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Aronoff A, Guan Y, Gurung S, Comeau DL, Singh RH. Assessing the lived experiences of females with phenylketonuria in their health management. Mol Genet Metab Rep 2024; 40:101095. [PMID: 38846519 PMCID: PMC11152756 DOI: 10.1016/j.ymgmr.2024.101095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 06/09/2024] Open
Abstract
Introduction The present study is a mixed-methods exploratory study aiming to understand the lived experiences of females with phenylketonuria (PKU) in managing their health. The study aims to identify what individual, interpersonal, and environmental factors serve as facilitators and inhibitors, and how PKU intrudes on different realms of health. Methods Attendees of Emory's Metabolic Camp and female users of Medical Nutrition Therapy for Prevention (MNT4P) were recruited. Participants were administered the Illness Intrusiveness Ratings Scale (IIRS) survey and qualitatively interviewed. The IIRS survey was analyzed using descriptive statistics and the interviews were coded and assessed using inductive and deductive analysis. Results In total, 25 participants were included in analysis (adults, n = 20; adolescents, n = 5). In the IIRS survey, diet had the highest average impact score of 5.74 (SD = 2.05) and religious expression had the lowest average impact score of 1.74 (SD = 1.65). The most salient themes that arose from the qualitative interviews were related to concerns of pregnancy (n = 25), interactions with health care providers relative to PKU care (n = 23) and independent of PKU care (n = 21), social support (n = 21) and isolation (n = 12), financial issues (n = 22), and illness intrusiveness on general health management (n = 22). Discussion Adolescent and adult female participants with PKU identified significant concerns in individual, interpersonal, and environmental factors affecting the management of their health. Additionally, the illness intrusiveness of PKU impacted their physical, mental, and gynecological health. Future research should further assess the unique challenges faced by females with PKU and potential interventions to better address these barriers.
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Affiliation(s)
- Abigail Aronoff
- Emory University School of Medicine, Department of Human Genetics, Atlanta, GA, United States of America
| | - Yue Guan
- Emory University Rollins School of Public Health, Department of Behavioral, Social, and Health Education Sciences, Atlanta, GA, United States of America
| | - Saran Gurung
- Emory University School of Medicine, Department of Human Genetics, Atlanta, GA, United States of America
| | - Dawn L. Comeau
- Emory University Rollins School of Public Health, Department of Behavioral, Social, and Health Education Sciences, Atlanta, GA, United States of America
| | - Rani H. Singh
- Emory University School of Medicine, Department of Human Genetics, Atlanta, GA, United States of America
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Sacharow S, Zhu E, Hollander S. The challenge of adults with phenylketonuria who have been lost to care; a single center's attempt to reach those diagnosed with PKU over 60 years of newborn screening. Mol Genet Metab Rep 2024; 40:101099. [PMID: 38962402 PMCID: PMC11219965 DOI: 10.1016/j.ymgmr.2024.101099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/22/2024] [Accepted: 05/28/2024] [Indexed: 07/05/2024] Open
Abstract
Background Those diagnosed with PKU in the early years of newborn screening (NBS) were often discharged from clinic in childhood. Long-term lost to clinic patients may be impacted by untreated PKU and uninformed about current recommendations. We aimed to contact adults away from clinic for 5-50+ years, share current recommendations, offer clinical care, and elicit factors underlying not returning to clinic. Methods Former patients were identified and offered a virtual meeting with a physician and dietitian for structured interview and education about current guidelines and treatments. Results We identified 53 eligible patients who had PKU and had not returned to clinic in ≥5 years. Of those 53, 27 were successfully contacted, 16 completed the educational intervention, and 5/16 returned to clinic. Reasons for having been away from clinic included discharge from clinic in childhood and inadequate insurance coverage. Experiences varied and some denied negative impacts after diet discontinuation. Individuals expressed a desire for convenient treatments that aligned with overall health goals. Most participants who completed the educational intervention expressed interest in returning to clinic; however, most did not return within the timeframe of the project. All 27 individuals successfully contacted agreed to be re-contacted with future updates or research opportunities. Discussion We successfully contacted half of individuals identified as having been lost to clinic follow-up long-term. Limitations included inability to make initial contact, and unwillingness to re-engage by some we reached. Those who agreed to participation desired ongoing PKU clinic and community connection. This experience will inform our process to engage current patients and re-engage those currently lost to care.
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Affiliation(s)
- S. Sacharow
- Boston Children's Hospital, Boston, MA 02115, United States of America
- Harvard Medical School, Boston, MA 02115, United States of America
| | - E. Zhu
- Boston Children's Hospital, Boston, MA 02115, United States of America
| | - S. Hollander
- Boston Children's Hospital, Boston, MA 02115, United States of America
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Tomm A, Thiele AG, Rohde C, Kirmse S, Kiess W, Beblo S. Executive functions & metabolic control in phenylketonuria (PKU) and mild hyperphenylalaninemia (mHPA). Mol Genet Metab 2024; 143:108544. [PMID: 39059271 DOI: 10.1016/j.ymgme.2024.108544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 07/18/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Due to newborn screening and early treatment, patients with phenylketonuria (PKU) and mild hyperphenylalaninemia (mHPA) develop largely normal, in terms of IQ testing and academic attainment. However, the impact of metabolic control in various stages of development on more complex cognitive abilities, i.e. executive functions (EF), is still unclear. METHODS EFs were tested in 28 patients with PKU/mHPA, aged 8-17 years, identified by newborn screening and continuously treated. The relation to current (testing day & past 10 phenylalanine (Phe) values) and long-term metabolic control (age periods: childhood <6, 6-10, adolescence >10 years, lifetime Phe) was analyzed. RESULTS EFs were in the lower normative range (IQR of T-values: 47.35-51.00). Patients reaction time was significantly slower than the population mean (divided attention/TAP: median 40, p < 0.01). Both, long-term and current metabolic control correlated with performance in EF tests: Higher current Phe impaired reaction times (Go/No-Go, r = -0.387; working memory, r = -0.425; p < 0.05) and performance in planning ability (ToL r = -0.465, p < 0.01). Higher long-term Phe values both in childhood and adolescence mainly affected attention (omissions/TAP r = -0.357 and - 0.490, respectively, both p < 0.05) as well as planning ability (ToL r = -0.422 and - 0.387, adolescence and lifetime, p < 0.05). CONCLUSION Current and long-term metabolic control in PKU/mHPA, including the adolescent period, influence EFs, especially affecting reaction time and planning abilities. This should be taken into account in patient counselling.
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Affiliation(s)
- Anne Tomm
- Center for Pediatric Research Leipzig, Department of Women and Child Health, Hospital for Children and Adolescents, University Hospital, Germany.
| | - Alena G Thiele
- Center for Pediatric Research Leipzig, Department of Women and Child Health, Hospital for Children and Adolescents, University Hospital, Germany.
| | - Carmen Rohde
- Center for Pediatric Research Leipzig, Department of Women and Child Health, Hospital for Children and Adolescents, University Hospital, Germany.
| | - Stefanie Kirmse
- Center for Pediatric Research Leipzig, Department of Women and Child Health, Hospital for Children and Adolescents, University Hospital, Germany.
| | - Wieland Kiess
- Center for Pediatric Research Leipzig, Department of Women and Child Health, Hospital for Children and Adolescents, University Hospital, Germany.
| | - Skadi Beblo
- Center for Pediatric Research Leipzig, Department of Women and Child Health, Hospital for Children and Adolescents, University Hospital, Germany; Leipzig University Center for Rare Diseases, Philipp-Rosenthal-Str. 55, 04103 Leipzig, Germany.
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Beghini M, Pichler M, Tinnefeld FC, Metz M, Möslinger D, Konstantopoulou V, Spenger J, Kautzky-Willer A, Frommlet F, Scherer T, Hufgard-Leitner M. Poor adherence during adolescence is a risk factor for becoming lost-to-follow-up in patients with phenylketonuria. Mol Genet Metab Rep 2024; 39:101087. [PMID: 38766496 PMCID: PMC11101879 DOI: 10.1016/j.ymgmr.2024.101087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 04/23/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024] Open
Abstract
Purpose A high rate of lost to follow-up (LTFU) in patients with phenylketonuria (PKU) represents a main challenge. In this study, we investigated potential risk factors for becoming LTFU related to adolescence as a critical period of life. Methods We retrospectively analyzed longitudinal data collected from 1993 to 2019 of patients diagnosed with classic PKU that were followed at our center during adolescence (14-18 y) and at least once in adulthood (>18 y). Patients who interrupted their contact with our center after the 18th birthday for at least 2 years were classified as LTFU. We performed a multivariate regression analysis to investigate following potential risk factors for becoming LTFU in adult life: sex, dietary compliance during adolescence assessed through the mean of the annual medians of phenylalanine plasma values, average number of contacts with the center during adolescence and age at first visit after the 18th birthday. Results 93 patients (52 males, 41 females) were included in the study. 58% became LTFU during adulthood. The mean age at the last visit before becoming LTFU was 26.2 ± 5.1 years. In the multivariate Cox regression analysis we found that poor dietary compliance during adolescence was significantly associated with a higher risk of becoming LTFU during adulthood (p-value = 0.028). Discussion Adult patients who displayed poor treatment adherence during adolescence should be identified and carefully monitored to prevent loss of contact.
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Affiliation(s)
- Marianna Beghini
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Maximilian Pichler
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Fiona Carolina Tinnefeld
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Matthäus Metz
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Dorothea Möslinger
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Vassiliki Konstantopoulou
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Johannes Spenger
- University Children's Hospital, Salzburger Landeskliniken (SALK) and Paracelsus Medical University (PMU), 5020 Salzburg, Austria
| | - Alexandra Kautzky-Willer
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Florian Frommlet
- Center for Medical Data Science (Institute of Medical Statistics), Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Thomas Scherer
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Miriam Hufgard-Leitner
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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Shen G, Li W, Zhang Y, Chen L. Next-generation sequencing based newborn screening and comparative analysis with MS/MS. BMC Pediatr 2024; 24:230. [PMID: 38561707 PMCID: PMC10985934 DOI: 10.1186/s12887-024-04718-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 03/21/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Newborn screening (NBS), such as tandem mass spectrometry (MS/MS), may yield false positive/negative results. Next-generation sequencing (NGS) has the potential to provide increased data output, efficiencies, and applications. This study aimed to analyze the types and distribution of pathogenic gene mutations in newborns in Huzhou, Zhejiang province, China and explore the applicability of NGS and MS/MS in NBS. METHODS Blood spot samples from 1263 newborns were collected. NGS was employed to screen for pathogenic variants in 542 disease-causing genes, and detected variants were validated using Sanger sequencing. Simultaneously, 26 inherited metabolic diseases (IMD) were screened using MS/MS. Positive or suspicious samples identified through MS/MS were cross-referenced with the results of NGS. RESULTS Among all newborns, 328 had no gene mutations detected. NGS revealed at least one gene mutation in 935 newborns, with a mutation rate of 74.0%. The top 5 genes were FLG, GJB2, UGT1A1, USH2A, and DUOX2. According to American College of Medical Genetics guidelines, gene mutations in 260 cases were classified as pathogenic or likely pathogenic mutation, with a positive rate of 20.6%. The top 5 genes were UGT1A1, FLG, GJB2, MEFV, and G6PD. MS/MS identified 18 positive or suspicious samples for IMD and 1245 negative samples. Verification of these cases by NGS results showed no pathogenic mutations, resulting in a false positive rate of 1.4% (18/1263). CONCLUSION NBS using NGS technology broadened the range of diseases screened, and enhanced the accuracy of diagnoses in comparison to MS/MS for screening IMD. Combining NGS and biochemical screening would improve the efficiency of current NBS.
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Affiliation(s)
- Guosong Shen
- Medical Laboratory Center, Huzhou Maternity & Child Health Care Hospital, Huzhou, Zhejiang Province, 313000, China.
| | - Wenwen Li
- Medical Laboratory Center, Huzhou Maternity & Child Health Care Hospital, Huzhou, Zhejiang Province, 313000, China
| | - Yaqin Zhang
- Medical Laboratory Center, Huzhou Maternity & Child Health Care Hospital, Huzhou, Zhejiang Province, 313000, China
| | - Lyuyan Chen
- Institut for Neuroscience, Technical University of Munich, 80802, Munich, Germany
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Esgi M, Ergun H, Kaya NY, Atakay DY, Erucar E, Celik F. Phenylketonuria from the perspectives of patients in Türkiye. Orphanet J Rare Dis 2024; 19:78. [PMID: 38378595 PMCID: PMC10880278 DOI: 10.1186/s13023-024-03079-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 02/03/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND The present study aimed to determine the problems, unmet needs and expectations of phenylketonuria (PKU) patients in Türkiye regarding follow-up and treatment in order to provide data for future planning and implementations on PKU. METHODS The study included patients diagnosed with PKU and/or their parents. They were informed about the study via phone calls and their verbal consents were obtained. Questions in the data collection forms, which were established separately for pediatric, adolescent, and adult age groups, were applied during the interviews and the answers were recorded. RESULTS Among 182 classical PKU patients, 66 (36.3%) were in the pediatric group (0-12 years old), 44 (24.2%) were in the adolescent group (13-19 years old), and 72 (39.5%) were in the adult group (≥ 20 years old). In all patient groups, phenylalanine-restricted diet and medical nutrition products were the main options for treatment. The median of the last measured blood phenylalanine concentration (patient-reported) was 290 µmol/L, 425 µmol/L, and 750 µmol/L in the pediatric, adolescent, and adult groups, respectively. The frequency of blood testing for serum phenylalanine level according to the age groups was appropriate in nearly half of the patients. While the majority of the patients have been visiting the metabolism center they have been diagnosed with PKU for control, considerable proportion of the patients would like to change the center or the doctor they visit for control if they could. It was determined that nearly half of the patients had trouble in accessing the metabolism center. Treatment options' being limited and expensive were the major problems. The main requests of the patients and patient relatives included easier access to the metabolism centers and more options for treatment and diet. CONCLUSIONS Access to the services should be easier to improve the patients' follow-up and treatment. There is need for low-cost, easily applicable, and accessible nutrition products and effective novel pharmacological agents. Focusing on these issues in health policies by providing pedagogic/psychological support, establishing support programs also comprising the families, and increasing the awareness activities were the key outcomes.
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Affiliation(s)
- Merve Esgi
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Kocaeli University, Kocaeli, Türkiye.
| | - Hakan Ergun
- Department of Medical Pharmacology, Ankara University Faculty of Medicine, Ankara, Türkiye
| | | | | | - Ege Erucar
- Faculty of Medicine, Altinbas University, Istanbul, Türkiye
| | - Fatma Celik
- Food and Drug Department, Parma University, Parma, Italy
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Ilgaz F, Ford S, O’Driscoll MF, MacDonald A. Adult PKU Clinics in the UK-Users' Experiences and Perspectives. Nutrients 2023; 15:4352. [PMID: 37892429 PMCID: PMC10610305 DOI: 10.3390/nu15204352] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/01/2023] [Accepted: 10/05/2023] [Indexed: 10/29/2023] Open
Abstract
Adults with PKU require life-long management, and ideally, their care should be in a specialised adult metabolic clinic. Their outcomes and co-morbidities have received much attention, but data are lacking on their experience, satisfaction and expectations about the care they receive. This survey reports the experiences and care adults with PKU receive from specialist metabolic clinics in the UK. The online survey developed by the UK NSPKU (National Society for Phenylketonuria), was placed on the NSPKU website from February 2021 to December 2022, and was completed by adults with PKU (≥18 years) or their carers/family members. Sixty-five adult PKU patients and 9 caregivers of adult patients completed the questionnaire (63% female in total). Only 32% of respondents were following a Phe-restricted diet with protein substitute intake as prescribed; the rest were partially adherent or not on dietary restrictions. Nineteen per cent (n = 14/74) had not been reviewed in clinic for two years. Half of the respondents (50%) described their experience in adult clinics as "good". Half of the patients were unable to contact their dietitians with questions or concerns, and only 24% considered that they received adequate support. Clinic reviews usually included anthropometric (82%) and dietary assessments (64%), discussion on management of PKU in daily life (78%) and a blood test (71%). Eighty-eight per cent reported they had at least one neurocognitive, mental health or behavioural co-morbidity but less than half of the patients reported an assessment on their neurocognitive functioning or mental health issues. Adult male patients appeared to have less detailed clinic review than females. Less than half (44%) of the respondents reported that they performed a blood spot for blood Phe at least monthly, but only 32% considered they had been informed about the risk of high Phe levels in adulthood. Although time, cost and stress related to travelling were barriers to a face-to-face review, more than 40% of patients had concerns about remote appointments. The frequency and extent of monitoring of adults with PKU, attending specialist adult services, were less than those specified by the PKU European guidelines. The care of women of reproductive age is prioritised over men. Adult metabolic health services require further attention, development and resources to provide a high standard and equitable service to patients with PKU.
