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Bugi MA, Jugănaru I, Simina IE, Nicoară DM, Cristun LI, Brad GF, Huțanu D, Isac R, Kozma K, Cîrnatu D, Mărginean O. Evaluating Therapy and Growth in Children with Phenylketonuria: A Retrospective Longitudinal Study from Two Romanian Centers. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1185. [PMID: 39064614 PMCID: PMC11279053 DOI: 10.3390/medicina60071185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 07/17/2024] [Accepted: 07/19/2024] [Indexed: 07/28/2024]
Abstract
Background and Objectives: Phenylketonuria (PKU) is a rare genetic disorder characterized by the inability to convert the essential amino acid phenylalanine into tyrosine. Early dietary treatment can successfully prevent complications, but controversies still exist regarding the attainment of normal growth in these patients. Materials and Methods: Eighteen patients with PKU from two Romanian reference centers were compared to eighteen non-PKU controls, matched for age and gender. The comparisons used weight-for-height, weight-for-age, height/length-for-age, and body mass index-for-age z-scores from birth to three years of age. Results: The PKU study group consisted of nine boys and nine girls, with a median follow-up period of thirty-six months (interquartile range = 9.75). While median values of all four growth metrics remained within the normal range across the entire study period, weight-for-age z-scores were significantly lower in PKU patients throughout most of the study (p < 0.001). Conclusions: The persistent lower weight-for-age z-scores of the PKU patients compared to controls indicate that ongoing monitoring and potential adjustments in dietary therapy may be necessary to further optimize growth outcomes.
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Affiliation(s)
- Meda-Ada Bugi
- Ph.D. School Department, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (M.-A.B.)
- Department of Pediatrics I, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania (G.-F.B.); (O.M.)
- Department of Pharmacy, University of Medicine and Pharmacy ‘Vasile Goldis’, 310025 Arad, Romania
| | - Iulius Jugănaru
- Department of Pediatrics I, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania (G.-F.B.); (O.M.)
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
- Department of Research Center for Disturbances of Growth and Development in Children–BELIVE, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300011 Timisoara, Romania
| | - Iulia-Elena Simina
- Department of Genetics, Center of Genomic Medicine, ‘Victor Babeş’ University of Medicine and Pharmacy, 300041 Timisoara, Romania;
| | - Delia-Maria Nicoară
- Ph.D. School Department, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (M.-A.B.)
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Lucian-Ioan Cristun
- Ph.D. School Department, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (M.-A.B.)
| | - Giorgiana-Flavia Brad
- Department of Pediatrics I, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania (G.-F.B.); (O.M.)
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Delia Huțanu
- Department of Biology-Chemistry, Biology-Chemistry-Geography Faculty, West University of Timisoara, 300115 Timisoara, Romania;
| | - Raluca Isac
- Department XI Pediatrics, Discipline III Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania;
| | - Kinga Kozma
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410000 Oradea, Romania;
- Regional Center of Medical Genetics Bihor, Emergency Clinical Hospital Bihor, 410000 Oradea, Romania
| | - Daniela Cîrnatu
- Department of Medicine, University of Medicine and Pharmacy ‘Vasile Goldis’, 310025 Arad, Romania
- Romanian National Institute of Public Health, Regional Centre, 300230 Timisoara, Romania
| | - Otilia Mărginean
- Department of Pediatrics I, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania (G.-F.B.); (O.M.)
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
- Department of Research Center for Disturbances of Growth and Development in Children–BELIVE, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300011 Timisoara, Romania
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Dixon M, Millington C, Bernstein L, Coughlin CR, Drumm M, Gaughan S, van Karnebeek CDM, van Wegberg AMJ. Dietary management for pyridoxine-dependent epilepsy due to α-aminoadipic semialdehyde dehydrogenase deficiency, a follow-on from the international consortium guidelines. JIMD Rep 2024; 65:188-203. [PMID: 38736635 PMCID: PMC11078710 DOI: 10.1002/jmd2.12418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 03/14/2024] [Accepted: 03/18/2024] [Indexed: 05/14/2024] Open
Abstract
Pyridoxine-dependent epilepsy (PDE-ALDH7A1) is a neurometabolic disorder in the lysine metabolism pathway. In 2014 and 2021, the International PDE consortium published consensus guidelines about diagnosis and management. In this follow-on, a literature review was performed and nutrition management was evaluated through an international dietary questionnaire with 40 respondents. This manuscript discusses consensus dietary statements and the practical provision of lysine reduction therapies. Results from the questionnaire, statements from the PDE consensus guidelines, new data from the literature, as well as clinical practice experience of the metabolic dietitian group form the basis of these updated practical diet recommendations. These dietary management recommendations can support dietitians, nutritionists, and physicians in initiation and monitoring of lysine reduction therapies for PDE-ALDH7A1 patients and families.
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Affiliation(s)
- Marjorie Dixon
- Dietetics DepartmentGreat Ormond Street Hospital for Children NHS Foundation TrustLondonUK
| | - Chloe Millington
- Dietetics DepartmentGreat Ormond Street Hospital for Children NHS Foundation TrustLondonUK
| | - Laurie Bernstein
- Section of Clinical Genetics and Metabolism, Department of PediatricsUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Curtis R. Coughlin
- Section of Clinical Genetics and Metabolism, Department of PediatricsUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Morgan Drumm
- Section of Clinical Genetics and Metabolism, Department of PediatricsUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Sommer Gaughan
- Section of Clinical Genetics and Metabolism, Department of PediatricsUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Clara D. M. van Karnebeek
- Emma Center for Personalized Medicine, Departments of Pediatrics and Human Genetics, Amsterdam Gastroenterology Endocrinology and MetabolismAmsterdam Univeristy Medical CenterAmsterdamThe Netherlands
| | - Annemiek M. J. van Wegberg
- Department of Gastroenterology and Hepatology‐DieteticsRadboud University Medical CenterNijmegenThe Netherlands
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Mezzomo TR, Dias MRMG, Santos T, Pereira RM. Dietary intake in individuals with phenylketonuria: an integrative review. NUTR HOSP 2024; 41:212-223. [PMID: 37705455 DOI: 10.20960/nh.04579] [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] [Indexed: 09/15/2023] Open
Abstract
Introduction Introduction: the dietary intake of individuals with phenylketonuria (PKU) may vary widely according to different cultural eating habits, lifestyle, access to multidisciplinary team, and metabolic formulas available. Thus, knowing the dietary intake of this population makes it possible to tailor nutritional treatment strategies to impact their health. Objective: to analyze the evidence on the dietary intake of individuals with PKU. Methods: an integrative literature review was conducted on the dietary intake of individuals with PKU in the databases PUBMED, BIREME and Science Direct. Original articles that addressed the energy and macronutrient food intake of children, adolescents and/or adults with PKU were included in the study, without time restriction, in any language. A total of 384 articles were found and 27 articles were selected and analyzed. Results: evidence about the nutritional composition of their diet showed that individuals with PKU consume between 1160-2721 kcal of energy -7.2-17.4 % (32.4-76.9 g) of energy as protein, 45.9-69.2 % of energy as carbohydrates, 16.6-39 % of energy as lipids- and between 7.6 and 20 g of fiber. Conclusion: most individuals with PKU have low energy, protein and fiber intake, adequate lipid intake, and high carbohydrate intake. Metabolic control of the disease is still a challenge in all countries. Nutritional strategies to improve dietary nutritional composition and phenylalanine blood levels in individuals with PKU remain an urgent issue.
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Affiliation(s)
- Thais Regina Mezzomo
- Graduate Master's and Doctoral Program in Child and Adolescent Health. University Federal of Parana
| | | | | | - Rosana Marques Pereira
- Pos-Graduate Master's and Doctoral Program in Child and Adolescent Health. University Federal of Parana
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Yılmaz BK, Baykan A, Kardaş F, Kendirci M. Evaluation of the effect of obesity, dietary glycemic index and metabolic profiles on the cardiovascular risk in children with classical phenylketonuria. Mol Genet Metab 2023; 140:107677. [PMID: 37544048 DOI: 10.1016/j.ymgme.2023.107677] [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: 04/26/2023] [Revised: 07/30/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVES To compare the glycemic index(GI),obesity,echocardiographic,and arterial stiffness measurements with the healthy control group to evaluate the cardiovascular risk of pediatric classical phenylketonuria(PKU). METHODS The study was a prospective observational,involving 104 pediatric volunteers between 2019 and 2020.Two groups were formed:the PKU patient group and the healthy control group.These two groups were further divided into three subgroups:obese,overweight,and normal weight.The patients' anthropometric measurements,body fat analysis,biochemical analysis, GI and glycemic load(GL),arterial stiffness measurements,and echocardiographic findings were recorded. RESULTS The PKU patient group's glucose,total cholesterol,LDL,and HDL values were significantly lower than the healthy control group(p = 0.010 for glucose and p = 0.001 for total cholesterol,LDL and HDL).Triglyceride levels were higher in the PKU patient group than in the healthy controls(109.6 vs. 76.7 mg/dl,p = 0.001). GI and GL were significantly lower in the PKU patient group than in the healthy control group(GI 453 vs. 392.9,p = 0.017 and GL 101.1 vs. 85.5,p = 0.036).Left ventricular mass(LVM)-z-score and LVM index were significantly higher in the PKU group than in the healthy control group(LVM z-score 0.9 vs. 0.5,p = 0.014 and LVM index 38.9 vs. 32.7 g/m2.7,p = 0.001). A moderately statistically significant positive correlation was found between the mean phenylalanine(phe) value and pulse wave velocity(PWV) among the PKU patient groups(R: 0.477,p < 0.001).A moderately statistically significant positive correlation was also found between waist circumference and PWV in the PKU patient group(R:0.541, p < 0.001). CONCLUSIONS Our study found that close follow-up of phe levels and PWV is more critical than obesity, GI, and GL in the cardiovascular evaluation of classical PKU patients.A large number of multicenter pediatric studies are needed in this area.
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Affiliation(s)
- Banu Kadıoğlu Yılmaz
- Department of Pediatric Metabolism, Konya City Hospital, University of Health Sciences, Konya, Turkey.
| | - Ali Baykan
- Department of Pediatric Cardiology, Erciyes University Medical Faculty, Kayseri, Turkey.
| | - Fatih Kardaş
- Department of Pediatric Metabolism, Erciyes University Medical Faculty, Kayseri, Turkey.
| | - Mustafa Kendirci
- Department of Pediatric Endocrinology and Metabolism, Bağcılar Medipol Mega University Hospital, İstanbul, Turkey
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McWhorter N, Ndugga-Kabuye MK, Puurunen M, Ernst SL. Complications of the Low Phenylalanine Diet for Patients with Phenylketonuria and the Benefits of Increased Natural Protein. Nutrients 2022; 14:4960. [PMID: 36500989 PMCID: PMC9740314 DOI: 10.3390/nu14234960] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/18/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022] Open
Abstract
Phenylketonuria (PKU) is an inherited disorder in which phenylalanine (Phe) is not correctly metabolized leading to an abnormally high plasma Phe concentration that causes profound neurologic damage if left untreated. The mainstay of treatment for PKU has centered around limiting natural protein in the diet while supplementing with medical foods in order to prevent neurologic injury while promoting growth. This review discusses several deleterious effects of the low Phe diet along with benefits that have been reported for patients with increased natural protein intake while maintaining plasma Phe levels within treatment guidelines.
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Besada C, Hakami A, Pillai G, Yetsko K, Truong N, Little T, Pantano S, Dmello A. Preformulation studies with phenylalanine ammonia lyase: essential prelude to a microcapsule formulation for the management of phenylketonuria. J Pharm Sci 2022; 111:1857-1867. [DOI: 10.1016/j.xphs.2022.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/22/2022] [Accepted: 03/22/2022] [Indexed: 01/10/2023]
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Al-Bari AA. Current Scenario and Future Direction of Newborn Screening and Management Program for Phenylketonuria in Bangladesh. JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2022. [DOI: 10.1590/2326-4594-jiems-2021-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Silveira AM, Lima PL, Alves MRA, Soares RDL, Kanufre VDC, Rodrigues VDM, Starling ALP, Norton RDC, Aguiar MJBD. Overweight/obesity in adolescents with phenylketonuria: protective and predisposing factors. J Pediatr (Rio J) 2022; 98:104-110. [PMID: 34144002 PMCID: PMC9432224 DOI: 10.1016/j.jped.2021.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE To estimate the prevalence and factors associated with overweight/obesity development in adolescents with early diagnosed phenylketonuria treated exclusively by diet. METHODOLOGY In this cross-sectional study anthropometric measurements, serum phenylalanine levels, and 10 metabolites associated with lipid and carbohydrate metabolism were analyzed in 101 adolescents aged 10-20 years. Adolescents were categorized into overweight/obesity and eutrophic/low body mass index groups. These patients were compared using Student's t-test, Pearson's chi-square test, Wald's chi-square test for multivariate analysis. Further, to verify whether the prevalence of overweight/obesity found in the study population was similar to that in the general population, the authors compared the nutritional status of 46 patients aged 13-17 years with that of healthy students of the same age from the National School Health Survey using the chi-square test for adherence. The significance threshold was p < 0.5. RESULTS The prevalence of overweight/obesity in adolescents was 27.7%. There was no difference in prevalence between sexes. Older age was a protective factor and Increased Homeostasis Model Assessment Insulin Resistance index and high phenylalanine and low-density lipoprotein cholesterol levels were predictive factors for overweight/obesity. The equality hypothesis was not rejected in the comparison of nutritional states of 46 patients aged 13-17 years and healthy students of the same age. CONCLUSION The prevalence of overweight/obesity in phenylketonuria adolescents was similar to what is found in healthy adolescents.
