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Marchuk H, Wang Y, Ladd ZA, Chen X, Zhang GF. Pathophysiological mechanisms of complications associated with propionic acidemia. Pharmacol Ther 2023; 249:108501. [PMID: 37482098 PMCID: PMC10529999 DOI: 10.1016/j.pharmthera.2023.108501] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/06/2023] [Accepted: 07/18/2023] [Indexed: 07/25/2023]
Abstract
Propionic acidemia (PA) is a genetic metabolic disorder caused by mutations in the mitochondrial enzyme, propionyl-CoA carboxylase (PCC), which is responsible for converting propionyl-CoA to methylmalonyl-CoA for further metabolism in the tricarboxylic acid cycle. When this process is disrupted, propionyl-CoA and its metabolites accumulate, leading to a variety of complications including life-threatening cardiac diseases and other metabolic strokes. While the clinical symptoms and diagnosis of PA are well established, the underlying pathophysiological mechanisms of PA-induced diseases are not fully understood. As a result, there are currently few effective therapies for PA beyond dietary restriction. This review focuses on the pathophysiological mechanisms of the various complications associated with PA, drawing on extensive research and clinical reports. Most research suggests that propionyl-CoA and its metabolites can impair mitochondrial energy metabolism and cause cellular damage by inducing oxidative stress. However, direct evidence from in vivo studies is still lacking. Additionally, elevated levels of ammonia can be toxic, although not all PA patients develop hyperammonemia. The discovery of pathophysiological mechanisms underlying various complications associated with PA can aid in the development of more effective therapeutic treatments. The consequences of elevated odd-chain fatty acids in lipid metabolism and potential gene expression changes mediated by histone propionylation also warrant further investigation.
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Affiliation(s)
- Hannah Marchuk
- Sarah W. Stedman Nutrition and Metabolism Center & Duke Molecular Physiology Institute, Duke University, Durham, NC 27701, USA
| | - You Wang
- Jining Key Laboratory of Pharmacology, Jining Medical University, Shandong 272067, China.; School of Basic Medicine, Jining Medical University, Shandong 272067, China
| | - Zachary Alec Ladd
- Surgical Research Lab, Department of Surgery, Cooper University Healthcare and Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Xiaoxin Chen
- Surgical Research Lab, Department of Surgery, Cooper University Healthcare and Cooper Medical School of Rowan University, Camden, NJ 08103, USA; Coriell Institute for Medical Research, Camden, NJ 08103, USA; MD Anderson Cancer Center at Cooper, Camden, NJ 08103, USA.
| | - Guo-Fang Zhang
- Sarah W. Stedman Nutrition and Metabolism Center & Duke Molecular Physiology Institute, Duke University, Durham, NC 27701, USA; Department of Medicine, Division of Endocrinology, and Metabolism Nutrition, Duke University Medical Center, Durham, NC 27710, USA.
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2
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Vockley J, Burton B, Jurecka A, Ganju J, Leiro B, Zori R, Longo N. Challenges and strategies for clinical trials in propionic and methylmalonic acidemias. Mol Genet Metab 2023; 139:107612. [PMID: 37245378 DOI: 10.1016/j.ymgme.2023.107612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/19/2023] [Accepted: 05/19/2023] [Indexed: 05/30/2023]
Abstract
Clinical trial development in rare diseases poses significant study design and methodology challenges, such as disease heterogeneity and appropriate patient selection, identification and selection of key endpoints, decisions on study duration, choice of control groups, selection of appropriate statistical analyses, and patient recruitment. Therapeutic development in organic acidemias (OAs) shares many challenges with other inborn errors of metabolism, such as incomplete understanding of natural history, heterogenous disease presentations, requirement for sensitive outcome measures and difficulties recruiting a small sample of participants. Here, we review strategies for the successful development of a clinical trial to evaluate treatment response in propionic and methylmalonic acidemias. Specifically, we discuss crucial decisions that may significantly impact success of the study, including patient selection, identification and selection of endpoints, determination of the study duration, consideration of control groups including natural history controls, and selection of appropriate statistical analyses. The significant challenges associated with designing a clinical trial in rare disease can sometimes be successfully met through strategic engagement with experts in the rare disease, seeking regulatory and biostatistical guidance, and early involvement of patients and families.