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Affiliation(s)
- Fatma Ilgaz
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Hacettepe University, 06100 Ankara, Turkey
| | - Suzanne Ford
- Southmead Hospital North Bristol Trust, Bristol BS10 5NB, UK;
- National Society for Phenylketonuria (NSPKU), Sheffield S12 9ET, UK
| | - Michael F. O’Driscoll
- Department of Adult Child & Midwifery, School of Health Social Care & Education, Middlesex University, London NW4 4BT, UK;
| | - Anita MacDonald
- Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK;
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Maissen-Abgottspon S, Muri R, Hochuli M, Reismann P, Barta AG, Alptekin IM, Hermida-Ameijeiras Á, Burlina AP, Burlina AB, Cazzorla C, Carretta J, Trepp R, Everts R. Health-related quality of life in a european sample of adults with early-treated classical PKU. Orphanet J Rare Dis 2023; 18:300. [PMID: 37740225 PMCID: PMC10517574 DOI: 10.1186/s13023-023-02917-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 09/11/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Phenylketonuria (PKU) is a rare inborn error of metabolism affecting the catabolism of phenylalanine (Phe). To date, findings regarding health-related quality of life (HRQoL) in adults with early-treated classical PKU are discrepant. Moreover, little is known about metabolic, demographic, and cognitive factors associated with HRQoL. Hence, we aimed to investigate HRQoL and its association with demographic, metabolic, and cognitive characteristics in a large European sample of adults with early-treated classical PKU. RESULTS This cross-sectional study included 124 adults with early-treated classical PKU from Hungary, Italy, Spain, Switzerland, and Turkey. All participants prospectively completed the PKU quality of life questionnaire (PKU-QoL), a questionnaire specifically designed to evaluate the impact of PKU and its treatment on HRQoL in individuals with PKU. In addition, information about Phe levels (concurrent and past year), demographic (age and sex), and cognitive variables (intelligence quotient, IQ) were collected. Most domains revealed little or no impact of PKU on HRQoL and more than three-quarters of the patients rated their health status as good, very good, or excellent. Nevertheless, some areas of concern for patients were identified. Patients were worried about the guilt that they experience if they do not adhere to the dietary protein restriction and they were most concerned about high Phe levels during pregnancy. Further, tiredness was the most affected symptom, and the supplements' taste was considered a main issue for individuals with PKU. The overall impact of PKU on HRQoL was higher in women (U = 1315.5, p = .012) and in adults with a lower IQ (rs = - 0.448, p = .005). The overall impact of dietary protein restriction was higher in adults with higher concurrent Phe levels (rs = 0.272, p = .007) and higher Phe levels during the past year (rs = 0.280, p = .009). CONCLUSION The impact of PKU on most domains assessed in the PKU-QoL was considered to be low. These results likely reflect the successful implementation of the newborn screening resulting in the prevention of severe adverse long-term outcomes. However, a particular clinical focus should be given to patients with lower IQ, higher Phe levels, and women, as these variables were associated with a lower HRQoL.
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Affiliation(s)
- Stephanie Maissen-Abgottspon
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raphaela Muri
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Support Center for Advanced Neuroimaging (SCAN), Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Michel Hochuli
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Péter Reismann
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - András Gellért Barta
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Ismail Mucahit Alptekin
- Faculty of Health Sciences, Department of Nutrition and Dietetics, Ankara University, Ankara, Turkey
| | - Álvaro Hermida-Ameijeiras
- Division of Internal Medicine, European Reference Network for Hereditary Metabolic Disorders (MetabERN), University Clinical Hospital, Santiago de Compostela, Spain
| | | | - Alberto B Burlina
- Division of Inborn Metabolic Diseases, Department of Pediatrics, University Hospital, Padua, Italy
| | - Chiara Cazzorla
- Division of Inborn Metabolic Diseases, Department of Pediatrics, University Hospital, Padua, Italy
| | - Jessica Carretta
- Neurological Unit, St. Bassiano Hospital, Bassano del Grappa, Italy
| | - Roman Trepp
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Regula Everts
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Division of Neuropediatrics, Development and Rehabilitation, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Rocha JC, Ahring KK, Bausell H, Bilder DA, Harding CO, Inwood A, Longo N, Muntau AC, Pessoa ALS, Rohr F, Sivri S, Hermida Á. Expert Consensus on the Long-Term Effectiveness of Medical Nutrition Therapy and Its Impact on the Outcomes of Adults with Phenylketonuria. Nutrients 2023; 15:3940. [PMID: 37764724 PMCID: PMC10536918 DOI: 10.3390/nu15183940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/28/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
Many adults with phenylketonuria (PKU) rely on medical nutrition therapy (MNT; low phenylalanine (Phe) diet with protein substitutes/medical foods) to maintain blood Phe concentrations within recommended ranges and prevent PKU-associated comorbidities. Despite disease detection through newborn screening and introduction of MNT as early as birth, adherence to MNT often deteriorates from childhood onwards, complicating the assessment of its effectiveness in the long term. Via a modified Delphi process, consensus (≥70% agreement) was sought on 19 statements among an international, multidisciplinary 13-member expert panel. After three iterative voting rounds, the panel achieved consensus on 17 statements related to the limitations of the long-term effectiveness of MNT (7), the burden of long-term reliance on MNT (4), and its potential long-term detrimental health effects (6). According to the expert panel, the effectiveness of MNT is limited in the long term, is associated with a high treatment burden, and demonstrates that adults with PKU are often unable to achieve metabolic control through dietary management alone, creating an unmet need in the adult PKU population.
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Affiliation(s)
- Júlio César Rocha
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Campo Mártires da Pátria 130, 1169-056 Lisboa, Portugal
- Reference Centre of Inherited Metabolic Diseases, Centro Hospitalar Universitário de Lisboa Central, Rua Jacinta Marto, 1169-045 Lisboa, Portugal
- CINTESIS@RISE, Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade NOVA de Lisboa, Campo Mártires da Pátria 130, 1169-056 Lisboa, Portugal
| | - Kirsten K. Ahring
- Departments of Paediatrics and Clinical Genetics, PKU Clinic, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Heather Bausell
- Division of Genetics, Genomics, and Metabolism, Ann & Robert H Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL 60611, USA
| | - Deborah A. Bilder
- Department of Psychiatry, Division of Child & Adolescent Psychiatry, University of Utah Huntsman Mental Health Institute, 501 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Cary O. Harding
- Department of Molecular and Medical Genetics, Oregon Health & Science University, 3222 SW Research Drive, Portland, OR 97239, USA
| | - Anita Inwood
- Queensland Lifespan Metabolic Medicine Service, Queensland Children’s Hospital, 501 Stanley St., South Brisbane, QLD 4101, Australia
- School of Nursing and Social Work, The University of Queensland, Chamberlain Building, St. Lucia, QLD 4072, Australia
| | - Nicola Longo
- Department of Pediatrics, Division of Medical Genetics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Ania C. Muntau
- Department of Pediatrics, University Children’s Hospital, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - André L. Santos Pessoa
- Albert Sabin Children’s Hospital, R. Tertuliano Sales, 544—Vila União, Fortaleza 60410-794, CE, Brazil
- Av. Dr. Silas Munguba, 1700—Itaperi, State University of Ceará (UECE), Fortaleza 60714-903, CE, Brazil
| | | | - Serap Sivri
- Division of Pediatric Metabolism, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Gevher Nesibe Cd., 06230 Ankara, Turkey
| | - Álvaro Hermida
- Diagnosis and Treatment of Congenital Metabolic Diseases Unit (UDyTEMC), Department of Pediatrics, Faculty of Medicine, Clinical University Hospital of Santiago de Compostela, University of Santiago de Compostela, CIBERER, MetabERN, Institute of Clinical Research of Santiago de Compostela (IDIS), Rúa de San Francisco s/n, 15706 Santiago de Compostela, Spain
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10
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Brunelli L, Sohn H, Brower A. Newborn sequencing is only part of the solution for better child health. LANCET REGIONAL HEALTH. AMERICAS 2023; 25:100581. [PMID: 37663526 PMCID: PMC10474049 DOI: 10.1016/j.lana.2023.100581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 09/05/2023]
Abstract
Newborn screening (NBS) aims to detect newborns with severe congenital diseases before the onset of clinical manifestations. Advancements in genomic technologies have led to proposals for the development of genomic-based NBS (G-NBS) in concert with traditional NBS. Proponents of G-NBS highlight how G-NBS could expand the number of diseases screened at birth to thousands and spur the development of new drugs and treatments for rare diseases. Balancing the excitement, some experts have pointed to the ethical dilemmas linked to G-NBS. The dialog, however, has yet to engage with sufficient urgency on how the new G-NBS might chart a course for improving the health of all children. Our analysis of more than 130 million births in the United States between 1959 and 1995 shows that traditional NBS led to improvements in infant mortality and health equity only when it was implemented in association with measures to improve healthcare access for children. We suggest that the new G-NBS will lead to better child health only when the same degree of attention devoted to genomic technologies will be directed to the promotion of public health measures that facilitate access to high-quality healthcare for all children.
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Affiliation(s)
- Luca Brunelli
- Division of Neonatology, Department of Pediatrics, Spencer Fox Eccles School of Medicine, University of Utah, and Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, United States
| | - Heeju Sohn
- Department of Sociology, Emory University, Atlanta, GA, United States
| | - Amy Brower
- American College of Medical Genetics and Genomics (ACMG), Bethesda, MD, United States
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11
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Charrière S, Maillot F, Bouée S, Douillard C, Jacob C, Schneider KM, Theil J, Arnoux JB. Health status and comorbidities of adult patients with phenylketonuria (PKU) in France with a focus on early-diagnosed patients - A nationwide study of health insurance claims data. Mol Genet Metab 2023; 139:107625. [PMID: 37329624 DOI: 10.1016/j.ymgme.2023.107625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 05/30/2023] [Accepted: 05/30/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND This study aimed at evaluating the health status and healthcare consumption of ≥16-year-old patients with phenylketonuria (PKU), with a focus on early-diagnosed patients. METHODS This retrospective observational study used health insurance claims data from the French SNDS (Système National des Données de Santé) database. Patients with PKU were identified between 2006 and 2018 by ICD-10 diagnosis codes E70.0 (classic PKU) or E70.1 (other causes of hyperphenylalaninemia). They were matched to controls by age, sex, and region. Patients with early-diagnosed PKU were defined as patients born after implementation of nationwide newborn screening in France in 1972. Outcomes were analyzed for the year 2018. RESULTS Overall, 3549 patients with PKU were identified on January 1st, 2018. Of those, 3469 patients could be matched to 17,170 controls without PKU. Of these patients, 2175 were at least 16 years old and suffered significantly more than controls from specific comorbidities of interest - osteoporosis (28.7% vs 19.8%, p < 0.0001), hypertension (20.9% vs 17.0%, p < 0.0001), hypercholesterolemia (12.8% vs 8.3%, p < 0.0001), diabetes (7.8% vs 4.7%, p < 0.0001), obesity (4.2% vs 1.3%, p < 0.0001), ischemic heart diseases (4.8% vs 2.0%, p < 0.0001), and depression (10.3% vs 8.2%, p = 0.0011). Prescriptions for many medications were also more frequent in patients with PKU than controls. Among ≥16-year-old patients, 1528 were categorized as early-diagnosed. Osteoporosis (0.3% vs 0.01%, p = 0.0035), chronic renal failure (0.6% vs 0.1%, p = 0.0020), hypertension (4.0% vs 2.7%, p = 0.0063), and obesity (2.5% vs 0.8%, p < 0.0001) were significantly more prevalent in early-diagnosed adult patients compared with matched controls. In total, 28.6% of ≥16-year-old patients with PKU and 40.4% of early-diagnosed patients with PKU received dietary amino-acid supplements. Sapropterin was prescribed to 5.0% and 7.0% patients, respectively. CONCLUSION The results indicate that PKU is associated with a significantly higher comorbidity risk along with increased pharmaceutical prescriptions in adulthood. The comorbidity burden is less distinct in early-diagnosed patients but still present. Few patients are treated specifically for PKU in adulthood. Healthcare of patients with PKU should include prevention and management of comorbidities and especially target PKU-specific treatment adherence and consistent care in specialized medical centers in adulthood.
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Affiliation(s)
- Sybil Charrière
- Hospices Civils de Lyon, Department of endocrinology, diabetologia, metabolic diseases and nutrition, Hôpital Louis Pradel, 69600 BRON, France. CarMen laboratory, INSERM, INRAE, Université Claude Bernard Lyon 1, 69310, Pierre Bénite, France.
| | - Francois Maillot
- Service de médecine interne, CHRU et Université de Tours, UMR INSERM 1253 « iBrain », Tours, France.
| | - Stéphane Bouée
- CEMKA, 43 boulevard du Maréchal Joffre, 92340, Bourg-La-Reine, France.
| | - Claire Douillard
- Service d'endocrinologie, diabétologie, métabolisme et nutrition, Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Huriez, CHU de Lille, 59037 Lille, France.
| | | | | | - Julia Theil
- Xcenda GmbH, Lange Laube 31, 30159 Hannover, Germany.
| | - Jean-Baptiste Arnoux
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Necker-Enfants Malades, APHP, 149 rue de Sèvres, 75015 Paris, France.
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12
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Balobaid A, Imtiaz F, Ramzan K, Afzal S, AlSayed M. Identification of Variants Underlying Phenylalanine Hydroxylase Deficiency in Saudi Arabia. Genet Test Mol Biomarkers 2023; 27:142-148. [PMID: 37257178 DOI: 10.1089/gtmb.2022.0218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
Background: Deleterious mutations in the human gene phenylalanine hydroxylase (PAH) encoding the phenylalanine hydroxylase enzyme give rise to classic phenylketonuria and hyperphenylalaninemia. Our study was designed to characterize the spectrum of variants in the PAH gene in Saudi patients. Materials and Methods: We screened a cohort of 72 Saudi patients with clinical and biochemical diagnoses of hyperphenylalaninemia at the largest tertiary care center in Saudi Arabia; the King Faisal Specialist Hospital and Research Center (KFSH&RC), Riyadh. All patient's charts were reviewed under an approved study by Institutional Review Board. Results: Twenty-one different PAH variants were identified among the 144 PAH alleles assessed by targeted gene sequencing. Within the studied cohort, 60 of 72 patients had homozygous mutations with the the remaining 12 being compound heterozygotes. The most prevalent of the disease alleles identified in this study was the p.(Arg252Trp) mutation, which accounted for 38 of 144 alleles (26.4%). With the high incidence of genetic disorders in the population, religiously permissible preventive reproductive measures are a priority in our practice. Prenatal diagnoses carried out on four fetuses revealed two that were homozygous for PAH pathogenic variants. In addition, pre-implantation genetic diagnoses were initiated for 19 families. Eight of these families completed more than one full cycle of treatment, from which one healthy newborn was delivered. Conclusions: This study describes the spectrum of PAH variants in the Saudi population and highlights the molecular heterogeneity underlying phenylketonuria and hyperphenylalaninemia. These results add to the existing knowledge about PAH variants in Middle Eastern Countries. These results can be further translated to provide: informed counseling; cascade carrier testing in extended family members; and pre-marital screening.