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Affiliation(s)
- Adriana Márcia Silveira
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Departamento de Pediatria, Belo Horizonte, MG, Brazil; Programa de Pós-Graduação em Ciências da Saúde - Saúde da Criança e do Adolescente, Ciências da Saúde, Belo Horizonte, MG, Brazil; Faculdade de Minas (FAMINAS-BH), Departamento de Nutrição, Belo Horizonte, MG, Brazil.
| | - Poliane Lopes Lima
- Faculdade de Minas (FAMINAS-BH), Departamento de Nutrição, Belo Horizonte, MG, Brazil
| | - Michelle Rosa Andrade Alves
- Pontifícia Universidade Católica de Minas Gerais (PUC-Minas), Departamento de Nutrição, Belo Horizonte, MG, Brazil
| | - Rosângelis Del Lama Soares
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Núcleo de Ações e Pesquisa em Apoio Diagnóstico (NUPAD), Belo Horizonte, MG, Brazil
| | - Viviane de Cássia Kanufre
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Núcleo de Ações e Pesquisa em Apoio Diagnóstico (NUPAD), Belo Horizonte, MG, Brazil; Universidade Federal de Minas Gerais (UFMG), EBSERH, Hospital das Clínicas, Serviço de Nutrição e Dietética, Belo Horizonte, MG, Brazil
| | - Valéria de Melo Rodrigues
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Departamento de Pediatria, Belo Horizonte, MG, Brazil
| | - Ana Lúcia Pimenta Starling
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Departamento de Pediatria, Belo Horizonte, MG, Brazil
| | - Rocksane de Carvalho Norton
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Núcleo de Ações e Pesquisa em Apoio Diagnóstico (NUPAD), Departamento de Pediatria, Belo Horizonte, MG, Brazil
| | - Marcos José Burle de Aguiar
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Departamento de Pediatria, Belo Horizonte, MG, Brazil
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Montanari C, Parolisi S, Borghi E, Putignani L, Bassanini G, Zuvadelli J, Bonfanti C, Tummolo A, Dionisi Vici C, Biasucci G, Burlina A, Carbone MT, Verduci E. Dysbiosis, Host Metabolism, and Non-communicable Diseases: Trialogue in the Inborn Errors of Metabolism. Front Physiol 2021; 12:716520. [PMID: 34588993 PMCID: PMC8475650 DOI: 10.3389/fphys.2021.716520] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/02/2021] [Indexed: 12/12/2022] Open
Abstract
Inborn errors of metabolism (IEMs) represent a complex system model, in need of a shift of approach exploring the main factors mediating the regulation of the system, internal or external and overcoming the traditional concept of biochemical and genetic defects. In this context, among the established factors influencing the metabolic flux, i.e., diet, lifestyle, antibiotics, xenobiotics, infectious agents, also the individual gut microbiota should be considered. A healthy gut microbiota contributes in maintaining human health by providing unique metabolic functions to the human host. Many patients with IEMs are on special diets, the main treatment for these diseases. Hence, IEMs represent a good model to evaluate how specific dietary patterns, in terms of macronutrients composition and quality of nutrients, can be related to a characteristic microbiota associated with a specific clinical phenotype (“enterophenotype”). In the present review, we aim at reporting the possible links existing between dysbiosis, a condition reported in IEMs patients, and a pro-inflammatory status, through an altered “gut-liver” cross-talk network and a major oxidative stress, with a repercussion on the health status of the patient, increasing the risk of non-communicable diseases (NCDs). On this basis, more attention should be paid to the nutritional status assessment and the clinical and biochemical signs of possible onset of comorbidities, with the goal of improving the long-term wellbeing in IEMs. A balanced intestinal ecosystem has been shown to positively contribute to patient health and its perturbation may influence the clinical spectrum of individuals with IEMs. For this, reaching eubiosis through the improvement of the quality of dietary products and mixtures, the use of pre-, pro- and postbiotics, could represent both a preventive and therapeutic strategy in these complex diseases.
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Affiliation(s)
- Chiara Montanari
- Department of Pediatrics, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Sara Parolisi
- UOS Metabolic and Rare Diseases, AORN Santobono, Naples, Italy
| | - Elisa Borghi
- Department of Health Science, University of Milan, Milan, Italy
| | - Lorenza Putignani
- Department of Diagnostic and Laboratory Medicine, Unit of Microbiology and Diagnostic Immunology, Unit of Microbiomics and Multimodal Laboratory Medicine Research Area, Unit of Human Microbiome, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Juri Zuvadelli
- Clinical Department of Pediatrics, ASST Santi Paolo e Carlo, San Paolo Hospital, University of Milan, Milan, Italy
| | - Cristina Bonfanti
- Rare Metabolic Disease Unit, Pediatric Department, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Albina Tummolo
- Metabolic Diseases and Clinical Genetics Unit, Children's Hospital Giovanni XXIII, Bari, Italy
| | | | - Giacomo Biasucci
- Department of Paediatrics & Neonatology, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Alberto Burlina
- Division of Inborn Metabolic Diseases, Department of Diagnostic Services, University Hospital of Padua, Padua, Italy
| | | | - Elvira Verduci
- Department of Pediatrics, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy.,Department of Health Science, University of Milan, Milan, Italy
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Casein Glycomacropeptide: An Alternative Protein Substitute in Tyrosinemia Type I. Nutrients 2021; 13:nu13093224. [PMID: 34579102 PMCID: PMC8467066 DOI: 10.3390/nu13093224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/08/2021] [Accepted: 09/14/2021] [Indexed: 12/25/2022] Open
Abstract
Tyrosinemia type I (HTI) is treated with nitisinone, a tyrosine (Tyr) and phenylalanine (Phe)-restricted diet, and supplemented with a Tyr/Phe-free protein substitute (PS). Casein glycomacropeptide (CGMP), a bioactive peptide, is an alternative protein source to traditional amino acids (L-AA). CGMP contains residual Tyr and Phe and requires supplementation with tryptophan, histidine, methionine, leucine, cysteine and arginine. Aims: a 2-part study assessed: (1) the tolerance and acceptability of a low Tyr/Phe CGMP-based PS over 28 days, and (2) its long-term impact on metabolic control and growth over 12 months. Methods: 11 children with HTI were recruited and given a low Tyr/Phe CGMP to supply all or part of their PS intake. At enrolment, weeks 1 and 4, caregivers completed a questionnaire on gastrointestinal symptoms, acceptability and ease of PS use. In study part 1, blood Tyr and Phe were assessed weekly; in part 2, weekly to fortnightly. In parts 1 and 2, weight and height were assessed at the study start and end. Results: Nine of eleven children (82%), median age 15 years (range 8.6–17.7), took low Tyr/Phe CGMP PS over 28 days; it was continued for 12 months in n = 5 children. It was well accepted by 67% (n = 6/9), tolerated by 100% (n = 9/9) and improved gastrointestinal symptoms in 2 children. The median daily dose of protein equivalent from protein substitute was 60 g/day (range 45–60 g) with a median of 20 g/day (range 15 to 30 g) from natural protein. In part 2 (n = 5), a trend for improved blood Tyr was observed: 12 months pre-study, median Tyr was 490 μmol/L (range 200–600) and Phe 50 μmol/L (range 30–100); in the 12 months taking low Tyr/Phe CGMP PS, median Tyr was 430 μmol/L (range 270–940) and Phe 40 μmol/L (range 20–70). Normal height, weight and BMI z scores were maintained over 12 months. Conclusions: In HTI children, CGMP was well tolerated, with no deterioration in metabolic control or growth when studied over 12 months. The efficacy of CGMP in HTI needs further investigation to evaluate the longer-term impact on blood Phe concentrations and its potential influence on gut microflora
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Growth and Body Composition in PKU Children-A Three-Year Prospective Study Comparing the Effects of L-Amino Acid to Glycomacropeptide Protein Substitutes. Nutrients 2021; 13:nu13041323. [PMID: 33923714 PMCID: PMC8073059 DOI: 10.3390/nu13041323] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/10/2021] [Indexed: 01/15/2023] Open
Abstract
Protein quality and quantity are important factors in determining lean body (muscle) mass (LBM). In phenylketonuria (PKU), protein substitutes provide most of the nitrogen, either as amino acids (AA) or glycomacropeptide with supplementary amino acids (CGMP-AA). Body composition and growth are important indicators of long-term health. In a 3-year prospective study comparing the impact of AA and CGMP-AA on body composition and growth in PKU, 48 children were recruited. N = 19 (median age 11.1 years, range 5–15 years) took AA only, n = 16 (median age 7.3 years, range 5–15 years) took a combination of CGMP-AA and AA, (CGMP50) and 13 children (median age 9.2 years, range 5–16 years) took CGMP-AA only (CGMP100). A dual energy X-ray absorptiometry (DXA) scan at enrolment and 36 months measured LBM, % body fat (%BF) and fat mass (FM). Height was measured at enrolment, 12, 24 and 36 months. No correlation or statistically significant differences (after adjusting for age, gender, puberty and phenylalanine blood concentrations) were found between the three groups for LBM, %BF, FM and height. The change in height z scores, (AA 0, CGMP50 +0.4 and CGMP100 +0.7) showed a trend that children in the CGMP100 group were taller, had improved LBM with decreased FM and % BF but this was not statistically significant. There appeared to be no advantage of CGMP-AA compared to AA on body composition after 3-years of follow-up. Although statistically significant differences were not reached, a trend towards improved body composition was observed with CGMP-AA when it provided the entire protein substitute requirement.
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Weng HL, Yang FJ, Chen PR, Hwu WL, Lee NC, Chien YH. Dietary intake and nutritional status of patients with phenylketonuria in Taiwan. Sci Rep 2020; 10:14537. [PMID: 32883979 PMCID: PMC7471922 DOI: 10.1038/s41598-020-71361-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 08/10/2020] [Indexed: 01/10/2023] Open
Abstract
Phenylalanine hydroxylase (PAH) deficiency leads to phenylalanine accumulation and results in phenylketonuria (PKU). Phenylketonuria can contribute to severe inability such as mental impairment. Early diagnosis and dietary intervention can have beneficial effects on maintaining normal neural and cognitive function in patients with PKU. However, a long-term low phenylalanine diet may put children at risk of malnutrition. A food supplement was therefore used for children with PKU under dietician supervision according to dietary reference intakes (DRIs). In this cross-sectional study, we enrolled patients with PKU and age-matched controls to compare their anthropometry data [weight, height, body mass index (BMI), and body composition using bioelectrical impedance analysis (BIA)], and correlated it with their dietary intake based on 24-h dietary recall. For continuous parameters, the data were expressed as median ± standard deviation (SD), and the Mann–Whitney U test was used to test the difference among the groups. Correlation by natural proteins, body fat, and fat-free mass were evaluated using the Pearson correlation coefficient. Twenty-two participants diagnosed with PKU (ages 8–27 years; mean 15.23 ± 5.23) and a control group of 22 non-PKU participants (ages 8–39 years; mean 19.73 ± 10.6) were recruited for this study. Between the two groups of participants, no significant difference was found in height, weight, BMI, muscle mass, or fat mass. The percentage of natural protein has no effect on body composition. We found a significant positive correlation between the total protein intake percentage of DRIs and muscle mass (r = 0.491, p = 0.020) and a significant negative correlation in the total protein intake percentage of DRIs and fat mass (r = -0.475, p = 0.025) in participants with PKU. There were no significant differences in body composition and nutrition intake between patients with PKU (under metabolic control) and healthy subjects. Thus, giving proper nutrition treatment may have beneficial effects on body growth and nutrition status in patients with PKU in Taiwan.
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Affiliation(s)
- Hui-Ling Weng
- Department of Dietetics, National Taiwan University Hospital, Taipei, Taiwan.,School of Nursing, College of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Feng-Jung Yang
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan. .,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan. .,Rare Diseases Center and Department of Internal Medicine, National Taiwan University Hospital Yun Lin Branch, Douliu, Taiwan.
| | - Pey-Rong Chen
- Department of Dietetics, National Taiwan University Hospital, Taipei, Taiwan
| | - Wuh-Liang Hwu
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan.,Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ni-Chung Lee
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan.,Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Yin-Hsiu Chien
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan. .,Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan.
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13
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Bik-Multanowski M, Madetko-Talowska A, Betka I, Swieczka E, Didycz B, Orchel-Szastak K, Bik-Multanowska K, Starostecka E, Jaglowska J, Mozrzymas R, Zolkowska J, Chyz K, Korycinska-Chaaban D. Carriership of the rs113883650/rs2287120 haplotype of the SLC7A5 ( LAT1) gene increases the risk of obesity in infants with phenylketonuria. Mol Genet Metab Rep 2020; 25:100640. [PMID: 32874918 PMCID: PMC7451426 DOI: 10.1016/j.ymgmr.2020.100640] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 01/01/2023] Open
Abstract
Purpose Phenylketonuria (PKU) can be effectively treated with the use of a low-phenylalanine diet. However, some patients become overweight despite proper dietary treatment. We hypothesized that this phenomenon could be explained by the presence of specific variants within the genes involved in phenylalanine transport or in the phenylalanine transamination/oxygenation pathway. Methods We selected a clinically homogenous group of 100 infants with PKU and assessed their growth patterns in the context of dietary phenylalanine tolerance. Next, within the sample, we performed exome sequencing and assessed a potential relationship between the observed phenotypical variability and the presence of structural variants in a priori selected genes of interest. Results We detected a highly significant association between overweight and carriership of the rs113883650/rs2287120 haplotype of the SLC7A5 (LAT1) gene, which encodes the main transmembrane transporter of large neutral amino acids and of thyroid hormones. Conclusions Our findings suggest a pharmacogenetic effect of the relatively common rs113883650/rs2287120 haplotype of the SLC7A5 gene. This can have practical implications for patients with PKU, since treatment protocols need to be reassessed to better prevent overweight in the carriers of the above variant.
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Affiliation(s)
| | - Anna Madetko-Talowska
- Department of Medical Genetics, Jagiellonian University Medical College, Krakow, Poland
| | - Iwona Betka
- Department of Medical Genetics, Jagiellonian University Medical College, Krakow, Poland
| | - Elzbieta Swieczka
- Department of Medical Genetics, Jagiellonian University Medical College, Krakow, Poland
| | - Bozena Didycz
- Department of Medical Genetics, Jagiellonian University Medical College, Krakow, Poland
| | | | - Kinga Bik-Multanowska
- Department of Medical Genetics, Jagiellonian University Medical College, Krakow, Poland
| | - Ewa Starostecka
- Department of Endocrinology and Metabolic Diseases, Polish Mother's Health Memorial Institute, Lodz, Poland
| | - Joanna Jaglowska
- Department Pediatrics, Hematology and Oncology, Medical University, Gdansk, Poland
| | | | - Joanna Zolkowska
- Department of Inborn Errors of Metabolism and Paediatrics, Institute of Mother and Child, Warsaw, Poland
| | - Katarzyna Chyz
- Department of Inborn Errors of Metabolism and Paediatrics, Institute of Mother and Child, Warsaw, Poland
| | - Dorota Korycinska-Chaaban
- Department of Inborn Errors of Metabolism and Paediatrics, Institute of Mother and Child, Warsaw, Poland
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14
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Study of the Potential of the Capsule Shell Based on Natural Polysaccharides in Targeted Delivery of the L-Phenylalanine Ammonia-Lyase Enzyme Preparation. Pharmaceuticals (Basel) 2020; 13:ph13040063. [PMID: 32283743 PMCID: PMC7243110 DOI: 10.3390/ph13040063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/03/2020] [Accepted: 04/07/2020] [Indexed: 12/14/2022] Open
Abstract
The treatment of classical phenylketonuria is currently represented by many new methods of disease management. A promising method is the use of the enzyme L-phenylalanine ammonia-lyase (PAL) in various forms. The widespread use of enzyme preparations in therapy is limited by a lack of understanding of the mechanisms and systems of the targeted transport of PAL into certain organs and tissues as a result of the incorporation of a drug into the carrier. To ensure the stability of enzymes during the delivery process, encapsulation is preferable, which, as a rule, ensures the preservation of the qualitative characteristics of the enzymes orally applied to the environmental effects of the gastrointestinal tract (acidity, temperature, oxidation, etc.). Capsule preparations showed sufficient stability in the model gastric fluids and sustained release of the drug in the simulated intestinal fluid. Currently, there is a wide range of polymers used for encapsulation. The use of natural sources in the production technology of capsule systems improves bioavailability, controls the release, and prolongs the half-life of active substances. The advantage of this method is that the used enzyme is completely protected by the cell membranes of the capsules, which preserve its stability in the aggressive environment of the gastrointestinal tract. Capsules were obtained on the basis of compositions of hydrocolloids of plant origin. The potential of the developed capsules for targeted delivery of the enzyme preparation was studied. The degradation of the encapsulated form of the PAL enzyme preparation was studied in vitro in model bio-relevant media simulating the gastric and intestinal environment. The dynamics of the breakdown of the capsule shell allow us to expect that the release of L-phenylalanine ammonia-lyase from capsules based on plant hydrocolloids will occur no earlier than reaching the upper intestines, where the interaction with the protein components of the consumed food products to neutralize phenylalanine should occur.