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Affiliation(s)
- Jerry Vockley
- Division Medical Genetics, Department of Pediatrics, University of Pittsburgh, School of Medicine, Center for Rare Disease Therapy, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Barbara Burton
- Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Agnieszka Jurecka
- CoA Therapeutics, Inc., a BridgeBio company, San Francisco, CA, USA.
| | - Jitendra Ganju
- Independent Consultant to BridgeBio, San Francisco, CA, USA
| | - Beth Leiro
- Independent Consultant to BridgeBio, San Francisco, CA, USA
| | - Roberto Zori
- Department of Pediatrics, Division of Genetics and Metabolism, University of Florida, Gainesville, FL, USA
| | - Nicola Longo
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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3
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Forny P, Hörster F, Ballhausen D, Chakrapani A, Chapman KA, Dionisi‐Vici C, Dixon M, Grünert SC, Grunewald S, Haliloglu G, Hochuli M, Honzik T, Karall D, Martinelli D, Molema F, Sass JO, Scholl‐Bürgi S, Tal G, Williams M, Huemer M, Baumgartner MR. Guidelines for the diagnosis and management of methylmalonic acidaemia and propionic acidaemia: First revision. J Inherit Metab Dis 2021; 44:566-592. [PMID: 33595124 PMCID: PMC8252715 DOI: 10.1002/jimd.12370] [Citation(s) in RCA: 107] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 02/03/2021] [Accepted: 02/15/2021] [Indexed: 12/13/2022]
Abstract
Isolated methylmalonic acidaemia (MMA) and propionic acidaemia (PA) are rare inherited metabolic diseases. Six years ago, a detailed evaluation of the available evidence on diagnosis and management of these disorders has been published for the first time. The article received considerable attention, illustrating the importance of an expert panel to evaluate and compile recommendations to guide rare disease patient care. Since that time, a growing body of evidence on transplant outcomes in MMA and PA patients and use of precursor free amino acid mixtures allows for updates of the guidelines. In this article, we aim to incorporate this newly published knowledge and provide a revised version of the guidelines. The analysis was performed by a panel of multidisciplinary health care experts, who followed an updated guideline development methodology (GRADE). Hence, the full body of evidence up until autumn 2019 was re-evaluated, analysed and graded. As a result, 21 updated recommendations were compiled in a more concise paper with a focus on the existing evidence to enable well-informed decisions in the context of MMA and PA patient care.
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Affiliation(s)
- Patrick Forny
- Division of Metabolism and Children's Research CenterUniversity Children's Hospital Zurich, University of ZurichZurichSwitzerland
| | - Friederike Hörster
- Division of Neuropediatrics and Metabolic MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Diana Ballhausen
- Paediatric Unit for Metabolic Diseases, Department of Woman‐Mother‐ChildUniversity Hospital LausanneLausanneSwitzerland
| | - Anupam Chakrapani
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust and Institute for Child HealthNIHR Biomedical Research Center (BRC), University College LondonLondonUK
| | - Kimberly A. Chapman
- Rare Disease Institute, Children's National Health SystemWashingtonDistrict of ColumbiaUSA
| | - Carlo Dionisi‐Vici
- Division of Metabolism, Department of Pediatric SpecialtiesBambino Gesù Children's HospitalRomeItaly
| | - Marjorie Dixon
- Dietetics, Great Ormond Street Hospital for Children NHS Foundation TrustLondonUK
| | - Sarah C. Grünert
- Department of General Paediatrics, Adolescent Medicine and Neonatology, Medical Centre‐University of FreiburgFaculty of MedicineFreiburgGermany
| | - Stephanie Grunewald
- Metabolic Medicine Department, Great Ormond Street Hospital for Children NHS Foundation Trust and Institute for Child HealthNIHR Biomedical Research Center (BRC), University College LondonLondonUK
| | - Goknur Haliloglu