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Affiliation(s)
- Ameera Balobaid
- Department of Medical Genomics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Faiqa Imtiaz
- Department of Clinical Genomics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Khushnooda Ramzan
- Department of Clinical Genomics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Sibtain Afzal
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Moeenaldeen AlSayed
- Department of Medical Genomics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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13
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Merkel M, Berg D, Brüggemann N, Classen J, Mainka T, Zittel S, Muntau AC. Characterisation and differential diagnosis of neurological complications in adults with phenylketonuria: literature review and expert opinion. J Neurol 2023:10.1007/s00415-023-11703-4. [PMID: 37081197 DOI: 10.1007/s00415-023-11703-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/31/2023] [Accepted: 04/01/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVE Phenylketonuria (PKU) is a rare inherited metabolic disorder characterised by elevated phenylalanine (Phe) concentrations that can exert neurotoxic effects if untreated or upon treatment discontinuation. This systematic review supported by expert opinion aims to raise awareness among the neurological community on neurological complications experienced by adults with PKU (AwPKU). METHODS The PubMed database was searched for articles on neurological signs and symptoms in AwPKU published before March 2022. In addition, two virtual advisory boards were held with a panel of seven neurologists and two metabolic physicians from Germany and Austria. Findings are supported by three illustrative patient cases. RESULTS Thirty-nine articles were included. Despite early diagnosis and treatment, neurological signs and symptoms (e.g. ataxia, brisk tendon reflexes, tremor, visual impairment) can emerge in adulthood, especially if treatment has been discontinued after childhood. In PKU, late-onset neurological deficits often co-occur with cognitive impairment and psychiatric symptoms, all of which can be completely or partially reversed through resumption of treatment. CONCLUSION Ideally, neurologists should be part of the PKU multidisciplinary team, either to bring lost to follow-up patients back to clinic or to manage symptoms in referred patients, considering that symptoms are often reversible upon regaining metabolic control. The current findings have been combined in a leaflet that will be disseminated among neurologists in Germany and Austria to create awareness.
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Affiliation(s)
- Martin Merkel
- Endokrinologikum Hamburg, Lornsenstraße 6, 22767, Hamburg, Germany.
- Asklepios Campus Hamburg, Semmelweis University, Hamburg, Germany.
| | - Daniela Berg
- Department of Neurology, Christian-Albrechts University, Kiel, Germany
| | | | - Joseph Classen
- Department of Neurology, Leipzig University Medical Center, Leipzig, Germany
| | - Tina Mainka
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
- Berlin Institute of Health at Charité Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
| | - Simone Zittel
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ania C Muntau
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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14
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Thomas L, Olson A, Romani C. The impact of metabolic control on cognition, neurophysiology, and well-being in PKU: A systematic review and meta-analysis of the within-participant literature. Mol Genet Metab 2023; 138:106969. [PMID: 36599257 DOI: 10.1016/j.ymgme.2022.106969] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022]
Abstract
Phenylketonuria (PKU) is a metabolic disease where Phenylalanine (Phe) rises much above normal levels. Cross-sectional and correlational studies provide valuable information on the importance of maintaining low blood-Phe to achieve good outcomes, but they may be confounded, at least partially, by differences in participant demographics. Moreover, the effect of Phe at older ages is difficult to ascertain because of strong associations between Phe levels across ages. Within-participant studies avoid confounding issues. We have reviewed these studies. We followed PRISMA guidelines to search the literature for studies reporting the impact of Phe changes within participants. Phe was either increased or decreased through diet relaxation/resumption or through pharmacological interventions. Forty-six separate articles reported, singly or in combination, results on cognition (N = 37), well-being (N = 22) and neurophysiological health (N = 14). For all studies, we established, in a binary way, whether a benefit of lower Phe was or was not demonstrated and compared numbers showing benefit versus a null or negative outcome. We then analyzed whether critical parameters (e.g., length of the study/condition for the change, size of Phe change achieved) influenced presence or absence of benefit. For a subset of studies that reported quantitative cognitive outcomes, we carried out a meta-analysis to estimate the size of change in cognitive performance associated with a change in Phe and its significance. There were significantly more studies with benefits than no benefits, both for cognitive and well-being outcomes, and a trend in this direction for neurophysiological outcomes. The meta-analysis showed a highly significant effect size both overall (0.55) and when studies with adults/adolescents were considered separately (0.57). There was some indication that benefits were easier to demonstrate when differences in Phe were larger and achieved across a longer period, but these effects were not always consistent. These results reinforce results from the literature by demonstrating the importance of lower Phe in children as well as in adolescents and adults, even when confounding factors in group composition are eliminated. The field would benefit from further studies where Phe levels are contrasted within-participants to ascertain how much Phe needs to be changed and for how long to see a difference and which measures demonstrate a difference (e.g., which cognitive tasks).
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15
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Thau-Zuchman O, Pallier PN, Savelkoul PJM, Kuipers AAM, Verkuyl JM, Michael-Titus AT. High phenylalanine concentrations induce demyelination and microglial activation in mouse cerebellar organotypic slices. Front Neurosci 2022; 16:926023. [PMID: 36248632 PMCID: PMC9559601 DOI: 10.3389/fnins.2022.926023] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 09/05/2022] [Indexed: 11/29/2022] Open
Abstract
Phenylketonuria (PKU) is an inborn error of metabolism. Mutations in the enzyme phenylalanine hydroxylase (PAH)-encoding gene lead to a decreased metabolism of the amino acid phenylalanine (Phe). The deficiency in PAH increases Phe levels in blood and brain. Accumulation of Phe can lead to delayed development, psychiatric problems and cognitive impairment. White matter (WM) damage is a neuropathological hallmark of PKU and can be seen even in early detected and treated PKU patients. The mechanisms linking high Phe concentrations to WM abnormalities remain unclear. We tested the effects of high Phe concentrations on myelin in three in vitro models of increasing complexity: two simple cell culture models and one model that preserves local brain tissue architecture, a cerebellar organotypic slice culture prepared from postnatal day (P) 8 CD-1 mice. Various Phe concentrations (0.1–10 mM) and durations of exposure were tested. We found no toxic effect of high Phe in the cell culture models. On the contrary, the treatment promoted the maturation of oligodendrocytes, particularly at the highest, non-physiological Phe concentrations. Exposure of cerebellar organotypic slices to 2.4 mM Phe for 21 days in vitro (DIV), but not 7 or 10 DIV, resulted in a significant decrease in myelin basic protein (MBP), calbindin-stained neurites, and neurites co-stained with MBP. Following exposure to a toxic concentration of Phe, a switch to the control medium for 7 days did not lead to remyelination, while very active remyelination was seen in slices following demyelination with lysolecithin. An enhanced number of microglia, displaying an activated type morphology, was seen after exposure of the slices to 2.4 mM Phe for 10 or 21 DIV. The results suggest that prolonged exposure to high Phe concentrations can induce microglial activation preceding significant disruption of myelin.
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Affiliation(s)
- Orli Thau-Zuchman
- Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and Dentistry, The Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Patrick N. Pallier
- Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and Dentistry, The Blizard Institute, Queen Mary University of London, London, United Kingdom
- *Correspondence: Patrick N. Pallier,
| | | | | | | | - Adina T. Michael-Titus
- Centre for Neuroscience, Surgery and Trauma, Barts and The London School of Medicine and Dentistry, The Blizard Institute, Queen Mary University of London, London, United Kingdom
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16
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A comprehensive assessment of neurocognitive and psychological functioning in adults with early-treated phenylketonuria. J Int Neuropsychol Soc 2022:1-10. [PMID: 36134437 DOI: 10.1017/s1355617722000686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Relative to youth with early-treated phenylketonuria (ETPKU), much less is known regarding the cognitive profile of adults with ETPKU. The present study aimed to address this gap by providing a comprehensive assessment of neuropsychological functioning among adults with ETPKU. METHOD A sample of 40 adults with ETPKU (ages 18 - 36) and a demographically matched group of 32 healthy individuals without PKU participated. Participants completed a comprehensive neuropsychological battery including the NIH Toolbox, Wechsler Abbreviated Scale of Intelligence - Second Edition (WASI-II), Conners' Continuous Performance Test (CPT-3), select subtests from the Weschler Adult Intelligence Scale - Fourth Edition (WAIS-IV) as well as several self-report measures of cognitive and psychoemotional functioning. Scores from these tests were combined to create cognitive composites reflecting overall task performance in the areas of verbal ability, visuospatial skills, executive functioning, motor skills, and processing speed. RESULTS No group differences were observed for full scale IQ or verbal ability. However, individuals with ETPKU demonstrated poorer performance on measures of executive functioning, processing speed, motor skills, and visuospatial skills as compared to the non-PKU group. Within the ETPKU group, recent blood phenylalanine levels (an indicator of metabolic control) were significantly correlated with performance across most cognitive domains and aspects of psychological functioning. CONCLUSIONS Present findings suggest that the neuropsychological profile of adult ETPKU is characterized by circumscribed impairments in select cognitive domains. In addition, the results underscore the importance of maintaining metabolic control across the lifespan in individuals with ETPKU.
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17
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Vucko ER, Havens KE, Baker JJ, Burton BK. Pegvaliase dose escalation to 80 mg daily may lead to efficacy in patients who do not exhibit an optimal response at lower doses. Mol Genet Metab Rep 2022; 32:100905. [PMID: 36046394 PMCID: PMC9421444 DOI: 10.1016/j.ymgmr.2022.100905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/23/2022] [Accepted: 07/24/2022] [Indexed: 11/15/2022] Open
Abstract
In 2018, pegvaliase was approved as the first enzyme substitution treatment for phenylketonuria (PKU) and is now the second medication available for PKU patients since the approval of sapropterin dihydrochloride in 2007. Historically, dietary management has been the mainstay of treatment for PKU. While sapropterin response rate is limited to approximately 50% of PKU patients, pegvaliase has the potential to reduce phenylalanine levels in all PKU patients (Vockley et al., 2014; Longo et al., 2019 [1,3]). Current FDA labeling for pegvaliase includes a dose maximum of 60 mg daily (Longo et al., 2019; BioMarin Pharmaceutical Inc., 2020 [3,4]). We report a case series of four phenylalanine hydroxylase (PAH) deficient patients, previously treated with dietary management only, who initiated treatment with pegvaliase and were titrated to 80 mg daily dosing. The safety profile in these four cases did not differ from lower maintenance dosing (Longo et al., 2019 [3]). Subsequent decreases in Phe levels were observed on 80 mg maintenance dosing, allowing for individualized dietary liberalization in three out of four patients. We conclude that pegvaliase dosing must be personalized to achieve therapeutic goals and that some patients may require higher doses than those included on the product label.
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Affiliation(s)
- Erika R Vucko
- Division of Genetics, Genomics, and Metabolism, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, United States of America.,Northwestern Feinberg School of Medicine, Chicago, IL, United States of America
| | - Kirsten E Havens
- Division of Genetics, Genomics, and Metabolism, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, United States of America
| | - Joshua J Baker
- Division of Genetics, Genomics, and Metabolism, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, United States of America.,Northwestern Feinberg School of Medicine, Chicago, IL, United States of America
| | - Barbara K Burton
- Division of Genetics, Genomics, and Metabolism, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, United States of America.,Northwestern Feinberg School of Medicine, Chicago, IL, United States of America
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18
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Burton BK, Hermida Á, Bélanger-Quintana A, Bell H, Bjoraker KJ, Christ SE, Grant ML, Harding CO, Huijbregts SCJ, Longo N, McNutt MC, Nguyen-Driver MD, Santos Pessoa AL, Rocha JC, Sacharow S, Sanchez-Valle A, Sivri HS, Vockley J, Walterfang M, Whittle S, Muntau AC. Management of early treated adolescents and young adults with phenylketonuria: Development of international consensus recommendations using a modified Delphi approach. Mol Genet Metab 2022; 137:114-126. [PMID: 36027720 DOI: 10.1016/j.ymgme.2022.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/16/2022] [Accepted: 07/23/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Early treated patients with phenylketonuria (PKU) often become lost to follow-up from adolescence onwards due to the historical focus of PKU care on the pediatric population and lack of programs facilitating the transition to adulthood. As a result, evidence on the management of adolescents and young adults with PKU is limited. METHODS Two meetings were held with a multidisciplinary international panel of 25 experts in PKU and comorbidities frequently experienced by patients with PKU. Based on the outcomes of the first meeting, a set of statements were developed. During the second meeting, these statements were voted on for consensus generation (≥70% agreement), using a modified Delphi approach. RESULTS A total of 37 consensus recommendations were developed across five areas that were deemed important in the management of adolescents and young adults with PKU: (1) general physical health, (2) mental health and neurocognitive functioning, (3) blood Phe target range, (4) PKU-specific challenges, and (5) transition to adult care. The consensus recommendations reflect the personal opinions and experiences from the participating experts supported with evidence when available. Overall, clinicians managing adolescents and young adults with PKU should be aware of the wide variety of PKU-associated comorbidities, initiating screening at an early age. In addition, management of adolescents/young adults should be a joint effort between the patient, clinical center, and parents/caregivers supporting adolescents with gradually gaining independent control of their disease during the transition to adulthood. CONCLUSIONS A multidisciplinary international group of experts used a modified Delphi approach to develop a set of consensus recommendations with the aim of providing guidance and offering tools to clinics to aid with supporting adolescents and young adults with PKU.
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Affiliation(s)
- Barbara K Burton
- Ann and Robert H. Lurie Children's Hospital and Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Álvaro Hermida
- Clinical University Hospital of Santiago de Compostela, University of Santiago de Compostela, CIBERER, MetabERN, Institute of Clinical Research of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | | | - Heather Bell
- Fred A. Litwin Family Centre in Genetic Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | | | - Shawn E Christ
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Mitzie L Grant
- Department of Psychiatry, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Cary O Harding
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, OR, USA
| | | | - Nicola Longo
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Markey C McNutt
- McDermott Center for Human Growth and Development, UT Southwestern Medical Center, Dallas, TX, USA
| | - Mina D Nguyen-Driver
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, OR, USA
| | - André L Santos Pessoa
- Pediatric Neurology Service, Albert Sabin Children's Hospital, University of Ceará State, Fortaleza, Ceará, Brazil
| | - Júlio César Rocha
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Portugal; Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia; Melbourne Neuropsychiatry Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Stephanie Sacharow
- CINTESIS-Center for Health Technology and Services Research, NOVA Medical School, Lisboa, Portugal; Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
| | - Amarilis Sanchez-Valle
- Reference Centre of Inherited Metabolic Diseases, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - H Serap Sivri
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA
| | - Jerry Vockley
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Mark Walterfang
- Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL, USA; Melbourne Neuropsychiatry Centre, Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia; University Children's Hospital, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Sarah Whittle
- Hacettepe University, Faculty of Medicine, Department of Pediatrics, Section of Pediatric Metabolism, Ankara, Turkey
| | - Ania C Muntau
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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19
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Measuring Burden of Illness in Phenylketonuria (PKU): Development of the PKU Symptom Severity and Impacts Scale as a Robust Patient-Reported Outcome. Adv Ther 2022; 39:971-991. [PMID: 34921666 PMCID: PMC8684342 DOI: 10.1007/s12325-021-01986-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022]
Abstract
Introduction Phenylketonuria (PKU) is a rare, metabolic genetic disorder that can cause various neuropsychological symptoms that often affect patients’ health-related quality of life, even for patients with good metabolic control. To date, no patient-reported outcomes (PRO) instrument combines the measurement of neuropsychological and dietary concepts to capture the broad impact of PKU on quality of life. This article presents the development of the PKU Symptom Severity and Impacts Scale (PKU-SSIS), a PRO instrument that is designed to evaluate neuropsychological symptoms and impacts in early-treated patients with PKU. Methods A draft instrument was developed based on a targeted literature review, PKU expert physician interviews, and an advisory board consisting of patients with PKU. Qualitative interviews combining concept elicitation/cognitive interviews were conducted with patients with classic PKU aged at least 15 years old. A separate sample of 20 patients with PKU completed the draft PKU-SSIS in a paper survey format, to enable preliminary assessment of any floor and ceiling effects. Results Patient interviews elicited four key symptom themes: neurocognitive function, emotional and behavioral, physical functioning, and physical health. Four impact themes were also identified: social function, physical health, emotions, and level of independence. No floor or ceiling effects were identified. Conclusion The final instrument included 22 items, covering three symptom domains (1. emotional, mood, and psychological; 2. (neuro)cognitive, executive, and intellectual function; and 3. physical health), and four impact domains (1. social relations, 2. level of independence, 3. general well-being, and 4. self-care). The PKU-SSIS will help to address an important gap in the evaluation of existing and future treatments for PKU.