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Sena BDS, Andrade MISD, Silva APFD, Dourado KF, Silva ALF. OVERWEIGHT AND ASSOCIATED FACTORS IN CHILDREN AND ADOLESCENTS WITH PHENYLKETONURIA: A SYSTEMATIC REVIEW. ACTA ACUST UNITED AC 2020; 38:e2018201. [PMID: 32159642 PMCID: PMC7063595 DOI: 10.1590/1984-0462/2020/38/2018201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/25/2018] [Indexed: 02/08/2023]
Abstract
Objective: To verify the occurrence of overweight in children and adolescents with
phenylketonuria and to identify possible causal factors. Data sources: A systematic review was performed in the SciELO, PubMed and VHL databases
using the descriptors “Phenylketonurias”, “Overweight”, “Child” and
“Adolescent”. Original articles conducted with children and adolescents,
published between 2008 and 2018 in Portuguese, English or Spanish languages
were included. Data synthesis: A total of 16 articles were identified and, after screening procedures, 6
studies were selected for the review. Overweight in children and adolescents
with phenylketonuria was a frequent occurence in the studies included in
this review, ranging from 7.8 to 32.6%. The female sex was the most affected
by the nutritional disorder. Furthermore, a high caloric intake combined
with a lack of stimuli to practice physical activities were main factors
associated with the excessive weight in the population of interest. Conclusions: Excess weight can be considered a common outcome in children and adolescents
with phenylketonuria. It is mainly caused by inadequate food consumption and
sedentary lifestyle. The importance of early identification of nutritional
disturbances in children and adolescents with phenylketonuria should be
emphasized, in order to prevent associated chronic diseases and to promote
health by encouraging continued healthy eating habits and the regular
practice of physical exercises.
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16
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Ilgaz F, Pinto A, Gökmen-Özel H, Rocha JC, van Dam E, Ahring K, Bélanger-Quintana A, Dokoupil K, Karabulut E, MacDonald A. Long-Term Growth in Phenylketonuria: A Systematic Review and Meta-Analysis. Nutrients 2019; 11:E2070. [PMID: 31484352 PMCID: PMC6769966 DOI: 10.3390/nu11092070] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 08/19/2019] [Accepted: 08/20/2019] [Indexed: 12/25/2022] Open
Abstract
There is an ongoing debate regarding the impact of phenylketonuria (PKU) and its treatment on growth. To date, evidence from studies is inconsistent, and data on the whole developmental period is limited. The primary aim of this systematic review was to investigate the effects of a phenylalanine (Phe)-restricted diet on long-term growth in patients with PKU. Four electronic databases were searched for articles published until September 2018. A total of 887 results were found, but only 13 articles met eligibility criteria. Only three studies had an adequate methodology for meta-analysis. Although the results indicate normal growth at birth and during infancy, children with PKU were significantly shorter and had lower weight for age than reference populations during the first four years of life. Impaired linear growth was observed until the end of adolescence in PKU. In contrast, growth impairment was not reported in patients with mild hyperphenylalaninemia, not requiring dietary restriction. Current evidence indicates that even with advances in dietary treatments, "optimal" growth outcomes are not attained in PKU. The majority of studies include children born before 1990s, so further research is needed to show the effects of recent dietary practices on growth in PKU.
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Affiliation(s)
- Fatma Ilgaz
- Faculty of Health Sciences, Department of Nutrition and Dietetics, Hacettepe University, 06080 Ankara, Turkey.
| | - Alex Pinto
- Department of Dietetics, Birmingham Children's Hospital, Birmingham B4 6NH, UK
| | - Hülya Gökmen-Özel
- Faculty of Health Sciences, Department of Nutrition and Dietetics, Hacettepe University, 06080 Ankara, Turkey
| | - Julio César Rocha
- Center for Health Technology and Services Research (CINTESIS), 4200-450 Porto, Portugal
- Centro de Genética Médica Dr Jacinto de Magalhães, Centro Hospitalar Universitário do Porto, 4099-028 Porto, Portugal
- Centro de Referência na área das Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto-CHP EPE, 4099-001 Porto, Portugal
| | - Esther van Dam
- Beatrix Children's Hospital, University of Groningen, University Medical Center, 9700 RB Groningen, The Netherlands
| | - Kirsten Ahring
- Department of PKU, Kennedy Centre, 2600 Glostrup, Denmark
| | | | - Katharina Dokoupil
- Department of Metabolism and Nutrition, Dr. von Hauner Children's Hospital, University of Munich, 80337 Munich, Germany
| | - Erdem Karabulut
- Faculty of Medicine, Department of Biostatistics, Hacettepe University, 06080 Ankara, Turkey
| | - Anita MacDonald
- Department of Dietetics, Birmingham Children's Hospital, Birmingham B4 6NH, UK
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17
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Evans S, Daly A, Wildgoose J, Cochrane B, Chahal S, Ashmore C, Loveridge N, MacDonald A. Growth, Protein and Energy Intake in Children with PKU Taking a Weaning Protein Substitute in the First Two Years of Life: A Case-Control Study. Nutrients 2019; 11:nu11030552. [PMID: 30841589 PMCID: PMC6471165 DOI: 10.3390/nu11030552] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/20/2019] [Accepted: 02/27/2019] [Indexed: 01/10/2023] Open
Abstract
Growth issues have been observed in young children with phenylketonuria (PKU), but studies are conflicting. In infancy, there is an increasing trend to introduce a second-stage semi-solid weaning protein substitute (WPS) but there is concern that this may not meet energy requirements. In this longitudinal, prospective study, 20 children with PKU transitioning to a WPS, and 20 non-PKU controls were observed monthly from weaning commencement (4–6 months) to 12 m and at 15, 18 and 24 months of age for: weight, length, head circumference, body mass index (BMI), energy and macronutrient intake. Growth parameters were within normal range at all ages in both groups with no significant difference in mean z-scores except for accelerated length in the PKU group. No child with PKU had z-scores < −2 for any growth parameter at age 2 years. Total protein and energy intake in both groups were similar at all ages; however, from 12–24 months in the PKU group, the percentage of energy intake from carbohydrate increased (60%) but from fat decreased (25%) and inversely for controls (48% and 36%). In PKU, use of low volume WPS meets Phe-free protein requirements, facilitates transition to solid foods and supports normal growth. Further longitudinal study of growth, body composition and energy/nutrient intakes in early childhood are required to identify any changing trends.
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Affiliation(s)
- Sharon Evans
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham B4 6NH, UK.
| | - Anne Daly
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham B4 6NH, UK.
| | - Jo Wildgoose
- Bradford Teaching Hospitals NHS Trust, Bradford BD9 6RJ, UK.
| | | | - Satnam Chahal
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham B4 6NH, UK.
| | - Catherine Ashmore
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham B4 6NH, UK.
| | - Nik Loveridge
- Danone Early Life Nutrition, Macquarie Park, New South Wales, Australia.
| | - Anita MacDonald
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham B4 6NH, UK.
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18
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Optimising amino acid absorption: essential to improve nitrogen balance and metabolic control in phenylketonuria. Nutr Res Rev 2018; 32:70-78. [PMID: 30284526 PMCID: PMC6536823 DOI: 10.1017/s0954422418000173] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
It has been nearly 70 years since the discovery that strict adherence to a diet low in phenylalanine prevents severe neurological sequelae in patients with phenylalanine hydroxylase deficiency (phenylketonuria; PKU). Today, dietary treatment with restricted phenylalanine intake supplemented with non-phenylalanine amino acids to support growth and maintain a healthy body composition remains the mainstay of therapy. However, a better understanding is needed of the factors that influence N balance in the context of amino acid supplementation. The aim of the present paper is to summarise considerations for improving N balance in patients with PKU, with a focus on gaining greater understanding of amino acid absorption, disposition and utilisation. In addition, the impact of phenylalanine-free amino acids on 24 h blood phenylalanine/tyrosine circadian rhythm is evaluated. We compare the effects of administering intact protein v. free amino acid on protein metabolism and discuss the possibility of improving outcomes by administering amino acid mixtures so that their absorption profile mimics that of intact protein. Protein substitutes with the ability to delay absorption of phenylalanine and tyrosine, mimicking physiological absorption kinetics, are expected to improve the rate of assimilation into protein and minimise fluctuations in quantitative plasma amino acid levels. They may also help maintain normal glycaemia and satiety sensation. This is likely to play an important role in improving the management of patients with PKU.
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19
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Couce ML, Sánchez-Pintos P, Vitoria I, De Castro MJ, Aldámiz-Echevarría L, Correcher P, Fernández-Marmiesse A, Roca I, Hermida A, Martínez-Olmos M, Leis R. Carbohydrate status in patients with phenylketonuria. Orphanet J Rare Dis 2018; 13:103. [PMID: 29945661 PMCID: PMC6020344 DOI: 10.1186/s13023-018-0847-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 06/20/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND In patients with phenylketonuria (PKU), a low-phenylalanine (Phe) diet supplemented with low-protein foods and a Phe-free amino acid mixture favors a dietary intake rich in carbohydrates, but little is known about how these molecules are metabolized in this setting. The objective of the present study was to analyze carbohydrate metabolism in patients with hyperphenylalaninemia. METHODS We conducted a multicenter cross-sectional study to investigate biochemical markers of basal and postprandial carbohydrate metabolism in PKU patients according to age, Phe tolerance, waist circumference and body mass index (BMI), diet, tetrahydrobiopterin (BH4) supplementation, and adherence to treatment. Basal biomarkers and anthropometric parameters were also evaluated in patients with mild hyperphenylalaninemia (MHPA) and in healthy controls. RESULTS A total of 83 patients aged 4-52 years were studied; 68.7% had PKU and 31.3% had MHPA. 68 healthy controls of similar sex and age were also evaluated Metabolic control was adequate in 71.9% of PKU patients. Fasting glucose levels (mean 80.77 ± 8.06 mg/dL) were high in just one patient, but fasting insulin levels, with a mean of 12.74 ± 8.4 mIU/L, were altered in 15 PKU patients (26.3%) and markedly higher than in patients with MPHA (p = 0.035). Fasting insulin levels and Homeostasis Model Assessment Insulin Resistance (HOMA-IR) were significantly higher than in healthy controls and correlated with body mass index, waist circumference, age, and also showed statistically significant differences according to diagnosis and Phe tolerance (p < 0.05). Patients under BH4 therapy had lower insulin levels and HOMA-IR. A higher mean carbohydrate intake from AA mixtures was observed in classic PKU patients. The caloric intake in the form of carbohydrates was also higher in PKU than MHPA patients (p = 0.038) and it was correlated with basal insulin (rho = 0.468, p = 0.006), HOMA-IR (rho = 0.423, p = 0.02), BMI (rho 0.533, p = 0.002), and waist circumference (rho 0.584, p = 0.0007). CONCLUSIONS This study shows that PKU patients are at risk of carbohydrate intolerance and insulin resistance, more evident in adults and overweight patients, probably related to their higher caloric intake in form carbohydrate content. A higher dependency of AA mixtures was demonstrated in PKU patients.
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Affiliation(s)
- María L. Couce
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, S. Neonatology, Department of Pediatrics, Hospital Clínico Universitario de Santiago de Compostela, CIBERER, Health Research Institute of Santiago de Compostela (IDIS), A Choupana, s/n, 15706 Santiago de Compostela, A Coruña, Spain
| | - Paula Sánchez-Pintos
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, S. Neonatology, Department of Pediatrics, Hospital Clínico Universitario de Santiago de Compostela, CIBERER, Health Research Institute of Santiago de Compostela (IDIS), A Choupana, s/n, 15706 Santiago de Compostela, A Coruña, Spain
| | - Isidro Vitoria
- Unit of Metabolopathies, Hospital Universitario la Fe, Bulevar sur s/n, 46021 Valencia, Spain
| | - María-José De Castro
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, S. Neonatology, Department of Pediatrics, Hospital Clínico Universitario de Santiago de Compostela, CIBERER, Health Research Institute of Santiago de Compostela (IDIS), A Choupana, s/n, 15706 Santiago de Compostela, A Coruña, Spain
| | - Luís Aldámiz-Echevarría
- Unit of Metabolism, Department of Pediatrics, Hospital de Cruces. Group of Metabolism, Biocruces Health Research Institute, CIBERER, Plaza de Cruces s/n, 48903 Barakaldo, Vizcaya Spain
| | - Patricia Correcher
- Unit of Metabolopathies, Hospital Universitario la Fe, Bulevar sur s/n, 46021 Valencia, Spain
| | - Ana Fernández-Marmiesse
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, S. Neonatology, Department of Pediatrics, Hospital Clínico Universitario de Santiago de Compostela, CIBERER, Health Research Institute of Santiago de Compostela (IDIS), A Choupana, s/n, 15706 Santiago de Compostela, A Coruña, Spain
| | - Iria Roca
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, S. Neonatology, Department of Pediatrics, Hospital Clínico Universitario de Santiago de Compostela, CIBERER, Health Research Institute of Santiago de Compostela (IDIS), A Choupana, s/n, 15706 Santiago de Compostela, A Coruña, Spain
| | - Alvaro Hermida
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, S. Neonatology, Department of Pediatrics, Hospital Clínico Universitario de Santiago de Compostela, CIBERER, Health Research Institute of Santiago de Compostela (IDIS), A Choupana, s/n, 15706 Santiago de Compostela, A Coruña, Spain
| | - Miguel Martínez-Olmos
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, S. Neonatology, Department of Pediatrics, Hospital Clínico Universitario de Santiago de Compostela, CIBERER, Health Research Institute of Santiago de Compostela (IDIS), A Choupana, s/n, 15706 Santiago de Compostela, A Coruña, Spain
| | - Rosaura Leis
- Unit of Gastroenterology and Nutrition, Department of Pediatrics, Hospital Clinico Universitario de Santiago, IDIS, Travesía da Choupana s/n,15706 Santiago de Compostela, A Coruña, Spain
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Handoom B, Megdad E, Al-Qasabi D, Al Mesned M, Hawary R, Al-Nufiee S, Al-Hassnan Z, Alsayed MD, Eldali A. The effects of low protein products availability on growth parameters and metabolic control in selected amino acid metabolism disorders patients. Int J Pediatr Adolesc Med 2018; 5:60-68. [PMID: 30805535 PMCID: PMC6363253 DOI: 10.1016/j.ijpam.2018.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/19/2018] [Accepted: 04/22/2018] [Indexed: 10/25/2022]
Abstract
BACKGROUND In Saudi Arabia, a diet for life policy has been adopted in the management of amino acid metabolism disorders for years. However, the specially designed low protein products/medical foods - which are one of the important treatment tools - were not available up until several years ago in Saudi Arabia (SA). Our aim was to measure the compliance and quality of life in patients affected with these disorders followed in the metabolic nutrition clinic at King Faisal Specialist Hospital & Research Centre (KFSH&RC), Riyadh, SA. METHODOLOGY We used a non-randomized retrospective/prospective study which utilized the growth parameters, biochemical data of patients plus questionnaires collected from patients and their family/caregivers. A total of n = 182 patients affected with selected amino acid metabolism disorders were enrolled. Some were excluded n = 84 for various reasons. Sample analyzed were: Phenylketonuria (PKU) (44), Maple Syrup Urine Disease (MSUD) (30), Tyrosinemia (TYR) (17) and Homocystinuria (HCU) (7). Tandem Mass Spectrometry (TMS) used to quantitate plasma amino acid concentrations. Data was obtained using (COMPLE) Microsoft-Access which was designed by the metabolic nutrition clinic at KFSH&RC-Riyadh. Student's paired t-test was used to investigate relationship between variables. RESULTS The main findings were the improvement of selected amino acid levels pre and post the usage of medical foods. In PKU patients, the TMS Phenylalanine (PHE) levels post usage was significantly decreased (P value < .0001). This was also the case in MSUD patients with significant decrease in Leucine & Isoleucine levels (P value .0008) but not in Valine levels (P value .1148) as 36.7% of them received Valine supplements while enrolled in the study. CONCLUSION Low protein products availability was successful in improving outcomes for selected amino acid metabolic disorders. However, due to compliance issues and impracticality of the diet, the results were not significant in all enrolled patients.
