and Child Health, Hospital for Children and Adolescents, Center for Pediatric Research Leipzig (CPL)University Hospitals, University of LeipzigLeipzigGermany
| | - Peter Freisinger
- Children's Hospital Reutlingen, Klinikum am SteinenbergReutlingenGermany
| | - René Santer
- University Medical Center Hamburg‐Eppendorf, University Children's HospitalHamburgGermany
| | - Eva Thimm
- Department of General Pediatrics, Neonatology, and Pediatric CardiologyUniversity Children's Hospital, Heinrich Heine University DüsseldorfDüsseldorfGermany
| | - Stephan vom Dahl
- Department of Gastroenterology, Hepatology and Infectious DiseasesUniversity Hospital, Heinrich Heine University DüsseldorfDüsseldorfGermany
| | - Natalie Weinhold
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Center of Chronically Sick ChildrenCharité ‐ Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Karina Grohmann‐Held
- Department of Pediatrics and Adolescent MedicineUniversity Medicine GreifswaldGreifswaldGermany
| | - Claudia Haase
- Department of Pediatrics and Adolescent MedicineHelios Hospital ErfurtErfurtGermany
| | - Julia B. Hennermann
- Villa Metabolica, Center for Pediatric and Adolescent MedicineMainz University Medical CenterMainzGermany
| | | | - Clemens Kamrath
- Department of General Pediatrics and NeonatologyUniversity Hospital of Gießen and MarburgGießenGermany
| | - Iris Marquardt
- Department of Child NeurologyChildren's Hospital OldenburgOldenburgGermany
| | - Thorsten Marquardt
- Department of General Pediatrics, Metabolic DiseasesUniversity Children's Hospital MuensterMuensterGermany
| | - Robert Behne
- Medical Faculty of Heidelberg, Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic MedicineHeidelberg UniversityHeidelbergGermany
| | - Dorothea Haas
- Medical Faculty of Heidelberg, Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic MedicineHeidelberg UniversityHeidelbergGermany
| | - Ute Spiekerkoetter
- Department of General Pediatrics, Adolescent Medicine and NeonatologyMedical Center ‐ University of Freiburg, Faculty of MedicineFreiburgGermany
| | - Georg F. Hoffmann
- Medical Faculty of Heidelberg, Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic MedicineHeidelberg UniversityHeidelbergGermany
| | - Sven F. Garbade
- Medical Faculty of Heidelberg, Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic MedicineHeidelberg UniversityHeidelbergGermany
| | - Sarah C. Grünert
- Department of General Pediatrics, Adolescent Medicine and NeonatologyMedical Center ‐ University of Freiburg, Faculty of MedicineFreiburgGermany
| | - Stefan Kölker
- Medical Faculty of Heidelberg, Center for Child and Adolescent Medicine, Division of Child Neurology and Metabolic MedicineHeidelberg UniversityHeidelbergGermany
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Lan X, Huang H, Liu J, Zhao J, Li G, Zuo M, Xing X, Ren X. Compromised very-low density lipoprotein induced polyunsaturated triglyceride accumulation in N-nitrosodiethylamine-induced hepatic steatosis. Food Chem Toxicol 2024; 186:114519. [PMID: 38369053 DOI: 10.1016/j.fct.2024.114519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/07/2024] [Accepted: 02/15/2024] [Indexed: 02/20/2024]
Abstract
N-Nitrosodiethylamine (NDEA), a carcinogen in some foods and medications, is linked to liver damage similar to non-alcoholic fatty liver disease (NAFLD). This study explores how NDEA disrupts liver lipid metabolism. Sprague-Dawley rats were given two doses of NDEA (100 mg/kg) orally, 24 h apart. Liver response was assessed through tissue staining, blood tests, and biochemical markers, including fatty acids, lipid peroxidation, and serum very-low density lipoprotein (VLDL) levels. Additionally, lipidomic analysis of liver tissues and serum was performed. The results indicated significant hepatic steatosis (fat accumulation in the liver) following NDEA exposure. Blood analysis showed signs of inflammation and liver damage. Biochemical tests revealed decreased liver protein synthesis and specific enzyme alterations, suggesting liver cell injury but maintaining mitochondrial function. Increased fatty acid levels without a rise in lipid peroxidation were observed, indicating fat accumulation. Lipidomic analysis showed increased polyunsaturated triglycerides in the liver and decreased serum VLDL, implicating impaired VLDL transport in liver dysfunction. In conclusion, NDEA exposure disrupts liver lipid metabolism, primarily through the accumulation of polyunsaturated triglycerides and impaired fat transport. These findings provide insight into the mechanisms of NDEA-induced liver injury and its progression to hepatic steatosis.
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Affiliation(s)
- Xuerao Lan
- School of Public Health, Sun Yat-Sen University, No. 74 Zhongshan Road 2, Guangzhou, 510080, China; Shenzhen Key Laboratory of Modern Toxicology, Shenzhen Medical Key Discipline of Health Toxicology (2020-2024), Shenzhen Center for Disease Control and Prevention, No 8 Longyuan Road, Nanshan District, Shenzhen, 518055, China
| | - Haiyan Huang
- Shenzhen Key Laboratory of Modern Toxicology, Shenzhen Medical Key Discipline of Health Toxicology (2020-2024), Shenzhen Center for Disease Control and Prevention, No 8 Longyuan Road, Nanshan District, Shenzhen, 518055, China
| | - Jianjun Liu
- Shenzhen Key Laboratory of Modern Toxicology, Shenzhen Medical Key Discipline of Health Toxicology (2020-2024), Shenzhen Center for Disease Control and Prevention, No 8 Longyuan Road, Nanshan District, Shenzhen, 518055, China
| | - Jing Zhao
- Shenzhen Key Laboratory of Modern Toxicology, Shenzhen Medical Key Discipline of Health Toxicology (2020-2024), Shenzhen Center for Disease Control and Prevention, No 8 Longyuan Road, Nanshan District, Shenzhen, 518055, China
| | - Guowei Li
- Shenzhen Key Laboratory of Modern Toxicology, Shenzhen Medical Key Discipline of Health Toxicology (2020-2024), Shenzhen Center for Disease Control and Prevention, No 8 Longyuan Road, Nanshan District, Shenzhen, 518055, China
| | - Mingyang Zuo
- Shenzhen Key Laboratory of Modern Toxicology, Shenzhen Medical Key Discipline of Health Toxicology (2020-2024), Shenzhen Center for Disease Control and Prevention, No 8 Longyuan Road, Nanshan District, Shenzhen, 518055, China
| | - Xiumei Xing
- School of Public Health, Sun Yat-Sen University, No. 74 Zhongshan Road 2, Guangzhou, 510080, China.
| | - Xiaohu Ren
- Shenzhen Key Laboratory of Modern Toxicology, Shenzhen Medical Key Discipline of Health Toxicology (2020-2024), Shenzhen Center for Disease Control and Prevention, No 8 Longyuan Road, Nanshan District, Shenzhen, 518055, China.
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Rouyer A, Tard C, Dessein A, Spinazzi M, Bédat‐Millet A, Dimitri‐Boulos D, Nadaj‐Pakleza A, Chanson J, Nicolas G, Douillard C, Laforêt P. Long-term prognosis of fatty-acid oxidation disorders in adults: Optimism despite the limited effective therapies available. Eur J Neurol 2024; 31:e16138. [PMID: 38015438 PMCID: PMC11235989 DOI: 10.1111/ene.16138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 09/25/2023] [Accepted: 10/21/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION Fatty-acid oxidation disorders (FAODs) are recessive genetic diseases. MATERIALS AND METHODS We report here clinical and paraclinical data from a retrospective study of 44 adults with muscular FAODs from six French reference centers for neuromuscular or metabolic diseases. RESULTS The study cohort consisted of 44 adult patients: 14 with carnitine palmitoyl transferase 2 deficiency (32%), nine with multiple acyl-CoA deficiency (20%), 13 with very long-chain acyl-CoA dehydrogenase deficiency (30%), three with long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (7%), and five with short-chain acyl-CoA dehydrogenase deficiency (11%). Disease onset occurred during childhood in the majority of patients (59%), with a mean age at onset of 15 years (range = 0.5-35) and a mean of 12.6 years (range = 0-58) from disease onset to diagnosis. The principal symptoms were acute muscle manifestations (rhabdomyolysis, exercise intolerance, myalgia), sometimes associated with permanent muscle weakness. Episodes of rhabdomyolysis were frequent (84%), with a mean creatinine kinase level of 68,958 U/L (range = 660-300,000). General metabolic complications were observed in 58% of patients, respiratory manifestations in 18% of cases, and cardiological manifestations in 9% of cases. Fasting acylcarnitine profile was used to orient genetic explorations in 65% of cases. After a mean follow-up of 10 years, 33% of patients were asymptomatic and 56% continued to display symptoms after exercise. The frequency of rhabdomyolysis decreased after diagnosis in 64% of cases. CONCLUSION A standardized register would complete this cohort description of muscular forms of FAODs with exhaustive data, making it possible to assess the efficacy of therapeutic protocols in real-life conditions and during the long-term follow-up of patients.
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Affiliation(s)
- Alice Rouyer
- Neurology DepartmentRaymond Poincaré University Hospital, Assitance Publique des Hopitaux de ParisGarchesFrance
| | - Céline Tard
- Neurology Department, University of Lille, Inserm, Centre Hospialo‐Niversitaire Lille, U1172–LilNCog (JPARC)–Lille Neuroscience and CognitionNord‐Est‐Ile‐de‐France Neuromuscular Reference Center, Cognitive‐Motor Unit of Expertise, Centre Hospitalo‐Régional Universitaire LilleLilleFrance
| | - Anne‐Frédérique Dessein
- Institute of Biochemistry, Biology, and Pathology Center, Metabolism Department and Medical Reference Center for Inherited Metabolic DiseasesLille University HospitalLilleFrance
| | - Marco Spinazzi
- Department of Neurology, Neuromuscular Reference Center Atlantique Occitanie CaraïbeUniversity HospitalAngersFrance
| | | | - Dalia Dimitri‐Boulos
- Internal Medicine DepartmentQuinze‐Vingts National Ophthalmology HospitalParisFrance
| | - Aleksandra Nadaj‐Pakleza
- Department of Neurology, Reference Center for Neuromuscular Disorders Nord‐Est‐Ile‐de‐France, European Reference Network for Rare Neuromuscular DiseasesUniversity Hospital of StrasbourgStrasbourgFrance
| | - Jean‐Baptiste Chanson
- Department of Neurology, Reference Center for Neuromuscular Disorders Nord‐Est‐Ile‐de‐France, European Reference Network for Rare Neuromuscular DiseasesUniversity Hospital of StrasbourgStrasbourgFrance
| | - Guillaume Nicolas
- Neurology DepartmentRaymond Poincaré University Hospital, Assitance Publique des Hopitaux de ParisGarchesFrance
- Nord‐Est‐Ile‐de‐France Neuromuscular Reference CenterFédération Hospitalo‐Universitaire PHENIXGarchesFrance
- U 1179 INSERMParis‐Saclay UniversityMontigny‐le‐BretonneuxFrance
| | - Claire Douillard
- Endocrinology–Diabetology–Metabolism Department and Medical Reference Center for Inherited Metabolic Diseases Jeanne de Flandre Hospital, Centre Hospitalo‐Régional Universitaire LilleLilleFrance
| | - Pascal Laforêt
- Neurology DepartmentRaymond Poincaré University Hospital, Assitance Publique des Hopitaux de ParisGarchesFrance
- Nord‐Est‐Ile‐de‐France Neuromuscular Reference CenterFédération Hospitalo‐Universitaire PHENIXGarchesFrance
- U 1179 INSERMParis‐Saclay UniversityMontigny‐le‐BretonneuxFrance
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Nurjanah S, Gerding A, Vieira-Lara MA, Evers B, Langelaar-Makkinje M, Spiekerkoetter U, Bakker BM, Tucci S. Heptanoate Improves Compensatory Mechanism of Glucose Homeostasis in Mitochondrial Long-Chain Fatty Acid Oxidation Defect. Nutrients 2023; 15:4689. [PMID: 37960342 PMCID: PMC10649308 DOI: 10.3390/nu15214689] [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: 09/22/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
Defects in mitochondrial fatty acid β-oxidation (FAO) impair metabolic flexibility, which is an essential process for energy homeostasis. Very-long-chain acyl-CoA dehydrogenase (VLCADD; OMIM 609575) deficiency is the most common long-chain mitochondrial FAO disorder presenting with hypoglycemia as a common clinical manifestation. To prevent hypoglycemia, triheptanoin-a triglyceride composed of three heptanoates (C7) esterified with a glycerol backbone-can be used as a dietary treatment, since it is metabolized into precursors for gluconeogenesis. However, studies investigating the effect of triheptanoin on glucose homeostasis are limited. To understand the role of gluconeogenesis in the pathophysiology of long-chain mitochondrial FAO defects, we injected VLCAD-deficient (VLCAD-/-) mice with 13C3-glycerol in the presence and absence of heptanoate (C7). The incorporation of 13C3-glycerol into blood glucose was higher in VLCAD-/- mice than in WT mice, whereas the difference disappeared in the presence of C7. The result correlates with 13C enrichment of liver metabolites in VLCAD-/- mice. In contrast, the C7 bolus significantly decreased the 13C enrichment. These data suggest that the increased contribution of gluconeogenesis to the overall glucose production in VLCAD-/- mice increases the need for gluconeogenesis substrate, thereby avoiding hypoglycemia. Heptanoate is a suitable substrate to induce glucose production in mitochondrial FAO defect.