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Bilder DA, Arnold GL, Dimmock D, Grant ML, Janzen D, Longo N, Nguyen-Driver M, Jurecki E, Merilainen M, Amato G, Waisbren S. Improved attention linked to sustained phenylalanine reduction in adults with early-treated phenylketonuria. Am J Med Genet A 2021; 188:768-778. [PMID: 34826353 PMCID: PMC9299696 DOI: 10.1002/ajmg.a.62574] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/22/2021] [Accepted: 10/29/2021] [Indexed: 12/03/2022]
Abstract
Pegvaliase is approved to reduce phenylalanine (Phe) levels for people with phenylketonuria (PKU). PRISM‐1 (NCT01819727) and PRISM‐2 (NCT01889862) data were analyzed to evaluate the relationship between Phe and inattention in adult participants with PKU. In the modified‐intent‐to‐treat population (N = 156), baseline mean (SE) plasma Phe was 1263 (29) μmol/L and the Attention Deficit Hyperactivity Disorder Rating Scale‐IV Inattentive (IA) symptoms score was 9.8 (0.5). Mean (SE) IA scores fell 9.0 (1.1) in Quartile 1 (Phe reduction between 1166 and 2229 μmol/L) versus 4.3 (0.7) in Quartile 4 (Phe reduction of 139 μmol/L to increase of 934 μmol/L), p = 0.004. Least squares mean (SE) change from baseline IA score was −7.9 (0.7) for participants with final Phe ≤ 360 μmol/L and −4.5 (0.7) for final Phe > 360 μmol/L, p < 0.001. In the inattention subgroup, IA scores fell 13.3 (1.5) in Quartile 1 (Phe reduction between 1288 and 2229 μmol/L) versus 6.2 (1.3) in Quartile 4 (Phe reduction of 247 to increase of 934 μmol/L), p = 0.009. Inattention symptoms improved among those whose Phe levels decreased, particularly those with high baseline IA scores. IA improvements were larger among participants with the greatest plasma Phe reductions, supporting this value as a therapeutic goal.
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Affiliation(s)
- Deborah A Bilder
- Department of Psychiatry, Division of Child & Adolescent Psychiatry, University of Utah Huntsman Mental Health Institute, Salt Lake City, Utah, USA
| | - Georgianne L Arnold
- Department of Genetics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David Dimmock
- Rady Children's Institute for Genomic Medicine, San Diego, California, USA
| | - Mitzie L Grant
- Department of Academic Psychiatry, Drexel University College of Medicine and St. Christopher's Hospital for Children, Philadelphia, Pennsylvania, USA
| | - Darren Janzen
- Department of Pediatrics, Division of Pediatric Psychology, Oregon Health & Science University, Portland, Oregon, USA
| | - Nicola Longo
- Department of Pediatrics, Division of Medical Genetics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Mina Nguyen-Driver
- Department of Pediatrics, Division of Pediatric Psychology, Oregon Health & Science University, Portland, Oregon, USA
| | | | | | - Gianni Amato
- BioMarin Pharmaceutical Inc., Novato, California, USA.,Biostats LLC, San Francisco, California, USA
| | - Susan Waisbren
- Department of Medicine, Division of Genetics and Genomics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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21
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Burton BK, Skalicky A, Baerwald C, Bilder DA, Harding CO, Ilan AB, Jurecki E, Longo N, Madden DT, Sivri HS, Wilcox G, Thomas J, Delaney K. A non-interventional observational study to identify and validate clinical outcome assessments for adults with phenylketonuria for use in clinical trials. Mol Genet Metab Rep 2021; 29:100810. [PMID: 34815941 PMCID: PMC8591457 DOI: 10.1016/j.ymgmr.2021.100810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/04/2021] [Accepted: 10/04/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction Current clinical outcome assessments (COAs) are not effectively capturing the complex array of symptoms of adults with phenylketonuria (PKU). This study aimed to identify concepts of interest relevant to adults with PKU. Based on these concepts, COAs for patient-reported outcomes (PROs), observer-reported outcomes (ObsROs), and clinician-reported outcomes (ClinROs) were selected or developed and content validity was assessed. Materials and methods Concept-elicitation interviews were conducted with an international cohort of adults with PKU (n = 30), family member observers (n = 14), and clinical experts (n = 8). Observers and clinical experts were included to overcome the risk of lack of self-awareness among adults with PKU. The concepts of interests endorsed by ≥30% of patients, observers, and/or clinical experts were selected, mapped to items in existing COAs, and used to develop global impression items for patients, observers, and clinicians. Next, the content validity of the COAs and global impression items was evaluated by cognitive interviews with patients (n = 22), observers (n = 11), and clinical experts (n = 8). All patients were categorized according to blood phenylalanine (Phe) levels (i.e., <600 μmol/L, 600–1200 μmol/L, and >1200 μmol/L). Results Concepts of interests were identified across four domains: emotional, cognitive, physical, and behavioral. After mapping, eight existing COAs were selected based on the concept coverage (six PROs, one ObsRO, and one ClinRO). The six PRO measures were considered as potentially fit-for-purpose. The ObsRO measure was not deemed relevant for use in observers of adults with PKU and only a subscale of the ClinRO measure was considered valid for assessing adults with PKU by clinicians. Due to the lack of existing COAs covering all concepts of interests, global impression items for symptom severity and change in symptoms were developed, which were limited to one question covering in total 14 concepts. Upon validation, some of the patient and observer global impression items were excluded as they were subject to lack of insight or could not be reported by observers. Due to the limited interaction time between clinician and patient, use of the clinician global impression items was not supported. Conclusion Existing COAs relevant to adults with PKU were selected and PKU-specific global impression items were developed by mapping the most frequently identified concepts of interests from internationally-conducted in-depth interviews. Future studies should address the appropriateness of the selected COAs and global impression items to assess if these can be used as efficacy endpoints in PKU clinical trials.
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Key Words
- ADHD RS-IV, Attention Deficit Hyperactivity Disorders Rating Scale-IV
- ADHD, Attention Deficit Hyperactivity Disorder
- Adults
- CAARS-O:Long, Conners' Adult ADHD Rating Scales-Observer Report Long Version
- CGI, Clinician Global Impression
- COAs, Clinical Outcome Assessments
- COIs, Concepts Of Interests
- ClinROs, Clinician-Reported Outcomes
- Clinical outcome assessments
- Clinician-reported outcomes
- FDA, Food and Drug Administration
- HRQoL, Health-Related Quality of Life
- IRB, Institutional Review Board
- Neuro-QoL, Quality of Life in Neurological Disorders
- OGI, Observer Global Impression
- ObsROs, Observer-Reported Outcomes
- Observer-reported outcomes
- PAH, Phenylalanine Hydroxylase
- PGI, Patient Global Impression
- PKU
- PKU, Phenylketonuria
- PKU-QOL, PKU Quality of Life
- PROMIS, Patient Reported Outcome Measurement Information System
- PROs, Patient-Reported Outcomes
- Patient-reported outcomes
- Phe, Phenylalanine
- Phenylketonuria
- QoL, Quality of Life
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Affiliation(s)
- Barbara K Burton
- Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anne Skalicky
- Patient-Centered Research, Evidera, Seattle, WA, USA
| | - Christoph Baerwald
- Rheumatology Unit, Department of Internal Medicine, Neurology and Dermatology, University Medical Center Leipzig, Leipzig, Germany
| | - Deborah A Bilder
- Department of Psychiatry, Division of Child & Adolescent Psychiatry, Huntsman Mental Health Institute, University of Utah, Salt Lake City, UT, USA
| | - Cary O Harding
- Department of Medical and Molecular Genetics, Oregon Health & Science University, Portland, OR, USA
| | | | | | - Nicola Longo
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | | | - H Serap Sivri
- Hacettepe University Faculty of Medicine, Division of Pediatric Metabolism, Ankara, Turkey
| | - Gisela Wilcox
- School of Medical Sciences, University of Manchester & The Mark Holland Metabolic Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Janet Thomas
- Department of Pediatrics, Section of Clinical Genetics and Metabolism, University of Colorado School of Medicine, Aurora, CO, USA
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Rohde C, Thiele AG, Baerwald C, Ascherl RG, Lier D, Och U, Heller C, Jung A, Schönherr K, Joerg-Streller M, Luttat S, Matzgen S, Winkler T, Rosenbaum-Fabian S, Joos O, Beblo S. Preventing maternal phenylketonuria (PKU) syndrome: important factors to achieve good metabolic control throughout pregnancy. Orphanet J Rare Dis 2021; 16:477. [PMID: 34794480 PMCID: PMC8600879 DOI: 10.1186/s13023-021-02108-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/06/2021] [Indexed: 11/22/2022] Open
Abstract
Background Insufficient metabolic control during pregnancy of mothers with phenylketonuria (PKU) leads to maternal PKU syndrome, a severe embryo-/fetopathy. Since maintaining or reintroducing the strict phenylalanine (Phe) limited diet in adults with PKU is challenging, we evaluated the most important dietary and psychosocial factors to gain and sustain good metabolic control in phenylketonuric women throughout pregnancy by a questionnaire survey with 38 questions concerning therapy feasibility. Among them, the key questions covered 5 essential items of PKU care as follows: General information about maternal PKU, PKU training, diet implementation, individual metabolic care, personal support. In addition, all participating PKU mothers were asked to estimate the quality of their personal metabolic control of the concluded pregnancies. 54 PKU mothers with 81 pregnancies were approached at 12 metabolic centers in Germany and Austria were included. According to metabolic control, pregnancies of PKU women were divided in two groups: group “ideal” (not more than 5% of all blood Phe concentrations during pregnancy > 360 µmol/l; n = 23) and group “suboptimal” (all others; n = 51). Results The demand for support was equally distributed among groups, concerning both amount and content. Personal support by the direct social environment (partner, family and friends) (“suboptimal” 71% vs “ideal” 78%) as well as individual metabolic care by the specialized metabolic center (both groups around 60%) were rated as most important factors. The groups differed significantly with respect to the estimation of the quality of their metabolic situation (p < 0.001). Group “ideal” presented a 100% realistic self-assessment. In contrast, group “suboptimal” overestimated their metabolic control in 53% of the pregnancies. Offspring of group “suboptimal” showed clinical signs of maternal PKU-syndrome in 27%. Conclusion The development of training programs by specialized metabolic centers for females with PKU in child bearing age is crucial, especially since those mothers at risk of giving birth to a child with maternal PKU syndrome are not aware of their suboptimal metabolic control. Such programs should provide specific awareness training for the own metabolic situation and should include partners and families. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-02108-5.
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Affiliation(s)
- Carmen Rohde
- Hospital for Children and Adolescents, Centre for Pediatric Research Leipzig (CPL), Department of Women and Child Health, University Hospital, University of Leipzig, Leipzig, Germany.
| | - Alena Gerlinde Thiele
- Hospital for Children and Adolescents, Centre for Pediatric Research Leipzig (CPL), Department of Women and Child Health, University Hospital, University of Leipzig, Leipzig, Germany
| | - Christoph Baerwald
- University Hospital Internal Medicine, University of Leipzig, Leipzig, Germany
| | - Rudolf Georg Ascherl
- Hospital for Children and Adolescents, Centre for Pediatric Research Leipzig (CPL), Department of Women and Child Health, University Hospital, University of Leipzig, Leipzig, Germany
| | - Dinah Lier
- Department of Pediatrics, Klinikum Am Steinenberg, Reutlingen, Germany
| | - Ulrike Och
- Pediatrics Department of the University Clinic, Münster, Germany
| | - Christina Heller
- Department for Inborn Metabolic Diseases, Children's and Adolescents' Hospital, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Alexandra Jung
- Center of Excellence for Rare Metabolic Diseases, Charité, University Medicin, Berlin, Germany
| | - Kathrin Schönherr
- Centre for Inborn Metabolic Disorders, Department of Neuropediatrics, Jena University Hospital, Jena, Germany
| | - Monika Joerg-Streller
- Clinic for Pediatrics, Inherited Metabolic Disorders, Medical University Innsbruck, Innsbruck, Austria
| | - Simone Luttat
- Clinic for Pediatrics, University Magdeburg, Magdeburg, Germany
| | - Sabine Matzgen
- Department for General Pediatrics, Metabolic Unit, University Clinic of the the Justus Liebig University, Giessen, Germany
| | | | | | - Oxana Joos
- University Hospital, Greifswald, Germany
| | - Skadi Beblo
- Hospital for Children and Adolescents, Centre for Pediatric Research Leipzig (CPL), Department of Women and Child Health, University Hospital, University of Leipzig, Leipzig, Germany
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McCandless SE, Wright EJ. Mandatory newborn screening in the United States: History, current status, and existential challenges. Birth Defects Res 2021; 112:350-366. [PMID: 32115905 DOI: 10.1002/bdr2.1653] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/12/2020] [Accepted: 01/17/2020] [Indexed: 01/09/2023]
Abstract
Beginning in the 1960s, mandatory newborn screening (NBS) of essentially all infants has been a major public health success story. NBS is not just a blood test, rather, it is a complex, integrated system that begins with timely testing, scrupulous follow up of patients, tracking of outcomes, quality improvement of all aspects of the process, and education of providers, staff, and parents. In the past, expansion of NBS programs has been driven by new testing technology, but now is increasingly driven by the development of novel therapeutics and political advocacy. Each state determines how the NBS system will be structured in that state, but there is increasing oversight and support for harmonization at a federal level. Several recent initiatives, together with the increased number of conditions screened and the concomitant increase in burdensome false-positive tests, are creating new scrutiny of NBS systems, and potentially pose an existential risk to the public acceptance of mandatory NBS. The history, current state and challenges for NBS are explored in this issue, with some suggestions as to how to address them.