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Affiliation(s)
- Bedour Handoom
- Nutrition Department, King Faisal Specialist Hospital & Research Centre (KFSH&RC), Riyadh, SA, USA
| | - Eman Megdad
- Nutrition Department, King Faisal Specialist Hospital & Research Centre (KFSH&RC), Riyadh, SA, USA
| | - Dana Al-Qasabi
- Nutrition Department, King Faisal Specialist Hospital & Research Centre (KFSH&RC), Riyadh, SA, USA
| | - Munirah Al Mesned
- Nutrition Department, King Faisal Specialist Hospital & Research Centre (KFSH&RC), Riyadh, SA, USA
| | - Reem Hawary
- Nutrition Department, King Faisal Specialist Hospital & Research Centre (KFSH&RC), Riyadh, SA, USA
| | - Samir Al-Nufiee
- Medical Genetic Department, Children Hospital Taif, Taif, SA, USA
| | - Zuhair Al-Hassnan
- Medical Genetic Deparmant, King Faisal Specialist Hospital & Research Centre (KFSH&RC), Riyadh, SA, USA
| | - Moeenaldeen Dia Alsayed
- Medical Genetic Deparmant, King Faisal Specialist Hospital & Research Centre (KFSH&RC), Riyadh, SA, USA
| | - Abdelmoneim Eldali
- Biostatistics Epidemiology & Scientific Computing Department, King Faisal Specialist Hospital & Research Centre (KFSH&RC), Riyadh, SA, USA
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21
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Tanaka NYY, Turcato MF, Nicoletti CF, Nonino CB, Martins LD, Iannetta O, Guerreiro CT, Santos GG, Marchini JS. Effects of Short-Term Calcium Supplementation in Children and Adolescents with Phenylketonuria. J Clin Densitom 2018; 21:48-53. [PMID: 28302355 DOI: 10.1016/j.jocd.2017.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 02/03/2017] [Accepted: 02/13/2017] [Indexed: 10/20/2022]
Abstract
Reduction of bone mineral density and the risk of osteopenia have been reported to occur in phenylketonuria (PKU) patients. This study aimed to evaluate the short-term effects of calcium supplementation in phenylketonuric children and adolescents. The study included 18 patients with PKU aged 5-18 yr (61% male) under clinical and nutritional treatment. Evaluation of food intake, anthropometry, and biochemical and phalangeal quantitative ultrasound were performed before (phase 1) and after (phase 2) calcium supplementation (1000 mg/d) for 34 d. Statistical analysis was performed using t test for paired samples, Wilcoxon's test, and McNemar's test (p <0.05). There was an inadequate intake of phosphorus and vitamin D, the same occurring with serum concentrations of these nutrients. About 50% of the patients had an accumulation of adipose tissue measures, with a negative correlation between Z-score, body mass index, and phalangeal quantitative ultrasound (amplitude-dependent speed of sound [AD-SoS]). There was a significant difference in urinary phosphorus excretion with higher values before supplementation. Comparison of the two phases revealed significantly higher AD-SoS values after the supplementation (p = 0.017). The reduction in phosphorus excretion associated with increased AD-SoS between the two phases suggested increased bone formation, and showed no negative effects in relation to short-term calcium supplementation in children and in adolescents with PKU.
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Affiliation(s)
- Nancy Y Y Tanaka
- Faculty of Medicine of Ribeirao Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.
| | - Marlene F Turcato
- Faculty of Medicine of Ribeirao Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Carolina F Nicoletti
- Faculty of Medicine of Ribeirao Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Carla B Nonino
- Faculty of Medicine of Ribeirao Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Luciana D Martins
- Faculty of Medicine of Ribeirao Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Odilon Iannetta
- Faculty of Medicine of Ribeirao Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Carlos T Guerreiro
- Faculty of Medicine of Ribeirao Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Gisele G Santos
- Faculty of Medicine of Ribeirao Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Júlio S Marchini
- Faculty of Medicine of Ribeirao Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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22
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van Wegberg AMJ, MacDonald A, Ahring K, Bélanger-Quintana A, Blau N, Bosch AM, Burlina A, Campistol J, Feillet F, Giżewska M, Huijbregts SC, Kearney S, Leuzzi V, Maillot F, Muntau AC, van Rijn M, Trefz F, Walter JH, van Spronsen FJ. The complete European guidelines on phenylketonuria: diagnosis and treatment. Orphanet J Rare Dis 2017; 12:162. [PMID: 29025426 PMCID: PMC5639803 DOI: 10.1186/s13023-017-0685-2] [Citation(s) in RCA: 421] [Impact Index Per Article: 60.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 07/11/2017] [Indexed: 12/22/2022] Open
Abstract
Phenylketonuria (PKU) is an autosomal recessive inborn error of phenylalanine metabolism caused by deficiency in the enzyme phenylalanine hydroxylase that converts phenylalanine into tyrosine. If left untreated, PKU results in increased phenylalanine concentrations in blood and brain, which cause severe intellectual disability, epilepsy and behavioural problems. PKU management differs widely across Europe and therefore these guidelines have been developed aiming to optimize and standardize PKU care. Professionals from 10 different European countries developed the guidelines according to the AGREE (Appraisal of Guidelines for Research and Evaluation) method. Literature search, critical appraisal and evidence grading were conducted according to the SIGN (Scottish Intercollegiate Guidelines Network) method. The Delphi-method was used when there was no or little evidence available. External consultants reviewed the guidelines. Using these methods 70 statements were formulated based on the highest quality evidence available. The level of evidence of most recommendations is C or D. Although study designs and patient numbers are sub-optimal, many statements are convincing, important and relevant. In addition, knowledge gaps are identified which require further research in order to direct better care for the future.
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Affiliation(s)
- A. M. J. van Wegberg
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, PO BOX 30.001, 9700 RB Groningen, The Netherlands
| | - A. MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Birmingham, UK
| | - K. Ahring
- Department of PKU, Kennedy Centre, Glostrup, Denmark
| | - A. Bélanger-Quintana
- Metabolic Diseases Unit, Department of Paediatrics, Hospital Ramon y Cajal Madrid, Madrid, Spain
| | - N. Blau
- University Children’s Hospital, Dietmar-Hoppe Metabolic Centre, Heidelberg, Germany
- University Children’s Hospital Zürich, Zürich, Switzerland
| | - A. M. Bosch
- Department of Paediatrics, Division of Metabolic Disorders, Academic Medical Centre, University Hospital of Amsterdam, Amsterdam, The Netherlands
| | - A. Burlina
- Division of Inherited Metabolic Diseases, Department of Paediatrics, University Hospital of Padova, Padova, Italy
| | - J. Campistol
- Neuropaediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - F. Feillet
- Department of Paediatrics, Hôpital d’Enfants Brabois, CHU Nancy, Vandoeuvre les Nancy, France
| | - M. Giżewska
- Department of Paediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, Szczecin, Poland
| | - S. C. Huijbregts
- Department of Clinical Child and Adolescent Studies-Neurodevelopmental Disorders, Faculty of Social Sciences, Leiden University, Leiden, The Netherlands
| | - S. Kearney
- Clinical Psychology Department, Birmingham Children’s Hospital, Birmingham, UK
| | - V. Leuzzi
- Department of Paediatrics, Child Neurology and Psychiatry, Sapienza University of Rome, Via dei Sabelli 108, 00185 Rome, Italy
| | - F. Maillot
- CHRU de Tours, Université François Rabelais, INSERM U1069, Tours, France
| | - A. C. Muntau
- University Children’s Hospital, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - M. van Rijn
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, PO BOX 30.001, 9700 RB Groningen, The Netherlands
| | - F. Trefz
- Department of Paediatrics, University of Heidelberg, Heidelberg, Germany
| | - J. H. Walter
- Medicine, Manchester Academic Health Sciences Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - F. J. van Spronsen
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, PO BOX 30.001, 9700 RB Groningen, The Netherlands
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23
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Evans M, Truby H, Boneh A. The relationship between dietary intake, growth and body composition in Phenylketonuria. Mol Genet Metab 2017; 122:36-42. [PMID: 28739202 DOI: 10.1016/j.ymgme.2017.07.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 07/19/2017] [Accepted: 07/19/2017] [Indexed: 10/19/2022]
Abstract
AIM Phenylketonuria (PKU) is an inborn error of protein metabolism that results from perturbation in phenylalanine hydroxylase activity leading to elevated blood levels of phenylalanine (phe). We aimed to explore the relationships between dietary patterns (total-protein, natural-protein, amino-acid formula), and the ratio of protein to energy intake with growth and body composition. METHOD Longitudinal prospective data (1-6 measurements) of growth, dietary intake and body composition in patients treated with phe-restricted diet only (D-PKU; n=32), and tetrahydrobiopterin (BH4)±phe-restricted diet (BH4-PKU; n=5) were collected over a two-year period. Healthy siblings provided control data (n=21). RESULTS There were no significant differences in weight-, height-, BMI z-score or percent body fat mass (%fatmass) between the D-PKU, BH4-PKU and control groups or between the all-types of PKU combined and controls, which confirmed 'normal' growth in the PKU cohort. Total-protein intake in the all-types of PKU group met or exceeded WHO safe protein recommendations. There were no significant relationships between anthropometric and dietary variables. Significant negative correlations were found in body composition: %fatmass and total-protein intake (rs=-0.690, p≤0.001), natural-protein intake (rs=-0.534, p=0.001), and AAF intake (rs=-0.510, p=0.001). Age was significantly correlated with %fatmass (rs=0.493, p=0.002) A total-protein intake of 1.5-2.6g/kg/day and natural-protein intake >0.5g/kg/day were associated with improved body composition. An apparent safe P:E ratio of 3.0-4.5g protein/100kcal was strongly associated with appropriate growth outcomes. CONCLUSIONS Clinical decision-making needs to consider both the enhancement of natural-protein tolerance and the application of an apparent 'safe' protein to energy ratio to support optimal growth and body composition in PKU.
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Affiliation(s)
- Maureen Evans
- Department of Metabolic Medicine, The Royal Children's Hospital, Flemington Road, Parkville, Melbourne, Victoria 3052, Australia; Department of Nutrition and Food Services, Royal Children's Hospital, Flemington Road, Parkville, Melbourne, Victoria 3052, Australia; Be Active Sleep Eat (BASE) Facility, Department of Nutrition and Dietetics, Monash University, Faculty of Medicine, Nursing and Health Sciences, Level 1, 264 Ferntree Gully Road Notting Hill, Melbourne, Victoria 3168, Australia.
| | - Helen Truby
- Be Active Sleep Eat (BASE) Facility, Department of Nutrition and Dietetics, Monash University, Faculty of Medicine, Nursing and Health Sciences, Level 1, 264 Ferntree Gully Road Notting Hill, Melbourne, Victoria 3168, Australia.
| | - Avihu Boneh
- Department of Metabolic Medicine, The Royal Children's Hospital, Flemington Road, Parkville, Melbourne, Victoria 3052, Australia; Be Active Sleep Eat (BASE) Facility, Department of Nutrition and Dietetics, Monash University, Faculty of Medicine, Nursing and Health Sciences, Level 1, 264 Ferntree Gully Road Notting Hill, Melbourne, Victoria 3168, Australia; Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052, Australia.
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24
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Jani R, Coakley K, Douglas T, Singh R. Protein intake and physical activity are associated with body composition in individuals with phenylalanine hydroxylase deficiency. Mol Genet Metab 2017; 121:104-110. [PMID: 28465125 DOI: 10.1016/j.ymgme.2017.04.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 04/25/2017] [Accepted: 04/26/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Determine whether body composition as it relates to dietary protein in patients with phenylalanine hydroxylase (PAH) deficiency is associated with genotype, dietary factors, and lifestyle choices. METHODS We examined associations between protein intake (intact and medical foods: MF) and body composition in PAH-deficient patients along with, physical activity, and genotype. Protein intakes (total, intact, and MF) were analysed from three-day food records with Nutrition Data System for Research (NDSR) in 59 children and 27 adults (N=86, median age=16.0years). The severity of PAH deficiency was classified using the genotype assigned value method (AV sum). Physical activity was assessed using a study-developed question (light vs. intense activity). Body composition was measured by DXA, including android:gynoid ratio (A:G), fat-free mass index (FFMI), fat mass index (FMI), and FMI:FFMI ratio. RESULTS High intact protein intake was associated with high FFMI (rs=0.75, p=0.008) and low FMI:FFMI (rs=-0.59, p=0.04) in adults. Only in children, MF protein (rs=0.38, p=0.04) was directly proportional to FFMI. Median intact protein intakes of adults (25.1 vs. 9.9g/d, p<0.001) and children (11 vs. 6g/d, p<0.001) were higher than prescribed. Only in adults, the actual median MF protein intake was lower than prescribed (53 vs. 60g/d, p=0.03). In adults and children, light activity was associated with higher fat mass indices compared to intense activity (adults: FMI:FFMI: β=1.1, p=0.001, children: FMI:FFMI: β=1.1, p=0.007; FMI β=2.1, p=0.01; A:G β=1.1, p=0.04). All associations remained significant after covariate adjustment. Genotype was not associated with body composition. CONCLUSIONS Although fat-free mass in adults was positively associated with intact protein intake, it should be consumed as prescribed per individual tolerance to maintain plasma Phe concentrations within treatment range. In children, total protein maximized with MF should be encouraged to promote lean mass. Nutrition counselling could be complemented with physical activity recommendations for optimal clinical outcomes.
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Affiliation(s)
- Rati Jani
- Department of Human Genetics, Emory University, Atlanta, GA, United States.
| | - Kathryn Coakley
- Department of Human Genetics, Emory University, Atlanta, GA, United States
| | - Teresa Douglas
- Department of Human Genetics, Emory University, Atlanta, GA, United States
| | - Rani Singh
- Department of Human Genetics, Emory University, Atlanta, GA, United States.