- Department of Pediatrics, Division of Pediatric NeurologyHacettepe University Children's HospitalAnkaraTurkey
| | - Michel Hochuli
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, InselspitalBern University Hospital and University of BernBernSwitzerland
| | - Tomas Honzik
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of MedicineCharles University and General University Hospital in PraguePragueCzech Republic
| | - Daniela Karall
- Department of Paediatrics I, Inherited Metabolic DisordersMedical University of InnsbruckInnsbruckAustria
| | - Diego Martinelli
- Division of Metabolism, Department of Pediatric SpecialtiesBambino Gesù Children's HospitalRomeItaly
| | - Femke Molema
- Department of Pediatrics, Center for Lysosomal and Metabolic DiseasesErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Jörn Oliver Sass
- Department of Natural Sciences & Institute for Functional Gene Analytics (IFGA)Bonn‐Rhein Sieg University of Applied SciencesRheinbachGermany
| | - Sabine Scholl‐Bürgi
- Department of Paediatrics I, Inherited Metabolic DisordersMedical University of InnsbruckInnsbruckAustria
| | - Galit Tal
- Metabolic Unit, Ruth Rappaport Children's HospitalRambam Health Care CampusHaifaIsrael
| | - Monique Williams
- Department of Pediatrics, Center for Lysosomal and Metabolic DiseasesErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Martina Huemer
- Division of Metabolism and Children's Research CenterUniversity Children's Hospital Zurich, University of ZurichZurichSwitzerland
- Department of PaediatricsLandeskrankenhaus BregenzBregenzAustria
| | - Matthias R. Baumgartner
- Division of Metabolism and Children's Research CenterUniversity Children's Hospital Zurich, University of ZurichZurichSwitzerland
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4
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AlOwain M, Khalifa OA, Al Sahlawi Z, Hussein MH, Sulaiman RA, Al-Sayed M, Rahbeeni Z, Al-Hassnan Z, Al-Zaidan H, Nezzar H, Al Homoud I, Eldali A, Altonen B, Handoom BS, Mbekeani JN. Optic neuropathy in classical methylmalonic acidemia. Ophthalmic Genet 2019; 40:313-322. [PMID: 31269850 DOI: 10.1080/13816810.2019.1634740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background: Classical MMA, caused by methylmalonyl-CoA mutase deficiency, may result in late-onset dysfunction in several organ systems. To date, 10 cases of optic neuropathy have been reported. The prevalence of optic neuropathy in visually asymptomatic patients has not been determined. This study sought to identify overt and subclinical optic neuropathy in a cohort with classical MMA. Methods and Materials: Neuroophthalmic examinations were performed on 21 patients identified with classical MMA, older than 10years. Diagnosis of optic neuropathy was determined by a combination of visual acuity, optic nerve appearance and electrodiagnostic tests. Tabulated data were analyzed for association of variables using SAS software. Significance was set at p < .05. Results: Two-thirds were Saudi nationals and one third, Syrian. Age range was 11-29years. Eleven (52.4%) patients had optic neuropathy. Nine (81.8%) of these were bilateral, seven (57.9% to 63.6%) reported decreased vision and four (33.1% to 36.4%) were asymptomatic. Two patients had catastrophic vision loss, following acute metabolic crises. Sixteen patients had chronic renal impairment while three had renal hypertension. Seventeen patients had short stature and eight, chronic pancreatitis. Methylmalonic acid levels ranged from 82 to 3,324µmol/L (Normal<1µmol/L). There was a significant association between optic neuropathy and female gender (p = .011) and none with age, nationality, renal impairment, pancreatitis or specific genotype. Conclusion: Optic neuropathy was a frequent finding in classical MMA. It was often bilateral and some cases were sub-clinical, lacking visual symptoms. These findings have important management implications. Full ophthalmic evaluations should be performed early and regularly in patients with MMA, even when patients are asymptomatic.