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Affiliation(s)
- Siti Nurjanah
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Centre, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany (U.S.)
- Faculty of Biology, University of Freiburg, 79104 Freiburg, Germany
| | - Albert Gerding
- Laboratory of Pediatrics, Systems Medicine of Metabolism and Signaling, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands (M.L.-M.)
- Laboratory of Metabolic Diseases, Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Marcel A. Vieira-Lara
- Laboratory of Pediatrics, Systems Medicine of Metabolism and Signaling, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands (M.L.-M.)
| | - Bernard Evers
- Laboratory of Pediatrics, Systems Medicine of Metabolism and Signaling, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands (M.L.-M.)
| | - Miriam Langelaar-Makkinje
- Laboratory of Pediatrics, Systems Medicine of Metabolism and Signaling, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands (M.L.-M.)
| | - Ute Spiekerkoetter
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Centre, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany (U.S.)
| | - Barbara M. Bakker
- Laboratory of Pediatrics, Systems Medicine of Metabolism and Signaling, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands (M.L.-M.)
| | - Sara Tucci
- Pharmacy, Medical Center, University of Freiburg, 79106 Freiburg, Germany
- G.E.R.N. Research Center for Tissue Replacement, Regeneration & Neogenesis, Department of Prosthetic Dentistry, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
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9
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Karunanidhi A, Basu S, Zhao XJ, D'Annibale O, Van't Land C, Vockley J, Mohsen AW. Heptanoic and medium branched-chain fatty acids as anaplerotic treatment for medium chain acyl-CoA dehydrogenase deficiency. Mol Genet Metab 2023; 140:107689. [PMID: 37660571 PMCID: PMC10840664 DOI: 10.1016/j.ymgme.2023.107689] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/05/2023]
Abstract
Triheptanoin (triheptanoylglycerol) has shown value as anaplerotic therapy for patients with long chain fatty acid oxidation disorders but is contraindicated in medium-chain acyl-CoA dehydrogenase (MCAD) deficiency. In search for anaplerotic therapy for patients with MCAD deficiency, fibroblasts from three patients homozygous for the most common mutation, ACADMG985A/G985A, were treated with fatty acids hypothesized not to require MCAD for their metabolism, including heptanoic (C7; the active component of triheptanoin), 2,6-dimethylheptanoic (dMC7), 6-amino-2,4-dimethylheptanoic (AdMC7), or 4,8-dimethylnonanoic (dMC9) acids. Their effectiveness as anaplerotic fatty acids was assessed in live cells by monitoring changes in cellular oxygen consumption rate (OCR) and mitochondrial protein lysine succinylation, which reflects cellular succinyl-CoA levels, using immunofluorescence (IF) staining. Krebs cycle intermediates were also quantitated in these cells using targeted metabolomics. The four fatty acids induced positive changes in OCR parameters, consistent with their oxidative catalysis and utilization. Increases in cellular IF staining of succinylated lysines were observed, indicating that the fatty acids were effective sources of succinyl-CoA in the absence of media glucose, pyruvate, and lipids. The ability of MCAD deficient cells to metabolize C7 was confirmed by the ability of extracts to enzymatically utilize C7-CoA as substrate but not C8-CoA. To evaluate C7 therapeutic potential in vivo, Acadm-/- mice were treated with triheptanoin for seven days. Dose dependent increase in plasma levels of heptanoyl-, valeryl-, and propionylcarnitine indicated efficient metabolism of the medication. The pattern of the acylcarnitine profile paralleled resolution of liver pathology including reversing hepatic steatosis, increasing hepatic glycogen content, and increasing hepatocyte protein succinylation, all indicating improved energy homeostasis in the treated mice. These results provide the impetus to evaluate triheptanoin and the medium branched chain fatty acids as potential therapeutic agents for patients with MCAD deficiency.
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Affiliation(s)
- Anuradha Karunanidhi
- Division of Genetic and Genomic Medicine, Department of Pediatrics, School of Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh; Pittsburgh, PA 15224, USA
| | - Shakuntala Basu
- Division of Genetic and Genomic Medicine, Department of Pediatrics, School of Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh; Pittsburgh, PA 15224, USA
| | - Xue-Jun Zhao
- Division of Genetic and Genomic Medicine, Department of Pediatrics, School of Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh; Pittsburgh, PA 15224, USA
| | - Olivia D'Annibale
- Division of Genetic and Genomic Medicine, Department of Pediatrics, School of Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh; Pittsburgh, PA 15224, USA; Department of Human Genetics, School of Public Health, University of Pittsburgh; Pittsburgh, PA 15260, USA
| | - Clinton Van't Land
- Division of Genetic and Genomic Medicine, Department of Pediatrics, School of Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh; Pittsburgh, PA 15224, USA
| | - Jerry Vockley
- Division of Genetic and Genomic Medicine, Department of Pediatrics, School of Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh; Pittsburgh, PA 15224, USA; Department of Human Genetics, School of Public Health, University of Pittsburgh; Pittsburgh, PA 15260, USA
| | - Al-Walid Mohsen
- Division of Genetic and Genomic Medicine, Department of Pediatrics, School of Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh; Pittsburgh, PA 15224, USA; Department of Human Genetics, School of Public Health, University of Pittsburgh; Pittsburgh, PA 15260, USA.
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10
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Vockley J, Burton BK, Berry G, Longo N, Phillips J, Sanchez-Valle A, Chapman KA, Tanpaiboon P, Grunewald S, Murphy E, Lu X, Rahman S, Ray K, Reineking B, Pisani L, Ramirez AN. Triheptanoin for the treatment of long-chain fatty acid oxidation disorders: Final results of an open-label, long-term extension study. J Inherit Metab Dis 2023; 46:943-955. [PMID: 37276053 DOI: 10.1002/jimd.12640] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 05/19/2023] [Accepted: 06/01/2023] [Indexed: 06/07/2023]
Abstract
Long-chain fatty acid oxidation disorders (LC-FAODs) result in life-threatening energy metabolism deficiencies/energy source depletion. Triheptanoin is an odd-carbon, medium chain triglyceride (that is an anaplerotic substrate of calories and fatty acids) for treating pediatric and adult patients with LC-FAODs. Study CL202 (NCT02214160), an open-label extension study of study CL201 (NCT01886378), evaluated the long-term safety/efficacy of triheptanoin in patients with LC-FAODs (N = 94), including cohorts who were triheptanoin naïve (n = 33) or had received triheptanoin in study CL201 (n = 24) or in investigator-sponsored trials/expanded access programs (IST/EAPs; n = 37). Primary endpoint was the annualized rate of LC-FAOD major clinical events (MCEs; rhabdomyolysis, hypoglycemia, cardiomyopathy). Mean ± standard deviation (SD) triheptanoin treatment durations were 27.4 ± 19.9, 46.9 ± 13.6, and 49.6 ± 21.4 months for the triheptanoin-naïve, CL201 rollover, and IST/EAP cohorts, respectively. In the triheptanoin-naïve cohort, median (interquartile range [IQR]) MCE rate significantly decreased from 2.00 (0.67-3.33) events/patient/year pre-triheptanoin to 0.28 (0.00-1.43) events/patient/year with triheptanoin (p = 0.0343), a reduction of 86%. In the CL201 rollover cohort, mean ± SD MCE rate significantly decreased from 1.76 ± 1.64 events/patient/year pre-triheptanoin to 1.00 ± 1.00 events/patient/year with triheptanoin (p = 0.0347), a reduction of 43%. In the IST/EAP cohort, mean ± SD MCE rate was 1.40 ± 2.37 (median [IQR] 0.57 [0.00-1.67]) events/patient/year with triheptanoin. Safety data were consistent with previous observations. Treatment-related treatment-emergent adverse events (TEAEs) occurred in 68.1% of patients and were mostly mild/moderate in severity. Five patients had seven serious treatment-related TEAEs; all resolved. Our results confirm the long-term efficacy of triheptanoin for patients with LC-FAOD.
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Affiliation(s)
- Jerry Vockley
- Division of Genetic and Genomic Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Barbara K Burton
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | - Gerard Berry
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nicola Longo
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - John Phillips
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amarilis Sanchez-Valle
- Department of Pediatrics, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Kimberly A Chapman
- Section Genetics and Metabolism, Children's National Health System, Washington, District of Columbia, USA
| | - Pranoot Tanpaiboon
- Section Genetics and Metabolism, Children's National Health System, Washington, District of Columbia, USA
| | - Stephanie Grunewald
- Metabolic Unit, Great Ormond Street Hospital and UCL Institute of Child Health NIHR BRC, London, UK
| | - Elaine Murphy
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Xiaoxiao Lu
- Ultragenyx Pharmaceutical Inc, Novato, California, USA
| | - Syeda Rahman
- Ultragenyx Pharmaceutical Inc, Novato, California, USA
| | - Kathryn Ray
- Ultragenyx Pharmaceutical Inc, Novato, California, USA
| | | | - Laura Pisani
- Ultragenyx Pharmaceutical Inc, Novato, California, USA
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11
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Stenlid R, Manell H, Seth R, Cerenius SY, Chowdhury A, Roa Cortés C, Nyqvist I, Lundqvist T, Halldin M, Bergsten P. Low Fasting Concentrations of Glucagon in Patients with Very Long-Chain Acyl-CoA Dehydrogenase Deficiency. Metabolites 2023; 13:780. [PMID: 37512487 PMCID: PMC10386500 DOI: 10.3390/metabo13070780] [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: 05/23/2023] [Revised: 06/18/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: Deficiencies of mitochondrial fatty acid oxidation (FAO) define a subgroup of inborn errors of metabolism, with medium-chain acyl-CoA dehydrogenase deficiency (MCAD) and very long-chain acyl-CoA dehydrogenase deficiency (VLCAD) being two of the most common. Hypoketotic hypoglycemia is a feared clinical complication and the treatment focuses on avoiding hypoglycemia. In contrast, carnitine uptake deficiency (CUD) is treated as a mild disease without significant effects on FAO. Impaired FAO has experimentally been shown to impair glucagon secretion. Glucagon is an important glucose-mobilizing hormone. If and how glucagon is affected in patients with VLCAD or MCAD remains unknown. (2) Methods: A cross-sectional study was performed with plasma hormone concentrations quantified after four hours of fasting. Patients with VLCAD (n = 10), MCAD (n = 7) and CUD (n = 6) were included. (3) Results: The groups were similar in age, sex, weight, and height. The glucagon and insulin levels were significantly lower in the VLCAD group compared to the CUD group (p < 0.05, respectively). The patients with CUD had glucagon concentrations similar to the normative data. No significant differences were seen in GLP-1, glicentin, glucose, amino acids, or NEFAs. (4) Conclusions: Low fasting concentrations of glucagon are present in patients with VLCAD and cannot be explained by altered stimuli in plasma.
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Affiliation(s)
- Rasmus Stenlid
- Department of Medical Cell Biology, Uppsala University, SE75123 Uppsala, Sweden
| | - Hannes Manell
- Department of Women's and Children's Health, Uppsala University, SE75185 Uppsala, Sweden
| | - Rikard Seth
- Department of Medical Cell Biology, Uppsala University, SE75123 Uppsala, Sweden
| | - Sara Y Cerenius
- Department of Medical Cell Biology, Uppsala University, SE75123 Uppsala, Sweden
| | - Azazul Chowdhury
- Department of Medical Cell Biology, Uppsala University, SE75123 Uppsala, Sweden
| | - Camilla Roa Cortés
- Department of Medical Cell Biology, Uppsala University, SE75123 Uppsala, Sweden
| | - Isabelle Nyqvist
- Department of Medical Cell Biology, Uppsala University, SE75123 Uppsala, Sweden
| | - Thomas Lundqvist
- Department of Women's and Children's Health, Karolinska Institute, SE17177 Stockholm, Sweden
| | - Maria Halldin
- Department of Women's and Children's Health, Karolinska Institute, SE17177 Stockholm, Sweden
| | - Peter Bergsten
- Department of Medical Cell Biology, Uppsala University, SE75123 Uppsala, Sweden
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12
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Lasio MLD, Leshinski AC, Ducich NH, Flore LA, Lehman A, Shur N, Jayakar PB, Hainline BE, Basinger AA, Wilson WG, Diaz GA, Erbe RW, Koeberl DD, Vockley J, Bedoyan JK. Clinical, biochemical and molecular characterization of 12 patients with pyruvate carboxylase deficiency treated with triheptanoin. Mol Genet Metab 2023; 139:107605. [PMID: 37207470 PMCID: PMC10330474 DOI: 10.1016/j.ymgme.2023.107605] [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: 04/04/2023] [Revised: 05/05/2023] [Accepted: 05/06/2023] [Indexed: 05/21/2023]
Abstract
Pyruvate carboxylase (PC) deficiency is a rare autosomal recessive mitochondrial neurometabolic disorder of energy deficit resulting in high morbidity and mortality, with limited therapeutic options. The PC homotetramer has a critical role in gluconeogenesis, anaplerosis, neurotransmitter synthesis, and lipogenesis. The main biochemical and clinical findings in PC deficiency (PCD) include lactic acidosis, ketonuria, failure to thrive, and neurological dysfunction. Use of the anaplerotic agent triheptanoin on a limited number of individuals with PCD has had mixed results. We expand on the potential utility of triheptanoin in PCD by examining the clinical, biochemical, molecular, and health-related quality-of-life (HRQoL) findings in a cohort of 12 individuals with PCD (eight with Type A and two each with Types B and C) treated with triheptanoin ranging for 6 days to about 7 years. The main endpoints were changes in blood lactate and HRQoL scores, but collection of useful data was limited to about half of subjects. An overall trend of lactate reduction with time on triheptanoin was noted, but with significant variability among subjects and only one subject reaching close to statistical significance for this endpoint. Parent reported HRQoL assessments with treatment showed mixed results, with some subjects showing no change, some improvement, and some worsening of overall scores. Subjects with buried amino acids in the pyruvate carboxyltransferase domain of PC that undergo destabilizing replacements may be more likely to respond (with lactate reduction or HRQoL improvement) to triheptanoin compared to those with replacements that disrupt tetramerization or subunit-subunit interface contacts. The reason for this difference is unclear and requires further validation. We observed significant variability but an overall trend of lactate reduction with time on triheptanoin and mixed parent reported outcome changes by HRQoL assessments for subjects with PCD on long-term triheptanoin. The mixed results noted with triheptanoin therapy in this study could be due to endpoint data limitation, variability of disease severity between subjects, limitation of the parent reported HRQoL tool, or subject genotype variability. Alternative designed trials and more study subjects with PCD will be needed to validate important observations from this work.