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25
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Turki A, Ueda K, Cheng B, Giezen A, Salvarinova R, Stockler-Ipsiroglu S, Elango R. The Indicator Amino Acid Oxidation Method with the Use of l-[1-13C]Leucine Suggests a Higher than Currently Recommended Protein Requirement in Children with Phenylketonuria. J Nutr 2017; 147:211-217. [PMID: 28053173 DOI: 10.3945/jn.116.240218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/01/2016] [Accepted: 12/01/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Phenylketonuria is characterized by mutations in the Phe hydroxylase gene that leads to the accumulation of Phe in plasma and the brain. The standard of care for phenylketonuria is nutritional management with dietary restriction of Phe and the provision of sufficient protein and energy for growth and health maintenance. The protein requirement in children with phenylketonuria is empirically determined based upon phenylketonuria nutritional guidelines that are adjusted individually in response to biochemical markers and growth. OBJECTIVE We determined dietary protein requirements in children with phenylketonuria with the use of the indicator amino acid oxidation (IAAO) technique, with l-[1-13C]Leu as the indicator amino acid. METHODS Four children (2 males; 2 females) aged 9-18 y with phenylketonuria [mild hyperphenylalanemia (mHPA); 6-10 mg/dL (360-600 μmol/L)] were recruited to participate in ≥7 separate test protein intakes (range: 0.2-3.2 g ⋅ kg-1 ⋅ d-1) with the IAAO protocol with the use of l-[1-13C]Leu followed by the collection of breath and urine samples over 8 h. The diets were isocaloric and provided energy at 1.7 times the resting energy expenditure. Protein was provided as a crystalline amino acid mixture based on an egg protein pattern, except Phe and Leu, which were maintained at a constant across intakes. Protein requirement was determined with the use of a 2-phase linear-regression crossover analysis of the rate of l-[1-13C]Leu tracer oxidation. RESULTS The mean protein requirement was determined to be 1.85 g ⋅ kg-1 ⋅ d-1 (R2 = 0.66; 95% CI: 1.37, 2.33). This result is substantially higher than the 2014 phenylketonuria recommendations (1.14-1.33 g ⋅ kg-1 ⋅ d-1; based on 120-140% above the current RDA for age). CONCLUSIONS To our knowledge, this is the first study to directly define a quantitative requirement for protein intake in children with mHPA and indicates that current protein recommendations in children with phenylketonuria may be insufficient. This trial was registered at clinicaltrials.gov as NCT01965691.
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Affiliation(s)
- Abrar Turki
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada.,Department of Pediatrics and
| | - Keiko Ueda
- Department of Pediatrics and.,Division of Biochemical Diseases, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Barbara Cheng
- Department of Pediatrics and.,Division of Biochemical Diseases, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Alette Giezen
- Department of Pediatrics and.,Division of Biochemical Diseases, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Ramona Salvarinova
- Department of Pediatrics and.,Division of Biochemical Diseases, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Sylvia Stockler-Ipsiroglu
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada.,Department of Pediatrics and.,Division of Biochemical Diseases, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Rajavel Elango
- Department of Pediatrics and .,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada; and.,Division of Biochemical Diseases, BC Children's Hospital, Vancouver, British Columbia, Canada
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26
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Couce ML, Vitoria I, Aldámiz-Echevarría L, Fernández-Marmiesse A, Roca I, Llarena M, Sánchez-Pintos P, Leis R, Hermida A. Lipid profile status and other related factors in patients with Hyperphenylalaninaemia. Orphanet J Rare Dis 2016; 11:123. [PMID: 27612877 PMCID: PMC5016957 DOI: 10.1186/s13023-016-0508-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/31/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The mainstay of treating patients with phenylketonuria (PKU) is based on a Phe-restricted diet, restrictive in natural protein combined with Phe-free L-amino acid supplements and low protein foods. This PKU diet seems to reduce atherogenesis and confer protection against cardiovascular diseases but the results from the few published studies have been inconclusive. The aim of our study was to evaluate the relationship between the lipid profile and several treatment-related risk factors in patients with hyperphenylalaninaemia (HPA) in order to optimize their monitoring. METHODS We conducted a cross-sectional multicentre study. A total of 141 patients with HPA were classified according to age, phenotype, type of treatment and dietary adherence. Annual median blood phenylalanine (Phe) levels, Phe tolerance, anthropometric measurements, blood pressure (BP) and biochemical parameters [(triglycerides, total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low density lipoprotein-cholesterol (LDL-C), apolipoprotein A (ApoA), apolipoprotein B (ApoB), vitamin B12, total homocysteine (tHcy), Methionine (Met), high sensitivity C-Reactive Protein (hsCRP)] were collected for each patient. RESULTS Plasma TC levels were lower in patients with PKU than in the mild-HPA group (150 ± 31 vs. 164 ± 22 mg/dL), and there was a weak inverse correlation between plasma TC and Phe levels. HDL-C, LDL-C, ApoA and ApoB levels were lower in the PKU group than in mild-HPA. Patients with PKU had higher systolic BP than the mild-HPA group and there was found a quadratic correlation between median Phe levels and systolic BP (p = 6.42e(-5)) and a linear correlation between median Phe levels and diastolic BP (p = 5.65e(-4)). In overweight or obese PKU patients (24.11 %), biochemical parameters such as TC, triglycerides, LDL-C, tHcy, hsCRP and BP were higher. By contrast, HDL-C was lower in these patients. CONCLUSION Our data show a direct correlation between lipid profile parameters and good adherence to the diet in PKU patients. However, lipid profile in overweight or obese patients displayed an atherogenic profile, in addition to higher hsCRP concentrations and BP. Our study contributes to a better understanding of the relationship between phenotype and treatment in patients with HPA, which could be useful in improving follow-up strategies and clinical outcome. TRIAL REGISTRATION Research Ethics Committee of Santiago-Lugo 2015/393. Registered 22 September 2015, retrospectively registered.
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Affiliation(s)
- María L. Couce
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases. S. Neonatology, Department of Pediatrics, Hospital Clínico Universitario de Santiago, CIBERER, Health Research Institute of Santiago de Compostela (IDIS), Travesía da Choupana s/n, 15706 Santiago de Compostela, A Coruña Spain
| | - Isidro Vitoria
- Unit of Metabolopathies, Hospital Universitario La Fe, Bulevar sur s/n, 46021 Valencia, Spain
| | - Luís Aldámiz-Echevarría
- Unit of Metabolism. Cruces University Hospital, Biocruces Health Research Institute, GCV-CIBER de Enfermedades Raras (CIBERER), Plaza de Cruces s/n, 48903 Barakaldo, Vizcaya Spain
| | - Ana Fernández-Marmiesse
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases. S. Neonatology, Department of Pediatrics, Hospital Clínico Universitario de Santiago, CIBERER, Health Research Institute of Santiago de Compostela (IDIS), Travesía da Choupana s/n, 15706 Santiago de Compostela, A Coruña Spain
| | - Iria Roca
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases. S. Neonatology, Department of Pediatrics, Hospital Clínico Universitario de Santiago, CIBERER, Health Research Institute of Santiago de Compostela (IDIS), Travesía da Choupana s/n, 15706 Santiago de Compostela, A Coruña Spain
| | - Marta Llarena
- Unit of Metabolism. Cruces University Hospital, Biocruces Health Research Institute, GCV-CIBER de Enfermedades Raras (CIBERER), Plaza de Cruces s/n, 48903 Barakaldo, Vizcaya Spain
| | - Paula Sánchez-Pintos
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases. S. Neonatology, Department of Pediatrics, Hospital Clínico Universitario de Santiago, CIBERER, Health Research Institute of Santiago de Compostela (IDIS), Travesía da Choupana s/n, 15706 Santiago de Compostela, A Coruña Spain
| | - Rosaura Leis
- Unit of Gastroenterology and Nutrition, Department of Pediatrics, Hospital Clinico Universitario de Santiago, Health Research Institute of Santiago de Compostela (IDIS), Travesía da Choupana s/n, 15706 Santiago de Compostela, A Coruña Spain
| | - Alvaro Hermida
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, Department of Internal Medicine, Universidad de Santiago, Santiago de Compostela, Spain
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27
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Giovannini M, Riva E, Salvatici E, Fiori L, Paci S, Verduci E, Agostoni C. Treating Phenylketonuria: A Single Centre Experience. J Int Med Res 2016; 35:742-52. [DOI: 10.1177/147323000703500602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hyperphenylalaninaemia (HPA) is an inherited disorder that results in raised plasma phenylalanine levels with a range of severities, including phenylketonuria (PKU). Since the first attempts at treatment using a low-phenylalanine diet and after more than 50 years of research, considerable progress has been made so we are now at a stage where mental retardation caused by high plasma phenylalanine can be prevented. We must, however, be aware of the new challenges we face in managing PKU. These include: maintaining optimal growth by providing enough phenylalanine without jeopardizing the child's psychomotor development; providing an optimal nutritional status that ensures other essential nutrients, such as long chain polyunsaturated fatty acids, are not excluded from the diet; ensuring optimal compliance to the dietary intervention; and considering patients' quality of life. New strategies, such as tetrahydrobiopterin (BH4) supplementation, need to be evaluated with regard to safety, efficacy and expected outcomes in specific types of HPA.
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Affiliation(s)
- M Giovannini
- Department of Paediatrics, San Paolo Hospital, University of Milan, Milan, Italy
| | - E Riva
- Department of Paediatrics, San Paolo Hospital, University of Milan, Milan, Italy
| | - E Salvatici
- Department of Paediatrics, San Paolo Hospital, University of Milan, Milan, Italy
| | - L Fiori
- Department of Paediatrics, San Paolo Hospital, University of Milan, Milan, Italy
| | - S Paci
- Department of Paediatrics, San Paolo Hospital, University of Milan, Milan, Italy
| | - E Verduci
- Department of Paediatrics, San Paolo Hospital, University of Milan, Milan, Italy
| | - C Agostoni
- Department of Paediatrics, San Paolo Hospital, University of Milan, Milan, Italy
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28
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Singh RH, Cunningham AC, Mofidi S, Douglas TD, Frazier DM, Hook DG, Jeffers L, McCune H, Moseley KD, Ogata B, Pendyal S, Skrabal J, Splett PL, Stembridge A, Wessel A, Rohr F. Updated, web-based nutrition management guideline for PKU: An evidence and consensus based approach. Mol Genet Metab 2016; 118:72-83. [PMID: 27211276 DOI: 10.1016/j.ymgme.2016.04.008] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/15/2016] [Accepted: 04/15/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND In 2014, recommendations for the nutrition management of phenylalanine hydroxylase deficiency were published as a companion to the concurrently published American College of Medical Genetics and Genomics guideline for the medical treatment of phenylketonuria (PKU). These were developed primarily from a summary of findings from the PKU scientific review conference sponsored by the National Institutes of Health and Agency for Healthcare Research & Quality along with additional systematic literature review. Since that time, the Genetic Metabolic Dietitians International and the Southeast Regional Newborn Screening and Genetics Collaborative have partnered to create a web-based technology platform for the update and development of nutrition management guidelines for inherited metabolic disorders. OBJECTIVE The purpose of this PKU guideline is to establish harmonization in treatment and monitoring, to guide the integration of nutrition therapy in the medical management of PKU, and to improve outcomes (nutritional, cognitive, and developmental) for individuals with PKU in all life stages while reducing associated medical, educational, and social costs. METHODS Six research questions critical to PKU nutrition management were formulated to support guideline development: Review, critical appraisal, and abstraction of peer-reviewed studies and unpublished practice literature, along with expert Delphi survey feedback, nominal group process, and external review from metabolic physicians and dietitians were utilized for development of recommendations relevant to each question. Recommendations address nutrient intake, including updated protein requirements, optimal blood phenylalanine concentrations, nutrition interventions, monitoring parameters specific to life stages, adjunct therapies, and pregnancy and lactation. Recommendations were graded using a rigorous system derived from the Academy of Nutrition and Dietetics. RESULTS AND CONCLUSION These guidelines, updated utilizing a thorough and systematic approach to literature analysis and national consensus process, are now easily accessible to the global community via the newly developed digital platform. For additional details on specific topics, readers are encouraged to review materials on the online portal: https://GMDI.org/.
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Affiliation(s)
- Rani H Singh
- Department of Human Genetics, Emory University School of Medicine, 2165 North Decatur Road, Decatur, Atlanta, GA 30033, USA; Nutrition Health Sciences Program, Graduate Division of Biological and Biomedical Sciences, Emory University School of Arts and Sciences, Atlanta, GA, USA.
| | - Amy C Cunningham
- Hayward Genetics Center, Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA 70112, USA.
| | - Shideh Mofidi
- Inherited Metabolic Disease Center, Maria Fareri Childrens Hospital, Westchester Medical Center, New York Medical College, Valhalla, New York, USA.
| | - Teresa D Douglas
- Department of Human Genetics, Emory University School of Medicine, 2165 North Decatur Road, Decatur, Atlanta, GA 30033, USA.
| | - Dianne M Frazier
- Division of Genetics and Metabolism, University of North Carolina School of Medicine, 1100 Manning Drive, Chapel Hill, NC 27599, USA.
| | | | - Laura Jeffers
- Cleveland Clinic, Center for Human Nutrition, 9500 Euclid Ave, Cleveland, OH 44195, USA.
| | - Helen McCune
- Pediatric Genetics and Metabolism, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32607, USA.
| | - Kathryn D Moseley
- Genetics Division, USC/Keck School of Medicine, 1801 Marengo St. Rm. 1G-24, Los Angeles, CA 90033, USA.
| | - Beth Ogata
- University of Washington, Department of Pediatrics, UW-CHDD, Box 357920, Seattle, WA 98195, USA.
| | - Surekha Pendyal
- Division of Genetics and Metabolism, University of North Carolina School of Medicine, 1100 Manning Drive, Chapel Hill, NC 27599, USA.
| | - Jill Skrabal
- Department of Medical Genetics, University of Nebraska Medical Center/Children's Hospital and Medical Center, 981200 Nebraska Medical Center, Omaha, NE. 68198-1200, USA.
| | - Patricia L Splett
- Evaluation Consultant Splett & Associates, LLC, 399 Badger Blvd W., Stanchfield, MN 55080, USA.
| | - Adrya Stembridge
- Department of Human Genetics, Emory University School of Medicine, 2165 North Decatur Road, Decatur, Atlanta, GA 30033, USA.
| | - Ann Wessel
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA.
| | - Frances Rohr
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA.
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Al Hafid N, Christodoulou J. Phenylketonuria: a review of current and future treatments. Transl Pediatr 2015; 4:304-17. [PMID: 26835392 PMCID: PMC4728993 DOI: 10.3978/j.issn.2224-4336.2015.10.07] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 10/26/2015] [Indexed: 01/16/2023] Open
Abstract
Phenylketonuria (PKU) is an autosomal recessive inborn error of metabolism caused by a deficiency in the hepatic enzyme phenylalanine hydroxylase (PAH). If left untreated, the main clinical feature is intellectual disability. Treatment, which includes a low Phe diet supplemented with amino acid formulas, commences soon after diagnosis within the first weeks of life. Although dietary treatment has been successful in preventing intellectual disability in early treated PKU patients, there are major issues with dietary compliance due to palatability of the diet. Other potential issues associated with dietary therapy include nutritional deficiencies especially vitamin D and B12. Suboptimal outcomes in cognitive and executive functioning have been reported in patients who adhere poorly to dietary therapy. There have been continuous attempts at improving the quality of medical foods including their palatability. Advances in dietary therapy such as the use of large neutral amino acids (LNAA) and glycomacropeptides (GMP; found within the whey fraction of bovine milk) have been explored. Gene therapy and enzyme replacement or substitution therapy have yielded more promising data in the recent years. In this review the current and possible future treatments for PKU are discussed.