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Affiliation(s)
- Mohammed AlOwain
- Department of Medical Genetics, King Faisal Specialist Hospital and Research Centre , Riyadh , Saudi Arabia.,College of Medicine, Alfaisal University , Riyadh , Saudi Arabia
| | - Ola Ali Khalifa
- Genetics Unit, Pediatrics Department, Ain Shams University , Cairo , Egypt
| | - Zahra Al Sahlawi
- Department of Pediatrics and Metabolic/Genetic Diseases, Salmaniya Medical Complex , Manama , Kingdom of Bahrain
| | - Maged H Hussein
- Department of Medicine, King Faisal Specialist Hospital and Research Center , Riyadh , Saudi Arabia
| | - Raashda A Sulaiman
- Department of Medical Genetics, King Faisal Specialist Hospital and Research Centre , Riyadh , Saudi Arabia.,College of Medicine, Alfaisal University , Riyadh , Saudi Arabia
| | - Moeen Al-Sayed
- Department of Medical Genetics, King Faisal Specialist Hospital and Research Centre , Riyadh , Saudi Arabia.,College of Medicine, Alfaisal University , Riyadh , Saudi Arabia
| | - Zuhair Rahbeeni
- Department of Medical Genetics, King Faisal Specialist Hospital and Research Centre , Riyadh , Saudi Arabia.,College of Medicine, Alfaisal University , Riyadh , Saudi Arabia
| | - Zuhair Al-Hassnan
- Department of Medical Genetics, King Faisal Specialist Hospital and Research Centre , Riyadh , Saudi Arabia.,College of Medicine, Alfaisal University , Riyadh , Saudi Arabia
| | - Hamad Al-Zaidan
- Department of Medical Genetics, King Faisal Specialist Hospital and Research Centre , Riyadh , Saudi Arabia.,College of Medicine, Alfaisal University , Riyadh , Saudi Arabia
| | - Hachemi Nezzar
- Image-Guided Clinical Neurosciences and Connectomics (IGCNC), Université d'Auvergne , Clermont-Ferrand , France.,Department of Ophthalmology, Dubai Hospital , Dubai , United Arab Emirates
| | - Iftetah Al Homoud
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre , Riyadh , Saudi Arabia
| | - Abdelmoneim Eldali
- Department of Biostatistics, Epidemiology and Scientific Computing, King Faisal Specialist Hospital and Research Centre , Riyadh , Saudi Arabia
| | - Brian Altonen
- Department of Biostatistics, Research Administration, Health & Hospitals Corporation , New York , NY , USA
| | - Bedour S Handoom
- Department of Nutrition Services, King Faisal Specialist Hospital and Research Centre , Riyadh , Saudi Arabia
| | - Joyce N Mbekeani
- Department of Surgery (Ophthalmology), Jacobi Medical Centre , Bronx , NY , USA.,Department of Ophthalmology & Visual Sciences, Albert Einstein College of Medicine , Bronx , NY , USA
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5
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Jurecki E, Ueda K, Frazier D, Rohr F, Thompson A, Hussa C, Obernolte L, Reineking B, Roberts AM, Yannicelli S, Osara Y, Stembridge A, Splett P, Singh RH. Nutrition management guideline for propionic acidemia: An evidence- and consensus-based approach. Mol Genet Metab 2019; 126:341-354. [PMID: 30879957 DOI: 10.1016/j.ymgme.2019.02.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 12/17/2022]
Affiliation(s)
- E Jurecki
- BioMarin Pharmaceutical Inc., Novato, CA, USA.