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Affiliation(s)
- M Laura Duque Lasio
- Department of Pathology, University of Utah, Salt Lake City, UT, USA; Division of Genetic and Genomic Medicine, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Angela C Leshinski
- Division of Genetic and Genomic Medicine, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nicole H Ducich
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Leigh Anne Flore
- Division of Genetic, Genomic and Metabolic Disorders, Children's Hospital of Michigan, Detroit, MI and Central Michigan University College of Medicine, Mount Pleasant, MI, USA
| | - April Lehman
- Division of Genetic and Genomic Medicine, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Division of Genetic, Genomic and Metabolic Disorders, Children's Hospital of Michigan, Detroit, MI and Central Michigan University College of Medicine, Mount Pleasant, MI, USA
| | - Natasha Shur
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, DC, USA
| | - Parul B Jayakar
- Division of Genetics and Metabolism, Nicklaus Children's Hospital, Miami, FL, USA
| | - Bryan E Hainline
- Department of Medical and Molecular Genetics, Riley Hospital at Indiana University Health, Indianapolis, IN, USA
| | | | - William G Wilson
- Department of Pediatrics, University of Virginia Health, Charlottesville, VA, USA
| | - George A Diaz
- Division of Genetics and Genomics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard W Erbe
- Departments of Pediatrics and Medicine, University at Buffalo, Buffalo, NY, USA
| | - Dwight D Koeberl
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Jerry Vockley
- Division of Genetic and Genomic Medicine, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Human Genetics, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Jirair K Bedoyan
- Division of Genetic and Genomic Medicine, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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13
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Successful management of rhabdomyolysis with triheptanoin in a child with severe long-chain 3-hydroxyacyl-coenzyme A dehydrogenase (LCHAD) deficiency. Neuromuscul Disord 2023; 33:315-318. [PMID: 36893607 DOI: 10.1016/j.nmd.2023.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 02/04/2023] [Accepted: 02/15/2023] [Indexed: 02/21/2023]
Abstract
Early-onset long-chain 3-hydroxyacyl-coenzyme A dehydrogenase (LCHAD) deficiency is a fatty acid β-oxidation disorder with a poor prognosis. Triheptanoin, an anaplerotic oil with odd-chain fatty acids can improve the disease course. The female patient presented here was diagnosed at the age of 4 months, and treatment was started as fat restriction, frequent feeding, and standard medium-chain triglyceride supplementation. In follow-up, she had frequent rhabdomyolysis episodes (∼8 per year). At the age of six, she had 13 episodes in 6 months, and triheptanoin was started as part of a compassionate use program. Following unrelated hospital stays due to multisystem inflammatory syndrome in children and a bloodstream infection, she had only 3 rhabdomyolysis episodes, and hospitalized days decreased from 73 to 11 during her first year with triheptanoin. Triheptanoin drastically decreased the frequency and severity of rhabdomyolysis, but progression of retinopathy was not altered.
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14
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Lund M, Heaton R, Hargreaves IP, Gregersen N, Olsen RKJ. Odd- and even-numbered medium-chained fatty acids protect against glutathione depletion in very long-chain acyl-CoA dehydrogenase deficiency. Biochim Biophys Acta Mol Cell Biol Lipids 2023; 1868:159248. [PMID: 36356723 DOI: 10.1016/j.bbalip.2022.159248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 10/09/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022]
Abstract
Recent trials have reported the ability of triheptanoin to improve clinical outcomes for the severe symptoms associated with long-chain fatty acid oxidation disorders, including very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency. However, the milder myopathic symptoms are still challenging to treat satisfactorily. Myopathic pathogenesis is multifactorial, but oxidative stress is an important component. We have previously shown that metabolic stress increases the oxidative burden in VLCAD-deficient cell lines and can deplete the antioxidant glutathione (GSH). We investigated whether medium-chain fatty acids provide protection against GSH depletion during metabolic stress in VLCAD-deficient fibroblasts. To investigate the effect of differences in anaplerotic capacity, we included both even-(octanoate) and odd-numbered (heptanoate) medium-chain fatty acids. Overall, we show that modulation of the concentration of medium-chain fatty acids in culture media affects levels of GSH retained during metabolic stress in VLCAD-deficient cell lines but not in controls. Lowered glutamine concentration in the culture media during metabolic stress led to GSH depletion and decreased viability in VLCAD deficient cells, which could be rescued by both heptanoate and octanoate in a dose-dependent manner. Unlike GSH levels, the levels of total thiols increased after metabolic stress exposure, the size of this increase was not affected by differences in cell culture medium concentrations of glutamine, heptanoate or octanoate. Addition of a PPAR agonist further exacerbated stress-related GSH-depletion and viability loss, requiring higher concentrations of fatty acids to restore GSH levels and cell viability. Both odd- and even-numbered medium-chain fatty acids efficiently protect VLCADdeficient cells against metabolic stress-induced antioxidant depletion.
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Affiliation(s)
- Martin Lund
- Research Unit for Molecular Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juel-Jensens Boulevard 99, 8200 Aarhus, Denmark.
| | - Robert Heaton
- School of Pharmacy, Liverpool John Moore University, Byrom Street, Liverpool L3 3AF, United Kingdom
| | - Iain P Hargreaves
- School of Pharmacy, Liverpool John Moore University, Byrom Street, Liverpool L3 3AF, United Kingdom
| | - Niels Gregersen
- Research Unit for Molecular Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juel-Jensens Boulevard 99, 8200 Aarhus, Denmark
| | - Rikke K J Olsen
- Research Unit for Molecular Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juel-Jensens Boulevard 99, 8200 Aarhus, Denmark.
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15
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Zhao J, Pike B, Huang J, Feng Z, Odle J, Lin X. Effects of medium chain triglycerides on hepatic fatty acid oxidation in clofibrate-fed newborn piglets. ANIMAL NUTRITION (ZHONGGUO XU MU SHOU YI XUE HUI) 2022; 12:334-344. [PMID: 36733783 PMCID: PMC9879763 DOI: 10.1016/j.aninu.2022.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/21/2022] [Accepted: 12/02/2022] [Indexed: 12/14/2022]
Abstract
To investigate whether increasing tricarboxylic acid (TCA) cycle activity and ketogenic capacity would augment fatty acid (FA) oxidation induced by the peroxisome proliferator-activated receptor-alpha (PPARα) agonist clofibrate, suckling newborn piglets (n = 54) were assigned to 8 groups following a 2 ( ± clofibrate) × 4 (glycerol succinate [SUC], triglycerides of 2-methylpentanoic acid [T2M], valeric acid [TC5] and hexanoic acid [TC6]) factorial design. Each group was fed an isocaloric milk formula containing either 0% or 0.35% clofibrate (wt/wt, dry matter basis) with 5% SUC, T2M, TC5 or TC6 for 5 d. Another 6 pigs served as newborn controls. Fatty acid oxidation was examined in fresh homogenates of liver collected on d 6 using [1-14C] palmitic acid (1 mM) as a substrate (0.265 μCi/μmol). Measurements were performed in the absence or presence of L-carnitine (1 mM) or inhibitors of 3-hydroxy-3-methylglutaryl-CoA synthase (L659699, 1.6 μM) or acetoacetate-CoA deacylase (iodoacetamide, 50 μM). Without clofibrate stimulation, 14C accumulation in CO2 was higher from piglets fed diets containing T2M and TC5 than SUC, but similar to those fed TC6. Under clofibrate stimulation, accumulation also was higher in homogenates from piglets fed TC5 than all other dietary treatments. Interactions between clofibrate and carnitine or the inhibitors were observed (P = 0.0004) for acid soluble products (ASP). In vitro addition of carnitine increased 14C-ASP (P < 0.0001) above all other treatments, regardless of clofibrate treatment. The percentage of 14C in CO2 was higher (P = 0.0023) in TC5 than in the control group. From these results we suggest that dietary supplementation of anaplerotic and ketogenic FA could impact FA oxidation and modify the metabolism of acetyl-CoA (product of β-oxidation) via alteration of TCA cycle activity, but the modification has no significant impact on the hepatic FA oxidative capacity induced by PPARα. In addition, the availability of carnitine is a critical element to maintain FA oxidation during the neonatal period.
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16
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Abstract
PURPOSE OF REVIEW Metabolic myopathies are disorders that affect skeletal muscle substrate oxidation. Although some drugs and hormones can affect metabolism in skeletal muscle, this review will focus on the genetic metabolic myopathies. RECENT FINDINGS Impairments in glycogenolysis/glycolysis (glycogen storage disease), fatty acid transport/oxidation (fatty acid oxidation defects), and mitochondrial metabolism (mitochondrial myopathies) represent most metabolic myopathies; however, they often overlap clinically with structural genetic myopathies, referred to as pseudometabolic myopathies. Although metabolic myopathies can present in the neonatal period with hypotonia, hypoglycemia, and encephalopathy, most cases present clinically in children or young adults with exercise intolerance, rhabdomyolysis, and weakness. In general, the glycogen storage diseases manifest during brief bouts of high-intensity exercise; in contrast, fatty acid oxidation defects and mitochondrial myopathies usually manifest during longer-duration endurance-type activities, often with fasting or other metabolic stressors (eg, surgery, fever). The neurologic examination is often normal between events (except in the pseudometabolic myopathies) and evaluation requires one or more of the following tests: exercise stress testing, blood (eg, creatine kinase, acylcarnitine profile, lactate, amino acids), urine (eg, organic acids, myoglobin), muscle biopsy (eg, histology, ultrastructure, enzyme testing), and targeted (specific gene) or untargeted (myopathy panels) genetic tests. SUMMARY Definitive identification of a specific metabolic myopathy often leads to specific interventions, including lifestyle, exercise, and nutritional modifications; cofactor treatments; accurate genetic counseling; avoidance of specific triggers; and rapid treatment of rhabdomyolysis.
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17
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Angelini C, Burlina A, Blau N, Ferreira CR. Clinical and biochemical footprints of inherited metabolic disorders: X. Metabolic myopathies. Mol Genet Metab 2022; 137:213-222. [PMID: 36155185 PMCID: PMC10507680 DOI: 10.1016/j.ymgme.2022.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022]
Abstract
Metabolic myopathies are characterized by the deficiency or dysfunction of essential metabolites or fuels to generate energy for muscle contraction; they most commonly manifest with neuromuscular symptoms due to impaired muscle development or functioning. We have summarized associations of signs and symptoms in 358 inherited metabolic diseases presenting with myopathies. This represents the tenth of a series of articles attempting to create and maintain a comprehensive list of clinical and metabolic differential diagnoses according to system involvement.
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Affiliation(s)
- Corrado Angelini
- Laboratory for Neuromuscular Diseases, Campus Pietro d'Abano, University of Padova, Padova, Italy.
| | - Alberto Burlina
- Division of Inherited Metabolic Diseases, Reference Center for Expanded Newborn Screening, University Hospital Padova, 35128, Padua, Italy.
| | - Nenad Blau
- Division of Metabolism, University Children's Hospital, Zürich, Switzerland.
| | - Carlos R Ferreira
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA.
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18
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Vockley J, Enns GM, Ramirez AN, Bedrosian CL, Reineking B, Lu X, Ray K, Rahman S, Marsden D. Response to triheptanoin therapy in critically ill patients with LC-FAOD: Report of patients treated through an expanded access program. Mol Genet Metab 2022; 136:152-162. [PMID: 35459555 DOI: 10.1016/j.ymgme.2022.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 12/31/2022]
Abstract
Long-chain fatty acid oxidation disorders (LC-FAOD) are a group of inborn errors of metabolism wherein patients are unable to process long-chain fatty acids into useable energy in the mitochondria. LC-FAOD commonly affects organ systems with high energy demand, manifesting as hypoketotic hypoglycemia, liver dysfunction, cardiomyopathy, rhabdomyolysis, and skeletal myopathy, as well as peripheral neuropathy and retinopathy in some subtypes. Collectively, LC-FAOD have a high mortality rate, especially in cases of early onset disease, and in the presence of cardiomyopathy. Triheptanoin is a synthetic medium-odd chain triglyceride, produced using a GMP-compliant process, which was designed to replenish mitochondrial metabolic deficits and restore energy homeostasis. Prior to its approval, triheptanoin was only available through clinical trials or to seriously ill patients as part of an expanded access program (EAP) following physician request. This retrospective study examined the impact of triheptanoin on cardiovascular parameters, in critically ill patients who participated in the EAP from February 2013 to January 2018. These patients persisted in critical condition despite receiving standard treatment in highly qualified centers by expert metabolic physicians and dietitians. Physician-completed questionnaires and narrative summaries were used to evaluate the disease presentation and management prior to the trigger event leading to triheptanoin request and use, and the response to triheptanoin treatment. Following triheptanoin initiation, most patients survived the initial trigger event (e.g., severe urinary tract infection, pneumonia) and demonstrated improvements in both short-term and long-term LC-FAOD manifestations. In patients with cardiomyopathy, stabilization or improvement from pretreatment levels was reported in left ventricular ejection fraction and left ventricular mass, in particular, all infants with cardiomyopathy showed improvement in cardiac function during triheptanoin therapy. Triheptanoin therapy was generally well tolerated. The study results are consistent with the existing positive benefit/risk profile of triheptanoin and reflect the effect of triheptanoin improving cardiac function in patients experiencing severe episodes of metabolic decompensation despite standard therapy.