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Affiliation(s)
- Shawn E McCandless
- Department of Pediatrics, Section of Genetics and Metabolism, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Erica J Wright
- Department of Pediatrics, Section of Genetics and Metabolism, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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24
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Beghini M, Resch FJ, Möslinger D, Konstantopoulou V, Karall D, Scholl-Bürgi S, Brunner-Krainz M, Plecko B, Spenger J, Kautzky-Willer A, Scherer T, Hufgard-Leitner M. Project "Backtoclinic I": An overview on the state of care of adult PKU patients in Austria. Mol Genet Metab 2021; 133:257-260. [PMID: 34083143 DOI: 10.1016/j.ymgme.2021.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND High rates of lost to follow-up (LTFU) adult patients are a major concern in the long-term management of phenylketonuria (PKU). To address this issue, we designed the project "Backtoclinic" with the purpose of identifying LTFU adult PKU patients in Austria as a first step to reestablish appropriate treatment. SUBJECTS AND METHODS Individuals born between 1966 and 1999 and diagnosed with PKU through the National Austrian Newborn Screening Program (NANSP) were identified using the NANSP's database. Follow-up data were collected in the Austrian metabolic centers (Medical University of Vienna, Graz, Innsbruck and Salzburg). Patients with no contact to any of these centers within the previous two years were classified as LTFU. Epidemiological characteristics of the whole study population as well as of LTFU- and currently in follow-up patients were analyzed. RESULTS Between 1966 and 1999, 281 individuals were diagnosed with PKU through the NANSP. Two patients died in their first year of life and were excluded from the analysis. Of the remaining 279 patients (mean age ± SD: 36.7 ± 9.1 y, 42.7% females), 177 (63.4%) are currently LTFU. The rate of LTFU patients is higher in men than in women (68.1% vs 57.5%), and markedly increases with age in both sexes. The gender gap is greatest in young adults (52.6% vs. 25.0% in the age range 20.0-24.9 y) and declines with age (94.4% vs. 80.0% in the age range > 45.0 y). CONCLUSIONS We found an alarming rate of 63.4% of LTFU adult PKU patients in Austria, and observed a gender gap in the PKU state of care. Our findings illustrate the urgent need for the metabolic community to identify LTFU adult PKU patients and to develop strategies to reestablish appropriate treatment for men and women with PKU.
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Affiliation(s)
- Marianna Beghini
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Felix J Resch
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Dorothea Möslinger
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Waehringerguertel 18-20, 1090 Vienna, Austria.
| | - Vassiliki Konstantopoulou
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Waehringerguertel 18-20, 1090 Vienna, Austria.
| | - Daniela Karall
- Division of Inherited Metabolic Disorders, Clinic of Pediatrics I, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Sabine Scholl-Bürgi
- Division of Inherited Metabolic Disorders, Clinic of Pediatrics I, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Michaela Brunner-Krainz
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036 Graz, Austria.
| | - Barbara Plecko
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036 Graz, Austria.
| | - Johannes Spenger
- University Children's Hospital, Salzburger Landeskliniken (SALK), Paracelsus Medical University (PMU), 5020 Salzburg, Austria.
| | - Alexandra Kautzky-Willer
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Thomas Scherer
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Miriam Hufgard-Leitner
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
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Borges R, Colby SM, Das S, Edison AS, Fiehn O, Kind T, Lee J, Merrill AT, Merz KM, Metz TO, Nunez JR, Tantillo DJ, Wang LP, Wang S, Renslow RS. Quantum Chemistry Calculations for Metabolomics. Chem Rev 2021; 121:5633-5670. [PMID: 33979149 PMCID: PMC8161423 DOI: 10.1021/acs.chemrev.0c00901] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Indexed: 02/07/2023]
Abstract
A primary goal of metabolomics studies is to fully characterize the small-molecule composition of complex biological and environmental samples. However, despite advances in analytical technologies over the past two decades, the majority of small molecules in complex samples are not readily identifiable due to the immense structural and chemical diversity present within the metabolome. Current gold-standard identification methods rely on reference libraries built using authentic chemical materials ("standards"), which are not available for most molecules. Computational quantum chemistry methods, which can be used to calculate chemical properties that are then measured by analytical platforms, offer an alternative route for building reference libraries, i.e., in silico libraries for "standards-free" identification. In this review, we cover the major roadblocks currently facing metabolomics and discuss applications where quantum chemistry calculations offer a solution. Several successful examples for nuclear magnetic resonance spectroscopy, ion mobility spectrometry, infrared spectroscopy, and mass spectrometry methods are reviewed. Finally, we consider current best practices, sources of error, and provide an outlook for quantum chemistry calculations in metabolomics studies. We expect this review will inspire researchers in the field of small-molecule identification to accelerate adoption of in silico methods for generation of reference libraries and to add quantum chemistry calculations as another tool at their disposal to characterize complex samples.
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Affiliation(s)
- Ricardo
M. Borges
- Walter
Mors Institute of Research on Natural Products, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Sean M. Colby
- Biological
Science Division, Pacific Northwest National
Laboratory, Richland, Washington 99352, United States
| | - Susanta Das
- Department
of Chemistry, Michigan State University, East Lansing, Michigan 48824, United States
| | - Arthur S. Edison
- Departments
of Genetics and Biochemistry and Molecular Biology, Complex Carbohydrate
Research Center and Institute of Bioinformatics, University of Georgia, Athens, Georgia 30602, United States
| | - Oliver Fiehn
- West
Coast Metabolomics Center for Compound Identification, UC Davis Genome
Center, University of California, Davis, California 95616, United States
| | - Tobias Kind
- West
Coast Metabolomics Center for Compound Identification, UC Davis Genome
Center, University of California, Davis, California 95616, United States
| | - Jesi Lee
- West
Coast Metabolomics Center for Compound Identification, UC Davis Genome
Center, University of California, Davis, California 95616, United States
- Department
of Chemistry, University of California, Davis, California 95616, United States
| | - Amy T. Merrill
- Department
of Chemistry, University of California, Davis, California 95616, United States
| | - Kenneth M. Merz
- Department
of Chemistry, Michigan State University, East Lansing, Michigan 48824, United States
| | - Thomas O. Metz
- Biological
Science Division, Pacific Northwest National
Laboratory, Richland, Washington 99352, United States
| | - Jamie R. Nunez
- Biological
Science Division, Pacific Northwest National
Laboratory, Richland, Washington 99352, United States
| | - Dean J. Tantillo
- Department
of Chemistry, University of California, Davis, California 95616, United States
| | - Lee-Ping Wang
- Department
of Chemistry, University of California, Davis, California 95616, United States
| | - Shunyang Wang
- West
Coast Metabolomics Center for Compound Identification, UC Davis Genome
Center, University of California, Davis, California 95616, United States
- Department
of Chemistry, University of California, Davis, California 95616, United States
| | - Ryan S. Renslow
- Biological
Science Division, Pacific Northwest National
Laboratory, Richland, Washington 99352, United States
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Bertmann F, Dunn CG, Racine EF, Fleischhacker S. The Risk of Homemade Infant Formulas: Historical and Contemporary Considerations. J Acad Nutr Diet 2021; 122:697-708. [PMID: 34016563 DOI: 10.1016/j.jand.2021.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 03/09/2021] [Accepted: 03/09/2021] [Indexed: 11/28/2022]
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27
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Richardson JS, Kemper AR, Grosse SD, Lam WKK, Rose AM, Ahmad A, Gebremariam A, Prosser LA. Health and economic outcomes of newborn screening for infantile-onset Pompe disease. Genet Med 2021; 23:758-766. [PMID: 33281187 PMCID: PMC8035228 DOI: 10.1038/s41436-020-01038-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 10/27/2020] [Accepted: 10/27/2020] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To estimate health and economic outcomes associated with newborn screening (NBS) for infantile-onset Pompe disease in the United States. METHODS A decision analytic microsimulation model simulated health and economic outcomes of a birth cohort of 4 million children in the United States. Universal NBS and treatment was compared with clinical identification and treatment of infantile-onset Pompe disease. Main outcomes were projected cases identified, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) over the life course. RESULTS Universal NBS for Pompe disease and confirmatory testing was estimated to cost an additional $26 million annually. Additional medication costs associated with earlier treatment initiation were $181 million; however, $8 million in medical care costs for other services were averted due to delayed disease progression. Infants with screened and treated infantile-onset Pompe disease experienced an average lifetime increase of 11.66 QALYs compared with clinical detection. The ICER was $379,000/QALY from a societal perspective and $408,000/QALY from the health-care perspective. Results were sensitive to the cost of enzyme replacement therapy. CONCLUSION Newborn screening for Pompe disease results in substantial health gains for individuals with infantile-onset Pompe disease, but with additional costs.
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Affiliation(s)
- John S Richardson
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
- RTI International, Research Triangle Park, NC, USA
| | - Alex R Kemper
- Division of Ambulatory Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Scott D Grosse
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Wendy K K Lam
- Duke Clinical & Translational Science Institute, School of Medicine, Duke University, Durham, NC, USA
| | - Angela M Rose
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ayesha Ahmad
- Division of Pediatric Genetics, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Achamyeleh Gebremariam
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Lisa A Prosser
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA.
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.
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Zubarioglu T, Hopurcuoglu D, Uygur E, Ahmadzada S, Oge-Enver E, Isat E, Cansever MS, Kiykim E, Aktuglu-Zeybek C. The Impact of Telemedicine for Monitoring and Treatment of Phenylketonuria Patients on Metabolic Outcome During Coronavirus Disease-19 Outbreak. Telemed J E Health 2021; 28:258-265. [PMID: 33719565 DOI: 10.1089/tmj.2020.0569] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background: The prognosis of phenylketonuria (PKU) in terms of neurocognitive outcome is directly related to lifelong phenylalanine (Phe) levels and adherence to treatment. Monitoring and treatment of PKU patients can be complicated in challenging circumstances as pandemics. This study aims to evaluate the impact of telemedicine for monitoring and treatment of PKU patients on metabolic outcome during coronavirus disease-19 (COVID-19) outbreak. Materials and Methods: Patients who were diagnosed as PKU and treated with low Phe diet, tetrahydrobiopterin (BH4), or BH4 adjunct with low Phe diet were enrolled. Study period was divided into two periods: prepandemic period wherein patients were followed up in outpatients' clinic and during pandemic wherein telemedicine was used. Demographic findings, laboratory results, and therapy responses were reviewed retrospectively and compared between the two periods. All procedures were in accordance with the ethical standards of the local ethical committee of Cerrahpasa Medical Faculty (17/11/2020-151640) and with the Helsinki Declaration of 1975, as revised in 2013. Results: Ninety-three (n = 93) patients were enrolled to this study. The ratio of the samples with Phe levels in the recommended ranges was found to be statistically higher during the pandemic wherein an online monitoring system was used in all treatment modalities (p < 0.05). The decrease in Phe washout frequency was statistically significant during the pandemic in the low Phe diet group (p < 0.05). Considering the relationship between Phe tolerance before and during the pandemic, a significant increase in Phe tolerance was noted during the pandemic in the low Phe diet group (p < 0.05). Conclusions: Telemedicine can be an appropriate and effective monitoring option for PKU patients during the COVID-19 pandemic.
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Affiliation(s)
- Tanyel Zubarioglu
- Cerrahpasa Medical Faculty, Division of Nutrition and Metabolism, Department of Pediatrics Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Duhan Hopurcuoglu
- Cerrahpasa Medical Faculty, Division of Nutrition and Metabolism, Department of Pediatrics Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Esma Uygur
- Cerrahpasa Medical Faculty, Division of Nutrition and Metabolism, Department of Pediatrics Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Saffa Ahmadzada
- Cerrahpasa Medical Faculty, Division of Nutrition and Metabolism, Department of Pediatrics Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ece Oge-Enver
- Cerrahpasa Medical Faculty, Division of Nutrition and Metabolism, Department of Pediatrics Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Esra Isat
- Cerrahpasa Medical Faculty, Division of Nutrition and Metabolism, Department of Pediatrics Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Mehmet Serif Cansever
- Division of Medical Laboratory Techniques, Department of Medical Documentation and Techniques, The Vocational School of Health Services, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ertugrul Kiykim
- Cerrahpasa Medical Faculty, Division of Nutrition and Metabolism, Department of Pediatrics Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Cigdem Aktuglu-Zeybek
- Cerrahpasa Medical Faculty, Division of Nutrition and Metabolism, Department of Pediatrics Istanbul University-Cerrahpasa, Istanbul, Turkey
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Implementing a Transition Program from Paediatric to Adult Services in Phenylketonuria: Results After Two Years of Follow-Up with an Adult Team. Nutrients 2021; 13:nu13030799. [PMID: 33671057 PMCID: PMC8001271 DOI: 10.3390/nu13030799] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/01/2021] [Accepted: 02/24/2021] [Indexed: 12/15/2022] Open
Abstract
We aimed to report the implementation of a phenylketonuria (PKU) transition program and study the effects of follow-up with an adult team on metabolic control, adherence, and loss of follow-up. Fifty-five PKU patients were analysed in the study periods (SP): 2 years before (SP1) and after the beginning of adult care (SP2). Retrospective data on metabolic control and number of clinic appointments were collected for each SP, and protein intakes were analysed. In SP2, three patients (6%) were lost to follow-up. There was a small but statistically significant increase in median number of annual blood spots from SP1 to SP2: 11 (7–15) vs. 14 (7–20); p = 0.002. Mean ± SD of median blood Phe remained stable (525 ± 248 µmol/L vs. 552 ± 225 µmol/L; p = 0.100); median % of blood Phe < 480 µmol/L decreased (51 (4–96)% vs. 37 (5–85)%; p = 0.041) and median number of clinic appointments increased from SP1 to SP2: (5 (4–6) vs. 11 (8–13); p < 0.001). No significant differences were found regarding any parameter of protein intake. Our results suggest that the implementation of an adult service was successful as impact on metabolic control was limited and attendance remained high. Continuous dietetic care likely contributed to these results by keeping patients in follow-up and committed to treatment.
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Burgess NM, Kelso W, Malpas CB, Winton-Brown T, Fazio T, Panetta J, De Jong G, Neath J, Atherton S, Velakoulis D, Walterfang M. The effect of improved dietary control on cognitive and psychiatric functioning in adults with phenylketonuria: the ReDAPT study. Orphanet J Rare Dis 2021; 16:35. [PMID: 33461585 PMCID: PMC7814424 DOI: 10.1186/s13023-020-01668-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/22/2020] [Indexed: 11/16/2022] Open
Abstract
Background Phenylketonuria (PKU) is an autosomal recessive inherited disorder characterised by a deficiency in phenylalanine hydroxylase. Untreated, PKU is associated with a wide range of cognitive and psychiatric sequelae. Contemporary management guidelines recommend lifetime dietary control of phenylalanine (Phe) levels, however many individuals who discontinue dietary control subsequently suffer symptoms of anxiety, depression and disturbances to cognition. We undertook a prospective cohort study of patients with early-treated phenylketonuria who had ceased dietary control to test the hypothesis that resumption of dietary control of PKU is associated with improvements in measures of psychiatric morbidity and cognitive functioning. Methods We re-initiated dietary control for early-treated patients with PKU and monitored cognitive and psychiatric outcomes over a twelve-month period. Assessments included objective cognitive function (measured by cognitive proficiency index (CPI)), anxiety and depression scales. General linear mixed model (GLMM) analyses were performed to assess change in psychometric variables from baseline over twelve months after resumption of dietary control. Results A total of nine patients were recruited. Mean age was 33 years (SD = 8.75), five were female. Mean time off dietary control was 19.1 years (SD = 11.3), and mean baseline phenylalanine (Phe) levels were 1108 µmol/L (SD = 293). GLMM analysis demonstrated a positive relationship between CPI and time on diet (b = 0.56 [95% CI = 0.17, 0.95]). Age, time off diet, Phe levels and depression scores were not associated with cognitive function. There was a negative relationship between time on diet and anxiety (b = − 0.88 95% CI = [− 1.26, − 0.50]) and depression ratings (b = − 0.61, 95% CI = [− 0.95, − 0.26]). Conclusions This study demonstrated improvements in cognitive function, anxiety, and depression ratings associated with resumption of dietary control of PKU. Raw Phe levels were not strongly associated with psychiatric or cognitive scores in this cohort. These findings support the importance of lifelong treatment for PKU in improving the cognitive and psychiatric sequelae of the disease.