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Crujeiras V, Aldámiz-Echevarría L, Dalmau J, Vitoria I, Andrade F, Roca I, Leis R, Fernandez-Marmiesse A, Couce ML. Vitamin and mineral status in patients with hyperphenylalaninemia. Mol Genet Metab 2015; 115:145-50. [PMID: 26123187 DOI: 10.1016/j.ymgme.2015.06.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 06/22/2015] [Accepted: 06/22/2015] [Indexed: 10/23/2022]
Abstract
Natural sources of protein and some vitamins and minerals are limited in phenylketonuria (PKU) treated patients, who should receive optimal supplementation although this is not yet fully established. We conducted a cross-sectional observational multicenter study including 156 patients with hyperphenylalaninemia. Patients were stratified by age, phenotype, disease detection and type of treatment. Annual median blood phenylalanine (Phe) levels, Phe tolerance, anthropometric measurements, and biochemical parameters (total protein, prealbumin, electrolytes, selenium, zinc, B12, folic acid, ferritin, 25-OH vitamin D) were collected in all patients. 81.4% of patients had biochemical markers out of recommended range but no clinical symptoms. Total protein, calcium, phosphorus, B12, ferritin, and zinc levels were normal in most patients. Prealbumin was reduced in 34.6% of patients (74% with PKU phenotype and 94% below 18 years old), showing almost all (96.3%) an adequate adherence to diet. Selenium was diminished in 25% of patients (95% with PKU phenotype) and also 25-OHD in 14%. Surprisingly, folic acid levels were increased in 39% of patients, 66% with classic PKU. Phosphorus and B12 levels were found diminished in patients with low adherence to diet. Patients under BH4 therapy only showed significant lower levels of B12. This study shows a high percentage of prealbumin and selenium deficiencies as well as an increased level of folic acid in PKU treated patients, which should lead us to assess an adjustment for standards supplements formulated milks.
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Affiliation(s)
- Vanesa Crujeiras
- Unit of Gastroenterology and Nutrition, Department of Pediatrics, Hospital Clinico Universitario de Santiago, Travesía da Choupana s/n, 15706 Santiago de Compostela, A Coruña, Spain
| | - Luis Aldámiz-Echevarría
- Unit of Metabolism, Department of Pediatrics, Hospital de Cruces, Group of Metabolism, Biocruces Health Research Institute, CIBERER, Plaza de Cruces s/n, 48903 Barakaldo, Vizcaya, Spain.
| | - Jaime Dalmau
- Unit of Metabolopathies, Hospital Universitario la Fe, Bulevarsur s/n, 46021 Valencia, Spain.
| | - Isidro Vitoria
- Unit of Metabolopathies, Hospital Universitario la Fe, Bulevarsur s/n, 46021 Valencia, Spain.
| | - Fernando Andrade
- Unit of Metabolism, Department of Pediatrics, Hospital de Cruces, Group of Metabolism, Biocruces Health Research Institute, CIBERER, Plaza de Cruces s/n, 48903 Barakaldo, Vizcaya, Spain.
| | - Iria Roca
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, S. Neonatology, Department of Pediatrics, Hospital Clinico Universitario de Santiago, Travesía da Choupana s/n, 15706 Santiago de Compostela, A Coruña, Spain.
| | - Rosaura Leis
- Unit of Gastroenterology and Nutrition, Department of Pediatrics, Hospital Clinico Universitario de Santiago, IDIS, Travesía da Choupana s/n, 15706 Santiago de Compostela, A Coruña, Spain.
| | - Ana Fernandez-Marmiesse
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, S. Neonatology, Department of Pediatrics, Hospital Clinico Universitario de Santiago, CIBERER, Health Research Institute of Santiago de Compostela (IDIS), Travesía da Choupana s/n, 15706 Santiago de Compostela, A Coruña, Spain.
| | - María L Couce
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, S. Neonatology, Department of Pediatrics, Hospital Clínico Universitario de Santiago de Compostela, CIBERER, Health Research Institute of Santiago de Compostela (IDIS), A Choupana, s/n, 15706 Santiago de Compostela, A Coruña, Spain.
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New insights in growth of phenylketonuric patients. Eur J Pediatr 2015; 174:651-9. [PMID: 25367055 DOI: 10.1007/s00431-014-2446-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 10/14/2014] [Accepted: 10/20/2014] [Indexed: 10/24/2022]
Abstract
UNLABELLED Treatment of phenylketonuria involves a restriction in the intake of natural proteins. This can lead to growth impairment. Weight, height and body mass index of 109 hyperphenylalaninemic patients (mild hyperphenylalaninemia (HPA) and phenylketonuria (PKU)) were determined from birth until 18 years, every 6 months, and differences to the healthy population, depending on the age, sex and phenotype, were analyzed. Data collection was longitudinal retrospective during 31 years. Statistical analysis of z-score values was performed by advanced statistical tools. Long-term evolution of anthropometric z-scores showed no significant statistical differences between PKU and mild HPA individuals, according to the general population. For PKU individuals, height is slightly lower and weight slightly higher than in the healthy population, but differences are smaller than one standard deviation. Nevertheless, over-time evolutions of female height z-scores are different in each type of pathology, with a crossover between 8 and 12 years (p = 0.0186). CONCLUSIONS It is nowadays possible to achieve a long-term normal growth in PKU patients with appropriate dietary treatment. There is however an acceleration of growth up to 8 years old for PKU female patients that leads to a slightly lower final height. Detection of this behaviour was possible by using nonlinear mixed effects models.
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Kochhar JS, Chan SY, Ong PS, Kang L. Clinical therapeutics for phenylketonuria. Drug Deliv Transl Res 2015; 2:223-37. [PMID: 25787029 DOI: 10.1007/s13346-012-0067-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Phenylketonuria was amongst the first of the metabolic disorders to be characterised, exhibiting an inborn error in phenylalanine metabolism due to a functional deficit of the enzyme phenylalanine hydroxylase. It affects around 700,000 people around the globe. Mutations in the gene coding for hepatic phenylalanine hydroxylase cause this deficiency resulting in elevated plasma phenylalanine concentrations, leading to cognitive impairment, neuromotor disorders and related behavioural symptoms. Inception of low phenylalanine diet in the 1950s marked a revolution in the management of phenylketonuria and has since been a vital element of all therapeutic regimens. However, compliance to dietary therapy has been found difficult and newer supplement approaches are being examined. The current development of gene therapy and enzyme replacement therapeutics may offer promising alternatives for the management of phenylketonuria. This review outlines the pathological basis of phenylketonuria, various treatment regimes, their associated challenges and the future prospects of each approach. Briefly, novel drug delivery systems which can potentially deliver therapeutic strategies in phenylketonuria have been discussed.
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Affiliation(s)
- Jaspreet Singh Kochhar
- Department of Pharmacy, National University of Singapore, 18 Science Drive 4, Block S4 Level 2, Singapore, Singapore, 117543
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Abstract
BACKGROUND Phenylketonuria is an inherited metabolic disorder characterised by an absence or deficiency of the enzyme phenylalanine hydroxylase. The aim of treatment is to lower blood phenylalanine concentrations to the recommended therapeutic range to prevent developmental delay and support normal growth. Current treatment consists of a low-phenylalanine diet in combination with a protein substitute which is free from or low in phenylalanine. Guidance regarding the use, dosage, and distribution of dosage of the protein substitute over a 24-hour period is unclear, and there is variation in recommendations among treatment centres. This is an update of a Cochrane review first published in 2005, and previously updated in 2008. OBJECTIVES To assess the benefits and adverse effects of protein substitute, its dosage, and distribution of dose in children and adults with phenylketonuria who are adhering to a low-phenylalanine diet. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which consists of references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conference proceedings. We also contacted manufacturers of the phenylalanine-free and low-phenylalanine protein substitutes for any data from published and unpublished randomised controlled trials.Date of the most recent search of the Group's Inborn Errors of Metabolism Trials Register: 03 April 2014. SELECTION CRITERIA All randomised or quasi-randomised controlled trials comparing: any dose of protein substitute with no protein substitute; an alternative dosage; or the same dose, but given as frequent small doses throughout the day compared with the same total daily dose given as larger boluses less frequently. DATA COLLECTION AND ANALYSIS Both authors independently extracted data and assessed trial quality. MAIN RESULTS Three trials (69 participants) are included in this review. One trial investigated the use of protein substitute in 16 participants, while a further two trials investigated the dosage of protein substitute in a total of 53 participants. Due to issues with data presentation in each trial, described in full in the review, formal statistical analyses of the data were impossible. Investigators will be contacted for further information. AUTHORS' CONCLUSIONS No conclusions could be drawn about the short- or long-term use of protein substitute in phenylketonuria due to the lack of adequate or analysable trial data. Additional data and randomised controlled trials are needed to investigate the use of protein substitute in phenylketonuria. Until further evidence is available, current practice in the use of protein substitute should continue to be monitored with care.
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Affiliation(s)
- Sarah HL Yi
- Emory Genetics Metabolic Nutrition Program2165 N. Decatur RoadDecaturGeorgiaUSA30033
| | - Rani H Singh
- Emory University School of MedicineDepartment of Human Genetics2165 North Decatur RoadDecaturGeorgiaUSA30033
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New Strategies for the Treatment of Phenylketonuria (PKU). Metabolites 2014; 4:1007-17. [PMID: 25375236 PMCID: PMC4279156 DOI: 10.3390/metabo4041007] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 10/27/2014] [Accepted: 10/30/2014] [Indexed: 12/19/2022] Open
Abstract
Phenylketonuria (PKU) was the first inherited metabolic disease in which dietary treatment was found to prevent the disease's clinical features. Treatment of phenylketonuria remains difficult due to progressive decrease in adherence to diet and the presence of neurocognitive defects despite therapy. This review aims to summarize the current literature on new treatment strategies. Additions to treatment include new, more palatable foods based on glycomacropeptide that contains very limited amount of aromatic amino acids, the administration of large neutral amino acids to prevent phenylalanine entry into the brain or tetrahydropterina cofactor capable of increasing residual activity of phenylalanine hydroxylase. Moreover, human trials have recently been performed with subcutaneous administration of phenylalanine ammonia-lyase, and further efforts are underway to develop an oral therapy containing phenylanine ammonia-lyase. Gene therapy also seems to be a promising approach in the near future.
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Humphrey M, Truby H, Boneh A. New ways of defining protein and energy relationships in inborn errors of metabolism. Mol Genet Metab 2014; 112:247-58. [PMID: 24916709 DOI: 10.1016/j.ymgme.2014.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 05/14/2014] [Indexed: 12/30/2022]
Abstract
Dietary restrictions required to manage individuals with inborn errors of metabolism (IEM) are essential for metabolic control, however may result in an increased risk to both short and long-term nutritional status. Dietary factors most likely to influence nutritional status include energy intake, protein quality and quantity, micronutrient intake and the frequency and extent to which the diet must be altered during periods of increased physical or metabolic stress. Patients on the most restrictive diets, including those with intakes consisting of low levels of natural protein or those with recurrent illness or frequent metabolic decompensation carry the most nutritional risk. Due to the difficulties in determining condition specific requirements, dietary intake recommendations and nutritional monitoring tools used in patients with IEM are the same as, or extrapolated from, those used in healthy populations. As a consequence, evidence is lacking for the safest dietary prescriptions required to manage these patients long term, as tolerance to dietary therapy is generally described in terms of metabolic stability rather than long term nutritional and health outcomes. As the most frequent therapeutic dietary manipulation in IEM is alteration in dietary protein, and as protein status is critically dependent on adequate energy provision, the use of a Protein to Energy ratio (P:E ratio) as an additional tool will better define the relationship between these critical components. This could accurately define dietary quality and ensure that not only an adequate, but also a safe and balanced intake is provided.
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Affiliation(s)
- Maureen Humphrey
- Metabolic Genetics, Victorian Clinical Genetic Services, Murdoch Children's Research Institute, The Royal Children's Hospital, Flemington Road, Parkville, Victoria, Melbourne 3052, Australia; Department of Nutrition and Food Services, Royal Children's Hospital, Flemington Road, Parkville, Victoria, Melbourne 3052, Australia; Be Active Sleep Eat (BASE) Facility, Department of Nutrition and Dietetics, Monash University, Faculty of Medicine, Nursing and Health Sciences, Level 1, 264 Ferntree Gully Road, VIC 3168, Melbourne, Australia.
| | - Helen Truby
- Be Active Sleep Eat (BASE) Facility, Department of Nutrition and Dietetics, Monash University, Faculty of Medicine, Nursing and Health Sciences, Level 1, 264 Ferntree Gully Road, VIC 3168, Melbourne, Australia.
| | - Avihu Boneh
- Metabolic Genetics, Victorian Clinical Genetic Services, Murdoch Children's Research Institute, The Royal Children's Hospital, Flemington Road, Parkville, Victoria, Melbourne 3052, Australia; Be Active Sleep Eat (BASE) Facility, Department of Nutrition and Dietetics, Monash University, Faculty of Medicine, Nursing and Health Sciences, Level 1, 264 Ferntree Gully Road, VIC 3168, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Flemington Road, Parkville, Victoria, Melbourne 3052, Australia.