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Affiliation(s)
- Jerry Vockley
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States of America.
| | - Gregory M Enns
- Stanford University, Division of Medical Genetics, Palo Alto, CA, United States of America
| | | | | | - Bridget Reineking
- Ultragenyx Pharmaceutical Inc., Novato, CA, United States of America
| | - Xiaoxiao Lu
- Ultragenyx Pharmaceutical Inc., Novato, CA, United States of America
| | - Kathryn Ray
- Ultragenyx Pharmaceutical Inc., Novato, CA, United States of America
| | - Syeda Rahman
- Ultragenyx Pharmaceutical Inc., Novato, CA, United States of America
| | - Deborah Marsden
- Ultragenyx Pharmaceutical Inc., Novato, CA, United States of America
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Medical Genetics Branch, Chinese Medical Association DOBAM, Chinese Association for Maternal and Child Health DOGAMCDAHCB. Expert consensus on diagnosis and treatment of very long-chain acyl-CoA dehydrogenase deficiency. Zhejiang Da Xue Xue Bao Yi Xue Ban 2022; 51:122-128. [PMID: 36161784 PMCID: PMC9109756 DOI: 10.3724/zdxbyxb-2022-0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 12/10/2021] [Indexed: 06/16/2023]
Abstract
Very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency is a metabolic disease of long chain fatty acid oxidation. The clinical manifestations are heterogeneous, mainly with heart, liver, skeletal muscle and brain damage, and the onset of which can be from newborn to adult. Cardiomyopathy type is more serious with high mortality. The liver failure type and myopathy type would be potentially lethal, but generally the prognosis is relatively good. Recurrent hypoglycemia, energy metabolism disorder, liver dysfunction, cardiomyopathy and serious arrhythmia are the main causes of death. Most patients can be identified through neonatal screening, and the prognosis is usually good in patients with early diagnosis and treatment. The purpose of this consensus is to standardize the diagnosis, treatment and management of VLCAD deficiency, so as to improve the prognosis of patients and reduce death and disability.
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20
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Williams-Hall R, Tinsley K, Kruger E, Johnson C, Bowden A, Cimms T, Gater A. Qualitative evaluation of the symptoms and quality of life impacts of long-chain fatty acid oxidation disorders. Ther Adv Endocrinol Metab 2022; 13:20420188211065655. [PMID: 35035873 PMCID: PMC8755934 DOI: 10.1177/20420188211065655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 11/22/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Long-chain fatty acid oxidation disorders (LC-FAOD) are a group of rare autosomal-recessive genetic disorders characterized by metabolic deficiencies in which the body is unable to convert long-chain fatty acids into energy. To date, however, there is limited understanding of the patient experience of LC-FAOD. METHODS The symptoms, observable signs, and quality of life (QoL) impacts associated with LC-FAOD were explored via a focus group (n = 8) and semi-structured interviews (n = 6) with patients and caregivers of patients with LC-FAOD, and interviews (n = 4) with expert clinicians. Data were analyzed via thematic analysis and summarized in a conceptual model. RESULTS Participants reported a wide range of signs and symptoms associated with LC-FAOD, broadly categorized as musculoskeletal, endocrine/nutritional/metabolic, neurological, gastrointestinal/digestive, sensory, cardiovascular, respiratory, urological, and constitutional. LC-FAOD were reported to have a significant impact on various aspects of patients' lives including physical functioning, participation in daily activities, emotional/psychological wellbeing, and social functioning. Lifestyle modifications (such as diet and exercise restrictions) were necessary because of the condition. Symptoms were typically episodic in presentation often arising or exacerbated during catabolic conditions such as prolonged exercise, fasting, physiological stress, and illness/infection. Symptoms were also commonly reported to lead to emergency room visits, hospitalization, and clinical complications. CONCLUSION LC-FAOD have a considerable impact on patients' lives. There is a high degree of concordance in the signs, symptoms, and impacts of LC-FAOD reported by patients, caregivers, and clinicians; however, there were many symptoms and impacts that were only reported by patients and caregivers, thus demonstrating that insights from patient/caregiver experience data are integral for informing medical product development and facilitating patient-centered care.
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21
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Lee SK, Gupta M, Shi J, McKeever K. The Pharmacokinetics of Triheptanoin and Its Metabolites in Healthy Subjects and Patients With Long-Chain Fatty Acid Oxidation Disorders. Clin Pharmacol Drug Dev 2021; 10:1325-1334. [PMID: 33789001 PMCID: PMC8597155 DOI: 10.1002/cpdd.944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/07/2021] [Indexed: 12/31/2022]
Abstract
Long-chain fatty acid oxidation disorders (LC-FAODs) are a group of life-threatening autosomal recessive disorders caused by defects in nuclear genes encoding mitochondrial enzymes involved in the conversion of dietary long-chain fatty acids into energy. Triheptanoin is an odd-carbon, medium-chain triglyceride consisting of 3 fatty acids with 7 carbons each on a glycerol backbone developed to treat adult and pediatric patients with LC-FAODs. The pharmacokinetics of triheptanoin and circulating metabolites were explored in healthy subjects and patients with LC-FAODs using noncompartmental analyses. Systemic exposure to triheptanoin following an oral administration was negligible, as triheptanoin is extensively hydrolyzed to glycerol and heptanoate in the gastrointestinal tract. Multiple peaks for triheptanoin metabolites were observed in the plasma following oral administration of triheptanoin, generally coinciding with the time that meals were served. Heptanoate, the pharmacologically active metabolite of triheptanoin supplementing energy sources in patients with LC-FAODs, showed the greatest exposure among the metabolites of triheptanoin in human plasma following oral administration of triheptanoin. The exposure of heptanoate was approximately 10-fold greater than that of beta-hydroxypentoate, a downstream metabolite of heptanoate. Exposure to triheptanoin metabolites appeared to increase following multiple doses as compared with the single dose, and with the increase in triheptanoin dose levels.
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Affiliation(s)
- Sun Ku Lee
- Ultragenyx Pharmaceutical Inc.NovatoCaliforniaUSA
| | - Manju Gupta
- Ultragenyx Pharmaceutical Inc.NovatoCaliforniaUSA
| | - Jack Shi
- Ultragenyx Pharmaceutical Inc.NovatoCaliforniaUSA
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Laemmle A, Steck AL, Schaller A, Kurth S, Perret Hoigné E, Felser AD, Slavova N, Salvisberg C, Atencio M, Mochel F, Nuoffer JM, Gautschi M. Triheptanoin - Novel therapeutic approach for the ultra-rare disease mitochondrial malate dehydrogenase deficiency. Mol Genet Metab Rep 2021; 29:100814. [PMID: 34712577 PMCID: PMC8529553 DOI: 10.1016/j.ymgmr.2021.100814] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 10/16/2021] [Indexed: 01/10/2023] Open
Abstract
Mitochondrial malate dehydrogenase (MDH2) deficiency (MDH2D) is an ultra-rare disease with only three patients described in literature to date. MDH2D leads to an interruption of the tricarboxylic acid (TCA) cycle and malate-aspartate shuttle (MAS) and results in severe early onset encephalopathy. Affected infants suffer from psychomotor delay, muscular hypotonia and frequent seizures. Laboratory findings are unspecific, including elevated lactate in blood and cerebrospinal fluid. Brain magnetic resonance imaging reveals delayed myelination and brain atrophy. Currently there is no curative therapy to treat this devastating disease. Here, we present a female patient diagnosed with MDH2D after a stroke-like episode at 18 months. Trio-whole exome sequencing revealed compound heterozygous missense variants in the MDH2 gene: c.398C>T, p.(Pro133Leu) and c.445delinsACA, p.(Pro149Hisfs*22). MDH2 activity assay and oxygraphic analysis in patient's fibroblasts confirmed the variants were pathogenic. At the age of 36 months, a drug trial with triheptanoin was initiated and well tolerated. The patient's neurologic and biochemical phenotype improved and she had no further metabolic decompensations during the treatment period suggesting a beneficial effect of triheptanoin on MDH2D. Further preclinical and clinical studies are required to evaluate triheptanoin treatment for MDH2D and other TCA cycle and MAS defects.
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Affiliation(s)
- Alexander Laemmle
- Institute of Clinical Chemistry, Inselspital, University Hospital Bern, Bern, Switzerland
- Department of Pediatrics, Inselspital, University Hospital Bern, Bern, Switzerland
- Corresponding author at: University Institute of Clinical Chemistry and Department of Pediatrics, Kinderklinik H524, Freiburgstrasse 15, 3010 Bern, Switzerland.
| | - Andrea Lisa Steck
- Department of Pediatrics, Inselspital, University Hospital Bern, Bern, Switzerland
| | - André Schaller
- Department of Human Genetics, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Sandra Kurth
- Institute of Clinical Chemistry, Inselspital, University Hospital Bern, Bern, Switzerland
| | | | - Andrea Deborah Felser
- Institute of Clinical Chemistry, Inselspital, University Hospital Bern, Bern, Switzerland
- Department of Pediatrics, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Nedelina Slavova
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Claudia Salvisberg
- Department of Pediatrics, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Mariana Atencio
- Paris Brain Institute (ICM), Sorbonne University UMR S 1127, Inserm U1127, CNRS UMR 7225, Paris, France
| | - Fanny Mochel
- Paris Brain Institute (ICM), Sorbonne University UMR S 1127, Inserm U1127, CNRS UMR 7225, Paris, France
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Genetics and Reference Center for Neurometabolic Diseases, Paris, France
| | - Jean-Marc Nuoffer
- Institute of Clinical Chemistry, Inselspital, University Hospital Bern, Bern, Switzerland
- Department of Pediatrics, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Matthias Gautschi
- Institute of Clinical Chemistry, Inselspital, University Hospital Bern, Bern, Switzerland
- Department of Pediatrics, Inselspital, University Hospital Bern, Bern, Switzerland
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23
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Rücklová K, Hrubá E, Pavlíková M, Hanák P, Farolfi M, Chrastina P, Vlášková H, Kousal B, Smolka V, Foltenová H, Adam T, Friedecký D, Ješina P, Zeman J, Kožich V, Honzík T. Impact of Newborn Screening and Early Dietary Management on Clinical Outcome of Patients with Long Chain 3-Hydroxyacyl-CoA Dehydrogenase Deficiency and Medium Chain Acyl-CoA Dehydrogenase Deficiency-A Retrospective Nationwide Study. Nutrients 2021; 13:nu13092925. [PMID: 34578803 PMCID: PMC8469775 DOI: 10.3390/nu13092925] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/21/2021] [Accepted: 08/22/2021] [Indexed: 12/27/2022] Open
Abstract
Long chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD/MTPD) and medium chain acyl-CoA dehydrogenase deficiency (MCADD) were included in the expanded neonatal screening program (ENBS) in Czechia in 2009, allowing for the presymptomatic diagnosis and nutritional management of these patients. The aim of our study was to assess the nationwide impact of ENBS on clinical outcome. This retrospective study analysed acute events and chronic complications and their severity in pre-ENBS and post-ENBS cohorts. In total, 28 children (12 before, 16 after ENBS) were diagnosed with LCHADD/MTPD (incidence 0.8/100,000 before and 1.2/100,000 after ENBS). In the subgroup detected by ENBS, a significantly longer interval from birth to first acute encephalopathy was observed. In addition, improvement in neuropathy and cardiomyopathy (although statistically non-significant) was demonstrated in the post-ENBS subgroup. In the MCADD cohort, we included 69 patients (15 before, 54 after ENBS). The estimated incidence rose from 0.7/100,000 before to 4.3/100,000 after ENBS. We confirmed a significant decrease in the number of episodes of acute encephalopathy and lower proportion of intellectual disability after ENBS (p < 0.0001). The genotype-phenotype correlations suggest a new association between homozygosity for the c.1528C > G variant and more severe heart involvement in LCHADD patients.
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Affiliation(s)
- Kristina Rücklová
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
- Department of Paediatrics, 3rd Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, 100 34 Prague, Czech Republic
- Correspondence: (K.R.); (T.H.)
| | - Eva Hrubá
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
| | - Markéta Pavlíková
- Department of Probability and Mathematical Statistics, Faculty of Mathematics and Physics, Charles University, 121 16 Prague, Czech Republic;
| | - Petr Hanák
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
| | - Martina Farolfi
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
| | - Petr Chrastina
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
| | - Hana Vlášková
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
| | - Bohdan Kousal
- Department of Ophthalmology, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic;
| | - Vratislav Smolka
- Department of Paediatrics, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (V.S.); (H.F.)
| | - Hana Foltenová
- Department of Paediatrics, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (V.S.); (H.F.)
| | - Tomáš Adam
- Institute of Molecular and Translational Medicine, Czech Advanced Technology and Research Institute (CATRIN), Palacký University Olomouc, 779 00 Olomouc, Czech Republic; (T.A.); (D.F.)
| | - David Friedecký
- Institute of Molecular and Translational Medicine, Czech Advanced Technology and Research Institute (CATRIN), Palacký University Olomouc, 779 00 Olomouc, Czech Republic; (T.A.); (D.F.)
| | - Pavel Ješina
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
| | - Jiří Zeman
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
| | - Viktor Kožich
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
| | - Tomáš Honzík
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
- Correspondence: (K.R.); (T.H.)