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Affiliation(s)
- Nicholas M Burgess
- Neuropsychiatry Unit, Royal Melbourne Hospital, Level 2, John Cade Building, Melbourne,, 3050, Australia
| | - Wendy Kelso
- Neuropsychiatry Unit, Royal Melbourne Hospital, Level 2, John Cade Building, Melbourne,, 3050, Australia
| | - Charles B Malpas
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia.,Clinical Outcomes Research Unit (CORe), Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Toby Winton-Brown
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Timothy Fazio
- Department of Metabolic Medicine, Royal Melbourne Hospital, Melbourne, Australia.,Melbourne Medical School, Department of Medicine and Radiology, University of Melbourne, Parkville, Australia
| | - Julie Panetta
- Department of Metabolic Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Gerard De Jong
- Department of Metabolic Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Joanna Neath
- Neuropsychiatry Unit, Royal Melbourne Hospital, Level 2, John Cade Building, Melbourne,, 3050, Australia
| | | | - Dennis Velakoulis
- Neuropsychiatry Unit, Royal Melbourne Hospital, Level 2, John Cade Building, Melbourne,, 3050, Australia.,Melbourne Neuropsychiatry Centre, University of Melbourne and North-Western Mental Health, Melbourne, Australia
| | - Mark Walterfang
- Neuropsychiatry Unit, Royal Melbourne Hospital, Level 2, John Cade Building, Melbourne,, 3050, Australia. .,Melbourne Neuropsychiatry Centre, University of Melbourne and North-Western Mental Health, Melbourne, Australia. .,Florey Institute of Neuroscience and Mental Health, Melbourne, Australia.
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31
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The diagnosis of inborn errors of metabolism in previously undiagnosed adults referred for medical genetics evaluation. Mol Genet Metab Rep 2020; 25:100653. [PMID: 33072517 PMCID: PMC7549142 DOI: 10.1016/j.ymgmr.2020.100653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/15/2020] [Accepted: 09/19/2020] [Indexed: 11/21/2022] Open
Abstract
Traditionally thought of as a pediatric diagnostic and therapeutic dilemma, the diagnostic rate and spectrum of inborn errors of metabolism (IEM) in the adult population is largely unknown. A retrospective chart review of patients seen by the Michigan Medicine Adult Medical Genetics Clinic for clinical evaluation from 2014 to 2018 was conducted. Patients referred for a primary indication possibly consistent with an IEM were considered. Variables included age at genetic evaluation, symptom onset age, sex, clinical course, organ systems involved, developmental history, family history and prior genetic testing. Of patients evaluated during the study period, 112 were referred for an indication possibly consistent with an IEM and underwent a complete biochemical workup with an IEM diagnostic rate of 9.8% achieved. An additional 9.8% were diagnosed with a non-IEM genetic diagnosis. Management changes were implemented in all IEM diagnoses. Metabolic disorders in the adult population are under-recognized and under-diagnosed. This report demonstrates the need for clinicians to consider these diagnoses in adults and either refer to a genetics clinic or initiate a biochemical workup. As advances in diagnosis, treatment, and life expectancy of patients with IEMs increases, recognizing and diagnosing these conditions can significantly impact care.
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Koppes EA, Redel BK, Johnson MA, Skvorak KJ, Ghaloul-Gonzalez L, Yates ME, Lewis DW, Gollin SM, Wu YL, Christ SE, Yerle M, Leshinski A, Spate LD, Benne JA, Murphy SL, Samuel MS, Walters EM, Hansen SA, Wells KD, Lichter-Konecki U, Wagner RA, Newsome JT, Dobrowolski SF, Vockley J, Prather RS, Nicholls RD. A porcine model of phenylketonuria generated by CRISPR/Cas9 genome editing. JCI Insight 2020; 5:141523. [PMID: 33055427 PMCID: PMC7605535 DOI: 10.1172/jci.insight.141523] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/17/2020] [Indexed: 12/17/2022] Open
Abstract
Phenylalanine hydroxylase-deficient (PAH-deficient) phenylketonuria (PKU) results in systemic hyperphenylalaninemia, leading to neurotoxicity with severe developmental disabilities. Dietary phenylalanine (Phe) restriction prevents the most deleterious effects of hyperphenylalaninemia, but adherence to diet is poor in adult and adolescent patients, resulting in characteristic neurobehavioral phenotypes. Thus, an urgent need exists for new treatments. Additionally, rodent models of PKU do not adequately reflect neurocognitive phenotypes, and thus there is a need for improved animal models. To this end, we have developed PAH-null pigs. After selection of optimal CRISPR/Cas9 genome-editing reagents by using an in vitro cell model, zygote injection of 2 sgRNAs and Cas9 mRNA demonstrated deletions in preimplantation embryos, with embryo transfer to a surrogate leading to 2 founder animals. One pig was heterozygous for a PAH exon 6 deletion allele, while the other was compound heterozygous for deletions of exon 6 and of exons 6-7. The affected pig exhibited hyperphenylalaninemia (2000-5000 μM) that was treatable by dietary Phe restriction, consistent with classical PKU, along with juvenile growth retardation, hypopigmentation, ventriculomegaly, and decreased brain gray matter volume. In conclusion, we have established a large-animal preclinical model of PKU to investigate pathophysiology and to assess new therapeutic interventions.
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Affiliation(s)
- Erik A. Koppes
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, and Universityof Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bethany K. Redel
- Division ofAnimal Sciences, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, Missouri, USA
- National Swine Research and Resource Center (NSRRC), College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Marie A. Johnson
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, and Universityof Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kristen J. Skvorak
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lina Ghaloul-Gonzalez
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, and Universityof Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Human Genetics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Megan E. Yates
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, and Universityof Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dale W. Lewis
- Department of Human Genetics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Susanne M. Gollin
- Department of Human Genetics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Yijen L. Wu
- Department of Developmental Biology, University of Pittsburgh, and UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shawn E. Christ
- Department of Psychological Sciences, University of Missouri, Columbia, Missouri, USA
| | - Martine Yerle
- GenPhySE, Université de Toulouse, INRAE, ENVT, 31326, Castanet-Tolosan, France
| | - Angela Leshinski
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, and Universityof Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lee D. Spate
- Division ofAnimal Sciences, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, Missouri, USA
- National Swine Research and Resource Center (NSRRC), College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Joshua A. Benne
- National Swine Research and Resource Center (NSRRC), College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Stephanie L. Murphy
- National Swine Research and Resource Center (NSRRC), College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Melissa S. Samuel
- Division ofAnimal Sciences, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, Missouri, USA
- National Swine Research and Resource Center (NSRRC), College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Eric M. Walters
- Division ofAnimal Sciences, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, Missouri, USA
- National Swine Research and Resource Center (NSRRC), College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Sarah A. Hansen
- Department of Veterinary Pathobiology, College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Kevin D. Wells
- Division ofAnimal Sciences, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, Missouri, USA
- National Swine Research and Resource Center (NSRRC), College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Uta Lichter-Konecki
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, and Universityof Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert A. Wagner
- Division of Laboratory Animal Resources, Office of Research, Health Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joseph T. Newsome
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Division of Laboratory Animal Resources, Office of Research, Health Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steven F. Dobrowolski
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jerry Vockley
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, and Universityof Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Human Genetics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Randall S. Prather
- Division ofAnimal Sciences, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, Missouri, USA
- National Swine Research and Resource Center (NSRRC), College of Veterinary Medicine, University of Missouri, Columbia, Missouri, USA
| | - Robert D. Nicholls
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, and Universityof Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Wild J, Shanmuganathan M, Hayashi M, Potter M, Britz-McKibbin P. Metabolomics for improved treatment monitoring of phenylketonuria: urinary biomarkers for non-invasive assessment of dietary adherence and nutritional deficiencies. Analyst 2020; 144:6595-6608. [PMID: 31608347 DOI: 10.1039/c9an01642b] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Management of phenylketonuria (PKU) requires lifelong restriction of phenylalanine (Phe) intake using specialized medical foods to prevent neurocognitive impairment in affected patients. However, dietary adherence is challenging to maintain while ensuring adequate nutrition, which can lead to sub-optimal clinical outcomes. Metabolomics offers a systematic approach to identify new biomarkers of disease progression in PKU when using urine as a surrogate for blood specimens that is more accurate than self-reported diet records. Herein, the plasma and urine metabolome of a cohort of classic PKU patients (median age = 11 years; n = 22) mainly prescribed (78%) a Phe-restricted diet were characterized using multisegment injection-capillary electrophoresis-mass spectrometry (MSI-CE-MS). Overall, there was good mutual agreement between plasma Phe and tyrosine (Tyr) concentrations measured from PKU patients when using an amino acid analyzer based on UPLC-UV as compared to MSI-CE-MS with a mean bias of 12% (n = 82). Longitudinal measurements of recently diagnosed PKU infants (n = 3) revealed good long-term regulation of blood Phe with dietary management, and only occasional episodes exceeding the recommended therapeutic range (>360 μM) unlike older PKU patients. Plasma metabolomic studies demonstrated that non-adherent PKU patients had lower circulating concentrations of Tyr, arginine, 2-aminobutyric acid, and propionylcarnitine (q < 0.05, FDR) that were inversely correlated to Phe (r ≈ -0.600 to -0.830). Nontargeted metabolite profiling also revealed urinary biomarkers associated with poor dietary adherence among PKU patients, including elevated concentrations of catabolites indicative of Phe intoxication (e.g., phenylpyruvic acid, phenylacetylglutamine, hydroxyphenylacetic acid). Additionally, PKU patients with poor blood Phe control had lower excretion of urinary compounds derived from co-metabolism of Tyr due to microbiota activity (e.g., cresol sulfate, phenylsulfate), as well as several metabolites associated with inadequate nutrient intake, including low carnitine and B vitamin status (e.g., folic acid, vitamin B12). Interestingly, an unknown urinary metabolite was strongly correlated with Phe excretion in PKU patients (r = 0.861), which was subsequently identified as imidazole lactic acid when using high resolution MS/MS. Overall, urine profiling offers a non-invasive approach for better treatment monitoring of individual PKU patients, which can also guide the design of novel therapies that improve adherence to Phe-restricted diets without acquired nutritional deficiencies.
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Affiliation(s)
- Jennifer Wild
- Department of Chemistry and Chemical Biology, McMaster University, Hamilton, Ontario, Canada.
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34
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Berry SA, Brown CS, Greene C, Camp KM, McDonough S, Bocchini JA. Medical Foods for Inborn Errors of Metabolism: History, Current Status, and Critical Need. Pediatrics 2020; 145:peds.2019-2261. [PMID: 32034080 DOI: 10.1542/peds.2019-2261] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2019] [Indexed: 11/24/2022] Open
Abstract
Successful intervention for inborn errors of metabolism (IEMs) is a triumph of modern medicine. For many of these conditions, medical foods are the cornerstone of therapy and the only effective interventions preventing disability or death. Medical foods are designed for patients with limited or impaired capacity to ingest, digest, absorb, or metabolize ordinary foods or nutrients, whereby dietary management cannot be achieved by modification of the normal diet alone. In the United States today, access to medical foods is not ensured for many individuals who are affected despite their proven efficacy in the treatment of IEMs, their universal use as the mainstay of IEM management, the endorsement of their use by professional medical organizations, and the obvious desire of families for effective care. Medical foods are not sufficiently covered by many health insurance plans in the United States and, without insurance coverage, many families cannot afford their high cost. In this review, we outline the history of medical foods, define their medical necessity, discuss the barriers to access and reimbursement resulting from the regulatory status of medical foods, and summarize previous efforts to improve access. The Advisory Committee on Heritable Disorders in Newborns and Children asserts that it is time to provide stable and affordable access to the effective management required for optimal outcomes through the life span of patients affected with IEMs. Medical foods as defined by the US Food and Drug Administration should be covered as required medical benefits for persons of all ages diagnosed with an IEM.
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Affiliation(s)
- Susan A Berry
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota;
| | | | - Carol Greene
- Department of Pediatrics, University of Maryland, Baltimore, Maryland
| | - Kathryn M Camp
- Office of Dietary Supplements, National Institutes of Health, Silver Springs, Maryland
| | - Stephen McDonough
- Follow-up and Treatment Workgroup.,Independent Doctors, Bismarck, North Dakota; and
| | - Joseph A Bocchini
- Advisory Committee on Heritable Disorders in Newborns and Children, Health Resources and Services Administration, Rockville, Maryland.,Department of Pediatrics, Louisiana State University, Shreveport, Louisiana
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Strategies to engage lost to follow-up patients with phenylketonuria in the United States: Best practice recommendations. Mol Genet Metab Rep 2020; 23:100571. [PMID: 32140415 PMCID: PMC7044524 DOI: 10.1016/j.ymgmr.2020.100571] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 01/24/2020] [Accepted: 01/24/2020] [Indexed: 12/04/2022] Open
Abstract
Background Phenylketonuria (PKU) is a rare autosomal recessive disorder caused by mutations in the gene encoding phenylalanine hydroxylase, an enzyme that converts phenylalanine to tyrosine. Untreated, PKU is characterized by a range of neuropsychological and neurocognitive impairments. Due to ubiquitous newborn genetic screening programs, treatment for PKU can be commenced shortly after birth and can prevent many of the severe manifestations of the disease. However, lifelong management is critical for patients with PKU as high levels of phenylalanine are neurotoxic. As for all chronic diseases, long-term management can be challenging and most adult patients with PKU become lost to follow-up (LTFU). A survey of PKU clinics across the United States and a multidisciplinary Expert Meeting were conducted to develop best practices to engage LTFU patients with PKU. Results We defined LTFU patients with PKU as “patients with no contact with the clinic for at least 2 consecutive years.” Combining the results from our survey and our discussion at the Expert Meeting, we have prepared six best practice recommendations to engage LTFU patients with PKU: 1) Ensure patients are aware of the current treatment guidelines for PKU; 2) Communicate to patients any new treatment and diet options as they become available for PKU; 3) Consider the neuropsychological and neurocognitive aspects of PKU; 4) Prioritize motivated LTFU patients; 5) Explore new approaches of outreach to LTFU patients; and 6) Formalize approaches to track and/or identify PKU patients. Conclusion We strongly advocate the importance of engaging LTFU patients with PKU and encourage implementation of our best practice recommendations. Although it takes time and effort to engage LTFU patients, we believe that clinics are capable of supporting this significant patient group.
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36
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Chan K, Petros M. Simple Test, Complex System: Multifaceted Views of Newborn Screening Science, Technology, and Policy. Glob Pediatr Health 2019; 6:2333794X19894812. [PMID: 31903414 PMCID: PMC6926981 DOI: 10.1177/2333794x19894812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 11/08/2019] [Accepted: 11/22/2019] [Indexed: 01/27/2023] Open
Abstract
Newborn screening (NBS) is a public health service provided for all babies born in the United States and in most countries of the developed world. A series of tests are applied to the blood taken from newborn babies to detect genetic and metabolic disorders that can be treated if identified early. With early treatment and therapy, the affected babies can usually live a normal, healthy life. Timing for sampling, testing, and reporting is vital for NBS to function as an effective system. In order to be an effective system, the evolution of science, technology, and policy gradually had to come into a synchronous partnership, where the discovery of new genetic disorders led to timely development of technology for screening, which is supported by policy and implemented into practice. The timely "dance" of these partnerships in an era of personalized health and medicine forms the integrated approach supporting NBS. This review will include a brief history of scientific development, policymaking, and the economic consideration in the expansion of the NBS.