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Camp KM, Parisi MA, Acosta PB, Berry GT, Bilder DA, Blau N, Bodamer OA, Brosco JP, Brown CS, Burlina AB, Burton BK, Chang CS, Coates PM, Cunningham AC, Dobrowolski SF, Ferguson JH, Franklin TD, Frazier DM, Grange DK, Greene CL, Groft SC, Harding CO, Howell RR, Huntington KL, Hyatt-Knorr HD, Jevaji IP, Levy HL, Lichter-Konecki U, Lindegren ML, Lloyd-Puryear MA, Matalon K, MacDonald A, McPheeters ML, Mitchell JJ, Mofidi S, Moseley KD, Mueller CM, Mulberg AE, Nerurkar LS, Ogata BN, Pariser AR, Prasad S, Pridjian G, Rasmussen SA, Reddy UM, Rohr FJ, Singh RH, Sirrs SM, Stremer SE, Tagle DA, Thompson SM, Urv TK, Utz JR, van Spronsen F, Vockley J, Waisbren SE, Weglicki LS, White DA, Whitley CB, Wilfond BS, Yannicelli S, Young JM. Phenylketonuria Scientific Review Conference: state of the science and future research needs. Mol Genet Metab 2014; 112:87-122. [PMID: 24667081 DOI: 10.1016/j.ymgme.2014.02.013] [Citation(s) in RCA: 157] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 02/25/2014] [Accepted: 02/26/2014] [Indexed: 01/17/2023]
Abstract
New developments in the treatment and management of phenylketonuria (PKU) as well as advances in molecular testing have emerged since the National Institutes of Health 2000 PKU Consensus Statement was released. An NIH State-of-the-Science Conference was convened in 2012 to address new findings, particularly the use of the medication sapropterin to treat some individuals with PKU, and to develop a research agenda. Prior to the 2012 conference, five working groups of experts and public members met over a 1-year period. The working groups addressed the following: long-term outcomes and management across the lifespan; PKU and pregnancy; diet control and management; pharmacologic interventions; and molecular testing, new technologies, and epidemiologic considerations. In a parallel and independent activity, an Evidence-based Practice Center supported by the Agency for Healthcare Research and Quality conducted a systematic review of adjuvant treatments for PKU; its conclusions were presented at the conference. The conference included the findings of the working groups, panel discussions from industry and international perspectives, and presentations on topics such as emerging treatments for PKU, transitioning to adult care, and the U.S. Food and Drug Administration regulatory perspective. Over 85 experts participated in the conference through information gathering and/or as presenters during the conference, and they reached several important conclusions. The most serious neurological impairments in PKU are preventable with current dietary treatment approaches. However, a variety of more subtle physical, cognitive, and behavioral consequences of even well-controlled PKU are now recognized. The best outcomes in maternal PKU occur when blood phenylalanine (Phe) concentrations are maintained between 120 and 360 μmol/L before and during pregnancy. The dietary management treatment goal for individuals with PKU is a blood Phe concentration between 120 and 360 μmol/L. The use of genotype information in the newborn period may yield valuable insights about the severity of the condition for infants diagnosed before maximal Phe levels are achieved. While emerging and established genotype-phenotype correlations may transform our understanding of PKU, establishing correlations with intellectual outcomes is more challenging. Regarding the use of sapropterin in PKU, there are significant gaps in predicting response to treatment; at least half of those with PKU will have either minimal or no response. A coordinated approach to PKU treatment improves long-term outcomes for those with PKU and facilitates the conduct of research to improve diagnosis and treatment. New drugs that are safe, efficacious, and impact a larger proportion of individuals with PKU are needed. However, it is imperative that treatment guidelines and the decision processes for determining access to treatments be tied to a solid evidence base with rigorous standards for robust and consistent data collection. The process that preceded the PKU State-of-the-Science Conference, the conference itself, and the identification of a research agenda have facilitated the development of clinical practice guidelines by professional organizations and serve as a model for other inborn errors of metabolism.
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Affiliation(s)
- Kathryn M Camp
- Office of Dietary Supplements, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Melissa A Parisi
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | | | - Gerard T Berry
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Deborah A Bilder
- Department of Psychiatry, University of Utah, Salt Lake City, UT 84108, USA.
| | - Nenad Blau
- University Children's Hospital, Heidelberg, Germany; University Children's Hospital, Zürich, Switzerland.
| | - Olaf A Bodamer
- University of Miami Miller School of Medicine, Miami, FL 33136, USA.
| | - Jeffrey P Brosco
- University of Miami Mailman Center for Child Development, Miami, FL 33101, USA.
| | | | | | - Barbara K Burton
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA.
| | - Christine S Chang
- Agency for Healthcare Research and Quality, Rockville, MD 20850, USA.
| | - Paul M Coates
- Office of Dietary Supplements, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Amy C Cunningham
- Tulane University Medical School, Hayward Genetics Center, New Orleans, LA 70112, USA.
| | | | - John H Ferguson
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | | | | | - Dorothy K Grange
- Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA.
| | - Carol L Greene
- University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Stephen C Groft
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Cary O Harding
- Oregon Health & Science University, Portland, OR 97239, USA.
| | - R Rodney Howell
- University of Miami Miller School of Medicine, Miami, FL 33136, USA.
| | | | - Henrietta D Hyatt-Knorr
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Indira P Jevaji
- Office of Research on Women's Health, National Institutes of Health, Bethesda, MD 20817, USA.
| | - Harvey L Levy
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Uta Lichter-Konecki
- George Washington University, Children's National Medical Center, Washington, DC 20010, USA.
| | | | | | | | | | - Melissa L McPheeters
- Vanderbilt Evidence-based Practice Center, Institute for Medicine and Public Health, Nashville, TN 37203, USA.
| | - John J Mitchell
- McGill University Health Center, Montreal, Quebec H3H 1P3, Canada.
| | - Shideh Mofidi
- Maria Fareri Children's Hospital of Westchester Medical Center, Valhalla, NY 10595, USA.
| | - Kathryn D Moseley
- University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA.
| | - Christine M Mueller
- Office of Orphan Products Development, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA.
| | - Andrew E Mulberg
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA.
| | - Lata S Nerurkar
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Beth N Ogata
- University of Washington, Seattle, WA 98195, USA.
| | - Anne R Pariser
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA.
| | - Suyash Prasad
- BioMarin Pharmaceutical Inc., San Rafael, CA 94901, USA.
| | - Gabriella Pridjian
- Tulane University Medical School, Hayward Genetics Center, New Orleans, LA 70112, USA.
| | | | - Uma M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | | | | | - Sandra M Sirrs
- Vancouver General Hospital, University of British Columbia, Vancouver V5Z 1M9, Canada.
| | | | - Danilo A Tagle
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Susan M Thompson
- The Children's Hospital at Westmead, Sydney, NSW 2145, Australia.
| | - Tiina K Urv
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Jeanine R Utz
- University of Minnesota, Minneapolis, MN 55455, USA.
| | - Francjan van Spronsen
- University of Groningen, University Medical Center of Groningen, Beatrix Children's Hospital, Netherlands.
| | - Jerry Vockley
- University of Pittsburgh, Pittsburgh, PA 15224, USA.
| | - Susan E Waisbren
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Linda S Weglicki
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Desirée A White
- Department of Psychology, Washington University, St. Louis, MO 63130, USA.
| | | | - Benjamin S Wilfond
- Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA 98101, USA.
| | | | - Justin M Young
- The Young Face, Facial Plastic and Reconstructive Surgery, Cumming, GA 30041, USA.
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Giovannini M, Riva E, Salvatici E, Cefalo G, Radaelli G. Randomized Controlled Trial of a Protein Substitute with Prolonged Release on the Protein Status of Children with Phenylketonuria. J Am Coll Nutr 2014; 33:103-10. [DOI: 10.1080/07315724.2013.857281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Singh RH, Rohr F, Frazier D, Cunningham A, Mofidi S, Ogata B, Splett PL, Moseley K, Huntington K, Acosta PB, Vockley J, Van Calcar SC. Recommendations for the nutrition management of phenylalanine hydroxylase deficiency. Genet Med 2014; 16:121-31. [PMID: 24385075 PMCID: PMC3918542 DOI: 10.1038/gim.2013.179] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 10/16/2013] [Indexed: 11/09/2022] Open
Abstract
The effectiveness of a phenylalanine-restricted diet to improve the outcome of individuals with phenylalanine hydroxylase deficiency (OMIM no. 261600) has been recognized since the first patients were treated 60 years ago. However, the treatment regime is complex, costly, and often difficult to maintain for the long term. Improvements and refinements in the diet for phenylalanine hydroxylase deficiency have been made over the years, and adjunctive therapies have proven to be successful for certain patients. Yet evidence-based guidelines for managing phenylalanine hydroxylase deficiency, optimizing outcomes, and addressing all available therapies are lacking. Thus, recommendations for nutrition management were developed using evidence from peer-reviewed publications, gray literature, and consensus surveys. The areas investigated included choice of appropriate medical foods, integration of adjunctive therapies, treatment during pregnancy, monitoring of nutritional and clinical markers, prevention of nutrient deficiencies, providing of access to care, and compliance strategies. This process has not only provided assessment and refinement of current nutrition management and monitoring recommendations but also charted a direction for future studies. This document serves as a companion to the concurrently published American College of Medical Genetics and Genomics guideline for the medical treatment of phenylalanine hydroxylase deficiency.
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Affiliation(s)
- Rani H. Singh
- Division of Medical Genetics, Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Fran Rohr
- Division of Genetics and Metabolism, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dianne Frazier
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Amy Cunningham
- Hayward Genetics Center, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Shideh Mofidi
- Inherited Metabolic Disease Center, Maria Fareri Children's Hospital, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Beth Ogata
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | | | - Kathryn Moseley
- Department of Pediatrics, University of Southern California Medical Center, Los Angeles, California, USA
| | - Kathleen Huntington
- Metabolic Clinic, Institute for Development and Disability, Oregon Health Science University, Portland, Oregon, USA
| | | | - Jerry Vockley
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Human Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sandra C. Van Calcar
- Division of Genetics and Metabolism, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Hennermann JB, Roloff S, Gellermann J, Vollmer I, Windt E, Vetter B, Plöckinger U, Mönch E, Querfeld U. Chronic kidney disease in adolescent and adult patients with phenylketonuria. J Inherit Metab Dis 2013; 36:747-56. [PMID: 23138985 DOI: 10.1007/s10545-012-9548-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 09/13/2012] [Accepted: 10/04/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES A lifelong phenylalanine-restricted diet with supplementation of a phenylalanine-free amino acid formula is recommended in patients with phenylketonuria (PKU). The effect of a long-term PKU diet on renal function and blood pressure has not been investigated yet. DESIGN We analyzed renal function in 67 patients with PKU, aged 15-43 years, by measuring glomerular filtration rate (GFR) and effective renal plasma flow by isotope clearance ((51)Cr-EDTA, (123)J-Hippuran), estimated GFR, blood retention parameters, urinary protein and electrolyte excretion. Renal ultrasound and 24 h ambulatory blood pressure monitoring were performed additionally. Patients were divided into three groups according to their: 1) current diet (CD), i.e., daily protein intake: ICD <0.8 g/kg, IICD 0.8-1.04 g/kg, IIICD >1.04 g/kg; 2) life-long diet time (LDT), i.e., cumulative years of life in which daily protein intake exceeded dietary recommendations: ILDT <15 years, IILDT 15-19 years, IIILDT >19 years. RESULTS GFR was decreased in 19 % of the patients. With increasing protein intake, GFR decreased significantly (ICD 111 ml/min; IICD 105 ml/min; IIICD 99 ml/min. ILDT 112 ml/min; IILDT 103 ml/min; IIILDT 99 ml/min). Proteinuria was detected in 31 %, microalbuminuria in 7 %, and hypercalciuria in 23 % of the patients. 23 % of the patients had arterial hypertension, and 41 % revealed a nocturnal non-dipping status. CONCLUSIONS In patients with PKU on a lifelong diet we could detect impaired renal function in 19 %, proteinuria in 31 %, and arterial hypertension in 23 %. Thus, chronic kidney disease may develop in PKU patients, and routine renal function tests should be performed during long-term follow-up.
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Affiliation(s)
- Julia B Hennermann
- Department of Pediatric Endocrinology, Gastroenterology and Metabolic Diseases, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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40
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Rocha JC, MacDonald A, Trefz F. Is overweight an issue in phenylketonuria? Mol Genet Metab 2013; 110 Suppl:S18-24. [PMID: 24055312 DOI: 10.1016/j.ymgme.2013.08.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 08/26/2013] [Indexed: 12/20/2022]
Abstract
Dietary treatment may be associated with an increased risk of obesity in phenylketonuria (PKU). The earliest studies describe a tendency for overweight in PKU, but not all recent publications confirm this, although there are an increasing number of studies describing increased obesity in female patients with PKU. There is little data describing the metabolic consequences of obesity in PKU. It is difficult to interpret and compare published results due to variable patient age, differing dietary treatment approaches, poor treatment adherence, inconsistencies in metabolic control achieved, variable criteria used to classify overweight. There is also a lack of comparison with normal population data which is widely variable between countries. Generally in PKU it is unknown if obesity etiology is a result of the underlying condition, a treatment consequence, or an outcome of inadequate metabolic control. Differences in treatment strategies, target ranges for blood phenylalanine concentrations and severity of PKU can alter nutritional intakes and dietary experiences which ultimately modulate the course of overweight development. It is clear further investigation is required. Treating overweight and obesity in the general population is difficult and no studies have described the impact of obesity treatment strategies in PKU. However, the PKU management team has an important role in monitoring nutritional status and preventing overweight and obesity. It is important that PKU treatment attends to the general aspects of nutrition, feeding behavior and exercise in order to prevent the development of overweight in these individuals.
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Affiliation(s)
- Júlio C Rocha
- Center of Medical Genetics Jacinto de Magalhães, CHP, EPE, Porto, Portugal.
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41
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Burrage LC, McConnell J, Haesler R, O'Riordan MA, Sutton VR, Kerr DS, McCandless SE. High prevalence of overweight and obesity in females with phenylketonuria. Mol Genet Metab 2012; 107:43-8. [PMID: 22846370 DOI: 10.1016/j.ymgme.2012.07.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 07/09/2012] [Accepted: 07/09/2012] [Indexed: 11/24/2022]
Abstract
The primary treatment for phenylketonuria (PKU) is a low phenylalanine diet together with an amino acid-based, phenylalanine-free formula. Thus, PKU patients tend to consume a diet enriched in carbohydrates which could predispose to obesity. Studies in the 1980s and 1990s demonstrated that school-age phenylketonuria (PKU) patients have a higher mean body weight compared to a control population. However, no recent studies in the United States PKU population have examined whether this trend has persisted or whether adolescents are also affected. To investigate whether pediatric PKU populations (ages 2-20 years) in two major metropolitan areas of the United States (Cleveland, OH and Houston, TX) have a higher than expected percentage of overweight (BMI≥85th percentile) relative to the general population in the United States (NHANES), a retrospective chart review of PKU patients born between 1990 and 2008 and followed in Cleveland, OH (Rainbow Babies and Children's Hospital/University Hospitals Case Medical Center) and in Houston, TX (Texas Children's Hospital) was performed. Based on data from the U.S., 40% of pediatric PKU patients were overweight or obese. However, the percentage of overweight females (55%) and obese females (33%) is 1.8× and 2.1× higher respectively than expected based on comparison data from U.S. children. Further studies are necessary to identify potential strategies for prevention of excessive weight gain in children with PKU, especially in females.
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Affiliation(s)
- Lindsay C Burrage
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030, USA.
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42
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Dokoupil K, Gokmen-Ozel H, Lammardo AM, Motzfeldt K, Robert M, Rocha JC, van Rijn M, Ahring K, Bélanger-Quintana A, MacDonald A. Optimising growth in phenylketonuria: Current state of the clinical evidence base. Clin Nutr 2012; 31:16-21. [DOI: 10.1016/j.clnu.2011.09.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 07/02/2011] [Accepted: 09/08/2011] [Indexed: 12/01/2022]
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43
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Belanger-Quintana A, Martínez-Pardo M. Physical development in patients with phenylketonuria on dietary treatment: a retrospective study. Mol Genet Metab 2011; 104:480-4. [PMID: 21878401 DOI: 10.1016/j.ymgme.2011.08.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 08/05/2011] [Accepted: 08/05/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVES To evaluate the growth and physical development in patients with phenylalanine hydroxylase deficiency who follow exclusively dietary treatment. METHODS Anthropometric measurements of 160 patients with hyperphenylalaninemia who were followed at our center over a 25 year period were obtained. Only patients treated exclusively with a protein-restrictive diet supplemented with amino acid mixtures were included. Height, weight and body mass index were measured at birth, at diagnosis, at 6 and 12 months of age, and annually until 18 years of age in patients with phenylketonuria or until 9 years of age in patients with mild hyperphenylalaninemia and compared to official national reference values. The final height of PKU patients was also compared to their expected family height. RESULTS The analysis of z scores suggested no significant differences in physical development between PKU patients and the healthy population during the study period. The final height of PKU patients revealed that they were 2 to 4 cm taller than expected when compared to the mean family height (p<0.001). The mean weight and BMI at puberty suggested that many patients with severe PKU, but not other phenotypes, were overweight during this period. CONCLUSION Physical development can be optimal in PKU patients regardless of their phenotype and the severity of the diet. A tendency to excessive weight gain is seen in adolescence in the most severe phenotypes.