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Metabolic Outcomes of Anaplerotic Dodecanedioic Acid Supplementation in Very Long Chain Acyl-CoA Dehydrogenase (VLCAD) Deficient Fibroblasts. Metabolites 2021; 11:metabo11080538. [PMID: 34436479 PMCID: PMC8412092 DOI: 10.3390/metabo11080538] [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: 04/16/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 11/16/2022] Open
Abstract
Very long-chain acyl-CoA dehydrogenase deficiency (VLCADD, OMIM 609575) is associated with energy deficiency and mitochondrial dysfunction and may lead to rhabdomyolysis and cardiomyopathy. Under physiological conditions, there is a fine balance between the utilization of different carbon nutrients to maintain the Krebs cycle. The maintenance of steady pools of Krebs cycle intermediates is critical formitochondrial energy homeostasis especially in high-energy demanding organs such as muscle and heart. Even-chain dicarboxylic acids are established as alternative energy carbon sources that replenish the Krebs cycle by bypassing a defective β-oxidation pathway. Despite this, even-chain dicarboxylic acids are eliminated in the urine of VLCAD-affected individuals. In this study, we explore dodecanedioic acid (C12; DODA) supplementation and investigate its metabolic effect on Krebs cycle intermediates, glucose uptake, and acylcarnitine profiles in VLCAD-deficient fibroblasts. Our findings indicate that DODA supplementation replenishes the Krebs cycle by increasing the succinate pool, attenuates glycolytic flux, and reduces levels of toxic very long-chain acylcarnitines.
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25
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Abstract
Triheptanoin (Dojolvi™), a synthetic medium-chain triglyceride, is being developed by Ultragenyx Pharmaceutical as a pharmaceutical-grade anaplerotic compound for use in the treatment of inherited metabolic disorders. In June 2020, triheptanoin received its first regulatory approval, in the USA, for use as a source of calories and fatty acids for the treatment of pediatric and adult patients with molecularly confirmed long-chain fatty acid oxidation disorders (LC-FAOD). Triheptanoin has also been investigated for use as a treatment in a range of other metabolic disorders or other diseases where energy deficiency is implicated. This article summarizes the milestones in the development of triheptanoin leading to this first regulatory approval for use in the treatment of pediatric and adult patients with LC-FAOD.
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Affiliation(s)
- Matt Shirley
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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26
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Vallejo AN, Mroczkowski HJ, Michel JJ, Woolford M, Blair HC, Griffin P, McCracken E, Mihalik SJ, Reyes‐Mugica M, Vockley J. Pervasive inflammatory activation in patients with deficiency in very-long-chain acyl-coA dehydrogenase (VLCADD). Clin Transl Immunology 2021; 10:e1304. [PMID: 34194748 PMCID: PMC8236555 DOI: 10.1002/cti2.1304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 05/06/2021] [Accepted: 06/03/2021] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Very-long-chain acyl-CoA dehydrogenase deficiency (VLCADD) is a disorder of fatty acid oxidation. Symptoms are managed by dietary supplementation with medium-chain fatty acids that bypass the metabolic block. However, patients remain vulnerable to hospitalisations because of rhabdomyolysis, suggesting pathologic processes other than energy deficit. Since rhabdomyolysis is a self-destructive process that can signal inflammatory/immune cascades, we tested the hypothesis that inflammation is a physiologic dimension of VLCADD. METHODS All subjects (n = 18) underwent informed consent/assent. Plasma cytokine and cytometry analyses were performed. A prospective case analysis was carried out on a patient with recurrent hospitalisation. Health data were extracted from patient medical records. RESULTS Patients showed systemic upregulation of nine inflammatory mediators during symptomatic and asymptomatic periods. There was also overall abundance of immune cells with high intracellular expression of IFNγ, IL-6, MIP-1β (CCL4) and TNFα, and the transcription factors p65-NFκB and STAT1 linked to inflammatory pathways. A case analysis of a patient exhibited already elevated plasma cytokine levels during diagnosis in early infancy, evolving into sustained high systemic levels during recurrent rhabdomyolysis-related hospitalisations. There were corresponding activated leukocytes, with higher intracellular stores of inflammatory molecules in monocytes compared to T cells. Exposure of monocytes to long-chain free fatty acids recapitulated the cytokine signature of patients. CONCLUSION Pervasive plasma cytokine upregulation and pre-activated immune cells indicate chronic inflammatory state in VLCADD. Thus, there is rationale for practical implementation of clinical assessment of inflammation and/or translational testing, or adoption, of anti-inflammatory intervention(s) for personalised disease management.
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Affiliation(s)
- Abbe N Vallejo
- Division of Pediatric Rheumatology, Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Department of ImmunologyUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPAUSA
| | - Henry J Mroczkowski
- Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPAUSA
- Division of Genetic and Genomic Medicine, Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Present address:
Department of PediatricsUniversity of Tennessee Health Sciences CenterMemphisTNUSA
| | - Joshua J Michel
- Division of Pediatric Rheumatology, Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Michael Woolford
- Division of Pediatric Rheumatology, Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Harry C Blair
- Department of PathologyUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Department of Cell BiologyUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Pittsburgh Veterans Administration Medical CenterPittsburghPAUSA
| | - Patricia Griffin
- Division of Pediatric Rheumatology, Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Elizabeth McCracken
- Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPAUSA
- Division of Genetic and Genomic Medicine, Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Center for Rare Disease and TherapyUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Stephanie J Mihalik
- Division of Genetic and Genomic Medicine, Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Department of PathologyUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Miguel Reyes‐Mugica
- Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPAUSA
- Department of PathologyUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Jerry Vockley
- Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPAUSA
- Division of Genetic and Genomic Medicine, Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Center for Rare Disease and TherapyUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Department of Human GeneticsUniversity of Pittsburgh Graduate School of Public HealthPittsburghPAUSA
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27
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Very long chain fatty acid metabolism is required in acute myeloid leukemia. Blood 2021; 137:3518-3532. [PMID: 33720355 DOI: 10.1182/blood.2020008551] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 02/21/2021] [Indexed: 12/28/2022] Open
Abstract
Acute myeloid leukemia (AML) cells have an atypical metabolic phenotype characterized by increased mitochondrial mass, as well as a greater reliance on oxidative phosphorylation and fatty acid oxidation (FAO) for survival. To exploit this altered metabolism, we assessed publicly available databases to identify FAO enzyme overexpression. Very long chain acyl-CoA dehydrogenase (VLCAD; ACADVL) was found to be overexpressed and critical to leukemia cell mitochondrial metabolism. Genetic attenuation or pharmacological inhibition of VLCAD hindered mitochondrial respiration and FAO contribution to the tricarboxylic acid cycle, resulting in decreased viability, proliferation, clonogenic growth, and AML cell engraftment. Suppression of FAO at VLCAD triggered an increase in pyruvate dehydrogenase activity that was insufficient to increase glycolysis but resulted in adenosine triphosphate depletion and AML cell death, with no effect on normal hematopoietic cells. Together, these results demonstrate the importance of VLCAD in AML cell biology and highlight a novel metabolic vulnerability for this devastating disease.
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28
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Huang L, Gao L, Chen C. Role of Medium-Chain Fatty Acids in Healthy Metabolism: A Clinical Perspective. Trends Endocrinol Metab 2021; 32:351-366. [PMID: 33832826 DOI: 10.1016/j.tem.2021.03.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 12/22/2022]
Abstract
Medium-chain fatty acids (MCFAs) serve not only as an energy source but also regulate glucose and lipid metabolism. The unique transport and rapid metabolism of MCFAs provide additional clinical benefits over other substrates such as long-chain fatty acids (LCFAs) and have prompted interest in the use of MCFAs for treating metabolic and neurological disorders. This review focuses on the metabolic role of MCFAs in modulating cellular signaling and regulating key circulating metabolites and hormones. The potential of MCFAs in treating various metabolic diseases in a clinical setting has also been analyzed.
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Affiliation(s)
- Lili Huang
- School of Biomedical Science and Institute for Molecular Bioscience, University of Queensland, St Lucia, Brisbane, Australia
| | - Lin Gao
- School of Biomedical Science and Institute for Molecular Bioscience, University of Queensland, St Lucia, Brisbane, Australia
| | - Chen Chen
- School of Biomedical Science and Institute for Molecular Bioscience, University of Queensland, St Lucia, Brisbane, Australia.
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Arnold GL, Yester J, McCracken E, Feingold BD, Vockley J. Successful orthotopic heart transplantation in CPTII deficiency. Mol Genet Metab 2021; 133:182-184. [PMID: 34020866 PMCID: PMC8899800 DOI: 10.1016/j.ymgme.2021.04.005] [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: 02/18/2021] [Revised: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 11/23/2022]
Abstract
Carnitine palmitoyl transferase II (CPT II) catalyzes the release of activated long-chain fatty acids from acylcarnitines into mitochondria for subsequent fatty acid oxidation. Depending on residual enzyme activity, deficiency of this enzyme leads to a spectrum of symptoms from early onset hypoglycemia, hyperammonemia, cardiomyopathy and death to onset of recurrent rhabdomyolysis in adolescents and young adults. We present a case of successful orthotopic heart transplantation in a patient with severe infantile onset cardiomyopathy due to CPT II deficiency identified through newborn screening. Excellent cardiac function is preserved 12 years post-transplantation; however, the patient has developed intermittent episodes of hyperammonemia and rhabdomyolysis later in childhood and early adolescence readily resolved with intravenous glucose. Successful heart transplant in this patient demonstrates the feasibility of this management option in patients with even severe forms of long chain fatty acid oxidation disorders.
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Engelstad K, Salazar R, Koenigsberger D, Stackowtiz E, Brodlie S, Brandabur M, De Vivo DC. Exploring triheptanoin as treatment for short chain enoyl CoA hydratase deficiency. Ann Clin Transl Neurol 2021; 8:1151-1157. [PMID: 33931985 PMCID: PMC8108413 DOI: 10.1002/acn3.51359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/17/2021] [Accepted: 03/19/2021] [Indexed: 12/31/2022] Open
Abstract
We explored the benefits of triheptanoin as a treatment for Short Chain Enoyl Co‐A Hydratase (SCEH) deficiency. One child with early onset, severe SCEH Deficiency was treated with triheptanoin, an odd chain oil with anapleurotic properties, for 37 months. Blood and urine chemistry safety measures, motor skills assessment, physical exam, and neurological assessment were monitored over a 27 month period. Modest sustained gains in motor skills, attention, muscle bulk, and strength were observed without any significant adverse effects. Triheptanoin appears to be a promising effective treatment for SCEH Deficiency.
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Affiliation(s)
- Kristin Engelstad
- Department of Neurology, Columbia University Irving Medical Center, New York City, New York, USA
| | - Rachel Salazar
- Department of Neurology, Columbia University Irving Medical Center, New York City, New York, USA
| | - Dorcas Koenigsberger
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, New York Presbyterian Hospital, New York City, New York, USA
| | - Erin Stackowtiz
- Department of Neurology, Columbia University Irving Medical Center, New York City, New York, USA
| | - Susan Brodlie
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, New York Presbyterian Hospital, New York City, New York, USA
| | | | - Darryl C De Vivo
- Departments of Neurology and Pediatrics, Columbia University Irving Medical Center, New York City, New York, USA
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Triheptanoin in the management of long-chain fatty acid oxidation disorders: a profile of its use. DRUGS & THERAPY PERSPECTIVES 2021. [DOI: 10.1007/s40267-021-00816-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Guffon N, Mochel F, Schiff M, De Lonlay P, Douillard C, Vianey-Saban C. Clinical outcomes in a series of 18 patients with long chain fatty acids oxidation disorders treated with triheptanoin for a median duration of 22 months. Mol Genet Metab 2021; 132:227-233. [PMID: 33610471 DOI: 10.1016/j.ymgme.2021.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Triheptanoin provides long-chain fatty acid oxidation disorder (LC-FAOD) patients with an alternative to medium-even-chain triglycerides therapy. MATERIAL-METHODS Retrospective analysis of 18 French LC-FAOD patients benefiting from early access to triheptanoin treatment. RESULTS Eight female and 10 male patients with LC-FAOD (VLCAD, LCHAD, CACT, CPTII and MTP) were treated with triheptanoin for a median duration of 22 months (range: 9-228 months). At last consultation, triheptanoin accounted for 15-35% of their daily caloric intake. In the year following the introduction of triheptanoin, patients reported a reduction of intermittent snacking and nocturnal meals. Three patients, including 1 adult, became free of severe hypoglycaemic events. Ten of 12 paediatric patients and 4 of 6 adult patients reported reduced fatigue with reductions in the number and severity of episodes of myalgia. Of 6 patients, including 1 adult, that had required the use of a wheelchair in the year prior to triheptanoin, all but one no longer required its use. The number of emergency hospitalizations decreased, and none were recorded for paediatric patients during these 12 months. Cumulative annual days of emergency care in the home were reduced from 286 to 51 days in the year before and after initiation, respectively, and 13 patients required no such interventions. Adverse events were limited to digestive issues that dissipated over time. CONCLUSIONS Our case-series suggests that long-term treatment of LC-FAOD paediatric and adult patients with triheptanoin is safe and leads to marked improvement of symptoms and an improved quality of life.