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Affiliation(s)
- Kee Chan
- University of Illinois, Chicago, IL, USA
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37
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Kemper AR, Boyle CA, Brosco JP, Grosse SD. Ensuring the Life-Span Benefits of Newborn Screening. Pediatrics 2019; 144:peds.2019-0904. [PMID: 31694980 PMCID: PMC7202673 DOI: 10.1542/peds.2019-0904] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
- Alex R. Kemper
- Division of Ambulatory Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Coleen A. Boyle
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jeffrey P. Brosco
- Mailman Center for Child Development, Miller School of Medicine, University of Miami, Miami, Florida
| | - Scott D. Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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38
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Romani C, Manti F, Nardecchia F, Valentini F, Fallarino N, Carducci C, De Leo S, MacDonald A, Palermo L, Leuzzi V. Adult cognitive outcomes in phenylketonuria: explaining causes of variability beyond average Phe levels. Orphanet J Rare Dis 2019; 14:273. [PMID: 31779649 PMCID: PMC6883518 DOI: 10.1186/s13023-019-1225-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022] Open
Abstract
Objective The objective was to deepen the understanding of the causes of individual variability in phenylketonuria (PKU) by investigating which metabolic variables are most important for predicting cognitive outcomes (Phe average vs Phe variation) and by assessing the risk of cognitive impairment associated with adopting a more relaxed approach to the diet than is currently recommended. Method We analysed associations between metabolic and cognitive measures in a mixed sample of English and Italian early-treated adults with PKU (N = 56). Metabolic measures were collected through childhood, adolescence and adulthood; cognitive measures were collected in adulthood. Metabolic measures included average Phe levels (average of median values for each year in a given period) and average Phe variations (average yearly standard deviations). Cognition was measured with IQ and a battery of cognitive tasks. Results Phe variation was as important, if not more important, than Phe average in predicting adult outcomes and contributed independently. Phe variation was particularly detrimental in childhood. Together, childhood Phe variation and adult Phe average predicted around 40% of the variation in cognitive scores. Poor cognitive scores (> 1 SD from controls) occurred almost exclusively in individuals with poor metabolic control and the risk of poor scores was about 30% higher in individuals with Phe values exceeding recommended thresholds. Conclusions Our results provide support for current European guidelines (average Phe value = < 360 μmol/l in childhood; = < 600 μmo/l from 12 years onwards), but they suggest an additional recommendation to maintain stable levels (possibly Phe SD = < 180 μmol/l throughout life). Public significance statements We investigated the relationship between how well people with phenylketonuria control blood Phe throughout their life and their ability to carry out cognitive tasks in adulthood. We found that avoiding blood Phe peaks was as important if not more important that maintaining average low Phe levels. This was particularly essential in childhood. We also found that blood Phe levels above recommended European guidelines was associated with around 30% increase in the risk of poor cognitive outcomes.
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Affiliation(s)
- Cristina Romani
- School of Life and Health Sciences, Aston University, Aston Triangle, Birmingham, England, B4 7ET, UK.
| | - Filippo Manti
- Department of Human Neuroscience - Unit of Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Francesca Nardecchia
- Department of Human Neuroscience - Unit of Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | | | | | - Claudia Carducci
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Sabrina De Leo
- Department of Clinical Medicine, Policlinico Umberto I, Rome, Italy
| | - Anita MacDonald
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Liana Palermo
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Vincenzo Leuzzi
- Department of Human Neuroscience - Unit of Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
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Darbà J. Characteristics, comorbidities, and use of healthcare resources of patients with phenylketonuria: a population-based study. J Med Econ 2019; 22:1025-1029. [PMID: 31237171 DOI: 10.1080/13696998.2019.1636381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background: Phenylketonuria is a well-known disease, yet the characteristics of the affected population and their use of healthcare resources have not been comprehensively evaluated. Patient characteristics and use of resources are subjects of interest for most governments, especially for a disease included in newborn screening programs. Objective: The aim of this study was to determine characteristics and use of healthcare resources of patients with phenylketonuria in the region of Catalonia. Methods: Records of 289 patients admitted with phenylketonuria between 2007 and 2017 were extracted from the PADRIS database that includes admission data from primary care centers, hospitals (inpatient and outpatient care), extended care facilities, and mental health centers. Results: The patient population was composed of 140 male patients and 149 female patients, and 102 patients were registered via newborn screening during the study period. Patients were admitted on average 2.19 times per year, mostly into primary care centers which concentrated the largest portion of direct medical expenses. Similar percentages of urgent and scheduled admissions were registered both in primary care and hospitals. Annual direct medical cost of treating patients with phenylketonuria was €667 per patient. Finally, 66.80% of the patients suffered from chronic conditions affecting two or more systems, likely to correspond to a wide variety of conditions. Conclusions: Altogether, phenylketonuria patient demographics and direct medical costs in Catalonia have been revised. Patients diagnosed with phenylketonuria appeared 1.3-times more likely to suffer from chronic conditions in distinct organ systems, which is expected to have an effect on their use of healthcare resources. These results support the need to adapt and improve the healthcare system, taking multimorbidity into consideration in an effort to control the medical expenses derived.
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Affiliation(s)
- Josep Darbà
- Universitat de Barcelona , Barcelona , Spain
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SriBhashyam S, Marsh K, Quartel A, Weng HH, Gershman A, Longo N, Thomas J, Zori R. A benefit-risk analysis of pegvaliase for the treatment of phenylketonuria: A study of patients' preferences. Mol Genet Metab Rep 2019; 21:100507. [PMID: 31497506 PMCID: PMC6722251 DOI: 10.1016/j.ymgmr.2019.100507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/20/2019] [Accepted: 08/20/2019] [Indexed: 12/02/2022] Open
Abstract
Background Phenylketonuria (PKU) leads to an accumulation of phenylalanine (Phe) in the blood and subsequent neurologic, cognitive, psychiatric, and behavioral dysfunction. Many patients report social isolation and decreased quality of life. Pegvaliase is an enzyme substitution therapy that reduces blood Phe levels in patients with PKU and is associated with a risk of hypersensitivity reactions. Objective To define the minimum acceptable benefit (MAB) of pegvaliase, i.e., the minimum probability of achieving a blood Phe level <360 μmol/L, which patients require to tolerate the risks of hypersensitivity associated with pegvaliase. Methods Adult, pegvaliase-naïve patients with blood Phe levels >600 μmol/L participated in a patient-preference web survey using two surveys: adapted swing-weighting and thresholding. Participants were asked to make ordinal choices between varying clinical benefit and severity levels for hypersensitivity. Disease effects and treatment satisfaction were also assessed. Results Among 45 participants, the mean (standard deviation) self-reported blood Phe level was 976.9 (429.9) μmol/L; only 28.8% reported satisfaction with their current treatment. Most (84.4%) indicated difficulty in following a PKU diet; 60% reported that the PKU diet was burdensome, and 58% reported feeling socially isolated. Most (≥69%) reported their MAB to be less than the expected clinical benefit provided by pegvaliase; the mean MAB was 22.7% and 34.4% in the swing-weighting and thresholding surveys, respectively. Conclusion Most participants felt the burden of PKU on their daily lives, were dissatisfied with current treatments, and were willing to accept the risks of hypersensitivity reactions to achieve recommended blood Phe levels with pegvaliase treatment.
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Affiliation(s)
- Sumitra SriBhashyam
- Patient Centered Research, Evidera, The Ark, 201 Talgarth Road, Hammersmith, London W6 8BJ, UK
| | - Kevin Marsh
- Patient Centered Research, Evidera, The Ark, 201 Talgarth Road, Hammersmith, London W6 8BJ, UK
| | - Adrian Quartel
- BioMarin Pharmaceutical Inc., 105 Digital Drive, Novato, CA 94949, USA
| | - Haoling H Weng
- BioMarin Pharmaceutical Inc., 105 Digital Drive, Novato, CA 94949, USA
| | - Ari Gershman
- BioMarin Pharmaceutical Inc., 105 Digital Drive, Novato, CA 94949, USA
| | - Nicola Longo
- Department of Pediatrics, Division of Medical Genetics, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Janet Thomas
- Department of Pediatrics, Section of Clinical Genetics and Metabolism, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Roberto Zori
- Department of Pediatrics, Division of Genetics and Metabolism, University of Florida, Gainesville, FL 32610, USA
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Bailey DB, Gehtland LM, Lewis MA, Peay H, Raspa M, Shone SM, Taylor JL, Wheeler AC, Cotten M, King NMP, Powell CM, Biesecker B, Bishop CE, Boyea BL, Duparc M, Harper BA, Kemper AR, Lee SN, Moultrie R, Okoniewski KC, Paquin RS, Pettit D, Porter KA, Zimmerman SJ. Early Check: translational science at the intersection of public health and newborn screening. BMC Pediatr 2019; 19:238. [PMID: 31315600 PMCID: PMC6636013 DOI: 10.1186/s12887-019-1606-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 06/30/2019] [Indexed: 01/06/2023] Open
Abstract
Background Newborn screening (NBS) occupies a unique space at the intersection of translational science and public health. As the only truly population-based public health program in the United States, NBS offers the promise of making the successes of translational medicine available to every infant with a rare disorder that is difficult to diagnose clinically, but for which strong evidence indicates that presymptomatic treatment will substantially improve outcomes. Realistic NBS policy requires data, but rare disorders face a special challenge: Screening cannot be done without supportive data, but adequate data cannot be collected in the absence of large-scale screening. The magnitude and scale of research to provide this expanse of data require working with public health programs, but most do not have the resources or mandate to conduct research. Methods To address this gap, we have established Early Check, a research program in partnership with a state NBS program. Early Check provides the infrastructure needed to identify conditions for which there have been significant advances in treatment potential, but require a large-scale, population-based study to test benefits and risks, demonstrate feasibility, and inform NBS policy. Discussion Our goal is to prove the benefits of a program that can, when compared with current models, accelerate understanding of diseases and treatments, reduce the time needed to consider inclusion of appropriate conditions in the standard NBS panel, and accelerate future research on new NBS conditions, including clinical trials for investigational interventions. Trial registration Clinicaltrials.gov registration #NCT03655223. Registered on August 31, 2018.
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Affiliation(s)
- Donald B Bailey
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, 3040 E. Cornwallis Rd., Research Triangle Park, NC, 27709, USA.
| | - Lisa M Gehtland
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, 3040 E. Cornwallis Rd., Research Triangle Park, NC, 27709, USA
| | | | - Holly Peay
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, 3040 E. Cornwallis Rd., Research Triangle Park, NC, 27709, USA
| | - Melissa Raspa
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, 3040 E. Cornwallis Rd., Research Triangle Park, NC, 27709, USA
| | - Scott M Shone
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, 3040 E. Cornwallis Rd., Research Triangle Park, NC, 27709, USA
| | - Jennifer L Taylor
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, 3040 E. Cornwallis Rd., Research Triangle Park, NC, 27709, USA
| | - Anne C Wheeler
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, 3040 E. Cornwallis Rd., Research Triangle Park, NC, 27709, USA
| | | | | | - Cynthia M Powell
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | | | | | - Beth Lincoln Boyea
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, 3040 E. Cornwallis Rd., Research Triangle Park, NC, 27709, USA
| | - Martin Duparc
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, 3040 E. Cornwallis Rd., Research Triangle Park, NC, 27709, USA
| | - Blake A Harper
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, 3040 E. Cornwallis Rd., Research Triangle Park, NC, 27709, USA
| | | | - Stacey N Lee
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, 3040 E. Cornwallis Rd., Research Triangle Park, NC, 27709, USA
| | | | - Katherine C Okoniewski
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, 3040 E. Cornwallis Rd., Research Triangle Park, NC, 27709, USA
| | | | - Denise Pettit
- North Carolina State Laboratory of Public Health, Raleigh, NC, USA
| | - Katherine Ackerman Porter
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, 3040 E. Cornwallis Rd., Research Triangle Park, NC, 27709, USA
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Sousa C, Almeida MF, Sousa Barbosa C, Martins E, Janeiro P, Tavares de Almeida I, MacDonald A, Rocha JC. The European Phenylketonuria Guidelines and the challenges on management practices in Portugal. J Pediatr Endocrinol Metab 2019; 32:623-629. [PMID: 31141484 DOI: 10.1515/jpem-2018-0527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/01/2019] [Indexed: 12/30/2022]
Abstract
Background Phenylketonuria (PKU) management practices differ between and within countries. In 2007, the Portuguese Society for Metabolic Disorders (SPDM) approved the Portuguese Consensus (PC) for the nutritional treatment of PKU. The recently published European PKU Guidelines (EPG, 2017) systematically reviewed recent evidence and aimed to harmonise treatment protocols in Europe. The objective of this study was to appraise the EPG acceptance and implementation in Portuguese treatment centres. Methods An electronic questionnaire was prepared and the link was sent to 135 SPDM members. It outlined the 10 EPG key recommendations and compared each statement with the consensus recommendations published by SPDM. Responses were recorded and descriptive analyses were performed. Results Twenty-five professionals completed the questionnaire, and over half (56%) were nutritionists/dieticians. At least one questionnaire from each of the 10 national treatment centres was returned. In general, responders accepted most of the recommendations. However, only the recommendation about target phenylalanine (Phe) concentrations between 120 and 360 μmol/L for patients <12 years received 100% consensus with a further seven recommendations gaining over 70% consensus. Almost half of the professionals (48%, n = 12) required further discussion about the EPG-safe upper target blood Phe concentration (600 μmol/L) suggested for patients aged ≥12 years. Almost one third (32%, n = 8) failed to agree with the recommendation in the EPG-proposed classification of Phe hydroxylase (PAH) deficiency. Conclusions The EPG received overall good acceptance, but there was divided opinion about some recommendations which require further discussion before implementation by the Portuguese treatment centres.
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Affiliation(s)
- Cátia Sousa
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto, Porto, Portugal
| | - Manuela Ferreira Almeida
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, Porto, Portugal
| | - Catarina Sousa Barbosa
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto, Porto, Portugal
| | - Esmeralda Martins
- Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, Porto, Portugal
| | - Patrícia Janeiro
- Reference Centre for the Treatment of Inborn Errors of Metabolism, CHULN, Lisbon, Portugal
| | | | | | - Júlio César Rocha
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Centro de Genética Médica, Doutor Jacinto de Magalhães, CHUP, EPE, Praça Pedro Nunes 88, 4099-028 Porto, Portugal.,Center for Health Technology and Services Research [CINTESIS], Porto, Portugal
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Ceberio L, Hermida Á, Venegas E, Arrieta F, Morales M, Forga M, Gonzalo M. Phenylketonuria in the adult patient. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1633914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Leticia Ceberio
- Inborn metabolic disease unit, Internal Medicine Service, Hospital Universitario de Cruces, Baracaldo, Vizcaya, Spain
| | - Álvaro Hermida
- Unit of Diagnosis and Treatment of Congenital Metabolic Diseases, Internal Medicine Service, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - Eva Venegas
- Endocrinology and Nutrition Service, C.U.S.R Congenital Metabolic Disease, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Francisco Arrieta
- Departament Endocrinology Metabolism and Nutrion, C.U.S.R Congenital Metabolic Disease, CIBER Physiopathology of Obesity and Nutrition (CIBERobn), Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | - Montserrat Morales
- Inborn Metabolic Disease Service, C.S.U.R of Congenital Metabolic Diseases, Internal Medicine Service, Hospital 12 de octubre, Madrid, Spain
| | - Maria Forga
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Montserrat Gonzalo
- UGC Endocrinology and Nutrition, Hospital Regional Universitario de Málaga, Instituto de Biomedicina de Málaga (IBIMA) & CIBER de Diabetes y Enfermedades Metabólicas asociadas (CIBERDEM), Málaga, Spain
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Admissions and Cost of Hospitalisation of Phenylketonuria: Spanish Claims Database Analysis. Clin Drug Investig 2019; 39:379-384. [PMID: 30778886 DOI: 10.1007/s40261-019-00760-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Phenylketonuria is a well-known rare disease included in the neonatal screening of many countries. Therefore, there are few published data on the admissions and costs of phenylketonuria in Spain. OBJECTIVE The objective of this study was to assess the number of admissions and the economic burden of phenylketonuria in Spain. METHODS Patients with phenylketonuria were identified from a Spanish database containing data from public and private healthcare centres from 1997 to 2015. The parameters obtained were characteristics of the patients, type of admissions, readmissions, discharges, length of stay, medical service, annual number of visits, annual number of patients, visit-associated costs and patient-associated costs. RESULTS Five hundred and ninety-four patients with phenylketonuria were identified: 48.32% were male with a mean (standard deviation) age of 4.50 (10.23) years. The hospital admissions were divided into emergency visits (55.94%) and scheduled visits (43.92%). The majority of patients were discharged home (98.86%). The mean (standard deviation) duration of stay was 4.04 (4.98) days. The number of admissions per year ranged between 13 and 88, with an average of 1.18 admissions per patient per year. Finally, the mean cost per visit increased from €1064.91 to €3709.40, and the mean cost per patient increased from €1818.90 to €4239.32 from 1999 to 2015. CONCLUSIONS The access to economic and social data on phenylketonuria in Spain has been updated. The number of admissions in Spain between 1997 and 2015 and healthcare costs between 1999 and 2015 were calculated. There were 24 admissions as a result of a phenylketonuria diagnosis in 2015 and the mean healthcare cost per patient was €4239.32. This information can help to adapt and improve each healthcare system to take into consideration rare diseases.