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Affiliation(s)
- Amaya Belanger-Quintana
- Unidad de Enfermedades Metabólicas, Servicio de Pediatría, Hospital Ramón y Cajal, Madrid, Spain.
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44
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Singh RH, Quirk ME. Using change in plasma phenylalanine concentrations and ability to liberalize diet to classify responsiveness to tetrahydrobiopterin therapy in patients with phenylketonuria. Mol Genet Metab 2011; 104:485-91. [PMID: 21986447 PMCID: PMC4029441 DOI: 10.1016/j.ymgme.2011.09.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 09/08/2011] [Accepted: 09/08/2011] [Indexed: 10/17/2022]
Abstract
Tetrahydrobiopterin (BH(4)) responsiveness is currently defined as a decrease in plasma phenylalanine concentrations in patients with phenylketonuria (PKU). This definition does not offer insight beyond the initial assessment of patients, which may lead to treatment ambiguity in patients who only experience an initial decrease in plasma phenylalanine concentrations. We present our experience with a novel classification approach using sequentially-applied criteria. Plasma phenylalanine concentrations were measured at baseline and after one month of BH(4) therapy (20 mg/kg/day) in 58 PKU patients (34 M, 24 F; age 17.3±11.0 years). Thirty-two patients (55.2%) were classified as "preliminary responders" at one month, experiencing at least a 15% decrease in plasma phenylalanine concentrations. Preliminary responders' ability to liberalize their dietary restrictions was then systematically assessed. "Definitive responders" were defined as preliminary responders who could increase their dietary phenylalanine tolerance by at least 300 mg/day and lower prescribed medical food needs by at least 25% while maintaining metabolic control (plasma phenylalanine ≤360 μmol/L) and consuming adequate dietary protein. Preliminary responders who could not liberalize their diets according to these criteria were classified as "provisional responders." Nineteen patients (32.8% of patients initiating BH(4) therapy) met the definitive responder criteria, increasing dietary phenylalanine tolerance from 704±518 mg/day to 1922±612 mg/day and reducing medical food to 16.7±19.5% of their baseline prescription. Nine patients (15.5% of patients initiating BH(4) therapy) were classified as provisional responders, all remaining on 100% of their baseline medical food prescription. From this classification approach, a subgroup of provisionally responsive patients emerged who experienced an initial decrease in plasma phenylalanine concentrations but who could not substantially increase their dietary phenylalanine tolerance or decrease medical food needs. Diet liberalization is an essential component of BH(4)-responsiveness classification.
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Affiliation(s)
- Rani H Singh
- Department of Human Genetics, Emory University School of Medicine, Decatur, GA 30033, USA.
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45
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Bélanger-Quintana A, Burlina A, Harding CO, Muntau AC. Up to date knowledge on different treatment strategies for phenylketonuria. Mol Genet Metab 2011; 104 Suppl:S19-25. [PMID: 21967857 PMCID: PMC4437510 DOI: 10.1016/j.ymgme.2011.08.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 07/23/2011] [Accepted: 08/05/2011] [Indexed: 11/18/2022]
Abstract
Dietary management for phenylketonuria was established over half a century ago, and has rendered an immense success in the prevention of the severe mental retardation associated with the accumulation of phenylalanine. However, the strict low-phenylalanine diet has several shortcomings, not the least of which is the burden it imposes on the patients and their families consequently frequent dietary non-compliance. Imperfect neurological outcome of patients in comparison to non-PKU individuals and nutritional deficiencies associated to the PKU diet are other important reasons to seek alternative therapies. In the last decade there has been an impressive effort in the investigation of other ways to treat PKU that might improve the outcome and quality of life of these patients. These studies have lead to the commercialization of sapropterin dihydrochloride, but there are still many questions regarding which patients to challenge with sapropterin what is the best challenge protocol and what could be the implications of this treatment in the long-term. Current human trials of PEGylated phenylalanine ammonia lyase are underway, which might render an alternative to diet for those patients non-responsive to sapropterin dihydrochloride. Preclinical investigation of gene and cell therapies for PKU is ongoing. In this manuscript, we will review the current knowledge on novel pharmacologic approaches to the treatment of phenylketonuria.
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Affiliation(s)
- Amaya Bélanger-Quintana
- Division of Metabolic Diseases, Pediatrics Department, Ramon y Cajal Hospital, Madrid, Spain.
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46
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Demirkol M, Giżewska M, Giovannini M, Walter J. Follow up of phenylketonuria patients. Mol Genet Metab 2011; 104 Suppl:S31-9. [PMID: 22018725 DOI: 10.1016/j.ymgme.2011.08.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 07/31/2011] [Accepted: 08/07/2011] [Indexed: 11/26/2022]
Abstract
In recent years our understanding of the follow up policies for PKU has increased substantially. In particular, we now understand the importance of maintaining control of blood phenylalanine (phe) concentrations life-long to achieve the best long-term neuropsychological outcomes. The concordance with the follow up strategy remains a key challenge for the future, especially with respect to adolescents and young adults. The recent therapies could ease the burden of the dietary phe restriction for PKU patients and their families. The time may be right for revisiting the guidelines for follow up of PKU in order to address a number of important issues related to PKU management: promotion of breastfeeding to complementary feeding up to 2 years of age for prevention of early growth retardation and later overweight development, treatment advancements for metabolic control, blood phe and tyr variability, routine screening measures for nutritional biomarkers, neurocognitive and psychological assessments, bone pathology, understanding the challenges of compliance and transitioning into adulthood as an individual with PKU and addressing unmet needs in this population.
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Affiliation(s)
- M Demirkol
- Div Nutrition and Metabolism, Children's Hospital, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey.
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47
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MacDonald A, Rocha JC, van Rijn M, Feillet F. Nutrition in phenylketonuria. Mol Genet Metab 2011; 104 Suppl:S10-8. [PMID: 21944460 DOI: 10.1016/j.ymgme.2011.08.023] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 08/24/2011] [Accepted: 08/24/2011] [Indexed: 12/31/2022]
Abstract
The same basic principles are used to deliver dietary treatment in PKU that was developed sixty years ago. Dietary treatment is undoubtedly very successful, but it has gradually evolved and been guided commonly by individual experience and expert opinion only. There is little international consensus about dietary practice with improvements in specialist dietary products concentrating on taste and presentation rather than nutritional composition. Many areas of dietary treatment have not been rigorously examined. In particular, the amino acid and micronutrient profile of Phenylalanine-free (phe-free) amino acids requires further study. In different formulations of phe-free amino acids, there are variations in the amino acid patterns as well the amount of essential and non essential amino acids per 100g/amino acids. The amount of added tyrosine and branch chain amino varies substantially, and in PKU specifically, there is little data about their relative absorption rates and bioavailability. In phe-free amino acids, there is evidence suggesting that some of the added micronutrients may be excessive and so the source and amount of each micronutrient should be scrutinized, with a need for the development of international nutritional composition standards exclusively for these products. There is a dearth of data about the life-long phenylalanine tolerance of patients or the nutritional state of adult patients treated with diet. There is a growing need to measure body composition routinely in children with PKU and with the rise in childhood obesity, it is important to measure body fatness and identify those who are at greatest risk of 'co-morbidities' of obesity. There is necessity for international collaboration to ensure robust data is collected on many basic aspects of nutritional care to guarantee that diet therapy is delivered to the highest standard.
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Albersen M, Bonthuis M, de Roos NM, van den Hurk DAM, Carbasius Weber E, Hendriks MMWB, de Sain-van der Velden MGM, de Koning TJ, Visser G. Whole body composition analysis by the BodPod air-displacement plethysmography method in children with phenylketonuria shows a higher body fat percentage. J Inherit Metab Dis 2010; 33 Suppl 3:S283-8. [PMID: 20574715 PMCID: PMC3757265 DOI: 10.1007/s10545-010-9149-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2009] [Revised: 05/17/2010] [Accepted: 05/25/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND Phenylketonuria (PKU) causes irreversible central nervous system damage unless a phenylalanine (PHE) restricted diet with amino acid supplementation is maintained. To prevent growth retardation, a protein/amino acid intake beyond the recommended dietary protein allowance is mandatory. However, data regarding disease and/or diet related changes in body composition are inconclusive and retarded growth and/or adiposity is still reported. The BodPod whole body air-displacement plethysmography method is a fast, safe and accurate technique to measure body composition. AIM To gain more insight into the body composition of children with PKU. METHODS Patients diagnosed with PKU born between 1991 and 2001 were included. Patients were identified by neonatal screening and treated in our centre. Body composition was measured using the BodPod system (Life Measurement Incorporation©). Blood PHE values determined every 1-3 months in the year preceding BodPod analysis were collected. Patients were matched for gender and age with data of healthy control subjects. Independent samples t tests, Mann-Whitney and linear regression were used for statistical analysis. RESULTS The mean body fat percentage in patients with PKU (n = 20) was significantly higher compared to healthy controls (n = 20) (25.2% vs 18.4%; p = 0.002), especially in girls above 11 years of age (30.1% vs 21.5%; p = 0.027). Body fat percentage increased with rising body weight in patients with PKU only (R = 0.693, p = 0.001), but did not correlate with mean blood PHE level (R = 0.079, p = 0.740). CONCLUSION Our data show a higher body fat percentage in patients with PKU, especially in girls above 11 years of age.
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Affiliation(s)
- Monique Albersen
- Department of Metabolic and Endocrine Diseases, Wilhelmina Children’s Hospital, University Medical Centre Utrecht, Huispost KC02.069.1, Lundlaan 6, 3584 EA Utrecht, The Netherlands
| | - Marjolein Bonthuis
- Division of Human Nutrition, Wageningen University and Research Centre, Wageningen, The Netherlands
| | - Nicole M. de Roos
- Department of Dietetics and Nutritional Sciences, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Dorine A. M. van den Hurk
- Department of Dietetics and Nutritional Sciences, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Ems Carbasius Weber
- Department of Dietetics and Nutritional Sciences, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Margriet M. W. B. Hendriks
- Department of Metabolic and Endocrine Diseases, Wilhelmina Children’s Hospital, University Medical Centre Utrecht, Huispost KC02.069.1, Lundlaan 6, 3584 EA Utrecht, The Netherlands
| | - Monique G. M. de Sain-van der Velden
- Department of Metabolic and Endocrine Diseases, Wilhelmina Children’s Hospital, University Medical Centre Utrecht, Huispost KC02.069.1, Lundlaan 6, 3584 EA Utrecht, The Netherlands
| | - Tom J. de Koning
- Department of Metabolic and Endocrine Diseases, Wilhelmina Children’s Hospital, University Medical Centre Utrecht, Huispost KC02.069.1, Lundlaan 6, 3584 EA Utrecht, The Netherlands
| | - Gepke Visser
- Department of Metabolic and Endocrine Diseases, Wilhelmina Children’s Hospital, University Medical Centre Utrecht, Huispost KC02.069.1, Lundlaan 6, 3584 EA Utrecht, The Netherlands
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Enns GM, Koch R, Brumm V, Blakely E, Suter R, Jurecki E. Suboptimal outcomes in patients with PKU treated early with diet alone: revisiting the evidence. Mol Genet Metab 2010; 101:99-109. [PMID: 20678948 DOI: 10.1016/j.ymgme.2010.05.017] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 05/27/2010] [Accepted: 05/28/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND The National Institute of Health (NIH) published a Consensus Statement on the screening and management of Phenylketonuria (PKU) in 2000. The panel involved in the development of this consensus statement acknowledged the lack of data regarding the potential for more subtle suboptimal outcomes and the need for further research into treatment options. In subsequent years, the approval of new treatment options for PKU and outcome data for patients treated from the newborn period by dietary therapy alone have become available. We hypothesized that a review of the PKU literature since 2000 would provide further evidence related to neurocognitive, psychosocial, and physical outcomes that could serve as a basis for reassessment of the 2000 NIH Consensus Statement. METHODS A systematic review of literature residing in PubMed, Scopus and PsychInfo was performed in order to assess the outcome data over the last decade in diet-alone early-treated PKU patients to assess the need for new recommendations and validity of older recommendations in light of new evidence. RESULTS The majority of publications (140/150) that contained primary outcome data presented at least one suboptimal outcome compared to control groups or standardized norms/reference values in at least one of the following areas: neurocognitive/psychosocial (N=60; 58 reporting suboptimal outcomes); quality of life (N=6; 4 reporting suboptimal outcomes); brain pathology (N=32; 30 reporting suboptimal outcomes); growth/nutrition (N=34; 29 reporting suboptimal outcomes); bone pathology (N=9; 9 reporting suboptimal outcomes); and/or maternal PKU (N=19; 19 reporting suboptimal outcomes). CONCLUSIONS Despite the remarkable success of public health programs that have instituted newborn screening and early introduction of dietary therapy for PKU, there is a growing body of evidence that suggests that neurocognitive, psychosocial, quality of life, growth, nutrition, bone pathology and maternal PKU outcomes are suboptimal. The time may be right for revisiting the 2000 NIH Consensus Statement in order to address a number of important issues related to PKU management, including treatment advancements for metabolic control in PKU, blood Phe variability, neurocognitive and psychological assessments, routine screening measures for nutritional biomarkers, and bone pathology.
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Affiliation(s)
- G M Enns
- Division of Medical Genetics, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Stanford, CA 94305-5208,USA.
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Blau N. Sapropterin dihydrochloride for phenylketonuria and tetrahydrobiopterin deficiency. Expert Rev Endocrinol Metab 2010; 5:483-494. [PMID: 30780801 DOI: 10.1586/eem.10.39] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Sapropterin dihydrochloride is the first registered synthetic form of the naturally occurring cofactor and cosubstrate, tetrahydrobiopterin (BH4). It is essential for the conversion of phenylalanine (Phe) by phenylalanine-4-hydroxylase (PAH) to tyrosine. BH4 is also the co-factor of rate-limiting enzymes involved in the synthesis of monoamine neurotransmitters. Phenylketonuria (PKU) is an inherited disorder of PAH, characterized by elevated Phe concentrations (hyperphenylalaninemia) in the blood and brain, with toxic neurological consequences. Sapropterin dihydrochloride is approved for treating patients (of all ages in the USA and >4 years old in Europe) with PKU who are BH4 responsive, and those with BH4 deficiency (Europe). It decreases blood Phe concentration and increases dietary Phe tolerance in some patients with PKU on a low-Phe diet, allowing dietary adjustment or even discontinuation of a low-Phe diet. This article reviews sapropterin dihydrochloride for the management of PKU - aimed at improving clinical outcomes and quality of life - and it considers the potential for incorporating such information into international consensus guidelines.
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Affiliation(s)
- Nenad Blau
- a Zürich Center for Integrative Human Physiology (ZIHP), Division of Clinical Chemistry and Biochemistry, University Children's Hospital, Steinwiesstrasse 75, CH-8032 Zürich, Switzerland.
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