Fish-odour syndrome and impaired N-oxidation

Regulation of flavin-containing mono-oxygenase (Fmo3) gene expression by steroids in mice and humans

Abstract Flavin-containing mono-oxygenases (FMOs) are a family of microsomal chemical- and drug-metabolizing enzymes. FMO3 is a major FMO form in adult mouse and human liver. FMO3 mutations have been associated with the incidence and severity of trimethylaminuria (TMAU), a metabolic disorder characterized by the inability of the affected individual to metabolize the odorous trimethylamine to its non-odorous N-oxide. In addition to this primary genetic form, there are other forms of TMAU that support the hypothesis that FMO3 activity may be modulated by steroid hormones. To understand the molecular mechanism involved in the regulation of Fmo3 gene expression by steroid hormones, we performed this study in an in vitro cellular system, mouse liver cells, and on the human FMO3 gene. Dexamethasone, 5α-dihydrotestosterone, thyroid hormone, and progesterone had no effect on the accumulation of Fmo3 mRNA. The use of increased concentration of theophylline inhibited estrogen receptor α (ERα)-mediated transcription of Fmo3 mRNA. 17β-Estradiol inhibited Fmo3 mRNA accumulation. The use of ICI 164,384 abolished the inhibitory effect induced by estrogen. Gel-shift analyses showed a binding in the 5' region of the Fmo3 gene. This binding was abrogated by an excess of a cDNA containing an estrogen-responsive element. An estrogen-binding site was also present in the first intron of the human gene, as demonstrated by the gel-shift assay. Supershift experiments confirmed the binding of ERα in both mouse and human samples. Furthermore, chromatin immunoprecipitation assay confirmed the binding of ERα in the promoter region of mouse Fmo3 and in the first intron of the human FMO3 gene. Thus, 17β-estradiol plays a fundamental role in the regulation of Fmo3 gene transcription.

Diagnosis of suspected trimethylaminuria by NMR spectroscopy

BACKGROUND

Trimethylamine (TMA) is a volatile substance produced in the gut, absorbed into the blood and further metabolized by healthy individuals into trimethylamine-N-oxide (TMAO) by TMA-oxidase and then excreted in urine. Patients suffering from trimethylaminuria (TMAU) show an impaired enzymatic oxidation of TMA, excreting this amine in breath, urine and other body secretions which confers an unpleasant body odor.

METHODS

We diagnosed a Brazilian adult male patient suspected of trimethylaminuria with a burden of choline bitartarate by monitoring the urinary excretion of TMA and TMAO by proton nuclear magnetic resonance spectroscopy ((1)H-NMR).

RESULTS

The patient's urinalyses showed an augmented TMA (12.64+/-0.95 mg/l) and TMAO (88.42+/-0.82 mg/l) excretion 6 h after the overload test representing an oxidation capacity of 84.6%, consistent with a heterozygosis condition. Diets containing tuna fish or eggs resulted in an excretion of TMA and TMAO similar to that of the control diet. Only the diet based on dogfish, rich in TMAO, enhanced the excretion of TMA and TMAO reaching 24.65 and 1055.55 mg/l, respectively, in the 0-24 h urine sample.

CONCLUSIONS

It was concluded first, that the patient was not able to metabolize the dietary overload of TMA and second, that more studies are needed to substantiate foods that should be avoided, especially regarding fish, due to their high TMA precursor contents.

Pharmacokinetics of L-carnitine

L-Carnitine is a naturally occurring compound that facilitates the transport of fatty acids into mitochondria for beta-oxidation. Exogenous L-carnitine is used clinically for the treatment of carnitine deficiency disorders and a range of other conditions. In humans, the endogenous carnitine pool, which comprises free L-carnitine and a range of short-, medium- and long-chain esters, is maintained by absorption of L-carnitine from dietary sources, biosynthesis within the body and extensive renal tubular reabsorption from glomerular filtrate. In addition, carrier-mediated transport ensures high tissue-to-plasma concentration ratios in tissues that depend critically on fatty acid oxidation. The absorption of L-carnitine after oral administration occurs partly via carrier-mediated transport and partly by passive diffusion. After oral doses of 1-6g, the absolute bioavailability is 5-18%. In contrast, the bioavailability of dietary L-carnitine may be as high as 75%. Therefore, pharmacological or supplemental doses of L-carnitine are absorbed less efficiently than the relatively smaller amounts present within a normal diet.L-Carnitine and its short-chain esters do not bind to plasma proteins and, although blood cells contain L-carnitine, the rate of distribution between erythrocytes and plasma is extremely slow in whole blood. After intravenous administration, the initial distribution volume of L-carnitine is typically about 0.2-0.3 L/kg, which corresponds to extracellular fluid volume. There are at least three distinct pharmacokinetic compartments for L-carnitine, with the slowest equilibrating pool comprising skeletal and cardiac muscle.L-Carnitine is eliminated from the body mainly via urinary excretion. Under baseline conditions, the renal clearance of L-carnitine (1-3 mL/min) is substantially less than glomerular filtration rate (GFR), indicating extensive (98-99%) tubular reabsorption. The threshold concentration for tubular reabsorption (above which the fractional reabsorption begins to decline) is about 40-60 micromol/L, which is similar to the endogenous plasma L-carnitine level. Therefore, the renal clearance of L-carnitine increases after exogenous administration, approaching GFR after high intravenous doses. Patients with primary carnitine deficiency display alterations in the renal handling of L-carnitine and/or the transport of the compound into muscle tissue. Similarly, many forms of secondary carnitine deficiency, including some drug-induced disorders, arise from impaired renal tubular reabsorption. Patients with end-stage renal disease undergoing dialysis can develop a secondary carnitine deficiency due to the unrestricted loss of L-carnitine through the dialyser, and L-carnitine has been used for treatment of some patients during long-term haemodialysis. Recent studies have started to shed light on the pharmacokinetics of L-carnitine when used in haemodialysis patients.

Trimethylamine and foetor hepaticus

BACKGROUND

In patients with various degrees of hepatocellular failure and portosystemic shunting of blood, the breath may acquire a sweet, musty, or even slightly faecal aroma, termed foetor hepaticus, which has been attributed mainly to volatile sulphur compounds with contributions from various nitrogenous substances. Not infrequently in such patients, unusual body odours are also encountered and, by analogy with the 'fish-odour syndrome' known to be caused by excessive trimethylamine, the availability of this latter graveolent amine to potentially contribute to odours associated with hepatic disease was investigated.

METHODS

Urine (0-24 h) was collected from 63 patients with various liver diseases previously confirmed in hospital by means of various biochemical, immunologic, pathologic, and radiologic investigations. Total trimethylamine and trimethylamine N-oxide levels in urine were measured with head-space gas chromatography.

RESULTS

In total, 50% (32 of 63) of the patients (primary liver disease, 25 of 47, or 53.2%; secondary liver disease, 7 of 16, or 43.8%) had urinary trimethylamine levels greater than the upper end of the range considered normal (0.08-1.84 microg/ml). Seventeen patients excreted large amounts of free trimethylamine (more than 10 microg/ml), above the threshold usually associated with the appearance of a 'fish-like' body odour and tainted breath.

CONCLUSIONS

Excessive amounts of trimethylamine may well contribute to the overall body odour problems encountered among patients with severe hepatic disease, precipitating in these individuals a secondary form of the 'fish-odour syndrome'.