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Affiliation(s)
- Nathalie Guffon
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hospices Civiles de Lyon, Hôpital Femme Mère Enfant, F-69500 Bron, France.
| | - Fanny Mochel
- AP-HP, Hôpital Pitié-Salpêtrière, Département de Génétique and Centre de Référence Neurométabolique Adulte, Paris, France; Institut du Cerveau et de la Moelle épinière (ICM), Sorbonne Université, UMR S 1127, Inserm U1127, CNRS UMR 7225, Paris, France
| | - Manuel Schiff
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Necker, Institut Imagine Université de Paris, Filière G2M, Paris, France; Inserm UMR_S1163, Institut Imagine, Paris, France
| | - Pascale De Lonlay
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Necker, Institut Imagine Université de Paris, Filière G2M, Paris, France; Inserm U1151, Institut Necker Enfants-Malades, Paris, France
| | - Claire Douillard
- CHU de Lille, Département d'Endocrinologie et Métabolisme, Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Huriez, Lille, France
| | - Christine Vianey-Saban
- CHU de Lyon, Centre de Biologie et de Pathologie Est, Unité Maladies Héréditaires du Métabolisme, Service de Biochimie et Biologie Moléculaire, Bron, France
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Sklirou E, Alodaib AN, Dobrowolski SF, Mohsen AWA, Vockley J. Physiological Perspectives on the Use of Triheptanoin as Anaplerotic Therapy for Long Chain Fatty Acid Oxidation Disorders. Front Genet 2021; 11:598760. [PMID: 33584796 PMCID: PMC7875087 DOI: 10.3389/fgene.2020.598760] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/27/2020] [Indexed: 12/15/2022] Open
Abstract
Inborn errors of mitochondrial fatty acid oxidation (FAO) comprise the most common group of disorders identified through expanded newborn screening mandated in all 50 states in the United States, affecting 1:10,000 newborns. While some of the morbidity in FAO disorders (FAODs) can be reduced if identified through screening, a significant gap remains between the ability to diagnose these disorders and the ability to treat them. At least 25 enzymes and specific transport proteins are responsible for carrying out the steps of mitochondrial fatty acid metabolism, with at least 22 associated genetic disorders. Common symptoms in long chain FAODs (LC-FAODs) in the first week of life include cardiac arrhythmias, hypoglycemia, and sudden death. Symptoms later in infancy and early childhood may relate to the liver or cardiac or skeletal muscle dysfunction, and include fasting or stress-related hypoketotic hypoglycemia or Reye-like syndrome, conduction abnormalities, arrhythmias, dilated or hypertrophic cardiomyopathy, and muscle weakness or fasting- and exercise-induced rhabdomyolysis. In adolescent or adult-onset disease, muscular symptoms, including rhabdomyolysis, and cardiomyopathy predominate. Unfortunately, progress in developing better therapeutic strategies has been slow and incremental. Supplementation with medium chain triglyceride (MCT; most often a mixture of C8–12 fatty acids containing triglycerides) oil provides a fat source that can be utilized by patients with long chain defects, but does not eliminate symptoms. Three mitochondrial metabolic pathways are required for efficient energy production in eukaryotic cells: oxidative phosphorylation (OXPHOS), FAO, and the tricarboxylic (TCA) cycle, also called the Krebs cycle. Cell and mouse studies have identified a deficiency in TCA cycle intermediates in LC-FAODs, thought to be due to a depletion of odd chain carbon compounds in patients treated with a predominantly MCT fat source. Triheptanoin (triheptanoyl glycerol; UX007, Ultragenyx Pharmaceuticals) is chemically composed of three heptanoate (seven carbon fatty acid) molecules linked to glycerol through ester bonds that has the potential to replete TCA cycle intermediates through production of both acetyl-CoA and propionyl-CoA through medium chain FAO. Compassionate use, retrospective, and recently completed prospective studies demonstrate significant reduction of hypoglycemic events and improved cardiac function in LC-FAOD patients, but a less dramatic effect on muscle symptoms.
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Affiliation(s)
- Evgenia Sklirou
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ahmad N Alodaib
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Newborn Screening and Biochemical Genetics Lab, Department of Genetics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Steven F Dobrowolski
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Al-Walid A Mohsen
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jerry Vockley
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States.,Center for Rare Disease Therapy, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
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Zöggeler T, Stock K, Jörg-Streller M, Spenger J, Konstantopoulou V, Hufgard-Leitner M, Scholl-Bürgi S, Karall D. Long-term experience with triheptanoin in 12 Austrian patients with long-chain fatty acid oxidation disorders. Orphanet J Rare Dis 2021; 16:28. [PMID: 33446227 PMCID: PMC7807521 DOI: 10.1186/s13023-020-01635-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/27/2020] [Indexed: 12/31/2022] Open
Abstract
Background Long-chain fatty acid oxidation disorders (LC-FAOD) are a group of rare inborn errors of metabolism with autosomal recessive inheritance that may cause life-threatening events.
Treatment with triheptanoin, a synthetic seven-carbon fatty acid triglyceride compound with an anaplerotic effect, seems beneficial, but clinical experience is limited. We report our long-term experience in an Austrian cohort of LC-FAOD patients. Methods We retrospectively assessed clinical outcome and total hospitalization days per year before and after start with triheptanoin by reviewing medical records of 12 Austrian LC-FAOD patients Results For 12 Austrian LC-FAOD patients at three metabolic centers, triheptanoin was started shortly after birth in 3/12, and between 7.34 and 353.3 (median 44.5; mean 81.1) months of age in 9/12 patients. For 11 pediatric patients, mean duration of triheptanoin intake was 5.3 (median 3.9, range 1.2–15.7) years, 10/11 pediatric patients have an ongoing intake of triheptanoin. One patient quit therapy due to reported side effects. Total hospitalization days per year compared to before triheptanoin treatment decreased by 82.3% from 27.1 (range 11–65) days per year to 4.8 (range 0–13) days per year, and hospitalization days in the one year pre- compared to the one year post-triheptanoin decreased by 69.8% from 27.1 (range 4–75) days to 8.2 (range 0–25) days. All patients are in good clinical condition, show normal psychomotor development and no impairment in daily life activities. Conclusion In this retrospective observational study in an Austrian LC-FAOD cohort, triheptanoin data show improvement in disease course. Triheptanoin appears to be a safe and beneficial treatment option in LC-FAOD. For further clarification, additional prospective randomized controlled trials are needed.
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Affiliation(s)
- Thomas Zöggeler
- Department of Pediatrics I (Inherited Metabolic Disorders), Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Katharina Stock
- Department of Pediatrics III (Cardiology), Medical University of Innsbruck, Innsbruck, Austria
| | - Monika Jörg-Streller
- Department of Pediatrics I (Inherited Metabolic Disorders), Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Johannes Spenger
- University Children's Hospital, Salzburger Landeskliniken (SALK) and Paracelsus Medical University (PMU), Salzburg, Austria
| | | | - Miriam Hufgard-Leitner
- Department of Internal Medicine III (Clinical Division of Endocrinology and Inherited Metabolic Disorders), Medical University of Vienna, Vienna, Austria
| | - Sabine Scholl-Bürgi
- Department of Pediatrics I (Inherited Metabolic Disorders), Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Daniela Karall
- Department of Pediatrics I (Inherited Metabolic Disorders), Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Affiliation(s)
- Jerry Vockley
- University of Pittsburgh School of Medicine and Graduate School of Public Health, UPMC Children's Hospital of Pittsburgh, Center for Rare Disease Therapy, Pittsburgh, Pennsylvania, USA
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Vockley J, Burton B, Berry G, Longo N, Phillips J, Sanchez‐Valle A, Chapman K, Tanpaiboon P, Grunewald S, Murphy E, Lu X, Cataldo J. Effects of triheptanoin (UX007) in patients with long-chain fatty acid oxidation disorders: Results from an open-label, long-term extension study. J Inherit Metab Dis 2021; 44:253-263. [PMID: 32885845 PMCID: PMC7891391 DOI: 10.1002/jimd.12313] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 12/20/2022]
Abstract
Long-chain fatty acid oxidation disorders (LC-FAOD) are autosomal recessive conditions that impair conversion of long-chain fatty acids into energy, leading to significant clinical symptoms. Triheptanoin is a highly purified, 7-carbon chain triglyceride approved in the United States as a source of calories and fatty acids for treatment of pediatric and adult patients with molecularly confirmed LC-FAOD. CL202 is an open-label, long-term extension study evaluating triheptanoin (Dojolvi) safety and efficacy in patients with LC-FAOD. Patients rolled over from the CL201 triheptanoin clinical trial (rollover); were triheptanoin-naïve (naïve); or had participated in investigator-sponsored trials/expanded access programs (IST/other). Results focus on rollover and naïve groups, as pretreatment data allow comparison. Primary outcomes were annual rate and duration of major clinical events (MCEs; rhabdomyolysis, hypoglycemia, and cardiomyopathy events). Seventy-five patients were enrolled (24 rollover, 20 naïve, 31 IST/other). Mean study duration was 23.0 months for rollover, 15.7 months for naïve, and 34.7 months for IST/other. In the rollover group, mean annualized MCE rate decreased from 1.76 events/year pre-triheptanoin to 0.96 events/year with triheptanoin (P = .0319). Median MCE duration was reduced by 66%. In the naïve group, median annualized MCE rate decreased from 2.33 events/year pre-triheptanoin to 0.71 events/year with triheptanoin (P = .1072). Median MCE duration was reduced by 80%. The most common related adverse events (AEs) were diarrhea, abdominal pain/discomfort, and vomiting, most mild to moderate. Three patients had serious AEs (diverticulitis, ileus, rhabdomyolysis) possibly related to drug; all resolved. Two patients had AEs leading to death; neither drug related. Triheptanoin reduced rate and duration of MCEs. Safety was consistent with previous observations.
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Affiliation(s)
| | - Barbara Burton
- Ann & Robert H. Lurie Children's HospitalChicagoIllinoisUSA
| | - Gerard Berry
- Boston Children's HospitalBostonMassachusettsUSA
| | | | - John Phillips
- Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | | | - Kimberly Chapman
- Children's National Health SystemWashingtonDistrict of ColumbiaUSA
| | | | - Stephanie Grunewald
- Great Ormond Street Hospital and Institute of Child HealthNIHR Biomedical Research Center (BRC), UCLLondonUK
| | - Elaine Murphy
- National Hospital for Neurology and NeurosurgeryLondonUK
| | - Xiaoxiao Lu
- Ultragenyx Pharmaceutical Inc.NovatoCaliforniaUSA
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Abstract
Fatty acid oxidation disorders (FAOD) are a group of rare, autosomal recessive, metabolic disorders caused by variants of the genes for the enzymes and proteins involved in the transport and metabolism of fatty acids in the mitochondria. Those affected by FAOD are unable to convert fatty acids into tricarboxylic acid cycle intermediates such as acetyl-coenzyme A, resulting in decreased adenosine triphosphate and glucose for use as energy in a variety of high-energy-requiring organ systems. Signs and symptoms may manifest in infants but often also appear in adolescents or adults during times of increased metabolic demand, such as fasting, physiologic stress, and prolonged exercise. Patients with FAOD present with a highly heterogeneous clinical spectrum. The most common clinical presentations include hypoketotic hypoglycemia, liver dysfunction, cardiomyopathy, rhabdomyolysis, and skeletal myopathy, as well as peripheral neuropathy and retinopathy in some subtypes. Despite efforts to detect FAOD through newborn screening and manage patients early, symptom onset can be sudden and serious, even resulting in death. Therefore, it is critical to identify quickly and accurately the key signs and symptoms of patients with FAOD to manage metabolic decompensations and prevent serious comorbidities.
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Affiliation(s)
| | - Erin MacLeod
- Children's National Hospital, Washington, DC, USA
| | | | - Bryan Hainline
- Indiana University School of Medicine, Indianapolis, IN, USA
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Norris MK, Scott AI, Sullivan S, Chang IJ, Lam C, Sun A, Hahn S, Thies JM, Gunnarson M, McKean KN, Merritt JL. Tutorial: Triheptanoin and Nutrition Management for Treatment of Long-Chain Fatty Acid Oxidation Disorders. JPEN J Parenter Enteral Nutr 2020; 45:230-238. [PMID: 33085788 DOI: 10.1002/jpen.2034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/22/2020] [Accepted: 10/14/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with severe long-chain fatty acid oxidation disorders (LC-FAODs) experience serious morbidity and mortality despite traditional dietary management including medium-chain triglyceride (MCT)-supplemented, low-fat diets. Triheptanoin is a triglyceride oil that is broken down to acetyl-coenzyme A (CoA) and propionyl-CoA, which replenishes deficient tricarboxylic acid cycle intermediates. We report the complex medical and nutrition management of triheptanoin therapy initiated emergently for 3 patients with LC-FAOD. METHODS Triheptanoin (Ultragenyx Pharmaceutical, Inc, Novato, CA, USA) was administered to 3 patients with LC-FAOD on a compassionate-use basis. Triheptanoin was mixed with non-MCT-containing low-fat formula. Patients were closely followed with regular cardiac and laboratory monitoring. RESULTS Cardiac ejection fraction normalized after triheptanoin initiation. Patients experienced fewer hospitalizations related to metabolic crises while on triheptanoin. Patient 1 has tolerated oral administration without difficulty since birth. Patients 2 and 3 experienced increased diarrhea. Recurrent breakdown of the silicone gastrostomy tube occurred in patient 3, whereas the polyurethane nasogastric tube for patient 2 remained intact. Patient 3 experiences recurrent episodes of elevated creatine kinase levels and muscle weakness associated with illness. Patient 3 had chronically elevated C10-acylcarnitines while on MCT supplementation, which normalized after initiation of triheptanoin and discontinuation of MCT oil. CONCLUSIONS Triheptanoin can ameliorate acute cardiomyopathy and increase survival in patients with severe LC-FAOD. Substituting triheptanoin for traditional MCT-based treatment improves clinical outcomes. MCT oil might be less effective in carnitine-acylcarnitine translocase deficiency patients compared with other FAODs and needs further investigation.