| | - K Ueda
- British Colombia Children's Hospital, Vancouver, BC, Canada
| | - D Frazier
- University of North Carolina, Chapel Hill, NC, USA
| | - F Rohr
- Boston Children's Hospital, Boston, MA, USA
| | - A Thompson
- Greenwood Genetic Center, Greenwood, SC, USA
| | - C Hussa
- BioMarin Pharmaceutical Inc., Novato, CA, USA
| | - L Obernolte
- Waisman Center, University of Wisconsin, Madison, WI, USA
| | - B Reineking
- BioMarin Pharmaceutical Inc., Novato, CA, USA
| | | | | | - Y Osara
- Emory University, Atlanta, GA, USA
| | | | - P Splett
- University of Minnesota, St. Paul, MN, USA
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6
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Ruzkova K, Weingarten TN, Larson KJ, Friedhoff RJ, Gavrilov DK, Sprung J. Anesthesia and organic aciduria: is the use of lactated Ringer's solution absolutely contraindicated? Paediatr Anaesth 2015; 25:807-817. [PMID: 25943188 DOI: 10.1111/pan.12673] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Organic acidurias (OAs) are rare inborn errors of metabolism that can present with various neurologic manifestations, propensity for acute metabolic decompensation with anion-gap metabolic acidosis, developmental delay, poor feeding, and failure to thrive. OBJECTIVE In this case series, we outline the anesthetic management and perioperative outcomes of OA patients. METHODS We reviewed demographic characteristics, comorbidities, and perioperative course of patients with four different OAs who underwent anesthetic care at our institution between January 1, 2000, and December 31, 2013. RESULTS Eleven patients with OA underwent 19 anesthetic procedures, of which 13 were <2 h in duration and seven were outpatient procedures. One patient with methylmalonic acidemia developed metabolic acidosis during a 10-h procedure with substantial blood loss but lacked evidence that this acidosis could be attributed to his underlying metabolic disease. The patients who received hydration with lactated Ringer's solution and/or nitrous oxide anesthetic had a perioperative course free of metabolic complication. Two patients died within 30 days of surgery from causes likely to be unrelated to anesthetic exposure. CONCLUSIONS Our patients with various forms of metabolically compensated OAs tolerated anesthetics for surgical procedures without metabolic decompensation, even when lactated Ringer's solution was used for hydration. Measures to prevent protein catabolism and intraoperative events that may precipitate metabolic acidosis, in addition to close monitoring of acid-base status during more extensive procedures, must be part of perioperative treatment of these patients.
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Affiliation(s)
- Katerina Ruzkova
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA.,Department of Anesthesia and Intensive Care, University Children's Hospital, Brno, Czech Republic
| | | | - Kelly J Larson
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | | | - Dimitar K Gavrilov
- Division of Laboratory Genetics and Department of Medical Genetics, Mayo Clinic, Rochester, MN, USA
| | - Juraj Sprung
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
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7
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Martinez Alvarez L, Jameson E, Parry NRA, Lloyd C, Ashworth JL. Optic neuropathy in methylmalonic acidemia and propionic acidemia. Br J Ophthalmol 2015. [PMID: 26209586 DOI: 10.1136/bjophthalmol-2015-306798] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Methylmalonic acidemia (MMA) and propionic acidemia (PA) are rare hereditary disorders of protein metabolism, manifesting early in life with ketoacidosis and encephalopathy and often resulting in chronic complications. Optic neuropathy (ON) has been increasingly recognised in both conditions, mostly through isolated case reports or small cases series. We here report the clinical features and visual outcomes of a case series of paediatric patients with a diagnosis of MMA or PA. METHODS Retrospective observational case series. A database of patients attending the Willink Biochemical Genetics unit in Manchester was interrogated. Fifty-three patients had a diagnosis of either isolated MMA or PA, of which 12 had been referred for ophthalmic review. RESULTS Seven patients had clinical findings compatible with ON. Visual outcomes in these patients were poor, with slow clinical progression or stability over time in five cases with follow-up. Presentation was acute in a context of metabolic crisis in two of the cases. Four patients with ON had electrodiagnostics showing absent pattern evoked potentials, with one showing a preserved flash response. All four showed marked attenuation of the dark-adapted electroretinogram with better preservation of the light-adapted response. CONCLUSIONS Our study suggests that ON is under-reported in patients with MMA and PA. Clinical presentation can be acute or insidious, and episodes of acute metabolic decompensation appear to trigger visual loss. Photoreceptor involvement may coexist. Active clinical surveillance of affected patients is important as comorbidities and cognitive impairment may delay diagnosis.