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Watson JN, Seagraves NJ. RNA-Seq analysis in an avian model of maternal phenylketonuria. Mol Genet Metab 2019; 126:23-29. [PMID: 30600150 DOI: 10.1016/j.ymgme.2018.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 09/03/2018] [Accepted: 09/03/2018] [Indexed: 01/28/2023]
Abstract
Cardiac malformations (CVMs) are a leading cause of infant morbidity and mortality. CVMs are particularly prevalent when the developing fetus is exposed to high levels of phenylalanine in-utero in mothers with Phenylketonuria. Yet, elucidating the underlying molecular mechanism leading to CVMs has proven difficult. In this study we used RNA-Seq to investigate an avian model of MPKU and establish differential gene expression (DEG) characteristics of the early developmental stages HH10, 12, and 14. In total, we identified 633 significantly differentially expressed genes across stages HH10, 12, and 14. As expected, functional annotation of significant DEGs identified associations seen in clinical phenotypes of MPKU including CVMs, congenital heart defects, craniofacial anomalies, central nervous system defects, and growth anomalies. Additionally, there was an overrepresentation of genes involved in cardiac muscle contraction, adrenergic signaling in cardiomyocytes, migration, proliferation, metabolism, and cell survival. Strikingly, we identified significant changes in expression with multiple genes involved in Retinoic Acid (RA) metabolism and downstream targets. Using qRTPCR, we validated these findings and identified a total of 42 genes within the RA pathway that are differentially expressed. Here, we report the first elucidation of the molecular mechanisms of cardiovascular malformations in MPKU conducted at early developmental timepoints. We provide evidence suggesting a link between PHE exposure and the alteration of RA pathway. These results are promising and offer novel findings associated with congenital heart defects in MPKU.
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Affiliation(s)
- Jamie N Watson
- Department of Biology, University of Central Oklahoma, Edmond, OK, USA.
| | - Nikki J Seagraves
- Department of Biology, University of Central Oklahoma, Edmond, OK, USA.
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Duan H, Liu N, Zhao Z, Liu Y, Wang Y, Li Z, Xu M, Cram DS, Kong X. Non-invasive prenatal testing of pregnancies at risk for phenylketonuria. Arch Dis Child Fetal Neonatal Ed 2019; 104:F24-F29. [PMID: 29353259 DOI: 10.1136/archdischild-2017-313929] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 10/16/2017] [Accepted: 12/07/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND Phenylketonuria (PKU) is a common metabolic disorder caused predominately by mutations in the phenylalanine hydroxylase (PAH) gene. The aim of the study was to design and validate the performance of a non-invasive prenatal test (NIPT) for PKU using circulating single molecule amplification and resequencing technology (cSMART). METHODS A total of 18 couples at genetic risk for having a child with PKU were recruited to the study. Gold standard invasive prenatal diagnosis (IPD) was performed on amniocyte or villus cell DNA by Sanger sequencing, targeting the known parental PAH mutations. Retrospectively, NIPT was also performed on stored maternal plasma samples from the 18 pregnancies by a multiplex cSMART assay designed to target all known DNA variants in the PAH gene. RESULTS Benchmarking against IPD results, NIPT correctly genotyped all fetuses, including six compound heterozygotes with PKU, four normal non-carriers of PKU and eight heterozygote carriers of PKU comprising five cases of a maternally inherited mutation and three cases of a paternally inherited mutation. CONCLUSIONS The NIPT cSMART PKU assay was highly sensitive and specific for mutation detection and correct assignment of fetal genotypes. Based on comprehensive mutation coverage across the PAH gene, the assay may initially have clinical utility as a pregnancy screening test for high-risk carrier couples.
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Affiliation(s)
- Huikun Duan
- Genetics and Prenatal Diagnosis Center, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ning Liu
- Genetics and Prenatal Diagnosis Center, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhenhua Zhao
- Genetics and Prenatal Diagnosis Center, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yiqian Liu
- Research and Development Department, Berry Genomics Corporation, Beijing, China
| | - Yin Wang
- Research and Development Department, Berry Genomics Corporation, Beijing, China
| | - Zhifeng Li
- Research and Development Department, Berry Genomics Corporation, Beijing, China
| | - Mengnan Xu
- Research and Development Department, Berry Genomics Corporation, Beijing, China
| | - David S Cram
- Research and Development Department, Berry Genomics Corporation, Beijing, China
| | - Xiangdong Kong
- Genetics and Prenatal Diagnosis Center, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Ashe K, Kelso W, Farrand S, Panetta J, Fazio T, De Jong G, Walterfang M. Psychiatric and Cognitive Aspects of Phenylketonuria: The Limitations of Diet and Promise of New Treatments. Front Psychiatry 2019; 10:561. [PMID: 31551819 PMCID: PMC6748028 DOI: 10.3389/fpsyt.2019.00561] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 07/17/2019] [Indexed: 12/30/2022] Open
Abstract
Phenylketonuria (PKU) is a recessive disorder of phenylalanine metabolism due to mutations in the gene for phenylalanine hydroxylase (PAH). Reduced PAH activity results in significant hyperphenylalaninemia, which leads to alterations in cerebral myelin and protein synthesis, as well as reduced levels of serotonin, dopamine, and noradrenaline in the brain. When untreated, brain development is grossly disrupted and significant intellectual impairment and behavioral disturbance occur. The advent of neonatal heel prick screening has allowed for diagnosis at birth, and the institution of a phenylalanine restricted diet. Dietary treatment, particularly when maintained across neurodevelopment and well into adulthood, has resulted in markedly improved outcomes at a cognitive and psychiatric level for individuals with PKU. However, few individuals can maintain full dietary control lifelong, and even with good control, an elevated risk remains of-in particular-mood, anxiety, and attentional disorders across the lifespan. Increasingly, dietary recommendations focus on maintaining continuous dietary treatment lifelong to optimize psychiatric and cognitive outcomes, although the effect of long-term protein restricted diets on brain function remains unknown. While psychiatric illness is very common in adult PKU populations, very little data exist to guide clinicians on optimal treatment. The advent of new treatments that do not require restrictive dietary management, such as the enzyme therapy Pegvaliase, holds the promise of allowing patients a relatively normal diet alongside optimized mental health and cognitive functioning.
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Affiliation(s)
- Killian Ashe
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Wendy Kelso
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Sarah Farrand
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Julie Panetta
- Statewide Adult Metabolic Service, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Tim Fazio
- Statewide Adult Metabolic Service, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Gerard De Jong
- Statewide Adult Metabolic Service, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Mark Walterfang
- Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Melbourne Neuropsychiatry Centre, University of Melbourne and North-Western Mental Health, Melbourne, VIC, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
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Burton BK, Jones KB, Cederbaum S, Rohr F, Waisbren S, Irwin DE, Kim G, Lilienstein J, Alvarez I, Jurecki E, Levy H. Prevalence of comorbid conditions among adult patients diagnosed with phenylketonuria. Mol Genet Metab 2018; 125:228-234. [PMID: 30266197 DOI: 10.1016/j.ymgme.2018.09.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/23/2018] [Accepted: 09/10/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Phenylalanine hydroxylase (PAH) deficiency, otherwise known as phenylketonuria (PKU), is an inborn error of metabolism that requires treatment to be initiated in the newborn period and continued throughout life. Due to the challenges of treatment adherence and the resulting cumulative effects of high and labile blood phenylalanine, PKU exerts a significant burden of disease. Retrospective studies using large databases allow for unique perspectives on comorbidities associated with rare diseases. An evaluation of comorbidities across various organ systems is warranted to understand the disease burden in adult patients. OBJECTIVES The aim of this insurance claim-based observational study was to assess the prevalence of comorbid conditions across various organ systems (e.g. dermatological, renal, respiratory, gastrointestinal, hematological, and others) among adult PKU patients compared with matched controls from the general population. METHODS This retrospective, case-controlled study selected patients from United States insurance claims databases from 1998 to 2014 using International Classification of Diseases, Ninth Revision (ICD-9) codes for diagnosis of PKU. The date of first diagnosis during the study period was index date and this was not necessarily the first time the patient was diagnosed with PKU. Cases were matched with a 1:5 ratio with general population (non-PKU controls) on age, sex, race, geographic location, duration of time in the database and insurance type. Prevalence and prevalence ratio (PR) calculations for comorbidities across various organ systems among adults (≥20 years old) with PKU were compared with the general population (non-PKU controls). The conditions were selected based on complications associated with PKU and feedback from clinicians treating PKU patients. RESULTS A total of 3691 PKU patients and 18,455 matched, non-PKU controls were selected, with an average age of 35 years. The mean healthcare costs incurred by the PKU patients during baseline, were approximately 4 times that of the controls ($4141 vs $1283; p < .0001). The prevalence rates of comorbidities across various organ systems during the follow-up period were significantly higher for those with PKU than in the control group. After adjusting for baseline characteristics, the adjusted prevalence ratios (PR) of 15 conditions studied (asthma, alopecia, urticaria, gallbladder disease, rhinitis, esophageal disorders, anemia, overweight, GERD, eczema, renal insufficiency, osteoporosis, gastritis/esophagitis and kidney calculus) were all above PR = 1.24 and significantly higher for the PKU cohort (p ≤ .001). The highest adjusted PR were for renal insufficiency with hypertension (PR [95% CI]: 2.20 [1.60-3.00]; p < .0001) and overweight (PR [95%CI]: 2.06 [1.85-2.30]; p < .0001). CONCLUSIONS The prevalence of selected comorbidities across several organ systems is significantly higher among PKU patients than for general population controls. Regular screening for common co-morbidities may be warranted as part of PKU management.
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Affiliation(s)
- Barbara K Burton
- Ann & Robert Lurie Children's Hospital, 225 E. Chicago Ave., Chicago, IL 60611, United States
| | - Kyle Bradford Jones
- University of Utah School of Medicine, Department of Family and Preventive Medicine, 375 Chipeta Way Ste A., Salt Lake City, UT 84108, United States
| | - Stephen Cederbaum
- University of California, Los Angeles, 635 Charles E Young Dr Los Angeles, CA 90095-7332, United States
| | - Fran Rohr
- Boston Children's Hospital and Harvard Medical School, 1 Autumn St., Rm #526, Boston, MA 02115, United States
| | - Susan Waisbren
- Boston Children's Hospital and Harvard Medical School, 1 Autumn Street, #525, Boston, MA 02115, United States
| | - Debra E Irwin
- Truven Health Analytics, An IBM Watson Health Company, 7700 Old Georgetown Rd, 6th Floor, Bethesda, MD 20814, United States
| | - Gilwan Kim
- Truven Health Analytics, An IBM Watson Health Company, 7700 Old Georgetown Rd, 6th Floor, Bethesda, MD 20814, United States
| | - Joshua Lilienstein
- BioMarin Pharmaceutical Inc., 105 Digital Drive, Novato, CA 94949, United States
| | - Ignacio Alvarez
- BioMarin Pharmaceutical Inc., 105 Digital Drive, Novato, CA 94949, United States
| | - Elaina Jurecki
- BioMarin Pharmaceutical Inc., 105 Digital Drive, Novato, CA 94949, United States.
| | - Harvey Levy
- Boston Children's Hospital and Harvard Medical School, 1 Autumn St., Rm #526, Boston, MA 02115, United States
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Zori R, Thomas JA, Shur N, Rizzo WB, Decker C, Rosen O, Li M, Schweighardt B, Larimore K, Longo N. Induction, titration, and maintenance dosing regimen in a phase 2 study of pegvaliase for control of blood phenylalanine in adults with phenylketonuria. Mol Genet Metab 2018; 125:217-227. [PMID: 30146451 DOI: 10.1016/j.ymgme.2018.06.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 05/30/2018] [Accepted: 06/20/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Phenylketonuria (PKU) is caused by a deficiency in phenylalanine hydroxylase enzyme activity that leads to phenylalanine (Phe) accumulation in the blood and brain. Elevated blood Phe levels are associated with complications in adults, including neurological, psychiatric, and cognitive issues. Even with nutrition and pharmacological management, the majority of adults with PKU do not maintain blood Phe levels at or below guideline recommended levels. Pegvaliase, PEGylated recombinant Anabaena variabilis phenylalanine ammonia lyase (PAL), converts Phe to trans-cinnamic acid and ammonia, and is an investigational enzyme substitution therapy to lower blood Phe in adults with PKU. METHODS Pegvaliase was administered using an induction, titration, and maintenance dosing regimen in adults with PKU naïve to pegvaliase treatment. Doses were gradually increased until blood Phe ≤ 600 μmol/L was achieved. The maintenance dose was the dose at which participants achieved and sustained blood Phe ≤ 600 μmol/L for at least 4 weeks without dose modification. Analyses were performed for participants who achieved (Group A, n = 11) and did not achieve (Group B, n = 13) maintenance dose during the first 24 weeks of study treatment. RESULTS Baseline mean blood Phe for Group A and Group B were 1135 μmol/L and 1198 μmol/L, respectively. Mean blood Phe ≤ 600 μmol/L was achieved for Group A by Week 11 (mean blood Phe of 508 ± 483 μmol/L) and for Group B by Week 48 (mean blood Phe of 557 ± 389 μmol/L). The most common adverse events involved hypersensitivity reactions, which were mostly mild to moderate in severity and decreased over time. One participant in Group B had four acute systemic hypersensitivity events of anaphylaxis consistent with clinical National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network criteria; all events were non-IgE mediated and resolved without sequelae, with pegvaliase dosing discontinued after the fourth event. The incidence and titers of anti-drug antibodies were generally lower in Group A compared to Group B. CONCLUSIONS Pegvaliase administered with an induction, titration, and maintenance dosing regimen demonstrated substantial efficacy at reducing blood Phe in both Group A and Group B by Week 48, with a manageable safety profile in most participants. Blood Phe reduction due to pegvaliase appears to be related to dose, treatment duration, and individual immune response; given additional time on treatment and dose titration, later Phe responders (Group B) achieved benefit similar to early Phe responders (Group A), with similar long-term safety profiles.
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Affiliation(s)
- Roberto Zori
- Department of Pediatrics in the College of Medicine, University of Florida, Gainesville, FL, USA.
| | - Janet A Thomas
- Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Natasha Shur
- Pediatrics Genetics Group, Albany Medical Center, Albany, NY, USA
| | - William B Rizzo
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Orli Rosen
- BioMarin Pharmaceutical Inc., Novato, CA, USA
| | - Mingjin Li
- BioMarin Pharmaceutical Inc., Novato, CA, USA
| | | | | | - Nicola Longo
- Division of Medical Genetics, University of Utah, Salt Lake City, UT, USA
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50
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Rocha JC, MacDonald A. Treatment options and dietary supplements for patients with phenylketonuria. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1536541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Júlio César Rocha
- Centro de Genética Médica, Centro Hospitalar do Porto - CHP, Porto, Portugal
- Faculdade de Ciências da Saúde, Universidade Fernando Pessoa, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
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