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Affiliation(s)
- Marie K Norris
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, USA.,Department of Nutrition, Biochemical Genetics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Anna I Scott
- Department of Laboratories, Biochemical Genetics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sarah Sullivan
- Department of Nutrition, Biochemical Genetics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Irene J Chang
- Department of Pediatrics, Biochemical Genetics, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Christina Lam
- Department of Pediatrics, Biochemical Genetics, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Angela Sun
- Department of Pediatrics, Biochemical Genetics, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sihoun Hahn
- Department of Pediatrics, Biochemical Genetics, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jenny M Thies
- Department of Pediatrics, Biochemical Genetics, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Melissa Gunnarson
- Department of Nutrition, Biochemical Genetics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kelly N McKean
- Department of Nutrition, Biochemical Genetics, Seattle Children's Hospital, Seattle, Washington, USA
| | - J Lawrence Merritt
- Department of Pediatrics, Biochemical Genetics, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
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Gaston G, Gangoiti JA, Winn S, Chan B, Barshop BA, Harding CO, Gillingham MB. Cardiac tissue citric acid cycle intermediates in exercised very long-chain acyl-CoA dehydrogenase-deficient mice fed triheptanoin or medium-chain triglyceride. J Inherit Metab Dis 2020; 43:1232-1242. [PMID: 33448436 DOI: 10.1002/jimd.12284] [Citation(s) in RCA: 4] [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: 05/21/2018] [Revised: 07/01/2020] [Accepted: 07/07/2020] [Indexed: 11/11/2022]
Abstract
Anaplerotic odd-chain fatty acid supplementation has been suggested as an approach to replenish citric acid cycle intermediate (CACi) pools and facilitate adenosine triphosphate (ATP) production in subjects with long-chain fatty acid oxidation disorders, but the evidence that cellular CACi depletion exists and that repletion occurs following anaplerotic substrate supplementation is limited. We exercised very long-chain acyl-CoA dehydrogenase-deficient (VLCAD-/-) and wild-type (WT) mice to exhaustion and collected cardiac tissue for measurement of CACi by targeted metabolomics. In a second experimental group, VLCAD-/- and WT mice that had been fed chow prepared with either medium-chain triglyceride (MCT) oil or triheptanoin for 4 weeks were exercised for 60 minutes. VLCAD-/- mice exhibited lower succinate in cardiac muscle at exhaustion than WT mice suggesting lower CACi in VLCAD-/- with prolonged exercise. In mice fed either MCT or triheptanoin, succinate and malate were greater in VLCAD-/- mice fed triheptanoin compared to VLCAD-/- animals fed MCT but lower than WT mice fed triheptanoin. Long-chain odd acylcarnitines such as C19 were elevated in VLCAD-/- and WT mice fed triheptanoin suggesting some elongation of the heptanoate, but it is unknown what proportion of heptanoate was oxidized vs elongated. Prolonged exercise was associated with decreased cardiac muscle succinate in VLCAD-/- mice in comparison to WT mice. VLCAD-/- fed triheptanoin had increased succinate compared to VLCAD-/- mice fed MCT but lower than WT mice fed triheptanoin. Cardiac CACi were higher following dietary ingestion of an anaplerotic substrate, triheptanoin, in comparison to MCT.
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Affiliation(s)
- Garen Gaston
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, Oregon, USA
| | - Jon A Gangoiti
- Department of Pediatrics, Genetics Division, Biochemical Genetics Program, University of California San Diego, La Jolla, California, USA
| | - Shelley Winn
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, Oregon, USA
| | - Benjamin Chan
- Biostatistics and Design Program, School of Public Health, Oregon Health & Science University, Portland, Oregon, USA
| | - Bruce A Barshop
- Department of Pediatrics, Genetics Division, Biochemical Genetics Program, University of California San Diego, La Jolla, California, USA
| | - Cary O Harding
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, Oregon, USA
| | - Melanie B Gillingham
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, Oregon, USA
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Knottnerus SJG, van Harskamp D, Schierbeek H, Bleeker JC, Crefcoeur LL, Ferdinandusse S, van Goudoever JB, Houtkooper RH, IJlst L, Langeveld M, Wanders RJA, Vaz FM, Wijburg FA, Visser G. Exploring the metabolic fate of medium-chain triglycerides in healthy individuals using a stable isotope tracer. Clin Nutr 2020; 40:1396-1404. [PMID: 32948349 DOI: 10.1016/j.clnu.2020.08.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/09/2020] [Accepted: 08/27/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS Medium chain triglyceride (MCT) supplementation is often recommended as treatment for patients with long-chain fatty acid β-oxidation (lcFAO) disorders, since they can be utilized as an energy source without the use of the defective enzyme. However, studies in mice and preterm infants suggest that not all medium-chain fatty acids (MCFA) are oxidized and may undergo elongation to long-chain fatty acids (LCFA). In this single blinded study, we explored the metabolic fates of MCT in healthy individuals using a 13C-labeled MCT tracer. METHOD Three healthy males in rest received on two test days a primed continuous infusion of glyceryl tri[1,2,3,4-13C4]-octanoate with either an isocaloric supplementation of 1) exclusively MCT (MCT-only) or 2) a mixture of MCT, proteins and carbohydrates (MCT-mix). Gas chromatography - combustion - isotope ratio mass spectrometry (GC-C-IRMS) was used to determine 13C-enrichment of long-chain fatty acids in plasma and of 13CO2 in exhaled air. RESULTS When provided as single energy source, an estimated 42% of administered MCT was converted to CO2. In combination with carbohydrates and proteins in the diet, oxidation of MCT was higher (62%). In both diets <1% of 13C-label was incorporated in LCFA in plasma, indicating that administered MCT underwent chain-elongation to LCT. CONCLUSIONS Although the relative MCT oxidation rate was higher when combined with carbohydrates and protein, quantitatively more MCT was oxidized when given an isocaloric meal with solely MCT. As these results were obtained in the resting state opposed to during exercise, it is too early to give a recommendation concerning the use of MCT in lcFAO disorders. The data show that in resting healthy individuals only a very small part of the MCT is traced back as LCFA in plasma, suggesting that MCT treatment does not result in a large LCFA burden, however further research on storage of MCT in tissues is warranted. REGISTRATION The study was registered in the Nederlands Trialregister. Protocol ID: Trial NL7417 (NTR7650).
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Affiliation(s)
- Suzan J G Knottnerus
- Amsterdam UMC, University of Amsterdam, Laboratory Genetic Metabolic Diseases, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology and Metabolism, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands; Section Metabolic Diseases, Wilhelmina Children's Hospital, University Medical Center Utrecht, Lundlaan 6, 3584, EA, Utrecht, the Netherlands
| | - Dewi van Harskamp
- Amsterdam UMC, University of Amsterdam, Stable Isotope Research Laboratory, Endocrinology, Amsterdam Gastroenterology Endocrinology and Metabolism, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands; Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Emma's Children's Hospital, Amsterdam Gastroenterology Endocrinology and Metabolism, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Henk Schierbeek
- Amsterdam UMC, University of Amsterdam, Stable Isotope Research Laboratory, Endocrinology, Amsterdam Gastroenterology Endocrinology and Metabolism, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands; Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Emma's Children's Hospital, Amsterdam Gastroenterology Endocrinology and Metabolism, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Jeannette C Bleeker
- Amsterdam UMC, University of Amsterdam, Laboratory Genetic Metabolic Diseases, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology and Metabolism, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Loek L Crefcoeur
- Amsterdam UMC, University of Amsterdam, Laboratory Genetic Metabolic Diseases, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology and Metabolism, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands; Section Metabolic Diseases, Wilhelmina Children's Hospital, University Medical Center Utrecht, Lundlaan 6, 3584, EA, Utrecht, the Netherlands
| | - Sacha Ferdinandusse
- Amsterdam UMC, University of Amsterdam, Laboratory Genetic Metabolic Diseases, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology and Metabolism, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Johannes B van Goudoever
- Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Emma's Children's Hospital, Amsterdam Gastroenterology Endocrinology and Metabolism, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Riekelt H Houtkooper
- Amsterdam UMC, University of Amsterdam, Laboratory Genetic Metabolic Diseases, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology and Metabolism, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Lodewijk IJlst
- Amsterdam UMC, University of Amsterdam, Laboratory Genetic Metabolic Diseases, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology and Metabolism, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Mirjam Langeveld
- Amsterdam UMC, University of Amsterdam, Department of Endocrinology and Metabolism, Amsterdam Gastroenterology Endocrinology and Metabolism, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Ronald J A Wanders
- Amsterdam UMC, University of Amsterdam, Laboratory Genetic Metabolic Diseases, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology and Metabolism, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Frédéric M Vaz
- Amsterdam UMC, University of Amsterdam, Laboratory Genetic Metabolic Diseases, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology and Metabolism, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Frits A Wijburg
- Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Emma's Children's Hospital, Amsterdam Gastroenterology Endocrinology and Metabolism, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Gepke Visser
- Amsterdam UMC, University of Amsterdam, Laboratory Genetic Metabolic Diseases, Amsterdam Cardiovascular Sciences, Amsterdam Gastroenterology Endocrinology and Metabolism, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands; Section Metabolic Diseases, Wilhelmina Children's Hospital, University Medical Center Utrecht, Lundlaan 6, 3584, EA, Utrecht, the Netherlands.
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Kritzer A, Tarrant S, Sussman‐Karten K, Barbas K. Use of skimmed breast milk for an infant with a long-chain fatty acid oxidation disorder: A novel therapeutic intervention. JIMD Rep 2020; 55:44-50. [PMID: 32905135 PMCID: PMC7463058 DOI: 10.1002/jmd2.12152] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 07/08/2020] [Accepted: 07/13/2020] [Indexed: 12/30/2022] Open
Abstract
The focus of dietary therapy for long chain fatty acid oxidation disorders (LC-FAODs) is to minimize fatty acid oxidation by avoiding fasting and providing sufficient calories. Dietary therapy involves restriction of long-chain triglycerides (LCT), and provision of medium-chain triglycerides as an alternate energy source. It is well established that the use of breast milk through the first year of a newborn's life has significant health benefits. While very few medical contraindications to breastfeeding exist, feeding an infant with a severe carnitine acylcarnitine translocase (CACT) deficiency typically requires cessation of breastfeeding as approximately 50% of the calories in human milk come from LCT. In this case report, we present the innovative and successful use of skimmed breast milk incorporated into the dietary management of an infant with severe CACT deficiency. Given the poor prognosis for individuals with severe CACT deficiency on standard dietary therapy, the use of skimmed breast milk represents an important measure to try to improve short-term and long-term outcomes. Given the many proven benefits of breast milk, this case illustrates that skimmed breast milk can be combined with appropriate fat sources to provide complete nutrition for children with severe CACT deficiency. After over 12 months on this regimen, this patient has experienced normal growth and development and has had no acute decompensations.
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Affiliation(s)
- Amy Kritzer
- Division of Genetics and GenomicsBoston Children's HospitalBostonMassachusettsUSA
| | - Stacey Tarrant
- Division of Gastroenterology, Hepatology, and NutritionBoston Children's HospitalBostonMassachusettsUSA
| | - Karen Sussman‐Karten
- Department of Nursing, Lactation Support ProgramBoston Children's HospitalBostonMassachusettsUSA
| | - Kimberly Barbas
- Department of Nursing, Lactation Support ProgramBoston Children's HospitalBostonMassachusettsUSA
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42
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Vockley J. Long-chain fatty acid oxidation disorders and current management strategies. THE AMERICAN JOURNAL OF MANAGED CARE 2020; 26:S147-S154. [PMID: 32840329 PMCID: PMC9850137 DOI: 10.37765/ajmc.2020.88480] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Long-chain fatty acid oxidation disorders (LC-FAODs) are rare, life-threatening, autosomal recessive genetic disorders characterized by acute crises of energy production and chronic energy deficiency. Patients may present with rhabdomyolysis induced by exercise; fasting or illness; hepatic dysfunction, including severe hypoglycemia and hyperammonemia; and cardiomyopathy. These clinical manifestations can lead to frequent hospitalizations and premature death. LC-FAODs are caused by mutations in nuclear genes encoding mitochondrial enzymes involved in the conversion of dietary long-chain fatty acids (LCFAs) into energy during times of fasting and physiologic stress. Despite newborn screening, current management options leave many patients continuing to experience major clinical events, and mortality rates remain elevated. The current standard therapy for LC-FAODs is avoidance of fasting and supplementation of medium-chain triglyceride oil, an even, medium-chain fatty acid that does not require the typical steps of LC-FAOD for metabolism. Despite this therapy, patients with LC-FAODs continue to experience recurring hospitalizations, and high morbidity and mortality rates. In recent years, the use of medium, odd-chain fatty acids, such as triheptanoin, have been studied as a treatment of LC-FAODs due to its anaplerotic properties. Due to favorable safety and efficacy data from clinical trials, this novel agent has the potential to transform the treatment of LC-FAODs and improve patient outcomes in this patient population. This article provides an overview of the epidemiology, pathophysiology, clinical manifestations, and current management approaches for the diagnosis and management of LC-FAODs. It also provides the most recent clinical safety and efficacy data for triheptanoin and other therapies under investigation.