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Affiliation(s)
- Lidia Martinez Alvarez
- Manchester Royal Eye Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Elisabeth Jameson
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, Manchester, UK
| | - Neil R A Parry
- Manchester Royal Eye Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK Faculty of Medical and Human Sciences, Centre for Ophthalmology and Vision Sciences, Institute of Human Development, University of Manchester, Manchester, UK
| | - Chris Lloyd
- Manchester Royal Eye Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK Faculty of Medical and Human Sciences, Centre for Ophthalmology and Vision Sciences, Institute of Human Development, University of Manchester, Manchester, UK
| | - Jane L Ashworth
- Manchester Royal Eye Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK Faculty of Medical and Human Sciences, Centre for Ophthalmology and Vision Sciences, Institute of Human Development, University of Manchester, Manchester, UK
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8
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Baumgartner MR, Hörster F, Dionisi-Vici C, Haliloglu G, Karall D, Chapman KA, Huemer M, Hochuli M, Assoun M, Ballhausen D, Burlina A, Fowler B, Grünert SC, Grünewald S, Honzik T, Merinero B, Pérez-Cerdá C, Scholl-Bürgi S, Skovby F, Wijburg F, MacDonald A, Martinelli D, Sass JO, Valayannopoulos V, Chakrapani A. Proposed guidelines for the diagnosis and management of methylmalonic and propionic acidemia. Orphanet J Rare Dis 2014; 9:130. [PMID: 25205257 PMCID: PMC4180313 DOI: 10.1186/s13023-014-0130-8] [Citation(s) in RCA: 392] [Impact Index Per Article: 39.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 08/05/2014] [Indexed: 12/15/2022] Open
Abstract
Methylmalonic and propionic acidemia (MMA/PA) are inborn errors of metabolism characterized by accumulation of propionic acid and/or methylmalonic acid due to deficiency of methylmalonyl-CoA mutase (MUT) or propionyl-CoA carboxylase (PCC). MMA has an estimated incidence of ~ 1: 50,000 and PA of ~ 1:100’000 -150,000. Patients present either shortly after birth with acute deterioration, metabolic acidosis and hyperammonemia or later at any age with a more heterogeneous clinical picture, leading to early death or to severe neurological handicap in many survivors. Mental outcome tends to be worse in PA and late complications include chronic kidney disease almost exclusively in MMA and cardiomyopathy mainly in PA. Except for vitamin B12 responsive forms of MMA the outcome remains poor despite the existence of apparently effective therapy with a low protein diet and carnitine. This may be related to under recognition and delayed diagnosis due to nonspecific clinical presentation and insufficient awareness of health care professionals because of disease rarity. These guidelines aim to provide a trans-European consensus to guide practitioners, set standards of care and to help to raise awareness. To achieve these goals, the guidelines were developed using the SIGN methodology by having professionals on MMA/PA across twelve European countries and the U.S. gather all the existing evidence, score it according to the SIGN evidence level system and make a series of conclusive statements supported by an associated level of evidence. Although the degree of evidence rarely exceeds level C (evidence from non-analytical studies like case reports and series), the guideline should provide a firm and critical basis to guide practice on both acute and chronic presentations, and to address diagnosis, management, monitoring, outcomes, and psychosocial and ethical issues. Furthermore, these guidelines highlight gaps in knowledge that must be filled by future research. We consider that these guidelines will help to harmonize practice, set common standards and spread good practices, with a positive impact on the outcomes of MMA/PA patients.
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