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Affiliation(s)
- Jerry Vockley
- Chief of the Division of Medical Genetics and Director of The Center for Rare Disease Therapy, UPMC Children's Hospital of Pittsburgh; and Cleveland Family Endowed Chair in Pediatric Research and Professor of Human Genetics, University of Pittsburgh, both in Pittsburgh, PA.
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43
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Donald E, Leb J, Bialer M, Axsom K. A Rare Presentation of Cardiomyopathy in Pregnancy. JACC Case Rep 2020; 2:1066-1069. [PMID: 34317416 PMCID: PMC8302089 DOI: 10.1016/j.jaccas.2020.05.022] [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: 02/18/2020] [Revised: 04/29/2020] [Accepted: 05/06/2020] [Indexed: 11/25/2022]
Abstract
Our patient presented in her third trimester of pregnancy with new onset of heart failure. A thorough workup in the initial postpartum period with detailed past medical history, advanced imaging modalities, and a multidisciplinary approach revealed a rare and treatable etiology of cardiomyopathy. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Elena Donald
- New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York
| | - Jay Leb
- New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York
| | - Martin Bialer
- Cohen Children's Medical Center, Northwell Health System, Great Neck, New York
| | - Kelly Axsom
- New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York
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44
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Seminotti B, Leipnitz G, Karunanidhi A, Kochersperger C, Roginskaya VY, Basu S, Wang Y, Wipf P, Van Houten B, Mohsen AW, Vockley J. Mitochondrial energetics is impaired in very long-chain acyl-CoA dehydrogenase deficiency and can be rescued by treatment with mitochondria-targeted electron scavengers. Hum Mol Genet 2020; 28:928-941. [PMID: 30445591 PMCID: PMC6400046 DOI: 10.1093/hmg/ddy403] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 12/12/2022] Open
Abstract
Very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency is the most common defect of mitochondrial long-chain fatty acid β-oxidation. Patients present with heterogeneous clinical phenotypes affecting heart, liver and skeletal muscle predominantly. The full pathophysiology of the disease is unclear and patient response to current therapeutic regimens is incomplete. To identify additional cellular alterations and explore more effective therapies, mitochondrial bioenergetics and redox homeostasis were assessed in VLCAD-deficient fibroblasts, and several protective compounds were evaluated. The results revealed cellular and tissue changes, including decreased respiratory chain (RC) function, increased reactive oxygen species (ROS) production and altered mitochondrial function and signaling pathways in a variety of VLCAD-deficient fibroblasts. The mitochondrially enriched electron and free radical scavengers JP4-039 and XJB-5-131 improved RC function and decreased ROS production significantly, suggesting that they are viable candidate compounds to further develop to treat VLCAD-deficient patients.
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Affiliation(s)
- Bianca Seminotti
- Division Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA.,Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Guilhian Leipnitz
- Division Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA.,Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Anuradha Karunanidhi
- Division Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Catherine Kochersperger
- Division Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Vera Y Roginskaya
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shrabani Basu
- Division Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yudong Wang
- Division Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Peter Wipf
- Department of Chemistry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bennett Van Houten
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Al-Walid Mohsen
- Division Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jerry Vockley
- Division Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
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45
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Microbial synthesis of functional odd-chain fatty acids: a review. World J Microbiol Biotechnol 2020; 36:35. [PMID: 32088779 DOI: 10.1007/s11274-020-02814-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 02/13/2020] [Indexed: 10/24/2022]
Abstract
Odd-chain fatty acids (OCFAs) naturally occur in bacteria, higher animals, and in plants. During recent years, they have received increasing attention due to their unique pharmacological properties and usefulness for agricultural and industrial applications. Recently, OCFAs have been identified and quantified in a few organisms, and new pharmacological functions of OCFAs have been reported. Some of the publications are related to the optimization of OCFA production through fermentation and genetic engineering. The present review aims to provide a summary on the recent progress in the field of microbial-derived OCFAs. More specifically, we outline the publications of OCFAs related to (i) different sources of OCFAs; (ii) endogenous synthesis of OCFAs; (iii) production of OCFAs through fermentation; (iv) genetic engineering related to OCFA; and (v) role of OCFAs in human health and disease. Finally, some areas that require further research are discussed.
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46
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Impairment of mitochondrial bioenergetics and permeability transition induction caused by major long-chain fatty acids accumulating in VLCAD deficiency in skeletal muscle as potential pathomechanisms of myopathy. Toxicol In Vitro 2020; 62:104665. [DOI: 10.1016/j.tiv.2019.104665] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/07/2019] [Accepted: 09/24/2019] [Indexed: 12/24/2022]
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Bastin J, Djouadi F. [Dysfunctions of mitochondrial fatty acid β-oxidation in rare and common diseases]. Med Sci (Paris) 2019; 35:779-786. [PMID: 31625900 DOI: 10.1051/medsci/2019156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Dysfunctions of mitochondrial fatty acid ß-oxidation (ß-FAO) in various tissues represent a hallmark of many common disorders, and are acknowledged to play an essential role in the pathogenesis of diabetes, obesity, and cardiac diseases. Moreover, inborn defects in ß-FAO form a large family of rare diseases with variable phenotypes, ranging from fatal multi-organ failure in the newborn to isolated adult onset myopathy. These pathologies highlight the critical role of ß-FAO in many tissues with high-energy demand (heart, muscle, liver, kidney). Furthermore, and unexpectedly, very recent data unveiled the possible involvement of ß-FAO in instructing complex non energy-related functions, such as chromatin modification, control of neural stem cell activity, or survival and fate of cancer cells. Pharmacological targeting of ß-FAO by small molecules might therefore open new avenues for the treatment of various rare or common diseases.
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Affiliation(s)
- Jean Bastin
- Centre de Recherche des Cordeliers, Inserm U1138, Sorbonne Université, USPC, Université Paris Descartes, Université Paris Diderot, 15 rue de l'École de Médecine, 75006 Paris, France
| | - Fatima Djouadi
- Centre de Recherche des Cordeliers, Inserm U1138, Sorbonne Université, USPC, Université Paris Descartes, Université Paris Diderot, 15 rue de l'École de Médecine, 75006 Paris, France
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48
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Madsen KL, Laforêt P, Buch AE, Stemmerik MG, Ottolenghi C, Hatem SN, Raaschou-Pedersen DT, Poulsen NS, Atencio M, Luton MP, Ceccaldi A, Haller RG, Quinlivan R, Mochel F, Vissing J. No effect of triheptanoin on exercise performance in McArdle disease. Ann Clin Transl Neurol 2019; 6:1949-1960. [PMID: 31520525 PMCID: PMC6801166 DOI: 10.1002/acn3.50863] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/21/2019] [Accepted: 06/22/2019] [Indexed: 12/25/2022] Open
Abstract
Objective To study if treatment with triheptanoin, a 7‐carbon triglyceride, improves exercise tolerance in patients with McArdle disease. McArdle patients have a complete block in glycogenolysis and glycogen‐dependent expansion of tricarboxylic acid cycle (TCA), which may restrict fat oxidation. We hypothesized that triheptanoin metabolism generates substrates for the TCA, which potentially boosts fat oxidation and improves exercise tolerance in McArdle disease. Methods Double‐blind, placebo‐controlled, crossover study in patients with McArdle disease completing two treatment periods of 14 days each with a triheptanoin or placebo diet (1 g/kg/day). Primary outcome was change in mean heart rate during 20 min submaximal exercise on a cycle ergometer. Secondary outcomes were change in peak workload and oxygen uptake along with changes in blood metabolites and respiratory quotients. Results Nineteen of 22 patients completed the trial. Malate levels rose on triheptanoin treatment versus placebo (8.0 ± SD2.3 vs. 5.5 ± SD1.8 µmol/L, P < 0.001), but dropped from rest to exercise (P < 0.001). There was no difference in exercise heart rates between triheptanoin (120 ± SD16 bpm) and placebo (121 ± SD16 bpm) treatments. Compared with placebo, triheptanoin did not change the submaximal respiratory quotient (0.82 ± SD0.05 vs. 0.84 ± SD0.03), peak workload (105 ± SD38 vs. 102 ± SD31 Watts), or peak oxygen uptake (1938 ± SD499 vs. 1977 ± SD380 mL/min). Interpretation Despite increased resting plasma malate with triheptanoin, the increase was insufficient to generate a normal TCA turnover during exercise and the treatment has no effect on exercise capacity or oxidative metabolism in patients with McArdle disease.
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Affiliation(s)
- Karen L Madsen
- Copenhagen Neuromuscular Center, Department of Neurology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Pascal Laforêt
- Centre de référence des maladies neuromusculaires Nord/Est/Ile de France, Service de Neurologie, Hôpital Raymond-Poincaré, AP-HP, Garches, France
| | - Astrid E Buch
- Copenhagen Neuromuscular Center, Department of Neurology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Mads G Stemmerik
- Copenhagen Neuromuscular Center, Department of Neurology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Chris Ottolenghi
- Metabolomics Unit, Service des Explorations fonctionnelles, Necker Hospital and Descartes University of Paris, AP-HP, Paris, France
| | - Stéphane N Hatem
- Institute of Cardiometabolism and Nutrition, La Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Cardiology Institute, La Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Daniel T Raaschou-Pedersen
- Copenhagen Neuromuscular Center, Department of Neurology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Nanna S Poulsen
- Copenhagen Neuromuscular Center, Department of Neurology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Maria Atencio
- Inserm U 1127, CNRS UMR 7225, ICM, F-75013, Paris, France
| | | | - Alexandre Ceccaldi
- Institute of Cardiometabolism and Nutrition, La Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Cardiology Institute, La Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Ronald G Haller
- Neuromuscular Center, Institute for Exercise and Environmental Medicine of Texas Health Presbyterian Hospital, Dallas, Texas.,Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center Dallas, Dallas, Texas
| | - Ros Quinlivan
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, Queen Square, London, England
| | - Fanny Mochel
- Inserm U 1127, CNRS UMR 7225, ICM, F-75013, Paris, France.,Sorbonne Université, UPMC-Paris 6, UMR S 1127, Paris, France.,Department of Genetics and Reference Center for Adult Neurometabolic diseases, La Pitié-Salpêtrière University Hospital, APHP, Paris, France
| | - John Vissing
- Copenhagen Neuromuscular Center, Department of Neurology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
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49
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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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50
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Rovelli V, Manzoni F, Viau K, Pasquali M, Longo N. Clinical and biochemical outcome of patients with very long-chain acyl-CoA dehydrogenase deficiency. Mol Genet Metab 2019; 127:64-73. [PMID: 31031081 DOI: 10.1016/j.ymgme.2019.04.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 04/04/2019] [Accepted: 04/04/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Very-Long-Chain Acyl-CoA Dehydrogenase (VLCAD) deficiency is a disorder of fatty acid oxidation included in the recommended uniform newborn screening (NBS) panel in the USA. It can have variable clinical severity and there is limited information on the natural history of this condition, clinical presentation according to genotype and effectiveness of newborn screening. METHODS Retrospective data (growth parameters, morbidity, biochemical and genetic testing results) were collected from patients with VLCAD deficiency, to evaluate biochemical and clinical outcomes. Descriptive statistics was used for qualitative variables, while linear regression analysis was used to correlate continuous variables. RESULTS VLCAD deficiency (screened by measuring elevated levels of C14:1-carnitine in blood spots) was more frequent in Utah than the national average (1:27,617 versus 1:63,481) in the first ten years of screening. Twenty-six patients had a confirmed diagnosis of VLCAD deficiency using DNA testing or functional studies. The c.848T>C (p.V283A) variant in the ACADVL gene was the most frequent in our population. Novel variants (c.623-21A>G (IVS7-21A>G); c.1052C>T (p.T351I); c.1183-7A>G (IVS11-7A>G); c.1281G>C (p.W427C); c.1923G>C (p.L641F); c.1924G>A (p.V642M)) were identified in this study, with their pathogenicity remaining unclear in most cases. C14:1-carnitine levels decreased with age and significantly correlated with CK levels as index of muscle involvement. There were no cases of HELLP syndrome nor liver disease during pregnancies in the mothers of VLCAD patients. None of our patients developed cardiac involvement after birth and all patients had normal growth parameters while on treatment. Clinical manifestations were related to concomitant infections and altered biochemical parameters. DISCUSSION VLCAD deficiency can be identified by neonatal screening. Most patients compliant with therapy normalized biochemical parameters and had no major clinical manifestations. Complications were completely prevented with a relatively low number of pre-emptive ER visits or hospital admissions. It remains unclear whether neonatal screening is now identifying less severely affected patient or if complications will arise as subjects become older. Observation beyond puberty is necessary to fully understand the impact of VLCAD deficiency on morbidity in patients with VLCAD deficiency.
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Affiliation(s)
- Valentina Rovelli
- Division of Medical Genetics/Pediatrics, University of Utah, Salt Lake City, UT, USA; Clinical Department of Pediatrics, University of Milan, San Paolo Hospital, Milan, Italy
| | - Francesca Manzoni
- Division of Medical Genetics/Pediatrics, University of Utah, Salt Lake City, UT, USA; Clinical Department of Neuropsychiatry, University of Milan, San Paolo Hospital, Milan, Italy
| | - Krista Viau
- Division of Medical Genetics/Pediatrics, University of Utah, Salt Lake City, UT, USA; Boston Children's Hospital, Boston, MA, USA
| | - Marzia Pasquali
- Division of Medical Genetics/Pediatrics, University of Utah, Salt Lake City, UT, USA; ARUP Laboratories, Salt Lake City, UT, USA; Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Nicola Longo
- Division of Medical Genetics/Pediatrics, University of Utah, Salt Lake City, UT, USA; ARUP Laboratories, Salt Lake City, UT, USA; Department of Pathology, University of Utah, Salt Lake City, UT, USA.
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